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Ask Stanford Med, Fertility, Pregnancy, Stanford News, Women's Health

Five million babies and counting: Stanford expert offers conversation on reproductive medicine

Five million babies and counting: Stanford expert offers conversation on reproductive medicine

newbornEarlier this week, an international group announced that reproductive medicine techniques, such as in vitro fertilization, have led to the birth of 5 million babies since 1978. “This is a great medical success story,” a member of the International Committee for the Monitoring of Assisted Reproductive Technology said in a statement, pointing out that the number of these babies equals the population of the state of Colorado.

At Stanford, Valerie Baker, MD, heads up the academic division that focuses on reproductive medicine. From now until Monday evening, she’s taking questions on the topic, as well as on infertility in general. Readers can share what’s on their mind with her in the comments section of this blog entry or by sending a tweet that includes the hashtag #AskSUMed.

Previously: Ask Stanford Med: Expert in reproductive medicine taking questions on infertility, Oh, baby! Infertile woman gives birth through Stanford-developed technique, Stanford researchers work to increase the odds of in vitro fertilization success, Sex without babies, and vice versa: Stanford panel explores issues surrounding reproductive technologies and New test predicts the success of IVF treatment
Photo by Emery Co Photo

Ask Stanford Med, Fertility, Men's Health, Pregnancy, Stanford News, Women's Health

Ask Stanford Med: Expert in reproductive medicine taking questions on infertility

Ask Stanford Med: Expert in reproductive medicine taking questions on infertility

4223909842_e028c12f28An estimated 10 to 15 percent of couples in the United States are infertile. One or a number of factors may render a couple unable to conceive, including hormone imbalances or blockages of sperm movement in men, and ovulation problems arising from a variety of causes in women. Those who turn to fertility treatments, a recent study showed, can expect to pay more than $5,000 out of pocket on average, or upwards of $19,000 for in vitro fertilization (IVF).

Strides in research to overcome barriers to conception have included a recent Stanford-developed technique to promote egg growth in infertile women who have experienced early menopause. Senior author Aaron Hsueh, PhD, professor of obstetrics and gynecology at Stanford, collaborated with scientists here and at the St. Marianna University School of Medicine in Kawasaki, Japan on a procedure known as “in virto activation,” in which a portion of a woman’s ovary is removed, treated outside the body, and then returned near her fallopian tubes. Through this specialized structure, a participant in the study recently gave birth.

For this edition of Ask Stanford Med, we’ve asked Valerie Baker, MD, to respond to your questions about infertility. Baker, who offered insights on Hsueh’s study and its possible implications for patients in a video and article last month, is division chief of reproductive endocrinology and infertility and director of Stanford’s Program for Primary Ovarian Insufficiency. Her research and clinical interests include primary ovarian insufficiency, and assisted reproductive technology and hormone therapy for fertility and reproduction.

Questions can be submitted to Baker by either sending a tweet that includes the hashtag #AskSUMed or posting your question in the comments section below. We’ll collect questions until Monday, October 21 at 5 PM.

When submitting questions, please abide by the following ground rules:

  • Stay on topic
  • Be respectful to the person answering your questions
  • Be respectful to one another in submitting questions
  • Do not monopolize the conversation or post the same question repeatedly
  • Kindly ignore disrespectful or off topic comments
  • Know that Twitter handles and/or names may be used in the responses
  • Baker will respond to a selection of the questions submitted, but not all of them, in a future entry on Scope.

Finally – and you may have already guessed this – an answer to any question submitted as part of this feature is meant to offer medical information, not medical advice. These answers are not a basis for any action or inaction, and they’re also not meant to replace the evaluation and determination of your doctor, who will address your specific medical needs and can make a diagnosis and give you the appropriate care.

Previously: Researchers describe procedure that induces egg growth in infertile womenOh, baby! Infertile woman gives birth through Stanford-developed technique and Sex without babies, and vice versa: Stanford panel explores issues surrounding reproductive technologies
Photo by Dylan Luder

Ask Stanford Med, Sleep, Sports, Stanford News

Ask Stanford Med: Cheri Mah responds to questions on sleep and athletic performance

Ask Stanford Med: Cheri Mah responds to questions on sleep and athletic performance

US Open TennisWhether you’re a student-athlete superstar or the mayor of your local gym, chances are your performance on the field, court or treadmill could be influenced by the way you sleep. So for this installment of Ask Stanford Med, we’ve asked Cheri Mah, a researcher with the Stanford Sleep Disorders Clinic and Research Laboratory, to respond to questions on sleep and athletic performance. Below are her answers, along with some tips to help you get the most out of your nightly slumber. We hope this will help you consider which of your own sleep practices are working, and what you might want to reconsider.

Michelle asks: Can you give a summary of your  research to date showing that sleep might help athletes? And what kind of studies are you working on now?

For past few years, William Dement, MD, PhD, and I have been studying the impact of sleep extension on the athletic performance in elite athletes. My interest in specifically studying sleep duration and sleep quality in athletes stems from a study in 2002. By chance, several Stanford swimmers were in our study, and although we weren’t investigating athletic performance, they mentioned that they had set several personal records in their last swim meet!

Over subsequent years, we’ve examined the impact of sleep extension across many sports at Stanford including basketball, football, tennis, and swimming to compare similarities and differences across sports. Our findings from men’s basketball published in 2011 indicate that several weeks of sleep extension improves reaction time, mood, levels of daytime sleepiness, and specific indicators of athletic performance including free throws, 3 point field goals, and sprint time. These findings suggest that sleep duration is likely an important component of peak performance.

Additionally, our study suggests that significantly reducing an accumulated sleep debt from chronic sleep loss may require more than one night or weekend of recovery sleep. Although sleep is frequently overlooked and often the first to be sacrificed, sleep duration and sleep quality should be important daily considerations for athletes aiming to perform at their best.

Currently, we’re continuing our research on sleep extension and examining the impact on different aspects of performance in various sports. We’re  also investigating the habitual sleep habits and patterns of elite athletes. Since each sport has it’s own unique culture and training, we’re  interested in examining the similarities as well as differences across sports among the Stanford student-athlete population.

Emily asks: What sort of sleep-related work have you done with Stanford athletes over the years? What kind of feedback have you gotten from the students?

Aside from research,  I’ve worked over the years with various teams and athletes at Stanford to help improve and optimize their sleep and recovery.

For many athletes, it’s their first time diving deep into the impact of sleep on performance – they had never before focused on their sleep as an important component of their daily training beyond being told to “get a good night of sleep” before a game or competition. Many of the athletes I work with are surprised at the difference sleep can have on their training, performance, and even schoolwork! For many, it’s their first experience having a strategic approach to optimizing sleep and tracking their progress through a season. It’s often only in hindsight – after they’ve significantly reduced their sleep debt over several weeks – that many athletes realize they were operating at a sub-optimal level. Additionally, athletes often realize after extending their sleep that they need more hours of sleep than they previously thought to perform at their best. Some athletes have gone on to play at the professional level and have even been advocates of the importance of sleep on sports performance.

Several coaches have been quite interested in improving sleep and recovery in their team. They’re often aware that their athletes aren’t  properly rested and thus have been interested in both educating their athletes and implementing strategies to improve their team’s recovery. Some coaches have also consulted me on their travel schedules to minimize jet lag and optimize performance on the road.

Dr. Dement and I are also part of the Stanford Performance Enhancement Alliance, which serves Stanford athletes through a multidisciplinary approach to sports performance.

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Ask Stanford Med, Sleep, Sports, Stanford News

Last day to submit questions on sleep and athletic performance to Stanford expert

CARTERAs a reminder, today is the final day to submit questions for our Ask Stanford Med installment spotlighting sleep and athletic performance. Questions related to research on the subject and to sleep patterns or exercise habits can be submitted to Cheri Mah either by sending a tweet with the hashtag #AskSUMed or by posting a comment here. We’ll accept questions until 5 p.m. Pacific time.

In our earlier post, we included details on Mah’s research:

Sleep and sports are the focus of Mah’s work, dating back to a 2002 study during which collegiate swimmers reported they had beaten personal swim records after getting extra hours of sleep as part of their participation in the trial. A light bulb went off in Mah’s head, who decided then to investigate whether sleep extension could have an impact on physical performance. Since then she has researched the effects of sleep on numerous groups of athletes, including elite college-level basketball players (as detailed in a 2011 study), and she has two soon-to-be-published papers measuring the impact of sleep on Stanford football players and on NFL players. Over the last several years, Mah has also worked with many of the Stanford sports teams and coaches to integrate optimal sleep and travel scheduling into their seasons, and she consults on sleep issues with professional hockey, football and basketball teams.

Previously: Ask Stanford Med: Cheri Mah taking questions on sleep and athletic performanceStanford expert: Students shouldn’t sacrifice sleepA slam dunk for sleep: Study shows benefits of slumber on athletic performanceCould game time affect a baseball player’s at-bat success? and Want to be like Mike? Take a nap on game day
Photo by ASSOCIATED PRESS

Ask Stanford Med, Health Costs, Research, Stanford News

What’s the going rate? Examining variations in private payments to physicians

What's the going rate? Examining variations in private payments to physicians

In this photo taken Tuesday, Sept. 2, 2009, University Muslim Medical Association Community Clinic family medicine physician Linh Vuong, right, checks vital signs of high school student Ericka Millan,15, at the UMMA Community Clinic in Los Angeles.  American Muslims want to ensure that they can fulfill "zakat," or obligatory charitable religious giving, following zakat pledge by President Barack Obama. (AP Photo/Damian Dovarganes)When a U.S. physician sees a patient – either for a routine visit or to administer some sort of treatment – there’s a good chance she’ll be paid a different amount for her work than another doctor doing the same thing one state, or perhaps even one county, away. Variation in the amounts that private insurers pay physicians is a known phenomenon, but extensive research on the practice – and the factors that account for such variation - has been lacking.

To better understand these differences in payments, Stanford health-policy experts Laurence Baker, PhD, and M. Kate Bundorf, MBA, MPH, PhD, teamed up with an Indiana University–Purdue University researcher to comb through more than 41 million insurance claims for four kinds of services: office visits with established patients, office visits with new patients, office consultations, and preventive visits with established patients. What they found was that physicians at the high-end of payments received were generally paid more than twice than what physicians at the low end were paid for the same service. They also found that the variation couldn’t be explained by patients’ and physicians’ characteristics – things like the age and sex of the patient, the physician’s specialty, and whether the doctor was a “network provider” – but that about one third of the variation was associated with the geographic area of the practice.

To find out more about the study, which was published online yesterday in Health Affairs, I contacted Baker. He answers my questions below.

Were you surprised by what you found?

Sort of. Some news reports have highlighted variations in health-care bills, so we were ready for some variations. But since we were looking at services that are quite common and pretty consistent from place to place, we weren’t expecting to find very big variations, which is what we got.

The other thing that’s interesting is the amount of variation that isn’t explainable by the things we looked at. I had expected a lot of it would be explainable, but most of it isn’t. This is another indication of the complexity of the health care system and the lack of understanding we have of the factors that determine prices.

Did you expect geography to be more of or less of a factor?

I had expected more. Geography is a proxy for many things – such as the costs in different areas, the competitiveness of areas, the preferences of the population and doctors. These could all influence prices. I had thought these would play a bigger role than what we found. But there’s a chance that these things still do, but in ways that are specific to individual doctors or groups, so that we need to do more work to fully measure them.

Why is a better understanding of price variation important?

Price variations could signal important problems with the functioning of health-care markets. Large price variations for similar services normally only exist where someone in a market has a lot of power to dictate prices, which is often a problem for consumers. Price variations can also exist for reasons we’d be less concerned about – for example, if some providers are much higher in quality than others. But knowing about the existence and patterns of price variations can guide us to examine areas that we may need to work on to improve the system.

Informing patients about price variations can also be important. Some patients – for example, the uninsured – can end up paying widely different prices for the same services. If they have more information, they’ll perhaps be better able to manage their health-care experiences and bills.

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Ask Stanford Med, Sleep, Sports, Stanford News

Ask Stanford Med: Cheri Mah taking questions on sleep and athletic performance

football kidIt’s football season and back-to-school time, which means evening routines in households across the country may be changing to accommodate homework, practice, dinner, and perhaps Monday Night Football-watching. For athletes of all ages and stripes, conversations may also be focused on optimizing performance and reducing the risk of injury, with such topics as conditioning technique and nutrition getting playing time in the discussions. But one thing that may not be getting enough attention is sleep, and its role in sports.

To boost the conversation of sleep’s part in athletic performance, we’ve asked Cheri Mah, a researcher with the Stanford Sleep Disorders Clinic and Research Laboratory, to respond to your questions on the topic. Sleep and sports are the focus of Mah’s work, dating back to a 2002 study during which collegiate swimmers reported they had beaten personal swim records after getting extra hours of sleep as part of their participation in the trial. A light bulb went off in Mah’s head, who decided then to investigate whether sleep extension could have an impact on physical performance. Since then she has researched the effects of sleep on numerous groups of athletes, including elite college-level basketball players (as detailed in a 2011 study), and she has two soon-to-be-published papers measuring the impact of sleep on Stanford football players and on NFL players. Over the last several years, Mah has also worked with many of the Stanford sports teams and coaches to integrate optimal sleep and travel scheduling into their seasons, and she consults on sleep issues with professional hockey, football and basketball teams.

Questions can be submitted to Mah by either sending a tweet that includes the hashtag #AskSUMed or posting your question in the comments section below. We’ll collect questions until Tuesday, September 17 at 5 p.m.

When submitting questions, please abide by the following ground rules:

  • Stay on topic
  • Be respectful to the person answering your questions
  • Be respectful to one another in submitting questions
  • Do not monopolize the conversation or post the same question repeatedly
  • Kindly ignore disrespectful or off topic comments
  • Know that Twitter handles and/or names may be used in the responses
  • Mah will respond to a selection of the questions submitted, but not all of them, in a future entry on Scope.

Finally – and you may have already guessed this – an answer to any question submitted as part of this feature is meant to offer medical information, not medical advice. These answers are not a basis for any action or inaction, and they’re also not meant to replace the evaluation and determination of your doctor, who will address your specific medical needs and can make a diagnosis and give you the appropriate care.

Previously: Stanford expert: Students shouldn’t sacrifice sleep, A slam dunk for sleep: Study shows benefits of slumber on athletic performance, Could game time affect a baseball player’s at-bat success? and Want to be like Mike? Take a nap on game day
Photo by Nick Weiler

Ask Stanford Med, Fertility, Women's Health

Ask Stanford Med: Director of Female Sexual Medicine Program responds to questions on sexual health

Ask Stanford Med: Director of Female Sexual Medicine Program responds to questions on sexual health

7058874009_eeff99aae6 (1)In some circles, the term “female sexual health” may elicit more blushing than productive conversation, even between a woman and her gynecologist. So for this installment of Ask Stanford Med, we invited Leah Millheiser, MD, director of Stanford’s Female Sexual Medicine Program, to respond to readers’ questions on the topic. Below are her answers, which we hope will generate more open discussion on a health subject important to both women and men.

Heather asks: Why are there no FDA-approved medications for female sexual disorders and several for men? Will there ever be a Viagra-type drug for women?

That’s an excellent question, Heather, and one that I am frequently asked by my patients. There are two drugs FDA-approved for the treatment of female sexual dysfunction (FSD) compared to the seven available for the treatment of male erectile dysfunction. Premarin vaginal cream has been around for many years for the treatment of vaginal atrophy in postmenopausal women. However, in 2008, the FDA approved Premarin for a new indication – the treatment of postmenopausal sexual pain (dyspareunia). Earlier this year, Osphena was also approved for the treatment of postmenopausal dyspareunia. Osphena is an oral pill taken on a daily basis that belongs to a class of drugs called Selective Estrogen Receptor Modulators (SERMs). Unfortunately, we still have a long way to go when it comes to closing the gap between FDA-approved treatments available to men vs. those available to women. Currently, many women are being treated for sexual dysfunction with off-label treatments. These are medications that have been shown in research to be safe and effective for the treatment of FSD (desire, arousal, orgasm, and pain disorders). The good news is that there are several drugs currently under investigation for the treatment of low libido and arousal disorders. Learn more about female sexual dysfunction here.

Emily asks: Is there any connection between female sexual health disorders and infertility?

There is definitely a connection between female sexual function issues and infertility, Emily. In a 2010 study (subscription required) published in Fertility and Sterility, we demonstrated that women with infertility were at a higher risk for sexual dysfunction compared to women without infertility. Specifically, the women with infertility had greater difficulty with sexual arousal and desire. On the flip side, when a woman is experiencing sexual dysfunction, she may limit or avoid sexual activity altogether. This limitation may prevent a woman from becoming pregnant. In fact, many patients are referred to me from infertility centers with a diagnosis of sexual pain, most commonly vaginismus. Vaginismus occurs when there is an involuntary contraction of the pelvic floor muscles during attempted or actual vaginal penetration. Oftentimes, partners of women with vaginismus will describe the sensation of “hitting a brick wall” whenever they try to enter the vagina. Individuals with this disorder may avoid seeing a gynecologist for yearly exams due to the fear of pain. The treatment for vaginismus is quite successful and, in the motivated patient, can be completed in a relatively short period of time. From a financial perspective, it is often more cost-effective to address the sexual dysfunction prior to embarking on what can end up being very expensive fertility treatments. Learn more about the relationship between infertility and female sexual dysfunction here.

Grace asks: What is the relationship between body image/low self-esteem and low sex drive in women?

When a woman comes to see me for a complaint of low sex drive, we focus on several areas of her health: general medical disorders, medications, surgeries, pregnancy history, mental health, relationship history, as well as psychosocial stressors. When taking a patient’s mental health history, I always screen for depression/anxiety and discuss body image and self-esteem. There are many reasons why a negative body image can affect a woman, including dissatisfaction with body image following pregnancy, menopause, or treatment for cancer (breast, gynecologic). In the case of pregnancy, the data shows that most couples resume intercourse after six weeks; however, the frequency is usually decreased compared to pre-pregnancy, which can be related to low body image. If a woman does not feel comfortable with her own body, she may avoid situations of intimacy with her partner. This avoidant behavior becomes associated with low sex drive. Following menopause, many women find that they gain weight easily, especially in the abdominal area, and have difficulty losing it. Additionally, they may develop low libido and vaginal atrophy, which can lead to painful intercourse. In many cases, women feel as though their bodies have “turned against them” following menopause and, as a result, their body image and sexual self-esteem are impacted. In the setting of breast cancer, women may experience negative body image as a result of chemotherapy-related hair loss or surgical treatment, including mastectomy or lumpectomy. In fact, data shows that premenopausal women who undergo mastectomy experience greater issues related to poor body image compared to postmenopausal women treated with the same surgery.

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Ask Stanford Med, Sexual Health, Stanford News, Women's Health

Ask Stanford Med: Director of Female Sexual Medicine Program taking questions on sexual health

Ask Stanford Med: Director of Female Sexual Medicine Program taking questions on sexual health

woman looking out window b7WWhile sexual dysfunction affects both genders, it is more common in women than men, with past research showing that prevalence of sexual complaints among women is 43 percent. Additional studies have shown that lack of desire is among the top sexual difficulties experienced by women, followed by inability to achieve orgasm and pain during intercourse.

Although discourse on the topic has grown over the past few years, there are still many misconceptions about factors contributing to sexual dissatisfaction or dysfunction. Leah Millheiser, MD, a clinical assistant professor of obstetrics and gynecology, is working to change that through her clinical work and recently launched blog and Twitter feed.

In an effort to foster a frank discussion of this important and often misunderstood health topic, we’ve asked Millheiser to respond to your questions on female sexual function. As this month’s Ask Stanford Med guest, she’ll address a variety of topics, including diagnosing and treating women’s sexual pain, low sex drive and chronic disorders such as vulvodynia.

You can submit a question by either sending a tweet that includes the hashtag #AskSUMed or posting it in the comments section below. We’ll collect questions until Tuesday (Aug. 13) at 5 PM Pacific Time.

When submitting questions, please abide by the following ground rules:

  • Stay on topic
  • Be respectful to the person answering your questions
  • Be respectful to one another in submitting questions
  • Do not monopolize the conversation or post the same question repeatedly
  • Kindly ignore disrespectful or off topic comments
  • Know that Twitter handles and/or names may be used in the responses
Millheiser will respond to a selection of the questions submitted, but not all of them, in a future entry on Scope.

Finally – and you may have already guessed this – an answer to any question submitted as part of this feature is meant to offer medical information, not medical advice. These answers are not a basis for any action or inaction, and they’re also not meant to replace the evaluation and determination of your doctor, who will address your specific medical needs and can make a diagnosis and give you the appropriate care.

Previously: Shining the spotlight on women’s sexual health and Birth control pill may lead to sexual problems for women
Photo by James Burrell

Ask Stanford Med, Autoimmune Disease, Pediatrics

Stanford pediatric gastroenterologist responds to your questions on celiac disease

Stanford pediatric gastroenterologist responds to your questions on celiac disease

gluten_free_072413In the second part of this month’s installment of Ask Stanford Med, we continue the conversation about pediatric gastrointestinal diseases with KT Park, MD, an instructor in pediatric gastroenterology at Stanford and attending physician for the gastroenterology and hepatology services at Lucile Packard Children’s Hospital. Below Park responds to questions related to celiac disease submitted by readers on the School of Medicine Facebook page and in the comments section on Scope.

Pratik Taur asks: What are treatment options for patients of celiac disease [who don't want a] gluten-free diet?

Unfortunately, the only proven treatment for biopsy-confirmed celiac disease is total gluten avoidance. In fact, research has shown repeatedly that even small amounts of gluten can cause detrimental long-term health consequences, including progressive bone loss. I wish there was a different answer for many patients with true celiac disease (whether they have symptoms or not). For now, a strict gluten-free diet for life is the only treatment option. Below I discuss future treatment options that may become available, but still only considered within research frameworks at this time.

Mylea Charvat asks: With celiac will I ever be able to eat regular pastas and breads again? Is there any research into medication to help those diagnosed with celiac disease digest and tolerate gluten?

I wish there were better news for the here and now. Unfortunately, as you know, a strict gluten-free diet – for now – is the only treatment option for celiac disease. Regular pastas and breads are definitely hard to give up, especially if you really enjoy them. With that said, many laboratories around the world are evaluating different strategies to offer celiac patients more therapeutic options in the future. One hopeful approach is “glutenase therapy” where an enzyme could break down the gluten and render it non-toxic. Other working ideas include: blocking the immune reaction (i.e., auto-antibodies) through an ingestible polymeric resin, “desensitizing” the body’s immune system response to gluten via serial protein-based injections and developing a celiac vaccine. Looking ahead, it is conceivable that celiac patients will one day be able to eat gluten-containing foods, but definitive alternatives to gluten avoidance are not yet ready for general consumer use.

Antonio Ruben Murcia Prieto asks: What about oats for celiac disease?

The topic of oats is very much an evolving discussion among celiac experts. Generally, oats are an excellent source of good nutrients, including vitamins, minerals and antioxidants, and dietary fiber, such as soluble beta-glucans. They are high in protein, and are even thought to help maintain steady insulin levels. The working idea is that the biochemical nature of oats is gluten-free, but the manufacturing process of oats contaminates it with a common cereal protein called prolamins, which are found in wheat, barley and rye containing seeds that celiac patients have to avoid.

One group of investigators analyzed 134 oat grains from various manufacturers in the U.S., Canada, and Europe, and they found that only 25 samples were uncontaminated by prolamins, and the majority of samples tested exceeded the threshold for what would be considered gluten-free. Unfortunately, results from clinical studies have been mixed. Also, even if the cross-contamination problem is resolved, the scientific community seems to agree that some celiac patients may be able to tolerate oats without any health consequences, while a subgroup of celiac patients simply cannot tolerate any oats.

For now, the Celiac Sprue Association says it best with this formal recommendation: “Oat products, grown, processed and packaged to be free of contamination with wheat, barley or rye appear to be suitable for some people with celiac disease, but not ALL people… Oats is not a risk-free choice for those on a gluten-free diet. Since oats are not a risk-free choice for all people with celiac disease, products containing oats do not qualify to use the CSA Recognition Seal.”

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Ask Stanford Med, Autoimmune Disease, Pediatrics

Stanford pediatric gastroenterologist answers your questions on inflammatory bowel diseases

Stanford pediatric gastroenterologist answers your questions on inflammatory bowel diseases

sick_kid_072313While nearly every adult and child experiences stomach issues once in a while, millions suffer from serious autoimmune problems in the intestine, such as celiac disease, and inflammatory bowel disorders, including Crohn’s disease and ulcerative colitis. These chronic digestive diseases, which have no known medical cure, commonly require a lifetime of care for patients.

Ongoing research at Stanford and elsewhere aims to forge new avenues for the diagnosis, therapy and prevention of these diseases. At Stanford, KT Park, MD, an instructor in pediatric gastroenterology, studies the pharmaco-economics of various therapeutic and diagnostic strategies for chronic gastrointestinal diseases, with particular interests in Crohn’s disease, ulcerative colitis, celiac disease and chronic abdominal pain. He is also an attending physician for the gastroenterology and hepatology services at Lucile Packard Children’s Hospital.

For this month’s Ask Stanford Med, we asked Park to answer your questions on advancements in research and treatments for pediatric gastrointestinal diseases. He responds to your questions in a two-part Q&A, first discussing research on fecal microbiota transplantation, the role of diet in treating Crohn’s, and IBD in the developing world.

Migdalia Ramos asks: Why isn’t fecal microbiota transplantation (FMT) seriously researched as a treatment for children with IBD?

You are correct in that the representative literature on fecal microbiota transplantation in IBD is lacking, although one small observational study in children was recently published. The paucity of data doesn’t  mean that scientists and IBD clinicians aren’t thinking about it. As you may know, FMT – after much advocacy by patients, various advocacy groups, and gastroenterology societies such as the American Gastroenterological Association – is now approved by the U.S. Food and Drug Administration for recurrent Clostridium difficile (C. difficile) infections and colitis, subject to ongoing regulatory oversight. Over 14,000 Americans die from C. diff annually. In fact, almost all major FMT literature is in the treatment of recurrent C. difficile colitis, which has over a 90 percent efficacy rate. Despite the success in eradicating C. difficile, FMT cannot be assumed to be safe or effective as a first-line therapy option in IBD, much less IBD in children. A recent systematic review (subscription required) which summarizes what is known and studied regarding FMT and IBD is published in Aliment Pharmacol Therapeutics and available (login required) for free on Medscape.

For now, I offer two additional items to consider. First, in the United States, FMT as per the FDA is considered an investigational new drug. As such, researchers are subject to the same jurisdiction as with any novel pharmacological agent. For clinicians, patient safety has to always take priority. At the moment, I know of one phase I study, which was approved by the FDA for research after two years of rigorous review, evaluating the safety and efficacy of FMT in ulcerative colitis in adults led by researchers at the University of Chicago. Second, despite the seemingly slow beginnings, I think there will be a future for FMT in IBD, but only after experience and applicability have been shown in recalcitrant C. difficile infections. Consider an editorial earlier this year in the New England Journal of Medicine, discussing the history and the future potential of FMT in gastrointestinal diseases. Like you, I’m hoping for and working to support the data needed to establish safety and standardization of FMT for adults and children with IBD in the foreseeable future.

EC Smit asks: Why isn’t diet part of the treatment plan for Crohn’s disease when people who have excluded known gastrointestinal irritants, such as gluten and carrageenan, have found relief and remission?

Let me first try to address your concerns and questions with a concession. Interventional dietary alternatives in the treatment of IBD are often underemphasized. Knowing this, our Stanford group is longitudinally recording and making some headway in characterizing how specific and modified carbohydrate diets have impacted health for patients with Crohn’s disease. We’re still in the early phases of our prospective study, but we hope to gain more momentum.

With that said, I understand your perspective. Presently, the medical community in the United States can place more focus on pharmacological therapies than nutritional ones. I think this tendency may have to do with two important considerations. First, although Crohn’s disease is a gastrointestinal disease, it is in essence an autoimmune problem. Conventional and experiential wisdom tells us that controlling immune dysregulation requires immune-modulating agents, such as drugs that can help the body stop attacking its own cells or block the biological response that causes inflammation. And historically, we have found success with this established framework – as most Crohn’s patients achieve sustained remission following an evidence-based treatment plan. Despite the potential severity of the initial disease presentation, most patients return to living life without a noticeable difference in their overall quality-of-life.

Second, patient tolerance and continued adherence to the type of diet programs shown to be potentially effective in Crohn’s disease are difficult, to say the least. As you may know, the Specific Carbohydrate Diet (SCD) is one purported dietary intervention for Crohn’s disease. Although substantially more efficacy data are needed, we know that the SCD dietary plan is a very restrictive low carbohydrate diet, which is difficult to maintain strict adherence for patients, especially among children and adolescents. Similarly, elemental or polymeric diets, which have been reported to be helpful in active Crohn’s disease, are also difficult to perpetuate on a day-to-day basis for long-term disease management. For clinicians, we have to do our part in informing patients of all the alternatives while helping patients and their family to optimize daily quality-of-life.

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