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Sequestration takes toll on research, education

UC leadership: Federal spending cuts put science at risk.

By Carolyn McMillan

>>UC leaders’ letter to Congress
>>Sequestration fact sheet

As Congress and the Obama administration try to reach agreement on a spending plan for 2014, University of California leaders are urging that the repeal of sequestration be a top budget priority.

In a letter to California’s congressional delegation signed by President Janet Napolitano and chancellors from all 10 campuses, UC leaders describe the economic and human toll from the indiscriminate federal spending cuts known as sequestration.

“Promising science is being delayed or terminated. Labs are being forced to lay off highly trained staff,” they write. “Perhaps most troubling, young researchers are questioning whether to pursue research careers because vital fellowships are threatened and it is taking increasingly longer for them to obtain their first independent research grants.”

Clock ticking on federal budget deal

Sequestration, a mechanism for across-the-board federal budget cuts, took effect in March and mandates $1.2 trillion in spending reductions over the next nine years. Federal agencies have cut $85 billion since March and the next round of cuts, totaling $109 billion, will be enacted in January unless Congress acts to repeal or modify the law.

With the clock ticking, UC leaders and a broad coalition of universities, economists, scientists and others are urging Congress to recognize that much of the nation’s economic growth stems from federal investment in education and scientific research.

“Sequestration threatens our nation’s educational, research and economic competitiveness at a time when many countries, including China, Singapore and Korea, are making significant investments,” the letter to Congress says.

Federally funded scientific research created the foundation for a whole range of U.S. businesses and industries — everything from vaccines, lasers and MRIs to the Internet — accounting for more than half of U.S. economic growth since World War II, according to economic analyses.

Student financial aid at risk

For the University of California, the impact of federal cuts goes beyond research: More than 72 percent of UC students receive some form of federal aid, and 42 percent of undergraduates are low-income Pell Grant recipients — a higher percentage than at any other private or public research university in the nation.

The Department of Education already has made some sequester-related cuts to financial aid programs for low-income students. It also has cut support for UC’s teacher training programs.

Pell Grants have been spared so far but remain vulnerable — a factor that makes it difficult for families to anticipate college costs, Napolitano and other UC leaders said.

“As students and their families make important decisions about higher education, they need to know that there is strong and sustained financial aid from year to year to help finance the costs of college,” they write in their letter.

UC’s five medical centers also are at risk, as they rely on federal Medicare and Medi-Cal reimbursements for patient care, and receive federal funding to assist with the cost of graduate medical education.

Federal research awards in decline

UC researchers already are feeling the pinch, as budgets for the National Institutes of Health, the National Science Foundation, the Department of Energy and other major sources of research funding shrink. UC received nearly $3 billion in federal research support in fiscal year 2011–12, accounting for more than 65 percent of its total research funding.

The university’s preliminary data, which do not yet reflect the final quarter of the 2012–13 fiscal year, show that federal research awards are down by $345 million, or roughly 12 percent, compared with 2011–12. That reflects the trends reported by other research institutions across the country.

Scientists and researchers at UC locations across California are reporting a range of funding-related problems from the federal cuts. Not only has it become harder to secure new grants, but previously approved funds have been reduced or eliminated, causing rollbacks to research projects that already are underway.

At UC San Francisco, for example, more than 50 researchers have reported funding difficulties.

Allan Balmain, a UCSF researcher studying the role played by genes in susceptibility to invasive cancers, said that students and postdoctoral fellows are the ones being most hurt by sequestration.

“They witness the struggles that even highly successful labs are going through just to keep research programs alive, and this is discouraging them from trying to build careers in basic research,” Balmain said. “We are in danger of losing a complete generation of young researchers due to the lack of foresight in Washington.”

Researchers report similar impacts across the university system. At UC Merced, an NIH grant related to children’s health was cut by 17 percent due to sequestration. As a result, the scope of the research has been scaled down, a postdoctoral fellow was let go and there now are fewer training and mentoring opportunities for students.

UC San Diego’s Scripps Institution of Oceanography, meanwhile, lost $5 million after learning that a proposed center for ocean observations and modeling would not be funded, despite initial approval from an NSF Blue Ribbon panel.

The ripple effect to California’s economy

Those kinds of impacts are likely to have a ripple effect that reverberates across California.

UC is the state’s third largest employer, and its research, teaching, health care and other activities produce $46.3 billion in annual economic activity.

“UC is educating the workforce, advancing scientific breakthroughs in research, providing world-class medical training and generating economic growth through new jobs, start up companies and spinoff industries,” UC leaders said in their letter to Congress.

“It is critical that our nation maintain its investments in education, scientific research and health care to ensure California and our nation’s economic prosperity continues to grow.”

Carolyn McMillan is the manager of content strategy in UC’s Office of the President.

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Eight UC members elected to Institute of Medicine

Newest class includes representatives from four UC campuses.

UC's Institute of Medicine class of 2013

UC's Institute of Medicine class of 2013

Eight University of California members have been elected to the National Academies’ Institute of Medicine.

They join a class of 70 new members and 10 foreign associates announced today (Oct. 21). Since 1970, the IOM has elected more than 200 members affiliated with UC.

Membership in the Institute of Medicine is considered one of the highest honors in the fields of medicine and health. Chosen by current active members, candidates undergo a highly selective process and are nominated based on their professional achievements and commitment to service.

The Institute of Medicine includes a diversity of talent, as its charter requires that at least one quarter of the membership selected be from outside the health professions, in fields such as law, engineering, social sciences and the humanities.

The newly elected UC members are:

UC Davis

  • Nancy E. Lane, M.D., director, Center for Musculoskeletal Health; Endowed Professor of Medicine and Rheumatology; and director, Building Interdisciplinary Research Careers in Women’s Health (BIRCWH)
  • Jonna Ann Mazet, D.V.M., M.P.V.M., Ph.D., professor of epidemiology and disease ecology, and executive director, One Health Institute, School of Veterinary Medicine

UCLA

  • Jody Heymann, M.D., Ph.D., dean, Fielding School of Public Health

UC San Diego

  • Joseph G. Gleeson, M.D., investigator, Howard Hughes Medical Institute; and professor, neurosciences and pediatrics
  • Richard D. Kolodner, Ph.D., member and professor, Ludwig Institute for Cancer Research

UC San Francisco

  • Jeffrey A. Bluestone, Ph.D., executive vice chancellor and provost; A.W. and Mary Margaret Clausen Distinguished Professor, UCSF Diabetes Center
  • Molly Cooke, M.D., professor of medicine and director of education, Global Health Sciences
  • Matthew W. State, M.D., Ph.D., Oberndorf Family Distinguished Professor and chair, Department of Psychiatry; and director, Langley Porter Psychiatric Institute

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California Health Secretary Diana Dooley discusses health care reform

Covered California is “off to a very good start,” she tells UC employees.

California Health and Human Services Secretary Diana Dooley, accompanied (left) by Dr. John Stobo, UC senior vice president for health sciences and services, greets California Health Benefits Review Program Director Garen Corbett after her Oct. 8 talk with UC Office of the President employees.

California Health and Human Services Secretary Diana Dooley, accompanied (left) by Dr. John Stobo, UC senior vice president for health sciences and services, greets California Health Benefits Review Program Director Garen Corbett after her Oct. 8 talk with UC Office of the President employees.

By Alec Rosenberg

It’s a historic time for health care in America. And California is helping lead the reforms, said Diana Dooley, state secretary of Health and Human Services.

California’s health insurance exchange launched Oct. 1. The online marketplace allows individuals, families and small businesses to compare policies and buy insurance.

The exchange was created as part of the federal Affordable Care Act, and is expected to increase access to health care, along with an expansion of Medicaid coverage to millions of low-income Americans. About 48 million Americans are uninsured, including more than 7 million Californians.

The state marketplace, called Covered California, in the first week received about 1 million unique visits to its website – second highest in the nation – along with 59,000 phone calls and more than 16,000 completed applications for health insurance.

Diana Dooley

Diana Dooley

“We’re certainly off to a very good start,” Dooley told UC Office of the President employees Oct. 8 at a talk in Oakland hosted by UC Health. “As California goes, so goes the nation.”

Exchange preparations have been complicated and fast paced. For example, only a few contractors were willing to bid on the California exchange’s IT contract, partly because of the compressed timeline: 15 months for a project that typically would take five years, Dooley said.

While there have been a few glitches, “it’s up, and it’s working,” said Dooley, who chairs Covered California.

Call waiting times also have improved – dropping from as long as 40 minutes during the first day to less than four minutes by the fourth day. The goal is 30 seconds, Dooley said.

Despite the current federal government shutdown, the Affordable Care Act is helping bring about a “culture of coverage,” Dooley said. The act requires nearly every American to have health insurance by Jan. 1 or pay a fine.  Eligible low-income residents can receive free or low-cost care through Medicaid, while moderate-income individuals and families using an exchange can receive financial assistance on a sliding scale. Californians using the exchange need to sign up by Dec. 15 to meet the Jan. 1 deadline.

The Affordable Care Act is a three-legged stool, Dooley said. One leg is expanded coverage. The other two legs also are important: improving how care is delivered and financed, and moving to a model that emphasizes prevention and wellness. To succeed, California will need to move from a fee-for-service model to a system of coordinated care that includes a focus on containing costs, she said. It also involves expanding efforts to make Californians healthier.

Dooley formed a task force, Let’s Get Healthy California, whose goal is to have California be the nation’s healthiest state by 2022.

“You’ve got to have some big goals or you don’t achieve very much,” Dooley said.

Dooley also discussed the issue of investment in medical education, saying it needs to be addressed to help fill workforce shortages. She noted UC’s role in training health care professionals. UC Health has the nation’s largest health sciences instructional program, enrolling more than 14,000 students with 17 professional schools on seven campuses.

Dr. John Stobo, UC senior vice president for health sciences and services, praised Dooley as a champion for innovation, transparency and for reforming the health care delivery system.

“She is really committed to addressing the health needs of underserved populations,” Stobo said. “It resonates with UC Health’s mission as a public trust.”

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Optimism meets pessimism at The Atlantic Meets the Pacific forum

Science, health, technology thought leaders gather at UC San Diego for event.

(From left) Nicholas Spitzer of UC San Diego, Kris Framm of GlaxoSmithKline and Ralph Greenspan of UC San Diego (photo by Erik Jepsen, UC San Diego)

(From left) Nicholas Spitzer of UC San Diego, Kris Framm of GlaxoSmithKline and Ralph Greenspan of UC San Diego

If there’s one thing the science, health and technology thought leaders at last week’s The Atlantic Meets the Pacific forum can agree on, it’s this: “Things are going to break a lot more before they get better.”

That sentiment, put into words by Smart Patients CEO and former Google Chief Health Strategist Roni Zeiger, was echoed again and again at the forum by some of the greatest minds from the worlds of academic research, small and big business, clinical medicine and public policy who were interviewed by journalists from The Atlantic magazine.

The third annual forum, which was held Oct. 2 to 4, is a collaboration between The Atlantic and the University of California, San Diego, and follows in the tradition of The Atlantic’s prestigious Aspen Ideas Festival and the Washington Ideas Forum.

This year’s panelists – among them several well known and up-and-coming professors and physicians from UC San Diego – were all in agreement that the world’s aging population, the advent of ‘smart’ devices and the resulting avalanche of scientific and medical data are creating both overwhelming opportunity and overwhelming challenges for healthcare, and in particular cancer care. It’s not yet clear, however, how quickly the coming revolution will take place, or who will pay for it.

Granted, those in attendance at the forum weren’t feeling especially optimistic given that the event coincided with a Congressional standoff over the nation’s Affordable Care Act, which had by then led to a government shutdown. In an interview with The Atlantic’s Washington Editor at Large Steve Clemons, alternative health advocate Deepak Chopra put the crisis in very Deepak Chopra-like terms: “The biofield of Washington, D.C., right now is certainly not coherent.”

Biofields, explained Chopra, are the magnetic fields transmitted by every cell in our bodies, and he claims they can be increasingly measured in scientific ways.

“[You can] correlate states of consciousness with states of biology using mathematical algorithms and correlate that with crime, with hospital admissions, with traffic accidents, with social unrest, with quality of leadership,” he said. “If you all hear the expression, ‘I went into this room, and it was very stressful, you could cut it with a knife, it was so tense,’ or, “I went into this holy temple or this shrine and I felt at peace’ – now we can biologically measure that.”

It’s a theory that no doubt sounds strange to researchers and clinicians used to measuring vital signs like heart rate and blood pressure, not vital signs pertaining to consciousness. But Big Data is forcing Big Medicine to change in big ways, and smart, wireless devices, combined with powerful algorithms, are now able to measure and analyze data that weren’t previously quantifiable.

Take cancer research. Several of The Atlantic Meets the Pacific sessions addressed advances in clinical treatments for cancer, as well as the elements that need to cohere for the many forms of cancer to be cured or, as Sanford Burnham Medical Research Institute CEO Kristiina Vuori put it, “to work toward a solution where cancer might be seen as a chronic disease you can live with.”

An oft-repeated observation at the forum related to the way that the so-called biological ‘-omics’ – genomics, proteomics and metabiomics – are changing the way cancer drugs are developed.

“The whole field of oncology is going through a transition similar to what the Internet went through in the ’90s,” remarked Dr. Scott Lippman, director of the UC San Diego Moores Cancer Center. “We’re looking now at redefining cancer, and the classic trial designs that we all grew up with don’t really apply now. This is not a vision we have that in 10 to 20 years we’ll get there. It’s happening now. If we identify certain genetic factors in a patient and correlate that with certain drug treatments, we’re seeing dramatic responses.”

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Randy Schekman wins Nobel Prize in Medicine

UC Berkeley professor is UC’s 13th Nobelist in medicine.

As photographers capture the moment -- and UC Berkeley Chancellor Nicholas Dirks savors it -- Nobel Prize winner Randy Schekman takes a congratulatory call from UC President Janet Napolitano. (Photo by Peg Skorpinski, UC Berkeley)

As photographers capture the moment -- and UC Berkeley Chancellor Nicholas Dirks savors it -- Nobel Prize winner Randy Schekman takes a congratulatory call from UC President Janet Napolitano.

Randy W. Schekman, professor of molecular and cell biology at the University of California, Berkeley, has won the 2013 Nobel Prize in Physiology or Medicine for his role in revealing the machinery that regulates the transport and secretion of proteins in our cells. He shares the prize with James E. Rothman of Yale University and Thomas C. Südhof of Stanford University.

Discoveries by Schekman about how yeast secrete proteins led directly to the success of the biotechnology industry, which was able to coax yeast to release useful protein drugs, such as insulin and human growth hormone. The three scientists’ research on protein transport in cells, and how cells control this trafficking to secrete hormones and enzymes, illuminated the workings of a fundamental process in cell physiology.

Randy Schekman will share the 2013 Nobel Prize in Physiology or Medicine (Photo by Peg Skorpinski, UC Berkeley)

Randy Schekman will share the 2013 Nobel Prize in Physiology or Medicine

Schekman is UC Berkeley’s 22nd Nobel laureate, and the first to receive the prize in the area of physiology or medicine. A total of 60 faculty and researchers affiliated with the University of California have won 61 Nobel Prizes, including 13 in medicine.

In a statement, the 50-member Nobel Assembly lauded Rothman, Schekman and Südhof for making known “the exquisitely precise control system for the transport and delivery of cellular cargo. Disturbances in this system have deleterious effects and contribute to conditions such as neurological diseases, diabetes, and immunological disorders.”

“My first reaction was, ‘Oh, my god!’ said Schekman, 64, who was awakened at his El Cerrito home with the good news at 1:30 a.m. “That was also my second reaction.”

Schekman and Rothman separately mapped out one of the body’s critical networks, the system in all cells that shuttles hormones and enzymes out and adds to the cell surface so it can grow and divide. This system, which utilizes little membrane bubbles to ferry molecules around the cell interior, is so critical that errors in the machinery inevitably lead to death.

“Ten percent of the proteins that cells make are secreted, including growth factors and hormones, neurotransmitters by nerve cells and insulin from pancreas cells,” said Schekman, a Howard Hughes Medical Institute investigator.

In what some thought was a foolish decision, Schekman decided in 1976, when he first joined the College of Letters and Science at UC Berkeley, to explore this system in yeast. In the ensuing years, he mapped out the machinery by which yeast cells sort, package and deliver proteins via membrane bubbles to the cell surface, secreting proteins important in yeast communication and mating. Yeast also use the process to deliver receptors to the surface, the cells’ main way of controlling activities such as the intake of nutrients like glucose.

In the 1980s and ’90s, these findings enabled the biotechnology industry to exploit the secretion system in yeast to create and release pharmaceutical products and industrial enzymes. Today, diabetics worldwide use insulin produced and discharged by yeast, and most of the hepatitis B vaccine used around the world is secreted by yeast. Both systems were developed by Chiron Corp. of Emeryville, now part of Novartis International AG, during the 20 years Schekman consulted for the company.

Various diseases, including some forms of diabetes and a form of hemophilia, involve a hitch in the secretion system of cells, and Schekman is now investigating a possible link to Alzheimer’s disease.

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UC consortium designated as Center for Accelerated Innovation

$12M grant to translate discoveries into products that help heart, lung health.

UCLA researcherA consortium of the five University of California medical campuses at Davis, Irvine, Los Angeles, San Diego and San Francisco has been awarded a $12 million grant and designated as one of three Centers for Accelerated Innovations by the National Heart, Lung and Blood Institute (NHLBI). The designation, among the first of its kind from NHLBI, recognizes the University of California’s potential to translate its leading-edge discoveries into innovative products that benefit patients.

The University of California Center for Accelerated Innovation (UC CAI) will leverage the expertise and resources of the system’s five medical center campuses and use industrial product-development practices to incubate technologies with high commercial potential. The five campuses accounted for 7 percent of NHLBI’s fiscal year 2012 grant funding, providing a rich research base to support a diverse pipeline of diagnostics, devices, therapeutics and tools for heart, lung and blood diseases.

The UC CAI, whose administration will be based at UCLA, has four goals:
• Engage University of California heart, lung and blood disease innovators in entrepreneurism through a comprehensive education, training and mentorship program.
• Solicit and select technologies with high commercial potential that align with NHLBI’s mission and address unmet medical needs or significant scientific opportunity.
• Incubate our most promising technologies in accordance with industry requirements to facilitate their transition to commercial products that improve patient care and enhance health.
• Create a high-performing sustainable infrastructure that will serve as a model to academic research centers.

The UC Biomedical Research Acceleration, Integration and Development (UC BRAID), which links the five medical campuses to facilitate contracting, data sharing, regulatory oversight and other activities, will oversee UC CAI.

“The launch of this program is a remarkable example of inter-institutional collaboration,” said Dr. Gary Firestein, director of UC San Diego’s Clinical and Translational Research Institute and chair of UC BRAID. “The leaders of engineering, business and medical schools across the five campuses developed a shared vision and worked with UC BRAID to create an extraordinary proposal. The new resources will dramatically accelerate the development of novel diagnostics, therapies and devices discovered at the University of California.”

The new center will be closely integrated with the translational research institutes and centers on each campus funded by Clinical and Translational Science Awards (CTSA). The CTSA-funded centers and institutes will provide full access to research resources on each campus, including clinical research facilities and labs, access to research cores, biostatistical support, bioinformatics, pilot funding, regulatory consultations and research education and training.

UCLA and several community partners in June 2011 received a five-year CTSA award of $81.3 million to establish the Clinical and Translational Science Institute on the Westwood campus.

The UC CAI also will have access to local biomedical industry organizations, healthcare agencies, clinical networks, public health departments, nonprofit research institutes, venture capitalists, investors and manufacturers of medical devices, diagnostic equipment and pharmaceuticals, which have developed close interactions with CTSA-funded institutes and centers.

“This is an excellent example of what we can accomplish through our CTSAs by collaborating across University of California campuses and disciplines for effective translation of our discoveries to products that will help our patients,” said Dr. Steven Dubinett, director of the UCLA Clinical and Translational Science Institute.

In addition to the considerable support from the CTSAs, each campus will bring its own unique expertise and resources.

Innovators can access resources across all five campuses, including UCLA’s tissue array and translational pathology cores, San Diego’s biomarker and cardiovascular physiology core, San Francisco’s small molecule discovery center and airway clinical research center, Irvine’s mechanical testing, microscopy and cell and tissue cores specifically for cardiovascular technology and Davis’ animal research center.

A skills development program will provide training and education in entrepreneurism and coordinated access to expert mentors. This educational training will help bridge the gap for scientists who lack an understanding of the commercialization potential of their discoveries.

“By aligning our efforts, researchers will have broad access to an even broader array of research cores and education programs,” said Dr. Lars Berglund, director of the UC Davis Clinical and Translational Science Center. “This collaboration will offer robust internship programs, expanded partnerships with outside private and public organizations and new curricular offerings to enrich and complement our already innovative approaches, while not detracting from or prolonging the existing training time.”

Faculty with experience in heart, lung and blood diseases will be available to innovators for consultations. Project managers with experience in industry and academia will ensure technologies developed by the center meet timelines and benchmarks.

“We have worked strategically with our collaborators to ensure a nimble, efficient, and transparent project management effort,” said Dr. Dan Cooper, director of the UC Irvine Institute for Clinical and Translational Science. “We have embedded mechanisms to ensure that specific goals for each project are established and timelines clear. We will work across BRAID to identify delays and obstacles and deal with them as rapidly as possible.”

“Each of the UCs is a powerhouse, but together they are unstoppable,” said Dr. Clay Johnston, director of the Clinical and Translational Science Institute at UCSF. “There is so much more we can do in collaboration and UC BRAID is helping us realize that.”

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UC Health helps ICU nurses bring palliative care to patients

Project aims to improve quality of care for seriously ill patients and their families.

Kathleen Puntillo (left) with UC San Francisco colleague Kathleen Turner

Kathleen Puntillo (left) and Kathleen Turner, UC San Francisco

By Diana Austin

In the six months before we die, more than 15 percent of Americans age 65 and older will spend a week or longer in the intensive care or cardiac care unit. But most of us will not receive the kind of care that studies consistently indicate people want at the end of life: supportive, holistic care that takes into account one’s values, desires and goals and addresses the entire spectrum of health-related needs that a seriously ill person may have.

A new two-year initiative led by UC San Francisco’s Kathleen Puntillo, Wendy Anderson and Steven Pantilat aims to expand access to that kind of care – known as palliative care – in intensive care units across five UC academic health centers, which along with UC’s 17 health professional schools are collectively known as UC Health. Titled IMPACT-ICU: Integrating Multidisciplinary Palliative Care into the ICUs, the project initially aims to help bedside critical care nurses understand how to integrate palliative care into their day-to-day work. The thinking is that while palliative care is a multidisciplinary effort, nurses are the most constant element in a patient’s care and are therefore well suited to becoming leaders in expanding access to this type of care in ICUs.

A new discipline

Palliative care is a relatively new clinical specialty. The National Board for Certification of Hospice and Palliative Nurses began certifying nurses in 1994, and palliative care was recognized by the American Board of Medical Specialties in 2006. Recognition and certification formalize expertise in aspects of care that go beyond treating a patient’s medical condition to include symptom management, psychosocial support, spiritual care, family care and other elements that affect quality of life.

“It’s trying to address all the dimensions that matter to people,” says Pantilat, director of UCSF’s Palliative Care Service. “Even something like pain isn’t just a physiological phenomenon. It’s got social, psychological and emotional implications, maybe even spiritual implications. You can’t just give morphine for that.”

That’s why a palliative care team typically includes physicians, nurses, social workers and chaplains – and, at times, pharmacists, dieticians and occupational therapists – to enhance a patient’s quality of life regardless of prognosis.

Not all ICU patients need that level of expert palliative care, but most would benefit from honest, compassionate conversations about prognosis, goals of treatment, symptom management and other stressors that affect them and their families. Unfortunately, such conversations don’t always happen, says Puntillo, professor emerita at UC San Francisco School of Nursing. The reasons for that failure, she says, include a fragmented health care system that often doesn’t reward talking with patients, misperceptions about what palliative care means – including confusing it with hospice – and lack of palliative care-specific education for clinicians.

While palliative care has begun to gain a foothold in many settings, IMPACT-ICU aims to advance the effort in a unique way with its focus on training bedside ICU nurses.

Birth of IMPACT-ICU

The project grew out of an End-of-Life Care Committee (now the Palliative Care Committee) that Puntillo and several other nurses and physicians from the UCSF medical-surgical ICU formed about 10 years ago. It was a response to nurses voicing concerns about the care dying patients were and weren’t receiving – and the nurses expressing an interest in getting more education about palliative care.

Wendy Anderson, UC San Francisco

Wendy Anderson, UC San Francisco

In response, Puntillo and Anderson, both of whom had taught related communication skills to clinicians, formed an interdisciplinary group that developed a series of workshops. Since 2010, they’ve trained 95 critical care nurses at UCSF Medical Center in palliative care communications. The program has proved so popular that each session has a waiting list within a day of being announced.

Then, last year, the Center for Health Quality and Innovation Quality Enterprise Risk Management – a joint venture of the UC Center for Health Quality and Innovation (CHQI) and the UC Office of Risk Services that provides funding for projects that have the potential to both improve care and reduce risk – put out a request for proposals. Anderson and Puntillo recognized the opportunity to increase patient access to palliative care throughout the UC system by empowering bedside nurses to become more actively engaged in making the important conversations happen.

Terry Leach, executive director of the CHQI, says their proposal was successful because palliative care is good for patients and families, and good communication is one of the pillars of risk reduction. The project received just over $1 million for a two-year rollout that began this summer and continues with workshops for critical care nurses at all five UC medical centers.

Initially, the IMPACT-ICU project is focused on ensuring that bedside nurses have the skills and resources they need to engage in palliative care discussions with families, physicians and other clinicians. Each of the five UC medical centers has identified two ICU sites and two nurse leaders (either nurse practitioners or certified nurse specialists with expertise in palliative care) to implement the program. The nurse leaders attended a three-day training at UCSF that taught them to lead quarterly workshops for other critical care nurses in their medical centers.

The workshops begin by outlining the ICU nurse’s role, rights and responsibilities in discussing prognosis and goals for care with patients and families. “Often, ICU nurses feel like they’re not supposed to participate in those discussions,” says Puntillo. “We give them the background to empower them and to understand that this is part of their nursing practice.”

During the workshops, the nurses also engage in role-playing that helps them practice leading palliative care discussions with families – and facilitating group meetings between nurses, physicians, patients and families.

Another aspect of the workshop focuses on nurses caring for themselves, an often-forgotten component of critical care bedside nursing that can affect quality of care. “These discussions are difficult,” says Janice Noort, a palliative care nurse practitioner and one of the leaders of the IMPACT-ICU project at UC Davis. “[Critical care nurses] are at high risk for burnout and compassion fatigue that comes from working in this life-and-death environment.”

In addition to leading the workshops, the nurse leaders round in the ICUs to provide real-time support to bedside nurses as they’re trying to apply the skills they’ve learned. “[This involves] looking at patients’ symptoms that may be uncontrolled and identifying other patient needs that really haven’t been looked at before,” says Noort.

Reducing costs by improving quality and meeting patient needs

By paying closer attention to patient needs, palliative care has the potential to improve outcomes and reduce costs. Pantilat notes that when a detailed palliative care discussion happens, patients often express a desire for care that is less invasive and more focused on symptom control and quality of life. That kind of care is less costly according to a 2008 study published in the Archives of Internal Medicine, and can free up resources for what patients really want, such as assistance with staying in their homes. Even if only a subset of the estimated 5 million Americans admitted to an ICU annually were to receive palliative care, the savings could be considerable.

That’s partly because the U.S. health care system has evolved to reward more, rather than better, care. Historically, because clinicians have been paid for procedures, not outcomes, Pantilat says aggressive, all-out care tends to be the default, even when patients might not want it and when it’s unlikely to be beneficial. Palliative care providers strive to interrupt that default thinking and step back to find out what’s really important to patients and families.

Both Pantilat and Puntillo stress that this approach is absolutely not about denying any medical care to patients who want and can benefit from it. Unlike hospice, which in the US requires that a patient be within six months of dying and asks patients to forgo aggressive care, palliative care can be given alongside all kinds of care, including curative treatment, and can benefit any patient with a serious, but not necessarily terminal, illness.

As a former practicing nurse and former hospital attorney, Leach has seen the problems that arise when communication about goals and needs doesn’t happen. “When you’ve got a seriously ill patient and their family members, all circuits are firing at a very stressful level,” she says. “When they don’t feel [the specialists] are talking to one another, it can be very frustrating.”

If critical care nurses can have conversations about goals and desires with families of seriously ill patients, it can defuse the situation and lead to happier patients and families. “We see it in patient satisfaction scores,” she says. “When we engage families and patients, we know that their care feels better – and they sue less.”

Why nurses

As the most consistent hospital presence for both patients and families, the bedside nurse is often the most logical choice to initiate palliative care discussions.

“Family members don’t necessarily have adequate opportunities to communicate with physicians, and one physician may not communicate with another team taking care of the same patient,” says Puntillo. “It can be very disjointed.”

On the other hand, a typical ICU patient has two primary nurses that work in 12-hour shifts, so they’re with the patient almost constantly and are privy to interactions and conversations that other members of the care team and family members aren’t. “It’s the nurse practicing shuttle diplomacy,” says Puntillo.

In addition, demand for palliative care services throughout the hospital and beyond is growing, and there aren’t enough palliative care specialists to meet it. Empowering nurses to be more proactive and engaged in discussions about goals of care can potentially change the structure for palliative care in the ICU setting, says Noort.

“There are limitations to the consultative model and a lot of strength to having the main people who are taking care of you [bedside nurses] provide your palliative care,” says Anderson. “What’s unique about [the IMPACT-ICU project] is that it creates a model for providing nurses with palliative care skills and also access to specialist palliative care nurses. At many hospitals, specialist palliative care can only be engaged through physicians. It is very challenging for critical care bedside nurses not to have direct access to palliative care expertise.”

Through the workshops and by placing palliative care nurse leaders directly in the ICU, the project will give bedside nurses both the skills they need and direct access to greater expertise when it’s needed.

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Surviving valley fever

Severe case treated at UC Davis highlights importance of awareness, expert care.

Virginia and Niels Cappel on one of their daily walks with Woody

Virginia and Niels Cappel on one of their daily walks with Woody

For seven months beginning in the fall of 2010, Virginia Cappel’s medical condition was touch-and-go.

The series of events that would change her life began simply, with flu-like symptoms, which Virginia and her husband Niels initially thought was bronchitis. But about a month later, when they left their home in Davis for a vacation in the Midwest, Niels began to notice more ominous signs: disruptions in Virginia’s speech, a slower gait and confusion, such as associating the wrong words with activities.

An immediate trip to the emergency room ruled out a stroke, and during the next few weeks, the diagnosis would continue to shift. There was concern that she had bacterial meningitis, followed by viral meningitis. Finally, a neurologist diagnosed valley fever, a fungal infection that affects about 150,000 people in the U.S. each year and has been on the rise in California. According to the California Department of Public Health, the number of reported cases in California has increased sixfold, from about 816 cases in 2000 to more than 5,366 cases in 2011.

Virginia Cappel updates UC Davis' George Thompson on her symptoms and overall health.

Virginia Cappel updates UC Davis' George Thompson on her symptoms and overall health.

“The disease can be difficult to manage,” said George Thompson, an assistant professor of infectious diseases who specializes in the care of patients with invasive fungal infections and helps direct the Coccidioidomycosis Serology Laboratory at UC Davis. “Sometimes there’s a delay in diagnosis because the symptoms resemble common illnesses such as flu and bacterial pneumonia. And despite the frequency of valley fever for those living in endemic regions, few clinicians think of this disease early in the course of a patient’s illness.”

For Virginia, the infection was diagnosed after the fungus had spread to her brain, a rare condition called valley fever-induced meningitis. Niels and Virginia sought treatment from valley fever experts in Arizona, where the disease is more common, but no one could develop a cohesive treatment plan.

While there, she had a shunt placed to relieve pressure in her brain, and a second surgery was performed to allow physicians to directly inject a potent medication known as amphotericin B into her spinal fluid. Despite attempts to control the raging fungal infection, Virginia got sicker and lapsed in and out of a coma. Unable to address her advanced infection and poor response to antifungal treatments, the Arizona hospitals advised Niels to find more advanced care elsewhere.

In December 2010, Virginia and Niels returned to California and sought answers at UC Davis Medical Center. After three months in the hospital, Thompson and a team of clinicians got Virginia’s condition under control.

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Putting the spotlight on global health

UC Irvine professor Brandon Brown is spreading the word about global health.

UC Irvine professor Brandon Brown (right)

UC Irvine professor Brandon Brown (right)

By Katherine Tam

Every few months, UC Irvine professor Brandon Brown returns to Epicentro Salud, a gay men’s community-based clinic in Lima, Peru, to help the staff brainstorm ways to encourage local men to get tested for HIV.

The stigma around homosexuality often deters the gay community from proactively getting tested in Lima, but Brown and clinic leaders have been working to change that these last three years. With Brown’s help, the clinic landed a USAID grant in October 2011 that provided funds to train HIV counselors and bought vital clinic and laboratory equipment.

“Epicentro staff did a lot of outreach to get started. We recruited on Facebook, on the streets, at bars, and were active in the gay pride parade,” Brown said. “We’re seeing more people visiting the center than ever. It’s a big asset for gay men and transgendered individuals in Peru.”

Whether it’s battling HIV stigma in Peru, finding new tools to diagnose malaria in Thailand, or improving sanitation in Kenya, Brown has made it his mission to spotlight the importance of global health and spread the word about the myriad opportunities here and around the globe that people can make a difference.

“Global health is an exciting field and there are lots of ways to get involved,” said Brown, who teaches global health, public health ethics, honors research, and epidemiology. “It’s easy for people to be comfortable in the bubble they’re in. But even if you’re studying say math, you can still be educated on things outside your area of expertise.”

That’s why two years ago, Brown launched a new initiative to put global health on more people’s radar at UC Irvine.

The initiative, Global Health Research Education and Translation (GHREAT),brings together researchers to collaborate on projects, and encourages students to get involved in global health. GHREAT offers courses students can take to earn a global health certificate. In addition, it also offers a global health mentorship program, seminar series and global health job opportunities.

Brown leads GHREAT on his own time and does not receive a salary for it. Neither do the motivated students and faculty who collaborate with him.

So far, students who have participated in GHREAT have become involved in a variety of projects here and abroad: studying how sanitation interventions can prevent contamination of the water supply in Kenya; investigating mental health issues of Iraqi refugees; identifying perceptions of genital warts in Peru; and producing a photo series chronicling the experiences of people living with HIV.

“I don’t think I could have asked for a better mentor,” said Karen Munoz, who graduated in May with a bachelor’s degree in public health and will seek a master’s degree in the same field this fall. “He’s always willing to help, especially when it’s a student’s passion and has to do with global health.”

Munoz credits Brown with her ability to successfully secure a grant from the Undergraduate Research Opportunities Program for her project, which focuses on access to health care among low-income women in Southern California for early detection of the human papillomavirus and cervical cancer.

“When we were applying for grants for our projects, he helped us revise our papers and showed us examples of his so we learned what to do,” Munoz said. “Many of us had never applied for a grant before.”

UC Irvine professor Brandon Brown (center) works closely with the staff at Epicentro in Lima, Peru to help gay men in the community.

UC Irvine professor Brandon Brown (center) works closely with the staff at Epicentro in Lima, Peru, to help gay men in the community.

When he’s not teaching at UC Irvine or spearheading GHREAT, Brown continues to work on global health projects. In addition to weekly Skype calls, he returns to Peru during the year to continue his collaborations with Epicentro.

Jerome Galea, founder of Epicentro, said the grant Brown helped secure early on was instrumental in getting the clinic off the ground.

“Probably if it weren’t for Brandon, Epicentro would not have a clinic today,” Galea wrote via email. “I’ve worked with Brandon for about 10 years and have found myself looking for projects to do with him – even though we’re on different continents – since he’s one of those people that you know you’ll have a great work experience with.”

Brown is working simultaneously on three research projects, including a study on syphilis among gay men in Peru that could lead to better treatment. And he has partnered with a UC San Diego team to research cervical cancer prevention among female sex workers in Tijuana, Mexico.

He hopes more students will take an interest in global health, whether they choose it as their major or not. Eventually, he plans to ask the university to establish an organized research unit in global health, which would provide more funding for projects, synergize global health efforts, help support student travel, and make researchers less dependent on grants.

“Few know what’s possible in global health and how to get involved,” Brown said. “Making more people aware could mean a big difference for all of us globally.”

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Inside the first year of medical school

UCTV series looks at foundations for future health care providers.

Foundations for future health care providers on UCTVHave you ever wondered what it would be like to be a first-year medical student? Are you planning to pursure a career in health care but want to learn more first? Learn from the same faculty who teach the fundamental concepts of medicine to first-year medical students at UC San Francisco. Take an exciting and in-depth look at the core concepts of anatomy, physiology and pathology.

UCTV programs include:

Immunology 201: Application of the Basic Concepts to People
First air date: Oct. 1

Genes, Genomes and Human Disease, Part 2
First air date: Sept. 26

Genes, Genomes and Human Disease, Part 1
First air date: Sept. 24

Pharmacology: Bugs and Drugs, Part 2
First air date: Sept. 19

Pharmacology: Bugs and Drugs, Part 1
First air date: Sept. 16

Immunology 101: The Basics and Introduction to our Patient
First air date: Sept. 9

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UC grant helps expand bedside ultrasound training at UCLA

Funding is part of an effort to improve patient care, satisfaction throughout UC Health.

Dr. Elizabeth Turner at Ronald Reagan UCLA Medical Center

Elizabeth Turner, UCLA

A successful training program in bedside ultrasound is expanding from UC Irvine to UCLA, thanks to a $250,000 University of California grant to improve patient care.

The two-year grant, “Impact on Quality and Safety of the Implementation of a Formal Curriculum for Bedside Ultrasound at UCLA,” will be led by Dr. Elizabeth Turner, UCLA director of bedside ultrasound in the Division of Pulmonary and Critical Care Medicine.

The grant is the result of a new partnership between the UC Center for Health Quality and Innovation and UC’s systemwide Office of Risk Services. The joint venture, called the Center for Health Quality and Innovation Quality Enterprise Risk Management, is part of an effort to improve patient care and satisfaction throughout UC Health.

“Bedside ultrasound monitoring rose to the top as a project that we would like to see expanded at UC medical centers,” said Terry Leach, executive director of the innovation center. She noted that using portable ultrasound machines when placing central lines was listed by the federal Agency for Healthcare Research and Quality as one of 10 strongly encouraged patient safety practices. This diagnostic tool is becoming more prevalent in other areas of hospitals as well.

Bedside ultrasound involves portable ultrasound exams – which use sound waves to see inside the body – performed and interpreted by the physician at the time of an exam. It’s a tool that can help quickly identify which medical test a patient should receive, and who should administer it.

Two years ago, Turner received a grant from the innovation center to develop a curriculum for bedside ultrasound training while she was working at UC Irvine. The curriculum helped critical care and cardiology fellows at UC Irvine gain knowledge and confidence equal or superior to that of experts and apprentice-based learners – in a shorter time than other training pathways.

The new grant will lead to implementing the bedside ultrasound training curriculum at several intensive care units at UCLA and will include assessment of the curriculum’s impact on care quality and safety.

Turner will focus training on treatment of circulatory shock, a condition that occurs as a result of inadequate blood flow to vital organs – a common issue in critically ill patients, and one that can be readily detected by ultrasound during an exam.

“Studies have shown that this diagnostic tool can improve the quality of patient care,” Turner said. “You can get the right therapy to the patient earlier, make better therapeutic decisions and improve the outcomes. There are direct and indirect cost savings, and patient satisfaction also may improve if we implement this as part of our practice.”

Media contacts:
UC Office of the President
(510) 987-9200

Rachel Champeau
UCLA Health System
(310) 794-2270
rchampeau@mednet.ucla.edu

About UC Health
University of California Health includes five academic health centers — UC Davis, UC Irvine, UCLA, UC San Diego and UC San Francisco — with 10 hospitals and 17 health professional schools on seven UC campuses. For more information, visit http://health.universityofcalifornia.edu.

About the UC Center for Health Quality and Innovation
UC Health launched the Center for Health Quality and Innovation in October 2010. The center is designed to promote, support and nurture innovations at UC medical center campuses and hospitals to improve quality, access and value in the delivery of health care. For more information, visit http://health.universityofcalifornia.edu/innovation-center.

About the UCLA Health System
The UCLA Health System has for more than half a century provided the best in health care and the latest in medical technology to the people of Los Angeles and the world. Comprising Ronald Reagan UCLA Medical Center; UCLA Medical Center, Santa Monica; the Resnick Neuropsychiatric Hospital at UCLA; Mattel Children’s Hospital UCLA; and the UCLA Medical Group, UCLA Health, with its wide-reaching system of primary care and specialty care offices throughout the region, is among the most comprehensive and advanced health care systems in the world. For more information, visit www.uclahealth.org.

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A vision realized

New home of UC Irvine’s Gavin Herbert Eye Institute has been years in the making.

The Gavin Herbert Eye Institute “offers patients from both the local community and around the world access to clinically advanced eye care from internationally renowned ophthalmologists in a thoughtfully planned physical environment,” says UC Irvine Chancellor Michael Drake. (Photo by Steve Zylius, UC Irvine)

The Gavin Herbert Eye Institute “offers patients from both the local community and around the world access to clinically advanced eye care from internationally renowned ophthalmologists in a thoughtfully planned physical environment,” says UC Irvine Chancellor Michael Drake.

When the Gavin Herbert Eye Institute opens its new 70,000-square-foot home on the UC Irvine campus in September, the community will gain access to a leading-edge center for the preservation of sight, with services ranging from eyeglass fittings to refractive surgeries to clinical trials of new therapies.

The comprehensive eye health institute, which is part of UC Irvine Health, includes 34 patient exam rooms with the latest in optical equipment, an optical shop, faculty offices and conference space. A dedicated pediatric area has play areas, video entertainment screens, kid-friendly restrooms and other features to make the experience more comfortable for the youngest patients, many with special needs. The interior design reflects recommendations from the Braille Institute that make it easier for low-vision patients to navigate around the building.

“This institute offers patients from both the local community and around the world access to clinically advanced eye care from internationally renowned ophthalmologists in a thoughtfully planned physical environment,” says UC Irvine Chancellor Michael Drake. “The Gavin Herbert Eye Institute is strategically located within walking distance of two major biomedical research centers and at the epicenter of the largest concentration of eye technology companies in the world. It’s well positioned to pursue its ambitious research goal of ending blindness by 2020.”

Ten Gavin Herbert Eye Institute physicians grace Best Doctors Inc.’s list of “Best Doctors in America,” including the institute’s founding director, Dr. Roger Steinert. An internationally recognized authority on cataract, cornea and refractive surgery, he is UC Irvine’s Irving H. Leopold Chair in Ophthalmology and a professor of both ophthalmology and biomedical engineering.

“I am fortunate to lead a talented team of 24 clinicians and researchers who are dedicated to making life better for people with vision issues,” Steinert says. “The Gavin Herbert Eye Institute has attracted the best and the brightest – ophthalmologists who are eager to be part of an institute that works at the edge of science, collaborating with medical peers and eye industry professionals to develop innovative technologies and clinical practices that improve sight. It’s rewarding to be able to see our patients from the local community and around the globe benefit from these advances.”

Gavin Herbert Eye Institute physicians are known for pioneering such medical procedures as refractive and corneal transplant surgery performed with femtosecond lasers and next-generation medical therapies for age-related macular degeneration. Research teams are investigating such advanced treatments as stem cell therapies to preserve and restore sight for individuals with retinitis pigmentosa and macular degeneration; infused contact lenses that replace eye drops to treat cystinosis; and a vaccine for ocular herpes, a leading cause of blindness.

The $39 million building is the first on the UC Irvine campus to be funded entirely through local corporate, foundation and individual philanthropic gifts; no government funding was required.

James V. “Jim” Mazzo, an operating partner with Newport Beach-based Versant Ventures and a UC Irvine Foundation trustee, led the very successful community campaign. The initial naming gift came in 2007 from Gavin Herbert, founder and chairman emeritus of Allergan Inc.; his wife, Ninetta; and his mother, Josephine Herbert Gleis.

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Match Day at UC San Diego School of Medicine

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UC Davis: Investigating liver cancer disparities

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