MN Healthcare News October 2016 by Minnesota Physician Publishing

October 2016 â&#x20AC;˘ Vol 14 Number 10

Broken bones By Kevin Lindgren, MD

Osteoporosis By Maja Visekruna, MD, CCD

Postpartum depression By Tessa Wetjen, MPA

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CONTENTS

4 7 8

OCTOBER 2016 • VOLUME 14 • NO. 10

NEWS

PEOPLE

PERSPECTIVE Parkinson’s disease A life-changing diagnosis

MINNESOTA HEALTH CARE ROUNDTABLE

HEALTH INSURANCE Understanding your coverage Cutting through confusion

FORTY-SIXTH SESSION

By Monica Engel

18 20

Value - Based Reimbursement:

CALENDAR

WOMEN’S HEALTH

A new way to pay for health care

Postpartum depression Much more than the “Baby Blues” By Tessa Wetjen, MPA

Okeanis Vaou, MD

10 QUESTIONS Orthomolecular medicine

CHRONIC DISEASE Osteoporosis A silent disease By Maja Visekruna, MD, CCD

GASTROENTEROLOGY Gallbladder disorders Diagnosis and treatment By Federico T. Rossi, MD

Joan Mathews-Larson, PhD

ORTHOPEDICS Broken bones Healing from fractures

A look at Hillary Clinton’s and Donald Trump’s health care policies

Peanut allergies A dangerous medical condition By Nancy Ott, MD, FAAP, FAAAAI

By Kevin Lindgren, MD

THE 2016 PRESIDENTIAL RACE

NUTRITION

PHARMACOLOGY “Off-label” drug use What you should know By Lowell Anderson, DSc, FAPhA

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Thursday, 2016 • • 1:00-4:00 1:00-4:00 PM PM Thursday, November November 3, 3, 2016

The Minneapolis Hilton Hilton and and Towers Towers The Gallery Gallery (lobby (lobby level), level), Downtown Downtown Minneapolis Background driven by by federal federal health health care care reform reform Background and and Focus: Focus: As As initiatives initiatives driven move forward, the term “Value-Based Reimbursement” (VBR) is being move forward, the term “Value-Based Reimbursement” (VBR) is being applied But what what does does this this mean? mean? CMS CMS is is applied to to aa wide wide spectrum spectrum of of issues. issues. But developing to date, date, to to define define what what “value” “value” developing measurements, measurements, well well over over 150 150 to means these metrics metrics will will be be used used to to means in in health health care. care. ItIt is is proposed proposed that that these create care in in every every element element of of health health create incentives incentives that that pay pay more more for for better better care care home care, care, and and long-term long-term care delivery. delivery. Hospitals, Hospitals, physician physician practices, practices, home care new math. math. care will will all all be be reimbursed reimbursed by by an an emerging emerging new

Objectives: We will explore the motivations behind this changing Objectives: We will explore the motivations behind this changing approach to purchasing health care. We will examine what is being approach to purchasing health care. We will examine what is being measured and what value really means. We will discuss the arguments measured and what value really means. We will discuss the arguments that claim VBR is a bad idea and those that believe it is the best solution. that claim VBR is a bad idea and those that believe it is the best solution. We will discuss how a collaborative, transparent system, that integrates We will discuss how a collaborative, transparent system, that integrates care teams, health information technology and improved reimbursement care teams, health information technology and improved reimbursement methods will help achieve increased access to high-quality, cost-effective methods will help achieve increased access to high-quality, cost-effective care for patients. care for patients. Panelists include: • Don Flott, Director of Utilization and Integration Panelists include: • Don Flott, Director of Utilization and Integration Services, Mayo Medical Laboratories • Allison LaValley, MBA, Executive Services,athenahealth Mayo Medical Allison LaValley, Executive Director, • Laboratories David Melloh,• JD, Chair, Health MBA, Law Practice Director, • DavidLLP Melloh, Chair, Health Practice • RossJD, D’Emanuele, JD,Law Co-Chair, Group at athenahealth Lindquist & Vennum • Ross JD,Lisa Co-Chair, Group Care at Lindquist & Group VennumatLLP Health Industry Dorsey & D’Emanuele, Whitney LLP • Simm, MBA, Health Care Industry Group at Dorsey & Whitney LLP • Lisa Simm, MBA, Manager of Risk Management, Coverys Manager of Risk Management, Coverys Sponsors include: • athenahealth • Lindquist & Vennum LLP include:Laboratories • athenahealth • Lindquist & Vennum LLP & Whitney LLP • Coverys •Sponsors Mayo Medical • Dorsey • Mayo Medical Laboratories • Dorsey & Whitney LLP • Coverys

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OCTOBER 2016 MINNESOTA HEALTH CARE NEWS

NEWS

MNsure Names In-Person Enrollment Centers

North Memorial Opens First Pediatric Clinic

North Memorial Health Care has opened its first pediatric clinic in its MNsure has announced that North Memorial Health Care Med21 health insurance agencies across ical Office Building at Maple Grove Minnesota will serve as broker enHospital. It has five pediatricians on rollment centers for the 2017 open staff and offers urgent care services enrollment period, which begins and easy access to acute pediatric Nov. 1, 2016, and ends on Jan. 31, hospital care at the hospital. 2017. They will provide and staff “Through our partnership with walk-in sites for residents of their the University of Minnesota Masonic communities. Children’s Hospital, children receive “Free support from brokers, li- expert care from hospital-based pedicensed insurance professionals cer- atricians and bridge communications tified by MNsure, is available,” said with primary care physicians when Bob Davy, broker coordinator that they’re admitted,” said Andy Cooversees MNsure’s broker enroll- chrane, CEO of Maple Grove Hospital. ment program. “Many people have a negative perception of the insurance industry and brokers. However, MNsure-certified brokers can help Minnesotans find an insurance plan that best fits their needs, all at no adThere was a 6 percent increase in ditional cost.” suicide deaths reported in Minnesota Twenty broker enrollment cen- from 2014 to 2015, according to new ters enrolled more than 4,200 Min- data from the Minnesota Department nesotans into health insurance plans of Health. The rate in 2015 was 13.1 through MNsure in the 2016 open per year per 100,000 Minnesotans, up from 12.2 in 2014. Before that, enrollment period.

Minnesota Suicide Rates Rise

the highest rate was 13 per 100,000 progress in preventing youth suicide. in 1986 (541 deaths). The data also We must focus on helping adult men show that firearms continue to be the and others find hope and help.” leading method of suicide. The number of suicides fell for “This alarming rise in the Minnesotans under the age of 25 (from number of suicides in Minnesota 119 in 2014 to 114 in 2015). However, reinforces for us the need for a con- annual suicide rates have been trending tinuum of mental health care in our upward nationally and in Minnesota communities—so that people can get since an all-time low in Minnesota of help when they need it,” said Emily 8.9 per 100,000 in the year 2000. Piper, Minnesota Department of Among American Indians and Human Services commissioner. “Let Minnesotans ages 45 to 64, rates us never forget that this is not about stayed steady from 2014 to 2015— statistics; each and every one of these both groups had been identified as 726 deaths is someone’s friend, rela- at-risk in the Minnesota State Suicide tive, and neighbor. We need to work Prevention Plan. together by focusing on prevention.” A key goal in Minnesota’s prevenThe increase from 2014 to 2015 was tion efforts for the 2015–2020 state driven by suicides among men, which suicide prevention plan is to assist increased to 20.5 per 100,000 in 2015, health care professionals and others while the rate among women stayed to identify individuals at risk for suisteady at 5.9 per 100,000. Half of the cidal behavior, assess them, and refer increase in suicides from 2014 to 2015 them to treatments, including those occurred among white men ages 25 to 34. for underlying conditions like mental “Today’s news clarifies that we illnesses and substance abuse. must do more to support and connect with those who are suffering and contemplating suicide,” said Ed Ehlinger, MD, Minnesota commissioner of health. “We know suicides are preventable. We have seen

TBD

MINNESOTA HEALTH CARE NEWS OCTOBER 2016

“More training of healthcare professionals and community members along with follow-up care is important in preventing suicide,” said Dan Reidenberg, PsyD, executive director of SAVE (Suicide Awareness Voices of Education).

Minneapolis VA Opens Surgery Center

Mississippi, and West Virginia. Louisiana had the highest rate at 36.2 percent. The lowest rates were found in the West (25.2 percent), followed The Minneapolis Veterans Afby the Northeast (26.4 percent), and fairs Health Care System opened the Midwest (30.7 percent). Colorado a new, 28-bed surgery center on its had the lowest rate at 20.2 percent. campus on Sept. 6. The adult obesity rate in MinneThe new center has expanded to sota had held steady since SHIP was more than 7,000 square feet of paenacted in 2008, until it rose from tient care space and has 17 additional 25.5 percent in 2013 to 27.6 percent private pre-procedure and post-proin 2014. SHIP spends about $17.5 cedure patient rooms. It also has admillion each year to fund grants and ditional space for special procedures, support local community partners physician consults, equipment storacross the state to expand healthy age, and staff work areas. eating habits and active living opThe health care system also re- portunities, as well as with tobacco cently completed a satellite outpa- prevention efforts. tient pharmacy, though an opening The CDC’s report includes date is still pending. The surgery 2015 state- and territory-specific center will support the current 18 opdata on adult obesity prevalence. erating rooms in addition to the two It used self-reported data from the hybrid operating rooms scheduled to Behavioral Risk Factor Surveillance open in January 2017. System. Every state showed an adult obesity rate of at least 20 percent.

Minnesota’s Obesity Rate Drops, Remains Lowest in Region The adult obesity rate in Minnesota shows a statistically significant drop from 2014 to 2015, according to new data released from the Centers for Disease Control and Prevention (CDC). The rate fell from 27.6 percent in 2014 to 26.1 percent in 2015. Other states in the region, which includes North Dakota, South Dakota, Wisconsin, and Iowa, all had adult obesity rates above 30 percent, with rates ranging from 30.7 percent to 32.1 percent. “Minnesota’s obesity rate is markedly lower than our surrounding states and we were still able to achieve a greater decrease in 2015 than our neighboring states,” said Ed Ehlinger, MD, Minnesota commissioner of health. “Achieving healthy weight for all Minnesotans is one of the key objectives for our Statewide Health Improvement Program (SHIP) and its community and private sector partners. By working together we’ve been able to increase opportunities for healthy eating and physical activity for all Minnesotans in every corner of the state.” The South showed the highest adult obesity rates. Four states in the region had obesity rates of at least 35 percent—Alabama, Louisiana,

Children’s, UMN to Connect Food Insecure Families with Resources Children’s Minnesota, the University of Minnesota, and Hennepin County Medical Center are partnering on a study to explore a new approach for connecting families experiencing food insecurity with food and nutrition resources. The study is being funded through a $200,000 Child Health Collaborative Grant Award, which supports research collaboration between the University of Minnesota and Children’s to address unmet child health issues. “Food insecurity has been linked with poor dietary outcomes, which lead to a higher burden of chronic health conditions like obesity and diabetes,” said Caitlin Caspi, ScD, assistant professor in the University of Minnesota’s department of family medicine and community health and lead researcher on the project. “This grant will help us find better ways to connect households experiencing food insecurity with food and nutrition resources in the community.” “The same factors that increase risk for food insecurity in children— such as poverty, public insurance, and low parental education—are also News to page 6 OCTOBER 2016 MINNESOTA HEALTH CARE NEWS

News from page 5

Nutrition Assistance Program (SNAP), the Special Supplemental Nuassociated with higher emergency de- trition Program for Women, Infants, partment utilization,” said Gretchen and Children (WIC), community food Cutler, PhD, MPH, program director shelves, and feeding programs. of emergency department research at “This research project—through Children’s Minnesota. “The majority funding from this unique collaboof patients at Children’s emergency rative grant program—will create a departments come from low-income partnership between the largest profamilies and include many immigrants viders of pediatric care in Minnesota, and refugees, who bear a disproporand ultimately may produce a model tionate burden of food insecurity.” to help improve care and outcomes First, the research team will iden- for food insecure Minnesotans across tify food insecure families through a every health care setting in the state,” two-question screening that will be said Mark Schleiss, MD, University incorporated into the Electronic Med- of Minnesota Child Health Collabical Record as part of patients’ care in orative Grant Award program lead the pediatric emergency departments and professor and director of the diof Children’s Minnesota’s St. Paul and vision of pediatric infectious disease Minneapolis locations. They will then and immunologist in the pediatrics test through a randomized controlled department at the University of Mintrial whether a text messaging-based nesota Medical School. system focused on improving connection to community resources helps improve satisfaction with medical care, reduce emergency department readmissions, and decrease the level of food insecurity among the families. The text messages would include information about resources HealthPartners has joined the such as Bridge to Benefits, the Min- Campaign for Sustainable Rx Pricnesota Food HelpLine, Supplemental ing, a coalition of organizations

HealthPartners Joins Campaign to End Rising Prescription Costs

MINNESOTA HEALTH CARE NEWS OCTOBER 2016

working to curb rising prescription drug prices. It is a project of the National Coalition on Health Care consisting of members such as hospitals, physicians, nurses, consumers, health plans, pharmacists, and employers.

campaign recently; HealthPartners is an ACHP member.

“Sustainable drug pricing is crucial to the mission of ACHP plans to provide the best care to their members,” said Ceci Connolly, president The campaign is asking drug and CEO of ACHP. “We look forcompanies for transparency (report- ward to working with the Campaign ing how much it costs to make a med- to ensure affordable care for all.” ication); competition (making generic drugs more available); and value (showing that new drugs are better than medications already available). “Medications help people live longer, better lives, and we want everyone to benefit from them,” said Mary Brainerd, president and CEO of HealthPartners. “But that can’t happen if people can’t afford them. And today, rising drug prices are the main cause of rising health care costs. This can’t continue. This campaign is about creating a prescription drug market so that it benefits all stakeholders. As an organization serving millions of patients and health plan members, we are eager to strengthen our partnerships with other groups to achieve this goal.”

Choices Psychotherapy Adds Chanhassen Location

Choices Psychotherapy opened a new location in Chanhassen on Aug. 22. The location is its second in the metro area—Susan Davis, owner and executive director of Choices Psychotherapy, opened its St. Louis Park location in 1993. A ribbon cutting ceremony was held at the clinic on Sept. 22.

“Since our founding, we have seen an increased interest in psychotherapy and therapy-based psychiatry among the general public and are pleased to see more people taking advantage of the benefits therapeutic counseling The Alliance of Commu- brings to whole person health and innity Health Plans also joined the dividual resilience,” said Davis.

PEOPLE LAUREL HOFF, director of Anoka County Community Health and Environmental Services, received the Jim Parker Leadership Award from the Minnesota Department of Health and the State Community Health Services Committee for her commitment to public health and leadership in improving public health in Minnesota. She was Laurel Hoff one of seven individuals to receive a Community Health Award at the annual Community Health Conference. Hoff has spent 38 years working in the field of public health, including leading two local health agencies. She previously served as Anoka County’s director of public health nursing. ROBERT SLOAN, MD, has joined Hennepin County Medical Center as a staff physician in the Physical Medicine and Rehabilitation Division with a special expertise in spine and back injuries. He also cares for patients with traumatic brain injuries. Sloan’s special interests include spine care and scoliosis; sports medicine, including Robert Sloan, performance arts such as musicians and dancers; MD and concussion evaluation and care. He has spoken extensively on concussions and was a founding member of the Hawaii State Traumatic Brain Injury Advisory Board for the Department of Health. Sloan graduated from the University of California, Davis, School of Medicine in Sacramento where he also completed a residency in physical medicine and rehabilitation. EILEEN KERN, health services supervisor at Bloomington Public Schools, has been selected as the Minnesota School Nurse Administrator of the Year by the School Nurse Organization of Minnesota. Kern has been with Bloomington Public Schools for the past 10 years, including five years as a licensed school nurse and the most Eileen Kern recent five years as health services supervisor. In her current role, Kern is responsible for the health policies, procedures, and guidelines for the district, as well as leading and supporting health services personnel at all Bloomington schools. QAMAR SAADIQ SAOUD, youth and administrative engagement specialist at Reclaim, has received the 2016 Virginia McKnight Binger Unsung Hero Award from the McKnight Foundation and the Minnesota Council of Nonprofits for doing life-changing work in communities across Minnesota with little or no recognition. He is Qamar Saadiq a tireless advocate for transgender youth in the Saoud Twin Cities—especially those who are homeless, as he once was. Saoud is a certified mediator and a part-time student working to become a licensed therapist to help at-risk youth find safe harbor through the GLBT Host Home Program, Avenues for Homeless Youth, Reclaim, and several other organizations.

OCTOBER 2016 MINNESOTA HEALTH CARE NEWS

PERSPECTIVE

Parkinson’s disease A life-changing diagnosis

arkinson’s disease (PD) is a progressive disease of the brain cells that produce dopamine, a chemical messenger that helps cells communicate and promotes normal movement, coordination, and balance. This shortage of dopamine is what causes the motor symptoms seen in people with Parkinson’s disease. PD affects 1 million people in the U.S., a number that is expected to double by 2030. While there is no cure, there is relief in the form of medications and treatment. Unfortunately, many people have misconceptions about the motor symptoms of Parkinson’s disease, the effectiveness of common medications, and the similarities between PD and other diseases.

Okeanis Vaou, MD Noran Neurological Clinic Dr. Vaou is a neurologist with the Noran Neurological Clinic. She is board-certified in neurology and sleep medicine, with a special interest in movement disorders. She has served separate fellowships in movement disorders and sleep disorders at Boston University Medical Center. Her clinical interests include Parkinson’s disease, dystonias, autonomic nervous system disorders, essential tremor, and sleep-related disorders. Dr. Vaou is medical director of the Minnesota chapter of the American Parkinson’s Disease Association and a member of the National Parkinson Foundation Minnesota’s Clinical Advisory Board.

Age

One common misconception is that PD is a disease of the elderly. While the average age of onset is 60, patients as young as four have also been diagnosed, and it can strike at any age. When it begins at ages 21–40, it is termed “young-onset Parkinson’s disease.”

Motor and non-motor symptoms

Many people associate Parkinson’s disease with tremor at rest, slow movements, stiff muscles, and poor balance. While these are the cardinal motor symptoms, they are just the tip of the symptom iceberg. Non-motor symptoms (NMS) also have an impact on the patient’s quality of life. Certain non-motor symptoms appear prior to the onset of motor symptoms, and are considered by some to mark early stages of PD. These include a decreased sense of smell, dream enactment, constipation, urinary urgency, erectile dysfunction, depression, anxiety, and apathy. Other non-motor symptoms may be seen at any stage of the disease: low blood pressure, lightheadedness, urinary frequency, memory problems, hallucinations, visual problems, drooling, pain, sleep problems, fatigue and excessive daytime sleepiness, and abdominal bloating. Neuropsychiatric symptoms, such as an inability to experience pleasure and a lack of positive emotional responses, apathy, memory complaints, and inattention, are seen close to the onset of motor symptoms. The risk of Parkinson’s may be higher among otherwise healthy individuals reporting these non-motor symptoms: smell loss, taste loss, constipation, dream-enacting behavior, frequent nightmares, and chest pain. The risk is especially high among those who report smell loss, constipation, and dream-enacting behavior in combination with other symptoms.

Dementia

Some people believe that all Parkinson’s disease patients suffer dementia, while others confuse PD with Alzheimer’s disease. Dementia is seen in 30–50 percent of Parkinson’s patients, typically around 10 years after the onset of motor symptoms. Old age, the long duration of the disease, declining motor disability, and depression all increase the risk of dementia, and poor balance and gait disorder may well be more predictive of dementia than the tremor-predominant form of Parkinson’s disease.

MINNESOTA HEALTH CARE NEWS OCTOBER 2016

Many common forms of cognitive impairment and dementia seen in Parkinson’s disease differ from those seen in Alzheimer’s disease. These include difficulty with memory, difficulty learning new information, impairment in executive functions, visuospatial skills, and free-recall memory. The association between Parkinson-like symptoms and dementia is a common and confusing problem, in part because some PD patients also have other types of dementia such as Lewy body dementia, frontotemporal dementia, and vascular dementia.

Treatment

Other misconceptions involve medications for Parkinson’s disease. While they do not cure or slow the progression of PD, many medications will help to control motor symptoms, especially in the early stages. As the disease progresses, these drugs seem to provide less

Regular exercise is the most effective way to delay progression of Parkinson’s disease.

effective symptom control—not because the patient has developed a tolerance to the medication, but because steadily decreasing dopamine levels require increased doses to achieve the same level of control. When medication alone cannot provide relief and daily activities become a challenge, deep brain stimulation (DBS) may provide relief. DBS helps control motor symptoms by using a fully implantable device that provides electrical stimulation in a targeted area of the brain. When combined with medication, patients enjoy hours of additional good movement control. The Food and Drug Administration has approved DBS treatment for people who have had Parkinson’s disease for at least four years, with at least four months of movement symptoms not well controlled by medications, or with medication side effects such as unintended dance-like movements (dyskinesia). For many patients, medication can be reduced. Regular exercise is the most effective way to delay progression of Parkinson’s disease.

Summary

A diagnosis of Parkinson’s disease is a life-changing event, but should not be thought of as a “death sentence.” Although every patient displays a different range of symptoms and a different rate of progression, optimal treatment with medication, regular exercise, and deep brain stimulation when indicated can provide a good quality of life with adequate symptom control for many years to come.

OCTOBER 15, 2016

9am – 3pm

Minneapolis Convention Center 1301 2 Avenue South, Hall E Minneapolis, MN 55403 nd

Learn how to be healthy, active and live well with diabetes Make Healthy Food Choices

• Cooking demonstrations • Healthy food sampling • Tasty and healthful recipes

Get Active

• Learn how to work fitness into your everyday life • Fitness demonstrations • Exercise tips

Free Health Screenings • • • • • • • • •

A1C Stroke Risk Assessments Blood Pressure Foot Screenings Diabetes Risk Assessments Eye Screenings BMI (body mass index) Oral Cancer Screenings Kidney Screenings

Ask the Expert

Come prepared with questions for health care professionals who can answer your diabetes questions one-on-one. Learn more about how to manage diabetes and prevent devastating complications.

Family Fun

Interactive entertainment for the whole family.

Faces of Diabetes

Look for areas within the exhibit hall featuring information tailored to meet the specific needs of you and your family.

Visit diabetes.org/expominneapolis to print a FREE Metro Transit pass to the event! Follow us for updates at: Facebook.com/ADA.Minnesota • Twitter: @DiabetesMN

For more info or to preregister: diabetes.org/expominneapolis or call 1-888-DIABETES ext 6592

OCTOBER 2016 MINNESOTA HEALTH CARE NEWS

10 QUESTIONS

Orthomolecular medicine JOAN MATHEWS-LARSON, PHD, is founder and executive director

of the Health Recovery Center, which follows a psychobiological model for treating addictions and emotional disorders. She holds a doctorate in human nutrition.

What is orthomolecular medicine? rthomolecular medicine is the practice of healing by providing substances that empower life. The term “orthomolecular medicine” was coined by two-time Nobel Laureate Dr. Linus Pauling, who formally defined it as “establishing the right molecules in the brain and body by varying the concentration of substances normally present and required for optimum health.” His definition specifically excludes drugs (pharmaceutical or otherwise). Drugs are not molecules that support life. They are not normally present in our systems and required for optimum health.

How was this therapeutic model developed? Orthomolecular medicine is an ex tension of Hippocrates’ ancient dictum: “Let food be thy medicine.” It calls for high concentrations of the same molecules that nature incorporates in the blueprint of life and the foods that sustain us. These life-giving molecules were mostly unknown until the start of the 20th century. Technological advancements in food processing brought an understanding of many unique molecules found in food (e.g., vitamins, minerals, amino acids, essential fatty acids, etc.). Refining food reveals how extracting key nutrients from food promotes diseases like pellagra and BeriBeri. Orthomolecular medicine concentrates (rather than drains) high doses of lifegiving molecules, providing tremendous support in reversing the progression of diseases. What kinds of conditions are best suited for treatment by orthomolecular medicine? Orthomolecular medicine states that diseases are based on nutrient deficiencies or the accumulation of toxic substances affecting metabolic functions in cells. This suggests that all diseases can be slowed and reversed with proper orthomolecular treatment. Orthomolecular means “correct molecules,” the substances life uses to build the essential metabolites required to support life. The art of orthomolecular medicine is a practice of working with those substances in synergistic combinations appropriate to reverse different diseases. As science learns more about the blueprint of life, the role of orthomolecular substances (in regards to the immune system, digestive system, cardiovascular system, endocrine system, and nervous system) becomes more obvious and universally appropriate for the treatment of all diseases.

MINNESOTA HEALTH CARE NEWS OCTOBER 2016

What are some of the reasons orthomolecular medicine is not practiced more widely? Hugh Riordan, MD, one of the founders of the nutrition-based Riordan Clinic, once said that “orthomolecular medicine is not the answer to any question posed in medical school.” His statement challenges us to recognize the limitations medical schools now impose on students in order to promote pharmaceutical interests. Drugs should be understood as toximolecular concoctions, or more specifically, as toxic poisons prescribed in sub-lethal doses. Over time they will short-circuit body systems, diminish your ability to enjoy life, and shorten it. By contrast, orthomolecular medicine reveals how generous amounts of the molecules that life thrives on offer tremendous support in healing and stabilizing people with diseases. Therein lies modern medicine’s failure, according to orthomolecular medicine: the brain and body cannot be restored by loading foreign chemicals (drugs) that offer no support to metabolic systems; only through orthomolecular practice can health be achieved. How does orthomolecular medicine incorporate behavioral health therapy? To quote Dr. Pauling: “The mind is a manifestation of the molecular structure of the brain itself”; therefore, it responds to biochemical repair. Behavior therapy hopes to fix the physical brain by talking to it with good advice. The return to drug and alcohol use one year after a behavioral therapy approach can be as high 90 percent, but is much lower three years after biochemical treatment. Please tell us about studies that support the efficacy of this therapeutic model. Based on his double-blind, placebo-controlled studies in the 1950s, Abram Hoffer, MD, PhD, published papers citing vitamin B-3 as a cure for schizophrenia, a disease and syndrome with biochemical origins that has the hallmarks of debilitating perceptual disorders and thought disturbances. Dr. Hoffer’s study on schizophrenia is just one of several performed by orthomolecular scientists. Some of the studies that helped shape our program at the Health Recovery Center (HRC) include those targeting hypoglycemia, pyroluria, histamine, candida, heavy metals, and hormonal imbalances.

What kind of training is required to practice orthomolecular medicine? The practice of orthomolecular medicine does not depend on medical knowledge, but rather, supports a reasoning of how life works. The best orthomolecular practitioners are those who are curious enough to search for the inexhaustible intricacies found in the blueprint of life. However, at any level, the practice of orthomolecular medicine is generally safe; after

photo credit: Greg Christensen

all, it uses the chemicals that life thrives on, not toxic poisons. The beauty of using the real molecules that support life, instead of toximolecular counterparts, is that they do no harm.

How does the orthomolecular model for treating substance abuse differ from other models? The most significant feature of treating substance abuse with an orthomolecular approach is that you’re treating/correcting the underlying cause of the addiction (i.e., the biochemical distortion itself), not just providing therapy or drugs in an attempt to manage the symptoms. How do you measure recovery rates? Historically, conventional treatment programs have measured recovery rates by the length of time abstinence is maintained. A person’s state of mind or well-being while abstinent was not considered relevant, since improvement was unattainable without biochemical repair. Pharmaceutical companies tried to fill this void using drugs; however, any mental improvement was short-term, followed by disastrous consequences (i.e. addiction, side effects, and withdrawal symptoms). However, an orthomolecular clinic like HRC delivers well-being as well as abstinence. “Alcoholism Treatment with Biochemical Restoration as a Major Component,” a peer-reviewed article appearing in the International Journal of Biosocial Research, states that 84 percent of clients reported alcohol cravings upon entry to the HRC; upon discharge, those cravings were reported at a rate of 9 percent. Other rates reported in the

article (the first number refers to reported symptoms upon entry, while the second refers to reported symptoms upon discharge): irritability (74%/18%); chronic fatigue (77%/15%), magnifying insignificant events (75%/11%); reduced initiative (79%/5%); headaches (51%/5%); poor memory (69%/11%); crying easily (42%/4%); mood swings (70%/5%); tremors, shakes (44%/2%); dizziness (53%/4%); depression (61%/5%); insomnia (44%/6%); fearfulness, anxiety (64%/11%); exhaustion (67%/3%); and physical weakness (44%/2%). Overall the average rate of abstinence among HRC clients was 74 percent after a 3.5 year followup.

Orthomolecular medicine…uses the chemicals that life thrives on. Please tell us about the issues of access and insurance coverage as they apply to orthomolecular medicine. Insurance does not cover the cost of nutrients; furthermore, since the Food and Drug Administration requires certain nutritional products to carry labels stating that they are “not intended to diagnose, treat, cure, or prevent any disease,” biochemical substances are regarded as non-medical and outside insurance’s scope of coverage. This places orthomolecular medicine at a great disadvantage against pharmaceutical competitors, who receive full support from insurance companies.

OCTOBER 2016 MINNESOTA HEALTH CARE NEWS

ORTHOPEDICS

Broken bones Healing from fractures

By Kevin Lindgren, MD

here is a good chance that each of us will break at least one bone in our lifetime. The good news is that, with proper care, bones almost always heal uneventfully. Human bones have healed on their own throughout history, and orthopedic surgeons have gotten quite good at sorting out which fractures should be allowed to heal naturally and which ones should be fixed through more aggressive means so that people won’t face the same morbidity from a poorly healed fracture that their ancestors once did.

A common experience Most of us remember children—perhaps ourselves—sporting a well-worn cast with drawings and well wishes from loved ones. We probably also know older people who needed to be treated for a broken bone after a fall at home. Studies show a high rate of fractures in young people up to about the age of 20, with a second spike in broken bones among the elderly. High-energy fractures, such as those sustained in motor vehicle crashes, are most common among young people. Between the ages of 15 and 49, males are about three times more likely than females to sustain a fracture. Among those over 50, osteoporosis is the underlying factor contributing to fractures for 1 in 3 females and 1 in 5 males. Osteoporosis is estimated to affect more than 200 million women worldwide, leading to around 9 million fractures annually in this group alone. Finding the break Identifying a fracture is not always easy. There is seldom any confusion in the high-energy injuries that result in limb deformity. Open fractures—in which bone protrudes through the skin—place patients at risk for bacterial infections, so early evaluation and treatment, often involving immediate surgery, is critical. Other types of fractures are less obvious. Sometimes it is a nagging pain in the foot, leg, back, or elsewhere that reveals an underlying fracture. While persistent pain is the most common symptom of a fracture, other signs include swelling, tenderness, redness, or, in the cases of vertebral fractures, occasional numbness. If these types of pain don’t go away within a reasonable time frame with ice, rest, or elevation, patients should have the area evaluated by a professional. This evaluation always begins with a thorough history of your symptoms and aggravating factors, often followed with an X-ray to look at the bony structures. In most cases, the health care provider will look closely at the joints above and below the suspected area for any concurrent or causing injury. Sometimes the fracture may

MINNESOTA HEALTH CARE NEWS OCTOBER 2016

be obvious on X-ray; other times it may not. In those cases, more advanced imaging may be required, most often with magnetic resonance imaging, or MRI. MRI is capable of identifying more subtle fractures that don’t appear on X-rays, including stress fractures resulting from repetitive injury. Treatment Once the fracture is identified, your doctor will discuss treatment options. In the case of a deformed limb, the most obvious first question is, how do we straighten it? This is usually achieved through manual manipulation of the area and splinting or casting while the patient is under anesthesia—either general anesthesia to place the patient asleep temporarily, or a nerve block to induce numbness throughout the region. The goal is always to make it as minimally painful and as safe as possible. After the bone is correctly aligned, it must be held in place to allow time to heal. Casts—either fiberglass or plaster—surround and immobilize the area. For many childhood fractures, casting is the treatment of choice, since young people have a remarkable ability to heal and straighten bones on their own. Splints, on the other hand, do not surround the bone, but immobilize the area with a rigid device on one or both sides. This typically allows for more swelling, which is safer as people age. For some, this may be sufficient; for others, splints provide temporary stability until final surgical treatment can occur.

Identifying a fracture is not always easy.

Casts and splints are not always enough, particularly for fractures resulting from severe high-energy injuries. In a trauma setting, a broken bone may easily be identified, but less obvious nerve or organ injury must also be considered. In these instances, immobilizing the area through either provisional (temporary) or definitive (long-term) fixation devices will allow time for the whole body to be assessed and to plan for follow-up treatment. This may take the form of pins inserted into the bone, connected together by rods and bolts to hold the fracture in alignment. In some cases this becomes the final fixation, but in most cases, it is a temporary alignment that allows time to plan for additional steps. Another temporary fixation device is the traction pin, in which a pin is placed through the bone and skin and then connected to

If surgical treatment is the final plan, the most common procedure involves “open reduction and internal fixation.” The fracture site is opened, the bones are aligned, and some type of device is used to “fix” or immobilize the fracture. These devices include: pins, rods, nails, plates, screws, or a combination thereof. Typically made of metal, these instruments are affixed to the bone to correct limb alignment and hold it in place until the body can do its job and heal the fracture. The body mends itself Fracture healing is a complex, four-phase process that occurs over months to years: Inflammation begins immediately with a cascade of events that send biochemical signals that an injury has occurred. This usually includes the first 1–7 days. During the soft callus formation phase, early fibrous and bone formation cells infiltrate the area and set the stage for a new bony framework. This phase encompasses about 2–3 weeks. The hard callus formation phase begins when the ends of the bones are united by soft callus. This phase carries on through the following several months until the fragments are firmly united by new bone. The final remodeling phase may take a few months to several years. The hard callus changes in form and appearance over this time until the bone is mature and indistinguishable from unaffected bone. In most cases it is a seamless transition through the stages. Sometimes, healing does not continue as expected and may stall in a phase before complete. In these cases, interventions may vary and a patient should be evaluated by a professional. The healed bone may not be the final point in recovery. While it may be easy to see the broken bone on X-ray, injuries to surrounding muscle and soft tissue are less easy to identify. The healing process itself, as well as immobility and loss of use throughout the healing phases, often produce weakness of the limb. Physical therapy and conditioning are often necessary after the bones have healed to aid in a full recovery and a return to normal function. Conclusion Proper identification, treatment, and recovery from a broken bone take time. When done properly, an excellent outcome may be achieved in most cases. The guidance of a professional such as an orthopedic surgeon will not only provide a watchful eye to ensure that the process continues smoothly, but will put the mind at ease with answers to difficult questions encountered during a difficult time.

a weight device that holds the affected limb in a safe position as final treatment is planned. In the past, this may have been the final treatment, with patients spending weeks to months in traction, but, with current advances in treatment and surgery, this is almost never the final treatment plan.

Kevin Lindgren, MD, is an orthopedic surgeon with Twin Cities Orthopedics, P.A., practicing out of St. Paul, Woodbury, and Stillwater. He received fellowship specialty training in hip and knee replacement at the University of Utah. OCTOBER 2016 MINNESOTA HEALTH CARE NEWS

The 2016 Presi What are the biggest challenges facing health care delivery today? Despite the progress represented by the Affordable Care Act (ACA), we have more to do to finish our long fight to provide universal, quality, affordable health care to everyone in America. We must do more to improve access to primary care, dental care, mental health care, and affordable prescription drugs. And with Hillary Clinton our population continuing to grow and age, our health care system must be equipped to meet our changing needs. We must support our health care professionals, who work long hours to ensure their patients get the best possible care. We must bring down out-of-pocket health care costs, and expand affordable health care access regardless of families’ immigration status. We must address immediate health care issues—from Alzheimer’s, to autism, to mental health, to substance use disorders to Zika. We must improve our public health infrastructure, and evaluate environmental factors that affect the well-being of many Americans, especially those that are low income. We must also protect women’s health care and their right to make personal health decisions. How do you propose to solve these problems? I support policies that protect and expand access to care. First, I will work with governors to expand Medicaid in every state, so

I support policies that protect and expand access to care. access to care no longer depends on where you live. It is a disgrace that 19 states have left 3 million Americans without health insurance by refusing to expand Medicaid. Second, I will get health care costs under control. I’ve put forth comprehensive plans to address increasing out-of-pocket and prescription drug costs. Third, I will fight to give Americans in every state the choice of public option insurance, and to expand Medicare by allowing people 55 years or older to opt in while protecting the traditional Medicare program. I also will fight to expand our system of Federally Qualified Health Centers, helping establish universal primary care. Please tell us the positive and negative results of the Affordable Care Act. Thanks to the ACA, 20 million more Americans have health insurance, regardless of their gender or preexisting condition. The ACA brought the number of Americans covered to 90 percent—a historic achievement. However, too many individuals still lack affordable insurance and access to primary care, dental care, and mental health care. This access disproportionately affects people of color, and the millions of Americans living in rural communities. Further, due to the unwillingness of 19 states to expand Medicaid, nearly 3 million low-income Americans remain uninsured. As president, I will work with governors to

MINNESOTA HEALTH CARE NEWS OCTOBER 2016

expand Medicaid, allow Americans over the age of 55 to buy into Medicare, and engage physicians and doctors to achieve our health care goals. I will also double the funding for primary care services at community health centers over the next decade. We will move our country closer to universal coverage and fight so location does not determine care. What role should government play in controlling pharmaceutical costs? We must deal with skyrocketing out-of-pocket health costs, specifically, the high prescription drug prices that burden hardworking Americans. Every month, approximately half of all Americans take a prescription drug—a proportion that increases to 90 percent when looking at seniors. We must hold pharmaceutical companies accountable to lower drug costs. To do that, we will deny tax breaks for direct-to-consumer advertising, and demand instead that these companies invest in R&D to receive taxpayer support. We must spur competition for prescription drugs to drive down prices. In addition to supporting the policies that help provide American consumers greater choice, I will require that health insurance plans place a monthly limit of $250 on covered out-of-pocket prescription drug costs for patients with chronic or serious health conditions. Further, I will demand higher rebates for prescription drugs in Medicare. Individuals fighting illness or coping with age should not be further burdened by the stress of affording care—we will help ease that burden. If you could fix health care without any obstacles (political or otherwise), how would you do it? Throughout my career, I have fought so that all Americans could have affordable health insurance—a basic right. There have been obstacles in this fight, but more important, there has been opportunity. As first lady, when Congress defeated health care reform, I worked with Democrats to help create the Children’s Health Insurance Program (CHIP). Today, I am proud to say that this program has provided coverage to over 8 million children. As president, I will continue to fight for universal health care. The Affordable Care Act made great strides, but we must do more to help insure the 10 percent of Americans still without coverage. We will also provide families the opportunity to buy health insurance on the exchanges, regardless of immigration status. There will always be obstacles, but I believe meaningful changes in access will help us begin to fix health care, and ensure that everyone in our great country leads a long and healthy life.

sidential Race Editor’s note: With every presidential election we pose questions to the candidates about their health care policies. The Trump campaign did not respond to our request. As of press time (10/5/16) we visited the Trump campaign web site and, to be as fair as possible, we excerpted the following comments organized as closely as possible in response to our questions.

Biggest challenges Providing healthcare to illegal immigrants costs us some $11 billion annually. If we were to simply enforce the current immigration laws and restrict the unbridled granting of visas to this country, we could relieve healthcare cost pressures on state and local governments. To reduce the number of individuals needing access to programs like Medicaid and Children’s Health Insurance Program we will need to install programs that grow the economy and bring capital and jobs back to America. The best social program has always been a job—and taking care of our economy will go a long way towards reducing our dependence on public health programs. Proposed solutions Completely repeal Obamacare. Our elected representatives must eliminate the individual mandate. No person should be required to buy insurance unless he or she wants to. Modify existing law that inhibits the sale of health insurance across state lines. As long as the plan purchased complies with state requirements, any vendor ought to be able to offer insurance in any state. By allowing full competition in this market, insurance costs will go down and consumer satisfaction will go up. Allow individuals to fully deduct health insurance premium payments from their tax returns under the current tax system. Businesses are allowed to take these deductions so why wouldn’t Congress allow individuals the same exemptions? As we allow the free market to provide insurance coverage opportunities to companies and individuals, we must also make sure that no one slips through the cracks simply because they cannot afford insurance. We must review basic options for Medicaid and work with states to ensure that those who want healthcare coverage can have it. Affordable Care Act Since March of 2010, the American people have had to suffer under the incredible economic burden of the Affordable Care Act—Obamacare.

This legislation, passed by totally partisan votes in the House and Senate and signed into law by the most divisive and partisan President in American history, has tragically but predictably resulted in runaway costs, websites that don’t work, greater rationing of care, higher premiums, less competition and fewer choices. Obamacare has raised the economic uncertainty of every single person residing in this country. As it appears Obamacare is certain to colDonald Trump lapse of its own weight, the damage done by the Democrats and President Obama, and abetted by the Supreme Court, will be difficult to repair unless the next President and a Republican congress lead the effort to bring much-needed free market reforms to the healthcare industry. But none of these positive reforms can be accomplished without Obamacare repeal. On day one of the Trump Administration, we will ask Congress to immediately deliver a full repeal of Obamacare. Pharmaceutical cost Remove barriers to entry into free markets for drug providers that offer safe, reliable and cheaper products. Congress will need the courage to step away from the special interests and do what is right for America. Though the pharmaceutical industry is in the private sector, drug companies provide a public service. Allowing consumers access to imported, safe and dependable drugs from overseas will bring more options to consumers.

Require price transparency from all healthcare providers. Ideal fix Allow individuals to use Health Savings Accounts (HSAs). Contributions into HSAs should be tax-free and should be allowed to accumulate. These accounts would become part of the estate of the individual and could be passed on to heirs without fear of any death penalty. These plans should be particularly attractive to young people who are healthy and can afford high-deductible insurance plans. These funds can be used by any member of a family without penalty. The flexibility and security provided by HSAs will be of great benefit to all who participate. Require price transparency from all healthcare providers, especially doctors and healthcare organizations like clinics and hospitals. Individuals should be able to shop to find the best prices for procedures, exams or any other medical-related procedure. Block-grant Medicaid to the states. Nearly every state already offers benefits beyond what is required in the current Medicaid structure. The state governments know their people best and can manage the administration of Medicaid far better without federal overhead. States will have the incentives to seek out and eliminate fraud, waste and abuse to preserve our precious resources. OCTOBER 2016 MINNESOTA HEALTH CARE NEWS

HEALTH INSUR ANCE

Understanding your coverage Cutting through confusion

By Monica Engel

ne big benefit of health insurance is peace of mind. But choosing the right coverage can be a major headache. That’s because the U.S. health insurance market has

Understanding these and other essentials of your coverage—or knowing where to seek information—is important, because making the wrong choice could increase your out-of-pocket costs.

become an increasingly complex place for consumers to navigate. The language can be confusing, and even the most savvy consumer can trip over terms that sound alike (such as copays, coinsurance, and supplemental insurance) but have very different meanings.

The U.S. health insurance market has become an increasingly complex place for consumers to navigate. Questions and answers For many consumers, cutting through the confusion requires more than a phone call or an online chat. They want a face-toface discussion with a real person—someone who can translate the terminology, clearly explain their insurance buying options and member benefits, and even help them resolve claims if the need arises. They also need someone who can answer new questions during the plan year. This kind of personalized service is now available at retail centers in Edina, Roseville, and Duluth created by Blue Cross and Blue Shield of Minnesota over the last two years. Blue Cross members and non-members alike are welcome in our centers, where knowledgeable representatives are ready to answer your health insurance questions. The centers also provide year-round educational and wellness programs. Here are some of the most common questions our representatives hear, along with their plain English answers that can help you take more control of your health coverage. What are deductibles? A deductible is the out-of-pocket amount you pay for health care services before your insurance coverage kicks in. Say your plan’s deductible is $1,500. In most cases, that means you will pay the full

MINNESOTA HEALTH CARE NEWS OCTOBER 2016

amount on medical bills until you reach your $1,500 deductible. Generally, the higher your deductible, the lower your monthly health care premiums. After your deductible is paid, you share the cost of medical services and prescriptions with your insurance carrier by paying coinsurance and copays.

The higher your deductible, the lower your monthly health care premiums.

• Generic drugs are identical, or “bioequivalent,” to brand name drugs in terms of dosage, safety, strength, quality, performance characteristics, and intended use. Although generic drugs are chemically identical to their branded counterparts, they are typically sold at substantial discounts. In addition, copays for generics are often lower than copays for their brand name equivalents. • Specialty drugs require special instructions and care. They are used to treat rare, serious, or chronic conditions, such as a severe food allergy. Many specialty medications are more expensive, and may fall into a higher tier of copays.

What is coinsurance?

What does open enrollment mean?

The percentage that you pay for health care services—versus what’s

Once a year, health insurance carriers offer an open enrollment

paid by your coverage carrier—is coinsurance. Once you have paid

period during which members can renew their current plan or shop

your plan’s deductible, you begin to pay coinsurance.

for a new one. Open enrollment often occurs before the start of a

Say you see a physical therapist regularly for a foot injury and you have a $1,500 deductible. Once you’ve paid the deductible in full, your insurance provider will begin to pay a percentage of the cost. For example, if your plan specifies “80/20” coinsurance, you would pay 80 percent of expenses after you paid your deductible in full. In most cases, the less you pay in monthly premiums, the more you will pay in coinsurance. What is a copay? An insurance copayment is the fixed amount people pay for prescriptions and services from a doctor, hospital, or other provider. Copayments are typically only a fraction of the actual cost of the service or medication. Insurance providers cover the difference.

new year, especially for people who receive their benefits from an employer, as well as for people covered by Medicare. What is a qualifying life event? Say you have a baby midway through a coverage year, and you want your little one to receive health care under your existing plan. That would be a qualifying life event, meaning you could quickly make that change without waiting for your next open enrollment period. Another such life event would be marriage, when you might want to include your spouse on your medical plan. Job changes (excluding promotions or reassignments under the same employer) and permanent moves may also be considered qualifying events. What are health savings accounts? Health savings accounts (HSAs) are personal savings accounts

If you take your child to a pediatrician whose standard rate for

available to individuals with high-deductible insurance plans.

an office visit is $200, for instance, your copay might be $25. Your

People enrolled in HSAs can put money aside—tax-free—to pay

insurance plan would then pay the remaining $175 at a later date.

for those deductibles, as well as for other medical-related costs not

If you visit your doctor or pharmacy often, you might consider

covered by their health care (eyeglasses, for instance, if you don’t

choosing an insurance plan that has a low copay for office visits

have vision insurance). You might consider an HSA if you’re trying

and prescriptions, even if it means a higher monthly premium.

to save up for future health care expenses and don’t anticipate many

How does prescription coverage work?

expenses up front.

When evaluating and enrolling in a health insurance plan, consider

How does Medicare work?

how much you spend on prescription medications, including copays

Medicare is the health insurance program offered by the U.S.

and/or coinsurance.

government to Americans age 65 or older and to those with certain

• The first thing to consider is your health carrier’s formulary— the list of preferred generic and brand-name medications

disabilities. Like non-government insurance plans, people who receive Medicare pay deductibles, copayments, and coinsurance for

covered by your drug benefit. The fact that a drug is listed in

hospital and medical expenses.

the formulary does not guarantee that it will be the medication

The difference between Medicare and private plans is that a portion of insurance costs is covered by taxes you’ve paid throughout

your physician chooses to prescribe. If you and your doctor choose a non-formulary drug, you would have the option of paying a higher price for that prescription, or switching to an equivalent medication that is on your plan’s formulary.

Understanding your coverage to page 19

OCTOBER 2016 MINNESOTA HEALTH CARE NEWS

DOMESTIC VIOLENCE AWARENESS MONTH

CALENDAR

During the month of October, the National Coalition Against Domestic Violence works to bring attention to the issues surrounding domestic violence and remind the nation of the countless people that are still being impacted by it. In the U.S., an average of 20 people are physically abused by intimate partners every minute, with more than 10 million abuse victims each year. It is most common among women between the ages of 18 and 24. Domestic violence intensifies over time, with the abusers becoming gradually more aggressive and controlling, both physically and emotionally. It can begin with behaviors that are easily dismissed, but can escalate into extreme control and abuse and can result in physical injury, psychological trauma, and, in severe cases, death. It affects people in every community regardless of age group, economic status, sexual orientation, gender, race, religion, or nationality. It may seem difficult to escape your abuser, but it is possible. For anonymous, confidential help available 24/7, call the National Domestic Violence Hotline at 1-800 -799-7233 (SAFE) or 1-800-787-3224 (TTY) now.

OCT. 17

Support Group for Survivors of Domestic & Sexual Violence

Alexandra House hosts this free weekly support group for women recovering from abuse and assault who are ready to explore their personal healing process and find hope. Free childcare may be available with prior notice. All services are confidential. Call (763) 656-1366 to sign up or for more information. Monday, Oct. 17, 6:30–8 p.m., Alexandra House, 10065 3rd St. NE., Blaine

OCT. 19

Scleroderma Support Group

The Scleroderma Foundation Minnesota Chapter presents this free support group for those affected by scleroderma to share concerns, information, peer support, and encouragement. For more information, call Karen at (952) 926-8848. Wednesday, Oct. 19, 6–7:30 p.m., Southdale Medical Building, Rm. C-73, 6545 France Ave. S., Edina

Binge Eating Disorder Class

Park Nicollet’s Melrose Center offers this free information session for anyone who would like to learn what binge eating disorder is and what treatments are available. No registration required. Call 952-993-1000 for more information. Thursday, Oct. 20, 5–5:45 p.m., Melrose Center, 3525 Monterey Dr., St. Louis Park

Talking to Your Teen About Sex

Tuesday, Oct. 25, 6:30–8 p.m., Brooklyn Park Library Mississippi Room, 8500 W. Broadway Ave., Brooklyn Park

Postpartum Depression Support Group

NOV. 2

Weight Loss Surgery Support Group

The University of Minnesota hosts this free monthly support group for patients who have undergone weight loss surgery and those who are considering it. Discussion at the November meeting will focus on complications after surgery. No registration necessary; friends and family members welcome. Call (612) 626-6666 for more information. Wednesday, Nov. 2, 6:30–8:00 p.m., University of Minnesota Medical Center, East Building–Brennan Education Center, 2450 Riverside Ave. S., Minneapolis

Autism Family Support Group

The Arc Greater Twin Cities hosts this support group for families affected by autism spectrum disorder. Meet others in similar situations and gain insights from their experiences. For more information or to sign up, call at (952) 920-0855. Tuesday, Nov. 15, 6:30–8:45 p.m., Faith Lutheran Church, 11115 Hanson Blvd. NW., Coon Rapids

Annex Teen Clinic educators host this free information session for parents to help you gain comfort, confidence, and courage to talk with your teen about dating, sex, puberty, sexuality, and health relationships. Registration required. Call 612-543-5669 for more information.

OCTOBER-NOVEMBER 2016

Memory Loss Support Group

The Alzheimer’s Association and Coventry of Mahtomedi host this free monthly support group for people living with memory loss and their family, friends, and caregivers. Come develop a support system, exchange practical information, share feelings, and learn about community resources. Call (651) 5288442 to RSVP or for more information. Tuesday, Nov. 15, 6–7 p.m., St. Jude of the Lake Parish–Kohler Hall, 700 Mahtomedi Ave., Mahtomedi

Allina Health hosts this free weekly support group for women who are experiencing or are at risk for postpartum depression. Learn more about how to navigate this experience and meet other women who understand. Mothers are invited to bring their babies to the group. Call (612) 8634770 for more information.

HealthEast hosts this free support group for brain tumor survivors and their loved ones. Join the informal group discussion for support, education, and a source of hope and encouragement. Free dinner provided. Call Kathy at (651) 232-3987 to sign up or for more information.

Wednesday, Oct. 26, 1:30–3 p.m., Dakota County Northern Service Center, 1 Mendota Road W., West St. Paul

Monday, Nov. 21, 7–8:30 p.m., St. Joseph’s Hospital, 3M Conference Center, Rms. A/B, 45 W. 10th St., St. Paul

Brain Tumor Support Group

Send us your news: We welcome your input. If you have an event you would like to submit for our calendar, please send your submission to MPP/Calendar, 2812 E. 26th St., Minneapolis, MN 55406. Email submissions to amarlow@mppub.com or fax them to (612) 728-8601. Please note: We cannot guarantee that all submissions will be used. CME, CE, and symposium listings will not be published.

America’s leading source of health information online 18

MINNESOTA HEALTH CARE NEWS OCTOBER 2016

Understanding your coverage from page 17

your working life. You may choose to pay for additional parts of the program to help manage out-of-pocket costs. One example of this cost: Medicare Part D, which pays for prescriptions not covered by the original Medicare. With the aging of the baby boomer generation, many more Minnesotans will need to make these choices in the coming years. In fact, nearly one in four Minnesota residents will be eligible for Medicare by 2030, double the number in 2000.

Even the most savvy consumer can trip over terms that sound alike.

What is supplemental insurance? Supplemental insurance generally covers medical costs not covered by a person’s primary plan. Medicare supplemental insurance is popular among those enrolled in the government program. Socalled Medigap coverage, sold by private companies, can help you cover copayments, coinsurance, and deductibles.

Some Medigap policies also cover services that original Medicare doesn’t, like medical care when recipients travel outside the United States. Additional resources This is just a sampling of the questions that Blue Cross representatives can answer when you visit a Blue Cross retail center. The centers also offer health screenings, fitness activities for all age groups, and wellness programs and services, from diabetes screenings to “silver fit” classes for seniors. We also provide free educational sessions on Medicare and private health insurance coverage. Nonprofit community organizations may book rooms in our community classrooms. You can also find health insurance answers by talking to your specific health care insurance provider. Whatever source you choose, remember: It’s essential to understand your coverage options, to pick the best plan to suit your needs and circumstances, and to continue to seek information throughout your plan year.

Monica Engel is vice president of consumer markets at Blue Cross and Blue Shield of Minnesota.

OCTOBER 2016 MINNESOTA HEALTH CARE NEWS

WOMEN’S HEALTH

Postpartum depression Much more than the “Baby Blues”

By Tessa Wetjen, MPA

sabel loved children and couldn’t wait to raise her own family. But when her husband went back to work, she started worrying that something bad would happen to her baby. No matter what

she did, the scary thoughts never stopped. She hid her private fears from others, perhaps unaware that she was experiencing perinatal mood and anxiety disorders—serious medical conditions too often dismissed as the “Baby Blues.”

Joy and stress The emotions of having a new baby, combined with lack of sleep, can affect the mental health of any new parent, leading to constant, alarming thoughts, fear of leaving home, sadness, and feeling disconnected with the newborn. All parents can experience bouts of depression and anxiety, some of which can become debilitating as time goes on. This is hardly news to anyone who has had a baby. Up to 80 percent of new mothers experience depression immediately after birth. For some, it’s a temporary, short-term depression that lasts less than three weeks, ending on its own without treatment. For others, it’s a different story. Pregnancy/postpartum depression and anxiety (also called perinatal mood and anxiety disorders) is not temporary. It can seriously affect the mother’s ability to care for herself and the baby, and will not end on its own.

It’s vital for parents to get help before it affects themselves and their children. Definitions What does postpartum depression or anxiety look like? In the case of depression, new parents may be very tearful, be prone to periods of deep sadness or numbness, experience “brain fogs” that leave them unable to concentrate on the joy of being a new parent, and find it hard to perform certain tasks or leave the home. Clinical anxiety might provoke more excessive worries about leaving home, sleepless nights, short tempers, and panic attacks or intrusive thoughts. Postpartum depression or anxiety occurs among both moms and dads, including those who adopt. Sometimes it is due to

MINNESOTA HEALTH CARE NEWS OCTOBER 2016

hormonal changes, but it can also be brought on by lack of sleep or a connection to past trauma or mental health issues. It’s vital for parents to get help before it affects themselves and their children. Depression impacts the parent’s ability to care for and create a nurturing relationship with children. Early experiences and interactions are critical factors affecting childhood brain development. Children of depressed mothers or fathers are more likely to perform lower on cognitive, emotional, and behavioral assessments. They often have difficulties in social and educational situations and have an increased risk of mental health issues later in life. Mothers with postpartum depression are less likely to breastfeed, have increased risk of substance use, are less likely to care for themselves or follow health care recommendations, and have an increased risk of future depression and even suicide. In 2014–2015, five Minnesota mothers with postpartum depression committed suicide within 12 months of childbirth. Fifteen Minnesota mothers with postpartum depression died during this same time period, and the condition may have been a factor in their deaths. Across the nation, an estimated 10–35 percent of new mothers experience postpartum depression. While the condition is seen in all socio-demographic groups, mothers at particular risk are those who are young, single, economically disadvantaged, socially isolated, or who have a previous history of depression. Pre- and post-natal depression can also affect fathers, with the highest rates occurring at 3–6 months postpartum.

If you notice that a new parent is not doing well, try to help in a supportive way. Acknowledge that this is a hard time, and that feeling stressed or overwhelmed is normal. Ask if they’ve considered talking to a professional about how they feel, help them identify whom to contact, and consider making the call with them. If you realize that the parent is suicidal or thinking of harm, act immediately by calling 911 or contacting the Crisis Connection at (866) 379-6363.

Pre- and post-natal depression can also affect fathers. Overcoming hurdles Getting help can be very difficult for a new parent suffering with depression or anxiety. There is a stigma to confront: many families aren’t comfortable talking about mental health in general, so talking about it during a joyful event like a new baby can be even more uncomfortable or taboo. Some parents fear they will be considered “crazy” or “just lazy,” and may not recognize that they are facing a medical condition, not just trying to adapt to a new baby.

Postpartum depression to page 25

Prevention and treatment While depression and/or anxiety often accompany pregnancy and postpartum, a focus on positive mental health and dealing with overwhelming emotions, depression, or anxiety will go a long way in helping families to raise healthy, happy babies. That could start long before the baby is born. Expectant parents should think early about how they will deal with potential stress and emotional changes. How will they help the new mom get sleep, especially while breastfeeding? Who will help with other children, if they have them? And, if new parents are starting to feel overwhelmed, or experiencing increased depression or anxiety, where can they turn? The Minnesota Department of Health (MDH) has developed a quick worksheet to help address these questions; look for the Maternal Wellbeing Plan, along with other resources, at www.health.state.mn.us/divs/cfh/topic/pmad/basics.cfm Multiple resources are available to support parents dealing with pregnancy or postpartum depression or anxiety. Primary care physicians can discuss possibilities such as medication or diet changes. Professional therapy can be very helpful, and there are therapists in Minnesota who specialize in working with pregnant or postpartum mothers. Community supports, such as family home visiting, new parent groups, or parent-child education, can also be very helpful, even though these are not considered “treatments.”

OCTOBER 2016 MINNESOTA HEALTH CARE NEWS

CHRONIC DISEASE

Osteoporosis A silent disease

By Maja Visekruna, MD, CCD

ew of us worry about our bones until a fracture occurs. The truth is, the more we build up our bones through healthy diet and exercise habits when we are young, the better we can

protect ourselves later in life against osteoporosis and potentially life-threatening fractures. While osteoporosis cannot be cured, new treatments are being developed and approved as the disease increas-

es in our aging population.

As bones age Osteoporosis is a widespread metabolic bone disease characterized by decreased bone mass and poor bone quality, leading to weakness of the skeleton and increased risk for fractures of the hip, spine, wrist, arm, pelvis, ribs, and other bones—often from minor falls or daily activities. Our bones are living tissue, and new bone replaces old throughout our lives. Until our mid-20s, our bones gain density and strength. From our 30s onward, they gradually lose density. Women can lose up to 20 percent of their bone mass during the five to seven years after menopause. Osteoporosis occurs primarily as a result of normal aging, but also can happen if the development of peak bone mass is impaired due to delayed puberty or undernutrition, or because of excessive bone loss during adulthood due to estrogen deficiency in women, undernutrition, or corticosteroid use. Osteoporosis is often called the “silent disease” because bone loss occurs without symptoms. In many cases, the first “symptom” is a broken bone. Even when a bone breaks, the patient may not know. For example, vertebral fractures may not be noticed until multiple broken vertebrae lead to pain, loss of height, or a hump on the back known as kyphosis, or dowager’s hump. These fractures can happen just with bending, lifting or turning, or coughing and sneezing. Osteoporosis affects more than 200 million people worldwide, and osteoporosis-related fractures increase sharply with age. Fractures of the hip—the most common type of osteoporotic fractures—are expected to rise from 1.66 million to 6.26 million annually worldwide by 2050. This disease puts a huge financial burden on health services. Hip fractures consume more hospital bed days than stroke, diabetes, or heart attack. An important women’s health issue One out of every two women and one in four men over 50 will have an osteoporosis-related fracture in their lifetime. Eighty percent of

MINNESOTA HEALTH CARE NEWS OCTOBER 2016

people with osteoporosis are female, and complications from the disease, usually related to fractures, make osteoporosis the fourth leading cause of death among women, following heart disease, cancer, and stroke. Caucasian and Asian women, on average, have bone density 5 to 10 percent lower than women of African American, Mediterranean, or Latino descent. Almost one-third of women who live to age 80 have hip fractures. A woman’s risk of a hip fracture equals the combined risk of breast, uterine, and ovarian cancer, and the risk of dying of hip fracture is equal to breast cancer mortality. Osteoporosis is also a serious problem for men. The lifetime risk of osteoporotic fracture in men over age 50 is 30 percent—the same as their risk of developing prostate cancer. Osteoporotic bones usually heal more slowly and less completely than normal bones. After an initial low trauma fracture,

Hip fractures consume more hospital bed days than stroke, diabetes, or heart attack.

Risk factors and prevention The risk factors associated with osteoporosis include: • Insufficient calcium intake and vitamin D deficiency • Sedentary lifestyle • A small, slender body • Smoking and excessive alcohol consumption • Family history of fractures • Hormonal imbalances related to diabetes, thyroid and parathyroid disorders, and anorexia • High-risk medications, including steroids, anti-seizure medications, Depo-Provera, and certain cancer treatments • Malabsorption (celiac disease, gastric bypass surgery, Crohn’s disease, ulcerative colitis) All of us—even those with these risk factors—can help keep our bones strong by eating a balanced diet with adequate calcium and vitamin D, not smoking, consuming fewer than three alcoholic drinks per day, and staying physically fit. Balance training and core strengthening reduce the risk of osteoporosis and fall-related injuries. Good bone building exercises include dancing, running, Osteoporosis to page 24

older people are at increased risk of more fractures within the next five to 10 years. Once a woman suffers a first vertebral fracture, there is a five-fold increase in her risk of developing a new fracture within one year. Diagnosis A bone mineral density test (BMD) is used to diagnose osteoporosis and low bone mass (formerly known as osteopenia) and to determine risk of bone fracture. Measured in the spine, hip, and/or wrist, this test is painless, noninvasive, and safe. A baseline Dual X-ray Absorptiometry (DXA) scan is recommended for all women at age 65 and all men at age 70. It is also recommended for premenopausal and postmenopausal women under 65 and men younger than 70 with risk factors for osteoporosis, including low body weight, prior fracture, family history of osteoporosis, diseases or conditions associated with bone loss, or high-risk medication use. During the DXA scan, we can also perform specialized tests to assess the 10-year fracture risk for hips and other major bones, measure bone quality in the lumbar spine and determine risk for osteoporotic fracture, and evaluate thoracic and lumbar spine images for vertebral fractures. These images can be obtained at the same time as a BMD measurement, at lower cost and radiation exposure than plain radiographs of the spine.

OCTOBER 2016 MINNESOTA HEALTH CARE NEWS

Osteoporosis from page 23

walking, aerobics, tennis, and golf. Resistance training with free weights or weight machines also can be very helpful. Fifteen minutes of daily exercise, three to four times per week, is enough to make real progress in strengthening bones. Treatment Your physician may also recommend additional treatment. Treatment plans should be individualized and discussed in detail, since all medications carry some potential risk. Before osteoporosis treatment starts, patients should have calcium and vitamin D levels in the normal range. When pharmacologic therapy is advised, continued use of calcium and vitamin D is recommended for optimal fracture risk reduction. Adequate nutrition with a calcium intake of 1,200 mg a day, including diet and supplements, and 800â&#x20AC;&#x201C;1,000 IU of vitamin D daily (more

[Osteoporosis] is preventable and can be treated.

postmenopausal bone loss with high fracture risk and for steroid-induced osteoporosis. Bisphosphonates suppress the breakdown and absorption of old bone (resorption) and reduce bone turnover. All four bisphosphonates (sold under the brand names of Fosamax, Boniva, Actonel, and Reclast) reduce vertebral fracture risk and increase bone mineral density, and some also reduce non-vertebral and hip fractures. These drugs bind to bone mineral and can stay in the bones for a few more years after therapy is stopped. Despite these benefits, some patients avoid bisphosphonates due to concerns over side effects involving femoral fractures and rotting jawbones. In fact, these side effects are extremely rare: 10â&#x20AC;&#x201C;40 per 100,000 patients experience femoral fractures, and less than 1 in 100,000 have the jawbone problem. While diet and exercise are important for patients with fragile bones, they are insufficient to protect them from life-threatening fractures. The benefits of bisphosphonates far outweigh their risks. Conclusion There is no cure for osteoporosis. However, it is preventable and can be treated. You can help prevent bone loss and fractures with proper diet, exercise and, when necessary, medications.

Maja Visekruna, MD, CCD, is medical director of HealthEast Osteoporosis Care.

during the winter and for those with malabsorption), are crucial components of osteoporosis prevention and treatment. Calcium suppresses parathyroid hormone secretion and reduces the rate of bone loss. Vitamin D increases intestinal calcium absorption and promotes mineralization of bone. FDA-approved medications for osteoporosis treatment include: Hormone therapy. Estrogen reduces bone turnover and bone loss and is approved for prevention of osteoporosis in postmenopausal women. Recent concerns that prolonged estrogen therapy may increase the risk of breast cancer, stroke, and heart disease, however, has reduced the use of hormonal replacement therapy. Selective Estrogen Receptor Modulators (SERMs) act in a similar way to estrogen on the bone and help maintain bone density and reduce fracture rates, specifically in the spine. Nasal salmon calcitonin. Because of the increased risk of malignancies, this is no longer considered first-line treatment. Denosumab suppresses development of bone-removing cells before they can reach the bones and cause damage. It is approved for the treatment of postmenopausal osteoporosis and for patients with prostate or breast cancer who are undergoing hormone ablation therapy. Teriparatide contains recombinant human parathyroid hormone and is the only available medication that stimulates new bone formation. It is FDA-approved for the treatment of

MINNESOTA HEALTH CARE NEWS OCTOBER 2016

Postpartum depression from page 21

Tips that may help parents suffering postpartum depression or anxiety to keep healthy and to care for themselves and their children: • Talk with a doctor or midwife, or ask a trusted loved one to help you call. • Learn more about the signs and symptoms of postpartum anxiety/depression at www.postpartumprogress.org • Talk to a therapist, alone or in group therapy.

Additional resources Many moms who have dealt with pregnancy or postpartum depression and anxiety report that, on top of the difficulty they felt in revealing their struggles, they also had trouble finding help after they started talking. In 2013, only 50 percent of lowincome Minnesota mothers with a diagnosis related to postpartum depression or anxiety received any treatment for it within the year after their child was born. It can be difficult to find effective, supportive treatment or therapies, but it’s vital to keep asking for help. A few helpful resources:

• Ask a care provider about medicines that can be used safely during pregnancy or while breastfeeding.

Fact Sheet on PPD and Maternal Wellbeing Plan

• Ask a faith or community leader about other support resources.

Mother-Baby HopeLine at Hennepin County Medical Center

• Ask friends and family for help with childcare, chores, and errands.

Pregnancy & Postpartum Support Minnesota

• Keep active by walking, stretching, and other physical activities. • Rest when the baby rests. • Eat a healthy diet.

4http://www.health.state.mn.us/divs/cfh/topic/pmad/pmadfs.cfm 4(612) 873-4673 4www.ppsupportmn.org/ Tessa Wetjen, MPA, a perinatal mental health planner with the Minnesota Department of Health (MDH), works on improving education and access to care for women experiencing perinatal mood disorders. She currently manages several perinatal projects, including the Postpartum Depression Screening Quality Improvement Project.

OCTOBER 2016 MINNESOTA HEALTH CARE NEWS

GASTROENTEROLOGY

Gallbladder disorders Diagnosis and treatment

By Federico T. Rossi, MD

he gallbladder is a hollow, pear-shaped organ approximately three inches long and one inch wide. Attached to the undersurface of the liver by connective tissue, its primary role is to collect and concentrate bile, a yellow-brown fluid produced in the liver that aids in digestion. Bile contains a number of materials, including bile salts, fatty acids, lipids, bilirubin, and hormones. After bile reaches the gallbladder through a duct from the liver, most of its water is

removed. As food leaves the stomach and enters the first part of the small intestine, a hormonal signal tells the gallbladder to release this concentrated bile into the small intestine, where it breaks down fats and absorbs fat-soluble vitamins. A common problem Gallstones, or cholelithiasis, are the most common problem in the gallbladder and associated ducts. In the majority of cases, gallstones form when the level of cholesterol is too high to be kept in solution in the bile. The excess cholesterol then precipitates out with other bile components to form solid crystals, which clump together and form gallstones. People with high cholesterol or high-fat diets may be more likely to develop gallstones. Gender also plays a role, with women between the ages of 20 and 60 being three times more likely to develop gallstones than men. The risk of cholesterol gallstones for both genders increases with age and with obesity. In a smaller number of cases (around 10 percent), gallstones are formed by the precipitation of pigments in the bile such as bilirubin. Unlike cholesterol stones, the prevalence of pigment stones is not influenced by gender. Risk factors for the formation of pigment stones include age, alcoholism, and the use of total parenteral nutrition (TPN), under which people receive all of their nutrients intravenously. Symptoms Gallstones may cause blockage or inflammation of the gallbladder (cholecystitis), producing symptoms that include: â&#x20AC;˘ Chronic indigestion, including nausea, gas, and bloating, which may be made worse after eating high-fat foods â&#x20AC;˘ Sudden, steady pain in the upper middle or upper right abdomen. The pain may occur a half-hour to two hours after eating and may last 30 minutes to several hours â&#x20AC;˘ Pain in the back between the shoulder blades or pain under the right shoulder

MINNESOTA HEALTH CARE NEWS OCTOBER 2016

• Nausea and vomiting • Fever with or without chills • Yellowish color of the skin or the whites of the eyes (jaundice) • Clay-colored stools Diagnosing gallstones Gallstones do not always cause symptoms. If you do have symptoms of gallstones, your doctor will take your medical history and perform a physical exam, and may also order blood tests to check for signs of infection, pancreatitis, or abnormal liver function. Your doctor may also order follow-up procedures: Transabdominal ultrasound is an economic, widely used test to locate gallstones and determine if the gallbladder itself is inflamed. Technicians use a transducer to create black and white images with sound waves. There is no radiation exposure during this test, which does not require special preparation.

People with high cholesterol or high fat diets may be more likely to develop gallstones.

Endoscopic retrograde cholangiopancreatography (ERCP) is a valuable tool used to diagnose and treat many diseases of the pancreas, bile ducts, liver, and gallbladder. As with the EUS test, an endoscope is inserted under sedation. When the common bile duct has been reached, the doctor injects dye into the ducts of the biliary system and takes X-rays. Structural abnormalities such as gallstones, tumors, or strictures (obstructing scar tissue) can be shown in detail, and biopsies of abnormal tissue can be obtained if necessary. In some cases ERCP can be used to determine whether or not surgery is necessary and, if it is, to provide anatomic details to help plan the operation. Several conditions of the biliary or pancreatic ducts can be cured or improved by therapeutic ERCP techniques that can open the end of the bile duct, remove stones, and place stents (plastic drainage tubes) across obstructed ducts to improve drainage. Complications The gallbladder, liver, and pancreas share a common outlet into the small intestine. Depending on the location of a gallstone as it leaves the gallbladder it can become lodged in a duct and: • Block drainage from the gallbladder, causing inflammation of the gallbladder (cholecystitis)

Gallbladder disorders to page 31

Computerized tomography (CT) scans combine a series of X-ray images taken from different angles, using computer processing to create cross-sectional images, or slices, of the body’s bones, blood vessels, and soft tissues. CT scans can help identify the presence of a tear in the gallbladder wall or an infection in the bile ducts. This imaging test is performed while you are awake. A hepatobiliary (HIDA) scan, also known as a cholescintigraphy, is an imaging procedure used to diagnose problems of the liver, gallbladder, and bile ducts. While you are awake, a small amount of radioactive dye is injected into your bloodstream, and a scanning device tracks the dye as it moves into the gallbladder. Your doctor might use a HIDA scan to identify gallbladder inflammation, bile duct obstruction, congenital duct abnormalities, or as part of a test to measure the rate at which bile is released from your gallbladder (gallbladder ejection fraction). Endoscopic ultrasound scanning (EUS) can be used to diagnose diseases of the pancreas, bile duct, and gallbladder. Under sedation, a thin flexible tube (endoscope) with a built-in ultrasound probe is passed through your mouth and toward the small intestine to examine the ducts of interest. Using ultrasound, doctors are able to create black and white images. Occasionally, a small tissue sample is collected during EUS to aid diagnosis.

OCTOBER 2016 MINNESOTA HEALTH CARE NEWS

NUTRITION

Peanut allergies A dangerous medical condition

By Nancy Ott, MD, FAAP, FAAAAI

“Peas! Peas! Peas! Peas! Eating goober peas! Goodness how delicious, eating goober peas!”

young. Explanations for the current rise in peanut allergies vary, but our Civil War soldiers may have had two advantages: their immune systems may have been less likely to react against certain foods

ivil War soldiers singing this song while marching probably never realized that their “goober peas,” or peanuts, would one day cause a dangerous food allergy affecting 2 percent

of Americans and causing 150 deaths each year, mostly among the

as if they contained an infectious agent, and the proteins in their boiled or fried peanuts differed from those found in today’s roasted peanuts. Not a “nut” Despite their name, peanuts are actually considered vegetables and are known as legumes, a part of the bean family. More than 90 percent of food allergy reactions are caused by just eight foods (milk, egg, wheat, soy, peanut, tree nuts, fish, and shellfish), but peanut allergy is one of the most dangerous. Proteins as triggers In food allergy reactions, small parts of proteins in food that are similar to proteins found in parasites trigger the same immune system responses designed to protect against genuine threats. In the case of peanut allergies, the antibody IgE (Immunoglobulin E) is generated against the peanut, and then binds with mast cells (another critical element of the immune system that protects against parasites). The mast cell then releases chemicals intended to destroy the peanut, but which damage body organ tissue instead. If it seems as if you’re hearing more about peanut allergies these days, you are. Food allergies have tripled in the past few decades, an increase that, under the Hygiene Hypothesis, may stem from the very health care strides that have made our lives better. This hypothesis suggests that decreased exposure to mild infections in infancy and early childhood has made our immune systems more likely to mistake certain food proteins as infecting agents. Proteins altered within roasting peanuts may be more likely to be perceived as threats.

MINNESOTA HEALTH CARE NEWS OCTOBER 2016

From itchy skin to life-threatening shock

Diagnosis

A peanut allergy reaction can develop within one minute and up

Peanut allergies are diagnosed based on the history of reactions,

to three hours after exposure. Reactions can affect the skin (itchy

physical exams, and results of blood or skin allergy tests. If you

hives, swelling, skin redness, and flushing), the eyes (itching,

suspect a reaction, take pictures immediately, as the physical signs

swelling, redness, and tearing), the nose (congestion and discharge),

can disappear long before you are seen by a doctor.

the respiratory system (coughing, wheezing, and difficulty breathing), the gastrointestinal system (nausea, abdominal pain, vomiting, and diarrhea), the cardiovascular system (low blood pressure and shock), and the brain (sense of impending doom and loss of or altered consciousness). Any of these reactions can signal the beginning of shock or anaphylaxis, a life-threatening state in which two or more organs are reacting.

If it seems as if youâ&#x20AC;&#x2122;re hearing more about peanut allergies these days, you are.

Hives are present in 90 percent of anaphylactic shock cases, which can occur moments after exposure and can prove fatal if not treated. Patients should inject epinephrine (adrenaline, the

For blood tests, higher levels of the IgE antibody against

ingredient in prescription EpiPens) immediately and seek emergency

peanut in the blood indicate that the patient is more likely to

medical help. Sometimes a mild allergic reaction can start and resolve

react to peanuts, but do not predict the severity of the reaction,

spontaneously. In 10â&#x20AC;&#x201C;20 percent of these cases, a secondary (biphasic)

and allergists may order additional blood work, called component

anaphylactic reaction can occur and be much worse. Peanuts are one

testing. Even with low numbers, severe reactions to peanuts can

of the most likely foods to cause anaphylaxis and death.

still occur, so further assessments are still necessary.

Most of the annual deaths from food allergies in the U.S. are attributed to peanuts. The risk of death is highest among those with

Peanut allergies to page 30

asthma; those who do not immediately inject epinephrine at the first sign of reaction; and teenagers. Peanut allergy is most common in children who have a parent or sibling with allergies, children with eczema, or children with existing egg allergies. Healthy infants that are brought up in urban or suburban cities are more likely to develop peanut and other food allergies than someone raised in rural areas or in developing countries. Research and recommendations It may seem best to avoid peanuts altogether, but research suggests differently. A 2000 recommendation to stop feeding peanuts to children under three did not result in less peanut allergy and the incidence continued to rise. In research studies in 2014 and 2015, infants with hen egg allergy or atopic dermatitis but whose skin tests did not suggest peanut allergy were placed in two separate groups. One group ate peanuts on a set schedule, while the other abstained altogether. Those studies showed a reduction in peanut allergies among the group that consumed peanuts. The bottom line? Start serving peanut butter or pureed peanut food at 4â&#x20AC;&#x201C;11 months, when the child is developmentally ready to eat solid foods. If an infant has eczema or egg allergy, an allergist should perform a skin test first to assess whether the child has a high risk of peanut allergy. To avoid choking risks, children under 4 should never eat whole peanuts.

OCTOBER 2016 MINNESOTA HEALTH CARE NEWS

Peanut allergies from page 29

Even those who diligently avoid peanuts may accidentally ingest peanut products. Peanut powder has been found in restaurant chili, as well as in candy, bakery items, and ethnic foods. Always check

Allergy skin tests involve pricking the skin with a small sharp

ingredient lists for peanuts and other allergens, but note that some

device, usually made of plastic, that has been dipped into a liquid

small companies do not have to adhere with the Food Allergen

extract of peanut. Although rare, an allergic reaction can occur

Labeling and Consumer Protection Act of 2004.

because the actual peanut protein is being introduced into the body. Skin testing, however, is slightly more sensitive than the sIgE blood test. The positive predictive value of skin or blood testing is only 30â&#x20AC;&#x201C;50 percent whereas the negative predictive value is around 90 percent. Component testing has better positive predictive value. Avoiding peanuts Seventeen percent of patients will lose or outgrow their peanut

Most of the annual deaths from food allergies in the U.S. are attributed to peanuts.

allergies, but it is crucial to confirm this through follow-up tests. If tests are negative, a supervised peanut challenge in a hospital or allergy clinic can be performed under controlled conditions. But most patients will never lose their peanut allergy. They

Also, avoid cross contact. If peanut butter is on a table,

must strictly avoid peanuts and peanut products, understand the

someone may use the same knife for jelly, butter, and peanut butter.

risks of cross-contact exposure, and have epinephrine available for

If peanut products are sprinkled on ice cream or baked goods, they

emergency use. Several organizations devote websites to educate

may accidently land on other foods. Peanut powder, particles, or

and support those with peanut allergies, including Food Allergy

paste used in cooking can end up in other foods. Talk to cooks in

Research and Education, Anaphylaxis and Food Allergy Association

restaurants to help decide what to eat safely. Remember that young

of Minnesota, and Food Allergy Support Group of Minnesota.

children may cough, drool, or spit, exposing others to peanuts, and that kissing at any age could spread peanut allergens. Many schoolchildren report being bullied about their peanut allergy. If this happens, talk to the principal immediately to rectify the situation. Bringing oneâ&#x20AC;&#x2122;s own food to school may ensure safety. Peanut-free lunchroom tables limit exposure, but some children feel isolated at a separate table. As children grow older, they can learn to assess the situation and make proper choices. For parties and gatherings, make your own peanut-free treats. Medic-alert bracelets or necklaces are also recommended to alert emergency responders. A written Anaphylaxis Plan is required for school, but is also helpful for anyone with a food allergy or history of anaphylaxis. All adults that oversee care of a child with a peanut allergy should be taught CPR and how to use the EpiPen. Conclusion Peanut allergy is a dangerous medical condition, but strict avoidance and rapid use of epinephrine will save lives. The more the general public learns about severe food allergies, the better it will be.

Nancy Ott, MD, FAAP, FAAAAI, practices at Allergy and Asthma Specialists in Minneapolis and Edina. Board-certified in pediatrics and allergy/immunology, she is an adjunct assistant professor in pediatrics at the University of Minnesota.

MINNESOTA HEALTH CARE NEWS OCTOBER 2016

Gallbladder disorders from page 27

• Cause infection of the common bile duct (cholangitis) • Prevent outflow from the pancreas, causing inflammation of the pancreas (pancreatitis) Treatment If you have gallstones without symptoms, you do not require treatment. Gallstones that do produce symptoms are usually treated by surgery. If your gallbladder attacks are frequent, your doctor may recommend removal of your gallbladder (cholecystectomy). If you have stones in the bile duct as well as in your gallbladder, your doctor may recommend surgical removal of your gallbladder and removal of stones from your bile ducts using endoscopic ERCP. There are two surgical methods to remove the gallbladder and its gallstones under general anesthesia. Open cholecystectomy, the classic surgical treatment for gallstones, requires a large

If you have gallstones without symptoms, you do not require treatment.

Gallbladder cancer In rare instances, cancer can strike the gallbladder. Occurring most frequently in women, gallbladder cancer accounts for approximately 3 percent of all cancers and is usually diagnosed later in life, with a peak incidence at age 70. Symptoms include nausea, vomiting, weight loss, jaundice, and right upper quadrant pain. Some patients experience none of these signs, and the symptoms may resemble other illnesses, making gallblabber cancer difficult to diagnose until it has spread to other parts of the body. If detected early enough, gallbladder cancer may be treated with surgery, followed by chemotherapy and radiation to help prevent recurrence. Summing up The gallbladder concentrates bile from the liver, releasing it into the small intestine to break down fats and absorb fat-soluble vitamins. In some individuals, cholesterol or pigments can crystallize and form gallstones, which in turn can block related ducts and lead to infection and inflammation. For patients whose gallstones produce symptoms and complications, surgery is the most common treatment. As with any part of the body, cancer can also strike the gallbladder, although this is quite rare. Federico T. Rossi, MD, a gastroenterologist at Minnesota Gastroenterology, P.A., is board-certified by the American Board of Internal Medicine and the American Board of Gastroenterology. He has a special interest in and experience with pancreatic and biliary disorders.

abdominal incision. Laparoscopic cholecystectomy is a newer surgical treatment whereby the gallbladder is removed through a small abdominal incision using a lighted tube (laparoscope). The surgeon views the entire procedure on a television monitor. Because there is no cutting through the muscle of the abdominal wall, the recovery period under this less invasive laparoscopic approach is much shorter. Non-surgical approaches are rarely used, but can be useful in special situations when surgery isn’t the best option. These are not a routine treatment option and are rarely recommended for healthy patients. Non-surgical options include bile salt tablets; targeted shock waves intended to break up gallstones (extracorporeal shock wave lithotripsy and percutaneous electrohydraulic lithotripsy); and topical agents that help dissolve gallstones. To help prevent gallstones from recurring after treatment, your doctor may recommend that you: • Maintain a healthy body weight. • Avoid crash diets. • Be active. • Choose a low-fat, high-fiber diet.

OCTOBER 2016 MINNESOTA HEALTH CARE NEWS

PHARMACOLOGY

Off-label” drug use

“

What you should know

By Lowell Anderson, DSc, FAPhA

ow should you respond when your physician tells you: “The prescription I am ordering for you today is for an unapproved drug”? Should you be concerned?

A rigorous path to approval To clarify, any medication prescribed by your physician is, by definition, approved—but not necessarily for the specific condition or disease that your doctor has identified.

The U.S. Food and Drug Administration (FDA) approves new medications after a series of extensive clinical trials conducted by the drug manufacturer under FDA regulation. These trials are designed to determine if the medication is both safe to use and effective for use in treating the specific health conditions that were studied in the clinical trials and for which the manufacturer is seeking approval. It is important to know that when a medication has been approved by the FDA as “safe,” that does not mean that it is without side effects. As part of its approval process, the FDA also approves instructions for health care providers on how to use the medication to treat specific diseases and conditions, as well as any risks in using the medication. In the market The FDA procedures are designed to approve medications for a specific purpose. An “unapproved” use occurs when a clinician wishes to use an approved medication for diseases or conditions other than those approved by the FDA. For example, antidepressants are approved to treat depression. Yet, certain antidepressants have also been found to be useful in treating some neuropathic pain, and are considered by clinicians as a first-line treatment option for this separate health issue, even though they are not FDA-approved for that purpose—resulting in off-label use. The term also applies when clinicians prescribe medications in doses or dosage forms that differ from those approved by the FDA. It is important to understand that using an approved medication in an unapproved (off-label) manner is legal. In fact, it is common and acceptable practice for clinicians to prescribe medications for off-label use. Clinicians base their decisions on experience in using particular medications—observing how the drugs work and how patients respond to the off-label use. Clinicians also get information from scientific journals and from collaboration with colleagues in their specialty.

MINNESOTA HEALTH CARE NEWS OCTOBER 2016

There is no legal responsibility for a clinician to advise a patient that the medication being prescribed is unapproved for the health problem in question. The clinician may feel that disclosure might cause undue anxiety in a patient, which could complicate treatment. Further, constant review of the current legal status of a medication and its disclosure would be an undue burden on his

questions of a prescriber and/or pharmacist are relevant for any new prescription that is being proposed, regardless of its approval status. • What is the drug approved for? • Are there other drugs or therapies that are approved to treat my disease or medical condition?

or her time. Potential benefits

• What scientific studies are available to support the use of this drug to treat my disease or medical condition?

When might it be reasonable or necessary to use a medication in an unapproved manner? Pediatric patients are often excluded from clinical studies, meaning that a particular medication may

• Is it likely that this drug will work better to treat my disease or medical condition than using an approved treatment?

only be approved for adults. Based on expertise and experience, the clinician may decide to use morphine for pain reduction in a child, even though this is off-label use. Aspirin is not approved for coronary disease prevention in a diabetic patient, yet it is recommended in diabetic treatment guidelines. Beta-blockers, approved for treating hypertension and heart problems, are commonly used to prevent migraine headaches, and even to alleviate the fear of public speaking. Gabapentin, a medication approved for controlling seizures, is used for fibromyalgia and “restless-leg syndrome.” It is also quite common for pharmacists to compound approved medications in ways that make them easier for a patient to use—such as making a tablet into an easy-to-swallow liquid. Since off-label use is so prevalent, one might wonder why the manufacturers don’t seek approval for the off-label uses. The reason is primarily financial. Clinical trials and getting FDA approval for

• What are the potential benefits and risks of treating my disease or medical condition with this drug? • Will my health insurance cover treatment of my disease or medical condition with this drug? • Are there any clinical trials studying the use of this drug for my disease or medical condition that I could enroll in? These questions would be in addition to those you should routinely ask whenever a new medication is ordered for you: • What results should I expect from using this medication? How will I know it’s working? • What are the side effects, if any? Should I contact you if any of these side effects appear?

a medication is expensive and time consuming—current estimates for a single new medication are $2.6 billion. Filing an approval

• Is this medication covered by my health plan? • If a prior authorization is necessary, has your office initiated the request from my health plan?

Any prescription can have side effects.

• If this is a maintenance medication, have you authorized refills? • If this is a short-term medication, how long should I use it before I stop?

request for a new use for an approved medication is also expensive

• How should I dispose of any unused medication?

and there may be insufficient revenue coming from the additional use to offset the cost. For many of the medications that have been on the market long enough to be available in generic form, there may be even less opportunity to recover the investment. Seeking answers

“Orphan diseases” Another off-label use is for “rare diseases”—often called “orphan diseases.” These are infrequently occurring diseases for which developing a new medication would not be a financially sound investment. To treat these diseases, clinicians often resort to

A recent FDA document suggests posing the following questions to health care providers who have told you they are considering issuing a prescription for off-label use. This author believes that similar

“Off-label” drug use to page 34

OCTOBER 2016 MINNESOTA HEALTH CARE NEWS

“Off-label” drug use from page 33

using medications that have only been FDA-approved for other treatments. Recognizing the need to provide additional therapies for orphan diseases, Congress passed the 1983 Federal Orphan Drug Act, which provides incentives to manufacturers to develop and market new medications for rare diseases. The FDA also offers financial grants for the development of these orphan drugs. These initiatives have been successful in increasing the development of new drugs for treatment of orphan diseases. Summing up All medications are potent chemicals. Any prescription can have side effects. These side effects can be as simple as an upset stomach or as significant as affecting the functioning of a body organ. Therefore, all medications should be taken as prescribed— regardless of their approval status. Patients are best served when they understand the goals of a treatment, the duration of treatment, and the effects—and side effects—of the medication. To assist in managing the medication therapy, a patient has access to highly competent advice from either the physician or the pharmacist. The use of an approved medication for an unapproved reason—off-label

prescribing—is an important tool for the clinician. Our legal system allows the clinician to consider the evidence and make decisions based on what is best for the patient. This policy vastly increases the treatment options available for many health problems. To answer the question: “Should you be concerned?” This author believes that if you have confidence in your health care providers, you should have confidence in their clinical decisions. But in the end, we as patients are each responsible for the outcomes of our own health care.

If you have confidence in your health care providers, you should have confidence in their clinical decisions.

Lowell Anderson, DSc, FAPhA, is a professor in the University of Minnesota’s Department of Pharmaceutical Care and Health Systems and co-director of the Center for Leading Healthcare Change. He has served as president of the Minnesota Pharmacists Association, Minnesota Board of Pharmacy, and the American Pharmacists Association.

September 2016 Survey

M I N N E S OTA H E A LT H C A R E

C O N S U M E R A S S O C I AT I O N

Each month, members of the Minnesota Health Care Consumer Association are invited to participate in a survey that measures opinions around topics that affect our health-care delivery system. There is no charge to join the association, and everyone is invited. 1. The health care policies of the presidential candidates will make a difference in my vote.

2. I feel that the Affordable Care Act has had a positive impact on health care delivery.

30 20 10 Strongly Agree

Agree

No Opinion

Disagree

25 20 15 10 5

20 15 10 5 Strongly Agree

Agree

No Opinion

Disagree

Strongly Agree

Agree

No Opinion

Disagree

Strongly Disagree

5. I feel that the option to buy into a Medicare plan should be made available at age 55. Percentage of respondents

Percentage of respondents

Strongly Disagree

4. I feel that the income level to qualify for federal assistance with purchasing health care insurance should be increased.

Percentage of respondents

3. I feel that the federal government should be more active in controlling pharmaceutical costs.

Strongly Disagree

MINNESOTA HEALTH CARE NEWS OCTOBER 2016

15 10 5 Strongly Agree

Agree

No Opinion

Disagree

40 30 20 10 0

Strongly Agree

Agree

No Opinion

For more information, please visit www.mnhcca.org. We are pleased to present results of the most recent survey.

Strongly Disagree

Disagree

Strongly Disagree

JOIN US.

Be heard in debates and discussions that shape the future of health care policy. There is no cost to join this informed and informative online community. Members receive a free monthly electronic newsletter and the opportunity to participate in consumer opinion surveys.

www.mnhcca.org OCTOBER 2016 MINNESOTA HEALTH CARE NEWS

rehabilitate T oowith rehabilitate aa body, body, we we start start with the the mind mind and and soul. soul.

If you or someone you know needs rehabilitation after an accident, surgery, illness or stroke, we have a If you or someone you know needs rehabilitation after an accident, surgery, illness or stroke, we have a simple premise for you to consider: To recover physically, you need support mentally and emotionally. How simple premise for you to consider: To recover physically, you need support mentally and emotionally. How positive and how determined someone is can make all the difference. We believe the most effective therapy positive and how determined someone is can make all the difference. We believe the most effective therapy treats your body, mind and soul. That’s our approach. treats your body, mind and soul. That’s our approach. Post-acute rehabilitation services from the Good Samaritan Society are offered at multiple inpatient and Post-acute rehabilitation services from the Good Samaritan Society are offered at multiple inpatient and outpatient locations throughout Minnesota and the Minneapolis/St. Paul area. outpatient locations throughout Minnesota and the Minneapolis/St. Paul area. To make a referral or for more information, call us at To make a referral or for more information, call us at (888) GSS-CARE or visit www.good-sam.com/minnesota. (888) GSS-CARE or visit www.good-sam.com/minnesota.

The Evangelical Lutheran Good Samaritan Society provides housing and services to qualified individuals without regard to race, color, religion, gender, disability, familial status, national origin or other protected statuses according to applicable federal, stateGood or local laws. Some services may housing be provided a thirdtoparty. All faiths or beliefs are welcome. 2015color, The Evangelical Lutheran Goodfamilial Samaritan Society. All rights 15-G1553statuses according The Evangelical Lutheran Samaritan Society provides and by services qualified individuals without regard to©race, religion, gender, disability, status, national origin reserved. or other protected to applicable federal, state or local laws. Some services may be provided by a third party. All faiths or beliefs are welcome. © 2015 The Evangelical Lutheran Good Samaritan Society. All rights reserved. 15-G1553