It’s been called the chimney technique, and it’s been called the double-barrel technique. But Jason Lee, MD, prefers to call it the snorkel technique.

In the latest issue of Inside Stanford Medicine, I write about Lee, one of the most experienced physicians in the world at using this minimally invasive procedure to treat complex abdominal aortic aneurysms. In such cases, the aneurysm, a balloon-like bulge, extends very close to or beyond one or more of the aorta’s branch arteries, such as the renal arteries. This can make it challenging to use a stent graft, a small tube, to bypass the section of weakened arterial wall without obstructing blood flow to the branch arteries.

But Lee is able to circumvent this problem by placing one or more additional stents, which when deployed look like snorkels, adjacent to the main stent to create pathways for blood to reach branch arteries.

“The Europeans like to call this the ‘chimney graft,’ but in a chimney the smoke is going up, right?” Lee told me. “I don’t think that analogy is quite right because the blood for the kidney or visceral organ isn’t going up, like smoke, through a stent; it’s going down — like the vital air that comes down through a snorkel.”

Lee and Ronald Dalman, MD, have performed more than 60 snorkel procedures in the past three years, and my piece describes how they recently used the technique to treat Geraldine Vitullo, a 65-year-old grandmother from Visalia, Calif.

Schematic drawing of “snorkel” stents adjacent to main stent reproduced with permission from the Journal of Endovascular Therapy.

A small percentage of patients admitted to hospital beds from emergency rooms — about 5 percent, according to recent studies — are then transferred to intensive care units due to an unexpected decline in their condition. What is striking about these so-called unplanned ICU transfers is that they account for 25 percent of all in-hospital deaths.

In a study (subscription required) published late last week in the Journal of Hospital Medicine, researchers led by M. Kit Delgado, MD, an emergency medicine physician at Stanford Hospital & Clinics, determined some of the risk factors for such transfers when they occur within 24 hours of patients being moved from the ER to a hospital bed. (About half of all unplanned ICU transfers happen within this time frame.)

The implications are that we need to figure out what is happening with patients with respiratory diseases in particular …

The researchers found, among other things, that the risk was higher during overnight nursing shifts. It was lower among female patients and in high-volume hospitals. But what really stood out was this: Respiratory conditions, such as pneumonia and chronic obstructive pulmonary disease, accounted for nearly half — 47 percent — of all conditions linked to the increased risk of unplanned ICU transfer.

About the study, Delgado told me:

The implications are that we need to figure out what is happening with patients with respiratory diseases in particular in terms of initial resuscitation, monitoring and determining the appropriate level of hospital care. We have found in previous research that these respiratory patients who experience an unplanned transfer to the ICU have higher mortality than those who are directly admitted. Perhaps with better initial resuscitation and closer monitoring, these unplanned transfers can be prevented, and lives can be saved.

The study was based on three years of admissions data at 13 Kaiser Permanente hospitals.

There are two ways to perform Roux-en-Y gastric bypass surgery, which is by far the most popular weight-loss operation in the United States: one is to operate in a traditional manner through a large incision in the abdomen; the other is to operate through a few miniature incisions using small instruments and a small camera for guidance. But how do these approaches compare?

A group of Stanford researchers looked into this question by tapping the Nationwide Inpatient Sample, the largest publicly available, all-payer inpatient database in the United States. What they found was that the minimally invasive procedure was safer and resulted in less expensive hospital bills. As I wr0te in my news release on the study, which was published today in the Archives of Surgery:

The patients who underwent the laparoscopic, or minimally invasive, procedure had lower mortality rates, lower complication rates, shorter hospital stays and lower hospital charges compared with those who underwent open surgery, even after adjusting for differences in the patients’ socioeconomic levels and co-morbidities, the study reports.

John Morton, MD, MPH, the study’s senior author, told me he wasn’t surprised that the laparoscopic technique got good marks for patient safety, but added: “What did surprise me was the degree of superiority pretty much across the board compared with open surgery.”

Previously: The challenges of dieting and the promises of bariatric surgery, Stanford expert weighs in on study comparing gastric bypass and banding, Study finds family members of weight-loss-surgery patients also shed pounds and Study hints at benefits of weight-loss surgery for less obese patients
Photo by riverofgod

Epiphanies and transformative experiences make great copy; these kinds of stories write themselves. They’re also pretty rare. But I recently found one in the tale of Nataly Kuznetsov, right, a nursing resident in Stanford Hospital & Clinics‘ Emergency Department.

Kuznetsov was 23 when she got in a horrible motorcycle accident. As I write in my story:

The motorcycle smashed into the driver’s side, sending Kuznetsov flying about 100 feet. She landed along the side of the northbound lane.

Her right femur had shattered into about 10 pieces. Some pieces had shorn through her skin. She was bleeding profusely from her leg. “The bone was basically completely blown,” she said. “My right leg was 4 inches shorter than my left one, just from the impact. You should see my X-rays. They’re phenomenal.”

She was airlifted to Stanford Hospital, where, after two weeks, she realized she wanted to be a nurse. She explains in the story:

What I’ve realized is just how much of an impact nurses have on patients’ lives. … They’re the ones who are next to you. They’re the ones who are looking after you. They’re the ones who are holding your hand. They’re the ones who are going to let you cry next to them.

Previously: Nursing: The need to make a difference and Nursing is not all science
Photo by Norbert von der Groeben

It’s almost summer, and the outdoors beckons. So to be on the safe side, I consulted a few of Stanford Hospital & Clinics’ wilderness medicine experts on avoiding and treating bites and stings from a few of the potentially hazardous critters one could encounter in the Bay Area while hiking, barbecuing or taking a dip in the ocean. I also referred to the definitive tome on the subject, the more than 2,300-page Wilderness Medicine, by Stanford physician Paul Auerbach, MD.

What may have surprised me most is how a safety razor can be used in treating a jellyfish sting. As I write in my article published today:

Rinse the wound with seawater. … Remove any attached tentacles with forceps or a gloved hand. Apply a soak-compress of vinegar or isopropyl rubbing alcohol to the wound for about 30 minutes or until the pain subsides. Then apply a lather of shaving cream and shave the affected area with a safety razor to remove any remaining nematocysts.

Meanwhile, my colleague Sara Wykes has investigated another peril of the active summer lifestyle: blisters. She spoke with Stanford’s Grant Lipman, MD, one of the foremost authorities on the subject. Her article, published today, talks about avoiding and treating those uncomfortable sores, which Lipman notes affect a surprising number of people:

An estimated 10 million Americans go out hiking each year, and at least one in seven will develop the classic blister caused by friction between foot, sock and shoe. The numbers also show that the less experienced hikers are more likely to develop a blister.

Have a question about wilderness medicine or health precautions to take before enjoying the outdoors? Submit it to Auerbach this week via Twitter using the hashtag #AskSUMed. Or type it in the comments section on Scope.

Previously: Ask Stanford Med: Chief of Emergency Medicine taking questions on wilderness medicine and Stanford’s Paul Auerbach writes on treating emergencies mid-adventure

Photo by Joel Levis, MD

Attention hikers, skiers, campers, mountain climbers and anyone aspiring to visit Denver or Tibet: A study published today in the Annals of Emergency Medicine finds that ibuprofen may help to prevent acute mountain sickness, also known as altitude illness or hypobaropathy.

The condition often occurs when people first find themselves at altitudes of roughly 8,000 feet or higher. Symptoms feel like a “really nasty hangover,” Grant Lipman, MD, told me. The Stanford Hospital & Clinics emergency medicine physician led the double-blind, placebo-controlled study of 86 men and women, who ascended 12,570 feet into an area of the White Mountains northeast of Bishop, Calif.

In my press release about the study, I discuss some of the findings:

Of the 44 participants who received ibuprofen, 19 (43 percent) suffered symptoms of altitude sickness, whereas 29 of the 42 participants (69 percent) receiving placebo had symptoms, according to the study. In other words, ibuprofen reduced the incidence of the illness by 26 percent.

Photo by bobwitlox

Today, an estimated 15 million people in the United States are morbidly obese — that is, 50 to 100 percent, or 100 pounds, above their ideal body weight. And though obesity-prevention programs are starting to take root, it will be roughly two decades for these efforts to begin yielding results, John Morton, MD, MPH, told me recently. “You end up losing a generation,” he said. “What do you do for people right here, right now?”

During a recent interview, Morton, one of the nation’s top weight-loss surgeons, reflected on the challenges of obesity in America and how bariatric surgery may be part of the solution for some. You can read what he had to say in my Q&A on the Stanford Hospital & Clinics website.

What especially struck me was his discussion of the body’s natural resistance to losing weight:

Look at the levels of ghrelin, the so-called hunger hormone, in a person who lost weight on a diet, and you’ll see they are much higher than before. Levels of another hormone, leptin, which suppresses hunger and speeds up metabolism, are lower. Your body’s not stupid. It knows you have lost weight and will do everything in its power to get that weight back.

He also highlighted how bariatric surgery can cut down on obesity-related disease, saying that “the real eye-opener is the improvements to diabetes”:

A 2001 study showed an 82 percent resolution rate of diabetes in morbidly obese patients who underwent laparoscopic gastric bypass surgery. They were able to stop taking medications — no Metformin, no Actos, no insulin, no Byetta — and that happened very quickly. This is where bariatric surgery certainly can make a difference.

Morton added that weight-loss surgery is now very safe, “especially compared to the risks of extreme obesity.”

Previously: Stanford expert weighs in on study comparing gastric bypass and banding, Study finds family members of weight-loss-surgery patients also shed pounds, Study hints at benefits of weight-loss surgery for less obese patients, Study: Outpatient bariatric surgery appears risky and Bariatric surgery may help protect teen patients’ hearts
Photo by -Paul H-

For treating prolonged seizures outside a hospital setting, a quick intramuscular shot of anti-convulsant medication with an auto-injector, a kind of spring-loaded syringe, is as effective — if not more effective — than starting an intravenous line to administer the medicine directly to the bloodstream.

That’s according to findings from a first-of-its-kind study by researchers at Stanford and 16 other universities and hospitals nationwide. Their work appears in the New England Journal of Medicine.

The finding is important because giving a shot into the muscle of someone who is convulsing is generally safer and less time-consuming than starting an IV, said James Quinn, MD, a professor of emergency medicine here and a study investigator.

The intravenous route has always been considered the gold standard for treating status epilepticus in the field. But, as Quinn pointed out, “If patients are having a grand mal seizure, it can be tough to find a vein and get the medicine started, and it may increase the chance of a needle-stick injury either to the patient or medic.”

The aim of this study was to gather and compare data on the safety and efficacy of the shot, which administers midazolam, a sedative, versus the IV drip, which administers lorazepam, a similar sedative. As described in a National Institutes of Health release:

The study found that 73 percent of patients in the group receiving midazolam were seizure-free upon arrival at the hospital, compared to 63 percent of patients who received IV treatment with lorazepam. Patients treated with midazolam were also less likely to require hospitalization than those receiving IV lorazepam.

…

[The study] involved more than 79 hospitals, 33 emergency medical services agencies, more than 4,000 paramedics and 893 patients ranging in age from several months old to 103.

An interesting, behind-the-scenes aspect aspect of the research: Because they were the first responders, roughly 250 firefighter-paramedics in Santa Clara and San Mateo Counties had to be trained on how to conduct the clinical trial. “It required tremendous coordination,” Quinn told me. “For most of the firefighters, it was the first time they had done research. They did a great job, and I am proud of the job they and our research team did in this unique endeavor.”

Photo by gregfriese

February is American Heart Month, and to mark the occasion I sat down with Robert Robbins, MD, chair of the Department of Cardiothoracic Surgery (and director of the Stanford Cardiovascular Institute), to ask him about innovations in cardiac care and what the future holds. My Q&A was recently posted on the Stanford Hospital & Clinics website, and I’ve included a few highlights below.

Robbins on minimally-invasive aortic valve replacement:

As part of a clinical trial, we’re doing some valve replacements transfemorally — that is, using a catheter to maneuver the new valve through blood vessels to the heart. Only one small incision to the femoral artery is needed, and the procedure generally takes little more than an hour. Recovery time is a few days.

On heart health and the human genome:

Much of the work in this area is being done at Stanford, where we have a lot of strength not only in mapping DNA but also interpreting the massive amount of data it produces. Our researchers will be able to create algorithms and ways to manage and interpret this data. One day you’ll probably be able to walk into your doctor’s office and say, “Here’s my genetic code. What does it mean?”

Another great hope is to customize drug therapy to specific cardiovascular diseases, such as hypertension, based on your genetic profile. If your genes make certain proteins or enzymes that metabolize a certain class of drugs better than another class, then doctors could use this so-called pharmacogenomic approach to customize treatments.

On stem cells:

I think they hold huge promise, but we’re not ready yet to employ stem-cell therapies to treat end-stage heart failure. But I do believe our group here at Stanford, one of the world’s leaders in this area, will be the first to put embryonic stem cells into the human heart.

Previously: Either you’re a woman or you know one: Help spread the message of women’s heart health, A focus on women’s heart health and At new Stanford center, revealing dangerous secrets of the heart
Photo by epSos.de

The Stanford Center for Inherited Cardiovascular Disease is one of only a small number of centers worldwide that focus on diagnosing and treating genetic heart disorders. The center also offers genetic counseling to enable patients and their families to better understand and cope with such disorders.

In an article posted today, I tell the story of Lauren Sassoubre, a 30-year-old Stanford PhD candidate who was diagnosed with arrhythmogenic right ventricular cardiomyopathy. The often deadly condition is inherited, meaning that other members of Sassoubre’s family were potentially at risk. For example, her older sister had recently discovered she was pregnant, so if she carried the disease-enabling DNA mutation it could be passed on to her baby.

Both sisters got help from the Center for Inherited Cardiovascular Disease, meeting with its genetic counselor, Colleen Caleshu. “What we do as genetic counselors is help patients understand and adapt to the hereditary conditions in their family,” Caleshu told me. “We help them navigate choices about family planning and even about whether or not they want to know predictive information about their health.”

She also is an expert in the science of inherited heart disease. As I write in my release:

Caleshu is trained to interpret the often subtle but significant implications of abnormal genetic markers. There are many unique gene variations and mutations among humans, so DNA test results require a close reading to avoid false positives or negatives, she said. After she gets results back from a lab, she analyzes them in light of her own expertise in cardiac genetics and also consults various peer-reviewed studies of the disease and of the possible gene mutations involved. “Genetic test results are probabilistic, never black and white,” she added. “Reading them often feels more like art than science.”

Photo mashup by qthomasbower