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Research Uncovers Risk Factors for Mysterious Kidney Disease in Farm Workers

Researchers from the Center for Health, Work & Environment at the Colorado School of Public Health (ColoradoSPH) on the University of Colorado Anschutz Medical Campus have identified new risk factors for a mysterious kidney illness affecting tens of thousands of farm workers worldwide. Their findings have been published in the Journal of Occupational and Environmental Medicine.

Partnering with Pantaleon, one of the largest sugar producers in Central America, ColoradoSPH researchers examined 330 sugarcane cutters in Guatemala over the course of a six-month harvest season. More than one-third of the workers showed a decline in kidney function over the course of the harvest, while the other two-thirds of the workers’ kidney function remained the same or improved. The researchers discovered that factors including smoking, living in the local community, and low kidney function before employment were associated with a decline in kidney function. The researchers found no association with other health conditions, the amount of water workers drank, sugary drink consumption, or home use of pesticides.

Following worker protection guidelines for rest and hydration set forth by the World Health Organization (WHO), Pantaleon already provides rest breaks, shade, water and electrolyte solutions similar to sports drinks to their employees. Based on the findings of this study, these preventive measures are not sufficient to protect all workers from kidney injury.

Previous studies have identified an illness called “Mesoamerican Nephropathy,” also referred to as Chronic Kidney Disease of Unknown Origin (CKDu). Notably, this new study shows that when a workforce has access to water, rest, and shade, the rates of CKDu onset and kidney injury are lower, and the injury is less severe than that seen in previous studies.

Hydration, rest, shade ‘probably not enough’

“Water, rest and shade are important for anyone doing heavy labor in hot climates. It’s vitally important that employers continue to focus on that. But our study shows that hydration, rest and shade are probably not enough to stop the global epidemic of kidney disease,” explained Dr. Jaime Butler-Dawson, lead author of the study and researcher at the Center for Health, Work & Environment. “We now have a better idea of some strategies to help keep workers safe and healthy,” she said.

Pantaleon has long prided itself on its commitment to worker health and sustainability. The company initially sought the input of Dr. Lee Newman, director of the Center for Health, Work & Environment in 2016 to conduct a rigorous third-party evaluation of their workplace health programs. The partnership has grown since and they have launched multiple studies. The goals of the collaboration are to evaluate Pantaleon’s progress towards achieving its sustainability goals and to help identify and eliminate the health risks of agricultural workers.

Researchers at the Center for Health, Work & Environment see these findings as part of a larger picture of evolving science in the field of Total Worker Health®, an integrated approach to workplace health and safety coined by the National Institute for Occupational Safety and Health (NIOSH), part of the Centers for Disease Control and Prevention.

Requires more holistic approach

“What we are seeing in our research is that protecting workers from hazards and supporting their health requires a more holistic approach, what NIOSH refers to as Total Worker Health. That is why we are examining work-related factors and personal risk factors. Both need to be addressed together,” said Butler-Dawson.

Dr. Butler-Dawson and her team are focusing future research on delving deeper into understanding the factors that contribute to declining kidney function, such as why workers who live closer to the sugarcane field are more likely to have impaired kidney function at the end of the harvest season. They are also examining why two-thirds of the workers in this study maintained healthy kidney function or improved their kidney function. Her team is collaborating with researchers in the Colorado School of Public Health’s Center for Global Health to design and test ways to improve the health of sugarcane workers and other agricultural workers in the region.

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Changes to rating system caused consumers to choose better providers

Health care report cards and quality ratings are intended to give consumers more information when choosing a care provider like a hospital or nursing home. Health economist Marcelo Perraillon of the Colorado School of Public Health at CU Anschutz evaluated whether a simplified rating system used by the website Nursing Home Compare motivated consumers to choose better-rated nursing homes.

It has been a difficult problem in health economics and policy whether public reporting of quality information actually works in the absence of experimental data.

Perraillon, lead author and a professor in the Department of Health Systems, Management and Policy at the Colorado School of Public Health at CU Anschutz, said, “Essentially, we used a statistical design that allowed us to create an experiment in order to show that consumers and their families do respond to public reporting of nursing homes quality information. It has been a pesky thing to show because policy changes are not designed as experiments.”

The main problem, researchers say, is that no control group exists to help evaluate the effectiveness of the policy, which is intended to help people choose the best providers by improving the quality and accessibility of information about nursing homes and other providers. The authors used a statistical method called regression continuity to show that consumers are indeed using the data to inform better decisions about care.

“At face value, it seems reasonable that consumers or their families will respond by choosing providers (hospitals, nursing homes, etc.) of better quality,” Perraillon said. “That’s the purpose of the policy, since it creates incentives for providers to improve quality of care, but this has been hard to prove.”

In a regression discontinuity study design, participants are assigned to a comparison group on the basis of a cutoff score on a quality measure. Health economists used this design to estimate changes in new nursing home admissions six months after the publication of the new ratings, which went into effect in 2008.

Their results also show that nursing homes that obtained an additional star on the one-to-five scale gained more admissions. They also identified that not all consumers responded to the change the same way, including low-rated nursing homes providing service in poorer areas which take mostly Medicaid patients.

“Disparities in quality of care and access is an ongoing problem in the nursing home market. Our results suggest that potential patients of lower rated nursing homes have fewer choices and they not benefit from ratings. In fact, ratings could lead to even more disparities,” Perraillon said. “These nursing homes tend to be crowded already so managers don’t care much about their ratings. Poorer patients don’t have a lot of options.”

Researchers conclude that the form of quality reporting matters to consumers and that the increased use of composite ratings like the five-star system is likely to cause more people to use the system to compare and choose providers that better fit their needs.

Consumer Response to Composite Ratings of Nursing Home Quality,” was published Dec. 28 in the American Journal of Health Economics. The study joins two earlier works by Perraillon. A July 2017 study evaluated provider perspective on Nursing Home Compare, and a 2016 study found that use of the Nursing Home Compare website was limited by lack of awareness and a mistrust of the data. Another study on the provider-side perspective is expected in 2018.

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CU Anschutz students present research to lawmakers at Capitol

More than 50 researchers greeted Colorado lawmakers entering the Capitol building on Jan. 19, with the aim of raising awareness of the importance of research. Colorful posters highlighting the young scientists’ projects lined the rotunda’s walls, as the presenters’ lively voices bounced around the room’s large marble structures while they explained their work.

Hannah Hathaway, PhD, is proud to share her research.

“This is such a great event,” said Hannah Hathaway, PhD, president of the University of Colorado Postdoctoral Association, as she stood amid the array of posters targeting a wide range of disciplines, from biomedical to atmospheric research. “Not only do we get to present our work in a unique way, but we also get to see other research going on in Colorado.”

Early-career scientists representing 11 state institutions of higher education, including the CU Anschutz Medical Campus, CU Denver and CU Boulder, attended the event, hosted by the CU Anschutz chapter of Project Bridge. Bruce Mandt, PhD, director of the CU Postdoctoral Office, and Jerry Johnson, the CU contract lobbyist for state relations, helped the group with the event.

Project Bridge

“The goal of Project Bridge is to give scientists more tools to succeed by teaching them to communicate outside the world of academia,” said Erin Golden, PhD, president of the national student organization. “We accomplish this through holding trainings, inviting speakers to campus and engaging in a variety of advocacy events like the Capitol Investment.”

Golden launched the CU Anschutz chapter last year after coming from Johns Hopkins University, where Project Bridge was founded.

Erin Golden, PhD, is excited with the turnout of Capitol Investment Day.

“It’s great to see everything come together,” Mandt said. “It is so important to showcase the broad range of scientific work from around the entire state of Colorado.”

Gov. Hickenlooper declared Jan. 19, 2018, “Early Career Scientist Day” to commemorate the event, aimed at showing lawmakers the importance of funding research. The event boasted 71 of 100 state legislators, who pledged their attendance as co-hosts.

Career Development

While waiting for the legislators to arrive, researchers shared their short presentations with one another. The presentations and posters were designed to be informal and jargon-free.

“This type of presentation is unusual for scientists,” Mandt said. “Our presenters are getting excellent experience in explaining their work to a lay audience. This is a wonderful career-development opportunity.”

“If I have accomplished something today, it would be relaying how impactful this scientific exploration is,” said Christopher Covey, a fifth-year graduate student in CU Anschutz School of Medicine’s Department of Immunology & Microbiology. “We’ve all worked so hard to approach scientific problems from new angles. Maybe one day we will uncover something that was previously overlooked.”

Golden hopes Project Bridge will grow to include more events and that Capitol Investment will become an annual event.

“We’re so excited with the turnout,” said Golden. “We really feel like we are making a difference in Colorado’s scientific community, while giving our peers the tools they need to succeed.”

Guest contributor: Photo at top by Katie Weeman, CIRES/CU Boulder.

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Powerful food-derived antioxidant can halt, prevent fatty liver disease

As obesity continues to rise in the U.S., non-alcoholic fatty liver disease (NAFLD) has become a major public health issue, increasingly leading to cancer and liver transplants.

But new research from the University of Colorado Anschutz Medical Campus has discovered that a powerful antioxidant found in kiwi fruit, parsley, celery and papaya known as pyrroloquinoline quinone, or PQQ, can halt or prevent the progression of fatty liver disease in the offspring of mice fed a high-fat Western-style diet.

Dr. Karen Jonscher
Karen Jonscher, PhD, associate professor of anesthesiology and a physicist at CU Anschutz.

Growing evidence suggests that childhood obesity and fatty liver disease is influenced by maternal diet and the infant’s microbiome, the community of microorganisms inhabiting the body.

Jonscher and her colleagues found that mother mice fed a Western-style diet passed on the negative impacts of that diet to their offspring.

Jonscher’s earlier work on PQQ showed it helped turn back these detrimental effects in newborn mice in milder forms of liver disease. In this study, she demonstrated that it also works on the early offspring microbiome to prevent the development of fatty liver disease.

Over the past decade, it has become clear that the developing infant gut microbiome affects maturation of the immune system and gastrointestinal tract, metabolism, and brain development.

“Increasingly, evidence suggests that exposure to maternal obesity creates an inflammatory environment in utero. This leads to long-lasting postnatal disruptions of the offspring’s innate immune system and gut bacterial health, which may increase the risk for development of fatty liver disease,” Jonscher said.

Obesity, which often stems from a high-fat, high-cholesterol, sugary diet, is a major cause of NAFLD. According to the Journal of the American Medical Association, nearly 60 percent of American women of childbearing age are overweight or obese. Numerous studies suggest their children tend to have increased liver fat and a higher risk of becoming obese.

Kiwi fruit, among others, contains a powerful antioxidant shown to halt or prevent fatty liver disease in young mice.
Kiwi fruit, among others, contains a powerful antioxidant shown to halt or prevent fatty liver disease in young mice.

“Fatty liver disease is the number one liver disease in the world,” Jonscher said. “It is now the leading cause of liver transplants, eclipsing hepatitis in many areas of the U.S.”

The researchers found that they could halt and prevent liver disease from developing in young mice by feeding their mothers PQQ.

“Our results highlight the importance of the neonatal period as a critical developmental window to protect obese offspring from the harmful effects of diet-induced lipotoxicity and potentially halt the devastating trend of increasing pediatric NAFLD associated with childhood obesity,” the study said.

Jonscher noted that more work is required to determine if these studies might apply to humans.

“But there is a possibility that people with fatty liver disease could potentially benefit,” she said. “The supplement is available online and in grocery stores but individuals should consult their doctors first before using it.”


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Colorado Consortium for Prescription Drug Abuse Prevention at CU Anschutz Receives $1.5 Million

The Colorado Health Foundation has invested more than $1.5 million to advance Colorado’s efforts to fight substance abuse and the opioid epidemic plaguing the state.

The grant supports the Colorado Consortium for Prescription Drug Abuse Prevention, housed at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences at the University of Colorado Anschutz Medical Campus.

Robert Valuck, PhD, a professor at the CU Skaggs School of Pharmacy and Pharmaceutical Science, directs the consortium, which was established by Gov. John Hickenlooper in 2013 to coordinate the state’s response to the misuse of medications including opioid painkillers.

Professor Rob Valuck, PhD, of the Skaggs School of Pharmacy and Pharmaceutical Sciences
Professor Rob Valuck, PhD, of the Skaggs School of Pharmacy and Pharmaceutical Sciences

“Our mission is to reduce the misuse and abuse of prescription drugs in Colorado through policy work, programs and partnerships throughout the state,” Valuck said. “This tremendous support from the Colorado Health Foundation will speed our efforts to create lifesaving change throughout our communities and to stem the rising tide of opioid abuse in Colorado.”

Since the Colorado Consortium’s establishment five years ago, this innovative collaboration has leveraged state and institutional investments to attract more than $30 million to advance its collective mission.  The Consortium and its staff have reached 19 of Colorado’s 64 counties through partnerships with state agencies, organizations and community coalitions, and have elevated Colorado as a leader in successful community engagement for opioid addiction prevention.

“The Consortium led by Dr. Valuck has laid a strong foundation and has had early success in addressing the opioid epidemic,” said Ralph J. Altiere, Dean of the CU Skaggs School of Pharmacy and Pharmaceutical Sciences.  “The Colorado Health Foundation investment will help us build on these successes and make a major impact on this epidemic in Colorado and nationally.”

The Colorado Consortium’s achievements include launching a statewide TakeMedsSeriously public awareness campaign, installing medication safe disposal boxes in 36 counties, distributing 2,500 lifesaving naloxone kits to first responders in high-risk counties, and training 2,500 health care providers about safe prescribing and pain management practices. This grant from the Foundation enables the Colorado Consortium to further expand its reach throughout the state and to build a model of prevention that is replicable nationwide.

“Prescription drug abuse is not just a Colorado problem. It is a national epidemic,” said Karen McNeil-Miller, president and CEO of the Foundation. “We are interested in helping change the destructive trajectory of this epidemic and want to ensure that future efforts spearheaded by the Colorado Consortium are as impactful as possible.”

Combined with a $1 million grant from the state of Colorado, this funding from the Foundation will accelerate efforts to combat the growing substance abuse crisis through a Center for Substance Abuse Prevention, established last May at CU Anschutz as a result of Senate Bill 17-193 to build on the Colorado Consortium’s successes in prevention, education and research.

CU Anschutz Medical Campus Chancellor Donald M. Elliman, Jr. said the university is committed to leveraging the momentum built through the consortium and the center to help Colorado effectively address the opioid epidemic.

“Addressing the opioid epidemic and preventing substance abuse are top priorities, not only for the CU Anschutz Medical Campus but for the entire state of Colorado,” he said. “The Colorado Health Foundation’s investment in this effort represents a critical milestone in our progress, and I am confident that we will build upon our shared commitment and early successes to save lives.”

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Method to assess early intervention programs for America’s youngest is flawed

The US Department of Education’s Office of Special Education Programs (OSEP) should change the way it evaluates state early intervention programs for infants and toddlers with developmental delays, according to research from the University of Colorado Anschutz Medical Campus.

In a study published in the American Journal of Evaluation, researchers from the CU School of Medicine and the Colorado School of Public Health at CU Anschutz show that the evaluation method OSEP uses to gauge effectiveness of early intervention (EI) programs for children under three years of age is scientifically invalid and produces misleading results.

“Millions of dollars and thousands of hours have been put into the OSEP evaluation process and states are being encouraged to use the child outcome results produced by this design to inform their efforts at quality improvement,” said Steven Rosenberg, lead author and associate professor of psychiatry at the University of Colorado School of Medicine at the Anschutz Medical Campus in Aurora. “Neither the states nor OSEP seem to understand that the results of their evaluation process should not be used to assess the quality of early intervention services.”

OSEP administers Part C of the Individuals with Disabilities Education Act (IDEA) which authorizes the provision of EI services in the US for children ages 0-3 who have developmental delays. Early intervention programs are administered at the state level and evaluated using OSEP’s evaluation process. OSEP reports these evaluation results to Congress to demonstrate the effectiveness of Part C EI nationally. These findings are also used to judge the quality of state programs.

OSEP’s evaluation uses a design called a single group pre-post comparison to assess program outcomes. Investigators say it is a poor method of evaluation because the evaluation design cannot distinguish between child progress produced by EI and changes that result from normal variability in child growth.

Researchers say that to justify the use of a single group pre-post design, OSEP has had to assume that children’s delays only improve in response to treatment and considers all child progress to be evidence of effectiveness. Not so, say the authors of this article.

“Real babies show variability in their rates of skill acquisition,” Rosenberg said. “OSEP’s approach incorrectly assumes that all improvements are due to intervention – that’s not the way young children work.”

“States need to understand the problems with this process — it shouldn’t be used to compare one state to another,” he said.

To show how drawing valid information about EI program effectiveness using the single group pre-post comparison evaluation design is flawed, the researchers examined the development of thousands of infants in a national sample of children who did not receive EI services. About 80 percent of children who had delays at nine months were found to have no delays at 24 months, even though they did not receive EI. The authors believe that the fact that children who received no EI appeared to make substantial progress raises serious questions about the extent to which the gains reported for children who received EI can be attributed to the effects of early intervention.

“The fact that Part C EI programs are expected to draw conclusions about their program’s quality based on the results of a single group pre-post comparison design does a disservice to Part C administrators, practitioners, families and other stakeholders who are invested in improving outcomes for infants and toddlers with developmental delays,” the authors wrote.




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ACA Medicaid expansion resulted in fewer hospital closures, especially in rural areas

A new report published in the January issue of Health Affairs is the first to examine hospital closures in the context of the Affordable Care Act and Medicaid expansion. The study from researchers at the Colorado School of Public Health at the University of Colorado Anschutz Medical Campus used data from 2008 to 2016, including multiple years of post-expansion hospital performance data.

The findings indicate the Medicaid expansion under the Affordable Care Act was positively associated with improved hospital performance and a substantially lower likelihood of hospital closure especially in rural markets and counties where residents were largely uninsured adults prior to Medicaid expansion.

Richard Lindrooth, PhD, and coauthors in the Department of Health Systems, Management and Policy at the Colorado School of Public Health, examined national data on local market conditions, comparing the fiscal years immediately before the implementation of the Affordable Care Act (2008-12) with the years just after implementation (2015-16). The analysis was limited to nonfederal, short-term, general and critical access hospitals that had been in operation for at least one year between 2007 and 2015. According to the results, hospitals in the 32 states that expanded Medicaid were about six times less likely (or about 84 percent less likely) to close than hospitals in non-expansion states.

“Access to health care is a fundamental element of our health care system,” explains Lindrooth. “Our results suggest that if future policies are adopted that both eliminate the Medicaid expansion and lower health insurance coverage rates, we will see an increase in hospital closures, especially in rural areas.”

The authors note that the effects of closures on access and patient welfare depend on the degree to which local residents rely on the hospital for inpatient care.

Gregory Tung, MPH, PhD, co-author of the study at ColoradoSPH, says some closures could be less detrimental in certain areas, especially if hospitals are inefficient or of poorer quality. In urban areas, patients have more options, but it is a different story in rural communities.

“In rural and smaller communities, hospital closures have a far greater impact because they not only affect the delivery of health care services and emergency care, but we also have to consider that these hospitals may be the largest employer and often are pillars in those communities. A closure could mean the loss of well-paid, highly skilled jobs which often leads to well-paid skilled labor leaving those areas for larger cities and urban areas,” Tung said.

The authors also add that virtually all closures will increase the travel time required for receiving care that can lead to worse outcomes for patients with conditions that need immediate attention.

“If patients do not have access to other hospitals, as is the case in many rural markets, access to health care will suffer–regardless of whether a person has health insurance or not,” added Lindrooth.

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Top stories of 2017

Shim Stem Cells5. Training cells as cancer killers

Researchers develop new line of attack that relies on reengineering a patient’s own cells to recognize, attack and kill cancer cells. The target in the Novartis therapy is acute lymphoblastic leukemia, the most common form of cancer in children.

Dr. Jay Lemery of CU Anschutz4. Sounding the alarm on climate change

In his book ‘Enviromedics,’ Jay Lemery, MD, associate professor of medicine in the CU School of Medicine, explores the link between global warming and human health. Lemery co-wrote the book with Paul Auerbach, MD, professor of emergency medicine art Stanford University SOM.

EMT checking in patient in ER3. Program reduces high ED use, increases primary care visits

Researchers at the CU Anschutz Medical Campus have found that a community-based, care-coordination program aimed at high users of hospital emergency departments succeeded: It reduced ED visits and hospital admissions, while increasing use of primary care providers.

Sleep pods in CU Anschutz library2. Library opens spacious and welcoming study zone

With over 4,000 students, it can sometimes be hard to find study space on the CU Anschutz Medical Campus. Students are loving the Health Science Library’s new and inviting 5,000-square-foot-space (and state-of-the-art sleep pods).

This miniature microscope allows researchers to see inside the living brain.1. CU researchers win prestigious $2 million NIH grant for brain study

CU Anschutz and CU Boulder scientists will refine and expand use of unique miniature microscope they’ve developed. The grant is part of the NIH’s new BRAIN initiative aimed at revolutionizing the understanding of the human brain.

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College of Nursing ranked fourth in Best Online Graduate Nursing Programs

The University of Colorado College of Nursing has been ranked fourth nationally in Best Online Graduate Nursing Programs by U.S. News & World Report.

The latest listing, released Wednesday, moves the College of Nursing up on the U.S. News rankings. Last year, it came in ninth nationally for its online graduate program among the nation’s masters’ degree granting institutions.

“The College of Nursing is proud to be ranked fourth nationally in online graduate nursing programs,” said Interim Dean Mary Krugman, PhD, RN, NEA-BC, FAAN. “We have outstanding faculty who are committed to delivering online programs that are expertly designed, creating successful outcomes for student learning.”

CU College of Nursing graduates
CU College of Nursing graduates

The College of Nursing at CU Anschutz has been strategically employing highly skilled, committed and diligent distance educators for 20 years who have not only delivered a quality education to a wide range of students, but have helped recruit even more.

That record of excellence has often landed the college’s online programs among the best in the nation.

“This recognition is a validation of a rich history of quality online education,” said  Diane J. Skiba, PhD, RN, FAAN. “It is particularly rewarding this year as we celebrate our 20th year of our online informatics graduate program that is built upon a learner-centric model of education.”

Skiba is a professor and specialty director of health care informatics at the CU College of Nursing.

U.S. News used five categories in determining their rankings for online nursing programs. These include faculty credentials, student engagement, admissions selectivity, peer reputation and student service and technology.  U.S. News has ranked distance education programs for six years and believes online learning is becoming integral to all types of education and that consumers are hungry for information related to online degrees.


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Staff Council collects coats, school supplies to benefit community

Staff Council, which represents both the University of Colorado Denver and the CU Anschutz Medical Campus, spearheaded two incredibly successful community service projects in recent months.

Staff Council’s Networking/Campus Engagement Committee once again participated in Coats for Colorado by offering multiple sites on both campuses where coats could be dropped off. In October and November, the effort collected 532 coats – far surpassing the 325 coats collected in fall 2016.

Last summer, the committee launched a school supplies drive in collaboration with the CU Anschutz Community-Campus Partnership (CCP). In cooperation with Aurora Public Schools (APS), the groups chose as recipient the APS Welcome Center, which assists immigrant and refugee families in the metro area. Staff Council and CCP set up collection bins across both campuses and gathered over 500 items, including backpacks, lunchboxes, pens, crayons, notebooks and more.

Staff Council school supply drive at CU Anschutz
From left, Ingrid Summers, co-chair of Staff Council’s Networking/Campus Engagement Committee, and council member Maria Hernandez hold backpacks donated to the school supply drive.

Looking ahead, Staff Council has more outreach efforts planned in 2018.

Due to the overwhelming response received last year, the group has reserved an entire week – Feb. 12-16 – to volunteer at Food Bank of the Rockies. The initiative ties in with CU in the Community, an annual opportunity for CU employees to spend four work hours volunteering for the charity of their choice.

“We are very excited about this event and hope to fill all eight shifts – 40 volunteers each – at the Food Bank of the Rockies,” said Ingrid Summers, Office of Student Life, and co-chair of the Networking/Campus Engagement Committee.

If you’d like to volunteer for one of the food bank shifts, or for any other questions about Staff Council, please contact the council at


Staff Council provides a means for the exchange and dissemination of information among and for CU Denver | Anschutz classified, university and professional research staff about concerns and/or procedures and policies which affect staff at both CU Denver and the CU Anschutz Medical Campus.

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