Could your car be a self-contained isolation compartment when you seek medical attention during a pandemic? And, is a drive-through approach an effective method to triage and screen a large number of patients? These possibilities will be tested in an exercise to compare actual times and outcomes of a drive-though method to the standard walk-in approach that was used at Stanford Hospital and throughout the country during the recent H1N1 event.

The exercise will be held Friday, June 12 (8 a.m. – 11:30 a.m.) on the Stanford University campus at Parking Lot 5 on Oak Road, near Stock Farm Road (see directions below). Media are invited to attend.

The exercise will be the first test of its kind in the U.S. Federal officials hope to incorporate its results into a protocol useful for all U.S. hospitals facing pandemic emergencies. Stanford’s data will be used to build a computer simulation. Eric Weiss, MD, Medical Director for Disaster Planning, Stanford Hospital & Clinics and Lucile Packard Children’s Hospital, and his colleagues have teamed with the U.S. Centers for Disease Prevention and Control to design the exercise and create the list of data to be collected.

Throughout the exercise, all medical personnel will be gowned, gloved and masked. More than a dozen physicians and nurses will be positioned at the various screening and treatment stations. Portable digital monitors will be ready. Blood and other specimen testing will be done with a portable lab. The exercise will also test the drive-through plan as a potential mechanism for dispensing medications or administering vaccines. Other health care professionals will act as observers and evaluators. Officials from the Santa Clara County Public Health Department will also be on hand.

“The main idea is to avoid infection,” Weiss said. When SARS emerged in Toronto, five hospitals had to close because people with the illness came into emergency rooms and infected others, as well as health care workers. “We feel that this mechanism of screening and evaluating patients during a pandemic will be safer for both patients and healthcare providers and much faster than traditional methods.”

Directions: From Hwy 101 – University exit towards Stanford; Rt. on El Camino, Lt. on Sand Hill Rd., Lt. on Stock Farm Rd., Rt on Oak Road.

Directions from Hwy 280 – Sand Hill Rd. exit; Rt. on Stock Farm, Lt. on Oak Road

The risks to an individual struggling with obesity are well-known: heart and endocrine issues, joint problems, psychological well-being, and more. A new study from Advanced Plan for Health shows that obesity is also risky to an employer’s bottom line, costing more than double to provide employee health insurance to those considered obese.

The study looked at a population of 128,000 employees and, of those, found that 2,000 were given a diagnosis of “obesity, unspecified,” as defined by the International Statistical Classification of Diseases and Related Health Problems (ICD codes), which can include individuals with a body mass index greater than 30.

Obese employees cost companies a staggering 135 percent more to insure than other, non-obese employees. Per-member-per-month spending for a non-obese employee ranged from $176.71 to $226.92, while the same range for the obese group was $414.86 to $536.53.

Even more alarming is that while only three percent of the non-obese population was identified as “high risk employees” for medical issues, 12 percent of those in the obese group was considered at high risk for significant medical issues. Additionally, those in the obese population were 25 percent more likely to have more than 15 different providers in the span of 12 months, meaning much more frequent medical visits.

“At a time when every business is looking at how to reduce health care costs – and some even eliminating insurance for employees, this kind of information is insightful,” said Rich Williams, principal of Advanced Plan for Health. “This reinforces the fact that employers need to be smarter about how they utilize their claims information. With proper case management, bringing down the obesity rate is something that will have significant impact on both employees’ lives and a company’s bottom line.”

Tumors need a healthy supply of blood to grow and spread. Researchers at the Stanford University School of Medicine have identified a molecule that regulates blood vessel growth that is often found at less-than-normal levels in human tumors. Blocking the expression of the molecule, called PHD2, allows human cancer cells to grow more quickly when implanted into mice and increases the number of blood vessels feeding the tumor.

“It appears to be acting as a tumor suppressor by negatively controlling blood vessel formation,” said cancer biologist Amato Giaccia, PhD, the Jack, Lulu and Sam Willson Professor and professor of radiation oncology. He and his colleagues are hopeful that targeting the downstream molecules activated when PHD2 levels are low may be an effective treatment for a variety of human cancers.

Giaccia is the senior author of the research, which will be published in the June 2 issue of the journal Cancer Cell. He is also a member of Stanford’s Cancer Center.

The finding was particularly surprising because PHD2 was already known to play a less-direct role in blood vessel formation: that of destabilizing another important cancer-associated protein, HIF-1. HIF-1, which stimulates blood vessel development, is induced by the low oxygen levels found in many solid tumors. Although the HIF-1 molecule is rarely modified in human cancers, its levels are often elevated as compared to normal tissue. Giaccia and his colleagues wondered if the higher levels of HIF-1 could be explained by decreases in the level of PHD2.

The researchers measured PHD2 levels in several human tumor samples, including breast and colon cancers, and compared them with surrounding tissue. They found that, in many cancers, the tumors did have lower-than-normal levels of PHD2. They then inhibited the expression of PHD2 in a variety of human cancer cells in the lab, transplanted these cells into mice with compromised immune systems and examined the tumors that resulted. Those arising from cells in which PHD2 expression had been blocked grew more quickly and were more highly vascularized than the unmodified control cells.

Surprisingly, however, these effects of PHD2 inhibition were evident even in cells engineered not to express HIF-1. “Nobody expected this,” said Giaccia. “It’s always been thought that the major role of PHD2 was in regulating HIF-1 activity. But now we’ve learned that it seems to control tumor growth through blood vessel formation in a variety of different cell types on its own.”

Upon further investigation, the researchers learned that blocking PHD2 expression increases the levels of two other important proteins involved in vessel formation: IL-8 and angiogenin. The researchers believe that blocking the activity of these proteins may be a good way to stunt tumor growth. “Prior to this study,” said Giaccia, “it was unclear which of the many proteins involved in vessel growth, or angiogenesis, should be targeted. But now we know they play a predominant role in tumor growth.”

He and his colleagues are planning to continue their studies in laboratory mice engineered to develop breast cancer. They will investigate whether a version of the mice lacking PHD2 expression develops more aggressive tumors, and whether blocking IL-8 or angiogenin slows tumor growth.

In addition to Giaccia, other Stanford researchers involved in the work include postdoctoral scholar Denise Chan, PhD; graduate student Tiara Kawahara; and associate professor of dermatology Howard Chang, MD, PhD. The study was funded by a Silicon Valley Community Fellowship, the National Cancer Institute and the National Institutes of Health.

An overwhelming number of Americans believe young adults and children should not have access to tanning salons without parental oversight because of the danger of skin cancer, suggests an online poll by dermanetwork.org.

More than 250 voted to encourage legislation to restrict or stop access to tanning salons without parental consent versus just 25 who disagreed. More than 20 states have legislation pending about restricting tanning bed usage. In March of 2009, Arkansas and Mississippi signed into law new legislation to restrict access for minors under 14 to tanning salons. Legislators failed to pass a similar law in Montana one month ago.

“About one million people per day in the U.S. tan in tanning parlors. Skin cancers are common. I treated someone with three skin cancers yesterday. People, including young people, die every day from melanoma. There is strong evidence that exposure to UV radiation during indoor tanning increases the risk of melanoma, especially when that exposure occurs at an early age. Public support for laws that would make it harder for teens to have access to tanning beds is very encouraging. Such legislation would literally save lives,” said Steven E. Zimmet, MD, of Zimmet Vein & Dermatology, Austin, Texas and an advisor to dermanetwork.org.

“Many states have enacted laws to stop the proliferation of teens seeking the tanning bed, or at least requiring a minor to have parental consent in order to tan,” said Lauren Wright, director of Dermanetwork.org, an online community of health education, news and patient inquiries to skin care specialists. “Other states have passed stiffer laws that require minors or those under 18 to have a written prescription from their doctor. These laws are needed to stem the tide of sun damage and the potential for more serious skin cancer diagnosis. The term ‘killer tan’ could have a whole new meaning for this generation.”

According to experts, most skin damage from the sun occurs before age 18. Many youths will receive 50 to 80 percent of their lifetime sun exposure during childhood, a fact that worries cancer researchers who predict a significant increase in skin cancer diagnosis among younger people.

“Breakthrough pain” (BTP) is a common, debilitating feature of chronic pain that frequently afflicts cancer patients. While persistent, or continuous, pain can usually be controlled through a patient’s normal oral pain medication regimen, breakthrough pain literally “breaks through” regular doses of pain medication.

Breakthrough pain can be sudden in onset and the pain very severe. If untreated or treated inadequately, BTP is often a disabling problem for patients with cancer. It can have a significant negative impact on physical functioning, psychological well being, and sleep. In addition, patients with cancer-related BTP are more likely to have pain-related hospitalizations and emergency room visits than patients without BTP.

Developed by Raleigh, North Carolina-based BioDelivery Sciences International, Onsolis is an opioid analgesic currently under review by the FDA for the potential management of breakthrough pain in cancer patients who are already receiving and who are tolerant to opioid therapy for their underlying persistent cancer pain. Onsolis utilizes the BioErodible MucoAdhesive (BEMA) drug delivery technology, which consists of a small, dissolvable, polymer film that is applied to the buccal membranes, or inner cheek lining. The film is specially designed to adhere to the inner cheek within seconds, bioerodes within fifteen to thirty minutes, and is designed to optimize fentanyl delivery across the mucous membranes.

While there are two fentanyl breakthrough cancer pain products already on the market—one a fentanyl lozenge, the other an effervescing tablet—the delivery system for Onsolis makes it unique. BEMA delivery technology may offer more convenience, be harder to misuse, and cause little irritation to the inside of the mouth. Onsolis has undergone two Phase III clinical trials in opioid tolerant adult cancer patients experiencing breakthrough cancer pain, and is currently not approved for use; if approved by FDA, Onsolis will be commercialized in the U.S. by Meda Pharmaceuticals.

A new study, published in the journal Menopause, found postmenopausal women with vasomotor symptoms—which include hot flashes and night sweats—had lower bone mineral density in the spine and hip.

Researchers at the University of California, Los Angeles, and colleagues analyzed data from over two thousand women between the ages of forty-two to fifty-two who participated in the bone sub-study of the Study of Women’s Health Across the Nation. The authors of the UCLA study also found premenopausal women and early perimenopausal women who had vasomotor symptoms were found to have lower femoral neck bone mineral density than those without vasomotor symptoms.

According to bone expert, Warren Levy, PhD, although the extent of correlation varied depending on the stage of menopause and the frequency of vasomotor symptoms, the findings did support earlier studies by others that have suggested an association between low estradiol levels, vasomotor symptoms, and low bone density.

“The concept of assessing bone health via the amount or intensity of hot flashes is interesting and may provide another method for screening for osteoporosis,” suggests Dr. Levy, who is also CEO of Unigene Laboratories Inc., a biopharmaceutical company focused on peptide-based nasally and orally delivered osteoporosis treatments. “However, the gold standard today is a bone scan which is widely available and inexpensive for most patients. The study does help raise awareness about the importance of being vigilant about bone loss during this part of one’s life, and encourages regular bone scans, if possible, because even early perimenopausal women can experience significant bone loss.”

Some patients may opt to wait out their hot flashes so as not to take estrogen supplementation. “We hope that the new findings will encourage physicians and patients to also consider the various treatment options that are available without the use of estrogen-based products,” says Dr. Levy, who believes that as life expectancy rates continue to rise, osteoporosis will have a greater impact on national health and quality of life. “If there are acceptable alternatives for patients with osteoporosis or low bone density, the side effect/safety profile of each drug should be considered carefully before treatment decisions are made.”

In his book, Dr. Cohen explains how three decades ago the Federal government tried to “fix” the problem of overweight adults by recommending low-fat diets for all Americans. They were wrong. As a result, four times as many Americans are overweight. Because most Americans believe that bad advice, they gain weight as they try to diet. The government blocks efforts to help those who are overweight or who may suffer from Type 2 Diabetes, unless they conform to that misguided government policy.

Dr. Cohen’s weight-loss program has helped many. In addition to losing weight, people suffering from Type 2 Diabetes have been able to come completely off medications and reverse their disease. His book has been featured on The Diabetes Power Show. Dr. Cohen developed his approach using a mathematical model that predicts the ability of a weight reduction of diet to suppress hunger. That model showed that diets are not equal, and the approach pushed by the government increases hunger, causing dieters to fail.

The book explains how Dr. Cohen studied older medical practices as a Fellow in the History of Medicine to find similarities to the approach he was using. He found parallels both in 19^th century Germany as well as 2400 year old recommendations of Hippocrates, the founder of rational Western medicine. The book offers practical, modern advice on how to use weight naturally, as was done in times past.

Dr. Cohen is a Board-Certified physician specializing in Preventive Medicine and a Fellow of the American College of Preventive Medicine. He trained in Preventive Medicine at Johns Hopkins University where he served as Chief Resident of Preventive Medicine. He has served as the Deputy Director of the New York State Research Institute on Addictions. He now practices in Kansas.

Once symptoms start, there’s only a tiny window of time for stroke victims to get life-saving treatment. Now, research from the Stanford University School of Medicine has cracked that window open a bit wider.

If a patient arrives at the emergency room within three hours of experiencing stroke symptoms, doctors can administer a potent clot-busting medication and often save critical brain tissue. But if more than three hours have passed, current clinical guidelines say the medication should not be used.

But the new study suggests that the traditional three-hour time window is too short. By combining data from multiple clinical trials, Maarten Lansberg, MD, PhD, assistant professor of neurology and neurological sciences at Stanford, and colleagues from Belgium and Germany showed that treatment can benefit patients up to 4.5 hours after they experience their first symptom. Their findings will be published online May 28 in the journal Stroke.

Every year, more than 750,000 Americans experience a stroke, or brain attack, due to a sudden drop in blood flow to the brain. Most strokes are ischemic, meaning they’re caused by a blocked artery. For these strokes, a medication called tissue plasminogen activator, or tPA, can open blocked blood vessels and help restore blood flow to the brain.

“We’ve known that this treatment works for ischemic stroke since 1995,” said Lansberg, the lead author of the study. “But in the United States, only about 3 percent of stroke patients end up getting treated. Most of them are ineligible because they come to the hospital after the three-hour time window.”

The timing of treatment is important, because giving a strong blood thinner like tPA during a stroke can cause bleeding inside the brain. The longer a patient waits to get treatment, the more likely it is that the risks of treatment will outweigh the benefits.

“Doctors from all over the world have tried to increase the treatment time window,” Lansberg said. But evidence from individual clinical trials has been confusing: Some studies demonstrated a benefit from treatment after three hours, while others were inconclusive or reported no benefit.

“Individually, the studies were too small to be convincing,” said Greg Albers, MD, professor of neurology and neurological sciences and director of the Stanford Stroke Center, who was not involved in the study. “Most of the studies showed a trend but weren’t statistically significant.”

But when Lansberg and colleagues combined data from all four of the major tPA stroke trials to date, they saw a much clearer picture. Among a total of 1,622 patients who arrived at the hospital between three and 4.5 hours after their symptoms started, treatment with tPA improved the odds of a favorable outcome by 31 percent.

“A favorable outcome means that patients are either completely back to normal or they have minimal symptoms, like some numbness or a slight facial droop,” Lansberg said. “But they can do everything in their normal life that they were able to do before the stroke happened.”

The study, funded by grants from the National Institutes of Health, found no change in the death rate among patients treated with tPA during the three- to 4.5-hour window. In other words, treatment improved outcomes without negatively affecting mortality.

Lansberg collaborated with Vincent Thijs, MD, PhD, professor of neurology at the University Hospitals of Leuven in Belgium, and Erich Bluhmki, PhD, who works for Boehringer Ingelheim Pharma GmbH & Co. Boehringer Ingelheim manufactures tPA for use in Europe.

A second study, also led by Lansberg and published online in Stroke on April 16, further supports these findings. Using data from six previous trials, the researchers calculated the likelihood that patients would benefit or be harmed by tPA treatment. Out of 100 patients treated three to 4.5 hours after the onset of stroke, the study estimated 16.9 patients would benefit and only 3.4 would be harmed.

“Although this is not as good as treatment at an earlier time, it is still a highly significant benefit for patients treated in this group,” Lansberg said.

Stanford doctors have already started to incorporate the new data into their clinical decision-making, Albers said. Although the FDA has not approved tPA for use more than three hours after the onset of symptoms, physicians can offer the treatment to patients as an “off-label” use.

“Until these data came out, we were treating patients up to three hours,” Lansberg said. “Now, after carefully explaining the risks and benefits, we give patients the option to get treatment up to 4.5 hours after their symptoms start.”

Albers estimates that roughly 15 percent of patients at Stanford come in during the three- to 4.5-hour time window. “It varies by location,” he said, “because if you live in a remote area, you’re less likely to get to the hospital in time. But with 750,000 strokes happening every year in the United States, it’s quite a large number of patients who could potentially benefit.”

Despite a longer window for treatment, Lansberg stressed the classic mantra of stroke researchers: “‘Time is brain’ still holds true,” he said. “When your brain doesn’t get the sugar and oxygen it needs, your brain cells die. For every minute you wait, your chances of getting better from the treatment drop.”

Health savings account (HSA) owners are overwhelmingly satisfied with their accounts, and 91 percent believe such accounts should remain an option for Americans, according to a nationwide survey released today by OptumHealth. More than 80 percent of respondents cite their ability to save for future health care expenses as the primary reason for opening and depositing money into their HSAs. The survey also found that 70 percent of HSA participants make $75,000 a year or less in income.

“HSAs have very strong support across a broad range of income levels and are helping people be better health care consumers,” said Chad Wilkins, chief executive officer for OptumHealth Financial Services.

OptumHealth’s survey found 82 percent of HSA owners are satisfied with their accounts; 78 percent believe the continued availability of HSAs should be part of any health care reform that may occur; and 74 percent agreed they would recommend an HSA to a friend or family member. Three out of 10 respondents said that they wouldn’t have health insurance if it were not for their HSAs.

The study also showed that HSA owners are engaged with their financial and physical well-being. For example, 64 percent of the respondents said they inquired about generic options for medication and 47 percent indicated they asked their care providers about charges.

HSA owners also agree that people need to become more engaged in their health care. The survey found that 83 percent of respondents agreed people should research health care options and try to get the best price — just like they do for other major consumer purchases; 72 percent of respondents said that individuals should be responsible for helping to manage their own health care costs.

Employers are increasingly turning to consumer directed health plans (CDHPs) and HSAs to provide health coverage to their employees and dependents. According to a Watson Wyatt Worldwide and National Business Group on Health survey, 51 percent of companies now have a CDHP in place, a 9 percent increase from last year. Inside Consumer-Directed Healthcare reported that the number of HSAs grew about 40 percent year-over-year as of January 2009 and average savings balances grew 45 percent.

“With increased employer demand, more HSA use by consumers and the positive responses from our survey, it is clear that these accounts are valued as a tool to help people meet their health care needs,” Wilkins said.

More than half of Americans said they would consider splitting their prescription pills to save money if their doctor said it would not be detrimental to their health, according to results of a national poll conducted by Opinion Research Corp. and sponsored by UnitedHealthcare.

Yet while 57 percent of Americans overall would consider pill-splitting, only 9 percent of those currently taking medications that are safe to split are actually splitting their prescription pills in half. Respondents attributed the global economic downturn for spurring them to find ways to save money when it comes to health care and lifestyle choices.

According to the data, 27 percent of Americans currently taking medications said they are not taking their prescription medications as directed by their physician, including 18 percent who said they are foregoing their medicines altogether.

Still, only about a third (31 percent) of Americans have asked their doctor or pharmacist about ways to save money on prescription medicines, according to the poll results.

“Pill-splitting under the direction of a physician can be a simple and safe way to receive the benefits of certain prescription drugs at half the cost,” said Dr. Sam Ho, UnitedHealthcare’s executive vice president and chief medical officer. “Some of our health plan customers have saved almost $400 a year by splitting a single prescription through our voluntary Half Tablet Program.”

Not all prescription pills should be split, including certain medicines that require a finely tuned dosage to be effective, or have a protective coating that can be damaged in the splitting process. Yet many common medicines that are taken on a daily, long-term basis can safely be split, including Crestor, Lipitor, Cozaar, Diovan, Lexapro and Zoloft. These six medicines, on which Americans spent nearly $15 billion alone in 2008, are among the 21 branded and generic prescription drugs appropriate for splitting under UnitedHealthcare’s Half Tablet program.

UnitedHealthcare considers medicines with all of the following characteristics as potential candidates for splitting with a physician’s approval:

• tablets that can be split relatively evenly without crumbling;
• medicines that have a wide margin of safety so that minimal differences in tablet sizes will not result in either under-dosing or over-dosing;
• medications that remain stable after splitting.

A study published in the American Journal of Managed Care (June 2007) also found that consumers were willing to split their pills if it meant a reduction in their out-of-pocket expenses.