Women and Cardiovascular Disease from Multiple Perspectives – I

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Three Lectures from Stanford University Medical Center faculty
Moderated by: Hannah Valantine, M.D.
Professor of Medicine, Cardiovascular, and Associate Dean for Diversity and Leadership
Stanford University Medical Center

Moderator’s Overview:
In her opening statement, Dr. Valantine shared the guiding and expansive vision that is the foundation of the program called Women’s Heart Health at Stanford. The program is designed to raise and help to answer one of the most compelling questions of the early 21st century: Is there a difference between men and women regarding heart health, and if so, should we be doing something different? Dr. Valantine reminded the audience that while death rates from heart disease are decreasing in men, they are in fact increasing in women, and it is important to know that women with cardiovascular diseases often arrive in a doctor’s office or emergency room with a different constellation of symptoms than men. This series of three topical lectures presented during one evening, offered an overview of the heart diseases most effecting women, a discussion of the treatments, and updates on the latest news on research at Stanford.

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For further information about the clinical trials and research being performed at Stanford, please visit the following websites:

Women’s Hearth Health At Stanford:

Ten Questions a Woman Should Ask Her Healthcare Provider:

Stanford Hospital & Clinics

American Heart Association (which includes information about women and heart disease)

The Risks and Benefits of Menopausal Hormone Therapy in Younger and Older Women

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Presented by: Marcia Stefanick, Ph.D.
Professor, Research, Stanford Prevention Research Center
November 16, 2006

Lecture Overview:
In one of the most stunning turnarounds in modern health care, it is no longer considered appropriate to give hormones to women to replace estrogen lost in the natural process of aging, i.e., at the time of menopause. According to Dr. Marcia Stefanick a series of myths became embedded in our culture, some of them actually hazardous, about using Menopausal Hormone Therapy (HT). In fact, it is now recommended that hormones are only given to menopausal women who have severe enough symptoms, for example, hot flashes and night sweats, that they feel they cannot carry on their normal lives, a far cry from the enthusiasm that once surrounded the use of HT with the expectation that it would prevent heart attacks, bone fractures, and dementia, and preserve youth. Dr. Stefanick discussed the landmark clinical trials that proved HT can, in fact, be harmful, by increasing heart attacks, strokes, blood clots, and dementia. Dr. Stefanick’s lecture recounted the highlights of several clinical trials that proved the new thinking on hormone use.

Furthermore, the truth is that there is relatively little known about hot flashes and night sweats or what a woman can to do, besides taking estrogen, to relieve these common symptoms. According to Dr. Stefanick a few useful hints include: dressing in layers that can be peeled off depending on the temperature, not wearing turtlenecks, and avoiding alcohol, caffeine and hot or spicy foods. Women are delighted by the simplicity and truth of this valuable advice. It is based on the fact that menopausal women do not dissipate heat well. There is also evidence that paced breathing might help. This is valuable advice indeed, as women everywhere await the results of new research initiatives that will hopefully yield a better understanding and clearer definition of menopause.

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Links to the Clinical Studies:
The Framingham Study

The SWAN Study

The HERS Trial

Links to Dr. Stefanick’s Stanford Profile and her work:

Farewell to Falls

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Presented by: Ellen Corman, MRA
Injury Prevention Coordinator, Trauma Services
Stanford Hospital & Clinics

Lecture Overview:

  • Fifty percent of adults 80 and older fall each year
  • Most falls take place at home
  • Older adults who fall are two to three times more likely to fall again
  • Take proactive steps in your home to avoid falls by installing handrails, removing clutter and keeping floors clear
  • Exercise to maintain strength, balance and coordination
  • Have your physician check your medications

Nearly 1 million older Californians experience a fall each year. For people 65 years and older, falls are the most common source of injury resulting in a visit to the emergency room.

The odds of falling each year after age 65 are about one in three; after age 80 the chance of a fall is about 50-50. People are more likely to fall as they get older because of common, age-related physical changes and medical conditions, along with the medications prescribed to treat such conditions, weakness related to a sedentary lifestyle, and home and environmental obstacles. About 20 to 30 percent of the people who do fall face reduced mobility, and many people-even those who are not injured-develop a fear of doing it again.

“Older adults who have fallen are two to three times more likely to fall again within the next year,” said Ellen Corman, MRA, injury prevention coordinator for trauma services at Stanford Hospital & Clinics, who gave an hour-long presentation at the Redwood City Public Library on April 30. “The older you get-and the more risk factors involved-set up an even greater chance of falling.”

Corman asserts that falls do not take place because “I wasn’t watching,” or “I just tripped.” The reasons behind a fall can range from being tired and not lifting your feet properly to poor vision, distractions, slower reaction time and medications that cause dizziness or lightheadedness. Other factors can include physical weakness, cognitive impairment, depression, dehydration or a balance disorder.

But many falls can be prevented by making even small adjustments in three specific areas: your home environment, your medications and your exercise routines.

Taking Positive Steps
“When it comes to home safety, there are specific changes you can make to control your environment. Be proactive. There is usually a combination of factors so it’s important to take a multifaceted approach to making changes,” said Corman. “Most falls are preventable.”

Because more than 60 percent of falls occur at home, she stressed the importance of making some simple modifications to make it safe:

  • Get rid of your throw rugs. Hang them on the wall or give them to someone who will appreciate it.
  • Remove clutter-including papers, pet toys and the grandkids’ playthings.
  • Move electrical cords out of the way.
  • Wear thin-soled, non-skid shoes, sneakers or slippers, especially in homes with hardwood floors.
  • Use nightlights, and bring a nightlight with you when you travel.
  • Install grab bars in the bathroom. An occupational therapist can aid in making an accurate assessment of where to place the bars to suit your height and movements.

“My dream is that all homes have grab bars in the bathrooms, no matter what the person’s age,” Corman said.

Fitness is Key
Older adults generally score between 20 and 49 percent lower on strength tests-an impairment that makes them three times more likely to fall. While today’s older adults realize that exercise is important and tend to remain active in their later years, for too many people retirement means a sedentary lifestyle.

Corman mentioned one study of men and women aged 88 to 92 years involved in a simple exercise program: All participants showed improvement in strength and balance after only eight weeks.

“It’s never too late to start some kind of exercise,” she advised. “Keep moving, and try to mix it up.”

Corman recommended tai chi or a walking routine in a safe, flat location such as a mall or school track. She also emphasized the importance of including weight training to maintain strength.

Check Medications
The number, type and combination of medications can affect a person’s balance, perception and reaction time. Medications should be checked for side effects listed like lightheadedness or dizziness as these drugs could contribute to the potential for a fall. Check regularly for expiration dates, and be aware of possible complications from polypharmacy-the use of multiple medications that may interact.

Corman suggested that all medications be placed in a plastic bag and brought to a physician or pharmacist for review.

Support System
Stanford established the Farewell to Falls program in 2005 to assess potential trouble spots for seniors at risk for falling. The home-based program, free for Santa Clara and San Mateo county residents 65 and older, provides two home visits from an occupational therapist who evaluates the home for potential problems, performs a sensory-motor review and does a health risk interview. The therapist then offers individualized suggestions and a review of medications from a pharmacist. Participants also receive an exercise video to help improve strength and balance.

In addition to the home visits, participants receive periodic follow-up phone calls from volunteers to see how they’re doing. One year after the start of the program the occupational therapist returns to reassess the risk factors and to provide additional fall prevention tips.

“We’re hoping that seniors take advantage of this opportunity to participate in a program that can help them to maintain their independence,” said Corman, who added that more than 200 people take part in the program each year.

About the Speaker
Ellen Corman is the Injury Prevention Coordinator in the Trauma Service at Stanford Hospital & Clinics and has been involved in injury prevention activities for more than 20 years.

She is an occupational therapist and has a master’s degree in rehabilitation administration. Corman participated in the California state injury prevention strategic planning workgroup and is an active member of the California Stop Falls Network. She developed and manages the Stanford Hospital & Clinics Farewell to Falls program and co-chairs the San Mateo County Fall Prevention Task Force.

For More Information:

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Stanford Hospital & Clinics Farewell to Falls

Centers for Disease Control

Fall Prevention Center of Excellence

American Geriatrics Society

Starting an Exercise Program: How Your Doctor Can Help

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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.

For More Information:

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About Dr. Wang

About Dr. Atwan

About the Stanford Cardiac Arrhythmia Service

American Heart Association

WebMD: Starting an Exercise Program

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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About Dr. Chueh

Maternal Fetal Medicine

Obstetrics & Gynecology


New Insights into Breast Cancer Treatment and Survivorship

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Moderator: Frederick M. Dirbas, MD
Physician Leader, Stanford Cancer Center’s Breast Disease Management Group
Thursday, October 7, 2010

Each year more than 190,000 American women are diagnosed with breast cancer, the second-most common type of cancer in the United States (skin cancer is first). As research and innovations in technology and treatments enable earlier detection and better care, more people are surviving cancer and living longer after a diagnosis. The National Cancer Institute estimates that 3 million people were living with cancer in the United States in 1971; today that number is close to 12 million.

There are more than 2 million breast cancer survivors today, which is creating a new niche of care because survivorship can lead to new health needs and concerns. Survivors can have heightened risks for long-term side effects from treatments or the disease, and they must deal with psychological issues, sexual concerns, pain, fatigue, and quality of life issues.

Stanford Supportive Care, a program that addresses these concerns by bridging medical care with non-medical healing, and the Stanford Health Library brought together several Stanford specialists to talk about the unique issues of breast cancer survivorship.

“After we treat the disease, we want to help patients live a full and healthy life,” said Frederick M. Dirbas, MD, Physician Leader of the Stanford Cancer Center’s Breast Disease Management Group, who moderated the panel of experts. “It’s important to bring our expertise together for patients, their families, investigators, and clinicians.”

Survivorship: Dealing With Feelings
David Spiegel, MD
Medical Director, Stanford Center for Integrative Medicine

Sadness and grief are normal reactions to a diagnosis of cancer, and for most people these feelings will come and go throughout treatment and afterwards. But as many as 25 percent of cancer patients suffer from depression and go undiagnosed.

“The worst time is when you are told you have cancer,” said Spiegel. “The second worst time is when the treatment is over. You lose your contacts and your routine, but your body reminds you all the time that you are a cancer survivor. It’s a difficult transition at many levels.”

It’s important to develop strategies to adjust to this transition, from health maintenance to social activities and family roles. And an important part of taking care of yourself is to manage your moods. Depression can have a direct effect on quality of life, and can also influence recovery time, pain thresholds, and even life expectancy.

“Cancer has an effect on the brain both in terms of emotion and cognition,” said Spiegel. “There is a relationship between psychological stress and cancer:  Emotional well-being can have a profound effect on health outcomes.”

Studies of cancer survivors have shown that that depression affects 25 percent of cancer survivors, compared to 3 percent of the general population. Depression, fatigue, poor sleeping patterns, and medications also affect memory, concentration, and mental agility-a condition referred to as “chemo brain.” Exercise and sleep can help, as can medication to help restore perspective.

Many cancer survivors benefit from group or individual psychotherapy. “Therapy can create an opportunity for emotional release, to learn new coping skills, and to develop new goals,” Spiegel said. “Dealing with your feelings-even negative ones-can help you covert from feeling damaged to being in a position of coping and even transcendence.”

Advances in Breast Cancer Surgery
Irene Wapnir, MD
Chief, Breast Surgery

How breast cancer is treated depends on the size of the tumor, whether the cancer is invasive or non-invasive, whether lymph nodes are involved, and whether the cancer has spread beyond the breast. There are gradients in each of those factors, however, that can complicate what surgery is most appropriate as well as outcomes.

For example, improved screening from mammograms and breast imaging has led to a 500 percent increase in finding invasive lesions, growths that can vary from normal cells to cancer. The surgical treatment of breast cancer has changed drastically over the years, from mastectomy to lumpectomy to axillary lymph node dissection (ALND).

Twenty years of data has shown outcomes to be almost equal for these surgical modalities, said Wapnir, but which one to use is based on the tumor size or whether the cancer is localized. “A lumpectomy preserves much of the breast but still increases chance of recurrence,” she said. “You have to be aware of how much risk you’re willing to accept.”

Improvements to lumpectomy techniques also make the option available to older and pregnant women as well as women with multiple cancers. Advances in reconstruction are also leading to better cosmetic outcomes.

“We are now in a better place in terms of choices, making the aftermath of surgery less frightening to women,” she said. “We have new procedures to avoid side effects like lymphedema and the ability to modify treatment regimens so we can get insight on what the tumor is like and select the best treatment more quickly and effectively.”

Sexuality and Breast Cancer Survivorship
Leah Millheiser, MD
Clinical Assistant Professor
, Obstetrics and Gynecology
Director, Female Sexual Medicine

Though there is not much data available on female sexuality problems after cancer treatment, it appears to be a significant issue. One large-scale study found that while 80 percent of responders reported a good or satisfying sex life before treatment, 70 percent reported sexual problems after treatment.

“The most common concerns are body image issues and hot flashes,” said Millheiser. “Since early-onset menopause is a result of cancer treatment, there are real physical problems, such as vaginal dryness, pain during intercourse, and vaginal shrinkage. And for younger women, especially, there is the increased emotional distress of dealing with infertility.”

Because estrogen is closely related to cancer, many women are leery of using vaginal estrogen to address dryness and sexual discomfort. But vaginal estrogen is minimally absorbed, unlike systemic estrogen, so many women can use it, Millheiser said. For those who cannot use vaginal estrogen, she advises using a moisturizer or vaginal dilator as soon as there is pain: Waiting will not help the problem and can lead to a cycle of miscommunication with your partner.

She recommends silicone-, water-, or oil-based personal lubricants during intercourse, such as Replens or K-Y Liquibeads, but warns that petroleum-based lubricants can harbor bacteria in the vagina and cause damage to latex condoms. Though there are no FDA-approved treatments to enhance female libido, a neutraceutical called ArginMax and a nonhormonal arousal oil called Zestra appear to increase desire. Studies also show that a Mediterranean diet, one high in fruits, vegetables, fish, and whole grains, may improve sexual function.

“After cancer therapy, women need to become comfortable with their body,” Millheiser said. “They need to use whatever methods work for them-self-exploration, pain medications, sexual lubricants-and they need to go slowly and chose the right timing to learn to relax with their sexuality.”

Breast Cancer and Cardiac Complications
Randall Vagelos, MD
Medical Director, Cardiac Care Unit

The heart can be affected by cancer therapy, especially in conjunction with other lifetime risk factors, such as smoking, high blood pressure, enlarged heart muscle, or other conditions. And many common side effects of treatment, like tightness in the chest, shortness of breath, or fatigue, can also be symptoms of a heart problem.

“It’s important to know the state of the heart before starting any cancer treatment,” said Vagelos. “Many cancer therapies can exacerbate cardiac conditions.”

Radiation can be a risk to heart heath and tends to amplify the effects of other therapies. Common anticancer drugs like anthracycline affect cell turnover and replication, which can cause cardiac damage over time. The long-term use of anthracyclines can lead to cardiomyopathy and congestive heart failure even years after exposure. Tyrosine kinase inhibitors, which can “turn off” certain cell functions, can weaken heart muscle, although its effects reverse as soon as the drug is stopped.

The condition of the heart can be carefully scanned and monitored with noninvasive imaging techniques and other technologies to make sure patients receive optimal benefits from their treatment. Minimizing cardiac toxicity requires knowing pre-existing conditions and risk factors; using medications like ACE inhibitors and B blockers to override risk; and monitoring the heart using imaging, biomarkers, cardiac biopsies, or echocardiograms.

“All medical interventions have some risk, but our challenge is to maintain the balance between risk and benefit,” he said.

Osteoporosis and Bone Health
David Feldman, MD
Professor, Endocrinology

Because estrogen is so intertwined with breast cancer, and the hormone is so crucial in protecting the bones, osteoporosis (loss of bone density) has become a common concern for cancer survivors, said Feldman.

All women dealing with lower estrogen levels-whether from cancer treatment or age-related menopause- should take a bone density scan (DXA) to measure and track osteoporosis. The test results compare your measurements with others your age (Z score) and with a normal young person (T score). FRAX, an online fracture assessment tool, can also allow you to measure your risk for osteoporosis.

To prevent osteoporosis, you need to take 1200-1500 milligrams a day of calcium supplements, maintain a regimen of weight-bearing and strengthening exercises, and be aware of strategies to prevent falls.

Most people do not get enough sun exposure to produce the necessary levels of vitamin D, which helps the body absorb calcium, so take at least 400 International Units per day. Feldman said he expects new guidelines will more than double the recommended dosage of this essential vitamin but suggests getting a blood test to know your starting point so you can track its benefits.

“Everybody should be on calcium and vitamin D,” said Feldman. “Vitamin D supplements are not just for your bones. They also stop cancer cells from dividing, modulate the immune system, and reduce hypertension, and they appear to have potential for other applications. The proof in humans is not quite there yet, but there’s undeniable benefit.”

He also recommends bisphosphonates like Fosamax, Boniva, or Actonel, which are safe and convenient, although bone loss tends to accelerate as soon as you stop taking the drug.

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Stanford Cancer Center

Stanford Health Library

Women’s Health @ Stanford

Stanford Center on Stress and Health

Stanford Hospital Heart Center

Changing Sleep Patterns As We Age

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Presented by: Mehrdad Ayati, MD
Clinical Instructor, Internal Medicine
Stanford University Medical Center
April 19, 2012

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You go to bed, only to start tossing and turning, with no rest in sight. Or you fall asleep, only to wake up at 3 am. Having trouble falling asleep—or staying asleep—is a common problem, especially among older people.

But what is sleep exactly? And why does it become so elusive as we age? The reasons can range from physiological factors, such as chronic pain, hormones, or gastrointestinal problems, to environmental elements like light or noise, according to Mehrdad Ayati, MD, a clinical instructor of medicine, who spoke at a presentation sponsored by the Stanford Health Library.

We spend about eight hours a day, 56 hours a week, and 2,920 hours a year sleeping—almost a full third of our lives. But though sensory activity and voluntary muscles are on low, our brains are still quite active.

“Sleep is still a mystery,” said Dr. Ayati, “but we are understanding more about its function and what factors can affect our ability to sleep.”

Series of Cycles
Sleep involves a series of cycles triggered by a complex group of neurochemicals that respond to cues from the body and the environment. This sleep pattern follows an alternating cycle throughout the night. The first phase is called slow wave sleep, which is the deepest and most restorative stage. Slow brain waves occur at the beginning of the night, with a deep drop of consciousness. As we get older, however, there is a marked drop in these stages of our deepest sleep.

About 25 percent of sleep involves rapid eye movement (REM), the second cycle, which is associated with dreaming. REM sleep is sometimes called paradoxical sleep because the brain is still quite active. Blood pressure is low and muscles are inactive during REM sleep to prevent us from acting out our dreams. REM phases can last from five to 30 minutes, and most people can recall at least snatches of their dreams if they are wakened from this cycle. People with dementia tend to have more REM sleep and can develop REM sleep behavior disorders like sleepwalking.

Sleep is regulated by a complex network driven by several neurotransmitters, including acetylecholine, which appears to affect dreams; dopamine, which enhances wakefulness and alertness; and histamine, which can induce wakefulness (which is why many antihistamines cause drowsiness).

These neurotransmitters work in conjunction with our circadian clock, a biological time keeper that synchronizes our chemicals, hormones, body temperature, and sleep patterns. The circadian clock is also involved in the production of melatonin, a hormone produced by the pineal gland in the brain that is suppressed by light. Among other influences, melatonin regulates the core body temperature and circulation.

Together these processes control when we sleep and how deeply we sleep, said Dr. Ayati. For example, younger people spend more time sleeping and a greater percentage of sleep in a REM state compared with adults. He also described a typical wake-sleep cycle: Highest melatonin rates occur around 9 pm and production stops at 7:30 am; highest body temperature and blood pressure take place around 7 pm; deepest sleep takes place at 2 am, followed by lowest body temperature at 4:30 am.

Factors that can Affect Sleep
But as we get older, more internal and external factors can make sleep elusive or less satisfying. We spend more time in bed but more time awake, and the kind of sleep we get is the lighter stage. Dr. Ayati said close to 40 percent of older women develop sleep problems, usually related to hormone changes associated with menopause.

Sleep can also be affected by COPD and other respiratory problems; gastrointestinal ailments like irritable bowel syndrome; blood sugar fluctuations from diabetes; and chronic pain stemming from fibromyalgia and arthritis. There is a strong association between cardiovascular disease and sleep problems: people with sleep apnea, for example, are at a higher risk for heart attack.

But simply getting older may be the biggest cause of problematic sleep patterns. About 40 percent of older adults report having trouble falling asleep, and 30 percent report waking up in the middle of the night. About half use medication to help induce sleep, and more than half report experiencing daytime drowsiness. Almost two-thirds have some physical condition that can affect sleep.

Dr. Ayati said a key problem is that circadian rhythms change, causing sleep to become more fragmented, with disruptions from tossing and turning, and trips to the bathroom (a condition called nocturnia). For many people this change might be due to lifestyle changes, such as losing a loved one or limited social contact, which can cause anxiety. Because of physiological changes, medications, alcohol, and stimulants can also exert more influence over sleep patterns. Common prescriptions like antidepressants can actually make matters worse, he added.

“Older people are awake longer and more susceptible to changes in routine,” he said. “Over time the circadian cycle will change by itself.”

In hospitals and nursing homes, circadian cycles are affected by daytime napping, inactivity, noise, medication, and changes in routine.

Management and Treatment
A change in sleep hygiene is the best first step to managing and treating sleep problems.

“You can help yourself find your own circadian rhythm,” Dr. Ayati said. ”Go to bed the same time every day—even on weekends—and never go to bed unless you are sleepy. The bed is not the place to read, watch TV, or think.”

Though not a big proponent of naps, he did say that short naps of 15-20 minutes can be helpful for some people. He also suggested:

  • Stay in bed only when asleep and get up as soon as you awaken
  • Exercise daily but not just before bedtime
  • Relax mentally before getting ready for bed
  • A light snack is OK unless you have reflux
  • Cut out caffeine, alcohol, and nicotine
  • Control the noise, light, and temperature in your bedroom
  • If you can’t sleep after 30 minutes, get up but keep lights low

He also recommends using cognitive behavioral therapy, a psychotherapeutic approach designed to influence behaviors and perceptions by modifying mental processes. Other approaches may include bright light therapy to enhance melatonin production and relaxation techniques. Prescription or over-the-counter medications can help but only as a short-term remedy since they can cause even more sleeping problems, he said.

About the Speaker
Mehrdad Ayati, MD, is a clinical instructor of internal medicine with a special focus in geriatric medicine. He received his medical degree from the Iran University of Medical Sciences. He completed his internship and residency at the University of California, Davis, and his fellowship at Stanford.

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Travel Medicine: What You Should Know Before You Go

Posted By SHL Librarian

Presented by: Brian Blackburn, MD
Assistant Professor, Medicine – Infectious Diseases
Stanford University Medical Center
May 10, 2012

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Getting sick is not usually on the itinerary when planning a trip. Unfortunately though, travelers can be exposed to a wide array of diseases that are uncommon at home that can wreak havoc on even the best-laid vacation plans. International visitors often forget that exotic destinations can be dangerous and can put themselves in jeopardy if they don’t prepare for potential health problems.

As international and adventure excursions increase in popularity, physicians are recognizing the importance of understanding the special medical needs of travelers, overseas workers, and adventurers. It’s estimated that more than 760 million people will cross international borders this year and that number is expected to grow, according to Brian Blackburn, MD, a clinical assistant professor of infectious diseases and director of Stanford’s new Tropical Medicine and Travelers Health Clinic, who spoke at a presentation sponsored by the Stanford Health Library.

Despite the escalating number of people leaving for foreign lands, only 35 to 60 percent seek any medical advice before leaving home, and only 10 to 20 percent visit a travel health clinic, he said. But between 25 percent and 65 percent report some sort of health problem while overseas or after returning home.

People visiting friends or relatives (VFR travelers) take travel health precautions even less often but tend to report getting sick more and require more hospitalizations. VFR travelers often consider themselves to be at little risk because they are simply “going home” or because they consider themselves immune since they were exposed when young. “These people are actually at higher risk, so they should see a physician before a visit overseas,” he added.

The numbers back him up: Only 9 percent of tourist travelers to Africa who developed a fever had malaria, compared to 45 percent of VFR travelers. And more than 90 percent of all travelers report taking a risk by not following appropriate health precautions regarding eating and drinking.

“Much of travel health involves using common sense and being safe,” said Dr. Blackburn. “Avoid insects by using bed nets, proper clothing, and repellents with DEET. Be safe with food and water. Don’t swim in fresh water in certain areas. Drive carefully: Traffic accidents are the most common problem abroad—more than infectious diseases.”

Malaria is the most deadly parasitic disease in the world, said Dr. Blackburn, causing nearly 1 million deaths a year worldwide. Usually transmitted by a type of night-biting mosquito, malaria can be fatal in a matter of days. It causes fever and flulike symptoms, which usually take between a week and month to manifest. It’s most common in sub-Saharan Africa, Oceania, Asia, and South and Central America.

There are several effective medications available that can prevent malaria. All involve taking the drug before, during, and after travel to an area with malaria. The choice of drug depends on the travel destination and resistance patterns of malaria in that area, so talk to a physician about your itinerary to determine the most appropriate medication.

These chemophrophylaxis drugs include malarone, chloroquine, mefloquine, doxycycline, and primaquine, which vary in terms of cost, treatment regimen, and possible side effects.

International travelers should be up to date on vaccinations for measles and mumps, influenza, and hepatitis B. Most U.S. residents are immune to polio, but a one-time booster shot is recommended for adults going to certain countries in Africa and Asia.

Hepatitis A is now a routine childhood immunization, and requires two doses over six months although most people develop good immunity after the first dose.

A type of bacterial meningitis can be rapidly fatal, even with antibiotics. Immunization is recommended for travelers to certain countries in Africa and the Middle East. Re-vaccination is required every five years for those at continued or renewed risk.

Japanese encephalitis, a viral disease endemic to much of East, South, and Southeast Asia, is spread by mosquitoes in the (summer and fall. Despite its rarity for travelers, about one-third of people who show symptoms die from the disease. Long-term travelers to these areas or those spending time in rural sites should be vaccinated.

Rabies immunization is optional for most travelers since the disease is not common and vaccinations are expensive. However, for high-risk travelers, such as wildlife workers, veterinarians, or people expecting prolonged stays or rural exposure where medical facilities may be unavailable, a rabies shot may be a good idea. “Rabies is nearly 100 percent fatal. There’s essentially no treatment, so the only approach is to prevent it,” said Dr. Blackburn. With any bite, it is very important to clean the wound thoroughly, and seek medical attention immediately.

Some countries require proof of immunization against yellow fever for entry. Common in tropical areas of Africa and South America, this viral disease is spread by mosquitoes and is fatal in 20-50 percent of those infected. The risk of exposure is about 10 times higher in Africa than in South America.

With no cure available, vaccination is the most important measure against yellow fever. Re-vaccination is required every 10 years and needs to be done at least 10 days before departure. About 10 to 30 percent get a mild reaction to the vaccine, which can range from flulike symptoms to headache. Infants, pregnant women, people with a thymus condition, and immunocompromised patients should not get the vaccine, and the risks of the vaccine are also higher in people over age 60, said Dr. Blackburn.

Travelers to most of the developing world should receive the typhoid vaccine. Typhoid is a bacterium acquired by consuming contaminated water or food, and causes fever, abdominal pain, and other symptoms. The injectable vaccine is given as a single shot that lasts about two years; the live vaccine requires four oral doses over eight days and lasts about five years.

Travelers’ Diarrhea
Even the most experienced globetrotters, using all recommended food and water preparation precautions, can suffer bouts of travelers’ diarrhea. The most common ailment affecting overseas visitors, diarrhea is caused by bacteria (80-90 percent), viral infections (5-10 percent), or parasites (less than 10 percent). High-risk areas include most of Asia, the Middle East, Africa, Mexico, and Central and South America. Daily doses of Pepto-Bismol can decrease the possibility of acquiring diarrhea, although this is not routinely recommended. A course of antibiotics can treat rather than prevent the condition.

About the Speaker
Brian Blackburn, MD, is a clinical assistant professor of infectious diseases and the director of Stanford’s Tropical Medicine and Travelers’ Health Clinic. He received his MD from Chicago Medical School and did his internship, residency, and fellowship at Stanford. His research and clinical work has brought him to Liberia, Nigeria, Kenya, India, and Bangladesh. He is certified by the American Society of Tropical Medicine and Hygiene in tropical medicine and travelers’ health and by the American Board of Internal Medicine in infectious diseases and internal medicine.

About the Clinic
Stanford’s Tropical Medicine and Travelers’ Health Clinic was established to provide consultation and treatment for visitors abroad. It is located at:
900 Blake Wilbur Drive
Second Floor
Palo Alto, CA 94034

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The Dawn of Personalized Medicine

Posted By SHL Librarian

Presented by: Euan Ashley, MD, PhD
Assistant Professor, Cardiovascular Medicine
Stanford University Medical Center
June 7, 2012

We know that genes play a crucial role in influencing how we look and act, as well as our susceptibility to disease. Now scientists are trying to use that knowledge in exciting new ways, such as preventing and treating health problems based on therapies tailored to an individual’s unique genetic makeup.

But to understand the future of genetically based personalized medicine, it’s important to understand the basics, says Euan Ashley, MD, PhD, an assistant professor of cardiovascular medicine and director of the Stanford Center for Inherited Cardiovascular Disease, who spoke at a presentation sponsored by the Stanford Health Library.

Human DNA is contained within 23 pairs of chromosomes, one half pair from each parent; genes are segments of DNA that determine specific characteristics, such as hair color or height. Some characteristics come from a single gene, while others come from gene combinations. Humans have about 20,000 genes (and so do worms), and the complete instructions they carry are called the human genome.

Genes hold the instructions for making the proteins that manage cell growth and function. When cells duplicate, this genetic information is passed along to the new cells. The genes may mutate over time, causing disease, and such variants can be passed along from parent to offspring. There are more than 3 billion units of information (letters) in the human genome.

Organizing the Information
But the human genome is not quite that straightforward. When mapping the genome, scientists found that blocks of DNA, called haplotype blocks, tend to stay together. By measuring single letter variants called SNPs in each of these blocks, they were able to look across the whole genome at once.

Using a chip to look at the genes or the cell messages that come from the genes was developed at Stanford and now is used as a tool by researchers worldwide. Over the past couple of decades, using such chips, researchers have identified more than 4,000 single genetic variants associated with disease. Most diseases, however, are caused by a multitude of variants acting together.

“Gene chips allowed researchers to look at large populations and associate a genetic variant with a disease,” said Dr. Ashley. “There was a deluge of strong associations within just a few years. Sequencing (spelling out the letters)  the entire genome has come down in price dramatically: 10 years ago a human genome sequence cost about $100 million; today it runs close to $1,000, making the process accessible to most labs and hospitals, and moving toward the day when the genome is used as a routine part of medical practice.

New Clinical Tool
Another enormous step occurred when a Stanford scientist sequenced his entire genome three years ago. He had a family history of severe heart disease that was reviewed by Dr. Ashley—a genetic heart specialist—which made Dr. Ashley the first physician with access to a patient’s complete genome. He put together a team of Stanford scientists to help analyze it.

“Having the patient’s genome available allowed us to look at the possibility of disease, the clinical risk, and what drugs he would or would not respond to,” said Dr. Ashley, referring to pharmacogenetics. “Access to a person’s genome enables us to look at the genetic information in a way that makes sense for clinical medicine. We can look at a patient’s potential response to medication based on their individual genetic makeup.”

Whole-genome sequencing could identify and help prevent heart problems—and other life-threatening diseases—in patients who seem healthy but may be at risk because of an inherited predisposition, he added. Because he could review his patent’s genome, Dr. Ashley was able to make a list of drugs to avoid based on genetic variations associated with reactions with common medicines. His analysis indicated that the patient would respond well to statins.

“Personalized medicine is about individual risk for disease and targeted preventive care,” said Dr. Ashley. “We are only now taking the first steps toward integrating this information into clinical care, and we still have a lot to learn in terms of interpreting the data.”

For now, he adds, clinical applications for an individual’s complete genome have more potential in challenging cases such as rare family syndromes, and studies are underway for genetic response to stent restenosis and drug resistance.

About the Speaker
Euan Ashley, MRCP, DPhil, FACC, FAHA, is an assistant professor of cardiovascular medicine and director of the Center for Inherited Cardiovascular Disease, a multidisciplinary program that coordinates care for adults and children with genetic disorders of the heart and blood vessels. He is a member of the leadership group of the American Heart Association’s Council on Functional Genomics, deputy director of the Stanford Cardiovascular Institute, and a member of the roundtable on genomics of the Institute of Medicine. An exercise physiology graduate of the University of Glasgow, Dr. Ashley received his PhD in molecular cardiology from the University of Oxford and his MRCP in medicine from the Royal College of Physicians. He joined Stanford in 2003.

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