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CU Anschutz faculty recognized for 25 years of service

Thirty-nine faculty members who have served the University of Colorado Anschutz Medical Campus (and its predecessor, the CU Health Sciences Center) for 25 years were honored at a reception at Fulginiti Pavilion on May 10.

Also attending the event were CU Anschutz Chancellor Don Elliman and Provost Roderick Nairn, as well as the deans from the CU Anschutz schools and colleges.

The leadership team lauded the faculty members – 15 were able to attend – for their lengthy service to the university. Each faculty member received a commencement medal, emblazoned with the seal of the University of Colorado, in appreciation for their service.

The 39 awardees:

Tamara Tobey, School of Dental Medicine

Anne Wilson, School of Dental Medicine

John Carpenter, Skaggs School of Pharmacy and Pharmaceutical Sciences

Steven Anderson, School of Medicine

Linda Barbour, School of Medicine

Kenny Chan, School of Medicine

Elisabeth Cheney, School of Medicine

Mark Earnest, School of Medicine

Raymond Estacio, School of Medicine

Bifeng Gao, School of Medicine

Edward Gill, School of Medicine

Roger Giller, School of Medicine

Brian Greffe, School of Medicine

Jennifer Hagman-Hazell, School of Medicine

Brack Hattler, School of Medicine

Karen Helm, School of Medicine

Vernon Holers, School of Medicine

Pamela Johnson, School of Medicine

Elizabeth Kozora, School of Medicine

Andrew Liu, School of Medicine

Kelly Maloney, School of Medicine

Connor McBryde, School of Medicine

James McManaman, School of Medicine

Samia Nawaz, School of Medicine

David Nowels, School of Medicine

David Olds, School of Medicine

David Price, School of Medicine

Tracy Price-Johnson, School of Medicine

Mona Rizeq, School of Medicine

Cordelia Rosenberg, School of Medicine

Steven Rosenberg, School of Medicine

Irene Schauer, School of Medicine

Deborah Seymour, School of Medicine

Albert Singleton, School of Medicine

Gary Thieme, School of Medicine

Thomas Whitehill, School of Medicine

Michael Wilson, School of Medicine

Michael Woontner, School of Medicine

Madalynn Neu, College of Nursing

Guest contributor: Kelly Mason, assistant director of events and partnerships, contributed the photo.

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Epperson named Chair of Psychiatry at CU School of Medicine

C. Neill Epperson, MD, an expert in women’s behavioral health, particularly the relationship of hormones and the brain, has been named chair of the Department of Psychiatry at the University of Colorado School of Medicine on the Anschutz Medical Campus, effective Sept. 1.

C. Neill Epperson, MDEpperson is currently professor of psychiatry and obstetrics and gynecology at the Perelman School of Medicine at the University of Pennsylvania. She was recruited to Penn from Yale School of Medicine in 2009 to launch and serve as director of the Division of Women’s Behavioral Health. In that capacity, Epperson founded and serves as the director of two clinical, research, and education programs: the Penn Center for Women’s Behavioral Wellness and Penn PROMOTES Research on Sex and Gender in Health.

“My career mission as a psychiatrist and physician-scientist has been to promote the centrality of the brain, with respect to all other areas of health,” Epperson said. “By doing so, I believe we can substantially reduce the stigma related to psychiatric conditions and improve uptake and utilization of behavioral medicine to improve the health and well-being of individuals, families and our society at large.”

Extensive research

Epperson’s research has been continuously funded for more than 20 years with grants from the National Institute of Mental Health (NIMH), the National Institute on Drug Abuse, the National Institute on Aging, the National Cancer Institute, the National Institute of Diabetes and Digestive and Kidney Diseases, the National Institutes of Health Office of Research on Women’s Health (ORWH) and private foundations and companies.

Epperson is committed to educating and training young clinician-scientists who draw their inspiration for research from the patients they treat.

“If our research does not ultimately lead to interventions that improve patient care and outcomes, we are not doing our job as scientists,” Epperson said. “I emphasize that we must listen to our patients and ask ourselves how we can better utilize research to address their particular clinical issues.”

She noted that some health problems, such as autoimmune disorders, migraines, depression, anxiety, and dementia, affect women to a greater degree than men.

Advancing science of gender issues

“So many of our current drug therapies were tested primarily in male populations, which means that we often do not know if these medications work as well or are as well-tolerated by women compared to men,” Epperson said. “This is one of the primary reasons it is critical for women to participate in clinical research studies whenever they can.”

Within two years at Penn, she was awarded one of nine Specialized Centers of Research focusing on sex and gender issues in health-related research from the ORWH and NIMH and is the principal investigator for Penn’s Building Interdisciplinary Research Careers in Women’s Health, also funded by ORWH.

“We are fortunate that Dr. Epperson will be joining the CU School of Medicine,” said Dean John J. Reilly, Jr., MD. “She has been a leader in advancing the science of sex and gender issues in psychiatry and improving our understanding of women’s behavioral health. She will continue to make outstanding contributions as a leader at CU Anschutz Medical Campus.”

Epperson said the role of reproductive and stress hormones on lifelong health has been a productive area of research.

“I first became interested in hormonal effects on the brain and behavior when I was a psychiatry resident at Yale and treating my first patient with postpartum depression,” Epperson said. “I had been taught throughout medical school that reproductive hormones are important for menstrual cycles, pregnancy and childbirth as well as breastfeeding. My professors never mentioned the growing literature that reproductive hormones have a profound impact on the brain and complex human behaviors.

Hormones and the brain

“This experience treating a new mother with postpartum depression inspired me to study how hormones effect the brain and behavior during periods of hormonal change across the female lifespan,” she said. “Some 26 years later, I continue to be astounded by the importance of reproductive hormones in complex human behaviors and how millions of women worldwide experience adverse mood and cognitive changes during these periods of hormonal flux.”

Having attended undergraduate and medical school at the University of North Carolina, Epperson said she understands the important role a state medical school plays in promoting health for the citizens of that state. She also connected with executive and faculty leadership at CU School of Medicine and affiliated hospitals, who understand the importance of brain health to all other areas of health.

“In my experience with a number of medical schools and health systems, these key stakeholders at CU School of Medicine, UCHealth, and Children’s Hospital of Colorado are extraordinary in their commitment to expanding and integrating behavioral medicine in primary and specialty care settings as well as in their outreach beyond the boundaries of the Anschutz Medical Campus to promote psychological well-being for all of Colorado’s citizens.”

Finally, Epperson said it is an honor to serve as chair for a Department of Psychiatry with faculty who have demonstrated commitment and accomplishment in all areas of the academic mission: clinical care, education and training, and research. She said she expects to continue interdepartmental and transdisciplinary collaborations with scientists and clinicians on campus to expand knowledge and improve care.

Epperson earned her MD from the University of North Carolina in Chapel Hill in 1991 and completed her residency in the Department of Psychiatry at the Yale University School of Medicine. She also served as a fellow at the Yale Child Study Center in its National Institute of Mental Health Training Program in Neuropsychiatric Disorders with Childhood-Onset. She was on the Yale School of Medicine faculty from 1999 to 2009.

Guest contributor: Mark Couch, chief of staff and director of communications, CU School of Medicine.

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Infant growth patterns affected by type of protein consumed

A new study by CU School of Medicine researchers has determined that choices of protein intake from solid foods has a significant impact on infant growth during the first year of life.

The study tested whether dairy-based or meat-based protein in an infant’s diet contributed to growth and weight gain. Sixty-four formula-fed infants were involved in the study, with the group evenly divided between those who ate dairy and those who ate meat in addition to their formula, fruits, vegetables and infant cereals.

“Although breastfeeding should be the norm, majority of the U.S. infants are formula fed and limited research has focused on formula-fed infants. We found that the source of protein may have an important role in regulating growth,” said Minghua Tang, PhD, assistant professor of pediatrics, who led the study. “Infants who consumed meat-based solid foods had a greater length gain while both groups gain similar weight.”

The study, published recently by the American Journal of Clinical Nutrition, is perhaps the first of its kind to evaluate the effect of protein from different food sources on growth in formula-fed infants during the first year of life. Such studies can provide evidence-based feeding guidance that can yield long-term benefits for optimal growth and obesity prevention.

Recruiting families

To conduct the study, the investigators recruited families in metro Denver with full-term, formula-fed infants who were three to five months old. If eligible, they were screened with a baseline visit and once enrolled they were randomized into dairy-based and meat-based groups. Those on the meat-based diet complemented their usual eating with commercially available pureed meats, while the dairy-based added infant yogurt, cheese and a powdered concentrate of whey protein.

From five to 12 months, the infants were measured for length, weight and head circumference. Blood samples were collected at baseline visit and again at the end of the study. Sources of protein did not seem to affect intake because both groups reported similar amounts of total calories, protein and fat consumption.

Based on the measurements, meat-based complementary foods promoted greater length. The analysis showed the length-for-age increased in the meat group and declined in the dairy group relative to the growth charts. At the same time, the weight-for-length measurements, similar to a “Body Mass Index” for infants, significantly increased in the dairy group compared with the meat group.

In addition to Tang, authors on the paper were Audrey E. Hendricks, PhD, assistant professor of biostatistics and informatics at the Colorado School of Public Health, and Nancy F. Krebs, MD, professor of pediatrics. The study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases, the National Center for Advancing Translational Sciences Colorado Clinical and Translational Science Awards, Abbott Nutrition, the American Heart Association, the Beef Checkoff through the National Cattlemen’s Beef Association, Leprino Foods and the National Pork Board.

Guest contributor: Mark Couch, chief of staff and director of communications, CU School of Medicine.

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Once a troubled teen, now a physician in training

William Mundo called it a “miracle” that he graduated from high school in 2012. Now the aspiring physician is graduating with his master’s degree in public health from the Colorado School of Public Health (ColoSPH).

“I almost dropped out of high school,” said Mundo, who also earned a bachelor’s degree in public health and ethnic studies from the CU Denver College of Liberal Arts and Sciences. “No one was expecting me to graduate.”

Now, the once-at-risk student is enrolled in the CU School of Medicine for the fall.

A child’s admiration

The son of Mexican immigrants, Mundo was born in Los Angeles and moved with his family to Leadville, Colo., when he was 6 years old.

“No one in my family had gone to college.”

He remembers, as a child, watching visitors arrive at his house to see his father. They came with sicknesses and injuries. They came to be healed.

Mundo thought his father was a doctor, and he wanted to follow in his footsteps.

“When I got older, I discovered that no one in my family had gone to college,” Mundo said. “My father didn’t have his medical doctorate. He’d dropped out of school in the sixth grade.”

But, Mundo learned, his father was a curandero, a community healer who provided traditional, indigenous forms of treatment. He decided he wanted to heal people, too.

A painful goodbye

When Mundo was 16, his father left the United States. He returned to his hometown in southern Mexico to take care of his own ailing father.

Mundo didn’t know if he would ever see his father again. He fell into despair and began getting into trouble. He was on the verge of dropping out of school when a mentor reached out to get him back on track – and took him to visit CU Denver.

The mentor knew of Mundo’s interest in health care and thought CU Denver would be a welcoming environment for him and – with its relationship to CU Anschutz – would help him on the path to med school.

“He was 100 percent right,” Mundo said. “From the moment I stepped foot on campus, I knew this was where I wanted to go.”

With his mentor’s support, Mundo applied to CU Denver and was accepted. He called his father in Mexico to share the good news. His father was proud of him and said he was making plans to come back to the United States and see him succeed in college.

But during Mundo’s very first week of college, his father passed away in Mexico.

“My father couldn’t come back to support me in my journey,” he said. “That solidified my motivation to honor his legacy as a healer.”

A pathway to success

William Mundo, CU Denver | Anschutz student
First-generation student William Mundo earned a bachelor’s degree from CU Denver and a master’s degree from CU Anschutz. Now, he’s enrolled at the CU School of Medicine.

A standout student at CU Denver, Mundo struggled a bit to find his way in the beginning.

“Being a first-gen student, I didn’t know what I was getting myself into,” he said. “I started as a pre-med biology major, but as I took more public health classes, I saw how it applied to my life and what I’d seen growing up in an underserved town.”

Leveraging a full-tuition scholarship from the university, Mundo completed his undergraduate education in 2016 – debt-free in spite of the fact that his family was not able to help support his education financially.

From there, he went straight to a master’s program at ColoSPH, where he studied Global Health Systems, Management and Policy.

“As I studied public health, I saw applications to my own identity and cultural heritage and opportunities to promote health equity and social justice,” he said. He graduates May 25 at the CU Anschutz Spring Commencement 2018.

“It’s been a very rewarding pathway,” said Mundo, who received both the Judith Albino Diversity Scholarship and the Hoffman Public Health Scholarship. “The university has provided me this opportunity to get an education and make history in my family and my community.”

An ultimate goal

And his pathway through the university won’t end there. Though he received offers from med schools across the country, Mundo chose the CU School of Medicine.

“It’s an excellent school,” he said. “I bleed black and gold.”

He has big dreams for helping not just his own but communities around the world.

“After I get my MD, I hope to be able to work with rural and Indigenous people around the world to preserve their culture and their health,” he said. “Then, I want to open my own clinic. I want to focus on health policy and social justice advocacy. I want to promote a narrative of creating healing spaces, incorporating restorative justice and pushing the United States to lead the world in health outcomes.

And then there’s his ultimate goal: to be the first Mexican-American U.S. president.

“I want to challenge the status quo and make a difference for others,” he said. “And I’m so thankful for everyone at the university who’s helped me out and allowed me to make something out of my life.”

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Opioid Awareness

Every nine hours and 36 minutes, a Coloradan dies from a drug overdose. This disturbing statistic underlines the rampant opioid abuse in the United States. Poor prescribing habits compounded by the spreading of misinformation has stalled any real progression toward ending this epidemic, experts say.

Inspired by the Dreamland Symposium held on campus last January, the CU Anschutz open chapter of the Institute of Healthcare Improvement (IHI) sponsored a seminar on April 25 to help clear common misconceptions regarding opioids. Students, faculty and staff from across campus, including the Graduate School, the Skaggs School of Pharmacy and Pharmaceutical Sciences and the College of Nursing, attended the event in the Education 2 building.

“We really wanted to educate our peers about the signs of opioid overdose,” Rikki Hanifin said of her involvement in the CU Anschutz chapter of IHI. “It’s so critically important that everyone is familiar with Naloxone, which can literally reverse overdoses,” said Hannifin, a second-year pharmacy student.

Debunking opioid myths

Opioids are a class of narcotics commonly prescribed to reduce pain. They are Schedule II drugs, indicating their accepted medical use with the moderate potential for abuse. However, the public erroneously uses this distinction to assume that opioids are more effective than unscheduled drugs, such as ibuprofen.

“The Drug Enforcement Agency (DEA) places drugs into schedules,” said Robert Valuck, PhD, during his opening remarks. “It doesn’t evaluate efficacy.”

Valuck went on to debunk several other myths, including the necessity of opioids in medicine. “Six percent of patients who use opioids exactly as they are prescribed will become addicted,” he said. “If there were any other disease that affected 6 percent of all patients, the hospitals would be shutting down to evaluate the problem. Addiction shouldn’t be treated any differently.”

Humanizing addiction

Lisa Raville, executive director of the Harm Reduction Action Center, said harm-reduction practices are common and should be employed in the opioid-abuse battle. “We wear seat belts, we use designated drivers, and we use nicotine gum to stop smoking. We need to approach opioid abuse in a similar manner.”

Providing addicts access to clean syringes is a good step toward reducing harm, including the spread of other communicable diseases, Raville said of the controversial issue. “We want to help get people back on their feet,” said Raville of rehabilitating users. “If they are infected with HIV or hepatitis C, then they are at that much more of a disadvantage. At the very least, it’s more cost effective to provide clean needles than provide life-long care of disease.”

Naloxone training

The event concluded with a hands-on demonstration on how to administer and obtain Naloxone, a prescription drug that can reverse opioid overdoses.

In Colorado, Naloxone is available at pharmacies without a prescription. Most major insurance companies cover the cost of Naloxone. For more information visit www.stoptheclockcolorado.org.

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New sunscreen dispensers

Colorado has one of the highest death rates in the United States from melanoma, the deadliest form of skin cancer. In hopes of reducing the numbers within its community, the CU Anschutz Medical Campus is spreading the word about sunscreen protection, offering both the message and the means.

Just in time for May’s Melanoma Awareness Month, three bright-yellow sunscreen dispensers now dot the campus, providing students, faculty and staff free sunscreen that they can slather on throughout the day.

“Many people forget to apply sunscreen in the morning, or they apply it only once,” said Nazanin Kalani, fourth-year student in the CU School of Medicine (SOM). “When free sunscreen is provided, you give people the opportunity to apply, or reapply, before they spend time outdoors.”

Spreading a message

Spearheaded by Robert Dellavalle, MD, PhD, and his dermatology/public health lab, with the help of Cody Glickman, president of the CU Anschutz Student Senate, the dispensers were installed last week. They will be funded by the Defeat Melanoma-Jeff Dulude Melanoma Foundation for the next three years.

“Skin cancer is the number-one most-preventable cancer,” said Claudia Dulude, founder of the foundation. “By placing free sunscreen around campus, we are making strides to end melanoma.”

Dulude launched the foundation after losing her husband and father of their two children to melanoma when he was 37. A Boulder engineer, Jeff Dulude was an outdoor enthusiast who especially loved taking his kids skiing.

Defeat Melanoma has placed more than 100 dispensers across the country, including on school campuses and at trailheads.

Bright yellow sunscreen dispensers can now be found in three locations on campus.

Coloradans at higher risk

In Colorado, residents are at a higher risk for skin cancer partly due to higher elevation and active outdoor lifestyles, both of which increase exposure to cancer-causing ultraviolet rays. Skiing offers a double-whammy, with its high-elevation locales and UV-ray reflection off the snow.

Although the dispensers are a step in the right direction, there are other important steps to ensuring skin safety, Dellavalle said.

“It’s a common misconception that we only need sunscreen to protect ourselves,” he said. “You should also avoid the midday sun using shade, clothing and hats. If you need to be outside, try to complete these activities before 10 a.m. or after 4 p.m.,” Dellavalle said.

“Having sunscreen on campus is a huge step in promoting sun safety and skin cancer prevention,” said Kalani. “Not only are we encouraging students to use sunscreen while on campus, but we are reminding them of the importance to educate their future patients.”

The CU Anschutz dispensers are in the north lobby of Education 2 North, the south lobby of Education 1 and the Etai lobby of Research 2.

“I hope that sunscreen dispensers at CU Anschutz encourages other campuses to push for sunscreen and shaded structures on their campuses,” said Kalani. “Hopefully, this push could trickle down to elementary and high schools as well. The earlier we can promote these habits, the better.”

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Milestones in Success 2018

From puppies and genomes to iPhones and brains, topics highlighting the annual ‘Milestones of Success’ celebration generated ample applause in the Krugman Conference Hall on May 2, as CU Anschutz Graduate School students, faculty and staff recognized the accomplishments of their peers.

“Milestones is meant to be a light-hearted, bragging event,” Inge Wefes, PhD, associate dean of the Graduate School, said of the end-of-the-year affair. “We wanted to recognize publications, graduation and just an overall job well done.”

Awards were presented to students and faculty for many different categories, including most outstanding faculty peer mentor taken home by Chad Pearson, PhD.

Following the recognitions, a competition dubbed the “three-minute talk” pitted students against each other and the clock, as they attempted to explain their academic work in three minutes or less. Participants included:

  • Rwik Sen, PhD, Julbert Caneus, PhD, and Sawako Tabuchi, PhD, who competed in the postdoc category. Tabuchi’s talk about comparing the brain to an iPhone camera won the crowd over, taking first prize.
  • Katie Mishall Barrett, Stephanie Garcia Alvarez and Esteban Lucero, who competed in the doctoral candidate group. Barrett won this category with her talk about thyroid cancer.
  • Liz Litkowski, Guttu Maskalo and Christophe Langouët-Astrie, who rounded out the competition in the master’s group. Litkowski’s talk compared puppies to statistical genomics and won the final category.

“It’s important to be able to present your research in a digestible way,” said Langouët-Astrie. “Our lab works with patients a lot and being able to break down the complicated research is incredibly important,” he said, adding that he’d do the competition again. “The more practice the better.”

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Gates Biomanufacturing Facility readies first shipment of clinical trial cancer treatments

The Gates Biomanufacturing Facility at the University of Colorado Anschutz Medical Campus has passed an important landmark in manufacturing its first clinical trial-grade product for direct infusion into patients.

The groundbreaking effort by the facility represents the culmination of several years of planning and work installing the requisite quality systems and trained team to deliver its first cell therapies for patient use.

The materials for a clinical trial in multiple myeloma treatment by a private research firm will soon be followed by clinical trial processing for pioneering teams at the Gates Center for Regenerative Medicine at the CU Anschutz Medical Campus.

“It’s the first product we’ve produced to infuse into a patient,” said Ryan Crisman, interim facility director at the Gates Biomanufacturing Facility.

The treatment, based on the production of CAR-T cells to attack cancer, is shipped to the locations of clinical trials around the nation.

“It’s a big benchmark for our facility, for the Gates Center and for the university,” Crisman said.

CU Anschutz Chancellor Don Elliman agreed.

“The Gates Biomanufacturing Facility has reached another important milestone in collaborative efforts at the CU Anschutz Medical Campus to be a leading bench-to-bedside research and treatment center,” he said. “This first material delivery should be a harbinger of opportunity and promise for our talented investigators and clinicians, for our campus and for patients. It’s exciting to be part of the safe and expedited translation of scientific discovery into new human therapies and cures.”

Gates Center Director Dennis Roop, PhD, who also conducts team research on inherited skin diseases with treatments headed for clinical trials, lauded the manufacturing success.

“Since we established the Gates Center of Regenerative Medicine in 2007, my dream has been to build a facility that would allow the translation of basic research into therapies that would benefit patients. This achievement by The Gates Biomanufacturing Facility has now brought this dream to fruition,” Roop said. “My new dream is that this is only the beginning.”

The Gates Biomanufacturing Facility also expects soon to assist recently recruited researcher Terry J. Fry, MD, in producing materials for additional clinical trials.

Fry, one of the nation’s leading cancer researchers, was named co-director of the Human Immunology and Immunotherapy Initiative on the CU Anschutz Medical Campus in February.

Fry was among the first scientists to investigate the potential to insert modified genes into a child’s own T-cells to combat lymphoblastic leukemia. Approved by the FDA for pediatric use in August 2017, the therapy achieved an astonishing 80 percent remission rate in kids with otherwise unresponsive cases of the leukemia. Fry is now working to develop targeted treatments to decrease resistance and increase durability of remission. He’s also working to apply CAR-T technology to other types of cancer.

The Gates Biomanufacturing Facility is one of six combined cell therapy and protein manufacturing facilities in the United States and the only one of its kind within an 800-mile radius: http://gatesbiomanufacturing.com/ The facility has been a key element in the recruitment and retention of some of the nation’s top regenerative medicine researchers for the CU Anschutz Medical Campus.

“It’s a very highly regulated field,” Crisman said. “Any time you are doing cutting edge research and clinical trials, you want to make sure the process is not in question. We are proud of our efforts to eliminate the process as a variable, so we can focus on the clinical efficacy for the patient.”

About the Gates Center for Regenerative Medicine

The Gates Center for Regenerative Medicine was established in 2006 with a gift in memory of Denver industrialist and philanthropist, Charles C. Gates, who was captivated by the hope and benefit stem cell research promised for so many people in the world. The Gates Center aspires to honor what he envisioned – by conducting leading-edge research in stem cell biology and regenerative medicine to accelerate discoveries from the lab through clinical trials leading to effective cures and therapies for patients.

Led by Founding Director Dennis Roop, PhD, the Gates Center is located at the University of Colorado’s Anschutz Medical Campus, the only comprehensive academic health sciences center in Colorado, the largest academic health center in the Rocky Mountain region and one of the newest education, research and patient care facilities in the world.

The Gates Center shares its services and resources, with a growing membership of researchers and clinicians at the Anschutz Medical Campus, which includes University of Colorado Hospital, Children’s Hospital Colorado and the future Veterans Administration Medical Center, as well as the Boulder campus, Colorado State University, the Colorado School of Mines, and business startups. This collaboration is designed to draw on the widest possible array of scientific exploration relevant to stem cell technology focused on the delivery of innovative therapies in Colorado and beyond.

Guest contributor: Article submitted by Michael Booth, Gates Center.

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Invasive procedures should be reserved for a sub-group of acid reflux patients, study says

As the number of Americans with acid reflux grows, a study by researchers at the University of Colorado Anschutz Medical Campus says invasive procedures to treat those who don’t respond to medication should be done for select patients.

“When you have a subset of patients who are not responding to drug therapy you need to respond in a thoughtful way,” said the study’s lead author, Rena Yadlapati, MD, MHS, assistant professor of medicine-gastroenterology at the University of Colorado School of Medicine. “Only a select few should be referred to surgery.”

The paper was published recently in The American Journal of Gastroenterology.

Rena Yadlapati, MD, MHS, assistant professor of gastroenterology.
Rena Yadlapati, MD, MHS, assistant professor of gastroenterology.

Currently, about 30 percent of the U.S. population suffers from gastroesophageal reflux disease (GERD) and most are treated with drugs like Nexium known as a proton pump inhibitors. Yet for 10-40 percent of patients, medication doesn’t eliminate symptoms. And for some, a hypersensitivity to symptoms may lead them to believe their acid reflux is worse than it is.

Yadlapati and her colleagues surveyed a panel of 14 gastroenterologists on treatment options when typical acid reflux drugs don’t work. They constructed a number of hypothetical scenarios involving patients who did not respond to double dose proton pump inhibitors.

“A nuanced understanding of both the literature and the patient’s unique physiologic profile is critical to appropriate decision-making, as inappropriate recommendations may compromise outcomes and patient safety,” Yadlapati said.

The panel investigated each hypothetical case and ranked the appropriateness of four invasive anti-reflux options. They also ranked their preference for drug and behavioral health treatment options.

“In the majority of cases, an invasive anti-reflux intervention was ranked as an inappropriate option,” the study said.

For patients with true refractory acid reflux demonstrated by ongoing abnormal esophageal acid exposure despite proton pump inhibitors more invasive options were recommended like laparoscopic fundoplication, where part of the stomach is wrapped around the lower end of the esophagus and stitched into place.

The researchers found that some patients who didn’t respond to acid reflux drugs had a hypersensitivity to the symptoms. In these cases, Yadlapati said, invasive procedures are unlikely to improve outcomes while possibly increasing morbidity, decreasing quality of life and adding up to higher health-care costs.

She said low-doses of antidepressants have a role in modulating symptoms.

“Behavioral modification and relaxation therapy are also potentially effective,” she said. “In a study of nine patients with functional heartburn, esophageal-directed hypnotherapy was associated with significant improvements in symptoms, visceral anxiety and quality of life.”

Ultimately, Yadlapati said, treatment options should be personalized for each patient. Surgery may be called for in some cases but it’s not usually the preferred option.

“We are not opposed to surgery for the right patients,” she said. “But we should not be reflexively referring patients for these invasive treatments before considering all of the options.”

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Researchers say issues of dementia and gun ownership need more discussion

As the number of adults with Alzheimer’s disease and dementia steadily increases, questions around their access to firearms remain largely unaddressed, according to a study by researchers at the University of Colorado Anschutz Medical Campus.

“Firearm access, like driving, can pose a risk of injury or death to both cognitively- impaired individuals and those with whom they interact,” said the study’s lead author Marian (Emmy) Betz, MD, MPH, of the University of Colorado School of Medicine. “How can health care providers, family members and friends balance firearm-related safety concerns with the rights and wishes of the individual?”

The study was published Monday in the Annals of Internal Medicine.

Betz and her colleagues from institutions including Johns Hopkins University, the University of Michigan and the University of California Davis, examined clinical perspectives relating to assessment and counseling about firearm access for those with dementia or other cognitive impairment.

They found that nearly 4.7 million adults had Alzheimer’s in 2010 and that number was expected to grow to 13.8 million by 2050. The disease accounts for about 70 percent of all dementia cases. That means the total number of people with cognitive impairment and a firearm at home will also grow.

The study noted that even in the highly politicized atmosphere surrounding gun ownership, about 89 percent of Americans support limiting firearm purchases and access to those with a mental illness. Americans also support temporarily reducing gun access in times of elevated suicide risks.

Dr. Emmy Betz, associate professor of emergency medicine.
Marian Betz, MD, associate professor of emergency medicine

“The primary firearm injury risk for individuals with dementia is likely to be death by suicide,” said Betz, an associate professor of emergency medicine at the CU School of Medicine. “Some 91 percent of older adults’ firearm deaths are due to suicide, and firearms are the most common method of suicide among people with dementia.”

People with dementia can experience hallucinations, delusions, agitation or aggression. If a person is delusional and believes people are breaking into their home, they may feel caregivers and family members are intruders and confront them with a gun.

Betz said conversations about guns in these situations are similar to talks with older drivers.

“When is it time to give up the keys, be they to a gun safe or a car?” she asked. “What are the relevant state and national laws? When and how should conversations occur?”

Right now there are no validated screening tools for assessing firearm access among cognitively-impaired people. For those with milder forms of dementia, some experts recommend discussions with the patient and family about setting a `firearm retirement date.’

Caregivers can also ensure that guns are securely locked so the patient can’t have access without supervision. They can reduce risks of gun injury by making firearms less lethal – removing ammunition from the home, storing firearms unloaded or having trigger mechanisms removed.

Betz said physicians have a right and a duty to ask and counsel patients about potential health risks so long as they balance the welfare of the person with the health and safety of the public.

Federal law forbids the sale of a gun to someone judged `mentally defective’ or who has been committed to a mental institution. Still, federal and state laws don’t explicitly prohibit those with dementia from buying guns.

Betz said working with stakeholders in the dementia and firearms community would go a long way toward creating effective materials and programs to address this problem.

She and her colleagues have developed a sample family firearm document. The person with dementia would be able to sign the agreement before symptoms become too severe. The agreement says that when the person with dementia can no longer make the best safety decisions, the family can control the possession of his or her firearm.

“It’s best to have these conversations early and be aware that you have to take action at some point,” Betz said. “This is not about the government or anyone else seizing guns, but about a family making the best decision for everyone involved.”

The co-authors of the study include Alexander McCourt, JD, MPH, Johns Hopkins Bloomberg School of Public Health; Jon S. Vernick, JD, MPH, Johns Hopkins Bloomberg School of Public Health; Megan L. Ranney, MD, MPH, Rhode Island Hospital/Alpert Medical School; Donovan T. Maust, MD, MS, Department of Psychiatry, University of Michigan Center for Clinical Management Research, VA Ann Arbor Healthcare System; Garen J. Wintemute, MD, MPH, University of California, Davis School of Medicine.

 

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