Living well January 2015

future of health jan/ Feb 2015

A Publication of the

stem cell research

organ registry

smartphone diagnosis January/ February 2015 ~ living well

1

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ANNIVERSARY

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living well ~ January/February 2015

A publication of the

publisher Mark Heintzelman

missoulian.com

People in Missoula and western Montana want to feel good, look good and live well. Available at more than 150 newsstand locations throughout the area, Western Montana Living Well is well suited to more than 30,000 readers monthly who want health tips on fitness, nutrition, family, financial advice, wellness, therapy and beauty.

art director Megan Richter

The opinions, beliefs and viewpoints expressed by the various authors and forum participants in this publication do not necessarily reflect the opinions, beliefs and viewpoints of the Missoulian or Lee Enterprises. The author of each article published in this publication owns his or her own words.

No part of the publication may be reprinted without permission. ©2015 Lee Enterprises, all rights reserved. Printed in the USA.

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January/February 2015 VOL. 27

in this issue

for sore eyes pg. 6

at the cellular level pg. 10

future of health

organ registry pg. 14

new stem cells pg. 24

health risks for cancer survivors pg. 28

on the horizon page 34 4

living well ~ January/February 2015

I “ have new friends.”

fu tu re of he al th

ude.

.

communitymed.org

jan/ Feb 2015

A Publication of the

st em ce ll re se ar ch

T

or ga n re gi st ry

sm ar tp ho ne di ag no sis

he future is now, and the outlook on health is better than ever! This issue of Living Well focuses on recent advances in medical technology, in addition to research on the horizon.

Learn about innovations in eye care that will have you seeing clearly with the aid of lasers, and how smart phones can aid medical researchers with data collection. There’s details on the organ registry program, and how the loss of one life can potentially save several, all of which could not be done without the aid of medical computers and software that reduces the potential for human error.

Stem cells are back in the news as well, with the discovery of a new class of cells that may offer more efficient methods of creating these vital components to healing.

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January/ February 2015 ~ living well

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living well ~ January/February 2015

For sore eyes Innovations in eye care prevent sight deterioration

By Jane Ammeson, Munster Times

E

ye exams have been routine for a long time — yet diagnostic tools and treatments for certain eye conditions aren’t what your grandfather experienced.

Innovations in eye care are even changing the routine eye exam. For people seeking LASIK — reshaping the cornea with a special laser to change the focusing power — Wavefront technology is making evaluation of patients’ vision more precise. Wavefront analysis looks into the eye, measures how the eye focuses light, and creates a map that an eye doctor can use to diagnose problems, says Dr. Neil

Watkins, an ophthalmologist on staff at Methodist Hospitals in Indiana.

“The new equipment gives a customized refraction. A corneal topographer, or mapmaker, analyses the surface of the eye and any aberrations,” says Watkins. Now, he says, the technology for LASIK patients is proving useful for routine eye exams, too, with the Wavefront-generated map determining a prescription for glasses. Eye charts on the wall won’t be disappearing just yet, but more and more patients will be wearing glasses with prescriptions determined by the new equipment, with its objective and precise measurements.

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eye care was the first medical area to use laser treatment, for diabetic retinopathy 8

living well ~ January/February 2015

Laser surgery

The use of laser for certain surgical procedures for the eyes has been around for a few decades, Wattkins says, Eye care was the first medical area to use laser treatment, for diabetic retinopathy. Since then laser has seen new opportunities for use, including for cataract surgery.

“Laser is a generic term,” explains Watkins. “There are all different types, depending on the particular wave length of the light spectrum that’s needed, such as the xenon red laser that was used for diabetic retinopathy and other retina surgeries.” There are even multiple lasers in one use, like the dual-frequency Nd:YAG lasers, now standard use for retina tears and detachments, Watkins says. The laser purposely scars the retina tissue so it adheres to the underlying tissue, preventing further retina detachment.

A condition that can lead to blindness is being much more prevalent. “Macular degeneration is probably the most common loss of vision in people over age 65 in the US. It’s a growing area because the baby boomers are hitting their 60s,” comments Dr. Jonathan Buka, an ophthalmologist at The Eye Specialists in Munster, Indiana.

There are two types of the condition, wet and dry.

“There are a bunch of layers in the back of the eye that, as we get older, don’t get as good blood perfusion, so the blood vessels just atrophy — fade away. That’s called dry macular degeneration and is much more common, usually progressing slowly over years or decades.” The Food and Drug Administration reports that this dry deterioration accounts for 90 percent of macular degeneration cases.

“In the wet condition, abnormal vessels can grow and leak out fluid or blood. It can progress much quicker and cause a dramatic cause of vision in a shorter time. You want to treat before so much scarring (prevents retaining vision),” Buka says. Symptoms can include loss of central vision or distorted or fuzzy vision.

Fortunately, says Buka, “In the last ten years there’s been a development in treating wet macular degeneration. There are a couple of products for injections to prevent the growth of those bad blood vessels.”

Cataract surgery is an area where laser is effective. “You don’t have to have laser for cataract surgery, but it makes it easier,” says Buka. “It cuts through the (clouded) lens, then the lens can be sucked out.”

The laser can also make perforated squares in a clouded lens so it can be cut into little cubes, says Watkins, making it easier to remove the lens, especially helpful if it has become hardened. It standardizes the opening and, instead of taking ten minutes, takes just seven.

But laser for cataracts is costly, says Buka, and Watkins agrees. Those three minutes cost about $5,000, considerably more than without the laser. “If the cost comes down, it will make it easier for the surgeon. Until then (using laser routinely) makes no sense.”

Other areas of advancement include new stents that make glaucoma surgeries a little easier, says Buka, but one thing is crystal clear: The satisfaction in the work is immense.

“You can greatly improve someone’s life from one day to the next with cataract surgery. It’s rewarding to see the excitement.”

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January/ February 2015 ~ living well

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living well ~ January/February 2015

Cellular level

Researchers see smartphones as health’s next frontier

By Eryn Brown, Los Angeles Times

T

he West Hollywood club scene was just picking up as Charles Lea and other UCLA grad students fanned out along Santa Monica Boulevard.

Their goal that evening: Find young black men, gay and bisexual, willing to participate in a study on how smartphone apps can help improve overall health and combat diseases such as AIDS and diabetes.

It wasn’t easy.

Relatively few young black men, a group with rising rates of HIV, congregate at go-to gay hot spots like West Hollywood. This night, most of those approached by Lea and the recruiters declined to participate.

“People don’t want to talk,” Lea said. “They want to party.”

But the research team pressed on, eager to assess how mobile phones can be used to spread information on testing and safe sex among minority men most likely to engage in risky behavior.

The effort reflects both the potential and the challenges facing investors, medical experts and government officials who want to harness the reach and power of mobile phones to revolutionize health care.

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By some estimates, 90 percent of adults in the United States have access to cellphones, which makes mobile health, sometimes called m-health, promising terrain for innovation — particularly when it comes to targeting hardto-reach groups such as young, gay black men.

“History will show that the mobile phone will be one of the most profound influences for improving public health ever invented,” said Dr. Kevin Patrick, director of the University of California, San Diego, Center for Wireless and Population Health Systems. “The potential is huge.”

But for that promise to pan out, researchers, medical providers and technology companies need to find a sweet spot, combining user appeal with tools that deliver valuable information and clear medical benefits.

That’s no simple task, as the West Hollywood HIV study hinted.

Entrepreneurs and researchers are committed to the cause, developing and testing a wide range of apps to monitor and manage conditions that plague millions of Americans and drive up medical costs.

Wireless phones are feeding real-time data to doctors from heart and blood glucose monitors, and from Bluetooth-enabled inhalers. Built-in cameras are being used to snap photos and diagnose suspicious growths, and GPS technology and cellphone accelerometers are tracking 12

living well ~ January/February 2015

patients’ physical activity. Text and other messaging systems are reminding patients to exercise, watch what they eat, use condoms, check blood sugar and take medications.

Some physicians hope to one day use phone-connected sensors to catch serious conditions, such as asthma and cardiac irregularity, before patients know anything is wrong.

That sort of advancement presents a major opportunity to make medicine more cost-efficient and more responsive, said cardiologist Leslie Saxon, founder of the digital-health-focused Center for Body Computing at the University of Southern California. She said she foresees a future “of everyone being continually diagnosed and continually treated.”

“If you could virtualize the care of many patients, you can save hospital beds for those who really need them,” Saxon said.

The street interviews in West Hollywood are part of a larger trial-and-error effort among Los Angeles AIDS workers trying to figure out how best to use smartphones.

While rates of HIV infection have plateaued nationwide, they have risen among younger men who have sex with men, and most acutely among young men of color, said Ian Holloway, an assistant professor at

90 percent of adults in the United States have access to cellphones, which makes mobile health promising terrain for innovation

the Luskin School of Public Affairs at the University of California, Los Angeles, and lead researcher on the Healthy Selfie project involving the grad students.

Despite some early wariness among members of those groups, as well as app developers, Holloway said mobile technology can offer young, gay black men something they don’t currently have: a centralized spot, at their fingertips, to get authoritative health guidance on HIV. “The new venues are phone applications, websites, chat rooms and message boards,” he said. “These are the places guys meet each other, for a variety of purposes. Why not bring prevention to those digital spaces?”

Investors have poured about $3 billion into digital health startups this year alone, including hundreds of millions into mobile health, according to MobiHealthNews, an online newsletter.

Los Angeles billionaire Dr. Patrick Soon-Shiong, along with Samsung, Qualcomm, Google and Apple, are among those funding m-health research and development.

The attraction of m-health technology, for health-care experts and investors alike, is the vast reach of smartphones across geographic, ethnic and socioeconomic groups.

But fully realizing the potential of mobile health technology requires protecting the privacy of health information and building user-friendly apps for patients that capture the sort of medical data professionals need.

“A lot of what’s being built is still in the research stage,” said Wendy Nilsen, who tracks developments in the field for the National Institutes of Health. There’s a widespread sense, she said, that of much of what’s being offered isn’t yet delivering proven benefits.

In clinical settings, researchers and technologists are trying to assemble the empirical evidence needed to persuade health systems and insurers to embrace — and pay for — large-scale m-health systems.

“We have all of this cool technology, and all kinds of cool applications,” said Bruce Dobkin, director of the neurologic rehabilitation program at UCLA. “But will anything meaningfully improve healthcare? We need clinical trials to show that.”

Dobkin is using custom, mobile-phone-linked motion sensors to monitor the gait of stroke and hip-replacement patients. Developing the proprietary technology is necessary because fitness trackers commonly available, such as Fitbit, don’t provide the spatial data or level of accuracy he needs, Dobkin said.

Scientists must figure out how to effectively collect and analyze the mountains of data mobile devices could one day stream to health professionals.

And securing personal information is vital to for m-health development and acceptance. One stroke patient who refused to be monitored told Dobkin “the NSA knows enough about me,” the researcher recalled.

Even among those already using cellphones to manage their health, there remains a question of commitment.

Surveys have found that half who use mobile fitness trackers to keep tabs on their workouts or diets stop using the programs within six months.

Holloway said the Healthy Selfie project was a departure from earlier health education research efforts that sought to tap into gay social media networks without always working with those networks. Online Buddies — which owns Manhunt and Jack’d and bills itself as the world’s largest gay brand centered on connecting people in search of friendships or lasting relationships — is collaborating on the project.

“We’re going back to the drawing board,” said David Novak, formerly of the Centers for Disease Control and Prevention and now the senior health strategist at Online Buddies. “Let’s ask black men what they think of health messaging. If they want messages, how do they want them?

What would be meaningful?”

In West Hollywood the night Lea and his team were recruiting subjects, Markqes Johnson, 24, said it makes sense to use mobile technology to educate people about HIV. But, he added, many could find the information irritating.

“People don’t want to look at that,” he said. “It’s like going to Pandora or YouTube and having to watch an ad.”

January/ February 2015 ~ living well

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The

organ registry

Connecting live donors with matches 14

living well ~ January/February 2015

By Shari Rudavsky, Indianapolis Star

I

NDIANAPOLIS — The two kidneys could have passed in the air somewhere over Tennessee.

Dinah Sampson’s organ traveled last week to a South Carolina transplant center, where surgeons then placed it in the body of a person Sampson had never met.

At about the same time Indianapolis surgeons were removing her kidney, a stranger in South Carolina underwent the same procedure there. That kidney would then have to be ferried to the airport and flown to Indianapolis.

Just as Sampson’s kidney was transplanted into the South Carolina patient, surgeons in a St. Vincent operating room replaced the failing kidney of Sampson’s father with one that had started the day in a South Carolina stranger’s body.

Two healthy donors, two sick recipients. In organ transplant circles, the whole procedure is called a kidney swap. But to Sampson and her father, Ed Hanson, a better phrase might be lifesaver.

For the past seven years, Hanson’s kidney function had been failing. His nephrologist told him to expect to need dialysis soon. In April, the day came and the Porter County man started at-home peritoneal dialysis.

The alarm on the machine he used at night went off every two hours, interrupting his sleep. So, he switched to manual dialysis, which required him to hook up to an IV pole four times a day.

In June, St. Vincent came to his local dialysis center to pitch their relatively new transplant program, which they offered in collaboration with Cleveland Clinic surgeons. Hanson, 66, was intrigued.

As Hanson started preliminary testing for a transplant, his daughter Dinah Sampson, 36, stepped forward to give him a kidney of her own.

“I feel like it’s just a foregone conclusion, anything I can do to help him,” she told the Indianapolis Star. “I was open to anything that could give him a kidney.”

On Aug. 21, Hanson was approved to go on the lengthy waiting list for a kidney from a deceased donor.

The next day, Sampson started her own testing. She knew it would be a long shot. Her blood type was A and his O, making them most likely incompatible. But about 20 percent of people with blood type A can donate to those January/ February 2015 ~ living well

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the longest chain the registry coordinated with O, said Tami Rader, living donor transplant coordinator at St. Vincent Health. On Sept. 5, the family learned that Sampson did not fall within that 20 percent.

Another possibility arose

Just the previous March, St. Vincent Health had joined the National Kidney Registry, an organization that strives to match living donors with recipients.

There are about 101,835 people on the waiting list for a kidney, according to the Organ Procurement and Transplantation Network. Most people in Indiana wait from two to four years for a kidney, Rader said.

Joining the National Kidney Registry could cut that time for those waiting who had family members or friends willing to donate their organ, Rader said.

“This is one way we felt like we could expand and help our patients who are listed get a kidney a little sooner,” she said.

St. Vincent had offered this option to other donor-recipient pairs before, but in some cases, the recipient wasn’t ready. In others, the donor wasn’t accepted, Rader said.

One other father-daughter pair almost enrolled in the registry, but the father received the offer of a kidney from a deceased person and said he’d prefer not to have his daughter lose her kidney unless it was necessary, Rader said.

So Hanson and Sampson could be the first.

The Registry

Seven years ago, an East Coast businessman planned to donate his kidney to his 10-year-old daughter only to learn just before the surgery that he would not be a good cross match. She received a kidney from a cousin instead. Realizing more help was needed, he decided to form the National Kidney Registry, which since then has facilitated more than 1,200 kidney swaps.

The simplest form of a kidney swap is a situation such as Hanson and Sampson’s in which one donor-recipient pair trades kidneys with another pair, said Joe Sinacore, director of education and development for the New Yorkbased National Kidney Registry.

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living well ~ January/February 2015

consisted of 30 donations in 2012 More common, however, is a chain that kicks off with a good Samaritan donor, who donates to a stranger, who has a noncompatible willing donor. That person’s kidney goes to the next person and so on.

The longest chain the registry coordinated consisted of 30 donations in 2012, Sinacore said.

“Chains are more common than swaps,” Sinacore said. “Chains are more durable.

In a closed-loop exchange, if any one party cannot move forward with the swap, you have to throw everybody back in the pool.”

While most patients in the registry received kidneys in less than three months, some prove harder to match. The only way to tell how long an individual patient will wait is to enroll.

After counseling Hanson and his daughter that they might have to wait a while, Rader started the process of enrolling the two.

Hanson’s testing had revealed no antibodies that could it make difficult for him to accept a kidney from certain donors, Rader said.

When they joined the registry, Hanson came up with about five potential donors that could work for him. Sampson, however, had no recipients that matched her makeup.

The registry has about 350 to 400 pairs on its list — donors and recipients affiliated with transplant programs at about 75 hospitals across the country, Sinacore said. Hospitals pay a small fee to join the registry. New pairs are entered almost every day, if not several times a day.

“It’s very fluid. If you get one more pair in a pool, if that pair’s donor happens to be a miracle match, it could create a huge chain,” Sinacore said. “It’s kind of fascinating to see how quickly things can take off.”

The swap

No one was expecting it to happen so soon. Both Hanson and figured it would take about a year.

Then on Nov. 18, Rader received an email, pointing her to a potential match. On

Wednesday, she confirmed the match on the registry. A few more tests for donors and recipients and by Nov. 26, the date was set.

On Dec. 11, Sampson’s surgery was scheduled to begin at 7 a.m., just as the donor in South Carolina was also going under the knife.

A courier came to pick up Sampson’s kidney. In South Carolina, a similar process occurred with the kidney headed for Hanson’s body. Often, organs fly cargo, but in this case because a plane change is needed, couriers took the kidneys as carry-on.

As the courier left with Sampson’s kidney, Dr. Alvin Wee, the transplant surgeon, and his partner closed up Sampson, taking extra care.

“Living donors are special, they’re very selfless, you want to give your time to them,” said Wee, who operates at St. Vincent but is an employee of the Cleveland Clinic.

The courier and Sampson’s kidney flew Delta, connecting through Charlotte. The donated kidney traveled USAir, connecting through Atlanta.

Wee had left the operating room after the morning surgery to spend his day seeing patients in his clinic. But by the time Hanson’s new kidney arrived, Wee was ready to go for the transplant part of the operation.

Within a few hours, St. Vincent’s first kidney swap transplant operation had ended.

Sampson, a South Bend attorney, left the hospital to return to her family, which includes two children under five.

She’s not sure if she’ll ever learn more about the person who gave her father a kidney or where her own kidney wound up once it left her body. Organ transplant experts recommend that donors and recipients wait about a year to decide whether or not to contact each other and to correspond a few times before meeting in person.

For now, Sampson’s just glad she had the chance.

“I feel maybe it’s even better than a direct match because you get to help more than one person,” she said.

January/ February 2015 ~ living well

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living well ~ January/February 2015

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January/ February 2015 ~ living well

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Mayo seeks to dominate with data

By Jackie Crosby, Minneapolis Star Tribune

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living well ~ January/February 2015

R

OCHESTER, Minn. – Patients arrive at the Mayo Clinic from all over the world, thousands a day, each presenting a different medical challenge.

Some have illnesses so rare that even medical journals don’t offer a time-tested treatment plan.

Others bring a complicated combination of ailments — diabetes with heart failure and kidney disease — that offer conflicting treatment options.

Each scenario is like a math problem with too many variables for a human doctor to fully consider.

But not for a computer.

For decades, doctors, pharmacies and insurance companies have routinely collected vast troves of information about the care and well-being of millions of Americans for their own use. Now, aided by technology and driven by unrelenting pressure to reduce costs, the industry

is trying to connect the disparate data in hopes of finding the best ways to treat the sick.

“It’s like you wanted to build a house, but never had bricks,” said Dr. Rozalina McCoy, a Mayo Clinic endocrinologist who is working on more than a dozen “big data” research projects. “I’m able to ask all of these questions that haven’t been answered before — because they couldn’t be answered before.”

Mayo Clinic sees the emerging field of big data analytics as a crucial strategy to defend and reinforce its standing as an elite medical institution, particularly as health-care reform and federal belt-tightening change how doctors get paid.

Although the Rochester-based health system is investing in a number of promising big data projects, an unfolding partnership with insurance giant UnitedHealth Group is its most ambitious.

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The two Minnesota powerhouses are leading an effort to pool data from a wide range of health-care organizations in a business venture known as Optum Labs. Leaders say the database is the nation’s largest and most comprehensive health-care database.

“What we’re trying to find out, if we can, is what does health care cost, and what of that spent really adds value to a patient’s outcome over time, especially with these high-impact diseases,” said Mayo Clinic chief executive Dr. John Noseworthy.

“Ultimately, we as a country have to figure this out, so people can have access to high-quality care and it doesn’t bankrupt them or the country.”

Researchers who query the Optum Labs database can access information on millions of patients across the decades, and determine whether one treatment worked better than another and how much was spent.

As the world’s largest private medical practice, Mayo can influence much of the U.S. medical system, and it intends to use whatever it learns through Optum Labs and other big data projects to do just that.

With more than 59,000 employees, Mayo’s geographic footprint includes major campuses in Minnesota, Arizona and Florida, as well as a system of regional hospitals and primary-care clinics. But its sphere of influence is growing exponentially as more health systems join the Mayo Clinic Care Network, which enables physicians at 31 health care organizations in 18 states, Puerto Rico and Mexico to consult directly with Mayo specialists.

“Obviously, we want to publish papers and get our information and knowledge out there more broadly,” said Dr. Mark Hayward, senior administrator at Mayo’s Center for the Science of Health Care Delivery. “But we won’t be successful unless we’ve made changes in our practice based on that.”

Computer age

Big data is a broad term for any collection of information so vast and complex that it can’t be handled with traditional data-processing tools.

Its growth in health care has been fueled by a $40 billion federal effort to urge the nation’s health-care practitioners to replace their manila folders with computers.

In 2008, just 17 percent of doctors’ offices in the United States had electronic health-record systems.

By the end of 2013, more than half of physicians and 80 percent of Medicare eligible hospitals were using computerized patient files, according to the federal government.

For the first time, it is possible to connect tens of millions of data sets from almost every facet of the health system — office visits, surgeries, lab tests, images, medical devices, prescriptions — and judge whether people got better or worse depending on

what kind of care they got.

“This is a key point in history, where data that’s already being collected is really going to become the dominant driver in what happens in health care,” said Philip Bourne, who is leading the federal government’s push into big data for the National Institutes of Health.

Mayo researchers such as McCoy and other big data believers hope that research will bridge gaps in the nation’s fragmented health care system, where the quality of care varies greatly from clinic to clinic and region to region.

Data level the playing field. What might seem like a rare case in one clinic – breast cancer in Hispanic women who once smoked, for example – can become a virtual clinical trial using the power of big data.

“Out of more than 100 million patients, somebody’s got to be just like your patient – or close enough,” McCoy said.

Inovative partnership

Mayo’s partnership with UnitedHealth took root several years ago when Noseworthy visited UnitedHealth Group chief executive Stephen Hemsley at his Minnetonka office. The leaders quickly realized the power of combining forces to share data. In a handshake deal, they laid the cornerstone for what would become Optum Labs, whose name is a nod to the innovative Bell Labs and UnitedHealth’s IT service’s division, Optum.

UnitedHealth contributed 20 years of its claims records on 150 million people to the project, which was launched two years ago near the Massachusetts Institute of Technology campus in Cambridge, Mass. Claims records have since been stripped of identifying information and will eventually be linked to 44 million medical records, including 5 million from Mayo.

A growing list of partners from across the health-care system have joined the venture, some contributing health data, others contributing expertise. Partners include consumer advocate AARP, pharmaceutical giant Pfizer, medical-device maker Boston Scientific, plus doctors’ groups, employers and academic centers.

Few other big data initiatives have brought so many divergent health-care players into the fold with the sole mission of fixing the nation’s system.

“Ours is unique, because each group is learning from the other,” said Optum Labs chief executive Dr. Paul Bleicher. “There’s a tendency to create automated approaches that spit out solutions. We have a charge to make this practical — and actually innovate and invent and prototype and develop.”

In the days before health-care reform began forcing hospitals and doctors to take more financial responsibility for overtesting and unnecessary rehospitalizations, Mayo might never have sought out a business partner like UnitedHealth Group, a $122 billion corporation whose leaders answer to Wall Street, not to patients.

But the changing health care landscape has made allies

out of organizations that once were at odds.

Insurers have the data doctors need to see if their efforts are working, because claims records follow people when they move among health systems. Claims records show whether a patient filled a prescription, showed up for physical therapy or wound up in the emergency room because something went wrong. Insurers know these things even when doctors don’t.

“Candidly, it was a bold move,” Noseworthy said of the partnership with UnitedHealth. “We had to be careful about it because it could have been an emotionally charged issue.

This could have gone sideways pretty fast.”

Laying the groundwork took nine months of secret preparations as Noseworthy sought to head off a potential culture clash between the nation’s largest insurance company and Mayo, a nonprofit that has been led by doctors for 150 years.

Mayo Clinic insisted that the for-profit Optum Labs venture be an “open R&D lab,” focused less on making money than on finding solutions for patients that would be publicly shared. In the end, teaming up with UnitedHealth turned out to be an easy sell, Noseworthy said, because everyone saw the potential of big data to make great leaps in improving care.

“With Mayo being a referral center, people come here and they leave. We don’t always know what happens to them,” said Nilay Shah, a health-data scientist who is leading Mayo Clinic’s big data effort at Optum Labs.

“Optum Labs gives us a sense of what are the long-term outcomes? What should we be shooting for? And what are things that make some places better than others?”

Mayo makes it easy for staff to tap into the Optum Labs database, requiring only a simple two-page summary of their research question – a far cry from the unwieldy process of applying for government research grants.

Interest is high, said Shah, with six to 10 project applications coming in each week. Hypothetical queries or those that don’t directly help patients are rejected.

To date, more than 90 projects are in the pipeline.

Mayo clinicians have published four papers in medical journals and presented 13 abstracts at medical conferences.

McCoy, a self-described “research nerd,” is using big data to research risk factors for people with multiple chronic illnesses and “waste” in the system from treatments that don’t help or end up costing more. She already has co-published a paper that compared common medications for Type 2 diabetes, finding that an older and cheaper drug worked as well or better, and cost less than newer and more expensive drugs.

The NIH is now conducting a clinical trial asking similar questions, which will cost millions of dollars and take decades to complete and analyze.

“Clinical trials are important,” McCoy said. “But ultimately with scarce resources, what if we can answer the question in a year by running models? It’s not a replacement for clinical trials, but it’s food for thought about research funding.”

January/ February 2015 ~ living well

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Researchers discover new class of

stem cells

By Monte Morin, Los Angeles Times

R

esearchers have identified a new class of lab-engineered stem cells — cells capable of transforming into nearly all forms of tissue — and have dubbed them F-class cells because they cluster together in “fuzzy-looking”

colonies.

The discovery, which was described in a series of five

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living well ~ January/February 2015

papers published in December in the journals Nature and Nature Communications, sheds new light on the process of cell reprogramming and may point the way to more efficient methods of creating stem cells, researchers say.

Because of their extraordinary shape-shifting abilities, so-called pluripotent cells have enormous value to medical researchers. They allow scientists to study the effects of

drugs and disease on human cells when experiments on actual people would be impossible, and they have given rise to the field of regenerative medicine, which seeks to restore lost or damaged organs and tissues.

The F-class cells were created using genetically engineered mouse cells, and may not occur naturally outside the lab, according to senior author Andras Nagy, a January/ February 2015 ~ living well

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pluripotent cells allow scientists to study the effects of drugs and disease when experiments on actual people would be impossible

stem cell researcher at Toronto’s LunenfeldTanenbaum Research Institute of Mount Sinai Hospital.

However, the find suggests that there may be other classes of pluripotent cells – or a spectrum of reprogrammed cells – yet to be discovered, authors say.

“We think that if we have time, and money and hands to do it, we might find additional novel cell lines,” Nagy said.

Until now, stem cells have been either obtained from embryos or produced in the lab through a painstaking process called induced pluripotency, whereby a virus is used to alter an adult cell’s genetic information and return the cell to a pliable, embryonic state.

That process, which was pioneered by Dr. Shinya Yamanaka and recognized with the Nobel Prize in Physiology or Medicine in 2012, is extremely inefficient, yielding embryonic-stem-cell-like cells just 1 percent of the time.

Nagy and his colleagues, a consortium of international researchers called Project Grandiose, began their research by looking more closely at the castoffs of that process, or those cells that did not closely match the description of embryonic stem cells.

“We looked at it in an unbiased way,” Nagy said. “Instead of ignoring or discarding those cells that don’t look like embryonic stem cells, we thought we might find more than just one alternative cell type.”

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living well ~ January/February 2015

Their hunch paid off when they identified half a dozen cells that were very similar to each other, yet very different from the gold-standard embryonic-like cells.

These F-cells were engineered in a slightly different way than most induced pluripotent stem cells. They were designed so that the cell reprogramming process would only occur when they were exposed to the antibiotic doxycline. Once the cells were no longer exposed to the medication, they either turned into an adult specialized cells or they died, Nagy said.

The newly discovered cells could reproduce quickly and were not “sticky,” Nagy said.

“The adhesion is not that high, so they are amenable to bioreactor type of growth,” Nagy said. “We can put these cells into a big jar of media and grow them up in a suspension, which is much more efficient, cheaper, and less work to produce a huge number of cells.”

It remains to be seen whether human cells can be converted into F-class cells, but researchers say it seems highly possible.

“I think it’s inevitable that human F-class cells can be achieved in the near future through reprogramming,” said Juan Carlos Izpisua Belmonte, a developmental biologist at the Salk Institute for Biological Studies in La Jolla, Calif.

However, Belmonte, who was not involved in the research but who co-wrote

the cells have given rise to the field of regenerative medicine

an accompanying News & Views piece, said that using human F-class cells for clinical applications might prove “problematic.”

The reason for this is that their constant need to express reprogramming factors may lead to tumor formation.

“So the next important step is to find culture condition(s) that can stabilize F-Class state without transgene expression,” Belmonte wrote in an e-mail.

Paul Knoepfler, a stem cell researcher at the University of California, Davis, who was also not involved in the study, said he guessed that F-class human cells could be made, but probably less efficiently.

“I’m most excited about the concept that there can be different kinds of reprogrammed states and pluripotent states,” Knoepfler wrote in an email.

“With the arrival of F-class cells on the scene … (who’s) to say that there aren’t additional types of pluripotent cells with unique properties that might be harnessed clinically?”

January/ February 2015 ~ living well

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living well ~ January/February 2015

Adult survivors of childhood cancer Remain aware of late effects of treatment

By Alan Bavley, Kansas City Star

K

ANSAS CITY, Mo. — With her bright eyes and peachesand-cream complexion, Ashley Dado is a picture of youthful health. You’d wonder why this 22-year-old college senior needs regular mammograms and heart scans.

To understand, you have to go back to when she was 10 years old, the summer before fifth grade. The avid softball player was having a hard time holding down food that July, vomiting so often that she eventually lost 20 pounds.

It wasn’t a stomach virus, as doctors first thought. It was a tumor pressing on the back of her brain.

After surgery and nearly a year of chemotherapy and radiation treatments, Dado, of Overland Park, Kan., has spent the last decade cancer-free.

The United States has an estimated 363,000 January/ February 2015 ~ living well

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study finds 98% of cancer survivors had at least one chronic health problem childhood cancer survivors like Dado. Their numbers have been increasing steadily as advances in treatment have drastically improved their odds.

It’s a medical success story, but with that success has come a growing recognition that these children often must struggle with “late effects” of their treatments that may not appear until decades after they are grown. They face increased risks of heart and lung disease, problems conceiving children, difficulty remembering or solving problems and the possibility of new cancers.

Cancer specialists say they should be receiving lifelong medical monitoring geared to these risks, but most don’t.

Consider Dado one of the lucky ones. She was one of the first patients to enroll in a new program at the University of Kansas Cancer Center for adult survivors of childhood cancers.

Opened in July, the Survivorship Transition Clinic already has 28 patients. It is one of just a half-dozen such adult care clinics in the U.S. The clinic schedules the follow-up screenings these cancer survivors need and arranges their care from KU Medical Center’s specialists.

“It’s reassuring,” Dado said. “They have everything you would need, all the doctors.”

Dado’s good health is a testament to the vast improvements in treating cancer in children over the last half-century. In the 1970s, the combined five-year survival rate for all childhood cancers was about 62 percent. Now, it is about 81 percent, far better than the 68 percent survival rate among adults.

“In the ’70s and ’80s we saw enormous increases in survival of childhood leukemia,” the most common childhood cancer, said Lisa Diller, the chief medical officer of the Dana-Farber/Boston Children’s Hospital cancer center and the medical director of its program for survivors of childhood cancer.

“We learned how to use many of the new cancer drugs that are regularly used today. In the ’90s and 2000s, we’ve learned about the genetics of tumors and how to determine which children are at high or low risk from aggressive therapy.”

It didn’t take long for cancer specialists of a generation ago to realize that therapies that were safe for adults could harm children’s growing bodies, Diller said. For example, at certain levels, radiation could stop young bones from growing. “It became obvious pretty quickly that we were seeing side effects,” she said.

Late effects

It has only been in more recent years, as early childhood cancer survivors have been maturing into middle age, that doctors realized the full extent of the late effects of cancer treatment.

Radiation and chemotherapy drugs can damage hearts and lungs, leading to future health problems. They can damage ovaries and testes, leading to fertility problems, as well as glands of the endocrine system, affecting growth during adolescence. Radiation to a girl’s chest may increase

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her risk of breast cancer. Certain chemotherapy drugs can cause hearing loss.

St. Jude Children’s Research Hospital has been following a group of childhood cancer survivors who were diagnosed with cancer an average of about 25 years ago. In a study published last year, the researchers found that virtually all the cancer survivors – 98 percent – had at least one chronic health problem. And by age 45, about 80 percent had at least one life-threatening, serious or disabling condition.

Just as troubling was another St. Jude finding: Just 31.5 percent of adult survivors were getting medical care that focused on their childhood cancers.

“I do fear there may be many survivors out there who aren’t getting appropriate care,” Diller said. “They grow up, move away, get married. They may not know about their treatment when they were 2 years old, and their parents may be gone.”

Wendy McClellan has encountered patients like these.

McClellan is the nurse coordinator of the Survive and Thrive program at Children’s Mercy Hospital for young patients a few years past their cancer treatments.

“We’d get calls from adult survivors asking where to go.

They’d come out of the woodwork. They wanted to be seen by someone who understood their condition,” McClellan said.

Survive and Thrive works with teenage patients and the parents of very young children, explaining the risks of late effects and offering advice for how to stay healthy and how to advocate for the children’s medical care once they become adults.

But Children’s Mercy doesn’t take adult patients. All McClellan could do for the adult survivors who called was encourage them to get a detailed summary of their cancer care from their hospitals so their doctors would understand what they needed.

With the possibility of an adult survivors program in mind, McClellan and researchers at Children’s Mercy and KU in 2010 surveyed their former childhood cancer patients who were in their late teens and twenties. Most of those young adults said they were in good health, but they wanted more information about the late effects of their treatments.

“What stood out the most was they didn’t feel understood by their health care provider,” McClellan said.

“The providers wouldn’t link their symptoms to their early treatment, when the patients thought they were (linked).

They wouldn’t know what to do with those symptoms.”

More than 80 percent of adult survivors of childhood cancer are seen by internal medicine specialists and other primary care doctors in their communities, but, on average, internists felt “somewhat uncomfortable” caring for these patients, a recent national survey found. When given a hypothetical case of a female patient who received radiation and chemotherapy as a child, the vast majority of these doctors failed to recommend mammograms every year or echocardiograms every other year, as called for in treatment guidelines for these cancer survivors.

“That probably is common. The awareness of late effects is still developing,” said Becky Lowry, the medical director

of the new KU survivorship clinic.

Prevention is key

Lowry recalls seeing a patient in her 50s who had leukemia when she was in high school. She was growing progressively short of breath and her heart was pumping less forcefully. The woman’s doctors never made the link between her medical problems and her cancer treatment, she said. At KU Hospital, the woman was sent to a cardiologist who specializes in cancer patients. She needs regular echocardiograms to monitor her heart.

“I think a big part of what we do is prevention,” Lowry said. “It’s knowing what to watch for to catch problems early.”

A patient generally comes to the clinic once a year.

A nurse practitioner walks the patient through the treatment he or she received as a child and discusses the risks the patient faces and what screenings he or she will need.

The program draws upon psychologists and social workers to help patients with the emotional issues that can arise from late effects of their cancer treatments. It also can make referrals to fertility experts.

“A program like this works best at a large academic medical center,” Lowry said. “We have the luxury of having a lot of the specialists here.”

Getting health plans to pay for mammograms for 25-year-old women or echocardiograms for patients who don’t have chest pains is another part of the program.

“We do have conversations with insurance companies, educating them about the guidelines” for cancer survivors, Lowry said.

Dado remembers her cancer treatment as a scary time in her life. “I had never heard of that cancer before. I thought I was going to die.”

At the base of her brain, surgeons found a tumor the size of a large strawberry that had started growing into her spinal column. They were able to remove most of it, but not the part that had reached her spine.

That required chemotherapy and radiation of her entire spinal column.

Those therapies now put her at greater risk of breast cancer and heart problems.

Dado also has some trouble with eyehand coordination and concentration, late effects of her treatment. But that hasn’t slowed her education. She plans to graduate this spring from MidAmerica Nazarene University with a degree in health and exercise science. Her goal is to become a health educator who can help children undergoing cancer treatment.

“I would have liked to have someone like that when I was a kid, someone who’s gone through it who can explain the process,” she said.

January/ February 2015 ~ living well

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on the horizon Fasting 15 hours a day wards off obesity in mice, study says

By Melissa Healy, Los Angeles Times

I

f obesity is linked to Americans’ 24/7 lifestyles, would it help to reset the clock that dictates our eating? A new study suggests it would, and in ways that go well beyond weight alone.

Even with a diet high in fat and sugar, mice that had their “eating day” compressed into eight to nine hours and then fasted for the remainder of the day were less likely to become obese, says new research. Mice that observed a lengthy daily fast also suffered less systemic inflammation, fatty liver disease, worrisome cholesterol and metabolic disturbance than did mice that ate whenever they pleased.

The difference wasn’t how much or what the mice ate: Mice kept on a daily fasting regimen ate the same fattening chow, and just as much of it, as did those who ate around the clock. The only difference was when they ate it — and how long they did without.

The study, published this week in Cell Metabolism, builds on the idea that our cells adhere to a sleep-wake cycle and process fuel differently at different times of the day.

Researchers at the Salk Institute for Biological Studies in the San Diego-area community of La Jolla subjected 392 male lab mice to a variety of feeding patterns and gauged the effects on a wide range of metabolic and physiological

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measures.

Compared with mice allowed to eat whenever they wanted, those who did all of their eating in nine hours a day gained only half as much weight, even though both groups consumed about the same number of calories.

The daily fasters also showed exercise endurance far superior to that of mice with no eating restrictions. They not only outran the chubby all-day eaters, they also left mice reared on normal, healthy chow in the dust.

A long daily fast also aided in weight loss among mice that were obese. Those switched from the eat-when-youwant mode to a 15-hour daily fast mode lost 5 percent to 12 percent of their body weight over three months, while the mice who continued to eat throughout the day saw their weight rise an additional 10 percent to 25 percent.

And mice that reaped the rewards of fasting could make an occasional dietary detour and still stay healthy.

“I wouldn’t run out and start doing this in humans,” said Kenneth P. Wright, director of University of Colorado at Boulder’s sleep and chronobiology lab, who wasn’t involved in the research. But “studying these effects in humans is certainly the next step,” he said.

Time-restricted feeding is a potentially powerful behavioral intervention that “de-emphasizes caloric intake, hence making it an attractive and easily adoptable lifestyle modification,” the Salk researchers wrote.

January/ February 2015 ~ living well

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Amber Jackson

Breast Cancer Survivor

My superpower is

attitude.

Stronger than her initial uncertainty, more powerful than her diagnosis, Amber’s ‘can-do-anything’ attitude helped her to kick cancer’s butt.

It’s this same attitude that gives her the power to embrace a new life.

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living well ~ January/February 2015 Embrace

your inner superhero to do great things.

communitymed.org