Q & A with Raul Coimbra: Treating Trauma as a Disease
Trauma. The word itself invokes images of an emergency: a car accident, heart attack, or bad fall. Something that cannot be anticipated but requires immediate action.
However, many causes of trauma can be prevented, and therefore fit the criteria for disease, according to Raul Coimbra, MD, PhD, chief of Trauma, Surgical Care, and Burns for UC San Health System and co-director of the Injury Epidemiology, Prevention and Research Center. We’ve asked Coimbra several questions about how people can prevent trauma and why trauma needs to be treated as a preventable disease.
Question: It’s trauma awareness month – why is it important for the community to recognize this and understand their role in prevention?
Answer: Trauma is a disease that kills more people between one and 45 years of age than any other disease in the world. In addition, trauma leads to more years of life lost than any other disease, including cardiovascular diseases and cancer. Productive individuals are being taken away from their families, their jobs, and their environment because of injuries. Many die, and for every death, six individuals will be forever disabled. However, this is a completely preventable disease. The public has a responsibility in preventing injuries, as in most circumstances, it is human behavior that leads to injury.
Q: What are some simple prevention tips people can implement in their homes, yards, etc. that could save them a trip to the trauma center or even their lives?
A: For children at home, the most frequent causes of injury are drowning and burns. Therefore, the use of fences with alarms around swimming pools and constantly watching kids in the kitchen so they cannot reach out to frying pans or boiling liquids on the stove is very important. For the adult population, drinking and driving is a very common cause of injury. Avoiding driving after drinking, finding a designated driver, or catching a cab would be examples of preventive strategies. In the elderly population, securing rugs and furniture on the floor, as an example, will decrease the risk of injury at home. For all ages, wearing a seat belt while driving is key.
Q: Most people don’t think of trauma as a disease. Please explain this philosophy.
A: Trauma is a disease like any other. We know how to define it, we know how to treat it, and more importantly, we know how to prevent it, therefore, it is a disease like any other. Unfortunately, the public’s perception is that trauma is an accident that only happens to somebody else, but that is not the case.
Q: San Diego’s trauma system is used as a model worldwide. What makes it successful and what are your goals for future trauma systems?
A: San Diego has one of the most organized trauma systems in the world. The commitment of six trauma centers and the county EMS has been the same for the last 28 years. This is a model trauma system, and I would go even further to say that our system is a model for regionalized care applicable to any disease. Competing healthcare systems work together, in a very collegial way, to provide the best care possible to trauma patients. As a result, the San Diego trauma system has one of the lowest preventable death rates in the world. In our system, we do not compete with each other; we work together on behalf of the injured patient.
The trauma program at UCSD has provided guidance and help to many other systems in the world, and we plan to continue with those activities. We have received healthcare providers from several countries who spend three weeks with us learning the intricacies of the system and how to build an effective trauma center. This international outreach is very important in disseminating the concept of trauma as a disease. Just as an example, in August 2012, we will be presiding the first World Trauma Congress in Rio de Janeiro, Brazil, where we will be discussing a global agenda for trauma care, particularly focusing in middle and low income countries, where trauma is the most important health care problem.
William Sandborn, MD, chief of gastroenterology, at UC San Diego Health System, discusses a clinical trial for a promising therapy for patients with ulcerative colitis that can be self-administered.
The Skin You’re In: three questions for our expert on melanoma
Researchers at the Mayo Clinic have reported that melanoma rates are on the rise in 18 to 39 year olds. For years we have been bombarded with information about sun-safety and the importance of wearing sunscreen and limiting exposure – so why this increase?
We’ve asked Greg Daniels, PhD, MD, associate clinical professor of Medicine at the UC San Diego School of Medicine and coordinator of UC San Diego Moores Cancer Center’s clinical melanoma program three questions about the rise of melanoma and what people can do to protect themselves.
Question: The Mayo study cites tanning bed exposure as one cause of this uptick in melanoma rates amongst younger patients but representatives for the tanning bed industry are denying that their beds are unsafe. Are tanning beds harmful? Is there a safe way to tan?
Answer: Melanoma is associated with intense intermittent exposure to UV. Tanning beds fit this description and melanoma incidence is higher in patients reporting tanning bed use.
Q: The message to wear sunscreen has been strongly promoted by the health care industry for years. How effective are sunscreens in preventing melanoma?
A: Sunscreen protection depends upon the proper use and quality of the block. The new FDA labeling guidelines will help clarify for consumers the protection afforded by the sun screens. Sun screens prevent non-melanoma skin cancers and damage to normal skin. The amount of protection sun screens offer regarding melanoma is not well defined.
Q: Many people know to pay attention to suspicious moles or skin abnormalities. Is there any one place where melanoma tends to show up on the body?
A: Skin awareness saves lives. Melanoma occurs at any site on the skin. Complete skin exams are essential. While some melanomas follow the pattern of pigmented lesion, some melanomas are not pigmented. It is important to look for any lesion that is either new or changing, particularly if the skin lesion is different than the lesions around them.
Grieving the Idealized Birth
May is recognized as Perinatal Depression Awareness Month, and national studies estimate one in five women suffer from postpartum depression. Many women enter pregnancy with an expectation of what the birthing experience might be like. One of the most common hopes that a woman has during her pregnancy is to have a natural childbirth, but if that doesn’t happen, it can lead to postpartum depression in some women. Amber Rukaj, MA, LMFT, reproductive and early childhood therapist with UC San Diego Health System, talks more about this condition and treatment options for women whose childbirth plan doesn’t go to plan.
“I had spent my whole pregnancy preparing to labor at home and have a natural childbirth. I felt strong and ready to connect with my inner birth warrior and deliver my baby without pain medication,” said new mom, Michelle Brubaker. “But, all that changed when my water started leaking and we were admitted into the hospital.”
Many women expect that if they are “strong enough” or “good enough” at labor that this hope will come to fruition. When Michelle and her husband, John, realized a C-section was the safest alternative for their baby, it was a huge learning lesson for the couple.
“We learned there is no plan in childbirt … except the one Mother Nature has for you. No matter how much you want things to go a certain way, it’s not up to you. It was time to surrender to Mother Nature, my body and our baby,” said Brubaker.
So what happens when the birth plan goes awry? Often it leaves women grieving their idealized birth and dealing with feelings of their body “failing” or even feeling “robbed” of their envisioned labor. Having a traumatic or perceived trauma of the delivery of a baby, can also result in postpartum post-traumatic stress disorder (PTSD). Approximately one to six percent of women experience postpartum post-traumatic stress disorder (PTSD) following childbirth. Most often, this illness is caused by a real or perceived trauma during delivery or postpartum. These traumas could include:
- Prolapsed cord
- Unplanned C-section
- Use of vacuum extractor or forceps to deliver the baby
- Baby going to the Neonatal Intensive Care Unit (NICU)
- Feelings of powerlessness, poor communication and/or lack of support and reassurance during the delivery
While not all women who don’t have their idealized pregnancy and labor experience suffer from Postpartum PTSD, many of them report feelings of grief and loss, depression, anxiety and an inability to fully enjoy being a new mom. Untreated, many of these feelings can develop into a postpartum mood and anxiety disorder (PMAD).
Symptoms of postpartum PTSD might include:
- Intrusive re-experiencing of a past traumatic event (which in this case may have been the childbirth itself)
- Flashbacks or nightmares
- Avoidance of stimuli associated with the event, including thoughts, feelings, people, places and details of the event
- Persistent increased arousal (irritability, difficulty sleeping, hypervigilance, exaggerated startle response)
- Anxiety and panic attacks
- Feeling a sense of unreality and detachment
Symptoms of Postpartum Depression might include:
- Feelings of anger or irritability
- Lack of interest in the baby
- Appetite and sleep disturbance
- Crying and sadness
- Feelings of guilt, shame or hopelessness
- Loss of interest, joy or pleasure in things you used to enjoy
- Possible thoughts of harming the baby or yourself
What should you do if you experience any of these symptoms? Please tell a family member and seek out support. You are not alone and you will eventually feel better. UC San Diego Health System’s Maternal Mental Health (MMH) program has trained clinicians who can help you grieve your idealized birth and help you adjust to motherhood.
Click here for more resources.
Anti-obesity research program at UC San Diego honored
The Active Living Research program, part of the Department of Family and Preventive Medicine in the UC San Diego School of Medicine, received the “Applied Obesity Research Award” yesterday, part of the Centers for Disease Control’s Pioneering Innovation Awards effort.
Jim Sallis, PhD, professor and director of Active Living Research, accepted the award at the CDC’s Weight of the Nation 2012 conference in Washington, DC.
Active Living Research is a national program, supported by the Robert Wood Johnson Foundation, that investigates how environments and policies influence physical activity among children and families, particularly among populations most at risk of obesity.
Placentophagia: Douglas Woelkers answers questions about the health benefits of ingesting human placenta
A recent paper by neuroscientists at the University of Buffalo and Buffalo State College asked why the practice of placentophagia – the ingestion of components of the placenta or afterbirth – was not more widely practiced among humans.
After all, it’s common practice among many other eutherian or placental mammals, where it’s believed to provide significant nutritional or health benefits to the mother. Why not human mothers too?
The scientists weren’t advocating the practice, only asking questions. Others, though, are already in the act. On the Internet, you can find businesses marketing human placentophagia for new mothers as a kind of post-natal health benefit. Typically, they offer to retrieve, process and encapsulate bits of the afterbirth – placenta-in-a-pill. Occasionally, the idea gets a boost from a celebrity endorser. In March, for example, the actress January Jones touted encapsulated placenta as her way to re-energize after giving birth.
Douglas Woelkers, MD, is an associate clinical professor in the Department of Reproductive Medicine at the UC San Diego School of Medicine and director of the UC San Diego Placenta Clinic, which assesses maternal and fetal health during pregnancy when there are risk factors for placental dysfunction. We asked him to assess placentophagia.
Question: First, the obvious biology question: What is the placenta? What does it do?
Answer: It’s a large, fast-growing, accessory organ that interfaces between the fetus and mother. It’s entirely derived from the conceptus, being genetically identical to the baby – not the mom. It has a short life-span, and naturally begins to regress by the end of pregnancy.
During pregnancy, it is connected to the baby by the umbilical cord and attaches loosely to the mother inside the uterus. Baby’s blood flows into the placenta through umbilical arteries, travels through a network of capillaries and returns, carrying back oxygen and nutrients delivered to the placenta by the mother’s blood.
The placenta is absolutely necessary for growth, development and birth of a healthy human baby. It’s sort of a life-support device that acts as the “lungs” for the baby. It delivers nutrients and removes wastes. It produces and regulates hormones involved in pregnancy and birth. It protects the baby from blood-borne pathogens. And it maintains an immunologically inactive interface with the mother to prevent rejection. In this way, the mother’s immune system becomes “tolerant” of the pregnancy.
Q: Why do many mammalian species practice placentophagy?
A: Biologists have proposed several reasons: cleaning the nest, eliminating bait for predators, carnivorous behavior reinforcement, hunger. For humans, the concept of eating or otherwise ingesting placenta is relatively new. A recent study of 179 human cultures did not find a single instance of accepted, ritualized maternal ingestion of placenta. The only historical references seemed to rise in the context of extreme starvation and deprivation, and even then only rarely.
Q: So why the interest now?
A: The practice seems to have originated in the 1970s in the U.S. and Mexico, where it was promoted for maternal rejuvenation and offered a health benefit based on nutritive speculation.
The placenta is made of structural support cells called cytotrophoblasts, which organize into small cavities that accommodate the mother’s blood. Overlying the structural cells is a metabolically active tissue layer that makes the hormones and such. There are also fetal capillaries and blood cells in the placenta. So, at delivery, the placenta contains quite a large mix of cell types, especially trapped maternal and fetal red blood cells. I am sure it would be rich in iron, but not particularly enriched with any other specific nutrient.
Q: What about those health claims, which range from boosting mother’s milk production to providing a psychological lift against postpartum depression?
A: There is no empirical evidence to support the claims of nutritional or psychological benefit. That’s not to say there can’t be some benefit, but to date, the data is sparse. I would argue that in a culture of sufficient nutrition such as ours, that there would be no benefit provided above and beyond that obtained by a normal balanced diet. It is improbable that women would gain any direct hormonal effect from placenta, as the protein hormones would be digested similarly to all other animal food products we consume. Eating chicken does not make you feel like a chicken.
Q: What about health risks of placentophagy?
A: The placenta serves as an intrauterine barrier to infection, and so it can and does get colonized by several types of human infectious agents. HIV, Hepatitis B and C, syphilis, chlamydia, gonorrhea and other bacteria can be identified in the placentas of women with these infections. At UC San Diego, we recently finalized a policy to address these issues, which prohibits retrieval of placental specimens once they have been processed by the pathology laboratory, or if the patient has tested positive for the above infectious agents during pregnancy. There are no laws to regulate retrieval or consumption of placentas; our policies seek to balance patient autonomy with public health risks.
Big Girls Don’t Cry
Study finds overweight teens who are satisfied with their bodies are less depressed, less prone to unhealthy behaviors
A study to be published in the June 2012 issue of Journal of Adolescent Health looking at the relationships between body satisfaction and healthy psychological functioning in overweight adolescents has found that young women who are happy with the size and shape of their bodies report higher levels of self-esteem. They may also be protected against the negative behavioral and psychological factors sometimes associated with being overweight.
3 Questions for our Expert on Fibroids
April 23 to 27 is Fibroid Awareness Week, a week dedicated to educating women on fibroids and empowering them to take control of their treatment options. In honor of this week, Shira Varon, MD, FACOG, assistant clinical professor in the UC San Diego School of Medicine’s Department of Reproductive Medicine, has answered three commonly asked questions about fibroids.
Question: What are fibroids?
Answer: Fibroids are smooth muscle tumors of the uterus that usually grow during reproductive years and shrink during menopause. They are hormone-responsive tumors and usually are not cancerous, however, oral contraceptives do not cause fibroids to grow, and in general, prevention of uterine fibroids is not possible unless a hysterectomy is performed. Forty percent of hysterectomies are performed due to symptoms of uterine fibroids. There are many genetic mutations that have been identified in fibroids, and they are more common in African American women.
Q: What treatment options are available for women with fibroids?
A: Treatment options include medical therapies to control heavy menstrual bleeding and shrink fibroids, minimally invasive surgical and nonsurgical options and major surgical procedures. One relatively new procedure being performed at UC San Diego is MR-guided focused ultrasound (ExAblate is the brand name of the procedure), and UC San Diego is one of three places in California to have this technology. Five UC sites (UC San Francisco, UC Davis, UC Los Angeles, UC Irvine, and UC San Diego) are collaborating for research and therapies to treat uterine fibroids. UC San Diego is creating a database of women with uterine fibroids that will be uses for research in the future.
Q: What are the symptoms of fibroids?
A: Common symptoms of fibroids include heavy menstrual bleeding, irregular menstrual bleeding, pelvic pain, painful periods, bloating, pain during sexual intercourse and urinary urgency/frequency.
Baby’s bony body
Newborns are a bundle of bones – more than 300 to be more precise. Over time, many of these bones fuse together. One obvious example: The 44 original, separate components of the skull, whose loose confederation allows a newborn’s head to more easily pass through the birth canal and to accommodate dramatic brain and head growth during in the first year of life outside the womb. Generally, an infant’s skull fuses together by age two to provide better protection of the brain.
Overall, the total number of bones in the body is reduced to 206 by the time humans reach adulthood.
Above is a human fetus visualized in the third trimester of pregnancy using a computed tomographic scan and volume rendering software. Courtesy of Philipp Gunz and Jean-Jacques Hublin at the Max Planck Institute for Evolutionary Anthropology in Germany.
From Shattered Elbow to Ground Breaking Mountain Climbs
Mountaineer, Ben Horne, has accomplished athletic endeavors that most people never even attempt in a lifetime – he’s finished marathons, climbed Mt. Whitney, ran the Grand Canyon from rim to rim, and most recently, made the first winter ascent of the Evolution Traverse – an eight mile route that links nine peaks in the Sierra.
“Our team climbed 36 hours over four days, enduring temperatures as low as negative seven degrees Fahrenheit,” said Horne, an economics graduate student at UC San Diego.
But three years ago, Horne never thought he would step foot on a mountain again after shattering his elbow during a long distance bike ride.
“I thought this was it – my lifestyle is over,” said Horne.
His elbow was crushed in five pieces upon impact.
“Because he is young, and an athlete, the team wanted to preserve his natural bone. We also wanted to avoid a prosthetic replacement, which is commonly used but unpredictable in terms of longevity. As a cyclist, I understood the flexibility and stability that Ben would require for cycling, climbing and swimming well into the future,” said Reid Abrams, MD, chief of hand and microvascular surgery at UC San Diego Health System.
During a delicate two-hour surgery, Abrams’ team re-built Horne’s elbow with a series of strategically placed plates, screws and pins woven with wire. After four months of healing, a second surgery was performed to remove hardware and to reduce bone adhesions to improve range of motion.
Now, due to surgery, physical therapy and Ben’s tenacity, he can fully flex his elbow.
“For mountain climbing, you have to be able to pull yourself up under rigorous conditions,” said Horne. “Since my surgery with Dr. Abrams, I’ve been able to climb at even higher levels. I’m a stronger athlete now because I had to learn different sports from cross training during the recovery process.”
“As a surgeon, and someone who has recovered from his own hand injury after a biking mishap, I understand the need to get back to doing what you love,” said Abrams. “I encourage every athlete to continue to pursue their passion after an accident. With the right surgery and follow-up care, the results can be amazing. Ben proves it every day.”
Since the surgery, Horne has completed an ironman and climbed Mt. McKinley in Alaska, referred to as “Denali,” which stands 20,320 feet tall and is the highest mountain in the United States.
“These latest accomplishments are a big deal for me personally. As my rock climbing group says, ‘go big and don’t cut corners,’ and Dr. Abrams made it possible to do so – I am forever grateful.”
