Knowledge Without Borders: Collab With Ethiopian Medical School Awakens Stanford Residents to Global Possibilities

by dom-wp-admin | Sep 20, 2024 | 2024, Partnerships

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Knowledge Without Borders: Collab With Ethiopian Medical School Awakens Stanford Residents to Global Possibilities

#Partnerships

Stanford physician Cybele Renault, MD, rounds and teaches on the wards with the attentive internal medicine faculty at Negele Arsi General Hospital.

Imagine starting a virtual education program at a site without reliable internet in an environment where the basic medical tools we take for granted in the U.S. are scarce or unavailable. That is exactly what Cybele Renault, MD, has done. Her infectious passion for both medical education and program development has led to a Stanford collaboration with a medical school in rural Ethiopia that offers a uniquely rewarding educational opportunity for everyone.

In 2019, Renault was forever changed following a site visit to Negele Arsi General Hospital and Medical College (NAGHMC) that was sponsored by Stanford’s Center for Innovation in Global Health (CIGH), where she is a faculty fellow. Negele Arsi, located a four-hour drive from the country’s capital of Addis Ababa, is a small city in rural Ethiopia nestled within the state of Oromia.

The potential for an educational collaboration with her Stanford Internal Medicine Global Health Track residents was immediately obvious. Historically, Stanford Medicine residents have contributed to global health via onsite clinical service and teaching.

On the arrival of Cybele Renault, MD, to Negele Arsi, the faculty of NAGHMC give a warm welcome to Dr. Renault and her family with a ceremony that includes banners, bouquets of flowers, and a cake.

Savannah Karmen-Tuohy, Cybele Renault, Nick Zehner

After delays due to COVID-19 followed by political instability in the northern Tigray region, Renault adapted this plan to monthly two-hour virtual case-based clinical reasoning sessions, for which NAGHMC medical students congregate on the medical school campus where the internet might last the duration.

Bidirectional Learning

Renault led the first session, but then her Global Health Track residents took the lead, with Natasha Mehta, MD, MS, the first to take the plunge. “It fascinates me how we can adapt and train learners side-by-side in very different contexts and in very different countries,” Mehta says. “[This program is] a perfect example of how you can leverage an international collaboration to make people stronger physicians and clinicians. Bidirectional learning [is something] a lot of us are really interested in furthering in global health. If we can keep these connections going past these two-hour sessions every month and form a true network of learners, I think that could be extremely impactful.”

Mehta recently graduated from her residency program and has moved on to Duke University, where she intends to co-lead the program alongside Renault, her residency mentor.

Universal Enthusiasm

Another Global Health Track resident, Savannah Karmen-Tuohy, MD, has found the NAGHMC medical students inspirational. “The enthusiasm with which they do their pre-work and how prepared they are … is truly unparalleled,” she says. They are learning and working in the absence of much of the technology taken for granted in the U.S. Forget CT scans and other expensive diagnostic technology; they don’t even have reliable or affordable internet access. “We are adjusting each session as we go and have a debrief call before and after with members of the NGO and the on-site faculty to think about how to work best during these sessions. That’s exciting from an educator’s perspective.”

The enthusiasm is as bidirectional as the learning. In a letter of thanks to Stanford University, the participating NAGHMC students wrote, “These lectures have been invaluable in expanding our knowledge and understanding of various medical conditions and their treatment. The case studies presented in these lectures have provided us with a deeper insight into the practical aspects of medicine and have equipped us with the necessary skills to approach similar cases in a clinical setting. The real-life scenarios discussed have helped us develop critical thinking and problem-solving abilities that are essential for a successful medical career. The expertise and professionalism of the instructors who have conducted these lectures are truly commendable.”

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“It’s incredible to see how the rewards of this initiative have prompted our residents to reflect on what they ultimately want to do and the impact they could have in their careers.”

– Cybele Renault, MD

Stanford resident Savannah Karmen-Tuohy, MD, leads a virtual clinical reasoning session with the NAGHMC medical students.

A Model for Future Educational Collaboration

A third participating Stanford resident, Nick Zehner, MD, MS, sees this collaboration as a scalable model for global education. “It takes advantage of technology that wasn’t as widespread before the pandemic, so we are on the cutting edge of a new way to transfer knowledge and education,” he says. He hopes this program can help in the development of best practices to replicate it all over the globe.

He also appreciates its nonpaternalistic approach. “One of the liabilities of global health is this colonial legacy of the haves giving to the have-nots,” he says. “But we probably get as much out of these sessions as the students. It takes so much dedication for the Ethiopian students to reach the point of becoming medical students. These students are on top of things. … I think that makes us better educators.”

Renault is effusive in her praise of the residents working with her. “It’s incredible to see how the rewards of this initiative have prompted our residents to reflect on what they ultimately want to do and the impact they could have in their careers,” she says.

In return, Renault’s Stanford residents cannot say enough good things about her leadership or the NAGHMC initiative. In July of 2024, Renault returned to Ethiopia to advance the initiative by meeting with the leadership and the students, familiarizing herself with the curriculum, and teaching in-person classes in infectious diseases for medical students and NAGHMC faculty.

Specialty Care Services Available Through Virtual Consults

In addition to its native population, Oromia is home to 100,000 internally displaced refugees. The region has limited access to health care and medical education. A decent standard of living for a family in the region is estimated to cost just $238 USD monthly, yet 90% of the population live below the poverty line.

NAGHMC was founded by Ethiopia Health Aid, an NGO co-founded in 2007 by Gudata Hinika, MD, an Ethiopian trauma surgeon who grew up in Oromia, and Katreena Salgado, an expert in public affairs and communication who is originally from the Philippines. Both founders are currently working at California Hospital Medical Center in Southern California.

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Navigating New Frontiers: The Pediatric-to-Adult Transition at Stanford Health

by dom-wp-admin | Sep 20, 2024 | 2024, Partnerships

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Navigating New Frontiers: The Pediatric-to-Adult Transition at Stanford Health

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Kian Keyashian, MD, leads a team of providers who help adolescents with inflammatory bowel disease transition from pediatric to adult care.

“I can’t go to the hospital now. I have a math test tomorrow!”

That was Sofia Laiton’s reaction to her father’s insistence that he take her to seek care immediately for her worsening inflammatory bowel disease (IBD) symptoms. She was 15 then and had recently been diagnosed with Crohn’s disease (a type of IBD). “In my junior year in high school, I had every symptom in the book: fatigue, blood loss, weight loss – it was scary,” she recalls.

Her father took her to Valley Children’s Hospital in Madera, California, a part of the Stanford Health Care system. What she thought would be an overnight stay turned into a 10-day admission for tests and treatment of an infection.

“I was in my worst condition back then,” she says. She was taking several medications, including monthly infusions of infliximab, an anti-inflammatory medication. “But over time I’ve come to see IBD as a journey. I couldn’t run to the finish line, but I could live a stable life by adapting and defining a new normal for me.”

In 2022, when Laiton was 21, her pediatric gastroenterologist suggested that she transition to adult care at Stanford Health Care. That was when she participated in the Pediatric-to-Adult IBD Transition Program and became a patient in the adult gastroenterology division.

Pediatric and Adult Care Are Different

Adolescence is a time of transition that is often fraught with emotional ups and downs. Teens begin to evolve from a state of total dependence on their parents into independent adults who are responsible for their own finances, health care, housing, and other segments of everyday life.

When you add coping with a chronic condition such as IBD to the list of skills needed to stay healthy without parental supervision, the transition to adulthood may become even more daunting.

Most teenagers with IBD are cared for by a pediatric gastroenterologist. But as these patients become young adults, their health care needs change too. At Stanford Health Care, the Pediatric-to-Adult Transition Program for IBD patients supports these changing needs for how, where, and when to seek a gastroenterologist who cares for adult IBD patients.

“Young adults who have IBD are at high risk for flares and lapses in treatment if they aren’t guided across the gap from pediatric to adult care,” says Kian Keyashian, MD. “I’m proud of what we have achieved in the first four years of this transition program.” Keyashian is a clinical associate professor of gastroenterology and hepatology, and clinical director for inflammatory bowel disease.

Inflammatory bowel disease is a chronic condition that is often accompanied by fatigue, pain, blood loss, diarrhea and other gastrointestinal symptoms.

“Young adults who have IBD are at high risk for flares and lapses in treatment if they aren’t guided across the gap from pediatric to adult care. I’m proud of what we have achieved in the first four years of this transition program.”

– Kian Keyashian, MD

Since the IBD Pediatric-to-Adult Transition Program was launched in 2020, more than 35 IBD patients, including Sofia Laiton, have made a smooth transition from pediatric to adult care, under the leadership of Keyashian and Rachel Bensen, MD, a clinical associate professor of gastroenterology at Stanford Medicine Children’s Health.

The need for this kind of support arises from some key differences between pediatric and adult healthcare delivery:

Pediatric care is family-centered, with parents serving as decision makers on behalf of the patient. Adult care is focused on the individual patient who acts on his or her own behalf.

Pediatric care is often multidisciplinary and team-based; adult care is usually driven by a single provider who taps into subspecialty care as needed.

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How the Transition Program Works

The foundation for the Stanford IBD Transition Program is a joint video meeting with the pediatric and adult gastroenterologists, and other members of the team as appropriate. These may include a pediatric social worker, psychologist, and registered dietitian, as well as an adult gastroenterologist nurse.

With the patient and parents present, the team reviews the patient’s history, most recent visit, work or school issues, patient concerns, and other relevant topics. The adult gastroenterologist explains what to expect from his or her practice. The nurse in the adult practice walks the patient through MyChart, a patient portal that allows people to view and manage their health information and to message their physician and care team.

Laiton says that she is “very grateful for the meeting we had with all the providers on one call. They made me feel I was in a safe space where I could ask questions and provide input. I felt respected.”

“In the past, we would do our best to collect and assess a new patient’s records,” notes Keyashian. “But it often felt as though we were either starting from scratch or playing catch-up.”

Now, the joint visit creates a true transition. Patients are free to have a final check-in after the adult visit with the pediatric social worker before becoming a full-fledged adult patient.

Laiton, now 23, graduated from the University of California, Davis, in 2022. She works in a high school as a student assistance specialist. She still needs medication to manage her condition, but with Keyashian’s help she’s down to one infusion every six weeks and no oral medications. Her Crohn’s disease is in remission.

Patient Feedback Is Positive

The frontier has been opened for establishing this program as the standard. Now, physicians are considering how to analyze available data to demonstrate outcomes and effectiveness of this way of providing care.

“I love this program,” declares Keyashian. “It’s what I’d want for my own kid.”

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Redefining Cardiovascular Care for Athletes

by dom-wp-admin | Sep 20, 2024 | 2024, Interventions

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Redefining Cardiovascular Care for Athletes

#Interventions

Jason Tso, MD, sports cardiologist and medical director of the Sports Cardiology Program at Stanford, is himself a dedicated cyclist and runner.

It’s a scenario that Jason Tso, MD, assistant professor of cardiovascular medicine, has heard too many times: An avid runner detects that something is possibly awry with their cardiovascular system. Their sports watch alerts them to an arrhythmia, or they find their heart rate spiking at paces that once felt easy. The runner’s primary care provider refers them to a general cardiologist, who tells them that if it only happens when they run, they should stop running.

His frustration is palpable when he hears the latest instance of this story. “See, I hate that. That’s what people come to see me for. They hear that, and that’s just not acceptable.”

The Nuanced Athlete’s Heart

Though common wisdom states that exercise is the best medicine, runners and other athletes are not immune to cardiovascular issues. Some young athletes have inherited cardiovascular diseases that pose risks regardless of fitness.

As athletes age, a percentage eventually face the standard ailments common in older adults, including coronary artery disease. And still other athletes discover through testing that they have an enlarged heart ventricle or aorta. It could be a heart condition. Or it could be the hypertrophy that any muscle experiences when it is regularly exercised.

“Taken out of context, a very healthy 25-year-old runner’s heart can look like someone with early heart failure,” Tso says. As the medical director of the Sports Cardiology Program at Stanford and Stanford’s first dedicated sports cardiologist, he specializes in that context.

In the case where an otherwise healthy athlete notices that something feels different, practitioners who do not usually care for athletes may dismiss their concerns. The patient is so fit, they must be well. “A general physician will have a lot of trouble distinguishing an unhealthy athlete from a healthy nonathlete,” says Jeff Christle, PhD, a clinical exercise physiologist and Tso’s colleague in the Stanford Sports Cardiology clinic.

That’s when the persistent athlete ends up seeing someone like Jason Tso.

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“We’re just seeing so many very active people now. It’s not just the running and the cycling. People like going to the gym. People like working out, and they find enjoyment in just being fit. Whether it’s weightlifting, mountain biking, whatever… it’s important that we support people through that.”

– Jason Tso, MD

An Athlete Treating Athletes

Too often, general cardiologists give athletes with cardiovascular concerns a rote mandate: Stop exercising, or stop exercising intensely. But this type of advice is anathema to athletes. For some, sports may be their career. For others, pushing their physical limits is central to their identity and quality of life. Many athletes, if simply told to stop, will not.

Tso is himself an athlete. Between university and medical school, he spent two years as a competitive cyclist – an amateur, but the kind of amateur whose name appears near the very top of race results and Strava leaderboards for fastest times on a given map segment. He runs as well, with a 2023 California International Marathon (CIM) time of 2:52, a time fast enough to qualify for the prestigious Boston Marathon.

In the clinic, Tso sees people ranging from Stanford student-athletes who undergo routine screening to Bay Area professional and recreational athletes with cardiovascular concerns. Patients undergo cardiopulmonary exercise testing (CPET), usually on a treadmill or stationary bike, to evaluate their cardiovascular system. The test measures a person’s VO₂ max, a common aerobic fitness metric that measures how much oxygen the body can use during exercise. It can also detect exercise-induced asthma and re-create exercise-induced symptoms, such as chest pain, in a controlled environment. Some patients receive additional testing, such as electrocardiograms to monitor their heartbeat or pre- and post-CPET ultrasounds to image the structure of the heart.

Defining Risk Thresholds

If the testing does reveal a heart condition, Tso assesses the condition’s severity level and works with the patient to set risk-based exercise thresholds.

Quantifying the danger is helpful. Most athletes want to keep exercising, he says, “but they don’t really want to push so hard they’re endangering themselves.” He may counsel an older runner with mild heart failure, for example, on safe intensity zones based on their own test results. The patient gets to continue doing what they love, and what may ultimately help their overall health, with a better understanding of where the risk lies.

Jeffrey Christle, PhD, with a test subject in the Stanford cardiopulmonary exercise testing lab

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Practicing at the Frontiers of Sports Technology

Patients’ ability to follow guidelines and adhere to risk thresholds is aided in part by rapidly evolving technology.

Athletes from professionals to amateurs have access to sophisticated sports watches, heart rate monitors, and other fitness wearables that track an array of cardiovascular data, such as resting heart rate, heart rate variability, and approximate VO₂ max.

“Athletes are coming in more now with their own data that might indicate something’s wrong,” Tso says.

It’s not perfect, he cautions. Along with quality data, “right now, we see a lot of nonsense.” Nonsense such as a purported abnormal heart rate that actually is a sports watch confounding a runner’s cadence with their heartbeat, which can result in an alarmingly high but ultimately incorrect reading. But there are also more reliable wearables on the market, such as chest strap heart rate monitors. As technology has improved, Tso considers it increasingly important.

Supporting the Full Spectrum of Active Individuals

The technological advancement in fitness wearables is driven in part by swelling consumer demand.

“People see sports cardiology as seeing super-high-level athletes and helping to prevent illness and disease, as well as trying to get them to perform at the highest level they can,” says Christle. Tso, Christle, and their Sports Cardiology clinic colleagues treat professional and Division I athletes for just those purposes.

But as institutions like the American College of Sports Medicine promote “exercise as medicine,” Christle says, and people follow that advice, it creates a huge demand for sports cardiology in the broader population.

“We’re just seeing so many very active people now,” Tso says. “It’s not just the running and the cycling. People like going to the gym. People like working out, and they find enjoyment in just being fit. Whether it’s weightlifting, mountain biking, whatever.”

As this cultural shift unfolds, he says, “it’s important that we support people through that.”

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Pioneering New Frontiers in Cancer Therapy: Stanford’s Breakthrough With CD22 CAR T Cells

by dom-wp-admin | Sep 20, 2024 | 2024, Methods

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Pioneering New Frontiers in Cancer Therapy: Stanford’s Breakthrough With CD22 CAR T Cells

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T cell attacking a cancer cell. Meletios Verras/Shutterstock.com

Most of the lymphoma patients who agreed to a new, experimental therapy at Stanford were told that they had only months to live. Enrolling in a clinical trial – in which their immune cells would be removed from their bloodstream, grown and altered in a lab, and then infused back into their body – was a last resort. So when more than half of the patients had a complete response, with their tumors becoming undetectable, even the researchers running the trial were surprised.

“These are patients who have really run out of options. They have huge tumors that are not responding to other therapies,” says Matthew Frank, MD, PhD. “So to have durable responses in this very high-risk population really blew us away.”

Today, when people with large B-cell lymphoma don’t respond to chemotherapy, they often receive CAR T-cell therapy, in which their immune cells are reengineered to recognize and destroy cancer cells. But the standard CAR T-cell therapy, which makes immune cells target a protein called CD19, does not always work.

Since 2018, Stanford researchers and clinicians have been working to make a CAR T-cell therapy that attacks a different protein found in some cancer cells, CD22. They began with basic research to design the CAR T cells, followed by studies on how to grow enough copies of the cells to make effective treatments. Then, they brought the therapy to patients.

The results of that phase I trial – which included 38 patients at Stanford whose tumors had not responded to CD19-directed CAR T-cell therapy – were published in The Lancet. Sixty-eight percent of the patients saw their tumors shrink, and 53% had a complete remission. Frank was one of the lead authors of the paper, along with David Miklos, MD, PhD, chief of the Blood and Marrow Transplantation and Cellular Therapy Division.

“We think this study is a big deal because it is so unusual for a single academic institution to carry a trial completely from concept through basic research and then patient treatment,” says Miklos. “We showed that this cell therapy is safe and effective, and we did it without venture capital funding or pharmaceutical company support, because Stanford Medicine funded the cell manufacturing costs.”

Stanford was able to carry out the full breadth of the work because of close collaboration between basic researchers and clinicians, says Miklos.

“Stanford is a nexus for cell therapy research and treatment right now; this is where we can bring it all together,” he says. “We can develop the preclinical ideas, we have the technical capabilities to produce cells, and we have dedicated clinicians who bring the therapy to patients.”

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“Stanford is a nexus for cell therapy research and treatment right now; this is where we can bring it all together. We can develop the preclinical ideas, we have the technical capabilities to produce cells, and we have dedicated clinicians who bring the therapy to patients.”

– David Miklos, MD, PhD

Matthew Frank, MD, PhD

Unrivaled Manufacturing Ability

One of the key players in the collaboration to develop and study CD22-directed CAR T-cell therapy was the Laboratory for Cell and Gene Medicine, which houses a state-of-the-art cell manufacturing facility that can grow the cells isolated from patients.

“Our manufacturing facility provides the opportunity for research to move smoothly through to patients,” says Steven Feldman, PhD, the laboratory’s scientific director. “We have control over the process, the infrastructure, and the data.”

When many academic medical centers study new cell therapies, they do so in collaboration with pharmaceutical companies. This means the data they collect on patients is sent back to the company for analysis, giving the clinicians themselves little control over the direction of the research.

Thanks to the manufacturing capabilities of the Laboratory for Cell and Gene Medicine, however, Stanford researchers and clinicians controlled every aspect of the CD22-directed CAR T-cell therapy trial. This sped up the process of innovation, and it continues to give researchers the ability to ask new questions about the therapy with the data they have already collected.

“We’re still analyzing lots of the samples we collected, to get some insight into why the therapy worked better for some patients than others,” says Frank. “That’s giving us a much richer understanding of how we make this go even better the next time.”

In the wake of the phase I trial, Frank is already helping lead a phase II trial at institutions around the country. He is also studying the use of the therapy in other cancer types and in combination with other CAR T-cell products. The Laboratory for Cell and Gene Medicine is producing the cells for all the avenues of research.

“Now that we have this infrastructure to run a trial, we can do this for anything,” says Feldman.

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Expanding Horizons: Lauren Eggert’s Mission to Transform Pulmonary Care in the East Bay

by dom-wp-admin | Sep 19, 2024 | 2024, Interventions

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Expanding Horizons: Lauren Eggert’s Mission to Transform Pulmonary Care in the East Bay

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Lauren Eggert, MD, who is working to expand the reach of Stanford’s chest clinic, to reach pulmonary patients throughout the East Bay

Stanford Medicine has grown substantially since 2017, but there still aren’t nearly enough experts and clinics to get patients with chronic obstructive pulmonary disease (COPD) and asthma the care they need.

Lauren Eggert, MD, had no specific fascination with pulmonary medicine in medical school until she started working with a mentor during her internal medicine residency. That mentor, she says, was a “fantastic clinician in the intensive care unit (ICU) and pulmonary clinic,” adding, “I wanted to be just like them.”

Eggert joined Stanford Medicine’s Division of Pulmonary, Allergy and Critical Care Medicine as a fellow in 2017 to follow in her mentor’s footsteps. She’s now a clinical assistant professor of pulmonary, allergy, and critical care medicine.

“A lot of patients of mine come all the way from San Luis Obispo, from Nevada, from Sacramento, from far out in the Central Valley,” she says.

“Finding alternative sites where we can have more space, have more providers, and also reach different communities has been an important goal of the chest clinic and pulmonary at Stanford.”

Resources and Clinical Trials for Asthma

“One of the things we are working on is building a stronger asthma program through the multidisciplinary allergy clinic,” says Eggert. One day a week, Eggert works at the allergy clinic to help patients with allergic asthma. The clinic has access to advanced tools such as fractional excretion of nitric oxide, which helps clinicians measure lung inflammation. The team schedules monthly meetings to discuss how to improve the care of complex patients.

She’s also teamed up with researchers at the Asian American Research Center at Stanford to study asthma, allergies, and other pulmonary conditions in Asian populations.

“We’ve published work on the importance of disaggregating Asian subgroups. For example, outcomes can be different between people who are Chinese and those who are Filipino.”

One of Eggert’s most recent studies showed that Filipino Americans get less sleep and have more difficulty falling asleep than other Asian Americans, which she points out could influence many other health outcomes.

Additionally, the chest clinic is planning to open an outreach clinic in Oakland’s Chinatown, with the future addition of allergists on staff to better support the needs of patients who live there. Several of the newest treatments for asthma and COPD are injections that require patients to visit the clinic. “We’re trying to build ways to get care into their neighborhoods, so they don’t have to come to Palo Alto from the East Bay, which is quite a hardship,” Eggert says.

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“Finding alternative sites where we can have more space, have more providers, and also reach different communities has been an important goal of the chest clinic and pulmonary at Stanford.”

– Lauren Eggert, MD

Keeping COPD Patients Out of the Hospital

Eggert is working on increasing access to pulmonary rehabilitation – an eight- to 12-week program that combines education, breathing exercises, endurance exercises, strength work, and more – that is well-known to improve quality of life for people with COPD and other lung conditions. It also helps keep patients out of the hospital. “It’s just being grossly underutilized, and one of the biggest factors is lack of access,” says Eggert.

Only about 5% of patients who could benefit from pulmonary rehabilitation use it. In rural areas, that number is even lower. It’s closer to 3% of patients who are likely to benefit. Stanford Medicine is partnering with an innovative virtual rehabilitation program to allow patients to work through the program without having to travel.

Eggert, her team, and her collaborators throughout Stanford Medicine are reaching new frontiers, building new spaces, making the most of telehealth technologies, and providing better care for more pulmonary patients than ever before.

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