stanford medicine




Dr. DMV?

Painful as it is to learn from your doctor you're unfit to drive it prevents serious accidents, according to a new study.

Jean-Francois MartinDr. DMV?

The researchers gathered data on 100,075 adult patients in Ontario, Canada, who received formal medical warnings between 2006 and 2010. Ontario, like six U.S. states including California, requires physicians to notify the department of motor vehicles of any patient with a condition making it dangerous to drive. Such reports sometimes lead to licenses being revoked.

The study, which appeared in the Sept. 27, 2012, New England Journal of Medicine, found a 45 percent reduction in the risk of serious road crashes in the year following the warnings; the patients had a total of 1,430 crashes over the study period, averaging about 466 per year. In the year post-warnings, the rate dropped to about 273 road crashes.

While medical warnings may protect people from road crashes, the researchers also found that patients who received these warnings were more depressed and less likely to pay a return visit to their doctor, note the study’s leaders, Robert Tibshirani, PhD, professor of health research and policy and of statistics at Stanford, and Donald Redelmeier, MD, professor of medicine at the University of Toronto.

“This doesn’t mean that doctors should stay silent about the situation,” Redelmeier cautions. Instead, he says, “Physicians need to be sensitive, compassionate and prepared to address adverse consequences in the aftermath of a warning.”— Margarita Gallardo

Wait training

Losing weight is hard; keeping it off can be even harder.

But School of Medicine researchers have found that women who spent eight weeks mastering weight-maintenance skills before losing any weight kept off more pounds than women who immediately started a weight-loss program.

Both groups on average lost about 17 pounds after 28 weeks. But a year later, the maintenance-first women had regained only 3 pounds on average, compared with the 7-pound average gain for the control group.

“Those eight weeks were like a practice run,” says Michaela Kiernan, PhD, who led the study published Oct. 29, 2012, in the Journal of Consulting and Clinical Psychology. “Women could try out different stability skills without the pressure of worrying about how much weight they had lost.” — Susan Ipaktchian

Too good to be true

If a study concludes that a new medical intervention — be it a drug, a device or a social program — has a major effect on a condition or symptom, the study is probably wrong and in reality the effect is probably lower. That’s the conclusion of a new analysis led by John Ioannidis, MD, DSc, chief of the Stanford Prevention Research Center.

Ioannidis and his colleagues parsed data from more than 85,000 previous meta-analyses (analyses that can include any number of medical trials on a particular intervention and outcome of interest) and determined that most medical interventions have only small or modest incremental effects, but that those effects are frequently over-estimated by small studies.

They published the results of the analysis Oct. 24, 2012, in the Journal of the American Medical Association.

The team discovered that in about 10 percent of the medical topics examined, a very large treatment effect was found in a first study, and another 6 percent found a very large treatment effect only in a later trial. But in more than 90 percent of all those cases, the very large effect disappeared when additional studies or meta-analyses were performed.

When Ioannidis looked into what kinds of trials most often concluded very large treatment effects, one thing stood out.

“Almost always, these very large effects are seen in very small trials — usually with fewer than 20 people in the study having the outcome claimed to be the very large effect,” he says.

This emphasizes the need for larger studies, Ioannidis says, and the fact that small studies concluding a large treatment effect need to be looked at skeptically. “Yes, a large study can cost more than a small study,” he says.

“But performing a well-done, larger, long-term, randomized study is better than wasting money left and right on very small, mediocre studies.” — Sarah C.P. Williams

Lung bugs

Jean-Francois MartinLung bugs

Healthy lungs teem with microbes — and they’re a different community of critters from those living in the lungs of cystic fibrosis patients, according to a study published Sept. 26, 2012, in Science Translational Medicine.

“This research confirmed a long-held suspicion that a forest of microbes exists in both healthy and diseased lungs,” says study author David Cornfield, MD, a pulmonologist at Lucile Packard Children’s Hospital and a professor of pediatrics in pulmonary medicine. More surprising, he says, the work suggests that the microbes help preserve lung health.

The researchers extracted and selectively copied bacterial DNA from the sputum and lung tissue of a small group of healthy people and CF patients. Healthy individuals had more diversity among their lung bacteria. Different bacterial phyla also predominated in the two groups.

“I think the tendency toward decreased diversity in CF can be metaphorically viewed as the same phenomenon that might happen in a rainforest,” Cornfield says. “When the ecosystem of a rainforest is disturbed and one organism predominates, it undermines a carefully constructed balance and causes disturbances in the overall ecosystem. I think it’s reasonable to assume something similar could happen in the lung microbiome.”

Future research might test whether CF or pneumonia patients could benefit from doses of probiotic bacteria to their lungs, he adds. — Erin Digitale

Parasite insight

Is the worm finally turning? Schistosomiasis, a disease caused by a tiny parasitic worm, ranks as a world-class tropical scourge.

Some 150,000 people die annually from kidney failure when the worm targets the bladder, says Stanford urologist Mike Hsieh, MD, PhD.

Perhaps that will change.

In a study published Nov. 29, 2012, in PloS-Neglected Tropical Diseases, Hsieh and his colleagues focused on a variety of the worm known as S. haematobium. If you simply infect mice with S. haematobium, the parasites head for the liver and intestine instead of the bladder.

But Hsieh’s team developed a new mouse model that involves directly injecting the parasite’s eggs into the bladder wall.

Examining excised bladder tissue at several distinct time points after infection, the team got the first look at the changes the infections had triggered in the activity of virtually every gene in the tissue.

These observations could lead to new drug approaches. — Bruce Goldman

Stroke Center award

Stanford Hospital & Clinics is the first hospital to earn the nation’s newest level of certification for advanced stroke care, awarded by The Joint Commission, a leading health-care organization accrediting body.

A team of Joint Commission expert surveyors evaluated the hospital and its stroke center in October for its compliance with the new comprehensive stroke center requirements, including advanced imaging capabilities, 24/7 availability of specialized treatments, participation in research, and staff with the education and competencies to care for complex stroke patients.

The surveyors found the hospital met or exceeded all required standards.

Stanford created its stroke center in 1992. “What we recognized from the start was that the best care would come from going beyond issues about turf,” says Michael Marks, MD, the center’s director of interventional neuroradiology. Marks founded the center with co-director Gary Steinberg, MD, PhD, and director Greg Albers, MD. — Sara Wykes

Feeling very, very... not sleepy?

Jean-Francois MartinFeeling very, very... not sleepy?

Some people can’t be hypnotized, which isn’t necessarily a good thing because hypnosis could help them manage pain, control stress and anxiety, and combat phobias. Now Stanford researchers have discovered differences between hypnosis-resistant brains and hypnotizable ones. Their study used data from magnetic resonance imaging scans to show that highly hypnotizable participants have greater activation of two areas of the brain — including the region that plays a role in focusing attention.

“There’s never been a brain signature of being hypnotized, and we’re on the verge of identifying one,” says psychiatrist David Spiegel, MD, who led the Archives of General Psychiatry study published in October 2012. He believes such an advance would enable physicians to better understand the mechanisms underlying hypnosis and to use the therapy more widely and effectively. — Michelle L. Brandt

New dean

Stanford’s medical school has a new leader: Lloyd Minor, MD. An expert in balance and inner-ear disorders and a surgical innovator, the new dean of the medical school served on the faculty of Johns Hopkins University for nearly 20 years, the last three as the school’s provost — its top academic officer. He came to Stanford in the fall and began his post as dean Dec. 1, 2012.

Minor’s focus since his arrival has been on absorbing and synthesizing his new colleagues’ insights about the school’s challenges and opportunities. “We’re engaged in a lot of dialogue about where we are right now and where we want to be in the future.”

He’s deeply appreciative of the Stanford community’s willingness to discuss and debate ideas, he says. “Stanford Medicine has a level of collective dialogue that I think is matched at few institutions. It’s part of the DNA.”

Out of his conversations have come three organizing themes for leading the school forward: advancing innovation, empowering future leaders and transforming patient care. His work now, says Minor, is to develop a plan that will enable Stanford Medicine to make an even greater impact.

Before Minor became immersed in leadership, his passion was for translating his discoveries in basic science to improvements in patient care. “I’m confident that in my career I’ve learned more from the patients with whom I’ve had the pleasure of interacting than they’ve learned from me,” says Minor.

As a result of listening to one patient describe unusual symptoms, Minor changed the field of otolaryngology — by identifying a new disease. The encounter pointed him to the cause of a debilitating type of sound- or pressure-induced dizziness, which he named superior canal dehiscence syndrome. After discovering the cause — an opening in a bone overlying an inner-ear balance canal — he developed a surgical procedure to correct it.

In October, the Institute of Medicine elected Minor as a member, one of the top honors in health and medicine. — Rosanne Spector






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