Minnesota Health care News January 2011 by Minnesota Physician Publishing

Your Guide to Consumer Information

FREE January 2011 • Volume 9 Number 1

Alzheimer’s disease Riley McCarten, MD

Blood-forming stem cells Dennis Confer, MD

Legislative preview Jesse Berg, JD

One Heart, One Mind, One Universe May 8, 2011 at Mariucci Arena, University of Minnesota Medicine Buddha Empowerment: A Tibetan Cultural and Spiritual Ceremony Promoting Personal and Societal Healing featuring His Holiness the 14th Dalai Lama 9:30 - 11:30 a.m. Peace Through Inner Peace: A Public Address featuring His Holiness the 14th Dalai Lama 2:00 - 3:30 p.m. May 9, 2011 at University Radisson Hotel Second International Tibetan Medicine Conference: Healing Mind & Body 9:00 a.m. - 7:30 p.m. (* His Holiness is not expected to be in attendance.)

2 Days Only, 3 Events

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

un n Fo dation ica Minnesota of

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

etan Ame Tib r

Examine the relationship between ethics, spirituality, and healing. Investigate participants' own unique constitution. Determine what lifestyle choices to make, based on participants' own constitution. Explain how to heal from the source and develop health through balance. Describe research about Tibetan medicine, as well as propose additional research needed. Apply teachings of Tibetan medicine personally and professionally.

CONTENTS

4 7 8

JANUARY 2011 • Volume 9 Number 1

NEWS

PEOPLE

TRANSPLANT MEDICINE Blood cell sources for cancer patients By Dennis Confer, MD

PERSPECTIVE David L. Smith, MD

CALENDAR Winter pool and water safety

St. Cloud Medical Group

10 QUESTIONS J. Riley McCarten, MD Minneapolis VA Medical Center

LEGISLATION Health care meets a new dynamic By Jesse A. Berg, JD, MPH

MINNESOTA HEALTH CARE ROUNDTABLE

PEDIATRICS Vision development in infants By Mary Gregory, OD

PHYSIATRY Low back pain

TAKE CARE Radon

26 28 32

By Thomas J. Cesarz, MD

By Joseph Leach, MD, Michele O’Brien, MSN, and Andrew Gilbert

NEUROLOGY Post-polio syndrome By Barbara P. Seizert, MD

RESEARCH The impact of EMPaCT By Selwyn Vickers, MD

FEATURE How I got here

www.mppub.com PUBLISHER Mike Starnes mstarnes@mppub.com

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

SESSION

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

The Wellness Revolution

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

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

Please send me tickets at $95.00 per ticket. Mail orders to Minnesota Physician Publishing, 2812 East 26th Street, Minneapolis, MN 55406. Tickets may also be ordered by phone (612) 728-8600 or fax (612) 728-8601. Name Company Address City, State, Zip

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JANUARY 2011 MINNESOTA HEALTH CARE NEWS

NEWS

VA Breaks Ground for New Veterans’ Clinic In Northwest Metro Construction of an outpatient clinic for veterans is under way in Ramsey after a groundbreaking ceremony on Nov. 8. The 20,000-square-foot clinic is scheduled to open next fall and will provide primary care, mental health services, and subspecialty care for up to 7,000 veterans living in the northwest metro area. The clinic was the subject of delays and controversy as different communities and developers jockeyed for approval from the U.S. Department of Veterans Affairs. The issue was finally resolved in October and the groundbreaking ceremony was attended by a number of politicians and VA officials. U.S. Rep. Michele Bachmann, who represents the district and has been pressing for construction to begin, expressed relief that the project was under way. “After years of discussion

and planning, I am pleased that we have reached a tangible step in progress towards this important veterans’ facility,” Bachmann says. “Our nation’s heroes deserve both timely and convenient care and this clinic will be a benefit to them and their families. I was honored to be part of the process to bring this clinic to the 6th Congressional District and I look forward to the day the clinic opens to serve the men and women that selflessly served our nation.”

Clinical Trial Uses Technology, Social Media to Fight Fat A clinical trial at the University of Minnesota will seek to use technology and social media to fight obesity among young adults. The Choosing Healthy Options in College Environments and Settings (CHOICES) trial will consist of a for-credit course model that incorporates social networking as a way to prevent

MINNESOTA HEALTH CARE NEWS JANUARY 2011

unhealthy weight gain in students at community colleges. The trial will be offered at Anoka-Ramsey Community College, Inver Hills Community College, and St. Paul College. It is part of a series of trials called Early Adult Reduction of Weight through Lifestyle Intervention (EARLY). The EARLY trials will attempt to engage young adults in controlling their weight through behavioral programs that use various technologies to encourage healthy eating and physical activity. “The question we’re hoping to answer is: How can we engage two-year college students over the course of 24 months and help them avoid unhealthy weight gain?” says School of Public Health Professor Leslie Lytle, PhD. “We’ve designed a forcredit class that provides them tools to improve their sleeping habits, help them eat a healthier diet, get more physical activity, and manage stress.”

Heart Clinic to Merge With Larger Systems Doctors from St. Paul Heart Clinic, the last large independent cardiology group in the Twin Cities, have joined Allina Hospitals and Clinics and HealthEast Care System, as of Jan. 1. The clinic will cease to exist as an independent organization and fold its services into existing programs within the two large health systems, officials announced recently. “It is important to remember that while the St. Paul Heart Clinic name will go away, we will stay in our community and look forward to meeting our patients’ needs,” says Thomas Johnson, MD, president, St. Paul Heart Clinic. “We are confident that our decision to integrate with Allina and HealthEast is the beginning of an exciting new era of delivering care at the vanguard of cardiology. As physicians, we can focus our efforts toward innovative care models and superior clinical outcomes.”

Officials with the clinic say there is a nationwide trend of mergers involving independent cardiology practices, with 70 percent of such groups taking steps to join larger health systems. In a letter to its patients, the St. Paul clinic noted that cardiology practice is changing, including a shift from inpatient to outpatient care. It added that changes at the federal level, including health care reform, have played a role in these changes, along with increasing emphasis on chronic disease management, prevention, and quality.

OptumHealth Offers Online Health Service UnitedHealth Group (UHG) has joined the recent trend in offering online health care services. OptumHealth, a division of Minnetonka-based UHG, recently announced it would offer NowClinic, an online service that makes physicians and other providers available to patients at any time over the Internet. The move comes after two other health plans in Minnesota announced comparable moves to provide health services online. Blue Cross and Blue Shield of Minnesota started a pilot program last year called Online Care Anywhere that allowed patients to access physicians via online connections from the workplace or from home. And HealthPartners recently unveiled Virtuwell, an online service that allows patients to describe their symptoms and receive a diagnosis from a nurse practitioner. The NowClinic service is being sponsored by OptumHealth and is open to all Minnesotans, with plans to roll out nationwide, officials say. The service will let patients talk to physicians and other providers via the Internet or over the phone. It will charge a standard $45 fee for a 10-minute visit, with an additional fee for longer visits. The service is not covered by insurance plans at this time and can be paid for by the consumer through a credit card.

Officials with OptumHealth say the service will meet a need for convenient care for many people who want quick access. “Today’s consumers are busy, mobile, and want easy access to services. Health care is no different,” says Rob Webb, CEO of OptumHealth Care Solutions. “Our response to this new reality is to develop health care solutions that link consumers directly to the resources available to them when, where, and at the time they need care.” The service could also be helpful to those in rural areas with limited access to health care facilities, officials add.

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Franken Celebrates New Regulations for Medical Loss Ratios Sen. Al Franken, who authored language in the health care reform law requiring health insurance companies to spend 80 to 85 cents of every premium dollar on health care rather than administrative expenses, praised the implementation of the measure in November. The U.S. Department of Health and Human Services (HHS) issued rules on Nov. 22 requiring insurers to have medical loss ratios of 85 percent on large group policies and 80 percent on small group and individual policies. HHS worked with the National Association of Insurance Commissioners in setting the new regulations. Franken has often noted that he drew on the example of Minnesota nonprofit health plans, which spend on average 91 cents of every premium dollar on health care. “Implementation of the medical loss ratio provision is a huge step toward ensuring consumers’ premium dollars go to actual health care, not insurance company coffers,” Franken says. “Many health insurers spend as little as 65 percent of your premiums on care, and the rest goes to enormous CEO salaries, advertising, or wasteful administrative

NOW hear this! D

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? The Minnesota Telephone Equipment Distribution Program can provide special telephone equipment at NO CHARGE to Minnesota residents of all ages!! The equipment includes ampliﬁed (corded and cordless) phones, speakerphones, captioned telephones, telephone ring signalers, deafblind equipment and other special equipment. To learn more about this program visit our Web site at: www.tedprogram.org or contact us at (800) 657-3663, (888) 206-6555 TTY. Eligibility requirements do apply. The Telephone Equipment Distribution Program is administered by the Department of Commerce Telecommunication Access Minnesota (TAM) and funded by a telephone surcharge.

News to page 6 JANUARY 2011 MINNESOTA HEALTH CARE NEWS

News from page 5 costs. These regulations will hold health insurers accountable and make sure consumers get more value for their money.”

HealthPartners Clinics Designated as Health Care Homes HealthPartners announced recently that its system of primary care clinics has been designated by the state as a health care home. Officials say 23 HealthPartners Medical Group primary care clinics in the Twin Cities were certified, including 250 physicians and 50 nurse practitioners and physician’s assistants, making it the first large health system in Minnesota to have all its primary care sites certified. A state health reform law passed in 2008 provides incentives for primary care clinics to move to the health care home model, which focuses on a coordinated, team approach to care, usually led by a physician. The

model is thought to be more efficient and better designed to handle chronic illnesses and promote preventive care while holding down costs. The law requires certified health care homes to be recertified annually, based on outcomes. HealthPartners officials say the health care home model fits with the patient-centered care the system has provided in the past. They note that HealthPartners was the first large system in the country to be recognized by the National Committee for Quality Assurance as a patient-centered medical home in 2008. “Certification as a health care home reflects the way we have been providing health care for several years,” says Bob Van Why, senior vice president of primary care with HealthPartners Medical Group. “Our goal has been, and continues to be, to ensure that primary care is patient-centered, care is coordinated and customized to meet our patients’ needs and values. Our plans now include enhancing the patient

experience by partnering with patients to set care goals and plans and to enhance access to care with tools such as phone visits and online visits.” There are currently 37 separate clinics designated as health care homes by the Minnesota Department of Health (MDH), with the majority of them in the Twin Cities metro area. In addition to the HealthPartners sites, MDH has given the health care home certification to clinics with Fairview Health Services in Minneapolis, Staples-based Lakewood Health System, Minneapolis-based Northpoint Health and Wellness Center, Park Nicollet in St. Louis Park, and Stillwater-based Bluestone Physician Services. Mayo Health System’s Austin Medical Center, Duluth-based SMDC Health System, and the practice of Christopher Wenner, MD, in Cold Spring also have gained health care home certification.

HCMC Opens New Primary Care Clinic In Brooklyn Park Hennepin County Medical Center (HCMC) has opened a new clinic in Brooklyn Park. Brooklyn Park Clinic is the fifth primary care clinic to join HCMC’s network of community clinics outside downtown Minneapolis, officials say. The new clinic will provide family practice services and complement the nearby Brooklyn Center Clinic, which is transitioning to a focus on adult health care. “These clinics are giving people outside the downtown community access to our nationally recognized health care in their neighborhoods,” says Lowell Stoltzfus, MD, medical director of Brooklyn Park Clinic. “We’re excited to experience this growth, and are committed to bringing our family-centered primary care to children and adults in the communities in and around Brooklyn Park.”

“Early diagnosis is vital and has made all the difference in my life. Knowing I have Alzheimer’s has given me time to plan.” It’s what you don’t know that will hurt you. Early detection matters.

The Alzheimer’s Association is here to help.

www.alz.org/mnnd 6

MINNESOTA HEALTH CARE NEWS JANUARY 2011

800.272.3900

PEOPLE School of Public Health nutrition expert Mary Story, PhD, RD, has been elected to the Institute of Medicine (IOM). Election to the IOM is consid-

Cataract Specialists

ered one of the highest honors in the fields of health and medicine; it recognizes individuals who have made major contributions to the advancement of the medical sciences, health care, and public health. A professor in the School Mary Story, PhD, RD

of Public Health’s Division of Epidemiology and

Community Health, Story is also associate dean for student life and leadership and an adjunct professor in the Department of Pediatrics in the School of Medicine at the University of Minnesota. Story’s expertise is in child and adolescent nutrition, and childhood obesity prevention; she has conducted numerous school and communitybased obesity prevention studies. Shelley Plude, MSW, has joined Arrowhead Psychological Clinic, Duluth. Her previous employment includes working with the Juvenile Assessment Center and Northwood Children’s Services and as social

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

Surgery Locations: Arlington Blaine Bloomington Maplewood

Minneapolis Mora New Prague Sandstone

worker for the Hermantown school district. Her areas of specialization include counseling services with children, adolescents, and adults. She will provide counseling services for couples and families as well. Lia Christiansen has been named operations executive for Bethesda Hospital, St. Paul. Bethesda, a member of HealthEast Care System, is one of only two specialty, long-term acute-care hospitals in Minnesota, providing care for patients who have experienced a life-changing illness or injury. Christiansen has been employed by HealthEast since 1996. As operations executive, Christiansen will have overall responsibility for a number of inpatient and outpatient clinical and support departments including pharmacy, psychology, radiology, physical medicine, facilities, and outLia Christiansen

patient services.

The March of Dimes has named Linda Olson Keller, DNP, APHNBC, FAAN, as Distinguished Nurse of the Year in Minnesota. Olson Keller is a clinical associate professor at the University of Minnesota School of Nursing, with a specialty in public health and leadership. Olson Keller was honored for her significant contributions to nursing in Minnesota, including the creation of the Public Health Intervention Wheel, which reinvigorated public health nursing prac-

Cataracts A cataract is a clouding of the eye’s natural lens that inhibits or diminishes the passage of light to the retina. Cataracts progress at different rates and can affect one or both eyes at the same time. When a cataract develops, a patient may wish to have it surgically removed. The surgery is performed as an outpatient procedure under local anesthesia and takes approximately 10-20 minutes. Once the cataract has been removed, a new clear lens, called an intraocular lens implant (IOL) is put in place of the natural lens. Most patients return to their normal work or lifestyle in a day or two. Cataract surgery is one of the most common and successful surgical procedures performed today. Many patients report vision that is even better than before they developed cataracts, especially with the optional newer implant that often eliminates the need for close vision glasses after surgery.

tice across the United States. The award also cited her leadership, compassion, and advocacy for patients and fellow nurses. The March of Dimes celebrated Nurse of the Year winners in Linda Olson Keller, DNP, APHN-BC, FAAN

13 categories at a dinner and awards program in Minneapolis in November.

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

Aaron Friedman, MD, takes over this month as dean of the University of Minnesota Medical School. He has been the RubenBentson Chair and a professor of pediatrics in the medical school, where he has served since arriving at the university in 2008. Before coming to the U of M, he was chair of the departments of pediatrics at Brown Medical School in Providence, R.I., and at the University of Wisconsin–Madison. Friedman also is pediatrician-in-chief at the University of Minnesota Amplatz Children’s Hospital. He replaces Frank Cerra, MD, who has been the medical school dean for more

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

than 20 years and announced his retirement in 2010. JANUARY 2011 MINNESOTA HEALTH CARE NEWS

PERSPECTIVE

Confronting childhood obesity An epidemic with lifelong consequences

T David L. Smith, MD St. Cloud Medical Group

he number of overweight children aged 6 to 19 in the United States tripled between 1970 and 2007, according to a 2007 New England Journal of Medicine (NEJM) study. These extra pounds are causing health problems for kids that once were confined to adults. These include diabetes, high blood pressure, and high cholesterol, all factors in coronary heart disease (CHD). The NEJM study estimated that, by 2035, the prevalence of CHD will increase to as much as 16 percent of the U.S. population, with more than 100,000 excess cases attributable to the increase in obesity. Unless changes intervene.

David L. Smith, MD, a pediatrician, received his medical degree from the Wright State University School of Medicine in Dayton, Ohio. He completed his pediatric residency at the Columbus Hospital in Columbus, Ohio. He is a member of the American Academy of Pediatrics and is certified by the American Board of Pediatrics. Dr. Smith practices at the St. Cloud Medical Group South Clinic in St. Cloud, and serves on the medical committee of the BLEND initiative to address the problem of childhood obesity.

The BLEND (Better Living: Exercise & Nutrition Daily) initiative, supported by the CentraCare Health Foundation, is a community collaborative begun in 2006 to improve the health of children in central Minnesota by addressing the problem of childhood obesity. The collaborative’s goal is a 10 percent reduction in obesity in central Minnesota by 2016.

Earth Day 1K Junior Run provides an excellent opportunity for children 12 and younger to begin their running routine and stresses the importance of starting a physical activity regimen early in life. Parade of Bikes teaches participants about the importance of healthy living by design, which includes Complete Streets policies (roadways designed for the safety of all users—motorists, bicyclists, public transportation, and pedestrians) and bike-friendly communities. People of all ages and abilities are invited to participate in this event. 5-2-1-0 raises awareness of the daily guidelines for nutrition and physical activity for children. Health care providers give their young patients a “prescription” for healthy living that includes these recommendations: 5 or more fruits and vegetables each day, 2 hours or less of screen time each day, 1 hour of physical activity each day, and 0 calories from sweetened drinks each day.

To learn more about

BLEND Beginnings builds a foundation for a healthy, active lifestyle by teaching children ages 3 to 5 how to make healthy food choices and the importance of physical activity. The curriculum includes a program guide, picture cards, games, posters, and more to help child care providers implement the program.

With the help of partners in the community, BLEND works BLEND, visit with schools, organizations www.blendcentralmn. that serve young people, local government, and the org or call Jodi Rohe medical community to at (320) 229-5199, increase awareness of the importance of daily physical ext. 71205. activity and good nutritional choices for kids and families. New project BLEND’s medical committee consists of seven BLEND has partnered with Coborn’s Inc. and Blue physicians on the staff at St. Cloud Hospital. Cross Blue Shield of Minnesota to bring the NuVal Creative approaches Nutritional Scoring System to eight Coborn’s groThe best way to address excess weight in a child cery stores in the St. Cloud area. Foods and beverand improve the nutritional and physical activity ages are rated on a scale of 1 to 100: the higher the choices they and their families make is multifac- score, the higher the nutritional value. Scores are eted. Among the projects the community has displayed on the shelf tags, making it easy for cusundertaken to address this important concern are tomers to compare the overall nutrition of the these: foods they buy. National Family Dinner Night encourages families An independent panel of nutrition and medical to turn off the television and sit the family down experts from leading universities and health for dinner. BLEND partners with Coborn’s grocery organizations, led by David Katz, MD, of the Yalestores, Golden Plump, and General Mills to pro- Griffin Prevention Research Center, takes more vide families with coupons for spaghetti dinner than 30 different nutrients and nutrition factors ingredients. into account when developing a score, helping Walk at School is a program that gives students a families improve overall nutrition with foods they healthy alternative to the unhealthy foods tradi- already eat. tionally sold in fund-raising campaigns. Instead, Success students ask family, friends, and neighbors to The BLEND program has a significant presence in sponsor them to walk during the school day. the community, with more than 10,000 individuals Kids’ Health and Fitness Expo features interactive and families participating in public events. In addiand engaging activities for all ages and abilities, as tion, more than 1,500 students at three local well as healthy food tasting. The annual event schools participate in Walk at School, and countteaches families how to make physical activity a less more have been reached through child care fun, everyday part of life. initiatives and the 5-2-1-0 medical intervention.

MINNESOTA HEALTH CARE NEWS JANUARY 2011

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10 QUESTIONS

& J. Riley McCarten, MD Dr. McCarten is a neurologist and medical director of the Geriatric Research, Education, and Clinical Center at the Minneapolis VA Medical Center and the University of Minnesota Medical Center–Fairview Memory Clinic. What is Alzheimer’s disease? Alzheimer’s disease (AD) is a type of dementia. Not everyone with dementia has AD, but for most older adults, dementia is caused by AD. Dementia is a syndrome of memory and cognitive loss that is severe enough to interfere with a person’s function. AD is a specific cause of dementia related to the abnormal processing of the brain proteins beta amyloid and tau. Clinically, AD begins insidiously and progresses gradually, typically over 10 to 20 years. Apart from memory and cognition, the nervous system in AD remains relatively normal until the late stages of the disease. How is AD diagnosed? AD is a clinical diagnosis. An experienced clinician makes the diagnosis based on the history of the onset, course, and character of symptoms; the presence or absence of associated symptoms; other factors in a person’s medical history; and the findings on the neurological, psychiatric, and physical examination. When symptoms are mild, neuropsychological testing—a detailed test of attention and concentration, memory, language, spatial, and executive skills—may be necessary to clarify the diagnosis. Imaging and blood tests are used primarily to rule out other, uncommon causes of dementia, such as brain tumors, vitamin deficiencies, or thyroid disorders. In older adults with dementia, AD is at the top of the list until something else can be proven to be the cause. How is AD treated? While there are medications to treat the symptoms of memory loss in AD, their effects are usually modest. The more important treatment interventions in AD have to do with recognizing that AD is a chronic, progressive disease associated with predictable problems. If the disease is identified and diagnosed, the patient and family can make plans to address potential problems before they become crises. Remaining socially engaged and physically active are perhaps the most important interventions to keep someone with AD healthy and happy. Tell us about your current research on Alzheimer’s disease. The field is at the point where translational research—bringing progress from the bench to the bedside—is ever more important. As a clinician, my role is to identify AD as early in its course as possible, and to identify those who age successfully, without any symptoms of AD. We hope that the cases we identify through clinical evaluations will lead to the discovery of a biomarker that will diagnose the disease with certainty and, more importantly, provide an indicator for successful treatment interventions.

Photo credit: Bruce Silcox

What are risk factors for AD? Just like many diseases, the No. 1 risk factor for AD is age. There are rare families in whom AD is clearly genetically based, and people with Down’s syndrome also develop AD pathology as they age. These genetic mutations are all directly related to the processing of beta amyloid protein. The much more common sporadic AD affects older adults, and the genetics are not nearly as clear. Can AD be prevented? There are many observational studies that suggest links between education, diet, certain medications, and a reduced risk of AD. More education may delay the onset of AD, perhaps through increased “brain reserve” to compensate for the damage

MINNESOTA HEALTH CARE NEWS JANUARY 2011

“

”

The No. 1 risk factor for Alzheimer’s disease is age.

caused by AD. So-called heart-healthy diets, certain spices (for example, curcumin), and moderate amounts of alcohol may reduce the risk of AD. Anti-inflammatory drugs, such as ibuprofen and naproxen, also are correlated with a decreased risk of AD later in life. The mechanisms through which diet or drugs may delay or prevent AD are not understood. It appears likely, however, that the benefits of any of these interventions are realized only well before the disease is clinically evident and are not helpful to those who have the disease. Large, long-term trials in people who do not have AD will be necessary to determine what, if anything, can delay or prevent AD. What is the relationship between mild cognitive impairment and Alzheimer’s disease? Mild cognitive impairment (MCI) is a condition in which a person scores below what is expected on tests of memory or another major area of cognition (language, spatial, or executive skills), but whose general cognitive and functional abilities remain intact. Generally, the term MCI is reserved for people in whom another cause of the symptoms, like a stroke or head injury, has been excluded. Such people, therefore, have memory or cognitive deficits without an apparent underlying cause. The symptoms of MCI may be the first symptoms of AD. Certainly, having MCI puts someone at increased risk for developing AD. Please tell us about proposals to revise the definition of Alzheimer’s disease. These proposals seek to incorporate biomarkers, such as neuroimaging (MRI) and cerebrospinal fluid pro-

teins, to enhance diagnostic accuracy and potentially to improve early identification of AD. While some biomarkers are reliably correlated with established AD, at that stage of the disease they add little. Their utility earlier in the course of the disease is still a question. What are the most important things family members can do to help a relative with Alzheimer’s? Patience and understanding are vital. Often, because patients look normal and typically do not recognize their own disabilities, family may believe they are fine. When the AD patient then forgets, makes mistakes, uses poor judgment, and perhaps blames others, it is easy to start an argument. If you want to have the same argument many times a day, you’ve found the right person in someone with AD. Confrontation is not productive. Helping the AD patient make a plan for the day and gently encouraging activities they still enjoy are winning strategies. What resources are available to help families cope with the stress of caring for an Alzheimer’s patient? Too often, a single family member bears the brunt of caregiving, which inevitably leads to burnout. Other well-meaning family may offer help if asked, but that is not enough. Schedule time for the AD patient to spend with a variety of people, including family, friends, and, if needed, adult day programs and in-home respite. Ask the “What if …?” questions. If Mom is the primary caregiver, what happens if she goes down? If you have plans you never use, so what? If you don’t have a plan when you need one, that’s a crisis.

A spine center approach to back & neck pain.

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L E G I S L AT I O N

Health care meets a new dynamic Can Republican Legislature, DFL governor find compromise? By Jesse A. Berg, JD, MPH

s the 2011 Minnesota Legislature convenes in St. Paul, the state’s newly minted senators and representatives find themselves up against a familiar problem: how to grapple with a massive budget deficit while addressing at least some of the campaign promises made during the election campaign. With the deficit over the coming biennium projected to be a staggering $6.2 billion, health care is once again a key target in the quest for spending cuts. Moreover, considering that the state has faced significant deficits for much of the past decade, many of the “easy” fixes, such as tapping one-time revenue sources, are now off the table, leaving only tough decisions for policymakers. Meanwhile, as the battle over 2010’s Affordable Care Act (ACA), derisively referred to as “Obamacare” by its detractors, continues to push Republicans and Democrats further apart, finding areas of con-

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sensus may prove even more difficult than in the past.

The new lineup Following a recount, DFL candidate Mark Dayton will be Minnesota’s first Democratic governor since Rudy Perpich left office in 1991. His Republican opponent, three-term state representative Tom Emmer, lost to Dayton by fewer than 9,000 votes in the Nov. 2 election, triggering a recount required by state law. Dayton took office on Jan. 3. Soon after, he was expected to sign an executive order for the state to receive substantial sums in connection with the Affordable Care Act that his predecessor, Republican Gov. Tim Pawlenty, had refused to accept. The election also brought seismic changes to the Legislature, with Republicans taking full control of both houses for the first time since 1974. By winning 16 new seats, Republicans captured the Senate and will hold a 37–30 lead in the Legislature’s upper chamber over the next two years. In the House, Republicans picked up 25 seats for a 72–62 majority. As a result of these wins, key health care committees will see new leadership in the 2011 session. In the House, Rep. Jim Abeler (R-Anoka) will lead the Health and Human Services Finance Committee and Rep. Steve Gottwalt (R-St. Cloud) will head up the Health and Human Services Reform Committee. In the Senate, Sen. David Hann (R-Eden Prairie) will take charge of the Health and Human Services Budget and Policy Committee. Amy Koch of Buffalo, the newly elected majority leader, will lead Republicans in the Senate. In the House, Rep. Kurt Zellers of Maple Grove will lead House Republicans as speaker. Rep. Paul Thissen of Minneapolis has been chosen to lead the DFL minority in the House, and Sen. Tom Bakk of Cook will hold the role of Senate minority leader.

Now that we have ACA, what’s next? The answer to this question likely depends on who is being asked. During the campaign, Emmer focused on what he called the “Health Care Freedom Act,” a series of reheated proposals broadly grouped around giving individuals tax deductions to purchase health insurance, “eliminating costly insurance mandates,” and allowing Minnesota residents to purchase insurance across state lines. For his part, Pawlenty has described the ACA as “an unconstitutional power grab by the federal government” that “needs to be stopped.” His salvos appear to be focused on positioning himself for the 2012 GOP presidential primaries. He also issued an executive order to “stop Minnesota’s participation in projects that are laying the groundwork for a federally controlled health care system.” Pawlenty has gone so far as to say that repeal of the ACA will be a major component of his platform if he runs for president. Dayton, meanwhile, is a major supporter of the Affordable Care Act. However, with Republicans in control of key House and Senate committees, the new governor likely will have a hard time finding

common ground. Abeler, the new chair of the House Health and Human Services Finance Committee, for instance, was a very vocal opponent of health care reform in 2010. Republicans are likely to introduce legislation to try to reshape the state’s health care system more to their liking, with proposals such as replacing MinnesotaCare with vouchers, creating tax incentives for individuals to use in purchasing their own insurance policies, repealing or reducing laws requiring that health plans cover various procedures or conditions, and allowing for the sale of insurance plans across state lines. Loath to reduce spending for education and united in their opposition to tax increases, Republicans likely will make state-sponsored health programs a key target for addressing the $6.2 billion deficit.

Meanwhile, many of the legislators who have long fought battles to reform the state’s health care system again have their eyes set on the 2011 session. Sen. John Marty (DFL-Roseville), for instance, has talked about a bill to establish the Minnesota Health Plan, a comprehensive plan that would offer broad coverage to all Minnesotans and for all medical issues. This and related pieces of legislation appear to stand little chance of passage, however, given Republican control of both houses and the significant budget deficit facing the Legislature over the next two years. On the other hand, efforts to further crack down on perceived instances of fraud and abuse are likely to see some success, considering the ample financial returns laws in this area have had on the federal level.

The shape of things to come

Jesse A. Berg, JD, MPH, is an attorney at Gray Plant Mooty in Minneapolis.

Regardless of these differing views over the merits of the Affordable Care Act, the fact remains that much about the law’s implementation needs to be determined. The direction taken by state policymakers in response to these choices will have profound implications for Minnesota. One of the most important decisions Dayton will face involves the future of Minnesota’s General Assistance Medical Care (GAMC) program and a possible expansion of the state’s Medical Assistance (Medicaid) program. As a result of a compromise between Pawlenty and the DFL-led Legislature to address past budget deficits, the GAMC program was preserved, albeit in a much different form. Under the Coordinated Care Delivery System that replaced the traditional GAMC program, four hospitals, all located in the Twin Cities metro area, received drastically reduced payments to cover the care they delivered to GAMC beneficiaries. Reduced payments made it difficult for the participating hospitals to deliver care, while the hospitals’ locations made it challenging for beneficiaries from rural Minnesota to get care. Dayton has made no secret of his desire to opt into an expansion of the state’s Medical Assistance (Medicaid) program made available as a result of the ACA. This would bring an additional $1.4 billion in federal revenue to the state, while likely permitting individuals formerly enrolled with GAMC to transition to Medicaid. Pawlenty chose not to accept this additional funding, arguing that Minnesota could not afford a long-term expansion. No less important are decisions legislators must make about the new “health insurance exchanges,” a key component of the ACA that will become effective in 2014. The idea with these exchanges is that consumers should be able to turn to a one-stop market to purchase health insurance, using tools that will allow comparing prices, products, and options across plans, not unlike the way most people buy airline tickets using online tools like Expedia and Travelocity. Under the Affordable Care Act, states have ample discretion to design their own type of health insurance exchange, tailoring the model used to the particular characteristics of the state and its population. Failure to adopt an exchange would result in the federal Department of Health and Human Services implementing its own model to be used by Minnesotans. The danger with this approach is that a centrally designed exchange will be less tailored to the unique needs and complexities of our state and, as a result, will likely be a less effective tool for consumers. Minnesota is already behind other states in the process of implementing an exchange. Minnesota and Alaska were the only two states to reject $1 million in federal grants to be used in designing the exchange.

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P E D I AT R I C S

Vision development in infants Learning how to see By Mary Gregory, OD

t is an amazing experience when your infant first opens his eyes to look at you. But what does he really see? The eye and the visual system are complete at birth, but infants have to learn how to see over the first year of life. Vision development starts with proper prenatal care and continues until your child is approximately 9 years old. Prenatally, it is important for your baby to receive omega-3 essential fatty acids and vitamin B. Salmon, walnuts, and flaxseed are good sources of omega-3; vitamin B-rich foods include bananas, eggs, and green vegetables. Your baby’s eyes will begin developing two weeks after conception. Over the next four weeks all of the major eye structures form. During the last seven months of pregnancy the eye continues to grow and mature—at birth a baby’s eye is around 75 percent of the size it will be as an adult—and the optic nerve, which connects the eye to the brain, is formed. Your baby will be examined at birth to determine whether any congenital defects such as cataracts are present. An antibiotic ointment, usually erythromycin, is placed on the baby’s eyes immediately after delivery to prevent any infections from bacteria present during the birth process. We all have the ability to focus our eyes on objects at different distances. Infants, however, are not yet capable of using this skill very accurately. Images as seen by a baby less than 3 months old are often out of focus and therefore blurry. The baby sees large shapes and images, but there is no sense of detail. This is about 20/400 on a vision acuity chart—the big E. An infant less than 2 months old sees you better when you are within 10 inches of her face.

Learning to focus

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In the first two months of life your baby will be learning to focus on your face. Gradually, she will be able to hold your gaze for longer and longer periods of time. An infant does see in colors and is even able to distinguish shades of gray, but high-contrast objects hold more interest for the child at this age. Surrounding your infant with black and white contrast will keep his attention as he continues to practice his focusing skills, but other colors will work too. Large, eye-catching objects like mobiles will also help with vision development during this time. Frequently changing objects around in the room and crib will continue to stimulate an infant’s interest and vision, as will talking to him while walking around the room. Soon he will be learning how to move his eyes without moving his head position and he will start to reach for objects. Using a nightlight in the child’s room will also stimulate vision at this age. An infant waking up in the dark needs a low amount of light to practice eye-focusing abilities. Around 3 to 4 months of age, an infant can focus on objects more accurately and is beginning to notice the world around her. At this time in development the baby is learning to see detail better. Even though objects are coming into focus better, babies at this age are not yet able to see as adults do. On the vision chart they can now see about 20/60. By 4 months old they are also practicing their eye-teaming skills, i.e., the ability to use both eyes together. Although it can be alarming to see your child’s eyes drifting in different directions, it is a normal occurrence at this stage. During this time you will also start to see your child reach for and accurately grasp nearby objects. Encourage this development with games such as patty-cake and peek-a-boo.

Visual exploration By 5 to 6 months your child should have eye-teaming skills mastered and be able to see the world in 3D. At 6 months of age your baby will have detail vision and be able to see about 20/30 on the visual acuity chart. At 6 to 12 months old your child is beginning to explore the world around her. She is learning to see detail and small objects. She is also learning to grasp accurately and use depth perception to determine the distance between herself and the objects around her. What a fun time to play and encourage this development. While playing on the floor with your baby you can encourage her to reach across her body for toys, play catch, and work with toys that pull apart and go back together. It is also important to encourage crawling to help develop eye and hand coordination. Do not be in a rush for her to begin walking. By 12 months the majority of vision development has taken place and your baby is ready for her first eye examination. It’s important to identify any visual concerns at this point so that development can be redirected and helped along if needed. At this appointment the optometrist will dilate your child’s pupils and make sure the structures in the eye developed normally and are healthy.

If the vision isn’t examined and the discrepancy between eyes is left untreated, amblyopia may begin to develop by age 2. It is important to have your infant examined at this age even if you believe nothing is wrong, because usually there are no outward signs of the problem. The first year of life is an extraordinary time for you and your infant. As a parent you are able to watch your child grow at a

The American Optometric Association, partnering with Johnson & Johnson Vision Care Group, established InfantSEE in 2005. InfantSEE is a public health program enabling parents to bring their infant aged 6 months to 1 year to a participating optometrist for a free eye exam. The Minnesota chapter of InfantSEE is taking part in “Healthy Start Day” on April 16, 10 a.m. to 4 p.m., at Open Cities Clinic in St. Paul. To pre-register, call 651-2909258.

remarkable rate. What isn’t as obvious is the complex development of the visual system and how it relates to an infant’s senses and perceptions. By providing proper nutrition, observing your infant’s eye development carefully, and scheduling an early eye exam, you can be assured your baby is growing with not only awareness of the world around him but with good vision and coordination to enjoy it. Mary Gregory, OD, is an optometrist at Uptown Eye Care in Monticello, Minn.

The first eye exam Eye doctors who work with infants are able to determine what they can see at this age, check eye-teaming skills, peripheral vision, and determine if a correction such as nearsightedness, farsightedness, or astigmatism is present. It is normal for an infant to have a small amount of correction at this age. However, if the amount is different between the two eyes or your baby has too much correction in one or both eyes, it may lead to a halt in vision development. This condition—called amblyopia, or lazy eye—affects 2 to 3 of every 100 children. It is the most common cause of visual impairment in children. By 12 months Amblyopia occurs when one your baby is ready eye learns to see better than the other. Often when people think of for her first eye “lazy eye,” they picture a child examination. with one eye turning out. This can be a type of lazy eye, but in most cases of true amblyopia the eyes appear normal. While amblyopia isn’t definite at this age, we can make sure it doesn’t develop by determining how each eye is working and using glasses to correct favoritism of one eye. Parents may wonder how you would keep glasses on a young child, but usually this isn’t a concern. Once the infant or toddler is starting to develop vision through the glasses he will prefer to wear them. Often a pair of glasses at this age will prevent amblyopia altogether.

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TRANSPLANT MEDICINE

Blood cell sources for cancer patients Marrow, cord blood, and peripheral stem cells By Dennis Confer, MD

or thousands of patients with life-threatening illnesses such as leukemia, lymphoma, and sickle cell anemia, the best hope for a cure is replacing their diseased blood cells with healthy ones that can then flourish. For decades, marrow was the main source of transplanted blood-forming cells. Today, there are two additional sources of healthy blood cells: umbilical cords and peripheral blood stem cells. Every year, more than 10,000 patients in the United States are diagnosed with diseases that could be treated with a transplant of blood-forming cells. But most patientsâ&#x20AC;&#x201D;about 70 percentâ&#x20AC;&#x201D;do not have the needed biological match within their families. The tissue types used for matching patients with donors are inherited, so patients are most likely to find a match within their own racial or ethnic heritage. Thatâ&#x20AC;&#x2122;s where the National Marrow Donor Program (NMDP) comes in. It manages the Be the Match Registry, which provides these patients with access to 8 million potential donors and 160,000 publicly donated cord blood units across America. Because of the NMDPâ&#x20AC;&#x2122;s international partnerships, patients also have access to donors and cord blood units around the world. As a result, the number of blood cell transplants in the United States has increased steadily, tripling from about 1,600 in 2000 to more than 4,800 in 2009.

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History of blood cell transplantation Until the late 1990s, most transplants used blood-forming cells found in bone marrow, because that is where the body forms new blood cells. Researchers now know that they can extract these healthy blood cells directly from a donor’s bloodstream, and today these peripheral blood stem cells (PBSCs) are the main source for transplants. PBSCs are not to be confused with embryonic stem cells, which have been the cause of some controversy in medical science in the last decade. Stem cells from embryos are not used for marrow, PBSC, or umbilical cord blood transplants. A third source of blood-forming cells is collected from the umbilical cord and placenta after a baby is born. Once considered medical waste, cord blood has become a valuable source for transplants—especially because patient and donor tissue types don’t have to match as closely as with the other sources. The size of the patient determines if more than one unit of cord blood is necessary. In 2009, nearly 30 percent of cord blood transplants used more than one cord blood unit. Using two cord blood units to increase the cell volume has become an increasingly important option for adult patients. When considering the best source for a specific patient, physicians consider the level of match between the patient and donor, as well as factors such as the age of the patient and timing—meaning how far the patient’s disease has progressed and how quickly he or she needs a transplant to survive. Regardless of the source of cells, the goal is for the healthy blood cells to multiply, thrive, and give the patient a second chance at life.

Every year, more than 10,000 patients in the United States are diagnosed with diseases that could be treated with a transplant of blood-forming cells.

particularly those with higher-risk diseases. Peripheral blood stem cells In the 1990s, doctors began successfully drawing the same lifegiving cells found in marrow directly from the bloodstream of donors. Unlike marrow donation, PBSC donaDuring marrow donation, doctors use tion is done in an outa needle to withdraw liquid marrow patient clinic and from the back of the donor’s pelvic requires no anesthesia. bone. Marrow donation is a surgical For five days prior to procedure always done under general or regional anesthesia in a hospital. the procedure, donors take a drug that drives the blood-forming cells out of the bone and into circulation. Then, through a needle in one arm, the donor is hooked up to a device, called an apheresis machine, which removes the blood, separates out the blood-forming cells, and returns the remaining blood through a needle into the donor’s other arm. Today, 60 percent of transplants use PBSCs because of the ease of the process and because the outcomes are often equal to transBlood cell sources to page 19

Marrow donation

When the NMDP first began its work in the late 1980s, bone marrow—the soft, spongy tissue inside larger bones—was the original source for bloodforming cells. It has been the standard source for more than 35 years. Because of its longevity, there is vast information and research about marrow transplant outcomes, as well as the marrow donation experience. Currently, marrow represents about 20 percent of all blood cell transplants. During marrow donation, doctors extract marrow from the donor’s hip bone during a surgical procedure that requires local or general anesthesia. The donated marrow often travels hundreds, even thousands of miles to the hospital where the patient is waiting for the transplant. In preparation for the transplant—whether it’s marrow, cord blood, or PBSC—the patient must undergo chemotherapy to kill his or her diseased cells. During the transplant, the patient receives the donor’s healthy cells intravenously. For many pediatric patients, marrow is the optimal choice as it increases the odds for long-term success. Marrow may not be the preferred cell source for many adults,

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educate.inform.empower JANUARY 2011 MINNESOTA HEALTH CARE NEWS

January Calendar 10

Post-Polio Awareness and Support Society (PPASS) The Minnesota chapter of PPASS provides education and support for those living with the effects of polio and post-polio syndrome. Individuals, their families, and caregivers are welcome. For more information, call Larry Kohout at 952-835-9714. Monday, Jan. 10, 12:30–3 p.m., Edina Library Community Rm., 5280 Grandview Square, Edina

Preparing for a Marathon Do you have a desire to finish a marathon, or are you thinking about trying one for the first time? Join Dr. Sedgley, Stillwater Marathon Medical Director, Dr. Vidlock, and running coach Kim Maxwell, MS, RRCA, as they discuss training plans, running gear, nutrition, injury prevention and treatment, and realistic goal-setting. Free, but advance registration is required. Call 651-430-4697. Tuesday, Jan. 11, 6–8 p.m., Lakeview Hospital, 927 Churchill St. W., Stillwater

55+ Dance Are you young at heart and do you love to dance? The Golden Tones Dance Band plays for you. Get exercise and have fun at the same time. $3 donation requested. For more information, please call 651298-5493. Wednesday, Jan. 12, 1–3 p.m., West 7th Community Ctr., 265 Oneida St., St. Paul

Pregnancy Loss Group Our group is for parents who have experienced a miscarriage, ectopic pregnancy, stillbirth, or newborn death. Moms and dads are invited to come together, individually, or with a family member. We provide a caring and accepting environment where we share experiences and feelings. Please check at the front desk to be directed to the room. Questions? Call 651-326-2273. Tuesday, Jan. 18, 7–8:30 p.m., St. John’s Hospital, 1575 Beam Ave., Front Desk, Maplewood

Winter Pool and Water Safety Regardless of its reputation, Minnesota’s winter recreation isn’t limited to sledding, skiing, and ice-fishing. We continue to enjoy water activities—at hotels, water parks, community pools, and health clubs, not to mention warm-weather getaways. Drowning occurs quickly and silently. About half of the children who drown are within 25 yards of a parent or other adult. In 10 percent of those drownings, the adult will actually witness the drowning, with no idea what is happening, according to the Centers for Disease Control and Prevention. A person must be able to breathe before he or she can speak. Unable to breathe, a drowning person is physically incapable of crying out for help. In pools and spas, uncovered and broken drains are extremely dangerous. Uncontrolled suction in these drains can exert a force of 500 pounds, enough to trap anyone underwater. Keep children safe around water: • Never take your eyes off children in a pool—even for a moment. Avoid distractions like texting, talking on the phone, or reading. • At all times, stay within reach of your child who cannot swim. Don’t rely on “water wings” to keep your child afloat. • Teach your children how to swim. Have your child in swimming lessons by age 4. It is a life skill. • Tell children to stay away from pool and hot tub drains. • Do not enter a pool or hot tub with a drain cover that is loose, broken, or missing. Notify the owner or operator immediately. • Tie up long hair securely to protect from drain entanglement. Visit Abbey’s Hope, a local foundation created in memory of a little girl who died as a result of being disemboweled by an uncovered pool drain, at www.abbeyshope .org to learn how to keep kids safe.

Post-Breast Cancer Support Group Your breast cancer journey doesn’t end when you’ve completed treatment. Meet with others who understand continuing challenges and successes of a breast cancer diagnosis. This group meets the fourth Monday each month. For more information, call the Coborn Cancer Center at 320-229-4907. Monday, Jan. 24, 7–8 p.m., CentraCare Health Plaza, 1900 CentraCare Circle, St. Cloud

Family Fit Force @ Laney Calling all parents: Does your family need to shape up? Fit Force provides 30 minutes of free nutrition counseling and aerobics led by a personal trainer. Classes are held Monday and Wednesday evenings. Free classes, fun prizes for kids, bus tokens, and a $20 Cub Foods certificate for every eighth class you complete. Contact Melanie Richie at 612-277-3195 for more information. Wednesday, Jan. 26, 7–8 p.m., Lucy Craft Laney School, 3333 Penn Ave. N., Minneapolis; enter through the front door and follow the signs

Jan. 27–May 3

Kids & Teens in Grief Kids & Teens in Grief is a six-week grief group for children (K–12) who have experienced the death of a loved one. The group is a collaborative project of community organizations interested in serving the needs of children and families. No cost, but registration is required. Please call 651-430-4586. Thursdays, Jan 27–May 3, 6–7:15 p.m., Boutwells Landing, 5600 Norwich Pkwy., Oak Park Heights

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

America's leading source of health information online 18

MINNESOTA HEALTH CARE NEWS JANUARY 2011

Blood cell sources from page 17

Improving outcomes

The NMDP, which has been matching patients with donors since 1987, is also dedicated to continuing research into each of these sources and the transplantaUmbilical cord blood tion process. Under its auspices, scientists have A newer source of blood-forming cells made great strides in more precisely matching used in transplants is from umbilical patients and donors, reducing complications, and cord blood of babies. Currently, this improving survival. source is used in about 20 percent of Research also has transplants. Immediately after the shown the importance of birth of an infant, the blood is collectoptimal timing: Patients who For more information ed, processed, and stored. Because it is receive transplants earlier in on the National Marrow stored and readily available, cord blood is their disease have more success Donor Program, particularly valuable for patients who need than those with advanced illness, visit www.bethematch.org. transplants quickly. It’s also valuable because regardless of the degree of the these young cells are easily adaptable and don’t match. have to match the patient’s tissue type as closely as marrow and For now, the NMDP does not recommend one type of PBSC. This holds special advantages for patients with diverse racial cell source over another. Ongoing clinical research is evaluatbackgrounds who have a more challenging time finding suitable ing the best source for each patient situation. More important matches is that, taken together, more patients—and a wider range of The adaptability of cord blood cells also reduces the chances diseases—are being treated through marrow, PBSC, and cord that a patient’s body will reject them. But if rejection or relapse does blood transplantation. occur, the patient may have to turn to another source because the Dennis Confer, MD, is chief medical officer for the National Marrow cord blood units are finite. With marrow and PBSC, patients can Donor Program, which is based in Minneapolis. ask the original donor to give again. plants using marrow. In fact, clinical studies even show that transplanted PBSCs produce healthy blood cells more quickly than the other sources.

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For directions or additional information about the Minneapolis Clinic of Neurology, visit us online at www.minneapolisclinic.com JANUARY 2011 MINNESOTA HEALTH CARE NEWS

P H Y S I AT RY

ow back pain is one of the most common and persistent health problems we humans face. Depending upon which study you reference, low back pain has a lifetime prevalence of between 60 percent and 80 percent. Studies show that about 10 percent of people with back pain will develop a chronic condition with marked disability. The good news is that 90 percent of acute low back pain episodes resolve sufficiently within a six-week period so that returning to a full life and work is possible. Yet lingering symptoms and exacerbations are not uncommon. Common types and causes of low back pain

Low back pain For most, symptoms resolve with conservative treatment By Thomas J. Cesarz, MD

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Back and nerve root pain can be frustrating and debilitating, and are the primary reasons patients come to our spine center. Pain that radiates down one leg, or sometimes both, is sometimes called sciatica because the pain can follow the course of the sciatic nerve. In actuality, this pain derives from an inflamed spinal nerve root that is commonly due to disc herniation, also known as a ruptured disc. Disc herniation (Figure 1), frequently accompanied by excruciating pain, causes patients to seek professional help, and is the focus of this article. A bulging disc, in which the disc simply extends outside the space it normally would occupy, is a common age-related finding that does not indicate an injury. Bone spurs and arthritis of the spineâ&#x20AC;&#x2122;s facet joints also commonly develop with age and are not necessarily painful. Many risk factors for low back pain have been studied, but previous back pain turns out to be the strongest predictor of future back pain. There is also a strong genetic component. Studies of identical twins have found

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similar levels of pain and disc degeneration even though smoking and workload differed. Back pain tends to peak in middle age. Smoking is especially deleterious to spine health, as it reduces blood flow and impairs healing of small injuries. Spine specialists There are multiple professionals who focus on treating the spine with varied disciplines and practice styles, ranging from chiropractors to surgeons. Spinal pain treatment as a professional discipline suffers from fragmentation in comparison to some of the well-defined treatment pathways for conditions like heart disease. There is a good reason for this. Spinal pain often has no definitive link to a demonstrable pathological condition. In other words, the cause of the pain is often difficult to pinpoint. Unlike chest pain that can be linked to a narrowed or blocked artery, back pain is not always due to a single source or structure. In some cases, back pain exists without any abnormal findings on the physical exam or radiographic studies. In addition, the cause of a patient’s pain can be explained differently depending on the specialist evaluating the patient—chiropractor, physical therapist, family physician, orthopedic or neurosurgeon, or physiatrist or pain physician. Likewise, the prescribed treatment pathway will vary depending upon the practitioner and his or her education and training. Too often, patients get whom they see rather than what they need.

FIGURE 1. Disc herniation of the low back commonly associated with low back pain.

therapy is a cornerstone of conservative treatment. It is imperative for patients to learn to move in order to return to life, and this is best taught through a guided program of physical activity. Spine-specialized physical therapy gently explores the patient’s limits of flexibility and strength with the goal of increasing function. The physical therapist ensures the safety of the prescribed exercise. Movement can be painful. Because of that, many patients erroneously believe they shouldn’t move until the pain is gone or that they should rest the painful area. A degree of pain is common and sometimes even necessary during physical therapy because muscles can rapidly weaken from inactivity, making it even more difficult to stabilize the spine and return to life. A typical course of spine-specialized physical therapy ranges, in general, from two to four weeks, followed by a recommended course of selfmanaged exercises to maintain a healthy spine. Between 75 percent and 90 percent of patients improve enough with physical therapy that additional intervention is not needed. Medication Medication is prescribed judiciously in patients with low back pain with the goal of improving function and reducing the need for more invasive procedures such as injections or surgery. Patients may be prescribed acetaminophen and non-steroidal anti-inflammatories for Low back pain to page 25

Spine-specialized evaluation and treatment Evaluation of back pain in a spine center with a conservative practice model begins with a thorough history and physical exam performed by a physiatrist, a physician who specializes in physical medicine and rehabilitation. Patients explore non-surgical interventions before progressively moving along the pathway toward more invasive types of intervention as indicated. If one is available, evaluation by a physiatrist with fellowship training in spine is recommended prior to a surgical evaluation. Patients are first screened for “red flag” conditions—dangerous causes of back pain such as disc infection, tumor, and fracture. Patients with one of these conditions require prompt treatment of the underlying condition. Others can be treated more conservatively. Education is the foundation of conservative treatment and involves explaining the process of screening and obtaining x-ray and MRI imaging as needed. Imaging commonly shows signs of agerelated degeneration including bone spurs, facet joint arthritis, and disc bulging. Such findings are common and found so frequently in asymptomatic people that they are not readily pinpointed as the cause of the patient’s pain. Patients can best understand the use of diagnostic imaging as reassurance when it does not reveal fracture, tumor, or infection. Since pain cannot always be traced directly to a structural cause—disc, nerve, or joint—it is often best treated first as a symptom, using moderate self-management techniques. We will review some of the most common treatment options for disc herniation.

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

Physical therapy Physical therapy, medication, and injections are treatment options used by the physiatrist to treat this type of low back pain. Physical

EXERTstudy.org JANUARY 2011 MINNESOTA HEALTH CARE NEWS

TA K E C A R E

here’s a simple, safe, and costeffective procedure that, if implemented on a national scale and performed roughly every five years at an average cost of $15 per household, has the potential to decrease the number of lung cancer deaths by more than 21,000 each year. For every 1,000 patients treated with this regime, it may be possible to prevent up to 27 lung cancer deaths a year in Minnesota. The procedure: testing homes for radon gas. The American Cancer Society estimates that in 2009, lung cancer killed 159,390 people, representing approximately 28 percent of all cancer deaths. It continues to be the No. 1 cause of cancer death in both men

RADON Risk reduction through patient education By Joseph Leach, MD, Michele O’Brien, MSN, ACNS-BC, AOCNS, and Andrew Gilbert

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and women, with a five-year survival rate of approximately 20 percent. There is little dispute at this point that smoking is the largest contributor to lung cancer. What’s often overlooked is that lung cancer in people who have never smoked is the seventh biggest cancer killer worldwide. Environmental hazards are thought to play an important role in the development of lung cancer in never-smokers. Reducing exposure to known environmental carcinogens is a rational strategy to reduce this burden of cancer. Unlike most cancers, the risk of exposure to the predominant environmental carcinogen in lung cancer— radon gas—can be easily tested for and, if present, eliminated. Unfortunately, public awareness of the dangers posed by this widespread toxin is low. Thousands of cancer deaths each year could be prevented if more people knew about the dangers of radon and acted on this information.

in the lowest frequently occupied level of the home for two to seven days before being sent to a laboratory for Radon gas is the second leading cause analysis. Basements are tested if the of lung cancer in our country. It is home’s occupants spend several hours the primary risk factor for non-smokeach day there; otherwise, test on the ing lung cancer and, when combined first floor. These kits offer a quick, with smoking, increases the risk of effective way to determine if your lung cancer even further. Exposure to home has a radon problem. radon in particular is often overMDH recommends that all looked as a risk factor because it is Radon building code homes, regardless of age or location, not detectable through smell, sight, As of June 2009, new homes built in the state must include be tested. The best time to test with or taste. radon-reducing features. These new home features, however, a short-term kit is during winter Radon occurs naturally in the do not always guarantee maximum risk reduction and may months because the home is closed soil throughout the country. need to be “activated” by a contractor. If your new home up. January is National Radon Action Minnesota in particular has large system has not been activated, test your home to determine if you should have a contractor activate your system. Visit Month and an ideal time to test. quantities of uranium and radium left MDH’s website at www.health.state.mn.us/radon for more Some local public health departments over in its soil from the last ice age. information. offer free or low-cost test kits to resiWhen these elements decay, they prodents. Check with your local health duce radon gas. This gas can be department to see if they offer kits. found at some level in all of the outside air we breathe, but generLong-term test kits, which generally cost from $20 to $50, ally only reaches dangerous levels in the place where we feel the are put in place for anywhere from 90 days to a year. These kits safest—our homes. provide a more accurate look at how much radon is in a home Minnesota homes are generally built with basements and tend to operate under a negative pressure in order to conserve heat dur- because they are not as sensitive to short-term variables such as temperature or weather that can sometimes affect the results of ing cold winters. This negative pressure draws air from the soil short-term test kits. under a home into its lowest level. This air brings with it all sorts of soil gases, radon Radon to page 24 being one of them. Once in a basement or lower level, radon has few avenues of escape and will accumulate to higher and higher levels. Radon in the air can be inhaled and deposited in the lungs. Keep in mind, howHave you subscribed to Minnesota’s best source of ever, that radon has decayed from uranihealth care information? To receive your personal um and radium and therefore is copy of Minnesota Health Care News each month, radioactive itself. As it continues to complete and return the form below. decay, it emits particles of alpha radiNearly 80 percent ation. When alpha particles interact of Minnesota counties are rated with lung tissue, injury to DNA high-radon zones. occurs. This increases the likelihood of mutations, which can lead to the ZONE 1: >4pCi/L development of lung cancer. ZONE 2: >2 <4pCi/L As an environmental hazard, radon appears to fall under the jurisdiction of public health. But this is not just a public health issue; it’s a personal health issue that puts many people at risk, of which Name/Title ____________________________________________________________________ most are unaware, for a lethal illness. Just as physicians and other Company ______________________________________________________________________ health care providers play a critical role in educating their patients Address ______________________________________________________________________ about the risks of tobacco and obesity, they are also in a prime City/State/Zip _____________________________________________________ position to educate their patients about the risks of radon expoPhone (________)_______________________ Fax (________)_________________________ sure and the importance of testing for it in their homes. Credit card orders may also be phoned in to (612)728-8600 Radon gas: most dangerous where we live

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Testing is the only way to determine the level of radon in a home. Fortunately, testing is easy, inexpensive, and can be done by anyone. Short-term test kits generally cost less than $15 and can be purchased online and at many hardware stores. These kits are left

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JANUARY 2011 MINNESOTA HEALTH CARE NEWS

sump pit, will be sealed to ensure maximum reduction. MDH maintains a listing of contractors who have passed a national exam certifying that they are qualified to install radon mitigation systems. Depending on the specifics, radon mitigation systems usually cost between $1,200 and $1,500. It is highly recommended that certified contractors install a system due to the special knowledge and skills required to effectively reduce radon levels in a home. A list of qualified contractors that operate in the state can be found on MDHâ&#x20AC;&#x2122;s radon website: www.health.state.mn.us/radon. The long-term impact of this intervention could prevent the deaths of thousands of unwitting victims from this unseen killer. Among the lives saved could be your own.

Radon from page 23

Radon exposure is expressed in units called picocuries per liter (pCi/L), which measure the number of radioactive disintegrations occurring in a liter of air. The EPA, while maintaining that any level of radon exposure can pose a risk, suggests that any result above 4.0 pCi/L is most dangerous. For this reason, it is generally advisable to reduce levels of radon to below 2.0 pCi/L. Once you receive your short-term test results, it will be up to you to determine how to proceed. If levels are between 2 and 8 pCi/L, you may want to perform a long-term test to get a better understanding of average annual exposure levels. You may call the MDH Indoor Air Unit at 651-201-4604 or 800-798-9050 with questions regarding your test results. If a test indicates that your home has dangerous levels of radon, you may want to consider having a radon mitigation system installed. In most cases this will involve a system, installed by a certified contractor, that is designed to draw soil gases from below the slab of your home and vent them into the atmosphere above the roofline. Additionally, cracks and openings in your slab, such as an open

Testing is the only way to determine the level of radon in a home.

Joseph Leach, MD, and Michele Oâ&#x20AC;&#x2122;Brien, MSN, ACNS-BC, AOCNS, practice with Minnesota Oncology. Andrew Gilbert works in the Indoor Air Unit of the Minnesota Department of Health.

Minnesota

Health Care Consumer December survey results... Association

3. I follow my doctor's instructions on the use of my medication(s).

36.4%

30.9%

Percentage of total responses

35 30 25 20 15

12.7%

7.3%

27.3%

25 20 14.5%

15 10.9% 10

7.3%

5 0

1-2

3-4

4. I feel confident that my primary care physician is aware of all the medications I am taking.

2. My medications create noticeable side effects. 40.0% 40

1. How many prescription medications do you take daily?

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 December survey.

4-5

Over 5

Strongly agree

58.2%

25.5% 20.0%

20 10

0.0% Strongly agree

Agree

Does Disagree not apply

50 40 30 21.8% 20

16.4%

10 3.6%

1.8% Strongly disagree

MINNESOTA HEALTH CARE NEWS JANUARY 2011

Percentage of total responses

25.5%

Strongly agree

Does Disagree not apply

Agree

Does Disagree not apply

0.0% Strongly disagree

Strongly disagree

5. I get more of my information about my medications from my clinic than from my pharmacy.

52.7%

Agree

25.5%

25 20

20.0% 18.2%

15 10.9% 10 5 0

Strongly agree

Agree

Does Disagree not apply

Strongly disagree

Low back pain from page 21

Outcomes

short periods provided there are no other medical issues for which medication would present a problem. Neuropathic pain medication (such as Lyrica or Neurontin/gabapentin) is useful in patients with nerve root pain. Those who respond well to neuropathic pain medication can often be spared injection or surgery. Pain medications such as Percocet/oxycodone, Vicodin/hydrocodone, and Tylenol/acetaminophen with codeine can be addictive and are rarely necessary to effectively manage pain.

Management of disc herniation with nerve symptoms is highly variable and ranges from immediate surgical evaluation to conservative exercise and medication treatment. The majority of cases without underlying conditions tend to heal naturally, though this can take many months. Surgery is rarely the first line treatment (with the exception of neurologic emergencies), but can be a path to more rapid resolution of symptoms in appropriate candidates. Symptoms of low back pain are common and rarely indicative of a serious medical problem. Conservative care includes physical therapy, non-addictive medications, and sometimes injections. The vast majority of patients respond well to conservative care. A thorough evaluation by a spine-specialized physician, preferably a fellowship-trained physiatrist, determines which patients are indicated for conservative care and which should be referred along the spine care pathway to explore further treatment options.

Injection therapy There are many types of injections for the spine. Some of the most effective injections, epidural steroid injections, are performed for nerve root pain. Other types of injections can be used for pain from the facet joints and sacroiliac joints. When the source of back pain is known to be the small joints in the back called the facet joints, there are effective minimally invasive procedures for long-term pain relief and management. Discuss these with your spine physician. If injection therapy does not provide relief from pain, surgery may be indicated.

Between 75 percent and 90 percent of patients with low back pain improve enough with physical therapy that additional intervention is not needed.

Thomas J. Cesarz, MD, is a spine-specialized physiatrist at Summit Spinecare in Woodbury.

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 wonâ&#x20AC;&#x2122;t even ask your name. Members receive a free monthly electronic newsletter and the opportunity to participate in consumer opinion surveys.

www.mnhcca.org

Join now.

We want to hear from you! JANUARY 2011 MINNESOTA HEALTH CARE NEWS

NEUROLOGY

Post-polio

syndrome Decades later, polio survivors challenged anew By Barbara P. Seizert, MD

In the next issue..

uring the 1940s and early 1950s, the United States experienced its worst epidemics of poliomyelitis, also known as infantile paralysis or, most commonly, polio. Nearly 60,000 cases of paralysis, the vast majority in children, and 3,000 deaths were reported in 1952. Polio could be treated, but not cured. The treatment consisted of bedrest, fluids, and, if necessary, mechanical help to breathe. Variable amounts of weakness in legs, arms, and swallowing and breathing muscles remained after the resolution of the febrile illness. Some spent their lives immobilized in an “iron lung” simply to breathe. In 1955 came the announcement that Dr. Jonas Salk had created a vaccine to prevent polio, made from an inactivated form of the virus. After the March of Dimes sponsored a mass immunization campaign, the epidemic ended. In 1958, Dr. Albert Sabin introduced an oral vaccine using live, weakened virus and polio was gradually extinguished in the United States and, eventually, most of the world. The polio virus entered the body through the mouth, and primarily infected the intestinal tract. Transmission was from fecal-oral contamination so there was a late-summer peak associated with outdoor activities such as swimming pools. During epidemics, it is estimated that 90 percent of individuals infected with the virus did not appear or feel ill in any way. This presence of large numbers of infected individuals with no symptoms enhanced the spread of the disease. Another 5 percent of individuals infected by the polio virus suffered only gastrointestinal symptoms of nausea, vomiting, and diarrhea. But in the remaining 5 percent, where the virus invaded the central nervous system, muscle weakness resulted. Most polio patients eventually regained much of their function and went on to lead active lives. Perhaps most famous among them was President Franklin D. Roosevelt. Though he downplayed—some would say hid—his polio early in his presidency, he created the National Foundation for Infantile Paralysis in 1937.

A sequel to polio

• Rheumatology • Lactose intolerance • Uterine fibroids

In the 1970s and 80s, decades after their battle with polio, survivors began to experience symptoms, some of which—muscle weakness and sometimes pain—were similar to those of polio. Along with the muscle problems came overwhelming fatigue. Post-polio syndrome (PPS) was first described in 1972 and finally was given a name at a medical conference in 1984. The diagnostic criteria are: • A prior episode of poliomyelitis with evidence of residual weakness • A period of at least 15 years after the acute onset of polio with neurologic and functional stability • Onset of new muscle weakness that persists for at least one year • Exclusion of other medical conditions that cause similar symptoms Estimates of polio survivors who fit these diagnostic criteria range from 25 per cent to 50 percent, depending on how strictly the criterion of new muscle weakness is applied. As the population ages, more cases are recognized. Risk factors for PPS include age above 12 at the time of polio, severity of the original paralysis, and greater extent of recovery from the initial paralysis. Pain, though also a fre-

MINNESOTA HEALTH CARE NEWS JANUARY 2011

apnea and daytime sleepiness. Pacing physical and mental activities by imposing rest is effective. Assessing the quality of sleep with a sleep study to rule out sleep apnea or other respiratory involvement may be beneficial. This can occur in PPS without prior respiratory or swallowing problems. Muscle fatigue and new muscle weakness have been studied extensively. Both resistance and cardiovascular types of exercise have been shown to help restore strength and prevent deterioration. Pyridostigmine has been evaluated in several controlled trials but did not statistically improve fatigue and is used on an Resource individual basis. Prednisone has not shown any benefit. A ran“Polio’s Legacy: An Oral History” domized trial found that intravenous immune globulin (IVIG) in by Edmund J. Sass, EdD, University two infusions three months apart improved median strength. A Press of America, 1996, is a smaller study found statistically significant improvement in pain compelling account of the at three months. There was no improvement in fatigue or quality Minnesota polio experience. of life in either study, however, and additional studies are needed to support use of this treatment. quent complaint of polio survivors, is not necessary for the Respiratory and swallowing problems can occur in polio surdiagnosis of post-polio syndrome. Post-polio syndrome does not vivors who had neither of these during their acute polio, or who include polio survivors who experience a modest decline in function recovered from them completely during the following 6–12 months. and strength similar to that in the general population after age 50. Treatment requires alteration in diet or even tube feeding to avoid Post-polio syndrome is a clinical diagnosis made by careful hisaspiration, the passage of food or fluid into the lungs. Aspiration tory and physical examination. Studies such as electromyography pneumonia or repeated episodes of bronchitis suggest undetected (EMG) to assess other neurological possibilities and the extent of aspiration and indicate need for study. About one-third of post-polio prior polio involvement, as well as lab tests for creatine kinase, a patients have this problem and an additional third are found to have muscle enzyme, may assist in estimating the extent of “overuse.” swallow impairments. Dysphonia (altered voice) may be treated with Overuse occurs in polio survivors due to the reduction in numbers of voice-strengthening techniques and by amplification devices. Respirnerves to the muscle and constant use of those remaining nerves and Post-polio syndrome to page 31 their muscles. Individuals who recovered all limb function and have functioned normally for years present a challenge to diagnose. EMG, along with medical records of an individual’s acute polio, may be helpful in diagnosing these cases.

Theories of what causes PPS The cause or causes of post-polio syndrome are unknown but there is support for three theories. The motor neuron, the nerve from the spinal cord to the muscle, is the chief area of loss in polio. Reinnervation, in which the body compensates for the loss by sprouting new nerve fibers or axons, leads to increased strength but also enlarges the motor neurons and the muscle groups they act on. With time, this larger motor unit fails. Overuse or underuse of affected muscles over time has been shown to predispose a former polio patient to new weakness. Some of the previously reinnervated nerve sprouts and muscle fibers die. The persistence of poliovirus and its reactivation have also been evoked to explain PPS symptoms. This theory has support from one study, but none since have supported that finding. Autopsy study on seven PPS patients supports inflammation and mechanisms related to autoimmune disease as possible causes of PPS. The spinal cord showed inflammation and cells with antibodies to nerve cells, along with degeneration of neurons.

Treatment of PPS Fatigue is one of the most common symptoms in any neurological disease, but particularly in post-polio syndrome. Amantadine and modafanil (brand name Provigil) have been used to treat PPS fatigue, but there is no clear evidence to support them. However, modafanil is still used, particularly in patients who also have sleep disorders—

Hope for Struggling Teens “I said I’d never use drugs, never pictured myself as an addict, but that’s where I ended up”. — Shane, 17 Mn Teen Challenge is a 13 month faith-based residential drug & alcohol program. While in the program, students are able to complete their high school education by attending Challenge Academy, a Minneapolis contract alternative school. If you know someone who is struggling with an addiction, please contact us. 612-FREEDOM www.mntc.org

JANUARY 2011 MINNESOTA HEALTH CARE NEWS

RESEARCH

inorities make up one-third of the U.S. population. And it has been shown that in many minority populations, cancer is caught later and has worse outcomes than in the general population. Yet less than 1 percent of participants in clinical trials come from minority populations. We need to change that. Five universities, led by the University of Minnesota, are working with a $4.1 million grant from the National Institutes of Health (NIH) to

The impact of

EMPaCT Program seeks more minority participants in clinical trials conduct research focused on increasing minority recruitment and retention in cancer clinical trials. The objective is to close the participation gap and, ultimately, increase positive outcomes for these populations. Besides Minnesota, other participants in the initiative, called Enhancing Minority Participation in Clinical Trials (EMPaCT), include the University of Alabamaâ&#x20AC;&#x201C;Birmingham, the University of Texas in Austin, the University of Californiaâ&#x20AC;&#x201C;Davis, and Johns Hopkins University in Baltimore. These institutions have experience working with minority population groups, including African American, Asian, Pacific Islander, Hispanic and Latino, and American Indian populations. The hope is that the insights gained from research at these five centers can be widely applied across the nation.

MINNESOTA HEALTH CARE NEWS JANUARY 2011

By Selwyn Vickers, MD

Changing populations It’s undeniable: Our population is shifting nationally and locally. • By 2040, the non-Hispanic white population is expected to drop to 50 percent of the total population. “Minority” populations are already the majority in several states. • In the United States, 47 percent of children under the age of 5 belong to minority groups. • Minnesota’s total minority population grew from 6.3 percent in 1990 to 11.8 percent in 2000 and a U.S. Census Bureau-estimated 14.2 percent in 2009. Our state also has the largest Hmong, Somali, and Liberian communities in the country. (See sidebar for cancer statistics for Minnesota minorities.)

Minnesota’s gaps in cancer care and treatment We have a long way to go in closing existing gaps in cancer care and treatment. Minnesota consistently rates as one of the healthiest states in the nation overall. Yet ethnic minorities, including African Americans, Asians, Latinos, and American Indians, have disproportionately higher rates of illness and death. The statistics are stark, as data from the Minnesota Cancer Surveillance System, the state’s cancer registry, indicate: • Overall cancer incidence rates are highest in African American and American Indian men. • African American men have the highest rate of prostate cancer, more than two times higher than white men. • Incidence rates for cervical cancer are more than twice as high for American Indians, African Americans, and Hispanic women as compared to the rate for white women.

Understanding the problem Although much is known about disease incidence rates in minority populations, little research exists to understand barriers and biases that limit participation and access to clinical trials. Our hope is that the results of this grant will be a step toward increasing minority participation in clinical trials. Historically, the medical community has perceived barriers to minority participation in clinical trials. These barriers date back to cases such as the Tuskegee syphilis experiment, a 40-year U.S. Public Health Service study involving 399 African American sharecroppers with syphilis, a sexually transmitted disease that can be fatal. Researchers neither told the men they had syphilis, nor did they treat their syphilis once it was discovered that penicillin could cure the disease. More recently, a similar case was uncovered in which the U.S. government supported research on sexually transmitted diseases on vulnerable populations in Guatemala from 1946 to 1948. During the course of the study, researchers purposely infected people with sexually transmitted diseases including gonorrhea, chancroid, and syphilis. As a result of this discovery, President For more information Obama issued a memorandum in November ask• For more about the Enhancing Minority Participation in Clinical ing for a panel to deterTrials (EMPaCT) initiative: mine whether standards www.med.umn.edu/che/links/ in place are sufficient to empact/home.html protect participants in • For more about health equity in research studies supported general: www.med.umn.edu/ by the federal governche/home.html ment, as well as embark • For more about the University on a fact-finding mission of Minnesota Medical School’s relating to the GuateProgram in Health Equality: malan study. www.healthdisparities.umn.edu/ Beyond the historical perception of mistrust, we haven’t really understood exactly what the other barriers are. Without this understanding, it is difficult to know how to overcome these hurdles and increase minority participation in clinical trials. To get a better sense of these obstacles, the grant will allow us

to conduct in-depth interviews to understand the internal environment at each of the five institutions. We will talk to the directors of the cancer centers and to clinical trial investigators to find out what barriers they experience, as well as what resources are available for the recruitment and retention of minorities in clinical trials. For example, having reliable access to interpreters could potentially increase the pool of minority patients who do not speak English. The combined results of our investigations will give us a sense of the national picture. The impact of EMPaCT to page 30

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JANUARY 2011 MINNESOTA HEALTH CARE NEWS

The impact of EMPaCT from page 29

Second, we will be speaking with minority groups in each of the five areas served by the participating organizations to candidly ask what prevents minority patients from seeking out clinical trials. This will help us understand the realities and concerns of each minority group. We will also connect with referring physicians to get their insight on why their patients may choose not to be a part of clinical research. The hope is that this external environmental scan will point us in possible directions to find solutions or approaches to increase minority participation.

Less than 1 percent of participants in clinical trials come from minority populations.

Designing strategies to address barriers After we gather information from our internal and external scans, we need to share the information and get feedback from our peers. We will start with cancer centers that have been designated by the National Cancer Institute as comprehensive cancer centers to design next steps and models that can be replicated to address this national problem. Each center may require a different combination of models to be successful in recruiting and retaining minorities in clinical trials.

For example, one approach that has been used in cancer treatment overall is the patient navigator system. Some cancer centers assign newly diagnosed patients a “navigator” who helps them through the treatment process by providing support and helping them overcome various barriers, whether related to finances, or transportation, or the health care system as a whole. We will be looking at whether this type of personal support might work in guiding people through the clinical trial process. More to come

The hope is that this is just the beginning. After we gather the information and come up with replicable models, we hope to garner additional grant support that would allow each of the five sites to reach out to other cancer centers in their regions. Selwyn Vickers, MD, is principal investigator of the EMPaCT program. He is the Jay Phillips Professor and Chairman of the Department of Surgery at the University of Minnesota Medical School, and specializes in pancreatic, bile duct, and gastrointestinal cancer.

WHO’S GOT BETTER MOVES ON THE DANCE FLOOR, YOU OR ME? Every day is a reason for a person with Down syndrome to smile. And find joy in things the rest of us often overlook. To learn more about the richness of knowing or raising someone with such an enthusiasm for life, call your local Down syndrome organization. Or visit ndsccenter.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 30

MINNESOTA HEALTH CARE NEWS JANUARY 2011

patients first appear. This may be due to the loss of regular weightbearing and exercise in the affected limb and overall. Exercise to improve muscle strength can be difficult when one or both lower extremities are paralyzed. Warm-water exercise can soothe painful muscles. Patients also Pacing physical benefit from a physical therapy program adapted to individual and mental requirements.

Post-polio syndrome from page 27

atory symptoms may emerge with subtle changes of endurance and breathlessness with exertion. Early intervention of respiratory support such as nasal oxygen or use of a machine that exerts positive airway pressure has been found to help PPS patients with respiratory dysfunction and may help avoid tracheostomy. Pain is managed by bracing, exercise, surgery, and medication. Scoliosis, cervical or lumbar stenosis, joint osteoarthritis, knee hyperextension (the knee bends backwards), and back pain all occur at earlier ages and present more diagnostic challenges for people with PPS. Tendon transfers, ankle fusions, and spinal fusions done at the time of polio may break down and require treatment. Bracing the ankle with a custom-molded, energy-storing carbon fiber brace addresses foot drop and weakness in the calf muscles. It can also support knee extension. Leg length discrepancies that have gradually promoted selective joint overuse in the longer leg may require lifts. Newer, lightweight braces can assist in knee extension when the quadriceps are weak. Prevention of falls is paramount. The casting and immobilization of a bone broken in a fall is frequently given as the historical point when the symptoms of weakness and fatigue in post-polio

activities by imposing rest is effective in treating fatigue from post-polio syndrome.

Personality traits of polio survivors

The medical community has observed that polio survivors tend to demonstrate determination and drive, as well as a higher-than-average tolerance for pain. These traits have assisted many of these individuals in taking excellent care of themselves. When confronted with new symptoms, this group of fighters tends to accept the challenge again and work hard to avoid additional disability. Barbara P. Seizert, MD, specializes in physical medicine and rehabilitation at Sister Kenny Rehabilitation Institute at Abbott Northwestern Hospital, and Children’s Hospitals and Clinics of Minnesota.

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F E AT U R E

How I got here Diverse paths led physicians to medical specialties “The very first step towards success in any occupation is to become interested in it.” So said the eminent physician William Osler, and his words still ring true more than a century later. With that in mind, we asked several physicians to tell us how they first became interested in their specialty.

David Feldshon, MD Gastroenterologist, Minnesota Gastroenterology, St. Paul Years in practice: 29

Independent Practitioners ... freer to give you: More Attention More Choices And be your best Advocate

How/why did you choose your specialty? I had little input into the decision regarding my primary specialty, internal medicine. I went through all my medical school rotations and found that I enjoyed all of the surgical specialties. However, surgical specialties were looked down on at my medical school. I went along with the flow and found myself at the end of a three-year internal medicine residency unhappy with my choice of a career. Finally, I decided general medicine was not for me. I took a year as a senior resident, tried several subspecialty rotations, and then decided what I liked the best. Nothing else mattered except that I liked it and found it to be fun. I kept coming back to gastroenterology (GI). It is the surgical end of medical specialties and fit my personality perfectly. I was accepted to a fellowship program, I signed up, and the rest is history. Rewards/challenges: GI, like many procedural specialties, allows the satisfaction of working with one’s hands and achieving something. Whether it’s as simple as carving off a polyp, or more complicated, like taking stones out of a bile duct, the work is always rewarding. I have found two challenges in my specialty. One is keeping up with the literature. It is a requirement. The greatest challenge, however, is dealing with adversity. It is an incredible challenge to keep your wits about you when a complication occurs or when, despite your best efforts, a patient deteriorates. No one practices perfect medicine, but I truly believe that we must learn from every adversity and use it to improve our practice. What lies ahead? Like every specialty, gastroenterology will contin-

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MINNESOTA HEALTH CARE NEWS JANUARY 2011

ue to become more complex and move beyond my ability to practice all parts of it. I have already selected certain areas that I enjoy more than others and am moving towards spending more of my time in these areas. The future is limitless. Endoscopic ultrasound allows diagnosis and staging more rapidly than ever before. We have new treatments for liver disease that were unheard of when I started my fellowship. Most importantly, I continue to love what I do every day.

Jill Funk, MD Pediatrician, Fridley Children’s and Teenagers’ Medical Center, Fridley Years in practice: 2

How/why did you choose your specialty? Pediatrics probably seemed like the obvious choice for someone who had an interest in medicine and grew up surrounded by children. I am the youngest of nine girls and at a very young age became an aunt to a lot of nieces and nephews. I do remember the moment when becoming a pediatrician became obvious to me. I was in high school, and my nephew Josh had just been diagnosed with a Wilm’s tumor. My parents and I went to visit him. As I walked into the children’s hospital, I had an overwhelming feeling that this is where it is. This is where science and the human spirit are pushed to the limit, taking on the ultimate challenge, to bring the best medical care to the most fragile of human life. I wanted to be one of those doctors who go to work every day with that mission. During my obstetrics rotation, when I was assisting a delivery, I carried the newborn baby over to the warming table and

started checking him over, just as I had learned during my pediatrics rotation. Soon, the obstetrician had to gently remind me to come back to the mom—that she was my primary patient. My heart was telling me otherwise. Rewards/challenges: Those precious little patients do bring some daily challenges—the crabby toddler who won’t let me look in her ears, the parents who question every single vaccine, and the insurance company that doesn’t seem to understand that a 3-year-old can’t swallow a capsule. However, the rewards are many. It’s almost impossible for me to have a bad day when all I have to do is walk into my next exam room and see my bald, chubby patient light up and smile at me when I walk in the door.

What lies ahead? Childhood diseases are changing. We see more and more children struggle with obesity and, with it, the problems that we used to see only in adults, such as hypertension, and type 2 diabetes. How children receive care is changing as well. As pediatricians we advocate for children to have a medical home, a single doctor or clinic that knows them well and helps coordinate all of their care. The expansion of retail-based clinics is a huge threat to this care model. Hanging right above my desk is my Pediatric Board Certification. It bears the phrase, “Jill Funk, MD, has been elected fellow of this academy, founded to foster and stimulate interest in pediatrics and in all aspects of the work for the welfare of children.” It is a constant reminder that my scope of practice goes beyond my office; it is my duty to advocate for all children. How I got here to page 34

JANUARY 2011 MINNESOTA HEALTH CARE NEWS

Anne Murray, MD, MS Geriatrician and epidemiologist, Hennepin Faculty Associates Senior Care Clinic, Minneapolis Years in practice: 20

How/why did you choose your specialty? I have two strong passions: geriatrics and epidemiology of dementia research. My maternal grandmother had a profound influence on my life and desire to be a geriatrician. Mary Rielly was the grand matriarch of our extended Irish family. She passed on her drive, love of learning and teaching, and desire to speak her mind to her numerous female grandchildren and greatgrandchildren. In medical school at the University of Minnesota, I enjoyed working with the older patients the most because they taught me so much. They appreciate so many of life’s daily gifts and the smallest things we do for them, things I believe much of our generation has lost the ability to appreciate. During my residency in internal medicine at the Mayo Clinic, I was torn among psychiatry, infectious disease, and geriatrics. It turned out that geriatrics was a nice combination of psychiatry (lots of depression and

dementia) and natural history of disease: You have to be a detective to string together the telltale and missing pieces of history to explain the presentation of acute or chronic diseases. My passion for research was kindled during my fellowship in geriatrics at Harvard, when I was exposed to the East Boston Study of dementia. I completed a master’s in epidemiology at the Harvard School of Public Health, where I was incredibly fortunate to be taught by many of the true masters of epidemiology. Rewards/challenges: I am still fascinated by dementia, the challenge of trying to understand what brain pathology can explain specific cognitive symptoms, and figuring out how to maintain the patient’s function at the highest levels possible. Clinically, my biggest challenge is working with patients’ families to manage their medications. It often takes about a year and two hospitalizations to convince the patient and the family that they need to have the medications administered by home health care to prevent falls, hospitalizations, and death.

REGENCY

H OSPITAL

The greatest challenge in my research career has been designing a way to combine my love of caring for patients with dementia with my passion for dementia research. What lies ahead? The biggest

challenge in geriatrics will be to recruit trainees into geriatric fellowships and to keep the current fellowships going. Residents are reluctant to go into geriatrics because they cannot make enough to repay their medical student loans quickly, due in part to extremely poor Medicare reimbursement for geriatric care. The ongoing challenge in my research career is to continue to write grants to fund my research, and to catch up with my long list of unwritten manuscripts for publication. Another challenge is getting a newly funded, seven-year NIH study called ASPREE (aspirin to prevent events in the elderly) off the ground. We are conducting the study to enroll 18,500 “healthy” subjects 70 and older to see if low-dose aspirin decreases the risk of cognitive and physical function decline. It’s a tremendously exciting study with very broad implications.

M IN N EAPOL IS

Giving People Their Lives Back Regency Hospital of Minneapolis is an intensive critical care hospital serving the needs of medically complex patients that require acute level care for a longer period of time than traditional hospitals are set up to provide. We are a national network of hospitals with a different way of thinking, a different way of caring, and a different way of treating, and it shows in everything we do.

R E G E NC Y PRO G R A M S A N D SE RV IC E S Pulmonary/ventilator program Medically complex/multi-system failure program Wound care program (stage III and IV decubitus) Low-tolerance rehabilitation services Regency Hospital of Minneapolis 1300 Hidden Lakes Parkway Golden Valley, Minnesota 55422 Main: 763.588.2750 Referral: 763.302.8340

MINNESOTA HEALTH CARE NEWS JANUARY 2011

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.

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

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Model is for illustrative purposes only.

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For formulary access specific to your area, visit www.novomedlink.com. *Intended as a guide. Lower acquisition costs alone do not necessarily reflect a cost advantage in the outcome of the condition treated because there are other variables that affect relative costs. Formulary status is subject to change. Reference: 1. Data on file. Novo Nordisk Inc, Princeton, NJ.

October 2009