Ask Stanford Med

Among school-aged children in the United States an estimated one in 50 has been diagnosed with autism spectrum disorder, according to a recent survey (.pdf) from the Centers for Disease Control and Prevention. In addition to raising concerns among researchers and parents about why the number of cases has increased, the findings underscored the need to do more autism research and to provide support and services for families caring for autistic children.

To help parents and others in the local community better understand the growing prevalence of autism and to learn about treatments and research advancements, the Stanford Autism Center at Packard Children’s Hospital will host its sixth annual Autism Spectrum Disorders Update on June 1. The event offers an opportunity for exchange between parents, caregivers and physicians and provides an overview of the center’s clinical services and ongoing autism research at the School of Medicine.

In anticipation of the day-long symposium, we’ve asked Carl Feinstein, MD, director of the center, to respond to your questions about issues related to autism spectrum disorder and to highlight how research is transforming therapies for the condition.

At the Stanford Autism Center, Feinstein works with a multidisciplinary team to develop treatments and strategies for autism spectrum disorders. In providing care and support for individuals with autism and their families, Feinstein and colleagues identify ways of targeting the primary autism symptoms, while also paying attention to associated behavior problems that may hold a child back from school or community involvement or seriously disrupt family life.

Questions can be submitted to Feinstein by either sending a tweet that includes the hashtag #AskSUMed or posting your question in the comments section below. We’ll collect questions until Wednesday (May 15) at 5 PM Pacific Time.

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

• Stay on topic
• Be respectful to the person answering your questions
• Be respectful to one another in submitting questions
• Do not monopolize the conversation or post the same question repeatedly
• Kindly ignore disrespectful or off topic comments
• Know that Twitter handles and/or names may be used in the responses

Feinstein will respond to a selection of the questions submitted, but not all of them, in a future entry on Scope.

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

Previously: New public brain-scan database opens autism research frontiers, New autism treatment shows promising results in pilot study, Autism’s effect on family income, Study shows gene mutation in brain cell channel may cause autism-like syndrome, New imaging analysis reveals distinct features of the autistic brain and Research on autism is moving in the right direction
Photo by Wellcome Images

As a reminder, today is the final day of our Ask Stanford Med installment focused on breast cancer. Questions related to breast cancer screening, dense breast notification legislation and advances in diagnostics and therapies can be submitted to Stanford surgeon Fredrick Dirbas, MD, by either sending a tweet that includes the hashtag #AskSUMed or posting your question in the comments section of our previous entry. We’ll accept questions until 5 p.m. Pacific time.

We provided details about Dirbas’ clinical work and research in our earlier post:

As head of the Breast Disease Management Group at the Stanford Women’s Cancer Center, Dirbas works with an interdisciplinary team of radiologists, oncologists, pathologists, researchers and support programs to provide patients with a comprehensive treatment approach. His research focuses on improving breast cancer therapy by refining existing diagnostic and treatment options and introducing new methods that reduce side effects and improve patients’ quality of life.

A 2011 Stanford Hospital Health Notes article describes how Dirbas and colleagues are at the forefront of exploring new ideas for delivering radiation in a more targeted and accelerated fashion, including methods such as intraoperative radiotherapy and another approach using external radiation therapy after surgery.

Previously: Ask Stanford Med: Surgeon taking questions on breast cancer diagnostics and therapies, California’s new law on dense breast notification: What it means for women and Five days instead of five weeks: A less-invasive breast cancer therapy
Photo by Wellcome Images

Society is increasingly becoming more data-driven. Noting the power of vast reservoirs of public information, the federal government launched the Big Data Research and Development Initiative — a $200 million commitment to “greatly improve the tools and techniques needed to access, organize and glean discoveries from huge volumes of digital data.” And the National Institutes of Health expanded its stake in the federal initiative in hopes of speeding up the translation of biomedical discoveries into bedside applications.

In an effort to bring together innovative thinkers from information-technology corporations, startups, venture-capital firms and academia to capitalize on the wealth of opportunities using data-mining in biomedicine, Stanford Medicine and Oxford University are sponsoring a three-day conference from May 22-24. Curious to know more about the event and promise of big data, I reached out to Atul Butte, MD, PhD, Stanford systems-medicine chief and the conference’s scientific program committee chair. Below he shares why he’s passionate about how data-mining can transform scientific research and health care and discusses the conference program.

A recent Stanford Medicine article called data-mining the “fastest, least costly, most effective path to improving people’s health” that you know. Can you explain why you believe this to be the case?

Data-driven science, or data-mining, works faster and effectively because we are already sitting on billions of measurements made across the health system! Every time a physician orders a medication, every time a nurse or pharmacist dispenses a drug, every time a blood test is performed, every x-ray or CT scan that’s performed… all of this information ends up in a database today. So the part of science or innovation that involves collecting the measurements is actually the easiest part now, because the measurements are already there, just waiting for the right question to be asked.

In the same article, you said “hiding within [existing] mounds of data is knowledge that could change the life of a patient, or change the world” - and that if you didn’t analyze those data or show others how to, you feared no one will. How did you grow so passionate about this area?

I think we in the biomedical field make these measurements, but we often don’t realize how these measurements can interrelate or be used together. Our example from one of our recent articles was on our use of two big sets of public data. One set covered the molecular changes seen in tissues affected by diseases, and another set covered the molecular changes seen in cells treated by drugs. We realized that we could partner just these two public data sets together, to get new ideas of what other diseases might be treatable by these drugs. And, we could do this in a purely computational approach – an approach that is nearly infinitely scalable to more diseases, more investigators and more ideas. When I see hard working investigators working tirelessly to make highly accurate and significant measurements, but so few people taking advantage of that data, I can’t help but be passionate!

Earlier this year, you published a study, which involved combing through large amounts of data, to find that beta carotene may protect people with a common genetic risk factor for type-2 diabetes. Can you describe other recent findings that have stemmed from researchers’ use of this “big data” approach?

Stanford professor Russ Altman, MD, PhD, and his team recently showed how search engine logs can be mined to discover side effect of release drugs that might not have shown up during the initial clinical trials on those drugs. Similarly, Nigam Shah, MBBS, PhD, assistant professor of medicine, showed how similar side effects for drugs are sitting in physician clinical notes. Both text-based clinical notes and search engine logs are massive sources of big data that to date have barely been tapped for medical research.

What was the catalyst for launching the Big Data in Biomedicine conference?

The Li Ka Shing Foundation has played the leading role in bringing us together with Oxford University in planning events on big data. Our first, smaller conference was held in Oxford last November. Based on the success of that event, we realized we could host a larger conference at Stanford and open it up to the public. We couldn’t have done this without the support of the Li Ka Shing Foundation.

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This month, a new California law went into effect requiring doctors statewide to notify women if their breast tissue is dense. Dense breast tissue has been linked to an increased risk of breast cancer because it can make tumors more difficult to spot. As Stanford breast cancer surgeon Fredrick Dirbas, MD, and colleagues explained in a recent Stanford Hospital & Clinics video, this notification isn’t meant to alarm women, but rather to educate them about their bodies and empower them in making better health-care decisions.

To expand on the conversation on the breast density notification law and clear up confusion over recommendations regarding mammograms, we’ve asked Dirbas to respond to your questions about breast cancer screening and advances in diagnostics and therapies. As head of the Breast Disease Management Group at the Stanford Women’s Cancer Center, Dirbas works with an interdisciplinary team of radiologists, oncologists, pathologists, researchers and support programs to provide patients with a comprehensive treatment approach. His research focuses on improving breast cancer therapy by refining existing diagnostic and treatment options and introducing new methods that reduce side effects and improve patients’ quality of life.

A 2011 Stanford Hospital Health Notes article describes how Dirbas and colleagues are at the forefront of exploring new ideas for delivering radiation in a more targeted and accelerated fashion, including methods such as intraoperative radiotherapy and another approach using external radiation therapy after surgery.

Questions can be submitted to Dirbas by either sending a tweet that includes the hashtag #AskSUMed or posting your question in the comments section below. We’ll collect questions until Wednesday (May 1) at 5 PM Pacific Time.

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

• Stay on topic
• Be respectful to the person answering your questions
• Be respectful to one another in submitting questions
• Do not monopolize the conversation or post the same question repeatedly
• Kindly ignore disrespectful or off topic comments
• Know that Twitter handles and/or names may be used in the responses

Dirbas will respond to a selection of the questions submitted, but not all of them, in a future entry on Scope.

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

Previously: California’s new law on dense breast notification: What it means for women and Five days instead of five weeks: A less-invasive breast cancer therapy
Photo by Army Medicine

Food allergies affect millions of children, who find it difficult to enjoy ordinary activities like birthday parties and restaurant meals because of worries that something they eat could send them into anaphylactic shock. As the New York Times described recently, Stanford scientist Kari Nadeau, MD, PhD, is studying how to desensitize children to their allergy triggers. Here on Scope, she recently took questions on food allergies and her desensitization research.

Many readers asked how they could enroll in Nadeau’s research or in similar allergy treatment trials near their homes. Information for prospective study subjects around the world is available here; enter “food allergy” in the “Search for Studies” field, and after searching, click the “On a Map” tab to see trials grouped by location. For those who live near Stanford, go here for details on participating in Nadeau’s research.

Below are Nadeau’s responses to a selection of questions submitted using the hashtag #AskSUMed the comments section on Scope. As a reminder, Nadeau’s answers are meant to offer medical information, not medical advice. They’re not meant to replace the evaluation and determination of your doctor, who will address your specific medical needs and can make a diagnosis and provide appropriate care.

@vikas_aditya asks: What’s the simplest way to identify the cause of an allergy in kids?

If you suspect an allergy to a specific food or environmental cause, skin prick testing is the simplest and least invasive way to initially identify the allergy but it is not the gold standard. A food challenge in the doctor’s office is the true way to test for food allergies.

Elizabeth P. asks: Is there anyone working to find the exact cause of why so many children, teens and adults are developing life-threatening food allergies today? On a related note, @ceband asks: What do you think of the theory that altered gut microbiomes have led to the rise in allergies and autoimmune disease?

Many scientists and researchers are trying to understand the rising prevalence of food allergies in children. Though there are many theories regarding the increase in this prevalence, we still lack definitive answers. Hypotheses have focused on hygiene, dietary fat, antioxidants, vitamin D and dual-allergen-exposure. Altered gut microbiomes might play a role. It does not appear that genetically modified foods are directly linked to food allergies.

Julie Barnes asks: I am currently pregnant and am wondering if I will possibly be creating a food allergy in my unborn child if I avoid all dairy and egg while pregnant and breastfeeding.

There is recent evidence that a diet in pregnancy and during breastfeeding that is high in Vitamin D, follows features of a Mediterranean diet and includes probiotics may be helpful to prevent asthma and allergies. And a healthy, balanced diet is important to your overall health and the health of your baby. However, we do not have evidence that mothers will create food allergies by food avoidance in pregnancy or breasfeeding. Similarly, there is no evidence from the general population that mothers can create food allergies by eating certain foods during pregnancy or breastfeeding.

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Migraines and other forms of headache disorders can cause debilitating pain, disrupt lives and lead to large economic and societal costs. At the Stanford Headache Clinic, director Robert Cowan, MD, who has suffered migraines his entire life, works with colleagues to relieve patients’ pain through a treatment approach focusing on prevention and integrating medical, physical, psychological and complementary medicine.

This month we asked Cowan to respond to questions about headache disorders, recent improvements in managing them, and the use of a multifaceted approach to treating symptoms. In the following Q&A, he answers a selection of questions submitted via our @SUMedicine Twitter feed and the Scope comments section.

As a reminder, these answers are meant to offer medical information, not medical advice. They’re not meant to replace the evaluation and determination of your doctor, who will address your specific medical needs and can make a diagnosis and provide appropriate care.

@ryderexpress34 asks: Are there any studies to see if migraines are physiological?

If, by your question, you mean are migraines “psychological,” then the answer is certainly that migraines are physiological. Migraine is a genetic disease and, as a result, it usually runs in families. There are distinct biochemical and anatomic abnormalities in the brains of people who have migraine. It is definitely not a “psychological condition.”

@mutterp asks: Why do doctors have a difficult time diagnosing migraines?

The problem is that most doctors do not receive proper training in the diagnosis and treatment of migraine. Fortunately, that is beginning to change. Today, there are just over 300 board certified headache specialists in the United States. While this is still not many when compared to the 60 million headache sufferers, we are moving in the right direction.

Terri asks: What’s your opinion of a holistic approach to migraine treatment where behavioral therapies are included in the treatment plan?

I think a holistic approach is far and away the best approach to managing headaches. When we combine “traditional” and “complementary” approaches, we call it “integrative” medicine. It is the approach we use here at Stanford and it is becoming the standard in many headache centers across the country.

Erin Digitale asks: I’m wondering if any research has been done to show how acupuncture or acupressure techniques prevent migraines. What do we know about the mechanism?

There have been a number of studies exploring acupuncture for migraine and several theories offered, but the truth is we still don’t know what the mechanism is. It probably has something to do with release of tiny molecules from nerve endings at the acupuncture sites. These molecules, called neurotransmitters, then modulate pain messages going to a part of the brain called the brainstem, where pain messages en route to the brain are modulated.

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Food allergies among children are a growing public health concern. An estimated six million children in the United States suffer from food allergies, and nearly 40 percent have experienced a severe allergic reaction as a result of consuming a food.

A recent New York Times Magazine story took a closer look at the issue and the research of Kari Nadeau, MD, PhD, a pediatric immunologist at Stanford and Lucile Packard Children’s Hospital. As my colleague previously reported, Nadeau has demonstrated that it’s possible to desensitize children to a single food allergen and is now working to identify treatments to safely address multiple food allergies at the same time.

To continue the conversation, we’ve asked Nadeau to respond to your questions about children’s food allergies and her ongoing projects at the Stanford Alliance for Food Allergy Research. Questions can be submitted to Nadeau by either sending a tweet that includes the hashtag #AskSUMed or posting your question in the comments section below. We’ll collect questions until Friday (March 15) at 5 PM Pacific Time.

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

• Stay on topic
• Be respectful to the person answering your questions
• Be respectful to one another in submitting questions
• Do not monopolize the conversation or post the same question repeatedly
• Kindly ignore disrespectful or off topic comments
• Know that Twitter handles and/or names may be used in the responses

Nadeau will respond to a selection of the questions submitted, but not all of them, in a future entry on Scope.

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

Previously: Searching for a cure for pediatric food allergies, Gesundheit! Spring allergy season is underway, New hope for people with severe milk allergies and New insight into asthma-air pollution link
Photo by Steven Depolo

Headaches are the most common form of pain. The condition affects an estimated 60 million Americans and accounts for $30 billion in lost worker productivity. Migraines, which cause pulsating or throbbing pain in the head lasting four to 72 hours, affect roughly 12 percent of Americans and more commonly occur in women than men.

While common treatments range from popping over-the-counter pain pills to lying in a dark room with an ice pack strapped to your head, Robert Cowan, MD, director of the Stanford Headache Clinic, will tell you that managing headache disorders goes beyond finding the right remedy and involves determining a proper diagnosis and developing a comprehensive treatment plan. And he should know: Cowan has suffered migraines his whole life. He understands that the condition can “become a footnote, or it can ruin your life.”

At the Stanford clinic, Cowan and colleagues offer a treatment approach that focuses on prevention and integrates medical, physical, psychological and complementary medicine. A nationally renowned leader in headache care, Cowan also serves as chair of the refractory headache section and in-office education section for the American Headache Society, and he is president of the Headache Cooperative of the Pacific.

We’ve asked Cowan to respond to your questions about headache disorders, recent improvements in managing them, and the use of a multifaceted approach to treating symptoms. Questions can be submitted to Cowan by either sending a tweet that includes the hashtag #AskSUMed or posting your question in the comments section below. We’ll collect questions until Friday (March 8) at 5 PM Pacific Time.

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

• Stay on topic
• Be respectful to the person answering your questions
• Be respectful to one another in submitting questions
• Do not monopolize the conversation or post the same question repeatedly
• Kindly ignore disrespectful or off topic comments
• Know that Twitter handles and/or names may be used in the responses

Cowan will respond to a selection of the questions submitted, but not all of them, in a future entry on Scope.

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

Previously: Managing headache disorders during the holidays and New Stanford headache clinic taking an interdisciplinary approach to brain pain
Photo by Diamond Farah

As I wrote about yesterday, new research in PLOS ONE suggests that sugar may play a stronger role in the origins of diabetes than anyone realized. Countries with more sugar in their food supplies have higher rates of diabetes, independent of sugar’s ties to obesity, other parts of the diet, and several economic and demographic factors, the researchers found.

Although the study focused on diabetes rates among adults aged 20 to 79, it got me thinking about children’s health. Type 2 diabetes, which accounts for 90 percent of adult cases and is tied to obesity, used to be unheard-of in kids. But over the last few decades, it has been showing up in many more children and teens at younger and younger ages. Meanwhile, reducing kids’ sugar intake is already the focus of several preventive-health efforts, such as campaigns to remove sugary drinks from schools and children’s hospitals.

To get some perspective on how the new findings apply to children, I turned to Thomas Robinson, MD, a Stanford pediatric obesity researcher who directs the Center for Healthy Weight at Lucile Packard Children’s Hospital. Though Robinson, also a professor of pediatrics at the School of Medicine, cautioned that the epidemiological, “10,000-foot view” given by this study doesn’t prove a cause-and-effect link between sugar and diabetes in individuals - “it does not prove that the amount of sugar an individual eats is related to his or her diabetes risk,” he said - he had lots to say about the new results.

What do you think the findings mean for children’s health?

Children’s behaviors and environmental exposures have an impact on adult health and disease. This study used sugar data for entire countries, not individuals. That means that both the children and the adults were living in countries where higher levels of sugars in the food supply were associated with higher rates of diabetes. The potential implications are even stronger for children than adults. Children are being exposed to that environment for a much longer time. This is particularly a problem in developing countries where their food supplies, diets and weights are changing so rapidly.

A number of us here at Stanford focus on what we can do in early life, and throughout the lifespan, to prevent diseases that have origins in childhood but only first become apparent in adulthood. One can consider our work on obesity, physical activity, sedentary behavior and nutrition in children as really the prevention of diabetes, heart disease, many cancers and other chronic diseases in adults.

What factors has prior research identified as the biggest contributors to the increase in diagnoses of type 2 diabetes in pediatric patients?

The biggest contributor identified has been increased weight, but the increasing rate of type 2 diabetes at younger and younger ages probably reflects obesity plus lots of different changes, including changes in our diets, such as more sugars and processed foods, and less physical activity. The CDC now projects that 1 in 3 U.S. children will have diabetes in their lifetimes, and it will be 1 in 2 among African-American and Latina girls. That is a pretty scary thought. That is why we focus so strongly on helping families improve their diets, increase activity levels, and reduce sedentary time. We want to prevent and control excessive weight gain and all the problems that go with it, of which diabetes is just one.

In light of the new findings, do you think that parents whose children are not obese should be concerned about how sugar consumption could raise their children’s diabetes risk?

This study doesn’t really address the question of what happens at the level of an individual child. However, it is still consistent with the advice we would give now, for both normal weight and overweight children. I definitely recommend that parents try to reduce sugars in their children’s diets. Most parents are not even aware how much sugar their children are eating. Sure, sodas and sweets are the obvious sources but sugars are also added to seemingly all processed foods, including even bread, pizza and French fries. The added sugars are just empty calories — providing extra calories and no additional nutritional benefit. So I recommend that all parents try at least to reduce the obvious sources of sugary drinks, sweets and desserts.

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As the leading cause of death among both men and women worldwide, cardiovascular disease is a health concern that’s near and dear to all our hearts. Earlier this month, we asked interventional cardiologist William Fearon, MD, to respond to questions about heart health and cardiovascular research in honor of American Heart Month. Below he answers a selection of questions submitted via our @SUMedicine Twitter feed and the Scope comments section.

As a reminder, these answers are meant to offer medical information, not medical advice. They’re not meant to replace the evaluation and determination of your doctor, who will address your specific medical needs and can make a diagnosis and provide appropriate care.

Heather asks: I’ve experienced infrequent heart palpitations my whole life, mostly when lying down. But lately I’ve been experiencing them daily. At what point do heart palpitations signal a more serious condition?

Palpitations are a very common condition and in most cases benign. When palpitations become bothersome or frequent, most patients will seek medical attention. Vital signs such as low blood pressure or rapid heart rate can be a sign that the palpitations represent a more serious cardiac arrhythmia. Some simple tests such as an electrocardiogram, echocardiogram, blood tests and wearing a cardiac monitor can help to rule out any worrisome arrhythmia. Often changes in lifestyle, such as abstaining from caffeine products and getting more sleep, will relieve palpitations. Occasionally, medications are necessary.

Don Stanathan asks: I was diagnosed with dilated cardiomyopathy and later diagnosed with stage 4 lung cancer. I am stable and going strong, but I have had high blood pressure and high cholesterol for years and have been on medications for both. My question is how high can you allow your overall cholesterol level go before it overrides the cancer issues?

This is a difficult question to answer because it depends on weighing the risk of cancer against the risk of heart disease and balancing these risks with the risk of taking medications to prevent either of the above. One method for determining one’s risk from heart disease is the Framingham Risk Score, which can be accessed from any search engine on the web. After determining your risk of suffering a heart-related issue, you can discuss with your physicians the pros and cons of taking medications to reduce this risk.

Rebecca asks: A recent study shows that individuals with a common genetic variant for a certain type of cholesterol have a significantly (60 percent) greater risk of developing aortic calcifications. How might these findings lead to new therapeutic treatments or prevention options?

The relationship between lipid abnormalities and the development of aortic stenosis has been recognized for many years. This has prompted studies aimed at lowering cholesterol in an attempt to slow the progression of aortic stenosis. Unfortunately, these studies did not show any benefit to this strategy, perhaps because the population of patients studied and the method of lipid lowering used. The recent study to which you are referring found that a genetic variant in the lipoprotein(a) locus results in elevated levels of lipoprotein(a) and the development of aortic valve disease. With this new information, studies can be designed to include patients with this genetic variation and to treat them with medications specifically aimed at reducing lipoprotein(a). Whether this will result in prevention of aortic valve disease remains to be seen.

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