March 2022 Department of Surgery Newsletter

SURGERY NEWS March 2022

NOTES FROM THE CHAIR It’s springtime in Colorado and we are getting some much-needed moisture as we enter one of our snowiest months. In this season, I am reminded of how things that have been dormant begin coming to life. It is especially poignant this year as it seemingly coincides with the COVID-19 pandemic on the downswing.

While we dream of the future, it is vital to remind ourselves of our accomplishments. In the following pages, we review the story of a bile duct cancer survivor, the work of our researchers in reducing cathetercaused UTIs, our strides in DEI as we work toward our goals, the importance of transitioning pediatric urology patients to adult care, and much more.

As a department, we embrace the vision of improving every life. It is heartbreaking to see the death, suffering, and destruction in Ukraine.

It is a reminder to be respectful and to care for each other.

As always, it continues to be my privilege to share these highlights with you.

ISSUE HIGHLIGHTS

BILE DUCT CANCER SURVIVOR SHARES HIS STORY

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Richard D. Schulick, MD, MBA Professor & Chair, CU Department of Surgery Director, CU Cancer Center The Aragón/Gonzalez-Gíustí Chair

REDUCING UTIs 8

DEI UPDATE 13

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Jim White shares his story from his life before cancer, through diagnosis, surgery, and chemotherapy, and now what it’s like living in survivorship.

NAVY VETERAN UROLOGY DONATES LIVER PEDS TO ADULT

Surgery News

6 YEARS AFTER BILE DUCT CANCER DIAGNOSIS, FOCUS SHIFTS TO NOT WASTING TIME “I always knew I was in the best possible hands. I am absolutely convinced Dr. Schulick saved my life.”

Rachel Sauer There were a lot of things Jim White thought he’d never do: stay in one place long enough to feel roots grow beneath his feet, meet the love of his life, have a child whose daily joy in discovering the world reignites White’s own joy.

But that’s what did happen. He met Kelsey Shiba when he became a professor of jazz studies at the University of Northern Colorado (UNC), and on December 30, 2017, they welcomed their son, Oliver.

After decades as a touring musician, and despite how he’d long envisioned his life unfurling, he’d built something in Greeley – a family, an amazing teaching career, a circle of friends and music, a life he loves living.

So, it’s still incredible to him that only two years before Oliver arrived, when White was a gaunt 50 pounds lighter 2

from chemotherapy and radiotherapy, still recovering from Whipple surgery, still battling bile duct cancer, everything that his life is now seemed intangibly beyond his reach.

“It was like I’d joined this club that nobody wants to be a part of, but once you’re in, you’re in,” explains White, who turned 53 in January. “I’m not sure you’re ever really free of the cancer, because every time I go in for a scan I’m nervous, there’s this anxiety that comes with it.

“But when you have cancer looking over your shoulder, I’ve realized that I’m going to do what I want to do. I don’t feel like I have to apologize for the things that I want, and I realize that life is short. I want to tell people that I love them, I don’t want to waste time or let any time go by because I was too busy to pay attention.”

A life of music before a cancer diagnosis For as long as he can remember, going back to his earliest memories growing up in Atlanta, Georgia, the things White paid attention to were the rhythms of the world around him. A born percussionist, he heard the sounds and syncopations of life, and translated them to his percussion studies with musical greats.

After earning his bachelor’s degree in music, he moved to New York and then to Nashville, becoming a sought-after studio and touring musician in jazz, pop, and country. During this time, he also earned his master’s degree in jazz studies/composition.

Through one of his music connections, he heard about a position at UNC teaching jazz studies and applied, partly thinking he’d never get the job. www.cusurgery.com

March 2022 But he did get it, and he embarked on a career teaching young musicians, directing UNC’s Lab II Big Band, supervising the jazz combo program, and touring and performing in his downtime.

to have this surgery.’ He knew I was upset about it and scared, so he tells me that over half the people that see him aren’t eligible for it, or they need chemo or radiation first, so I realized it was pretty lucky that I was eligible.”

Then he met Shiba, a fellow musician, A CT scan from the week before and fell in love. They got married and White’s May 2015 surgery showed a began building their life together, mass at the end of White’s bile duct dreaming of children somewhere down “I’m alive,” he says. “It’s been six the road. years, and every time my scans are

clear I know that’s a gift. I don’t know In May 2015, though, White what’s going to happen tomorrow, knew something but I’m grateful for today.” - White was wrong.

For weeks he felt constant and no evidence that disease had exhaustion and an itch that wouldn’t spread to other parts of his body, go away. Because he had a history “which is great,” Schulick says. “Then, of headaches, he’d regularly seen when I went ahead and did the a neurologist, so he called her operation, I was a little bit worried after and explained his symptoms. She I got the pathology results because recommended he get a blood panel they showed 10 of his lymph nodes “and that showed my liver enzymes had cancer. I took them out, but that being through the roof,” he recalls. signals that somewhere else in the He had met a local oncologists’ wife at body there are cancer cells, so various arts events, so he messaged the chemotherapy he had was her through Facebook and within 15 absolutely vital.” minutes Doug Kemme, MD, called him.

White recovered in the hospital for “He said, ‘There’s this incredible guy, several weeks, a time when Schulick Richard Schulick, and you have to go came by his room every day, White meet with him’,” White remembers. recalls, “and sometimes it was 4 in Surgery and then chemotherapy for the morning when he’d come by. I bile duct cancer remember one morning he showed up in my room wearing a three-piece “Jim’s diagnosis was bile duct cancer, suit because he was on his way to the which is rarer than pancreas cancer,” airport,” White says. explains Richard Schulick, MD, MBA, director of the University of Colorado (CU) Cancer Center and chair of the Department of Surgery at CU School of Medicine. “The head of the pancreas and the bile duct occupy the exact same space, so if a cancer develops in one it can give the exact same symptoms as the other. Sometimes we don’t even know if it’s pancreas cancer or bile duct cancer until we take it out.”

“He’s a great teacher, and I’m a teacher, so I would watch him teach the students who came to my room with him. He would always take a moment to teach them and to show them why and what he was doing, and he would do it in an incredibly kind way. I always knew I was in the best possible hands.

I am absolutely convinced Dr. Schulick saved my life.”

White was seen by the CU Cancer Center multidisciplinary care team, which included Schulick. White remembers feeling “scared to death.

Dr. Schulick was like, ‘Look, you’ve got

A sometimes rocky but steady recovery White’s journey of recovery was not perfect – a common experience for

most people diagnosed with cancer.

After being discharged from the hospital following his surgery, he was back in the emergency room several days later with an infection and having his stomach pumped.

Chemotherapy also took a significant physical toll, but he credits not only the support of his multidisciplinary care team for his steady recovery, but the unwavering support of his wife.

He also participated in UCHealth cancer survivorship programs, making some great friends who understood what he was experiencing – not just the physical toll, but the mental and emotional ones, too.

Living in survivorship White says he’s had a lot of time to think in the more than six years since his cancer diagnosis, and he balks at the word “survivor.”

“I don’t want to imply that I did anything different than my friends who died,” he says. “I didn’t fight some lion, I didn’t kill a dragon, I wasn’t any more courageous or brave than they were.

We’re all survivors, regardless of the outcome.”

Of all the perspectives cancer has given him, he says, some of the most important have been to take care of his mental health and to appreciate each moment as it comes, like bright beads on a string.

Featured Expert

Richard Schulick, MD, MBA Professor and Chair, Department of Surgery Director, CU Cancer Center 3

Surgery News were kept in for the ease of the patient — so they could recover and not have to worry about getting up to go to the bathroom. But the downstream effect of indwelling catheters is that patients can have problems with retaining urine upon removal. It’s not natural for the bladder to be continually drained with a catheter removing the sensation when full that you need to ‘go.’ We were actually potentiating the problem of retention by not mindfully and quickly removing the catheters and getting natural processes back up to speed as quickly as possible.”

Back on top

REDUCING CATHETER-CAUSED UTIS IN SURGERY PATIENTS Janet Kukreja, MD, and Shannon Bortolotto, RN, led an initiative to remove catheters earlier — if they were needed at all.

Greg Glasgow When they realized their number of patients with urinary tract infections caused by urinary catheters was tracking above the national average, urologic oncologist Janet Kukreja, MD, and Shannon Bortolotto, APRN, clinical nurse specialist at UCHealth University of Colorado Hospital, knew they had to take action.

The pair pioneered a perioperative quality improvement project to look at how — and when — urinary catheters were placed and removed, even considering whether catheters are needed for some operations. As UTIs can be deadly, especially for older patients, it was an important issue to address.

“It’s a new way of thinking about catheters and realizing that they really have more potential causes of 4

harm than we probably recognized for a really long time,” Kukreja says.

“Sometimes they’re absolutely needed, but we wanted to transform the thought process about who actually needs them, and for what reasons.”

Preventing other problems The new protocol, which began in July 2020, calls for no urinary catheters in operations lasting four hours or less, unless required by the surgeon. The new pre-surgery routine includes a step where patients are asked to empty their bladder. Catheters also are now formally screened for removal in the operating room immediately after surgery, rather than remaining in the patient for hours or days afterward.

Kukreja and Bortolotto say surgeons across the board were eager to implement the new protocol and help reduce CAUTI (catheter-associated urinary tract infections) throughout the department.

“We had to get out of the habit of placing them just because that’s what we’ve always done,” Bortolotto says. “Then circling back with the surgeons and showing them successful adapters, and that it can be done, was really key. Dr. Kukreja approached it in a spirit of celebrating success, as opposed to saying, ‘You’re not doing what we’d like you to do.’ I think that was really helpful to her colleagues.”

In the 18 months since the new catheter protocol was implemented, the CU Department of Surgery at UCH has contributed to the hospital’s return to the top 25% of institutions in preventing CAUTI, dropping from 12 to 15 cases per month to an average of just two or three.

Click here to learn more about their research.

“That was a real culture change,” Bortolotto says. “Previously, the lines

www.cusurgery.com

March 2022

BOB SAGET’S DEATH BRINGS AWARENESS TO SIGNS OF ACCIDENTAL HEAD INJURY Michael Cripps, MD, says to watch for symptoms that don’t fade.

Rachel Sauer Comedian Bob Saget’s death on January 9 was a shock to fans who loved him as Danny Tanner on “Full House” or for his stand-up comedy, and for those who admired and respected him as a colleague.

Saget’s family announced that an autopsy revealed his cause of death was accidental head trauma, likely the result of an unwitnessed fall. No illegal drugs or toxins were found in his system.

After the announcement, a lot of discussion turned to the common occurrence of hitting your head and how to know when it’s serious enough to seek medical attention.

We spoke with Michael Cripps, MD, associate professor of GI, trauma and endocrine surgery and trauma medical director, about the important things to know if you hit your head.

It’s not unusual to accidentally hit your head just going about your day, so after hearing about Bob Saget’s cause of death, how concerned should people be?

That’s true, we hit our heads all the time, and in the overwhelming majority of cases we go about our business because the sort of injury that likely led to Bob Saget’s death is extremely rare.

That’s the hard part of talking about this, because we don’t want to freak everybody out and make them think that every time they hit their head it can lead to death.

The things we need to watch out for are ongoing symptoms: headache, confusion, dizziness, nausea, vomiting, slurred speech, weakness in your limbs, trouble walking. There’s a difference between hitting your head and true traumatic brain injury, and a big part of

that difference is the duration of ongoing symptoms. If you hit your head and it hurts, maybe you even see a bright flash, but the symptoms fade pretty quickly, then that’s generally not going to be a big cause for concern. It’s when you have those symptoms I mentioned and they don’t go away that you want to seek medical attention.

Are there any people or groups who should pay particular attention to symptoms when they hit their heads?

The most common injury associated with hitting your head is falls, and people over age 75 and those taking blood thinners are two groups at high risk for head injuries. If there’s a fall associated with hitting your head, especially if there’s a loss of consciousness, then that’s a real concern, and I would advise people to seek help.

Click here to read our entire interview with Cripps.

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Surgery News

Featured Open Positions

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WELCOME NEW HIRES FACULTY

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Danielle Aquila, PNP Instructor Pediatric Surgery

Jacky Bonds Administrative Assistant III Vascular Surgery

Laura Archambeau, FNP-C Instructor Cardiothoracic Surgery

Rylee Funkhouser Research Services Entry Professional Urology

Jacquelyne Brafford, PA-C Instructor GI, Trauma, and Endocrine Surgery

Sophia Gordon Laboratory Tech I Center for Surgical Innovation

Kelsey Heil, MSN, RN Instructor Cardiothoracic Surgery

Nargis Kalia Research Services Professional Plastic and Reconstructive Surgery

Jennie Johnson, PA Instructor Surgical Oncology

Dayana Leyva Post Award Specialist Finance and Administration

Sarah Longyhore, PA Instructor Cardiothoracic Surgery

Jennifer Nevener HR Specialist Finance and Administration

Caren Millard, MD Assistant Professor GI, Trauma, and Endocrine Surgery

Ashleigh Prout HR Recruitment Sr. Specialist Finance and Administration

Amy Miller, MSN, FNP-C, CWOCN Instructor Plastic and Reconstructive Surgery

Alina Rich Division Administrative Director Plastic and Reconstructive Surgery

Jessica Outten, PNP-AC Instructor Pediatric Surgery

Victor Rodriguez Quality Improvement Data Analyst Pediatric Surgery

Jordan Paley, PA-C Instructor Plastic and Reconstructive Surgery Peggy Walsh, PA-C Instructor Plastic and Reconstructive Surgery

Project Manager II APPLY NOW

Julian Winocour, MD, CM, FACS, FRCSC Associate Professor Plastic and Reconstructive Surgery Allison Zurawski, PA-C Instructor Transplant Surgery

Click here to view all open positions.

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www.cusurgery.com

March 2022 2. Creating an environment in which everyone is educated in DEI.

DIVERSITY, EQUITY, AND INCLUSION UPDATE Recruitment, education, and leadership are priorities in 2022, says Kia Washington, MD, FACS, vice chair of DEI. Greg Glasgow The Diversity, Equity, and Inclusion Committee in the CU School of Medicine Department of Surgery (DOS) has made great strides over the past year, working toward their goal of becoming the most diverse, equitable, and inclusive department of surgery in the country by 2030.

After a two-year period in which racial disparities were underscored by the COVID-19 pandemic, as well as the deaths of George Floyd, Breonna Taylor, Ahmaud Arbery, and many others, critical awareness around diversity, equity, and inclusion continues to grow, says Kia Washington, MD, head of the DEI committee.

“I’m definitely hopeful. I think things continue to be on the upswing,” she says. “People are really receptive to DEI. That’s definitely changed over the past three years, and that’s made my job a lot easier. It’s a great climate to really bring about some positive changes.”

We talked with Washington about the progress the committee has made on some key initiatives.

1. Expanding the applicant pool to include communities that are underrepresented in medicine.

“We’ve started marketing our strengths in DEI: We made a DEI recruitment video where we talk about the diverse aspects of our department and our commitment to diversity,” Washington says. “We’re going to use that for recruitment for faculty, as well as at the residency and fellowship level.”

The DOS HR team has begun posting open positions to DEI-specific job boards and highlighting them on social media to reach a broader network.

The Diversity, Equity, and Inclusion Committee established the annual Diversity Lectureship in 2021. Its second annual lecture, held on February 14, 2022, featured Professor Velma Scantlebury, MD, of Texas Christian University. Scantlebury is the first Black woman transplant surgeon in the country, and her lecture was titled “Do You See Me? Looking Beyond Our Biases and Practices.” In it, she talked about identifying medical practices that highlight racial inequities, analyzing physician biases that manifest themselves in the care of patients, and strategies to decrease practices that contribute to structural inequities.

Continuing education and training on DEI is also a critical focus for the committee. Over the past year, the committee developed a DEI curriculum that is presented quarterly at Grand Rounds, including topics around gender, race and ethnicity, and the LGBTQ population. It also offers a DEI resource page that lists a number of books, articles, and videos on different DEI topics.

3. Future plans with an eye on 2030.

“We’re going to continue to work to create the most equitable environment we can,” Washington says. That work includes conducting a climate survey to assess the current state of DEI in the department, as well as efforts to ensure a more diverse leadership.

“We also hope to create members at large for the Executive Leadership Committee — to give more people the opportunity to sit in leadership and get that leadership experience,” Washington says.

Click here to read the complete interview with Washington.

“All of the divisions now have pipeline programs where visiting medical students from underrepresented backgrounds are sponsored to do sub-internships.”

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Surgery News

NAVY VETERAN DONATES PART OF HIS LIVER TO SOMEONE HE’D NEVER MET CU transplant team helps two strangers create a lifetime bond.

Khushnuma Damkevala Service members join the military with a passion to serve, and that passion remains long after they have fulfilled their formal commitments. Upon their departure from military service, many veterans remain committed to serving others. Their military experience often inspires them to become active in their communities at home.

James Pomposelli, MD, PhD Professor Transplant Surgery

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This rings very true for Joel Doebele.

As a member of the U.S. Navy, he was prepared to lay down his life to protect millions of Americans he would never meet. When he had the chance to donate part of his liver to a stranger in need, Doebele called upon that same spirit of service.

A fateful homecoming While Doebele was in the Navy, he trained other service members to handle complex nuclear-powered

submarines and aircraft. He was based near Charleston, South Carolina, and remained there for the entire four years of his service.

After fulfilling his commitment, Doebele moved to Grand Junction, Colorado.

On New Year’s Eve in 2017, he attended the Sunday morning service at the Downtown Vineyard Church. During the service, pastor Paul Watson announced a blood drive for Jeremy Jolley, a member of the congregation who was battling primary sclerosing cholangitis (PSC), a disease of the bile ducts that can lead to liver failure and cancer. Not only did Jolley need blood donations, Watson told the congregation, but he was in search of a liver donor as well.

Anyone with O-positive or O-negative blood was eligible to see if they were a compatible donor.

www.cusurgery.com

March 2022 Doebele knew his blood type was O-positive, and while he was being baptized that same day, he envisioned the donation happening.

At that moment, he felt a strong desire to drive to Denver to see if he could be an acceptable donor.

“I didn’t even have to think about it,” Doebele says. “This is an area where I can serve and be of assistance to somebody. I immediately decided to get myself tested. The CU transplant team where Jolley was listed for a living donor transplant said that I was a perfect match, so that was great.”

The gift of a living donor Doebele knew little about living liver donation before starting the process to donate part of his own liver. He had only heard about people donating organs after death and had no idea that a living adult can donate 40% to 60% of their healthy liver, and that the liver completely regenerates after donation.

With a living liver donation, surgeons take part of the liver from a healthy adult and place it into a patient with end stage liver failure. Most living donors can enjoy a normal life after the surgery. CU has one of the largest living donor programs in the country, and the CU Transplant Center has performed over 1,000 living donor surgeries. Living donation is a great alternative for the thousands of patients waiting for a deceased organ donor. This gives the patients the opportunity to get off the waitlist and get a second chance at life.

“We know that live-donor liver transplant recipients transplanted at high-volume centers have better outcomes than deceased donor liver transplant recipients,” says Whitney Jackson, MD, associate professor of gastroenterology and hepatology and medical director of the Living Donor Liver Transplantation at UCHealth. “These improved outcomes are due to decreased likelihood of dying while on the waitlist and better postoperative outcomes.

Having control over the timing of

the transplant allows the patient to undergo a liver transplant when they have been optimized medically instead of having to wait for an acceptable deceased donor liver.”

The transplant journey begins Jolley was 44 and had been battling PSC for nearly seven years when he received the news from his team of doctors that he was approved to proceed with a living donor liver transplant. PSC is an extremely serious disease, and in Jolley’s case, it had reached a point where his liver started to fail.

Jolley’s brother and family all tested to donate part of their liver, but unfortunately, they were all ruled out.

When Jolley’s pastor spoke at the New Year’s Eve service, 18 people stepped forward and got tested to donate their liver. Seventeen of them were deemed not to be optimal donors for Jolley, but one remained.

That was Doebele.

“I missed the most important call of my life, but Joel left a voicemail saying that he’s a perfect match,” Jolley says. “I still have that voicemail saved.”

On April 19, 2018, after Doebele completed all the testing required for transplantation, the surgery took place on the Anschutz Medical Campus. The miracle that Jolley had hoped for came true. The surgery was a success, and now Jolley shares a portion of Doebele’s liver, which has given him a new life.

State of the School 2022 CU School of Medicine Dean John J. Reilly Jr., MD, highlighted the accomplishments of 2021 and looked forward to 2022 during his annual address.

Greg Glasgow Despite the challenges of the COVID-19 pandemic, the University of Colorado School of Medicine still had many accomplishments to celebrate in 2021.

That was the message from Dean John J. Reilly Jr., MD, in his annual State of the School address on January 12.

Among those accomplishments were getting faculty and staff vaccinated against the coronavirus; continuing to build the school’s informatics and data science capacity with the creation of a new department this summer; moving programs into the recently completed Anschutz Health Sciences Building this spring; launching a new curriculum for the medical student Class of 2025; and opening a branch campus at Colorado State University in Fort Collins. The CU School of Medicine also saw a record number of applications in 2021. More than 14,000 candidates from around the world applied for one of just 184 seats in the class of 2025, a 35% jump from the previous year, compared to an increase of 18% nationwide.

Click here to read more about this transplant journey.

Click here to read our coverage of the event and to link to the video.

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Surgery News • When heating food in the microwave, use microwave-safe cookware that allows steam to escape.

• Allow food to rest before removing from the microwave.

• When frying, use a pan lid or splash guard to prevent grease splatter.

FIRE SAFETY IN THE KITCHEN Paul Bauling, MD, with the CU Burn Center, offers tips for Burn Awareness Week 2022.

Greg Glasgow As cooking is the number-one cause of all home fires, this year’s Burn Awareness Week — February 6 –12, 2022 — had as its theme “Burning Issues in the Kitchen.”

Paul Bauling, MD, of the University of Colorado Burn Center in the CU Department of Surgery, offers these tips for staying safe from burns in the kitchen: Wear short or close fitting sleeves when cooking: One of the most common scenarios Bauling sees at the burn center is burns resulting from long-sleeved, synthetic garments like robes or nightgowns that get ignited by a gas flame on the stove.

Avoid distractions: Stepping away from the stove even for a minute to watch the end of a TV program can have disastrous consequences, Bauling says.

Make sure you have the right lid: Especially when cooking with grease or oil, Bauling says, make sure you have the correct, tight-fitting lid for the pots and pans you are using. “When the

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fire flames up, all you need to do is calmly put the lid back on, and the fire instantly dies.”

Invest in a high-quality fire extinguisher: Not all fire extinguishers are created equal, Bauling says — look for an “ABC” fire extinguisher that contains a dry chemical suitable for kitchen and grease fires, as well as chemical and electrical fires, and fires involving ordinary combustibles like wood, paper, and cloth.

If you do get a burn, know who to call: “Fire stations, emergency rooms, and urgent cares typically can give you instructions over the phone,” he says, “or call the CU Burn Unit and ask for the charge nurse.”

• If you are simmering, baking, roasting, or boiling food, check it regularly. Remain in the home while food is cooking, and use a timer to remind you to check on your food.

• After cooking, check the kitchen to make sure all burners and other appliances are turned off.

If a fire does happen, the American Burn Association recommends: • Cover the pan with its lid. A cookie sheet works too. Leave covered until the pan is cool. NEVER move the pot or carry it outside — the pot is too hot to handle and the contents may splash, causing a severe burn.

• Turn the heat off. With the lid on and the heat off, the fire should quickly put itself out.

• NEVER use water to put out a kitchen fire. Water will cause the oil to splatter and spread the fire, or scald you as it vaporizes.

• If the fire is inside the oven or microwave, keep the door shut and turn it off. Keep closed until the oven is cool.

• If the fire gets out of control, get out, stay out and call 911. Don’t return inside for any reason.

The American Burn Association offers these additional tips for staying safe from kitchen burns: • Always wipe clean the stove, oven, and exhaust fan to prevent grease buildup.

• Turn pot or pan handles toward the back of the stove.

Paul Bauling, MD Assistant Professor GI, Trauma, and Endocrine Surgery

www.cusurgery.com

March 2022 and French began to record the reactions of those using the product.

In April 2021, they published a paper, “Evaluation of skin care concerns and patients’ perception of the effect of NanoSilk Cream on facial skin,” compiling the results. A majority of participants said the product gave them “excellent” benefit in skin care concerns including overall skin appearance, hydration, smoothness, and firmness.

NEW COSMETIC CREAM LEAVES SKIN ‘SILKY’ SMOOTH Ken Liechty, MD, created NanoSilk and is partnering with Brooke French, MD, to measure its effectiveness.

Add to that list NanoSilk, a silk-based skin cream created by University of Colorado School of Medicine faculty member Ken Liechty, MD, a pediatric surgeon at Children’s Hospital Colorado.

Looking for ways to aid healing in diabetes patients, whose skin doesn’t heal as quickly or thoroughly as that of people who don’t have diabetes, Liechty hit upon a way to suspend actual silk particles in pluronic gel. It didn’t take long to discover the resulting product had beneficial effects for all skin types.

“Silk is a strong fiber,” says Liechty, a professor of surgery. “In diabetics, the extracellular matrix is impaired, so we thought a fiber could strengthen the skin at baseline. Then we saw additional effects, like hydration and smoothing out the appearance of fine lines and wrinkles. When you use the cream, it

Next steps to effectiveness and commercialization

Launching Le Ver

Recently, French received a grant to buy a special 3-D cosmetic camera system to provide more objective measures of NanoSilk’s effectiveness, and the team is working on another paper, to be published later this year, detailing those findings.

Working with CU Innovations, Liechty created Le Ver, a cosmetic company that offers two NanoSilk products — a face cream called Scaffold, and an eye cream called Restore. He brought another CU School of Medicine faculty member, Brooke French, MD, an associate professor of plastic and reconstructive surgery, into the fold to test the product on her patients and conduct research on its effects.

“We can actually say, ‘There’s this much improvement in fine lines and wrinkles,’ or, ‘This much improvement in hydration,’ whereas the first paper was just based on perceptions,” French says. “There aren’t many published articles detailing scientific objective measurements of improvement in skin in a commercially available cosmetic line that’s available without a prescription.”

Greg Glasgow From Silly Putty to the microwave oven, there is a long history of consumer products “accidentally” discovered during the scientific discovery process.

“There was one woman who said, ‘I’ve always had very dry skin. I tried so many high end brands of skin care that I’m embarrassed to think of how much I’ve spent,’” Liechty says. “She said, ‘This is the first cream I’ve used that keeps my skin feeling moisturized and healthy all day. I’ve noticed that wrinkles are not as visible, and that it actually looks like my face is firmer. I can’t imagine not using it now.’”

feels like your skin actually tightens up as it dries.”

“Once Ken realized its cosmetic qualities and potential impact, he really ‘grassrooted’ it,” French says. “He gave samples to colleagues and nurses who wanted to try the product.

And he garnered a bit of a cult following from it. Everybody wanted to try it. I tried it, and I thought it was an outstanding product.”

Click here to learn more about Le Ver.

With the help of CU School of Medicine resident Amanda Louiselle, MD, Liechty 11

Surgery News

CHANGING THE STANDARD OF CARE FOR STAGE III MELANOMA SURGERY A study by CU Cancer Center researchers shows that immunotherapy alone may have equivalent or better outcomes than completion node dissection for stage III melanoma.

Greg Glasgow For years, surgery for patients with stage III melanoma — melanoma that has spread to the lymph nodes — involved removing those lymph nodes along with the primary tumor. Known as completion lymph node dissection (CLND), the surgery was meant to ensure that no cancer remained after surgery. More recently, however, cancer surgeons have discovered that CLND has the potential to cause more problems than it solves. In most cases, patients do better on immunotherapy alone than they do when their surgery involves removal of the lymph nodes, due to potential complications from lymph node surgery.

In a paper published in February in the Annals of Surgery Oncology, University of Colorado (CU) Cancer Center members Martin McCarter, MD, Camille Stewart, MD, Karl Lewis, MD, William Robinson, MD, Ana Gleisner, MD, PhD, and Rene Gonzalez, MD — along with CU School of Medicine resident Robert Torphy, MD, PhD — reviewed their patient data to determine if immunotherapy alone resulted in better outcomes than CLND. “In the few years prior to immunotherapy being available, some surgical trials were done asking if regional node dissection by itself improves overall survival for the patients,” says McCarter, a professor of surgical oncology at the CU School of Medicine. “And the answer came back: no, it did not improve survival. That had been the standard forever, because we didn’t have other effective therapies,

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but once the definitive trials were done, we learned that CLND wasn’t helping, it wasn’t improving survival.

Subsequent trials demonstrated that immunotherapy can improve survival in metastatic melanoma.”

Better outcomes with immunotherapy For the study, Torphy, working with McCarter and the other researchers, looked at data on 90 patients who underwent sentinel lymph node biopsy (a procedure to determine if a skin melanoma has spread microscopically) only for stage III melanoma but did not undergo CLND. Of those patients, 56 received immunotherapy and 34 did not. Those who received immunotherapy had better rates of distant metastasis-free survival, meaning their cancer was less likely to come back.

“As treatments for melanoma have evolved, the standard of care may be evolving as well,” McCarter says. “This study took a look at the patients who had a sentinel lymph node biopsy, so we knew the patient had a positive melanoma metastasis to their regional node. Those folks historically used to go on and get the completion lymph node dissection, but recently, people started to forego doing that lymph node dissection, which did not improve survival, and instead moved directly to immunotherapy, which did improve survival in other clinical trials.

We proved that this is acceptable, that we’re not causing more harm to

patients by doing it, and that those who do go on to get the immunotherapy seem to benefit from it.”

The de-escalation movement Forgoing CLND is part of a recent movement in cancer treatment known as de-escalation (or de-implementation) — giving patients only the surgery absolutely necessary to treat their immediate disease. It’s especially important when it comes to lymph node surgery, McCarter says, as on top of the risks inherent to all surgeries, CLND has a 20% to 30% risk of permanent lymphedema, potentially harmful tissue swelling caused by an accumulation of protein-rich fluid that’s usually drained through the body’s lymphatic system.

“If you could avoid that complication and not compromise a patient’s survival, that would be beneficial,” McCarter says. “That’s what we guessed was happening outside of definitive clinical trial evidence, and that’s what we were able to show.

We know that we often overtreat patients, and this fits in that paradigm of finding ways to de-escalate unnecessary therapies, which has been done in breast cancer and other cancers as well.”

Click here to learn more about melanoma surgery.

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March 2022 huge change for them. There needs to be a trusting relationship, and they need to trust that the care they’ve been receiving will continue.

TRANSITIONING PEDIATRIC UROLOGY PATIENTS TO ADULT CARE Daniel Wood, MD, PhD, is a leading specialist in helping young patients make the change.

Greg Glasgow For children with urologic disorders, the relationships they form early on with their urologists often turn out to be among the most important connections of their young lives.

School of Medicine in September 2021 to build a transitional urology team at Children’s Hospital Colorado and UCHealth University of Colorado Hospital.

Years later, as those children approach adulthood and their condition takes on new levels of urological, psychosocial and sexual importance, the patienturologist relationship becomes even more important. It is critical for care to be thoughtfully transitioned as the patient moves from pediatric to adult urology.

We spoke to Wood about the concept of transitional urology and why it’s so important to have a thoughtful transfer of care between childhood and adulthood.

The growing field of transitional urology aims to effectively manage the shift from pediatric to adult care, encouraging young adults to play a leading role in their own health care.

What are the biggest challenges of transitioning patients from pediatric to adult urologic care?

Daniel Wood, MD, PhD, who helped to pioneer the practice of transitional urology in London, came to the Division of Urology at the University of Colorado

These children have been looked after by a team since they were very young, and they’ve invested enormous trust in that team. And suddenly, at the age of 17 or 18, there’s a discussion about moving on from that team. That is a

The second big challenge is how you manage parents in that setting. I’m humbled by parents who put in all of the effort they do, and the support they give to their children when some of them have had really difficult diagnoses and multiple surgeries in childhood. Then, suddenly, there’s an expectation that they’ll step back from that, and allow that child to make all the decisions. How you manage that with a parent is really important — for them to understand the importance of giving independence, but also to help their child develop independence. The two mirror each other. And getting that balance right is difficult.

Then there are the clinical challenges.

Many of these patients have had multiple operations — often big reconstructions — so they’re vulnerable to long-term difficulties or complications that can develop. Our work can be similar to a night watchman, looking after patients, surveying them, making sure we’re not missing changes in their renal function or development of bladder complications like stones, how they manage difficult problems like urinary tract infections and supporting them with advice they may need.

A woman who was born with spina bifida (a birth defect that occurs when the spine and spinal cord don’t form properly and can cause bowel and bladder problems) may want to go on and have a family, but there are certain preventative things we need to do for her, advice we need to give her to reduce her risk of having an affected child herself. Many of our patients will go on to have children, and because they’ve had complex reconstruction, we’ll work with the OB/GYN team to make sure that that pregnancy is safe and that the delivery is successful.

Click here to read the complete interview with Wood.

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Surgery News

RESEARCH FINDS PATIENTS AND PROVIDERS DIFFER IN OPINIONS ABOUT IMMEDIATE ACCESS TO MEDICAL RECORDS A 21st Century Cures Act requirement gives patients immediate access to electronic medical records and causes some clinicians to worry about added stress for patients.

Rachel Sauer While both patients and clinicians prioritize information transparency, a 21st Century Cures Act requirement for the immediate release of test and lab results is proving more controversial, according to recently published survey results of clinicians and patients.

The study, published recently in The American Journal of Surgery, found that of the clinicians surveyed, nearly 63% agreed that immediately released results would be more confusing than helpful for patients, whereas about 16% of patients surveyed agreed with that statement.

“I think for clinicians, the concern has been that it’s going to cause stress to patients getting these really complex reports that are not written at a level that’s easy for non-medical professionals to understand,” says 14

Laura Leonard, MD, the study’s primary author and chief resident of quality and safety for the University of Colorado Department of Surgery.

“I’ve called patients back within 20 minutes of receiving their results and they’re already down in the fine print,” adds Sarah Tevis, MD, a study co-author and an assistant professor of surgical oncology. “As clinicians, we may have just received the results ourselves, so we’re not only going through them for the first time, but trying to help patients know where to focus and to know what these results mean for them.”

Studying the impact in real time The 21st Century Cures Act, which became law in 2016, includes a requirement that went into effect in 2021 requiring health care institutions to

release all electronic health information (EHI) to patients immediately.

“We recognized at the time that we had a unique opportunity to study the impact of something as it was happening,” Leonard says, adding that UCHealth, whose patients and clinicians were surveyed, was proactive in working with and preparing clinicians for the change beginning in 2020.

Leonard, Tevis, and the research team designed a voluntary cross-sectional survey to administer via e-mail to clinicians at UCHealth in October 2020. Clinicians who regularly work with oncology patients were invited to participate. A corresponding survey was administered to patients recruited from breast cancer and pancreatic cancer multi-disciplinary clinics and breast radiology patient lists. These www.cusurgery.com

March 2022 participants were specifically selected to represent patients who have had significant experience with testing as well as reviewing test results.

Survey results showed that of those surveyed, about 90% of patients and 81% of clinicians agreed that providing patients with access to their health information is necessary in delivering high-quality care. However, providers were more likely to disagree that patients are comfortable reviewing blood work results, radiology results, and pathology reports on their own.

The survey results also showed that about 75% of patients felt their provider should contact them within 24 hours of the release of abnormal results, whereas 9% of clinicians agreed with that timeframe.

Balancing transparency and patient benefit “For a lot of providers, the concern is that these results can come back at 6 o’clock on a Friday night, at 9 o’clock on Saturday morning,” Tevis explains.

“I’ve had patients whose results came in on Thanksgiving Day. So, as providers, one of the concerns is how to provide the best care to patients while also managing time.

“With my patient whose results came in on Thanksgiving, I was going back and forth with, ‘Do I call my patient?

Do I not call my patient?’ I tend to send a message through the electronic medical records system saying, ‘This looks good for these reasons and I’ll call you tomorrow’ or ‘I’ll call you at an appropriate time’.”

When the transition to immediate release of EHI was announced, Leonard says, many providers expressed concern about the impact it would have on their patients, as well as how they could adjust their workflows so they could call or message their patients right away.

UCHealth has been at the forefront of connecting patients with access to their EHI, led in particular by CT Lin, MD, a professor of internal medicine in the CU School of Medicine. The access and transparency benefits

and empowers patients in their health care, Leonard says, but an area of concern for providers is how to help patients navigate the complex medical terminology and data generally found in lab and test results.

The survey included a section asking patients to define certain medical terms to get a baseline of their understanding, Leonard says, as well as sections asking for their opinions about receiving results and their experience with online portals for medical records.

Understanding patient comfort level Results from the survey offer significant insights into areas of differing expectations between patients and providers, Leonard says. They also can inform institutions and providers in creating resources to support patients in receiving and understanding their EHI. “One of the things that was interesting in the survey is how patients view their comfort with interpreting results compared with how providers view patients’ comfort,” Leonard says.

“In general, patients reported they felt more comfortable interpreting lab results, pathology results, and radiology results than providers felt patients were. So how do we address that disconnect between what providers think patients can do and what patients think patients can do?”

“It’s really hard for anybody – patients, providers, anybody in health care – to determine what’s good information and not good information on the internet.

It can be hard to make your way to reliable resources, especially if you’re now trying to understand complex lab results.”

Creating resources for patients Leonard recently received a quality improvement grant provided through the CU School of Medicine’s Clinical Effectiveness and Patient Safety (CEPS) program to create and pilot educational tools that patients can use while viewing their EHI in the online portal. The goal, Tevis says, is to involve patients in the process of creating these tools.

The survey results also are significant in guiding conversations with providers, Leonard says, who are looking to give patients the best quality of care while also working with them to manage their expectations about when providers contact them about results.

“Based on the survey results, I don’t think provider concerns were coming from a place of not wanting patients to have access to data or not wanting to communicate with patients in a timely way,” Leonard says. “We saw in the comments we received that people who were concerned about this were worried about patient distress and causing undue harm”.

Other areas for further research and “I think for clinicians, the concern resource has been that it’s going to cause development stress to patients getting these really include complex reports that are not written addressing at a level that’s easy for non-medical the digital professionals to understand,” - Leonard divide and supporting patients with less or no access “Nobody felt that patients shouldn’t to devices to view their electronic have the information, they were just records, as well as supporting patient concerned about the immediacy populations with lower health literacy, aspect. They wanted to be able Tevis says. to speak with the patient first or at least have a plan in place for when “Even before the 21st Century Cures they would speak to the patient and Act, it’s been a challenge in health care how they would go through the to support patients who might want to results together.” immediately turn to Google,” Tevis says.

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Surgery News require more pain medication after traumatic injuries and after surgery, but nobody has ever compared this to blood levels of cannabinoids,” Stewart says. “We don’t actually know how cannabis affects postoperative surgical outcomes because right now, there’s conflicting data. There’s some preliminary data that says that it doesn’t make a difference, and there is some preliminary data that shows that it can be detrimental.”

Lamping says the results of the study will be helpful to patients as well as providers.

MEDICAL STUDENT RECEIVES GRANT TO HELP WITH CANNABIS STUDY Emma Lamping awarded $5,000 to support her work comparing postoperative pain medication requirements among cannabis users and nonusers.

Greg Glasgow Emma Lamping, a second-year student at the University of Colorado School of Medicine, has received a $5,000 “Emerging Scientist Award” from the Institute of Cannabis Research in Pueblo, Colorado, for her work on a research study comparing postoperative pain medication requirements and surgical outcomes after major abdominal surgery for the treatment of cancer between daily cannabis users and nonusers of cannabis. The study is led by CU School of Medicine faculty member Camille Stewart, MD, an assistant professor of surgical oncology.

“A lot of states have legalized cannabis use, and many cancer patients use cannabis to help with pain and various other symptoms,” says Lamping, whose role in the research includes identifying patients to enroll, helping with sample collection, and evaluating patients for complications after surgery.

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“There’s no good data to support any benefits or risks that cannabis use might bring to the patient, and with so many people using it, I feel like there should be data so we can actually make recommendations on whether it’s going to possibly benefit them or if it’s something they should consider stopping because of the risks.”

Improving care for cannabis users The study, underway now, will measure circulating blood levels of cannabinoids in cannabis users so that providers can ultimately can give informed recommendations to patients who use cannabis about the risks or benefits of use in the perioperative period. The results of the study also will help inform future research on how cannabis affects surgical patients.

“There is some preliminary data that suggests that cannabis users

“If they need more pain medicine, that’s something that would be good to know, for the patient and for the team taking care of them,” Lamping says. “Or if there are more complications, that’s also something that would be good to be aware of. It will help to improve care for patients who use cannabis.”

A valuable mentorship Lamping was first paired with Stewart through a program that connects medical students with faculty members in the Department of Surgery. Lamping helped out with a melanoma study Stewart was conducting, and the two developed a mentor-mentee relationship that led to Lamping getting involved with the cannabis study as well.

“She is incredibly self-motivated and very hard-working,” Stewart says of Lamping. “Those qualities will make her successful in her research career moving forward.”

Lamping comes to the CU School of Medicine from Montana, where a lifelong love of science and helping others led to her jobs at a nursing home and on a ski patrol unit before she applied to medical school. She is grateful to receive the Institute of Cannabis Research award so early in her career, and is thankful for Stewart’s mentorship and training in good research practices.

Click here to read more about Lamping’s research.

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March 2022

NEW SURGICAL TRAINING TOOL SIGNIFICANTLY IMPROVES RESIDENTS’ ABILITY TO PRACTICE ESSENTIAL SKILLS The low cost and adaptability of the GlobalSurgBox make it a useful tool for residents and students around the world.

Rachel Sauer A tool designed to help surgical trainees practice skills such as knot tying, suturing, vascular and bowel anastomoses, and other techniques has helped eliminate barriers to simulation resources.

The results of a study recently published in Surgery in Practice and Science show that of the 30 general surgery residents surveyed, having access to the GlobalSurgBox significantly improved their ability to practice essential surgical skills.

The GlobalSurgBox was originally envisioned by Yihan Lin, MD, MPH, a cardiothoracic surgery fellow in the University of Colorado School of Medicine Department of Surgery.

“The concept of the GlobalSurgBox originated out of necessity – I needed a way to teach my junior residents how to do certain anastomoses,” Lin explains. “I wanted them to practice beforehand so they could shine in the operating room, but I was having a hard time finding an effective and realistic way to do this in a low-stress environment.”

Designing a resource to learn surgical skills “We have a state-ofthe-art simulation center on campus, but it’s on the other side of the university complex and our residents may not feel like walking over there when they’re working 80 hours a week,” Lin says.

Lin and her colleagues envisioned a more portable and affordable method of simulation. Using a wooden board as the platform for all the surgical exercises and commonly available supplies, they included fishing line and shoelaces to practice knot tying, hair ties for suturing practice, and linear balloons for vascular anastomoses. They organized all the supplies in a 12-inch toolbox for portability, creating the GlobalSurgBox. Lin mentioned the GlobalSurgBox to a friend in Kenya training to be a cardiac surgeon, who was very enthusiastic about also getting one for practice. Soon thereafter, his program director asked for a GlobalSurgBox for every surgical resident in his program.

In May 2021, with a donation from Jay Pal, MD, PhD, an associate professor of cardiothoracic surgery, Lin and a group of colleagues assembled the first 50 GlobalSurgBoxes. The idea was that for every box created for a CU School of Medicine student or resident, participants would create a second box for medical partners in low- or middle-income countries.

Adapting GlobalSurgBox to specific contexts Through several iterations, the GlobalSurgBox has evolved into a training tool that can be assembled with inexpensive, readily available items and adapted to various countries or medical contexts, Lin says.

Yihan Lin, MD, MPH Fellow Cardiothoracic Surgery

“I think it’s important to contextualize it based on what setting you’re working in,” Lin says. “We were just in Rwanda, and they’ve modified the box to be able to practice suprapubic catheterization, which is something we don’t do as general surgery residents here but they need to know how to do in their context.”

As more CU School of Medicine students and residents have participated in making and adapting GlobalSurgBox, some have created a website and instructional videos with skills training. Students have put together a comprehensive guide on how to assemble a box, from links to purchase each of the materials, documents to guide in assembling a GlobalSurgBox, and even templates on how to write grants so that this can be scaled up to other institutions.

This will support students and surgical trainees in countries outside the U.S. to assemble boxes with locally available materials, Lin says.

Click here to learn more about the GlobalSurgBox.

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Surgery News

GRANDMOTHER’S WORLD WAR II EXPERIENCES SHAPES STUDENT’S DECISION TO PURSUE MEDICINE Second-year medical student Rebecca Henkind attributes part of her passion for medicine informed by social justice to the woman she called Oma. Rachel Sauer Rebecca Henkind grew up seeing the example of her grandmother’s volunteer work with people experiencing homelessness – at the Flemington (New Jersey) Area Food Pantry and with Flemington Presbyterian Church’s shelter.

She saw that it was a labor of love for the woman she called Oma, and when she was old enough, she learned why: As a teenager in Amsterdam during World War II, Elisabeth F. Kurz temporarily experienced homelessness after her father died and her Jewish stepmother was sent to and killed in a concentration camp. In the middle of winter, in the middle of war, Elisabeth was on the streets until she was able to find a home with her aunt and cousins.

Henkind grew up with this profound legacy, and it played a significant role in guiding her to working with people experiencing homelessness and, eventually, to medical school.

As a member of the University of Colorado School of Medicine class of 2024, she draws not only from her own experiences but from her grandmother’s in pursuing medical practice guided by humanity and helping hands.

“Whatever path (in medicine) I choose, I know I’ll always want to make sure it’s informed by social justice,” she explains. “It’s easy for people to fall through the cracks or even just to be invisible, and working together within our communities there’s a lot we can do to help.”

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Pursuing opportunities after college Medicine seemed like the obvious path for Henkind, which maybe is why it wasn’t the one she initially chose. Her father is a physician and her mother is a nurse, both grandfathers were ophthalmologists, and an aunt is a pediatrician, so she pursued paths other than medicine as a means of branching out. As an undergraduate at Emory University, she studied economics, math, and Chinese, including two summers at Nanjing University and Beijing Normal University in China. After finishing her degree in an intense three and a half years, and free to consider the future during what otherwise would have been her last semester, she accepted a job as a ski instructor at Vail Ski Resort.

“I had this time where I should have been in school if I hadn’t already graduated, so I wanted to just go do something I really enjoy and see what I was truly interested in and drawn to,” she says.

“I hadn’t really done that in college because college was a set track and the goal was graduating, so I was scouring the internet and trying to envision my life in 10 years. I just kept coming back to medicine.”

She decided to start with an intensive, three-week EMT training course at SOLO Southeast in North Carolina, and returned to Vail working as a full-time medical assistant at Vail Summit Orthopedics and part-time on the

county ambulance with Eagle County Paramedic Services.

“I really enjoyed being an EMT and being a medical assistant, being part of a care team,” she says. “EMTs have set protocols and a set of skills that are in their scope of practice, but there wasn’t always a lot of opportunity for clinical decision making. Physicians do have the ability to make calls, and I realized I wanted to be able to provide a higher level of care.”...

Considering different paths in medicine Now completing her second year of medical school, Henkind says she still is considering which specific path of medicine she’d like to pursue. Working with mentor Kathryn Boyd-Trull, MD, an assistant professor of family medicine, on CU Street Medicine has given her a broad view of general practice, while working with research advisor Catherine Garrison Velopulos, MD, an associate professor of GI, trauma, and endocrine surgery, has expanded her understanding of general surgery. Working with Velopulous, she completed and recently presented research analyzing Centers for Disease Control and Prevention data relating to violent death among people experiencing homelessness.

Click here to read Henkind’s complete story.

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