All posts by Greg Hack

Celebrating lives saved by TMC lung cancer screening

Dr. Justin Stowell, a radiology resident at Truman Medical Center, talked about the success of an early lung cancer screening program he leads.

The UMKC Health Sciences District marked Lung Cancer Awareness Month on Thursday with “Smokin’ Out Lung Cancer,” a midday event that outlined the district’s early lung cancer screening, treatment and prevention efforts, led by Truman Medical Centers.

TMC’s screening program emphasizes early detection and treatment for longtime smokers and ex-smokers. The event Thursday celebrated its patients’ and doctors’ success in committing to healthy living and saving lives. The screening program uses low-dose CT scans and is the only one in the nation to be driven by resident physicians, who are supervised by faculty from the UMKC School of Medicine.

Among the speakers at the event was Dr. Justin Stowell, the radiology resident who started the screening program and who has compiled statistics on its early success. When lung cancer is detected in its early stage, he said, cure rates of 70 to 80 percent are possible.

And besides catching lung cancer early, Stowell said TMC’s  program has had success in getting more than one-fifth of the people tested to quit smoking.

Lung cancer is responsible for 155,000 U.S. deaths a year, more than breast, prostate and colon cancer combined, which emphasizes the need for awareness events such as “Smokin’ Out Lung Cancer.” Stowell also noted that Medicare covers the early screening for many longtime smokers, and insurance companies have been adding coverage as the success of the screenings has been demonstrated.

The event, which included a barbecue lunch, was attended by some lung cancer survivors who had benefited from the screenings and subsequent treatment or surgery to remove their cancer. A video was shown that told the survival story of Thaddus Owens, who was at the luncheon.

The event also drew some smokers whose doctors had encouraged them to attend. One of them was 64-year-old Carl Kendall, who said he had tapered off in recent years but still smoked at least half a pack a day.

“I started smoking in 1968,” he said. “I have a doctor’s appointment next week, and I’m going to ask about this screening.”

Charlie Shields, TMC president and CEO, kicked off the presentations. Besides highlighting the screening program’s success, he noted that “Smokin’ Out Lung Cancer” was the first event sponsored by the UMKC Health Sciences District—a newly formed, premier academic health district made up of collaborating health care institutions on Hospital Hill.

Representatives of the School of Pharmacy presented information on smoking and lung cancer.

 “Truman Medical Centers is proud to be part of this exciting partnership,” Shields said. “The UMKC Health Sciences District is proving to do what it was intended, and that is to improve the health of the community in a variety of ways.”

The UMKC Health Sciences District is a cooperative partnership formed by 12 neighboring health care institutions on Hospital Hill: University of Missouri- Kansas City and its School of Medicine, School of Nursing and Health Studies, School of Pharmacy and School of Dentistry; Truman Medical Centers; Children’s Mercy; Kansas City, Missouri, Health Department; Missouri Department of Mental Health Center for Behavioral Medicine; Jackson County Medical Examiner; Diastole Scholars’ Center; and Ronald McDonald House Charities of Kansas City. 

 

‘Slow Medicine’ aims to foster more thoughtful care

Pieter Cohen, M.D., gave the 31st lecture in the William Goodson Jr., M.D., Memorial Lectureship series.

In an age of rapidly advancing technology and conflicting economic forces, it is important to guard against overuse of medical treatments and interventions, according to Pieter Cohen, M.D. He was this year’s William Goodson Jr. lecturer.

Cohen, an associate professor of medicine at Harvard Medical School, spoke Nov. 3 about “Slow Medicine,” the approach he and others promote at slowmedupdates.com. Cohen described Slow Medicine as thoughtful practice that involves patients, relies on the best evidence available and is “applied to help decrease excessive and potentially harmful interventions.”

Relatively high use of medical resources and procedures does not produce better results in many areas, Cohen said. For example, research indicates that 30 percent of U.S. knee replacement surgeries are not appropriate. That’s 200,000 major surgeries a year that should have been avoided, he said, resulting in 14,000 people needlessly suffering serious complications and side effects.

Similarly, aggressively ordering lots of CT scans and other tests can result in other overtreatments, not to mention increased anxiety and other side effects, he said, especially when tests produce false positive results.

Cohen cited research in 1973 by John Wennberg, M.D., author of “Tracking Medicine,” who identified the two main drivers of medical overuse. One is supply, so that adding physicians, specialists and hospital beds to an area will increase its use of medicine. The other is the style of medical practice prevalent in an area.

When Wennberg did his research, it was rejected by the Journal of the American Medical Association. But Dartmouth University then financed Wennberg’s work and started the Atlas Project, which examined patterns of medical use and resource intensity in the U.S.

According to Cohen, Wennberg’s conclusions have been proven correct, and Slow Medicine “digs deeper into the style issue to figure out what we can do better.” By involving patients, fully looking at options and not quickly reaching for a specific diagnosis and treatment, he said, Slow Medicine can improve care.

Economic pressures from pharmaceutical companies and medical device makers can promote overuse of some treatments, while cost pressures can curb others than might be beneficial. Slow Medicine tries to put the focus back on what’s best for the patient, which can end up saving money, but for the right reasons. It also keeps physicians from doing things mainly to make themselves feel better, and can prevent extending a treatment that works for some types of patients to others for whom it really wouldn’t be beneficial.

Cohen said Slow Medicine also can take more effort, to fully explain possible risks and rewards of different treatment choices, so that patients have more information and can know that there’s a good case to be made for more than one treatment option. In the end, more thoughtful, appropriate and caring practice can result.

Slow Medicine also is “about letting go of a specific, certain diagnosis” in favor of a more general assessment and then watchful waiting for signs of a particular ailment or for a clearer indication that treatment is needed. The slower approach often provides time for healing without intervention, he said, or provides the data needed to take the best treatment approach possible.

Cohen was the 31st speaker in the William B. Goodson Jr., M.D., Memorial Lectureship, which was established in 1987 by a group of families, patients, colleagues and friends to honor Goodson’s many contributions to medicine.

Pieter Cohen, M.D., associate professor of medicine at Harvard Medical School, was flanked by David Wooldridge, M.D., associate professor of medicine at the UMKCSchool of Medicine, and John Goodson, M.D., also an associate professor of medicine at Harvard, who presented last year’s lecture in the series named for his father, William Goodson, M.D.

Hundreds of Hospital Hill students participate in IPE poverty simulation

Students take on various family roles in IPE poverty simulation sessions.

More than 400 students from the UMKC School of Medicine, School of Pharmacy, School of Dentistry and School of Nursing and Health Studies have taken part this fall in five interprofessional education sessions of the Missouri Community Action Poverty Simulation.

In each simulation, about 80 students act as people living for a month in poverty. Students are assigned to families and receive a description of their role and goals of the simulation. They work to keep their home, pay all bills, keep their jobs, and feed their family each day. Some students serve as teenagers or young children and are asked to behave as their character descriptions.
 
Participants receive challenges such as an illness in the family, expenses to repair their plumbing, and getting robbed or fired. Students spend four “weeks” living in poverty. Each “week” lasts 15 minutes. There are stations around the room for students to visit to help meet their goals, such as the employer, a “Foodarama” for groceries, a health care center, child care, community action agency, inter-faith services, social services, and a pawn shop and quick cash business.
 
The simulation is required for students pursuing M.D., D.D.S. B.S.N., Pharm.D. and P.A. degrees. Doctor of Nursing Practice graduate  students help run the simulations along with past participants and volunteer faculty and staff.
 
The final session this semester took place on Nov. 11.

The right dose of research could help children, professor says

J. Steven Leeder

The challenge of finding the right dosage of medicines for young patients is complex and requires fresh thinking, J. Steven Leeder, Pharm.D., Ph.D., told the audience for the latest installment of the Health Sciences Deans’ Seminar Series.

Leeder, a professor of pediatrics and pharmacology at the UMKC School of Medicine, spoke Oct. 25 in the Health Sciences Building on Hospital Hill on “Exploring Inter-Individual Variability in Drug Response: Moving Beyond the Dose-Exposure Relationship.”

Leeder, who leads the pediatric clinical pharmacology group at Children’s Mercy Hospital, noted that many drugs are initially developed for adults and tested on them, making dosage calculations for children more difficult. On top of that, he said, the typical differences in how people respond to a drug can be magnified in children, given great differences in patient weight and in how rapidly different biological mechanisms in children can change during growth and development.

 The maturation of the brain, Leeder said, implies that receptors and transporters affecting drugs’ effectiveness may be changing in children and adolescents, but there’s relatively little research knowledge of these changes.

Given those challenges, he said, it makes sense to invert the usual sequence of “dose-exposure-response”:  administering a standard dosage of a drug and then seeing how much of that dosage is present in a patient’s body and how much the patient’s condition responded to the drug. Instead, he favors looking at “response-exposure-dose”: identifying the desired response or therapeutic outcome, and determining the amount of drug that needs to be in the body – the “exposure” — to achieve the desired response. Given that knowledge, he said, then a dosage can be tailored to the patient.

Leader, who practices at Children’s Mercy Hospital, noted that many drugs are initially developed for adults and tested on them, making dosage calculations for children more difficult. On top of that, he said, the typical differences in how people respond to a drug can be magnified in children, given great differences in patient weight and in how rapidly different biological mechanisms in children can change.

The maturation of the brain, Leeder said, means receptors and transporters that affect drugs’ effectiveness must be changing in children and adolescents, but there’s relatively little research knowledge of these changes.

Given those challenges, he said, it makes sense to invert the usual sequence of administering a standard dosage of a drug and then seeing how much of that dosage was used by a patient, and how much the patient’s condition responded to the drug. Instead, he favors looking at the response or outcome that’s desired, and then trying to gauge how well an individual patient’s system will use a drug. Given that knowledge, he said, then a dosage can be tailored to the patient.

Such an approach, he said, might best use the “more information on everyone” being provided by the increase in genomics, bioinformatics and population-wide data from electronic health records.

Leeder holds the Marion Merrell Dow Endowed Chair in Pediatric Clinical Pharmacology and is division director for clinical pharmacology and therapeutic innovations. He earned his pharmacy degree at the University of Minnesota and his doctorate at the University of Toronto. He completed a fellowship in clinical pharmacology at the Hospital for Sick Children in Toronto.

Stanford explores physicians’ role in countering intimate partner violence

Carol Stanford, M.D.’79, associate professor at the UMKC School of Medicine, delivered the annual Marjorie Sirridge Outstanding Women in Medicine Lecture.

Domestic violence deeply touched the life of Carol Stanford, M.D. ’79, when one of her colleagues was murdered many years ago.

At a Sept. 28 lecture at the UMKC School of Medicine, Stanford shared the story of that crime while exploring what physicians can do about the problem of intimate partner violence.

Stanford, delivering the 2017 Marjorie Sirridge Outstanding Women in Medicine Lecture, said such violence causes “tremendous emotional, social and economic dislocations” and crosses all demographic lines.

To illustrate that, Stanford told about reading a newspaper report of a “Johnson County soccer mom” who had been killed, and her businessman husband arrested. She found out a few hours later that the victim was her nurse practitioner.

“This is real and touches each of us,” said Stanford, associate professor at the School of Medicine. Most victims are women in heterosexual relationships, she noted, but men also can be victimized. Abuse also occurs in same-sex relationships and ones involving bisexual or transgender partners.

According to Stanford,  2 million women in the United States suffer intimate partner violence annually. Of those, more than 300,000 are pregnant women. One-third of homicides stem from intimate partner violence, Stanford said.

In their lifetimes, one in four women and one in seven men will experience severe intimate partner violence. By one estimate, the costs of care and economic loss from intimate partner violence are more than $8 billion a year. A victim’s health care needs can be increased for 15 years after such abuse, Stanford said.

She went on to say that it’s important for physicians to be aware and look for a wide range of physical symptoms that can indicate abuse, along with psychological problems, including depression, low self esteem, anxiety and substance abuse.

“I’ve started asking routinely, ‘Have you ever been abused?’ or ‘Do you feel safe in your relationship?’ ”

Prenatal care calls for particular vigilance, she said, given women’s vulnerability during that time. The safety of children in an abusive household also must be considered and physicians must report abuse if there are minor children.

In educating future physicians, Stanford said that it’s important to include clinical experience with victims, and suggested integrating more education about intimate partner violence into the curriculum. Students are becoming more aware of the issue through their community involvement, such as volunteering at such places as the Rose Brooks Center for domestic violence victims.

Stanford also said it was important for physicians to do their part because to raise awareness and battle domestic violence. An abused partner’s situation can be difficult and complicated, so a physician may provide a confidential ear, limited by the need to report child endangerment. The criminal justice system, a victim’s employer and other institutions simply can’t address the problem alone, she said.

Stanford also provided several resources to aid physicians in referring victimized patients for  help.

“I think it’s important that we empower patients, because they are the expert on their own situation.”

As violent as the world is, Stanford says she is optimistic. “I think the key to solving this, ultimately, is gender equity. We need a multi-disciplinary educational approach.”

Stanford is a longtime faculty member and docent, known for her dedication to students and involvement with their activities. She has served as faculty adviser or sponsor for many students groups and programs, including the Gold Humanism Honor Society, the UMKC chapter of the American Medical Women’s Association and Camp Cardiac.

At the lecture she thanked her husband, James Stanford, M.D. ’80, and son, Ian Stanford, both in attendance. She also thanked the several members of the Sirridge family present and praised the late Drs. William and Marjorie Sirridge as giants in the success of the School of Medicine and its “humanistic approach to interacting with patients.”

The Marjorie S. Sirridge, M.D., Outstanding Women in Medicine Lectureship was established in 1997 to recognize her dedication, compassion and advancement of patient care and medical education in Kansas City.

Munger takes reins of national family physicians group

Mike Munger, M.D. ”83, addresses the AAFP convention in San Antonio. | Sheri Porter/AAFP News

 

Mike Munger, M.D. ’83, a family physician in Overland Park, Kansas, this month became president of the American Academy of Family Physicians at its annual convention. The academy represents 129,000 physicians and medical students nationwide.

As president, Munger advocates on behalf of family physicians and patients nationwide. The organization fosters education and training, provides other extensive resources for its members, and encourages research and best practices in family medicine to promote health and reduce overall health care costs.

Munger became president-elect a year ago and also has served three years as a director on the AAFP Board.

Munger has been a practicing family physician in the Kansas City metropolitan area for 30 years. He is in practice at Saint Luke’s Physicians Group in Overland Park, where he also serves as vice president of medical affairs for primary care. The group has 105 physician members at 14 different sites, three of which maintain Level 3 medical home designation from the National Committee for Quality Assurance, and 11 of which are participants in the Comprehensive Primary Care Plus Initiative. CPC+ is an outcome of the Center for Medicare and Medicaid Services Innovation Center.

After earning his bachelor of arts and medical degrees from UMKC, Munger completed his family medicine residency at what was then the Goppert Family Practice Residency Program at Baptist Medical Center, also in Kansas City. He is board certified by the American Board of Family Medicine and has the AAFP Degree of Fellow, an earned degree awarded to family physicians for distinguished service and continuing medical education.

 

 

Brain tumor research follows unusual path

Tom Curran, Ph.D.

A promising therapy to combat brain tumors in children has emerged from a confluence of bold research, scientific insight and luck, a Children’s Mercy research director said Aug. 30 in the latest installment in the UMKC Health Sciences Deans’ Seminar Series.

The research aims to block a pathway that mutant cells often take when forming tumors near the brain stem. The work’s progress and hurdles were detailed by Tom Curran, Ph.D., who is the executive director and chief scientific officer of the Children’s Research Institute and a professor of pediatrics at the UMKC School of Medicine.

His presentation was titled “How mice, sheep, corn lilies and a beer helped children with brain tumors: Targeting the hedgehog pathway in medulloblastoma.”

When he started the hedgehog inhibitor work, Curran already had contributed extensively to the understanding of tumor formation – and knew plenty about mice. He discovered the Fos-Jun tumor-generating complex, and had identified reelin, the gene responsible for reeler, the mutation that makes mice lose muscle control.

Curran wanted to extend his mutation research to the tumors that form during brain development, “so we made the decision that we would take a take a precision medicine approach to medulloblastoma, even though we knew nothing about it at the time.”

He said his team came up with “a very naive concept” for proceeding: to identify molecules involved in tumor formation and then develop inhibitors for them, confirming both the mutations and their inhibition in mouse studies. After cause and prevention were demonstrated in mice, clinical drug trials in humans would follow.

The plan, however naive, has generated significant research success.

“That’s what translational research is about,” he said. “You have to develop a simple model … with milestones that let you know you’re making progress toward the goals.

“The other factor that is really important to this kind of science is luck. You need to be in the right place at the right time.”

The project’s first indication of good timing came quickly.

“Three weeks after we decided we were going to target medulloblastoma, the very first paper came out linking the sonic hedgehog pathway and … these tumors.” (A family of mutant genes with a spiky appearance is called hedgehog genes, and one of those was named after the Sonic Hedgehog computer game a Harvard researcher’s son was fond of.)

Sheep and corn lilies entered the picture when Curran was looking for a hedgehog-path inhibitor to work with and recalled a story about sheep giving birth to one-eyed lambs. What might have been a genetic defect was determined instead to be caused by a chemical in the corn lilies the ewes had eaten. The chemical, named cyclopamine, was found to block the sonic hedgehog path, the effect Curran was looking for. But it also was toxic and eventually seemed unlikely to lead to a suitable drug for humans.

Fortune intervened again when Curran was having a beer with a colleague after a conference in Taos, N.M. The friend was an expert on the sonic hedgehog pathway and referred Curran to another researcher whose team was doing similar work but running out of money for testing. Curran got in touch with the other team and was able to do the testing, which produced good results.

The project also has had its share of challenges to overcome, including recurrence of tumors after initial success in a human trial. That often happens in cancer treatment, Curran said, as drug resistance develops. But a biopsy from that case has provided further information, and trials continue.

Besides his positions at the Children’s Research Institute and UMKC, Curran is the Donald J. Hall Eminent Scholar in Pediatric Research and a professor of cancer biology at the University of Kansas School of Medicine.

Before coming to Kansas City, he led the Translational Brain Tumor Program for a decade at St. Jude Children’s Research Hospital; was deputy scientific director of the Children’s Hospital of Philadelphia Research Institute for another decade; and set up the multi-institution Children’s Brain Tumor Tissue Consortium.

Curran earned his doctorate for studies at the Imperial Cancer Research Fund Laboratories in London. His work has been published in nearly 300 papers and cited more than 50,000 times.

 

 

 

Neurology residency, endocrinology fellowship add to school’s offerings

The School of Medicine’s graduate programs have expanded with a residency in neurology and a fellowship in endocrinology, diabetes and metabolism.

The neurology residency started July 1 with two residents, Dr. Ellen Troudt and Dr. Nikita Maniar. Troudt, currently at Truman Medical Center, and Maniar, at Saint Luke’s Hospital, will work for a year in internal medicine and then three years in neurology. Research Medical Center, Children’s Mercy Hospital and the Center for Behavioral Medicine also are affiliates for the residency.

Troudt
Maniar

Dr. Charles Donohoe, the Neurology Department chairman and associate professor of neurology, said adding the residency was “integral to sustaining the TMC-UMKC neurology program.”

“Five years ago we had no full-time neurology faculty,” said Donohoe. “Now we have five faculty members in the Neurology Department, and to add a residency in such a short time is quite an achievement. We also think it’s important to have a solid neurology presence at a safety net hospital such as Truman.”

Now that the program is underway, Donohoe said, it will use the match system next year and aim to add three physicians a year, eventually having a dozen residents. Dr. Sean Gratton, who is the program director, said this was “the first new residency program at TMC or UMKC in many years.”

Troudt is from New York and earned her medical degree at the Ross University School in the Caribbean island nation of Dominica. Donohoe said she had recently worked in cutting-edge stroke treatment as part of an ambulance team that had the rare advantage of having a CT scanner in their vehicle.

Maniar is from Florida and also earned her medical degree in the Caribbean, at the St. George’s University School of Medicine in Grenada. She then earned an MBA there and recently was a research fellow at the Brooklyn Hospital Center in New York.

The new endocrinology position is a two-year fellowship held by Dr. Maha Abu Kishk, an internist who earned her medical degree in 2003 and has been a hospitalist with Truman Medical Centers. This fellowship is affiliated with Hellman & Rosen Endocrine Associates, which will be a primary training site along with Truman Medical Center.

“We’re excited to add this fellowship, which helps address the shortage of endocrinologists,” said Dr. Betty Drees, professor of medicine and program director for the fellowship. “As diabetes continues to increase in prevalence, so does the need for endocrinologists.” 

Lead remains a hazard for children, alumnus writes in Pediatrics

Public health systems still are failing to prevent lead poisoning in children, Bruce Lanphear, M.D. ’86, writes in an editorial in the journal Pediatrics.

Bruce Lanphear, M.D. ’86

Lanphear, whose research on lead poisoning put him in the national spotlight when the lead crisis in Flint, Mich., came to light, said children in hundreds of other cities had blood lead levels higher than the children of Flint.

The American Academy of Pediatrics Council on Environmental Health, Lanphear said, “recommends greater emphasis on screening children’s environments to identify lead hazards before a child is poisoned, using tools to sample and test house dust, soil, or water for lead.”

He also said pediatricians could push for lead abatement in older homes and regulations to cut environmental hazards. Testing of chemicals to establish their safety before they can be released into the environment also should be required, Lanphear said, but prospects for such regulation are dim.

The editorial accompanied research by others finding that, as lead levels have declined in many areas, testing labs are having trouble accurately detecting low levels of lead in children’s blood. There appears to be no safe threshold for lead exposure, especially in children, so detection at low levels is still important.

Lanphear also was one of three School of Medicine alumni whose work was reported last year in a UMKC Medicine article.

UMKC alumnus, TMC involved in latest antibiotic research

Mark T. Steele, M.D. ’80.

The addition of a second antibiotic to treat cellulitis skin infections did not result in significantly better cure rates in research recently published in JAMA, the Journal of the American Medical Association.

The study was the latest from an emergency medicine research group that includes Truman Medical Centers and Mark T. Steele, M.D. ’80. Steele is associate dean for TMC Programs at the UMKC School of Medicine and chief medical officer and chief operating officer for Truman Medical Centers.

“I’ve been involved with this group for more than 20 years,” Steele said. “It has 11 sites across the country and studies infectious diseases relevant to emergency medicine. This latest study used five of those sites, including Truman.”

The study involved 500 patients who had cellulitis that was not accompanied by abscess or a wound. Half of those patients were treated with cephalexin, an antibiotic effective against streptococci that typically is used in such cases. The other half got cephalexin plus trimethoprim-sulfamethoxazole, an anti-staph antibiotic that more patients with skin and soft-tissue infections have been receiving “just in case” MRSA — methicillin resistant Staphylococcus aureus — is present.

For the entire group treated, the added antibiotic seemed to help, producing a cure rate of 76.2 percent, versus a 69 percent cure rate for those who received just cephalexin. But that difference was not considered statistically significant. In addition, when the results were narrowed to the patients who were known to have taken at least 75 percent of the recommended doses of their antibiotics, the cure rates were almost identical, 83.5 percent for those who also got the second antibiotic, and 85.5 percent those who received just cephalexin.

MRSA has been showing up as a cause of more severe, abscessed skin infections, which has led to more dual prescribing of the antibiotics. Steele said this study’s results could inform emergency physicians that for cellulitis, absent abscess or a wound, the addition of the second antibiotic wasn’t more effective.

Amy Stubbs, M.D.

Amy Stubbs, M.D., helped oversee Truman’s portion of the research. She’s an assistant professor of emergency medicine at the School of Medicine and director of the school’s emergency medicine residency program. She completed her residency in emergency medicine at UMKC and was chief resident.

The National Institutes of Health sponsored the study, which Steele said was particularly well constructed to meet the standards of JAMA, the world’s most widely circulated medical journal.

It was the third in a series of published studies by the emergency research group, called the EMERGEncy ID NET. One dealt with treatment of abscesses and was published in the New England Journal of Medicine. Another looked at infected wounds seen by emergency physicians and was published in the journal Clinical Infectious Diseases.