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Bridging the gap in precision medicine

UCSF takes steps to solve the ‘last mile’ problem.

By Pete Farley, UC San Francisco

For entertainment giants such as Netflix and HBO, there’s an oft-cited concept known as “the last mile.”

It refers to the performance bottleneck that can arise in the short, final stretch of cable that links their vast, sophisticated server farms to the humble jack on a subscriber’s wall.

More than a decade after the immense promise unleashed by the completion of Human Genome Project, precision medicine has struggled with its own “last mile.” Despite major leaps in the field as a whole, the technical work needed to integrate a patient’s genomic information into the day-to-day practice of medicine has lagged far behind.

This month, UCSF is unveiling its bridge across that persistent gap.

Through its Genomic Medicine Initiative (GMI), UCSF has integrated data from a comprehensive cancer genetic testing program into the electronic medical records of patients at the Helen Diller Family Comprehensive Cancer Center. Not only does it allow for continuity of care with all testing and treatment results tied to the same electronic record, but it also allows physicians and researchers to identify larger patterns in the data that can lead to the development of better treatments.

“Many major medical institutions, including UCSF, have long had the science and the technology to generate genomic test results,” said Kristen McCaleb, Ph.D., program manager for the GMI. “The problem we’ve had is a lack of IT infrastructure to return those results to the clinicians who order the tests in a clearly actionable, doctor-friendly format.

This new project is a powerful new cloud-based software platform built in partnership with Palo Alto-based Syapse that seamlessly unites genomic testing and analysis, personalized treatment regimens, clinical data, and outcomes data, and –  crucially – integrates all of these features directly into APeX, UCSF Medical Center’s Epic-based electronic medical record (EMR) system.

“Genomics has the potential to dramatically improve patient care in oncology, but the full promise of precision medicine cannot be realized without a software platform to bring genomics to the point of care,” said Jonathan Hirsch, who founded Syapse six years ago as a 23-year-old Stanford University graduate student. “It is critical that genomic data be integrated with the patient’s medical history and presented to the clinician within the workflow of their EMR.”

One of the most comprehensive genetic tests for cancer

A major feature of the UCSF-Syapse partnership is that, beginning in the spring of 2015, UCSF oncologists will be able to order the “UCSF 500,” a panel of more than 500 gene mutations that have been implicated in a range of cancers. The test results will automatically feed into their adult and pediatric patients’ EMRs.

The assembly of the UCSF 500 wouldn’t have been possible without UCSF’s medical oncologists collaborating with Syapse to define which genomic alterations in which cancer types can be best treated with targeted therapies,” he said.

“The collaboration between the UCSF Helen Diller Family Comprehensive Cancer Center and Syapse is just one example of what the UCSF Genomic Medicine Initiative, launched two years ago, is doing to bring genomics to bear on clinical medicine,” said Robert Nussbaum, M.D., director of the GMI. “We are excited with the results and look forward to using it to improve the care of our patients here in the Cancer Center.”

When completed, test results from the UCSF 500 will automatically appear in a Syapse-powered window in the EMR, and from there, physicians can trigger consultation by a newly formed Molecular Tumor Board, a group of expert physicians and researchers that can recommend customized treatment plans for each patient.

These recommendations are recorded in Syapse alongside the physician’s decisions, and the patient’s clinical course will be continuously tracked. The resulting information is displayed to the physician in an easy-to-understand graphical format, and clinical notes and summaries are automatically populated in the EMR.

Learning from the data

Because the Syapse system is cloud-based, on Amazon Web Services (AWS), physicians and members of the Molecular Tumor Board can query a patient’s test results in real time against the latest entries in UCSF’s knowledge-base, which is also drawn from public genetics, oncology and clinical trial databases, as well as the current scientific literature. AWS was selected for its robust security, support for compliance with medical information privacy laws, scalability and redundancy, Hirsch said.

A de-identified version of each patient’s clinical history from APeX and information on how patients respond to treatments is simultaneously added to a dedicated clinical research knowledge-base within Syapse, so future recommendations of the Molecular Tumor Board for any patient’s case will always be informed by the latest clinical experience.

Because APeX is based on Epic, a widely used EMR system, the new platform is easily scalable, and could easily capture clinical data from many medical centers in a consistent, easily accessible form, said Hirsch.

“Our top priority is benefitting our patients today, but if we can begin to collect and leverage the knowledge we gain from each positive patient outcome, and combine our experience with that of others doing similar work worldwide, future patients may be able to sidestep conventional therapies and go directly to the best targeted therapy as a first-line treatment,” McCaleb said.

“And that would be truly powerful.”

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New software platform bridges gap in precision medicine for cancer

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Bay Area Science Festival’s grand finale draws large crowd

Free extravaganza at AT&T Park caps 10-day festival.

UC President Janet Napolitano examines a brain at a science booth staffed by UCSF graduate students.

Ten days of the Bay Area Science Festival activities culminated in the Discovery Days event at AT&T Park, a huge display of science interactive exhibits, experiments and games. About 30,000 people attended the free science extravaganza.

The event was filled with over 150 different booths and exhibits, staffed by volunteer UCSF scientists and students eager to share their science with the public. Children and their families could see and handle pieces of animal brain to learn about neuroscience, watch a partial dissection of different sea creatures, pilot an underwater remotely operated vehicle (ROV) and take part in experiments to learn about basic science concepts like the effects of heating and cooling on water.

This year marks the 4th annual Bay Area Science Festival, which was created by the Bay Area’s scientific, cultural and educational institutions, including Science & Health Education Partnership (SEP) at UCSF. Other partners include UC Berkeley, Lawrence Berkeley National Laboratory and Lawrence Livermore National Laboratory.

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Microscopic monsters and more at the Bay Area Science Festival

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Stem cell therapy coming of age

With first clinical trials, UC San Diego pushes stem cell therapies into new era.

Photos by Erik Jepsen, UC San Diego

In 2004, the therapeutic potential of stem cells persuaded more than 7 million Californians to approve Proposition 71, which allocated a whopping $3 billion for research and development of stem cell-based drugs and therapies that might someday address a medical dictionary’s worth of diseases and conditions.

Now, stem cell research is being put to the test in full force as years of cellular and animal studies make the leap to human clinical trials—a requisite step before any new drug or therapy is approved for market. Nowhere is this progress more visible than at UC San Diego, which in recent weeks has launched the three first stem-cell-based clinical trials in patients to pursue potential treatments for spinal cord injury, Type 1 diabetes and chronic lymphocytic leukemia.

And last week, the California Institute for Regenerative Medicine (CIRM), the state stem cell agency established by Prop.71, named the Sanford Stem Cell Clinical Center at UC San Diego Health System one of three “alpha clinics,” a highly sought-after designation that comes with an $8 million grant to further speed stem cell clinical development. The other two alpha clinic sites are City of Hope hospital near Los Angeles and UCLA, which is partnering with UC Irvine.

“A UC San Diego alpha clinic will provide a vital infrastructure for establishing a comprehensive regenerative medicine clinical hub that can support the unusual complexity of first-in-human stem cell-related clinical trials,” said Dr. Catriona Jamieson, deputy director of the Sanford Stem Cell Clinical Center, director of the UC San Diego Moores Cancer Center stem cell program and the alpha clinic grant’s principal investigator.

“The designation is essential in much the same manner that comprehensive cancer center status is an assurance of scientific rigor and clinical quality. It will attract patients, funding agencies and study sponsors to participate in, support and accelerate novel stem cell clinical trials and ancillary studies for a range of arduous diseases.”

Lawrence Goldstein, director of the UC San Diego Stem Cell Program and Sanford Center

Such work is well underway. Last week, doctors at UC San Diego and Veterans Affairs San Diego Healthcare System, in collaboration with the San Diego-based biotechnology firm ViaCyte, Inc., treated the first patient in an unprecedented phase one-two trial of a stem-cell-derived therapy for patients with Type 1 diabetes. The trial involves implanting specially encapsulated embryonic stem-cell-derived cells under the skin where it’s hoped they will mature into pancreatic beta and other cells able to produce a continuous supply of needed insulin and other substances.

Last month, a 26-year-old woman paralyzed in a car accident a year ago successfully underwent the first experimental procedure to test whether neural stem cells injected at the site of a spinal cord injury is safe and could be an effective treatment. It is hoped that the procedure – the first of four in the phase one trial sponsored by the Sanford Center and Maryland-based Neuralstem Inc. – will ultimately lead to a treatment in which transplanted neural stem cells will develop into new neurons that bridge the gap created by an injury, replace severed or lost nerve connections and restore at least some motor and sensory function.

Also last month, researchers at UC San Diego Moores Cancer Center and the Sanford Center treated the first participant in a novel phase one trial to assess the safety of a monoclonal antibody treatment that targets cancer stem cells in patients with chronic lymphocytic leukemia, the most common form of blood cancer.

“What we are seeing after years of work is the rubber hitting the road,” said Lawrence Goldstein, director of the UC San Diego Stem Cell Program and Sanford Center. “These are three very ambitious and innovative trials. Each followed a different development path; each addresses a very different disease or condition. It speaks to the maturation of stem cell science that we’ve gotten to the point of testing these very real medical applications in people.”

Goldstein noted that the number of patients involved in these first trials is small. Their focus is upon treatment with low doses to assess safety, but also with hope of patient benefit. As these trials progress – and additional trials are launched – Goldstein predicts greater numbers of patients will be enrolled at UC San Diego, the Sanford Center and elsewhere.

Achieving alpha clinic status should help, he said. One element of the new grant is expanded public outreach to raise awareness and understanding of stem cell science, in part to combat what Goldstein calls “stem cell tourism” and the marketing of unproven, unregulated and potentially dangerous therapies.

“Clinical trials are the fastest and safest way to develop therapies that are truly safe and that actually work. You want to prove that a new therapy will work for more than just a single, random patient. These alpha clinic awards not only provide valuable support that will help accelerate experimental stem cell therapies into clinical trials, they also bring with them a ‘stamp of approval’ that our center meets important standards set by peers for testing of stem cell therapy trials.”

The alpha grant reflects CIRM’s continued support for UC San Diego’s stem cell research and development efforts. Since 2004, CIRM has approved 74 awards totaling more than $147 million to UC San Diego stem cell scientists and programs. The three clinical trials launched are just the first of many to come, said alpha clinic principal investigator Jamieson. Other trials for heart failure, amyotrophic lateral sclerosis (Lou Gehrig’s disease) and blindness are in the planning stages.

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Two UC centers named stem cell ‘alpha clinics’

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UC research spans the globe

UC’s global reach can be seen from health to agriculture to sustainability and more.

By Alec Rosenberg

From addressing the Ebola outbreak in Africa to exploring aquatic environments in Antarctica, University of California researchers span the globe to serve the public and create new knowledge.

As UC President Janet Napolitano likes to say, “UC teaches for California and researches for the world.”

UC’s global reach can be seen from health to agriculture, sustainability to tech commercialization and bridge-building efforts such as the president-led UC Global Food Initiative and UC-Mexico Initiative.

UC’s global clout is reflected in its strong showing in international rankings. UC placed four campuses in the top 20 and nine in the top 150 in the Academic Ranking of World Universities, and scored similarly in the Times Higher Education World University Rankings and the inaugural U.S. News and World Report Best Global Universities rankings.

On the front lines of global health

One sign of UC’s strength is its 62 Nobel Prizes, the latest of which was announced this month in physics to UC Santa Barbara’s Shuji Nakamura for the invention of efficient blue light-emitting diodes. Another sign can be seen in Sierra Leone, a West African nation at the center of the Ebola crisis.

UCSF’s Dan Kelly became interested in Africa as a student at Albert Einstein College of Medicine. Inspired by a roommate from Sierra Leone, Kelly co-founded Wellbody Alliance in 2006 to provide health care to the poor in that country, which had been ravaged by a decade-long civil war.

From California, Kelly watched as the epidemic progressed rapidly this summer and close friends died.

“It hit me really hard,” Kelly said. “Within 48 hours, I went to Sierra Leone. I was there 3 ½ weeks and trained 1,000 health care workers. It restored my hope.”

Working with colleagues at UCSF and a coalition of partner organizations, Kelly started a crowdfunding campaign to ramp up relief — one of a variety of UC-led efforts to tackle Ebola.

“We’ve got a long way to go,” said Kelly, who has taken a leave as a UCSF infectious disease fellow to dedicate himself full time to the Ebola crisis.

Kelly was a speaker at UCSF’s sold-out global health symposium, held Oct. 2 to celebrate the 10th anniversary of UCSF’s Global Health Sciences program.

International health research at UCSF, which got its start in the late 1980s with a small AIDS program in Uganda, now spans 600 investigators working in 190 countries. Similarly, hundreds of faculty and an increasing number of students across UC’s 10 campuses are engaged in global health, reflected by the 2009 launch of the systemwide UC Global Health Institute, the 2011 establishment of the Global Health Research, Education and Translation Program at UC Irvine and the launch this fall of a global health major at UC San Diego.

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Ebola crisis

UC helps battle the outbreak: See list of experts, travel guidelines, preparedness information.

Credit: iStock

(Note: Updated as of Jan. 30)

The Ebola virus outbreak centered in West Africa has claimed more than 8,000 lives thus far, including a Liberian man who fell ill and died in Texas — the first case of Ebola diagnosed in the United States.

Physicians and researchers with the University of California are actively involved in battling the epidemic. Some are treating patients in Africa; others are helping to protect the American public; others still are involved in the urgent quest for effective treatment and a possible vaccine.

UC medical center preparedness

UC medical centers have been preparing — and continue to prepare — for the possibility of a patient with Ebola symptoms. On Jan. 29, a patient being evaluated for the Ebola virus was transferred to UC Davis Medical Center from Mercy General Hospital in Sacramento. That patient ended up testing negative for the Ebola virus (See UC Davis news release for more information.)

On Oct. 24 the UC Office of the President informed the California Department of Public Health (CDPH) that all five UC medical centers are positioned to provide in-patient care for Californians who have confirmed cases of Ebola if necessary. CDPH continues working with health officials to prepare for potential cases of Ebola in California and the Division of Occupational Safety and Health is providing updated, specific guidelines on the protective equipment, training and other measures that must be in place to protect workers’ health and safety. As of Dec. 18, all five of UC’s medical centers have received a visit from a U.S. Centers for Disease Control and Prevention Ebola preparedness team and have been named among the designated U.S. hospitals with Ebola treatment centers. Read joint UC-CDPH announcement and related UC Davis article, UC Davis news release, UCSF Medical Center statement on Ebola preparationsU.S. Health and Human Services announcement and updated CDC list of hospitals with Ebola treatment centers, UC announcement about Ebola treatment center designation, UC Davis news release about the CDC designation, UCSF coverage of its CDC visit, and UCSF news release about the CDC designation.

UC Regents received an update Nov. 20 on UC Health’s preparedness for Ebola. UC Davis hosted a media briefing Oct. 16 on  preparations for Ebola at UC Davis Medical Center and hosted another Ebola preparedness media briefing Nov. 6. UCLA, which has created an Ebola information page, hosted an Ebola preparedness exercise Oct. 17. UCSF, which has created an Ebola resource page, hosted a town hall meeting (read coverage) Oct. 24 to discuss its Ebola treatment preparations and provided an update Oct. 31 on preparations and training. UC Irvine hosted a panel discussion about Ebola on Oct. 27 and hosted a panel discussion on the constitutional implications of Ebola on Nov. 19, with panelists including the Rev. Jesse Jackson and UC Irvine law school Dean Erwin Chemerinsky. UCLA hosted an informational forum about Ebola on Oct. 28. UC San Diego hosted a tour of its Ebola isolation unit Oct. 31. UC Riverside immunologist Ilhem Messaoudi discussed facts and myths about Ebola on Nov. 4.

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Travel guidelines

UC students, faculty, staff and others considering travel to or from affected areas of West Africa should make themselves aware of local conditions and take appropriate precautions. The Centers for Disease Control and Prevention have compiled guidelines specifically for colleges and universities. UC campuses have distributed these guidelines and other information via their websites and campus health facilities.

Faculty experts

The following are faculty experts and their areas of expertise:

UC Berkeley

Art Reingold, School of Public Health. Expertise: epidemiology, emerging and re-emerging infections in the United States and in developing countries

UC Davis

  • Stuart Cohen, professor and chief, Division of Infectious Diseases. Expertise: infectious disease
  • J. Douglas Kirk, chief medical officer, UC Davis Medical Center. Expertise: hospital procedures
  • Jonna Mazet, One Health Institute and UC Global Health Institute. Expertise: epidemiology and disease ecology

UC Irvine

  • Brandon Brown, Global Health Research, Education, and Translation Program (GHREAT), UCI Program in Public Health. Expertise: infectious diseases in developing countries
  • Shruti Gohil,  UC Irvine Medical Center. Expertise: infectious disease
  • Kristi Koenig, UC Irvine School of Medicine. Expertise: disaster medicine, public health preparedness
  • Carl Schultz, UC Irvine Medical Center: Expertise: disaster medical services

UCLA

  • David Eisenman, David Geffen School of Medicine and Fielding School of Public Health. Expertise: bioterrorism, disaster preparedness and response
  • Peter Katona, David Geffen School of Medicine. Expertise: bioterrorism, infectious disease
  • Mark Morocco, David Geffen School of Medicine. Expertise: emergency medicine, infectious disease
  • Anne Rimoin, UCLA Fielding School of Public Health. Expertise: epidemiology, infectious disease, Ebola
  • Zachary Rubin, UCLA Health. Expertise: infectious disease
  • Daniel Uslan, UCLA Health. Expertise: infectious disease

UC Riverside

G. Richard Olds, dean, UC Riverside School of Medicine. Expertise: tropical diseases, international health

UC San Diego

Julia Ponomarenko, San Diego Supercomputer Center. Expertise: data analysis

UCSF

  • Charles Chiu, UCSF School of Medicine. Expertise: infectious disease, genomics, diagnostics, Ebola
  • George Rutherford, UCSF School of Medicine. Expertise: public health, international disease surveillance, infectious disease epidemiology, disease control

UC Santa Cruz

Jim Kent, UC Santa Cruz Genome Browser Project. Expertise: bioinformatics

See the accompanying links below for more on UC’s role in combating Ebola and providing information:

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UC receives nearly a quarter of NIH brain research grants

14 projects are led by researchers from six UC campuses.

The National Institutes of Health awarded UC researchers nearly a quarter of the $46 million in grants announced today (Sept. 30) in support of President Barack Obama’s BRAIN Initiative.

UC scientists have long been at the frontline of efforts to understand the brain’s inner workings — a pre-eminence reflected by the grants: Of the 58 NIH awards, 14 are projects led by researchers from UC Berkeley, UC Davis, UC Irvine, UCLA, UC San Diego and UC San Francisco.

Collectively, UC researchers will receive more than $10 million of the $46 million that the NIH is awarding for 2014.

“The human brain is the most complicated biological structure in the known universe. We’ve only just scratched the surface in understanding how it works — or, unfortunately, doesn’t quite work when disorders and disease occur,” said NIH Director Dr. Francis S. Collins in a statement. “There’s a big gap between what we want to do in brain research and the technologies available to make exploration possible.”

The BRAIN Initiative was launched last year by Obama as a large-scale federal effort to help scientists develop new tools and technologies to gain a deeper understanding of how the brain functions and to accelerate the creation of new treatments for neurological disorders.

“These initial awards are part of a 12-year scientific plan focused on developing the tools and technologies needed to make the next leap in understanding the brain,” Collins said. “This is just the beginning of an ambitious journey and we’re excited about the possibilities.”

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UC innovation grants produce healthy returns

Report finds return on investment of more than 5 to 1.

UC San Diego Dr. Greg Maynard leads a five-campus UC project to reduce dangerous blood clots (venous thromboembolism, or VTE), which prevented an estimated 140 VTE occurrences in 2013 for an annual savings of $1.45 million.

By Alec Rosenberg

A University of California center that fosters health care innovation at UC’s five medical centers is proving to be a boon to both patient health and the bottom line.

A report assessing the impact of grants made by the Center for Health Quality and Innovation (CHQI) found that UC’s investment is paying off with improvements such as fewer blood clots and improved post-surgery care at UC hospitals. Based on current cost savings, revenues and additional funds received, the projected net financial gain in 2016 of the center’s grants will be about $40 million from a $7.3 million allocation from UC medical centers — a return on investment of more than 5 to 1.

“The investment has been a good one,” said Dr. John Stobo, UC Health senior vice president and CHQI chairman. “The innovation center has done a lot of good in terms of improving quality and saving costs.”

CHQI was established in 2010 to foster innovations developed at UC medical center campuses and hospitals in order to improve quality, access and value in the delivery of health care. To date, the center has issued a total of 50 grants. In addition to funding from UC’s five medical centers, CHQI also has awarded $7.7 million it received from the UC Office of Risk Services for grants designed to reduce the risk of clinical harm to UC patients.

“We’ve been able to support innovative projects that produce better outcomes for patients, reduce costs and are being expanded across the UC Health system,” said CHQI Executive Director Karyn DiGiorgio. “This report helps quantify our impact.”

Examples include:

  • A five-campus project led by UC San Diego’s Greg Maynard to reduce dangerous blood clots (venous thromboembolism, or VTE) prevented an estimated 140 VTE occurrences in 2013 for an annual savings of $1.45 million.
  • A project at UC Irvine reduced the median length of stay for high-risk abdominal surgery patients by two days, resulting in fewer complications and projected annual savings of $816,000 (Maxime Cannesson).
  • The 2012 UC San Diego colorectal postoperative program reduced length of stay by 4.5 days for high-risk surgical patients and 0.9 days for moderate-risk patients, resulting in projected annual savings of $553,000 (Elisabeth McLemore).
  • A 2012 UCSF palliative care intervention resulted in 45 additional palliative care consults in the intensive care unit, generating $167,000 in annual savings from reduced ICU bed-days (Wendy Anderson).
  • A 2012 UC Davis specialty pharmacy initiative led to contracts that generated $18,000 in revenue at UC Davis and $1.36 million in revenue at UCSF during a CHQI fellowship (John Grubbs).
  • The 2012 UCLA elective surgery discharge program increased net revenues through a discharge pharmacy program for surgical services by $639,000 during a CHQI fellowship (Michael Yeh).

The report projects at least $25 million in grant-generated cost savings and revenues by the end of 2016. Also, seven project teams have received an additional $16 million in external funding based on their CHQI work, including a UCSF-led radiation safety project (Rebecca Smith-Bindman), a UC Davis pediatric telehealth project (James Marcin) and a UCSF-led eConsult project (Nathaniel Gleason).

In addition, 16 papers in national journals have been published based on work funded by CHQI.

The report did not assess the center’s other activities, such as hosting three systemwide colloquiums and convening multicampus collaboratives to develop and implement evidence-based practices.

The report was prepared by the center’s Innovation Evaluation Committee, which includes Michael Ong of UCLA, Patrick Romano of UC Davis, Andrew Auerbach of UCSF, Sheldon Greenfield of UC Irvine, Theodore Ganiats of UC San Diego and Stephen Shortell of UC Berkeley, and Karyn DiGiorgio, executive director of the center. CHQI plans to issue a yearly update, and by 2016 expects to present an in-depth review of the overall impact of the programs funded by the center.

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UCLA volunteers help the underserved at free clinic

Health care workers give back at Care Harbor event.

An estimated 4,000 people showed up for this year's Care Harbor free clinic held at the L.A. Sports Arena, an increase from last year's 3,000 who attended. This year, about 50 health care workers from UCLA volunteered their services. (Photos by Ann Johansson, UCLA)

It was a typical misunderstanding that could have led to disastrous consequences. The man had run out of medication to control his hypertension. But he couldn’t afford to get it refilled, or so he thought.

So instead of picking up a simple, generic medication at Wal-Mart or Target for $4, the man decided to go without it and unknowingly put himself at risk for a stroke. All because he didn’t realize he could obtain the medication cheaply.

UCLA Dr. Patrick Dowling checks a patient's arm.

Fortunately, he was one of hundreds who were treated by UCLA health care workers volunteering at the Care Harbor’s annual health clinic held Sept. 11-14 at the Los Angeles Sports Arena. His story is typical of many who come to this free clinic for the poor and underserved, said Dr. Patrick Dowling, chief of the UCLA Department of Family Medicine at the David Geffen School of Medicine.

About 30 percent of those who saw a UCLA health care worker at the clinic had prescriptions that went unfilled.

“These are people with hypertension and diabetes who can’t afford to get these medications — or think they can’t — and wind up in the ER, costing thousands when they simply needed to maintain their medications,” said Dowling, who, along with Dr. Carol Mangione, headed a UCLA contingent of about 50 volunteer health care workers. Mangione is the Barbara A. Levey M.D. and Gerald S. Levey M.D. Endowed Chair and professor of medicine and health services.

The man’s predicament, which was remedied by a simple referral to a local pharmacy, also explains why UCLA’s participation in the annual free clinic is so important and gratifying for the volunteers, among them, nurses; cardiologists; ear, nose and throat specialists; family medicine physicians and ophthalmologists from the Stein Eye Institute. Their ranks also included family medicine sports medicine doctors, International Medical Graduate (IMG) program participants, and medical residents and students from UCLA.

This year, an estimated 4,000 people attended the clinic, up from around 3,000 last year.  Mostly poor and uninsured, they came for dental work, eye care, general internal health care and other services.

The volunteers also gain something valuable, said Dr. Brenda Green, a third-year family medicine resident at UCLA. She is a graduate of the IMG program, which assists bilingual, bicultural immigrant medical school graduates from Latin America who reside in the U.S. legally, with earning a California medical license and obtaining a residency in family medicine.

Working at the Care Harbor clinic gave her the opportunity to work with the underserved populations that she will treat once she’s finished her residency.  To be in the IMG program, physicians must commit to practicing in one of the state’s more than 500 underserved communities for two to three years after completing their three-year family medicine residency.

“I love working with the Hispanic population since I speak Spanish and I can communicate with them,” said Green, who volunteered at the clinic last year as well.

Most of the people she saw suffered from chronic pain or women’s health problems; diabetes was particularly common, she said. The clinic offers referrals to patients who are diagnosed with other untreated health conditions, some of them serious.

“There’s a strong Hispanic population, and diabetes is prevalent among them,” said Green. “A lot of it is uncontrolled.”

A medical student in the IMG program, Daniel  Handayan found that volunteering at the clinic gave him the opportunity to use some of the skills he had learned at the Universidad Autonomo de Guadalajara, where medical students are exposed to clinical care earlier than in the U.S.

“I wanted to give back to Los Angeles,” said Handayan, who was born in Pasadena. “This is a great opportunity to use the skills I learned in Mexico.” He was one of nine IMG students who participated during the four-day clinic.

“They’re valuable because of the language and culture,” Dowling said.

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Creating a pathway to practice

 

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UC president encourages aspiring doctors in Fresno

Janet Napolitano meets with Doctors Academy students at UCSF Fresno.

UC President Janet Napolitano talks with high school students from UCSF Fresno’s Doctors Academy at a discussion that included officials from UCSF (pictured from left are UCSF Fresno Associate Dean Joan Voris, Doctors Academy founder Katherine Flores and UCSF Chancellor Sam Hawgood), UC Merced and UC medical students and residents. (Photos by Francis Fung, UCSF Fresno)

By Alec Rosenberg

University of California President Janet Napolitano visited UCSF Fresno today (Sept. 5), where she encouraged high school students to pursue their dreams of becoming doctors and help address the severe physician shortage in the San Joaquin Valley.

Napolitano met with 20 students from UCSF Fresno’s Doctors Academy, a challenging academic preparation program at three high schools in Fresno County. The star students, who come from educationally disadvantaged backgrounds, had questions about whether they could afford college and how they could overcome their self-doubt.

The path to become a physician is long and intense, but it’s a worthy journey that’s within reach, said Napolitano and colleagues who included UCSF Chancellor Sam Hawgood, UC Merced Chancellor Dorothy Leland and UC medical students and residents.

“Never doubt that you have what it takes to succeed as a doctor, nurse or whatever field you’re considering,” said Napolitano, who described how she overcame challenges in college, explained its affordability and encouraged students to consider applying to UC.  “You are exactly the kind of smart, motivated and compassionate students UC wants.”

High school students at UCSF Fresno’s Doctors Academy tell UC President Janet Napolitano why they are in the Doctors Academy and interested in becoming health professionals.

Napolitano’s message resonated with Doctors Academy students such as Sunnyside High School senior Carlos Villalobos, who wants to become a physician in the valley so he can serve his community. “I feel it’s my calling,” he said.

Villalobos had been interested in attending an Ivy League college, but after listening to Napolitano, he was inspired to change his mind.

“I want to go to UC,” Villalobos said. “I got to see how big a family we are with UC.”

Indeed, UC trains nearly half of the medical students and residents in California. In the San Joaquin Valley, UCSF, UC Merced and UC Davis all have efforts to address health issues and the shortage of physicians practicing in the region.

The UCSF Fresno Medical Education Program was established in 1975. UCSF Fresno annually now trains approximately 290 medical residents and fellows (an increase of 100 in the past 10 years) and about 250 medical students on a rotating basis. Since its inception, the program has graduated more than 2,000 resident physicians. About 40 percent of medical residents who graduate from UCSF Fresno stay in the area to provide care for community members.

“It shows the efficiency of training residents locally — they tend to stay here,” said Dr. Joan Voris, UCSF Fresno associate dean.

UCSF Fresno also has pipeline programs to prepare health care professionals. The Doctors Academy serves 336 high school students. The Junior Doctors Academy is an academic enrichment program for 186 motivated seventh- and eighth-grade students, while the Health Careers Opportunity Program at Fresno State provides academic support to prepare select students for entry into graduate programs and health professional schools

Dr. Katherine Flores, a Fresno native who was raised by her migrant farmworker grandparents and became the first in her family to attend college, founded the Doctors Academy in 1999 to open doors for students like her. All Doctors Academy graduates go on to college, with 98 percent matriculating into four-year colleges and universities. Three students from the inaugural class have received medical degrees and are in primary care residencies.

“In the Central Valley, we don’t have enough health care providers,” said Flores, who directs the UCSF Fresno Latino Center for Medical Education and Research. “We wanted to grow our own.”

The Doctors Academy students also met with San Joaquin Valley PRIME students. PRIME is an innovative training program focused on meeting the needs of California’s underserved populations, with 330 total students in six programs. UC Davis, UC Merced and UCSF Fresno collaborate on SJV PRIME, which launched in 2011 and now enrolls 27 students — all of whom have expressed interest in staying in the Valley to practice and/or work with underserved communities.

Maricela Rangel-Garcia, a third-year SJV PRIME student and Clovis native who was part of the inaugural class at UC Merced, encouraged Doctors Academy students to find mentors.

“The doubt will never go away,” she said. “Don’t be afraid to reach out to new people who will help you along the way.”

Agustin Morales, a fourth-year SJV PRIME student and Mexico native who received a bachelor’s degree from UC Santa Cruz, agreed.

“Look for people who are positive, inspirational, who will guide you in unfamiliar terrain,” said Morales, who is interested in internal medicine and plans to apply for residency at UCSF Fresno. “You end up empowering yourself to do what you want to do.”

Along with SJV PRIME, UC Merced continues to develop health sciences research programs. It has established a Health Sciences Research Institute, offers a minor in public health and collaborates with UCSF Fresno on research into valley fever.

As part of her visit to Fresno, Napolitano met with UC Merced and UCSF campus leaders to discuss health issues in the San Joaquin Valley and how UC is addressing needs and the funding challenges associated with efforts to help improve health in the region. For example, the Doctors Academy used to receive nearly $1 million a year in federal grant funding, but that has stopped. Also, state funding only covers about one-third of all PRIME slots.

In the meantime, the San Joaquin Valley has just 45 primary care physicians per 100,000 people, while the recommended level is 60 to 80.

UCSF Fresno medical resident Andres Anaya, a Fresno native, encourages high school students from UCSF Fresno Doctors Academy to become physicians. (From left: Sidra Suess, a fourth-year San Joaquin Valley PRIME student, and Erica Gastelum, a UCSF Fresno pediatric resident.)

UCSF Fresno medical resident Andres Anaya encouraged Doctors Academy students to join him in addressing that shortage. Anaya was born the eldest son of Mexican immigrants, both of whom are deaf. His first language was American Sign Language. At the age of 5, he began translating for his family. His college guidance counselor told him college wasn’t for everyone. Later in life, he suffered an industrial accident, which landed him in the emergency department and left him temporarily paralyzed.

“It changed my perception,” Anaya said. “Everything became possible.”

Anaya graduated from UCSF medical school and now is a physician in Fresno.

“Every day I get to do something I love,” Anaya said. “I’m literally living the dream. I’m home.”

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Docs who rock

Band of surgeons, started at UCLA, plays gigs to raise money for charity.

From left: Drs. Solomon Poyourow, Phuong Nguyen, Jason Roostaeian and Robert Kang.

Watch out Weezer and Smashing Pumpkins. Help the Doctor, an indie rock band made up of four surgeons moonlighting as hip musicians, is generating cutting-edge buzz.

A project that began as a much-needed release from their demanding careers has become a successful band, complete with a fan base, a sold-out performance at the House of Blues and gigs at the Troubadour, the Roxy, the Viper Room and the Dragonfly.

UCLA plastic surgeon Dr. Jason Roostaeian

Dr. Jason Roostaeian, a plastic surgeon on staff at Reagan UCLA Medical Center, performs on bass and vocals alongside his colleagues and fellow plastic surgeons Dr. Robert Kang, with vocals and guitar, and Dr. Phuong Nguyen, adding lead vocals and guitar. Completing the fab four is oral surgeon Dr. Solomon Poyourow on drums.

The four surgeons met during their residency training at the medical center in 2011 and discovered they shared a passion for music that started long before they became doctors. They had all played for different bands.

So they decided to put their talents to work to help raise funds for organizations like “Facing Forward,” which provides pro bono surgeries for children with severe facial and skull deformities. “Being able to create music together is the fun part, but now having the opportunity to help raise money for charities has made it truly special for us,” Roostaeian said.

The group decided to use the title, “Help the Doctor,” based on a common operating room experience, Roostaeian said in an email. “As surgeons, you would give each other flack if your assistant surgeon or nurses were not helping the way you saw fit.”

At first, the band members used aliases on stage — Jay Roost, Rip Towns, P. Danger and Sol Power.  “We wanted to separate our professional names from stage names because we feared it would give patients the wrong impression,” Roostaeian said. “However, at this point, most of our patients appreciate the fact that we perform and give to charity so we’d rather use our real names.”

Coordinating practice time for four busy doctors can be challenging. While Roostaeian works at UCLA, the others are in private practice, at City of Hope and at the University of Toronto temporarily doing a fellowship.

Typically, they squeeze in jam sessions when they can, usually after full days of surgery when everyone shows up in scrubs, said Kang. “It’s not easy, but the end product has been well worth it!” Roostaeian said.

For their next gigs, the UCLA plastic surgeon said they are looking at possible dates in late November. Meanwhile, fans, many of whom are UCLA doctors, nurses and staff, can listen to their music on the band’s Facebook page and iTunes.

But don’t look for Help the Doctor to go on tour soon. “I wouldn’t call the band a second career,” said Roostaeian. “Plastic surgery is my career. Creating music is a passion of mine that I have always had, and I am just happy to be able to continue it, especially with such a great group of guys and for charity. It really doesn’t get any better.”

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UC autism summit offers hope for help

First step toward collaborating systemwide to address need for treatments.

Leonard Abbeduto, director of the UC Davis MIND Institute, speaks at the UC summit on autism in Sacramento. (Photo by UC Davis)

By Alec Rosenberg

Researchers from across the University of California convened Thursday (Aug. 14) for a first-ever summit on autism — an initial step toward collaborating systemwide to address the urgent need for treatments.

Epidemiologists and geneticists joined neuroscientists and psychiatrists as more than 50 researchers from five UC campuses participated in the daylong summit at the UC Davis MIND Institute in Sacramento. They shared what they are doing in autism research and discussed ways to increase coordination and have a greater impact in improving the lives of children with autism and their families.

Autism spectrum disorder is one of health’s toughest challenges — a lifelong developmental condition with varying symptoms and severity that can affect social interactions, behavior and the ability to think, learn and problem solve. It has no single known cause and no known cure, though early behavioral-based treatments can help. And its prevalence is rising rapidly: Estimates are that autism affects more than 3 million individuals in the U.S., increasing the need for breakthroughs.

“How can we provide high-quality care for kids when the numbers are increasing dramatically and the resources are not?” said Leonard Abbeduto, Tsakopoulos-Vismara Endowed Chair and director of the UC Davis MIND Institute. “We’re all here because we want to impact the lives of kids and families.”

The autism summit, sponsored by the UC Office of the President, is the first step in an 18-month process aimed at accelerating progress toward treatments and strategies for prevention. The effort will include drafting a strategic plan for a coordinated approach to UC autism research, identifying research opportunities, increasing the number of multicampus grants and launching a series of public statewide autism forums to discuss ways of translating research into improved services.

“These are ambitious goals, but this is the group to make it happen,” Abbeduto said.

Harnessing UC’s expertise

The campuses participating in the summit — Davis, Irvine, UCLA, San Diego and San Francisco — are those with interdisciplinary autism research programs, integrated health care systems and programs that train pediatric health care professionals. Other UC campuses will participate in follow-up meetings.

The summit arose from discussions within the systemwide UC BRAID (Biomedical Research Acceleration, Integration and Development), which identified autism as an area of expertise that was ripe for increased coordination.

“This is really the beginning,” said Dan Cooper, chair of the Department of Pediatrics and director of the Institute for Clinical and Translational Science at UC Irvine. “The summit is designed to harness the unique basic science and translational research talent across the UC system in a way that will profoundly benefit children and adults with autism and related disorders.”

As one of the world’s largest and most prestigious research institutions, UC is uniquely positioned to address the mysteries surrounding autism.

“If we combine and band together, the promise is tremendous,” said Elysa Marco, a cognitive and behavioral child neurologist at UC San Francisco. “I think this represents a wonderful opportunity for us to do something greater.”

A timely collaboration

Thomas Insel, director of the National Institute of Mental Health, who delivered a summit presentation by videoconference, encouraged UC’s efforts, which he said could be a model at the statewide level.

“If you can get a group of people across the state sharing things, that’s a great way to accelerate our understanding and development of treatments,” said neurologist Jeffrey Neul of UC San Diego.

Autism is considered a public health crisis, with an incidence that has increased by more than 600 percent during the past two decades. The U.S. Centers for Disease Control and Prevention estimates that autism now affects 1 in 68 children. More than 350,000 Californians live with autism today.

Los Angeles Unified School District alone has 10,000 students with autism, said James McCracken, the Joseph Campbell Professor of Child Psychiatry and director of the Division of Child and Adolescent Psychiatry at UCLA. He’s optimistic that the UC autism summit will lead to positive outcomes.

“It’s an exciting first step,” McCracken said.

Making an impact

At the summit, researchers split into six working groups aimed at tackling different aspects of autism: genetic risk factors; environmental risk factors; neurobiology; diagnosis, symptoms and developmental trajectories; treatment, pharmacology and services; and research infrastructure.

They identified opportunities for collaboration such as multicampus research projects, hosting workshops to share data and provide training, and developing a systemwide autism patient registry and research repository. They encouraged using the UC ReX (Research eXchange) Data Explorer, a UC BRAID effort that enables UC investigators to identify potential research study cohorts at the five UC medical centers. Several mentioned that offering incentives would spur broader collaborations.

Ultimately, UC summit participants want to help prevent autism and speed treatments and cures. They’re working on many fronts, from behavior to medications to stem cells.

UC Davis MIND Institute researcher Sally Rogers helped develop the Early Start Denver Model, an intensive early intervention therapy for children with autism that fuses play- and relationship-based approaches with teaching practices of applied behavior analysis (a model developed at UCLA).

The Early Start Denver Model is being used around the world. Last week, Rogers trained a group that included participants from Brazil, Canada, Mexico, Spain and Turkey. She wants to have an even bigger impact and sees potential in a universitywide autism collaboration.

“It’s about trying to enhance the quality of life,” Rogers said.

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Providing a medical home for HIV patients

UC San Diego transforms HIV care as part of DSRIP pay-for-performance initiative.

UC San Diego Dr. Amy Sitapati (left) directs the Owen Clinic, which has become a model medical home for HIV patients.

By Rebecca Vesely, Special to UC Newsroom

Though incurable, HIV today is a manageable, chronic condition. With advances in drug therapy, those infected with HIV in North America can expect to live into their early 70s — almost as long as the general population.

However, HIV is a chronic illness that typically requires a complex treatment regimen and has the added layer of social stigma.

At UC San Diego Health System, providers have implemented a novel multidisciplinary approach to HIV care management that is improving outcomes for patients. This approach could be a model for chronic care management in other populations.

UC San Diego’s HIV care delivery transformation began under the California HIV/AIDS Research Program and was implemented as a special Delivery System Reform Incentive Program (DSRIP). DSRIP is a novel, pay-for-performance initiative in which California’s 21 designated public hospitals receive Medicaid dollars in exchange for meeting pre-set milestones.

California’s public hospitals had the option of participating in a fifth DSRIP category focused on HIV care. UC San Diego is one of the state’s 10 public hospitals working in this category.

UC San Diego, through DSRIP Category 5, was able to overhaul its outpatient care delivery for HIV/AIDS patients into a medical home model.

‘Truly transformative’

“This is what the ‘triple aim’ is all about,” said Dr. Angela Scioscia, chief medical officer at UC San Diego Health System. “This project has been truly transformative. We took a clinic that had lost its way in terms of structure and turned it into a model for care delivery.”

Also known as the Owen Clinic, the UC San Diego HIV/AIDS outpatient center is located on the third floor of a medical office building across the street from UC San Diego Medical Center at Hillcrest. The clinic treats about 3,500 patients annually. Last year, 500 new patients joined, with the demand for services growing by approximately 40 percent in the past five years, said Dr. Amy Sitapati, Owen Clinic director.

About 70 percent of patients served at the clinic are in Medi-Cal managed care plans. DSRIP support enabled the clinic to hire more staff, with a total of 60 personnel, both full- and part-time.

Team-based approach

The clinic uses a team-based approach, with four teams, each led by a primary care physician. Two of the teams have Spanish-language fluency.

Each morning, the teams meet in “huddles” and review the patient panel for that day. A computer printout shows patient names, ages and reasons for the visit, status on preventative screenings and viral loads. The printouts also show each patient’s Veterans Aging Cohort Study (VACS) score, an evidence-based score that assesses HIV patient risk of mortality. The Owen Clinic may be the only outpatient clinic in the country using patient VACS scores in daily huddles.

Knowing a patient’s risk of mortality helps to frame the office visit because providers understand before the patient walks through the door his or her need for additional support services, Sitapati said. A patient with a high VACS score might need more time in the clinic to meet with a staff pharmacist or psychiatrist or social worker, for instance.

Comprehensive, coordinated services are available to all patients. Because of the complexity of many of these patients’ treatment regimens (patients take on average seven medications each day), the staff aims to make each visit as productive as possible. For instance, staff pharmacists on site work together with physicians to educate patients about their prescriptions, help them find affordable options, get adequate reimbursement from payers and avoid adverse reactions to drugs.

Eight to 10 drugs are commonly used in HIV treatment, meaning there are between 30 and 50 total drug combinations. Finding the right balance for patients can be a challenge, especially with myriad side effects, co-payments and insurance pre-authorization requirements to fill a prescription.

“There are a lot of barriers to patients taking the right medications,” Sitapati said.

Incorporating health information technology

Access to health information technology resources has been crucial to the clinic’s transformation. UC San Diego assigned a four-person team of health IT specialists — including a physician informaticist, a data analyst, a programmer analyst and a Master of Public Health team member — to work on the clinic’s patient-centered medical home innovation projects. Having a clinical informatics team that understands the patient population, is invested in the clinic’s success and is aligned with the project’s vision and goals has been absolutely critical, Sitapati said.

Ongoing communication with patients is an important component to care. Patients at the clinic are avid adopters of MyUCSDChart, a Web portal that sends reminders for appointments and preventative screenings.

In 2013, there were an average of 1,003 MyUCSDChart patient encounters per month, up from 288 MyUCSDChart encounters in 2012. These patient portal interactions are on par with in-person and phone visits in 2013, which averaged 1,135 office visits and 1,455 average phone calls per month in 2013.

Perhaps one of the most valuable clinic informatics tools is SmartSet — an electronic medical record tool that allows clinicians to order lab tests in batches for patients who haven’t received recent laboratory screenings. The Centers for Disease Control and Prevention recommends annual screening for sexually transmitted diseases (STDs) in HIV-positive individuals. The SmartSet allows clinicians to quickly identify patients due for screenings and then order tests without manually ordering each lab for each patient, increasing clinic efficiencies and productivity.

Focusing on care transitions

The Owen Clinic focuses on care transitions for its patients. The clinic has a dedicated “nurse transition specialist” skilled in HIV/AIDS care to assist patients moving between inpatient care and the Owen Clinic. The nurse transition specialist program is part of another DSRIP project at UC San Diego.

These proactive, integrated approaches are garnering results. Viral load monitoring rose from a baseline of 63 percent in 2011 to 81.9 percent for the period of January through December 2013. Screening for both chlamydia and gonorrhea increased from 57.4 percent in 2011 to 84.2 percent for the period of January 2013 through December 2013. Wrap-around services for HIV care — including nutrition, substance abuse counseling, pharmacy, psychiatry and case management — increased 34 percent.

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