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Health 3.0: A Discussion about Medicine at the Cutting Edge with the Mayo Clinic's Dr. Nicholas LaRusso

Question: What initiatives are you working on at Mayo?

 

Nicholas LaRusso: We now have active pilot projects testing the ability to provide what we call eConsoles, or virtual consoles, electronically to providers all over the country, primary care providers. We believe that the initial effort should not be directly to patients but the patients to their primary care provider because we think that patients are ultimately going to need a continuous relationship with a team of providers in their own community. That’s a second initiative that we have. It’s something called the Advanced Medical Home where we’re organizing teams of providers to maintain a continuous relationship with patients within their community.

The third initiative, that gets to the genetic profiling, is we’re trying to understand through designer-centered research. This is available commercially. There are three companies out there that will provide you with a genetic analysis if you provide them with the biological specimen, whether it’s a blood sample or a spit sample or a hair sample. We’re trying to find out what do patients expect when they do this, and when they get the information that says they have, based on your genetic profile, 40% increased chance of getting type II diabetes or threefold increase in the chance of getting Alzheimer’s disease. How do they understand that? How does that affect the way they think about their health? What do they do with that information? What do the primary care providers that they may go to with that information, how do they understand it? How does this affect their ability to modify their lifestyle? And so, that will be a third concrete project that we’re engaged in.

 

Question: What is the future of organ transplantation?

 

Nicholas LaRusso: One of the great things about the liver is that it regenerates. So, if you cut half of someone’s liver, it grows back. That’s why we can now not only use cadaver livers, but we can use portions of living donors. It’s entirely possible, and there’s work being done in this area, that in the future a liver transplant will be no more than an injection of a number of cells that will implant somewhere in the body and will grow and form an entire new liver. This is the whole area of stem cell transplantation

Then I think the last area, and this is a fairly controversial area, but I think has great potential, and the background here is, that as you maybe aware, there are many people particularly with liver disease, many more people that need livers than we currently have livers for.

There’s a whole area called xenotransplantation in which the idea is that we would take animals, pigs are currently the preferred animal, and be able to modify them genetically in such a way that a human would not only not reject a pig liver, but that any potential diseases that would be unique to animals would not be able to be contracted by a human. This is a big concern right now.

You can envision 20 years from now everyone who needs a liver having access to one because you walk in to a facility, you take out a pig and you use the pig liver for the patient.

Technical advances, leading to minimally increasingly, minimally evasive surgery, new drugs and ultimately sufficient understanding of the immune system that no drugs would be necessary, the use of cells rather than whole organs, and potentially the use of animal organs--are probably the four areas of the future when it comes to solid organ transplantation.

 

Topic: Apple CEO Steve Jobs’ liver transplant.

 

Nicholas LaRusso: I guess there are at least two aspects to his situation that have caught the public’s attention. One is the whole issue of whether or not someone of his prominence was given special attention in terms of access to a liver. And the other has to do with the indication for his liver transplantation.

With regard to the former, let me say that the distribution system for solid organs has advanced, particularly livers, has advanced tremendously to a more fair and equitable system with the evolution of the MELD system [the Model for End-Stage Liver Disease (MELD) system] of scoring. So, the system allocates organs based generally on the severity of the liver disease. It’s organized on a regional basis.

Some areas of the country have better access to more livers than other areas of the country. According to the press, he got his transplant in Tennessee. Based on what I know, the availabilities of livers in Tennessee might be better than say on either coast. If that was the case, there was nothing inappropriate about that. He was not “gaming” in the system in any way. Many people will have themselves listed in more than one region in an attempt to get access to a liver. That’s how I would comment on that aspect of.

With regards to the indication, again it’s not clear what he--he had a pancreatic tumor. There are number of different kinds of pancreatic tumors. The most common is what’s called an adenocarcinoma of the pancreas, and this is a devastating disease with very poor prognosis that has a five years survival, in general less than 5%. It would be highly, highly unlikely that that was the kind of tumor that he had, or that anyone would consider a liver transplant for that kind of a tumor when the tumor went to the liver. The likelihood is that he had some type of a neuroendocrine tumor, which are generally slow growing tumors. And the likelihood is from what I’ve read that the tumor was receptive but probably had metastasized to the liver, and that was the indication for a liver transplant. In fact, at many centers a transplant for a neuroendocrine tumor that’s metastasized to the liver is considered appropriate.

 

Question: How should healthcare be overhauled?

 

Nicholas LaRusso: Our new president [Barack Obama] has identified as one of his three major areas of attention, health care which by the way I personally applaud and Mayo has worked through its health policy institute to articulate the four pillars that are necessary for transforming healthcare. Those 4 pillars then provide the environment with which the Center for Innovation, and innovation across the country in health care delivery can evolve.

Those pillars are pretty simple. Conceptually, they include creating value, coordinating care, restructuring the payment system, and providing universal access. Those are the four pillars.

For the innovations that we envision helping to catalyze through our Center activities, to be maximally effective, there needs to be policy changes that address those four areas. Care coordination, value, payment reform and universal access.

 

Topic: An example of healthcare reform.

 

Nicholas LaRusso: If you’re in charge of a delivery system, and you’re being reimbursed because of the quality or value of the care that you provide, and because of the coordination that you provide, rather than on the number of tests that are done, then that provides a whole different set of incentives for you to reorganize the way you deliver health care.

This gets back to one of the four pillars of our policy initiative, and that is payment reform. Right now the payment system results in just what you expected it to do. That is, if people get paid because they do a lot of stuff, they’re going to keep doing more and more stuff to get more and more pay. But if you pay people for the quality of what they deliver, and you define quality or value, and you have metrics for value, and you make those metrics publicly available so the consumer knows where to go to get the highest value care, and you coordinate things.

 

Question: How can hospitals improve health outcomes?

 

Nicholas LaRusso: Increasingly we’re going to have a much more demanding set of consumers in health care. That’s going to result in, and that’s the good thing, that’s going to result in the need for us to be able to make transparent to them the concrete outcomes of what it is we’re providing.

For example, if a patient needs a liver transplant, they’re going to be able to go online and find out who does the most transplants? Who does the most transplants from my particular condition? What they should be able to find out is, what’s the approximate range of cost? And what’s the likelihood that I’m going to get out of the hospital in a week, two weeks, three weeks? How many patients that have this kind of a transplant need another operation?

These are the outcomes that we have to be accountable for, and that we need to make transparent to the public. I think that’s the right thing to do.

If we believe, and we do at Mayo, the Mayo mantra which is the needs of the patient come first. They have to be fully informed and we have to be held accountable for the outcomes of the things that we do.

 

Recorded on: June 24, 2009.

 

 

 

A conversation with Professor of Medicine at Mayo Medical School, and Medical Director of the Center for Innovation at Mayo Clinic.

The “new normal” paradox: What COVID-19 has revealed about higher education

Higher education faces challenges that are unlike any other industry. What path will ASU, and universities like ASU, take in a post-COVID world?

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Sponsored by Charles Koch Foundation
  • Everywhere you turn, the idea that coronavirus has brought on a "new normal" is present and true. But for higher education, COVID-19 exposes a long list of pernicious old problems more than it presents new problems.
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A massive star has mysteriously vanished, confusing astronomers

A gigantic star makes off during an eight-year gap in observations.

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  • The massive star in the Kinsman Dwarf Galaxy seems to have disappeared between 2011 and 2019.
  • It's likely that it erupted, but could it have collapsed into a black hole without a supernova?
  • Maybe it's still there, but much less luminous and/or covered by dust.

A "very massive star" in the Kinman Dwarf galaxy caught the attention of astronomers in the early years of the 2000s: It seemed to be reaching a late-ish chapter in its life story and offered a rare chance to observe the death of a large star in a region low in metallicity. However, by the time scientists had the chance to turn the European Southern Observatory's (ESO) Very Large Telescope (VLT) in Paranal, Chile back around to it in 2019 — it's not a slow-turner, just an in-demand device — it was utterly gone without a trace. But how?

The two leading theories about what happened are that either it's still there, still erupting its way through its death throes, with less luminosity and perhaps obscured by dust, or it just up and collapsed into a black hole without going through a supernova stage. "If true, this would be the first direct detection of such a monster star ending its life in this manner," says Andrew Allan of Trinity College Dublin, Ireland, leader of the observation team whose study is published in Monthly Notices of the Royal Astronomical Society.

So, em...

Between astronomers' last look in 2011 and 2019 is a large enough interval of time for something to happen. Not that 2001 (when it was first observed) or 2019 have much meaning, since we're always watching the past out there and the Kinman Dwarf Galaxy is 75 million light years away. We often think of cosmic events as slow-moving phenomena because so often their follow-on effects are massive and unfold to us over time. But things happen just as fast big as small. The number of things that happened in the first 10 millionth of a trillionth of a trillionth of a trillionth of a second after the Big Bang, for example, is insane.

In any event, the Kinsman Dwarf Galaxy, or PHL 293B, is far way, too far for astronomers to directly observe its stars. Their presence can be inferred from spectroscopic signatures — specifically, PHL 293B between 2001 and 2011 consistently featured strong signatures of hydrogen that indicated the presence of a massive "luminous blue variable" (LBV) star about 2.5 times more brilliant than our Sun. Astronomers suspect that some very large stars may spend their final years as LBVs.

Though LBVs are known to experience radical shifts in spectra and brightness, they reliably leave specific traces that help confirm their ongoing presence. In 2019 the hydrogen signatures, and such traces, were gone. Allan says, "It would be highly unusual for such a massive star to disappear without producing a bright supernova explosion."

The Kinsman Dwarf Galaxy, or PHL 293B, is one of the most metal-poor galaxies known. Explosive, massive, Wolf-Rayet stars are seldom seen in such environments — NASA refers to such stars as those that "live fast, die hard." Red supergiants are also rare to low Z environments. The now-missing star was looked to as a rare opportunity to observe a massive star's late stages in such an environment.

Celestial sleuthing

In August 2019, the team pointed the four eight-meter telescopes of ESO's ESPRESSO array simultaneously toward the LBV's former location: nothing. They also gave the VLT's X-shooter instrument a shot a few months later: also nothing.

Still pursuing the missing star, the scientists acquired access to older data for comparison to what they already felt they knew. "The ESO Science Archive Facility enabled us to find and use data of the same object obtained in 2002 and 2009," says Andrea Mehner, an ESO staff member who worked on the study. "The comparison of the 2002 high-resolution UVES spectra with our observations obtained in 2019 with ESO's newest high-resolution spectrograph ESPRESSO was especially revealing, from both an astronomical and an instrumentation point of view."

Examination of this data suggested that the LBV may have indeed been winding up to a grand final sometime after 2011.

Team member Jose Groh, also of Trinity College, says "We may have detected one of the most massive stars of the local Universe going gently into the night. Our discovery would not have been made without using the powerful ESO 8-meter telescopes, their unique instrumentation, and the prompt access to those capabilities following the recent agreement of Ireland to join ESO."

Combining the 2019 data with contemporaneous Hubble Space Telescope (HST) imagery leaves the authors of the reports with the sense that "the LBV was in an eruptive state at least between 2001 and 2011, which then ended, and may have been followed by a collapse into a massive BH without the production of an SN. This scenario is consistent with the available HST and ground-based photometry."

Or...

A star collapsing into a black hole without a supernova would be a rare event, and that argues against the idea. The paper also notes that we may simply have missed the star's supernova during the eight-year observation gap.

LBVs are known to be highly unstable, so the star dropping to a state of less luminosity or producing a dust cover would be much more in the realm of expected behavior.

Says the paper: "A combination of a slightly reduced luminosity and a thick dusty shell could result in the star being obscured. While the lack of variability between the 2009 and 2019 near-infrared continuum from our X-shooter spectra eliminates the possibility of formation of hot dust (⪆1500 K), mid-infrared observations are necessary to rule out a slowly expanding cooler dust shell."

The authors of the report are pretty confident the star experienced a dramatic eruption after 2011. Beyond that, though:

"Based on our observations and models, we suggest that PHL 293B hosted an LBV with an eruption that ended sometime after 2011. This could have been followed by
(1) a surviving star or
(2) a collapse of the LBV to a BH [black hole] without the production of a bright SN, but possibly with a weak transient."

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