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Treatment for multiple recurrent meningioma

Jill Penafiel (second from left) with her daughters and husband
Jill Penafiel (second from left) with her daughters and husband

Ten years ago, Jill Penafiel was watching her teenage daughters play competitive volleyball and noticed that she couldn’t see whether the ball went over the net or not.  She blamed her failing vision on age; after all, she was nearing 40. But when her left eyeball started to protrude slightly, she decided that “something is not quite right here.”

A trip to the doctor—the first of many—confirmed her suspicion. Her left optic nerve was swollen, pushing her eye forward. When she underwent a test of her field of vision, she kept asking when the test would start, not realizing that it had already begun. She was “flunking with flying colors.”

“The doctor said it could be MS or it could be a brain tumor,” she said. “I stopped listening after that. It was just too horrifying.”

Jill had been employed by the University of Colorado since 1993 and was working on the Anschutz Medical Campus at that time. There was no doubt in her mind that she would seek treatment at CU. But she could hardly have imagined the long path her care would follow—and the collaboration between multiple physicians that would ultimately save her vision.

Diagnosis:  Meningioma

In 2007, further testing showed that Penafiel had a meningioma—a benign tumor—almost as big as her thumb wrapped around the optic nerve and invading her brain. Kevin Lillehei, MD, professor and director of the Neuro-Oncology Program, remembers the tumor as “quite significant” because it had invaded the orbit, the bony socket that protects the eyeball and allows the optic nerve to pass from the eye to the brain.

“I don’t feel like I am just a case here. I know my doctors really care.”

“When you go into the orbit, you have all the tiny nerves feeding the muscles that move the eye and you put them at risk,” Lillehei said. “You can end up with good vision, but one eye doesn’t move like the other and that causes continuous double vision.”

Lillehei performed a frontotemporal craniotomy, going underneath the left frontal lobe, drilling away bone at the skull base and removing bone along the lateral part of the orbit. He removed the tumor piecemeal, stopping short of taking all of it because he believed it would be too risky—Penafiel could lose her vision in the eye.

She remembers the first eye test after the day-long surgery. “They handed me a tiny chart to read,” she said. “I could read it! And they were all so excited, saying, ‘She can see!’”

Lillehei remembers that day with characteristic understatement. “We were quite pleased.”

The history:  Chernobyl

Jill Penafiel
Jill Penafiel

Like any person who experiences an unexpected health crisis, Penafiel asked, “Why me?” Lillehei may have provided a clue to that question when he told her that he thought the meningioma had been growing for as long as 20 years.

“He asked me what I was doing 20 years ago,” Penafiel said. “And I told him I was a teenager on scholarship living in Finland.” She arrived in the country in June 1986—five weeks after the catastrophic nuclear accident at Chernobyl. Living with a host family on an archipelago, Penafiel ate fish out of the Baltic Sea every day for three months while a radioactive cloud moved through the area.

“We have no way of knowing if this caused her meningioma,” Lillehei said. “Some are just spontaneous. But we do know that some can be induced by previous radiation. We are seeing that in a pediatric population about 15 to 20 years after they are treated with radiation. She fits that profile.”

Pivotal question:  What kind of birth control?

Penafiel’s tumor was an atypical meningioma (WHO grade II), meaning it was particularly aggressive. “We knew this one had to be watched very carefully,” Lillehei said.

In 2007, after the surgery, she underwent 30 radiation treatments, spent nearly four months recovering her strength, and then put the episode behind her except for annual MRI tests to check on the original tumor.

Six years later, at Thanksgiving 2013, she received more bad news. The original tumor had not changed, but she had developed two additional meningiomas, one at top of her head and one on the side.

“I asked, ‘Why again?’” Penafiel said. “It was hard for my family to hear this news.”

She was referred to Laurie Gaspar, MD, MBA, professor and former chairman in the Department of Radiation Oncology. Gaspar suggested that Penafiel undergo stereotactic radiosurgery, non-surgical radiation therapy which could precisely target the two small asymptomatic meningiomas with fewer high-dose treatments than traditional therapy.

“It was very frightening to her,” Gaspar recalls. “I had to reassure her.”

It took only about a week to recover from the stereotactic radiosurgery. Penafiel returned to her position at the CU Cancer Center, but not before Gaspar asked her what would prove to be a pivotal question. What kind of birth control was she on? Penafiel told her that she used a quarterly contraceptive injection of progesterone. 

Recurrence: A great memory and a gut feeling

In December 2016, Penafiel was looking ahead to 2017. One daughter was graduating from college, she had a trip planned with both her daughters and she was exceptionally busy in her job as the CU Cancer Center Education and Program Manager. She was preparing for “Learn About Cancer Day” for 120 high school students, and managing the Cancer Research Summer Fellowship Program which brings in 40 college undergraduates from all over the U.S. to perform cancer research with CU’s top cancer physicians and researchers.

Then, on Christmas Eve, the phone rang. Lillehei was calling to say that her most recent MRI showed a new nodule at the site of the original tumor behind her left eye.

“He told me that it needed to be dealt with surgically because of the location,” Penafiel said. “It was urgent, and very tough to receive the news about a fourth meningioma.”

Lillehei planned to present the case to the January meeting of the Skull Base Tumor Board. Then, in what would prove to be a prescient move, Penafiel contacted Gaspar to ask if she would attend the board meeting. Gaspar had a gut feeling and a great memory. She asked Penafiel if she was still using the same kind of birth control. Penafiel said yes. With just a hunch, Gaspar dug deeper. She did some literature searches, with a sneaking suspicion the birth control was connected to recurring meningiomas.

“As luck would have it, I was getting together with Dr. Ryan Ormond to talk about recent research,” Gaspar said. “So I asked him if he advises people with recurring meningiomas to steer clear of progesterone, or am I the only one? And he said to me, ‘That’s so weird you should ask me about that.’”

Ormond, who is an assistant professor and director of the CU School of Medicine Brain Tumor Program, told Gaspar that he was researching the association between hormones and recurrent meningiomas. Although the research was not yet published, initial results showed that people on progesterone had a higher rate of meningioma recurrence compared to patients not on the hormone. That information was, Gaspar said, “good enough for me.” She called Penafiel to say that new research supported her hunch and advised her to change her method of birth control—immediately.

The future:  “I  am eternally grateful”

When the tumor board convened, the game plan for Penafiel changed dramatically.

“It certainly changed our mind from going in surgically,” Lillehei said.

Instead, Penafiel started a mild oral chemotherapy designed to attack the meningioma. She will not spend months recovering from surgery and radiation—all because of a conversation between two physicians that Gaspar says is indicative of the collegiality at CU Anschutz which leads to better outcomes and happier patients.

“A lot of things happen just because we talk to each other in informal ways,” Gaspar said. “We learn from each other.”

Lillehei praises Penafiel for her willingness to advocate for herself. “She’s been a trooper,” he said. “She knows what she is up against but she has a tremendous attitude. And after everything she has been through, her vision is 20-20!”

Penafiel is willing to talk about her decade-long care at the CU Cancer Center because she feels she was never alone in the journey. She calls herself a “brain tumor survivor,” and says she is fortunate to have her family and her physicians. “I don’t feel like I am just a case here,” she said. “I am a person. I know my doctors really care. And I am eternally grateful.”

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Type 2 diabetes diagnosis in youth leads to increased health complications

A new report published this month in the Journal of the American Medical Association points to a significantly higher burden of diabetes-related complications in adolescents and young adults with type 2 diabetes compared to type 1 diabetes, with greater health complications in minority youth.

The study, from researchers involved with the nationwide SEARCH for Diabetes in Youth Study, looked at five health complications and co-morbidities of diabetes, including: retinopathy (eye disease), diabetic kidney disease, peripheral neuropathy (altered sensation in the feet), arterial stiffness and high blood pressure.

The researchers studied 1,746 adolescents and young adults with type 1 diabetes and 272 with type 2 diabetes. Their findings showed that, after less than eight years following a diagnosis, approximately one-third of teenagers and young adults with type 1 diabetes and almost 75 percent of those with type 2 diabetes had at least one health complication or comorbidity. Additionally, any adjustment for differences in age, sex, race/ethnicity, and levels of glucose control over time, did not remove the excess prevalence among those with type 2 diabetes.

“The high burden of early complications in youth with diabetes requires additional research to clarify the underlying causes and to identify effective intervention strategies,” said Dr. Dana Dabelea, lead author and co-chair of the national SEARCH Study and professor of epidemiology at the Colorado School of Public Health at the University of Colorado Anschutz Medical Campus. “It is extremely useful to have these estimates of the presence of complications in adolescents and young adults who are being treated with current therapies, especially because the complications are frequent. We need to make sure each risk factor is under the best control possible to reduce future problems.”

The SEARCH for Diabetes in Youth Study has been monitoring the burden of diabetes in youth with onset less than 20 years of age since 2000. Five U.S. clinical centers and principal investigators participated, including: Seattle Children’s Hospital, (Dr. Catherine Pihoker); Kaiser Permanente Southern California, (Dr. Jean Lawrence); Colorado School of Public Health (Dr. Dana Dabelea); Cincinnati Children’s Hospital, (Dr. Larry Dolan); and the Universities of North and South Carolina Schools of Public Health, (Dr. Elizabeth Mayer-Davis, SEARCH co-chair). The central laboratory is at the Northwest Lipid Research Laboratory, (Dr. Santica Marcovina) and the Coordinating Center is at the Wake Forest School of Medicine (Dr. Ralph D’Agostino and Dr. Lynne Wagenknecht, co-directors).

SEARCH is funded by the National Institutes of Health and the Centers for Disease Control and Prevention.

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Water fluoridation saves Americans over $6 billion in dental work

Americans enjoyed savings of $32 per capita in tooth decay prevention, according to a national assessment of fluoridation by Colorado School of Public Health (ColoradoSPH) researchers published in Health Affairs.

The work updates a 2001 comprehensive study of U.S. community water fluoridation program costs and benefits. Joan O’Connell, PhD, associate professor in the Community & Behavioral Health Department of the ColoradoSPH at CU Anschutz, and coauthors developed a model to update that national study using more recent information on fluoridation costs, the incidence of tooth decay and treatment costs.

They used data from multiple sources including the Centers for Disease Control, NNER, 2013 administrative data from private dental insurers and from water systems located throughout the U.S. They estimated the types of initial and follow-up treatment for dental caries, or tooth decay, and their associated costs to treat over time.

Researchers found that in 2013 more than 211 million people had access to fluoridated water through community water systems serving 1,000 or more people. They estimated 2013 savings associated with caries averted as a result of fluoridation to be $6.8 billion, or $32 per capita. The estimated cost to community water fluoridation programs providing fluoridation was $324 million, with net savings estimated at $6.5 billion and a $20 return on investment for each $1 spent. Estimates of per capita savings associated with community water fluoridation may be used by states to estimate net savings and a return on investment using local data on fluoridation costs.

Approximately 75 percent of Coloradans served by public water systems receive optimal levels of fluoride.  Community water fluoridation has been identified as the most cost-effective method of delivering fluoride to all members of the community regardless of race/ethnicity, age, gender, educational attainment or income.

The Colorado Department of Public Health and Environment’s Oral Health Unit oversees the Community Water Fluoridation program. The Oral Health Unit, in collaboration with the Safe Drinking Water Program, administers the community water fluoridation program, ensuring that the addition of fluoride is in accordance with the latest scientific, dental and health guidelines.

The Oral Health Unit collaborates with local communities to increase awareness of the benefits, safety and efficacy of water fluoridation; provide technical assistance to communities who are considering implementing a water fluoridation program; address possible community water fluoridation rollback attempts, provide funding for new or replacement fluoridation equipment, and support public water systems that are fluoridating meet operational guidelines.

In 2015, the U.S. Public Health Service updated its recommendation on fluoridation levels to 0.7 milligrams per liter (mg/L) from the previous 1962 recommendation range of 0.7 to 1.2 mg/L. This updated recommendation was initiated in 2011 and decided by a panel of scientists from several federal agencies after public comment. The panel reviewed a substantial body of peer-reviewed evidence to ensure optimal health and reduction in tooth decay while minimizing the risk of cosmetic fluorosis in the general population.

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Even after treatment, brains of anorexia nervosa patients not fully recovered

Even after weeks of treatment and considerable weight gain, the brains of adolescent patients with anorexia nervosa remain altered, putting them at risk for possible relapse, according to researchers at the University of Colorado Anschutz Medical Campus.

Dr. Guido Frank, associate professor of psychiatry and neuroscience, is an expert in eating disorders

The study, published last week in the American Journal of Psychiatry, examined 21 female adolescents before and after treatment for anorexia and found that their brains still had an elevated reward system compared to 21 participants without the eating disorder.

“That means they are not cured,” said Guido Frank, MD, senior author of the study and associate professor of psychiatry and neuroscience at the University of Colorado School of Medicine. “This disease fundamentally changes the brain response to stimuli in our environment. The brain has to normalize and that takes time.”

Brain scans of anorexia nervosa patients have implicated central reward circuits that govern appetite and food intake in the disease. This study showed that the reward system was elevated when the patients were underweight and remained so once weight was restored.

The neurotransmitter dopamine might be the key, researchers said.

Dopamine mediates reward learning and is suspected of playing a major role in the pathology of anorexia nervosa. Animal studies have shown that food restriction or weight loss enhances dopamine response to rewards.

With that in mind, Frank, an expert in eating disorders, and his colleagues wanted to see if this heightened brain activity would normalize once the patient regained weight.

Study participants, adolescent girls who were between 15 and 16 years old, underwent a series of reward-learning taste tests while their brains were being scanned.

The results showed that reward responses were higher in adolescents with anorexia nervosa than in those without it. This normalized somewhat after weight gain but still remained elevated.

At the same time, the study showed that those with anorexia had widespread changes to parts of the brain like the insula, which processes taste along with a number of other functions including body self-awareness.

The more severely altered the brain was, the harder it was to treat the illness, or in other words, the more severely altered the brain, the more difficult it was for the patients to gain weight in treatment.

“Generalized sensitization of brain reward responsiveness may last long into recovery,” the study said. “Whether individuals with anorexia nervosa have a genetic predisposition for such sensitization requires further study.”

Frank said more studies are also needed to determine if the continued elevated brain response is due to a heightened dopamine reaction to starvation and whether it signals a severe form of anorexia among adolescents that is more resistant to treatment.

In either case, Frank said the biological markers discovered here could be used to help determine the likelihood of treatment success. They could also point the way toward using drugs that target the dopamine reward system.

“Anorexia nervosa is hard to treat. It is the third most common chronic illness among teenage girls with a mortality rate 12 times higher than the death rate for all causes of death for females 15-24 years old,” Frank said. “But with studies like this we are learning more and more about what is actually happening in the brain. And if we understand the system, we can develop better strategies to treat the disease.”

The study co-authors include Marisa DeGuzman, BA, BS, Megan Shott, BS, Tony Yang, MD, PhD and Justin Riederer, BS.

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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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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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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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