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THE YEAR AHEAD: The Future is Now

David Katzenstein

Rafael Pelayo

Irv Weissman

Robert Jackler

Nelson Teng

Harvey Cohen

Debra Ketchell

Myriam Curet

BY THE STAFF OF MEDICAL CENTER REPORT

One thing won't change in 2006: Medicine is going to continue to change at a rapid clip. If you need evidence of that trend, here's a sample of forecasts from members of the medical school community about events and developments to watch in the coming months.

AIDS: New response to global plague

"Time to Deliver" is the theme of the 2006 World AIDS Conference, and professor of medicine David Katzenstein, MD, predicts that a more effective response to the global pandemic will start to emerge in August at this biannual gathering. Indeed, he said that he expected to see recent advances in the treatment and prevention of AIDS being integrated into a comprehensive strategy to combat the disease.

"The focus is now on 'operational research' as opposed to either basic or even translational research," said Katzenstein who will be among those presenting work at the event. He explained that this year's gathering would reflect the growing recognition that fighting AIDS requires far more than stronger drugs and more condoms. Such an effort entails "creating new models of health care and health-care research," he said.

The challenge extends to other infectious diseases, but the task for the AIDS campaign is particularly daunting: "It means anticipating all the commitments that will have to be made," he said, "if you want to provide drugs for the 20 million people in sub-Saharan Africa who are infected with HIV." —Mitzi Baker

Sleep: More pills for insomnia

This is likely to be a year that increasing numbers of insomnia sufferers get a good night's sleep—thanks to a slew of new medications.

"Over the last year, there has been a sea-change in the attitude about insomnia and an acknowledgment that there is a role for medication and behavior therapy in this condition," said Rafael Pelayo, MD, assistant professor of psychiatry and behavioral sciences. Many of Pelayo's patients suffer from insomnia, which, according to the National Institutes of Health, affects more than 70 million Americans.

Three new sleeping pills, including Lunesta, were brought to market in 2005, and several more are expected to be approved by the U.S. Food and Drug Administration this year.

Another change for patients: the generic version of Sanofi-Aventis' Ambien, the most widely prescribed sleeping aid on the market, will be available in October.

Pelayo emphasized that a sleep doctor's ultimate goal is to help patients sleep without medication; at Stanford this is achieved by its pioneering behavioral treatment programs. Still, he added, sleeping pills can play an early, important role in treatment.

According to IMS Health, a provider of health-care information, nearly 25 million prescriptions for sleep medications were written in the first half of 2005. Pelayo, who consults for several drug makers, thinks these numbers will rise in 2006, as the new pills are safer than older-generation sleeping drugs. "We can now prescribe these pills with greater confidence," he said. —Michelle L. Brandt

Stem cells: Go west, young scientist

In the next year more stem cell researchers from outside California are likely to move to the state to take advantage of funding made available through the creation of the California Institute for Regenerative Medicine, according to Irv Weissman, MD, director of the Stanford Institute for Stem Cell Biology and Regenerative Medicine. Last year two such researchers came to Stanford to join the institute.

There is one potential hitch: Two pending lawsuits currently prevent the CIRM from distributing its grants, including one already awarded to Stanford. If the suits are resolved in the CIRM's favor—and decisions are expected in 2006—the institute can start distributing money for training, research and new labs and buildings.

Although South Korean claims to have generated new embryonic stem cell lines using nuclear transfer were recently shown to be false, researchers will continue attempting to create new stem cell lines using that technique, according to Weissman. Nuclear transfer, which has been carried out successfully in a variety of other mammals, is necessary for some promising therapies that involve creating stem cells from a person's own tissues.

"We hope to recruit scientists who will in the future find ways to do nuclear transfer, first in animal models and then with human cells, using the safest and most effective methods," Weissman said. —Amy Adams

Hearing aids: New fashion statement

Those trendy techies out on the streets wearing elegantly designed ear devices may not realize it, but they're helping battle a stigma attached to hearing loss.

"You put on a hearing aid and suddenly you lose 30 IQ points and age 20 years," remarked Robert Jackler, MD, chair of otolaryngology.

Thanks to the latest technology trends, that's about to change. "Within a few years, wearing a device in your ear will be as common as wearing a wristwatch," Jackler explained. "We are in the midst of an ear-level device revolution."

It's estimated that one in three adults over the age of 65 has a handicapping hearing loss. Yet only 20 percent of the nation's hearing impaired wear a hearing aid to combat the problem.

With the growing trendiness of sleek, wireless electronic ear devices, Jackler predicts that in 2006, the percentage of hard-of-hearing Americans wearing ear devices—such as the ones fitted with the latest Bluetooth technology—will soar.

Ear devices of the future will have numerous purposes, Jackler said, including cell phone, MP3 player, computer and GPS interface and Web access. In November, one cellular company began marketing to the hearing-impaired by offering the ability to turn select hearing aids into wireless Bluetooth hands-free headsets.

"Once you have these devices on everyone's ears, you have the ability to use them to overcome hearing loss," Jackler said. "I can see grandma wearing a Bluetooth, and being proud of it!" —Tracie White

Ovarian cancer: Living longer

Women with ovarian cancer are more likely in 2006 to receive a treatment that will significantly extend their lives, said Nelson Teng, MD, director of gynecological oncology.

Until last week the standard treatment for ovarian cancer involved intravenous chemotherapy. On Jan. 5 results of a major trial were published in the New England Journal of Medicine showing that women who received additional chemotherapy pumped directly into their abdominal cavity lived on average 16 months longer than women who got the standard care.

"Sixteen months is the biggest improvement in lifespan we've seen in the treatment of ovarian cancer in several decades," Teng said.

Due to the impressive results, the National Cancer Institute has urged all doctors to add the abdominal chemotherapy treatment.

Stanford Hospital & Clinics is one of a limited number of hospitals nationwide that offer the treatment, and Teng and Jonathan Berek, MD, the new chair of obstetrics and gynecology, are both experienced in performing the procedure.

Teng noted that evidence has been mounting for years that chemotherapy pumped directly into the abdomen could help women with ovarian cancer. Despite such evidence, many doctors resisted that approach because of severe side effects such as bloating, nausea, weakness and infections from the tubes that deliver the drugs. Teng recently reported a new way of delivering the abdominal chemotherapy that could reduce the risk of infections. He hopes this work and other ongoing studies at Stanford will make the abdominal treatment even more effective in treating the cancer. —Amy Adams

Children: Threats to pediatric care

2006 could be a seminal year in children's health-care coverage, according to Lucile Packard Children's Hospital chief-of-staff Harvey Cohen, MD, PhD. The proposed cuts to Medicaid, coupled with an ongoing push to enroll many of those children receiving state coverage into managed-care plans, threaten kids' access to specialty care.

"It is important that those of us who care for and about children realize that we are putting them at risk if we decide to decrease funding for their health or try to alter the current ways they receive care," said Cohen.

About 35 percent of Packard Children's patients are enrolled in Medicaid or a related state program, California's Healthy Families. If the new federal budget passes as currently written, millions of children covered by Medicaid could be required to pay as much as 20 percent of the cost of their care—up to 5 percent of the families' income—while simultaneously receiving less-comprehensive benefits. Many pediatric specialists also have grave concerns about the ability of managed-care plans to appropriately treat children with complex medical problems.

"Children's access to high-quality care is at risk, especially for those with chronic or life-threatening conditions," said Cohen, "These changes would make it more difficult for these children to see pediatric specialists, and they would instead be sent to adult specialists who don't know as much about children's illnesses."

Packard Children's and other pediatric hospitals are working to inform lawmakers of the proposals' consequences. There's not much time, though: Congress is likely to cast its final vote on the 2006 budget by February. —Krista Conger

Library: Farewell to paper

A half-dozen trolleys full of old journals line the hallway from Debra Ketchell's office in Lane Medical Library's basement to an elevator leading to the ground level. This is the year that the books are leaving.

"By the end of 2006, most of the older books and journals will be gone," said Ketchell, the library's director. They'll be chillin' in Stanford's high-density storage space in Livermore—where they're stored at 50 degrees Fahrenheit for preservation.

Like other medical libraries, Lane is quickly moving toward digital access to journal articles and reference books. The allure: Digital libraries allow collections to transcend time and space; they permit users to access information from anywhere, at any time.

But what makes Lane's move especially urgent is the plan to start building the new Learning and Knowledge Center in 2007, which includes renovating the current space. "We'll need to move everything out. Then we'll move the core essentials into our temporary housing," she said.

The grand plan has the library opening in a new building in 2009. It will have only a fraction of the books that were on site in 2005.

"We'll have a core collection of reference and study materials—for instance, study guides, core textbooks and new books that aren't online," said Ketchell.

Journal articles not online will be sent digitally within eight hours; books can be requested online for delivery in 24 hours. —Rosanne Spector

Surgery: Relying on robots

Six years ago robotic surgery jumped from the pages of science fiction books into the operating room. Although debate still continues about its cost effectiveness, Myriam Curet, MD, associate professor of surgery, predicts that in 2006 you can expect to see it sink new roots and extend into new territory.

"Robotic surgery is a tool looking for applications," said Curet, who pioneered an effective way to use the technology for gastric bypasses.

In 2005, more than 20 percent of U.S. prostatectomies were done with a robot. This year, expect that figure to double.

Robotic surgery should also gain new ground in advanced laparoscopic procedures, along with esophageal, pancreatic, colon and rectal surgeries, Curet said.

Since Intuitive Surgical's da Vinci system was approved by the U.S. Food and Drug Administration in July 2000 (the only robotic system to get FDA approval) about 350 of the units have been purchased at about $1.3 million each.

The system places the surgeon in front of a console where he or she uses knobs to maneuver tiny surgical instruments with cameras attached to adjustable robotic arms.

It has been used in a variety of surgeries from kidney transplants to hysterectomies. About 36,600 robotic surgeries were done in 2005, up nearly 50 percent from 2004. Analysts predict the figure will grow at a similar rate in the coming months. —Tracie White