Minnesota Health care News May 2013 by Minnesota Physician Publishing

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May 2013 â&#x20AC;˘ Volume 11 Number 5

Pediatric bipolar disorder Joel Oberstar, MD

COPD Amit Chandra, MD

Foodborne illness April Bogard, MPH

To learn more, please call the Minnesota Lung Center Research Department. 3 Convenient Locations: Minneapolis (952)852-5324 â&#x20AC;˘ Edina (952)852-5274 â&#x20AC;˘ Woodbury (952)852-5259

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CONTENTS

4 7 8

MAY 2013 • Volume 11 Number 5

NEWS

WOMEN’S HEALTH Breast cancer screening

18 20

CALENDAR Don’t Fry Day

PEOPLE

PERSPECTIVE Maureen Gaedy Goodwill/Easter Seals Minnesota

BEHAVIORAL HEALTH Pediatric bipolar disorder By Joel V. Oberstar, MD

10 QUESTIONS Elizabeth Maloney, MD Partnership for Healing and Health, Ltd.

PULMONOLOGY Chronic obstructive pulmonary disease (COPD) By Amit Chandra, MD

DRUG CLASS Corticosteroids By Anita Sharma, PharmD, and Chrystian Pereira, PharmD, BCPS

MINNESOTA HEALTH CARE ROUNDTABLE

By Annelisa Carlson, MD, MS, and Ellen L. Abeln, MD

POLICY Cancer in the workplace

PUBLIC HEALTH Foodborne illness

TAKE CARE Caregiver stress

INSURANCE Viatical settlements

By Lindy Yokanovich, Esq.

By April K. Bogard, MPH, RS

By Chris Rosenthal, MSW, LISW

By Paul Hanson

www.mppub.com PUBLISHER Mike Starnes mstarnes@mppub.com EDITOR Donna Ahrens dahrens@mppub.com ASSOCIATE EDITOR Janet Cass jcass@mppub.com ASSISTANT EDITOR Scott Wooldridge swooldridge@mppub.com

FORTIETH

SESSION

Background and focus: For the majority, end-of-life is the most medically managed part of life. With it come complex issues that involve economics, ethics, politics, medical science, resources and more. Advances in technology are extending life expectancies and require a redefinition of the term “endof-life.” It now entails a longer time frame than Addressing end-of-life issues one’s final weeks or hours and debate as Thursday, October 24, 2013 to when life is really 1:00 – 4:00 PM • Symphony Ballroom Downtown Mpls. Hilton and Towers over. Mechanisms exist to facilitate personal direction around this topic, but there is a need for improved coordination among the entities that provide end-of-life support.

Advanced care planning

Objectives: We will discuss the significant infrastructure that supports end-of-life care. We will examine the roles of long-term care/assisted living, palliative care, gerontology, and hospice. We will review the elements that go into creating advanced directives, societal issues that make having them necessary, and the difficulties encountered in bringing them to their current state. We will present a potential road map to optimal utilization of end-of-life support today and how it may best be improved in the future.

ART DIRECTOR Elaine Sarkela esarkela@mppub.com OFFICE ADMINISTRATOR MaryAnn Macedo mmacedo@mppub.com ACCOUNT EXECUTIVE Iain Kane ikane@mppub.com

Minnesota Health Care News is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; phone (612) 728-8600; fax (612) 728-8601; email mpp@mppub.com. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc., or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of this publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $36.00. Individual copies are $4.00.

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MAY 2013 MINNESOTA HEALTH CARE NEWS

NEWS

Many with Diabetes Are Unaware of It, MDH Says Approximately 80,000 adults in Minnesota may have diabetes and not know it, say officials with Minnesota Department of Health (MDH). MDH officials note that the percentage of adults in Minnesota with diabetes nearly doubled between 1994 and 2010 and that these numbers underrepresent the true number of people living with the condition. About 290,000 adults in Minnesota, or 7.3 percent, have been diagnosed with diabetes, but officials say national data suggest that another 80,000 Minnesotans may have the disease and not be aware of it. “Diabetes is a very treatable disease and it is important that everyone with diabetes takes steps to get their blood sugar under control and lead a healthier life,” says Minnesota Health Commissioner Ed Ehlinger, MD.

Officials say anyone can take a simple paper or online test at www.diabetes.org/diabetesbasics/prevention/diabetes-risktest to check his or her risk for diabetes or prediabetes. Those with a high score are encouraged to follow up with a health care provider.

Legislators Propose Cutting HHS Budget In March, House and Senate DFLers proposed cutting the state’s health and human services (HHS) budget. “It’s going to swallow up our entire budget,” said House Speaker Paul Thissen (DFLMinneapolis), who recommended cutting $150 million from the budget. If enacted, the cut would reduce the governor’s proposed $11.3 billion budget for health and human services to $11.2 billion. “It’s the part of the budget that’s growing too quickly to keep up with the revenues that are coming in,” explained Thissen. In response, a letter signed by

more than 50 groups, including the Minnesota Hospital Association, the Minnesota Medical Association, Children’s Defense Fund–Minnesota, the Minnesota Safety Net Coalition, and Hennepin County Medical Center, called for Senate and House majority leaders to reconsider the HHS cuts. The health and human services budget serves some of the sickest, poorest, and oldest Minnesotans and the agencies, hospitals, and nursing homes that care for them. The House and Senate have proposed budget increases for almost every other state agency.

U of M Expands Parkinson’s Research The University of Minnesota has been named one of five clinical sites for BioFIND, a two-year, multisite study that has the goal of discovering new Parkinson’s disease (PD) biomarkers. Biomarkers are biological indicators of a per-

son’s health status and are used to help researchers and clinicians better diagnose, understand, and track the progression of a given disease. One example of a biomarker is blood sugar level, which can help determine if a person has diabetes and, if so, whether that disease is progressing. Researchers also use biomarkers as tools in developing disease-modifying therapies to slow or stop the progression of disease. Paul Tuite, MD, an associate professor in the university’s Department of Neurology, leads the BioFIND study at the University of Minnesota Medical Center. “This research is critical to our efforts to help find a biomarker for Parkinson’s disease, a disease that affects the central nervous system in an estimated one million people,” he says. “With the support of the Michael J. Fox Foundation for Parkinson’s Research (MJFF) in partnership with the National Institute of Neurological Disorders and Stroke (NINDS), we hope to learn more

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MINNESOTA HEALTH CARE NEWS MAY 2013

about PD and ultimately put us on the right course for a cure.” Tuite and the University of Minnesota have an established history of researching PD and therapy for it. “Since our foundation’s inception, we have invested $65 million in the pursuit of Parkinson’s biomarkers,” says Mark Frasier, PhD, vice president of research programs at MJFF. “Finding such biomarkers would allow scientists to predict, diagnose, and monitor the disease, and determine which medications might work and which won’t. Biomarkers would be invaluable tools to the development of new treatments for patients. We’re optimistic that BioFIND can play a critical role in this search, and look forward to working together with the University of Minnesota and NINDS.” Tuite and his research team seek volunteers to participate in the clinical research study. Candidates are men and women over the age of 55 who have had PD for more than five years, as well as men and women over the age of 55 who do not have either PD or a first-degree blood relative with PD. (A first-degree blood relative is a biologically related parent, child, or sibling). BioFIND studies are also being conducted at Columbia University Medical Center, New York; Rush University Medical Center, Chicago; Cornell University Medical Center, New York; and the University of Chicago Medical Center, Chicago. BioFIND is sponsored by the Michael J. Fox Foundation for Parkinson’s Research and funded in part by the National Institute of Neurological Disorders and Stroke.

North Memorial, MultiCare Open Urgency Center North Memorial, along with MultiCare Associates, has opened a stand-alone emergency room at Blaine Medical Center. Officials say the North Memorial Urgency Center will be similar to a regular hospital emergency room, and

will be staffed by physicians from North Memorial’s Level I Trauma Center. A stand-alone emergency room at a medical office building is new to Blaine, but the idea has been cropping up in the Twin Cities metro area recently. The Abbott Northwestern–WestHealth Emergency Department in Plymouth, for example, opened in January. The North Memorial facility will be able to care for the same kinds of illnesses and injuries that hospital emergency rooms see, officials say, including chest pain, sports injuries, broken bones, cardiac arrest, abdominal pain, and concussions. Patients that need hospitalization can be transferred to North Memorial Medical Center in Robbinsdale, officials say. Patients also will be able to get follow-up treatment at the adjacent MultiCare Associates clinic.

HealthPartners Joins Heart Attack Initiative Bloomington-based HealthPartners has joined a national public-private health initiative that aims to prevent 1 million heart attacks and strokes by 2017. The Million Hearts campaign was launched by the U.S. Department of Health and Human Services in 2011 and includes numerous state and federal government partners along with private groups such as Kaiser Permanente, Walgreens, and the American Medical Association. As a partner, HealthPartners will set goals for cardiovascular measurements and strategies such as aspirin use, blood pressure control, treatment of high cholesterol, smoking cessation efforts, reducing sodium intake, and cutting fat consumption. “HealthPartners has a long tradition of investing in programs that prevent disease by keeping our patients and members healthy,” says Michael McGrail, MD, MPH, vice president and associate medical director for HealthPartners Health Solutions. News to page 6

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MAY 2013 MINNESOTA HEALTH CARE NEWS

News from page 5 Officials say the efforts have resulted in clinical outcomes that include 90 percent of members being tobacco-free and more than 85 percent of HealthPartners Medical Group patients with cardiovascular disease and diabetes having their blood pressure under control.

ACA Benefits Minnesotans’ Preventive Care More than 70 million Americans, including 1.4 million Minnesotans, have received free preventive health care services because of the Affordable Care Act (ACA), federal health officials say. Health and Human Services (HHS) Secretary Kathleen Sebelius announced in March that approximately 71 million Americans in private health insurance plans received coverage for at least one free preventive health care service, such as a mammogram or flu shot, in 2011 and 2012 because of

the ACA. HHS also estimates that 34 million Americans in Medicare and Medicare Advantage plans have received at least one preventive service. Officials say that, in total, 105 million Americans have been helped by the ACA’s prevention coverage improvements. According to Ellen Benavides, Minnesota assistant commissioner of health, Minnesota is similar to other states in the number of people receiving preventive services under the ACA. She says that removing copays from preventive health services increases access to such services. “The benefit of that is that you have people who access services that we all know improve the health of population,” she says. However, Benavides adds, the data from the HHS report show that there are continued disparities in how different ethnic groups access preventive services. “We’ve got enormous health disparities despite making enormous investments in our health care system,” she notes.

Two Mayo Hospitals To Combine Mayo Clinic is combining its two Rochester hospitals into one facility, officials announced in March. Effective Jan. 1, 2014, Saint Mary’s and Methodist Hospitals will become a single licensed hospital, named Mayo Clinic Hospital. Mayo Clinic currently has a “single integrated hospital practice” divided between two hospital licenses and two legal entities, a relationship created during a reorganization in 1986. The two hospitals file separate reports on quality, financial, and operating data to organizations such as the Centers for Medicare & Medicaid Services, the Joint Commission, and the Leapfrog Group. Officials say such reporting has increasingly resulted in an incomplete and incorrect picture of Mayo Clinic’s care. “We know patients seek information from government and nongovernment entities to obtain important quality and financial data,” says John Noseworthy, MD,

president and CEO of Mayo Clinic. “By continuing the integration we began in 1986, patients can have a more complete, accurate picture of the care we provide at Mayo Clinic.”

Health Insurance Exchange Becomes Law One of the most controversial pieces of health care legislation in the state’s history, a measure to create a health insurance exchange for Minnesota, has been signed into law. The exchange goes into effect Jan. 1, 2014, and will be called MNsure. State agencies say MNsure will save Minnesota families and businesses $1 billion in health care costs by 2016. With ACA tax credits, officials say, individual consumers could see an average 34 percent decrease in premiums for insurance purchased through the exchange.

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MINNESOTA HEALTH CARE NEWS MAY 2013

PEOPLE Patrick J. Flynn, MD, received the David King Community Clinical Scientist Award at the 39th national meeting of the Association of Community Cancer Centers in Washington, D.C., in March. Flynn is a medical oncologist and medical director for the Cancer Research Program at Minnesota Oncology, where he has practiced since 1985. The award recognizes active commuPatrick J. Flynn, MD

nity clinical research leaders. Award winners are

physicians who have demonstrated leadership in the development, participation, and evaluation of clinical studies and/or who are active

Prevent Pre vent strokes. strokess. Lower your your risk ttoday. oday.

in developing new screening, risk assessment, treatment, or supportive care programs for cancer patients. Flynn has been vigorously engaged in clinical research for many years. Hennepin County Medical Center (HCMC) has added staff at its Alternative Medicine Clinic in Minneapolis. Acupuncturist Jessica Brown, MOM (Master of Oriental Medicine), is

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licensed by the Minnesota Board of Medical Practice and is certified by the National Commission for the Certification of Acupuncture and Oriental Medicine. She earned her degree from

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Northwestern Health Sciences University in Bloomington, Minn., and completed an advanced studies program at Tianjin University of Traditional Chinese Medicine in Tianjin, China, with

Jessica Brown, MOM

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training that emphasized severe conditions such as stroke and other neurological disorders. Prior to joining HCMC, Brown was an acupuncturist at the Acupuncture Health Center in the Southdale Medical Center, Edina. Her areas of special interest include pain management, oncology support, womenâ&#x20AC;&#x2122;s health issues, and post-stroke rehabilitation. Chiropractor Ben Backus, DC, specializes in treating patients with chronic and acute musculoskeletal pain and dysfunction. His areas of

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special interest include treating patients with back, neck, and extremity pain, and headaches. Backus earned his doctor of chiropractic from Northwestern Health Sciences University and is a member of the American Chiropractic Association Ben Backus, DC

and the Minnesota Chiropractic Association.

The Minnesota Medical Association (MMA) and the MMA Foundation has presented Therese Zink, MD, MPH, with its Physician

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research study on the effective management of chronic kidney disease in primary care settings. Zink practices family medicine and is a professor in the Department of Family Medicine and Community Health at the University of Minnesota

Therese Zink, MD, MPH

Medical School. John Manion, MD, has received the 2013 Trustee of the Year Award from Aging Services of Minnesota. Since 1994, Manion has served on the board of directors at Saint Therese, a nonprofit that provides

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in the Upper Midwest. MAY 2013 MINNESOTA HEALTH CARE NEWS

PERSPECTIVE

A helping hand during recuperation Goodwill/Easter Seals Minnesota’s medical equipment loan program

I Maureen Gaedy Goodwill/Easter Seals Minnesota

Maureen Gaedy is a mission services director with Goodwill/Easter Seals Minnesota, overseeing its medical equipment loan program. Goodwill/Easter Seals helps people overcome barriers to education, employment, and independence in order to achieve their goals. Believing in the transformative power of work to change lives, this nonprofit organization helped more than 15,000 individuals receive 70,000 services in 2012. Goodwill/Easter Seals provides job skills training, work experience, job placement, mental health counseling, and no-cost loans of medical equipment.

magine that you or a family member needed to stay at home to heal from an accident, surgery, or debilitating illness. Now imagine that you needed a wheelchair or other durable medical equipment during your recuperation. Could you afford to purchase it? What if your insurance company’s authorization and reimbursement for that equipment took weeks to approve? Or worse, covered only a small portion of your costs?

Because post-surgery recovery typically lasts six to eight weeks, it is our policy to loan equipment for two months at a time. Wheelchairs are in high demand; as soon as one is returned by a borrower it is cleaned and sanitized, checked to ensure it still operates safely, and sent out on loan again. Happily, so many crutches and canes are donated that, at this time, we are able simply to give them away to those in need.

That scenario is all too real for many Minnesotans. That’s why Goodwill/Easter Seals Minnesota loans medical equipment to the public—at no cost—in the Twin Cities, Rochester, Willmar, and St. Cloud. More than 11,000 people borrowed 19,434 pieces of medical equipment in 2012.

Who benefits?

is donated. We constantly are in need of donations of all assistive living and medical equipment. These include such items as wheelchairs, walkers, commodes, bathtub grab rails, tub seats, transfer benches, children’s wheelchairs, and other specialty equipment. Wheelchairs and other items specifically designed for children are in particularly high demand because children outgrow their equipment so quickly.

In addition, borrowing equipment that will be needed permanently allows the person who needs it to start using it while awaiting insurance coverage approval to purchase their own equipment. And for someone who must use equipment but isn’t sure how long it will be needed, the loan program saves him or her money by not having to invest in equipment that may turn out to be needed for two months or less.

The need for equipment continues to grow. For example, while 8,036 people borrowed equipment in 2005, that number increased to 10,023 in 2011. And in 2012 it rose again, to 11,360 people. Need for this service is increasing an average of 12 percent to 15 percent each year.

Everyone benefits

How it works

To inquire about equipment availability, call one of the following numbers:

Most borrowers are over the age of 61, female, and have an acute medical need such as recovering from surgery. Based on what it would cost to buy the medical equipment we loan, Goodwill/Easter Seals estimates that this loan proHow it began gram saves Minnesotans more than $1 million a year. It also saves taxpayer This loan program began dollars, which help fund in St. Paul in 1987, after Medicare. One metro area If you no longer need a Goodwill merged with Easter physical therapist who reguSeals, an organization that piece of durable medical larly refers patients to our focused on helping individuloan program tells us, “The equipment, donate it. als with disabilities and other program makes a big, big difbarriers to independence. ference. My clients who are Additional loan program sites on Medicare are not able to get all their needs met were added in 1995. through their coverage. ” Every piece of medical equipment in our inventory

Unwanted durable medical equipment can be donated at any of the drop-off donation centers located at our 29 retail stores throughout the state, and it will get funneled to our equipment loan program. All donated equipment is cleaned, reconditioned, and sanitized. If we cannot utilize an item in our program, we either recycle the raw materials or donate the item for use overseas.

MINNESOTA HEALTH CARE NEWS MAY 2013

If you no longer need a piece of durable medical equipment, donate it. Donation benefits the donor because it is typically tax deductible. If you do need a piece of durable medical equipment, borrow it.

• St. Paul (651) 379-5922 • St. Cloud (320) 654-9527 • Willmar (320) 214-9238 • Rochester (507) 287-8699 To learn more, visit www.goodwilleasterseals.org

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10 QUESTIONS

Lyme disease Elizabeth Maloney, MD Dr. Maloney is a board-certified family physician who develops educational programs on Lyme disease. She is the president of Partnership for Healing and Health, Ltd., a medical information company based in Wyoming, Minn. How does someone contract Lyme disease? Deer ticks infected with bacteria that cause Lyme disease transmit that disease to people through their bite. Congenital infections, which are uncommon, occur when the bacteria pass from infected pregnant women to their unborn children. Tell us about the symptoms of Lyme disease. Lyme disease produces a wide variety of symptoms that differ from person to person. Symptoms tend to come and go with variable intensity. More symptoms may develop the longer an individual is untreated. The hallmark of early Lyme is a rash that appears two to 30 days after a tick bite and may be accompanied by influenza-like symptoms. The rash commonly appears as a solid reddish oval that expands and then shrinks over several weeks. The classic “bull’s-eye” rash occurs in less than 20 percent of all cases. Most importantly, data from the Centers for Disease Control and Prevention demonstrate that 30 percent of patients never have the rash. For this reason, those who live in or who have visited areas where Lyme disease has been reported should seek treatment for Lyme disease if they develop flu-like symptoms. How is it diagnosed? Diagnosis is based on a person’s risk of exposure to infected ticks, symptoms, and physical exam findings. In symptomatic patients, blood tests that detect antibodies to the bacteria support a clinical diagnosis of Lyme disease, but negative results cannot rule it out because antibodies may be absent. Early in the disease the body hasn’t had time to make antibodies, which is why antibody testing is inappropriate at this stage. What happens if Lyme disease is untreated? Untreated infection may cause many problems, such as severe and persistent fatigue. Sixty percent of those infected experience recurrent episodes of arthritis. Some experience heart rate abnormalities. These problems are readily identified and treated. Nervous system problems are also common but often go unrecognized. Untreated Lyme disease can also cause, meningitis, nerve pain, diminished sensation, balance difficulties, Bell’s palsy, visual problems, sensitivity to light and/or sound, fevers, chills, headaches, neck stiffness, numbness/tingling, trouble sleeping, and new onset of depression, anxiety, or mood swings. Many people with untreated infection report persistent difficulty with memory, thinking, and concentrating. Photo credit: Bruce Silcox

MINNESOTA HEALTH CARE NEWS MAY 2013

What can be done to reduce the risk of contracting Lyme disease? Avoiding deer ticks entirely prevents Lyme disease but when that’s not possible, be aware of potential tick exposure, use tick repellents and insecticides while in tick habitat, and promptly remove ticks. Stay in the center of hiking trails; avoid fallen logs and long grasses. Before going outside, apply insecticides and repellents. Apply insecticides containing permethrin to clothing, hats, boots, and gear to kill ticks out-

Highly effective prevention

treatment result from a lack of information. right. Repellents make ticks leave treated uses awareness of potential Doctors don’t know which approaches are areas before biting; DEET and picaradin are two repellents that can be applied to unbrobest for different types of patients, and there exposure, repellents ken skin. BioUD is a natural repellent for use is very little evidence regarding what to do and insecticides, and on gear and skin. Perform body-wide checks for patients who remain ill. If your symptoms prompt tick removal. for the tiny tick daily while in tick habitat persist, seek a second opinion from a doctor and again after leaving it to find and remove who is knowledgeable about tickborne disattached ticks. Highly effective prevention uses awareness of poteneases and the diseases they mimic. tial exposure, repellents and insecticides, and prompt tick removal. Why is there controversy about the possibility that there In Wisconsin, the number of reported Lyme disease cases is a chronic form of Lyme disease? Many within the medical increased dramatically between 1997 and 2007. To community are unfamiliar with the scientific evidence. Cases of perwhat do you attribute this? The increase in reportable cases is sistent infection in humans following antibiotic therapy are well docdue to greater exposure to ticks in their usual habitat, expansion of umented in medical literature. Antibiotics alone do not completely the areas where ticks can be found, and greater awareness of Lyme eliminate infections; the immune system also plays a role. Researchers disease by the public and physicians. Exposure can happen in one’s have discovered bacterial strains that tolerate certain antibiotics and own backyard. Minimizing exposure can be as simple as keeping have identified several mechanisms that allow the bacteria to elude grass no more than 2–3 inches tall. the immune system. Multiple research studies of animals confirm that antibiotic treatment in late-stage disease can be unsuccessful, resultHow is Lyme disease treated? Because Lyme disease is a bacteing in a persistent infection. While most patients will not become rial infection, antibiotics are the primary treatment. The type of chronically infected, claims that no one is are simply wrong. antibiotic and the duration of treatment depend on several factors, including the stage and severity of the disease and whether a person What does the future hold for improving diagnosis of has concurrent tickborne illnesses or medical conditions that may Lyme disease? A recently published scientific paper (International weaken the immune system’s ability to combat the bacteria. Journal of Medical Sciences, 2013) described a new laboratory method for culturing, or “growing,” bacteria obtained from patients. Why do professional opinions differ as to the best way This breakthrough may eventually help doctors diagnose Lyme disease to treat Lyme disease? Most differences in opinion regarding earlier and determine when the infection has been fully cleared.

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MAY 2013 MINNESOTA HEALTH CARE NEWS

PULMONOLOGY

Chronic obstructive pulmonary disease (COPD)

hronic obstructive pulmonary disease (COPD) is the overall name for several conditions that make it hard to breathe. It includes emphysema, chronic bronchitis, and asthma. Emphysema is caused by destruction of lung tissue. This traps air in the lungs and overinflates them, leading to difficulty inhaling and shortness of breath. In chronic bronchitis, mucus is overproduced, gets infected, and clogs airways. Asthma’s hallmark is inflammation that constricts airways, making it difficult to inhale and exhale. People with COPD may have one or more of these conditions.

How to handle it By Amit Chandra, MD

Who has it? An estimated 4.1 percent of Minnesotans, or 164,652 individuals, have COPD, the fifth-leading cause of death in the state. It occurs equally in men and women and is more likely to be diagnosed with increasing age.

Risk factors Cigarette smoking is the main culprit, but exposure to lung irritants at home and in the workplace, including air pollution, chemical fumes, dust, and secondhand smoke, also can be contributing factors. A less common cause is the inherited disorder alpha1-antitrypsin deficiency, which can cause COPD in someone who does not smoke and worsen the disease in someone who does. Eighty percent of Minnesotans with COPD smoke or used to smoke and unfortunately, one-third of them still do. It is important to note that risk of developing COPD increases with the number of years someone smokes and the number of packs smoked. So the best way to minimize this risk is never to start smoking or to stop smoking if you currently do. Symptoms and diagnosis

Symptoms can begin as early as someone’s late 30s. Although COPD almost always develops slowly over the course of years, symptoms often feel to the person who has them as if they’ve appeared over the course of only months or even weeks. Because everyone is different, the severity of someone’s shortness of breath may not correlate with the degree of reduction in that person’s breathing capacity. Diagnosis is typically accomplished by a simple, painless breathing test called spirometry. (Alpha-1-antitrypsin deficiency is diagnosed by blood tests.) Many people attribute breathing problems to getting older or being out of shape. As a result, they delay consulting a doctor until they are having a lot of trouble breathing. However, it’s important to consult a doctor if you have a cough or shortness of breath that persists. Although COPD can’t be cured, initiThe best way ating treatment promptly helps control symptoms, slows the rate of decline in to minimize this breathing function, and improves a risk is never to person’s quality of life. Treatment

start smoking or to stop smoking if you currently do.

It’s tough to quit smoking. If you need help quitting, talk to your doctor about medication and nicotine replacements that support tobacco cessation. In addition, research shows that smokers who use phone counseling are more likely to quit than those who don’t use phone counseling. Everyone in Minnesota can take advantage of free phone counseling for smoking cessation. This support is typically covered by health

MINNESOTA HEALTH CARE NEWS MAY 2013

insurance and is also available to those without health insurance through QUITPLAN (see Resources). Self-care 1. Exercise. Poor physical condition worsens shortness of breath. Everyone with COPD can benefit from regular physical activity; a person’s level of activity will vary according to the severity of his or her condition. 2. Pulmonary rehabilitation. COPD sufferers who become short of breath when walking at their own pace on level ground should engage in pulmonary rehab therapy programs, offered through many hospitals. During therapy, individuals participate in regular, monitored exercise. This helps them learn to gauge when shortness of breath is acceptable and when it poses unnecessary risks. It teaches breathing techniques to help them get through episodes of shortness of breath, and also includes an educational component that helps individuals understand and manage life with COPD. 3. Use medication properly. Medications help reduce symptoms, reduce frequency and severity of flareups, and improve overall health and exerEveryone cise tolerance. People with milder COPD with COPD may use only one inhaler on an as-needed basis. Those with more advanced COPD can benefit might use one or more medications on a from regular regular basis. Steroid pills (prednisone) physical may be prescribed for flare-ups or for activity. regular use. Supplemental oxygen also may be prescribed. It is vital to have your doctor explain the role of each COPD medication and to follow proper technique for using your inhaler(s). 4. Learn about your equipment. Nebulizers, oxygen delivery systems, and secretion-clearance devices are some of the equipment used by people with COPD. Understanding how to use equipment correctly, how to clean and maintain it, what to expect from it, and how to contact the equipment supplier with questions is essential. This information can be overwhelming when first presented, so it is helpful to have a family member present during instruction. Oxygen delivery systems are not “one size fits all.” They each have different capabilities so the only way people can ensure they are receiving enough oxygen to meet their needs is to have the amount of oxygen received tested while using the oxygen delivery system at home. Testing is done with an oximeter, a noninvasive device that measures the amount of oxygen in a person’s blood without requiring a blood sample. Some people choose to measure this while they perform different activities so that they can adjust the amount of oxygen they consume accordingly. 5. Prevent infections. Respiratory infections often trigger COPD flare-ups. Get influenza and pneumococcal vaccinations, clear mucus from your lungs, use good hand-washing and general hygiene practices, and avoid sick people. You know your body best, so it makes sense that you would be the first to identify early signs of a flare-up. Signs can include a change in the amount, consistency, or color of your secretions. Another sign can be a significant increase in shortness of breath that differs from your normal shortness of breath, especially if it is not relieved by using your inhalers. Ask your physician to help you to

Resources • QUITPLAN: Free, one-on-one telephone counseling for quitting smoking. (888) 354-7526. www.quitplan.com • To find Better Breathers Clubs and Pulmonary Rehabilitation Programs, or to be added to the mailing list for the free airLINES newsletter, contact (651) 227-8014/(800) LUNG USA or visit www.lungmn.org • LungHelp Line: Speak with a respiratory therapist, nurse, or tobacco cessation expert who will answer your lung health questions. (800) LUNG USA. www.lunghelpline.org

develop an action plan to identify early signs of an infection or flare-up and medications you can use to quickly address those symptoms. 6. Realize that you are not alone. Having a chronic disease can feel overwhelming and test your coping skills. Getting your family involved in your care and knowledgeable about COPD is important, as is interacting with others who have chronic lung disease. Better Breathers Clubs are support groups for adults with chronic lung disease, feature speakers on respiratory topics, and offer opportunities for learning and camaraderie with others who can easily relate to your concerns and share information about how they have tackled problems. Armed with proper education about your condition, you CAN live a full life with COPD. Amit Chandra, MD, is a board-certified pulmonologist who practices at Respiratory Consultants, PA, in Robbinsdale.

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DRUG CLASS

Corticosteroids

here is a lot of talk about corticosteroids in the media these days, usually focusing on the shorthand name for this class of drugs, which is “steroids.” Typically the discussion is about performance-enhancing products used by athletes, but in truth, this class includes a variety of drugs that are used for medicinal purposes. Steroids have a wide range of use because they are man-made versions of the hormone cortisol, which plays a role in many bodily processes, including response to physical stress, maintaining blood pressure, and ensuring biological equilibrium. While the effects of corticosteroids on the body range widely, members of this drug class are used mainly for decreasing inflammation and for inhibiting processes that trigger the immune system. This By Anita Sharma, PharmD, article will discuss common forms of drugs in this class, their and Chrystian Pereira, PharmD, BCPS uses, and their side effects.

Powerful inflammation-fighters

Topical “Topical” means that something is applied to the skin, and corticosteroids have been delivered to the body in this manner for more than 50 years. Topical corticosteroids exist as ointments, creams, and lotions. Because ointments stay on the skin longer than do creams and lotions, this permits longer contact between drug and skin, thus enhancing absorption of the drug by the skin. Topical corticosteroids are used to treat inflammatory skin conditions such as eczema, psoriasis, and atopic dermatitis. The drug decreases the size of a skin lesion by suppressing the allergic reaction, which is an immune response that makes the lesion visible. All topical steroids can induce skin atrophy, or thinning of the skin. This risk is increased by using higher potency topical steroids for prolonged duration and by use in older patients who already have agerelated thin skin. Permanent skin atrophy from topical corticosteroids is not a common problem if the drugs are used properly. However, increased duration of use can cause permanent stretch marks, usually on the upper inner thighs, under the arms, and in elbow and knee creases. Graduate School of Health & Human Services

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MINNESOTA HEALTH CARE NEWS MAY 2013

Oral Oral corticosteroids are available in the form of tablets, capsules, or syrups. These forms are digested and the drug is absorbed into the bloodstream. The drug can then travel throughout the entire body, which means that it’s called a “systemic” drug. The fact that orally administered steroids are systemic gives them the potential to affect the immune system and reduce inflammation in all different regions of the body. The amount of suppression from the steroid depends on how much exposure a given part of the body has to the drug, which is determined primarily by the size of the dose. The anti-inflammatory effect of the steroid prednisone, for example, is used to help manage the pain and joint destruction caused by inflammation in autoimmune conditions such as rheumatoid arthritis and systemic lupus erythematosus. If the dose is increased, the same immunosuppressive property of this drug class can be used to help an organ recipient prevent rejection of the transplanted organ.

Risk of negative side effects of oral corticosteroids increases the can cause skin to longer the drug is used and the greater the dose that is used. Longbecome thin at the term use of oral corticosteroids can cause the body to produce less point of repeated injection. It is also possible to have steroids travel natural steroid, thereby decreasing the body’s ability to respond to outside the joint and cause other problems, similar to side effects physical stress. Additionally, prolonged suppression of the immune associated with oral corticosteroids. However, the extent of this system increases the risk of infections. Long-term use systemic influence varies among patients. also has been associated with decreased bone density. Make sure Important tool The effects of systemic corticosteroids on the eye condito discuss any Corticosteroids remain an important class of drugs for tion called open angle glaucoma are mild, and are more treating many types of inflammatory conditions, and plans to use likely to develop after a year or more of systemic cortiapplications continue to expand. For example, a new costeroid treatment. Glaucoma is associated most often steroids with oral corticosteroid, Uceris (budesonide), was approved with longer-acting oral steroids, such as betamethasone your health by the Food and Drug Administration in February 2013 and dexamethasone, and less often with immediatecare provider. for the treatment of ulcerative colitis. Uceris’ effects are acting steroids like prednisone and with short-acting local and target predominantly the colon. Patients using steroids such as hydrocortisone and cortisone. The elethis drug should avoid grapefruit juice because it can increase levels vated eye pressure that can cause glaucoma is usually reversible after of Uceris in the blood and therefore magnify its effects. an individual stops using the drug. Corticosteroids have been an important part of health care treatOther common side effects associated with oral corticosteroid use ment for decades, and generally have been used safely. The amount of include increased appetite and resulting weight gain, increased blood sugar levels and blood pressure, and trouble sleeping. Not all patients corticosteroid, its form, and the duration of its use are all factors that influence how the medication affects the body. experience these side effects, and how often side effects occur varies Make sure to discuss any plans to use steroids with your health from one patient to another. Techniques to minimize side effects of care provider and consider both known benefits and cautions before oral corticosteroids include using them for the shortest duration posextended or prolonged treatment. sible, taking the smallest dose possible, and monitoring for expected side effects. When long-term use is needed, consider additional calAnita Sharma, PharmD, is a Pharmaceutical Care Leadership resident at the University of Minnesota and at Smiley’s Family Medicine Clinic, Minneapolis. cium supplements to moderate the risk of Chrystian Pereira, PharmD, BCPS, is an assistant professor in the University decreased bone density.

Inhaled corticosteroids are a valuable tool in the control of asthma, which is a chronic inflammatory disorder. Corticosteroids released by inhalers reduce inflammation, thereby opening the lung’s air passages. In the process, these drugs also decrease the amount of mucus inside airways, produced by the body as part of the inflammatory response. Decreasing inflammation and the amount of mucus makes it easier for oxygen to move through the airways. In its inhaled form, most of this drug stays in the lungs and only very small amounts of it are absorbed into the body. Therefore, these medicines do not tend to cause the more serious long-term side effects associated with oral forms of this drug class. Research published in the New England Journal of Medicine in 2006 assessed effects of inhaled corticosteroids on children and their physical development later in life. The researchers reported that even though using inhaled corticosteroids may slow a child’s growth when the child first starts using inhalers, the child typically grows to a normal height by adulthood. In general, inhaled corticosteroids are well tolerated and safe at the recommended dosages. Injected Injectable steroids may be prescribed for patients who do not respond to or tolerate other anti-inflammatory therapies, and can also be injected directly into joints to reduce inflammation. For example, injection of the steroid cortisone directly into a shoulder is sometimes performed to treat so-called “frozen shoulder,” arthritis, and rotator cuff injury. However, use of this type of therapy is limited; repeated injections into a joint can damage that joint’s connective tissue and

of Minnesota College of Pharmacy and a clinical pharmacist at Smiley’s Family Medicine Clinic.

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The Telephone Equipment Distribution Program is funded through the Department of Commerce Telecommunications Access Minnesota (TAM) and administered by the Minnesota Department of Human Services MAY 2013 MINNESOTA HEALTH CARE NEWS

WOMEN’S HEALTH

Breast cancer screening Detection, treatment, and prevention of breast cancer Photo credit: Suburban Imaging/Jodi Fiedler

By Annelisa Carlson, MD, MS, and Ellen L. Abeln, MD

In the next issue.. • Spinal fusion • Nail salon safety • Pancreatic cancer research

Breast cancer is the most common cancer among women, accounting for approximately 34 percent of female cancers diagnosed in Minnesota, similar to the national average. According to the Minnesota Department of Health, about 3,700 new cases of breast cancer are diagnosed in Minnesota women each year. (Breast cancer occurs in men, too, but far less often. Any changes in a man’s chest should prompt him to contact his health care provider.) Recently, the media has publicized women with a diagnosis of breast cancer who decided to prevent breast cancer in the opposite, healthy breast by removing it. This procedure is called contralateral prophylactic mastectomy. Also, there have been reports of women who chose to remove both breasts before cancer was detected. This procedure is called bilateral prophylactic mastectomy. Such reports, plus conflicting screening recommendations publicized during the past few years, have produced confusion. What should women know about screening for breast cancer? If a woman is diagnosed with it, what are her treatment options? Should she consider removing both breasts? How can a woman minimize her risk of developing this cancer? Early detection of breast cancer Let’s start with what we know: The sooner breast cancer is detected and treated, the greater a woman’s likelihood of survival. Mammography is the best method to find breast cancer at its earliest stage and has been shown to decrease death from breast cancer. However, its benefits for women may differ depending on a woman’s age. For women ages 40–49, most major health organizations have concluded that mammography’s survival benefits outweigh its risks (which include false positive results) and recommend yearly mammograms for women 40–49. In women 50–69, mammography’s benefits are more clear. Based on evidence from many research studies, women ages 50–69 should have annual mammograms. In women age 70 and older, the role of screening mammography in saving lives becomes less certain, perhaps because there are significantly fewer studies on mammography in older women. Most major health organizations recommend that healthy women age 70 and older schedule mammograms on a regular basis since breast cancer risk increases with age. Mammography maintains success in early detection, regardless of a woman’s age. If there is any question about whether a woman should continue getting screened, she should consult her primary physician. Prophylactic mastectomy When a woman is diagnosed with breast cancer, she and her surgeon discuss her options. One is to remove the cancer and some surround-

MINNESOTA HEALTH CARE NEWS MAY 2013

Mammography has been shown to decrease death from breast cancer. ing normal tissue, which is called a lumpectomy. Sometimes, lumpectomy is not an option because of the size or extent of the cancer. If that’s the case, a woman typically elects to remove the entire breast, which is called a mastectomy. Some women decide to remove the other breast at the same time, i.e., to have a contralateral prophylactic mastectomy. Contralateral prophylactic mastectomy Why would someone consider removing a healthy breast? Women with cancer in one breast may benefit from removing the healthy breast if they’re at high risk of breast cancer. This includes those with an Women underlying gene mutation such ages 50-69 as the BRCA1 or BRCA2 gene, should which can be detected with the help of a genetic counselor rechave ommended by the woman’s annual health care provider. It also mammoincludes those who have additional factors that make it hardgrams. er to evaluate the healthy breast via mammography or ultrasound. Such factors can include dense breast tissue or calcifications within the breast. Some women choose to remove the opposite healthy breast for cosmetic reasons, believing it will increase the likelihood that both breasts will look alike after surgical reconstruction.

Shivering cold.

Between 1993 and 2003, contralateral prophylactic mastectomy in the U.S. among patients with breast cancer on one side increased by 150 percent. While this procedure has been shown to reduce the risk of developing cancer in the healthy breast, it may not actually decrease a woman’s risk of death from breast cancer. In addition, in women with breast cancer that is detected at an early stage, the risk of removing the opposite healthy breast may outweigh the benefit. That’s because surgery to remove the healthy breast carries with it the risk of infection and other complications inherent in surgery. In other words, it may cause more harm to a woman to remove her healthy breast than it may help prevent her risk of dying of breast cancer. Overall, removing the opposite healthy breast is reported to decrease incidence of breast cancer in that healthy breast by nearly 95 percent. This procedure’s reduction of cancer risk is never 100 percent because there is always a small amount of residual breast tissue left behind following mastectomy. A woman’s decision to remove the healthy breast should be made following consultation with the team of physicians caring for her during breast cancer treatment. This includes her surgeon, medical oncologist, radiation oncologist, and a genetics counselor, particularly if the patient is young or has a strong family history of breast cancer. Women considering removal of the opposite breast should know that one nonsurgical way to reduce the risk of breast cancer in Breast cancer screening to page 19

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May Calendar Through Aug. 31 Anatomy Exhibit University of Minnesota presents Appliances of Science: Anatomical Substitutions through Time. Come learn about the history of prostheses and rehabilitation through primary resources, text, instruments, and artifacts. Free. Call (612) 626-6881 for more information. Monday–Saturday, through Aug. 31, 8 a.m.–4:30 p.m., Wangensteen Historical Library, 5th Floor Diehl Hall Duels, 505 Essex St. S.E., Minneapolis

Multiple Sclerosis Acorda Therapeutics presents Gareth Parry, MD, as he discusses multiple sclerosis (MS) and how it can affect you or someone you care for. Come join us for a free interactive and educational program. Complimentary food served. To register or for more information, call (866) 397-8082. Monday, May 6, 12:15 p.m.–1:15 p.m., 50 Willey Hall, MPC Seminar Rm., 225 19th Ave. S., Minneapolis Thyroid Health Mississippi Market Co-op presents Sara Jean Barrett, ND, as she discusses thyroid health. Learn how sluggish thyroid function can impede overall health and what key nutrients are necessary for optimal thyroid function. Cost is $5 for co-op member/ owners; $10 for nonmember/owners. Register at www.eventbrite.com Thursday, May 9, 6–7 p.m., Mississippi Market Co-op, 1500 W. 7th St., St. Paul Ataxia Support The National Ataxia Foundation offers this support group for people afflicted by ataxia and their friends and family. Come and receive support from others suffering from this same condition. No registration necessary. Call Lenore at (612) 724-3784 for more information. Saturday, May 18, 10 a.m.–12 p.m., Langton Place, 1910 W. Cty. Rd. D, Roseville

18–19

Health Expo My Health and Wellness Expo is a two-day event featuring vendors, nonprofits, city agencies, healers, and providers from all

Infant CPR Regina Medical Center offers a basic infant cardiopulmonary resuscitation class for parents and caregivers. No certification is given with this class. Free. Call (651) 4041200 to register or for more information. Monday, May 20, 7–9 p.m., Regina Medical Ctr., Family Birthing Ctr., 1st Floor Classroom, 1175 Nininger Rd., Hastings

Caregiver Support Allina Health presents this free caregiver support group. Receive emotional support from peers and learn about the resources and activities available to caregivers. No registration required. Call (763) 236-8910 for more information. Thursday, May 23, 3:30–5:00 p.m., Mercy Hospital, 4050 Coon Rapids Blvd., Coon Rapids

RESOLVE Infertility Lakeview Health presents a support group for those struggling with infertility. Come to share your experiences and receive support. This group meets the fourth Tuesday of every other month. Free. No registration required. Call (651) 430-1758 or (651) 253-2746 for more information. Tuesday, May 28, 7–8:30 p.m., Lakeview Hospital, 927 Churchill St. W., Stillwater

Disability Workshop PACER Center presents Lori Guzmàn, JD, as she discusses what families should consider when planning to protect and assist a child with disabilities in the transition to adulthood. Learn about guardianship and conservatorship. Free. Register at www.pacer.org. Call (952) 838-9000 for more information. Tuesday, May 28, 6:30–8:30 p.m., PACER Ctr., 8161 Normandale Blvd., Minneapolis

Don’t Fry Day Did you know that skin cancer is the most common form of cancer in the United States? Over 2 million new cases of skin cancer are diagnosed in the U.S. each year, comprising about half of all other types of cancers combined. It is estimated that one American dies every hour from skin cancer. Skin cancer is one of the most preventable forms of cancer, yet the incidence rate for it is rising while the incidence rate of other common cancers is falling. For these reasons, the National Council on Skin Cancer Prevention has designated the Friday before Memorial Day “Don’t Fry Day.” There are several steps that you can take to protect your skin this summer: • Seek shade when possible. • Limit the amount of time in direct sun, especially from 10 a.m. to 4 p.m. • Wear protective clothing: sunglasses, long sleeves, and a wide-brimmed hat. • Avoid intentional tanning and sunburning. • Wear sunscreen of SPF 15 or higher on all skin that isn’t covered, even on cool or cloudy days. For more information on Don’t Fry Day or skin cancer, visit: www.skincancerprevention.org

22 Minnesota Cancer Alliance Minnesota Cancer Alliance hosts a meeting so participants can learn about Minnesota’s cancer burden, current cancer legislative activities, and discuss future Alliance actions. Free. Register at www.mncanceralliance.org Contact Heather at heather.hirsch@state.mn.us for information. Wednesday, May 22, 1–5 p.m., Wilder Foundation, 451 Lexington Pkwy. N., St. Paul over the country. Learn about a healthy lifestyle and products that are available. Admission is free and open to all ages. Call (602) 625-3000 for more information. Saturday, May 18, 10 a.m.–5 p.m., Sunday, May 19, 11 a.m.–4 p.m., Minnesota State Fair Grandstand, 1265 Snelling Ave., St. Paul

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. Fax submissions to (612) 728-8601 or email them to mmacedo@ mppub.com. 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 MAY 2013

Breast cancer screening from page 17

the healthy breast is by using medications such as Tamoxifen or aromatase inhibitors. Bilateral prophylactic mastectomy If a woman has a family history of breast cancer, she should be evaluated to see if she carries the breast cancer gene BRCA1 or BRCA2. Women with this genetic predisposition to breast cancer may wish to talk with their physician about undergoing removal of both healthy breasts before breast cancer develops. This procedure is called a bilateral prophylactic mastectomy. Use of medications such as Tamoxifen or aromatase inhibitors by high-risk women who have not yet been diagnosed with breast cancer has been shown to decrease their risk of a future diagnosis of breast cancer. The type of surgical procedure chosen by a woman diagnosed with breast cancer or with a high risk of developing breast cancer is a highly personal decision. A woman should be aware that all members of her health care team can give her valuable information that can help her make the best decision for her own unique circumstance. How to reduce risk of breast cancer The American Cancer Society recommends the following to reduce the risk of developing breast cancer: • Maintain a healthy body weight throughout life. • Practice portion control; avoid excessive weight gain. • Engage in at least 150 minutes of moderately intense physical activity or 75 minutes of vigorous physical activity each week, preferably spread throughout the week.

other screen-based entertainment. • Consume a healthy diet, emphasizing plant-based foods. • Limit alcohol intake. Women should also determine their personal risk for breast can-

The sooner breast cancer is detected and treated, the greater a woman’s likelihood of survival. cer by learning their family health history. If a woman’s mother or sister was diagnosed with breast cancer before age 40, or if she has multiple relatives with a diagnosis of breast and/or ovarian cancer, she should talk with her physician about being evaluated for a genetic predisposition to breast cancer. Despite controversy surrounding breast cancer care, women should be confident that their health care team is always available to help them navigate information regarding diagnosis and treatment. We have the tools to detect breast cancer early, and we have the ability to treat women successfully. Schedule your mammogram today. Annelisa Carlson, MD, MS, is a breast-imaging fellow at the University of Minnesota. Ellen L. Abeln, MD, is a board-certified radiologist and is the  medical director of the Breast Center of Suburban Imaging in Coon Rapids, a facet of Suburban Radiology.

• Limit sedentary behavior such as sitting, watching television, and

Health care for the whole person.

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MAY 2013 MINNESOTA HEALTH CARE NEWS

B E H AV I O R A L H E A L T H

Pediatric bipolar disorder Vigilance is the key to management By Joel V. Oberstar, MD It’s estimated that between 0.5 percent and 5 percent of youth in the U.S. suffer from the chronic mental health condition called bipolar disorder. The good news is that with diagnosis and treatment these youngsters can lead productive and satisfying lives.

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What is it? Previously referred to as manic-depressive disorder, bipolar disorder is an illness in which patients suffer from varying “mood episodes.” At times they are extremely depressed, while at other times their mood and energy are quite elevated. It is likely caused by a variety of factors that include genetics and life stressors, and exists in three forms: bipolar I disorder, bipolar II disorder, and bipolar disorder NOS. Diagnosing bipolar illness A diagnosis of any form of this condition is made by identifying a mix of one or more of the following mood episodes. A major depressive episode is a period of severe depression lasting two weeks or longer. A manic episode is characterized by mania. Mania consists of euphoria and high energy and can include psychosis, which is characterized by defective contact with reality and can be accompanied by hallucinations or delusions. Manic episodes typically last one week or longer. Hypomania is less intense than mania and typically lasts less than one week. A mixed episode typically lasts one week or longer and involves a patient meeting criteria for both manic and major depressive episodes. Patients with bipolar I disorder are those who have experienced at least one manic or mixed episode. Those with bipolar II disorder have experienced at least one episode of major depression and one episode of hypomania. Patients who experience multiple symptoms of one of these four episodes at varying times, but whose symptoms do not meet full criteria for I or II, are described has having “bipolar disorder not otherwise specified,” or bipoMany patients lar disorder NOS.

with chronic bipolar illness go on to lead very fruitful, fulfilling, and productive lives.

or something completely different? Such cases can be quite difficult to diagnose accurately. For other kids, especially adolescents, a diagnosis of bipolarity can sometimes be crystal clear. Consider a 16-year-old male with no previous psychiatric history who, after a heated debate with a classmate, slips into a five-day period of sleeplessness, racing thoughts, rapid speech, agitation, and grandiose delusions of being Jesus Christ. His behaviors are so dramatic that he requires hospitalization in a psychiatric facility. He has no history of using drugs or alcohol and has a paternal uncle whom every family member characterizes as having classic bipolar I disorder. This patient undoubtedly is experiencing an acute manic episode. In this case, a diagnosis of bipolar I disorder is quite appropriate.

Mood Episode Symptoms Major Depressive Episode Sadness Irritability Hopelessness Suicidal thinking Manic Episode Grandiosity Euphoria Pressured speech (rapid, urgent, difficult to interrupt) Flight of ideas Decreased need for sleep

Accurate diagnosis is the first step

Hypomanic Episode Increased goal-directed activity Decreased need for sleep

Parents who wonder if their child’s mood or behavior suggests bipolar

Highly productive behavior

Pediatric bipolar disorder to page 25

Irritability

Diagnostic challenges

While the expression of bipolar illness in adults is frequently quite apparent, making the diagnosis in youngsters is often much more challenging because many kids do not meet full criteria for a diagnosis of bipolar I disorder or bipolar II disorder. One reason is that a child or adolescent may not exhibit symptoms of sufficient duration. Additionally, many young patients have a mix of symptoms that are not easily classified into one specific illness. Consider a 10-year-old boy with a history of fetal alcohol exposure, who was adopted from an orphanage (where he may have experienced neglect, abuse, or both) at age 5, and who exhibits dramatic mood swings from rageful aggression to weeping hopelessness. Does he have pediatric bipolar disorder, a fetal alcohol spectrum disorder, post-traumatic stress disorder, some combination of these conditions,

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POLICY

Can I be fired because I have cancer? My supervisor said I’d better come back full time when my leave is up or else there won’t be a job to come back to. Is that legal?

Cancer in the workplace Know your rights By Lindy Yokanovich, Esq.

I haven’t told anyone at work that I’m receiving cancer treatment. It’s my business; why should they know? These and other work-related questions confront people who already may feel overwhelmed by juggling cancer treatment in addition to the practical and legal complications that arise as a direct result of their cancer diagnosis. Although a diagnosis of cancer can feel overwhelming, employees need to know their rights in order to advocate effectively for themselves in the workplace. Legal protection Three main laws protect Minnesota cancer survivors in the workplace: the Americans with Disabilities Act (ADA), the Minnesota Human Rights Act (MHRA), and the Family Medical Leave Act (FMLA). It’s easy to get lost in the alphabet soup of various laws, but it’s important for cancer survivors to understand what each law is designed to do. The ADA

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MINNESOTA HEALTH CARE NEWS MAY 2013

and MHRA aim to keep people with disabilities in the workplace by providing reasonable accommodations and protections against discrimination. The MHRA provides additional protections beyond what the federal ADA would otherwise provide to Minnesota employees. The FMLA provides employees with job-protected leave that allows them to step out of the workplace to care for themselves or a loved one with a serious health condition.

appointments, or leave to seek or recuperate from treatment. Undue hardship typically is interpreted as causing the employer significant difficulty or expense and is determined on a case-by-case basis. Both the ADA and MHRA require only those employers with 15 or more employees to provide reasonable accommodation. Arriving at a reasonable accommodation requires both employee and employer to engage in an informal “interactive process.” The employer isn’t required to accept the employee’s proposal unquestioningly. However, the two must work together to try to arrive Where to get help at a workable solution. It’s prudent for the employee to maintain a written record of these interactions. This Cancer Legal Line coordinates pro bono (i.e., free) legal services includes email to the employer requesting a meeting and for Minnesotans affected by cancer and who otherwise would not be able to afford an attorney’s help for legal issues that accompany the reason for it, and follow-up email to the employer reita cancer diagnosis. Cancer Legal Line provides legal assistance erating what was discussed and agreed upon, including calin the following areas: endar dates agreed upon for employee absences. • Insurance (COBRA, health insurance coverage denials, STD/LTD) Telling a supervisor about one’s cancer can be frighten• Housing and Financial (foreclosure, eviction, debtor/creditor, ing. However, an employee who does not inform his or her bankruptcy) employer of a disability or the need for reasonable accom• Employment (ADA/MHRA, FMLA) modation is not eligible for ADA/MHRA protection. • Legal Planning (wills, guardianships, health care directives, For example, an employee may think that the best way Powers of Attorney) to keep his job is to schedule radiation treatments around • Public Benefits (SSI, SSDI) his regular workday and not discuss his need for a reasonable accommodation with his employer. All too often, though, this actually works against him. Fatigued by treatment, the Staying on the job Protections against discrimination The ADA and employee may think he is still meeting job expectations. However, his employer notes that his job performance is slipping and decides to the MHRA are similar laws that do two very terminate the employee for poor performance. In this case, because important things to protect cancer survivors in

the workplace. The first is to provide protections against discrimination by an employer on the basis of an employee’s disability. Under the ADA, “disability” is defined as (a) a physical or mental impairment that substantially limits one or more major life activities, (b) a record of such an impairment, or (c) being regarded as having such an impairment. People diagnosed with cancer will almost always meet these laws’ definition of having a disability because “major life activity” includes “the operation of a major bodily function, including but not limited to … normal cell growth …” Since cancer is defined as “uncontrolled growth and spread of abnormal cells,” it is hard to imagine a situation in which a person diagnosed with cancer would not be found disabled according to the ADA and MHRA. Individuals whose cancer is in remission are also protected. That’s because the ADA states that an impairment which is “episodic or in remission” is disabling if it substantially limits a major life activity when the impairment is in its active state. The ADA applies these protections to employees of employers with 15 or more employees, but in almost every circumstance the MHRA extends them to all Minnesota employees.

Providing reasonable accommodation The second protection the ADA and the MHRA provide for cancer survivors is to require employers to provide “reasonable accommodation” to employees unless doing so would cause the employer “undue hardship.” Generally, this means modifying the work environment to enable a qualified disabled individual to perform essential functions of the job. Reasonable accommodations may include: adjusting work schedules, reallocating marginal tasks to another employee, allowing periodic breaks throughout the day to take medication, leave for medical

Cancer in the workplace to page 24

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MAY 2013 MINNESOTA HEALTH CARE NEWS

ment by a health care provider.” Most forms of cancer typically satisfy this requirement. If an employee has, as a benefit of employment, the employee did not tell the employer of his disability and his need paid time off in the form of vacation time, sick leave, or other paid for a reasonable accommodation, and because the employer did not time off, the employer may require the employee to take that paid know about the disability, the employee is not protected by the ADA leave concurrent with the FMLA time. or MHRA. In that case, if an employee has two weeks of paid Time off vacation and one week of paid sick leave, he or she still is entitled to only 12 weeks of job-protected leave. FMLA leave permits 12 weeks of unpaid, job-protected The employee would have three weeks paid leave (two leave in a 12-month period for employees to care for weeks of paid vacation plus one week of paid sick their own “serious health condition” or that of their leave) and nine weeks unpaid, not three weeks of paid spouse, parent, or child. (Domestic partners are not leave followed by 12 weeks of FMLA. The employer included in FMLA leave protection. Some employers may require certification from the employee’s health provide job-protected leave allowing an employee to An employee care provider to support the request for time off. care for a partner, although it’s not legally required.) FMLA leave may be taken in one 12-week block of To qualify, all of the following conditions must be met: who does not time or intermittently as needed. (1) The employer must employ 50 or more employees inform his or Often, cancer patients who use their 12 weeks confor 20 or more calendar workweeks in the current or preceding calendar year. her employer is secutively in one block of time find they need additional time off due to their cancer diagnosis or treatment. (2) The employee must have been employed for at least not eligible for At this point, additional unpaid time from work might 12 months by the employer from whom leave is be requested as reasonable accommodation under the ADA/MHRA requested. ADA/MHRA. Whether or not such a request is granted (3) The employee must have worked at least 1,250 protection. depends entirely on whether it would be an “undue hours during the last 12 months. hardship” on the employer’s business. (4) The employee works at a location at which the Lindy Yokanovich, Esq., is the founder and executive employer has 50 employees within 75 miles.

Cancer in the workplace from page 23

FMLA defines “serious health condition” as “an illness, impairment, or physical or mental condition that involves … inpatient care … or continuing treat-

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Pediatric bipolar disorder from page 21

illness should consult their child’s primary care provider to explore whether the child’s symptoms indicate the presence of mental illness. Because pediatric bipolar disorder is quite rare compared with other illnesses (anxiety, depression, and ADHD, for example, are much more common), consideration must be given to identifying what is causing the child’s symptoms. Referral to a mental health professional such as a psychologist or child and adolescent psychiatrist may be appropriate depending on the primary care provider’s findings. Early diagnosis and treatment are likely to result in improved outcomes. Patients who are diagnosed early and accurately are more likely to have improvements in their mood, behavior, and social functioning than those who go undiagnosed and untreated. Additionally, early attention to psychiatric symptoms may allow early interventions that make it easier to manage the course of the illness and to prevent relapses; this can improve the child’s— and family’s—quality of life.

nonlinear and likely continues into a person’s 20s. Consequently, some patients may no longer experience symptoms of a mental illness as they move from childhood to adolescence and into adulthood. Nonetheless, many patients with chronic bipolar illness can and do go on to lead very fruitful, fulfilling, and productive lives. As a local example, television meteorologist Ken Barlow revealed in the fall of 2012 that he had been diagnosed five years earlier with bipolar I disorder. In talking about his experience with the disorder, he said, in an interview with the Pioneer Press, “My episodes are pretty much Early under control these days. I have good days and bad days just like anybody. I take my medication relidiagnosis and giously. I go to my doctors. I get my blood tested. I treatment are do what they tell me to.” likely to result Those of us working with children and adolescents suffering from mental illness are reminded every in improved day that children have a tremendous capacity for outcomes. resilience and growth. Kids from all walks of life who experience a range of mental illnesses have the potential to live happy, successful, and productive lives.

Treatment Treatment guidelines from the American Academy of Child and Adolescent Psychiatry suggest that a multipronged approach of carefully selected and monitored prescribed medication, psychotherapy, and education helps youth and their families manage bipolar illness. Typically, after a patient is diagnosed with bipolarity, he or she spends several months receiving psychotherapy and, if appropriate for the patient’s age, education about the importance of chemical sobriety and maintaining healthy sleep patterns. Then, the patient’s symptoms are monitored to determine if the dose of medication can be reduced or discontinued. Close monitoring of symptoms by the patient, family, and physician is critical, because once a youngster has experienced one mood episode he or she is predisposed to have another one. Some patients will not experience another episode for years, while others may slip into “rapid cycling,” where they experience four or more episodes within one year. Part of learning to live with bipolar disorder is learning to recognize what can trigger a mood episode. Triggers can include sleep disturbance, such as staying up all night studying for final exams. Other triggers can be a breakup with a boyfriend or girlfriend, or abusing stimulants like Adderall XR, which is sometimes prescribed for treatment of ADHD.

Joel V. Oberstar, MD, is CEO and chief medical officer of PrairieCare, an organization providing inpatient psychiatric care to children and adolescents and outpatient care to patients of all ages at three locations in the Minneapolis–St. Paul area. He is board-certified in psychiatry and in child and adolescent psychiatry, and is an adjunct assistant professor of psychiatry at the University of Minnesota Medical School.

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As with other chronic health conditions, patients living with bipolar disease must be vigilant to avoid flare-ups of their illness. If a flare-up occurs, the youngster’s physician may recommend resuming medication that had been stopped, or increasing the youngster’s existing dose of medication. Some youth benefit from long-term maintenance medication. Youth who are diagnosed with bipolar disorder should see their physician regularly throughout their childhood. In addition, the accuracy of the diagnosis should be reassessed as the child develops because relatively recent research indicates that brain development is

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MAY 2013 MINNESOTA HEALTH CARE NEWS

PUBLIC HEALTH

Foodborne illness

astric distress is not a souvenir that anyone wants to take away from a family picnic or a graduation open house. Queasiness, bloating, gas, vomiting, and diarrhea are no fun, not to mention the more serious possible outcomes of permanent organ damage and death. And while severe or life-threatening complications of food poisoning are more likely to occur in the very young and the very old, pregnant women, and the immunocompromised, anyone can contract a foodborne illness. The risk of many types of food poisoning rises during warm weather. Although it’s impossible to determine how many cases of home-related foodborne illness occur each year—such incidents are largely unreported and the Minnesota Department of Health (MDH) can’t investigate unreported incidents—it’s nonetheless sensible to learn how to prepare and store food safely at home and on the go.

How not to get sick By April K. Bogard, MPH, RS

Supporting Our Patients. Supporting Our Partners. Supporting You. In 2008, Tanzanian missionaries brought little Zawadi Rajabu to the U.S. to seek treatment for her two severely clubbed feet. A physician referred Zawadi to Dr. Mark T. Dahl of St. Croix Orthopaedics. Using the Ilizarov Method, Dr. Dahl surgically changed the course of Zawadi’s feet and her life. Dr. David Palmer and Russ McGill, OPA-C, recently traveled to Tanzania on another of their frequent medical missionary trips. They dedicated an entire day to checking in on their partner’s patient. To their delight, they were greeted by 6-year-old Zawadi her face aglow, her healed feet dancing toward them.

David Palmer, M.D. & Zawadi’s brother Russ McGill, OPA-C & Zawadi

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MINNESOTA HEALTH CARE NEWS MAY 2013

Wash your hands • Wet hands with warm, running water.

sonably possible and promptly refrigerate what isn’t served, because cold temperatures slow the growth of bacteria.

Refrigerate/freeze correctly To facilitate the rapid cooling of foods, get in the habit of doing this: • Rub hands vigorously for 20 seconds. Divide hot leftovers into small portions and place them Be sure to wash: in clean containers that weren’t used in the cooking process. Backs of hands Wrists This speeds the food’s cooling and enhances air circulation Between fingers Tips of fingers inside the fridge, which additionally cools the food and keeps Thumbs Under fingernails the temperature of the fridge from rising too much. (Use a nailbrush if possible.) Air circulation is also enhanced by not over-filling the • Rinse, with fingers pointing down. fridge or freezer. • Dry vigorously with paper or clean cloth towel. Place a thermometer somewhere in the fridge and an• Turn off faucet with towel and open door with towel. other one in the freezer. The fridge should be between 35 and 40 degrees F; this keeps food from freezing and also from getting warm enough to spoil quickly. The freezer should Food safety at home be at or below 0 degrees F. Wash your hands To prevent bacteria and viruses Food safety during a power outage from contaminating food and If the power goes out, keep refrigerator and freezer doors closed. An causing illness, don’t prepare unopened refrigerator will keep food cold for about four hours. Left food for others while you’re unopened, a full freezer will maintain its temperature for approxisick, especially if you are mately 48 hours, and for approximately 24 hours if it is half full. If vomiting or have diarrhea. the power is predicted to be out for a prolonged period of time, put Foodborne Wait at least 24 hours after dry ice or block ice in the refrigerator and in the freezer. Fifty Illness Hotline your symptoms are gone pounds of dry ice should maintain the temperature of a full freezer Report gastroenteric before preparing food for of an 18-cubic-foot fridge for two days. illness to MDH: others. Wash your hands If food in the freezer is partially or completely thawed by the (800) FOOD-ILL thoroughly before handling Foodborne illness to page 34 ingredients and utensils. Washing hands after taking a bathroom break is always a must, and even more so when you’re preparing and serving food. • Add soap.

Avoid cross-contamination Bacteria and viruses can be spread throughout the kitchen and get onto hands, cutting boards, utensils, countertops, and food. To avoid this: Before you start preparing food, have all utensils, cooking containers, and ingredients on hand so you don’t have to open drawers or cabinets with hands contaminated by raw food. Keep raw meat securely contained so that it doesn’t drip onto other food in the refrigerator or onto countertops. Store raw meat on the bottom shelf of your refrigerator so it doesn’t drip onto other foods. Wash produce All fresh produce, except commercially washed, pre-cut and bagged produce, should be washed under running water before cutting, eating, or cooking. Even if you plan to peel the produce, it is important to wash it under running water first. Scrub items that have a tough rind or peel, such as carrots, melons, and citrus. Then, place the food in a colander and rinse thoroughly under running water. Blot it dry with a paper towel. Cook properly Food is cooked safely when it reaches a high enough internal temperature to kill the harmful bacteria that cause foodborne illness. Follow the cooking directions for your oven, grill, slow cooker, and other equipment. Color is not a reliable indicator of doneness, so always measure the final, cooked, internal temperature of meats by using a digital thermometer (readily available at most stores that sell kitchen utensils). Chill quickly Once food is cooked, serve it as quickly as is reaMAY 2013 MINNESOTA HEALTH CARE NEWS

TA K E C A R E

Caregiver stress

regular care or assistance for a friend or family member who has a health problem. The Metropolitan Caregiver Service Collaborative reports the estimated annual value of care provided by informal caregivers is $8.9 billion.

Be kind to yourself By Chris Rosenthal, MSW, LISW

any of us don’t think of ourselves as caregivers, but when we help someone with daily needs by shopping, running errands, doing laundry, providing a ride to the doctor or drugstore, talking with doctors on behalf of a patient, and helping that patient understand what needs to be done, we are performing caregiver tasks. Most of us will find ourselves in this role at some point, whether as a neighbor, relative, or friend. In Minnesota, one in six people age 18 and older provide

Stressors However, we cannot successfully care for others unless we are fully functioning. That’s why pilots tell us, in case of emergency, “Put on your own oxygen mask before helping your loved one with his or hers.” We all understand the importance of this message when it relates to a split-second crisis. Yet, when we look at long-term caregiving, this critical need for self-preservation can be forgotten. Helping out with occasional tasks feels manageable, but when we find ourselves spending an increased amount of time providing care on an ongoing basis, we can start to feel overwhelmed. This feeling is understandable when you consider that most caregivers in the U.S. also handle job-related responsibilities. The majority of U.S. caregivers are 35–64 years of age. Of those aged 50–64, an estimated 60 percent work full or part time. So it is only natural that stress and fatigue impact caregivers. But it’s important to reduce stress before you reach the breaking point. The Family Caregiver Alliance reported in 2007 that caregivers are at increased risk for depression and alcohol abuse, are more susceptible to chronic conditions, tend to postpone their own self-care such as routine medical care and needed surgeries, and therefore have higher mortality rates compared with people who don’t provide care. How can you recognize the symptoms of stress that often sneak up on caregivers? Here are 10 common signs. Symptoms • Feelings of sadness, loneliness, or depression • Excessive worrying or anxiety about what tomorrow will bring • Feelings of frustration and anger at the situation, the care recipient, or both • Sleep problems/fatigue • Difficulty concentrating and making decisions • Weight loss or gain/poor eating habits • Decreased focus on personal care • Decreased participation in meaningful activities/social withdrawal • Decreased physical activity • Decreased attention to your own medical concerns

MINNESOTA HEALTH CARE NEWS MAY 2013

Stress reduction strategies Although recognizing caregiver stress is important, taking the time and energy to address it is paramount, both for the health of the caregiver and for the care recipient. Here are ways to reduce it. • Honor yourself. Most caregivers have had to make the choice of sacrificing some part of their dreams, even if only for the short term, for the benefit of another person. Caregivers often speak with guilt about feeling resentful of the time they are devoting to another but you don’t need to feel guilty because it’s only natural to experience resentment. Your loved one needs you and you are there for your loved one. Give yourself a pat on the back! • Educate yourself. When I was a first-time mother, I never could have managed without the support and knowledge of the community that surrounded me. I picked up the phone almost daily to call my mother, my sister, my friends, and the doctor to ask questions. Somehow, caregivers often feel that they should instinctively know what to do in every situation they encounter. If the person you care for has a specific illness or disability, learn all you can about it. You will feel more in control of the situation when you know more, and you also will be better equipped to advocate for your care recipient’s health care needs and other needs. • Learn about resources for caregivers and seek help. Asking for help is a sign of strength, not weakness. Contact these types of support networks in your community: ✓ Caregiver coaching and training ✓ Support groups

For more information, including culturally appropriate information for Hmong and Spanish-speaking caregivers, visit: • Metropolitan Caregiver Service Collaborative www.caregivercollaborative.org • Family Caregiver Alliance, www.caregiver.org • National Family Caregivers Association www.nfcacares.org • Caregiver Minnesota, www.caregivermn.org ✓ Respite care ✓ In-home care ✓ Disease-specific associations such as the Alzheimer’s Association and the Multiple Sclerosis Society ✓ Friends/family/spiritual community • Take care of yourself. This is the hardest thing of all to do. Often caregivers ask, “How can I take time for myself? I have no extra time.” If you think you are being selfish by putting your needs first, then you need to know this sobering fact: Thirty percent of caregivers die before the person they are caring for dies. If you are not caring for yourself, you jeopardize your health and, ultimately, your ability to care for your loved one. To take care of yourself: ✓ Make a list of the things for which you could use help. Give this list to family members/friends and let them choose things they would like to do. Caregiver stress to page 32

WHO’S A BIGGER BASEBALL FAN, YOU OR ME? You’ll find that people with Down syndrome have a passion for knowledge and learning that can rival anyone you’ve met before. To learn more about the rewards of knowing or raising someone with Down syndrome, contact your local Down syndrome organization. Or visit www.dsamn.org today. It is the mission of the Down Syndrome Association of Minnesota to provide information, resources and support to individuals with Down syndrome, their families and their communities. We offer a wide range of services, programs and materials at no charge. If you are interested in receiving one of our information packets for new or expectant parents, please email Kathleen@dsamn.org or For more information please call:

(651) 603-0720 • (800) 511-3696

MAY 2013 MINNESOTA HEALTH CARE NEWS

INSURANCE

Viatical settlements One way to pay health care costs By Paul Hanson

John has a terminal illness. Most of his medical bills have been covered by health insurance but his available cash is dwindling. He’s ready for hospice care but because his medical insurance doesn’t cover it, he needs to raise cash. One way to do this is through a viatical settlement. A viatical settlement typically occurs when a terminally or chronically ill person who owns a life insurance policy sells that policy, usually for a certain percentage of the policy’s face value. For example, if John’s policy pays his beneficiary $100,000 upon his death, John might find a viatical settlement broker who would buy the policy for 70 percent of its face value. John would therefore get $70,000. How much would John’s spouse, the original beneficiary of John’s policy, receive when John dies?

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Nothing. That’s because whoever buys a life insurance policy through a viatical settlement becomes the beneficiary. In this case, the insurance company whose broker bought John’s policy will receive $100,000 when John dies. Clearly, viatical settlements present potential pitfalls as well as benefits. Before entering into a viatical settlement John should consider: 1. Why was the policy originally purchased? Was it to ensure financial survival of his spouse and their children? 2. What are the current financial needs of John and his beneficiaries? If the children are now self-supporting, they no longer need financial support that the policy would have provided. 3. If the original reason for the policy no longer exists, are there other reasons why the policy should be kept? Has John’s spouse developed a medical condition that makes employment impossible? 4. Have the future financial needs of John or his beneficiaries changed? Presumably, John’s policy met some important financial objective(s) when he bought it. Anyone considering a viatical settlement should revisit the original reasons for having the policy.

Regulation The primary regulator of Minnesota’s viatical insurance industry is the Minnesota Department of Commerce. If you feel that you were taken advantage of in a viatical insurance settlement or that the law was not upheld, file a complaint. 1. Fill out the complaint form at mn.gov/commerce/topics/ consumer-information/Licensed-Industry.jsp 2. Mail the form to: Minnesota Department of Commerce 85 7th Place East, Suite 500 St. Paul, MN 55101 Or file a complaint by emailing consumer.protection@state.mn.us For more information, call the Consumer Protection Division of the Department of Commerce at (651) 296-2488 or (800) 657-3602. The Department may investigate and take actions where violations of Minnesota law have occurred.

2. Viaticating his policy affects his ability to use public assistance such as Medicaid. John should be aware that funds from the settlement may be pursued by creditors if his medical costs lead to credit problems. If John wants to buy more life insurance

Tax consequences You may viaticate—i.e., sell—your life insurance policy in Minnesota without being either terminally or chronically ill, but you may be taxed on the amount you sell it for, so consult a tax professional. Two important terms to understand are “terminally ill” and “chronically ill.” “Terminally ill” means having an illness or sickness that reasonably can be expected to result in death within 24 months. “Chronically ill” means: (1) being unable to perform at least two activities of daily living such as eating, toileting, bathing, and dressing; (2) requiring substantial supervision to protect the individual from threats to health and safety due to severe cognitive impairment; or (3) having a level of disability similar to that described in (1).

John’s circumstances no longer include dependent children with future needs such as college. And with a terminal illness it is unlikely that he’ll need additional life insurance. However, if he does have Viatical settlements to page 33

Non-viatical options John and his spouse should consider all options available for deriving cash from John’s life insurance and should consult an attorney, tax advisor, or financial planner when evaluating them: 1. Surrender the life insurance policy to the insurance company for its cash surrender value (CSV), which is less than the face amount of the policy. 2. Determine if accelerated death benefits are available from the policy. 3. Take policy loans against the life insurance, i.e., borrow money from the insurance policy. When John dies, the amount he borrowed will be subtracted from the amount the policy pays the beneficiary. 4. Obtain other financing, such as bank loans. Evaluating options If John decides to viaticate his life insurance policy, he needs to find out whether: 1. The life insurance brokers or companies giving him quotes (of what they’ll pay him for his policy) are properly licensed. To find out, call the Department of Commerce phone number (see sidebar). MAY 2013 MINNESOTA HEALTH CARE NEWS

✓ Remember to laugh. This may sound trite, but it is truly helpful. When you’re a caregiver, so much of life can feel serious. Laughter increases the body’s levels of endorphins, which are chemicals the body manufactures that are natural mood elevators. Laughter also helps us take ourselves and the situation less seriously, even if only for the moment.

Caregiver stress from page 29

✓ Promise yourself to take a break from caregiving each week. If an afternoon away seems too difficult, start with one hour each week and pick something meaningful to do during that hour. Maybe it’s going for a walk or

Rewards In her book “The Gifts of Caregiving,” author Connie Goldman says, “Caregiving is probably the most rewarding thing I’ve done and also the most difficult.” With all the talk of stress and fatigue, it is important to consider why people accept the role of caregiver. One participant in a caregivers’ support group I facilitate explained it this way, in talking about taking care of his spouse for more than a decade: “The only reward I know for caregiving is the love you have for the other person, knowing the only reward will be the look in her eyes when she is grateful for something I’ve done ...” Although caregiving sometimes forces us to see our loved ones as their least pleasant and most vulnerable selves, it also allows us to be present for some of the most humorous, tender, and certainly insightful moments in the lives of those we love.

It’s important to reduce stress before you reach the breaking point. going to the local coffee shop. ✓ Take advantage of community services to provide a break for you. The loved one we care for needs more people in his or her life than just us. As caregivers, we may start to feel like “No one can do this like I can.” However, this go-it-alone attitude may inadvertently worsen the crisis that can occur if a caregiver is suddenly unable to fulfill caregiving duties. At such times it is very helpful for a care recipient to have an established relationship with another trusted caregiver who understands the recipient’s needs.

Chris Rosenthal, MSW, LISW, is the director of the Senior Service Department at Jewish Family Service of St. Paul.

Minnesota

Health Care Consumer April survey results ... Association

1. I have wanted a diagnostic procedure, but my

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

40 Percentage of total responses

Percentage of total responses

40 29.41%

30 20 14.71%

8.82%

20 15

11.76%

Strongly agree

Agree

Does not apply

Disagree

Strongly disagree

0% Strongly agree

20 14.71%

15 11.76% 10 5

Does not apply

Disagree

was necessary, but cost issues caused me to postpone seeking this care.

60 52.94%

40 30 23.53%

23.53% 20 10

5.88%

Percentage of total responses

23.53%

Agree

50 40 30 20 10

14.71%

14.71% 8.82%

8.82%

2.94%

Strongly agree

Agree

Does not apply

Disagree

Strongly disagree

MINNESOTA HEALTH CARE NEWS MAY 2013

Strongly agree

Agree

Does not apply

Disagree

Strongly disagree

5. My doctor and I both thought a diagnostic procedure

44.12% Percentage of total responses

23.53%

26.47% 23.53%

26.47% 25

necessity of a diagnostic procedure recommended by my physician.

38.24%

4. I would consider getting a second opinion on the

Percentage of total responses

but I have personal concerns that are causing me to postpone action on the recommendation.

47.06%

3. An insurance company or health system has made it difficult to obtain a proposed diagnostic procedure.

2. My physician recommended a diagnostic procedure,

physician played a role in my decision to postpone seeking this care.

Strongly agree

Agree

Does not apply

Disagree

Strongly disagree

miums during the time he remains alive

Viatical settlements from page 31

5. The insurer that issued the policy

future life insurance needs, he should realize that a person may have so much coverage from life insurance that it’s not possible to obtain additional life insurance. That’s because life insurers consider the total amount of life insurance a person has when underwriting a new policy and may decline to issue one because of the amount of life insurance already in effect. The reason is related to “moral hazard risk.” This means that if the amount of coverage on someone is high, it may change that person’s risk of dying because that person is now worth more dead than alive, thus creating a moral hazard.

The viatical settlement process includes independent medical examinations and reviews of medical records to confirm John’s diagnosis and prognosis. Anyone considering a viatical settlement needs to realize that personal medical information will be Viatical exchanged between multiple parties. The more John knows about his own financial settlements affairs and the brokers and businesses he requests present potential quotes from, the more he will be in the driver’s seat. pitfalls as well That will help him get the best price for his policy. Licensing of viatical settlement brokers is required as benefits. in Minnesota, and determining the licensing status The viatical settlement process and history of each broker John deals with is imporJohn is known as the viator—the person selling the life insurance pol- tant. Licensees must submit information about themselves and allow icy—in a viatical settlement. During the selling process John most the state’s Department of Commerce to check their backgrounds. likely will work with a viatical settlement broker. Before deciding John should contact the state insurance departments in other which broker will buy his policy, it’s a good idea for John to obtain states where a broker does business, to see if complaints have been quotes from several licensed viatical settlement brokers. John should filed against the broker in those states. Check a broker’s reputation ask these brokers for a better price for his life insurance policy than using multiple sources; information on the Internet is not necessarily the policy’s CSV. The price John obtains through a viatical settlement true. And don’t rush through decisions or the viatical settlement will depend upon many factors, including: process: Selling a life insurance policy is a major decision that will 1. His policy’s expected death benefit have an impact on the viator and his or her significant others. 2. John’s diagnosis 3. John’s prognosis and its possible variability 4. The present value of any premium payments over John’s expected remaining life span, i.e., the amount of money John owes for pre-

Paul Hanson is chief examiner at the Minnesota Department of Commerce. The opinions expressed in this article are the author’s and do not necessarily reflect those of the Department of Commerce.

Minnesota

Health Care Consumer Association

Welcome to your opportunity to be heard in debates and discussions that shape the future of health care policy. There is no cost to join and all you need to become a member is access to the Internet. Your privacy is completely assured; we won’t even ask your name. Members receive a free monthly electronic newsletter and the opportunity to participate in consumer opinion surveys.

www.mnhcca.org

Join now.

We want to hear from you! MAY 2013 MINNESOTA HEALTH CARE NEWS

Foodborne illness from page 27

time power comes back on, don’t taste it to determine its safety! You will have to evaluate each item separately. Discard any items in either the freezer or the refrigerator that have come into contact with raw meat juices. If the freezer thermometer reads 40 degrees F or below when the power comes back on, food in the freezer can safely be left in the freezer to refreeze. If a thermometer has not been kept in the freezer, check each package of food to determine its safety but don’t rely on appearance or odor. If the food still contains ice crystals or is 40 degrees F or below, it is safe to refreeze. Refrigerated food should be safe as long as power is out no more than four hours and the fridge door is kept closed. Discard any perishable food (such as meat, poultry, fish, eggs, milk, cheese, and leftovers) that has been above 40 degrees F for two hours. And if you’re not sure: When in doubt, throw it out.

When serving foods, don’t leave them at room temperature for more than two hours.

affect the final color of cooked meat, including fat content and seasoning. Use a meat thermometer to be sure that the meat’s internal temperature has reached that recommended by the U.S. Department of Agriculture (USDA): • Ground beef = 160 degrees F. Consider using ground beef treated with irradiation for an extra measure of safety. • Poultry (including ground chicken and ground turkey) = 165 degrees F. • Pork = 145 degrees F. • Whole-muscle meat (chops, steaks, and roasts) = 145 degrees F.

Serve safely Keep cold foods cold and hot foods hot. When serving foods, don’t leave them at room temperature for more than two hours. After two hours at room temperature, discard uneaten food that typically requires refrigeration, such as potato salad, egg salad, salad dressing, cream pies, cheese, and meat. Stay healthy

Food safety on the go

Prevent cross-contamination When you’re packing the cooler, wrap raw meat securely to avoid its juices coming in contact with ready-to-eat foods.

The number of people who get sick from food poisoning goes up during the summer. Be sure you and your family aren’t among them. April K. Bogard, MPH, RS, is a supervisor in the food, pools, and lodging services area of the MDH.

Cook properly Don’t be deceived by the browning of the meat. Color is not a reliable indicator of doneness because many factors Now accepting new patients

A unique perspective on cardiac care Preventive Cardiology Consultants is founded on the fundamental belief that much of heart disease can be avoided in the vast majority of patients, and significantly delayed in the rest, by prudent modification of risk factors and attainable lifestyle measures.

Elizabeth Klodas, M.D., F.A.S.C.C is a preventive cardiologist. She is the founding Editor in Chief of CardioSmart for the American College of Cardiology www.cardiosmart.org, a published author and medical editor for webMD. She is a member of several national committees on improving cardiac health and a frequent lecturer on the topic.

We are dedicated to creating a true partnership between doctor and patient working together to maximize heart health. We spend time getting to know each patient individually, learning about their lives and lifestyles before customizing treatment programs to maximize their health. Whether you have experienced any type of cardiac event, are at risk for one, or

are interested in learning how to prevent one, we can design a set of just-for-you solutions. Among the services we provide • One-on-one consultations with cardiologists • In-depth evaluation of nutrition and lifestyle factors • Advanced and routine blood analysis • Cardiac imaging including (as required) stress testing, stress echocardiography, stress nuclear imaging, coronary calcium screening, CT coronary angiography • Vascular screening • Dietary counseling/Exercise prescriptions

To schedule an appointment or to learn more about becoming a patient, please contact: Preventive Cardiology Consultants 6545 France Avenue, Suite 125, Edina, MN 55435 phone. 952.929.5600 fax. 952.929.5610 www.pccmn.com

MINNESOTA HEALTH CARE NEWS MAY 2013

• Serious low blood sugar (hypoglycemia) may occur when Victoza® is used with other diabetes medications called sulfonylureas. This risk can be reduced by lowering the dose of the sulfonylurea.

Important Patient Information This is a BRIEF SUMMARY of important information about Victoza®. This information does not take the place of talking with your doctor about your medical condition or your treatment. If you have any questions about Victoza®, ask your doctor. Only your doctor can determine if Victoza® is right for you. WARNING During the drug testing process, the medicine in Victoza® caused rats and mice to develop tumors of the thyroid gland. Some of these tumors were cancers. It is not known if Victoza® will cause thyroid tumors or a type of thyroid cancer called medullary thyroid cancer (MTC) in people. If MTC occurs, it may lead to death if not detected and treated early. Do not take Victoza® if you or any of your family members have MTC, or if you have Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). This is a disease where people have tumors in more than one gland in the body. What is Victoza® used for? • Victoza® is a glucagon-like-peptide-1 (GLP-1) receptor agonist used to improve blood sugar (glucose) control in adults with type 2 diabetes mellitus, when used with a diet and exercise program. • Victoza® should not be used as the first choice of medicine for treating diabetes. • Victoza® has not been studied in enough people with a history of pancreatitis (inflammation of the pancreas). Therefore, it should be used with care in these patients. • Victoza is not for use in people with type 1 diabetes mellitus or people with diabetic ketoacidosis. ®

• It is not known if Victoza® is safe and effective when used with insulin. Who should not use Victoza®? • Victoza should not be used in people with a personal or family history of MTC or in patients with MEN 2. ®

• Victoza® may cause nausea, vomiting, or diarrhea leading to the loss of fluids (dehydration). Dehydration may cause kidney failure. This can happen in people who may have never had kidney problems before. Drinking plenty of fluids may reduce your chance of dehydration. • Like all other diabetes medications, Victoza® has not been shown to decrease the risk of large blood vessel disease (i.e. heart attacks and strokes). What are the side effects of Victoza®? • Tell your healthcare provider if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath while taking Victoza®. These may be symptoms of thyroid cancer. • The most common side effects, reported in at least 5% of people treated with Victoza® and occurring more commonly than people treated with a placebo (a non-active injection used to study drugs in clinical trials) are headache, nausea, and diarrhea. • Immune system related reactions, including hives, were more common in people treated with Victoza® (0.8%) compared to people treated with other diabetes drugs (0.4%) in clinical trials. • This listing of side effects is not complete. Your health care professional can discuss with you a more complete list of side effects that may occur when using Victoza®. What should I know about taking Victoza® with other medications? • Victoza® slows emptying of your stomach. This may impact how your body absorbs other drugs that are taken by mouth at the same time. Can Victoza® be used in children? • Victoza® has not been studied in people below 18 years of age. Can Victoza® be used in people with kidney or liver problems? • Victoza® should be used with caution in these types of people. Still have questions?

What is the most important information I should know about Victoza®? • In animal studies, Victoza® caused thyroid tumors. The effects in humans are unknown. People who use Victoza® should be counseled on the risk of MTC and symptoms of thyroid cancer. • In clinical trials, there were more cases of pancreatitis in people treated with Victoza® compared to people treated with other diabetes drugs. If pancreatitis is suspected, Victoza® and other potentially suspect drugs should be discontinued. Victoza® should not be restarted if pancreatitis is confirmed. Victoza® should be used with caution in people with a history of pancreatitis.

This is only a summary of important information. Ask your doctor for more complete product information, or • call 1-877-4VICTOZA (1-877-484-2869) • visit victoza.com Victoza® is a registered trademark of Novo Nordisk A/S. Date of Issue: May 2011 Version 3 ©2011 Novo Nordisk 140517-R3 June 2011

FOR TYPE 2 DIABETES

Victoza® helped me take my blood sugar down…

and changed how I manage my type 2 diabetes. Victoza® helps lower blood sugar when it is high by targeting important cells in your pancreas—called beta cells. While not a weight-loss product, Victoza® may help you lose some weight. And Victoza® is used once a day anytime, with or without food, along with eating right and staying active.

Model is used for illustrative purposes only.

Indications and Usage: Victoza® is an injectable prescription medicine that may improve blood sugar (glucose) in adults with type 2 diabetes when used along with diet and exercise. Victoza® is not recommended as the first medication to treat diabetes. Victoza® is not insulin and has not been studied in combination with insulin. Victoza® is not for people with type 1 diabetes or people with diabetic ketoacidosis. It is not known if Victoza® is safe and effective in children. Victoza® is not recommended for use in children. Important Safety Information: In animal studies, Victoza® caused thyroid tumors—including thyroid cancer—in some rats and mice. It is not known whether Victoza® causes thyroid tumors or a type of thyroid cancer called medullary thyroid cancer (MTC) in people which may be fatal if not detected and treated early. Do not use Victoza® if you or any of your family members have a history of MTC or if you have Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). While taking Victoza®, tell your doctor if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath. These may be symptoms of thyroid cancer. Inflammation of the pancreas (pancreatitis) may be severe and lead to death. Before taking Victoza®, tell your doctor if you have had pancreatitis, gallstones, a history of alcoholism,

If you’re ready for a change, talk to your doctor about Victoza® today.

or high blood triglyceride levels since these medical conditions make you more likely to get pancreatitis. Stop taking Victoza® and call your doctor right away if you have pain in your stomach area that is severe and will not go away, occurs with or without vomiting, or is felt going from your stomach area through to your back. These may be symptoms of pancreatitis. Before using Victoza ®, tell your doctor about all the medicines you take, especially sulfonylurea medicines or insulin, as taking them with Victoza® may affect how each medicine works. Also tell your doctor if you are allergic to any of the ingredients in Victoza®; have severe stomach problems such as slowed emptying of your stomach (gastroparesis) or problems with digesting food; have or have had kidney or liver problems; have any other medical conditions; are pregnant or plan to become pregnant. Tell your doctor if you are breastfeeding or plan to breastfeed. It is unknown if Victoza® will harm your unborn baby or if Victoza® passes into your breast milk. Your risk for getting hypoglycemia, or low blood sugar, is higher if you take Victoza® with another medicine that can cause low blood sugar, such as a sulfonylurea. The dose of your sulfonylurea medicine may need to be lowered while taking Victoza®.

Victoza® may cause nausea, vomiting, or diarrhea leading to dehydration, which may cause kidney failure. This can happen in people who have never had kidney problems before. Drinking plenty of fluids may reduce your chance of dehydration. The most common side effects with Victoza® include headache, nausea, and diarrhea. Nausea is most common when first starting Victoza®, but decreases over time in most people. Immune system-related reactions, including hives, were more common in people treated with Victoza® compared to people treated with other diabetes drugs in medical studies. Please see Brief Summary of Important Patient Information on next page. If you need assistance with prescription drug costs, help may be available. Visit pparx.org or call 1-888-4PPA-NOW. You are encouraged to report negative side effects of prescription drugs to the FDA. Visit fda.gov/medwatch or call 1-800-FDA-1088. Victoza® is a registered trademark of Novo Nordisk A/S. © 2011 Novo Nordisk 0611-00003312-1 August 2011

To learn more, visit victoza.com or call 1-877-4-VICTOZA (1-877-484-2869).

Non-insulin • Once-daily