Minnesota Health care News August 2012 by Minnesota Physician Publishing

Your Guide to Consumer Information

August 2012 â&#x20AC;˘ Volume 10 Number 8

Adverse drug interactions Julie K. Johnson, PharmD

Home health care Jennifer Sorensen, MEd

A healthy liver Jeffrey Rank, MD

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CONTENTS

4 7 8

AUGUST 2012 â&#x20AC;˘ Volume 10 Number 8

NEWS

PERSPECTIVE Dawn Simonson, MPA

10 QUESTIONS Ann Settgast, MD, DTM&H HealthPartners Travel and Tropical Medicine Center

HOME CARE Introduction to home care By Jennifer Sorenson, MEd

20 22 24

PATIENT TO PATIENT Sports-related concussions

26 28 30 32

DIGESTION A healthy liver

National Immunization and Awareness Month

PEOPLE

Metropolitan Area Agency on Aging

CALENDAR

TAKE CARE Voice care By Axel Theimer, DMA (Doctor of Musical Arts)

By Matt Hovila

Life after concussions By Kayla Meyer

A personal letter to all health care professionals By Mandy Meyer

By Jeffrey Rank, MD

PHARMACY Adverse drug interactions By Julie K. Johnson, PharmD

NUTRITION Food labels By Liz McMann, MA

RESEARCH New drug-delivery method By William H. Frey II, PhD

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

To CHANGE your life (For the better)

ASSISTANT EDITOR Scott Wooldridge swooldridge@mppub.com ART DIRECTOR Elaine Sarkela esarkela@mppub.com BUSINESS DEVELOPMENT DIRECTOR Juline Birgersson jbirgersson@mppub.com ACCOUNT EXECUTIVE Iain Kane ikane@mppub.com

Advisory Board: Minnesota Medical Association (MMA), Minnesota Hospital Association (MHA), Minnesota Medical Group Management Association (MMGMA), Buyers Health Care Action Group (BHCAG), Minnesota Business Partnership (MBP), Minnesota Healthcare Network (MHN), Advocates for Marketplace Options for Mainstreet (AMOM), Minnesota HomeCare Association (MHCA), Minnesota Physician-Patient Alliance (MPPA), Physicians Service Network (PSN), Minnesota Center for Rural Health, and Minnesota Council of Health Plans. 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.

Contact: Sentinel Medical Associates Laser Center Gallery Professional Building 514 St. Peter, Suite 220 St. Paul MN 55102

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AUGUST 2012 MINNESOTA HEALTH CARE NEWS

NEWS

Supreme Court Rules ACA Is Constitutional On June 28, the Supreme Court issued its long-awaited ruling on President Obama’s Affordable Care Act (ACA). The 5–4 decision largely let stand the ACA’s health care reforms. The court upheld the key provision known as the individual mandate, which requires virtually all citizens to buy health care insurance. That provision is considered by many to be the pillar of health care reform legislation. In addition, the court let stand the ACA’s major expansion of the government-funded Medicaid program. However, the ruling allows states to choose whether or not to expand their Medicaid programs, without facing the financial penalties the law called for. Reaction from the health care community in Minnesota was generally positive. The Minnesota Medical Association (MMA) issued a statement calling for the state to move ahead with a state-run health

insurance exchange system, and said the ACA provides the foundation for improving the nation’s health care system overall. “With the Supreme Court upholding the ACA, it will allow us to continue working on reducing costs and expanding health care coverage for all Minnesotans,” said MMA president Lyle Swenson, MD. “Although not perfect, the ACA has already stimulated innovation in care delivery.” Matt Schafer, government relations director with the Minnesota chapter of the American Cancer Society, said the ACA’s reforms will be critical to helping people with cancer and other life-threatening diseases access quality, affordable care. “Access to care saves lives. Scientific research from the American Cancer Society has shown that people without health coverage are more likely than those with private insurance to be diagnosed with cancer at its more advanced stages and less likely to survive the disease,” Schafer said. “Now that the Supreme Court has

ruled, it is time for all of our elected officials in Minnesota to work together … to implement the health care law as strongly as possible for cancer patients, survivors, and their families.”

Medica Offers Mayo Sites, Providers for Individual Plans Mayo Clinic and Medica have announced a new agreement that will allow residents from 22 counties in southern Minnesota to purchase individual and family health plans. Medica already had an arrangement with Mayo Clinic that allowed those on employerbased health plans in-network coverage at Mayo facilities. The new arrangement will allow people in the growing individual market segment to purchase Medica products that feature Mayo providers in their networks. The agreement will allow Medica enrollees to be seen at any Mayo Health System facility

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and the Mayo Clinic campus in Rochester. “This agreement with Medica gives southern Minnesota residents in these 22 counties access to a new competitive health-care coverage option,” says John Noseworthy, MD, Mayo Clinic president and CEO. “We welcome the opportunity to serve Medica members in this region of the state.” Officials with the two organizations note that the new arrangement is an incentive-based system that will reimburse Mayo Clinic providers based on how well the system manages the population’s health overall. “We know that the health care system needs to improve the way care is delivered and the way it is paid,” says David Tilford, Medica president and CEO. “This arrangement with Mayo Clinic provides the impetus for change through its focus on more efficient and effective delivery of care and a better understanding of the true costs of care. It takes on the fundamental issues facing the health care industry today: how to

o you know of family members, friends or neighbors who have difﬁculty using their telephone? Do they have trouble hearing, speaking or have a physical disability that prevents them from using a standard telephone?

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improve quality and patient experience while reducing cost.” Medica officials say there are currently 5,000 to 10,000 Medica enrollees in southeastern Minnesota. With the expanding market for individual products, the company expects substantial growth in the number of enrollees in that area, they add.

DHS to Promote Long-Term Care The Minnesota Department of Human Services (DHS) has created a coalition of business and community leaders to raise public awareness about the importance of long-term care planning. The group is led by Lt. Gov. Yvonne Prettner Solon and includes 25 other members, including Commerce Commissioner Mike Rothman, AARP Minnesota executive director Michele Kimball, Minnesota Chamber of Commerce policy analyst Kate Johansen, and the Minnesota Business Partnership’s health policy director Beth McMullen. The panel will develop a statewide public awareness campaign to promote long-term care planning to Minnesota citizens. The campaign will be called “Own Your Future,” and will stress to state residents the importance of planning now to ensure more control and choice in meeting future long-term care needs, officials say. DHS hopes to increase the number of Minnesotans planning effectively for their later years. With the state’s aging population, public participation in long-term care planning could help stem mounting costs to governmental bodies in the future. “We need to engage all Minnesotans in thinking about how they will plan for and pay for the care they are likely to need, as we, as a society, are living longer and growing older,” said Prettner Solon. “We are grateful for the assistance in this effort of Minnesotans representing key sectors of labor, business, health care, the faith community, and nonprofit organizations.” The panel is particularly

focused on engaging employers, as long-term care insurance could become a more common part of benefits offered by companies. Officials note that employers are seen by many workers as a good source of information on longterm care options.

Report Finds Health Inequities In Twin Cities A report by the Blue Cross and Blue Shield of Minnesota Foundation and Wilder Research finds health inequities still exist in the Twin Cities. The researchers found that Twin Cities residents in highincome neighborhoods have an average life expectancy of 84 years, while those in the lowestincome neighborhoods have a life expectancy of 76 years. In addition, age-adjusted mortality rates improved among all racial/ethnic groups except for U.S.-born African American residents. Mortality rates decreased as much as 47 percent among foreign-born African American residents, compared to a slight increase of 3 percent among U.S.-born African American residents. “Our analysis found that there continue to be strong relationships between socioeconomic status, race, and health. While the study suggests that health inequities may be narrowing in our region, it is a snapshot comparing two points in time and may not reflect larger trends. In addition, we do not know how future health outcomes may be impacted by the recent economic downturn,” says Melanie Ferris, research scientist and author of the report. The study identified several areas of worsening socioeconomic conditions, including the percentage of residents living below the poverty level, which increased from 7 percent in 2000 to 11 percent in 2010. Also, the average median household income in the Twin Cities region was $62,000 in 2010, a decrease of nearly $9,000 since 2000. News to page 6

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News from page 5

Allina Launches Neighborhood Health Connection Allina has launched a large, new community health project called Neighborhood Health Connection, which will fund more than 250 community groups engaged in activities such as free health screenings or exercise programs. The program will support efforts during the summer in Minnesota and western Wisconsin, and Allina officials say the response has exceeded expectations. “We thought our citizens would be interested in health improvement, and we were prepared to support 30 neighborhoods in this endeavor,” says Kenneth H. Paulus, president and CEO of Allina Health. “What we didn't expect was such an overwhelming interest in organizing these healthy initiatives, with more than 400 interested neighborhoods. The creativity and pas-

sion around improving health was encouraging, and gives me great hope for a healthier future for our nation.” In total, Allina officials say the programs will benefit more than 43,000 people in Minnesota and Wisconsin. In addition to 37 health screening events, Allina will fund activities such as exercise classes in neighborhood parks for families with young children; disc golf equipment and GPS devices for at-risk youth programs; nutrition education, recipes, and healthy food demonstrations for people receiving groceries from a neighborhood food pantry; and free pedometers and fitness challenges for youth and adults.

State Well Suited For Clinical Trials, PhRMA Report Finds Minnesota is well suited to host clinical trials of pharmaceutical drugs, a new report from PhRMA says. The report says Minnesota

t a P

– UCare member St. Louis Park, MN

has an excellent infrastructure for testing pharmaceuticals, with major research facilities and health-care delivery capabilities. Jeff Trewhitt, senior director of communications and public affairs for PhRMA, says the report shows that although pharmaceutical companies are not as highly visible in Minnesota as device manufacturers such as Medtronic or St. Jude’s, drug trials are still important to the state’s health care industry. “Although the biopharmaceutical research industry may not have a very prominent brick-andmortar presence in Minnesota, it does, nevertheless, have a very positive impact on the state through its sponsorship and conduct of clinical trials,” Trewhitt says. “Not only are these trials that have been sponsored and conducted by [pharmaceutical] companies good for patients, they’re also good for the state’s economy as well as the advance of science.” According to the report, pharmaceutical companies have con-

ducted more than 2,400 clinical trials of new medicines since 1999 in Minnesota. The report notes that the University of Minnesota and Mayo Clinic are sites of major research, and the health care systems in the state are also excellent partners for research. The PhRMA report emphasizes the work of the Minnesota Clinical Research Alliance, a coalition of research groups that formed one year ago to promote clinical trials in Minnesota. According to Trewhitt, one of the challenges that companies conducting clinical trials face is the difficulty in recruiting enough patients to fill trials. “More than 70 percent of all clinical trials have patient enrollment problems, and those problems lead to clinical trial delays of anywhere from a month to six months,” Trewhitt says. “That means drug development is being slowed down, and that means patients who need these new medications are waiting longer than they should to get them.”

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MINNESOTA HEALTH CARE NEWS AUGUST 2012

PEOPLE Jaimi Anderson, certified nurse practitioner, has joined Clinic Sofia, an ob-gyn clinic. Anderson will work at the clinic’s recently opened

MINNESOTAHEALTH HEALTH CARE ABLE MINNESOTA CAREROUNDT ROUNDTABLE

facility near Maple Grove Hospital. Anderson brings nearly 20 years of experience in caring for all aspects of women’s health. Previously a nurse practitioner at an ob-gyn clinic in Edina, Anderson has also supported women’s health needs through her work at the Center for

T H I R T Y- E I G H T H

SESSION

Background and Focus

Reproductive Medicine and the Midwest Center for Reproductive Health. She holds a nursing degree from the University of Minnesota and nurse practitioner certification through the Women’s Health Care Nurse Practitioner Program at Planned Parenthood. The MetLife Foundation recently named Clifford R. Jack Jr., MD, the recipient of a 2012 Award for Medical Research in Alzheimer’s Disease. Jack is a professor of radiology and the Alexander Family Professor of Alzheimer’s Disease Research at Mayo Clinic, Rochester. Jack, who has developed and applied imaging methodologies to determine and track the stages of Alzheimer’s disease, was honored for his work as an innovator in clinical studies of brain structure in the disease. The Minnesota Hospital Association recently honored two physicians at its annual awards ceremony. Terry Pladson, MD, received the Stephen Rogness Distinguished Service Award. Pladson, who is president and CEO of CentraCare Health System, St. Cloud, has worked in health care for more than three decades. In addition to recognizing his stewardship of CentraCare, the award Terry Pladson, MD

cited his support for the nursing program at the

College of St. Benedict, St. Joseph, Minn., and for the development of the St. Cloud State University Nursing Program. Steve Mulder, MD, received the Patient Safety Leadership Award. Mulder is president and CEO of Hutchinson Area Health Care and has been involved in patient safety initiatives both within that organization and on a statewide level. He is the immediate past chair of the MHA’s Patient Safety Committee and also serves on MHA’s Physician Leadership Council and its Registry Advisory Council. Sara Criger has been named president of Mercy Hospital in Coon Rapids and a senior vice president with Allina Health. Her 28 years of experience in managing hospitals and clinics include work in developing a neurovascular pro-

The recent Supreme Court ruling on the Affordable Care Act clears the way for implementation of Health Insurance Exchanges. States have the option of creating their own exchange or joining one created by the federal government by January 2014. A Health Insurance Exchange would provide consumers a place to compare and shop for health insurance coverage. In Minnesota this idea was first proposed as part of the Assuring they are meaningful Pawlenty administration’s health care reform task force, Thursday, November 1, 2012 and Gov. Dayton is a strong 1:00 – 4:00 PM • Duluth Room supporter of creating a stateDowntown Mpls. Hilton and Towers run program. Though simple and compelling at first brush, creating a consumer-accessible, “apples to apples” website for comparing health insurance costs is challenging and very complex.

Health Insurance Exchanges:

Objectives We will define what a health care insurance exchange is and, considering the detailed and proprietary design of health insurance coverage, how it can be meaningful. Health insurance policies contain terms like “medically necessary,” “investigative,” “cosmetic,” “not medically necessary” and “contract/benefit exclusion”—all terms that are defined differently by different insurers. This alone makes it virtually impossible for anyone to compare plans effectively. Further, networks of providers vary, depending on whether you choose the “bronze,” “silver,” “gold,” or “platinum” option within a given insurer, as will access to hospital-based facilities, DME providers, and ancillary services. Throw in features like “deductibles,” “co-insurance,” “maximum out-of-pocket expenses,” “formulary design” and “covered preventive services,” and you have a bewildering mathematical matrix. We will offer suggestions as to how an insurance exchange can address these issues and provide a meaningful, consumer-friendly comparison service.

gram with physician partners at HealthEast Care System, where Criger was a vice president and the CEO of St. Joseph’s Hospital in St. Paul.

Sara Criger

Ain Dah Yung Center recently honored Beth Holger-Ambrose, Minnesota Department of Human Services homeless youth services coordinator, with its annual Ally of the Year Award for her years of

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work, particularly among American Indian communities throughout

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Minnesota. The center, which provides a broad spectrum of culturally

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relevant social services to American Indian youth and their families,

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is a grantee of the department. Holger-Ambrose has worked for the Minnesota Department of Human Services since 2005. Her work focuses primarily on securing services for runaway, homeless, and sexually exploited youth. Most recently, she worked in collaboration with

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the Bois Forte Band of Chippewa and Leech Lake Band of Ojibwe to

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open the first housing and supportive services program for homeless

youth on reservations in Minnesota.

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Please mail, call in or fax your registration by 10/25/2012

AUGUST 2012 MINNESOTA HEALTH CARE NEWS

PERSPECTIVE

Metropolitan Area on Aging Partnering with seniors and their caregivers for healthy, vital aging

Dawn Simonson, MPA Metropolitan Area Agency on Aging

Dawn Simonson, MPA, executive director of the Metropolitan Area Agency on Aging (MAAA), has more than 20 years of experience in the field of aging. She is also president of the National Association of Area Agencies on Aging and, in 2004, helped found the Minnesota Leadership Council on Aging. MAAA administers the federal Older Americans Act funding program, provides Senior LinkAge Line information and assistance services to residents of the seven-county metro area, hosts the Upper Midwest Pension Rights Project, and develops innovative services and programs.

ccording to the Minnesota State Demographic Center, one in every eight Minnesotans today is 65 years old or older. By 2030, that number will be nearly one in four. For many people, getting older means learning to manage chronic disease, recovering from a hospital stay, redefining mobility after an injurious fall, and dealing with confusing choices about inhome care and insurance coverage. How can elders or their families get help handling these and other challenges of aging?

services and supports. Several of MAAA’s provider partners offer culturally appropriate age-specific services, including meals and caregiver support. While our partner organizations typically assist those older adults who are in greatest financial need, most people age 60 and older can receive services via sliding fee schedules or voluntary contributions.

tion about aging issues, in-home care, housing options, nursing homes, and other services, as well as resources that include Medicare and other public programs. Second, we help seniors make informed choices about which services to use.

Medicare benefits

How to get information

Personalized, in-depth information is provided during home visits and via one-on-one telephone We can help consultations by Area Agency on Aging staff at Help is available from the Metropolitan Area the toll-free Senior LinkAge Line. Senior LinkAge Agency on Aging (MAAA), a nonprofit agency Line is open 8 a.m. to 4:30 p.m. weekdays at serving the seven-county metropolitan area. Help (800) 333-2433, staffed by social workers, outside the metro area is availgerontologists (professionals able from Minnesota’s five trained specifically in the field The goal is to help other regional Area Agencies of aging), and other highly on Aging and the Minnesota trained, empathetic care conolder adults stay Chippewa Tribe Area Agency sultants. Senior LinkAge Line healthy so they can on Aging. is available throughout Minnesota, with callers automatiThe goal of all of these agenstay in their homes. cally routed to their local cies is to help older adults stay Area Agency on Aging or, healthy so they can stay in on request, to the Minnesota Chippewa Tribe Area their homes. We accomplish that using a Agency on Aging. two-pronged approach. First, we provide informa-

Services available Services in the community are provided by MAAA’s partner organizations, which offer meals, grocery delivery, transportation, homemaker services, medication management, help with outdoor chores, classes and services to manage chronic disease and prevent falls, and limited legal education and casework. In addition, some of our partner organizations specialize in caregiver support that includes assessment, counseling, and respite. Some of our other partners specialize in meeting the needs of minority, immigrant, and refugee elders. This includes Native American elders as well as new Americans, who often face cultural and language barriers to obtaining and using long-term

MINNESOTA HEALTH CARE NEWS AUGUST 2012

Understanding federal Medicare and related insurance can be daunting. MAAA offers expert guidance about Medicare Part D prescription drug plans, supplemental insurance, and Medicare Savings Programs. Senior LinkAge Line professionals and certified volunteers help in a variety of ways: via the toll-free number, at community sites, and through in-home visits to frail older adults. Senior LinkAge Line To help make aging as healthy and vital as possible for you or an aging loved one, Minnesota residents are encouraged to contact their local Area Agency on Aging via the Senior LinkAge Line, (800) 333-2433. For web-based information about long-term services and supports, visit www.MinnesotaHelp.info.

A philosophy of caring is good. A history of it is better. Caring. It would be nice if you could see it, like an amenity. Or tour it, like an apartment. But you can’t. All we can do is give you our definition: Caring is believing that everyone is someone who deserves to feel loved and valued, and be treated with dignity. That’s not just something we say. As the nation’s largest not-forprofit provider of senior care and services, it’s what we’ve been doing for almost 90 years.

www.good-sam.com

To learn more about our communities in Minnesota, call 1-888-GSS-CARE.

The Evangelical Lutheran Good Samaritan Society provides housing and services to qualified individuals without regard to race, color, religion, sex, disability, familial status, national origin or other protected statuses according to federal, state and local laws. All faiths or beliefs are welcome. Copyright © 2010 The Evangelical Lutheran Good Samaritan Society. All rights reserved. 10-G2016

10 QUESTIONS

Travel medicine and health care policy Ann Settgast, MD, DTM&H Dr. Ann Settgast, an assistant professor of internal medicine at the University of Minnesota, is a primary care physician at HealthPartners Center for International Health and practices travel medicine at HealthPartners Travel and Tropical Medicine Center. You earned a diploma in tropical medicine and health (DTM&H). How did you become interested in that field and in international health in general? I’m fascinated by other countries and cultures, and love to travel. Most Western medical education doesn’t provide extensive coverage of diseases encountered in developing countries (malaria, leprosy, malnutrition, etc.). I obtained my DTM&H to be better prepared to work in parts of the world, and with populations, where these conditions are common. Many of your patients are foreign-born. Is working with them different than with U.S.-born patients? It’s a privilege to work with people from entirely different backgrounds than my own. I’m fascinated by my patients’ histories and perspectives, and learn a great deal from them. For many, coming to the U.S. from, say, a refugee camp, preventive medicine and chronic disease management are foreign concepts. I enjoy the opportunity to improve health by building relationships that allow me to promote these concepts, working with patients to combine their non-Western approaches to health with our own in order to obtain the best outcomes. Some travel requires advance medical planning, such as immunizations. How can a traveler find out what is needed? The best way is to visit a travel clinic. Many patients think the only thing we do at travel clinic is give shots, but there is much more. Significant time is spent reviewing malaria risk and prevention. Malaria is an illness that can be fatal quickly in patients who are not immune to it. Choice of prophylactic medication is individualized based on side-effect profile, patient medical history, and other factors. We discuss prevention and management of traveler’s diarrhea, which is very common, and review travel risks. Some preexisting conditions require special planning for travel abroad. Please give us some examples. Changes in diet, activity, and time zone can all affect diabetes control and may require readjustment during travel. Risk of altitude illness can be affected by various cardiopulmonary conditions. Patients who are immunosuppressed, whether due to a disease like AIDS or to medication, require special management.

Photo credit: Bruce Silcox

Have you found an effective way to handle jet lag? Starting a trip well rested helps. People are typically affected when crossing more than three time zones, and traveling west is easier than going east. For example, someone traveling west across six time zones can expect to feel well within two or three days. But the same distance going east can require double that time to feel synchronized with local time. In addition to circadian rhythm disturbance, sleep loss itself—common during travel—contributes to jet lag. I advise patients to use daylight, outdoor activity, and intense activities during the day of arrival when going east to help them stay awake at their destination until local bedtime. Some providers recommend melatonin or zolpidem to help with sleep the first few nights. Recently, you had a short-term teaching appointment in Tanzania. Please tell us about that. I taught on the internal medicine service at Selian Hospital outside Arusha, Tanzania, which serves northern Tanzania’s rural Masaai. My students were train-

MINNESOTA HEALTH CARE NEWS AUGUST 2012

ing to be assistant medical officers, mid-level providers who lessen Tanzania’s profound physician shortage. They were among the most eager and motivated learners I have ever met; teaching and learning from them was fun and inspiring. They requested multiple topics for lectures, and would attend any time of day for as long as I would teach!

toward a single-payer solution at the state level. While the ACA will help some patients, it will not solve our crisis. More than 200,000 Minnesotans will remain uninsured while many more will be underinsured without proper access to health care. Single-payer still provides the only means to cover everyone at reduced cost. More information is at www.pnhpminnesota.org.

What can the United States learn about health care delivery from other countries? The U.S. has much to learn from other wealthy democracies, all of which have truly universal health care systems, most at less than half the cost of ours. There is a constant search in American medicine for the “holy grail” of cost control. We often try to do this via mechanisms to reduce care based on the misperception that our system is so expensive because we provide too much care. However, if one looks at discrepancies in spending between us and these countries, it’s not because the U.S. provides too much unnecessary care (although this problem certainly exists). Rather, our huge spending is on the administrative side due to our fragmented, multipayer, for-profit system.

What are obstacles to implementing single-payer health insurance? The main obstacle is the private health insurance industry. Another obstacle is lack of education about what “single-payer” really means. Some erroneously confuse it with socialized medicine or think it would lead to reduced care. However, the savings come not from reducing care but from streamlining the administrative side of the system. The Lewin fiscal analysis of a Minnesota single-payer system, published in March 2012, revealed that Minnesota could reduce health care spending by 9 percent and cover ALL Minnesotans with comprehensive coverage if single-payer was enacted here.

U.S.-style health insurance does not benefit patients.

Please tell us about Physicians for a National Health Program and this group’s reaction to the June 28 Supreme Court ruling on the Affordable Care Act (ACA). Physicians for a National Health Program (PNHP) is a national nonprofit research and education organization dedicated to implementing a single-payer health care system in the U.S. Our Minnesota chapter, with nearly 1,000 provider and medical student members, works

PNHP-MN has introduced legislation for single-payer insurance. What can you tell us about this? PNHP-MN has worked closely with Sen. John Marty, chief author of Minnesota’s single-payer legislation. The bill made progress during the first few years after introduction, passing through several legislative committees. However, since the 2010 election and subsequent changes in House and Senate leadership, the bill has stalled. Single-payer is not a partisan issue. It is the most fiscally conservative approach to health care reform.

Need glasses to read this? Is your near vision not what it used to be? Arms not long enough to read a menu or magazine? Are you getting more dependent on reading glasses? Near Vision Research Study Dr. Ralph Chu at Chu Vision Institute is studying an investigational, outpatient procedure designed to improve near vision. The procedure takes about 15 minutes, and may help reduce or eliminate the need for reading glasses. If you choose to join the study, you will receive the procedure and all study-related care at no cost by a team of local specialists.

To learn more, and to see if you might qualify, call 952.835.1235 or visit – Y. Ralph Chu, M.D. International Leader in Vision Correction Surgery

www.chuvision.com AUGUST 2012 MINNESOTA HEALTH CARE NEWS

HOME CARE

Introduction to home care Mrs. Johnson is an 85-year-old widow who lives alone. Like many elderly people, she takes several medications to manage multiple conditions. Lack of communication between her physicians meant that no one realized drug interactions were making her dizzy. Last winter, she fell and broke her hip. When she was ready to leave the hospital, a doctor suggested she transfer to a nursing home. Instead, Mrs. Johnson is at home, visited regularly by a physical therapist and by a home care nurse who treats her hospitalacquired bedsore and communicates with her By Jennifer physicians to ensure she is on the right medSorensen, MEd ications. Surrounded by the familiarity of her home, Mrs. Johnson is recovering quickly. How did Mrs. Johnson know which services she needed and how to obtain them? Here’s an introduction to services that are available under the umbrella term of “home care” and an overview of who qualifies for this care, how to obtain it, and how it’s paid for.

Accessing services

Available services Home care is a method of health care delivery that’s a cost-effective alternative to extended hospital stays. It provides individualized

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services to recovering, disabled, chronically ill, or terminally ill individuals; usually costs less than institutional care offering the same services; and encompasses a wide range of health and social services that are designated either skilled or unskilled.

by Medicare to be homebound and must have a doctor’s order for skilled home care. Application for unskilled home care does not require a doctor’s order or any other type of physician involvement if home care will be “hands-off.” “Hands-on” care, such as providing personal hygiene, requires a doctor’s order. Patients seeking Minnesota state plan services, also called Medical Assistance, should contact their county’s department of

Unskilled Unskilled home care includes live-in or visiting companionship, 24-hour care, transportation to medical appointments, and certified nursing aides’ assistance with essential daily activities such as bathing, dressing, toileting, There are financial limitations feeding, meal preparation, shopping, laundry, to receiving Medicaid respite care, medication reminders, and care and Medicare services. coordination to organize appointments and services, all provided under the supervision of a human services or managed care organization (MCO) to have an registered nurse. assessment. The level of assessment and eligibility is determined by Skilled a patient’s insurance coverage, and helps to determine a person’s Skilled home care may include regular visits from a registered nurse level of need and to identify appropriate services. who provides oversight and medication management. Medication management, for example, might include measuring out the proper number of pills and organizing them in different containers, each with a label that tells the patient what time of day to take them. Skilled home care can also include physical, occupational, and speech-language therapy; cardiac and pulmonary care; wound care; infusion therapy; dialysis; and chemotherapy. Social services in this category of care help people determine which community resources can help them achieve their health goals and how to access those resources, and include short-term counseling to cope with mental health issues that can accompany physical illness.

Arranging home care Once services for which a person qualifies have been identified, accessing them can be as simple as calling a home health care agency. Medicare, Medicaid, and other pay plans stipulate which agencies may be used. Most agencies will contact a person’s physician (with that person’s informed consent) to arrange services. The reason for contacting the physician is to confirm that the physician has written an order for the person to receive skilled home care. Introduction to home care to page 17

Home hospice A person who has received a diagnosis of a terminal condition and a life expectancy of six months or less may qualify for hospice care. Home care in this situation might include a registered nurse’s case management and Anyone visits; aides to assist with essential daily denied living tasks; social services and spiritual counselors to help the patient and family financial cope with the dying process; a medical assistance director to advocate for the patient’s may appeal. decision to have hospice; 24-hour on-call nursing; massage, music, and healing touch therapies; and bereavement counseling for family members. Qualifying for home care People in what is called the “private pay” category qualify for any type of service because they pay for it with their own money. The type and cost of services available to them depend on the specific home care agency and type of care these individuals choose. People who require financial assistance to pay for part or all of their home care must first qualify to receive home care. Qualification is determined by state or federal guidelines or both, depending on the source of funding. As part of the qualification process, applicants are assessed to determine their level of need and to identify appropriate services. People seeking financial assistance for skilled home care from the federally funded Medicare program must be on Medicare at the time they apply for aid. In addition, they must be determined

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TA K E C A R E

Voice care

Tips from a professional singer By Axel Theimer, DMA (Doctor of Musical Arts) We take our voices for granted, expecting them to work on command when we wake up in the morning, when we pick up the phone, or when we greet an acquaintance. When the voice doesn’t work as we expect, whether from overuse by cheering at an athletic event or because we have a cold, we tend to keep using it. That isn’t the wisest course of action, however. When to seek medical attention Hoarseness or other unexpected vocal changes may indicate the presence of a medical condition that merits a visit to a health care provider. Easily diagnosed and treated medical causes of a change in vocal quality

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able voice, and the need for extra force to include strep throat and produce sound, among other symptoms. seasonal allergies. Other While nodes usually disappear once common culprits are gastrothe voice has had a chance to rest, the esophageal reflux disease period of rest required may be long and (GERD) and laryngopharynrehabilitation or surgery may ultimately geal reflux disease (LPRD), Hoarseness can indicate the be needed. So it’s sensible to rest the voice both of which include hoarsepresence of real injury. ness among their symptoms when hoarseness first appears. and require medical attention The anatomy of vocal overuse for proper diagnosis and treatWhile the vocal apparatus is a relatively small and seemingly ment. These conditions develop from acid reflux delicate sound-making instrument, it is actually quite resilient that makes stomach acid travel up into the throat, and able to withstand plenty of use and, to a certain extent, where it causes the voice box to become irritated overuse. But sooner or later, overuse causes tissue to react and swollen. Smokers are also candidates for self-protectively. When vocal folds react this way, hoarseness chronic hoarseness and throat irritation caused by results. tobacco smoke. Vocal folds swell as the body deposits fluid between But if our voice changes because we overused superficial and deeper layers of tissue in order to avoid injury our vocal apparatus, it’s the body’s way of telling us to even deeper layers. This is similar to blister formation. to give the voice some rest. Who has time for that, though—as long Swelling prevents the vocal folds from closing completely, which as we still can communicate, the voice is okay, right? allows air to escape and makes the voice sound husky. In addition, Wrong. Continued use of a voice that is hoarse may eventually swollen vocal folds can result in a lower-pitched voice and may require longer rehabilitation and, potentially, surgery to remove diminish the ability to make subtle pitch fluctuations because nodes from the vocal cords. swelling also makes the vocal folds stiffer. This prevents the vocal Hoarseness cords from vibrating easily, resulting in a more monotonous speech Hoarseness results from injury to the vocal cords, more properly pattern and making the speaker feel as though it takes more effort called vocal folds, which are inside the voice box, or larynx. to speak. The entire sound system consists of three eleVoice care to page 16 ments: larynx, lungs, and a resonance system. Vocal folds are muscles that vibrate to Hoarseness produce sound. They results are covered with several layers of tissue, which, from injury because it’s elastic, to the allows the folds to vocal cords. vibrate. The folds also function as a valve to prevent food and other foreign objects from entering the lungs. Lungs produce the flow of air that makes the vocal folds vibrate and propels sound out of the mouth. The resonance system (throat, tongue, teeth, and lips) amplifies Have healthcare or IT experience? and refines sound. Only MnHIT training lets you learn The main difference between an injury that causes hoarseness at home and jump start a career in and an injury to another part of the body is the absence of pain the rapidly expanding job market receptors in the vibrating part of the folds, which is where hoarsefor Health IT professionals. ness-causing injury commonly occurs. The lack of pain receptors makes it easy to ignore mild injury to the folds that can, if use conYou may qualify for a government tinues, lead to the development of nodes on the vocal folds. stipend for 75% of the cost!

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Nodes Vocal fold nodes are benign growths of tissue that may be thought of as calluses, and are typically caused by sustained strenuous voice practices such as yelling and coughing. They can interfere with the production of easily understood speech and may indicate their presence by hoarseness, the need for frequent throat clearing, an unreli-

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TIPS Voice care from page 15

Stay hydrated to keep mucus membranes covering the vocal cords lubricated. Alcohol and caffeinated drinks contribute to dehydration by promoting water loss from the body; their consumption should be balanced by drinking other fluids.

None of these symptoms is permanent if properly treated. However, it is important to address the cause of vocal changes and not simply treat the symptoms. Those that persist signal the need to seek medical care. Maintaining vocal health Vocal health is enhanced by the same factors that promote overall health: sufficient sleep, a healthy diet, having a wellhydrated body, and avoiding both smoking and exposure to secondhand smoke. If you have a clean bill of health but experience voice challenges that don’t recover after a weekend of rest, consider consulting a speechlanguage pathologist or a voice teacher. Both types of voice professionals can detect vocal habits that may cause hoarseness or recurring or persistent voice loss. Such habits include consistently using a loud, “edgy” voice or initiating vowel sounds with a harsh, explosive onset, referred to as a glottal attack. A closing note To maintain a healthy voice and still enjoy cheering at athletic events, ask a voice professional to guide you through vocal exercises and develop specific strategies that will allow you to not lose your voice as quickly or to the same extent. Your voice will be in better condition to withstand ‘athletic voicing.’

Avoid talking and singing outside your normal range and using an edgy, overly loud voice. Certain over-the-counter medications, such as aspirin, increase the risk of bleeding within the vocal cords. Check with a pharmacist before using these medications. Or maybe, now that you know that hoarseness can indicate the presence of real injury to the vocal cords and may be avoided by not screaming or yelling, you’ll discover that you can enjoy athletic events without excessive vocalizing. Let other spectators—those who don’t mind not having a healthy, effective voice for a few days—do it for you. And make sure, if you do get carried away and cheer to excess, to give your voice rest and time to heal afterward. Axel Theimer, DMA, sang in the Vienna Boys Choir as a child and is now a professor in the department of music at Saint John’s University and the College of Saint Benedict in Collegeville. He also performs as a vocal soloist and serves on the faculty of VoiceCareNetwork (www.voicecarenetwork.org).

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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 AUGUST 2012

Introduction to home care from page 13

Paying for home care Private pay is the method used by people who can pay with their own money. Since not all home health care agencies charge identical rates for identical services, people paying by this method should compare the hourly cost of a given service from several agencies before signing a contract with any agency.

Most people would rather be in their home than in an institution.

Private insurance. Different health plans have different menus of services and eligibility criteria, and specify varying lengths of time that they will insure a given service. People with private insurance should call their insurance company’s benefits department before signing up for home health care, to make sure they understand what will be covered. An added benefit that health plans provide to their customers is care coordination. This service coordinates all services a client receives to ensure that all of that person’s needs are met and that services do not overlap. Medicaid. There are several Medicaid programs in Minnesota, each of which has its own menu of home care services it will pay for. To qualify, applicants can apply online at www.dhs.state.mn.us by clicking on “Health Care,” then clicking on “Medical Assistance,” and then filling out the application. Alternatively, applicants can fill out a form in person at their local county human services office. After applying, they will be contacted by a case manager from the applicant’s county department of human services, who assesses an applicant for functional eligibility. Assuming the applicant qualifies, the case manager then determines a service plan. It is important to note that there are financial limitations to receiving Medicaid and Medicare services, but each county’s department of human services can assist an applicant residing in that county with the qualification process and suggest ways to obtain services and funding. For more information about qualifying for Medicaid and Medicare, call your local county human services office, call the state department of human services at (651) 4312000, or visit www.dhs.state.mn.us.

paid for by veteran’s assistance. To find the closest VA center or for more information, visit www.va.gov/healthbenefits or call (877) 222-VETS (8387). Appeals process Anyone denied financial assistance after a county assessment for Medicaid eligibility may appeal to the county that did the assessment. A person denied eligibility for either Medicaid or Medicare after being assessed by a health plan may appeal through the health plan. Anyone who is denied eligibility, regardless of which entity performed the assessment, is notified of the denial and informed of any available appeal options. There’s no place like home Sometimes, being in a hospital or other institution is unavoidable. But sometimes, home health care is an alternative. Home health care can be initiated quickly and effectively to prevent hospitalization or nursing home placement, and has been shown to decrease emergency room visits. Most people would rather be in their home than in an institution, and home care helps them do just that. Jennifer Sorensen, MEd, is the executive director of the Minnesota HomeCare Association (www.mnhomecare.org).

Medicare covers people age 65 or older as well as people of any age who have been determined by Medicare to be disabled, including those with end-stage renal disease. Get information about qualifying for this option by visiting the Area Agency on Aging website, www.mnaging.org, and clicking on the Senior LinkAge Line. The Senior LinkAge Line phone number is (800) 333-2433. Minnesota Senior Health Option (MSHO) covers seniors who are eligible for both Medicaid and Medicare. Information about qualifying for this option is at www.Minnesotahelp.info. An application can be filled out online at www.dhs.state.mn.us and in person at an applicant’s local county human services office. People who are eligible for MSHO are automatically enrolled in it but have the option to opt out. Veteran’s assistance. A local VA center can connect an applicant or an applicant’s family with a VA social worker. The social worker determines if the applicant is eligible to receive home health care, identifies his or her needs, and determines which services can be AUGUST 2012 MINNESOTA HEALTH CARE NEWS

August Calendar 1–24

Drop Off School Supplies Again this year, The Marsh is a drop-off site for Interfaith Outreach and Community Partners Annual Back-to-School program serving more than 600 families. Most needed supplies include solid colored, heavyduty backpacks, three-ring binders, USB and binder drives, TI-15 and graphing calculators. A complete list of supplies is available at TheMarsh.org. Please drop off your donations in the main lobby by August 24. Questions? Call (952) 935-2202. August 1–24, The Marsh, 15000 Minnetonka Blvd., Minnetonka

Family-to-Family Support for Mental Illness We meet each Thursday to provide ongoing support for families and friends of people with mental illness. Sponsored by the MN chapter of NAMI, National Alliance on Mental Illness (www.namihelps.org). For more information, call Sarah at (320) 396-0443. Thursday, Aug. 9, 6:30–7:30 p.m., Cambridge Medical Ctr., 701 S. Dellwood St., Administrative Conference Rm., Cambridge

Daddy Boot Camp At Boot Camp for New Dads, classes are taught by experienced dads who bring their own babies! Breastfeeding, diaper changing, and dealing with mom are all new experiences for first-time fathers. This threehour workshop will help you feel more confident in your ability to be a great dad. Call (651) 480-4175 to register. Saturday, Aug. 11, 9 a.m.–noon, Regina Medical Center, Family Birthing Ctr., 1175 Nininger Rd., Hastings

Hematology Education and Support Informal education and group discussions for patients and families touched by leukemia, lymphoma, or myeloma. Free refreshments. Two oncology-certified RNs facilitate meetings. For more information, call (763) 852-3012 or email hemoncjtss@gmail.com. Tuesday, Aug. 14, 6–7 p.m., Great River Regional Library, 1300 W. St. Germain St., St. Cloud

16 National Immunization Awareness Month Be the example! Immunizations have had an enormous impact on improving the health of children in the United States. Most parents today have never seen firsthand the devastating consequences that vaccine-preventable diseases have on a family or community. While these diseases are not common in the U.S., they persist around the world. It is important that we continue to protect our children with vaccines because outbreaks of vaccine-preventable diseases can and do occasionally occur in this country. Vaccination is one of the best ways parents can protect infants, children, and teens from 16 potentially harmful diseases. Vaccine-preventable diseases can be very serious, may require hospitalization, and can even be deadly, especially in infants and young children. You’re not just helping to protect your own children by getting them vaccinated. You're helping to protect other children and adults in your community, too. For example, your community may have children who can't receive certain vaccines for medical reasons or because they’re too young to be vaccinated. If these children are exposed to someone with an infectious disease, they can catch the disease. By getting immunized, your community—school, playgroup, neighborhood, faith group—could help protect these children by reducing the chance of disease spreading from person to person. Review your entire family’s vaccinations and ensure everyone is up to date on their shots. Remember, influenza can trigger asthma episodes. Get a flu shot every year, preferably in the fall. The Minnesota Department of Health recommends that children with asthma have a well-asthma visit with their doctor in the summer. For more information about vaccines, visit http://www.cdc.gov/vaccines/. For information about asthma, visit www.health.state.mn.us/asthma. Childhood asthma action plans are available at www.health.state.mn.us/asthma/ AAP-nonpro.html.

Meet the Midwives You are invited to meet HealthEast certified nurse midwives. Whether you already are a patient or are looking for a care provider, this free event is for you. Partners, friends, and family are welcome. Refreshments will be served. Call (651) 232-8080 to register. Thursday, Aug. 16, 7–8 p.m., Woodwinds Health Campus, 1925 Woodwinds Dr., Woodbury

18 or 22

Mindfulness-Based Stress Reduction (MBSR) Information Sessions MBSR will teach you to consciously and methodically deal with stress, pain, illness, and demanding challenges of everyday life. Learn more by attending one of these complimentary sessions. For more information, call (952) 935-2202. Saturday, Aug. 18, 9:30–10:30 a.m. or Wednesday, Aug. 22, 6:30–7:30 p.m., The Marsh, 15000 Minnetonka Blvd., Minnetonka

Lung Cancer Education and Support Members of this group understand the challenges of a lung cancer diagnosis, and work together to make sense of diagnosis, treatment, and life’s changes. The evening’s agenda rotates between educational and group discussion. We meet the fourth Tuesday of the month. No charge. Please register by calling (763) 520-5285. Tuesday, Aug. 28, 5:30–7 p.m., North Memorial Outpatient Education Ctr., 3425 W. Broadway, Birch Rm., Robbinsdale

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 jbirgersson@ mppub.com. Please note: We cannot guarantee that all submissions will be used. CME, CE, and symposium listings will not be published.

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PAT I E N T T O PAT I E N T Editor’s note: Fifty thousand high school students have sports-related concussions each year in Minnesota, reports the Minnesota Brain Injury Alliance. The results can be serious and long lasting, as you’ll read in the following personal accounts of two students’ ongoing struggles with concussion. Since teens may not report a head injury, parents, teachers, and coaches will want to read these accounts to learn to recognize behavior that may indicate the presence of concussion-caused brain injury. The first line of defense in managing sports-related head injury and concussion is prevention. If your child is involved in a sport, ask the coach what school, league, and state rules mandate for safety in terms of protective equipment, behavior allowed during practice and competition, and coaching oversight. Protective equipment and banned behavior for most high school sports are listed on the Minnesota State High School League’s website, www.mshsl.org: click on “Activities” and select a sport from the drop-down list. Some researchers believe that until the brain has recovered from a concussion, it is more vulnerable to subsequent injury. “Second-impact syndrome” can produce catastrophic outcomes ranging from severe neurological dysfunction to death. Prompt medical assessment of a head injury and waiting for medical approval before resuming athletic activity are critical.

Sports-related concussions

Coping with mild traumatic brain injury By Matt Hovila

have mild traumatic brain injury but there is nothing “mild” about what a brain injury does to you. My brain injury from sports-related concussions has impacted nearly every aspect of my life. My first concussion occurred when I was in fourth grade and playing football. The doctor had me sit out for two weeks, after which I resumed play and subsequently had a whiplash injury that started concussion symptoms all over again. I had behavioral problems at school the rest of that year, but no one connected them to the concussion. Knowing what I know now, I suspect the concussion caused my behavior-based school troubles that year. My real love was basketball. In sixth grade, a player from the opposing team and I were chasing each other to their basket. I blocked the player, fell from the momentum, and my head hit the hardwood floor. The other player landed on my head, bashing it into the floor a second time. I sat out the rest of this game with my head spinning; I couldn’t focus my eyes or brain on anything. We headed to the emergency room, where a CAT scan was “normal” but didn’t explain why, for two weeks afterward, I couldn’t walk without holding a wall or why my head felt like it was cracking in half. Post-concussive syndrome Symptoms lasted for months. My neurologist had a name for it: post-concussive syndrome. Great—a name, but no tips on how to manage my life, school, etc. This same doctor suggested that I should “try harder” at school. Those two words make me so angry. Before my concussion, I was a straight-A student with a strong work ethic and tremendous time management and organization. This doctor insinuated that I was a slacker, the first of many people throughout my school years who would put that same label on me. Here’s the truth: My brain injury didn’t wipe out my memories of who I was and what I could accomplish before my injury. I wanted to be that person again; I worked hard at being that person. The LAST thing I wanted to be was a slacker; it just went against my values. NO ONE will ever know how hard I have had to work after my brain injury to do the schoolwork I accomplish. Brain injury changed how my brain works, but has not changed my values or the expectations I have of myself.

MINNESOTA HEALTH CARE NEWS AUGUST 2012

“Keep My Brain in the Game”

Struggling

More than 50,000 Minnesota high school athletes each year have a Academically, I struggled through the rest of sixth grade. concussion. That summer, my behavior worsened. No one knew what Sports-related brain injuries continue to be a concern for youth athletes. was going on. My parents assumed I was acting like a teen, As part of the Minnesota Brain Injury Alliance’s 2012 mission to support but I felt out of control. My impulse control didn’t exist; I youth athletes and their families living with sports-related brain injury, the took more risks and began hanging out with different kids. MBIA, in partnership with Hennepin County Medical Center, has launched One day, I ran away from home. Maybe I was running the “Keep My Brain in the Game” campaign. Through our “take the away from the person I had become due to my brain injury. pledge” initiative, we encourage youth athletes to remove themselves from During the first few months of seventh grade, nothing athletic activity if their head gets injured during play. went right at school. I couldn’t concentrate; I couldn’t read. The pledge helps youth to take an active stance against brain injury and to My world literally wavered. Nobody understood the drastic encourage their friends to do so as well, by including the pledge on their change in my personality or my academic ability. I was Facebook pages. The pledge states, “If I am hurt, I will sit out until a medanxious and depressed. We spent much time in and out of ical professional tells me I am OK to play. My brain is more important than doctors’ offices trying to find the answer for all these a game. It is the only one I have!” Youth athletes can take the pledge at changes. I was placed on medication for headaches and www.savethisbrain.org. anxiety but found no relief. After taking Zoloft for depression, I became suicidal from the medication. In fact, all antidepressant medications carry an increased risk of suicidal than 100 days the second half of my senior year. Fatigue, headaches, symptoms for young adults 18 to 24 years of age. and a sense of overwhelming loss filled my days. I grieved over losWe changed doctors many times over the years, trying to find ing the most important activity in my life. I was depressed and, one that understood traumatic brain again, risk-taking behaviors appeared. My medical team placed me injury. My mom took me to a new neurolThere is on an antidepressant even though my mom raised the red flag of ogist, who determined that I was severely what had happened with Zoloft. Again, I had suicidal thoughts and nothing sleep deprived from disruption caused by needed to be weaned off the antidepressant. “mild” my brain injury. I was placed on medicaOne very important symptom that physicians and parents miss tion that decreased my anxiety and helped about what is the behavioral aspect of brain injury. If a person is irritable, has a me sleep. By the end of eighth grade, I a brain Sports-related concussions to page 25 was finally able to start concentrating at injury does school. That summer, I saw a pediatric neuro-ophthalmologist (after seeing three to you. other ophthalmologists) who determined that the brain injury had caused vision changes. My glasses and contacts were corrected to allow me to read and I now use additional reading glasses when I need to read for prolonged periods. The Clinics of Northwestern

Designed esiigned to Meet Mee Care Desi C YYour o ourr Need Needs Needss

A glimmer of hope Due to these two simple changes—vision correction and medication to improve sleep—freshman year of high school was calm and productive. My individualized education plan (IEP) from middle school was retained throughout high school due to the many brain injury-related health issues that affect academics. After being injury-free and symptom-free for a few years, I entered my senior year of high school as cocaptain of the basketball team. During our first conference game, an opposing player’s elbow came down on the base of my skull. There were no immediate symptoms, but about an hour later, that sickening feeling returned. I knew I had sustained a concussion, which was subsequently confirmed by a doctor. I have not returned to the court since. A sense of loss But that doesn’t really tell you about the journey after that final blow, does it? I missed more

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AUGUST 2012 MINNESOTA HEALTH CARE NEWS

PAT I E N T T O PAT I E N T

Life

after concussions

t was December of 2008 and I was in seventh grade when I suffered my first concussion. At the end of hockey practice I fell forward, hitting the top of my head on the ice. It hurt badly and I was crying. The next day, I went to the emergency room, had an MRI, and was told that everything was normal and that I had “almost had a concussion.” We discovered later that I had. The second concussion happened in December 2009, once again, at hockey practice. During a drill, two girls slid into me and I fell backward, hitting the back of my head on the ice. I did not experience any symptoms of a concussion until the next day, when my head started pounding. A few days after this, I was complaining to my friends about a constant headache—it felt like my head was in a vise—and they reminded me that I had hit my head at practice a few days earlier.

There had already been three concussions on my team before mine and we were only in the second month of the season. I continued playing hockey for a week and a half and then saw a doctor because nothing helped my constant headache. After hearing my story, the doctor said that I’d suffered a concussion and needed to sit out from hockey for the next two weeks. I had an MRI, then saw my first neurologist, who put me through impact testing that was inconclusive because I had never had a baseline test. I was put on pain medications for headaches but they didn’t help. We went to the Mayo Clinic and tried various chiropractors, acupuncturists, massage therapists, and physical therapists. All had ideas but none of them cured my headaches. So, I returned to school and tried to get on with my life.

When in doubt, sit out! By Kayla Meyer

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

(651) 603-0720 • (800) 511-3696 22

MINNESOTA HEALTH CARE NEWS AUGUST 2012

Sensory overload

I was put on pain medications but they didn’t work.

The first day back at school after the second concussion was sensory overload. Everything was too loud, there was too much to focus on, and I couldn’t concentrate at all because of a headache. It was so bad I ended up leaving school in the middle of the day. The next couple of days were the same, but I managed to push through to stay all day at school, until something unexpected happened. In language arts class, a boy hit me in the head with a book and I burst into tears. It was only a paperback book and he was merely goofing around, but the pain was unbelievable. My head was incredibly sensitive to the touch. I went straight to the nurse and had to convince her that I was really hurt. A couple of weeks afterward, I was attending school for half days. The next year, when I began high school, I went half days and took online courses at home to avoid classes that included too much stimulation and noise, which triggered headaches. I don’t remember ever completing five days of high school in a row; I started to fall behind and even fail some of my classes. I used to be a straight-A student, so this was a major problem. My family and I decided that something needed to change. I have a Working with school administraheadache tors, we decided that the best option 24 hours was to be a homebound student. A tutor visits three times a week for about a day, an hour or so. She brings schoolwork seven days from my teachers, helps me complete it a week. and study for tests, proctors my tests and quizzes, and brings my work back to the teachers. I only do work that my teachers deem essential to pass classes. This includes mostly tests and quizzes, a couple of projects, and a few small assignments. In addition, a special education teacher and a social worker visit once a week to make sure I’m keeping up with my school work and that I’m interacting outside my house since I’m home all day except for doctor appointments. Headache 24/7 I have a headache 24 hours a day, seven days a week. It’s there when I go to bed and when I wake up. I barely ever see friends anymore and when I do, it’s for short periods of time and we do quiet things like watch movies. I can’t be on the computer for long periods of time because the brightness and stimulation of the screen can increase my headache. I have at least three doctor appointments a week.

I’ve missed school field trips, sleepovers, parties, school assemblies, pep fests, dances, parades, and much more. I had to quit choir and glee club because the noise was too much. I had to drop out of the sound crew for our school musical because, once again, the noise was too much to bear. I can no longer play hockey; I can’t even watch my former teammates play because the noise is just too much. Needless to say, my life has changed considerably because of my concussions. Speaking out

I’ve had the opportunity to become an advocate for other young people who suffer concussions, and have spoken to youth groups and medical professionals on behalf of the Minnesota Brain Injury Alliance. My message to kids is always that they are not alone: There is someone else going through the same thing. The other key point to get across is that concussions are very serious. Health is more important than a game or practice. A person only has one brain, so she needs to take care of it. I encourage young people to be strong enough to say to parents and coaches, “I’m feeling a little off; I need to take a break.” I know kids are young and want to play sports and hang with friends, but they must listen to what their body is telling them. I tell young people to remember that no matter what others say, if they’re pushing you to get back out there and play with the team but you Life after concussions to page 24

In the next issue.. • New Medicare options • The dentalheart connection • ALS (Lou Gehrig’s Disease) AUGUST 2012 MINNESOTA HEALTH CARE NEWS

A personal letter to all health care professionals

Life after concussions from page 23

no, he did not have a referral for us. Did I Until the day of Kayla’s second conA mother mention we have payment plans set up all cussion I was just a normal hockey speaks over the metro area and beyond? mom: carpools, volunteer jobs and committees, announcer for high By Mandy Meyer “It was yesterday that I talked with the tutor, school hockey games. What else right?” “Yes, I did talk to the tutor to catch up would the mother of an overachiever do? Kayla was on the homework and how the label of special educaup early to glee club before school, on the honor roll tion affects her credits for graduation. Thanks for not in school, and off to hockey after school. giving up on her. You’re the best.” Why was it the

feel that something is wrong after hitting your head, don’t. When in doubt, sit out! Kayla Meyer, cofounder of Connections4Concussion, is 16 years old and lives with her parents and pets on a hobby farm outside New Prague.

The inside of our house now stands quiet and lonely. Kayla is inside. Hey, on the bright side we have met an amazing group of health care professionals. Some brightness comes from the physical therapists we have had the privilege to have on our concussion care team. “Thanks for explaining that, again.” Craniosacral chiropractors have given us great insight into the working of the skull and brain and how that affects the whole body. Tell me, how does acupuncture work? No pain when the needles are in. Wow, no pain for a kid who has had headaches 24/7 for two and a half years. If only she was not so terrified of needles, if only the pain did not return so quickly. Neuropsychology is still a mystery to me. Neurologists, please keep in mind that parents are already stressed and have ill children who require parents to miss work, fight traffic, talk to insurance companies, and set up daunting medical schedules. I remember the day the pain management doctor said there was nothing more he could do for Kayla and

school counselor, not a health care professional, who gave Kayla information on the Minnesota Brain Injury Alliance, 14 months after her injury? We are all just looking for help and information. For everyone who has explained all the medications she is on, thanks for your knowledge. Have you taken a call from me: “Do we come in or do we head for the emergency room?” Thanks for helping when I was really stressed. Have you translated my messages to others and then had to call back to explain it all to me? I know I told you ‘thank you.’ But really—Thank You!! Everyone, keep in mind our concussion-injured kids are missing their friends, their teams, and, yes, even being at school. I don’t want to be that hockey mom again. I just wish for painless days and restful nights for my child. I wish for Kayla’s singing to fill my silent house. Sincerely, Kayla’s mom Mandy Meyer is the mother of two children and operates a dog boarding and training facility in New Prague with her husband.

Minnesota

Health Care Consumer July survey results ... Association

1. Have you ever attended a public health care seminar presented by either a health plan, health care system, private business, or drug company?

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 July survey.

3. What kind of post-seminar contact did the sponsor generate?

10 0

Percentage of total responses

40 30 20 10 0

Yes

9.1%

12.1%

Much more More than Does Less than than expected expected not apply expected

None

MINNESOTA HEALTH CARE NEWS AUGUST 2012

30 21.2%

6.1% 0.0% Very useful

30 21.2%

3.0%

Useful

Somewhat Not useful Does useful at all not apply

66.7%

21.2%

75.8%

5.How effective was the seminar in helping you deal with a medical condition?

0.0%

Percentage of total responses

50 40

12.1%

51.5%

48.5%

80 66.7%

60 51.5%

4. How would you describe the tone of this follow-up?

2. How useful did you find this information?

60 50 40 30

10 0.0%

0.0%

Overly Informative Does Uninformative Unrelated aggressive to seminar not apply

21.2%

9.1% 3.0% Very effective

0.0% Effective

Does not apply

Not very effective

Ineffective

Sports-related concussions from page 21

short fuse, is anxious, and can’t concentrate, focus, or organize, it indicates that he or she is still having brain injury symptoms and should NOT resume their previous level of activity. There is no doubt that treating brain injury requires a team of specialists due to its complexity. Finding success It’s now been about 18 months since my last injury. Migraines, fatigue, and a roller coaster of good days and bad days continue. Finding the perfect blend of medications to ease my headaches seems elusive. I spend many nights in the ER receiving IV medications when my migraines and headaches escalate to a point where the daily medications don’t help. I still don’t have the physical endurance or stamina to be as physically active as I’d like to be. Yet, in spite of these symptoms, I am finding success as a student at the University of Minnesota. A second, incredible success came this year: cofounding a youth-led support group for youth with mild traumatic brain injury, called Connections4Concussions. The idea for it started after an event coordinated by the Minnesota Brain Injury Alliance. My family met the family of Kayla Meyer, a hockey player in New Prague who had also been forced to give up her sport due to brain injury. Kayla and I jokingly said to each other, “Wouldn’t it be great if there was a support group for kids with brain injury?” Our dream of a support group came to life on

February 28 as Kayla and I led our first meeting for youth with brain injury. There was an immediate emotional connection among the attendees as we shared our experience and journey. I am grateful to the Minnesota Brain Injury Alliance for their support and for making resources available to families struggling with brain injury. Finding the positive So yes, my life has changed in many ways. But I have also grown in many ways and find that my outlook on life is positive. I’ve learned to be flexible, creative, and how to explain my injury and self-advocate to my professors and others. I’ve had to learn to “read” my headaches to figure out what I need and how to manage my health the best I can. I’ve discovered that on my good days, I have to push myself to complete a lot of my homework because tomorrow I might start a headache cycle that takes me out of “life” for two weeks at a time. As much as a young adult can, I try to find the right balance in my life to minimize my symptoms and create an environment for success. The changes in my life have not been mild and neither was my brain injury, but I am strong and will continue to battle everything thrown in my path. Matt Hovila, cofounder of Connections4Concussion, is a sophomore at the University of Minnesota and has mild traumatic brain injury.

Matt Hovila and Kayla Meyer cofounded Connections4Concussions, a youth concussion support group that meets at 6 p.m. the fourth Tuesday of each month at the Penn Lake Library, 8800 Penn Ave. S., Bloomington.

Minnesota

Health Care Consumer Association

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

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DIGESTION

he liver is an essential organ that is located under the rib cage in the upper right abdomen. Roughly three pounds in a healthy adult, it functions much like the industrial area of a city, by manufacturing, processing, recycling, and warehousing. It manufactures proteins that are responsible for blood clotting, for keeping fluid inside blood vessels, for immune function, and for several other functions. It produces and releases bile into the gut to aid fat absorption. It processes everything a person eats and drinks before that food or drink enters the blood, thereby detoxifying most of the harmful substances ingested. It also removes many of the waste products the body produces during the course of normal metabolism. The liver is also a terrific recycler, capturing and liver reprocessing building blocks of proteins and other important molecules from what we ingest and from byproducts of metabolism. Finally, it serves as a warehouse for fats and sugars, the bodyâ&#x20AC;&#x2122;s essential energy sources. Overall, it is difficult to think of another organ that is as versatile as the liver.

A healthy liver Avoiding risks, recognizing symptoms By Jeffrey Rank, MD

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Gout is the most common form of inďŹ&#x201A;ammatory arthritis in men and affects millions of Americans. In people with gout, uric acid levels build up in the blood and can lead to an attack, which some have described as feeling like a severe burn. Once you have had one attack, you may be at risk for another. Learn more about managing this chronic illness at www.goutliving.org

MINNESOTA HEALTH CARE NEWS AUGUST 2012

Risk factors: Can they be controlled? There is a great deal of extra capacity in the liver, which is why nearly 90 percent of it can be nonfunctioning before symptoms of liver disease become noticeable. At that point, however, the liver is often past the stage at which it can recover. For that reason, it is important to know what increases the risk of liver disease. Risk factors include several treatable hereditary liver diseases, so anyone with a family history of liver disease should make sure his or her doctor knows about it. Because exposure to viral hepatitis is associated with an increased risk of developing liver failure, people from areas of the world where viral hepatitis is common should ask their physicians for a blood test to determine if they have been exposed to viral hepatitis, as should anyone who received a blood transfusion before 1989. Lifestyle choices also present risk. People who have used IV drugs or intranasal cocaine, had a tattoo or body piercing outside a licensed salon, or who have had a sexual partner with viral hepatitis are at risk for contracting hepatitis B and C. The Centers for Disease Control and Prevention recommend that anyone born between 1945 and 1965 be tested for hepatitis C, as the prevalence of the virus in this age group is high enough to justify the costs of screening. Controllable risk factors Fortunately, two of the most common liver diseases have potentially controllable causes: alcohol consumption and obesity. These lifestyle choices cause alcoholic liver disease and fatty liver disease, respectively. Alcohol consumption of more than five drinks daily by a male, or two drinks daily by a female, leads to cirrhosis (scarred liver) in 20 percent to 30 percent of chronic alcohol users. (A drink is defined as a 12-ounce beer, a 1.5-ounce distilled beverage, or 5 ounces of wine.) People who regularly use alcohol are advised to let their doctor know that fact. Obesity causes fatty liver disease, which is approaching epidemic proportions worldwide, especially in the United States. This condition occurs most often in patients who are obese and have an elevated body mass index (BMI).

However, it can also occur in patients who have a healthy BMI but who also have diabetes and hyperlipidemia (excess fat in the blood). Fatty liver disease was once considered fairly benign but is now clearly recognized as a major cause of end-stage liver disease. People with a significantly elevated BMI should have their liver function tested. The risk of either alcoholic liver disease or fatty liver disease can be lowered significantly by discontinuing alcohol consumption, greatly reducing excess weight, or both. Undertaking either preventive step should first be discussed with your physician. Medication can affect liver function, as indicated by elevated levels of liver enzymes that are detectable by a routine blood test. Some elevations are benign, but some can indicate the presence of significant liver damage. Among over-the-counter medications, problems are most commonly associated with ibuprofen-like medicines and acetaminophen (Tylenol). It is important to follow instructions on the bottles of these medications and not to overuse them. Antibiotics can also be associated with liver damage, although this rarely occurs. Cholesterol-lowering agents and antiseizure drugs also present a risk of liver damage, which is why doctors typically monitor the liver function of patients taking these medications. Gallbladder malfunction is another common cause of liver disease. The liver normally excretes bile, which is stored in a sac that is called the gallbladder and is located below the liver. There, bile may crystallize into gallstones. Gallstones can obstruct the flow of bile through the bile duct that empties the gallbladder, causing pain in the chest or abdomen, especially the right upper abdomen. This pain usually waxes and wanes and can last for minutes to hours. Gallstones are more common in women who have had children, in obese people, and in those with a family history of The importance gallstone disease. Rapid weight loss and gain are also factors that can facilitate of avoiding gallstone formation and therefore should excess alcohol be avoided. cannot be Eventually, a gallstone-plugged bile overemphasized. duct can lead to dark urine and/or to jaundice, a yellowing of the skin and eyes. Such episodes may happen only once but be severe enough to require surgery or other medical intervention; or they may recur and be relatively mild. It is important to report these symptoms to your doctor, since methods to fix this problem are very safe and are usually easily tolerated.

As liver damage progresses, the liverâ&#x20AC;&#x2122;s decreasing ability to detoxify results in hormonal irregularities that produce muscle wasting. Fatigue, while not specific to liver disease, often appears as liver disease progresses. More advanced liver damage can be associated with progressive confusion and even coma, caused by accumulation of toxins that would otherwise be removed by a functioning liver. Gastrointestinal bleeding is a common symptom of end-stage liver disease and is often indicated by stool that appears black and, some-

People with a significantly elevated BMI should have their liver function tested. times, tar-like. Any of these symptoms is a reason to see a physician right away. Staying healthy Clearly, discussing risk factors for liver disease with your physician is critical in order to protect the liver before damage occurs. The importance of avoiding excess alcohol cannot be overemphasized. And since an increasing incidence of obesity is leading to an epidemic of fatty liver-associated liver damage, it is important to keep your BMI near 25. If symptoms of liver disease do develop, inform your doctor promptly. Jeffrey Rank, MD, is a board-certified gastroenterologist. He also serves as vice-president of Minnesota Gastroenterology, PA, whose six metro locations include a Hepatology Center of Excellence that provides diagnosis and treatment for patients living with liver diseases.

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Symptoms of liver disease When symptoms of liver disease develop, it is usually not until fairly significant damage has occurred. By that time, irreversible scarring of the liver has often taken place. Anyone who notices any of these symptoms should see a doctor quickly to have the best chance of diagnosing and treating any reversible causes of damage. Early indications of liver disease include swelling of the ankles. While ankle swelling can also be caused by heart and kidney disease, this symptom requires medical evaluation. As liver disease progresses, a person may develop a bloated, extended belly that is caused by fluid accumulation in the abdomen. Small spider veins on the skin may be present as well and, later, jaundice.

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PHARMACY dietary supplements on a regular basis, the potential for adverse medication interaction is high. Fortunately, the risk of adverse interactions can be minimized by following a few simple guidelines. Types of adverse interactions

Adverse drug interactions Guidelines to help you avoid them By Julie K. Johnson, PharmD

he medication you take may interact with more than just the cholesterol it’s intended to lower or that headache it’s meant to subdue. Sometimes, when prescription or over-the-counter (OTC) medications are taken at the same time, they interact in a manner that leads to life-threatening consequences. In fact, both prescription and OTC medications have the potential to cause harm by interacting not only with other medications but with food and dietary supplements as well. With nearly 40 percent of the U.S. population taking four or more prescription medications and 50 percent or more of U.S. adults using

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There are three categories of medication interactions: medication-food, medication-dietary supplement, and medicationmedication. Interactions in any of these categories may cause medication levels to increase or decrease within the body, or may even produce a new effect. Medication-food One common interaction between food and medication results from consuming an inconsistent amount of dark green, leafy vegetables or green tea while taking warfarin (also known as Coumadin), a commonly prescribed medication that is used to thin the blood to prevent strokes. These foods decrease warfarin’s effectiveness, an interaction that can be prevented by consuming a consistently small amount of these foods and by not suddenly increasing that amount. In contrast, warfarin’s effectiveness can be enhanced by drinking large amounts of cranberry juice, which can lead to internal bleeding. Grapefruit juice and certain other citrus products interact with many medications, including the commonly used antihistamine fexofenadine (Allegra). In the case of Allegra, its absorption is decreased and its effect thereby diminished. However, in the case of other medications, citrus products have been found to increase levels of certain medications to toxic, overdose levels. Taking the medication and citrus product at different times does not prevent an adverse interaction. However, some adverse food-medication interactions can be prevented by waiting a prescribed length of time after consuming a given food or liquid. Since different foods remain in the stomach for varying lengths of time after consumption, it’s important to follow instructions on medication and supplement containers that say to wait a certain length of time after eating before taking medication. People who use the synthetic thyroid hormone levothyroxine (Synthroid), for example, should not take it either four hours before or after consuming antacids that contain aluminum, such as Tums and Mylanta. Otherwise, the hormone’s effectiveness is decreased. Alcohol should never be consumed in conjunction with prescription or OTC medication, nor with dietary supplements. When alcohol is consumed by someone taking certain antibiotics, for example, the resulting adverse interaction can cause nausea, vomiting, dizziness, and an abnormally rapid or irregular heartbeat. Alcohol and certain antidepressants are another toxic combination, one that can produce a potentially fatal increase in blood pressure. Medication-dietary supplement Adverse interactions between medication and dietary supplements commonly occur with the use of St. John’s wort, a supplement used to treat mild forms of depression. This supplement interacts with a variety of medications, including combined oral contraceptives, statins (prescribed to lower cholesterol), metoprolol (also known as

Lopressor, a beta-blocker used to treat certain heart rhythm disorders and high blood pressure), diltiazem (a calcium channel blocker also known as Cardizem, Dilacor, and Tiazac, all of which are used to treat high blood pressure, angina, certain heart rhythm disorders, and cluster migraine), omeprazole (also known as Prilosec, a proton pump inhibitor used to treat peptic ulcer disease and certain gastrointestinal conditions), and alprazolam (also known as Xanax, a benzodiazepine used to treat anxiety). If St. John’s wort is taken at the same time as any of these medications, the medication’s concentration in the body can decrease, thus decreasing its desired effect. Medication-medication This type of adverse interaction is by far the most common because so many people take multiple medications: Two of every three people who visit a doctor leave with at least one prescription Help for for medication, according adverse interactions to a 2007 report by the Insti• Call the doctor or pharmacy tute for Safe Medication listed on the medication Practices. People over age label immediately in case 65 typically take between of a suspected adverse two and seven prescription medication interaction. medications each day, the • Help is also available from Minnesota Poison Control the Minnesota Poison ConSystem reports. trol System: Call toll-free Once someone receives at (800) 222-1222, 24 hours a day/365 days a year. four or more prescriptions, the chance of an adverse • Overdose symptoms include unconsciousness, nausea, drug reaction increases expovomiting, weakness, slow or nentially. And with nearly 40 shallow breathing, dizzipercent of the U.S. populaness, confusion, unusually tion using four or more preslow heartbeat, seizures, scription medications and an drowsiness, and fainting. increasing over-65 population, the potential for adverse interactions between medications will only increase. One of the most common interactions in this category involves taking a prescription medication that treats high blood pressure, such as lisinopril (an ACE inhibitor also known as Prinivil, Tensopril, and Zestril), at the same time as OTC medication for pain relief, such as ibuprofen, aspirin, or naproxen (Aleve). This combination of medications is important to avoid because it can harm the kidney and potentially decrease kidney function. This potential outcome represents a new effect that can occur despite medication levels in the body remaining unchanged by the combination of medications. Guidelines Before starting to take new medications or dietary supplements, discuss current and past medications—prescription, nonprescription, and supplements—with your physician, pharmacist, or both. He or she can identify substances that should be avoided in order to eliminate the risk of an adverse interaction. It is in your best interest to keep your health professionals up to date on all of the medications and supplements you take. In addition, it is important to know the signs of possible adverse medication interactions and to call a pharmacist or physician immediately if they occur. Read labels and warnings on medica-

tion bottles to learn about interactions to avoid and their symptoms. And finally, follow these guidelines: • Keep medications and supplements in their original containers so they are easily identifiable. • Use only one pharmacy to fill all prescriptions. Obtain supplements from that pharmacy, if possible. • Maintain an up-to-date record of all prescription medication, nonprescription medication, and dietary supplements, and carry a copy of it. • Do not consume medication or supplements with alcohol without approval from a doctor or pharmacist. • Follow the instructions on medication labels. Julie K. Johnson, PharmD, is the executive vice president and CEO of the Minnesota Pharmacists Association. She gratefully acknowledges the assistance of Kandace Schuft, University of Minnesota PharmD candidate, in the preparation of this article.

Nearly 40 percent of the U.S. population uses four or more prescription medications.

Leg Pain Study Do your legs hurt when you walk? Does it go away when you rest? Or, have you been diagnosed with PAD? You may have claudication, caused by lack of blood supply to the leg muscles The University of Minnesota is seeking volunteers to take part in an exercise-training program, funded by the National Institutes of Health

To see if you qualify, contact the EXERT Research Team at

612-624-7614 or email EXERT@umn.edu or visit EXERTstudy.org

EXERTstudy.org AUGUST 2012 MINNESOTA HEALTH CARE NEWS

NUTRITION

FOOD LABELS Understanding what they mean for your health By Liz McMann, MA

Most of us struggle to understand all the information on food packages. Food labeled “natural,” “organic,” and “gluten-free” may cost more than food that doesn’t, but is it worth it? Do these specialty labels guarantee health benefits? Here’s what some of the most common labels mean. Natural foods While “natural” on a food package may make shoppers assume that the contents are healthy, the reality is that the label can be misleading. The federal Food and Drug Administration (FLA) has not defined “natural” for use in food labeling but allows its use as long as foods so labeled do not contain added colors, artificial flavors, or synthetic substances.

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But here is where the trouble lies: The word “natural” assesses only an ingredient list, not whether or not a product is healthy. Illustrating the challenge of this ill-defined term are ongoing lawsuits against manufacturers of beverages sweetened with high-fructose corn syrup (HFCS) that bear the “natural” label. While proFoods must duction of HFCS uses geneticontain at cally modified enzymes, the least 95 courts, in lieu of the FDA, currently support such beverages percent being labeled natural. Although certified some HFCS-sweetened beverorganic ages may have some nutritional value, such as providing vitaingredients min C, HFCS itself provides no to bear the nutrition other than calories. certified There are healthier, truly natuorganic seal. ral beverages available that provide this vitamin, including organic juices that do not contain HFCS. Certified organic If there is one food label that is more reliable and informative than other labels, it is “certified organic.” National standards for organic food that were established in 2002 by the United States Department of Agriculture (USDA) stipulate that foods must contain at least 95 percent certified organic ingredients to bear the certified organic seal. The remaining 5 percent must be approved for use according to USDA organic regulations. Foods containing 70 percent to 94 percent organic ingredients may state, “Made with organic ingredients” on the front of the package, but are allowed to list only three of them on the principal display panel. Any additional organic ingredients are identified as organic in the ingredients list. To have a product certified as organic, each farmer, manufacturer, or retailer must keep extensive records verifying that every ingredient or material used in production is either certified organic itself or on a list of allowed synthetic or nonorganic ingredients, such as colors derived from agricultural products. Specifically disallowed are most synthetic pesticides, any synthetic fertilizers, antibiotics, growth hormones, and genetically modified foods. Farmland must be free of these substances and managed using organic methods for a full three years before crops grown on it may be labeled as certified organic. Additionally, the business must be inspected each year in order to continue to be allowed to produce and label a product as organic. Inspections are rigorous, requiring documentation of all aspects of organic handling procedures. Organic labeling is constantly being refined. For example, while organic standards have always required “access to pasture” for cattle, it became known in 2010 that some large-scale organic farmers were not upholding the spirit of this requirement. They were opening a gate that provided access to pasture for a few minutes every day, but their cattle were kept largely confined. In response to demand from consumer advocates, the Organic Standards Board

revised standards to require that organic cows in the U.S. be fed on pasture for a minimum of 120 days. Gluten-free Sales of gluten-free products continue to skyrocket throughout the U.S. despite the fact that most consumers don’t have a medical need for a diet free of gluten, which is a protein found in wheat, rye, barley, and related grains. The FDA has While not harmful to most not yet defined people, this protein must be avoided by the estimated “gluten-free.” 1 percent of Americans whose health is harmed by exposure to it, including those with the autoimmune condition celiac disease. Whether because of celiac disease, gluten intolerance, allergy to wheat, or curiosity, more and more Americans are purchasing products labeled “gluten-free,” sometimes written “G-F” or “GF.” What that label actually means, though, is questionable. That’s because the FDA has not yet defined “glutenfree.” At present, the FDA allows manufacturers to label products with that term as long as the claims are “truthful and not misleading.” However, without a firm definition of this term, those who require gluten-free foods are left wondering if they can trust this label. While wheat can be found on ingredient lists, thanks to the Food Allergen Food labels to page 34

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AUGUST 2012 MINNESOTA HEALTH CARE NEWS

RESEARCH

New drug-delivery method he public is waiting for the medical and scientific community to develop new treatments for Alzheimer’s disease, Parkinson’s disease, frontotemporal dementia, post-traumatic stress disorder (PTSD), stroke, brain tumors, head injury, spinal cord injury, depression, anxiety, autism, and many other disorders of the central nervous system. In the minds of many, the only way to do this is to develop new drugs. However, drug delivery and formulation are often as important or perhaps even more important than drug discovery. For example, during the last 30 years, hundreds of millions of dollars have been spent trying to create a new drug that improves memory for Alzheimer’s patients. So far, these efforts have failed.

Yet, without developing a new drug, the discovery at the HealthPartners Alzheimer’s Research Center of a simple, noninvasive intranasal method of drug delivery has resulted in a new treatment that not only improves memory, attention, and functioning in patients with Alzheimer’s disease but improves memory in normal, healthy adults as well. This treatment involves intranasal delivery of insulin. Delivering medicine intranasally— through the nose—bypasses the blood-brain barrier to deliver medication directly to the brain. Intranasally delivered insulin reaches the brain and spinal cord within 10 minutes and does not alter blood levels of insulin By William H. or glucose. Frey II, PhD This new method of drug delivery not only allows insulin and other drugs to enter the brain without the need to modify the drug, but also reduces unwanted side effects. Using this delivery method, researchers around the world have successfully treated research animals with stroke, brain tumors, Parkinson’s disease, and other brain disorders.

Intranasal treatments bypass blood-brain barrier to treat Alzheimer’s and other brain disorders

Targeting “diabetes of the brain” Insulin has been used to treat diabetes since its discovery in 1921. We now know that patients with Alzheimer’s disease have a brain deficiency of insulin that prevents them from properly absorbing the glucose (blood sugar) the brain needs in order to function. This results in what can be thought of as diabetes of the brain. In fact, neuroscientist Suzanne de la Monte, MD, has referred to Alzheimer’s as “type 3 diabetes,” since type 1 diabetes and type 2 diabetes have already been identified. Without glucose, brain cells are deprived of energy and do not function normally. Memory and thinking decline and, with no energy available to replace worn-out parts, the brain degenerates. When insulin enters the brain, it increases the uptake and utilization of glucose in the hippocampus, an area critical to memory. Intranasal insulin has been shown in four clinical trials in the United States to improve memory in Alzheimer’s patients. And in four clinical trials in Germany, the same treatment was shown to improve memory in healthy young adults. Other researchers in Germany have reported that intranasal insulin treatment minimizes the hormonal and nervous system response to psychosocial stress in young men. This raises the possibility that intranasal insulin might be beneficial as a means of treating or preventing PTSD.

MINNESOTA HEALTH CARE NEWS AUGUST 2012

While these results are encouraging, many more studies are needed to obtain FDA approval for the use of intranasal insulin to treat brain disorders. Intranasal stem cell treatment Intranasal therapy using adult stem cells offers another significant hope for treating many central nervous system disorders. Multiple studies to date have studied the outcome of stem cells surgically implanted into the brain. This is an expensive procedure with significant risk of adverse side effects. In addition, simply cutting or injecting into the brain to implant stem cells results in neuroinflammation that kills most of the stem cells once they are implanted. In some clinical trials, stem cells have been administered intravenously, but this distributes the stem cells throughout the body, not just to their intended target in the brain. Further, only a small number of stem cells administered that way cross the blood-brain barrier to reach the brain and spinal cord. In contrast, my colleagues in Germany and I have shown that intranasally delivered adult bone marrow–derived stem cells rapidly reach the brain and spinal cord, and do so without distributing large numbers of stem cells to the heart, liver, kidneys, spleen, and lungs. When these intranasal stem cells are administered to animals with Parkinson’s disease, the stem cells migrate preferentially to damaged areas of the brain. Once in the brain, the stem cells rapidly reduce the neuroinflammation characteristic of Parkinson’s disease and, over a period of weeks, dramatically improve motor function in the animals. Motor function is the ability to control bodily movement, and is impaired in people with Parkinson’s disease. Researchers in the Netherlands have also used intranasal stem cell treatment to successfully treat newborn animals that had cerebral ischemia (insufficient blood flow to the brain), which is involved in stroke.

Delivering medicine intranasally— through the nose— bypasses the blood-brain barrier.

Bypassing the blood-brain barrier

The blood-brain barrier protects the brain from substances we ingest and from substances that get into the blood and may be harmful to the central nervous system. So why would there be open access to the brain through the nose? In fact, access is not easy and open, since, among other factors, the efficiency of delivery from the nose to the brain is relatively low. That is partly because very few substances can navigate around the intranasal architecture to reach the brain in an amount sufficient to have an effect. In addition, there is evidence suggesting the presence of a biological pump in the lining of the nose that inhibits delivery of some substances to the brain.

Patients with Alzheimer’s disease have a brain deficiency of insulin. the HealthPartners Center for Dementia and Alzheimer’s Care. In addition to intranasal insulin for Alzheimer’s disease, intranasal delivery of the neuroprotective drug davunetide is being tested in clinical trials for progressive supranuclear palsy and other tauopathies, a group of diverse dementias and movement disorders. Intranasal oxytocin is being tested for autism and frontotemporal dementia, and intranasal neuropeptide Y is being tested for PTSD. A pressing need The discovery of a simple noninvasive intranasal method to bypass the blood-brain barrier may change treatment of neurological, psychiatric, and behavioral disorders that involve the central nervous system. Considering the pressing need to develop new methods of treating and preventing Alzheimer’s disease and other brain disorders, we can all hope that one or more of these treatments will eventually be found to be safe and effective enough to obtain FDA approval and become available to patients. William H. Frey II, PhD, is director of the HealthPartners Alzheimer’s Research Center at Regions Hospital in St. Paul. He invented and patented intranasal delivery of therapeutic proteins to the brain in 1989, intranasal delivery of insulin to the brain in 1999 and, with Drs. Danielyan and Gleiter, intranasal delivery of stem cells to the brain in 2007.

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Potential future applications Development and testing of intranasal treatments for disorders of the central nervous system continues. According to www.Clinical Trials.gov, a service of the National Institutes of Health, three centers within the United States are currently conducting trials studying the use of intranasal insulin in Alzheimer’s disease. One of these is

educate.inform.empower AUGUST 2012 MINNESOTA HEALTH CARE NEWS

Food labels from page 31

Labeling and Consumer Protection Act of 2004, other gluten-containing foods can be harder to identify, such as malt extract (contains barley), pumpernickel bread (contains rye), and soy sauce, which may be made with wheat-derived alcohol. The FDA intended to have published a voluntary rule for gluten-free labeling by now, but it has not publicly commented on the matter since August 2011, when it opened the period during which the public was invited to comment on the proposed rule. By going to www.regulations.gov and entering docket number FDA2005-N-0404, the public still has time to tell the FDA what it thinks of the following proposed regulation for gluten-free labeling: The FDA currently allows any food containing less than 20 parts per million (ppm) of gluten to be labeled gluten-free. Twenty ppm is the lowest level at which scientists can reliably detect traces of gluten. Which labels are most important? Despite food labeling being less than perfect, there are plenty of reasons to consider food choices carefully. Eating certified organic produce, for example, has been shown to reduce exposure to pesticides and to provide higher levels of healthful antioxidants than those found in conventionally farmed produce. Gluten-free foods help prevent gastrointestinal distress and serious medical consequences in those who must avoid gluten. Because many specially labeled foods cost more, it is important to know when it matters the most to buy them. For example, gluten-free raisins that bear

a higher price tag aren’t worth their extra cost since dried grapes are inherently gluten-free. But being able to eat gluten-free pizza may be well worth a few extra dollars to someone who can’t tolerate the gluten in a typical, wheat-based pizza crust. Similarly, the “dirty dozen” list published annually by the Environmental Working Group alerts shoppers to the 12 conventionally grown fruits and vegetables that contain the highest level of pesticide residues and therefore offer the greatest health benefits when purchased as organic. Apples, celery, and strawberries top the 2011 list, which can be viewed at www.ewg.org/foodnews/guide. (The 2012 list had not been released at the time this issue went to press.) Knowledge = smarter shopping Understanding which health benefits are assured by a particular food label helps consumers make the best use of their grocery dollars. In addition to reading labels, another way to find out what food contains and how it is produced is to buy locally grown food, since the grower communicates directly with stores about growing practices and ingredients. Farmers’ markets, community supported agriculture (CSA), and food cooperatives all offer additional opportunities to get to know your food and its labels so that you can make informed choices to derive the greatest health benefit from your food. Liz McMann, MA, is the consumer affairs manager for Mississippi Market Natural Foods Co-op, St. Paul (www.msmarket.coop).

“Multiple sclerosis upended the plans I had, forcing me to face uncertainty. I’ve learned to adapt and focus on what’s truly important to me.” — Susan, diagnosed in 1995

MS = dreams lost. dreams rebuilt. What does MS equal to you? Join the Movement® at MSsociety.org 34

MINNESOTA HEALTH CARE NEWS AUGUST 2012

• 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