TAG: "Pediatrics"

$13M gift launches new maternal and child health center


UC Berkeley’s School of Public Health to launch Wallace Maternal and Child Health Center.

By Jose Rodriguez, UC Berkeley

Dr. Helen Wallace, a world-renowned professor, mentor and advocate known for her passion for improving the lives of women and children, has left a bequest valued at more than $13 million to UC Berkeley’s School of Public Health. The funds will launch the Wallace Maternal and Child Health Center, the campus announced today (March 2).

The new center will engage in innovative, evidence-based research aimed at creating healthier generations of women, mothers, children and families in the United States. It will focus on educating and training public health leaders primarily, but not exclusively, from states west of the Mississippi River through interdisciplinary scholarships and fellowships. The funds also will create a new endowed chair.

By fostering partnerships at every level of research, from discovery science to implementation and dissemination of evidence, the Wallace Center will complement the school’s existing maternal and child health (MCH) program — one of the pre-eminent MCH leadership training programs in the nation — and the Bixby Center for Population, Health and Sustainability.

Wallace, who died in 2013 at the age of 99, mentored generations of students as a professor and chair of the school’s MCH program from 1962 to 1980. She laid important groundwork in the field by fostering collaboration across disciplines at a time when it was rare to do so, and she implemented these practices within the school, in research partnerships and in her writing. She was particularly interested in infant health, maternal mortality, health systems that improved health outcomes, and expanded delivery of health care to mothers and children.

“We are extremely excited and gratified to move our work forward with greater focus and commitment in the arena of maternal and child health, which was the vision of Dr. Helen Wallace,” said Dr. Stefano Bertozzi, dean of the School of Public Health. “The School of Public Health has been taking a leadership role on these issues at the global level for some time now through the Bixby Center for Population, Health, and Sustainability. The new Wallace Maternal and Child Health Center will deepen our work and allow us to focus on attracting and supporting students from the western United States.”

The Wallace Center will embody the values of the School of Public Health: equity, excellence, diversity, innovation, impact and collaboration. By supporting and engaging faculty and students and attracting new talent, the center will play an important role in workforce development while sustaining UC Berkeley’s reputation as a game-changer at the forefront of public health.

Wallace is remembered for visionary efforts that brought together scholars from separate disciplines, such as public health and social welfare, to advance common research goals, and for attracting the school’s first maternal and child health training grant from the federal government.

“She was well-known for mentoring her students and ensuring that what they learned on campus was put to use to benefit society,” said Sylvia Guendelman, professor and chair of the maternal and child health program at UC Berkeley. “She inspired her students to be leaders, to make a positive difference in the world.”

Among the leaders Wallace trained was Dr. Peter van Dyck, who served as associate administrator of the U.S. Health Resources and Services Administration’s Maternal and Child Health Bureau from 1999 to 2011.

“Helen Wallace assured me and others at Berkeley that in maternal and child health, we could touch individual children as well as influence public health by implementing good policy,” said van Dyck. “She was correct. She was a great mentor.”

Guendelman, who will lead the planning effort, said that the center will allow new generations of students to see Wallace’s “vision, spirit and effort endure over time.”

Wallace received her bachelor’s degree from Wellesley College in 1933, her master’s in public health cum laude from the Harvard School of Public Health in 1943 and her medical degree from the Columbia University College of Physicians and Surgeons in 1937.

She was the author of 336 journal articles and 16 textbooks — most recently, ”Health and Welfare for Families in the 21st Century,” the second edition of which was published in 2003. Besides serving as the national health chair of the National Congress of Parents and Teachers, Wallace was secretary of the maternal and child health section and a member of the committee on child health of the American Public Health Association.

She was, in addition, assistant editor of the Journal of the American Women’s Medical Association, as well as a diplomate of both the American Board of Pediatrics and the American Board of Preventive Medicine. She consulted with the World Health Organization in many countries including Uganda, the Philippines, India, Turkey, Iran, Thailand, Burma, Sri Lanka and Nepal, and trained numerous physicians in Africa and Asia.

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UCSF Medical Center at Mission Bay opens


Large-scale transport completed with support of city of San Francisco agencies.

More than 130 patients were carefully transported from Parnassus and Mount Zion campuses to the new UCSF Medical Center at Mission Bay on Feb. 1. (Photo by Noah Berger)

>>Related: UCSF Medical Center at Parnassus and Mount Zion to expand care

>>Related: President Bill Clinton tours new UCSF hospitals

By Karin Rush-Monroe, UC San Francisco

With 40 ambulances, approximately 300 UCSF staff and faculty, as well as 100 emergency medical services personnel, UCSF Medical Center on Sunday, Feb. 1,  safely transported 131 patients to the new UCSF Medical Center at Mission Bay from its Parnassus and Mount Zion campuses.

The move day started at 7 a.m. on the UCSF Parnassus campus; later in the day patients also were transported from the UCSF Mount Zion campus. The last patient to be moved arrived at UCSF Medical Center at Mission Bay at 3:33 p.m. The new medical center also greeted the first baby born at the new hospitals, a healthy boy who entered the world at a little more than seven pounds.

The opening of the new hospitals was the culmination of more than 10 years of planning and construction of the complex, which includes UCSF Benioff Children’s Hospital San Francisco, UCSF Betty Irene Moore Women’s Hospital, UCSF Bakar Cancer Hospital and the UCSF Ron Conway Family Gateway Medical Building.

The move day, itself, reflected significant planning. “Patient safety was our top priority during the patient move, along with minimizing disruption to our neighbors. We achieved both goals, thanks to the superb work of our medical center faculty and staff as well as our partners in the City of San Francisco,” said Mark R. Laret, CEO of UCSF Medical Center and UCSF Benioff Children’s Hospitals. “We have been looking forward to this day for some time, and the opportunity to start providing care in our new location at UCSF Mission Bay.”

The majority of patients who made the trip on Sunday were children, as UCSF Benioff Children’s Hospital San Francisco moved from Parnassus to its new home at UCSF Mission Bay.

Strategically located on UCSF’s world renowned UCSF Mission Bay biomedical research campus, the new medical center puts UCSF physicians in close proximity to UCSF researchers and nearby biotechnology and pharmaceutical companies in Mission Bay and beyond who are working to understand and treat diseases ranging from cancer to cardiovascular disease to neurological conditions.

“Placing the hospitals on our Mission Bay campus underscores our commitment to driving discoveries toward patient care, ensuring that our world-class researchers are working in close proximity to our leading clinical researchers and physicians in the hospitals,“ said Sam Hawgood, M.B.B.S., chancellor of UC San Francisco.  “They also will provide invaluable training for our medical students, the next generation of clinicians who will take care of patients at health care facilities across California and nationally.

“Significantly, the move also frees up space on our Parnassus and Mount Zion campuses, which will allow us to enrich our medical programs for adult patients there. With the opening of the hospitals at Mission Bay, we now have integrated clinical care and research programs on all of our campuses, the critical factor that has contributed to UCSF’s local, regional and global impact.”

The UCSF Parnassus campus will be restructured to provide more specialized clinical services, such as transplants, and the UCSF Mount Zion campus will become a world-class hub for outpatient care.

“UCSF Medical Center’s new $1.5 billion, state-of-the-art campus in our city’s Mission Bay neighborhood will help improve the health of children, women and cancer patients,” said San Francisco Mayor Ed Lee. “This is not just a milestone for UCSF; this is a milestone for our city and our city’s health care industry, which is at the heart of our economy providing good jobs for our residents.

“Right before our eyes, we have seen the transformation of this underutilized railyard in Mission Bay into an epicenter where new discoveries and innovation in medicine are saving lives around the world. By working together with our great partner UCSF, and the many generous philanthropists that helped build these new hospitals, we will continue to ensure our residents get the highest quality of health care.”

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Obesity poses serious health risks for moms and their babies


‘Eating for two’ no longer holds weight.

By Shari Roan, U Magazine

Veronica Romero was 21 years old and worried. Pregnant with her first child, she was putting on a lot of weight. Her obstetrician leveled with her: “You’re gaining too much.” But as she approached 50 pounds of weight gain near the end of her pregnancy, Romero felt helpless.

“I tried to watch what I was eating, but it was so hard. Pregnant women get cravings, and my cravings were sugary,” she recalled.

“I tried to eat carrots and small appetizers, but it didn’t work. I was disappointed. I didn’t want to get bigger.” The pregnancy set into motion a health crisis on two fronts: for Romero, now 38, and her son, Anthony, now 17. Romero eventually grew to nearly 300 pounds, and Anthony became a big baby, then a chubby toddler and now an obese adolescent.

This mother-child pair is not unique. The obesity tsunami that has washed across the United States over the past four decades has swept up pregnant women and their offspring too. In fact, pregnant women today are considered by some medical authorities to be at the nexus of the obesity crisis. Abundant research has revealed that pregnancy is a key period of increased risk for developing obesity in women and that obesity in pregnancy may genetically “program” offspring to become overweight or obese later in life.

The concept, commonly known as fetal programming, is rapidly altering the fields of obstetrics and pediatrics, said Dr. Sherin Devaskar, Mattel Executive Endowed Chair of the Department of Pediatrics, physician-in-chief of Mattel Children’s Hospital UCLA and assistant vice chancellor of children’s health. “There have been many studies to prove beyond a doubt that fetal programming is real. If a mother is obese, her babies are at very high risk for obesity and chronic disease.”

In the United States, more than half of all pregnant women are overweight or obese, according to the American College of Obstetricians and Gynecologists. An estimated 9 percent of babies are born macrosomic — weighing too much for their gestational age. Fetal macrosomia is typically defined as a birth weight of more than 9 pounds, 15 ounces, regardless of gestational age.

However, obesity in pregnancy can also result in babies who are born prematurely or underweight. These infants also seem to be predisposed to obesity and related diseases, such as diabetes and heart disease, later in life, Devaskar explained.

More than three decades ago, Dr. David Barker, a British physician and epidemiologist, linked birth weight, either excessively high or low, to a heightened risk of heart disease, type 2 diabetes and obesity in offspring. He posited that these diseases had their roots, at least in part, in under- or over-nutrition during pregnancy. If a pregnant woman is under-nourished, her infant is prone to low birth weight with a rapid “catch-up” gain in body fat later when exposed to plentiful food. If a pregnant woman is over-nourished, her infant is prone to high birth weight and a booming growth trajectory that increases the risk of obesity later in life.

The amount of nutrients provided to a developing fetus, as well as the type of nutrients, appears to chemically modify genes that predispose a child to obesity and obesity-related diseases, said  Devaskar, whose own research on the subject resulted in her election to the prestigious Institute of Medicine in 2012. Her current research focuses on whether or not it’s possible to further modify those genes to reverse the propensity to gain weight. “In the fetus, the organs are still developing,” she explained. “It’s a critical window of development, and it’s very plastic at that time. Any insult — whether it’s from diet, drugs or toxins — creates a permanent mark that lasts for one’s lifetime. The hypothalamus — the part of the brain governing metabolism and hunger — is already programmed. The infant is used to seeing so much nutrition coming from the mother. These children are ever-hungry; they are born hypersensitive to high-calorie foods. Their insulin sensitivity is low, so they are at high risk for developing diabetes, obesity and heart disease.”

In 2009, the Institute of Medicine issued revolutionary new guidelines to begin to address obesity in pregnancy. The group put tighter limits on weight gain in pregnancy, warning doctors to help their patients stay within a healthy range and even strictly limit weight gain in obese pregnant women to 11 to 20 pounds.

“It’s a major change,” said Dr. Aisling Murphy, assistant professor in the Division of Maternal-Fetal Medicine. “More recent data have suggested that obese women really don’t need to be gaining as much weight as women who enter pregnancy at a normal weight.”

Moreover, doctors are encouraging pregnant women to exercise — something many women had been fearful of doing. “Sometimes, women are under the impression that they shouldn’t be walking or going to the gym when they are pregnant. That is not the case,” Murphy said. “They really should be active.”

In addition to the risk of fetal programming, obesity during pregnancy is linked to several other potential complications. The chances of developing both hypertension and gestational diabetes are higher in pregnant women who are obese. About 7 percent of pregnant women in the United States develop gestational diabetes. Studies show that these women have an increased likelihood of developing type 2 diabetes later in life. In essence, gestational diabetes often isn’t a “temporary” condition that goes away after childbirth.

Obesity during pregnancy also raises the risk of some types of birth defects and other complications, such as an increased risk of Cesarean section or complications during childbirth, Murphy noted.

While two decades ago, few pregnant women were given extra resources and support they needed to manage weight gain, overweight or obese women who are planning to have children are now encouraged to seek pre-conception counseling, where they are given advice and resources to help them lose weight before becoming pregnant. And pregnant women who are obese are typically referred to a registered dietician for assistance with a healthy diet. Breastfeeding for at least six months is highly recommended to help the mother lose weight.

“If we can take care of young women before pregnancy and during pregnancy, we will end up with a healthier society, and it will bring down health care costs dramatically,” Dr. Devaskar said.

Read the complete story in the latest issue of U Magazine.

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Wearable electronics device makes it easier to image infants


Flexible, lightweight and wearable electronics strategy has led to plans for clinical trials.

New wearable electronics will allow an infant to be swaddled in a blanket laced with a network of nearly weightless, printed “coils” for more comfortable, less expensive MRI scanning.

By Wallace Ravven

An infant born three months prematurely fails to flush pink at birth and has an alarmingly low blood pressure. Ultrasound identifies a heart abnormality and doctors rush the newborn to an MRI suite to confirm the diagnosis. But the scanning itself can cause physical agitation that interferes with clear imaging. In some cases, it can make it harder for the baby to breathe.

When scans require high sensitivity on a small area of the body, a hard, heavy vest of metal coils must press down on the baby. The bulky burden weighs more than the newborn. Infants squirm under the pressure, but anesthesia to calm them down adds an unwanted risk. Lightening the load by securing the weighty apparatus off the baby leads to degraded resolution, prompting a need for longer MRI exposures.

The hardware is part of the radio frequency (RF) coil assembly that receives the MRI’s electromagnetic signals. Besides being awkward and heavy, the coils are expensive to manufacture and must be reused for years. Sanitizing the bulky assembly is difficult.

Cut to a faculty lunch in 2011. UC Berkeley MRI expert Miki Lustig hears his colleague Ana Claudia Arias describe her lab’s progress adapting a technique similar to conventional ink jet printing to fabricate electronic devices.

It was a technology, Lustig says, that was “well beyond my comfort zone.” But he wondered if Arias’ printable electronics techniques could fabricate ultra-lightweight, “two-dimensional” RF coils to ease the trauma to tiny tots and improve image quality.

Lustig and Arias, both faculty members in the electrical engineering and computer sciences department, walked back to their offices together.

“I asked her if she thought RF coils could be printed. It just seemed like a good idea. She said ‘let me think about it.’ A few days later — almost immediately — she said we should give it a try. She started ordering materials to test different substrates and putting a team together.”

Printing electronic circuits and devices based on metals and semiconductors from solution is a very young field that Arias first entered in 2003 at the near-legendary Xerox PARC in Palo Alto. She came to PARC from Plastic Logic Limited, where she worked after finishing her Ph.D. in physics at the Cavendish Laboratory at Cambridge University, U.K.

While at Xerox, Arias began to explore fabrication of wearable sensors. Her group developed several components of a flexible sensor that targeted the prevention of brain injuries by monitoring pressure, acoustic and light levels in the battlefield.

When she joined the Berkeley EECS faculty in 2011, she began to expand her collaborations to developed wearable medical devices that could track vital signs and give doctors feedback on their patients health.

“Printed electronics is an ideal technology for fabrication and integration of devices with different functionality, such as sensors, light sources and simple circuits. It is ideal for deposition of unique and customized designs. And when one adds flexible substrates to the equation you could start thinking about truly wearable — and comfortable — electronics”

To make “wearable electronics” for infant MRI patients, her team first tried to print directly onto cloth fabric.

“We wanted to make our coil feel like a swaddle blankie that fits snugly and softly around the babies,” she says.

But the cloth’s texture interfered with the ability to print high-quality capacitors, so the team turned to printing the “electronic inks” layer by layer onto plastic thin film, like what is used in photo transparencies. The lab succeeded in fabricating and demonstrating functioning RF coils with performance properties comparable to conventional RF coils.

Arias is supported by a Bakar Fellowship at Berkeley, support intended to help commercially promising research make the leap from the lab to the real world. She and Lustig plan to start a company to advance the technology into clinical use.

“We, researchers, don’t usually have experience and training with steps such as securing IP protection and developing a business plan to attract investment and ensure success. Mentors we met through the Bakar Program have been very helpful,” she says.

Their proof-in-principle of the flexible, lightweight and wearable electronics strategy has led to plans for clinical trials early next year. She and Lustig are collaborating with pediatrician Shreyas Vasanawala at Lucile Packard Children’s hospital to test the wearable RF coils on babies needing MRI scans. Vasanawala has been a key clinical consultant to the project from the beginning.

Arias sees the technology’s potential for adult MRI scanning as well — helping to make the MRI experience more comfortable and less scary to everyone, while getting better images of parts of the body that the bulky conventional RF coil assemblies don’t fit very well.

Meanwhile, she still has her eyes on developing that electronic blankie. “When you see kids in the hospital, it’s scary for them. When they’re in a blanket, it’s a much more comforting experience. We want to swaddle them.”

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Study taps into healthy drink choices


Low-quality water in rural immigrant communities could be prompting kids to drink sugary beverages.

The water study is part of a five-year project investigating whether community-based intervention can help prevent childhood obesity.

By Jeannette Warnert, ANR

Having established a link between obesity and sugary beverages, doctors and nutritionists recommend that children instead drink plain tap water. In virtually all of the United States and California, tap water is the best drink available for good health.

However, a team of UC Cooperative Extension and UC Davis scientists have found that low-quality tap water in some rural immigrant communities could be an obstacle to making this healthy dietary change.

The study was conducted in conjunction with a five-year research and outreach project underway in Firebaugh and San Joaquin, small communities in the San Joaquin Valley with high Mexican-American populations. The researchers are investigating whether a community-based intervention – involving nutrition education, a monthly voucher of $25 to purchase fruit and vegetables, and a physical activity program – can help prevent childhood obesity in Californians of Mexican descent living in low-income rural communities. UC Agriculture and Natural Resources and UC Davis were recipients of a $4.8 million National Institute for Food and Agriculture grant to carry out this research.

Twenty-seven mothers in the study shared with the researchers whether they use tap water and gave their perceptions of tap water quality. In addition, the researchers assessed local water quality by the frequency of violations reported by Cal EPA and contaminant-level data from the California Department of Public Health.

Contamination concerns

All 27 mothers said they avoid drinking tap water due to unpleasant taste, dirty or yellow appearance, excessive iron or general “contamination.” Most of the women rely instead on bottled, and to a lesser extent, home filtered water for drinking and cooking.

“This cost is an extra burden for these families, many of whom have limited incomes,” said Lucia Kaiser, UC Cooperative Extension specialist in the Department of Nutrition at UC Davis.

The mothers shared in interviews that at least 38 percent of their children aged 3 to 8 years old drank sugar-sweetened beverages – such as soda, energy drinks, powered drink mixes or fruit punch – more than two or three times per week.

“The children may be drinking sugar-sweetened beverages so frequently because of real or perceived low quality of water coming from their taps,” Kaiser said. “I’m not surprised. One time I was in our Firebaugh office and turned on the tap and the water came out brown. “

Two state-regulated water systems serve the majority of people in Firebaugh and San Joaquin. The rest rely on at least 11 small public or private systems. All of the 13 systems have had monitoring violations in the last 12 years. Two have had reporting violations, indicating that they either did not test for contaminants or did not report their findings.

Seeking solutions

The mothers’ perception that tap water was unappealing or contaminated was confirmed when the researchers took a close look at regulatory analyses reports from previous years. There were low-levels of arsenic detected, which fell above the benchmark for safe drinking water in the U.S. The analyses also detected high levels of manganese and iron, which are considered secondary contaminants and do not have enforceable limits set by the EPA. However, the World Health Organization has set health benchmarks for manganese, which were exceeded in some samples.

“The neurotoxic effects of manganese and chronic exposure to low levels of arsenic warrant further study,” Kaiser said. “Even if it’s not dangerous, the high level of manganese and iron can give the water an off taste.”

Regardless, removing the contaminants may not matter if perceptions and drinkability are not improved. A possible solution is better communication.

“A simple step could be sending easy-to-understand water quality reports to all residents,” Kaiser said. “Sending reports to renters in addition to property owners and in Spanish as well as English will help raise awareness about the safety of local tap water.”

The study was funded in part by the UC Davis Center for Poverty Research, which developed a two-page policy brief outlining the research findings. UC Davis doctoral student Caitlin French was the main author. Other contributors, in addition to Kaiser, were postdoctoral researcher Rosa Gomez-Camacho, UC Cooperative Extension nutrition, family and consumer sciences advisor Cathi Lamp and UC Davis nutrition professor Adela de la Torre.

In the policy brief, the authors included some additional suggestions to address the issue:

  • Increase state funds to agencies working to identify who is at risk in order to bring more water systems into compliance
  • Provide subsidies for home water filters
  • Provide subsidies to private well owners in exchange for testing reports
  • Step up outreach to owners of targeted private water systems in known problem areas
  • Provide funding for additional research to inform outreach messages about substituting tap water for sugar-sweetened beverages

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MRI technique developed for nonalcoholic fatty liver disease in children


UC San Diego study makes strides toward noninvasive diagnostic for pediatric liver disease.

By Heather Buschman, UC San Diego

Between 5 and 8 million children in the United States have nonalcoholic fatty liver disease (NAFLD), yet most cases go undiagnosed. To help address this issue, researchers at UC San Diego School of Medicine have developed a new magnetic resonance imaging (MRI)-based technique to help clinicians and researchers better detect and evaluate NAFLD in children. The study is published today (Feb. 5) in Hepatology.

“Currently, diagnosis of NAFLD requires a liver biopsy, which is not always available or performed. This leads to both misdiagnosis and missed diagnoses, hampering patient care and progress in clinical research,” said Jeffrey B. Schwimmer, M.D., professor of clinical pediatrics at UC San Diego, director of the Fatty Liver Clinic at Rady Children’s Hospital-San Diego and the first author of the study. “Thus, a noninvasive method for diagnosing and/or evaluating NAFLD has the potential to impact millions of children.”

NAFLD is characterized by large droplets of fat in at least 5 percent of a child’s liver cells. Obesity and diabetes are risk factors for NAFLD. Doctors are concerned about NAFLD in children because it can lead to hepatitis, liver scarring, cirrhosis and liver cancer.

Traditionally, NAFLD is diagnosed by a gastroenterologist in consultation with a pathologist, who examines the patient’s biopsied liver tissue under a microscope. The presence and severity of liver fat is graded by the pathologist as none, mild, moderate or severe, based on the percentage of liver cells that contain fat droplets.

In an effort known as the MRI Rosetta Stone Project, Schwimmer and colleagues used a special MRI technique known as magnitude-based MRI, which was previously developed by researchers in the UC San Diego Liver Imaging Group, to estimate liver proton density fat fraction (PDFF), a biomarker of liver fat content.

“Existing techniques for measuring liver fat are dependent upon the individual scanner and the center at which the measurements were made, so they cannot be compared directly,” said Claude B. Sirlin, M.D., professor of radiology at UC San Diego and senior author of the study. “By comparison, PDFF is a standardized marker that is reproducible on different scanners and at different imaging centers. Thus, the results of the current study can be generalized to the broader population.”

In this study, the researchers compared the new MRI technique to the standard liver biopsy method of assessing fat in the liver. To do this, the team enrolled 174 children who were having liver biopsies for clinical care. For each patient, the team performed both MRI-estimated PDFF and compared the results to the standard pathology method of measuring fat on a liver biopsy.

The team found a strong correlation between the amount of liver fat as measured by the new MRI technique and the grade of liver fat determined by pathology. This is an important step towards being able to use this technology for patients. Notably, the correlation was influenced by both the patient’s gender and the amount of scar tissue in the liver. The correlation between the two techniques was strongest in females and in children with minimal scar tissue.

Depending on how the new MRI technology is used, it could correctly classify between 65 and 90 percent of children as having or not having fatty liver tissue.

“Advanced magnitude MRI can be used to estimate PDFF in children, which correlates well with standard analysis of liver biopsies,” Schwimmer said. “We are especially excited about the promise of the technology for following children with NAFLD over time. However, further refinements will be needed before this or any other MRI technique can be used to diagnose NAFLD in an individual child.”

Study co-authors include Michael S. Middleton, Cynthia Behling, Kimberly P. Newton, Hannah I. Awai, Melissa N. Paiz, Jessica Lam, Jonathan C. Hooker, Gavin Hamilton and John Fontanesi, all at UC San Diego.

This research was funded, in part, by the National Institutes of Health (grants UL1RR031980, DK088925-02S1 and R56-DK090350-01A1) and the National Science Foundation (grant 414916).

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A simple information sheet can help women avoid birth defects


Sheet for women being treated for severe acne improves understanding of risks.

By Phyllis Brown, UC Davis

An information sheet for women being treated for severe acne improves understanding of contraceptive effectiveness and ways to avoid pregnancy and medication-induced birth defects, a study published today (Feb. 4) in JAMA Dermatology has found.

Isotretinoin (brand name, Accutane), a medication used to treat severe acne, is well-known for its risk of medication-induced birth defects, which include facial deformities, missing or malformed earlobes, and mental retardation. Although use of isotretinoin has been strictly regulated, pregnancies affected by the medication continue to be reported, because many women who take it rely on contraceptives that may fail.

For the study, conducted between April and May 2014, researchers asked 100 English-speaking women, 18 to 45, seated in the waiting room of one urban dermatology practice to indicate the contraceptives of which they were aware and categorize their effectiveness before and after reviewing a contraceptive information sheet. A research assistant noted how long each participant spent reviewing the information sheet and collected demographic information about each participant.

The study found that prior to receiving the contraceptive information sheet, over half of the women overestimated the typical effectiveness of condoms, contraceptive injections and oral contraceptives, and many had never heard of the subdermal contraceptive implant or the intrauterine device, which are among the most effective contraceptives. Fifty-five percent of participants overestimated the typical effectiveness of condoms and many overestimated the effectiveness of oral contraceptives, which typically fail in 9 percent of women within their first year of use.

Eleanor Bimla Schwarz, UC Davis

“We found that women who spent less than one minute reviewing a contraceptive information sheet while waiting to see their dermatologist demonstrated significant improvement in their knowledge of highly effective contraceptives,” said Eleanor Bimla Schwarz, professor of medicine in the UC Davis School of Medicine and the study’s senior author.

Physicians who treat women with isotretinoin participate in a program called iPledge, which is aimed at protecting women from pregnancy while taking isotretinoin. Schwarz and her colleagues said the study highlights the need to update the iPledge program materials to ensure that women prescribed isotretinoin receive effectiveness information about their contraceptive options.

She noted that subdermal contraceptives, like all medications that suppress ovulation, improve acne for the majority of women. The study indicates that up-to-date information about modern contraceptives methods, linked with prompt referral to a clinician able to place implants or intra-uterine devices (IUDs), may dramatically decrease rates of medication-induced birth defects related to this powerful acne medication.

Other study authors include Carly A. Werner, Melissa J. Papic and Laura K. Ferris of the University of Pittsburgh School of Medicine. The study was funded by the Food and Drug Administration grant U01FD004235-01.

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Newborn foals may offer clues to autism


Common link, researchers suggest, may be abnormal levels of naturally occurring neurosteroids.

Veterinary researchers at the University of California, Davis, are teaming up with their colleagues in human medicine to investigate a troubling disorder in newborn horses and are exploring possible connections to childhood autism. The common link, the researchers suggest, may be abnormal levels of naturally occurring neurosteroids.

The horse disorder, known as neonatal maladjustment syndrome, has puzzled horse owners and veterinarians for a century. Foals affected by the disorder seem detached, fail to recognize their mothers and have no interest in nursing.

“The behavioral abnormalities in these foals seem to resemble some of the symptoms in children with autism,” said John Madigan, a UC Davis veterinary professor and expert in equine neonatal health.

The maladjustment syndrome in foals also caught the attention of Isaac Pessah, a professor of molecular biosciences at the UC Davis School of Veterinary Medicine and a faculty member of the UC Davis MIND Institute, who investigates environmental factors that may play a role in the development of autism in children.

“There are thousands of potential causes for autism, but the one thing that all autistic children have in common is that they are detached,” Pessah said

Madigan, Pessah and other researchers in veterinary and human medicine recently formed a joint research group and secured funding to investigate links between the two conditions.

(See news feature story. A press kit, including video b-roll and high-resolution still images, is available.)

Maladjusted foal syndrome

In newborn foals, neonatal maladjustment syndrome, or dummy foal syndrome, occurs in 3 to 5 percent of live births. With around-the-clock bottle or tube feeding plus intensive care in a veterinary clinic for up to a week or 10 days, 80 percent of the foals recover. But for horse owners, that level of care is grueling and costly.

For years, the syndrome has been attributed to hypoxia — insufficient oxygen during the birthing process. Madigan and UC Davis veterinary neurologist Monica Aleman began sleuthing around for other potential causes, however, noting that hypoxia usually causes serious, permanent damage, while most foals with the maladjustment syndrome survive with no lingering health problems.

One of their prime suspects was a group of naturally occurring neurosteroids, which are key to sustaining pregnancies in horses, especially in keeping the foal “quiet” before birth.

Foals remain quiet in the womb

“Foals don’t gallop in utero,” Madigan is fond of saying, pointing out the dangers to the mare if a four-legged, hoofed fetus were to suddenly become active in the womb. The prenatal calm is made possible, he explains, by neurosteroids that act as sedatives for the unborn foal.

However, immediately after birth, the infant horse must make an equally important transition to consciousness. In nature, a baby horse would be easy prey for many natural enemies, so the foal must be ready to run just a few hours after it is born.

In short, somewhere between the time a foal enters the birth canal and the moment it emerges from the womb, a biochemical “on switch” must be flicked that enables the foal to recognize the mare, nurse and become mobile. Madigan and Aleman suspect that the physical pressure of the birthing process may be that important signal.

“We believe that the pressure of the birth canal during the second stage of labor, which is supposed to last 20 to 40 minutes, is an important signal that tells the foal to quit producing the sedative neurosteroids and ‘wake up,’ ” Madigan said.

Neurosteroids persist in the bloodstream

The theory, he says, is supported by the fact that the maladjusted foal syndrome appears more frequently in horses that were delivered via cesarean section or experienced unusually rapid births. Perhaps those foals do not experience significant physical pressure to trigger the change in neurosteroids, Madigan said.

Furthermore, the research team has found for the first time that sedative neurosteroids persist, and their levels often rise, in the bloodstream of foals born with symptoms of the maladjustment syndrome. These neurosteroids are known to be able to cross the blood-brain barrier and impact the central nervous system, acting on the same receptor as do sedatives and anesthetics.

The researchers also have demonstrated that maladjustment symptoms can be brought on temporarily in normal, healthy foals by administering short infusions of a neurosteroid called allopregnanolone. When the neurosteroid levels drop, the foals return to their normal state.

Foals ‘wake up’ with gentle harness pressure

Amazingly, the veterinary researchers have found that they can reduce maladjustment symptoms in foals by using several loops of a soft rope to gently squeeze the foal’s upper torso and mimic the pressure normally experienced in the birth canal. When pressure is applied with the rope, the foal lies down and appears to be asleep.

After 20 minutes — about the same time a foal would spend in the birth canal — the rope is loosened and the squeeze pressure released. In initial cases, the foals have responded well to the procedure and recovered, some rising to their feet within minutes and then bounding over to join the mare and nurse.

The researchers suspect that the pressure triggers biochemical changes in the central nervous system that are critical for transitioning the foal from a sleeplike state in the womb to wakefulness at birth.

While larger studies are underway, the researchers have presented their results at national and international meetings of equine veterinarians, and many veterinarians and clinics are treating maladjusted foals with the squeeze procedure — now called the Madigan Foal Squeeze Procedure.

Madigan cautions that, in spite of the strong observational effects, a larger, controlled clinical trial of national and international scope is now needed to reproduce those observed results and provide a better understanding of the mechanisms at work in the foals.

Foal behaviors resemble autism

The early findings have compelling implications for the health of newborn foals, and have caused the researchers to also explore possible links to autism, which includes a group of complex brain-development disorders. While the symptoms vary, these disorders are generally marked by difficulties with social interactions, verbal and nonverbal communication, and repetitive behaviors.

“The concept that a disruption in the transition of fetal consciousness may be related to children with autism is intriguing,” said Pessah, noting that the behaviors seen in the maladjusted foal syndrome truly are reminiscent of those in some autistic children.

He notes that some children with autism do outgrow autistic behaviors by the time they reach their teen years. Could this be a parallel to the recovery of the foals with the maladjustment syndrome?

Investigating possible links

A new group called the Comparative Neurology Research Group, consisting of veterinarians, physicians, epidemiologists and basic-science researchers, has formed to pursue further studies in this area. Madigan is working with researchers at the Stanford School of Medicine, exploring the mechanisms of post-birth transitions of consciousness related to neonatal care of infants.

Using data from the foal research, Pessah and Madigan are working with environmental epidemiologist Irva Hertz-Picciotto at the UC Davis MIND Institute to investigate neurosteroids in children with varying degrees of autism, ranging from some developmental delay to full-spectrum autism.

The researchers are exploring whether abnormal regulation of neurosteroids during the time around childbirth could be one of many factors that might contribute to autism and related neurodevelopmental disorders. A recent study has reported elevated levels of neurosteroids in children with autism spectrum disorder.

Pessah and colleagues will be looking to see whether there are alterations in blood levels of certain neurosteroids that may serve as a marker for the disorder. They caution, however, that the relationship right now is just a theory that remains to be validated or disproven.

More information about this research effort.

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Caring for the child’s brain


Pediatric Brain Center provides holistic care for patients’ full range of brain-related needs.

Audrey Price

By Kathleen Masterson, UC San Francisco

Fifteen-year-old Audrey Price slowly reaches for an orange plastic cup sitting on the counter. In a concerted effort, her fingers close around it, and she lifts it to chest height, shaking ever so slightly.

For Audrey, this simple act marks a tremendous journey from diagnosis to brain surgery to therapy and slow healing.

Just 11 months ago, she was living a typical middle-schooler’s life in a Bay Area suburb, hanging out with friends, playing tennis and obsessing over the British boy band, One Direction.

Then Audrey began developing weakness in her right side. After a series of doctor’s appointments, she ended up visiting a neurologist, who ordered scans of her brain that showed an aneurysm the size of a golf ball pressing on her brain stem.

That’s when her neurologist called UC San Francisco.

Audrey was brought into the newly formed Pediatric Brain Center at the UCSF Benioff Children’s Hospital San Francisco, which integrates neurology, neurosurgery, physical and occupational therapy, speech, social work and neuro-psychology to provide seamless holistic care for patients’ full range of brain-related needs. It’s one of just a few specialized pediatric brain centers in the U.S.

The center’s unique structure and specializations ended up being an ideal match for Audrey’s rare and complex condition.

Heather Fullerton and Nalin Gupta lead UC San Francisco's Pediatric Brain Center, which opens a new, centralized location at the new UCSF Benioff Children's Hospital at Mission Bay on Feb. 1. (Photo by Cindy Chew)

Bringing the doctors to the patient

The Pediatric Brain Center was founded about two years ago, spearheaded by Heather Fullerton, M.D., and Nalin Gupta, M.D. The center brings together a diverse range of UCSF experts from across multiple departments to treat patients together, as a team.

Rather than the typical experience in which a patient may see one doctor and then be referred to another specialist, and then another, chasing multiple appointments over weeks, at the Pediatric Brain Center the physicians, nurses and other key staff coordinate the care around the patient. One coordinator books all the patient’s appointments, from check-ups to arranging tests to surgery, and each patient is treated by a team assembled specifically to meet his or her unique medical needs.

“The goal was to make not only the patient experience, but also the problem solving and treatment, more rational. We wanted to be able to design our care around the patient’s medical issue, as opposed to simply following the organizational structure of the institution,” said Gupta.

Initially the center existed mainly as an organization change, with all the experts still located in separate offices at Parnassus. With the Feb. 1 opening of the UCSF Medical Center at Mission Bay, the Pediatric Brain Center will soon have it’s own central location to further streamline the patient experience.

“It’s so much easier for the family to have one place to go for all their child’s care, all the way from the initial treatment to rehabilitation,” said Fullerton.

Unique expertise in research and care

Having a centralized space will help make the patient experience smoother, but the crux of the Pediatric Brain Center is its network of highly specialized researchers, clinicians and surgeons.

“Having clinicians and researchers together helps inform what we study,” said Fullerton, a practicing neurologist who also researches pediatric strokes. “So many of our clinicians are also researchers, so when a question comes up in clinic, we can use our own local expertise to start the search for an answer. For example if I keep seeing this strange-looking blood vessel, I can turn around and start a study to investigate what’s happening.”

That’s a distinct advantage of an academic medical center. Private practices couldn’t afford the freedom to develop deep expertise in narrow areas, said Gupta. Furthermore, a child’s brain isn’t like the adult brain; treating a growing brain requires specialized neurology expertise.

“With the Pediatric Brain Center, we’re explicitly trying to leverage the strengths of the institution,” said Gupta. “We have people that have lot of expertise in narrow areas, and by definition those are often rare things.”

Building a specialized team

The Pediatric Brain Center brings all these diverse experts together, forming a unique treatment team made up of specialists relevant to each patient’s needs.

That’s vital for patients like Audrey, said Gupta.

“What Audrey had was very rare and complex. She’s an example of type of patient that there isn’t a list of 500 patients like that,” he said. “It’s not like other conditions where we could simply look to see what did we do for last 500.”

So Audrey’s doctors assembled a team of neurologists and neurosurgeons to develop a plan to remove the brain aneurysm.

“Audrey’s surgical team in consultation was so calm, they really explained things really well in terms we understood,” said her mother, Barbara Price. “We left there feeling very relieved this was treatable, that we were not in emergency situation and we had one of best surgical teams in the world that would treat her.”

Audrey’s surgery went well, and the team was able to remove the brain aneurism safely.

However, when she came out of surgery, she could hardly move the right side of her body. Her doctors quickly called in another team member, Jonathan Bixby, M.D., who specializes in physical rehabilitation.

“Unlike some other aspects of medicine, rehabilitation is dependent on how much effort the patient puts in,” said Bixby.

“Audrey was great. With any patient dealing with significant changes to the body, there can be issues adjusting. Audrey adjusted quickly, and was very willing to work with a therapist.”

Ongoing team care

Audrey is continuing to get stronger every day. She does her physical therapy daily at home, has learned to do nearly everything with her left hand and was able to start high school last fall.

She got there after spending six weeks living at the hospital after her surgery; she practiced physical therapy six hours a day, six days a week. It’s exhausting work, but her therapists strived to incorporate Audrey’s interests into her exercises to make it more fun, including using therapy dogs and playing One Direction’s music during sessions.

“The hardest part is not knowing when my body is going to be back to the way it was,” she said. “The doctors said, ‘all brains are different,’ and that was the most frustrating part.”

Throughout her hospital stay, her bed was covered in a fleece blanket with the One Direction’s faces on it, including her favorite singer, Niall.

Barbara Price recalled that one day Audrey came back to her room to find a note atop her One Direction blanket that read something like: “‘Dear Audrey, I’m really proud of all the hard work you’re doing’ then the note quoted lyrics from one of the songs. It was signed,  ‘Love, Niall,” she said with a laugh. One of the doctors had scripted this joking note of encouragement.

“The team was so funny and thoughtful, so we had a lot of laughs that got us through some tough times.”

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UCSF, CMC sign letter of intent to increase pediatric, women’s health services


Collaboration to expand services in Valley would build on foundation of existing relationship.

By Karin Rush-Monroe, UC San Francisco

UCSF Medical Center and Community Medical Centers (CMC) have signed a letter of intent (LOI) to expand women’s and children’s services to the Central Valley, which has an undersupply of specialists for a growing population. The collaboration also would broaden medical education services in the area.

CMC, a Fresno-based regional health system, owns and operates Community Regional Medical Center (CRMC) and other licensed general acute care hospitals and outpatient centers in Fresno and Clovis that serve Fresno County and the surrounding counties.

“The delivery of health care is changing. We’re going to rely on medical information technology and strong alliances with private and academic physicians to more efficiently manage the health of entire families. This project with UCSF will be a key part of that,” said Craig Wagoner, CEO at Community Regional Medical Center.

The shared vision of CMC and UCSF includes development of a clinically integrated health system to facilitate better sharing of information in order to manage patient health; improved access to high-quality pediatric services in Fresno and surrounding communities; higher acuity pediatric services at CRMC to reduce the need for patients’ families to travel outside of Fresno; and increased integration of the academic and training missions of UCSF and CRMC.

An immediate goal for 2015 is to increase the availability of specialists at CRMC by this summer.

UCSF School of Medicine, which consistently is ranked among the nation’s top medical schools, has for decades operated a graduate medical education program in collaboration with Community, the San Joaquin Valley’s largest hospital organization.

About 300 UCSF medical residents and fellows currently practice on the Community Regional Medical Center campus, which is the Valley’s Level 1 trauma center. Pediatrics is one of 22 specialties currently offered in the Fresno-based graduate medical education program.

The collaboration among UCSF Fresno, CRMC and Valley Children’s Healthcare has afforded UCSF residents the ability to receive high-quality residency training across the entire spectrum of pediatric needs within a diverse set of clinical settings. UCSF remains firmly committed to maintaining and strengthening this long-time, top-ranked pediatric residency program for the benefit of patients, the community and the entire San Joaquin Valley.

“This is the next logical step in our relationship with Community,” said Michael Peterson, M.D., interim associate dean for UCSF Fresno. “The medical school is committed to serving the Valley, and our leadership team in San Francisco is excited about the opportunity to partner with the Community Regional Medical Center and build a leading-edge women’s and children’s program.”

“We have a great relationship with Fresno and the Central Valley, and this partnership with Community Medical Centers will strengthen that relationship,” said Stephen Wilson, M.D., Ph.D., associate chief medical officer for UCSF Benioff Children’s Hospital San Francisco. “This is an opportunity to better integrate our women’s and children’s services in the region and support UCSF’s mission to provide care to patients in areas that are underserved.”

UCSF has been providing services in Fresno for decades. Established in 1975 and now celebrating its 40th anniversary, the UCSF Fresno Medical Education Program plays a substantial role in providing health care services to residents of California’s San Joaquin Valley and training medical professionals in the region. A clinical branch of UCSF, the Fresno medical education program has trained approximately one-third of Central San Joaquin Valley physicians.

Faculty and medical residents at UCSF Fresno engage in a broad spectrum of research addressing health issues pertinent to the Valley. Faculty and residents also care for the overwhelming majority of the region’s underserved populations at health care facilities like CRMC.

In addition, UCSF Fresno provides academic preparation programs for middle- and high school students interested in the health professions through the Junior Doctors Academy and the Doctors Academy. UCSF Fresno academically prepares students at Fresno State to become competitive applicants to health professional schools and ultimately aims to prepare them for careers in health and medicine. UCSF Fresno also is a key partner in the UC Merced San Joaquin Valley Program in Medical Education.

The collaboration is anticipated to be finalized in the fall of 2015.

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Tiny infant has big impact on his community


Tiny Smiles Half Marathon is scheduled for Feb. 7.

By Tricia Tomiyoshi, UC Davis

“Miles” Keiser, though nicknamed “Tiny” by his family, an infant treated at UC Davis Children’s Hospital in 2011, is having a big effect on the lives of children with congenital heart disease in Sacramento and on his community.

Born in Northern California in June 2011, Tiny would undergo the first of three planned surgeries to correct hypoplastic left heart syndrome 10 days after birth, and would be treated afterward in the UC Davis Children’s Hospital Pediatric Intensive Care Unit/Pediatric Cardiac Intensive Care Unit.

The infant received his diminutive nickname from his pre-adoptive parents, Rick and Jean Keiser of Galt, who already had adopted two of Tiny’s siblings and were in the process of adopting their brother.

Tiny would spend most of his young life with his family at the hospital, punctuated by short visits in the Keiser home. The Keiser family was always by his side. Despite the best efforts of his physicians, chief among them associate professor of surgery and pediatrics Gary Raff, in December of 2011 Tiny lost his struggle to survive at just 6 months of age.

“We made some great friends in the hospital, including Dr. Raff and his team, all of the physicians in the PICU/PCICU and his cardiologists Michael Choy and Mark Parrish,” Rick Keiser said. “Everyone was amazing, from the housekeeping staff to Dr. Raff. They were incredible.”

After struggling with the loss of their child, the Keisers decided to establish a commemorative race in Tiny’s honor, the Tiny Smiles Half Marathon – “the tiny half,” to give back to the Children’s Hospital and other pediatric cardiac organizations. This year, 2015, Tiny Smiles has made the Children’s Heart Foundation one of its beneficiaries.

The Tiny Smiles Half Marathon is scheduled for Saturday, Feb. 7. On-site registration starts at 6 a.m. and the event ends at noon. It will combine a half-marathon of 13.1 miles starting at 8 a.m.; a 5 kilometer and 10 kilometer race starting at 8:15 a.m.; and a kids’ fun run starting at 9 a.m.

The race starts at Civic Drive and Chabolla Avenue in Galt; it ends at the Galt Fairgrounds. The half-marathon registration fee is $70; the 5k and 10k registration fee is $40. Registration closes on Thursday, Feb. 7, and is available through this link.

Tiny Smiles already has had some fundraising successes, including holding multiple blood drives and raising more than $10,000 for the UC Davis Children’s Hospital Pediatric Intensive Care Unit/Pediatric Cardiac Intensive Care Unit. Race sponsors include Fleet Feet Sports of Stockton; Central Valley Physical Therapy; SMUD, UC Davis Children’s Hospital, The City of Galt, Pro Transport Ambulance, The Taylor Family Foundation, Spaans Cookies and more.

For additional information about the race, please contact Rick Keiser at rick@tinysmilesrace.org, or (209) 329-4692.

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Project ADAM’s first California affiliate established at UC Davis


Program helps prevent sudden cardiac arrest in children and teens.

Stuart Berger, UC Davis

By Tricia Tomiyoshi, UC Davis

A life-saving program that helps to prevent sudden cardiac arrest in children and teens has now arrived in California.

UC Davis Children’s Hospital in Sacramento has become the first California affiliate for Project ADAM (Automated Defibrillators in Adam’s Memory), a nonprofit organization dedicated to establishing comprehensive defibrillation programs in schools across the country. The program’s mission is to reach out to schools to ensure that automated external defibrillators (AEDs) are installed and that staff, faculty, students and families are trained how to use them and to perform CPR.

Stuart Berger, chief of the Division of Pediatric Cardiology at UC Davis Children’s Hospital, founded Project ADAM while he was working at the Children’s Hospital of Wisconsin in 1999. The program has since expanded to 10 states in its 15 years of operation and more than 85 lives have been saved in children and adolescents as well as adults.

“I’m very excited to bring Project ADAM to the Sacramento region,” said Berger. ”This has been such a wonderful community outreach project. It has brought the community together at multiple levels and it has saved livesIt would be wonderful to institute this program in every school in the state of California as well as in the entire country.”

The Sacramento Kings will host a night dedicated to heart health awareness on Feb. 20. A portion of proceeds from tickets purchased through this ticket link (using passcode: Kings) will be donated to the Sacramento Project ADAM.

Project ADAM was named in honor of 17-year-old Wisconsin high school basketball player, Adam Lemel, who died on the court due to an undiagnosed genetic heart condition. According to Berger, at least 100 to 200 children and teens experience sudden non-traumatic cardiac death each year in the U.S., although the exact number is unclear and this number could be an underestimate of the true incidence. Multiple studies, including the new National Institutes of Health and Centers for Disease Control and Prevention’s Sudden Death in the Young registry, have been designed to get more specific data about the incidence of this devastating problem.

Schools, organizations and community members interested in being a part of Sacramento Project ADAM are welcome to attend the next community meeting on Thursday, Jan. 29, at 5:30 p.m. at the UC Davis Health System Facilities Support Services Building, 4800 2nd Ave., Sacramento in Room 2030.

For more information, please contact Amber Lindgren, administrator for the Sacramento Project ADAM, at (916) 734-2460 or amber.lindgren@ucdmc.ucdavis.edu.

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