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The hero and the dental student: A tale of friendship

Willie Peterson is an Army veteran who has lived through his share of hard times. He has learned to cherish small blessings and pay attention to positive role models. One such role model sat across from him over a string of dental appointments which saw Willie’s once-shy smile transform into a mouth of pearly whites.

That person is Bill Berguin, a recent graduate of the CU School of Dental Medicine. Bill has been the architect of Willie’s new dentures and a close witness to the inspired and ever-upward trajectory of Willie’s life.

Willie and Bill at the Heroes Clinic at CU Anschutz
Army veteran Willie Peterson, left, proudly shows off his new teeth, which were created by Bill Berguin, his Heroes Clinic caregiver.

At a recent dental appointment, Willie was all smiles. Besides gaining his stellar teeth, the soldier was excited to fill in Bill about yet another achievement. “Check out my credit score,” he said with a beaming grin. “Also, I’ve got a job. I haven’t had a good job in a long time.”

‘He’s a good man’

Willie met Bill about a year ago when he became the first Pathway 1 patient in the dental school’s Heroes Clinic, a Delta Dental of Colorado-sponsored program which provides free and discounted dental care to military veterans. Pathway 1 provides dental care to veterans served through the Bill Daniels Veteran Services Center, which helps link homeless veterans to jobs.

They come from different backgrounds – Willie is from Wisconsin and Bill hails from the Western Slope – but they bonded during Willie’s many visits to the dental chair. “I got to sit and talk with him about life – where he’s from and what he’s doing and how he was trying to go back to school,” Bill said. A few good-natured jabs also found their way into the conversations. Bill likes to razz Willie about being a Green Bay Packers fan, while Willie dishes it right back on the Broncos.

Kidding aside, Willie once confided to Bill, who was in the fourth year of dental school, that he had planted in the soldier’s mind the notion of returning to school. “I thought that was really neat,” Bill said. “I told him he might want to see a graduation, so he’s going to come to my graduation.”

Sure enough, early last Friday morning, Willie boarded a bus near his Denver apartment and rode to the CU Anschutz Medical Campus to attend Bill’s graduation. He hadn’t been to a graduation since his own from high school some 40 years ago. When Bill said he was looking forward to having his new friend meet his family, Willie smiled, extended a hand for a firm shake and said, “I want Bill to come to my graduation, too.”

Willie Peterson and Bill Berguin at CU Dental School graduation
Willie Peterson shakes hands with Bill Berguin at Bill’s graduation on May 26.

Willie has his sights on becoming a technician in heating, ventilation and air conditioning (HVAC). He recently enrolled in the HVAC program at Emily Griffith Technical College in Denver.

Asked what he found inspiring about Bill, Willie said, “I just think he’s a perfectionist. He’s a good man.” 

Putting his life back together

Willie performed a seven-year hitch in the Army, serving in Korea and Japan and, stateside, in Florida and California. He was discharged in 1983, but soon fell into drug abuse and homelessness. “The whole thing,” he said, shaking his head, “just a few years after I got out of the service.”

Gradually, he began to pay heed to the few positive influences in his life. He reconnected with a Lutheran pastor he’d first met during a spell of living in California. When the pastor moved to Wisconsin, Willie followed and began seeking the clergyman’s counsel.

“He helped me kick drugs,” Willie said. “I needed that – I really did – because I was heading down a bad street.”

Things turned more for the better when he sought the help of his mother. “I was just tired of how I was living, so I had to make a change. I started to hang out with my mom and going to church, and then I got the hang of it.”

About a year ago Willie made the move to Colorado, where his sister lives. Still, life was a struggle, as the veteran didn’t have a place to call his own. The Bill Daniels Veteran Services Center connected him to the Samaritan House, a transitional housing facility. Willie was riding the 16th Street Mall shuttle one day when he bumped into Heidi Tyrrell, RDH, assistant director and clinical instructor in the dental school’s Heroes Clinic.

“He was grinning ear to ear and wearing a suit that was a little too big for him,” said Tyrrell, who also noticed that Willie was in need of some dental work. “He ‘ma’amed’ me and I said, ‘Are you a veteran?’ He said yes and I handed him my card.”

Willie, Bill and Heidi at CU School of Dental Medicine graduation
At the CU School of Dental Medicine’s graduation on May 26 are, from left, Army veteran Willie Peterson, graduate Bill Berguin and Heidi Tyrrell, assistant director and clinical instructor in the dental school’s Heroes Clinic.

That’s how Willie ended up in a dental chair with Bill as his care provider. Growing up in Grand Junction, where he saw many friends join the military, Bill has a built-in respect for veterans and he felt honored to care for Willie. “I treated him the way I treat all my patients,” Bill said. “He’s a really good guy, so it was easy.”

With each visit, Willie’s smile brightened and his sense of accomplishment soared. “One less thing to do,” he said with another big grin.

‘Cool to feel like I was helping’

Willie enjoys his job as a housekeeper at the VA Medical Center in Denver. Besides his recent enrollment in technical college, he now has a permanent home, a new girlfriend and a burgeoning sense of security.

“I’m tired of living poor – I don’t want to keep living like that,” said Willie, sporting a U.S. Army hat and the ever-present Packers lanyard. “I feel good about myself now.”

Bill likes the idea of giving back to veterans and said that of all his clinical rotations during dental school, the Heroes Clinic became his favorite. Willie was even more special in that he is the clinic’s first Pathways 1 patient. “Folks in that population are a little more at risk,” Bill said, “so it was cool to feel like I was really helping somebody out.”

Bill will return to Grand Junction with a goal of eventually having his own practice. His father is a dentist, and he plans to join his dad’s practice to learn the ropes of daily dentistry while paying off student loans.

Bill said his rotation in the Heroes Clinic, especially his time with Willie, will remind him of the very reason he aspired to become a dentist – to help people. “I want to do community service and whatever I can to volunteer and give my time, so I can provide care for people who can’t afford it,” he said. “It’s something I want to continue and not lose sight of.”

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Palliative Care includes Creative Arts Therapy

 

A patient in the Natalie Kutner Palliative Care Creative Arts Therapy Program plays the guitar
A patient in the Natalie Kutner Palliative Care Creative Arts Therapy Program plays the guitar

After being diagnosed with cancer of the intestines in November 2016, Nick Gonzales was in and out of the University of Colorado Hospital (UCH) over a period of several months. By the time he began receiving palliative care, Nick and his wife Carol were stressed by multiple hospital visits and struggling to process his declining health.

They found relief through supplies you might not expect to find at a hospital—colored pencils and a camera.

Learn More

For information about the Creative Arts Therapy Program, contact Jean Kutner: Jean.Kutner@ucdenver.edu

To learn about ways to give, contact Cheryl Balchunas: 303-724-6871, Cheryl.Balchunas@ucdenver.edu

The Gonzales family participated in the Natalie Kutner Palliative Care Creative Arts Therapy Program, one of UCH’s newest approaches to care for people with serious illness. According to Program Director of the UCH Palliative Care Service Jeanie Youngwerth, MD, the program combines “the creative arts with therapy to make a patient feel like a person again.”

Nick and Carol used coloring and photographs taken by their art therapist to discover how creating art enables a patient to express deep and difficult feelings. “Poetry, art and music—they help to get your feelings out,” Nick Gonzales said. “It’s motivating, and I expressed more when I got involved with the program.”

His wife Carol agreed. “For me, coloring releases the stress of being in the hospital for so long.”

A personal connection to palliative care

The Natalie Kutner Palliative Care Creative Arts Therapy Program was created to honor the memory of Natalie Kutner—artist, medical social worker, Parkinson’s patient and the mother of Jean Kutner, MD, and CU Anschutz School of Medicine Professor of Medicine. Jean Kutner serves as a physician on the UCH palliative care team, and she played an instrumental role in starting the program.

Although she was already a palliative care physician when her mother’s health began to decline, being a family member of a terminally ill patient expanded Kutner’s perspective. “As a relative, I gained an even deeper appreciation of palliative care,” Kutner said. “The care team provided an extra layer of support that our family relied on.”

Untitled (House) by Natalie Kutner
Untitled (House) by Natalie Kutner

In the final stages of her disease, Natalie Kutner received eight months of palliative care. When Natalie died, Jean Kutner and her father designated the memorial donations for palliative care. Those funds and a generous anonymous donation made it possible to expand palliative care at UCH to include creative arts therapy.

Establishing a creative arts therapy program in Kutner’s honor resonated with her family because of Natalie’s volunteer work in the community and her legacy as an artist. When discussing her own work, she described the power art has to “transmute the ordinary into the extraordinary.”

Creators, not ‘reactors’

A similar transformation occurs in creative arts therapy at UCH, which helps patients cope with the existential pain of a terminal illness and communicate with their loved ones. “The program is an interdisciplinary approach to decreasing suffering and clarifying meaning,” Youngwerth said. “The therapists weave their skills and knowledge of art and music into their counseling and therapy.”

Palliative Care Art Therapist Amy Jones and Music Therapist Angela Wibben maintain a well-stocked “Art Cart” and an ample supply of musical instruments for patients and families.  “Sometimes patients have difficulty coping, overly identify with their disease or worry about leaving their children and grandchildren,” Wibben said. “Creative art therapy expands their definitions of themselves.”

Patient art becomes part of the legacy they leave for their families. One young mother with cancer constructed a bird’s nest out of weaving materials. She included a ceramic egg for each of her children and pebbles to represent the years she spent with her husband. “Creative art therapy looks at a person’s whole life,” Jones said. “It looks for metaphors that ease suffering beyond the reach of words.”

Wibben agrees. “Experiential music therapy may begin by listening to music and lead to a conversation that reveals what music means in our lives,” she said. “That might lead to songwriting, which makes the patient a creator, not a ‘reactor.’”

Turning a life into a legacy

Photographs of Nick and Carol Gonzales' hands, taken by their art therapist Amy Jones
Photographs of Nick and Carol Gonzales’ hands, taken by their art therapist Amy Jones

For Nick and Carol Gonzales, the couple found art creation to be relaxing, but their therapy also brought them closer together. When they left UCH, they took their artwork, as well as Jones’ photographs of Nick and Carol’s hands.

The photographs are a part of Nick’s legacy. “The pictures are really expressive,” Carol Gonzales said. “Seeing his hand over mine—I think of how he protected me.”

“Palliative care is not just medication, it’s emotional and spiritual help,” Nick Gonzales said. “When you share, it helps to heal. I look at those pictures of our hands, and I think of Carol and me taking care of one another.”

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Landmark gift makes CU Anschutz a national leader in veterans health care

Thanks to a gift of $38 million from the Marcus Foundation, the University of Colorado Anschutz Medical Campus will soon become a national model for the diagnosis and care of veterans who have suffered from traumatic brain injuries and related psychological health conditions.

Leaders of the Marcus Institute for Brain Health at CU Anschutz
Standing on the second floor of the CU Anschutz Health and Wellness Center, where the Marcus Institute for Brain Health will be located, are, from left, retired Navy SEAL Lt. Cmdr. Pete Scobell, U.S. Rep. Mike Coffman, philanthropist Bernard Marcus, Dr. James P. Kelly, and CU Anschutz Chancellor Don Elliman.

The Marcus Institute for Brain Health (MIBH) opens this summer in the CU Anschutz Health and Wellness Center. The one-of-a-kind institute will be the cornerstone of a planned national network devoted to innovative and intensive treatment of military veterans who served our nation and now suffer the invisible wounds of war.

The MIBH was announced Friday by CU Anschutz leaders and Bernard Marcus, whose Atlanta-based philanthropic organization has steadfastly supported the health and well-being of military veterans. The luncheon celebration drew more than 100 attendees, including leaders from CU Anschutz’s hospital partners as well as CU President Bruce Benson, CU First Lady Marcy Benson and U.S. Rep. Mike Coffman.

‘Ideal place’ for innovative institute

Bernard Marcus and CU President Bruce Benson
Bernard Marcus, retired co-founder of The Home Depot and founder of The Marcus Foundation, with CU President Bruce Benson.

CU Anschutz Chancellor Don Elliman said the campus is “the ideal place” to establish an institute that promises to transform health care for military veterans. CU Anschutz, once home to the Fitzsimons Army Medical Center, has a long history of serving veterans in addition to providing world-class mental health and wellness care. “We have leading-edge research and innovative programs that literally surround the institute’s efforts,” he said. “The campus is driven by a vision of delivering the best care and pioneering new approaches to treatments that get patients and families back to their lives.”

MIBH Executive Director James P. Kelly, MD, a neurologist and pioneer of customized diagnostic and treatment plans for veterans, led the National Intrepid Center of Excellence (NICoE) at the Walter Reed National Military Medical Center for seven years. The MIBH is designed after NICoE, which has successfully treated more than 1,300 active-duty servicemen and women suffering from traumatic brain injuries (TBI) and psychological health conditions. “Dr. Kelly came to us with that vision,” Elliman said, “and without him we would not be standing here today.”

Dr. Kelly stepped to the podium and, after acknowledging Chancellor Elliman and CU School of Medicine Dean John J. Reilly, Jr., MD, for their leadership, gave an emotional thanks to his wife of 30 years for her unwavering support throughout his career.

Dr. James Kelly of the Marcus Institute for Brain Health
Dr. James P. Kelly, executive director of the Marcus Institute for Brain Health

“The Marcus Institute of Brain Health is uniquely designed to address combined neurological and psychological conditions by targeting underlying causes,” Dr. Kelly said. “Where better to create such a place than the Anschutz Health and Wellness Center on an academic medical campus with a proud tradition of caring for military service members and their families?”

Immersive care

Retired Navy SEAL Lt. Cmdr. Pete Scobell
Retired Navy SEAL Lt. Cmdr. Pete Scobell

The MIBH will immerse veterans in treatment by a team of professionals in one place, rather than having them travel from clinic to clinic, Dr. Kelly said. The institute will optimize the functions of conventional medical diagnostic treatment while integrating alternative approaches such as mindfulness training, physical therapy and massage, acupuncture, yoga, and canine and equine therapy.

Care will be customized to each patient’s needs. “The Marcus Institute for Brain Health will share its lessons learned with systems across the country in real time. … What’s happening in Colorado will reverberate beyond our state’s borders to every corner of this nation,” Dr. Kelly said. “The need for such a program is huge.”

Nearly 400,000 U.S. servicemen and women have been diagnosed with TBI since 9/11 and as many as 600,000 suffered related psychological health conditions, he said.

‘I know I’m not alone’

One of these patients, retired U.S. Army Staff Sgt. Spencer Milo, has been named director of veteran programs at the MIBH. “As a military veteran who sustained injuries in Afghanistan, I am a huge advocate for the Marcus Institute for Brain Health,” Milo said. “Treatment like the traumatic brain injury therapies now being offered here saved my life, and I know I’m not alone.”

Plaque of Marcus Institute for Brain Health at CU Anschutz
CU Anschutz Chancellor Don Elliman points to a replica of the permanent Marcus Institute for Brain Health plaque as Dr. James P. Kelly, MIBH executive director, and Bernard Marcus, philanthropist and retired co-founder of Home Depot, look on.

Retired Navy SEAL Lt. Cmdr. Pete Scobell explained how he was the second SEAL to go to NICoE for treatment of TBI and related psychological conditions. He recalled sitting in a room with a dozen physicians representing “all specialties. They were out to solve the problem, not just treat the symptoms,” he said. “I know this can change lives – it’s unique.”

Cohen Veterans Network partnership

In addition to the announcement of the $38 million gift to create the Marcus Institute for Brain Health, the CU Anschutz Medical Campus announced it will work with the Cohen Veterans Network.

The network, in a partnership totaling $9.8 million, will work with CU Anschutz to build a mental health clinic to serve veteran and military families in greater Denver with free, or low-cost, personalized care and integrated case management support.

Founded by hedge fund manager and Connecticut philanthropist Steven A. Cohen, the Cohen Veterans Network is creating 25 Steven A. Cohen Military Family Clinics throughout the U.S. over a five-year period. Clients, veterans and family members will be treated by high-quality, culturally competent, network-trained clinicians, and will receive referrals to additional services at the CU Anschutz Medical Campus and in metro Denver.

Another distinctive aspect of the MIBH will be its service to military veterans regardless of their discharge status or ability to pay.

“It’s incumbent upon all of us across the nation to help those who have suffered as a result of their military service,” Dr. Kelly said, noting that the care at CU Anschutz will be further augmented by the soon-to-open Denver VA Hospital. Colorado will serve as a national model of seamless transitions of health care for veterans, he said. “It’s our intention that the Marcus Institute for Brain Health collaborate with academic and private-sector partners and the network of specialty centers – all working together to meet the needs of our veterans in multiple locations across the nation.”

Only the first step

Bernie Marcus, the retired co-founder of The Home Depot, said it’s an honor for his foundation to support veterans’ health because proper care for these selfless servicemen and women has been inadequate in the United States. He praised Dr. Kelly’s leadership of NICoE at Walter Reed National Military Medical Center and said the center’s innovative vision will carry forward at MIBH.

“We’re starting here in Colorado with this medical campus,” Marcus said. “This building is only the first step of a major organization that’s going to be unaffiliated; we’ll join together and try to create the best of the best, and that’s what my foundation is all about.”

CU President Bruce Benson said the University of Colorado system has long been committed to serving those who have served our country. “Our campuses and communities are better places for the presence of veterans and military-connected students, families, faculty and staff,” he said. “These new initiatives further strengthen that commitment. We are deeply appreciative of this tremendous support and proud to be able to do our part.”

While the Marcus Foundation’s gift of $38 million is over five years for the MIBH, which will also serve civilian adults who have sustained mild to moderate TBI, the institute is set up for the long term, according to Chancellor Elliman. “Our commitment is to keep this institute going for as long as there is a need,” he said.

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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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