Ovarian Cancer: Current and Novel Treatment Strategies

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Presented by: Oliver Dorigo, MD, PhD
Associate Professor of Gynecologic Oncology
Stanford University Medical Center
August 22, 2013

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Ovarian cancer affects about a quarter million women worldwide each year. When detected early on—when still confined to just the ovaries—it is a highly curable disease. However because it has no distinct symptoms, ovarian cancer is usually detected at a late stage. Once it metastasizes, survival rates are about 30 percent after five years. It is the 10th most common cancer in the United States and the fifth most common cause of cancer death.

New understanding of the basic biology of ovarian cancer has led to more accurate diagnosis and specialized treatments that are based on the location of the cancer and its cellular anatomy.

“There are several kinds of cells in the ovaries, and each cell type can generate a different tumor type with different prognosis and response to chemotherapy,” said Oliver Dorigo, MD, PhD, a professor of gynecologic oncology, who spoke at a presentation sponsored by the Stanford Hospital Health Library. “Even within each group there are different subtypes, so not every cancer is treated the same.”

Most ovarian cancer arises from the epithelial cells, which cover the surface of the ovaries. However it can also originate in the germ cells that produce eggs, in the stromal cells that produce hormones, or in the lining of the abdomen (peritoneum).

Though it’s not clear what causes ovarian cancer, at some point a genetic mutation turns normal cells into abnormal cells that grow and multiply out of control. As abnormal cells accumulate, they form a tumor, and cells can spread to nearby tissues and metastasize throughout the body.

Current Treatment Strategies
Treatment usually involves surgery followed by chemotherapy based on a detailed analysis of the genetics, genomics, and pathways of the disease. Scientists are consolidating their research in the Cancer Genome Atlas (TCGA), a National Institutes of Health-sponsored effort to study molecular aspects of human cancer to improve diagnosis, treatment, and prevention. “It’s a database for new knowledge,” said Dr. Dorigo. “The project will be extremely useful for developing future therapies, when we will have a different way to classify cancer based on specific genetic mutations.”

Currently initial treatment usually involves site reduction—an extensive operation to remove both ovaries, fallopian tubes, and the uterus as well as nearby lymph nodes and abdominal tissue known as the omentum, where ovarian cancer often spreads. Surgery involves the use of extremely accurate, minimally invasive robotic surgery techniques that require very small incisions and shorter recovery times.

“The first surgery is of utmost importance because the more cancer disease is removed the better the prognosis,” Dr. Dorigo said.

For almost all ovarian cancer patients, surgery is followed by several cycles of chemotherapy to destroy any remaining cancer cells, usually comprising a combination of a platinum drug and a taxane, such as Taxol. Chemotherapy can be done either intravenously through a vein or directly into the abdomen using intraperitoneal chemotherapy, which increases tumor exposure to the drugs.

Researchers are tracking patients and working with animal models in the laboratory to refine all aspects of chemotherapy, from dosage to timing of treatment to new combinations of drugs.

One recent study showed that intraperitoneal chemotherapy resulted in both longer progression-free survival when the disease does not get worse (an average of 24 months cancer-free compared to 18 months with intravenous chemotherapy) and overall survival (65 months compared to 49 months). Another study looked at modifying the timing of conventional chemotherapy (Taxol) from every three weeks to every week, and found marked improvement in survival rates. “The timing of treatment made a big difference,” said Dr. Dorigo.

Most women who undergo a combination of surgery and chemotherapy do go into remission. However 70 to 90 percent will have a recurrence of disease at some point. One of the biggest challenges in treating ovarian cancer is the development of platinum resistance, a change in the cancer cells’ DNA that makes them unresponsive to chemotherapy. Research is providing new insights into the molecular mechanisms of DNA repair pathways in these cells, and studies are looking adding new treatments to the initial therapy to prolong remission or prevent disease from returning.

Dr. Dorigo said there are a number of factors to consider when a cancer recurs, such as platinum resistance and platinum sensitivity, the extent of recurrence, the women’s tolerance for therapy or another surgery, quality of life, and clinical trials that may be available.

New Approaches
The future of ovarian cancer treatments lies in developing new targets based on how cancer cells grow, such as enzyme inhibitors to block growth factor pathways. Some studies are looking at ways to deprive cancer cells of the nutrients they need to grow and thrive. Tumors create an environment that encourages the growth of new blood vessels to deliver nutrients to the site, a process called angiogenesis. One anti-angiogenesis approach combined conventional chemotherapy with antibodies to stop vessels from growing in patients with advanced stage ovarian cancer.

Recently a promising new study combined an oral drug called pazopanib with conventional chemotherapy, and showed an increase in six-month progression-free survival.

Other research is looking at drugs that override mutations in the BRCA tumor suppressor genes. Mutations in BRCA1 and BRCA2 have been linked to an increased chance of developing ovarian cancer. In one study, a new drug called olaparib used BRCA as a biomarker and showed significant tumor shrinkage in subjects with BRCA mutations.

“These drugs use antitumor inhibitors to slow progression and decrease tumors, and appear to be very promising,” said Dr. Dorigo. “They are using completely different mechanisms than have been targeted prior.”

Another approach involves teaching the immune system to recognize and attack cancer. Tumors are able to block the immune system by using the molecule CD47 as a “don’t-eat-me” signal to immune system cells called macrophages. Early studies have shown that anti-CD47 antibodies can block this signal and allow macrophages to destroy the tumor cells.

“The CD47 trial is meaningful because high CD47 levels are associated with poor survival rates. The research showed impressive control of tumor development, and may be a step toward cancer vaccines and personalized medicine,” Dr. Dorigo said. “However these are still very early studies and it will be a while before they are approved as treatment.”

Dr. Dorigo encouraged women to take part in clinical trials to speed the process of refining scientific insights into new therapies and to gain access to treatment options that are not yet available.

About the Speaker
Oliver Dorigo, MD, PhD, is director and associate professor of the Division of Gynecologic Oncology and the director of the gynecologic clinical care program at the Women’s Cancer Center at Stanford. He is also director of the Mary Lake Polan Gynecologic Oncology Research Laboratory. Dr. Dorigo received his MD from the University of Heidelberg Medical School in Germany. He did a residency in obstetrics and gynecology at the University of Munich, followed by a research fellowship in cancer gene therapy at the Sidney Kimmel Cancer Center in San Diego. He completed his PhD in molecular biology at University of California, Los Angeles, and a clinical fellowship in gynecologic oncology at UCLA/Cedars Sinai Medical Center. Dr. Dorigo was an assistant professor at UCLA until he joined the Stanford faculty in 2013.

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Prenatal Genetic Screening and Diagnosis

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Presented by: Jane Cheuh, MD
Director, Prenatal Diagnosis and Therapy
Stanford University Medical Center
March 21, 2013

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Prenatal screening, including ultrasounds and blood tests, gives pregnant women an important heads-up on possible birth defects and allow women to make decisions about their pregnancy.  The most common test is for Down syndrome (trisomy 21), a condition in which an extra chromosome causes delays in the child’s mental and physical development. It affects about 1 in every 800 babies born in the United States.

Down syndrome and other chromosomal abnormalities are tested by chorionic villus sampling (CVS), which is done when the pregnancy is at 10 to 14 weeks. CVS involves taking a small sample of cells through the cervix. The main advantage of CVS is that it can be done earlier than an amniocentesis, which is generally done between 15 and 20 weeks.

Twenty years ago, the procedure was associated with a very small risk of miscarriage (1 percent) compared to amniocentesis (.5 percent), although the risk today is minimal when performed by an experienced physician, said Jane Chueh, MD, a clinical professor of maternal fetal medicine who practices at Stanford Hospital and at Packard Children’s Hospital. Dr. Chueh spoke at a presentation sponsored by the Stanford Hospital Health Library.

Prenatal screening should be done by women over age 35, since the risk of a chromosomal anomaly tends to be higher in older mothers. However since most mothers are under age 35, the majority of Down syndrome cases occur in younger women, so she advocates that all women should be screened early in their pregnancy.

“Age is only one factor,” she said. “Age 35 is an arbitrary number and is no longer the threshold for screening.”

Dr. Chueh said the average risk of Down syndrome for women age 35 is 1 in 380,, which is considered moderate. In comparison, the risk is 1 in 11 (high) in women age 49 or older; and is 1 in 667 (low risk) in 20-year-old women. First and second trimester screening tests are available through the state of California State. If the results show high risk, the state will pay for subsequent diagnostic testing

First Trimester Tests
Several tests are offered during the first trimester. A prenatal test called a nuchal fold scan, or NT, uses ultrasound to measure the space in the tissue at the back of the developing fetus’ neck. A fetus with an abnormality tends to accumulate more fluid at the back of the neck during the first trimester, causing the space to be larger than average. The NT scan must be done between 11.5 and 14 weeks of pregnancy. The result is combined with concurrent tests for PAPP-A (pregnancy-associated plasma protein A and free beta hCG.

“Increased NT is associated with chromosomal abnormalities, cardiac problems, and other fetal anomalies,” Dr. Chueh said. “But timing is important. Being off by even one day can throw it off, and if it’s done too early we may need to redraw blood or re-measure another day”

“Screening is not the same as a diagnosis. It’s important to realize that there are certain algorithms for these tests that consider detection rates and the chance of a false positive. Testing positive means there is a possibility of Down, but the test is not definitive,” she said.

Second Trimester Tests
Second trimester screenings, which are generally integrated with the first series of tests,  include a quad marker screen, a blood test for increased risk of Down syndrome and neural tube defects such as spina bifida. The quad screen is done between 15 and 20 weeks of pregnancy and can detect about 80 percent of fetuses affected by Down syndrome.

Ultrasounds may also detect soft markers which, while not necessarily an anomaly, may increase the statistical chances of chromosomal abnormalities. These markers include an enlarged nuchal fold, echogenic bowel, and short humerus or femur bones. Often these markers have no real impact on risk if the patient has a low risk to begin with, said Dr. Chueh, and may soon become obsolete with the advent of cell free DNA screening on maternal blood.

The Future of Screenings
While current diagnostic tests such as amniocentesis and CVS are reliable and readily available, they are invasive and carry a slight risk of miscarriage. The goal, said Dr. Chueh, is to identify a technique for noninvasive and accurate diagnosis.

That goal is closer, thanks to a new finding that assesses fetal DNA circulating in the mother’s blood. Minute amounts of free-floating DNA (CfDNA) from fragments of the placenta appear to increase with gestational age and completely disappear 48 hours after birth. Physicians are able to look at the DNA sequences of certain chromosomes and match them up to determine if the fetus is normal. If the counts run less or more than normal, there is a possibility of an  anomaly. Several companies now offer cfDNA tests.

The advantages to this approach over traditional screening tests are numerous, said Dr. Chueh, including a shorter wait time for results, a single blood draw, and an earlier window of opportunity for screening. Integrated first and second trimester screening results are available after six weeks and have a 90 percent detection rate; cfDNA tests have a 99.4 percent detection rate and take one to two weeks. They are also automated, which make them more consistent and less time-consuming.

There is a downside, however, she added. These tests are still new and are more expensive than standard tests, which are covered by the state. They test for only a few conditions and have a higher failure rate in which the tests are not able to get a result.

“The success of cell free DNA has opened up renewed interest in noninvasive prenatal diagnosis. The next step is finding intact fetal cells in maternal blood with no invasive procedure to the pregnancy,” Dr. Chueh says. “We are looking for strategies that are faster, cheaper, and more comprehensive than current screening tests, but more studies are needed.”

About the Speaker
Dr. Chueh is a clinical professor of obstetrics and gynecology and the director of Prenatal Diagnosis and Therapy in the Division of Maternal Fetal Medicine. She received her MD from the University of California, San Diego, did her internship and residency at University of Washington Medical Center, and did a fellowship at University of California, San Francisco. She is Board Certified in Maternal and Fetal Medicine and in Obstetrics and Gynecology by the American Board of Obstetrics and Gynecology.

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Prescribing Drugs for an Aging Population

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Presented by: Mehrdad Ayati, MD
Clinical Assistant Professor, Medicine
April 24, 2013

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In 1950, 8 percent of the U.S. population was 65 and older; by 2050, thanks to increased longevity and a dwindling birth rate, that number is expected to increase to 21 percent. In developing nations, the growth rate of the senior population is even more pronounced, opening up important questions about how these countries’ infrastructures and cultural traditions will need to change to accommodate a virtual tidal wave of older citizens.

Modern medication is a key reason why people are living so much longer. About a third of all medications today are prescribed to patients 65, and it’s projected that more than half will be prescribed to seniors by 2030. Part of this increase is because chronic diseases that arise in a person’s 30s and 40s tend to show complications at age 60-70. In addition, comorbidities tend to arise over time, which often leads to multiple medications, also known as polypharmacy. Comorbidities refers to more than one disease that develops in addition to a primary disease.

Increased Numbers

In today’s health care system, a patient may have several physicians, which can result in a situation known as a prescription cascade. A cascade occurs when a new medicine is prescribed to treat an adverse reaction to another drug because it appears that a new medical condition requiring treatment has developed. A second drug can cause another adverse reaction or increase the severity of the first response, according to Mehrdad Ayati, MD, a clinical professor of medicine, who spoke at a presentation sponsored by the Stanford Hospital Health Library.

Dr. Ayati described the process: A patient has trouble with sleeping and is prescribed a sleeping pill. Feeling drowsy, she receives a stimulant, which gives her heart palpitations. Her doctor prescribes a beta blocker for her racing heart, which make her depressed. She is prescribed an antidepressant.

“In six months a person like this could be on six medications,” he said, “though the real problem was simply the first drug. It’s a very typical situation, especially for older people.”

Polypharmacy can lead to a greater possibility of adverse drug events, which account for between 5 and 28 percent of acute admissions to both hospitals and clinics. Adverse drug events include errors in the way the medicine is used and reactions from the pharmacological properties of the drug itself, either alone or in combination with other medicines.

“The best prevention of an adverse drug event is knowing what is happening in the body,” Dr. Ayati said.

Different Metabolisms
Pharmacodynamics is the study of the biochemical and physiological effects of drugs on the body. Pharmacokinetics is how the body reacts to the drug and includes the processes of absorption, metabolism, distribution, and elimination. While absorption in the stomach and small intestine is the same biologically for both young and old, as you age, steady changes that can affect your ability to absorb medications, from changes in Ph balance to ongoing stress.

Most drugs are metabolized in the liver, which Dr. Ayati described as the body’s “central post office” organizing drug delivery by “Zip codes.” The liver’s cytochrome (CYP) system is responsible for 75 percent of drug metabolism by activating different enzymes that inhibit or metabolize a drug. Different metabolic rates will determine the effect of a drug, and a physician needs to know how fast a person’s metabolism is to avoid overprescribing and to avoid interactions that could lead to an adverse drug reaction.

“Slow metabolizers means that the drug stays active longer, so less is needed. In fast metabolizers the drug will dissipate quickly,” he said. “There’s not a universal response to a medication. For pain medication, for example, some people may need more frequent or larger dosages—which does make them drug addicts. Their body simply metabolizes differently.”

Important steps are being made toward personalized medicine—technology that uses a person’s unique genetic makeup to predict, monitor, and treat disease, including prescribing medication based on genetic background. Personalized medicine can identify people who have certain mutations in their CYP system, allowing physicians to know in advance how fast they will metabolize a drug.

Mixing Medications
Drug-to-drug interactions (DDI) occur in more than 80 percent of patients taking more than six medications at a time and in about 13 percent of patients using two medications or more. Interactions can be caused by over-the-counter medications, such as multivitamins, fish oil supplements, baby aspirin, or herbal remedies like St. John’s wort, garlic, echinacea, or gingko biloba. Herbal medicines are not regulated by the FDA and almost a third of them cause a drug-to-drug interaction. Even diet can affect a drug’s efficacy: Grapefruit is known to inhibit CYP for short periods after consumption.

“People often don’t realize that over-the-counter medications are pharmaceutical agents. There’s such an enormous number that no doctor can know them all,” Dr. Ayati said.

Once a drug is absorbed it is distributed around the body in the bloodstream. Drug distribution is affected by the changes in body composition associated with age, such as more body fat and lower hydration. The decreased muscle and tissue mass that accompanies aging also influences the distribution of certain drugs, as will the reduced blood flow to tissues and organs. And even healthy adults lose some renal function as they age, which affects elimination.

Drugs that require high levels of water and muscle to be absorbed may require lower dosages that are increased slowly or current dosages may need to be reduced as a patient ages. Drugs that are distributed through fat may require a larger volume for distribution and may take longer to be eliminated. Other drugs need to bind to albumin, a protein in the blood plasma; since older adults have less of this protein medications can compete for the available resource, making one stronger and the other impotent.

Be proactive
To optimize drug therapy, Dr. Ayati advised that patients and physicians work together to develop the most beneficial approach. “Start slow and low,” he said, “and don’t start to medications at the same time.”

Patients should ask some fundamental questions:

  • Is this medication necessary?
  • Will I die if I don’t take it?
  • What is the benefit?
  • What is the risk?
  • How can I assess the benefit?
  • What is the potential DDI?

Patients should also let all their doctors know of all their medications, prescribed and over-the-counter, and bring their prescriptions with them to office visits to avoid prescription cascade.

About the Speaker
Mehrdad Ayati, MD, is a Board Certified geriatrician. He is the Stanford medical director of the Sunnyvale Health Center and the Los Altos Subacute & Rehabilitation and Palo Alto Rehabilitation centers. He received his medical training from the Iran (Tehran) University of Medical Sciences and did his residency in the UC-Davis School of Medicine and his fellowship at Stanford.

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Starting an Exercise Program: How Your Doctor Can Help

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Posted By SHL Librarian

Presented by: Paul Wang, MD
Director, Stanford Cardiac Arrhythmia Service

Nawal Atwan, MD
Clinical Instructor, Internal Medicine
Stanford University Medical Center
October 21, 2010

Lecture Overview:

  • Many heart conditions often have no symptoms, so it is important to screen young athletes before they start a sport or activity.
  • Screening should include a health history and a complete physical, which may include an electrocardiogram.
  • People over 40 who have symptoms of chest pain or shortness of breath should have a stress test before starting a new sport.
  • Mix up your routine to include exercises for cardiovascular health, weight training for strengthening muscles, and stretches for flexibility and balance.
  • Start with a plan and steadily increase your goals to measure improvement.

Most people know the many benefits of exercise. Including workouts into your routine has shown to increase longevity, reduce the risk of heart attack and stroke, improve cholesterol levels, lower blood pressure, prevent diabetes, and make you feel better. It helps with weight loss, strengthens bones, and enhances cognitive function-all concerns that affect the quality of life as we age.

Screen for Heart Conditions The only paradox to exercise is a very slight increase in the risk of heart attacks or death from cardiac arrest. Sudden cardiac arrest-when the heart ceases to beat without any warning-is one of the largest heart health problems in the United States. The heart’s electrical system goes awry, making it unable to pump blood to the rest of the body.

The chance of successful resuscitation drops 10 percent every minute, said Paul Wang, MD, director of the Stanford Cardiac Arrhythmia Service and Cardiac Electrophysiology Laboratory, who spoke about cardiovascular evaluation and screening at a presentation sponsored by the Stanford Health Library.

There are more adults with congenital heart defects than ever before, due in large part from improved surgeries. According to the 36th Bethesda Conference, which establishes guidelines for people with cardiac disorders, most congenital heart disease patients have a reduced ability to exercise. Experts are still debating how much exercise is appropriate and whether teens with a heart condition should be allowed to participate in sports.

Many heart conditions often have no symptoms, so it is especially important to screen young athletes before they start to participate in a sport or activity. In athletes younger than age 40, the most common underlying cause of heart problems is known as hypertrophic cardiomyopathy. This rare genetic disease causes the heart muscle (myocardium) to become abnormally thick, making it harder for the heart to pump blood.

The condition tends to manifest in the late teens, and the risk remains an ongoing concern, said Dr. Wang.

“If you’ve had an arrhythmia once, or have a condition that could lead to arrhythmia, the likelihood is higher that you can suffer from cardiac arrest,” he said. “The recommendations are that you should be excluded from most competitive sports.”

There are other conditions that young people should be screened for before taking on a strenuous sport, including anomalous coronary artery, a rare condition that can be detected by an angiogram. These youths should also be restricted in their athletic activities, said Dr. Wang.

In older athletes, the most common cause of problems is coronary artery disease-the buildup of plaque inside the blood vessels. Other conditions of concern include myocarditis, an inflammation of the heart wall, and Marfan syndrome, a disease that weakens the walls of the aorta.

Dr. Wang recommends that all young people see their doctor for a complete physical that includes a health history. An electrocardiogram may be helpful in some cases, but experts are still discussing its benefits. Athletes over 40 who have possible symptoms of heart disease such as chest pain or shortness of breath, and sedentary people with risk factors for heart disease should have a stress test before starting a new regimen. These tests can provide clues to help your physician uncover underlying disease.

“Screening athletes is an important aspect of safety,” he said. “Then follow-up is essential.”

Before You Start to Exercise Nawal Atwan, MD, provided more detail about the benefits of exercise and how to start a healthy regimen. She recommended working out at least 30 minutes five times a week and mixing activities for cardiovascular health, strengthening muscles, and stretching.

She suggested that you start with a plan and steadily increase your goals to measure improvement. Use a pedometer for inspiration, and be realistic about what you can and can’t do. Start with lower goals and then build up the intensity and frequency, she said.

Dr. Atwan suggested a visit to the doctor before starting a new exercise or to assess risk. The physical should assess your blood pressure, heart rate, cholesterol, body mass index (BMI), percentage of body fat, gait, balance, and hand grip. Your doctor may recommend an electrocardiogram or a stress test to measure your heart capacity.

Talk to your physician if you have joint pain or how to prevent developing joint problems. If you have arthritis, you may benefit from a low-impact activity like swimming or water aerobics, which studies have shown can decrease pain, she said. All participants should be sure to stretch as a warm-up and cool-down, holding each position for at least 30 seconds.

“There are lots of excuses to not exercise: no time, no motivation, it’s boring, it hurts. But it’s a matter of getting out there and doing something,” Dr. Atwan said. “Exercise is the cheapest drug around-you can get the same benefits as some medications and without any side effects.”

About the Speakers
Paul Wang, MD, is a professor of medicine (cardiology) and director of the Stanford Cardiac Arrhythmia Service and Cardiac Electrophysiology Laboratory. He received his medical education at the College of Physicians & Surgeons at Columbia University in New York, did his internship at New York Presbyterian Medical Center, and did his fellowship at Brigham and Women’s Hospital at Harvard Medical School.

Nawal Atwan, MD, is a clinical instructor of medicine (internal medicine) who specializes in women’s health, athletic health, and chronic disease management. She received her MD from Harvard Medical School and did her residency at Stanford. She joined Stanford in 2009. She is Board Certified by the American Board of Internal Medicine.

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About the Stanford Cardiac Arrhythmia Service
http://stanfordhospital.org/clinicsmedServices/COE/heart/DiseasesConditions/arrhythmia/

American Heart Association
http://www.americanheart.org/presenter.jhtml?identifier=4749

WebMD: Starting an Exercise Program
http://www.webmd.com/fitness-exercise/guide/fitness-beginners-guide

The Fatigue Prescription: Four Steps to Renewing your Energy, Health, and Life

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Presented by: Linda Hawes Clever, MD
Clinical Professor of Medicine, UCSF
Thursday, November 4, 2010

Modern life is full of annoyances, irritations, frustrations, and demands. There are the big concerns like work and family and health, and there are the little things like traffic, dishes, barking dogs, and lost to-do lists. These stresses, great and small, can take a heavy toll, and for many people the constant barrage causes a real drain-physically, emotionally, and spiritually.

Chronic exhaustion can undermine your day-to-day functioning, said Linda Hawes Clever, MD, a clinical professor of medicine at University of California, San Francisco, at a presentation sponsored by the Stanford Health Library. Dr. Clever wrote a book called The Fatigue Prescription: Four Steps to Renewing Your Energy, Health, and Life, which provides some tips she has developed to treat physical and spiritual exhaustion. The trick is to develop tools to keep you going while you stick to your values, personal strength, and inner motivation.

Dr. Clever’s insights come from personal experience. Fifteen years ago she was barraged by bad luck: both of her parents died, she lost two jobs, and her husband was diagnosed with cancer-all in the span of 18 months. She took her years of expertise as a clinician and researcher, interviewed thousands of people about how they maintained their energy, and came up with four steps to put her theories of personal renewal into practice.

“We tend to take better care of our cars than we do of ourselves,” she said. “We need to find ways to renew and refresh ourselves. The way to do that is to find meaning in your life. By that I mean getting back in touch with your basic values and organizing your life around them.”

Whether your stress and fatigue come from dramatic events or just from the daily grind, Dr. Clever said one key is to identify the activities that refresh your spirit and to make room on your calendar to take part in them. Her approach involves personal reflection to help you rediscover your lost energy.

“Most of us want to have meaning in our lives,” she said. “Happiness comes from finding meaning, not from looking to be happy. In our search for purpose we can also find ways to renew, which replenishes our ability to be creative, optimistic, and energized.”

One of Dr. Clever’s tools is called a Renew-O-Meter, a series of questions designed to measure how well you juggle your commitments. Questions range from how many sit-down dinners did you have with your family or friends in the past week to when did you feel bold enough to take a risk to how many times did you really laugh yesterday?

Rating a high score in your willingness to take a risk reflects on your self-esteem and personal efficacy-feelings that can pervade all aspects of your daily life. In that way the meter can help raise self-knowledge, she said.

She highlighted four basic steps that can be used to renew your energy:

  • Awareness assesses the nature of your fatigue and its external and internal causes.
  • Reflection enables you to probe the sources of your feelings and to identify the positive people, activities, and experiences that support you.
  • Conversation creates opportunities for heartfelt openness in communication and feedback from loved ones and associates; it implies a willingness to share and to learn.
  • Plan-and-act allows you to develop a process of systematic change made up of small steps.

“Most of us tend to want to act but don’t love change,” she said, “so we need to change incrementally. By making a plan with small steps, your change is like stepping off a curb, not jumping out of an airplane.”

It’s important to note what aspects of your nature or habits can stop you from changing, and to be aware that resisting change can actually cause more fatigue. Your guidepost should be your personal values-the things that give you direction and satisfaction. Dr. Clever said a good way to define your values is to think about what you want written up in your obituary.

“Think about how you would like to be described. By living your values you can find meaning and have joy in your life,” she said. “Talk about them with your partner or family-shared values keep a family or community together and create common ground.”

She also discussed five traits of people who consider themselves capable of dealing with the vagaries of a stressful life. These people tend to:

  • Have close relationships with family and friends
  • Have a strong sense of spirituality or religious beliefs
  • Take care of their health
  • Like what they do for a living
  • Have a certain level of acceptance of their situation: They feel they can play the hand that’s dealt them.

“We can learn to exert power over ourselves,” said Dr. Clever. “You can find the freedom to choose your attitude, and that will energize and sustain you.”

About the Speaker
Linda Hawes Clever, MD, is a clinical professor of medicine at University of California, San Francisco, and the founder of RENEW, a nonprofit dedicated to helping people find purpose and direction. She received her medical degree from Stanford, where she completed her residency and fellowships, and she now serves as the medical school’s associate dean for alumni affairs. Dr. Clever is board certified in internal medicine and occupational medicine.

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About Dr. Clever’s book
http://www.thefatigueprescription.com/

How is Your Memory? Evaluating Memory and Its Relationship to Alzheimer’s Disease

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Posted By SHL Librarian

Presented by: Wes Ashford, MD, PhD
Clinical Professor, Psychiatry and Behavioral Sciences (affiliated)
Senior Research Scientist, Stanford/ VA Aging Clinical Research Center
May 19, 2010

Lecture Overview:

    MRI brain scan

  • While mild forgetfulness affects most people as they age, serious memory problems affect your ability to participate in everyday activities.
  • See your doctor if you have concerns about memory and forgetfulness.
  • Alzheimer’s is a type of dementia that progresses slowly over time and causes irreversible changes in the brain.
  • Brain imaging for dementia is pointing to specific patterns of amyloid plaque and neurofibrillary fiber build-up in the brain, and these patterns appear to be associated with genetic makeup.

Dementia is a medical condition that impairs memory and thinking processes, from remembering words to how to behave. While everyone forgets words or a person’s name at times, the condition is not dementia unless it is severe enough to interfere with a person’s ability to carry out daily activities and it declines over time.

The most common form of dementia among older people is Alzheimer’s disease, which initially involves the parts of the brain that control memory, and language. The disease was first diagnosed in 1907 in a patient with what are now considered classic symptoms of the disease. Her brain had both senile plaques (filled with a protein called beta-amyloid) and neurofibrillary tangles (made up of tau protein) that affected specific regions of the brain.

The cognitive decline associated with dementia and Alzheimer’s disease is an issue not only for affected individuals but also for society. New understanding, improved treatments, and viable preventive strategies are becoming more crucial since more than 5 million Americans are already living with Alzheimer’s disease, and its prevalence is expected to double by 2020.

“The problem is that it is difficult to recognize when people have a problem,” said Wes Ashford, MD. PhD, a clinical professor of psychiatry and behavioral sciences, at a presentation sponsored by the Stanford Health Library. “People with a memory problem often try to cover it up, and as much as 90 percent of patients are misdiagnosed early in the disease course. After a certain point they don’t recognize that they have a memory problem and by then they need to be in a nursing home.”

Making Connections
Ashford has spent his career researching the process of memory loss associated with aging. He and the other members of the group at the Stanford/VA Aging Clinical Research Center are involved in a variety of studies to measure the effectiveness of medications, mood, sleep, and other factors on disease progression. He has developed a simple memory test that can help track changes over time, using colorful images to detect early signs of memory loss.

Ashford explained that the brain is constantly creating new connections among its billions of neurons as it registers new information. As dementia progresses, the brain no longer maintains this neural network, affecting first short-term memory and then older, more established connections. Brain autopsies show that the hippocampus, the part of the brain involved in forming and maintaining memories, shrinks dramatically and becomes riddled with amyloid plaques and neurofibrillary tangles.

“Plaques and tangles occur in very specific areas of the brain that are responsible for learning and storing new information,” Ashford said, adding that plaques appear to be associated with Alzheimer’s disease, while tangles show a closer relationship with the dementia that accompanies Alzheimer’s in its later phases. “The disease progresses in a variable but measurable fashion, following a specific pattern. It may progress slowly but it tracks logically, and eventually old memories become destroyed.”

Genetic Differences
By using different imaging technologies, such as MRI, PET, and CT scans, scientists have been able to follow the progression of dementia and Alzheimer’s, and found that genetic factors play a significant role the age when patients develop brain patterns associated with amyloid plaques and with neurofibrillary tangles.

“We can actually see where the tangle develops and where the amyloid is depositing,” said Ashford. “We can track progression over time while it is still considered mild cognitive impairment, before it is officially dementia.”

For one common genotype (20 percent of the population), there is a 40 percent chance of developing Alzheimer’s by age 76; another genotype (one that affects only 2 percent of the population) has 10 times greater chance of having the disease by age 67; another group appears to develop Alzheimer’s only after age 95.

For Ashford, these studies may help to measure the early progression of disease and then identify a way to prevent its development in the people who would most benefit from intervention. Though a genetic approach to prevention is not on the immediate horizon, these studies do point to the possibility of targeted interventions based on genotype.

“If we can understand the genetics better, we will be able to understand how Alzheimer’s develops and the best method and timing to make changes,” he said. “To make progress we need diagnostic and treatment centers for humans and accessible genetic testing.”

In the meantime, other factors have been shown to decrease the risk of Alzheimer’s, such as maintaining a healthy lifestyle, interacting with others through social activities, keeping the brain exercised through games and learning, and keeping up with screening tests for high blood pressure and cholesterol.

About the Speaker
J. Wesson Ashford, MD, PhD, is a senior research scientist at the Stanford/Veterans Affairs Aging Clinical Research Center and a clinical professor of Psychiatry and Behavioral Sciences at Stanford. He is also the director of the War Related Illness and Injury Study Center at the VA Palo Alto Health Care System. Ashford received his MD and his PhD in neuroscience from UCLA, where he was a founding member of the Neurobehavior Clinic and the first chief resident and associate director on the Geriatric Psychiatry Inpatient Unit. He joined Stanford and the VA Palo Alto in 2003.

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Stanford / Veterans Affairs Aging Clinical Research Center
http://svalz.stanford.edu/

Dr. Ashford’s online memory test
http://www.medafile.com/

VA Palo Alto Heath Care System
http://www1.va.gov/grecc/

Alzheimer’s Association
http://www.alz.org/

Alzheimer’s and Communication

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Posted By SHL Librarian

Presented by: Judith L. London, PhD
Licensed Clinical Psychologist
Author, Connecting the Dots
February 24, 2010

Lecture Overview:

More than 5 million Americans are living with Alzheimer’s disease (AD), a long-term progressive disease that affects memory, intellectual ability, judgment, and behavior, depriving people of their independence and ability to communicate. Alzheimer’s accounts for 70 percent of all types of dementia, and more than half of these cases are in the middle to late stages, when individuals require extensive help with daily activities and lose the ability to respond to their environment.

There’s no known cause of AD, a slow but irreversible mental decline that lasts an average of seven years but that can linger for as long as 20. People in mid- to late-stage Alzheimer’s can no longer survive in society without an extensive support system.

“So many people mistakenly assume that there’s nothing left as the disease advances, and don’t bother trying to connect and communicate on a meaningful level,” said Judith London, PhD, a clinical psychologist specializing in dementia, who spoke at a presentation sponsored by the Stanford Health Library. “But when you focus on what’s still there rather than what’s gone and reach out, you discover the part that’s still there and very much alive.”

London, who worked extensively in public long-term health facilities, described how Alzheimer’s precipitates damage to the neurons in the brain, preventing cells from communicating with each other.

“You can help ‘connect the dots’ of scattered information and memories in a meaningful way. You become the connector, and help the person express him or herself,” she said.

Because Alzheimer’s patients often feel isolated, it’s up to the visitor or caregiver to initiate interactions. The easiest first step, London advised, is to make eye contact: Get into their field of vision and say who you are. “Start with a smile,” London advised, “and approach the person as you would want to be treated-with respect, kindness, and dignity.”

Make sure you can be seen and heard: Speak slowly and clearly, and use gestures, she said, and use anything you know about the person’s interest or background as a basis to communicate. Use the person’s name, not a nickname or term of endearment, to help validate their identity.

“They also often have poor vision and hearing, which adds to their sense of isolation,” said London. “Don’t assume they are no longer interested in engaging.”

She also suggested that instead of using distraction when people are repeating themselves to try to help them express what’s on their mind. “They are reacting to something that is emotionally important to them,” she said. “Be positive about their efforts to make a connection and communicate.”

London suggested that visitors carefully observe the immediate circumstances to find possible triggers for episodes of depression, paranoia, or anger. If you can identify a pattern by examining what happened right before, during, and after an incident, the time it occurred, and who else was involved, you may be able to alter the circumstances to head off an outburst. She advised caregivers to not take accusations personally.

In group therapy with dementia patients, London found that that people responded to personal questions and empathy even when they seldom initiated a dialog.

“Unconscious memory is still present in those with Alzheimer’s and is the last part of memory to go. People with late-stage Alzheimer’s can understand even when they cannot let you know in a direct way,” London said. “When you reach out to connect and communicate, the person will connect back with you.”

About the Speaker
Judith London, PhD, is a clinical psychologist licensed in New York and California who has worked with patients with Alzheimer’s and other forms of dementia for more than 20 years. A former adjunct professor at New York University, she now conducts seminars on Alzheimer’s, dementia, and maintaining brain health. She is the author of Connecting the Dots: Breakthroughs in Communication as Alzheimer’s Advances.

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Stanford Aging Adult Services
http://www.stanfordhospital.com/forPatients/patientServices/geriatricHealth

Stanford Alzheimer’s Translational Research Center

http://alzheimers.stanford.edu/

The Alzheimer’s Association

http://www.alz.org

National Institutes of Health
www.nia.nih.gov/Alzheimers

Robotic Surgery in Urologic Oncology

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Posted By SHL Librarian

Presented by: Mark L. Gonzalgo, MD, PhD
Associate Professor of Urology and Director of Robotic-Assisted Urologic Cancer Surgery
Stanford University School of Medicine
January 14, 2010

Lecture Overview:

    robotic.JPG

  • Since the early 2000s, when robotic surgical systems were first used to treat prostate cancer, urologic surgeons have increasingly employed the technology and expanded its applications to kidney and bladder cancer.
  • Robotic surgical systems may offer advantages in the treatment of certain cancers, however they are not a “magic tool” and should be considered simply as one of the methods at a surgeon’s disposal.
  • The most important consideration for the cancer patient is not the surgical technique, but rather the skill and experience of the surgeon.
  • There is a dearth of randomized clinical trials involving robotic surgical systems and additional research is needed.

No matter the type of surgery used to combat prostate, kidney or bladder cancer, the urologic surgeon’s goals are the same: control the cancer and interfere as little as possible with the patient’s quality of life. Surgeons have traditionally employed either “open” or laparoscopic surgery methods to remove these cancers, which collectively strike more than 300,000 Americans annually.

Robotic surgical systems have added a new tool to the surgeon’s arsenal, allowing for increased surgical dexterity and a three-dimensional, high-resolution view of the operative area.

These robotic instruments have garnered attention, in part, for the futuristic imagery they evoke. We may eventually learn that they offer significant advantages with regard to post-surgical complications, blood loss, nerve preservation, and recovery times, but it is important to remember that robotic systems are only as good as the surgeons who employ them, explained Dr. Mark L. Gonzalgo, director of Robotic-Assisted Urologic Cancer Surgery at Stanford University Medical Center, at a January presentation sponsored by the Stanford Health Library. “Robotic instrumentation is simply another tool at the surgeon’s disposal,” he said. “It is not a magic tool.”

“One of the most interesting aspects of robotic instrumentation is that the surgeon is dislocated from the patient, at a console about 10 or 15 feet away,” Dr. Gonzalgo explained. “Because the surgeon is not next to the patient, he or she relies on a specialized surgical team at the bedside.”

Robotic Surgery and Prostate Cancer
Today, most prostate cancers are detected at an early stage through PSA (Prostate-Specific Antigen) screening and rectal exams. Most are curable. Risk factors for prostate cancer include age, race and family history.  According to statistics shared during the presentation, 192,280 men in the United States were diagnosed with prostate cancer in 2009 and 27,360 died.

If surgery is determined to be the preferred treatment, the primary options are: a retropubic prostatectomy (the incision is made in the abdominal wall), a perineal prostatectomy (the incision is made in the area between the anus and scrotum), laparoscopic surgery (small incisions are made in the abdomen and a camera is used as a surgical aid), and robotic-assisted laparoscopic surgery (a robotic surgical system allows the surgeon to see vital anatomical structures more clearly and to perform a more precise surgery).

No matter the option deemed appropriate for the particular patient, “the challenge for the surgeon is how to best remove the cancer while sparing the nerves and surrounding anatomy in order to preserve sexual and urinary function,” said Dr. Gonzalgo.

Questions remain about the extent to which robotic-assisted laparoscopic surgery leads to superior outcomes.

Dr. Gonzalgo cited an October 2009 study that appeared in the Journal of the American Medical Association. The study, which relied on statistics from Medicare databases, had “several limitations,” according to Dr. Gonzalgo. However, it is one of the few upon which we can draw conclusions.  The study showed that robotic-assisted surgery resulted in shorter hospital stays and fewer post-surgical complications. However, it also showed an increase in post-surgical urinary incontinence and erectile dysfunction. “When you look into the studies that have been published, it turns out what matters most is the experience of the surgeon and the accompanying knowledge of the anatomy,” Dr. Gonzalgo said.

Robotic Surgery and Kidney Cancer
In 2009, 57,760 Americans were diagnosed with kidney cancer and 12,980 died from the disease. The primary risk factors are smoking and there are also familial forms of kidney cancer. As is the case with prostate cancer, more people are being diagnosed at the cancer’s early, more-treatable stages. In addition, surgical advances in the past five to ten years have meant that far fewer patients are losing their entire kidneys in surgery.

“Five to ten years ago, a patient with a tumor that was two centimeters in size likely would have had his entire kidney removed,” Dr. Gonzalgo said. “That’s not true today. We are learning more and more about ways of preserving kidney function via partial nephrectomy.”

Treatment options for kidney cancer include surgery (open, laparoscopic, and robotic-assisted laparoscopic), ablative therapies (the use of cold or heat energies to destroy cancer cells) and active surveillance, also known as watchful waiting or observation.

Dr. Gonzalgo cited a recent study, the largest of its kind, which involved nearly 2,000 patients with kidney tumors of seven centimeters or less who underwent partial removal of their kidneys. The study compared laparoscopic surgery to traditional open surgery and found equivalent functional and early cancer outcomes.  Minimally-invasive partial nephrectomy, however, was associated with a higher complication rate compared to open partial nephrectomy highlighting the importance of surgical experience with this procedure.

Robotic Surgery and Bladder Cancer
In 2009, 70,980 people in the United States were diagnosed with bladder cancer and 14,330 died from the disease.  Smoking is a primary risk factor.  At the turn of the century in England, doctors found a correlation between bladder cancer and certain chemicals used in the manufacture of textiles, making bladder cancer one of the first cancers to be associated with exposure to environmental agents.

Evidence of blood in the urine is the most common way bladder cancer is detected. Often, the blood is at microscopic levels and is detected as part of a physical examination. Other times, the patient may observe blood in his or her own urine. Other symptoms of bladder cancer include an increase in the frequency of urination and painful urination. These symptoms are often associated with other health issues and are not necessarily indicative of cancer.

Cystectomy is the term for the surgical removal all or part of the bladder. The surgeon’s goal is to excise the cancer with the least impact possible on the patient’s quality of life. The surgeon will employ one of several techniques to make up for the loss of all or part of the bladder and urethra, including using a portion of the small intestine to create a conduit or an internal reservoir for the urine. Dr. Gonzalgo reported that researchers are in the early stages of using stem cells to create native bladders for transplant. “We are hopeful that in five to ten years, this could become a reality,” he said.

Meanwhile, surgeons are increasingly using robotic systems in bladder surgery, citing less blood loss, fewer transfusions, and shorter hospital stays. The robotic systems can potentially result in longer operating times. Nevertheless, length of the surgery is more dependent on the skill and experience of the doctor than any other factor, Dr. Gonzalgo said.

About the Speaker
Mark L. Gonzalgo, MD, PhD, is an Associate Professor of Urology and the Director of Robotic-Assisted Urologic Cancer Surgery at the Stanford University School of Medicine. He focuses on the treatment of prostate, bladder, kidney, and testicular cancer. He also is engaged in research into the role of DNA methylation in prostate and bladder cancer, which looks at how certain genes may be useful molecular markers for disease detection.  He received his MD and PhD from the University of Southern California, did his residency at Johns Hopkins, and completed a fellowship in urologic oncology at Memorial Sloan-Kettering Cancer Center.

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Robotic-Assisted Urology Surgery at Stanford Hospital
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Stanford Cancer Center
http://cancer.stanford.edu/

Stanford Urology
http://stanfordhospital.org/clinicsmedServices/clinics/urology/

Stress Fitness for Seniors

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Posted By SHL Librarian

Presented by: Joan Vernikos, PhD
Director Emeritus, NASA Life Sciences
November 19, 2009

Lecture Overview:

  • Stress is neither inherently good nor bad-it’s simply the physiological and psychological response to external or internal tension.
  • Not everyone experiences stress the same way, but there are tactics that can help you deal with stressors more effectively.
  • Most stress is generated by the brain but if you can create it, you can also control it.
  • Older adults can often handle stress better because they have more experiences to draw from to deal with it.
  • Recognize the difference between effective and ineffective coping mechanisms in responding to stress

How early humans responded to stress was a matter of survival. Facing a predator, searching for food, and protecting a family were very real dangers that instigated an automatic, innate reaction that prepared them to attack or run away-the fight or flight response. Today, our bodies still instigate the same primitive response system even though our stressors have changed.

“Our genes are pretty much identical to our prehistoric ancestors, and the response to stress is identical even though the stressors are different,” said Joan Vernikos, PhD, former head of NASA Life Sciences, who spoke at a presentation sponsored by the Stanford Health Library. “However, you can learn stress fitness. By that I mean learning to engage the brain to enable it to be ready to encounter and deal with any stress that comes your way.”

For seniors, today’s stressors are less about sheer survival and more about personal trials, such as dealing with financial uncertainty, ailing health, the loss of a loved one, or family concerns. But the same biological cascade takes place, flooding our bodies with a surge of hormones, including adrenaline and cortisol, that increase your heart rate, elevate your blood pressure, and boost energy.

“But stress itself is neither good nor bad,” said Dr. Vernikos. “Stress is simply a stimulus. It’s our body telling us what we need to do. What’s important is not the stress but how we respond to it. It’s mostly a matter of perception.”

The fact is, everyone reacts to stress differently. Some people seek stress for stimulation or fun. A ride on a roller coaster can be great fun or a terrifying ordeal, depending on your personal perspective. And it’s impossible to eliminate stress completely – nor should we want to since it’s such an effective tool for both protecting and enhancing our health. The problem arises when we respond excessively to stress. That’s when the system can turn against you and do harm, said Dr. Vernikos.

“We need the response to stimuli to switch on energy,” she said. “But managing stress is fundamental. Most of the stress you feel is self-generated in the brain, which means that if you can create it, you can also control it.”

Dr. Vernikos said you can train your brain to respond differently to stress, much like how a computer can be programmed to filter out spam. If the brain creates the “what ifs” that keep you awake at night, you can design tactics to control them. “The brain is producing all sorts of worries, fears, and anxieties about things that have not happened yet,” she said. “Learn how to press the delete key.”

One way to do this is to draw upon your experiences as a sort of database to identify how you have successfully handled similar stressors in the past. Older adults can often handle stress better because they have a larger database to draw on. Culling your memories helps you build a strong, positive database to retrieve relevant information and respond rationally.

Another important factor is to recognize the difference between effective and ineffective coping mechanisms in responding to stress. Ineffective coping wastes energy does not address the problem and often involves tactics like eating, drinking, insomnia, or misdirected anger. Effective coping allows you to assess, take charge, and be prepared. It involves asking others for help and learning to say no as a way to step back and reprogram your thinking.

Dr. Vernikos also suggested that you be aware of your body language when stressed: By dropping your shoulders, taking deep and slow breaths, and opening your mouth to relax your jaw, you can provide instant relief. Other soothing tactics include laughter, pets, music, and developing a strong social network.

About the Speaker
Joan Vernikos, PhD, a space pioneer researcher and former head of NASA Life Science, is a member of the Space Studies Board of the National Academy of Sciences and an advisor to the European Space Agency. She is the author of “Stress Fitness for Seniors” and “The G-Connection: Harness Gravity and Reverse Aging.”

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Stanford Aging Adult Services
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Stanford Center on Stress and Health
http://stresshealthcenter.stanford.edu/

Modern Rhinoplasty: Aesthetic and Functional Surgery of the Nose

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Posted By SHL Librarian

Presented by: Sam Most, MD, FACS
Director, Division of Facial Plastic Surgery
Stanford University Medical Center
November 5, 2009

Lecture Overview:

  • Breathing problems can be caused by fixed or variable structures in the anatomy of the nose.
  • Rhinoplasty reshapes the internal and external components of the nose.
  • Functional rhinoplasty can improve breathing function and sometimes enhance facial harmony.
  • There is no ideal profile, and each patient needs to be evaluated individually, assessing breathing, overall health, expectations, and prior surgeries

Our noses look the way they do for a reason. Not only are they an essential component of the movement of air during respiration, they also filter particles, provide the sense of smell, help in vocal communication, and regulate humidification.

The nose is made up of a fleshy casing over cartilage, somewhat like the set-up of a tent. And like a tent, changes to the support system can change the appearance of the covering. Understanding normal nasal airflow is a complex formula based on the laws of fluid dynamics in which changes in radius affect flow rate.

Breathing problems can be caused by variable obstacles, such as when the lining of the nose thickens from allergies or sinusitis, or with fixed obstacles, which include the septum; internal structures called turbinates; and the internal nasal valve, the narrowest section of the airway.

“The anatomy of the nose dictates that any changes done to the outside will affect the inside as well,” said Sam Most, MD, director of Stanford’s Division of Facial Plastic and Reconstructive Surgery, who spoke at a presentation sponsored by Stanford Hospital Health Library. “You’re not just changing the shape of the nose. The most important aspect to consider is how to improve or maintain nasal airway function.”

Restoring Function
For many people, rhinoplasty, or a nose-job, is traditionally thought of as an operation to change the shape of the nose. However, in any rhinoplasty, function must be considered along with aesthetics-a mistake too often made by inexperienced rhinoplasty surgeons. Functional rhinoplasty is surgery that exclusively addresses fixed obstacles-the structures within the nose, though it can be combined with aesthetic (traditional) rhinoplasty.

Fixed obstacles include the septum, which is rarely perfectly straight and can sometimes block the nasal passage. A septoplasty can be performed to manipulate and straighten the septum, with almost no changes to the appearance. When swollen, an abnormal turbinate can also block the passage by changing the vascular lining. Dr. Most said the first line of defense in this case should be medical therapy, such as antihistamines or nasal steroids. If those don’t help, surgical options include radiofrequency ablation, microdebridement to remove the soft tissue, or a mucosal-sparing resection.

One of the most common causes of nasal obstruction is internal valve collapse, which may be caused by trauma or prior surgery. The degree of collapse is determined by the angle of the valve to the septum and wall. Surgery to address this problem can affect the appearance even though the primary goal is to improve breathing by widening the airway, said Dr. Most, so it is often combined with other procedures.

There are two adjacent zones involved in lateral wall support problems. For Zone 1, external nasal valve dilator strips often provide temporary relief by increasing the size of the nasal valve area. “First we try to treat this problem medically,” said Dr. Most. “But when there is a structural problem, then you need to restore the nasal structural support.”

In Zone 2, closer to the nostrils, the valve has no resistance to negative pressure and needs to be repaired. Adding cartilage (alar batten grafts) has not been proven to be effective in the long term said Dr. Most; another, more promising technique involves using a suture to stiffen the area to counteract the force when breathing.

Cosmetic Surgery
Aesthetic rhinoplasty is about both form and function. Although ideal standards have been analyzed using tip rotation, chin position, and other factors, there really is no ideal nasal form, said Dr. Most. “There’s no cookie-cutter rhinoplasty, where one size fits all,” he emphasized. “Each person needs to be evaluated individually, assessing breathing, overall health, expectations, and prior surgeries.”

Computer imaging has drastically changed the practice of cosmetic surgery, providing an educational opportunity for both the surgeon and the patient in terms of outcome and possibilities. Procedures are done on an outpatient basis and usually take between 1-1/2 to 3 hours or more. Most people will experience post-surgery bruising, and final results can take as long as one year as the soft tissue and skeleton settle and adjust.

Dr. Most showed several before-and-after shots of patients, showing some of the more common rhinoplasty procedures, ranging from rotation of the nasal tip (the direction of the tip of the nose) by adjusting the tip’s cartilage to straightening a crooked nose by manipulating the supporting structures. He suggested that people of Asian or African descent retain an ethnically appropriate appearance by augmenting the nasal bridge without choosing an overly Westernized profile.

About 30 to 40 percent of his referral practice involves revisions to earlier rhinoplasties, he said. “Revisions are complex because of scarring so they really need to be done by experts who know the options for repair.”

About the Speaker
Sam Most, MD, FACS, is director of Stanford’s Division of Facial Plastic Surgery and an associate professor of Otolaryngology-Head and Neck Surgery. His research and clinical priorities involve assessments of new and existing plastic surgery techniques to enhance results and quality of life for patients. He received his MD from Stanford, did his internship at Yale-New Haven Hospital, and completed his residency and fellowship at University of Washington Medical Center, where he was chief of the Division of Facial Plastic Surgery. Dr. Most has been on the Stanford faculty since 2006.

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About Dr. Most
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Stanford Plastic Surgery
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Stanford Department of Otolaryngology
http://med.stanford.edu/ohns/

San Francisco Rhinoplasty
http://www.sfrhinoplasty.com/