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An Epic Sprint to aid clinics

In February 2011, the University of Colorado Anschutz Medical Campus took a major step toward fundamentally changing its health care delivery. The change would eventually affect every provider, researcher and staff member on the campus and beyond – and the reverberations continue today.

The revolution began with a handful of ambulatory clinics at University of Colorado Hospital that began using the Epic electronic health record (EHR). The aim: shelve dozens of discrete applications and towering paper stacks in favor of a single system that would allow all providers to view a patient’s entire medical record online.

Sprint Team Conference Room
Sprint team at work near the end of its four weeks of work in the OB/Gyn Clinic.

The Epic implementation included a massive training effort and a phased, multi-year rollout that ensconced the EHR on the Anschutz Medical Campus and at UCH satellite clinics. With the formation and growth of UCHealth, Epic now links hospitals and clinics up and down the Front Range and beyond.

But the challenges of ­working efficiently and effectively with an EHR remain. Memorizing sequences of clicks in record charting can be frustrating for providers focused on patient care. Patients now have an electronic conduit to their providers through My Health Connection; figuring out how best to route and respond to questions can be challenging and time-consuming for clinics. The basic Epic framework requires ongoing customization to meet the needs of dozens of specialists and subspecialists – most them with the CU School of Medicine – and their UCHealth patients.

These challenges help to explain why Epic training, in the form of tip sheets, webinars, emails, and other support, has never ended. The past year has produced a new twist: a dedicated team that gives clinic providers and staff focused, face-to-face help with making the most of the EHR.

On the run

The Sprint team, as it’s called, consists of Epic analysts, trainers, and a project manager, as well as a nurse and physicians who combine clinical and information technology skills. Together they help to define the clinical and operational needs of providers and staff and collaborate with IT, clinical and other experts to meet them. Their guiding principle: people learn best when they have face-to-face help from people who are interested in listening to them, answering their questions and solving their problems.

“It’s a collaborative effort,” said Christine Gonzalez, the Sprint team’s project manager. “When you need to make rapid changes, nothing beats live help. Providers and staff feel safe with working one-on-one.”

The Sprint team is a response to a problem that is both local and national, said Amber Sieja, MD, a physician informaticist for the Anschutz Medical Campus and an internist with the CU School of Medicine. Maintaining paper medical records might have been cumbersome, but for many providers meeting the demands of an electronic system has made practicing medicine more difficult than ever.

“The problem we face is that providers are burned out with their clinical practice,” Sieja said. She noted that in national surveys, providers routinely identify EHRs as a major contributor to that problem. “Locally, our providers have told us the EHR takes up too much time,” she added. “That’s our problem to solve.”

That’s a tall order, however. Epic is a dynamic tool that receives annual upgrades as well as ongoing customized changes for specific clinical areas. How to communicate the changes to the couple of thousand providers with the School of Medicine and UCHealth Medical Group? The Epic team has tried spreading the word with regularly scheduled Skype videos, newsletters, tip sheets, and open training sessions. It’s all fallen well short of reaching anywhere near most providers, Sieja said.

“The message we got is ‘we want somebody in our clinics,’” she said.

Face time

Sprint Team
Members of the Epic Sprint team outside the OB/Gyn Clinic at University of Colorado Hospital. Left to right, back row: Amber Sieja, MD – physician informaticist; Todd Andrews – lead analyst; Dan Golightly – analyst; Rob Lewis – analyst; Dan Kroening – trainer; Diane Pruitt, RN – clinical informaticist. Left to right, front row: Scott Carpenter – lead trainer; Barbara Noble – trainer; Christine Gonzalez – project manager; Megan Cortez – analyst; Tally Talyai, PA – physician informaticist.

That demand spurred the creation of the first “Sprint” in 2016. Sieja, fellow physician informaticist Katie Markley, MD, and UCHealth Chief Medical Information Officer CT Lin, MD, put together a team that parachuted into the Endocrinology Clinic at UCH for a two-week, hands-on helping stint. Their work drew praise from both providers and staff for helping to decrease burnout, reduce charting time and improve patient care.

The Endocrinology pilot wasn’t perfect, Sieja said. Most importantly, it showed that future Sprint projects would need more lead time to prioritize clinic needs, schedule rooms and meeting times, identify potential new EHR builds, and so on. They settled on 90 days of preparation, said Sieja, who used that time to develop a curriculum for the Neurology Clinic at UCH.

The Sprint project in Neuro, which began in January 2017, represented a major challenge. Its nearly 100 providers handled more than 26,000 patient visits in 2016. It also includes eight subspecialties, all with specific patient care needs. A major part of the work involved meeting with “clinical content leaders” to identify priorities for new Epic builds, such as flowsheets to help ensure that patients with neuromuscular diseases like ALS (amyotrophic lateral sclerosis, or Lou Gehrig’s disease) and other complex neurologic conditions receive evidence-based standards of care.

“These are tools that allow us to track patients over time,” said Laura Strom, MD, an epilepsy specialist who helped to lead the Sprint effort in the Neurology Clinic. “They are invaluable in Epic.” The flowsheets, however, had to be built from scratch, a time-consuming process, she added. All told, seven subspecialties requested and received customized builds as part of the Sprint project.

The Sprint team spent a pair of two-week stints, separated by a one-week break, in the Neurology Clinic, wrapping up the work in February. Much of the effort focused on helping providers use Epic more efficiently for their basic work: pulling needed information from patient charts; ordering labs, imaging studies and other tests; responding to patient questions and referral requests; and preparing to address patients’ chief complaints in advance of the visit. Providers learned to use templates, preference lists, keywords and phrases, and other shortcuts to reduce the number of clicks – and therefore time – they spend at the keyboard, Sieja said.

Making work simpler

The key is to reduce frustration with practical help, said Gonzalez, who handles the planning, coordination and other logistical details of each Sprint mission.

“I feel we come in to take a good tool [Epic] that we already have and make it better,” Gonzalez said. Many providers on the Anschutz Medical Campus, she noted, have not had additional guidance in using Epic since the first go-live six-plus years ago.

“Who doesn’t need more training?” Gonzalez asked. She cited the example of a UCHealth Colorado Springs provider who was surprised when she found how much time she could save by using Epic’s Dragon voice-recognition software for her progress notes instead of typing. The shortcut helped her get home to her family earlier.

“She told us the change helped her to become a better mother,” Gonzalez said.

Strom said more than 90 percent of the Neurology Clinic’s providers received the Sprint training in some form. The attention generally helped to increase individuals’ confidence in using shortcuts in Epic to trim their documentation time, she said. One example: “dictionaries” Epic uses to translate shorthand for frequently used terms into the real word.

“People applauded the one-on-one teaching,” Strom said. Some critics of Epic who had viewed it as nothing more than a “billing tool,” she added, changed their minds after the Sprint initiative.

“They saw that Epic could be used to take better care of patients and to help to improve the growth of understanding about their disease,” Strom said. A post-intervention survey showed that both providers and staff viewed Epic in a more favorable light than they had before the Sprint team worked with them. For example, the percentages of those who agreed that the clinic improved its use of the EHR and the patient care it provided increased significantly in both groups.

The Sprint team followed the Neurology Clinic assignment with a regular schedule of visits to UCHealth facilities in Northern and Southern Colorado as well as the Anschutz Medical Campus. For example, they worked with the respective Hematology/Oncology practices at UCHealth’s Memorial Hospital in Colorado Springs and Poudre Valley Hospital in Fort Collins. They wrapped up a four-week stint with the OB/Gyn Clinic at UCH – another with close to 100 providers and several subspecialties – on July 21. They are booked on a two-week on, one-week off schedule through June 2018 (with some extra time off for the next Epic upgrade this October), Gonzalez said.

Important challenges remain, including how to ensure that the positive changes in clinics visited by Sprint continue. Sieja points to the importance of super users and clinical content leaders to “carry the improvements forward.” Sprint success also brings to light questions of “scalability,” said Chief Medical Information Officer Lin, noting that it could be increasingly difficult for a single Sprint team to meet clinic demand. For now, the team splits to work with clinics with fewer providers and subspecialists.

“We need people to bring along others at the basic level,” Strom agreed. “But the sense of what is possible with Epic is now much more keen. More people are saying, ‘We really can use this tool.’”

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Researchers find creosote bush could treat Giardia and brain-eating amoeba infections

Compounds produced by the creosote bush, a desert shrub common to American Southwest, exhibit potent anti-parasitic properties against two deadly parasites responsible for Giardia infections (Giardia lamblia) and the amoeba that causes an often-lethal form of encephalitis (Naegleria fowleri), according to researchers at the Skaggs School of Pharmacy and Pharmaceutical Sciences at CU Anschutz and UC San Diego.

Daniel LaBarbera, PhD, associate professor of drug discovery and medicinal chemistry at Skaggs School of Pharmacy and Pharmaceutical Sciences.
Daniel LaBarbera, PhD, associate professor of drug discovery and medicinal chemistry at Skaggs School of Pharmacy and Pharmaceutical Sciences.

The findings, published online this month in PLOS Neglected Tropical Diseases, may give scientists the chance to widen their arsenal of antimicrobial agents effective against deadly parasitic infections. The current standard treatment for both infections involve antibiotics and anti-parasitic drugs.

The World Health Organization estimates giardiasis, a diarrheal illness, is linked to approximately 846,000 deaths worldwide each year. Infection usually occurs through ingestion of contaminated water or food. Though rarely lethal in the United States, it’s estimated there are more than a million cases of giardiasis in the country annually. Infections due to N. fowleri, sometimes called the `brain eating amoeba,’ are much less common than Giardia.

Compounds from the creosote bush may fight two deadly parasitic infections.
Compounds from the creosote bush may fight two deadly parasitic infections.

“However, it is a far deadlier parasite that is found in warm fresh waters and infects the central nervous systems of their victims through the nasal passages causing lethal brain damage known as primary amoebic meningoencephalitis (PAM),” said principal investigator Dan LaBarbera, PhD, associate professor of drug discovery and medicinal chemistry at the Skaggs School of Pharmacy and Pharmaceutical Sciences at CU Anschutz.

Due to its rapid infection cycle and high mortality rate, the CDC has been given special approval to provide the drug miltefosine to clinicians as a treatment option for N. fowleri infection. But it is still not FDA approved and has limited availability in the U.S. This new compound potentially provides a less expensive, more effective treatment option.

Scientists from CU Anschutz and UC San Diego collaborated as part of the Skaggs Scholars program, which matches investigators from Skaggs-funded schools of pharmacy with complementary expertise to discover potential drug breakthroughs. UC San Diego scientists provided expertise in parasitology, while the CU Skaggs School of Pharmacy provided expertise in natural products, compound libraries and active compounds from plants. The researchers investigated these tropical diseases because of their occurrence in Mexico and South America and found indigenous peoples treating infections with creosote compounds.

“The significance and intrigue about our study is that it shows the value of prospecting for new medicines from plants traditionally used by indigenous people as medicine,” said co-principal investigator Anjan Debnath, Ph.D., an assistant adjunct professor at Skaggs School of Pharmacy and Pharmaceutical Sciences at UC San Diego.

The creosote bush (Larrea tridentata), is a tough evergreen bush with small waxy leaves, yellow flowers and a distinctive turpentine-like scent. Native Americans in both the United States and Mexico have long used the plant for a variety of ailments, including intestinal complaints. There is also an existing body of scientific work documenting the plant’s pharmacologically active compounds, notably nordihydroguaiaretic acid (NDGA). NDGA has antiviral, antibacterial, anti-inflammatory and anticancer properties.  The study is the first to show that NDGA and five other compounds are active against both pathogenic parasites.

In other studies, NDGA has been shown to be a neuroprotective agent. It protects human monocytes and other cells and tissues through its powerful antioxidant activity.

“In our study the creosote natural product, NDGA, proved to be a more potent anti-parasitic agent against N. fowleri compared to miltefosine,” LaBarbera said. “Therefore, NDGA may lead to a more effective drug therapy option for N. fowleri infection.”

This research was funded in part, by a grant from The ALSAM Foundation and National Institutes of Health.

 

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Major communication gaps between doctors and home health care nurses revealed

Researchers at the University of  Colorado Anschutz Medical Campus have found serious gaps in communication between physicians and home health care agencies (HHC) responsible for caring for often elderly patients discharged from hospitals. The problem, the study said, can contribute to hospital readmissions.

The research, published today in the Journal of General Internal Medicine, cites an array of communication challenges between HHC agencies and physicians following hospital discharge.

Dr. Christine Jones, assistant professor of medicine and lead author of the study.
Dr. Christine Jones, MD, MS, assistant professor of medicine and lead author of the study.

The study cited frequent discrepancies in medication lists, confusion over who was responsible to write patient care orders, inaccessible hospital records and resistance from clinicians and staff for accountability.

Led by Christine D. Jones, MD, MS, assistant professor at the University of Colorado School of Medicine, the researchers conducted six focus groups with HHC nurses from six different agencies in Colorado to ask about their general experience with caring for patients after discharge from any of their referring hospitals.

“We found that communication breakdowns can have consequences for patients,” said Jones, lead author of the study. “These are some of our most fragile patients, most are over 65, and more seamless communication is needed.”

Some of the HHC nurses interviewed complained of a lack of accountability, medical errors and difficulty in reaching doctors.

“As a general rule, I’ve been told you’re not to contact the hospitals. I actually got in trouble for contacting the hospital, trying to find out, get more information, trying to track a doctor down,” one nurse said in a focus group.

Another nurse said even if they reach a primary care physician, they often say they didn’t know the patient was in the hospital and they don’t have a report on them.

“The communication between the hospital and the primary care providers is just as bad as it is for us because the PCP’s don’t have the information,” the nurse said.

Dr. Jones said another complicating factor is that insurance often requires doctors to order HHC services. So if a nurse practitioner is providing primary care for a patient, obtaining HHC immediately becomes more difficult.

The researchers found another serious problem when it came to ordering medication. HHC nurses and staff said most of the medication lists they receive are incorrect due to the number of doctors and specialties involved.

“As hospitalists, we need to think about what happens beyond the hospital walls and how we can support our patients after discharge, especially when it comes to home health care patients who can be very vulnerable.” Jones said.

She noted that the study did not focus on any one specific hospital, but hospitals in general.

The study proposes a series of solutions to these problems including the following:

  • Hospitals and primary care physicians could provide HHC agencies direct access to Electronic Medical Records and direct phone lines to doctors.
  • Enact laws allowing nurse practitioners and physician’s assistants to write HHC orders. A bill was under consideration to do this but was not acted upon by Congress.
  • Clearly establishing accountability for hospital clinicians to manage HHC orders until a primary care physician can see a patient and help HHC nurses with questions.
  • Create better communication methods with PCPs to ensure safer transitions

“Our findings suggest that improvements to accountability and communication could address patient needs and goals, avoid medication discrepancies and ultimately improve safety for patients and HHC nurses,” Dr. Jones said.

 

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Senior Executives from Film and Virtual Reality Industries Join NBHIC

The National Behavioral Health Innovation Center announced today that Rick Rekedal, a former senior executive with DreamWorks Animation, and Dr. Walter Greenleaf, a pioneer and leading authority on virtual reality for medical use, have joined its staff.

Rick Rekedal joins NBHIC as Senior Creative Advisor
Rick Rekedal joins NBHIC as Senior Creative Advisor

“Walter and Rick are recognized internationally as leaders in their fields,” said Matt Vogl, executive director of NBHIC at the University of Colorado Anschutz Medical Campus. “Their knowledge and insight are powerful assets to our mission of finding bold new solutions to the country’s mental health crisis.”

In 2016, Rekedal completed over 20 years with DreamWorks as Chief Creative of franchise development and the global franchise director of the hit movie “Trolls.” Rekedal has also worked on properties such as “How To Train Your Dragon,” “Shrek,” “Kung Fu Panda,” and “The Lost World: Jurassic Park,” developing merchandising, interactive and licensing programs. Rekedal’s work has been recognized with two Annie Awards, two Kids Choice Awards and Toy of the Year. He is a frequent speaker and serves on advisory boards for The Wedgwood Circle; Michael W. Smith Group and Seabourne Pictures; and Belmont University’s film school.

Dr. Walter Greenleaf is NBHIC’s new Director of Technology Strategy
Dr. Walter Greenlef joins NBHIC as Director of Technology Strategy

Rekedal joins NBHIC as Senior Creative Advisor, consulting on how to elevate an open and urgent national conversation on mental health.

Greenleaf is a behavioral neuroscientist and a medical product developer who has been on the cutting edge of virtual reality and augmented reality applications in healthcare for more than 30 years.

In his role as NBHIC’s Director of Technology Strategy, Greenleaf brings his considerable knowledge to the Center’s approach to digital initiatives. He continues to work as a Visiting Scholar at the Stanford University Virtual Human Interaction Lab.

He has developed several clinical product streams, founded medical companies, and served as a scientific advisor and reviewer for the U.S. Public Health Service, National Science Foundation, National Institutes of Health, NASA and the U.S. Department of Education. He holds a PhD in Neuro and Bio-behavioral Sciences from Stanford University.

“Our approach is to seek out unexpected partners as we look beyond the current mental health system for new solutions,” said Vogl. “Walter and Rick fit that approach. Walter’s depth of knowledge in virtual reality and Silicon Valley are leading us to work with new technology partners in developing cutting edge tools for mental health treatments. Rick’s extraordinary creative abilities can help steer powerful human connections to combat the awful stigma that is so harmful to many people in need.”

Guest contributor: Lauren Baker, marketing and communications strategist for the National Behavioral Health Innovation Center at CU Anschutz.

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Immune system may keep body from neutralizing HIV-1 virus

Researchers at the University of  Colorado Anschutz Medical Campus have discovered that a process protecting the body from autoimmune disease appears to prevent it from creating antibodies that can neutralize the HIV-1 virus, a finding that could possibly help lead to a vaccine that stimulates production of these antibodies.

Dr. Raul Torres, professor of immunology and microbiology at CU Anschutz
Raul Torres, PhD, professor of immunology and microbiology at the University of Colorado School of Medicine.

The study, led by Raul M. Torres, PhD, professor of immunology and microbiology at the University of Colorado School of Medicine, was published Tuesday in The Journal of Experimental Medicine.

Torres and his team sought to better understand how the body’s own immune system might be getting in the way of neutralizing the HIV-1 virus.

They knew that some patients infected with HIV-1 developed what are known as ‘broadly neutralizing antibodies,’ or bnAbs, that can protect against a wide variety of HIV-1 strains by recognizing a protein on the surface of the virus called Env. But the patients only develop these antibodies after many years of infection.

Because of shared features found in a number of HIV-1 bnAbs, researchers suspected the inability or delayed ability to make these type of protective antibodies against HIV was due to the immune system suppressing production of the antibodies to prevent the body from creating self-reactive antibodies that could cause autoimmune diseases like systemic lupus erythematosus.

At the same time, patients with lupus showed slower rates of HIV-1 infection. Scientists believe that’s because these autoimmune patients produce self-reactive antibodies that recognize and neutralize HIV-1.

The process by which the body prevents the creation of antibodies that can cause autoimmune disease is known as immunological tolerance.

Torres wanted to break through that tolerance and stimulate the production of antibodies that could neutralize HIV-1.

“We wanted to see if people could make a protective response to HIV-1 without the normal restraint imposed by the immune system to prevent autoimmunity,” Torres said.

The researchers first tested mice with genetic defects that caused lupus-like symptoms. They found that many of them produced antibodies that could neutralize HIV-1 after being injected with alum, a chemical that promotes antibody secretion and is often used in vaccinations.

Next, they treated normal mice with a drug that impairs immunological tolerance and found that they began producing antibodies capable of neutralizing HIV-1. The production of these antibodies was increased by alum injections. And if the mice were also injected with the HIV-1 protein Env, they produced potent broadly neutralizing antibodies capable of neutralizing a range of HIV-1 strains.

In every case, the production of these HIV-neutralizing antibodies correlated with the levels of a self-reactive antibody that recognizes a chromosomal protein called Histone H2A. The researchers confirmed these antibodies could neutralize HIV-1.

“We think this may reflect an example of molecular mimicry where the virus has evolved to mimic or look like a self protein,” Torres said.

Torres suggested that the difficulty in developing a vaccine against HIV-1 may be because of the ability of the virus to camouflage itself as a normal part of the body.

“But breaching peripheral immunological tolerance permits the production of cross-reactive antibodies able to neutralize HIV-1,” Torres said.

Since the research was done on animals, scientists must still determine its relevance for HIV-1 immunity in humans.

“The primary consideration will be determining whether immunological tolerance can be temporarily relaxed without leading to detrimental autoimmune manifestations and as a means to possibly elicit HIV-1 bnAbs with vaccination,” he said.

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National study shows interventions like telephone calls can reduce suicides

In perhaps the largest national suicide intervention trial ever conducted, researchers at the University of  Colorado Anschutz Medical Campus and Brown University found that phone calls to suicidal patients following discharge from Emergency Departments led to a 30 percent reduction in future suicide attempts.

The study was published recently in JAMA Psychiatry.

The year-long trial, which involved 1,376 patients in eight locations nationwide, provided suicidal patients with interventions that included specialized screening, safety planning guidance and follow-up telephone calls.

Dr. Michael Allen, professor of psychiatry and emergency medicine at the Helen and Arthur E. Johnson Depression Center at CU Anschutz, co-authored the study.
Dr. Michael Allen, professor of psychiatry and emergency medicine at the Helen and Arthur E. Johnson Depression Center, co-authored the study.

“People who are suicidal are often disconnected and socially isolated,” said study co-author Dr. Michael Allen, MD, professor of psychiatry and emergency medicine at the Helen and Arthur E. Johnson Depression Center at CU Anschutz. “So any positive contact with the world can make them feel better.”

Allen is also medical director of Rocky Mountain Crisis Partners in Denver which has already implemented a similar program where counselors call suicidal patients following their discharge from Emergency Departments (EDs).

Suicide is the 10th leading cause of death in the U.S. In 2015, there were 44,193 deaths by suicide nationally. Over one million people attempt to take their own life every year.

Colorado routinely ranks among the top 10 states for suicide with about 1,000 deaths a year. Last year, it was number seven in the country. The state Legislature has set a goal of reducing suicides by 20 percent by 2024.

Allen said simply handing a suicidal patient a psychiatric referral when discharged isn’t enough.

“We call them up to seven times to check on them after discharge,” he said. “If they aren’t there we leave a message and call again. For many, this telephone call is all they get.”

The crisis center has worked with 17 of Colorado’s 88 EDs and is hoping to increase that number and eventually go statewide.

“We don’t need more brick and mortar buildings, we can reduce suicide risk by simply calling people on the phone,” Allen said.

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

His colleague and study collaborator Dr. Emmy Betz agreed.

“Telephone follow-up programs offer a great way to help bridge an ED visit to outpatient mental health care and hopefully save lives,” said Betz, an associate professor of emergency medicine at CU Anschutz who has conducted extensive research on suicide. “It would be great to see such programs become more widely implemented. Suicide is a leading cause of death, especially in Colorado, and a shortage of inpatient and outpatient mental health care options make innovative approaches like telephone counseling even more attractive.”

The study was led by Brown University and Butler Hospital psychologist Ivan Miller.

Miller, a professor of psychiatry and human behavior at the Warren Alpert Medical School of Brown University, said he was encouraged that they were able to impact suicide attempts among this population with a relatively limited intervention.

While suicide prevention efforts such as hotlines are well known, published controlled trials of specific interventions are much rarer, Miller said.

“We were happy that we were able to find these results,” he said.

This report was one of several from the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) study led by Miller, Professor Edwin Boudreaux of the University of Massachusetts and Dr. Carlos Camargo of Massachusetts General Hospital and Harvard University.

Dr. Betz was the principal investigator for Colorado’s ED-SAFE site.

The trial took place in three phases to create three comparison groups. In the first phase, 497 patients received each ED’s usual treatment as a control group. In phase two universal screening was implemented and 377 patients received additional attention in the ED. In the third phase, 502 patients received the experimental intervention.

Those patients received the same Phase 2 care including additional suicide screening from ED physicians, suicide prevention information from nurses and a personal safety plan they could fill out to prepare for times when they might begin harboring suicidal thoughts again.

Over the next year, they also received periodic phone calls from trained providers at Butler Hospital in Providence, R.I., who would discuss suicide risk factors, personal values and goals, safety and future planning, treatment engagement, and problem solving.

The number of suicide attempts and the proportion of people attempting suicide declined significantly in the intervention group compared to treatment as usual. The middle group, which received only additional screening, did not show a significant drop compared to the treatment as usual group.

“This is a remarkably low cost, low tech intervention that has achieved impressive results,” Dr. Allen said.

 

 

 

 

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Scientists use high tech microscope to find clue to an autoimmune disease

Using a unique microscope capable of illuminating living cell structures in great detail, researchers at the University of  Colorado Anschutz Medical Campus have found clues into how a destructive autoimmune disease works, setting the stage for more discoveries in the future.

The scientists were trying to visualize antibodies that cause neuromyelitis optica (NMO), a rare autoimmune disorder that causes paralysis and blindness. Using a custom STED (Stimulated Emission Depletion) microscope built at CU Anschutz, they were able to actually see clusters of antibodies atop astrocytes, the brain cell target of the autoimmune response in NMO.

Dr. Jeffrey Bennett, MD, PhD, is senior author of the study.
Dr. Jeffrey Bennett, MD, PhD, is senior author of the study.

“We discovered that we could see the natural clustering of antibodies on the surface of target cells. This could potentially correspond with their ability to damage the cells,” said Professor Jeffrey Bennett, MD, PhD, senior author of the study and associate director of Translational Research at the Center for NeuroScience at CU Anschutz. “We know that once antibody binds to the surface of the astrocyte, we are witnessing the first steps in the disease process.”

When that domino effect begins, it’s hard to stop. But Bennett said the ability to see the antibodies on the brain cells offers a chance to develop targeted therapies that do not suppress the body’s immune system like current treatments for the disease do.

“By applying this novel approach we can see firsthand how these antibodies work,” said the study’s lead author, John Soltys, a current student in the Medical Scientist Training Program at CU Anschutz. “We are looking at the initiation of autoimmune injury in this disease.”

The breakthrough was made possible with the STED microscope, a complex instrument that uses lasers to achieve extreme precision and clarity. It was built by physicist Stephanie Meyer, PhD, at CU Anschutz. This is the first time it has been used in a research project here.

“This would have been impossible to see with any kind of normal microscope,” said study co-author Professor Diego Restrepo, PhD, director of the Center for NeuroScience.  “We are inviting other scientists with research projects on campus to use the STED microscope.”

According to Meyer, lower resolution microscopes are blurrier than the STED due to diffraction of light. But the STED’s lasers illuminate a smaller area to acquire a higher resolution image . Unlike electron microscopes, STED users can see entire living cells at super high resolution, as they did in this study.

Restrepo said there are only a handful of STEDs in the nation and just one in Colorado.

The researchers said the discovery is the result of a unique partnership between clinical neurology, immunology and neuroscience coming together to solve a fundamental question of how antibodies can initiate targeted injury in an autoimmune disease.

“These are the building blocks that we can use to carry our research to the next level,” Bennett said.

The study was published this week in Biophysical Journal.

 

 

 

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Cannabinoids may soothe certain skin diseases, say CU Anschutz researchers

Cannabinoids contain anti-inflammatory properties that could make them useful in the treatment of a wide-range of skin diseases, according to researchers at the University of Colorado Anschutz Medical Campus.

The new study, published online recently in the Journal of the American Academy of Dermatology, summarizes the current literature on the subject and concludes that pharmaceuticals containing cannabinoids may be effective against eczema, psoriasis, atopic and contact dermatitis.

Dr. Robert Dellavalle, associate professor of dermatology, is senior author of the study.
Dr. Robert Dellavalle, associate professor of dermatology, is senior author of the study.

Currently, 28 states allow comprehensive medical cannabis programs with close to 1 in 10 adult cannabis users in the U.S. utilizing the drug for medical reasons. As researchers examine the drug for use in treating nausea, chronic pain and anorexia, more and more dermatologists are looking into its ability to fight a range of skin disease.

“Perhaps the most promising role for cannabinoids is in the treatment of itch,” said the study’s senior author Dr. Robert Dellavalle, MD, associate professor of dermatology at the University of Colorado School of Medicine.

He noted that in one study, eight of 21 patients who applied a cannabinoid cream twice a day for three weeks completely eliminated severe itching or pruritus. The drug may have reduced the dry skin that gave rise to the itch.

Study shows cannibinoids may ease some skin disease
Study shows cannibinoids may ease some skin disease.

Dellavalle believes the primary driver in these cannabinoid treatments could be their anti-inflammatory properties.  In the studies he and his fellow researchers reviewed, they found that THC (tetrahydrocannabinol) the active ingredient in marijuana, reduced swelling and inflammation in mice.

At the same time, mice with melanoma saw significant inhibition of tumor growth when injected with THC.

“These are topical cannabinoid drugs with little or no psychotropic effect that can be used for skin disease,” Dellavalle said.

Still, he cautioned that most of these studies are based on laboratory models and large-scale clinical trials have not been performed. That may change as more and more states legalize cannabis.

Dellavalle said for those who have used other medications for itch and skin disease without success, trying a cannabinoid is a viable option especially if it has no psychotropic effect. He did not recommend such medications for cancer based on current evidence.

“These diseases cause a lot of problems for people and have a direct impact on their quality of life,” he said. “The treatments are currently being bought over the internet and we need to educate dermatologists and patients about the potential uses of them.”

The other authors of the study include Jessica S. Mounessa, BS, Julia A. Siegel, BA and Cory A. Dunnick, MD.

 

 

 

 

 

 

 

 

 

 

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Tragedy turns into advocacy

Advocate Patty Skolnik speaks to students in the IPED course.
Advocate Patty Skolnik speaks to students in the IPED course.

On a recent Wednesday afternoon on the Anschutz Medical Campus, students in the Interprofessional Education and Development (IPED) course welcomed some special visitors to their classrooms: patients, acting as advocates, were there to speak about how future health care professionals can empower patients to be health care partners.

More than 700 CU Anschutz students from the Anesthesia Assistant Program, School of Dental MedicineSchool of Medicine, College of Nursing, Skaggs School of Pharmacy and Pharmaceutical SciencesPhysical Therapy Program, and Physician Assistant Program met with patient advocates including Patty Skolnik, whose mission comes from a personal passion. She believes that better communication might have saved the life of her only child, Michael.

Skolnik’s presence on campus is the fulfillment of a promise she made to her son Michael, a nursing student who loved working in medicine. She vowed that she would work to improve communication between health care professionals and patients.

“I want patients and their families to know their rights and be presented with options,” she said.

Tragedy turns into a mission of advocacy

In 2001, Michael had a seizure while visiting his parents. On the advice of a neurosurgeon, who thought he saw an abnormality on his brain in a CT scan, Michael had emergency surgery at a community hospital in Colorado, not affiliated with the CU Anschutz Medical Campus. No tumor was found, and he never recovered from the operation. Three years after the surgery, he died.

Patty Skolnik, founder of Citizens for Patient Safety.
Patty Skolnik, founder of Citizens for Patient Safety.

After Michael died, his case was reviewed, and although the neurosurgeon’s actions were found to be “within the standard of care,” Skolnik believes that the decision to have surgery was rushed in the hectic hours after his seizure. She believes that Michael and the family were not informed of all their available options, including not having surgery.

From this tragedy, Skolnik’s patient advocacy was born. She has testified at the state capitol, been involved in creating legislation to increase transparency about health care and produced PSAs about patient rights. A large part of Skolnik’s work for Citizens for Patient Safety, the organization she founded in 2005 to improve health literacy and empowerment in patients, is visiting medical campuses around the country.

Advocates at Anschutz

‘I find it empowering to communicate in a team environment that will contribute to providing the best care possible.’ – Tanya Gunter, a student in the College of Nursing

CU Anschutz has made the perspective of patient advocates one of the key components of the curriculum for the IPED course required of students from the anesthesiology assistant, dental, medical, nursing, pharmacy, physical therapy, and physician assistant programs. The class places students in interprofessional teams to review case studies, discuss shared approaches to healthcare, develop teamwork and collaboration skills and have their work reviewed by interprofessional faculty from the health professions programs on campus and community.

“The course is designed to provide experiential learning about the power of teamwork and collaboration while highlighting key principles around roles and responsibilities, values and ethics, quality and safety,” said Suzanne Brandenburg, MD, professor and facilitator for the class that Skolnik visited. “It prepares our students to become effective health care providers in real health care teams.”

The course, which extends over two semesters, also provides students with a new perspective for their future professions: patients as partners working jointly with their health care providers to co-develop a plan for their health care. The course develops this perspective gradually. “Engaging with patients and seeing them as partners in their care is an attitude that needs to be developed over time,” said Wendy Madigosky, MD, MSPH, director of the IPED course.

Suzanne Brandenburg, MD and facilitator of an IPED class.
Suzanne Brandenburg, MD and facilitator of an IPED class.

The students appreciate the interprofessional experiences that the course offers them. “This course has helped me cultivate respect for the other health professions and how they each work to take care of patients,” said Jessica Smith, a School of Medicine student.

Wendy Madigosky, MD, MSPH and director of the IPED course.
Wendy Madigosky, MD, MSPH and director of the IPED course.

 

Empowering students to empower patients

On the day of Skolnik’s visit, student teams, consisting of one student from each school or program where possible, discussed the case study they had been assigned. Each student made suggestions about listening to patient concerns and inviting partnership based on the unique perspective of their field.

“As a future nurse, I find it empowering to communicate in a team environment that will contribute to providing the best care possible,” Tanya Gunter, a student in the College of Nursing, said. “Each member of the patient’s health care team needs to be asking the patient how they feel about their health care plan.”

Jason Platt, a student in the Physical Therapy Program in the School of Medicine, agreed. “Every provider needs to be comfortable encouraging patients to speak up,” he said. “If the patient doesn’t understand, they aren’t empowered.”

At the end of the day, Skolnik reminds the students that their discussions are not just hypothetical. As future health care professionals, they could be her doctor, physical therapist or nurse one day. “This generation of students can change the culture of medicine to one of seeing patients as a resource and a partner,” she said.

Advocating for Patients Rights: For more information about Skolnik’s advocacy, please visit the website for her organization, Citizens for Patient Safety.

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States can lower risk of measles outbreak by strengthening exemption policies

States with weaker non-medical exemption policies for vaccinations can reduce the likelihood of a measles outbreak 140 to 190 percent by strengthening them, a new study from the University of Colorado Anschutz Medical Campus shows.

Researchers said the magnitude of those outbreaks can also be cut in half by strengthening exemption policies for children.

“In the year 2000 measles was no longer being transmitted in the U.S.,” said the study’s lead author Melanie Whittington, PhD., a health services researcher. “Compare that to 2015 when we had over 150 cases in the first three months. Suddenly measles is an issue again despite having an effective vaccine.”

Jonathan Campbell, associate professor at the CU Skaggs School of Pharmacy and Pharmaceutical Sciences
Jonathan Campbell, associate professor at the CU Skaggs School of Pharmacy and Pharmaceutical Sciences, is senior author of the paper.

Whittington and her colleagues, including the study’s senior author Jonathan Campbell, PhD, associate professor of clinical pharmacy at the CU Skaggs School of Pharmacy and Pharmaceutical Sciences, wanted to find out why.

Using mathematical models, they simulated the magnitude, likelihood and cost of a measles outbreak under different non-medical vaccine exemption policies.

Every state has such policies. Those with “easy” exemption policies typically only require a parent signature on a standardized form. States with “medium” exemption policies require parents to obtain a form from a health department and/or attend an educational session on vaccinations, or write a statement of objection. Finally, states with “difficult” exemption policies require parents to get a standardized form or statement of objection notarized.

The researchers, using data from the Centers for Disease Control and Prevention’s National Immunization Study, found easier non-medical vaccine exemption policies to be associated with a greater risk for outbreaks of vaccine-preventable diseases.

The state they modeled was Colorado, which has one of the lowest vaccination rates for measles. Only 87.4 percent of children between the ages of 19-35 months are covered. And 5 percent of kindergartners report an exemption.

“We modeled an environment where the population had low vaccination coverage and then simulated measles outbreaks under different exemption policies,” said Whittington. “We found that a state like Colorado is 140 to 190 percent more likely to experience an outbreak with an easy exemption policy than if it had a medium or difficult non-medical exemption policy.  The outbreak size can also be reduced nearly by half with stronger policies.”

While the researchers focused on measles, strengthening exemption policies could benefit other vaccine-preventable diseases, such as mumps.

“There is a tradeoff here,” said Campbell, who specializes in pharmaceutical outcomes research. “It’s a trade between freedom and risk. Are we willing to give up a small piece of freedom that nudges us toward vaccination in order to halve the risk of a detrimental outbreak of a preventable disease?  I think Colorado should be willing to make that trade.”

The researchers urged the strengthening of non-medical exemption policies as a way to increase vaccination coverage.

“We are not saying you can’t have non-medical exemptions,” Campbell and Whittington said. “But if we strengthen them, we can improve health and reduce the economic impact of a potential outbreak.”

The study was published online this month in Academic Pediatrics.

The co-authors include Allison Kempe, MD, MPH; Amanda Dempsey, MD, PhD and Rachel Herlihy, MD, MPH.

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