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National survey says many, not all, open to doctors talking about guns

In perhaps the first national survey of its kind, two-thirds of people sampled said it is at least sometimes appropriate for health care providers to talk to patients about firearms. The remainder said it is never appropriate.

The study, conducted by researchers from the University of Colorado Anschutz Medical Campus, the Harvard School of Public Health and Northeastern University, may encourage more providers to have these conversations with patients.

The study was published this week in the journal `Annals of Internal Medicine.’

Dr. Marian `Emmy’ Betz, associate professor of emergency medicine at the CU School of Medicine.

The 3,914 adults who completed the survey were asked: “In general, would you think it is never, sometimes, usually or always appropriate for physicians and other health professionals to talk to their patients about firearms?”

The survey posed the same question about alcohol, seat belts and cigarettes in the household.

Overall, 66 percent said it is at least sometimes appropriate for doctors to talk about firearms with patients.  About 81 percent said it is at least sometimes appropriate to talk about seatbelts.

The respondents were almost equally divided between men and women with a mean age of 49. Thirty percent had one child under 18 living at home. And 35 percent of respondents said they had one or more guns in the household.

More women (71 percent) than men (61 percent) said it is at least sometimes appropriate for providers to talk to patients about guns. Gun owners with a child at home or who viewed the firearm as a risk factor for suicide were more likely to support the idea of having the topic brought up.

“This suggests that discussions may be best received when they are clearly relevant to the clinical context,” the study said.

Dr. Marian Betz, MD, MPH, an associate professor at the University of Colorado School of Medicine and co-author of the study, said the survey results may encourage more healthcare providers to talk to patients about guns in the home.

“A doctor working with a patient with depression or risk factors for suicide should suggest that the patient considering making firearms less accessible until they recover, for example by storing the guns away from home,” Betz said. “And doctors are wise to recommend to parents of children or teenagers that they keep any household guns locked.”

Betz said it was important to recognize that 66 percent, not 100 percent, of respondents said it was sometimes acceptable to ask about guns.

“Patients can always decline to answer those questions,” she said. “But that shouldn’t deter a physician from bringing up the topic – in a respectful, nonjudgmental way – when relevant.”

Betz also noted that more work needs to be done to understand how to make these conversations more acceptable and impactful. Collaborations between public health professionals and firearm organizations could help in developing educational materials and messages.

The co-authors of the study include Deborah Azrael, PhD and Catherine Barber, MPA from the Harvard School of Public Health and Matthew Miller, MD, ScD from Northeastern University’s Bouvé College of Health Sciences.

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Rituximab and Ocrelizumab show promise in fighting MS

When Cathy Bryant went to the emergency room in 2011, she thought she was having a stroke. Her health had been perfect, so something sudden and unexpected seemed like the only logical explanation. However, the doctor had another diagnosis—she had Multiple Sclerosis (MS).

“It rocks your world when you find out something like that,” Bryant said. “My health had been wonderful, and then suddenly my world was upside down.”

Five years after her diagnosis, Bryant has fought the progression of MS with Rituximab, a cancer treatment drug that has shown astonishing potential in treating MS.

Augusto Miravalle and Cathy Bryant

Augusto Miravalle, MD, has been treating Cathy Bryant since she was first diagnosed with Multiple Sclerosis. The two have seen success in using Rituximab to treat MS.

Fighting MS head-on

After her ER diagnosis, Bryant sought treatment from the best doctors in the country. Her search eventually led her to Augusto Miravalle, MD, associate professor and vice chair of education in the Department of Neurology and member of the University of Colorado Multiple Sclerosis Center.

Cathy Bryant

Cathy Bryant

“I told him that I wanted him to treat me like he would a family member,” Bryant said. “I wanted to do everything to stop the progression of the MS. I didn’t want to be in a wheelchair.”

Bryant was drawn to Miravalle by his patience in making sure she and her family understood available options. She also appreciated the idea of treating the MS head-on.

“What differentiates our MS Center here at CU Anschutz is that we tend to be very proactive in stopping the disease from progression early on,” Miravalle said. “That’s why our patients tend to have better outcomes. We don’t waste time in using ineffective therapies.”

Time is of the essence when treating MS. According to Miravalle, without treatment, 50 percent of individuals with MS will require a cane for ambulation within 10 years of onset, 30 percent will need to use a wheelchair and life span is decreased. The disease is thought to affect more than 2.3 million people worldwide according to the National Multiple Sclerosis Society, including more than half a million Americans.

How Rituximab works

While there are 13 approved medications to treat MS, Miravalle and his colleagues have seen great success with Rituximab, a drug typically used to treat lupus or lymphoma.

Augusto Miravalle, MD

Augusto Miravalle, MD

MS, which impacts the central nervous system, is a disease in which the immune system is triggered to attack the brain and spinal cord. As a result, myelin, which protects nerve fibers, is destroyed, causing the disruption of signals to and from the brain, which creates a variety of symptoms of differing severity. Originally, doctors and researchers tried to treat MS with treatments that eliminate T Cells, which attack myelin. However, drugs like Rituximab are showing greater success by focusing on B Cells.

“Killing T Cells can create a great deal of problems with infections and immune suppression,” Miravalle said. “B Cells activate T Cells, so without the B Cells, T Cells don’t activate and can’t cause the disease.”

Rituximab is an antibody that attaches to, and then kills, B Cells. As a result, the drug both improves function and prevents new attacks. In addition, infusions of Rituximab are only necessary every six months to destroy new B Cells. Other drugs commonly used to treat MS can require monthly infusions or daily shots and are also not as effective as Rituximab.

The University of Colorado Multiple Sclerosis Center currently has 400 patients with relapsing MS who are being treated with Rituximab. Miravalle and his colleagues have been pleased with results so far. Only 5 percent of patients saw occurrences of new lesions—essentially a 95 percent efficacy rate. In addition, patients who are not on other medications have not seen any negative side effects from Rituximab.

“Medications like this are educating us,” Miravalle said. “We never thought about B Cells in MS. Now by knocking them down, we have this amazing effect on the disease itself. It is telling us a lot about the immune cells.”

Using Rituximab off-label

Despite the effectiveness of Rituximab, not all patients have access to the drug, since its use for MS is still considered off-label. Miravalle and his colleagues have been offering Rituximab primarily to patients who cannot get other approved medications or who are not having success with other approved medications.

Bryant was one patient who did not have success with other drugs. Before Rituximab, she tried Copaxone and Tysabri, both of which are officially designated for use in treating MS. Health complications while on these drugs caused her to seek a new option. That is when Miravalle introduced her to Rituximab.

“Rituximab is considered experimental, but with my health conditions, I didn’t have any other options,” Bryant said. “Since I have been on Rituximab, I have had no problems with MS. The only bad part is that because it is not approved for MS, I have to pay out of pocket, and the drugs are not cheap.”

Miravalle said that some of the MS Center’s patients are able to get Rituximab at no charge through a patient assistant program, but some patients have to pay out-of-pocket since they do not qualify for the program and many insurance providers will not pay for a drug that is being used off-label.

This may change if Ocrelizumab, a modified version of Rituximab that is currently in clinical trials, is approved. The company responsible for Ocrelizumab frames the new drug as one that will cause fewer allergic reactions in patients.

“It could become a game changer for MS,” Miravalle said. “It is too early to say for sure since Ocrelizumab has not been released yet. I do not expect a difference between Rituximab and Ocrelizumab, but it has the potential to change the way we treat MS patients.”

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High school girls seek health care careers

In early June, over 50 high school girls from around Aurora and Denver had the extraordinary opportunity to get an inside look at several centers operating on the University of Colorado Anschutz Medical Campus. The one-day program, “Exploring Careers in Health Care,” is hosted by the Center for Women’s Health Research and UCHealth. Its goal is to expose a diverse group of young women to careers in health care that they may not know about and to connect them with mentors who can share insight into their own career paths.

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Participants test out medical instruments for surgery.

The participants toured the Gates Biomanufacturing Facility, learning about stem cell therapy and personalized medicine. The Gates researchers explained how following a path of biology, chemistry or engineering could lead to unique careers in health care to treat and cure various cancers, skin and muscle diseases, and type 2 diabetes. One participant was particularly interested, noting, “This is a field that you don’t hear about on a regular basis, but has the potential to change the world of medicine and the future.”

At the Skaggs School of Pharmacy and Pharmaceutical Sciences, the girls heard from students about their varied paths into pharmacy and the rewarding careers for which they are training. The Skaggs students guided the girls through activities to make their own lip balm and to experiment with drink flavoring. They also had an interactive discussion with Laura Borgelt, PharmD, FCCP, BCPS, associate dean for administration and operations at Skaggs School of Pharmacy and Pharmaceutical Sciences, about the complications, challenges and opportunities in medical marijuana research.

A visit to the University of Colorado Eye Center allowed the girls to learn about eye health, diseases of the eye, and the state-of-the-art treatment and surgery happening at CU Anschutz. Using blindfolds and special glasses to simulate visual impairments, the girls helped each other through common tasks such as pouring water into a cup and typing on a keyboard. They could momentarily experience how a patient interacts with the world, and how a caregiver helps guide them through treatment.

The highlight of the day was the visit to the Center for Surgical Innovation where the girls got to try their hand at suturing and experimenting with medical instruments for surgery. One participant said, “I loved it. I came home excited and ready to learn more. It opened up my mind to medical professions I had never heard of.”

Surgical training at CWHR Girls Career Day, 2016

Surgical training at CWHR Girls Career Day, 2016

As they interacted with doctors, pharmacists, research assistants and ophthalmologists, the girls had smiles on their faces and asked thoughtful questions. “We were delighted to welcome these young women to campus. We know the importance of helping young people learn about careers in science and also connecting them with leaders and mentors in the field to help them navigate various career paths in healthcare and research,” said Judy Regensteiner, PhD, director of the Center for Women’s Health Research, professor of medicine, and holder of the Judith and Joseph Wagner Chair in Women’s Health Research.

The program is in its second year and was a tremendous success. With such high demand, the Center for Women’s Health Research and UCHealth plan to make this an annual activity.

Guest Contributor: Sarah Westmoreland, MPH, Public and Community Education Liaison, Center for Women’s Health Research

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