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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Researchers say issues of dementia and gun ownership need more discussion

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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Study shows prenatal cannabis use associated with low birth weights

With marijuana use during pregnancy on the rise, a new study led by the Colorado School of Public Health shows that prenatal cannabis use was associated with a 50 percent increased likelihood of low birth weight, setting the stage for serious future health problems including infection and time spent in Neonatal Intensive Care Units.

Cannabis Sativa leaf
New study shows association between prenatal cannabis use and low birth weights.

“Our findings underscore the importance of screening for cannabis use during prenatal care and the need for provider counselling about the adverse health consequences of continued use during pregnancy,” said the study’s lead author Tessa Crume, PhD, MSPH, assistant professor of epidemiology at the Colorado School of Public Health at the University of Colorado Anschutz Medical Campus.

The study was published last month in The Journal of Pediatrics.

Crume and her colleagues utilized survey data from 3,207 women who participated in the Colorado Pregnancy Risk Assessment Monitoring System in 2014 and 15. They found the prevalence of marijuana use in the state of Colorado was 5.7 percent during pregnancy and 5 percent among women who were breastfeeding.

Tessa Crume, assistant professor of epidemiology at the Colorado School of Public Health
Tessa Crume, PhD, MSPH, assistant professor of epidemiology at the Colorado School of Public Health

They also discovered that prenatal marijuana use was associated with a 50 percent increased chance of low birth weight regardless of tobacco use during pregnancy. Prenatal marijuana use was three to four times higher among women who were younger, less educated, received Medicaid or WIC, were white, unmarried and lived in poverty.

Crume said the numbers are surprising but also reflect changing attitudes toward marijuana, especially in a state like Colorado where it is legal.

“There is increased availability, increased potency and a vocal pro-cannabis advocacy movement that may be creating a perception that marijuana is safe to use during pregnancy,” Crume said.

The National Survey on Drug Use and Health suggests that cannabis use among pregnant women has increased as much as 62 percent between 2002 and 2014. At the same time, the potency of the drug has increased six or seven fold since the 1970s along with the ways it is consumed – eating, vaping, lotions etc.

“Growing evidence suggests prenatal cannabis exposure has a detrimental impact on offspring brain function starting in the toddler years, specifically issues related to attention deficit disorder,” Crume said. “But much of the research on the effects of prenatal cannabis on neonatal outcomes was based on marijuana exposures in the 1980s and 1990s which may not reflect the potency of today’s cannabis or the many ways it is used.”

The study found that 88.6 percent of women who used cannabis during pregnancy also breastfed. The risk of cannabis to the infant through breastmilk remains unknown. Various studies have found that cannabinoids are passed to the baby in this way. One of the study’s co-authors, Dr. Erica Wymore, MD, MPH, from Children’s Hospital Colorado and the CU School of Medicine, is currently conducting a study to evaluate this issue.

The researchers recommend that health care providers ask pregnant women about their cannabis use and advise them to stop during pregnancy and lactation.

“Obstetric providers should refrain from prescribing or recommending cannabis for medical purposes during preconception, pregnancy and lactation,” Crume said. “Guidance and messaging about this should be incorporated into prenatal care. And screening of pregnant women at risk for cannabis dependency should be linked to treatment options.”

The study co-authors include Ashley L. Juhl MSPH, of the Colorado Dept. of Public Health and Environment; Ashley Brooks-Russell, PhD, MPH, of the Colorado School of Public Health; Katelyn E. Hall, MPH, of the Colorado Dept. of Public Health and Environment; Erica Wymore, MD, MPH of the University of Colorado School of Medicine and Children’s Hospital Colorado and Laura M. Borgelt, PharmD, of the CU Skaggs School of Pharmacy and Pharmaceutical Sciences.

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Vascular problems associated with symptoms of menopause and quality of life measures

A new study shows that more frequent and severe menopausal symptoms such as hot flashes, sleep disturbance, loss of sexual interest, weight gain and other quality of life measures, were associated with markers of vascular aging, according to researchers at the University of Colorado Anschutz Medical Campus.

The researchers, however, found no association between these vascular markers and symptoms of depression. The study was published online today in Menopause, the Journal of the North American Menopause Society.

Kerry Hildreth, MD
Dr. Kerry Hildreth, MD, assistant professor in the Division of Geriatric Medicine, CU School of Medicine.

“The menopausal transition is a vulnerable time for women in terms of vascular health,” said the study’s lead author Kerry Hildreth, MD, assistant professor in the Division of Geriatric Medicine at the University of Colorado School of Medicine. “Many women also experience menopausal symptoms that can negatively affect their quality of life and can contribute to depression, which is an established risk factor for cardiovascular disease. We investigated whether these symptom and mood aspects of menopause were associated with markers of vascular aging.”

Hildreth and her colleagues studied 138 healthy women grouped according to the stage of menopause. They found that arteries were stiffer, and the endothelium, the layer of cells that line the blood vessels, was progressively less healthy across the stages of menopause. Menopausal symptoms and depression symptoms were greatest, and quality of life was lowest, in the late-perimenopausal and early postmenopausal stages. Importantly, more severe menopausal symptoms and lower quality of life were associated with worse vascular function.

Unique study

“To our knowledge this was the first study to examine the association of mood, menopausal symptoms, and quality of life measures with these key markers of vascular aging in a well-characterized population of women spanning the stages of menopausal transition,” the study said.

Dr. Kerrie Moreau, PhD, associate professor
Dr. Kerrie Moreau, PhD, associate professor in the Division of Geriatric Medicine, CU School of Medicine

Women entering menopause experience profound hormonal changes coinciding with adverse changes in cardiovascular disease risk factors like high blood pressure, weight gain and insulin resistance, the study said. This may help explain the acceleration of vascular aging during the menopause transition.

Although the majority of women do not experience depression during the menopause transition, the risk is two to three times higher than in premenopausal women. One hypothesis is that the brain has to adapt to the irregular fluctuations in estrogen, a potent neurosteroid, during perimenopause, and eventually to a new, lower baseline level after menopause. This may explain why depressive symptoms returned to lower levels in the late postmenopausal women.

But while the researchers did not find an association between depression and vascular dysfunction across the stages of menopause, they did find an association with common menopausal symptoms. These include vasomotor symptoms, such as hot flashes, palpitations and headaches, and general symptoms, such as sleeplessness, poor appetite, constipation, weight gain, and poor concentration.

Estrogen loss could play role

The reasons behind these changes are unclear but loss of estrogen could play a key role.

“Estrogen modulates the synthesis and uptake of serotonin which has neuromodulatory, thermoregulatory, and cardiovascular actions,” the study said. “Fluctuating and declining levels of estrogen with the menopausal transition may alter serotonin activity.”

Another culprit could be oxidative stress. Estrogen is a potent anti-oxidant and higher levels of oxidative stress are seen in estrogen-deficient, post-menopausal women compared to premenopausal women, according to the study. Hot flashes are also associated with higher oxidative stress.

Hildreth said the next step is studying the mechanisms underlying these associations between vascular aging and symptoms of menopause.

“A better understanding of these aspects of the menopausal transition will be important for developing effective lifestyle and therapeutic interventions to promote psychosocial well-being and cardiovascular health in women,” Hildreth said.

The other authors of the study include Kerrie Moreau, Ph.D.*, University of Colorado School of Medicine; Cemal Ozemek, Ph.D., University of Illinois at Chicago; Wendy Kohrt, Ph.D.*, University of Colorado School of Medicine, Associate Director of the Center for Women’s Health Research; Patrick Blatchford, Ph.D.*, Colorado School of Public Health.
*Also affiliated with the Eastern Colorado VA Geriatric Research, Education and Clinical Center

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Those living near oil and gas facilities may be at higher risk of cancer and other diseases

Study says health risks increase closer to oil and gas facilities.
Study says health risks increase closer to oil and gas facilities.

People living near oil and gas facilities along Colorado’s Northern Front Range may be exposed to hazardous air pollutants, including carcinogens like benzene, that could pose health risks above levels deemed acceptable by the U.S. Environmental Protection Agency, according to researchers at the Colorado School of Public Health, Boulder County Public Health, CU Boulder, the National Aeronautics and Space Administration (NASA) and the University of California Irvine.

The study, led by the Colorado School of Public Health at the University of Colorado Anschutz Medical Campus, used ambient air samples to estimate and compare risks for four residential scenarios. They found the lifetime cancer risk of those living within 500 feet of a well was eight times higher than the EPA’s upper level risk threshold.

“We found that air pollutant concentrations increased with proximity to an oil and gas facility, as did health risks,” the study said. “Acute hazard indices for neurological, hematological and developmental health effects indicate that populations living within 152 meters (500 feet) of an oil and gas facility could experience these health effects from inhalation exposures to benzene and alkanes.”

Dr. Lisa McKenzie
Dr. Lisa McKenzie, PhD, MPH, of the Colorado School of Public Health

The cancer risk estimate of 8.3 per 10,000 for populations living within 500-feet of an oil and gas facility exceeded the U.S. EPA’s 1 in 10,000 upper threshold, according to study published recently in the journal Environmental Science & Technology.

“Our results suggest that Colorado’s current regulations that specify a 500 foot distance between a newly drilled oil and gas well and an existing home may not protect people from exposures to hazardous air pollutants that could impact their health,” said the study’s lead author Lisa McKenzie, PhD, MPH, of the Colorado School of Public Health. “Our previous work shows that thousands of people along the Front Range of Colorado live closer than 500 feet from a well and related infrastructure and that the population living close to these facilities continues to grow.”

The previous study examined the expansion of oil and gas wells along Colorado’s Northern Front Range. In the Denver Julesburg Basin, the industry is rapidly growing along with housing construction. As a result, 19 percent of the population or about 356,000 people, live about a mile from an active oil and gas site.

Colorado requires a new oil and gas well to be 500 feet from a residence and 1,000 feet from high occupancy buildings serving more than 50 people like schools and hospitals.

The study focused on the emission of non-methane hydrocarbons (NMHCs) that the wells emit into the air. These include benzene, toluene, ethylbenzene and xylenes, all considered hazardous.

Dr. John Adgate, PhD, MSPH, of the Colorado School of Public Health
Dr. John Adgate, PhD, MSPH, of the Colorado School of Public Health

The highest concentrations of hazardous air pollutants were measured in samples collected nearest to an oil and gas facility,” McKenzie said. “For example, average benzene concentrations were 41 times higher in samples collected within 500 feet of an oil and gas facility than in samples collected more than a mile away.”

The researchers noted that due to high atmospheric stability, nighttime emissions do not disperse as easily as they do during the day. That means benzene levels might be twice as high at night compared to daytime levels.

“The study provides further evidence that people living close to oil and gas facilities are at the greatest risk of acute and chronic health issues due to air pollutants emitted by those facilities,” said study co-author Pam Milmoe, Boulder County Public Health Air Quality Program Coordinator. “The results underscore the importance of having policies that require effective monitoring and reducing emissions from oil and gas facilities, particularly those near homes, schools, and recreation areas.”

Previous studies in Colorado observed that infants with congenital heart defects and children diagnosed with leukemia are more likely to live in the densest areas of oil and gas wells. Studies in Pennsylvania and Texas found associations between fetal death, low birthweight, preterm birth, asthma, fatigue, migraines and chronic rhinosinusitis and proximity to oil and gas wells.

The study acknowledged substantial uncertainties and the need for more research. Nonetheless, there is considerable evidence that benzene can cause cancer in those who work in and around it, but less evidence about its impact on non-occupational populations. The researchers also noted that air pollutants from other sources can contribute to the elevated risks, but stressed that because risks increased with proximity to wells, mitigation strategies should focus on controlling emissions from oil and gas facilities.

The study is available here https://pubs.acs.org/doi/10.1021/acs.est.7b05983.

The study co-authors include John Adgate, Colorado School of Public Health; Benjamin Blair, Colorado School of Public Health; John Hughes, Colorado School of Public Health; William Allshouse, Colorado School of Public Health; Nicola Blake, University of California Irvine; Detlev Helmig, University of Colorado Boulder; Pam Milmoe, Boulder County Public Health; Hannah Halliday, NASA Langley; Donald Blake, University of California Irvine.

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Shaping behavior, not changing minds, more effective in boosting vaccination rates

A comprehensive review of scientific literature surrounding the psychology of vaccinations has shown that shaping behavior rather than trying to change minds is far more effective at persuading people to get immunized.

“There is very little evidence to suggest that we can change people’s beliefs or knowledge in a way that will lead to increased immunizations,” said study co-author Allison Kempe, MD, MPH, professor of pediatrics at the University of Colorado School of Medicine. “What the evidence shows is that interventions tied to directly facilitating vaccination and changing behavior without trying to change beliefs are the most effective.”

Those interventions, she said, include things like sending vaccination reminders by calls, mail or texts, using standing orders and presumptive announcements that patients are due for vaccination in the primary care site and generally reducing barriers to immunizations. At the policy level, school and daycare vaccine requirements and more stringent criteria for vaccination exemptions have been very effective.

Increased outbreaks

The study, published Wednesday in Psychological Science in the Public Interest, a journal of the Association of Psychological Science, comes at a time when outbreaks of influenza and other communicable diseases are cropping up with seemingly increased frequency.

While less than 3 percent of parents refuse to vaccinate their children, they can have an outsized impact on others via the media and other social networks. Others accept the science of vaccination, but fail to get the full course or get them on time.

Allison Kempe, MD, MPH, professor of pediatrics at the University of Colorado School of Medicine
Allison Kempe, MD, MPH, professor of pediatrics at the University of Colorado School of Medicine

Kempe, who directs the Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS) at the CU School of Medicine, said the study illustrates that trying to change people’s minds or worse, arguing with them, rarely works to increase vaccinations.

“Changing behavior and making vaccination as easy as possible have been shown to be effective at increasing vaccination rates,” she said. “Simply providing educational information to people about vaccines or trying to confront myths they might have heard about vaccines tend to be ineffective at changing vaccination behaviors and can sometimes backfire.”

Research shows that the best way to confront misinformation about vaccinations is to reiterate the facts clearly.

“Countering misinformation directly can actually reinforce false beliefs so we need to be careful how we do it,” Kempe said. “When correcting misinformation, research shows it is best to state clearly and often what is true in a way that matches people’s intuitive beliefs rather than directly countering their beliefs.”

One way of doing this, she said, is through motivational interviewing techniques which have shown promise as a way to better counter misinformation and possibly change vaccination behavior. These techniques involve first acknowledging a parent’s concern, then identifying potential motivations for vaccinations based on the parent’s own feelings.

Three propositions for intervening

According to the study, psychology offers three general propositions for understanding and intervening to increase vaccine rates. The first is that thoughts and feelings can motivate getting vaccinated.

“We were surprised to find that few randomized trials have successfully changed what people think and feel about vaccines, and those few that succeeded were minimally effective in increasing uptake,” the study said.

The second proposition is that social processes can motivate vaccination. Studies have shown that social norms can in fact influence immunizations, few interventions examined whether they increase vaccination rates.

The third idea is that interventions can directly facilitate vaccinations by leveraging, but not trying to change, what people think and feel. These interventions are the most influential and common in current scientific studies.

“To increase vaccine uptakes, these interventions build on existing favorable intentions by facilitating action (through reminders, prompts and primes) and reducing barriers (through logistics and health defaults),” the study said. “These interventions also shape behavior (through incentives, sanctions and requirements.)”

‘More work to do’

Kempe said she was surprised by how little information is available in the scientific literature about what actually works to persuade people to get vaccinated.

“There haven’t been a lot of good studies on how to influence parents to vaccinate their children, especially interventions that might work in a busy primary care setting, where most of the discussions are going on” she said. “I think we have a lot more work to do in this area.”

The study is accompanied by a commentary by Victor J. Dzau, President of the United States National Academy of Medicine.

He said the authors offered psychological insights into why people engage in behaviors like vaccinations.

In publishing this study, he writes, the authors “are performing a service to society by integrating the disconnected literature on psychological theories and vaccination, which can inform practical interventions to address the challenges of vaccination.”

The first author of the study is Noel Brewer of the Gillings School of Public Health at the University of North Carolina and co-authors include Gretchen Chapman, Rutgers University; Alexander Rothman, University of Minnesota; Julie Leask, University of Sydney.

A link to the study is here:
“Increasing Vaccination: Putting Psychological Science Into Action”
http://journals.sagepub.com/stoken/default+domain/10.1177/1529100618760521-free/full

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Deadly Medicine at CU Anschutz Center for Bioethics and Humanities

Greeted by angry German voices, more than 130 CU Anschutz students, teachers, faculty and other Aurora community members filled the Fulginiti Pavilion on March 22 for the opening of “Deadly Medicine: Creating the Master Race.” Nazi artifacts and propaganda posters lined the walls, as the noise from the exhibit’s propaganda videos filled the air.

Attendees watched videos as they toured the ‘Deadly Medicine’ exhibit.

The traveling exhibit from the United States Holocaust Memorial Museum (USHMM) in Washington, D.C., spreads the USHMM’s message to remember and learn from the Holocaust and confront genocide and antisemitism.

The exhibit explores the roles of doctors and scientists in furthering the Nazi agenda and comes to the University of Colorado Anschutz Medical Campus as part of the University’s annual Holocaust Remembrance Week activities. Free and open to the public, the exhibit runs through May 22.

‘We have to own it’

“I’m Jewish, and I’ve heard and learned about the Holocaust since a very young age,” said Mayla Boguslav, second-year computation bioscience student in the Graduate School. “But I didn’t understand the impact that doctors, scientists and researchers had on the movement.”

Matthew Wynia, MD, presented to a packed house at the Fulginiti Pavilion.

Complementing the opening of the exhibit, Matthew Wynia, MD, director of the CU Anschutz Center for Bioethics and Humanities, told a story about how German healers and doctors turned into cold-blooded killers, using exhibit pieces of Nazi propaganda posters as visual aids.

“There are people who own this history in ways that I never will, because I’m not Jewish, and I’m not German” said Wynia, as he emphasized the story’s importance. “But if there’s one thing I’ve learned from my work with the Holocaust museum over the years, it’s that we have to all own this history. This isn’t just Jewish history; it’s the history of our profession, and we all have to own it to learn from it, to never repeat it.”

Holocaust Remembrance Week

  • Monday, April 9, at noon – Panel discussion at CU Boulder Law School – Room 205.
  • Monday, April 9, at 7 p.m. – Panel discussion at CU Boulder Eaton Humanities Building – Room 130.
  • Tuesday, April 10, at noon – Presentation and panel: Children’s Hospital Colorado Grand Rounds in Education II South auditorium.
  • Tuesday, April 10, from 5 – 7:30 p.m. – “Deadly Medicine” exhibit and panel discussion at the Fulginiti Pavilion
  • Wednesday, April 11, at noon – Presentation at UCHealth Schroffel Conference Center
  • Wednesday, April 11, at 1:30 p.m. – Panel discussion at the Fulginiti Pavilion
  • Thursday, April 12, at noon – Presentation at CU Colorado Springs
  • Friday, April 13, at noon – Panel discussion at CU Denver, 1250 14th, Room 470

Turning healers into killers

Wynia walked a captivated audience through the history of how medical and scientific leaders within the Nazi party perverted public health, biosciences and economics to further its agenda. The bottom line was their aim to create the “master race” through the tools of eugenics, an internationally-supported idea at the time. The Nazi leadership included many prominent German physicians and scientists of the era, Wynia said.

In fact, doctors designed and tested the gas chambers that were ultimately used to kill millions. They “euthanized” first infants and children and later institutionalized adults based on hypothesized “genetic defects,” which were often traits with no actual genetic basis but that were deemed socially undesirable. Doctors trained in “racial hygiene” saw it as their duty to choose those who were “fit” to contribute to the German gene pool, Wynia said.

“The medicalization of the death process really makes it clear how healers became killers,” he said. “Certain people came to be seen not merely as sub-human animals, but as pathogens, a true danger to the state. It was the doctors’ jobs to ‘protect’ the German community from these pathogens.”

Holocaust Remembrance Week

The exhibit opening was a kick-off to the Center’s annual set of events in commemoration of Holocaust Remembrance Week, which runs April 9 – 13. Full of educational programming and panel discussions, the activities will span all four CU campuses for its second year. Each event is free and open to the public.

“This event really highlights how we can all play a part in preventing this from happening again, regardless of what we’re studying,” Boguslav said. “It’s really special that our school provides us with events like this.”

 

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Study reveals lack of self-awareness among doctors when prescribing opioids

As health providers struggle to curb the epidemic of opioid abuse, researchers at the University of Colorado Anschutz Medical Campus and the University of Massachusetts Medical School have found that 65 percent of emergency department (ED) physicians surveyed underestimated how often they prescribed the highly addictive pain killers to patients.

Those rates dropped after they saw their actual data.

The year-long study, published this month in the journal Academic Emergency Medicine, focused on how doctors perceive themselves relative to their peers when it comes to prescribing opioids. Most felt they were restrained, but the results showed otherwise.

Dr. Sean Michael, assistant professor of emergency medicine and author of the study.
Dr. Sean Michael, assistant professor of emergency medicine and author of the study.

“We surveyed 109 emergency medicine providers at four different hospital EDs,” said study author Sean Michael, MD, MBA, assistant professor of emergency medicine at the University of Colorado School of Medicine. “We asked them to report their perceived opioid prescribing rates compared to their peers. Then we showed them where they actually were on that spectrum.”

Some 65 percent of those surveyed prescribed more opioids that they thought they did. Michael and his team found participants discharged 119,428 patients and wrote 75,203 prescriptions, of which 15,124 (or about 20 percent) were for opioids over the course of the 12-month study.

The researchers then monitored the doctors after they were shown their actual prescription rates.

“Everyone showed an overall decrease in prescribing opioids,” Michael said. “After seeing their real data, the people with inaccurate self-perceptions, on average, had 2.1 fewer opioid prescriptions per 100 patients six months later and 2.2 percent fewer prescriptions per 100 patients at 12 months.”

The study likened the physicians’ initial self-perceptions to the majority of drivers feeling they are above average – a statistical impossibility.

“Thus an intervention to identify and unmask inaccurate self-perception – and correct that perception using a provider’s actual data – appears to have enabled more robust behavior change for a subset of providers who may have otherwise had difficulty internalizing the need to change,” the study said.

The researchers believe the shock many felt upon seeing the reality of their actions versus their perceptions primed them to change their behavior.

Michael pointed out that this problem extends beyond emergency departments. In fact, only about 5-10 percent of all opioid prescriptions are generated by ED physicians.

“Despite making progress on the opioid epidemic, we can’t assume providers are behaving optimally and have all the information they need to do what we are asking of them,” Michael said. “Most believe they are doing the right thing, but we need to directly address this thinking to be sure they are not part of the problem.”

The other authors include Kavita Babu, MD, Christopher Androski Jr., MS, and Martin Reznek, MD, MBA, all from the University of Massachusetts Medical School, Worcester, MA.

 

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Shared decision-making between patients and clinicians can result in better choices

As more and more older patients are offered advanced treatments for chronic diseases, including surgeries and implantable devices, new questions have arisen over how these decisions are made.

In a study published Monday in JAMA Internal Medicine, researchers at the University of Colorado Anschutz Medical Campus examined this question by focusing on the decision-making that goes into whether a patient should proceed with a therapy called left ventricular assist device or LVAD.

They found that shared decision-making between patients and clinicians can improve the quality of the final decision in these often high-risk interventions.

Dr. Larry Allen, associate professor of medicine-cardiology at the CU School of Medicine.
Dr. Larry Allen, associate professor of medicine-cardiology at the CU School of Medicine. Allen co-authored the study.

“LVAD is growing rapidly among people dying from end-stage heart failure who are unable to get a heart transplant,” said study co-author Dr.Larry Allen, MD, associate professor of medicine-cardiology at the University of Colorado School of Medicine. “These patients decide to live out the remainder of their lives dependent on a partial artificial heart—so-called destination therapy (DT). Although patients may live longer with a DT LVAD, it also poses many risks, including stroke, serious infection, and bleeding, and comes with big lifestyle changes.”

Deciding whether to go forward with LVAD is often difficult for patients. Yet until recently, there were few tools available for patients and health care providers to use in LVAD shared decision-making.

“Because of this, the Colorado Program for Patient Centered Decisions spent years developing unbiased pamphlet and video decision aids for patients and caregivers, and paired them with training for doctors and nurses,” said study co-author Jocelyn Thompson, MA, of the CU School of Medicine.

The researchers set out to see how well these decision aids worked in routine care to help patients make quality choices around DT LVAD.

Six hospitals across the United States participated in a trial called the Decision Support Intervention for Patients and Caregivers Offered Destination Therapy Heart Assist Device (DECIDE-LVAD).

They switched from their current pre-LVAD education practices—usually consisting of locally made documents and pamphlets from the companies that make the LVADs—to using the formal decision aids and providing decision support training for the staff.

Patients were surveyed during the hospitals’ usual process, called the control period, and during the time the formal decision aids were used, called the intervention period. Researchers wanted to see how the new process changed LVAD decision-making.

A total of 248 patients were enrolled in the study. Some 95 percent of those in the intervention period received the formal decision aids. When compared to those in the control period, patients exposed to the decision aids had an improved understanding of the DT LVAD decision. This was demonstrated by a 5.5% increase in correct answers on a knowledge test.

The decision aids also improved values-choice agreement. In the intervention period, patients who said they were willing to undergo risky surgery for a chance to extend life were more likely to get an LVAD while those who didn’t want to be dependent on a machine were more likely to turn down LVAD.

Overall, patients who received the decision aids were more likely not to get an LVAD.

Allen said the DECIDE-LVAD trial shows that the use of formal, unbiased, patient decision aids for LVADs can help patients dying from heart failure improve the quality of decision-making. It may also change the rate at which they decide to proceed with such high-risk, high-reward treatment.

The study was funded by the Patient-Centered Outcomes Research Institute (PCORI).

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Honor Society: A small dose of compassion goes a long way

In the end, his patient died. But as Ajay Major, MD, MBA, then an intern, flipped through the old veteran’s medical record, he found comfort in the memories the notes inspired.

Now Major, a second-year internal-medicine resident on the University of Colorado Anschutz Medical Campus, calls up those memories of the witty old man with terminal cancer who always asked for bourbon (and his devoted wife who always rolled her eyes in response) as a continual reminder of the importance of compassion in health care.

“Medicine is hard,” Major said. “We see a lot of patients with a lot of difficult medical issues, and I think burnout stems not just from feeling overworked, but also from feeling that we’re not truly caring for our patients on a human level.”

Major, co-president of the CU Anschutz School of Medicine (SOM) Resident Chapter of the Gold Humanism Honor Society, spread his message during the society’s annual Solidarity Week Feb. 12-16 by encouraging his colleagues to take part in the week’s centerpiece program, Tell Me More (TMM).

Changing the conversation

Dr. Griff with Cory
Megan Griff, MD, chats with University of Colorado Hospital patient Frances Cory as part of a program aimed at teaching the value of compassion in medicine.

Armed with a TMM questionnaire and a smile, second-year internal-medicine resident Megan Griff, MD, entered her patient’s room, finding Betty Redwine, 77, wrapped in a light blanket and relaxing in a chair. “Is it OK to talk and find out about your life?” Griff asked, after explaining the program and introducing Major and attending physician, Jeannette Guerrasio, MD.

“OK,” Betty Redwine said, returning her doctor’s smile. “But it’s nothing exciting,” she said, grinning up from beneath a black-suede, shower-like cap she informed her guests was taming her unruly hair.

Prompted by four TMM questions, Redwine soon was sharing pieces of her past. Topics of capillaries and high blood pressure gave way to children’s feats and life’s treasures, sounding more like tea-time chatter than hospital-room discussion. When Redwine let a little secret slip, the room exploded in utterances of disbelief.

“What?” Guerrasio said, after Redwine revealed she worked as a registered nurse for 35 years. “Why didn’t you tell us?” asked Griff. “My mom is a nurse, too,” Griff said, when the commotion subsided. “You guys are hard-workers,” she said, patting Redwine’s hand.

Staying centered on the cause

While it might seem miniscule, a small dose of compassion can result in an array of benefits, Major said.  “It allows the patient to feel that the care team really cares about them, but it also brings some catharsis for providers. Just finding out a little bit more about our patients’ lives outside of the hospital can help re-center us in the work that we are doing as physicians and, I believe, help prevent burnout.”

On the patient side, studies show compassionate healthcare results in higher patient satisfaction, a higher pain threshold, reduced anxiety and better outcomes, according to the Gold Foundation, which cites supporting studies on its website.

TMM team meets with nurse
Ajay Major, MD, MBA, left, and Jeannette Guerrasio, MD, right, talk with Anne Marie Fleming, RN, about the Tell Me More program.

“People develop diseases for lots of reasons, and everyone’s lives really affect the way they respond to health problems,” said SOM Chair of Medicine David Schwartz, MD. It makes sense that trusted patient-provider relationships result in better care, he said. “We need to know how their lives might be contributing to the development of disease, and how their lives might contribute to our ability to effectively treat their disease,” he said.

Remembering: ‘I’m a person’

Looking up from her bed as the TMM trio walked into her room, Frances Cory, 79, had them laughing before even agreeing to chat. “You want to talk beyond my medical condition? You mean you don’t care about my medical condition anymore?” said the mother and grandmother, who later responded to a question about her biggest strength: “My sense of humor.”

Cory, who shared with her visitors that she had served more than 5,000 volunteer hospital hours during her lifetime, said she thought the program was important. “It’s nice to know that you take the time to talk to your patients. I’m a person.”

The TMM program offers a valuable reminder for medical students that their patients are people, and not just medical mysteries to solve, Guerrasio said. “I actually, as a doctor, find these conversations really helpful. And it’s what makes me come to work every day.”

Notes about the patient-doctor chat are jotted down on the TMM questionnaire, which is then displayed on the wall so that everyone involved in that patient’s stay, from therapists and nurses to doctors and janitors, can use it as conversation fodder, Major said.

‘The more passionate individuals are about their profession, and the more they enjoy what they are doing, the more engaged they become. These things feed on each other in very positive ways.’   ̶   David Schwartz, SOM Chair of Medicine  

Seeing nothing as too small

By getting to know his end-stage cancer patient and his wife as an intern, Major learned not just about his patient’s bourbon routine, but that he was a strong war veteran who had “always been a fighter.” That helped Major, when the man opted for a late chemo-treatment that was questionable at his stage and age. While the patient fared well through therapy, he developed an infection afterward that ended his fight.

When his patient was transferred to hospice, Major told his palliative caregivers about the bourbon. As he looked through his patient’s medical record after learning of his death, Major was jolted by one caretaker directive: Bourbon, one ounce at bed time as needed.

“It seems like such a small detail,” said Major, who published an article in JAMA Oncology about the patient experience. “But when his fighting wasn’t working anymore, he started thinking about things he really enjoyed in life. And having his little bit of bourbon was kind of important to him. So we made sure he could have that to the end.”

 

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