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Patient Care, Stanford News

Improving communication between doctors and patients

pizzo-09-150.jpgI was speaking recently with a friend who, concerned about his father’s health, accompanied his dad to the doctor’s office. The doctor asked his dad how he felt, and the dad replied that everything was fine. That seemed to satisfy the doctor until my friend spoke up, pointing out the weakness in one of his father’s arms as well as increased memory problems. Why wasn’t the doctor better able to spot the father’s problems during multiple visits in recent months, my friend wondered?

Poor patient-physician communication is a problem that many people experience. Philip Pizzo, MD, dean of Stanford’s School of Medicine, has co-authored a commentary on the need for improvements in this area in the Journal of the American Medical Association.

In a Q&A in today’s issue of Inside Stanford Medicine, he talks about the problem, noting that, “Listening to the patient is not the same as simply asking questions and getting answers. It begins with allowing patients to tell their stories – and to have the time to do so.”

Pizzo also addresses the ways that academic medical centers like Stanford can help solve this problem.

Chronic Disease, Public Safety, Stanford News

Studies document risky use of powerful clotting drug

Studies document risky use of powerful clotting drug

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What happens when physicians latch onto a “wonder” drug for uses that are distinctly different from its original purpose? Stanford researchers today showcase a clear example of the harm that can potentially be done to patients.

In a pair of studies published in the Annals of Internal Medicine, the Stanford team documents the use of recombinant factor 7a – a powerful clotting drug that was intended for a subgroup of hemophilia patients. However, the researchers estimate that in U.S. hospitals from 2000 through 2008, only 4 percent of the drug’s use was for treating hemophilia patients. A staggering 96 percent of the drug’s use involved cases of heart surgery, trauma, brain hemorrhages and a host of other surgical and medical problems.

The team also found that the use of RF7a increased the risk of blood clots without improving the mortality rates. What’s more, RF7a is pricey – it costs an estimated $10,000 for an average dose.

As first author Veronica Yank, MD, notes in our news release, “The stakes are high with this one. Because it’s such a powerful clotting agent, it has the potential when used off-label to damage the lives of patients without providing any real benefit.”

An accompanying editorial by Harvard researchers commends the Stanford team for providing “compelling data about the runaway use, uselessness and risk for this expensive treatment.”

Yank says she hopes the two studies will prompt physicians and surgeons to be more cautious about the off-label use of RF7a. “Despite the miraculous ability of this drug to stop bleeding, we have an obligation to ‘first do no harm,’” she says.

Photo by Steve Fisch

Health and Fitness

Become a blood donor

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Do you know your blood type? I was surprised when many of my friends and family members said they didn’t know theirs. But here’s an easy way to find out and also do a little good work at the same time – become a blood donor.

I’ve been a regular donor at the Stanford Blood Center for nearly six years. I already knew my blood type, thanks to an experiment in a high school biology class, and that’s part of what prompted me to become a donor in the first place. I have AB+ blood, which is on the rare side (about 3.4 percent of Americans have that blood type). What I didn’t know was that I had never had cytomegalovirus, or CMV, a widespread virus that rarely causes symptoms but can be dangerous to people who have weak immune systems. The Stanford center routinely tests donated blood for the presence of CMV antibodies as well as other viruses. That’s because the center is primary supplier of blood products to Stanford Hospital & Clinics and Lucile Packard Children’s Hospital, which cares for transplant patients and others with compromised immune systems.

Because I had never contracted CMV, I was asked to become a platelet donor. Platelet donations take a little longer (the whole process usually lasts about 2 hours), but they make it comfortable by providing individual DVD players and a library of movies and TV shows to choose from. You can relax in a warmed, reclining seat and watch a movie while an apheresis machine removes your blood, separates the components, retains the platelets and returns the remaining blood through the same needle.

Two weeks ago, I made a whole-blood donation for a specific patient who matched my blood type. Whole-blood donations are much shorter, usually under an hour. But no matter which type of donation you make, you always get juice and a snack – great cookies! – at the end. (Fellow blood donors, which cookies are your favorites? I crave the chocolate-chocolate chip ones.)

Each blood donation also provides a nice little snapshot of your health. They’ll check your blood pressure, pulse, temperature, cholesterol and hemoglobin (a protein in red blood cells that carries oxygen). Stanford’s center posts the results in each donor’s online profile, making it easy to track your numbers.

So, if you’d like to learn more about your overall health and do some good for others at the same time, contact your local blood center and find out about the guidelines for becoming a donor. And if you’re squeamish or have medical reasons that prevent you from being a donor, consider volunteering to assist with some of the administrative tasks. They’ll definitely appreciate the help.

Photo by American Red Cross – Oregon Trail Chapter

Medical Schools, Stanford News

Advancing the careers of women in academic medicine

Studies have shown that low expectations for particular groups of people often cause these people to perform poorly, becoming something of a self-fulfilling prophecy. So, how do you counteract the effects of negative expectations?

Researchers at Stanford’s medical school are embarking on an interesting approach to this situation by examining how a phenomenon known as “stereotype threat” may affect women engaged in academic medical careers. Stereotype threats are situations in which individuals find themselves being evaluated on the basis of a negative stereotype.

Women have long been in the minority in the faculty ranks at the nation’s medical schools, especially among the ranks of full professors. With the aid of a $2 million grant from the National Institutes of Health, a team led by Hannah Valantine, MD, will try to identify some of the reasons that women don’t advance up the career ladder at the same rate as their male counterparts.

After first identifying the cues that trigger stereotype threat among women who are junior faculty members, the team will develop and test strategies aimed at counteracting the cues.

“Currently, the factors that prevent women from advancing in academic medical careers are ambiguous, and medical school administrators end up guessing as to how to best to address them,” Valantine recently told me. She hopes the study will give them concrete guidance as to the best ways to help women move forward in their careers.

Previously: Molly Carnes: Gender bias persists in academia

Complementary Medicine, Nutrition, Research, Stanford News

Pine-bark extract doesn’t lower blood pressure levels

The list of nutritional supplements that live up to their promises keeps getting shorter. The latest one on the firing line is pine-bark extract. Although it’s been touted by supplement makers as a way to lower blood pressure, researchers here discovered that it doesn’t.

In a study published today in the Archives of Internal Medicine, researcher Randall Stafford, MD, PhD, and his colleagues report that a 12-week trial found that the extract, which is an antioxidant, didn’t have any effect on the blood pressure levels of people involved in a clinical trial.

“While there’s a good biological basis to presume that antioxidant supplements might have a beneficial effect on heart health, this study is another example that they don’t,” said Stafford, associate professor of medicine at the Stanford Prevention Research Center.

The study did confirm that the pine-bark extract was safe for consumption even though it didn’t improve heart health, but Stafford said many other dietary supplements haven’t undergone the same rigorous safety testing.

The study is yet another warning to consumers to be cautious about the health claims for nutritional supplements.

Research, Stanford News

Expert on ‘study of studies’ to head Stanford Prevention Research Center

ioannidis.jpgWe often hear news reports about the latest scientific research, but just how reliable are those findings? John Ioannidis, MD, DSc, has devoted much of his career to strengthening the way that research is planned, carried out and reported. And now he is bringing that expertise to Stanford.

On Sept. 1, Ioannidis will take over as division chief of the Stanford Prevention Research Center – an organization renowned for its work in identifying ways that individuals can control and prevent such disorders as heart disease, diabetes, obesity and high blood pressure.

Ioannidis, an expert in clinical research methodology, said he hopes to expand the Stanford center’s collaborations with geneticists, biostatisticians and epidemiologists to develop both population-based and personalized approaches to health improvement.

Ioannidis is perhaps best-known for his 2005 essay in PLoS-Medicine titled, “Why most published research findings are false.” The essay remains the most-downloaded article in the history of the Public Library of Science, according to the journal’s media relations office.

Photo by Jonathan Rabinovitz

Cardiovascular Medicine, Stanford News

Failing at prescribing the best heart-failure treatments

stafford-pharm.jpgMost of us put a great deal of faith in the medications that our physicians prescribe for us, believing that our doctor is adhering to medical guidelines in deciding which pill will best treat our illness. But that isn’t always the case.

Randall Stafford, MD, PhD, associate professor of medicine at the Stanford Prevention Research Center, has spent several years studying how well doctors change their practices to response to clinical trial evidence and to new medical guidelines. What he’s found is that doctors are often slow to adapt.

His latest such findings appear today in the Archives of Internal Medicine. Stafford and his colleague, Dipanjan Banerjee, MD, tracked the types of medications that physicians are prescribing for a condition known as congestive heart failure. They found that the use of two types of drug therapy – both of which have proven highly effective in treating the disease – has steadily declined since the early and mid-2000s.

“Our expectation was that there would be continued improvement in the use of these drugs, but that hasn’t happened,” Stafford said. “We’re not sure what’s gone wrong.”

It’s a good reminder that patients should seek out information about the therapies recommended by reputable sources (such as guidelines from medical societies) for conditions that affect them. In some cases, there may be legitimate reasons for prescribing alternate therapies – for instance, the recommended medication may have side effects that would be particularly bad for certain patients. But the dialogue between patient and physician is always important.

More information about the heart-failure study is available in this news release.

Photo by Steve Fisch

Nutrition, Research, Stanford News

Losing vitamins – along with weight – on a diet

Losing vitamins - along with weight - on a diet

If you’re looking to shed a few pounds, you’re probably focused on the amounts of fats, carbs or protein you can eat under the various diet plans available. But a new Stanford study suggests that you should also pay attention to how a diet will affect your consumption of key vitamins and minerals.

The study involving four popular diets – Atkins, Zone, Ornish and the LEARN diet based on the U.S. Department of Agriculture’s food pyramid – showed that only those assigned to follow the Zone diet were able to avoid increasing their risks for inadequate intake of essential vitamins and minerals.

Christopher Gardner, PhD, associate professor of medicine at the Stanford Prevention Research Center and the lead author of the study, urged people to consider the overall nutritional quality of any diet plan they select, rather than focusing solely on the “macronutrients” such as carbohydrates and fats.

The study, which will be published in the August issue of the American Journal of Clinical Nutrition, is a follow-up to a 2007 paper in which Gardner and his colleagues did a head-to-head comparison of the four diet plans.

In the new study, Gardner looked at the vitamin and mineral levels of participants at the time they enrolled in the study and compared them to the levels eight weeks into their diets – when the women were the best at sticking to the new food plans. They found that in three of the diet groups, significant portions of the women increased their risk for inadequate intake of several micronutrients, such as vitamin C, vitamin E, thiamine, folic acid, iron, calcium and zinc.

That wasn’t the case for the women assigned to the Zone diet, who actually increased their intake of some nutrients. Gardner noted that the Zone plan is a “moderately low-carbohydrate” diet, and speculated that this approach to reducing carbs may help dieters maintain a healthier balance. “You can cut a lot of calories out of your diet by eliminating refined grains and added sugars – the least nutritious carbs – without sacrificing nutrient adequacy,” Gardner said.

Genetics, Medical Education, Research, Stanford News

Genotype testing for medical, graduate students

The Stanford School of Medicine will offer an elective course this summer in which medical and graduate students will have the opportunity to have their own personal genotyping done, and then use the data to understand the benefits and limitations of such testing. As far as school officials know, Stanford is the first medical school to offer such a course:

“Over decades, Stanford scientists have contributed substantially to our understanding of the human genome, and now the potential clinical implications of these discoveries are being investigated,” said Charles Prober, MD, the school’s senior associate dean for medical education. “It is critical for our students to develop a deep, rich understanding of the hope and the limitations of personal genomics. We are in the perfect place and at the perfect time for this type of educational approach.”

Stanford’s decision to offer the course during an uproar over the propriety of genetic testing for college students. In May, the University of California announced plans to ask incoming first-year students to be tested for genes linked to the ability to metabolize alcohol, lactose and folic acid, with the goal of spurring discussion about the evolving world of medicine and genetics. At Stanford, the testing will assess a broader number of genes but will be limited to medical and graduate students who enroll in the course and elect to be genotyped.

You can read more about the elective class in the School of Medicine’s news release.

Health Policy, Stanford News

Convincing physicians to change their prescribing patterns

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There’s a multibillion marketing practice in the pharmaceutical industry known as “detailing” in which representatives visit physicians’ offices to share information about their company’s newest drug in hopes of convincing them to prescribe it. While the practice has its critics, it’s been an effective way of boosting drug sales.

And now a Stanford researcher who has spent years examining the marketing practices of the pharmaceutical industry says it might be time for the National Institutes of Health to consider funding an independent form of “detailing” to educate physicians about treatments for which there is clear evidence of benefit for their patients.

Randall Stafford, MD, PhD, is the lead author of a study published today in the Archives of Internal Medicine on the subject. He and his colleagues examined a highly regarded 2002 clinical trial (known as the ALLHAT study) in which researchers determined that thiazide-type diuretics should be the initial drug of choice for reducing high blood pressure. Stafford said the diuretics are low-cost medication that have been on the market for years and have a good safety profile. However, many physicians and patients often incorrectly believe newer, costlier medications to be better than the old standbys.

To determine whether an educational effort would persuade physicians to follow the ALLHAT guidelines, Stafford and his colleagues analyzed an NIH-funded “academic detailing” effort in which 147 trained representatives made presentations to small groups of practitioners on the blood-pressure recommendations.

The result was that in the areas where the academic detailing effort was the most intense, prescriptions for the diuretics increased as much as 8.6 percent compared to areas where there was little or no educational outreach.

“The bottom line is that it made a difference, but it was a modest effect,” Stafford said. “It’s a testament to how difficult it is to change these physician practices, even when we have what seems like overwhelming evidence.”

With all of the money that the NIH spends on research, Stafford said he thinks it would be worth a further investment to make sure that physicians are prescribing drugs that are beneficial and cost-effective for their patients.

“Without academic detailing, clinical trials will have a suboptimal impact on physician prescribing patterns,” Stafford said. “But if you are going to do it, you need to put enough resources into the process to reach physicians, convince them that the data are reliable and help them change their prescribing patterns.”

Photo by Steve Fisch Photography

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