Minnesota Health care News April 2013 by Minnesota Physician Publishing

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April 2013 • Volume 11 Number 4

Bladder cancer Gregory Hanson, MD

Donated blood Jeffrey McCullough, MD

Children’s eyesight Jill Schultz, OD

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CONTENTS

4 7 8

APRIL 2013 • Volume 11 Number 4

NEWS

PERSPECTIVE Glenn Nemec, MD

10 QUESTIONS

OPHTHALMOLOGY Children’s eyesight

PUBLIC HEALTH Fish consumption guidelines

Vic Liengswangwong, MD Minnesota Oncology

CALENDAR Distracted Driving Awareness Month

By Jeffrey McCullough, MD

MINNESOTA HEALTH CARE ROUNDTABLE

PEOPLE

Monticello Clinic

HEMATOLOGY Donated blood

T H I R T Y- N I N T H

SESSION

By Jill Schultz, OD, FAAO, FCOVD

By Deborah Durkin, MPH

COMMUNITY CAREGIVERS By Scott Wooldridge

Patient engagement

POLICY “I know I need to improve my health—but how?”

Creating measures that work

By Naomi Hertsgaard, MPH, and William Nersesian, MD, MHA

Thursday, April 25, 2013

UROLOGY Bladder cancer By Gregory Hanson, MD, FACS, and Basir Tareen, MD, FACS

Background and focus: The next step in health care reform involves the patient becoming more actively engaged with staying healthy. New physician reimbursement models reward improved population health but bring new dynamics into the exam room. Incorporating patient attitude and lifestyle choices into health care delivery is necessary, but how should it be done? Creating conceptual and empirical clarity around this question may be best addressed by the term Patient Activation Measure (PAM).

Objectives: We will examine the development of PAM, what it means and how it works. We will explore patient engagement methods that have been successful and the role of health insurance companies and employers in this process. We will explore how PAM may be used across the continuum of care and whose job it will be to implement and track these measures. We will discuss the challenges that are inherent within the concept of PAM and how it may realize its best potential. 1:00 – 4:00 PM • Duluth Room Downtown Mpls. Hilton and Towers

Panelists include: Vivi-Ann Fischer, DC, Chief Clinical Officer, Chiropractic Care of Minnesota, Inc. www.mppub.com PUBLISHER Mike Starnes mstarnes@mppub.com EDITOR Donna Ahrens dahrens@mppub.com ASSOCIATE EDITOR Janet Cass jcass@mppub.com ASSISTANT EDITOR Scott Wooldridge swooldridge@mppub.com ART DIRECTOR Elaine Sarkela esarkela@mppub.com

Laura Gandrud, MD, Children's Hospitals and Clinics of MN, Diabetes and Endocrinology Peter Mills, MD, CEO, nGage Health William Nersesian, MD, MHA, Chief Medical Officer, Fairview Physician Associates Pam Van Zyl York, MPH, PhD, RD, LN, MDH Health Promotion and Chronic Disease Division Sponsors: ChiroCare • nGage Health

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

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Please mail, call in or fax your registration by 04/18/2013 APRIL 2013 MINNESOTA HEALTH CARE NEWS

NEWS

$3.6 Billion Spent On Community Care, Report Finds The Minnesota Hospital Association (MHA) reports that its members spent more than $3.6 billion on programs that benefit their communities, including treatment for patients unable to pay for care. According to the Community Benefit Report, spending for community services was up 7 percent over the amount spent in 2010. The report looks at spending that covers shortfalls in government reimbursement; uncompensated care for patients; and spending for education, public health, and other community programs. Uncompensated care continues to be a driver of community spending for hospitals. Charity care (defined as cases where patients cannot pay for services) and bad debt (defined as patients who don’t pay their share of a hospital bill that’s partially paid by insurance), totaled $509.5 million in 2011, MHA says. This is an

increase of 2.6 percent over 2010. Ongoing reforms at both the state and federal level could help hospitals with uncompensated care, officials with MHA say. “As nonprofits, hospitals and health systems provide access to care to patients—regardless of their ability to pay—24 hours a day, seven days a week,” says Lawrence Massa, MHA president and CEO. “That’s why Minnesota hospitals support the expansion of Medicaid to provide insurance coverage to more Minnesotans and the creation of a Minnesotabased insurance exchange to insure more Minnesotans.” However, government payers are also part of the community cost equation, the report says. In 2011, there was nearly a 26 percent increase in the difference between actual costs of providing care and what hospitals were paid by the government for Medicaid services. “State and federal government payments to Minnesota hospitals and health systems for Medicaid and Medicare patients

were nearly $1.5 billion below the actual costs of providing the care,” the report says. In addition, the report finds hospitals in Minnesota spent $1.3 billion in 2011 on public health services, education, and healthcare workforce development; research to develop new and better treatments and find cures for disease; community building activities; and donations to other local nonprofits.

Transitional Care Facilities Planned Allina Health System is partnering with two long-term care providers to create a new model of transitional care that allows patients to move from hospital care to a rehabilitative care setting before moving back home. Minneapolis-based Allina is working on the new model with Duluth-based Benedictine Health System (BHS) and Presbyterian Homes & Services (PHS), based in Roseville. Officials say two ini-

Health care for the whole person.

tial projects are in the works: a transitional care center on the campus of Unity Hospital in Fridley, to be managed by BHS; and a similar center at Allina’s WestHealth facility in Plymouth, to be managed by PHS. The new model will seek to provide advanced rehabilitation and recovery services at locations that feature comfortable, spa-like settings. In addition to easing the process of moving from a hospital setting back home, officials say the approach will reduce the amount of rehospitalization for patients. “As health care reform moves forward, our communities will need new approaches to ensuring that after people leave the hospital they receive the care they need to make a successful transition back home and don’t end up back in the hospital,” says Kenneth Paulus, president and chief executive officer of Allina Health. “By bringing together the acute care and rehabilitation expertise of our three organizations, we will be

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able to forge new paths that ease the transition from hospital to home.” The organizations have a long-term goal of making branded centers available on a franchise basis. Officials say the collaboration of organizations that provide skilled nursing facilities and longterm care with the clinical expertise of an organization such as Allina will allow for integrated, seamless care. Allina officials estimate the WestHealth facility will cost $17 million; the Unity facility is projected to cost $15 million.

Lawmakers Pass Medicaid Expansion A measure that would expand the state’s Medicaid program was approved by the state Legislature and signed by Gov. Mark Dayton in February. The bill, HF 9/SF 5, officially adopts a Medicaid expansion for Minnesota under the Affordable Care Act (ACA). It will also change how eligibility for the program is calculated from Minnesotans’ income. The expansion will move thousands of impoverished Minnesotans from primarily statebased programs to Medicaid coverage, which is run jointly by the state and federal government. Under the new ACA rules, the federal government will pick up 100 percent of coverage costs for childless adults earning less than $15,414 annually for the first few years after expansion officially begins Jan. 1, 2014. After that date, the federal government will fund 90 percent of those costs. Rep. Thomas Huntley (DFLDuluth), chair of the House Health and Human Services Finance committee, says the bill will increase the number of insured Minnesotans by approximately 35,000. “It will result in a surplus in the Minnesota budget because the feds are picking up a lot of people that we already pay [for],” says Huntley. “In addition to that, it brings in about $1.7 billion of extra federal money into the state that will all go to health care

providers and hospitals and those sorts of things. It’s a huge economic impact and it saves the state money and it increases the number of insured in the state.” Gov. Mark Dayton already signed the state up for an early version of Medicaid expansion. Dayton and DFL leaders have been pushing to complete the latest bill under ACA deadlines. The Minnesota Department of Human Services estimates that the combination of early and full expansion of Medicaid eligibility will save the state more than $1 billion during the 2011–2015 fiscal period. Supporters say the bill will bring down costs by reducing uncompensated hospital emergency room care for poor Minnesotans. Those costs have burdened hospitals in the state and often are passed on to insurance companies, resulting in premium increases.

Flu Shots OK for Pregnant Women, Study Finds A new study by HealthPartners Institute for Education and Research says that pregnant women who receive flu shots are not any more likely to experience health complications than those who do not receive shots. The study was published Feb. 6 in Obstetrics & Gynecology, the official publication of the American College of Obstetricians and Gynecologists. Using national data from systems such as HealthPartners in Minnesota and Wisconsin, the Kaiser Permanente Health System in the western U.S., and Marshfield Clinic in Wisconsin, the study included 75,906 vaccinated and 147,992 unvaccinated pregnant women between ages 14 and 49. The women were matched by age, site, and pregnancy start date to observe any health events associated with the flu shot. The researchers found that receipt of the vaccine during pregnancy was not associated with an increased risk of the complications studied,

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News to page 6 APRIL 2013 MINNESOTA HEALTH CARE NEWS

News from page 5 including allergic reactions, cellulitis, and seizures within the first three days; or cases of Guillain-Barré syndrome, optic neuritis, transverse myelitis, or Bell’s palsy within the first 42 days. “We’ve been recommending that women at all stages of pregnancy get a seasonal flu vaccine for years, but concerns regarding its safety have remained,” says Jim Nordin, MD, MPH, the study’s lead author and a pediatrician with HealthPartners in St. Paul. “I hope this study will reassure women and their health care providers about the safety of the influenza vaccination.”

MNCM Report Looks at Quality Measurements Minnesota Community Measurement (MNCM) has released its ninth annual Health Care Quality Report, which looks at 2012 performance data in 21

clinical quality measures for health care clinics and hospitals throughout the state. Among the report’s findings are improvements in several areas such as diabetes care and colorectal cancer screening. The report also looked at two new areas: cesarean delivery rates and immunizations for adolescents. The report finds that 26 percent of births to first-time mothers in Minnesota are by cesarean delivery, a rate that some experts say is higher than it needs to be. Although the MNCM report does not address whether individual operations are appropriate, the report does show that cesarean delivery rates vary widely in the state. The percentage of cesarean births to first-time mothers at all medical groups ranged from 14 percent to 51 percent. Improvements in performance data included the number of patients getting optimal diabetes care, the number of children getting follow-up treatment after being prescribed ADHD medication, better rates of remission for

patients with depression, a 4 percent increase in the number of Minnesotans receiving colorectal screening, and a 7 percent increase in the number of children up to date on immunizations. MNCM officials say they are working on including cost measurements in future reports, and that the group plans to report data on total cost of care measurements this year. The group is also working with the Minnesota Department of Health on a statewide way to measure patient experience of care. Results from that research will be posted online this summer, officials say. The full report for 2012 can be found at www.mncm.org

North Memorial Makes HealthGrades’ Best Hospitals List North Memorial Medical Center in Robbinsdale was named among HealthGrades’ America’s 50 Best Hospitals last week. The yearly list recognizes hospitals that have

risk-adjusted mortality and complication rates low enough to place them in the top 1 percent of all hospitals nationwide. North Memorial was joined by St. Luke’s Hospital in Duluth on the HealthGrades list of America’s 100 Best Hospitals, which recognizes the top 2 percent of hospitals in the nation. In addition, the Minneapolis/St. Paul metro area was listed 9th in the nation for having the lowest overall average risk-adjusted in-hospital mortality rates among major cities. “The America’s Best Hospitals distinction provides a measure of confidence for consumers,” says Evan Marks, executive vice president of informatics and strategy for HealthGrades. “Each hospital’s exceptional performance reflects a dedication and approach to quality which has been evidenced across the organization and has been demonstrated consistently in terms of superior clinical outcomes.”

Chemical dependency in older adults is hard to recognize We help them live a healthier life Alcohol and drug abuse by seniors often goes unnoticed because of isolation and loneliness. As a result, the older adult continues to suffer in silence. Senior Helping Hands is a program of St. Cloud Hospital Recovery Plus and a recognized national leader providing support and services to stop the suffering. Senior Helping Hands serves individuals age 55 and older. Services • Outreach service and consultation with family or concerned persons • Evaluation and assessment for chemical dependency and/or mental health issues completed by qualified professionals • Volunteer support for older adults who are chemically dependent • Support from peer volunteer counselors for older adults with mental health issues Programs Older Adult Chemical Dependency Primary Treatment Program A comprehensive program that involves physical/psychosocial/chemical use assessments performed by professionals trained in chemical dependency and mental health, including a full time Medical Director who is an addictionist. The program provides a slow pace, holistic approach to recovery. Transportation and temporary housing are available if needed.

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MINNESOTA HEALTH CARE NEWS APRIL 2013

PEOPLE Pat Pulice, director of Fraser Center of Autism Excellence, recently received an Outstanding Service Award from the Minnesota Association for Children’s Mental Health. The award recognizes individuals who have shown extraordinary achievement and/or leadership in the field of children’s mental health. Pulice has more than 30 years of experience working with children on the autism spectrum. She provides program development, resources, and continuity of intervention at Fraser, a Minnesota nonprofit serving children and adults with special needs. Pulice also served on the state’s Autism Spectrum Disorder Task Force and has provided testimony to the state legislature over the years regarding the needs of children on the autism spectrum and their families. She is now consulting with Fairview Hospital system to increase hospital staff knowledge and skills so they can work more effectively with children and youth who are severely affected by autism. John Manion, MD, has received the 2013 Trustee of the Year Award from Aging Services of Minnesota. The Trustee of the Year Award honors individuals whose volunteer leadership as a board member has benefited their older adult services organization and enhanced the work environment of its employees and the quality of life of the seniors it serves. Since 1994, Manion has served on the board of directors at Saint Therese, a nonprofit that provides senior care services and housing in the Twin Cities metro area. He established a palliative care unit at Saint Therese, the first of its kind in the upper Midwest. Hennepin County Medical Center (HCMC) has announced the hiring of several physicians. Jackie Kawiecki, MD, has joined HCMC’s Physical

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Medicine and Rehabilitation Clinic. She is a diplomate of the American Board of Physical Medicine Jackie Kawiecki, MD

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rehabilitation, as well as spinal cord injury medicine. Kawiecki treats rehabilitation of spinal cord injury, stroke, brain injury, trauma, cerebral palsy, and amputees. She has a special interest in spasticity management, botox injection, and phenol nerve block procedures. Paul Nystrom, MD, has joined HCMC’s Department of Emergency Medicine. Nystrom went to medical school at the University of Iowa and completed his emergency

Paul Nystrom, MD

medicine residency at HCMC. Nystrom has a special interest in tactical

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of Emergency Medicine. Gaurav Guliani, MD, has joined HCMC’s Neurology Department. Guliani attended medical school at the University of Illinois in Chicago, and completed a residency in neurology at the University of Minnesota and a fellowship in neuromuscular medicine and electromyography at Washington University in St. Louis. Guliani’s clinical interests include Gaurav Guliani, MD

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PERSPECTIVE

Recreational waterborne illness Come on in, the water’s fine—if you take precautions

o jump in the lake! As temperatures rise, this is a way of life for many people in the land of 10,000 lakes. But what dangers lurk in the water? Waterborne illness

Glenn Nemec, MD Monticello Clinic

Glenn Nemec, MD, is a board-certified family physician with Monticello Clinic. He has practiced in Monticello for 25 years and is a member of the Minnesota Academy of Family Physicians. In 2008, the Minnesota Pollution Control Agency began a 10-year cycle of intensively monitoring an average of eight watersheds each year. This monitoring includes lake water chemistry, stream chemistry, and biology, such as fish populations. The resulting data help determine if lakes meet the standards for public health, recreation, and aquatic life.

In Minnesota, public sanitation has rendered serious waterborne illness virtually extinct; there is generally far more danger from accidental drowning than there is from any microorganism. This does not mean that you should enter any body of water with total abandon. But it should reassure you that even if you do contract a waterborne illness, you likely will live to complain about it.

Swimmer’s itch is caused by parasitic microscopic worms that live in water snails and waterfowl found in calm, shallow, warm water. When the parasites leave the snails and swim in an attempt to find waterfowl to infect, they may accidentally penetrate human skin. That person’s immune system reacts to the parasite and causes small, There are rare exceptions to this rule and last intensely itchy red bumps. Some of the itchiness year’s deaths from Nocardia make that point. is relieved by over-the-counter antihistamines Nocardia is a parasite that lives in shallow, warm, and cortisone creams, but mostly you just have stagnant water that tends to to wait it out. Avoiding calm, have algae growing on top of shallow, warm water is the it. Nocardia can enter the Never swallow water only prevention. Toweling off body through the mouth and vigorously after leaving the from natural bodies nose and travel to the nervwater helps reduce the risk of of water. ous system. There, it causes a swimmer’s itch by dislodging severe and difficult-to-treat the parasites from the skin. form of meningitis, which is inflammation of the membranes that cover the Minimize risk brain and spinal cord. Avoiding such bodies of water and not getting water in your nose or mouth are the only ways to prevent infection. Although this infection occurs rarely, and primarily in people with weakened immune systems, it’s a good idea to avoid water that has algae growing on it.

• Don’t swallow water or get water in your mouth while swimming; spit it out.

The much more common and relatively harmless illnesses that can be contracted during recreational water use fall into two general categories, diarrheal illness and swimmer’s itch. The latter is often wrongly called “chiggers,” which is a related disease contracted in grassy areas.

• Take kids on frequent bathroom breaks; waiting to hear “I have to go” may mean that it’s too late.

Diarrheal illness. The typical cause of diarrhea from a waterborne source is viruses from animals and humans. If someone swallows virus-infected water, these viruses multiply in the person’s intestine and cause a usually short-lived case of diarrhea. Occasionally, diarrhea is caused by a parasite called Giardia. This pest lives in some animals and is flushed by rain into the water system from animal droppings. It also can be transmitted in the stool of a human infected with it. It causes a longer-lasting watery diarrhea that can be accompanied by bloating, gas, loss of appetite, nausea, stomach cramps, vomiting, and fever. Someone whose diarrhea has lasted more than 10 days, who has other accompanying symptoms,

and who recently has been in a natural body of water should consult a physician. Giardia is treatable with certain antibiotics, but in the vast majority of healthy people it goes away by itself within two to six weeks. The best prevention is to avoid getting water in the nose and mouth and to never swallow water from natural bodies of water.

MINNESOTA HEALTH CARE NEWS APRIL 2013

• Shower after swimming. • Do not go in the water when you have diarrhea. You can pass Giardia or viruses in your stool and contaminate water.

• Change diapers in changing rooms, not next to the water. • Wash hands after changing diapers. The best way to minimize exposure to all waterborne illness in Minnesota is to confine recreational water activities to higher-quality bodies of water. You can find these waters by checking the Minnesota Pollution Control Agency’s website, which posts water quality assessments. However, since not all Minnesota waters have been assessed yet, follow this guideline: The clearer the water, the safer it is. Water quality information on specific lakes and rivers in the state can be found at cf.pca.state.mn.us/water/watershedweb/datasearc h/waterSearch.cfm

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Radiation oncology Vic Liengswangwong, MD Dr. Liengswangwong is board-certified in radiation oncology and practices at Minnesota Oncology-Maplewood Cancer Center. What is radiation oncology? Radiation oncology combines principles of physics and biology. It uses ionizing radiation, either alone or in combination with treatments from other medical specialties, to treat cancers and certain benign diseases such as heterotopic ossification, in which bony material sometimes grows in soft tissues following bone injury or surgery involving bone. How do diagnostic radiology and radiation oncology differ? Although radiologists and radiation oncologists are both certified by the American Board of Radiology, diagnostic radiology—imaging and diagnosing medical conditions—and radiation oncology are different specialties that require different training. Radiation oncologists undergo specialized residency training for at least five years after graduating from medical school, followed by fellowship training in radiation oncology. How do radiation oncologists interact with other medical specialists? Patients are referred to radiation oncologists by physicians in different specialities, so that we can evaluate whether radiation treatment will benefit the patient. We work closely with primary care physicians, surgeons, internists, gynecologists, medical oncologists, radiologists, pathologists, medical geneticists, and other cancer specialists to ensure patient-centered care and optimal outcomes. What is brachytherapy? It is one way to deliver radiation treatment. Brachytherapy involves placing sealed radioactive sources inside the patient’s body, close to or in contact with the cancer. This technique allows delivery of a high dose of radiation safely to the treatment target area over a short period of time, while minimizing radiation exposure to healthy tissue. It has been used extensively to treat, for example, prostate cancer, certain gynecological cancers, breast cancer, ocular melanoma (retinoblastoma), and certain benign conditions such as age-related macular degeneration. At the completion of treatment, the radioactive sources are removed. One exception to removal is permanent prostatic seed implant, in which radioactive sources are purposely left inside a patient’s prostate.

Photo credit: Bruce Silcox

How does CyberKnife work? This delivers stereotactic irradiation in highly precise, narrow beams of high-dose radiation to the target tissue while minimizing radiation to surrounding normal tissue. X-ray beams are delivered via a robotic arm that moves around the patient. Accuracy is monitored during delivery by using a sophisticated computerized imaging system. This technique makes it possible to treat certain cancers that formerly were treatable only by risky surgery. Compared with traditional surgery, stereotactic radiation treatment is less invasive and affords greater precision. These advantages can reduce the length of a patient’s hospital stay and the cost of treating certain conditions. These advantages are also true of other equipment used for stereotactic radiosurgery and stereotactic radiotherapy, such as Gamma Knife, linear accelerator SRS/SRT, and tomotherapy equipment. What clinical trials are being conducted in radiation oncology? One current area of research investigates the most effective way to combine radiation

MINNESOTA HEALTH CARE NEWS APRIL 2013

and novel chemotherapeutic agents. Another area of research focuses on reducing side effects of cancer treatment. One example of work in this area involves assessing the potential protective effects of memantine (a medication for Alzheimerâ&#x20AC;&#x2122;s patients) in preserving memory and brain function in patients who receive whole brain irradiation for brain tumors.

No reward to physicians is more valuable than the privilege to care for and heal patients.

females include surgically repositioning the ovaries away from areas of radiation treatment before starting treatment and banking embryos, eggs, and ovarian tissue. Options for males include banking sperm and testicular tissue and shielding the testicles during radiation treatment. All patients of reproductive age who will undergo cancer treatment capable of damaging the reproductive system are candidates for fertility preservation.

Experts predict a shortage of radiation oncologists by 2020. How do you explain this? Between 2010 and 2020, the total number of patients receiving radiation therapy is expected to increase by 22 percent, while the number of full-time radiation oncologists is expected to increase by only 2 percent. The probable reason for the expected increase in patients is the ongoing change in demographics in this country. Since the number of people age 65 years and older will increase, so will the need for cancer care. What should patients of childbearing age know about radiation therapy and fertility? In females, cancer treatment can cause impaired fertility and premature menopause in several ways. Radiation treatment to the pelvic area can lead to premature ovarian failure and decreased numbers of eggs. It can cause uterine fibrosis and damage to the endometrium (the lining of the uterus), thereby interfering with embryo implantation. Radiation treatment to the brain can disrupt hormonal pathways, resulting in a loss of fertility. Irradiation also can result in infertility in male cancer survivors by causing an inability to ejaculate or to have an erection necessary for intercourse. It also can damage the testes, leading to abnormal sperm or a low sperm count. Strategies for fertility preservation in

Are advances on the horizon in radiation oncology? Advances in prostate cancer treatment may come from current clinical trials of novel radiation treatment using radium-223 chloride for men who have prostate cancer that has spread to their bones despite hormonal treatment or chemotherapy. Research into radiation treatment for benign disease, such as epimacular brachytherapy for wet age-related macular degeneration, also holds promise. Please share a success story. One of my patients was found to have breast cancer spreading to her brain about a year after she completed chemotherapy, mastectomy, and radiotherapy for locally advanced breast cancer. She had surgery to remove that cancer and subsequent radiation treatment. I continue seeing her for follow-up, and she has been cancer-free for the past seven years. She returned to full-time teaching; enjoys her friends, her husband, and their schoolaged children; and is active in her community. No reward to physicians is more valuable than the privilege to care for and heal patients who, as a result of medical care, are able to live joyful and productive lives.

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POLICY

t 31, Travis weighed 308 pounds. But it wasn’t until his friends dropped him from their plans for a fishing trip that Travis started to think seriously about what his weight was doing to his relationships and ability to enjoy life. When Deborah’s first grandchild was born, Deborah knew she finally had to do something about her pack-a-day smoking habit if she wanted to see little Hailey grow up. But she didn’t know where to start. Barriers

“I know I need to improve my health—but how?” Patient engagement By Naomi Hertsgaard, MPH, and William Nersesian, MD, MHA

Is diabetes in your family tree?

Research has shown that lifestyle behaviors such as inactivity and eating a poor diet promote obesity and type 2 diabetes. These, in turn, contribute to seven of the top 10 causes of death in the U.S., including heart disease. Strategies and tools to change these behaviors come at us from all angles: doctors, television, magazines, and websites. Even so, the number of people with obesity and type 2 diabetes continues to rise. If we know our unhealthy habits threaten our current or future health, why don’t we change? Perhaps that’s because we traditionally have viewed our health care providers like our car mechanics: We expect them to fix our health problems for us. We want to hear the equivalent of “take two aspirin and call me in the morning.” This way of thinking puts the responsibility for our health and wellness on the doctor instead of on us. Providers offer expertise, but they can’t make behavior changes for us. Increasingly, they are trying new ways to help us reach our health goals. Instead of “take two aspirin,” health care providers are inviting us to participate in our own care. Here are three ways we can accept this invitation and become engaged and effective in achieving lasting health. Find motivation

Eat more fruits, vegetables & whole grains and less fat Be active 30 minutes a day, 5 times a week Don’t smoke Eat smaller portions and lose 10 pounds if you are overweight Watch your blood pressure and cholesterol Talk to your doctor about all serious health problems in your family tree

MINNESOTA HEALTH CARE NEWS APRIL 2013

We naturally visit health care professionals when something is wrong. We might walk away with diagnoses such as high cholesterol, prediabetes, or obesity. For some of us, simply hearing these words prompts action but for others, such diagnoses lack meaning. Deborah’s doctor had urged her for years to quit smoking. Yet until she saw her first grandchild, Deborah did not feel motivated to change her habit. Many of us can relate to Deborah. We might not be motivated by our doctors’ words like “overweight,” “shortness of breath,” or “knee pain.” But we might respond to exclusion from an activity with friends or knowing we might not see our grandchildren grow up. One way to find the motivation to change behavior is to reflect on our values. We all value something: relationships, independence, sports, work, competition, the outdoors, volunteering, and mobility, among others. To make lasting change, it helps to associate our values with our behaviors. Deborah connected something she values— family—to her smoking habit and realized that smoking threatened to rob her of time with her family.

Focus on what you can do

Start with a single step

When we open our eyes to the resources and people around us, we For most of us, unhealthy behaviors develop over time and, likesee that we are not alone in our struggles. We might even discover wise, take time to change. We often give up trying to change our behaviors before we get very far because of personal barriers such that we can help others on their journeys to health and wellness. as self-doubt and fear of change. Finances, competing responsibiliWhen searching for support among friends or in your communities, ties, or a lack of support from those around us can further comfollow the same rules as when looking for a provider: How do you pound our barriers. We fixate on our deficiencies and fall prey to “all or nothing” thinking. If we can’t even run It helps to identify small, around one block, why bother? Travis blamed his inactivity on his weight; it hurt to run around his block. incremental changes we know To combat this self-defeating attitude, it helps to identify we can make. small, incremental changes we know we can make. Instead of running around the block, Travis decided he could walk around one block each day without feeling pain. After two weeks of feel? Can you be honest? Do those around you want to work walking around one block each day without pain, he increased his together? walk to two blocks a day. The journey toward enjoying improved health starts with a Unless we tell our providers what changes we believe we can single step, followed by small, incremental steps. To make that first step, discover your motivation. To stay on track, focus on small make, they might expect more of us than we realistically can changes over time and build supportive relationships to help yourachieve. Instead of nodding his head as his provider tells him to exercise, Travis can share the small changes he is ready to make. self make those changes. Travis and Deborah, with the help of Together, he and his provider can create a plan. Small changes, others, are taking steps to plan and shape their future health—and made consistently over weeks and months, generate change and so can you. lead to success. Build supportive relationships Recognizing your motivation and identifying small changes you can make are first steps. Enlisting the support of a health care provider, friend, coworker, neighbor, or community group can help you stick with your plan. Finding a supportive provider is just as important as finding a hairdresser you are happy with or an accountant you trust. Paying attention to how you feel when you are with your provider will help you determine if you can work as a team or not. Can you ask questions? Is your provider asking you questions? Can you be honest, and not sugarcoat your answers about whether and how you can make a change? If we know Responding “no” to these questions our unhealthy means it is time to shop around for a new provider or to have a candid discushabits sion with an existing one. Look for a threaten our provider who wants to know you, to listen to you, and who is committed to current or partnering with you. future health, Loved ones and community groups why don’t we also can support us as we make positive lifestyle changes. Examples include faithchange? based organizations, community centers, local gyms, friends, family, neighbors, or even online communities. After several weeks of walking around his neighborhood, Travis decided to join a community gym where his neighbor worked out. Because Travis planned to meet the neighbor twice a week at the gym, he was less likely to skip his workouts. Similarly, Deborah paired up with a coworker who also was motivated to quit smoking. They agreed to check in with one another whenever either one wanted a cigarette, which helped each one control the urge to smoke.

Naomi Hertsgaard, MPH, is a quality data analyst at Fairview Physician Associates. William Nersesian, MD, MHA, is a pediatrician with a background in public health. He is currently chief medical officer at Fairview Physician Associates.

APRIL 2013 MINNESOTA HEALTH CARE NEWS

UROLOGY Despite the often aggressive nature of this disease and its relatively common occurrence, there is insufficient public awareness of it. This is unfortunate, because greater awareness of symptoms could lead to earlier detection and improved survival.

Bladder cancer

hat did Hubert Humphrey, Jack Lemmon, and Telly Savalas all have in common? All three died of bladder cancer. Bladder cancer occurs when the normal lining of the urinary tract changes into abnormal cells that grow out of control to form a mass called a tumor, which typically forms inside the bladder. This disease is one of the most expensive cancers in the U.S., with nearly $3 billion spent annually on its diagnosis and treatment. It’s also the fourth most common cancer in men, and the second most common cancer of the urinary tract for both men and women, in this country. In 2011, approximately 69,250 people were diagnosed with bladder cancer in the U.S. and an estimated 14,990 people died from it.

A diagnosis of

Cancer is overwhelming news.

Symptoms

The most common symptom is blood in the urine. Blood can make urine appear red, pink, or dark brown. Eighty percent to 90 percent of patients diagnosed By Gregory Hanson, MD, FACS, with bladder cancer report seeand Basir Tareen, MD, FACS ing blood in their urine for six months before consulting a physician. Additional symptoms can include pain during urination, increased urinary frequency, cystoscope pain in the pubic region, fatigue, weight loss, and fevers. However, for most patients diagnosed with bladder cancer, the only symptom is blood in their urine. Any blood in your urine means that you should consult a physician promptly. Too often, a patient’s delay in contacting a physician delays treatment that has It raises many questions few the potential to cure the cancer. of us are prepared to answer, such as: Risk factors • How can I take time off Smoking causes half of bladder cancer cases in both men and from work? women. In fact, the most common cause of bladder cancer is • Can I get help paying bills? tobacco exposure, whether from smoking or secondhand smoke. • What is the difference Current smokers and people exposed to smoke are four to five between a health care directive times more likely to develop this disease than people who have and a power of attorney? never smoked. In addition, patients exposed to certain dyes, petrol• Can I keep my health insureum products, diesel fumes, hair spray, and printing presses are at ance even if I lose my job? higher risk. A family history of bladder cancer also increases risk. • And many others.

Know the symptoms

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MINNESOTA HEALTH CARE NEWS APRIL 2013

Diagnosis Diagnosis starts by ruling out other reasons that a patient might have bloody urine. These include urinary tract infections, kidney stones, and some prostate disorders, most of which are benign. If these causes are ruled out, patients are referred to a urologist. This is a specialist who addresses medical disorders related to the prostate, bladder, kidneys, and testicles. For a patient who has blood in the urine, a urologist will often perform an imaging test of the kidneys to detect abnormalities. (Urine is produced in the kidneys.) This test is typically an ultrasound or CT scan. The urologist may also examine the inside of the bladder via a procedure called a cystoscopy. This involves inserting a narrow flexible tube into the bladder through the urethra, the anatomical struc-

The most ture though which urine leaves the body. Attached to Patients who want to decrease their risk of develthe tube is a fiber optic camera called a cystoscope. common cause oping bladder cancer should reduce their exposure to This procedure is relatively painless, is performed in tobacco by quitting smoking if they smoke and by of bladder the doctor’s office with a local anesthetic, and usually avoiding secondhand smoke whether or not they cancer is lasts less than a minute. smoke. Risk is also reduced by limiting or avoiding The advantage of this procedure is that while the exposure to chemicals found in petroleum products, tobacco urologist is looking at the inside of the bladder, tissue diesel fuel, pesticides, and aerosolized chemicals exposure. samples from any suspicious-looking areas can be such as those used with printing presses and those in snipped out using a tool attached to the cystoscope. hair spray. Samples are then sent to a pathologist to help make the diagnosis. In addition, studies suggest that increasing daily fluid intake may help reduce bladder cancer risk. Diet may play a protective Treatment role as well, according to a 2008 study commissioned by the World The method of treatment depends on whether the cancer is a less Health Organization. The study reported that certain fruits and aggressive or more aggressive variety. The less aggressive variety vegetables may help reduce the risk of bladder cancer. These include occurs 60 percent to 70 percent of the time, is found only in the lin- yellow-orange vegetables, citrus fruit, and cruciferous vegetables ing of the bladder, and can be managed by removing the tumor via such as broccoli. cystoscope. These tumors often come back, but, if they do, can be Bloody urine? See your physician managed by the same cystoscopic removal method. Recurring tumors of this type typically will not grow deeper into the bladder. Bladder cancer is a significant medical problem in the U.S., espeApproximately 40 percent of bladder cancers are the more cially among the elderly. Quit smoking, reduce your environmental aggressive variety and have invaded deeper layers of the bladder by exposure to chemicals, consult your doctor if you have a family the time they are diagnosed. These more aggressive tumors carry a history of this disease, and see a physician at the first sign of blood significant risk of spreading to different parts of the body. They are in your urine. typically treated with a cystectomy (removal of the entire bladder) Gregory Hanson, MD, FACS, and Basir Tareen, MD, FACS, are boardand, in some cases, with chemotherapy or radiation. Even with certified urologists with Metro Urology in Minneapolis/St. Paul. Both are aggressive treatment, the five-year survival rate for advanced bladfellowship-trained in urologic oncology and co-chair the Metro Urology Cancer Committee. der cancer is only about 60 percent to 70 percent. Cystectomy is a surgical procedure that involves removing the bladder and surrounding lymph nodes as well as reconstructing a way for urine to exit the body. This procedure traditionally has been done through a large incision that extends from the belly button down Any blood in to the pubic bone. More recently, your urine however, surgeons have begun permeans that you forming it using a robotically assisted laparoscope, which allows the proceshould consult dure to be performed through a small a physician incision in the abdomen. The advanpromptly. tages of this laparoscopic approach include less blood loss, less pain, and, sometimes, a shorter hospital stay. Urine collection. After a cystectomy, some patients elect to collect their urine in an artificial external bladder. This is a bag called a urostomy, which is attached to the outside of the patient’s abdomen and fits under the patient’s clothing. Urine is rerouted from the kidney through a small portion of the intestine and into the bag, which is emptied periodically by the patient. Other patients are candidates for a new internal bladder constructed from a piece of their intestine. Urine from this neobladder exits the body through the patient’s urethra just as it did before surgery. Prevention If bladder cancer is found early, many patients can live long, productive lives after diagnosis. However, bladder cancer has one of the highest risks of recurrence of any malignancy, so patients who are diagnosed with it should have regular cystoscopic exams in their urologist’s office to ensure that the cancer has not returned. APRIL 2013 MINNESOTA HEALTH CARE NEWS

H E M AT O L O G Y

Donated blood We often hear about the need to donate blood after a natural disaster has occurred, but in truth, there is always a need for blood. In Minnesota, 700–800 units of blood are used each day. (A unit equals about two cups.) It’s used in emergency rooms to help keep trauma victims from bleeding to death, and to help cancer patients, burn victims, surgical patients, new mothers who may have lost blood during delivery, and people whose Safe— own blood functions improperly. and critically One unit of donated blood can save three lives. needed By Jeffrey McCullough, MD

What is it?

Blood is a complex mixture of a liquid called plasma and several kinds of cells, including red cells and platelets. After blood is collected it is separated into the three blood products used most frequently: red cells, plasma, and platelets. Red cells carry oxygen to tissues and are often used by patients who lose blood during surgery. Plasma contains proteins, nutrients, and clotting factors that help prevent and stop bleeding. It is used

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MINNESOTA HEALTH CARE NEWS APRIL 2013

Blood collection Of the roughly 15 million units of blood collected annually in the U.S., 10 percent is collected in hospitals. The nonprofit organization American Red Cross collects approximately 40 percent. The remaining 50 percent of the U.S. blood supply is collected by other nonprofits and by for-profit organizations. Blood is considered a drug, so it and the organizations that collect and provide it are regulated by the federal Food and Drug Administration. Before giving blood, potential donors are asked confidential questions to determine whether donation is safe for them and whether their blood might One unit pose risks for recipients. Questions identify donors who may have exposure to of donated blood-transmissable diseases such as hepblood can atitis and malaria or behaviors that save three could put them at risk for HIV, the virus lives. that causes AIDS. Blood is collected by single-use needles and containers. Collection usually takes about 5–7 minutes, after which donors are offered fluids such as juice to replace the amount of donated blood. That amount represents only about 10 percent of an average adult’s blood and is quickly regenerated by the body. Blood can also be collected by apheresis, a process in which the donor is connected to a machine that separates his or her blood into components called platelets and plasma, and returns most of the blood to the donor. Either collection method takes 45 minutes to an hour. Blood safety Improvement in the safety of donated blood is one of the most impressive and gratifying advances in medicine during the last

30 years. It’s been accomplished by refining protocols to acquire a more extensive donor history before collection to screen out potential donors who pose health risks, and by improved laboratory testing of collected blood. As a result, transfusion-transmitted disease occurs only a handful of times annually in the U.S. Donated blood underDonated blood goes extensive testing to assure that it is safe. It is undergoes extensive tested for HIV virus, testing to assure that which causes AIDS; hepait is safe. titis; syphilis; and another HIV-like virus. Testing for additional infectious agents is performed on blood destined for transfusion into certain patients. One such agent is cytomegalovirus, which typically produces no symptoms when it infects a healthy adult but can cause serious disease in immunosuppressed patients such as those undergoing transplants. Complications of receiving donated blood, in addition to transmissible disease, include fever, bacterial contamination of the blood product, and allergic reactions due to blood group incompatibility. Strategies are Donated blood to page 34

Telephone Equipment Distribution (TED) Program

most frequently by people with trauma, burns, or blood diseases. Platelets help blood clot. Donated platelets are often used by people who have either low numbers of their own platelets or nonfunctioning platelets, since either situation predisposes them to bleed during chemotherapy, bone marrow transplantation, major surgery, liver disease, or severe trauma. Platelets also contain growth factors that help repair damaged body tissue. All of these components have a short shelf life. Red cells can be refrigerated for up to 42 days. Platelets cannot tolerate cold and are stored at room temperature but only for five days before they must be discarded. Plasma can be frozen for one year. Most patients do not need whole blood replacement. Therefore, separation of donated blood into components allows physicians to choose the specific component that is best for each patient. For instance, a patient who loses one or two units of blood during surgery needs red cells to improve his or her blood’s oxygen-carrying capacity. Such a person usually does not have a deficiency of platelets or clotting factors and, thus, does not need to have those blood components replaced. Those components can be used by other patients, such as those who have lost blood to trauma or those undergoing cancer chemotherapy. Chemotherapy sometimes necessitates platelet transfusion to prevent bleeding. In contrast, a trauma patient receiving a large number of transfusions and who needs replacement of clotting proteins would receive plasma.

Do you have trouble using the telephone due to hearing loss, speech or physical disability? If so…the TED Program provides assistive telephone equipment at NO COST to those who qualify. Please contact us, or have your patients call directly, for more information.

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

April Calendar 11

Widowed Support Park Nicollet presents a support group for young widowed people. If you have lost a spouse, partner, fiancé, or fiancée, come and receive support from peers and grief counselors. Free. Call (952) 993-6165 to register or for more information. Thursday, Apr. 11, 6:30–7:45 p.m., Park Nicollet Frauenshuh Cancer Ctr., 3931 Louisiana Ave. S., St. Louis Park

Advance Care Planning Lakeview Health presents Advance Care Planning for Minnesotans. This class will help you assess goals, values, and beliefs about end-of-life care. Learn how to pick a surrogate decision maker and talk with your loved ones. To register or for more information, call (651) 430-4697. Tuesday, April 16, 1–2 p.m., Lakeview Hospital, 927 Churchill St. W., Stillwater

Cancer Legal Seminar Cancer Legal Line presents Chris Wheaton, Esq., and Brea Buettner-Stanchfield, Esq., discussing cancer survivors’ financial concerns and dealing with creditors. Free. Call (651) 472-5599 to register or for more information. Thursday, April 18, 6:30–8 p.m., Angel Foundation, 700 3rd St. S., Ste. 106W, Minneapolis

Women’s Health Fair West 7th Community Center’s Women’s Health Fair offers health screenings; learn about health and wellness throughout the lifespan. Free. Call (651) 298-5493 to find out more. Saturday, April 20, 10 a.m.–1 p.m., West 7th Community Ctr., 265 Oneida St., St. Paul

Free Health Screenings Medtronic and Shiloh Missionary Baptist Church offer blood pressure, glucose, and cholesterol screening to the public. Free. Call Kelly at (770) 367-3150 to find out more. Sunday, April 21, 9:30–11:30 a.m., Shiloh Missionary Baptist Church, 501 W. Lawson Ave., St. Paul

Distracted Driving Awareness Month Did you know that 18 percent of injury crashes in 2010 were reported as distraction-affected crashes? Distracted driving is any activity that could divert a person’s attention away from driving, such as text messaging, using a cell phone, eating and drinking, or even adjusting the radio. By far the most dangerous of these distractions is text messaging, since it requires visual, manual, and cognitive attention from the driver. Sending or reading a text takes a driver’s eyes off the road for 4.6 seconds, which at 55 mph, equals about the length of a football field. Text messaging while driving is illegal in Minnesota. Though 16 percent of all distracted driving crashes involve drivers under 20 years old, all drivers benefit from limiting distractions in their vehicles. Commit to driving phone-free, and turn your cell phone off when you turn on the ignition. For more information on distracted driving, including how you can take the pledge for safer roads, visit: www.distraction.gov

23 Driving Refresher St. Cloud State University offers a four-hour driving refresher course for ages 55 and up. Learn defensive driving tips and the latest changes in laws and vehicle technology. $20 fee. Call (888) 234-1294 or visit www.mnsafetycenter.org to register. Tuesday, Apr. 23, 9 a.m.–1 p.m., Apple Valley Senior Ctr.,14601 Hayes Rd., Apple Valley

Disability Day Join Minnesota Brain Injury Alliance for Disability Day at the Capitol. Tell the story of your disability to legislators and advocate for the support you need. Call (800) 669-6442 to register and for information. Thursday, April 25, 10 a.m.–1 p.m., Minnesota State Capitol, 75 Rev. Dr. Martin Luther King Jr. Blvd., St. Paul

Exercise With Autism Minnesota Life College presents a class for people with autism. Learn tai chi, yoga, and meditation techniques to help cope with stress. Free. Register at www.eventbrite.com. Call (612) 869-4008 for more information. Thursday, April 25, 6:30–7:30 p.m., Southdale YMCA, 7355 York Ave. S., Edina

Health Disparities Roundtable University of Minnesota presents “Engaging Communities in Public Health Research, Practice, and Policy,” a roundtable discussion featuring Byllye Avery, MEd, Amy Jo Schulz, PhD, and the Latino Voices program. Free. Register online at www.sph.umn.edu/details/course/11309/ Friday, April 26, 9 a.m.–12 p.m., Coffman Memorial Union, 300 Washington Ave. S.E., Minneapolis

May 1

Caregiver Support FamilyMeans and Stillwater Medical Group present a support group for caregivers of those with memory loss. Free. Call Lisa at (651) 789-4004 for more information or to register. Wednesday, May 1, 1–3 p.m., FamilyMeans, Desch Rm., 1875 Northwestern Ave. S., Stillwater

May 6

Disability Trends University of Minnesota presents Linda Martin (RAND Corp.) discussing disability and chronic conditions among older Americans from 1997–2010. Free. Call (612) 626-5818 for information or disability accommodations. Monday, May 6, 12:15 p.m.–1:15 p.m., 50 Willey Hall, MPC Seminar Rm., 225 19th Ave. S., Minneapolis

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

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MINNESOTA HEALTH CARE NEWS APRIL 2013

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OPHTHALMOLOGY

Children’s eyesight Healthy eyes = better learning By Jill Schultz, OD, FAAO, FCOVD

Vision is the primary way we absorb information and learn, with over 20 different visual skills needed for adequate visual development. This critical sense develops as infants explore their world, and, as a child grows, visual information is integrated with gross motor, fine motor, tactile, and other skills. Healthy vision allows us to identify objects and patterns, and to process what we see. Poor visual skills make learning difficult, and untreated vision problems can put children at risk for academic underachievement and behavior problems. When vision development goes awry Vision problems are common during childhood. Risk factors include premature birth; complicated birth and delivery; developmental delays; certain inherited conditions; or a pregnant mother’s smoking, exposure to smoke, or certain medications during pregnancy. Unlike other common childhood conditions such as speech delays or poorly aligned teeth, vision issues are usually not noticeable. Adults assume that children see the way the adults see. Children with vision problems don’t realize that anything is amiss, and therefore don’t indicate that anything’s wrong.

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Many parents assume their child has adequate vision if the child passes a vision screening. What parents may not realize is that screenings only assess distance vision. Screenings do not detect all visual disorders, nor a child’s visual functioning at close distance. It’s especially important to check visual functioning at close distance since that is used for “near work” such as reading and computer use, and thus is vital for classroom activity.

Vision issues are usually not noticeable.

Vision, learning, and behavior

Because vision and learning are intimately connected, students with visual problems can be misdiagnosed as having learning disabilities such as ADHD or dyslexia. For example, children who have learning-related visual problems cannot sustain attention to near work at school and may become bored or misbehave. They may be misdiagnosed as having ADHD because children with ADHD sometimes also have difficulty sustaining attention to classwork. Symptoms of vision problems Although most vision problems often have no obvious signs, the following symptoms can indicate a vision problem and warrant a comprehensive vision examination. • A child loses her place when reading • Avoiding reading or other near work

precision. This allows the eyes to move along the lines of print in a book and to make quick and accurate shifts from far to near. Poor tracking skills produce poor reading skills. Focusing, or accommodation, is the ability to maintain a clear view of something at different distances. This is needed for reading and writing, as well as for rapidly and efficiently changing visual clarity from distance to near, such as when sitting at a desk and copying something written on the board. Visual focus is also needed to sustain visual attention. Poor focusing skills can lead to blurred vision, headaches, and avoidance of reading. Eye teaming is the ability to keep a target single, a skill used frequently in reading. The closer the target, the more your eyes have to turn to keep it single. If the eyes are not accurately teaming, it takes more effort to process visual information. Faulty teaming can reduce visual attention, negatively impact spatial judgment, and can cause crossed or wandering eyes. Poor teaming skills are common and have been associated with ADD and ADHD. Many studies demonstrate the effectiveness of vision therapy to improve eye teaming. Post-concussion vision syndrome. Most individuals who experience a concussion have visual disturbances afterward. Common vision symptoms after concussion include headache, avoidance of reading, light sensitivity, double vision, blurred vision, and dizziness. Early identification and treatment of these problems can lead to better outcomes and faster recovery. Delayed visual processing. Some children struggle with reading and early learning because they do not have adequately developed visual processing skills. Symptoms may include poor letter recogniChildren’s eyesight to page 25

• Poor attention, especially during near tasks or reading • Tilting or turning the head to see • History of ADD/ADHD or learning difficulties

Minnesota Optometric Association

• History of receiving physical or occupational therapy • Below-average school performance • Poor or inconsistent performance in sports • Frustration during homework or school tasks • Headaches, blurred vision, or double vision Common vision problems These symptoms can be caused by one or more of the following conditions, all of which are treatable or curable if detected early. Refractive error encompasses nearsightedness, farsightedness, and Resources astigmatism. Each of these conditions www.covd.org can cause blurred vision that can be http://minnesota.aoa.org/ improved with glasses or contact www.pavevision.org lenses. In some cases, if this condition www.infantsee.org is not corrected, 20/20 vision will fail to develop in one or both eyes, fine motor skill development can be delayed, or both. Amblyopia, or “lazy eye,” describes the condition in which one eye is not capable of seeing 20/20, even with the help of glasses. Scientists once believed that amblyopia could not be treated after a child had reached the age of 6–8 years, but now we know that this condition can be improved at older ages, even in adulthood. Strabismus, or “crossed eyes,” can cause amblyopia if untreated. Eye tracking requires that the eyes move together with exquisite

Doctors on the frontline of eye and vision care Did you know? • Diabetic retinopathy can be controlled and diabetic patients need regular eye exams to maintain vision and good eye health. • Diabetes Type ll can also cause vision changes. • Glaucoma must be diagnosed in early stages in order to prevent vision loss. • All children entering school need a comprehensive eye exam, because vision screenings do not detect a number of eye disorders. • To maintain eye health, everybody from babies to boomers to older adults needs a regular eye exam by a family eye doctor. To locate an optometrist near you and find comprehensive information about eye health visit http://Minnesota.aoa.org APRIL 2013 MINNESOTA HEALTH CARE NEWS

PUBLIC HEALTH

Fish consumption guidelines Which fish, and how much fish, is safe to eat? By Deborah Durkin, MPH

hysicians and other health experts recommend that people of all ages eat fish twice a week. Yet, we also know that most fish are contaminated with mercury and that some fish are contaminated with additional chemicals. Isn’t this contradictory? Why should we eat fish if it’s contaminated with chemicals? Why eat fish? Mounting scientific evidence shows that eating fish low in mercury and other contaminants—particularly fish rich in omega-3 fatty acids, like sardines and salmon—is good for the health of adults and for the growth and development of babies and children. Consumption of fish by adults has been strongly linked to a lower risk of cardiovascular disease. Other research indicates

lower risk of stroke, depression, age-related mental decline, and improved arthritis symptoms, among many other benefits. In babies and children, omega-3 fatty acids from fish promote brain growth and development. In several studies, mothers who ate fish while they were pregnant gave birth to babies who had better eyesight and higher scores on cognitive tests as infants and at age four than babies whose mothers did not eat fish. Other studies have shown that eating fish during pregnancy may result in newborns with higher birth weights and may help prevent premature births. However, you can’t tell by tasting, smelling, or looking at a fish whether it is contaminated with chemicals, nor the amount of mercury or other chemicals it may contain. That’s why the Minnesota

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MINNESOTA HEALTH CARE NEWS APRIL 2013

Department of Health (MDH) provides Safe-Eating Guidelines. MDH uses monitoring results from fish caught in Minnesota to determine how much Minnesota-caught fish a person can eat without risking too much exposure to contaminants. MDH also provides Safe-Eating Guidelines for purDon’t be chased fish based on afraid to information from the federal government eat fish. and other sources. How to choose fish Whether you eat fish that are caught in Minnesota, canned tuna, fresh fish from the grocery store, or fish at a restaurant, MDH safe-eating guidelines help you choose fish that maximize health benefits and minimize potential risk from chemical contaminants. Statewide guidelines cover all fish caught or purchased in Minnesota. For people who want information about a particular Minnesota lake or river where they like to fish, there are site-specific guidelines. Site-specific guidelines provide detailed information on fish found in approximately 1,500 Minnesota lakes, rivers, and streams

Safe Eating Guidelines for Minnesota-caught fish: Pregnant Women, Women Who Could Become Pregnant, Children Under Age 15

Safe Eating Guidelines for Minnesota-caught fish: Men, Boys Age 15 and Older, and Women Not Planning to Become Pregnant No more than 4 servings/week of Minnesota-caught: • Bullhead • Crappie • Sunfish • Yellow perch

1 serving/week of any Minnesota-caught: • Bullhead • Crappie • Sunfish • Yellow perch AND ALSO 1 serving/month In addition to fish from the group above, you can also have 1 serving each month of Minnesota-caught: • Bass • Catfish • Northern pike smaller than 30 inches • Walleye smaller than 20 inches • Other Minnesota species Do Not Eat Minnesota-caught: • Muskellunge • Northern pike longer than 30 inches • Walleye longer than 20 inches

where fish have been tested for chemicals. Consumption advice for fish from these tested waters may be the same or slightly different from statewide advice, so it’s a good idea to check site-specific guidelines if you fish the same waters frequently.

OR 1 serving/week of Minnesota-caught: • Bass • Catfish • Northern pike • Walleye • Other Minnesota species

Guidelines for mothers and children Within each set of guidelines—statewide and site-specific—there is more restrictive advice designed to protect babies and young children. This is necessary because even small amounts of mercury can damage a brain that is just starting to form or grow. Consequently, developing fetuses and children under age 15 are at greatest risk from mercury contamination. Pregnant women should be extra careful about the fish they eat because pregnant women provide nutrition for their babies Fish consumption guidelines to page 24

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Fish consumption guidelines from page 23

before birth. Because mercury takes time to leave the mother’s body, women who might already be pregnant or who plan to become pregnant should follow the same guidelines as pregnant women. While it is healthful for pregnant women and children to eat fish, they should be careful to eat fish that are low in mercury, and to consume that fish according to the recommended guidelines. Resources All of the MDH safe-eating guidelines can be found on the MDH website at www.health.state.mn.us/divs/eh/fish/ Site-specific safe-eating guidelines are also on the Minnesota Department of Natural Resources (DNR) LakeFinder at www.dnr.state.mn.us/lakefind/index.html To learn more, order the following materials

online or toll-free by phone; they are provided free of charge and free from shipping charges. • Eat Fish Often? A Minnesota Guide to Eating Fish: Health-based advice on eating fish from lakes and rivers in Minnesota • A Family Guide to Eating Fish: Safe-eating guidelines for fish from Minnesota waters and fish bought in restaurants and stores (in English and Spanish) • Talk about Fish and Way of Eating Fish: Hmong-language video explains how to choose fish low in mercury. • Eat Smaller Fish magnet reminds you that smaller fish typically have lower levels of contaminants. Order online at: www.health.state.mn.us/divs/eh/fish/forms/in dex.html or by telephone at (651) 2014911/(800) 657-3908; press 1.

You can also email Fish Advisory Program Outreach Coordinator Deborah Durkin (deborah.durkin@state.mn.us). Wise consumption nets benefits Scientific evidence continues to grow: Eating fish low in mercury and other contaminants, particularly fish that is rich in omega-3 fatty acids, is good for adult health and for the growth and development of babies and children. Don’t be afraid to eat fish. Eat fish low in contaminants every week to get all of its health benefits while lowering your exposure to mercury and other contaminants. Deborah Durkin, MPH, is the fish advisory program outreach coordinator within the Site Assessment and Consultation Unit of the Minnesota Department of Health.

Choose fish that maximize health benefits and minimize potential risk from chemical contaminants.

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Children’s eyesight from page 21

Comprehensive vision examination

tion; difficulty grasping the concept of right and left; letter reversals, such as interpreting b as d; and failure to recognize patterns or familiar words or objects. These skills can be learned.

Unlike a screening, a comprehensive vision examination assesses eyesight, eye health, and how the eyes focus and work together during near work. Because most vision conditions have no obvious signs or symptoms, a comprehensive exam by an eye doctor trained in visual development is needed to identify problems that could impact the future potential of the child. The American Optometric Association recommends all children receive their first eye examination between 6 and 12 months of age, at 3 years, before kindergarten, and every one to two years thereafter.

Enhance your child’s vision • Play! Visual skills are learned through motor activities and experience, so play catch or roll a ball with your child. Expose your child to real, three-dimensional objects so he or she learns how to focus the eyes at different distances. Television and video games do not teach this skill. • Healthy eyes and vision need a nutritious diet that includes vitamins A, C, D, and E, as well as the essential fatty acids EPA and DHA. • Wear sunglasses. Eighty percent of sun damage occurs before 18 years of age. Sunglasses should be polarized and protect against UVA, UVB, and UVC rays.

Students with visual problems can be misdiagnosed as having learning disabilities.

• Wear sports glasses, which can help prevent the 600,000 sports-related eye injuries that occur each year.

Good vision promotes full potential Because visual skills are learned, they can be developed. Possible treatment options include glasses, contact lenses, patching one eye, vision therapy, and, in rare cases when other efforts have been exhausted, surgery. Vision therapy is similar to speech, physical, and occupational therapy in that it treats deficient visual skills. Many children notice great improvement in school and sports performance after this therapy—good visual skills help children reach their full potential.

Jill Schultz, OD, FAAO, FCOVD, is board-certified in vision therapy and visual development. She serves on the Children’s Vision Committee of the Minnesota Optometric Association and practices at Bright Eyes Vision Clinic in Otsego and Minnetonka.

• Educate children about risks associated with sharp objects near their eyes. Select toys carefully and seek immediate professional care after any eye injury.

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COMMUNITY CAREGIVERS 2013

Making a difference in Recognizing Minnesota’s volunteer physicians Each year, Minnesota Physician Publishing honors physicians who have volunteered medical services in recent years. Through volunteer medical activities that span the globe, Minnesota’s volunteer physicians have provided medical care and medical education while expanding crosscultural skills and understanding. Their compassion, commitment, and generosity reflect deeply held values of Minnesota’s medical community. By Scott Wooldridge Assistant editor Minnesota Physician Publishing

MINNESOTA HEALTH CARE NEWS APRIL 2013

Blogging from the epicenter considered a large hospital, with approximately 70 beds. Yoon notes that the hospital has a number of issues that would give U.S. physicians pause but which are not unusual for a Haitian facility. These include power shortages, sanitation issues, and a staff that is overworked and underpaid. Since his first trip in July 2010, Yoon has collaborated with Tom Slater, a surgical technician from HCMC who also participated in the Haiti mission trips, to blog about the team’s experience of providing health care in Haiti after the earthquake. The blog provides remarkable insights into the experiences of the American health care workers. Providers write about looking out over tent cities of injured Haitians and their families, choking on air thick with smoke from trash fires, or hunkering down to weather out hurricanes that further complicate their efforts to deliver health care. The topics can be relatively lighthearted as well, such as when the bloggers note the temporary loss of Internet service because the hospital didn’t pay its bill, or compare notes on local food, or write of enjoying their trips to local orphanages. (“Every Haitian kid I see is the absolute cutest kid ever ... until I see the next one,” one provider writes.) “It’s a way to process what we’ve been through,” Yoon says of the blog. “A lot of Our team resting at night after a long day in the OR. times you have very strong emotions that can country’s severe poverty have combined to cre- occur with all the stress of working 17-, 18hour days under what can be sometimes very ate ongoing demand for volunteer health care hectic conditions. It’s a way to digest it and I experts such as the HCMC providers. guess vent in a way so that you don’t keep it “There’s absolutely a need,” Yoon says. all bottled up inside. There are oftentimes “There’s been a shift from taking care of the emotional moments where there are patients acute injuries from the quake to taking care of you can’t save or who’ll never walk again. It’s a some of the long-term sequelae and complicaway to process all that and deal tions of injuries, for example, with it in our own way.” nonhealing bones and chronic Yoon says the blog, which infections.” often features photographs of HCMC providers have been providers and patients alike, has traveling to Haiti about twice a drawn a following back home in year, Yoon says, working primarMinnesota, including followers ily out of Hospital Adventiste on Facebook. “It’s somewhat d’Haiti, in the town of Carrefour. educational to let them know On his trip in March 2012, Yoon how bad people have it down says his team saw a mix of condithere in a country that’s really tions, including chronic infections not very far away at all,” he says. due to injuries from the quake, “There are congenital deformities in chilpatients you can’t “We try to not just treat patients as numbers, but [also show] dren, and acute broken bones, save or who’ll faces to put with the names and which he notes is a common problem in a city with many never walk again.” show that these are human beings, no better than you or roads that are still in bad shape. Patrick Yoon, MD me, just the same as us, that The Adventist hospital is have had horrible things happen located 20 miles outside Haiti’s to them and need help.” capital of Port-au-Prince, and is “On Wednesday night there was a magnitude 4.5 earthquake. We only felt it as a slight vibration where we were, but it very understandably caused a lot of concern.” So goes an entry in the blog “Project Ortho: From Hennepin to Haiti,” which chronicles the work of Patrick Yoon, MD, and other providers from Hennepin County Medical Center (HCMC) as they provide health care services in Haiti. Orthopedists from HCMC have been traveling to Haiti on a regular basis since a January 2010 earthquake devastated that country. The severity of that earthquake, its effect on Haiti’s infrastructure and economy, and the

n Minnesota and the world Giving back For the past seven years, S. Jafar Hasan, MD, an ophthalmologist with Edina Eye Physicians and Surgeons, has offered free eye-care clinics on a bimonthly basis. He says he was motivated to launch the clinics primarily by seeing the number of people without access to good health care. Hasan notes that doing something as simple as providing glasses can make a tremendous difference to people with poor vision. “Getting a pair of glasses can really change someone’s life, so it’s a really easy thing to do, with a big reward,” he says. The free clinics screen for basic eye conditions and provide eye exams. Hasan says Edina Eye provides eyeglass prescriptions at a significant discount for patients of the free clinic. Hasan has also been involved with Big Brothers, Big Sisters organization, and has worked with local schools to provide preventive eye care to children. He says he’s always had an interest in helping others. “My father is a social worker, so he just kind of ingrained that in me.” Hasan, who is Muslim, says his religion influences his community work. “We’re taught

to give back, and that’s what I’m trying to do,” he says. Hasan and some colleagues started Muslim Physicians of Minnesota a few years ago. “Basically our goal is to provide access to health care and education for all people, not just Muslims; our goal is to incorporate everybody,” he says. The group provides health care services at health fairs and educational seminars, and at

“ We’re taught to give back, and that’s what I’m trying to do.” Jafar Hasan, MD

Day of Dignity, an annual community event sponsored by the Masjid An-Nur mosque and Islamic Relief USA. Day of Dignity has been held on Minneapolis’ north side in October the past two years. Hasan says the annual event allows groups like his to reach out to the community. “It’s kind of an open house for people who don’t

have access to many social services,” he says. “They’ll have financial people there, nurses giving out flu shots. We had a booth there, not just for eye care; we had a cardiologist, blood pressure screenings, cholesterol screenings, and other things.” According to Hasan, Muslim Physicians of Minnesota has a membership of approximately 200 people, which includes health care workers other than physicians. He says the group has been trying to raise its visibility and the response has been good so far. In addition to the eye clinics he provides, the group also sponsors primary care and pediatric clinics at different locations around the Twin Cities. “The other thing we’re working on now is outreach to try and get mentors for students, particularly Somali students,” he says. “Many of them don’t have [mentors] in the community if they’re interested in the medical field.” Hasan hopes to begin offering his eye clinic on a monthly basis, in response to increasing demand. “There’s definitely a need,” he says. “There are more and more people without access to good health care. There’s been a pretty significant backlog of people needing eye care.” Caregivers to page 28

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APRIL 2013 MINNESOTA HEALTH CARE NEWS

COMMUNITY CAREGIVERS 2013 and provide training at the medical school in Gondar, in an effort to leave a self-sustaining medical legacy behind, Kobrin notes. Many physician volunteers go on medical missions that involve traveling Northern Ethiopia is beautiful, Kobrin says, not the desert that one from developed nations to relatively impoverished regions. Jerry Kobrin, might expect. “The northern region is mountainous and quite green, MD, along with his wife Hilary Stecklein, MD, have worked to prepare actually. It has a fascinating history and very warm and friendly people.” thousands of people from a poor region of Africa to travel to new, However, he adds, the people of northern Ethiopia are often quite healthier lives in Israel. impoverished, with most working as subsistence farmers. “It’s very hard Kobrin and Stecklein are both physicians with HealthPartners; for them to scratch out a living there,” Kobrin says. Emigrating to Israel Kobrin is an ophthalmologist and Stecklein, a pediatrician. They have gives them a future of new opportunities, he says, but the transition is recently been working with Jewish Healthcare International (JHI) on an not easy. He says the Ethiopian emigrants are “terrified and excited. It’s ongoing project that has relocated thousands of Ethiopian Jews. The a whole new life for them. It’s like going to another planet.” Ethiopians have been working with the Israeli government since the To help with that, JHI and the Israeli government have instituted a 1980s to relocate members of this ethnic minority to Israel, a process number of programs to educate emigrants and help them with language called aliyah. According to JHI officials, the Israeli training and other acclimation issues. JHI’s program government is planning to relocate the approximately to identify health conditions and create medical 8,000 Jews remaining in Ethiopia to Israel by 2015. records is part of those transition efforts, Kobrin says. As part of that effort, Kobrin and Stecklein travThe JHI program, he says, “… tries to identify eled last June to Gondar, Ethiopia, a region where medical problems early and pay attention to the many Ethiopian Jews are located. The two doctors types of medical conditions these people are bringing provided physicals and medical screenings for indiwith them. It’s like going back 2,000 years on the viduals who were scheduled for aliyah. Health issues clock. In developed countries, you don’t see rampant such as tuberculosis and malnutrition are not uncommalnutrition, malaria, tuberculosis. With the help of mon, and the Israeli government, along with JHI, is the medical university there, when we identify someworking to make sure that the emigrants are relaone who is really sick, we can provide them with care tively healthy and have up-to-date medical records. to get them on their feet again so they can be healthy Kobrin says the program identifies those with the enough for the journey.” “It’s like going back most pressing medical needs and treats them, usuKobrin, who worked with JHI on earlier medical 2,000 years on the clock.” ally at a local hospital. “It all depends on the urgmissions to Eastern Europe, says the work with Jews Jerry Kobrin, MD, and ency,” he says. “It could be a minor thing like dental preparing for aliyah was very fulfilling. “It was wonHilary Stecklein, MD care. We can alert the authorities so the proper apderful to get back to the basics. It was very heartpointments are made. If it’s an urgent situation, we warming working side-by-side with my spouse,” he can make sure they’re taken care of and healthy says. “These are gentle people, very appreciative, enough to go.” Physicians with JHI also give lectures and it was wonderful to help them start a new life.”

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MINNESOTA HEALTH CARE NEWS APRIL 2013

Outside the comfort zone

ering from surgery. Bretzke says the surgical team does five to six cases a day, with restrictions due to lack of supplies and medical supMargit Bretzke, MD, has been part of a small, Minneapolis-based medport. “We have to do the kind of surgeries that keep people in the hospiical mission to Guatemala for the past eight years. The organization, tal maybe one or two nights, that aren’t going to need an intensive care Medical Teams Serving Guatemala, sends teams of surgeons and other unit, that are unlikely to need a blood transfusion.” providers for a total of three weeks (one week for every team) each fall Even within those limits, there are many serious conditions to treat. to the city of Antigua, west of Guatemala’s capital, Guatemala City. “They can be like the biggest hernias you’ve ever seen; the gallbladder’s There, the teams provide treatment for Guatemalans who otherwise always hard, but people have had these issues for years and years and would have little hope of being seen by a surgeon. haven’t had access to health care,” she says. “The other thing that is Bretzke says the trips have been something that she has enjoyed always so remarkable to us is that they don’t require much for pain. I sharing with her family. Her husband, Jeff Hanson, MD, has an extenthink these people live with a lot of pain in their lives, and they’re just so sive history of working in community clinics in Minneapolis as a family happy to have things taken care of. You’ll send them home with ibupropractice physician, and her son, Peter, has been on sevfen and that’s it. They never complain, and they may have eral trips, starting when he was 10 years old. She notes to walk 10 miles. It’s just remarkable.” that Peter has always helped out with jobs associated Despite having to operate in less than ideal condiwith the Catholic church where the mission is based. tions, Bretzke says the surgeons who participate in the “One year he helped inoculate chickens; he helped mission enjoy the trip and often will chip in extra money to build prefab houses that they would send into the mounhelp fund the mission. “You can have a lot of fun, and you tains for people. He and Jeff would do language school,” learn,” she says. “Most surgeons, I think, are thrill seekers she says. “Peter actually had the opportunity to come into in one way or another. You’re doing things really out of the operating room a couple times just to see what that your comfort zone. You’re not sure about your equipment, was like.” When asked if the experience had left an always; you’re not sure what you’re going to find.” impression on Peter, Bretzke laughs. “Yes, he’s real clear Bretzke says that another program that has become that he doesn’t want to go into medicine.” She adds that important to her is the Common Hope initiative, which “Most surgeons, while visits to the operating room were rare, children of gives providers on the mission the opportunity to help I think, are thrill providers have often come on the missions and have sponsor a Guatemalan child’s education. “The deal is that always gotten a lot out of the trips. seekers in one way Common Hope will continue to support this child as long “It’s a really good experience,” she says. “They realas they stay in school. A lot of people who have gone or another.” ize how lucky they are in the United States. We’ve down there ended up doing this,” she says. “Every year always wanted our son to think globally, and this helps, Margit Bretzke, MD we visit the family. That last day you’re not operating; most to do things like this and understand what people are up people go visit the child they’re helping support. That is against.” unbelievably powerful, to get to know that family.” The patients served by the mission come from all Caregivers to page 30 around the region, and stay at a local facility while recov-

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COMMUNITY CAREGIVERS 2013 “People were already lined up outside of the building, which was kind of their community center, but it was really kind of the equivalent Aaron Johnson, MD, has seen firsthand how important building trust is of a barn. There were three incandescent light bulbs down the length when U.S. providers undertake medical missions in impoverished areas of this room, which was probably 35 feet,” Johnson says. “So we just of Mexico and Guatemala. Johnson, who has been traveling to commu- kind of set up makeshift partitions, and each provider had one light nities in those countries for four years with Minnesota Doctors for bulb above us. We went until about midnight. There were just so many People (MDP), knows the troubled history of the region, which has people there that had walked to this little town, which was a big town seen political corruption, crime, and civil war. for them, but still a pretty small place. So we just kept seeing people.” “There’s always been that trust piece; they have a hard time knowJohnson says the providers see a wide range of conditions, from ing who to trust,” says Johnson, a family practice physician from United diabetes, to infections, to muscle strains. In some cases, they perform Hospital District in Blue Earth. “In Chiapas, I noticed when we were minor surgeries. With chronic conditions, such as diabetes, they can down there last year, people came back to us and said, offer only limited help. Other conditions are easier to ‘Yeah, we remember your group.’ That’s huge, because deal with. “We see a lot of parasite-type stuff, which is the indigenous Indians there have a fair amount of disone of the things we can actually treat, so it’s fairly trust and they’re not sure they should even talk to you, rewarding,” he says. “We can give them a three-day let alone let you look in their mouth or at their back. Just course of anti-worm medicine and know it’s going to be breaking down those barriers is progress. But it’s slow.” taken care of. Doesn’t mean that they’re not going to Johnson says it helps that his group works closely get it again; but at least you can treat it.” with local providers and hospitals, especially in The missions can be eye-opening, Johnson notes, as Guatemala where MDP has a longer history, to provide the MDP teams regularly encounter conditions very supplies and support. “We try to do as much teaching as rarely seen in the U.S. “There’s lots of really bizarre we can,” he says. “It’s more than just going down and pathology that you’d see in a textbook in a medical throwing Band-Aids on; we’re actually trying to help the school—rheumatic heart disease, for example. Most “We see a lot of local parishes and communities, and local individual parasite-type stuff, people go through medical school and their practice [caregivers]. Some of them are the equivalent of an RN, and [never see it], unless it’s in a 90-year old, a true which is one of and for a lot of stuff, they would be very qualified to rheumatic heart murmur. You’ll hear it in 20-, 30-, 40manage things like high blood pressure.” year-olds all the time down there.” the things we A typical trip for Johnson and the other MDP Johnson adds that the experience is both emotioncan actually treat.” providers lasts from seven to 10 days. Physicians and ally draining and, at the same time, invigorating. “It Aaron Johnson, MD medical staff see up to 60 patients a day, usually at kind of takes you back to why most individuals want to makeshift clinics set up in remote villages. He recalls one be a nurse or a doctor,” he says. “It takes you back to visit from last year’s trip, when they arrived in a small the basic level of just being able to help somebody.” town and started seeing patients in the early afternoon.

A mission of trust

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MINNESOTA HEALTH CARE NEWS APRIL 2013

very good successes, and we had some that didn’t work so well.” More recently, Hart has been working with the March of Dimes on projects such as “Healthy Babies Are Worth the Wait,” a program Richard Hart, MD, has a long history of medical missions and commuencouraging expectant mothers to carry babies to 39 weeks. March of nity work to his credit. The St. Cloud pediatrician’s latest recognition Dimes officials note that some births are being scheduled earlier than was being named the recipient of the 2012 Caduceus Award from 39 weeks for nonmedical reasons, and they warn of health problems St. Cloud’s CentraCare Health Foundation. The Caduceus award recognizes physicians who have made a com- that can come from early deliveries. Hart says that he and his wife, Patricia, a neonatal nurse practitionmitment of $10,000 or more to support the mission of improving er who serves on the March of Dimes state board, strongly support the health and health care in central Minnesota. Winners are selected by Healthy Babies program. “A lot of maturation of the fetus occurs in the their peers in the medical community. Officials with CentraCare note last few weeks [before birth],” he says. “Before 37 weeks, there can be that Hart was instrumental in forming a program developed by a significant number of problems, and before 39 weeks, they don’t St. Cloud State University that created care plans for severely disabled have their full nutrition. They’re still prone to jaundice children. and other problems that can show up a little bit later.” The award also highlighted Hart’s long history of With his history of community service and volunteer medical missions, such as work with HELPS International, work for medical missions, Hart says he appreciates the an Addison, Texas–based charitable foundation that volunteering spirit of health care providers in the works with nongovernmental organizations to provide St. Cloud area. “There’s a lot of local interest in volunhealth care, education, economic development, and teering for a variety of programs,” he says. “We’re not other services to impoverished areas. on as big a scale as the bigger programs in the Twin Hart recalls working with HELPS in the ‘90s, when he Cities, but we’re finding more and more people [who participated in medical missions to rural communities in volunteer].” Guatemala. “It was about a 10-hour or 12-hour bus ride Hart also says his experience suggests that physithrough the tropical forest,” he says. “We had to take cians and health care groups should pay attention to the two buses, because if one would get stuck, the second “There’s a lot of feedback they receive from communities they serve. one would be able to pull the first bus out.” local interest in “From a volunteer standpoint, that becomes the most Closer to home, Hart’s work with St. Cloud State University brought together school specialists, psycholovolunteering for a important thing,” he says. “Rather than us deciding we’re going to do, see where the patients or famigists, public health officials, and pediatricians to address variety of programs.” what lies demonstrate a need—then you can help them out the needs of disabled children in local schools. “We took Richard Hart, MD with that specific need.” children who were having a great deal of difficulty in the school system,” he says. “We spent half a day evaluating Caregivers to page 32 each student and tried to come up with a care plan that would work. We did get some feedback. We had some

Committed to community service

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APRIL 2013 MINNESOTA HEALTH CARE NEWS

COMMUNITY CAREGIVERS 2013

Mogadishu Spring

In addition to treating patients, Ahmed, an internal medicine resident at HCMC, worked to educate some of the hospital staff that Last spring, Hani Ahmed, MD, returned to Somalia, a country she had lacked medical training. She taught staff to take vital signs and doculeft 23 years earlier as a child. Ahmed volunteered in 2012 with the ment medication for patients. She set up an isolation ward for tubercuAmerican Refugee Committee (ARC) to work for a month at a hospital losis patients. “I had to learn to do as much as I could with as little in the capital of Mogadishu. The timing was not perfect: Somalia was possible,” she says. “Those kinds of experiences make you realize what suffering from a famine and some of the worst factional fighting in is a priority.” recent years. Despite the lack of resources and the dangerous state of the city, Ahmed’s coworkers at Hennepin County Medical Center (HCMC) Ahmed describes the experience as tremendously rewarding. “I can’t were not eager to see her travel into a war zone. “My program director think of any better feeling,” she says. “It was overwhelming when I was concerned; I remember her saying, ‘We want you to be safe,’” went there, but when I left I felt very happy.” She said Ahmed says. “I really pushed for it. I felt I had to do it.” the knowledge that she could make a real difference was It’s not hard to understand her director’s concern. one reason why she pushed to go to Mogadishu. “Being Ahmed described having trouble sleeping at night due to Somali myself, I knew the biggest impact I was going to mortar shells overhead. She heard gunshots on a daily make was going to be in a place like Somalia,” she says. basis. Minneapolis-based ARC provided her with an armed “I speak the language. The people are my people. I felt escort and evacuation insurance. like I could just do so much more.” “There was a lot of violence when I was there,” Ahmed says she plans to return to Somalia, probably Ahmed recalls. “Driving through the city, we had to in 2014. She notes that the security situation is improving wear bulletproof vests every day and a helmet because and that the country is now more politically stable. of possible stray bullets. You couldn’t go anywhere at In the meantime, Ahmed is raising funds for ARC and night. You had this constant sense of agitation; you just sharing her story with other health care providers and the couldn’t really relax.” “We had to wear community. She is talking with Somali physicians about The hospital where she worked, Benadi Children’s bulletproof vests the possibility of regular trips to the country and of sendHospital, had also been marked by war. She describes a equipment and money to hospitals like Benadi every day and a ing facility lacking in supplies and run by a handful of young Children’s Hospital. To help with fundraising, she has doctors just out of medical school. “Probably some of my helmet because of developed a slideshow of pictures she took during her earliest reactions were shock and despair,” she says. mission. “The concern of donors is always whether stray bullets.” “Especially the first two weeks; it was really overwhelming money is going to reach the people in need,” she says. “I Hani Ahmed, MD to take in how bare it was. There was no monitoring think seeing pictures from the ground, they see firsthand equipment of any kind. There were times when there what ARC is doing. They see exactly what the sort of were no physicians. All the medications were locked in a need is and how much need there is.” cabinet because they could be sold in the market. We just had the absolute minimum of everything we needed.”

Minnesota

Health Care Consumer March survey results ... Association

1. I trust the professional advice of my

Each month, members of the Minnesota Health Care Consumer Association are invited to participate in a survey that measures opinions around topics that affect our health-care delivery system. There is no charge to join the association, and everyone is invited. For more information, please visit www.mnhcca.org. We are pleased to present the results of the March survey.

2. I get most of my health care advice from a

medical doctor.

40 35.29% 30 20 11.76% 10

Strongly agree

Agree

Does not apply

40 30

26.47%

20 14.71% 10

5.88%

2.94%

50%

50 Percentage of total responses

Percentage of total responses

medical doctor.

50%

Disagree

2.94% 0

Strongly disagree

Strongly agree

Agree

Does not apply

Disagree

Strongly disagree

5. I, or a member of my family, have requested specific

26.47%

20 14.71% 8.82%

10 0% Strongly agree

Agree

Does not apply

Disagree

Strongly disagree

MINNESOTA HEALTH CARE NEWS APRIL 2013

Percentage of total responses

58.82%

medication and been unable to receive it because it was not covered by my health insurance.

prescriptions due to drug shortages.

50%

4. I, or a member of my family, have had difficulty filling

50 40 29.41%

30 20 8.82%

10 0

38.24%

Strongly agree

Agree

Does not apply

30 23.53%

25 20 15

17.65% 14.71%

10 5.88% 5

2.94%

Percentage of total responses

3. I have had trouble following the instructions of my medical doctor.

Disagree

Strongly disagree

Strongly agree

Agree

Does not apply

Disagree

Strongly disagree

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.

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

www.mnhcca.org

Join now.

â&#x20AC;&#x153;A way for you to make a differenceâ&#x20AC;? APRIL 2013 MINNESOTA HEALTH CARE NEWS

Donated blood from page 17

used to minimize these complications and to make sure that donor and recipient blood are compatible. Transfusion alternatives During the past 25 years, medicine has learned that patients do very well with less blood than was previously believed necessary. Therefore, transfusion now is done less frequently. In addition, strategies to avoid transfusion are used increasingly. These include operating room machines that recover a patient’s blood lost during surgery and return it to the patient. Patients planning a surgical procedure that may involve transfusion can donate blood for their own use. However, this is not done often because: • Donor blood is extremely safe. • Medical reasons such as anemia (insufficient oxygen in the blood) may make self-donation dangerous for the patient.

Transfusion now is done less frequently, and strategies to avoid transfusion are used increasingly. • Complications can arise from transfusion of a patient’s own blood. Self-donation is rarely recommended by surgeons. Ongoing need Since efforts to develop a blood substitute have been unsuccessful and since all blood components have a short shelf life, donation of this life-giving substance continues to be vitally important. To donate or to learn more, visit www.redcross.org or call (800) 733-2767. Jeffrey McCullough, MD, is a professor in the Department of Laboratory Medicine and Pathology at the University of Minnesota, where he holds the American Red Cross chair in transfusion medicine in the medical school. He has served as the scientific director of the St. Paul Regional Red Cross Blood Service since 1992.

• A limited amount of blood can be self-donated, potentially replacing only part of the need. • Storing self-donated blood costs more than using publicly donated blood.

Now accepting new patients

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

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

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

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

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

MINNESOTA HEALTH CARE NEWS APRIL 2013

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

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

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

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

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

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

FOR TYPE 2 DIABETES

Victoza® helped me take my blood sugar down…

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

Model is used for illustrative purposes only.

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

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

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

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

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

Non-insulin • Once-daily