Minnesota Health care News April 2011

Your Guide to Consumer Information

FREE April 2011 • Volume 9 Number 4

Dance injuries Brad Moser, MD

Food safety Craig Hedberg, PhD

Osteoporosis Christine Simonelli, MD

One Heart, One Mind, One Universe May 8, 2011 at Mariucci Arena, University of Minnesota Medicine Buddha Empowerment: A Tibetan Cultural and Spiritual Ceremony Promoting Personal and Societal Healing featuring His Holiness the 14th Dalai Lama 9:30 - 11:30 a.m.

Peace Through Inner Peace: A Public Address featuring His Holiness the 14th Dalai Lama 2:00 - 3:30 p.m.

May 9, 2011 at University Radisson Hotel Second International Tibetan Medicine Conference: Healing Mind & Body 9:00 a.m. - 7:30 p.m. (* His Holiness is not expected to be in attendance.)

2 Days Only, 3 Events

The Minnesota Visit 2011 His Holiness the 14th Dalai Lama

A special invitation to health professionals: The Second International Tibetan Medicine Conference May 9, 2011 This event will bring to the Twin Cities the foremost practitioners of Tibetan medicine from the Men-Tsee-Khang, the Tibetan Medical Institute of His Holiness the Dalai Lama, in Dharamsala, India. By the end of the conference, participants will be able to meet the following objectives involving Tibetan Medicine: Examine the relationship between ethics, spirituality, and healing.

Investigate participants' own unique constitution.

Determine what lifestyle choices to make, based on participants' own constitution.

Explain how to heal from the source and develop health through balance.

Describe research about Tibetan medicine, as well as propose additional research needed.

Apply teachings of Tibetan medicine personally and professionally.

etan Ame Tib r

Minnesota of

For tickets and more information, visit www.dalailama.umn.edu or call 612-624-2345

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CONTENTS

4 7 8

APRIL 2011 • Volume 9 Number 4

NEWS

PEOPLE

PERSPECTIVE

16 18

PUBLIC HEALTH Food safety

20 24

FEATURE How I got here

By Craig W. Hedberg, PhD

CALENDAR National Public Health Month

Laurel Baxter, MA, RN Ecumen

10

10 QUESTIONS MaryBeth Mahony, DO

12

PHYSICAL THERAPY AND REHABILITATION Keeping dancers on their toes

By Brad Moser, MD

14

MENTAL HEALTH The neurobiology of loneliness

By Kevin Turnquist, MD

Partners in Pediatrics

26 30

MINNESOTA HEALTH CARE ROUNDTABLE

OSTEOPOROSIS Minimize your risk

By Christine Simonelli, MD

COMMUNITY HEALTH Addressing disparities

By Diana DuBois, MPH, MIA

T H I R T Y- F I F T H

SESSION

Background and focus: Until recently, when the word wellness came up in organized medicine it was regularly dismissed as pseudo-science. Our health care delivery system, or as many call it “sick care delivery system,” evolved in a way that doctors were not paid to keep patients well and thus wellness strangely fell outside the purview of medicine. Obviously it is better to stay healthy than try to fix complex and sometimes avoidable medical conditions. Selling servA changing focus in health care ices supporting this approach was often criticized for lack of randomized clinical trial April 28, 2011 research; inadequate licensing, 1:00 – 4:00 PM • Duluth Room credentialing, and oversight for practitioners; and many other Downtown Mpls. Hilton and Towers concerns. Wellness as an industry, with its wide diversity of methods and approaches, was kept at arm’s length by the medical establishment. Economics have forced this to change.

The Wellness Revolution

Objectives: We will explore the definition of wellness, why today there is a wellness revolution, and why doctors now embrace the concept.

Examining multiple collection methodologies and sets of data, we will discuss how and why employers are driving this new approach to health care. We will consider privacy issues and many other challenges to an already overburdened administrative process posed by collecting and storing individual health care data in places such as work sites and health clubs. We will discuss the breadth of wellness initiatives, their pros and cons, and how they can lower the cost of health care while improving individual health status.

NEUROLOGY Spinal stenosis

By Andrew J. Will, MD

Panelists include: N Julia Halberg, MD, MS, MPH, Vice President Global Health and Chief Medical Officer, General Mills N Karen L. Lawson, MD, Director Health Coaching, U of M Center for Spirituality and Healing www.mppub.com PUBLISHER Mike Starnes mstarnes@mppub.com

N William Litchy, MD, Chief Medical Officer MMSI, Mayo Clinic N Mark T. Zeigler, DC, President, Northwestern Health Sciences University Sponsors: Pfizer • Mayo Clinic Health Solutions Northwestern Health Sciences University

EDITOR Donna Ahrens dahrens@mppub.com ASSOCIATE EDITOR Martha Malan mmalan@mppub.com ASSISTANT EDITOR Scott Wooldridge swooldridge@mppub.com ART DIRECTOR Elaine Sarkela esarkela@mppub.com OFFICE ADMINISTRATOR Juline Birgersson jbirgersson@mppub.com

Please send me tickets at $95.00 per ticket. Mail orders to Minnesota Physician Publishing, 2812 East 26th Street, Minneapolis, MN 55406.

Tickets may also be ordered by phone (612) 728-8600 or fax (612) 728-8601.

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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; e-mail 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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APRIL 2011 MINNESOTA HEALTH CARE NEWS

3

NEWS

Adult Smoking Rate Down in Minnesota

Nurses Praise Dayton At “Day on the Hill”

A new report finds that Minnesota is making progress in reducing tobacco use and exposure to secondhand smoke in public places.

The Minnesota Adult Tobacco Survey (MATS), published on Feb. 10, says that Minnesota’s adult smoking rate has declined to 16 percent—down from 22 percent in 1999. In addition, exposure to secondhand smoke significantly declined after the Freedom to Breathe Act was implemented in October 2007.

The data in the study was collected by ClearWay Minnesota, along with the Minnesota Department of Health.

The MATS study found a significant increase in the use of smokeless tobacco products.

ClearWay officials say the tobacco industry has put a new emphasis on smokeless products to maintain a market for tobacco.

Members of the Minnesota Nurses Association (MNA) spoke out in support of unions in Wisconsin and state officials noted the expansion of Minnesota’s Medicaid program at the MNA’s annual “Day on the Hill.”

The March 1 rally, which featured Gov. Mark Dayton as a speaker, came at a time when a major battle about organized labor was taking place in neighboring Wisconsin. Linda Hamilton, MNA president, called the ongoing labor strife “historic” and praised Dayton and Department of Human Services (DHS) Commissioner Lucinda Jesson for their pro-labor stance.

“The situation is dire here in Minnesota and all over the nation,” Hamilton said. “Without [Dayton and Jesson], we’d be spending weeks at this rotunda to defend our own rights and protect the very lives of our patients.” Hamilton praised

4

MINNESOTA HEALTH CARE NEWS APRIL 2011

Dayton for enrolling Minnesota in the Medicaid extension program that has brought federal funds into the state and expanded the former General Assistance Medical Care program.

Dayton thanked the nurses for their dedication and work in taking care of patients throughout the state. He said as a gubernatorial candidate, he publicly supported the MNA when they were in negotiations with hospitals last year. “I wrote, ‘Doctors are important, nurses are essential,’” he said, to loud cheers.

Dayton also talked about his Medicaid expansion, noting that the former administration said it would take nine months to get the program up and running.

“Today we’re celebrating on March 1—less than two months after I signed the order—the beginning [of the program].”

March 1 marked the first day that state residents could enroll in the new Medicaid program. With the expansion, officials say, approximately 95,000

Minnesotans will eventually be able to join the Medical Assistance program. DHS projects the program will create or save 20,000 jobs in the state.

ACA Funds to Help Medicaid Recipients Get Out of Institutions Minnesota is one of 13 states that will receive new federal grants to help move Medicaid beneficiaries out of institutions and into their own homes or community-living arrangements, officials announced last week.

The grants, part of the Affordable Care Act (ACA), total more than $4 billion over six years. Minnesota will receive $187 million during that time period, with first-year funding at $13 million.

In Minnesota, the funds will be distributed as part of the Money Follow the Person (MFP) pilot program, which already had the participation of 29 states in recent years and was refunded

in 2010 through the ACA. Minnesota had not previously applied for MFP funding.

Minnesota officials say the program will simplify and improve transition services that help people return to their homes after a stay in a hospital or nursing facility, advance best practices for individuals with complex needs, and decrease the need for institutional care by addressing specific issues with facilities in the state.

“This grant is a great opportunity for the Department of Human Services to provide more value to our clients,” says Minnesota Human Services Commissioner Lucinda Jesson. “With it we are able to better provide more individual choice while at the same time streamlining the home- and community-based service delivery system.”

HCMC Program Offers Medical Training for Area Law Officers Metro-area law enforcement officers will receive emergency medical training under a new program offered through Hennepin County Medical Center (HCMC).

The Tactical Emergency Medical Peace Officer (TEMPO) course is based on the idea that law enforcement officers can benefit from emergency medical training to deal with unique and dangerous situations they may find at crime scenes.

“TEMPO provides officers training in emergency medical aid practices and may increase their odds of survival by up to 66 percent,” says HCMC emergency physician Jeffrey Ho, MD, who is also an active law enforcement officer in Minnesota. “The goal is to allow an officer to save his or her own life or the life of a suspect or civilian in a medical emergency.”

Officials note that in 2010, a record number of law enforcement officers were killed in the line of duty. They point to recent events such as the mass shooting in Tucson, Ariz., as examples of

crime scenes that call for immediate medical response under extremely stressful conditions.

Officials say the TEMPO training is helpful in law enforcement situations because it allows officers to treat injured or ill civilians or fellow officers when the scene is not safe for other rescue personnel to enter.

Offered through HCMC’s Department of EMS Education and the Division of Tactical Medicine, the TEMPO course development was overseen by Ho, who in addition to emergency medicine practice has worked extensively in military, EMS, and SWAT operations.

Report Advocates More Patient Input In Decision-Making A new Dartmouth Atlas report finds wide variations in elective surgery decisions in Minnesota.

The report, the first in a series that will look at variation of treatment in individual states and regions, finds that decisions on how to treat medical conditions can vary widely depending on where a patient lives.

“If you have heart disease and live in St. Cloud, you are half as likely to undergo cardiac bypass surgery than if you live in Detroit Lakes,” the report says.

“If you have gallstones and live in Wadena, you are three times more likely to have your gall bladder removed than if you live in Minneapolis.”

Officials with the Dartmouth Atlas, which has become a leading authority on variations in practice and on how medical resources are distributed, say the findings show the need for patients to be better informed about their choices and to work with clinicians on medical decision-making.

“Clinicians are not mind readers,” the report says. “They often do not know or ask their patients about their values and preferences; or they may assume that the patient’s values are simi-

Cataract Specialists

From left (top): Sherman W. Reeves, MD, MPH; David R. Hardten, MD, FACS; Richard L. Lindstrom, MD; Thomas W. Samuelson, MD; Patrick J. Riedel, MD. From left (bottom): Elizabeth A. Davis, MD, FACS; William J. Lipham, MD, FACS.

Surgery Locations: Arlington Blaine Bloomington Maplewood

Minneapolis Mora New Prague Sandstone

Cataracts A cataract is a clouding of the eye’s natural lens that inhibits or diminishes the passage of light to the retina. Cataracts progress at different rates and can affect one or both eyes at the same time.

When a cataract develops, a patient may wish to have it surgically removed. The surgery is performed as an outpatient procedure under local anesthesia and takes approximately 10-20 minutes. Once the cataract has been removed, a new clear lens, called an intraocular lens implant (IOL) is put in place of the natural lens. Most patients return to their normal work or lifestyle in a day or two.

Cataract surgery is one of the most common and successful surgical procedures performed today.

Many patients report vision that is even better than before they developed cataracts, especially with the optional newer implant that often eliminates the need for close vision glasses after surgery.

New alternatives for treatment In choosing an intraocular lens for cataract surgery, you have several options. Speak with your family eye doctor and your surgeon to determine which is best for your eye and your lifestyle.

Meet us online at mneye.com or call us at 1-800-Eye-To-Eye

News to page 6 APRIL 2011 MINNESOTA HEALTH CARE NEWS

5

News from page 5 lar to their own. As a result, they may recommend treatment that is different from what their patients would have chosen had they been fully informed.”

Legislature Considers Lawsuit Challenging Federal Health Law The Minnesota Legislature is considering a bill that would require the state’s attorney general to join a lawsuit against the federal health care reform law. The Freedom of Choice in Health Care Act (HF199) would put the state on record as opposing the individual mandate provision of the Affordable Care Act (ACA) on constitutional grounds.

Rep. Steve Gottwalt (R-St. Cloud), the bill’s author, said at a Feb. 15 hearing of the House Health and Human Services Reform Committee that the measure is an effort to protect Minnesota’s lead in health care reform. “We must not surrender

our health care leadership,” said Gottwalt. “... While we know there are areas in which we must improve, we know Minnesota has the ability to get there without a massive government takeover of health care.”

DFL members of the committee questioned the need for the state to challenge ACA in court.

“For me it’s [about[ freedom to have coverage and not go bankrupt from health care costs,” said Rep. Tina Liebling (DFLRochester). She said the federal law provides many important protections.

The bill has passed initial committee votes in both House and Senate.

Recession Has Swelled Uninsured Ranks, Data Show The recent recession has had a significant impact on rates of uninsurance in this state, a new report from the Minnesota Department of Health (MDH) finds.

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The MDH report updates previously released data on uninsurance in Minnesota from 2007 to 2009. It found that during that period, the state’s uninsured rate went from 7.7 percent to 9 percent, with some of the increase coming from demographic groups that traditionally have low rates of uninsurance.

For example, Minnesotans with higher incomes traditionally have low rates of uninsurance.

However, from 2007 to 2009, Minnesotans with incomes of 301 percent of poverty to 400 percent of poverty—the second-highest income category—saw their uninsurance rate go from 4.8 percent to 7.2 percent. The study also found that males in Minnesota had a higher chance (11.9 percent) of being uninsured than females (6.3 percent).

The data also show that the number of Minnesotans with health insurance coverage through their employer continues to decline. In 2007, 62.5 percent of Minnesotans had employersponsored health coverage; in

2009 that number had dropped to 57.4 percent. The report notes that in 2001, the percentage of Minnesotans with employerbased coverage was 68.1 percent.

Overall, young adults continue to be the most likely to lack insurance. Minnesotans in the 18-to-24 age group saw the rate of uninsurance go from 18.7 percent to 22.3 percent from 2007 to 2009; those in the 24-to-34 age group saw an increase from 11.4 percent to 15.4 percent. By comparison, the rate of insurance for Minnesotans in the 35-to-54 age group rose from 4.2 percent to 6 percent.

CORRECTION An article recognizing community caregivers in the March issue of Minnesota Health Care News misidentified a Summit Orthopedics physician who was part of a team that offered assistance in Haiti after the Jan. 12, 2010, earthquake. His name is Jerome Perra, MD, not Joseph.

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MINNESOTA HEALTH CARE NEWS APRIL 2011

PEOPLE Stefan Friedrichsdorf, MD, director of Children’s Hospitals and Clinics of Minnesota’s Department of Pain Medicine, Palliative Care, and Integrative Medicine, is one of five American physicians honored by the Cunniff-Dixon Foundation for improving the care of patients near the end of life. Friedrichsdorf received the Hastings Center CunniffDixon Physician Award for his “innovative symptom management of pediatric patients, compassion, and family-centered care.“ Joseph Lemker, MD, has joined the orthopedic surgery staff at

Nationally recognized.

Patient-focused.

Community Memorial Hospital in Cloquet, Minn. Lemker is boardcertified in orthopedic surgery and specializes in sports medicine,

Areas of Expertise

shoulder/elbow surgery, general knee surgery, trauma care, all types

Artificial Disc Replacement Disc Degeneration Disc Herniation Discectomy Fractures Fusion Kyphosis (hump) Minimally Invasive Surgery Pediatric Curvature Sciatica Scoliosis - Juvenile - Adult

of fracture care, total joint replacement, and conservative treatment for arthritis. He graduated from the University of Minnesota– Duluth and St. Louis University School of Medicine. He completed a residency in orthopedic surgery at St. Louis University Hospital and Clinic. He previously practiced with Essentia Health East Region and Virginia Regional Medical Center.

Jen Van Liew, PhD, RN, has taken over as executive director and chief executive officer of nonprofit home health and public health care provider Minnesota Visiting Nurse Agency (MVNA). Van Liew comes to MVNA from the Jen Van Liew, PhD, RN

Visiting Nurse Services of Iowa, in Des Moines,

where she has been president and CEO since 2003. Van Liew brings

Spinal Arthritis Spinal Cord Injury Spondylolisthesis (shifted vertebrae) Stenosis Tumors/Infections Pain Treatment & Diagnostics - Injections - Radiofrequency Neuroablation - Spinal Cord Stimulators - Vertebroplasty

more than 33 years’ experience in a variety of health care settings to her new role. In addition to her leadership role with Visiting Nurse Services of Iowa, Van Liew has cared for patients in hospital and community settings, served as a professor of nursing at Grand View University in Des Moines, and worked as a consultant with the Iowa Department of Public Health. Van Liew replaces Mary Ann Blade, RN, who had been MVNA CEO since 1990 and retired in February. Over the past 20 years, under Blade’s leadership, MVNA has grown from a $3 million to a $25 million agency and has developed one of the largest visiting nurse agency flu immunization programs in the country. She also led the purchase of Hospice of the Twin Cities, a subsidiary company of MVNA. Carolyn Phelps, a licensed psychologist at the

Mary Ann Blade, RN

Human Development Center (HDC) in Duluth, was promoted to clinical director for outpatient therapy service at the main Duluth office. She will continue to see clients. Phelps specializes in the treatment of peo-

Stefano M Sinicropi M.D. (spine surgeon), Glenn R. Buttermann M.D. (spine surgeon), Louis C. Saeger M.D. (interventional pain physician), Daniel W. Hanson M.D. (spine surgeon), Thomas V. Rieser M.D. (spine surgeon) Seated - Mark A. Janiga M.D. (MN Interventional Pain Associates), Mark K. Yamaguchi (interventional pain physician)

ple with eating disorders and is the co-host of the HDC-sponsored television series “Speak Your Mind” on WDSE-WRPT/PBS North.

James Donovan, MD, a family practice

Physicians specializing in restoring lives affected by spinal injury and disorder

physician at Miller Creek Medical Clinic, a St. Luke’s (Duluth) clinic, has been named a diplomate of the American Board of Bariatric Medicine (ABBM). The ABBM is an independent medical specialty board responsible for certifying physicians in the field of bariatric medicine, a medical

Locations throughout the Twin Cities and Western Wisconsin

specialty involved in treating obesity and its James Donovan, MD

related comorbidities. Certification ensures an

elevated standard of care and that doctors and other medical professionals have the knowledge to treat patients effectively.

800.353.7720 / 651.430.3800 / fax 651.430.3827 MidwestSpineInstitute.com APRIL 2011 MINNESOTA HEALTH CARE NEWS

7

PERSPECTIVE

Awakening dementia patients to a better life Beyond drugs to human interaction

W

e expect medicine to help us and those we love.

But in America’s culture of Alzheimer’s care, how medicine is used can sometimes harm a patient. For many of the 5.3 million Americans with Alzheimer’s, inappropriate use of antipsychotic drugs diminishes quality of life.

Laurel Baxter, MA, RN Ecumen

Laurel Baxter, MA, RN, is director of the Awakenings initiative at Ecumen’s 15 Minnesota care centers. Ecumen (www.ecumen.org), based in Shoreview, provides senior housing and services across Minnesota. Baxter has overseen clinical quality improvement efforts for Ecumen’s care centers and home care services since 2004. She is a consultant, educator, and clinical expert. During her 30-plus year nursing career, she has worked in acute care and subacute care settings. Before joining Ecumen, Baxter spent nearly two decades with the Minnesota Department of Health.

With Alzheimer’s and other forms of dementia, instances can occur where a normally mild-mannered person can become disruptive or physically violent toward caregivers or family members. The oft-used “treatment” is antipsychotic drugs, which often calm the patient, but which, over time, can become chemical restraints. Prolonged use can lead to what has been described as a “zombie” effect, where a person under heavy sedation might have an empty gaze or stop talking.

As residents in the Two Harbors facility were weaned off antipsychotics, staff engaged more with residents, taking them on walks, playing games, and exercising. Certified nursing assistants assumed a more important role. Therapies using validation, reminiscence, music, aroma, and pets were employed to improve residents’ physical and cognitive functions.

Within six months, we eliminated the use of antipsychotics among all residents, and antidepressant use decreased by 30 to 50 percent. Before the The Awakenings initiative proposes to change pilot project, the home was quiet; several residents preferred to stay in bed and oththe way antipsychotic drugs ers held a vacant gaze.Today, it’s are used in nursing homes and not uncommon to see residents how physicians, nursing home Within six months, playing balloon volleyball. teams, and families work together. We want to awaken residents who have Alzheimer’s or other dementia-related illness to a fuller, richer life.

we eliminated the

Reawakening

Here is one example of how Awakenings worked with one resident, whose name has been and antidepressant We piloted Awakenings at changed in this article to protect Ecumen Scenic Shores, a Two her privacy. Marjorie had a fear use decreased by Harbors, Minn., nursing home, of incontinence. That fear led to in 2009. Based on remarkable her desire to continually go to 30 to 50 percent. results, and thanks to a $3.8 milthe restroom. It was an intense lion state grant, we’re expanding and repetitive thought process Awakenings to Ecumen’s other that prevented her from partici14 Minnesota nursing homes. We’re hopeful that pating fully in daily life. Antipsychotic drugs she’d what we learn will provide Alzheimer’s best-prac- been prescribed to stop the behaviors hadn’t suctice guidance to others nationally. ceeded. The care team went beyond medications to get to the core of her anxiety.

Overuse of antipsychotic drugs in nursing homes

use of antipsychotics,

To understand Awakenings, it helps to understand the way medicine is often used to treat people with Alzheimer’s and other types of dementia. It’s common for antipsychotic drugs to be prescribed to stop violent or aggressive behavior that can accompany these diseases. For some people, anti-psychotic drugs can play an appropriate role. For others, they can effectively end life for the still-living.

Long-term use often results in a “zombie” effect— and antipsychotic use in some cases has worsened cognitive functioning among people with dementia, causing stroke, pneumonia, or other adverse effects.

Relationship care—a better way We piloted Awakenings to see whether residents with behavioral symptoms related to Alzheimer’s or other dementias could enjoy better life quality if behavioral and environmental interventions were fully integrated into the care plan.

8

This shift requires significant collaboration to get to the root cause of behavioral issues. “Circle of care” teams are built around each resident, involving doctors, nurses, other nursing home staff, and family.

The focus goes beyond drugs to human connections and interactions.

MINNESOTA HEALTH CARE NEWS APRIL 2011

Using talk therapy and interventions, engaging family members, building her self-confidence, stopping antipsychotic medications, and introducing exercise back into Marjorie’s life have made an enormous difference. She has moved to regularly scheduled bathroom breaks, breaking free of her desire to repeatedly visit the restroom and stay there. She’s eating and sleeping again, which has led to a new, healthy way of dealing with incontinence and her fears. Marjorie is awake and living, and her family shares the happiness she can still convey.

No Alzheimer’s cure exists today. But we believe that an integrated relationship-care approach like Awakenings can bring many of the estimated 27,000 Minnesota nursing home residents on antipsychotic drugs new vitality, joy, and dignity.

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10 QUESTIONS

& MaryBeth Mahony, DO Dr. Mahony is a board-certified pediatrician who sees patients at the Rogers, Minn., office of Partners in Pediatrics.

Whom does a pediatrician treat? We treat children from birth to age 23.

By caring for children, we provide education, guidance, and support to their parents, siblings, and, often, extended families.

What determines when a patient is too old to see a pediatrician?

The American Academy of Pediatrics defines the pediatric age group to include children up to age 23. That means children can stay with their pediatricians through college.

How does a pediatrician approach the challenges of diagnosing patients who are too young to use language to communicate what’s wrong? Pediatricians rely heavily on a child’s caregiver to report that something is amiss with the child. We pay close attention to nonspecific symptoms like irritability, fever, poor feeding, and poor sleeping. In the very young, we may also need to run lab tests from blood or urine to give us clues to the illness.

A child that grows in a supportive family is a healthy child.

Please tell us about some of the major pediatric subspecialties.

Pediatric subspecialties are related to organ systems (such as cardiology, pulmonology, gastroenterology), as in adult medicine. We also have subspecialists related to the child’s age or developmental stage. These include neonatologists (specializing in premature and ill full-term infants), adolescent specialists, and developmental/behavioral specialists (specializing in children with delays or abnormalities in their development).

Photo credit: Bruce Silcox

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MINNESOTA HEALTH CARE NEWS APRIL 2011

Why is obesity such a serious threat to the overall health of children? Obesity is a serious threat to children’s health because it can cause medical problems for them that are lifelong. These problems include heart disease, type 2 diabetes, and musculoskeletal problems. The longer a child is obese, the more likely that child will be obese for his or her entire life.

“

The benefit of protection from disease that immunizations provide far outweighs any risk.

What accounts for the rise in the prevalence of autism, and how has thinking around this condition evolved?

No one knows for sure what accounts for the rise in autism spectrum diagnoses in the pediatric population. Many believe it is simply being diagnosed more and covering a wider range of disabilities, while others believe it is a real increase. The thinking regarding autism has evolved to include diagnosing those with milder disabilities, such as Asperger’s syndrome, so that these children receive services as early as possible.

What do you tell parents who are reluctant to have their young children immunized against an array of diseases such as measles, mumps, chickenpox, and others? These are terrible, life-threatening diseases that can be prevented by immunizations. The benefit of protection from disease that immunizations provide far outweighs any risk.

”

What are the biggest challenges in your field? The biggest challenge I face in my pediatric practice is helping parents decipher the enormous amounts of information they have gathered from the Internet or social media. Many times having more information is helpful, but there is a lot of misleading information out there regarding medical issues.

What is the single most important thing parents can do to ensure the health of their children? Spending quality time with their children, getting to know them, playing with them, teaching them, loving them. A child that grows in a supportive family is a healthy child.

From a pediatrician’s perspective, what is the most important part of health care reform for children? Health care reform will improve access for children. This means that all children will be able to get their check-ups and immunizations.

Your quality of life deserves our quality of care.

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P H Y S I C A L T H E R A P Y A N D R E H A B I L I TAT I O N

M Keeping

dancers on their

toes

Physical demands on dance athletes result in unique injuries

By Brad R. Moser, MD

innesota has one of the largest dance populations in the U.S., ranking between fourth and sixth nationally. The state’s dance community, encompassing about 250 dance studios, schools, companies, and teams, contributes to the overall quality of the Minnesota arts culture.

The art and athletics of dance place unique demands on its participants, resulting in distinctive injuries and injury rates in comparison to other athletes in other sports. Complicating the injury picture, an estimated 30–40 percent of the professional dancers in Minnesota and 20–30 percent of the amateur dancers are uninsured or underinsured, according to the Taskforce on Dancer Health of Dance/USA, the national, nonprofit service organization for professional dancers.

Dance injuries Dance injuries are unique and require knowledge of the terminology and technique of a dancer in order to properly diagnose these injuries. Dance injuries are treated in many ways depending on the severity and extent of the injury. The treatments of dance injuries may range from a thorough physical therapy program to possible surgical intervention to heal the injury and prevent recurrence.

Among the most common injuries that befall dancers are: Stress fracture/injuries in the ankle and foot. These painful injuries result primarily from overuse, biomechanical malalignment (muscular imbalances), poor surfaces, and improper fit of pointe shoes, the specially blocked shoes that ballet dancers use to dance on the tips of their toes.

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The equipment includes amplified (corded and cordless) phones, speakerphones, captioned telephones, telephone ring signalers, deafblind equipment and other special equipment.

To learn more about this program visit our Web site at: www.tedprogram.org or contact us at (800) 657-3663, (888) 206-6555 TTY. Eligibility requirements do apply.

The Telephone Equipment Distribution Program is administered by the Department of Commerce Telecommunication Access Minnesota (TAM) and funded by a telephone surcharge.

12

MINNESOTA HEALTH CARE NEWS APRIL 2011

FHL (flexor hallucis longus) tendinitis. This affects the main tendon that flexes the big toe in pointe work, including relevé, rising from any position to balance on pointe or demi-pointe, standing on the balls of the feet with the ankles maximally stretched. It is due to weakness in foot muscles and biomechanical malalignment.

Posterior ankle impingement. Multiple causes can contribute to tissue damage that results in pain in the back of the ankle with pointing of the foot. X-rays and MRI sometimes are needed to help diagnose the cause.

Hip impingement and snapping syndrome. It is important to distinguish between these. Impingement is caused by problems in the joint. Snapping syndrome is quite common in dancers. It is caused by an injured or weak tendon overlying the joint, which causes a snapping sensation when the hip is flexed.

Dance medicine Established in 2009, the Minnesota Dance Medicine Foundation (MDM) is a 501(c)(3) nonprofit organization of dance medicine professionals dedicated to conducting research and creating educational initiatives to study dance injuries and prevention. Its staff of volunteers is composed of physicians and physical therapists who

sional athletes, dancers have been taught to “work through the pain”—even though doing so can worsen an injury and cause irreparable harm to the dancer athlete. In addition to recognizing the dancer’s dedication and devotion to the sport, medical providers also need to be aware of the dancer’s technique and movements, to better evaluate and treat injuries.

To provide dancers with better access to more accurate information, MDM collaborates with dancers, dance teachers, choreographers, companies, studios, and schools around the state in conducting research. Results of this research are disseminated throughout the medical community to doctors, physical therapists, and athletic trainers through medical journals and educational programs. The foundation’s current research includes a statewide study of dancer injuries and the injury rates at all levels of dance and dancer experience. A large posterior ankle impingement outcomes study in dancers is also being done. MDM’s research is aimed at further educating the dance and medical community on the most common injuries and treatment of those injuries. In addition, the research will add to the national medical literature in dance medicine.

Screenings and seminars

Dance medicine, in general, is not well funded, leaving scarce resources dedicated to research. MDM works to obtain grants through local and national medical fundMore information about ing sources. This allows the organization to offer free educational programs to dance companies, studios, Minnesota Dance Medicine is and schools throughout the state. In addition to con-

available at www.mndancemed.org. have had years of experience treating dancers. They provide medical care to dancers in addition to conducting research and offering educational presentations to individual dancers and the dance community at large.

Medical services. To help meet the Minnesota dance community’s needs for specialized care, the foundation provides complimentary injury evaluations and screenings so dancers can continue to perform without fear of being unable to afford proper instruction and care. MDM’s dance injury clinic is located in the Cowles Center for Dance and the Performing Arts (formerly the Minnesota Shubert Center for Performing Arts), in Minneapolis. The clinic is staffed by medical professionals, who evaluate dancers for injury (or potential injury) and answer their questions.

Research and education. The foundation conducts research and education activities aimed at improving treatment of dancers’ injuries—and helping prevent such injuries from occurring in the first place.

Recent studies have shown that dancers tend to get their injury information from their friends and teachers, rather than a specialized dance medicine professional. This is worrisome, as a dancer’s injury that remains unaddressed can lead to more severe and potentially career-ending injuries. It is essential that an injured dancer get a proper diagnosis that includes an evaluation of the dancer’s biomechanics, which may have led to the injury.

Misperceptions exist in the medical community as well. A health care provider may feel that a dancer’s injury must not be very severe because the dancer continues to dance. However, like other profes-

Keeping dancers on their toes to page 34

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13

NEUROLOGY

F

rom middle age on, the normal wear and tear of our bodies can affect our level of functioning and enjoyment of life. This is particularly true when the spine is involved. Within the spine, we expect some degree of degeneration that may include disc dehydration and loss of height, disc bulging or herniation, thickening and hardening of ligaments, osteoarthritis, and joint instability. These effects of aging can lead to spinal stenosis—narrowing and pressure around the spinal cord or nerve roots. Men and women have an equal risk of developing this problem. Less often, spinal stenosis can be caused by an injury, congenital defect, genetic disorder, or tumor. As the most common cause of central stenosis, age-related degeneration is the focus of this article.

How does spinal stenosis happen?

This abnormal narrowing of the spine can be present at any level but is common in the cervical spine (neck) and is most often seen in the lumbar spine (low back). Cervical stenosis creates pressure on the spinal cord that may cause pain

Spinal stenosis Age-related degeneration commonly the culprit

By Andrew J. Will, MD

or weakness in the neck, arms, back, or legs. However, there may not be any pain at all. Some patients notice clumsiness or lack of coordination and difficulty walking. Other symptoms may include numbness and tingling. Lumbar spinal stenosis may cause pain in the low back, buttocks, and/or legs, particularly with activity. Symptoms often develop gradually and worsen when standing upright or walking. Often, relief is found with sitting or bending forward because these positions open the spinal canal, allowing more space around nerves.

Complications of spinal stenosis are rare and generally involve the cervical spine. In the neck, stenosis compresses the spinal cord and may cause severe weakness, bowel or bladder incontinence, or paralysis. In the lumbar spine, cauda equina syndrome—which involves the cluster of nerve roots at the tail end of the spinal cord—may develop from severe compression of the lumbar nerve roots. Although quite rare, it can also cause loss of bowel or bladder control and paralysis in the legs and is considered a surgical emergency.

Symptoms and diagnosis

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Diagnosis of spinal stenosis is usually based on history, physical exam, and imaging. The patient’s description of symptoms and functional status is valuable in ruling out other conditions. The health care provider will also examine the patient for weakness, loss of sensation, decreased range of motion, and gait disturbances. If the history and physical exam indicate a potential spine problem, an MRI is ordered to confirm the diagnosis. An MRI is the preferred test to visualize the spinal cord and nerves and the condition of the spinal discs. The MRI will show the degree of spinal stenosis and how many levels are involved.

Symptoms of spinal stenosis are usually managed non-surgically.

Conservative treatment includes medications, physical therapy, activity modification, and injections. Over-the-counter pain relievers such as aspirin, naproxen, and ibuprofen are commonly used because of their anti-inflammatory effect. Antidepressants, anti-seizure medications, and opioids may also be prescribed for pain relief.

Nonsurgical treatments

Physical therapy is usually one of the first steps in treating spinal stenosis. Therapists are trained to use a variety of methods and techniques to create individualized programs for patients based on specific needs. Exercises that focus on strengthening the muscles of the back and abdomen help to improve spinal support. Therapists can also teach the patient how to stretch properly to restore flexibility.

The long-term goal of physical therapy is to educate the patient about how to manage symptoms and prevent further debilitation. Patients are encouraged to continue exercises at home and to try to stay as

active as possible. In addition to physical therapy, exercises including stationary biking, limited walking, and swimming can help to control pain. Yoga, Pilates, and tai chi can improve flexibility. Maintaining a healthy weight reduces pressure on the spine. For those who are overweight, a reduction in pain can occur with even a 10-pound weight loss.

Oral and injectable steroid medications can also control pain from spinal stenosis. A short course of prednisone or Medrol can be a relatively inexpensive and convenient option. Cortisone is a strong anti-inflammatory that temporarily reduces swelling and relieves pain.

Epidural spinal injections of cortisone provide a more direct delivery of the medication around the affected nerves. Injections can be repeated but, because of the possibility of side effects, are usually limited to no more than three per year.

Alternative medicine is another potential treatment but evidence is lacking regarding its effectiveness for spinal stenosis. Insurance coverage may also be limited. The most common therapies include chiropractic, acupuncture, and massage.

Surgical treatments

When symptoms of spinal stenosis are not relieved by conservative measures, surgery to relieve pressure on the spinal nerves may be an option. Most patients pursue surgery if more conservative treatments have failed and their pain or weakness is disabling and affecting their level of functioning and quality of life. A consultation with a spine surgeon will determine if surgery is an option and what type of procedure would be most effective.

The most common types of surgery for spinal stenosis are laminectomy and fusion. The goal is to relieve pressure on the affected nerves by making the spinal canal larger. Laminectomy (the most common surgery) involves removing bone and other sources of compression to create more space. Fusing the spinal vertebrae may be recommended if there is pain caused by instability in the spine. There is also the option of open or minimally invasive surgery. With minimally invasive surgery, the incision is smaller, which allows for a shorter recovery period. However, if proper visualization of the area is not possible, open surgery is recommended.

In most cases, surgery succeeds in relieving the pain and discomfort of central stenosis. All surgery carries a risk, so the decision should be considered carefully. The most common risks include bleeding, blood clots, infection, nerve injury, spinal fluid leak, and complications from anesthesia. There is also the possibility that the pain may not improve or may worsen afterward.

Some patients with lumbar spinal stenosis may be candidates for a metal spine spacer called X-STOP in place of a laminectomy. It is an FDA-approved device that is inserted between the bones of the spine at up to two affected levels. The implant limits extension, or bending too far backward, which in turn reduces narrowing. It is a same-day procedure and reversible.

Another implantable device option is the spinal cord stimulator (SCS). This may be an alternative for patients with chronic pain from spinal stenosis in which surgery is contraindicated or if previous spine surgery has been unsuccessful and further surgery is not recommended. The device delivers a mild electrical current that blocks pain and replaces it with a more pleasant tingling sensation where the pain is usually felt. The patient initially undergoes a short trial with a temporary stimulator to determine if significant pain relief is achievable

before committing to an implanted device. The implanted neurostimulator involves a minor surgical procedure and is reversible.

For most, stenosis can be managed

We cannot prevent the physiological changes of aging that sometimes cause pain and affect our level of functioning. Fortunately, most patients are able to successfully manage spinal stenosis with conservative measures and continue living an active and fulfilling life. Patients who are experiencing symptoms of spinal stenosis should see their health care provider for further evaluation and recommendations. A referral to a spine-specialized physician or physiatrist offers an expert approach to spinal conditions and can help facilitate treatment.

Andrew J. Will, MD, is a physiatrist and medical director of Twin Cities Pain Clinic in Edina.

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15

PUBLIC HEALTH

S

afety is so essential to the food we eat that most processors choose not to publicize their safety activities for fear of arousing public concern, and legislators would never think of playing politics with food safety. Or would they? In spite of widespread bipartisan support, the Food Safety Modernization Act (FSMA) languished in the Senate until the waning hours of the 111th Congress. In the end, it passed and was signed into law by President Obama on Jan. 4. Had Congress adjourned without passing the FSMA, the first major overhaul of the Food and Drug Administration’s (FDA) regulatory authority over food in more than 60 years would have been sent back to the drawing board.

Now that the FSMA has passed, what is the future of food safety?

Food safety Federal legislation takes step in the right direction

By Craig W. Hedberg, PhD

A mixed bag The title of the FSMA and much of the reasoning supporting its passage suggest we are moving into a modern era of food safety, with a new focus on prevention rather than response, and increased regulatory authority and effectiveness promised for FDA on a global basis.

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MINNESOTA HEALTH CARE NEWS APRIL 2011

The reality, though, is that most of the increased authority for the FDA will take several years to develop, in the form of new rules and procedures.

In addition, the Congressional Budget Office has estimated the cost of fully implementing the FSMA at $1.4 billion over five years. The bill, as passed, included no appropriation. That leaves funding dependent on the current Congress and, given the results of the recent election and the need to cut budgets, finding the political will to finance major new investments in food safety is far from certain.

In one sense, however, passage of the FSMA does change everything. For the first time, all food producers and processors are being given a mandate to develop a system to evaluate hazards, identify and implement preventive controls, monitor the performance of those controls, and keep records of the monitoring. This type of approach, based on the principles of hazard analysis and critical control points (HACCP), was originally established by the Minneapolis-based Pillsbury Co. in the 1960s when the National Aeronautics and Space Administration (NASA) needed to guarantee the safety of foods they sent into space with astronauts. In fact, most large food manufacturers and many progressive smaller firms have used this type of approach for years. Expanding the approach for facilities across the food system should lead to better-

run facilities and a greater awareness of risks up and down the supply chain. These provisions should lead to improved prevention measures against all of the major and emerging food safety hazards.

Coupled with the mandate for food companies to document hazards and their preventive controls is expanded FDA authority to inspect records. FDA oversight of HACCP records should reinforce industry adherence to effective prevention measures. As part of the investigation of a suspected food contamination event or outbreak, it should also provide more effective tools for a rapid response. This is an area where there has been considerable need for improvement.

The Minnesota Departments of Health (MDH) and Agriculture (MDA) have developed a very efficient and effective rapid-response team for investigating outbreaks of foodborne disease. Investigators from MDA rapidly trace back the source of suspicious food items identified by MDH. Using modern communications channels, MDA rapidly obtains and analyzes food product distribution and source information, which can then be used by MDH to implicate a specific food source as the cause of an outbreak. It was just such a collaboration that helped make Minnesota investigators the first to identify peanut butter as the source of a nationwide outbreak of Salmonella Typhimurium infections in 2009. The increased authority given to FDA in the FSMA should help the agency develop more rapid and flexible approaches to collecting this critical information.

The Salmonella outbreak of 2008–09 The S. Typhimurium outbreak caused by contaminated peanut butter produced by the Peanut Corporation of America (PCA) highlights two other major provisions of the FMSA. According to testimony at congressional hearings and company records obtained by the FDA, this outbreak allegedly resulted from unethical behavior on the part of the company’s owner, Stewart Parnell. Faced with test results confirming Salmonella contamination of peanut butter samples, he allegedly chose to have other samples tested and to include the negative results from the clean samples in shipments that included the contaminated products. While the product was not uniformly contaminated, PCA shipped enough contaminated product to infect thousands of consumers, of whom 714 in 46 states had laboratoryconfirmed infections of the Salmonella strain associated with the outbreak, and at least nine people died. A The Food Saftey federal criminal investigation into the outbreak continues.

Modernization With its new authority, the FDA could suspend the registration of a food Act is the first facility, effectively shutting it down, major overhaul if food from the facility “has a reasonable probability of causing serious of the FDA in adverse consequences or death.” Thus, more than 60 operators like PCA, which did not go out of business until after the outbreak, years. could be shut down earlier, reducing the number of illnesses and deaths that result from harmful practices.

dent that having mandatory recall authority would be very useful in rapidly removing contaminated products, such as PCA peanut butter, from the market place. In fact, if the FDA had possessed access to PCA test results, and had required the earlier withdrawal of the products from the marketplace, the bulk of that outbreak may have been prevented. However, most outbreaks do not follow this pattern, and food companies are generally willing to pull their products off the market when presented with credible information describing a problem that puts their customers at risk. For example, when a nationwide outbreak of Salmonella Enteritidis infections was linked to ice cream manufactured by Schwan’s Foods, based in Marshall, Minn., the company shut down its ice cream plant and issued a nationwide recall within hours of first learning that a problem existed.

At the time, the paradigm for recalling food products required microbiological confirmation that the product was contaminated. In this case, the company followed recommendations by the MDH, MDA, and FDA before samples had time to be collected and tested. Ten days later, S. Enteritidis was isolated from unopened containers. Initiating the recall based on epidemiologic evidence prevented thousands of additional cases.

While the goal of mandatory recalls is to promote more effective Food safety to page 19

Mandatory recall The FSMA also authorizes a mandatory recall procedure for adulterated foods.

This provision of the FSMA has gotten much favorable publicity. It seems eviAPRIL 2011 MINNESOTA HEALTH CARE NEWS

17

April Calendar 11

Dinner Club Meet for dinner and conversation with fellow survivors of stroke, brain injury, and neurological disorders. Have fun, eat a good meal, and support each other all at the same time. Call Methodist Hospital’s INSPIRE program at 952-993-6789 to reserve your spot.

Monday, April 11, 6:30–8:30 p.m., Lookout Bar & Grill, 8672 Pineview Ln. N., Maple Grove

12 & 19

Cholesterol Basics This two-session class is designed to promote healthy eating and physical activity to help individuals lower elevated blood cholesterol and triglycerides. Participants will learn how to identify personal risk factors for heart disease. Physical activity tips and strategies for grocery shopping, recipe adaptation, and eating out are provided.

To register, call 952-993-3454. Cost: $40 (A support person may attend for free).

Tuesdays, April 12 & 19, 6–8 p.m., Park Nicollet Clinic, 14000 Fairview Dr., 3rd Floor Conference Rm., Burnsville

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Preparing for Recovery What happens after a hospital stay for illness or surgery? What options are available? Recovery can require unexpected time and resources. Being prepared in advance will help you feel more confident in the recovery process. RSVP to Tara Heisler at 952-404-7306 or tara.heisler@goldenliving.com. Refreshments will be provided.

Thursday, April 14, 3–4 p.m., Golden LivingCenter, 725 2nd Ave. S., Hopkins Healthy Start Day and InfantSEE Exams Families are encouraged to attend a free open house that includes a complimentary InfantSEE eye exam, performed by an optometrist, for babies aged six months to one year. Also included: free dental exams for infants, health and wellness information, refreshments, and a gift for each family.

Parents are asked to pre-register by calling 651-290-9258.

Saturday, April 16, 10 a.m.–4 p.m., Open Cities Health Clinic, 407 Dunlap St., St. Paul

National Public Health Week April 4-10 During National Public Health Week 2011, the American Public Health Association (APHA) reminds us that, together, we can help Americans live injury-free in all areas of life: at work, at home, at play, in our communities, and anywhere people are on the move. We all need to do our part to prevent injuries and violence in our communities. Visit www.nphw.org for ways to make your home and surroundings safe.

State and local public health resources are also available to get healthy and stay active. You may access information about social, financial, and clinic services; community partnerships; emergency preparedness; family health programs; health promotion; disability services; and senior health.

You can learn more about state and local public health initiatives by visiting the Minnesota Department of Health at www.health.state .mn.us/ or by calling 651-201-5000 (888345-0823 toll-free, 651-201-5797 TTY).

13

Hearing Screening for Seniors

The effects of hearing loss may be social, such as withdrawing from one’s surroundings or having less frequent and personal conversations. Good hearing, especially the ability to hear sirens and other sound alerts while driving, is a safety issue. A hearing test provides an opportunity to talk about options for improved hearing and coping skills. Screenings are held the second Wednesday of even months. For an appointment, call 952-563-4944. Interpreters and transportation information are available upon request.

Wednesday, April 13, 1–3 p.m., Creekside Community Center, 9801 Penn Ave. S., Bloomington

20

Postpartum Depression Education This ongoing group offers education and support for women who are experiencing or are at risk for postpartum depression.

Babies are welcome to attend with their mothers. Free parking and free drop-in child care are available. Please call Rosalyn Voigt, MS, registered nurse and certified lactation counselor, at 612-863-4770, before attending your first meeting or for more information. A group also meets in Minneapolis.

Wednesday, April 20, 1:30–3 p.m., Dakota County Northern Service Center, 1 Mendota Rd. W., West St. Paul

25

Fibromyalgia Support Group This support group is free and new members are welcome. Groups are confidential and facilitated by trained medical staff and/or volunteers. Due to fragrance and chemical sensitivities, we request attendees refrain from wearing fragrances to the meetings. Call 651-351-2364 for more information.

Monday, April 25, 7–8:30 p.m., Courage St. Croix, 1460 Curve Crest Blvd., Stillwater

27

CARITAS (Come and Receive Insight, Trust and Support) Patients and families in need of communication and support after a cancer diagnosis are invited to join. In an atmosphere of acceptance, freedom, and caring, members find comfort through discussion and exchanging concerns. Drop-ins welcome and no registration is required. This group meets each Wednesday. For more information, call 651-326-2273.

Wednesday, April 27, 10:30 a.m.–noon, St. Joseph’s Hospital, 45 W. 10th St., 4th Floor Family Lounge, 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 e-mail them to jbirgersson@ mppub.com. Please note: We cannot guarantee that all submissions will be used. CME, CE, and symposium listings will not be published.

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MINNESOTA HEALTH CARE NEWS APRIL 2011

Food safety from page 17

Food safety challenges are a constantly moving target.

and timely control measures to a food contamination event or outbreak, this is best accomplished by early and honest engagement between public health and regulatory officials and the food company’s senior management. Information thresholds required to initiate a mandatory recall could actually delay the recall of food items in some instances.

Producers, consumers hold key to food safety Although the FSMA establishes a preventive approach, food safety challenges are a constantly moving target. Foodborne diseases result from the dynamic interactions of agent, host, and environment. We cannot simply talk about the burden of foodborne disease or the epidemiology of foodborne disease. The landscape of food safety is populated by many foodborne diseases. Because of this we will always need a robust public health system to detect and respond to emerging food safety threats. One of the most important and least promoted provisions of the FSMA was the idea of Sen. Amy Klobuchar (DMinn.) to establish a network of Centers of Excellence for Foodborne Disease Surveillance, based on the effective model of MDH. At the heart of this model is a dedicated group of students from the University of Minnesota School of Public Health. MDH hires these students, proudly and affection-

ately known as Team Diarrhea, as student workers. Under the supervision of the nation’s best foodborne disease epidemiologists, they rapidly conduct the interviews that make Minnesota’s outbreak investigations successful. Along the way, they get the best practical training available.

The implementation of the FSMA could have many beneficial impacts on our system of food safety. Critical decisions on funding will affect how quickly and effectively these changes will be made.

However, it is always wise to remember that the more things change, the more they stay the same. Food safety is and always will be in the hands of the producers and consumers of food. The vigilance and dedication of food producers is the biggest prerequisite for safe food.

Consumers must also do their part by washing their hands, cooking foods thoroughly, and expressing their willingness to pay for the safety of their food.

Craig W. Hedberg, PhD, is a professor in the Division of Environmental Health Sciences at the University of Minnesota School of Public Health. His research and teaching interests relate to the surveillance and control of foodborne diseases.

Orthopedic & Sports Medicine Injury Walk-in Clinics Now open in seven locations. Open days, nights and Saturdays in Edina.

Twin Cities Orthopedics understands time is an important commodity when an injured patient needs to be seen by an orthopedic surgeon. We now have weekday orthopedic injury walk-in clinics at seven locations. Our Edina clinic also offers afterhours walk-in consultations.

Patients will be treated by board-certified orthopedic surgeons. No appointment necessary.

To refer an injured patient to a specific physician or a location not offering walk-in hours, please call the clinic and we will see your patient as soon as possible.

Monday - Friday 9:00 a.m. - 4:00 p.m.

Fridley 8290 University Ave NE Suite 200 763-786-9543

Burnsville 1000 West 140th St Suite 201 952-808-3000

Maple Grove 9825 Hospital Dr Suite 104 763-520-7870

Coon Rapids

Be your best. Again. www.TCOmn.com 19

MINNESOTA HEALTH CARE NEWS APRIL 2011

3111 124th Ave NW Suite 200 763-427-7300

Otsego 8540 Quaday Ave NE 763-441-0298

Monday - Friday 9:00 a.m. - 9:00 p.m.

Saturday 9:00 a.m. - 1:00 p.m.

Edina 4010 West 65th St 952-456-7000

Call for hours Shoreview 4570 Churchill St Suite 300 651-481-1071

How I got here

F E AT U R E

Diverse paths led physicians to medical specialties

“The very first step towards success in any occupation is to become interested in it.”

So said the eminent physician William Osler, and his words still ring true more than a century later. With that in mind, we asked several physicians to tell us how they first became interested in their specialty.

Suzette E. Sutherland, MD female urology, Metro Urology, Centers for Continence Care and Female Urology and Center for Pelvic Floor Disorders, Minneapolis/St. Paul; adjunct associate professor, Department of Urologic Surgery, University of Minnesota, Minneapolis Years practicing: 7

How/why did you choose your specialty? One reason is my true passion for empowering women through education about our bodies. I emphasize the impact our health has not only on our own well-being, but also on the wellbeing of our families and broader communities. As women, we are natural nurturers and caretakers; we are seemingly hard-wired to address the needs of others. But we are unable to fully play those important roles in our families and communities unless we maintain our own personal health. I also appreciate the opportunities I have to educate the general public, providing women with a venue—as well as permission—to talk about subjects that are often too personal and embarrassing to discuss, even among family and close friends.

Read us online wherever you are!

Rewards/challenges: The most rewarding aspect of my specialty is helping women reclaim their active lifestyles. While not life-threatening conditions, both incontinence and pelvic prolapse can significantly impact the way a woman lives her daily life. I have had patients who were homebound for years because they were fearful of losing bladder control in a public setting. After surgery, they are once again able to lead full, productive, and dry lives.

When I entered the male-dominated field of urology as a firstyear resident in 1997, there had been only two other women in the history of my training program at Case Western Reserve University Hospitals. By the time I was in my sixth and final year of residency, women held one-third of the positions in my program. However, there is still much room for improvement. Today only 6 percent of all urologists in the U.S. are women, with only six female urologists serving the entire state of Minnesota.

What lies ahead? As with most medical specialties, one of the largest

www.mppub.com 20

MINNESOTA HEALTH CARE NEWS APRIL 2011

challenges is to remain current with regard to new medical research findings and enhanced surgical procedures. In the past 10 years, the minimally invasive surgical options available for treatment of incontinence, pelvic prolapse reconstruction, and other such pelvic issues have more than doubled with the development of successful transvaginal approaches, as well as robotic-assisted laparoscopy.

Patients will continue to take more control of their health and will seek to educate themselves about their conditions. While the Internet provides immediate access to a wealth of data, not all of it is necessarily accurate or helpful. It is critical that a physician be skilled in assisting patients navigate the information to determine the most appropriate course of treatment.

Richard D. Lentz, MD, MS psychiatrist, Park Nicollet Health Services, St. Louis Park; clinical professor of psychiatry, University of Minnesota Medical School Years practicing: 29 How/why did you choose your specialty?

My peripatetic path to psychiatry began when I entered the University of Rochester (N.Y.) School of Medicine and Dentistry.

Although planning to become an internist, I was stimulated by the creative ferment in psychiatry at Rochester. I learned that psychoanalytic and other psychological theories, biological concepts, and social systems research offer different paths to understanding people. Each path informs some aspect of the human condition; synthesis is essential.

While in medical school, I became interested in neurology as another path to understanding behavior and took a year out, earning a master’s degree in neuropathology.

With an interest in childhood aspects of neurological disease, I took an internship and residency in the Department of Pediatrics at the University of Minnesota.

Still excited by pediatrics, I returned to the university for a fellowship in pediatric kidney disease. This was punctuated by two

years as chief of pediatric nephrology at Walter Reed Army Medical Center. I returned to Minnesota to complete my nephrology fellowship and then accepted an assistant professorship in pediatric nephrology at the University of Maryland.

After a few months in Maryland, I returned to the U of M to test the psychiatric waters with a consultation-liaison fellowship in psychiatry. After completing a formal psychiatric residency, I took a position at the Nicollet Clinic, now Park Nicollet. For the first 20 years, I treated both inpatients and outpatients. Although I loved inpatient psychiatry, combining inpatient and outpatient work was exhausting and pressured. I ended inpatient work in 2002.

Rewards/challenges: In addition to general psychiatry, I enjoy working with patients with medical and neurological illnesses; evaluating physicians with professional and behavioral problems; working with physicians who have been sued; and practicing non-criminal forensic psychiatry, frequently involving traumatic brain injury. Other pro-

fessional activities include research, publishing, and teaching, and studying psychiatric aspects of pancreas transplantation.

I have experienced the practice of medicine as a privilege.

The trust of my patients; the collegiality of physicians, nurses and therapists; and the interaction of teacher and student continue to animate my professional life.

What lies ahead? It is difficult to predict

the future of psychiatry, especially with the uncertain implications of health care reform.

There is a marked shortage of psychiatrists in Minnesota, and many primary care physicians are uncomfortable treating psychiatric problems or lack essential skills. There is a need for more certified nurse specialists in psychiatry. Telepsychiatry and a more consultative approach may ensue.

There is considerable risk, as we learn more about the brain, that psychiatrists will lose touch with the conceptually sound, remarkably practical, integrated biopsychosocial model of Dr. George Engel, by focusing exclusively on biology.

How I got here to page 22

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my master’s program, I proposed to study whether human-generated high atmospheric dust might cancel the warming effects of CO2.

My adviser, however, would not allow me that topic, saying: “With a thesis titled ‘The Impact of Air Pollution on the Weather,’ no one will ever hire you!”

As I finished the master’s program, I was again accepted into medical school and I knew I wanted to be a family physician who could deliver babies, manage general health problems, and talk with people who were troubled. As a resident, I also took extra graduate school courses and became a certified family therapist as well.

I completed my second master’s degree after residency and co-authored a book, “Family Therapy and Family Medicine.”

After five years in rural practice, I entered academic medicine hoping to humanize physician education and to enable families to be more integrated into health care decisionmaking.

Since leaving rural practice, I have been a residency director at the University of Oklahoma; chair of family medicine at Upstate Medical Center in Syracuse, New

Macaran Baird, MD, MS professor and head, Department of Family Medicine and Community Health, University of Minnesota Years practicing: 32

How/why did you choose your specialty?

When I was growing up in southern Minnesota, we had a wonderful general practitioner in town who made house calls, delivered babies, talked with people who were troubled, and generally did what we needed.

I was deeply impressed by that generalist physician and role model.

At Macalester College, I pondered a career in the clergy, but my parents were concerned that I might be frustrated and take too many personal risks (as had my uncle, a clergyman involved in the Chicago civil rights struggles in the 1950s and 60s).

In the midst of the anti-war sentiment sweeping the country, and trying to find the right personal challenge, I was accepted into the University of Minnesota Medical School.

But I declined, opting instead to chair Macalester’s first Earth Day conference and then accepting a scholarship to attend the U of M’s School of Environmental Health to study air pollution. Shortly after starting

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Rewards/challenges: I treasure seeing patients once a week and speaking about the integration of behavioral health and medical care. As an academic leader, I have the added privilege of helping students, residents, therapists, faculty, and other health professionals, as well as staff, grow to their full potential.

The challenges for family medicine and academic medicine in general are parallel.

Much of our work must be done more effectively and efficiently, but is hard to measure and difficult to fund. This challenges us to be creative and humble. Engaging patients/ citizens and families remains a good strategy.

What lies ahead? Our future is bright because

we are attracting smart, young physician leaders who are simultaneously idealistic and optimistic. Improved technology, multidisciplinary teamwork, and improved payment models that reward health outcomes will support our rewarding specialty.

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MINNESOTA HEALTH CARE NEWS APRIL 2011

Joseph Tashjian, MD radiologist (breast and chest radiology), St. Paul Radiology Years practicing: 31

How/why did you choose your specialty?

My interest in radiology was first stimulated by my interest in photography. I very much enjoy both the art and science behind imaging, whether it is a photograph, an x-ray, or an ultrasound image. The task of obtaining the best possible image, and the challenge of taking that two-dimensional image and constructing a three-dimensional structure from which a diagnosis can be made has always been an attraction.

I was fortunate to have a number of mentors early in my career who nurtured my interest. My very first mentor was a radiologist of considerable talent, who was able to both teach and inspire us in radiology. In fact, he brought so many of us into radiology that our medical school decided there were enough radiologists and discontinued his being an adviser.

Finally, the ability to solve a patient’s problem with radiology is dependent on both skill and intellect. To me, this is very enticing.

Rewards/challenges: The most important rewards for me have been (1) the development of the radiologist as both a “physician’s physician,” providing diagnoses on a timely basis, such as in concert with our colleagues in the emergency department; and (2) the development of the radiologist as a primary care provider, particularly in breast and interventional radiology. For me, to be able to use the advantages we have with imaging and then join them with the clinical evaluation of the patient to provide an integrated diagnosis for patients in a cohesive and timely fashion has been very rewarding.

Our major challenge has also been our

major stimulus for improvement. Radiology has gone from being practiced in a dark room in the basement from 7 a.m. to 4 p.m. on weekdays to a specialty that is involved in almost every aspect of patient care at all hours of every day and night. The ability to participate in and improve the care of our patients has more than compensated for the difficulty of providing continuous care.

What lies ahead? The use of functional imag-

ing, including molecular imaging, will allow us to tailor imaging and treatment specifically to each patient. Improvement in the ability to obtain direct, three-dimensional images of larger areas of the body and head may have a large impact on how we are able to diagnose disease.

The continued improvement in percutaneous devices used under imaging guidance will allow us to extend our role in treatment. The ability to percutaneously coil intracranial aneurysms, stent abdominal aneurysms, drain abscesses, place chest tubes, differentiate benign and malignant tumors through biopsy, and place permanent devices—all at a reduced cost and with less morbidity—will only continue to evolve into more effective treatments.

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M E N TA L H E A LT H

“The person who tries to live alone will not succeed as a human being. His heart withers if it does not answer another heart. His mind shrinks away if he hears only the echoes of his own thoughts and finds no other inspiration.” — Pearl S. Buck, novelist

The

neurobiology of loneliness Like everyone else, people with mental illness need human connection

By Kevin Turnquist, MD

24

MINNESOTA HEALTH CARE NEWS APRIL 2011

How strange that Pearl Buck’s view of loneliness would turn out to be true on a basic neurological level nearly half a century after she wrote these words. For neurobiologists are now learning that loneliness does indeed have profound effects on brain structure and functioning.

Human beings are troop primates by nature.

Prolonged loneliness is contrary to our primal impulse to be a part of a group. The brain reacts to loneliness as an emergency situation. The hormones of our stress response—the glucocorticoids—are kept at an elevated level. On an unconscious level we essentially prepare our bodies to travel in search of other humans.

Those glucocorticoid hormones have widespread effects on our brains and bodies. The stress hormones oppose the actions of insulin.

Weight gain, abdominal obesity, and type 2 diabetes become more likely. The resultant abdominal fat secretes hormones of its own and those hormones predispose people to anxiety and depression.

Researchers have also discovered that lonely people tend to sleep poorly. Adequate sleep is necessary for the healthy functioning of one

of the most important brain areas involved in emotional well-being—the hippocampus. This crucial structure manufactures new brain cells every day in response to a protein called brain-derived neurotropic factor (BDNF). Our antidepressant treatments work though this pathway.

When people are depressed, their hippocampi

Despite technological advances in communication that would have been unimaginable 50 years ago, we as a population are becoming more alone.

impediments to successful treatment. Focusing tightly on medication treatments alone may result in escalating dosages of diabetic meds, sleeping pills, or pain-relievers when what is actually needed is the company of other humans.

Even a casual observer of our current mental health system will recognize that we have a problem here. Many mentally ill patients cannot provide these essential social commodities for themselves and, historically, the medical profession has not done a good job of helping them in these areas. Far too many of our mentally ill people live extremely isolated lives. They have no sense of belonging to a greater community. And their loneliness cuts them off from one of the single healthiest factors for their brains: Laughter reduces the effects of those toxic stress hormones in ways that no medication can replicate.

Creating communities

may shrink by almost 20 percent, and recovery requires building new brain cells here. In the schizophrenic illnesses, the hippocampi are often small and misshapen from birth. Patients with borderline personality disorder also commonly have malstructured hippocampi, often in response to emotional traumas suffered while their brains were developing.

We’ve learned that both poor sleep and prolonged exposure to stress hormones reduce BDNF levels. Interestingly, lack of physical exercise and living in unstimulating environments have exactly the same effect. So if we truly want to optimize the mental health of our mentally ill citizens, we must find ways to provide them with the things that their brains require on a fundamental level. They need mentally stimulating activities, physical exercise, healthy diets, adequate sleep, and freedom from excessive stress hormones. Most of all, they need to feel that they are connected with other humans.

Of course, loneliness and social isolation are not confined to people with severe mental illnesses. Despite technological advances in communication that would have been unimaginable 50 years ago, at the same time we as a population are becoming more alone. The tightly knit family groupings that have always typified humans have been replaced by casual electronic relationships with relative strangers. Just because we don’t yet understand the long-term effects of such changes on our brain functioning doesn’t mean that they aren’t important.

“What should young people do with their lives today? Many things, obviously. But the most daring thing is to create stable communities in which the terrible disease of loneliness can be cured.”

—Kurt Vonnegut, novelist

Like Pearl Buck, Kurt Vonnegut must have had a real intuitive sense for neurobiology, for creating stable communities is exactly what we must accomplish as a society. There is a widespread tendency to believe that advances in the treatment of the mentally ill will come in the form of new and improved medications, yet the most effective pills for the major mental illnesses have all been around for decades.

The neurobiology of loneliness to page 29

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Effects of loneliness manifest physically The effects of loneliness on a person’s physical health are not always readily apparent. Common symptoms include difficulty stabilizing blood sugars with conventional diabetic regimens and persistent complaints of insomnia. Some people will abuse alcohol or other drugs in an effort to deal with the pain of social isolation. And depression itself may present in any number of “medical” ways: Unexplained bowel problems, weight loss or gain, fatigue, pain, and heightened anxiety are all commonly encountered.

When patients don’t respond to conventional treatments in conventional ways, a wise physician will ask whether there are psychosocial factors—such as profound loneliness—that might stand as

It raises many questions few of us are prepared to answer, such as: • How can I take time off from work?

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• Can I keep my health insurance even if I lose my job?

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25

OSTEOPOROSIS

Minimize your risk general health. In women, loss of bone density happens steoporosis is the most common bone very slowly over time until menopause. Then falling disease in adults, affecting more than estrogen levels accelerate the rate of bone loss for 8 million Americans. It is predicted several years. Bone loss in men is slow until that by 2020, over 1 million Minnesotans around age 65, when it increases. Still, their will have or be at high risk for developrate of bone loss is not as great as that in ing osteoporosis, a 42 percent increase women. On average, older men and womfrom 2002. In addition to the personal en will lose bone at a rate of one-half

By Christine Simonelli, MD consequence of fractures—pain, percent to 1 percent a year for the rest disability, and loss of independence— of their lives. At age 50, a woman has a the economic burden of osteoporosis 40–50 percent chance of having a fracin Minnesota is expected to be $350 ture from osteoporosis in her remaining lifemillion by 2015. Each year the incidence of time, and a male about 20 percent chance of a fracture. osteoporosis-related fractures is greater than the incidence of heart attacks, strokes, and breast cancer combined.

Assessing risk Bone is living tissue that is constantly undergoing a remodeling Osteoporosis doesn’t generally cause any symptoms until a fracture process by which old bone is broken down and dispersed (resorbed) occurs. So how do we know our particular risk? Bone density testing and new bone is formed. Osteoporosis is the process of bone thinning allows us to measure the amount of bone in a certain area of the that occurs over time after bone mass peaks at an average age of 30 lumbar spine, the hip regions, and forearm and get a very accurate years. The consequence of declining bone density is risk for a fracmeasure of the bone density. The bone density by DXA (dual-energy ture. The most common fractures associated with osteoporosis are x-ray absorptiometry) measurement is an excellent tool to assess risk spine, hip, and forearm fractures. Others may also occur, such as because we know that, as bone density declines, fracture risk infractures of the pelvis, upper arm (humerus), ankle, and ribs. creases in both men and postmenopausal women. This gives us an Among the many factors that determine an individual’s peak important indicator of risk and helps us decide who may need addibone mass are genetics, diet and exercise habits in one’s youth, and tional evaluation and treatment.

With the DXA test we are able to measure the T-score, which is a measure of current bone density compared to the average peak bone density matched for gender and ethnicity, and also the Z-score, a comparison of the individual’s bone density with the average genderand age-matched population. A person whose bone density T-score is -2.5 or lower is classified as having osteoporosis; a T-score better than -1.0 is considered normal. All bone density measures in between are classified as “low bone mass” (previously called osteopenia).

The newest tool we have is the FRAX (fracture risk-assessment tool). This allows us to predict the 10-year probability of a fracture, so that treatment recommendations are now made on calculated risk and not just a bone density number.

O

Nutrition, exercise form first line of defense

In the next issue..

• Asthma action plans • Chiropractic care • Crohn’s disease

Who needs a bone density test?

These recommendations are endorsed by all major public health organizations, including Medicare, the U.S. Public Health Service, the International Society for Clinical Densitometry, as well as the local Institute for Clinical Systems Improvement (www.icsi.org): • All women 65 and older • Younger postmenopausal women who have another risk factor for osteoporosis • Men 70 and older • All adults who have experienced a fracture after age 40 that was not trauma-related • Adults who have used high-risk medications such as prednisone or anti-seizure medications, or who have had cancer treatments known to cause bone loss • Individuals with certain diseases associated with bone loss such as

26

MINNESOTA HEALTH CARE NEWS APRIL 2011

Osteoporosis doesn’t generally cause any symptoms until a fracture occurs. rheumatoid arthritis, liver disease, kidney disease, inflammatory bowel disease, various endocrine diseases, or other rheumatologic diseases.

Lifestyle and osteoporosis risk There are important lifestyle measures that can help reduce our risk for osteoporosis. These include adequate nutrition with a calcium intake of at least 1,200 mg a day—including diet and a supplement if needed. Most adults will have some calcium in their diet: Each serving of dairy product contributes 250–300 mg calcium and the rest of an average diet about 250 mg of calcium. People whose diet includes two or three servings of a dairy product daily and an adult multivitamin may not need a calcium supplement. Calcium recommendations that come with the supplement assume that you have NO dietary calcium, so it is important to subtract the calcium you are getting in your diet.

Adequate vitamin D is necessary for good absorption of calcium and has other potential health benefits. The current recommendation suggests an intake of 800–1,000 International Units a day. Many adults will need significantly higher doses of vitamin D in the winter months or if they have any absorption problems. Data from patients with hip fractures in two Minnesota hospitals evaluated over a sixmonth period showed that 80 percent were vitamin D-deficient.

And according to the U.S. Department of Health and Human Services, the Midwest has the highest rate of osteoporosis hospitalizations in the nation.

We know that current cigarette smokers and those who consume three or more alcoholic beverages a day have a lower bone density and more fractures.

Exercise is important to help reduce risk for a fracture. Exercise that improves muscle strength and balance can reduce fracture risk by reducing falls and improving posture. Core abdominal strength improves balance and reduces falls. We also encourage back-strengthening exercises and good posture. Most important is regular aerobic activity such as walking. Aim for 10,000 steps a day.

Beyond nutrition and exercise

Prescription options Over the last 25 years the FDA has approved several medications for osteoporosis. In addition to oral medications, we now have IV medications and small injections. No one medication is right for every individual who needs treatment, and it is important that the treatment plan be individualized. Before medication is prescribed, laboratory testing is done to identify factors that will influence the choice of medication. Typically, this would include a vitamin D level, calcium and phosphorus level, parathyroid hormone level, and other studies based on the individual’s personal profile.

All medications offer potential benefit and pose some risk. The important thing is to use them wisely (in high-risk individuals), so that the benefit far outweighs the risk. It is important to discuss these issues with your health care provider if a medication is recommended. Current approved osteoporosis medications include: • Medications that slow bone turnover, thereby increasing density and strength. These include: ❍

Bisphosphonates: Oral preparations are to be taken in the morning with water only and the patient should wait 30–60 minutes before eating or drinking anything else. The exception is Atelvia, which is taken with the morning meal.

■

Alendronate (Fosamax), given orally, daily or once a week; approved for men and postmenopausal

Minimizing your risk to page 28

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There are three categories of adults in whom we seriously consider treatment with osteoporosis medications beyond calcium and vitamin D: 1. Those diagnosed with osteoporosis by bone density testing (a Tscore of -2.5 or lower) 2. Those with a bone density T-score between -1 and -2.5 who have a calculated 10-year risk of a fracture of 20 percent or greater, or a hip fracture risk of 3 percent or greater using the FRAX risk calculation 3. Adults who have experienced an osteoporosis-related fracture after age 40

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Minimizing your risk from page 27

women and those with osteoporosis induced by certain steroid hormones ■

Risedronate (Actonel), given orally, daily, weekly, or monthly, and Atelvia, given weekly; approved for men and postmenopausal women and those with osteoporosis induced by certain steroid hormones

■

Ibandronate (Boniva), given orally once a month or every three months by an intravenous injection; approved for postmenopausal women

■

❍

❍

■

Estrogen; approved for prevention of osteoporosis in postmenopausal women

■

Nasal salmon calcitonin (Fortical, Miacalcin), a daily nasal spray no longer considered first-line treatment; approved for women at least five years postmenopause Testosterone, sometimes used in testosterone-deficient men; not approved to treat osteoporosis in men or women

Estrogen agonist/antagonist is a drug class that acts like estrogen on some cell types but is an anti-estrogen on other cell types.

■

❍

Zoledronic acid (Reclast), given intravenously once a year; approved for men and postmenopausal women and those with steroid-induced osteoporosis

Hormone therapy.

■

No one medication is right for every individual who needs treatment, and it is important that the treatment plan be individualized.

Raloxfene (Evista), an oral daily medication; approved for postmenopausal women

Leg Pain Study Do your legs hurt when you walk?

Does it go away when you rest?

Or, have you been diagnosed with PAD?

RANK ligand inhibitor is a new class of drug that interferes with the formation, function, and survival of the cells that take away bone.

■

Denosumab (Prolia), given every six months as a subcutaneous (small, shallow) injection; approved for postmenopausal women considered at high risk

• Medication that stimulates the formation of new bone. The only approved treatment in this class is a particular part of the parathyroid hormone molecule. ❍

Teriparatide (Forteo), is given as a daily subcutaneous selfinjection for a maximum of two years; approved for postmenopausal women and men considered at high risk for a fracture and steroid-induced osteoporosis

The best defense against osteoporosis is to know your risk with bone density testing, modify any lifestyle factors that may cause more rapid bone loss, maintain good nutrition, and exercise. It’s never too early to prevent and never too late to treat osteoporosis.

Christine Simonelli, MD, is medical director of HealthEast Osteoporosis Care and practices at the Osteoporosis Care Center in Woodbury.

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The neurobiology of loneliness from page 25

Far too many of our mentally ill people live extremely isolated lives. They have no sense of belonging to a greater community.

The real breakthroughs in treatment will come, instead, in the form of specially designed living environments that will provide people with mental illness the things their brains so vitally need, and the things they have such a hard time obtaining for themselves. This is what the nonprofit organization Touchstone Mental Health is trying to accomplish with its proposed model community for the mentally ill, the Rising Cedars facility, in the Seward neighborhood of south Minneapolis.

Rising Cedars will be a 40-unit assisted-living facility for people with severe mental illnesses. Each client will have an independent apartment that he or she can call “home,” but congregate dining and activities will be offered as well. Lounges and common areas will be set up so that people will have opportunities for socialization when they want it.

On-site medical and psychiatric care will be combined with a wellness center that will provide a variety of complementary therapies, groups, educational activities, and physical exercise. Work, healthy diets, reliable transportation, horticulture, and ties to existing community supports are all essential elements of the program.

When people are in need of increased services, the staff will bring those services right to the client’s residence, rather than continually transport patients back and forth from psychiatric hospitals based on fluctuations in their clinical condition.

Among the principles central to this novel program is the commonsense idea that we should directly involve mentally ill

clients when we are designing housing or supportive programs for them. Literally hundreds of suggestions for the development of this facility have been solicited from Touchstone clients and staff. Project for Pride in Living, the Urban Works architectural firm, and the University of Minnesota College of Design are helping to create a physical environment that will be as close to optimal as possible.

The hope is that this program will serve as a template for a new generation of residential facilities for the mentally ill and will ultimately change the way that severe mental illnesses are treated for decades to come.

Kevin Turnquist, MD, is a psychiatrist at Anoka Metro Regional Treatment Center and a consulting and treating psychiatrist for the ICRS (Intensive Community Rehabilitation Services) pilot program at Touchstone Mental Health. This article is adapted from one that appeared in Touchstone’s Winter 2010 Newsletter.

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

©2007 National Down Syndrome Congress

APRIL 2011 MINNESOTA HEALTH CARE NEWS

29

COMMUNITY HEALTH

Addressing disparities Minnesota’s Somali community. The approach involves creating culturally sensitive programming that includes the Somali community in planning, research, implementation, and evaluation of all programs.

A program to reduce chronic disease among Somalis

By Diana DuBois, MPH, MIA

Photo credit: Nick Giuliani

I

n Minnesota and the United States, the cost of treating chronic diseases is skyrocketing. While Minnesota ranks high nationally on the quality of health care, huge health disparities remain, especially for African Americans, Native Americans, and newly arrived refugees and immigrants.

For the past 10 years, WellShare International (formerly called Minnesota International Health Volunteers), a local nonprofit with over 30 years of experience in East Africa, has been pioneering a new approach to addressing chronic disease prevention and care in

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Background WellShare International began its work with the Somali community in 2000. Somalis constitute one of the largest immigrant communities in the seven-county metro area, with population estimates ranging from 25,000 to 50,000. (Secondary migration precludes a more precise count.) The Twin Cities is known as the Somali capital of the United States and, according to the U.S. Census Bureau’s most recent American Community Survey, one in three U.S. Somalis live in Minnesota.

WellShare began to work with this large refugee group as it had worked on community health, education, and disease management for more than 20 years in East Africa and was knowledgeable about the history and culture in the horn of Africa.

The large influx of Somali refugees to Minnesota is due to the ongoing civil war and the collapse of the government of Mogadishu, the capital of Somalia. Because refugees have been arriving in Minnesota since the early 1990s, the population includes some early arrivals who had more financial resources and education, as well as later groups that included more farmers and nomads. While the majority of Somali refugees have resettled in the Twin Cities, there are growing numbers who have moved to the suburbs, as well as to large and small towns in Greater Minnesota.

As with any new refugee group, there were numerous health barriers, including understanding and navigating our complex health care system and a lack of awareness of disease prevention. In addition, the community had enormous ongoing challenges such as finding adequate housing, learning English, and finding schools for their children, while trying to maintain traditional cultural values.

Somalis, however, bring a wealth of cultural assets to the state, including their rich oral tradition and history, poetry, and a long history of trading and creating businesses, to name just a few.

When WellShare began its work with Somalis 10 years ago, there was almost no health data on Somalis in Minnesota.

Surveillance data at the state level often was not separated by ethnicity or country of origin. Even today, many health statistics list Somalis under the category of “Black” or “African American” on health forms. These categories often mask important cultural differences among distinct populations.

Partnership yields data

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30

MINNESOTA HEALTH CARE NEWS APRIL 2011

WellShare partnered with two Somali organizations and started gathering critical baseline health data in 2003–04. More than a dozen focus groups were held, and WellShare and its partners also created and conducted an 87-question Somali health survey with approximately 300 adults. This yielded important information about Somalis’ knowledge of various infectious and chronic diseases, barriers to accessing care, and current health-seeking behaviors. It also highlighted where many of the refugees went for care.

WellShare Center for Somali Health Programs WellShare also learned Nutrition Promotion Gatherings—Emphasizes Somali Health Care Initiative—Trains Somali comthat the concept of prevenhealthy eating by introducing Somali women to new munity health workers (CHW) to work with community tion was new to Somalis. healthy foods in home settings. members to educate and manage diabetes and provides training to CHWs from a variety of backgrounds In their home country, Somali Child Spacing—Navigates the sensitive issue on chronic diseases. of Somali family planning and reproductive health by Somalis had a more training health providers and providing the Somali Healthy Housing, Healthy Communities—Works to straightforward system of community access to free, culturally appropriate increase healthy eating and exercise and decrease health care. They would resources and education. smoking and secondhand smoke. generally seek care only if Somali Youth Wellness Classes—Promotes healthy Somali Elders’ Connection Project—Promotes they were sick, and they lifestyles among Somali youth by providing culturally community connectedness among Somali elders were often able to just wait appropriate fitness and nutrition classes. living in Minneapolis through community health in line to see the physician. workers who work one-onSomali Youth Group—After-school program that uses one to resolve health This is in sharp contrast to the creative arts and technology to promote healthy issues and barriers. the U.S. health system, living and post-secondary school and career options. which is extremely comPainting of Somali family (Abdul Aziz Osman) plex and difficult for newaccompanied women to get their first mammogram comers to navigate and has numerous health insurance (if desired), ensured they were aware of other programs to decipher, a strong prevention component, resources, and encouraged women to get regular more variation in the levels of health workers, and a breast and cancer screenings. strong focus on keeping scheduled appointments. Somalis have to learn numerous new concepts upon their arrival in Cardiovascular disease the U.S., including the importance of getting preventive care such as Heart disease and stroke are the second and third causes of death in regular prenatal care and screening for chronic diseases.

Minnesota. Our WellShare Somali health survey revealed that very few Somali adults were even moderately physically active on a daily Breast and cervical cancer One example of WellShare’s work on a chronic disease that began as basis. This was in sharp contrast to their lives in Somalia, where exercise was built into their daily life. As Somalis acculturate to life a result of the baseline health survey was in the area of breast and in the U.S., many of the negative nutrition and exercise habits of the cervical cancer. general population are becoming ingrained. This is exacerbated for Breast cancer is the most common cancer diagnosed in women in Minnesota. Related to health disparities in breast and cervical cancer, women of color, particularly African American women, are less likely to be screened for these cancers and therefore more likely to be diagnosed with cancer at a later stage. This, in turn, leads to diminishing chances for survival.

Results from WellShare’s Somali health survey showed that 68 percent of Somali women surveyed had had a mammogram at some time in their lives. In Minnesota as a whole, 80 percent of women in 2004 had undergone a mammogram within the past two years.

Rates of cervical cancer screening in the Somali community (55 percent from the survey) were far below the general population, of whom 83 percent of women 18 and older in 2004 had received a Pap test in the past three years.

During focus group sessions, WellShare uncovered some common myths about cancer. These included comments such as “Somali women don’t get cancer,” “I don’t feel sick so I don’t need the test,” and “Mammograms cause cancer.” Based on the data, WellShare began a five-year Somali breast cancer initiative. The program included visiting small groups of women in their homes to provide them with health education about cancer, dispelling myths and reducing stigma. WellShare, in partnership with the Susan G. Komen Foundation and Twin Cities Public Television, also produced a high-quality DVD in the Somali language, which built on the oral storytelling tradition in the Somali community. This DVD was widely distributed and shown on public television and Somali cable TV channels. The small-group education combined with community education efforts greatly reduced stigma and fear around the topic of cancer and increased the number of Somali women who received mammograms. WellShare Somali community health workers also

Addressing disparities to page 32

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31

Addressing disparities from page 31

many new arrivals by the need to work several jobs to meet expenses. In addition, some Somalis are more isolated in high-rise buildings without walking paths or access to stores within walking distance that carry fresh fruit and vegetables.

WellShare built on the strengths of the Somali community in creating cardiovascular programming. For example, it is not tradi-

When WellShare began its work with Somalis 10 years ago, there was almost no health data on Somalis in Minnesota. tionally acceptable for Somali women to smoke. Our projects encourage women to continue this positive preventive behavior.

We also created nutrition and exercise classes for youth, adults, and elders in order to promote a healthy lifestyle. In order to work on some of the social determinants of health such as access to healthier foods, WellShare and its Somali partners mapped stores in the Cedar-Riverside area and other locations that have a high concentration of Somalis. The project looked at the proximity and types of stores, the availability of fresh fruits and vegetables, as well as basic food prices. Based on the results, the project worked to bring a local farmers market to one of the populated community centers during the summer. Future plans include WellShare partnering with a county program to co-create a Somali cookbook that will include lower-

fat versions of traditional recipes.

In addition to working directly with the Somali community, WellShare has also conducted dozens of community forums and a conference series for physicians, nurses, and other allied health professionals in order to provide education on the Somali culture as it relates to health. WellShare also created numerous Somali-specific health materials such as an anatomy flipchart for use by nurses, a family planning booklet that lists the Photo credit: Nick Giuliani pros and cons of contraceptive methods, and a recent DVD entitled Healthy Moms, Healthy Babies II, which describes the importance of healthy eating and attendance at prenatal visits. It also addresses a topic of much concern to Somali women: why cesarean deliveries are sometimes necessary to save the life of a mother or baby.

WellShare’s numerous Somali programs are part of its Center for Somali Health. The organization works at the individual, provider, and community level to design health education programs through the life cycle—from prenatal care, to the safe delivery of a baby, to postpartum issues, early childhood development, youth activities, programming for adults, and finally to providing one-onone care to Somali elders. Through culturally appropriate programming, WellShare International has been able to use its lessons learned from 31 years of global health work to decrease chronic disease health disparities in the Somali community in Minnesota.

Diana DuBois, MPH, MIA, is executive director of WellShare International.

Minnesota

Health Care Consumer March survey results...

Association

1. Has any member of your family ever been in a long-term care facility?

59.5%

50 40.5%

40 30 20 10

50

23.8% 20 10 0

32

16.7% 9.5%

7.1%

Very satisfied

Satisfied

Does Unsatisfied Very not apply Unsatisfied

MINNESOTA HEALTH CARE NEWS APRIL 2011

Percentage of total responses

Percentage of total responses

30

Yes

No

10 0

Very satisfied

19.0% 9.5%

7.1%

20

16.7% 11.9%

10

Very satisfied

Satisfied

Does Unsatisfied Very not apply Unsatisfied

5. To the best of your knowledge, was (is) this family member satisfied with his or her overall experience in the long-term care facility?

42.9%

30 19.0%

26.2%

50

40

20

30

0

45.2%

42.9%

40.5%

40

4.8%

4. Were you satisfied with how continuum of care issues (e.g., coordinating doctor visits with in-house care, ) were handled by this facility?

50 40

50

Percentage of total responses

Percentage of total responses

60

0

3. Were you satisfied with the value received for the costs of this care?

2. Were you satisfied with the quality of care this person received?

Percentage of total responses

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 March survey.

40 28.6%

30 23.8% 20 10 4.8%

Satisfied

Does Unsatisfied Very not apply Unsatisfied

0

0.0% Very satisfied

Satisfied

Does Unsatisfied Very not apply Unsatisfied

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.

SM

Members receive a free monthly electronic newsletter and the opportunity to participate in consumer opinion surveys.

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APRIL 2011 MINNESOTA HEALTH CARE NEWS

33

A growing field

Keeping dancers on their toes from page 13

Dancers’ injuries are unique and require specialized knowledge of the technique and requirements of dancers in order to properly diagnose injuries—or potential injuries—and safely return a dancer to activity. dancer’s injury that Dance medicine is a young and • Teaching dancers and dance teachers how to apply growing medical field. It has quickly remains unaddressed objective medical criteria to determine when a become a subspecialty in sports medidancer is ready to dance en pointe. can lead to more cine and physical therapy. Though • Assessing strength and/or muscular deficits that research in dance medicine to date is severe and potentially dancers can correct to prevent injury from minimal, the large numbers of dancer occurring. career-ending injuries. athletes in this sport could benefit from • Identifying common injuries in dancers (or in a parimprovements in treatment supported by ticular dance company) and teaching how to prevent research studies. these injuries.

Minnesota Dance Medicine and the MDM’s dance medicine professionals also speak on Minnesota Dance Medicine Foundation dance medicine topics at local and national conferences. appreciate the need for a well-trained group Dance medicine conference. Each fall, the foundation conducts of dance medicine professionals to conduct education and dance an annual dance medicine conference. This year’s will be held in late medicine research on this dedicated group of athletes to prevent September or early October. Past participants have included dancers, injury and to further knowledge in this field. dance teachers, and choreographers, and presentations cover aspects Brad R. Moser, MD, is the founder and director of the Minnesota Dance of dance injuries and how to prevent them. MDM conducts a free Medicine Foundation, a member of the Dance/USA Taskforce on Dancer injury screen to all dancers at the conference. ducting free screenings for dancers, staff members lead educational seminars for dance teachers and choreographers.

The aim is to help these organizations prevent injury in their dancers and to teach the dancers how to protect themselves from injury. The seminars or screenings include (but are not limited to): A

Health, and a sports and dance medicine specialist at MOSMI–Minnesota Orthopedic Sports Medicine Institute in the Twin Cities.

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