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METHOD fitness app prescribes personalized exercise as medicine

The patient breathes harder as his workout intensifies. His metabolic fingerprint – heart rate, oxygen level and other data – streams onto a tablet in the form of a colorized digital bar that shows exactly what his muscles are doing and the fuels he’s burning.

Nicholas Edwards at CU Anschutz
Nicholas Edwards is the director of Exercise-Medicine Integration in the Department of Family Medicine at the CU School of Medicine.

“In the purple zone he’s stressing his anaerobic system, and in the red he’s going to burn muscle mass if he stays up there too long,” says Nicholas Edwards, director of Exercise-Medicine Integration in the Department of Family Medicine, CU School of Medicine. “The blue here represents his prime zone, where he performs best during exercise and creates the most energy, so he’s safely burning the most pound for pound right at this second.”

Edwards is also co-founder and chief scientific officer of METHOD, a CU spinoff company, that is proving to be a health game-changer by connecting exercise to medicine. The system gives thousands of pro athletes and patients access to individualized, real-time metabolic information that, when combined with a prescribed fitness regimen, builds strength and stamina, reduces injury, sheds weight and improves their response to treatment.

‘Medically based fitness plan’

METHOD app shows individualized biometric data
The METHOD app shows individualized, real-time metabolic information of athletes and patients.

These metabolic data points help tailor regimens to a specific physiology – whether the person be a pro athlete, weekend warrior or couch potato – to provide healthy outcomes across the continuum of care. “It’s literally like a medically based fitness plan,” says Edwards, who three years ago launched METHOD with an eye toward college and pro athletes. Among the first users were elite athletes who were patients in the Ascent Program at the Center for Dependency, Addiction, and Rehabilitation (CeDAR). The METHOD system has expanded to thousands of patients and athletes, including the NHL’s Colorado Avalanche, NFL teams as well as fitness facilities and centers for orthopedics and physical therapy from coast to coast.

Besides being a breakthrough approach –  making exercise a prescribed medicine – the METHOD app is a testament to the collaborative innovations regularly occurring on the CU Anschutz Medical Campus. Family Medicine owns a stake in the enterprise, which was assisted in its launch by CU Innovations. “We collaboratively worked on a system that covers the spectrum – orthopedics through physical therapy to human performance,” says Edwards, who has two business partners.

“Previously, there was nothing that quantified what a person in the gym, the rehab center or the weight room is doing metabolically in real-time,” he says. “Anaerobic exercise was a guess. Through METHOD, we’ve been able to identify somebody’s unique metabolic fingerprint to know what’s going on physiologically as they exercise.”

‘It’s been amazing’

Dan, a patient at UCHealth, went through the three stages of the METHOD system – evaluation, prescription for exercise, and monitoring – under Edwards’ supervision. Dan is a high-level crossfit competitor and works as a paramedic, so he understands the value of physiological data such as heart rate and energy thresholds. “Using the METHOD data, Nick built a training program specific to my capabilities that matched my heart rate and everything,” Dan says. “It’s been amazing. I’ve gotten stronger, faster and more physically fit in the last month and a half than I’ve done on my own, just kind of blind training, over the last year.”

‘This system really dials everything in.’– Nicholas Edwards, METHOD chief scientific officer

Meanwhile, people on the other end of the spectrum, the sedentary and obese, often tell Edwards they don’t know how to workout, feel pain when exercising or are simply intimidated. “The great thing about this system is we’re able to give them specific parameters to know exactly where they should exercise, the exact kind of exercise, and when to start and stop, so they change their body in a healthy and safe way,” he says. “This system really dials everything in.”

Because the app loads onto smartphones and synchs with heart rate monitors, it’s able to monitor whether a user is staying in a metabolic zone too long. “The phone will literally buzz and tell them to speed up or slow down their workout,” Edwards says. “The app has built-in coaching mechanisms across the board.”

‘Solidify best practices’

And the app acts as massive data repository that allows clinicians to view real-time data from users around the country. “I can monitor somebody on an exercise prescription in Maine or in Southern California and compare their outcomes to somebody here in Colorado,” says Edwards, who played college football at North Dakota State and is a former mixed martial professional. “Our goal is to solidify best practices over time.”

Colorado Avalanche and METHOD
The Colorado Avalanche use the METHOD system to monitor and analyze the metabolic fingerprint of each player in order to achieve optimum fitness.

Improved outcomes mean athletes get back on the ice or field faster, while patients, either those recovering from surgery or just going through physical therapy, return to their normal lives sooner, Edwards says. “The big payoff is that by optimizing patient outcomes we’re lowering the cost of care, because you’re eliminating guesswork and duplication of services.”

Ditching a worn-out formula

For example, METHOD renders obsolete the timeworn 220-minus-your-age formula for determining a person’s maximum heart rate. Edwards gives the example of a 55-year-old couch potato and a former pro hockey player of the same age. “If you do that old formula, they should exercise the exact same way, which is ludicrous,” he says. “We need to find something different that’s happening with that individual every single day, and that’s what we do with METHOD.”

When not directly coaching athletes and patients through exercise regimens, Edwards speaks about the benefits of METHOD and proper training across the U.S. at the NFL Combine, behavioral health and strength and conditioning conferences and other events. He notes that the system is “really starting to catch fire” as more people turn to individualized exercise regimens.

Edwards says METHOD will further elevate CU SOM’s stature as a global leader in innovation, wellness and health care outcomes. “We’re developing a lasting change – to make medicine and exercise collaborate long term.”

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Pharmacy professor teaches personalized medicine in Egypt

Christina Aquilante, PharmD, was struck by many things during a recent trip to Egypt. Foremost was the profound thirst for knowledge displayed by health providers and students who enrolled in Aquilante’s intensive weeklong training program on clinical pharmacogenomics.

Group of students at Egypt hospital
About 90 attendees participated in the pharmacogenomics program taught by Christina Aquilante in Cairo, Egypt, in January.

“It was one of the best experiences of my career. The folks just wanted to learn so much,” said, Aquilante, associate professor in the Department of Pharmaceutical Sciences at the CU Anschutz Medical Campus. “I could have stayed probably 10 hours a day and they would have kept asking questions. They have such dedication and passion for taking care of their pediatric patients.”

Christina Aquilante of CU Anschutz
Christina Aquilante, PharmD, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences

The 90 attendees included practicing pharmacists and physicians as well as medical and pharmacy students. Aquilante taught at Children’s Cancer Hospital Egypt (CCHE), which partnered with the CU Skaggs School of Pharmacy and Pharmaceutical Sciences on the clinical course. Sherif Abouelnaga, MD, and a few other leaders from CCHE, visited CU Anschutz last October and learned about Aquilante’s online certificate program on pharmacogenomics – the use of a person’s genetic makeup to inform the safe and effective use of medications. Abouelnaga asked if Aquilante would be interested in delivering the program live in Egypt.

Threefold purpose for visit

Pyramids of Egypt
Christina Aquilante did some sightseeing while in Egypt, including an excursion to see the pyramids outside Cairo.

“I said sure – I love to teach. They have a sophisticated hospital there and they’d just bought a new machine to do genotyping,” she said. “They are highly motivated to start incorporating genetic makeup into patient care at their institution.”

Aquilante arrived in Cairo in early January and, while enjoying a crash course in Egyptian culture, she launched the live training program, which had a threefold purpose:

  • Educate providers on pharmacogenomics.
  • Serve as the first program for CCHE’s new Health Care Sciences Academy.
  • Introduce active and practice-based learning to the Egyptian participants.

A team effort

Christina Aquilante, PharmD, was assisted with her pharmacogenomics course in Egypt by these health care professionals in Cairo and faculty at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences: Sherif Kamal, RPh, MSc; Mohamed Nagy, RPh, MSc; Jodie Malhotra, PharmD; Kari Fransom, PharmD, PhD; Manal Zamzam, MD; and Sherif Abouelnaga, MD.

While active learning is the norm in CU Anschutz classrooms, Egyptian education is still centered around didactic lectures, Aquilante discovered. “To change the dynamic, I’d give a lecture and then the attendees did exercises in teams and then we talked about answers to the case-based scenarios,” she said. “It was really an introduction of interactive and practice-based learning for them.”

Because world-class clinical personalized medicine and pharmacogenomics education – Aquilante’s course is required for all third-year PharmD students – is deeply rooted at CU Anschutz, the expertise of our campus’s researchers and educators is often helpful in developing countries where precision medicine is in its early stages. But it’s not always the case that these nations are short on resources, Aquilante said. In Egypt, for example, the hospital is equipped with sophisticated technology, she said, but the providers lack formal education on pharmacogenomics.

CU reaches out to all

“I think my trip speaks to how CU reaches out to all cultures and regions, promoting diversity and education across the world,” Aquilante said. She hopes the groundwork has been laid for an ongoing partnership between Skaggs School of Pharmacy and Pharmaceutical Sciences and the Cairo pediatric hospital.

Online class coming up

Christina Aquilante’s online course on Pharmacogenomics is so popular that she had to offer another session, which begins May 3. For more information or to register visit www.ucdenver.edu/pharmacy/continuingeducation

Aquilante submitted an abstract about her experience to an education symposium – Pharmacy Education and Collaboration for Global Practice – taking place in Italy this summer. The abstract, which is under consideration for acceptance, details how her trip “not only fostered clinical collaborations with health care providers in Egypt, but it fostered potential research collaborations, too.”

Aquilante returned to Colorado with gifts from appreciative attendees, photos of the pyramids and other sights around the ancient city of Cairo, as well as 90 new Facebook friends. One of the attendees said this about Aquilante’s class: “You were fantastic at explaining this course, making it easy for us to have new knowledge that we can use in our research and clinical implementation for our patients.”

A formal graduation ceremony was held for the attendees at the end of the 30-hour, five-day program. Participants literally jumped for joy, Aquilante said, and they celebrated with music, disco lights and even some dancing. “I wish more people had the opportunity to experience what I, personally, think Egyptian culture is all about,” she said. “They were really lovely people – extremely kind and hospitable.”

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Fighting opioid misuse by linking electronic health records, databases

Emergency Department staff
A pilot project at the University of Colorado School of Medicine is linking its electronic medical records to state prescription drug database.

Doctors should be able to rely on new technology to fight opioid misuse, University of Colorado School of Medicine (SOM) Assistant Professor Jason Hoppe, DO, believes. But so far, existing systems such as online databases that track prescriptions have not lived up to their promise.

Dr. Hoppe, an emergency room physician and medical toxicologist, wants that to change, and he thinks a pilot project at the CU Anschutz Medical Campus might be a step in the right direction. Hoppe and a team of physicians and software developers have linked the state’s online opioid prescription database, the Colorado Prescription Drug Monitoring Program (PDMP), and University of Colorado Hospital’s electronic medical records system.

CU Anschutz fights the opioid epidemic

This is the third in a series of articles that examines how University of Colorado Anschutz Medical Campus faculty and students are finding ways to solve the opioid epidemic.

The new connection already saves doctors in the Emergency Department time. With a single click, physicians can see if a patient might be at risk for misuse, abuse or diversion of controlled medications, or if a patient might be going from provider to provider trying to get new prescriptions. It also could stop a doctor from prescribing medications that could be lethal when mixed with an opioid. So that single click could save a life or prevent or stop addiction, Hoppe said.

The federally funded project is an example of how CU Anschutz faculty and researchers could have a national impact on the opioid abuse epidemic. The project could lead to better software that helps doctors and hospitals across the country improve patient safety, identify people vulnerable to addiction, and stop prescription medication misuse.

Diagnosing a digital disconnect

Jason Hoppe
School of Medicine professor Jason Hoppe

Software that tracks prescription medications has been available for years. Since 2008, Colorado has had an online statewide database that records whenever a pharmacy dispenses a controlled substance. That includes opioids such as Vicodin and OxyContin, as well as other potentially addictive medications, such as stimulants like Adderall and benzodiazepines. Doctors and other health care providers can review a patient’s history before writing a prescription.

Hoppe said such databases could also be effective tools for identifying people who try to persuade multiple doctors to write prescriptions for opioids or addictive medications. Doctors could then refer them to treatment. Databases also can warn doctors if a patient takes a dangerous combination of medications, and in the future software could create risk profiles that could identify a patient susceptible to addiction.

“I think there are positives, and there is evidence that shows they improve patient safety,” Hoppe said. “But there are a lot of barriers to using it.”

Hoppe cited national statistics to support his view. Doctors only check the databases in their states 12 to 20 percent of the time before they write a prescription for a controlled substance.

“We would like to get that number a lot higher,” Hoppe said. He is in a position to help, as the co-chair of the Colorado Consortium for Prescription Drug Abuse Prevention’s working group focused on improving the database.

The critical element is time. Doctors need to quickly diagnose and treat patients while simultaneously reading and updating electronic medical records (EMR). Switching to a different software program to check the state database takes several steps and distracts both doctors and patients.

“If you’re in a busy primary care clinic or emergency department, and you’re seeing patients for only five minutes, and it takes you five minutes to load the system, you’re unlikely to use it,” Hoppe said. If doctors think a patient needs an opioid painkiller and do not see signs that raise concerns about possible misuse or abuse, they often write prescriptions without checking the state’s database. Then they have to move on to the next patient.

Testing the link

Opioid abuse by the numbers

 

329 people died in Colorado from misusing prescription opioids in 2015

 

224,000 Coloradans misuse prescription drugs each year

 

Colorado ranks 15th in the nation for opioid abuse—down from second in 2011

An obvious solution would be to integrate the state database and EMR systems. Hoppe said doing that took about a year. To overcome technical problems, the team worked with Epic, the software company that sells one of the most widely used EMR systems. UCHealth uses Epic’s software and is part of the project.

The initial rollout is small, Hoppe said, with doctors in the SOM’s Emergency Medicine Department and the University of Colorado Hospital being the first users.

“We have to see how it does, how people like it, and if we can make it solvent in terms of cost,” Hoppe said. The U.S. Department of Justice funded the pilot project, and the software will have to show results before receiving more financial support.

Users at CU Anschutz like the system so far, Hoppe said, and it already has made his job easier.

“I use it for 90 percent of patients now that it’s just one click,” he said.

Ultimately, Hoppe would like to see the system or a similar one used nationally, but it won’t happen overnight. He said it could take several years and millions of dollars before every hospital and doctor’s office has quick access to their state’s prescription drug database. Health care providers will need to find money for an expensive upgrade. They also will have to work with many software companies to overcome the challenges of connecting hundreds of systems.

But Hoppe remains optimistic. Doctors need a system that works better, and the severity of the opioid epidemic provides urgency. The software CU Anschutz helped develop and the lessons learned from the pilot program could cut the number of opioid addictions, save lives and help end a crisis.

“There’s a lot of pressure to integrate these systems,” he said. “This gives us a big tool to help.”

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Flash Forward events, online challenge put simple financial strategies in focus

Whether you’re 25 or 65, making smart decisions about your money and debt now will benefit your entire future.

If you’re ready to get a clearer picture of your financial future and learn how to shape it, sign up for Flash Forward: a CU Financial Event, held at CU Anschutz on Friday, March 10. There are three tracks – Participate, Plan and Prepare. Each one covers different topics relevant to your life and career.

“Throughout my career at the University of Colorado, I have had the privilege of seeing many employees transition into retirement. My hope is that all employees have a solid plan in place so they can be excited and prepared for retirement,” said Michelle Martinez, Director of Benefits Administration in Employee Services. “You all work hard, so take some time out of your busy day and do this for yourself.”

Take a look at each category below to find out which group applies to you then visit our website to register.

Participate

Did you just start your career? Get a late start saving? These presentations will give you tips on maximizing your money, managing your debt and getting on solid financial ground.

Talks include:

Student Loans and Public Service Loan Forgiveness: Did you know that as a CU employee, you may be eligible for Public Service Loan Forgiveness? Be sure to stop by and discover information about the Public Service Loan Forgiveness program, your student loan repayment and forgiveness options, and ways to deal with defaulted loans.

Max Out Your Credit (Knowledge): Credit impacts many aspects of our lives including our ability to buy a car or even get a job. This presentation will help you ensure your credit report reflects the real you. Take steps to better understand credit fundamentals such as ways to improve your credit, information that impacts your credit report, and implications of your credit score.

PERA Fundamentals: For PERA enrollees, this session presents a variety of topics that will help you get the most out of your money and PERA account. Learn about choices upon terminating PERA-covered employment, ways to access 401(k) and 457 voluntary tax-deferred savings plans, and the availability of post-retirement health insurance plans.

Find the full presentation schedule and register here.

Plan

If you’re more established in your career, it’s time to start planning for retirement and thinking about conditions that affect your long-term goals. Take this opportunity to make sure you’re on track with your savings plan, budgeting strategy and credit knowledge.

Talks include:

Half-Way There: A Retirement Checkup: Adjust your retirement plan and maximize savings with this personal evaluation. This financial checkup will assist you in evaluating your current savings, managing competing priorities and formulating a plan to reach your financial goals.

Wills & Trusts 101: Uncommon Solutions to Common Problems: You don’t have to be a millionaire to create a plan for your estate. Preparation can help you distribute your assets according to your wishes and the needs of your loved ones. Let us help walk you through trusts, the probate process, fees and more.

Other talks include:

  • PERA Fundamentals
  • Max Out Your Credit (Knowledge)

Find the full presentation schedule here.

Prepare

If you’re preparing to retire, or maybe not quite ready, this track was designed to help faculty and staff within five years of retirement arrange the transition. Topics range from PERA and your 401(a) to income options after retirement.

Talks include:

CU’s Process for Retiring: 401(a) Participants: Are you a CU 401(a) participant? Stop by to learn about your university retiree benefit options, the process behind becoming a university retiree, eligibility requirements for retirement and more.

Paying Yourself: Income Options in Retirement: You’ve finally saved enough and you’re ready to retire, what are your income options now? This discussion will provide you with all the information you need including when to tap into different assets and flexible income choices offered by TIAA.

Social Security: Social Security is a large part of retiring and often leaves people confused. This interactive lecture will give you the clarity you seek by addressing questions about Social Security retirement benefits, Medicare, working while retired and pre-retirement planning.

CU’s Process for Retiring: PERA Participants: Are you a PERA participant? This presentation will help you learn about your university retiree benefit options, the process of retiring with CU, and your benefit options.

Preparing for Retirement from PERA: Planning to retire in the next five years? This insightful PERA session will give you the valuable information you need to plan accordingly to meet your retirement goals. We’ll discuss the availability of PERA-sponsored post-retirement life and health insurance, your monthly and lump-sum benefit options, and annual increases.

Other talks include: Wills & Trusts 101: Uncommon Solutions to Common Problems

Find the full schedule and register here.

Take the Financial Challenge

Don’t forget to take our Financial Challenge and test your financial know-how. Running from Feb. 10 to March 10, five challenges aim to boost your knowledge. For each one completed, you’ll be entered for a chance to win one of eight $50 prizes. You’ll even earn one entry by attending a Flash Forward talk!

Join us at a campus near you:

  • UCCS, Monday, Feb. 27
  • CU Denver, Wednesday, March 1
  • CU Boulder, Monday, March 6
  • CU System, Tuesday, March 7
  • CU Anschutz, Friday, March 10

Visit our website to sign up and see the full schedule. You can even sign up the day of the event, so bring along your spouse or a coworker!

Guest Contributor:  RyAnne Scott, Manager of Communications and Outreach, Employee Services, University of Colorado, Office of the President

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Middle schoolers dissect brains, peer into healthcare careers

Student outreach at CU Anschutz
Students and teachers at West Leadership Academy visit CU Anschutz as part of the WeLLCOMe Program.

As soon as 20 middle school students step into the hall and put on white lab coats and glasses, a noticeable change comes over them. There’s a sense of confidence, of feeling important.

“It feels like I’m a scientist,” Denajsha Vialpando says while flashing a smile. “It just feels like I’m working here, like I’m a medical student.” Another eighth-grader, Jacqueline Tarin, adds, “I feel like I’m in health care training. When I grow up I want to dissect brains and stuff like that.”

Just down the hall in the “bone room,” they will perform a cranial nerve exam, slice away slivers of brain, and study the three-dimensional images of the Visible Human.

This hands-on exploration of science, health and health careers is the idea of the WeLL-COMe Program at the University of Colorado Anschutz Medical Campus. WeLL-COMe stands for Wellness, Lifelong Learning and Career Orientation Mentorship, and it’s geared toward middle-school students.

The program is a collaboration between the Department of Neurology, the Department of Cell & Developmental Biology, the master’s program in Modern Human Anatomy – all within the CU School of Medicine (SOM) – and Colorado Uplift, a nonprofit that provides guidance to underrepresented minority students. This spring, six waves of students from Denver and Aurora schools will participate, touring in groups of 10 to 25 students.

‘Change in their mindset’

On a recent morning, the group from Denver’s West Leadership Academy tours the anatomy labs on the fifth floor of Education 1. They are led through various health stations, including the brain dissection room, by several graduate-student volunteers from the Modern Human Anatomy program.

Brain lab at CU Anschutz
Maureen Stabio, PhD, assistant professor in the Department of Cell & Developmental Biology, hands students from West Leadership Academy parts of a human brain to inspect.

The group starts with an introductory lesson in neurons and brain plasticity. “We teach the students that their brains have enormous capacity to learn and change. Through practice and hard work, they can do science,” says Maureen Stabio, PhD, assistant professor in the SOM’s Department of Cell & Developmental Biology. “I think that change in their mindset is important.”

Hannah Benjamin, an anatomy graduate student, enjoys volunteering for the outreach sessions because they blend two of her passions – working with kids and studying human anatomy. “My favorite part is getting in the labs and doing hands-on work, because I don’t think this kind of opportunity is as available for middle school students as it is for high school students,” Benjamin says. “Watching their faces when they pick up a brain makes my day.”

Students in bone room at CU Anschutz
Denajsha Vialpando, left, a student at West Leadership Academy, and fellow student Jacqueline Tarin, right, perform a cranial nerve exam along with a teacher from the academy, in the bone room in Education 1 at CU Anschutz.

She says the students are especially fascinated by the brain slicing and cranial nerve demonstrations. When Vialpando steps up to cranial nerve station, she’s repulsed and fascinated at the same time. “Oh my God, are those eyes?!” she exclaims as she grasps the eyeballs dangling from slender nerves. In her next breath, the eighth-grader asks the graduate student, “What’s this black thing?” as she points to a blood vessel at the base of a brain.

“It’s squishy,” another student observes as he touches the gray matter.

Opening doors to science

Veronica Contreras de Raya, marketing and communications coordinator for Colorado Uplift, says the CU Anschutz outings leave a profound impression. “A lot of kids don’t consider a future in math or science as a possibility, so this kind of hands-on experience can really open doors,” she says.

Colorado Uplift is an essential collaborator for the program, says Alina Rich, education manager in the Department of Neurology, since the organization has strong connections to schools across Denver and Aurora.

In fact, the 3-year-old WeLL-COMe program, which is funded by the Maggie George Foundation, this year expanded to include Aurora Public Schools, joining Denver Public Schools students in the lab rotations.

Benjamin, who helped develop the outreach curriculum, has been accepted into the CU SOM for fall 2017. She’s delighted that she will be able to continue promoting healthy lifestyles and interest in health professions among middle school students.

“Hopefully some of them will walk out of here wanting to wear a lab coat again and be a doctor, nurse or other health care professional someday,” Benjamin says.

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Psychologists with holistic approach to rehabilitation bring therapy into homes

Rehabilitation psychologists might not be as well-known as physical and occupational therapists, but the specialists have emerged as integral players in the recovery process for many victims of catastrophic injuries or life-altering illnesses.

According to University of Colorado School of Medicine (SOM) Professor Lisa Brenner, PhD, that is because rehabilitation psychologists like herself have a unique view of the recovery process. They are able to work with patients after they leave the hospital or a rehabilitation clinic to help them restore as much of their old lives as possible. Rehabilitation psychologists coordinate care between doctors, therapists and family members to help patients cope with new challenges and build fulfilling and meaningful relationships.

Lisa Brenner, right
University of Colorado School of Medicine Professor Lisa Brenner, at right, at an American Psychological Association conference for rehabilitation psychologists

This holistic approach can improve the well-being of patients as they adapt to a different world, which can be a difficult process.

“For many people, the big adjustment is after they go home, and that’s when the psychological impact for them and their families really begins to unfold,” said Dr. Brenner, who is a member of the SOM’s Department of Physical Medicine and Rehabilitation.

Dr. Brenner has spent her career studying traumatic injuries and helping people recover from disabilities caused by accidents or chronic illnesses. Her work at the CU Anschutz Medical Campus puts her on the front line of a rapidly expanding and evolving field as the medical world becomes more aware of how holistic care benefits patients. Rehabilitation psychologists treat a wider range of conditions than ever before, including strokes, multiple sclerosis and AIDS.

Focusing on the whole patient

Rehabilitation psychologists are one of many different therapists a recovering patient could encounter. Their job bridges the divide between specialists who focus on physical recovery or provide support for mental health issues.

Dr. Brenner gives the example of someone with a traumatic brain injury (TBI) who has returned home from the hospital. Often, a physical therapist might focus on improving a patient’s coordination, and an occupational therapist might help them relearn how to do household tasks. A doctor might prescribe an antidepressant if the patient became depressed.

When different doctors and therapists focus on separate problems, they might not communicate effectively with each other, which Dr. Brenner said could lead to gaps in treatment. Rehabilitation psychologists coordinate the work of multiple therapists to develop an integrated treatment plan.

“The more we’re able to provide holistic and comprehensive care, the better it will be for our patients,” Dr. Brenner said. Rehabilitation psychologists also form long-term relationships with patients and their families to establish reasonable expectations for recovery and make sure the treatment plan is working. A rehabilitation psychologist’s training in mental health care could help them see emerging mental health issues before anyone else.

Greater urgency for treating veterans

Rehabilitation psychology has existed for decades, but the field has developed rapidly in the past 15 years. One cause has been the U.S. military campaigns in Iraq and Afghanistan. Veterans have returned with life-changing injuries such as TBI or amputations, and doctors and therapists have had to develop new ways to help them adapt.

The suicide rate among veterans also has skyrocketed, bringing added urgency to those who help veterans recover from injuries and post-traumatic stress disorder. Dr. Brenner, who directs the Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC) for the U.S. Department of Veterans Affairs hospital in Denver, sees the difference rehabilitation psychologists and new holistic approaches can make.

“TBI and negative psychiatric outcomes such as suicide travel together, and we need to be thinking of them together,” Dr. Brenner said. “It doesn’t need to be one set of providers addressing the mental health problems and challenges, and one set of providers dealing with the brain injury.”

An expanding discipline

Lisa Brenner
University of Colorado School of Medicine professor Lisa Brenner, PhD, discusses rehabilitation psychology with peers in Israel in December 2016 as part of an exchange program.

Dr. Brenner, who is the president of the American Psychological Association’s Division of Rehabilitation Psychology, said the field has expanded its scope beyond TBI and catastrophic injuries. Strategies that have proven effective for treating veterans and accident victims have started being applied to other chronic conditions. Rehabilitation psychologists now treat patients who might live decades with a chronic disease such as AIDS.

“Many more people are thinking holistically,” Dr. Brenner said. “We’re rethinking the way we’ve siloed things.”

Rehabilitation psychology has spread worldwide. Recently, Brenner led a delegation to Israel as part of an exchange program that visited 15 hospitals, rehabilitation centers and other facilities across Israel. A delegation from Israel will visit the U.S. this summer.

The purpose is to share best practices, develop collaborative research opportunities and draw lessons from different experiences. One difference Dr. Brenner noticed is that Israelis have more experience helping civilians with post-traumatic stress disorder manage the strain that comes from being in a region that experiences repeated conflicts close to home. Because the sources of stress cannot be removed from individuals’ lives, therapists have to help them cope in an environment that often does not feel safe.

“There’s a lot we can learn from each other,” Dr. Brenner said.

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What is the best way to treat older HIV infected patients?

Louis and his poodle, Doodles, on one of their four walks every day
Louis and his poodle, Doodles, on one of their four walks every day

A year ago, HIV patient Louis Zimmerman considered himself sedentary. But thanks to his participation in a CU Anschutz exercise study, he now is able to walk his one-year-old poodle, Doodles, four times a day.

“I’m walking faster with more pep in my step,” says Zimmerman, 66, one of about 50 participants in a study of HIV-infected patients, run by Kristine Erlandson, MD, assistant professor of infectious diseases in the CU School of Medicine, with an adjunct appointment in geriatric medicine.

Kristine Erlandson, MD
Kristine Erlandson, MD

Erlandson, who is board certified in internal medicine and infectious disease, specializes in treating frail and older HIV-infected patients. Affiliated with CU Anschutz since 2008, Erlandson also conducts research studies on patients who have lived decades with HIV.

Erlandson says she became interested in learning about AIDS in high school and was an HIV educator in college. She particularly remembers Ryan White, an Indiana teen who got HIV from a blood transfusion and helped start the movement to stop AIDS discrimination.

“He was a similar age as I was and it stood out for me,” she says.

As for her interest in HIV and aging, she added:  “As a fellow during my infectious diseases training, I was most surprised by the HIV patients who would come into the hospital – they had diseases that should be impacting much older people.”

Erlandson sees commonalities in the challenges of her older HIV patients and hopes her studies will improve lives.

“Most of the people I focus my research on are those diagnosed with HIV back in the late ‘80s or early ‘90s who are now experiencing the long-term side effects of drug therapies that go back 20 or 30 years,” she says.

Zimmerman is a participant in one of Erlandson’s studies that measures how exercise can improve the health of sedentary people ages 50-75. One group is HIV-infected and the other study subjects don’t have HIV. Both groups are in stable health and work out as part of the study for six months at the university’s research gym.

During the study, Zimmerman walked on the treadmill and worked with weights three days a week.  At the end of six months, he says he felt stronger and had more energy. His outcomes are similar to other participants’ experiences, Erlandson says.

“Almost everyone has marked improvements in their strength and endurance,” she says. “And we’ve seen good improvements in basic physical function measures, such as the ability to walk a quarter mile and the speed to rise from a chair.”

A patient’s experience

Louis and Doodles
Louis and Doodles

Doctors diagnosed Zimmerman with HIV and Hepatitis C in 1996 at age 47.

A delivery person for Dolly Madison Bakeries, Zimmerman said he tried to go to work one day and collapsed.

“I couldn’t stand up any longer,” he says. He learned he had pneumocystis pneumonia, an infection fairly common in people with compromised immune systems.

At first, Zimmerman, who had many friends and acquaintances die of AIDS, thought it was a death sentence. But then he started doing research on HIV.

“I didn’t have any information prior to the diagnosis,” he says. “But I started doing research and I’ve kept it up ever since. That’s my job now.”

Zimmerman also has been active in HIV research studies. He’s participated in nine clinical trials since his diagnosis. A tough treatment regimen cured his Hepatitis C, but the early HIV treatments were harder on the body than today’s drug regimens. As a result, he’s suffered neuropathy and had fat loss (lipatrophy) in his face. He also was diagnosed with a rare form of skin cancer that has required 25 radiation treatments.

The work ahead

In addition to her exercise study, Erlandson has also studied the factors that contribute to frailty in HIV patients and how to prevent them. She’s recently started a study in conjunction with the AIDS Clinical Trials Group to look at the effect of statins on physical function in HIV patients.

Erlandson’s hope is that her work will not only help her HIV patients, but that her trainees will have a greater understanding of how to manage HIV and help prevent HIV-associated complications in aging.

“There’s still a lot of research to be done by the next generation of physician scientists,” she says. 

Living a positive life

In the nearly 20 years since Zimmerman was diagnosed with HIV, he says he’s stronger than he realized and he doesn’t give up.

“If I start thinking about anything negative, I get it out of my brain right away,” he says. “Dying is the last thing I think about.”

His advice to fellow HIV patients is to stay positive and build a social network of supportive friends and family.

Zimmerman’s year-old poodle, Doodles, is his constant companion. He laughs as he talks about how she walks on her hind legs like a bear. He says he wants to stay healthy for her.

Says Zimmerman, “A dog lives 15 years, so I have 14 more years to be alive for my puppy.”

Guest Contributor: Kathleen Bohland

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Four generations of one family receive MDs at CU

The line of physicians in the Kenagy-Vance family stretches across states, continents and generations. For centuries, these medical men have guided the health of communities from Switzerland to Pennsylvania to Idaho and beyond.

And most of their skills were acquired in the same place – the University of Colorado School of Medicine (SOM). Four generations of the family received their MDs here. Dr. John Brough (JB) Kenagy started it all when he graduated from the SOM – located in Boulder then – in 1906.

The family’s next two physicians – Drs. Fayre H. Kenagy (class of 1920) and J. Corwin (Corky) Vance (class of 1971) – attended the medical school in Boulder and then the CU Health Sciences Center in Denver. Corky’s father, Edward Pershing Vance, who married Barbara Eloise Kenagy, took a different path: He enjoyed a successful career in natural resource stewardship in the Pacific Northwest. Dr. Karl Kenagy Vance, son of Corky and Karen Vance, extended the family’s black-and-gold legacy into the 21st century by attending medical school at the CU Anschutz Medical Campus from 2005 to 2009.

Fayre Kenagy at Denver General Hospital
Fayre H. Kenagy, center, is pictured at the old Denver General Hospital circa 1917. Fayre was the second member of the Kenagy family to receive his MD from the CU medical school.

Karl applied to about 10 medical schools, but chose CU. “The combination of the high-quality education at the medical school and the lifestyle of being in Colorado factored in,” says the avid cyclist and skier. “Also, it was something I thought would be cool – that I would be the fourth generation of my family to go to the CU School of Medicine.”

Swiss start

The family history of physicians goes back to Bern, Switzerland, where Corky’s sixth great grandfather, Hans Gnage, practiced medicine before fleeing the country over religious persecution of Mennonites. “Family legend has him seeing a patient when the police came to arrest him for draft evasion,” Corky says. “His wife had the policeman sit down to wait for him and offered food and drink, but then sent their son to tell his father to leave the country instead of coming home. His family joined him later.”

Hans arrived in Pennsylvania in 1742 and joined the Amish community, where he resumed work as a physician. It would be several generations later when JB Kenagy, born and raised in a Mennonite community in Ohio, would leave his career as an educator and move from Gunnison to Boulder. After graduating from CU medical school in 1906 he moved to Rupert, Idaho, to practice internal medicine.

His son, Fayre Kenagy, aspired to become a doctor just like his father. He was drafted into World War I but received a deferment to finish his medical degree.

Keeping the CU tradition going

It was Fayre who delivered J. Corwin Vance in August 1945, starting a lifelong bond with the boy who went by the nickname Corky. “I was in awe of my grandfather and wanted to follow in his footsteps. I therefore also attended the CU medical school,” Corky says. “When Karl was born, we named him Karl Kenagy Vance, after his grandfather. He later decided to attend the CU medical school as well, having heard how great it was.”

Drs. Vance sip cappuccinos in Italy
Drs. Corky and Karl Vance take a break from cycling to enjoy cappuccinos during a family vacation in Italy last fall.

The elder Dr. Vance is now retired, but Karl worked with his father during the final year of his practice in Minneapolis. Karl now works with several of Corky’s longtime staff members, though in a different dermatology practice. The Twin Cities are a fitting home for the Vances as twin interests abound in father and son, including a shared love of fine food and wine. When they aren’t pursuing culinary interests, you can find Corky and Karl on their bicycles or in planes traveling the world. Sometimes they’re globetrotting and cycling – as they did on a recent family trip to Italy.

Incidentally, they both met their wives while attending the CU medical school. Corky met Karen while she was a lab technician, and Karl hit it off with Pamela while out on the town with classmates.

Karl and Corky Vance in the CU School of Medicine
On Karl’s graduation day in 2009, Drs. Karl and Corky Vance stand in front of the photos of CU School of Medicine classes of 1919 and 1920 in the SOM. Corky was inspired to pursue medicine by his grandfather, Fayre H. Kenagy, who is pictured in the class of 1920.

Just as Corky was inspired to pursue medicine by his grandfather, Karl looked up to his father, who became the first dermatologist in the Twin Cities to perform Mohs surgery – a micrographic procedure that removes skin cancers. “He found it rewarding. Growing up around medicine, you get an understanding of the process, the responsibilities and the ups and downs of it,” Karl says. “Mostly, it’s a fulfilling career because it’s a daily opportunity to help people.”

Camaraderie with CU classmates

Excellence in clinical care

“If you want to get clinically grounded, the CU School of Medicine is as good as any,” says Dr. Corky Vance, who attended the SOM from 1967 to 1971. “I got to see acute and emergency care at Denver General, and at University Hospital I got to see the rare cases you heard about from your professors. We also went out to the Fitzsimons Army Hospital (as it was known then) and saw cases and procedures that you were going to see in your own practice. There was a real advantage to having that much exposure to clinical practice.”

The retired physician says the SOM is even better since moving to the CU Anschutz Medical Campus. “Having everything together – with the hospitals on campus, as well as the VA – it really makes it even easier to get clinical exposure.”

Unlike the camaraderie he enjoyed at CU Anschutz, Karl struggled to connect with his pre-med classmates as an undergraduate at Stanford University. But he excelled in chemical engineering, and it wasn’t long before he connected that discipline to his burgeoning interest in wine. After graduating from Stanford, he became an assistant wine maker in Northern California and Australia. A few years later, however, he realized that winemaking couldn’t quite match the fulfillment of medicine.

At CU Anschutz, Karl loved his classmates – “It was hard to find people who weren’t into skiing and biking,” he says. And he was influenced by Dr. J. Ramsey Mellette, the faculty member who trained him on Mohs surgery. Back in the 1970s when Corky first performed Mohs, it was a new and innovative procedure. “Now, this procedure is pretty widespread,” Karl says. “I like it because of the precision in which we take the cancer out, and I enjoy the creativity involved in the reconstruction (of the tissue).”

Mohs is usually performed on a patient’s face, so the reconstruction of the skin requires utmost precision to minimize scarring.

Finding a mentor in the SOM

Corky was inspired to pursue dermatology by Dr. Robert Goltz, who in the late 1960s served as head of the Dermatology Department in the medical school. Corky so enjoyed Goltz’s teaching that he took the professor’s early-morning class on public health. “Dr. Goltz noticed that I was a hard worker, that I liked dermatology and was good at it,” Corky says. “I was good at visual learning, and that’s why dermatology appealed to me. You have to be able to memorize what rashes and other conditions on the skin look like.”

Goltz proved to be the catalyst for Corky’s career in Minnesota. Goltz, who had just accepted a job as chair of dermatology at the University of Minnesota, suggested Corky pursue his residency in the Land of Lakes.

Drs. Vance at CU medical school graduation
Drs. Karl and Corky Vance at Karl’s graduation from the CU School of Medicine in 2009.

Now, as Corky and Karen settle into retirement, they watch their progeny carry on the Kenagy-Vance caregiver tradition. Karl has established his own thriving practice in Minneapolis, while his sister Chardonnay, who attended medical school at Wake Forest University, is a family practice doctor. The life in medicine has made for a full, satisfying ride for the elder Vances – and a lasting family legacy that’s anchored in CU’s SOM.

“The most important thing is your job,” Corky says. “If you have a miserable job, you’ll be miserable wherever you are. If you have a rewarding job – as we are lucky enough to have – you’ll be happy.”

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Study: Light-intensity activities may play role in maintaining weight loss

Light-intensity activities such as washing the dishes, making the bed, and walking the dog may play a significant role in helping people maintain weight loss, according to a study by researchers at the Colorado School of Public Health (ColoradoSPH) and the University of Colorado Anschutz Health and Wellness Center.

The researchers noted that moderate-to-vigorous physical activity has been shown to strongly correlate with long-term weight-loss maintenance, but few studies have examined patterns of light-intensity activity and sedentary behavior in people who successfully keep the pounds off.

Woman walking a dog in the city
Simple light-intensity activities such as walking the dog could play a significant role in helping maintain weight loss.

“We conducted the study to better understand whether patterns of light-intensity activity and sedentary behavior were different in those who were successfully maintaining a weight loss compared to those who are not,” said Danielle Ostendorf, a CU Anschutz doctoral student in epidemiology who worked on the study.

Three groups of participants

In the National Institute of Health (NIH)-funded study (Principle Investigator Victoria A. Catenacci, MD), subjects wore a small, lightweight activity monitor (activPALTM, PAL Technologies LTD, Glasgow, Scotland) for seven days as they went about their normal activities. Participants were drawn from three groups:

  • weight-loss maintainers (individuals who had lost at least 30 pounds and were maintaining that weight loss for at least two years);
  • controls of normal body weight (matched to the current Body Mass Index (BMI) of the weight-loss maintainers);
  • controls with overweight/obesity (matched to the pre-weight-loss BMI of the maintainers).

Data from the 90 healthy adults in their mid-40s was collected and analyzed at the Center, with all three groups having a similar number of participants and distribution of age and sex. In a study such as this, it is critical to have groups with similar age and sex make-up, as physical activity varies by both age and sex.

Catenacci, a Department of Medicine faculty member in endocrinology, was lead author of the abstract. Ostendorf presented the abstract’s findings at the recent annual American Public Health Association conference in Denver.

Surprising results

“We had hypothesized that the weight-loss maintainers would be significantly different than the other two groups in terms of sedentary behavior and light activity,” Ostendorf said. “What was surprising was that the weight-loss maintainers and normal weight controls were similar in terms of their overall sedentary time and their time spent doing light activity, but differed dramatically from the controls with overweight/obesity in these parameters.”

Fitness room at University of Colorado Anschutz Health and Wellness Center
A woman works out on a treadmill at the University of Colorado Anschutz Health and Wellness Center.

The weight-loss maintainers and normal weight controls spent 4.8 hours (290 minutes) and 4.7 hours (281 minutes) a day doing light-intensity activity, respectively, while they were sedentary for 9.9 hours (596 minutes) and 10.3 hours (617 minutes) a day. The overweight/obese control arm spent 3.9 hours (234 minutes) a day in light-intensity activity and 10.9 hours (654 minutes) a day being sedentary. Compared to the controls with overweight/obesity, weight-loss maintainers and normal weight controls were doing about one hour more of light activity and one hour less of sedentary time each day.

Top student abstract

Danielle Ostendorf won the “Outstanding Student Research in Physical Activity” award at the recent American Public Health Association conference in Denver. It was selected among the top three student abstracts at the October conference.

Consistent with other studies, weight-loss maintainers also engaged in more exercise than controls of both types. Weight-loss maintainers spent 38.8 minutes a day doing moderate-to-vigorous exercise (accumulated in sustained bouts of 10 minute or more) compared to 16.7 minutes a day for the normal control group and just nine minutes a day for the controls with overweight/obesity.

Citing U.S. Office of Disease Prevention and Health Promotion (ODPHP) guidelines, Ostendorf said moderate-to-vigorous exercise is emphasized when it comes to maintaining weight loss. For example, the ODPHP recommends that weight-loss maintainers do 300 minutes of moderate-intensity aerobic activity (such as brisk walking, jogging, or swimming laps) each week compared to the 150 minutes of comparable activity for people in a normal weight range.

Benefits of light-intensity activities

The 300-minute guideline can be intimidating for people who are trying to maintain their weight loss, especially for those who struggle to exercise in a moderate to vigorous manner, Ostendorf said. “The fact that people may benefit from increasing light-intensity activities like doing household chores or taking the dog for a walk is encouraging information,” she said. “However, future weight loss interventions need to test whether increasing light-intensity activities can help people maintain weight loss.”

As part of her dissertation, Ostendorf plans to test the 300 minutes of moderate-intensity exercise guideline for weight-loss maintenance. She wonders if a lower amount of moderate-intensity activity, when coupled with less time being sedentary and more time doing light-intensity activity, would be just as effective in maintaining weight loss.

Track at the University of Colorado Anschutz Health and Wellness Center
A woman runs the track at the University of Colorado Anschutz Health and Wellness Center.

The potential exists, Ostendorf believes, to incorporate both reduced sedentary behavior and increased light-intensity activity into the ODPHP maintenance guidelines. “This would lead to future weight-loss interventions that people can do at the workplace, or at home because it involves physical activity that doesn’t require people to get their heart rate up, which can be uncomfortable for some people,” she said.

Not typically examined

Light-intensity activity is typically not examined in weight-loss maintenance studies because it’s more difficult to monitor than heart-pumping moderate-to-vigorous exercise. “Light-intensity activity is like walking in a grocery store – it’s movement, but it’s not really getting the heart rate up,” Ostendorf said.

She said workplace interventions, such as standing at your desk and taking more frequent breaks from sitting, can be beneficial to help break up dangerous sedentary behaviors. These easy-to-implement interventions would be helpful for health care professionals as they consult with patients about how to keep shed pounds from coming back.

“Understanding how people maintain weight loss is really important,” Ostendorf said. “If we can have an impact on helping people maintain their weight loss then we can help prevent chronic disease and early mortality. Excess weight is connected to so many disease pathways.”

 

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WWII vet receives hero’s welcome at Heroes Clinic

Charles Walters doesn’t consider himself a hero, but the moment he enters the University of Colorado School of Dental Medicine the retired Naval Captain and World War II veteran receives a hero’s welcome from the clinicians who will repair his chipped tooth.

Walters is greeted by Heidi Tyrrell, RDH, assistant director and clinical instructor in the dental school’s Heroes Clinic, who cheerfully tells him his care will be free of charge. Tyrrell says it’s a small gesture of gratitude to someone who so honorably served our country.

“The Dean of our School of Dental Medicine, Dr. Denise Kassebaum, insists (on the free care), and I couldn’t agree more,” she says to Walters. “It’s such an extraordinary honor for us to take care of someone like you. The fact that you not only served in World War II but re-upped and served in the Korean War – there are no words to express how much I admire and respect you.”

Charles Walters and Olga Hamilton at Heroes Clinic
Charles Walters, a WWII and Korean War veteran, shows his chipped tooth to student provider Olga Hamilton at the Heroes Clinic in the CU School of Dental Medicine.

Walters, a widower who lives on his own, is visibly touched by the news, noting that he gets by on a modest fixed income – Social Security and his Navy retirement. In addition to his wartime service, Walters spent 32 years in the Naval Reserve.

The Southern California native enlisted in the Navy immediately after the bombing of Pearl Harbor and served in the Pacific Theater of WWII. Instead of being dispatched to a Destroyer, which was his hope, Walters was assigned to Naval communications intelligence where he served on a team that deciphered Japanese transmissions. “It was exciting work, breaking the enemy’s coded messages,” he says.

Walters returns the gratitude to the CU clinicians – the Heroes Clinic is staffed by faculty and fourth-year students – and says, “I appreciate what you’re doing – there’s nothing that’s too good for the service people, and I mean that primarily for the people who fought – and still are fighting – in battles.”

‘All dental specialties under one roof’

The Heroes Clinic launched in August 2014 thanks to a $1 million grant from Delta Dental of Colorado. The program originated to provide free dental care to student veterans enrolled at CU Denver and CU Anschutz. They are an underserved population as most veterans do not quality for or receive coverage for dental care when they leave the military. The Heroes Clinic fills this gap by providing dental services which supplement health care provided through the Veteran’s Administration.

Veteran receives dental care at CU Heroes Clinic
Heroes Clinic patient Charles Walters has a chipped tooth treated by Dr. Doug Wilson, a dental school faculty member and Air Force veteran, and student provider Olga Hamilton.

Delta Dental kicked in another $1 million grant in 2015, allowing the program to also serve student veterans on CU’s Boulder and Colorado Springs campuses. In 2016, the Heroes Clinic expanded again to serve student veterans from the Community College of Aurora, Metropolitan State University of Denver and Emily Griffith Technical College. That year, the clinic also added “pathway” programs: Pathway 1 provides dental care to veterans served through the Bill Daniels Veteran Services Center, which helps link homeless veterans to jobs, while Pathway 2 provides dental services to low-income veterans.

“It’s the greatest joy to talk to these vets. It’s a privilege to help such a deserving population.” – Heidi Tyrrell, clinic assistant director

Now, the Heroes Clinic is looking to expand care to even more veterans, and the dental school has the faculty and students ready to serve. “Our faculty is amazing. We have all the different dental specialties under one roof,” Tyrrell says. “And Delta Dental loves what we’re doing; they love the stories they get every quarter about veterans and what we’ve done for them.”

Heroes Clinic a ‘godsend’

Since 2015, the Heroes Clinic has served more than 500 veterans, including Walters, who is making his first visit as a Pathway 2 recipient.

Sitting in the next patient chair over, Micah Marmaro, one of the first Heroes Clinic adherents, gets prepped for a tooth crown. Marmaro, who served in the Marines for four years, calls the clinic an “incredible” service. He needed some fillings replaced two years ago, but lacked dental coverage. “I was quoted $5,000 or $6,000 to get the work done, and as a student that’s not easy to pay for,” he says. “It was either have it done or continue to have pain in my teeth. It was a godsend this came along.”

Micah Marmaro is a Heroes Clinic patient
Micah Marmaro is one of the original patients at the Heroes Clinic. He served in the Marines for four years.

He’s been to the Heroes Clinic multiple times since that first visit. “Overall,” Marmaro says, “it’s fantastic to be able to come in and get the level of care you get here.”

Meanwhile, Walters’ chipped tooth gets examined by Olga Hamilton, a fourth-year dental student, and then repaired by Dr. Doug Wilson, a dental school faculty member and retired Air Force Colonel.

Walters happily chats with both providers, while Tyrrell beams at the sight of this 92-year-old enjoying this long-overdue visit to the dental clinic.

“It’s the greatest joy of my job to talk to these vets, and Mr. Walters is so amazing. He’s like a hot fudge sundae with peanuts, caramel and a cherry on top – the whole nine yards,” she says. “The big thing is the extraordinary gift from Delta Dental. It’s such a privilege to help such a deserving population.”

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