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Research, Stanford News, Surgery

Stanford researchers reveal how mechanical forces contribute to scarring

Stanford researchers reveal how mechanical forces contribute to scarring

When you get a cut, fibrous connective tissue replaces normal skin, sometimes leaving a visible scar. This process is called fibrosis, and it’s a normal part of the healing process. But sometimes scar formation can be dangerous, disfiguring or just unsightly.

Now Stanford researchers have unraveled how mechanical force contributes to inflammation and scarring in mice, a finding that could potentially lead to new therapies for fibrotic diseases, such as pulmonary fibrosis, and inflammatory diseases, such as rheumatoid arthritis, in humans. Their findings were reported yesterday in Nature Medicine.

“Our study exposes one of the fundamental mechanisms by which the mechanical environment can directly increase inflammation, which is strongly implicated in scarring,” Stanford microsurgeon Geoffrey Gurtner, MD, told me. As I explain in a press release:

Mice genetically engineered to lack an enzyme that is activated by mechanical force demonstrated less inflammation and fibrosis — the formation of excess fibrous connective tissue — in their incisions than mice in a control group, the study found. Inflammation and scar formation also were reduced among mice injected with an organic compound, a small molecule called PF-573228, that blocks this enzyme, which helps cells sense changes in the mechanical environment.

Study results showed that 48 percent fewer scar-tissue cells formed around incisions in mice missing the enzyme than those with the enzyme. Although further testing is needed to determine the validity of the findings in humans, researchers hope the work paves the way for treatment strategies for a variety of diseases that involve inflammation and scarring.

Previously: In scar wars, a new hope
Photo by johnnyalive

Aging, Chronic Disease, Stanford News, Surgery

Surgery for chronic acid reflux goes scarless

Surgery for chronic acid reflux goes scarless

A resident of Los Altos, Calif., recently became the first patient at Stanford Hospital & Clinics to undergo a scarless surgery for gastroesophageal reflux disease. Until a few years ago, surgery for the disease, also known as chronic acid reflux, could only be performed through a traditional open chest or laparoscopic approach, which involves inserting instruments through several abdominal incisions.

The development of the EsophyX has changed that. “The ability to do this procedure through the mouth — with no dissection around areas where there are nerves — is a quantum leap forward,” Stanford surgeon John Morton, MD, MPH, told me.

The EsophyX, as I describe in a press release,

looks like a high-tech fishing pole. With the patient under general anesthesia, the flexible rod is inserted through the mouth and throat until it reaches the stomach. There, a small, retractable wire grabs a 1- to 2-inch section of the stomach wall and pulls it down. The two sides of the resulting flap are then pressed together and shaped with the help of a tissue mold and held in place with plastic fasteners. The process is repeated on adjoining sections of stomach wall until a 270- to 310-degree semi-circular valve is formed just beneath the lower esophagus. The valve looks like a three-dimensional omega: Ω.

Chronic acid reflux is more common than you probably think. Roughly 10 to 20 percent of people living in the Western world suffer at least weekly from heartburn or the regurgitation of stomach acid, or both, according to a 2005 review in the journal Gut (subscription required). Some studies put the incidence even higher. And while lifestyle changes, such as losing weight and elevating one’s head while sleeping, and medication, including proton-pump inhibitors, can help to manage the disease, many turn to surgery when these remedies fail. According to a 2008 study in the World Journal of Surgery, EsophyX was effective at reducing symptoms. I cite results of that study in my release:

A year after surgery, 81 percent of the patients were able to stop using proton-pump inhibitors completely, the study said. The study also said that 56 percent of patients were cured, based on their discontinuation of the medication and the reduction of symptoms. The most common adverse side effect was pain in the left shoulder. This affected 18 percent of patients in the study. Other side effects included abdominal pain (15 percent), sore throat (8 percent) and nausea (8 percent). In practically all cases, these side effects lasted no longer than a month.

Photo by Phoney Nickle

Health Costs, Health Policy

When it comes to health-care spending, U.S. is “on a different planet”

For some eye-popping facts on U.S. health-care spending compared to that of other nations, check out a post from Ezekiel Emanuel, MD, PhD, on The New York Times’ Opinionator blog. Emanuel acknowledges that we’ve heard gloomy statistics about health-care costs many times before but adds that “few people really understand how much we spend on health care, how much we need to spend to provide quality care, and the difference between the two.”

He asks, “Do we spend too much? Would cutting costs require rationing, or worse, death panels?” And his answers aren’t pretty.

If you suffer from hypertension, I advise you to read no further. For the rest of us, here goes: Noting that the Unites States spent $2.6 trillion on health care in 2010, Emanuel writes:

If we stacked single dollar bills on top of one another, $2.6 trillion would reach more than 170,000 miles — nearly three-quarters of the way to the moon. Or, compare our spending to that of other countries. France has the fifth largest economy in the world, with a gross domestic product of nearly $2.6 trillion. The United States spends on health care alone what the 65 million people in France spend on everything: education, defense, the environment, scientific research, vacations, food, housing, cars, clothes and health care.

And we’re not getting better care, either:

Almost no matter how we measure it — whether by life expectancy or by survival for specific diseases like asthma, heart disease or some cancers; by the rate of medical errors; or simply by satisfaction with health services — the United States is actually doing worse than a number of countries, like France and Germany, that spend considerably less.

But it was the following statements that reduced me to a state of head-cradling doom:

The fact is that when it comes to health care, the United States is on another planet. The United States spends around 40 percent more per person than the next highest-spending countries, Switzerland and Norway.

Previously: U.S. health-care costs rising faster than abroad
Photo by Veeyawn

Obesity, Research, Stanford News, Surgery

Study finds family members of weight-loss-surgery patients also shed pounds

Study finds family members of weight-loss-surgery patients also shed pounds

You’ve heard about the Atkins diet and the South Beach diet, but have you heard about the weight-loss-surgery-patient-in-your-living-room diet?

In a study (subscription required) published today in the Archives of Surgery, Stanford researchers describe how obese family members of patients who underwent Roux-en-Y gastric bypass surgery also lost weight — an average of eight pounds over a year — simply, it seems, by hanging out with the patients.

These “family members were able to lose weight comparable to being part of a medically controlled diet,” said senior author John Morton, MD, MPH, associate professor of surgery and director of bariatric surgery at Stanford Hospital & Clinics.

As I wrote in a press release about the findings:

The bariatric patients shared a house with their family members participating in the study; these family members, as Morton noted, also accompanied the patients to all of their pre- and post-operative clinical visits, where they received dietary and lifestyle counseling. These sessions would emphasize a high-protein, high-fiber, low-fat and low-sugar diet and small, frequent meals. The sessions also set daily goals for exercise and stressed a good night’s sleep, alcohol moderation and less time in front of the television.

Adult family members made significant changes in their eating habits, with less emotional and uncontrollable eating. Both adults and children made substantial increases in their activity levels. For adult family members, metabolic equivalent task hours, a measure of physical-energy expenditure, more than doubled from 7.8 to 16.8; for children, the increase was from 12.9 to 22.4.

In addition, the adults in the study consumed fewer alcoholic drinks.

“Can you imagine if every one of these bariatric patients were an ambassador for good health?” Morton said. “You would have a huge, grassroots movement with bariatric surgery providing a vehicle for healthy change for patient and family alike. Obesity is a family disease and bariatric surgery sets the table for future, healthy family meals.”

Previously: Study hints at benefits of weight-loss surgery for less obese patients and Bariatric surgery may help protect teen patients’ hearts
Photo by puuikibeach

Mental Health, Sports, Stanford News

High-tech mouthpieces used to advance medical understanding of concussions in football

High-tech mouthpieces used to advance medical understanding of concussions in football

As my colleague mentioned earlier today, the problem of concussions among football players is a very real one. To learn more about the issue, Dan Garza, MD, associate director of Stanford’s Lacob Family Sports Medicine Center and medical director for the San Francisco 49ers, and a team of researchers have launched a study during which Stanford University football players are equipped with mouthpieces containing high-tech sensors. As I explain in a release:

The goal is to help medical scientists better understand what sorts of football collisions cause concussions, as well as whether there are any positions or particular plays associated with a greater risk of these traumatic brain injuries. The mouthpieces contain accelerometers and gyrometers that measure the linear and rotational force of head impacts.

“This study will build towards establishing clinically relevant head-impact correlations and thresholds to allow for a better understanding of the biomechanics of brain injuries,” said Garza… “It also will serve as a helpful tool to aid in diagnosis and subsequent management of concussions.”

Stanford is the only university in the country to use the device to collect research data on its athletes; members of the Stanford women’s field hockey and lacrosse teams are also being outfitted with the mouthpieces.

Previously: Researchers develop new test for diagnosing concussions on the sidelines, Deceased athletes’ brains reveal the effects of head injuries, When can athletes return to play? Stanford researchers provide guidance and New concussion guidelines for NFL players
Photo by Court_59

Emergency Medicine, Evolution, Humor, Stanford News

He’s not a caveman doctor, but he plays one on TV

He’s not a caveman doctor, but he plays one on TV

Grant Lipman, MD, recently provided medical aid to 10 people living like cavemen in near-Paleolithic conditions – an area of the Rockies three hours by car and all-terrain vehicle from Steamboat Springs, Colo.

Lipman was serving as medical director for the production of “I, Caveman,” a kind of reality TV show that is airing at 8 p.m. Sunday, Oct. 2, as part of the Discovery Channel’s Curiosity series.

“We wanted to ask, ‘Were people better off as cavemen?’ How would our lives work without all the material stuff we depend on today?” Alan Eyres, an executive producer at the Discovery Channel, told me in a phone interview about the show.

I describe Lipman’s role in the production in my press release:

As an expert in wilderness medicine, he was particularly well suited for the job of treating members of a 10-person clan – six men and four women – who hunted with stone weapons and wore animal skins last summer in a remote patch of wilderness in the Southern Rocky Mountains.

And Lipman got plenty of opportunities to use his particular skills:

In one case, the most skilled hunter in the group badly cut his hand – his throwing hand, for that matter – while fashioning an obsidian spear tip. The cut got infected, and Lipman had to intervene with some antibiotics. Others suffered from mild hypothermia, altitude sickness and, in one case, acute bronchitis, which he closely monitored. “It could have led to high altitude pulmonary edema” – a life threatening condition in which fluid builds up in the lungs, he said. In another case, a cavewoman partially dislocated a rib, which he had to realign.

“Even though my patients were cavemen, they got the highest standard of modern medical care,” he said.

Lipman also treated production crew members, some of whom suffered from mild hypothermia, altitude sickness, twisted ankles and leech wounds.

Photo by Lord Jim

Cardiovascular Medicine, Clinical Trials, Genetics, Stanford News

Could patients’ knowledge of their DNA lead to better outcomes?

Could patients' knowledge of their DNA lead to better outcomes?

What if seeing genetic-test results related to your risk for a disease helped motivate you to reduce that risk? A team of Stanford researchers led by Joshua Knowles, MD, PhD, want to find out whether that could be the case for people at risk for coronary artery disease. As I discuss in a news release today, they’ve launched a clinical trial during which:

Stanford Hospital & Clinics physicians will tell some of the patients recruited for the randomized trial whether they have any genetic markers for coronary artery disease, the leading cause of death in the United States. The researchers want to see whether these patients, armed with their genetic information, make positive changes to their lifestyle and eating habits, as well as adhere more faithfully to their prescribed drug regimens, compared with members of a control group.

There is some evidence, based on a few European studies, that people react more to genetic information than to traditional diagnostic evaluations. “It’s a concept called genetic exclusivity,” Knowles said. “It’s surprising and not necessarily intuitive.”

Knowles also told me there’s a “huge need” for study in this area, in part because the American Heart Association has concluded that, given the absence of data on how genetic testing actually affects patient outcomes, there isn’t enough information to advocate for such testing.

For those local readers interested in learning more or possibly enrolling, contact Aleksandra Pavlovic at (650) 736-1147 or apavlovi@stanford.edu.

Photo by blarfiejandro

Research, Stanford News, Surgery, Technology

Reconnecting severed blood vessels without sutures

Reconnecting severed blood vessels without sutures

As someone who struggles with threading a needle, I naturally was awed with a story Geoffrey Gurtner, MD, a microsurgeon at Stanford Hospital & Clinics, told me about an operation he did in 2002 requiring some major-league dexterity: reattaching an infant’s finger, including severed arteries and veins, that had been amputated by the wheel of spinning exercise bike. “The blood vessels were so small – maybe half a millimeter,” said Gurtner, who is also a professor of surgery at Stanford University School of Medicine. “The surgery took more than five hours, and at the end we were only able to get in three sutures.”

The experience started him thinking about possible ways to reconnect blood vessels without sutures. Today, Nature Medicine published a study by Gurtner and his colleagues about one possible alternative that makes use of a poloxamer gel and bioadhesive rather than a needle and thread.

The gel is made of molecular polymer blocks and solidifies at higher temperatures. When injected into both ends of a severed vessel and heated, it distends the openings to allow the surgeons to glue them together precisely using a surgical sealant. As I wrote in our news release:

The researchers used a simple halogen lamp to heat the gel. In tests on animals, the technique was found to be five times faster than the traditional hand-sewn method, according to the study. It also resulted in considerably less inflammation and scarring after two years. The method even worked on extremely slim blood vessels – those only 0.2 mm wide – which would have been too tiny and delicate for sutures. “That’s where it really shines,” Gurtner said. . . .

Gurtner said he believes the new technique could satisfy a huge unmet need and prove especially useful in minimally invasive surgeries, in which manipulating sutures takes on a whole new level of difficulty.

Cardiovascular Medicine, Stanford News, Technology

Heart-attack data gets to hospital before patient does

Heart-attack data gets to hospital before patient does

A new study published online yesterday in Circulation found that people suffering from major heart attacks are being treated much faster than just five years ago: The median time it took for patients to undergo the artery-widening procedure, balloon angioplasty, from the moment they arrived at a hospital’s doors declined from 96 to 64 minutes between 2005 and 2010, the study says.

At Stanford Hospital & Clinics, the so-called door-to-balloon time averaged just 61 minutes in 2010, and the hospital is working on bringing that figure down even more with the help of wireless technology, which I wrote about in a news release:

The system, which launched March 1, enables Stanford emergency physicians to examine a patient’s electrocardiogram, or ECG, before that patient even departs in the ambulance for the hospital. It also gives the hospital an opportunity to assemble a team of cardiovascular nurses and interventional cardiologists … before the patient arrives. …

Although the portable monitor/defibrillator – a boombox-sized device you often see with paramedics treating someone in the field – has long been a fixture on ambulances, its ability to share ECGs with medical personnel who are not at the scene has greatly advanced with the growth and sophistication of wireless broadband technology over the last several years.

Orthopedics, Pain, Research, Stanford News

For people with herniated disc, biomarker may signal whether pain treatment will work

For people with herniated disc, biomarker may signal whether pain treatment will work

For people suffering from back pain, there’s about a 25 percent chance the culprit is a herniated disc, commonly known as a slipped disc, which occurs most often in the lower back. While the condition generally gets better within six months, it can be quite painful, resulting in soreness in the legs and rear end. Physicians often try to relieve this pain with a steroid injection in the spine, but according to Stanford orthopaedic surgeon Gaetano Scuderi, MD, there’s only about a 50 percent chance this approach will work.

“Most people figure, ‘Hey, I have nothing to lose,’” Scuderi recently told me. “However, there is a significant expense, not to mention the procedural risks and lost productivity.”

In a study appearing in the Aug. 15 edition of Spine, Scuderi and colleagues show how they identified a unique protein complex that may signal whether a patient will respond to an epidural steroid injection. As I write in a press release, testing for this biomarker could offer several advantages to patients:

If patients with lower-back pain could be screened to determine whether they would respond to the injections, they could be spared the discomfort and cost of a futile procedure, Scuderi said, as well as its potential complications, such as bleeding, infection and thinning and even death of bone tissue.

This research involved 26 patients, and the authors say larger trials are needed.

Photo by planetc1

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