Minnesota Health care News July 2012 by Minnesota Physician Publishing

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FREE July 2012 â&#x20AC;˘ Volume 10 Number 7

Smoking and oral health Laura Howley, DDS

Drug shortages Sen. Amy Klobuchar

Childhood wellness Robert Jacobson, MD

You call it â&#x20AC;&#x153;reminding mom to take her pills.â&#x20AC;?

We call it caregiving.

You or someone you know may be a caregiver. WhatIsACaregiver.org

CONTENTS

4 7 8

JULY 2012 • Volume 10 Number 7

NEWS

PEOPLE

PERSPECTIVE Envoy William Miller Harbor Light Center

10 QUESTIONS Mark Bergeron, MD, MPH Associates in Newborn Medicine, PA

POLICY What Washington is doing By U.S. Sen. Amy Klobuchar

14 16 18

PHYSICAL THERAPY Knee replacement By Rick Hjelm, PT

CALENDAR National Cleft & Craniofacial Awareness & Prevention Month

PEDIATRICS Know your child’s numbers By Robert M. Jacobson, MD, FAAP

DENTAL HEALTH Smoking and oral health By Laura Howley, DDS

SPECIALTY CARE Hyperbaric oxygen therapy By Cheryl Adkinson, MD, FACEP

ARCHITECTURE 2012 Honor Roll

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

To CHANGE your life (For the better)

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

Advisory Board: Minnesota Medical Association (MMA), Minnesota Hospital Association (MHA), Minnesota Medical Group Management Association (MMGMA), Buyers Health Care Action Group (BHCAG), Minnesota Business Partnership (MBP), Minnesota Healthcare Network (MHN), Advocates for Marketplace Options for Mainstreet (AMOM), Minnesota HomeCare Association (MHCA), Minnesota Physician-Patient Alliance (MPPA), Physicians Service Network (PSN), Minnesota Center for Rural Health, and Minnesota Council of Health Plans. Minnesota Health Care News is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; phone (612) 728-8600; fax (612) 728-8601; email mpp@mppub.com. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc., or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of this publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $36.00. Individual copies are $4.00.

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JULY 2012 MINNESOTA HEALTH CARE NEWS

NEWS

Supreme Court Ruling Leaves Health Law Largely Intact On June 28, the Supreme Court issued its long-awaited ruling on President Obama’s Affordable Care Act (ACA). The 5-4 decision upheld most of the ACA’s health care reforms. The court upheld the key provision known as the individual mandate, which requires virtually all citizens to buy health care insurance. That provision is considered by many to be the pillar of health-care reform legislation. In addition, the court let stand the ACA’s major expansion of the government-funded Medicaid program. However, the ruling allows states to choose whether or not to expand their own Medicaid programs, without facing the financial penalties called for by the ACA. Minnesota commissioners Lucinda Jesson of Human Services, Mike Rothman of Commerce, and Ed Ehlinger

of Health, released a statement calling the ruling “an affirmation of the reform efforts currently underway in Minnesota to improve health and lower the cost of care. The ruling signifies real progress and important protection for citizens across Minnesota: affordable insurance for small business, young people can stay on their parents’ insurance until age 26, and guaranteed coverage for those with pre-existing conditions."

Health Care Homes Serving 2 Million Minnesotans More than 2 million Minnesotans are served by health care homes, according to the Minnesota Department of Health (MDH). The health-care home model was adopted as part of reforms passed by the Minnesota Legislature in 2008, and state officials say that since then, 22 percent of clinics in the state have been certified as health care homes.

The model provides a coordinated, patient-centered primary care approach that stresses prevention and chronic disease management, officials say. Health reformers see health care homes, along with innovations such as accountable care organizations, as a key part of improving the quality of care while bringing down health care costs. “Enhancing and transforming primary care is central to Minnesota’s health-care reform efforts,” says Ed Ehlinger, MD, Minnesota commissioner of health. “This is a significant milestone in our efforts to help clinics adopt an approach that puts the patient at the center of a care team dedicated to meeting the patient’s health goals.” The 2 millionth patient mark was reached sometime in 2011, according to an MDH report submitted to the Legislature this spring. Clinics qualifying for health-care home certification must provide 24-hour access, maintain a method of tracking patient health histories, monitor

and report the clinic’s quality performance, and provide care planning and coordination to patients. The report finds that state programs have approximately 135,000 enrollees, or 18 percent of those on public health plans, served by health care homes. “We are committed to supporting health care homes as the crucial delivery model of a new health system,” says DHS Commissioner Lucinda Jesson. “In this practice model, health care is integrated at the primary care site for all medical care. Even beyond these health care services, health care homes are the right partners to integrate medical and community services to provide care for the people and families we serve.”

Company Executives Apologize at Franken Hearing Officials with Accretive Health and Fairview Health Services offered public apologies for their debt col-

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lection practices at a dramatic public hearing chaired by Sen. Al Franken recently. The hearing came after Accretive and Fairview were the subject of a scathing report by Minnesota Attorney General Lori Swanson, which accused the two companies of violating patient privacy laws. Minneapolis-based Fairview has since cut ties with Accretive and effectively fired Fairview CEO Mark Eustis, who was instrumental in forging a partnership with the Chicago-based firm. At the May 30 hearing, Franken said he was exploring whether federal laws were needed to protect people from the kind of high-pressure tactics Accretive is alleged to have used with Fairview patients, some of whom were waiting for treatment in emergency rooms. “Being in the hospital is a stressful experience. When you or someone you love are in urgent need of care, nothing else matters,” Franken said. “At that moment, the last thing on your mind is your wallet. … I would find it absolutely abhorrent if patients had been badgered by debt collectors in the emergency room or if patients had been given the impression they wouldn’t be seen unless they had prepaid for their care. That type of activity is not acceptable anywhere and certainly not acceptable here in Minnesota.” The hearing included testimony from two patients, as well as from Swanson and Minnesota Commissioner of Commerce Mike Rothman. But the executives from Accretive and Fairview received the most pointed questions. Fairview Board Chair Greg Mooty, who will become interim CEO when Eustis steps down on Aug. 1, spoke at the hearing and offered a personal apology for the practices outlined in the report. “Moving forward, Fairview leadership and governance members are going to do a better job of listening to and acting upon patient and staff concerns and recommendations,” he said. Gregory Kazarian, senior vice president and corporate responsi-

bility officer for Accretive, said his company was working to address the issues discussed at the hearing. “Many of the allegations we’ve heard here this morning are deeply troubling,” he said. “To any patient who experienced any interaction with us or with Fairview employees that lacked compassion and professionalism, we apologize.” Franken wrapped up the hearing by saying health care organizations should foster a corporate culture that doesn’t allow employees to unfairly pressure patients during stressful times. “It really seems like something went wrong here,” he said. “It seems to me there is a right way and a wrong way, a right time and wrong time, to do these things.” Franken added he would continue to investigate the matter and possibly introduce legislation to address the issue.

Applications for DHS Programs Available Online The Minnesota Department of Human Services (DHS) has streamlined its application for public assistance programs. People applying for public health plans can now simultaneously apply for other programs, and vice versa. The ApplyMN form is available online at applymn.dhs.mn. gov, and will allow state residents to fill out a single online application for a range of programs. “ApplyMN is an easy, secure way for Minnesotans in need to apply for assistance from more than one program,” said Human Services Commissioner Lucinda Jesson. “This will streamline the application process, increase administrative efficiencies, and is an important step in our effort to make government easier to navigate.” The new online form is a “smart application” that asks applicants questions and can show them what programs they are eligible for. Although paper applications

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News to page 6 JULY 2012 MINNESOTA HEALTH CARE NEWS

News from page 5 will still be available to those applying for state programs, experts say there are several advantages to using the online approach. “ApplyMN will be a useful tool for clients to be able to fill out an application on the Internet and immediately submit it, and not have to incur the cost of driving to the county office to turn in a paper application or return it by mail,” says Khou Vue, outreach specialist with Second Harvest Heartland.

Essentia Launches Telemedicine Project A new telemedicine project is connecting patients and physicians in Aurora to specialists in Duluth. The program was launched by Duluth-based Essentia Health in January and uses cameras, microphones, and a secure network connection to allow specialists at Essentia Health–St. Mary’s Medical Center in Duluth to assist physicians at Essentia Health–

Northern Pines in Aurora. The program allows heart attack patients who come to the emergency room at Northern Pines, a 16-bed critical access hospital, to have access to specialists at St. Mary’s. “Telemedicine in the ER is beneficial to patients because we will be able to collaborate with the emergency room specialists in Duluth directly and they will actually have eyes on the patient at the same time that we do,” explains Dr. Michelle Oman, an Essentia Health physician based in Aurora. “The St. Mary’s physicians can help us through procedures and processes, and they’ll be ready to accept the patient if we are transferring them to Duluth.” Essentia also launched a similar program in February, which allows health care providers caring for hospitalized patients in Aurora to consult with an internal medicine physician and hospitalist in Duluth.

Union, Hospitals Reach Contract Deal The union representing hospital workers in eight metro-area hospitals recently voted to accept a new contract. Service Employees International Union Healthcare Minnesota (SEIU HCMN) had earlier voted to go on strike after the old contract expired in February and new talks had not been productive. But a breakthrough allowed the union to recommend ratifying the contract, and on May 23, the union announced its 3,500 members had “overwhelmingly” accepted the new terms. SEIU HCMN members say the original contract represented significant cuts, which would put low-wage workers at risk. “While the hospitals were asking us workers to work more for less, we were simply trying to hold the line on proposed cuts that would have reduced benefits like overtime and health insurance. I’m satisfied with what we protected and achieved,” says Jermaine Rayford,

a longtime cook at Fairview Southdale Hospital. The hospitals affected by the strike were Fairview Southdale Hospital in Edina; University of Minnesota Medical Center, Fairview, in Minneapolis; Children’s Hospitals in Minneapolis and St. Paul; HealthEast’s Bethesda Hospital in St. Paul and St. John’s Hospital in Maplewood; North Memorial Hospital in Robbinsdale; and Park Nicollet/Methodist Hospital in St. Louis Park. The workers include dietary aides, ER techs, food service workers, maintenance personnel, registration staff, and nursing assistants. The hospitals involved in the negotiations expressed satisfaction with the final contract. “Our hospitals truly value our employees and we are pleased that they voted to ratify this contract,” a statement says. “Side by side, day after day, we work with our service coworkers—we are proud of their dedication and the service they provide to our health care communities.”

Now accepting new patients

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

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

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

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

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

MINNESOTA HEALTH CARE NEWS JULY 2012

PEOPLE The National Association of Pediatric Nurse Practitioners (NAPNAP) has presented its Loretta C. Ford Distinguished Fellow Award to Patsy Stinchfield, RN, MS, CPNP, director of infectious disease and immunology at Children’s Hospitals and Clinics of Minnesota. NAPNAP annually presents the award to the individual who has made significant contributions to children’s health Patsy Stinchfield, RN, MS, CPNP

and has helped advance the pediatric nurse prac-

titioner profession. Stinchfield has become nationally recognized for her dedication to infection prevention and improving Minnesota’s vaccination rates. Michele O’Brien, RN, CNS, survivorship navigator at Minnesota Oncology’s Edina clinic, recently attended a three-day course for professional nurses on survivorship care. The course, held in New York City, was hosted by City of Hope Cancer Center, Sloan-Kettering Cancer Center, and the National Cancer Institute. O’Brien was one of 50 competitively selected nurses from around the United States. The principal goal of the seminar was to provide nurses with information on survivorship care issues and resources to help implement goals aimed at improving survivorship care in their own practices and cancer care settings.

Michele O’Brien, RN, CNS

A top immunization expert in Minnesota has been named the state’s recipient of the first Childhood Immunization Champion Award from the federal Centers for Disease Control and Prevention (CDC). Diane Peterson, associate director for immunization projects with the Minnesota-based Immunization Action Coalition, won the CDC award for Minnesota. The award recognizes individuals who make a significant contribution toward improving public health through their work in childhood immunization. The CDC cited Peterson’s work “not only

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on speaking to parents about the importance of childhood immunization, but also on assisting with the development of immunization legislation. She also created the plan for implementing the Vaccines

EARLY DETECTION MATTERS

for Children program in Minnesota. For nearly 20 years, this program has provided 40 to 50 percent of the state’s children with the vaccines they need.” Three psychiatrists from Minnesota were among 17 nationwide honored by the National Alliance of Mental Illness (NAMI) at its annual conference in Philadelphia. The annual Exemplary Psychiatrist Awards recognize psychiatrists who go the extra mile in providing care, reducing the stigma surrounding mental illness, and working in their communities to provide public education and advocacy. The three Minnesotans selected for the award were Ivan Sletten, MD, from Stillwater; Scott Crow, MD, from Minneapolis; and David Einzig,

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MD, from St. Paul. Jaimi Anderson, certified nurse practitioner, has joined Clinic Sofia, an ob-gyn clinic. Anderson will work at the clinic’s recently opened facility near Maple Grove Hospital. Anderson brings nearly 20 years of experience in caring for all aspects of women’s health. Previously a nurse practitioner at an ob-gyn clinic in Edina, she has also supported women’s health needs through her work at the Center for Reproductive Medicine and the Midwest Center for Reproductive Health. She holds a nursing degree from the University of Minnesota and nurse practitioner certification through the Women’s Health Care

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PERSPECTIVE

Harbor Light Center The first clinic in Minnesota specializing in providing health care to the homeless

ince 1886, the Salvation Army has served the most vulnerable members of our community by meeting basic needs and offering dignity to every guest at multiple locations across the state, including Harbor Light Center in Minneapolis. Here, at the oldest and largest homeless shelter in the state, we offer spiritual support, meals, transitional housing, and chemical dependency treatment.

Envoy William Miller Salvation Army

Envoy William Miller has served as the executive director of The Salvation Army Harbor Light Center since 2001. One of Harbor Light Centerâ&#x20AC;&#x2122;s partners is Northwestern Health Sciences University (NHSU). Initially, NHSU acupuncture interns delivered free care to shelter guests and the public. Supervised by licensed instructors, acupuncture students attained required internship hours and clients received the health benefits of free treatment. This pilot program was so successful that permanent space for acupuncture was added.

Many of those receiving social services at Harbor Light Center also need health care. Since this location houses as many as 650 guests each night, it is an ideal location for many ad-hoc medical services, including health screenings and immunizations. Through informal collaborations and our deeper partnerships, Harbor Light Center is committed to improving the health and quality of life of all its guests by serving as a center for integrated care of the whole person. Health care becomes available

illness and those who have been recently discharged from the county hospital are provided service in partnership with the shelter, where designated rooms are set aside for respite care. In coordination with medical services, county social workers conduct eligibility determinations for public benefits and initiate case management. This program serves more than 4,000 clients annually through more than 10,000 patient visits. As a result, homeless individuals receive more care, experience better overall health, and utilize emergency health care resources much less than if they had to seek emergency care on their own. Partnerships, services, expand

In 2008, the NHSU acupuncture clinic added chiropractic care. Interns gain experience assessing and treating patients with complex medical conditions and diverse psychosocial needs, and clients benefit from holistic care. In 2011, this clinic served 400plus clients through more Light Center than 2,000 visits.

In 1988, Harbor Light Center Harbor hosted the first clinic in is committed to Minnesota that specialized in In 2011, Hennepin County providing health care services launched a new program, improving the health to homeless individuals. Hennepin Health, to serve the and quality of life Hennepin County Healthcare unique needs of the most for the Homeless Project, a challenging and costly segof all its guests. federally funded program, ments of the countyâ&#x20AC;&#x2122;s safetyderives its capacity to meet net population, many of the needs of homeless individuals and families whom use shelter services at Harbor Light Center. from its unique organizational structure. By integrating medical, behavioral health, and Healthcare for the Homeless partners with other county programs, such as those providing mental health, chemical health, economic assistance, and foster care, and with Hennepin County Medical Center. This cooperation makes it possible to provide a seamless continuum of care. Shelter guests undergo a thorough screening process at the shelterâ&#x20AC;&#x2122;s walk-in clinic, after which appropriate service entities are engaged based on assessed needs. Staffed primarily by nurse practitioners and supervising physicians, Healthcare for the Homeless decreases barriers to health care by bringing critical services to the target population. Its service model includes providing acute medical care, including diagnosis and treatment for illness and injury; care for chronic medical conditions; preventive exams; immunizations; and health screenings. Homeless individuals recovering from acute

MINNESOTA HEALTH CARE NEWS JULY 2012

human services in a patient-centered model of care, Hennepin Health seeks to improve health outcomes dramatically and to lower the total cost of providing care and services to this population. Hennepin Health representatives at the shelter facilitate enrollment into this benefit-rich, coordinated health services model, free to anyone living below 75 percent of the federal poverty guideline. This population often receives minimal preventive care, is at high risk for acute-care needs, and has poor health outcomes and health status. This is precisely the population that will benefit most from the proactive, comprehensive, and integrated care management offered by this project. For more information, visit www.thesalarmy.org/harborlight and www.nwhealth.edu/salvation-army/

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

www.good-sam.com

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

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

10 QUESTIONS

High-risk infant care Mark Bergeron, MD, MPH Dr. Mark Bergeron practices neonatology with Associates in Newborn Medicine, PA, at Children’s Hospitals and Clinics of Minnesota–St. Paul, Regions Hospital, HealthEast St. John’s, St. Joseph’s, and Woodwinds Hospitals. He is immediate past-president of the Minnesota Perinatal Organization. What does a neonatologist do? A neonatologist is a pediatrician with additional training in neonatal-perinatal medicine. We deliver comprehensive medical care to newborn infants and work in special nurseries called Neonatal Intensive Care Units (NICUs). While some of our patients are in the NICU for just a few days, many require treatment for weeks or months. Many neonatologists provide developmental assessments in NICU follow-up clinics to former preterm infants at risk for developmental problems. What are the leading preventable causes of premature births? We don’t know what causes premature birth in most cases. Intrauterine infection is often implicated as a cause. For some women, the cervix or uterus has difficulty functioning normally to maintain a pregnancy for the full 40 weeks. None of these causes is usually preventable, however. What is preventable is elective induction or cesarean section deliveries before term, especially in the absence of a medical indication. Hospitals in Minnesota, along with the Minnesota Department of Human Services, are working together to reduce preterm birth by enacting policies preventing unnecessary early deliveries. Smoking and poor nutrition during pregnancy negatively impact a developing fetus and increase the risk of preterm delivery. How do neonatologists interact with other medical professionals? When a problem is discovered during pregnancy by an obstetric provider, we are often consulted to meet with the family and describe management of the newborn’s anticipated problem even before birth. We usually first encounter our patients in the delivery room or upon arrival in the NICU. We are often consulted by physicians at other hospitals to arrange transport of an ill infant to our NICU by specialized neonatal transport teams. We work with other pediatric specialists in cardiology, pulmonology, surgery, neurology, and other personnel, to coordinate care of complex patients. We also coordinate with pediatricians and family practice providers in the community to transition care once an infant is ready for discharge from the NICU. We work closely with nurses, neonatal nurse practitioners, respiratory therapists, and other professionals to deliver care around the clock.

Photo credit: Bruce Silcox

Perhaps the most difficult challenge a neonatologist faces is when there is no hope for a neonate’s survival. What can you tell us about this? It’s true that this is the toughest part of our role. In those situations our job is clear, however. We continue to ensure our patients’ comfort and evaluate the situation to ensure we avoid causing suffering. We can often provide precious time for families to spend with their baby, which is an irreplaceable gift. In those situations, our NICU patient room transforms itself from a high-tech, seemingly machine-driven environment to a calm, soft, warm place where parents can touch and hold and experience their infant for as long as possible. Is the need for neonatologists increasing? According to the American Academy of Pediatrics (AAP), there are over 4,000 neonatologists in the United States, for a ratio of about 1,000 live births per neonatologist. The AAP estimates the median age of neonatolo-

MINNESOTA HEALTH CARE NEWS JULY 2012

gists to be 53 years. I think the need for neonatologists will be stable, if not grow.

Smoking and poor nutrition increase the risk of preterm delivery.

How has survival for premature births changed in the past 50 years? The term “neonatologist” was coined in 1960. Since then, we’ve seen a dramatic improvement in survival and outcomes of preterm infants. Development of mechanical ventilators specifically for newborn lungs, antenatal steroids, and the availability of animalderived lung surfactant allow us to save babies who previously would have died because their lungs were too immature, even 15 to 20 years ago. Today, some of the tiniest babies survive after birth at 23 weeks’ gestation, and even, rarely, at 22 weeks, with birth weights as little as 14 ounces. Survival for these tiniest patients is not a given, and those that do survive face a high likelihood of neurological impairment. However, for patients at 24 weeks or beyond the prognosis continues to improve, with survival around 70 percent or greater and the majority without severe impairment. At or beyond 28 weeks the survival is well over 90 percent, with most of those kids developing without any major problems. What percent of babies who need neonatology care have lifelong problems? The vast majority of infants requiring neonatology care do not have lifelong problems. Even those we see in follow-up with developmental delays often “catch up” with therapies through early intervention programs. Please share some of your favorite success stories. It’s a privilege being part of an infant’s care and interacting with his or her

family for a relatively short period of the child’s life during the NICU stay. However, during that time, bonds are definitely formed and to see these kids with their families in follow-up clinic or even on the playground at my own children’s school is the best feeling in my profession. Recently, I got a hug from one of my former NICU patients, now a toddler. It felt like a million bucks! What are the newest advances in your field? The newest exciting treatment options involve treating infants who have received brain injury from lack of blood flow or oxygen around the time of birth. We now have a program to cool these infants for 72 hours and reduce their brain injury, dramatically improving their brain’s recovery and neurologic outcome. We can continuously monitor their EEG tracing [an image of the brain’s electrical activity] right at the bedside. New ventilators help us treat immature lungs gently to improve lung development, and we’re looking at new ways of supporting an infant’s fragile lungs without having to place them on the ventilator in the first place. What do you want people to know about neonatology? There’s a misconception that the NICU is a sad place. While there are some sad family stories, most of my patients have very happy endings; the NICU is a place where you feel the hope all around you. I work with the most dedicated team of professionals, with endless amounts of compassion and optimism, and that drives an incredible level of care for our patients and families.

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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. JULY 2012 MINNESOTA HEALTH CARE NEWS

POLICY

What Washington is doing

innesota is a state that rightly prides itself on providing top-quality, efficient health care. Our hospitals, nurses, and physicians have consistently been recognized as a model for patient-driven care that promotes both quality and efficiency. I think the rest of the country could learn a few things from Minnesota, especially as we continue to face challenges in our nation’s health care system. Recently, I’ve been hearing about the current crisis involving shortages of many major drugs. Here’s what we’re doing in Wash-ington to ensure that patients, providers, and pharmacists continue to have access to affordable drugs. Drug shortages

Ensuring medications are available, affordable, and effective By U.S. Senator Amy Klobuchar

Last year I had the opportunity to meet Axel Zirbes, a cute 4-year-old boy from Minnesota. Axel has bright eyes and a big smile. He also happens to have no hair on his head. That’s because Axel is being treated for leukemia. When Axel was scheduled to start chemotherapy last year, his parents learned that an essential drug (cytarabine) was in short supply and might not be available for their son. Understandably, they were thrown into a panic and desperately looked for any available alternatives. They even prepared to take Axel to Canada, where the drug was still readily available. Fortunately, it didn’t come to that. At the last minute, the hospital was able to secure the medication from a pharmacy that still had a supply. But Axel and his parents aren’t alone.

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MINNESOTA HEALTH CARE NEWS JULY 2012

Across the country, patients, hospitals, physicians, and pharmacists are confronting unprecedented shortages of important medications, especially for cancer. Many of these are generic drug products that have been widely used for years and are proven effective. The number of drug shortages has nearly tripled over the last six years—jumping from 61 drug products in 2005 to more than 200 in 2011. A survey by the American Hospital Association found that virtually every hospital in the United States has experienced shortages of critical drugs in the past six months. More than 80 percent reported delays in patient treatment due to the shortages. For some of these drugs, no substitute drugs are available; or, if they are, they’re less effective and may involve greater risks of adverse side effects. The chance of medical errors also rises as providers are forced to use second- or third-tier drugs that they’re less familiar with. For anyone struggling with cancer, the last thing they want to hear is that they might lose access to an essential medication. Experts cite a number of factors behind the shortages, including a scarcity of raw materials, manufacturing problems, and unexpected demand. Business decisions within the pharmaceutical industry are also a factor, such as mergers and cutting back on the production of low-cost generic drugs in favor of more profitable brandname drugs. When drugs are made by only a few companies, a decision by any one company can have a large impact.

Whatever the causes of drug shortages, the results are clear. Widespread and prolonged shortages have reached crisis proportions. Pharmacists, doctors, and nurses are spending more and more time looking for medications instead of looking at patients. That’s just wrong. Hospitals also report that a flourishing “gray market” has emerged, with middlemen hoarding scarce drugs and jacking up prices to exorbitant levels. Under current law, the Food and Drug Administration (FDA) can’t require a drug company to report a shortage unless it is the sole source of a “medically necessary” drug. But even then, there is no penalty if a company doesn’t comply. Last fall, President Obama directed the FDA to speed up its review of alternative drugs and new suppliers. He also ordered the Justice Department to investigate potential price gouging. And he cautioned the pharmaceutical industry that it would be in its own best interest to be more forthcoming with the FDA about potential shortages. These are positive steps. But the fact remains that the FDA remains poorly equipped under current law to respond effectively to the numerous drug shortages. One solution is the Preserving Access to Life-Saving Medications Act, which I introduced in 2011. It has support from both Democrats and Republicans in Congress; from the president; and from many health care groups, including the American Medical Association. In effect, this bipartisan legislation would establish an “early warning system.” It would give the FDA the authority to require early notification from a pharmaceutical company at least six months in advance of any planned interruption, disruption, or discontinuation of a drug. This will help the FDA take the lead in working with pharmacy groups, drug manufacturers, and health care providers to better prepare for impending shortages, to manage shortages more effectively when they occur, and to minimize their impact on patient care. Given that the When new FDA has successfully averted hundreds of treatments shortages using notification this year, we become know it can make a difference. The legislation would also direct the available, FDA to provide up-to-date public notificawe need to tion of any actual shortage situation and make sure the actions the agency would take to that patients address them. The FDA would be required to develop an evidence-based list of drugs can afford vulnerable to shortages and to work with them. the manufacturers to come up with a continuity-of-operations plan to address potential problems that may result in a shortage. Alongside this legislation, I am participating in a working group with my colleagues on both sides of the aisle, which is focusing on additional long-term solutions to this drug shortage crisis. More research, less regulation A continued emphasis on affordable, innovative new treatments is also important. That means we need to continue to foster an envi-

ronment that promotes innovation and research when it comes to new treatments and cures for patients struggling with disease. Minnesota has always invested in research and development to look for new and groundbreaking ways to improve the health of patients. We need to be doing all we can at the federal level to support basic medical research and ensure regulations aren’t stopping a new breakthrough from being developed.

The number of drug shortages has nearly tripled over the last six years. Addressing regulatory burdens in the health care industry will help create a streamlined process for safe, life-saving technologies and treatments to be made available for patients. That’s why last fall I introduced legislation with Sens. Richard Burr (R–N.C.), and Michael Bennet (D–Colo.) that would help improve the conflict-of-interest provisions at the FDA so the agency can properly utilize outside experts and continue to approve and help develop new treatments for patients. While it’s important to ensure that the process for approving and advising the FDA is free from outside influence, it’s also necessary to ensure that the agency is able to take advantage of available expertise. A coalition of 77 patient advocacy groups—such as the Alzheimer’s Association and the Parkinson’s Action Network—has called for reform to the selection process for FDA advisory commitWhat Washington is doing to page 31

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PHYSICAL THERAPY

Steps to take before and after By Rick Hjelm, PT Total knee replacement, or TKA (total knee arthroplasty), involves replacing worn surfaces of the knee and is performed primarily to relieve the pain and decreased function caused by severe osteoarthritis. In general, patients seeking this procedure are advised to first exhaust nonsurgical care such as physical therapy because an

Knee

replacement artificial knee has a finite survival time that can be shortened by activity level. That may not pose a problem for older patients who are modestly active, but younger, active people are increasingly seeking TKA. In fact, the incidence of knee replacement surgery more than doubled among middle-aged people between 1997 and 2009, reported the Agency for Healthcare Research and Quality (2011). This trend, along with other factors that

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include an increase in obesity among the general population—a risk factor for eventually needing TKA—helps explain why the total number of knee replacement surgeries in the United States also more than doubled between 1997 and 2009, to 549,707 procedures annually. Having TKA at a younger age may mean that the artificial knee may need to be replaced in the future. But regardless of age, anyone planning to have a knee replaced can benefit from exercises performed before and after surgery to shorten postoperative recovery time and help ensure the new knee functions optimally for a long time. Before starting these or any new exercises, first obtain your physician’s approval.

Clinical trials demonstrate that TKA is safe.

Before replacement Prehab refers to physical conditioning undertaken before surgery. The focus of prehab before TKA is to keep the leg muscles, specifically the thigh muscle (quadriceps), as strong as possible. No special equipment is needed. While sitting up in bed or in a chair, simply tighten the thigh while keeping the thigh, knee, and foot in a straight line, and push the knee straight down onto a bed, recliner, or ottoman. If the leg doesn’t flatten completely, place a rolled towel underneath the knee. Do this 10 times daily. The beauty of this exercise is that it can be done in so many settings, including a doctor’s office waiting room, while watching TV, and in a lawn chair in the backyard. Keeping the quadriceps strong not only speeds recovery and helps maximize how functional the new knee will be after surgery, but also helps the replacement knee to last as long as possible before it may need to be replaced. According to the July 2005 issue of the Journal of Orthopedic and Sports Physical Therapy, patients who had greater quadriceps strength before surgery demonstrated the highest degree of functional performance afterward. Any activity that uses leg muscles and maintains or increases the leg’s range of motion can be considered Avoid prehab. This includes balancing on exercising one leg, calf raises, bridging, moving from a sitting position to a standing to the point one, bicycling, straight-leg raises, and of pain. mini-squats. However, it is important to select exercises that are appropriate for an osteoarthritic knee and to avoid exercising to the point of pain. Ask your physician to authorize one prehab physical therapy visit at least six weeks before TKA; authorization should help ensure that this visit is covered by insurance.

In the hospital. Exercise initiated while the patient is still in the hospital focuses on early efforts at using the knee to bear weight, restoring range of motion, and preventing arthrofibrosis, the development of soft tissue adhesions that can limit the new joint’s range of motion. Rehabilitation during this stage of recovery involves physical therapy to progressively increase the knee’s weight-bearing ability by using parallel bars, walkers, and canes, in addition to careful but intentional efforts at bending and extending the knee. Continuous passive-motion devices are often used to automatically and continuously move the new knee to restore range of motion and prevent adhesions.

Transitional care unit. After discharge from the hospital, patients who cannot yet perform activities of daily living (ADLs) on their own and do not have assistance in-home may be encouraged to move temporarily to a transitional care unit (TCU) until their rehabilitation has progressed to the point at which they can manage ADLs independently. TCUs are available within assisted living centers and at related facilities, and temporary care at a TCU is typically arranged by a hospital social worker once a patient has been cleared to leave the hospital. Physical therapy at a TCU is more aggressive than at the hospital, and continues to restore knee bending and straightening and increasing the strength required for such daily tasks as transfer from Knee replacement to page 17

After replacement A patient who has just had TKA can expect the new joint to feel painful and stiff at first. This discomfort can linger during part or all of postoperative rehabilitation since rehab is intentionally physically challenging and because leg muscles may be weak. JULY 2012 MINNESOTA HEALTH CARE NEWS

July Calendar National Cleft & Craniofacial Awareness & Prevention Month

1–31

Testing Makes Us Stronger The Centers for Disease Control and Prevention (CDC) developed Testing Makes Us Stronger for black gay and bisexual men with input from black gay and bisexual men across the country. Knowing one’s HIV status is important and empowering information. Plan now to be tested. Enter your zip code at http:// hivtest.cdc.gov/stronger/about/index.html to find free, fast, and confidential HIV testing near you.

Younger Onset Alzheimer’s Caregiver Support The Alzheimer’s Association provides education and support to caregivers or anyone concerned about memory loss. This group is a safe place to learn and to offer and receive helpful tips. Meetings are held the second Monday of every month. Call Emily Woddall at (612) 384-0377 with any questions. Monday, July 9, 6:30–7:30 p.m., Augustana Lutheran Church, 1400 S. Robert St., West St. Paul Parkinson’s Exercise Group Bring questions and discuss with rehabilitation staff and nurses who specialize in Parkinson’s disease. Dress comfortably for exercising. Refreshments provided. $5 suggested donation per participant; no one turned away for inability to pay. Limited space, so call to register: (763) 898-1533 or (763) 898-1532. Tuesday, July 10, 1–3 p.m., Fairview Maple Grove Medical Ctr., 14500 99th Ave. N., Arbor One Rm., Maple Grove Taking the Pressure Off: Reducing Your Blood Pressure Led by Lakeview Hospital dieticians, this class teaches you how to improve your eating and lifestyle habits to lower your blood pressure. Fee: $20. Advance registration required; call (651) 430-8715. Tuesday, July 17, 3–4:30 p.m., Lakeview Hospital, 927 Churchill St. W., Stillwater

In the United States, a baby is born with a facial cleft every hour of every day of the year, or approximately one in 700 babies annually. Cleft lip (a separation in the upper lip) and cleft palate (a split in the roof of the mouth) are craniofacial malformations that are among the most common structural birth defects. Craniofacial malformations are present at birth because separate areas of a baby’s face normally develop individually and then fuse during early pregnancy. Improper fusion results in a cleft, or split, in the lip and/or palate. Genetic and environmental factors such as vitamin deficiencies are believed to each play a causative role. Children of a parent with a cleft have a 4 to 6 percent chance of also having clefts. Some ethnicities have a higher incidence of clefts, including Asians and some groups of Native Americans. Up to 13 percent of children born with clefts may have other health complications, including: • Missing or improperly positioned teeth in the cleft area • Speech and language delays • Increased risk of ear infections and secondary hearing loss • Feeding problems during infancy For more information about cleft lip and palate, call Gillette’s Center for Craniofacial Services at (651) 312-3131 or (800) 7194040 (toll-free), or visit www.gillette childrens.org. The center uses a multispecialty team approach to treating cleft lip, meeting with the child’s family, often before the baby leaves the hospital, to discuss treatments and feeding techniques. Additional information is available from AmeriFace: www.nccapm.org; (888) 486-1209.

Car Seat Check-Up Have your car seat evaluated for its suitability for the child. Learn whether or not your car seat has been recalled, receive information on child passenger safety, and learn to install your car seat properly. By appointment only; call (320) 229-5139. Wednesday, July 18, 3–6 p.m. Gold Cross Garage, 2800 7th St. North, St. Cloud

MOCA Ovarian Cancer Survivors’ Group Sponsored by Minnesota Ovarian Cancer Alliance (MOCA), this group is designed for longer-term survivors or women who have experienced a recurrence. Please contact facilitator Judy Prokosh at (612) 203-3456 prior to your first meeting. For more information on support group options for recently diagnosed women, call (612) 822-0500. Saturday, July 21, 2–3:30 p.m., Macalester College, 1600 Grand Ave., Old Main Bldg., Rm. 003, St. Paul (visit www.mnovarian.org/ for a campus map)

We ‘R’ Able Aquatics Class Are you experiencing a health challenge or disability? Have fun in the water! At your own pace, you’ll get to use balls and noodles and be in the warm pool afterward. Caregivers must be in the water. Fee: $5 each pair, client and staff, Preregister one week prior to the session. Classes are also scheduled Aug. 8 and 22. For more information, call Dana Johnson at (320) 358-1220. Wednesday, July 25 (6:30 p.m. arrival), 6:45–7:45 p.m., Chisago Lake High School Pool, 13750 Lake Blvd., Lindstrom

27–29

Camp for Kids Processing Loss Camp Erin helps kids ages 6–17 cope with the death of a friend or family member. Free, but space is limited, so apply early. For more information, call (952) 892-2111 or visit www.youthgriefservices.org. Friday–Sunday, July 27–29, One Heartland Center, 26001 Heinz Rd., Willow River, MN

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

America's leading source of health information online JULY 2012 MINNESOTA HEALTH CARE NEWS

Knee replacement from page 16

a sitting position to a standing one, walking unaided, and climbing up and down stairs. For people who are able to function independently at home but cannot transport themselves to an outpatient facility, this therapy can be provided at the patient’s home via home care agencies. Outpatient physical therapy continues rehabilitation for the patient who is now back at home, and focuses aggressively on restoring strength, range of motion, and function. During this stage of recovery, TKA patients learn soft tissue and joint mobilization techniques designed to restore soft tissue extensibility and joint mobility. The most common goals at this stage include motion restoration to 120 degrees flexion and full knee extension, walking without a limp, and going up and down stairs with minimal use of a handrail. Patients at this point in recovery typically attend physical therapy twice each week for three to six weeks.

rehab phase of six to eight weeks during which pain decreases and regaining function is emphasized, and a period of continuing rehabilitation that may last up to one year. Optimal results are enjoyed by patients who are motivated to exercise independently for up to one year to regain as much functional strength as possible. A patient’s physical therapist will provide exercises to be performed during this phase. Appropriately aggressive physical therapy and a patient who is motivated to do prehab and rehab exercise can significantly minimize the chance of developing Stiffness and the stiff knee that the Journal of Arthroplasty reportpain generally ed (2006) occurred in 3.7 percent of 1,216 TKA resolve with patients studied. Other studies have reported an incidence of post-TKA stiff knee as high as 10 perphysical therapy cent, but stiffness and pain generally resolve with physical therapy. Clinical trials demonstrate that TKA is safe, has a high patient satisfaction rate, reduces pain, and increases range of motion. With a can-do attitude, prehab, and rehab, the TKA patient can get the most from his or her new knee.

Hard work, but worth it A TKA candidate can expect an initial, painful postoperative phase of rehabilitation that lasts one to two weeks, a mid-

t a P

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Rick Hjelm, PT, is a physical therapist with MultiCenter Physical Therapy LLC, which has offices in Blaine, Roseville, St. Paul, and Fridley.

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your child’s numbers Childhood wellness is not merely the absence of disease and injury. It means thriving in such a way that a child can live up to his or her full potential. Among other things, childhood wellness encompasses healthy habits in eating and play, limited screen time, and mental health. Campaigns to Know your Numbers call for adults to know our numbers as they pertain to our blood By Robert M. Jacobson, MD, FAAP sugar, lipid panels, and blood pressure. That way we can focus our efforts on improving these numbers to prevent diseases like diabetes, heart disease, and high blood pressure— major diseases that plague adults and cause the majority of adult deaths. However, these numbers do not work well for children. Frankly, there are more important numbers to guide parents in making sure that their children are thriving.

A formula for healthy living

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

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MINNESOTA HEALTH CARE NEWS JULY 2012

It raises many questions few of us are prepared to answer, such as: • How can I take time off from work? • Can I get help paying bills? • What is the difference between a health care directive and a power of attorney? • Can I keep my health insurance even if I lose my job? • And many others.

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The following numbers are helpful guides that parents should use to make sure that their children thrive.

85 This number refers to the cutoff percentile for healthy body mass index. It is a harder number to measure than BMI because, while BMIs of 25 and higher represent being overweight for adults, no single BMI works for children. That’s due to the fact that BMIs differ between boys and girls and vary normally with age. Therefore, parents need to know if their child’s BMI percentile is above or below 85; the actual BMI number is not as important. Children who appear healthy can nonetheless exceed the 85th percentile and thus need to beat the risk of becoming overweight or obese. Knowing their child’s BMI percentile can help parents reassess dietary habits, family activities, and their child’s recreational activities. If a child is above the 85th percentile, make sure to follow the following 5-2-1-0 guidelines and follow up regularly with your child’s clinician to problem solve and to monitor your progress in course-correcting your child’s BMI percentile.

5-2-1-0 The Minnesota chapter of the American Academy of Pediatrics recommends that pediatricians and family physicians teach families to follow the 5-2-1-0 guideline whether or not their children are at the 85th BMI percentile. Here is what each of these numbers means.

5 Five or more fruits and vegetables a day. Every child 2 years of age and older should eat five or more fruits and vegetables a day. These are low-calorie, natural sources of fiber and water, vitamins, and minerals. Thanks to their bulk and the effort expended in consuming them, fruits and vegetables displace highly processed, higher calorie, less nutritious foods.

first and foremost from the residue left on the caregiver’s clothing and, perhaps just as importantly, by modeling unhealthy behavior.

100 percent Parents should make sure their children receive the recommended vaccinations for each age and that they receive them on time. The percent of Minnesota children who are up to date for childhood vaccinations is a matter for concern. In 2010, the percent of children who had received the overall childhood series of vaccinations due by age 24 months was reportedly 46.3 percent. The same year, Minnesota had more measles cases than any other state and, during the last decade, had the largest outbreak in the country of meningitis and sepsis. Vaccinations are key. Parents should work hard to make sure their children are 100 percent up to date with the recommended vaccines.

1 It only takes one parent to set good examples with diet, exercise, screen time, smoking, and vaccination. Vaccination? Yes, adults are due for vaccines. Each year parents should get their flu vaccines and talk to their children about why they get vaccinated and why children need their vaccines too.

Prevent injury While childhood diseases can be scary, they are rarely the cause of death and disability; injuries are. The following numbers can help prevent injury. Childhood wellness to page 32

2 No more than two hours of screen time a day. No one younger than two should spend time in front of a screen and no child older than two should spend more than two hours a day in front of a screen for entertainment or recreation. Screen time slows metabolism, and messages in the media fool children into unhealthy eating habits that last a lifetime.

1 At least one hour of vigorous

Read to your child at least once a day.

exercise each day. Every child should spend an hour at hard play, outdoors when possible. Of course, our long Minnesota winters make this more difficult, but parents can dress children for the cold and wind and wet and get them outdoors.

0 Zero sugar-sweetened drinks, including fruit juice and fruit juice blends. Liquid sources of sugar and corn syrup are particularly concerning because of their lack of nutrition combined with their association with childhood obesity. 0 Give another zero to smoking exposure. Studies of secondand third-hand smoke indicate that children should neither be exposed to active smoke nor to the residue it leaves on clothing. A caregiver who smokes outside the house still puts the child at risk: JULY 2012 MINNESOTA HEALTH CARE NEWS

D E N TA L H E A LT H

he effects of smoking on systemic health are well documented. More recent research has looked at the effects of smoking on oral health. According to the Journal of Dentistry (2006), current and former smokers have a higher prevalence of oral health problems than people who have never smoked. The Journal of Dental Education suggested in 2001 that the risk of oral diseases increases with greater use of tobacco and that quitting smoking can result in decreased risk. The magnitude of the effect of tobacco on the occurrence of oral diseases is high, with users having many times the risk of nonusers. These problems can range from cosmetic effects to serious, life-threatening conditions such as oral cancer. Reported effects of smoking on the oral cavity include tooth loss, periodontal disease, oral cancer, stained teeth, delayed

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wound healing, increased failure of dental implants, halitosis (bad breath), loss of taste, and black hairy tongue, a condition in which the tongue’s surface appears to be covered with black fur due to the growth of elongated, black stained projections (papillae) on its surface.

of oral cancer patients, quitting smoking and decreasing alcohol use remain the key elements in preventing and controlling oral cancer. Routine oral cancer screenings are extremely important for current smokers, in order to identify precancerous lesions before they become cancerous.

Smoking is bad for you and your mouth.

Periodontal disease and tooth loss The Journal of Dental Education reported in 2001 that smokers are four times more likely than nonsmokers to develop periodontal disease. This condition attacks the gums and bone that surround teeth, creating tooth mobility and tooth loss. Smoking accomplishes this because it increases susceptibility of oral tissue to bacterial growth by decreasing oxygen in the periodontal pocket (where the tooth sits in the gum). This alters the normal balance of bacteria and increases the percentage of destructive, periodontal disease-causing bacteria. As if that weren’t bad enough, smoking reduces the body’s ability to fight these destructive bacteria. That comes about because smoking reduces blood flow to gum tissue (and everywhere else in the body). Reduced blood flow, known as vasoconstriction, also slows development of the red, bleeding gums that are normally the early symptoms of periodontal problems. The resulting delay in appearance of symptoms gives smokers a false sense of oral health, which in turn can delay their seeking dental treatment. After a person’s oral cavity is infected with periodontal pathogens, the body sends in immune system cells to fight those pathogens. Studies show that smoking decreases the functionality of the immune system cells, thereby decreasing the body’s ability to defend itself against pathogens. Without the appropriate immune response mechanisms in place, periodontal disease progresses. Bone loss and tissue destruction increase, leading to tooth mobility and loss. Smokers’ teeth fall out approximately twice as often as the teeth of nonsmokers, reported the Journal of Periodontology (2007).

Tobacco increases the incidence of oral cancer six-fold.

Discolored teeth Smoking stains and discolors teeth due to the nicotine and tar that are common ingredients in cigarette smoke. These products leave sticky deposits on teeth that make teeth yellow. This yellowish hue, if not removed, becomes permanent as it seeps into microscopic cracks and porosities in the tooth enamel. With chronic smoking, teeth eventually turn brown as the stain becomes permanently embedded in the enamel. Delayed wound healing Smoking delays wound healing, which can lead to postoperative complications following periodontal or implant surgery. The mechanism of this delayed healing begins with vasoconstriction caused by the nicotine in cigarette smoke. Vasoconstriction reduces the blood flow to the wound site, reducing the flow of oxygen and nutrients needed to heal the wound. According to the American Journal of Medicine (2003), smoking also decreases the numbers of red blood cells as well as other cells that play key roles in healing. Smoking and oral health to page 34

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Oral cancer Smoking is a major risk factor for oral cancer—the Journal of Head and Neck Oncology reported in 2012 that the use of tobacco increases the incidence of oral cancer six-fold. Oral cancer is a serious, life-threatening condition with a five-year survival rate of only 50 percent, according to the Journal of Dentistry (2006). Combining smoking with alcohol consumption and poor diet is implicated in more than 90 percent of head and neck cancer cases. Research shows that smoking and alcohol interact synergistically to magnify each other’s harmful affects. Due to the poor survival rates

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Hyperbaric oxygen therapy

yperbaric oxygen therapy (HBOT) delivers high levels of oxygen to tissue and has long been recognized as vital in the treatment of such emergency medical conditions as carbon monoxide poisoning, gas gangrene, decompression sickness (â&#x20AC;&#x153;the bendsâ&#x20AC;?), and cerebral air embolism. However, HBOT is also used for nonemergency treatment of certain medical conditions and is increasingly appreciated as important adjunct therapy for specific wound-healing conditions. Simply put, this treatment involves a patient breathing 100 percent oxygen while in a pressurized chamber. (The air we breathe is typically about 20 percent oxygen.) Why it wo s

Breathing 100 percent oxygen while the entire body is at increased atmospheric pressure causes the lungs to deliver much more oxygen to the blood because under these conditions several times the normal amount of oxygen is dissolved in the blood. When the blood is loaded with oxygen like this, even tissues that have poor blood flow receive a normal or greater than normal amount of oxygen. And when adequate oxygen is available, the bodyâ&#x20AC;&#x2122;s normal healing

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By Cheryl Adkinson, MD, FACEP

processes can take place: Cells reproduce and function normally to fight infection, clean up debris, create new capillaries, and grow new tissue to heal wounds. How it works

(1) 60

A look inside the chamber

In a multiplace chamber, multiple patients receive treatment simultaneously and there is a medical attendant inside with the patients to deliver hands-on care during the entire treatment. The chamber is filled with pressurized air and patients inside the chamber breathe 100 percent oxygen from a mask, hood, or tracheal (windpipe) tube. Hyperbaric oxygen treatment may be given instead in a monoplace chamber, which accommodates one patient at a time. In this chamber, there is no room for an attendant to be inside with the patient. A monoplace Treatment chamber may be filled with pressurized air for approved or pressurized oxygen. If it is filled with air, the patient breathes 100 percent oxygen conditions from a mask or tracheal tube. Surgical applications

is covered by most insurance plans.

In the mid-1960s, reports of successful experimental open heart and organ transplant surgery during HBOT prompted some academic medical centers, including Hennepin County Medical Center (HCMC), to build hyperbaric chambers to study this idea. Successful experimental open-heart surgeries and organ transplantations were performed in HCMCâ&#x20AC;&#x2122;s hyperbaric chamber and elsewhere. However, not long after that, new methods of providing critical oxygen to tissues during these procedures were developed that allowed these surgeries to be performed in standard operating rooms instead of the unique environment of a hyperbaric chamber.

Hennepin County Medical Center’s (HCMC) new, multiplace hyperbaric oxygen chamber. Courtesy HCMC.

Academic interest in hyperbaric medicine waned. For the next 20 years, research in the field was relatively inactive, although HBO treatment at major institutions continued for gas gangrene, decompression sickness, cerebral gas embolism, and carbon monoxide poisoning. Renewed interest

Hyperbaric oxygen treatment helps diabetic patients with chronic nonhealing foot wounds.

But since the 1980s interest in HBOT has been renewed, reflected by substantial growth in the number of hyperbaric treatment facilities in the United States. In 1990, there were 200 facilities; in 2011, there were 1,000. Much of this new interest is due to improved understanding of the role oxygen plays in wound healing, better understanding of the way that lack of oxygen (hypoxia) contributes to poor wound healing, and greater appreciation for HBOT’s ability to improve oxygen levels in wounds that resist healing. Two medical conditions that contribute the most to the growing number of nonemergency hyperbaric treatments are diabetes and delayed radiation injury. Chronic diabetic foot ulcers are associated with life- and limb-threatening infections, amputations, and nonhealing amputation sites. These ulcers develop in people with diabetes because the disease damages blood vessels that deliver oxygen throughout the body. This leads to low tissue oxygen levels and poor healing. As the U.S. population ages and becomes more obese, there are more people suffering from diabetes and therefore more people with chronic foot ulcers. Delayed radiation injury is found among some cancer survivors whose tumors were treated with radiation and who experience delayed manifestations of radiation injury. Irradiated tissues become more scar-like over time, contain fewer normal cells, and have fewer capillaries to bring oxygenated blood to the tissues. Irradiated tissue and bone may spontaneously break down, fail to heal after surgery, or fail to provide an adequate site for the tissue flaps and grafts needed for reconstruction. As the number of people surviving cancer increases, so does the population experiencing problems related to delayed effects of radiation. Hyperbaric oxygen treatment helps diabetic patients with chronic nonhealing foot wounds and radiation patients who need surgery, have spontaneous tissue breakdown, or are not healing a surgical site in irradiated areas. HBOT helps these patients by getting oxygen to their oxygen-deprived tissues. However, this is a complex process that does not happen rapidly. Patients receiving HBOT in preparation for surgery or to heal wounds can expect to

have approximately six to eight weeks of treatment. Accessing treatment

Nonemergency patients, such as those who need care because of diabetic ulcers or radiation injury, require a referral from their treating physician to a hyperbaric medicine physician for evaluation. The patient remains under the care of the referring physician throughout the course of HBOT, although wound care may be provided by the hyperbaric team at the discretion of the referring physician. Treatment for approved conditions is covered by most insurance plans. Considerations

All medical procedures carry some risk. However, HBOT is a very safe treatment for those patients who are determined to be appropriate candidates by a physician specializing in hyperbaric medicine and who are treated in an accredited facility. Even infants and children may safely receive HBOT. Research into new applications for HBOT continues. Cheryl Adkinson, MD, FACEP, is an associate professor of emergency medicine at the University of Minnesota and medical director of the Center for Hyperbaric Medicine at Hennepin County Medical Center (HCMC). She is a practicing emergency physician with board certification in emergency medicine and in diving and hyperbaric medicine. HCMC is the only hospital in Minnesota offering 24/7 emergency hyperbaric oxygen treatment and is one of two Minnesota facilities accredited by the Undersea and Hyperbaric Medical Society (www.uhms.org); the other accredited facility is the Mayo Clinic in Rochester.

In the next issue.. • Keep your liver healthy • Sports concussions • Toxic drug interactions JULY 2012 MINNESOTA HEALTH CARE NEWS

health care architecture honor roll

Minnesota Physician Publishing’s 2012 Health Care Architecture Honor Roll recognizes eight outstanding projects completed in the past year. This year’s Honor Roll projects include new clinic and hospital construction, remodeled spaces, facility expansions in urban, suburban, and greater Minnesota, and one project out of state. Medical services provided range from routine clinic visits to specialized urgent and emergency treatment. Populations served run the gamut from newborn patients to patients receiving hospice care. Many of the projects emphasize ties to the community, by, for example, incorporating artwork by regional artists, using locally sourced building materials, and designing a street landscape that enhances the facility’s social impact on the surrounding neighborhood. Principles of sustainability and energy-saving design support the goals of patient safety and staff efficiency. Minnesota Physician Publishing thanks all those who participated in the 2012 honor roll.

MINNESOTA HEALTH CARE NEWS JULY 2012

Children’s Hospitals and Clinics of Minnesota Minneapolis campus expansion and modernization

Type of facility: Specialty hospital Location: Minneapolis Client: Children’s Hospitals and Clinics of Minnesota

Architect/Interior design: AECOM Engineer: Harris Mechanical and Hunt Electric, mechanical/electrical/plumbing; Ericksen Roed & Assoc., structural Contractor: Knutson Construction Co. Completion date: March 2012 Total cost: Confidential per owner request Square feet: 169,500 gsf (new children’s specialty center); 597,695 gsf (hospital new construction and renovation); 24,330 gsf (new power plant); 679-car parking structure To maintain its status as a regional leader in pediatric care, Children’s Hospitals and Clinics of Minnesota embarked on the most significant campus development in its history. Architecture, landscape, science, and art merge to transform the health care experience of patients who come to its Minneapolis campus, revitalizing a sense of place and urban renewal.

Campus expansion to the west of Chicago Avenue includes a new Specialty Care Center with specialty clinics (including the hematology and oncology clinic), outpatient pharmacy, retail center, and a new parking structure linked to the existing hospital by a curved, glass skybridge. Upgrades to existing facilities to the east of Chicago Avenue include a new hospital entry and a seven-story addition. The addition offers new patient rooms, enlarged and enhanced operating rooms, a new emergency department, renovated neonatal and pediatric intensive care units, a new cardiovascular center, and an in-house Ronald McDonald House. All existing patient rooms were converted to private rooms with sleep-in space for parents. This expansion and modernization provides a new brand image for Children’s, establishes a cohesive campus, provides a new experience for patients and their families, expands health care services, and creates a positive social impact on Chicago Avenue and the surrounding neighborhood.

Left: The focal point of the new campus is a public space with solar light sculptures designed by Brad Goldberg and named “Healing Stones.” Top inset: The second-floor lobby extends from the parking structure on the west side of Chicago Ave., through the Specialty Care Center, across Chicago via skybridge, and ends with the welcome desk and twostory atrium. Bottom inset: Family rooms on each floor of the new bed tower provide views of downtown Minneapolis and space for patients and families to gather outside patient rooms to relax, read, play games, and socialize. ©2011 Don F. Wong

Olmsted Medical Center, Northwest Clinic Type of facility: Clinic Location: Rochester Client: Olmsted Medical Center Architect/Interior design: HGA Architects and Engineers Engineer: HGA Architects and Engineers Contractor: Weis Builders Completion date: July 2011 Total cost: Confidential Square feet: 65,000 sf Designed for LEED certification, this replacement facility expands primary care outpatient services while integrating numerous sustainable design features and geothermal technology. Design was oriented vertically instead of horizontally to accommodate a 20foot elevation change from one side of the site to the other, allowing for a future two-story vertical expansion. Patients enter along the main entrance or through lower-level walkout entries. Exterior Dolomite limestone is from Mankato; two textures of grey limestone address scale and add visual interest. The stone will oxidize over

time to a warm grey. HGA used a stone panelized system similar to precast concrete construction to permit quick assembly of the exterior skin once structural steel was installed. The south facade is a glass curtain with silk-screened glazing to assist with sun control. Interior waiting areas stretch along the south side of the building, with light from the full-height curtain-wall system illuminating the space. Department reception areas flow into exam areas, with staff and physician offices at the north side of the building. Design features • A geothermal mechanical system provides heating and cooling for the building through use of groundwater in a closed-loop system. The well field is located under the parking lot. • Natural light in the lobby streams into the lower level via the open staircase, creating visual connection between levels. • Corridors with physician work

alcoves enhance patient and staff flow. • Patient coffee shop in waiting area. • Physical therapy and cardiac rehabilitation space. • Water use is reduced by more than 40 percent through water-conserving fixtures and faucets.

Top: Interior commissioned art hangs over an open staircase to a lower level, with waiting spaces beyond. Inset below: Main level reception/ check-in desk for family medicine and pediatrics incorporates bright colors and warm wood tones. Bottom: View from southwest of upper level south-facing facade

All photos by Josh Banks Photography.

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Hennepin County Medical Center Hyperbaric Medicine Department and Wound Clinic

Type of facility: Hospital Location: Minneapolis Client: Hennepin County Architect/Interior design: HDR Architecture, Inc. Engineer: HDR Architecture, Inc. Contractor: Kraus-Anderson Construction Co. Completion date: May 2012 Total cost: $4.3 million Square feet: 6,782 sf (new); 6,612 sf (remodel) The Hyperbaric Medicine Department provides hyperbaric oxygen therapy for patients requiring urgent and emergency treatment as well as patients who are treated daily for wound healing problems. In addition to the hyperbaric wound and treatment area, a wound clinic is included within the department. The wound clinic has separate exam rooms and

workspace for providers and shares reception and support areas with the hyperbaric department. The hyperbaric department cares for inpatients and outpatients of all ages and treats two distinct types of patients: patients who are treated daily for wound healing and patients who need emergency hyperbaric oxygen therapy Hyperbaric oxygen therapy sessions typically last 1 hour and 50 minutes. In addition to hyperbaric patients, the department includes a separate wound clinic for patients that are not in the hyperbaric treatment program. The department must handle scheduled patient flow as well as surge volumes of emergency cases. The new Hyperbaric Medicine Unit comprises a multilock, class A multiplace hyperbaric chamber; class B monoplace chamber; main waiting room and staging waiting areas; male and female handicap-accessible dressing areas with lockers and toilets; intake areas for vital signs, weight, and point-of-care testing; four exam rooms; technician instrument console; medical console; and department support. The existing monoplace chamber formerly located adjacent to the ICU was relocated to the new hyperbaric unit. Hyperbaric clinic exam room capacity was increased from one exam room to four in the new department, allowing more privacy and improving patient confidentiality. The additional exam rooms enable the department to see additional patients in the clinic. During sessions, additional patients are seen in the exam rooms for follow-up or new patient assessment. Four additional wound clinic exam rooms are provided in the department, located separately from the hyperbaric patient exam rooms. Top: View inside the hyperbaric chamber Inset: Hyperbaric chamber leaving Fink Engineering’s hyperbaric chamber fabrication shop in Australia

Essentia Health St. Joseph’s Baxter Clinic Type of facility: Multispecialty outpatient clinic Location: Baxter Client: Essentia Health Architect/Interior design: Widseth Smith Nolting & Associates, Inc. (WSN), firm of record; HGA, programming, schematic design, and interior design Engineer: Widseth Smith Nolting & Associates, Inc. Contractor: Hy-Tec Construction Completion date: January 2012 Total cost: $12 million Square feet: 46,000 sf WSN provided architectural, structural, mechanical, electrical, civil, land survey, and landscape architecture services for this project, while HGA provided the programming, schematic design, and interior design. The building’s material palette blends well with the natural surroundings and includes stone, precast concrete, glass, stucco, and metal panel. The clinic has two levels with multiple specialty areas that include family practice, women’s health, pediatrics, lab, X-ray, pharmacy, and urgent care. Patient-centered care is the concept that directed building design and is addressed in several ways. A greeter meets patients immediately as they enter the clinic, redirecting them to more private, decen-

tralized check-in areas. Natural light and framed views to the exterior combine with material selections, artwork, and furnishings to create a sense of comfort. The decentralized concept allows patients to feel as though their visit is one-on-one with the provider. Insulated walls in the exam rooms, as well as insulated ductwork, decrease transfer of sound, which reinforces the patient-centered care concept. The Baxter Clinic will provide a welcoming environment for patients in this community for many years. Top: Decorative, etched glass walls line the waiting areas, offering privacy while allowing natural light to stream into the space. Top inset: Natural light floods the two-story atrium. Bottom inset: Exterior with parking lot

Sanford Heart Hospital Type of facility: Specialty hospital Location: Sioux Falls, S.D. Client: Sanford Health Architect/Interior design: AECOM Engineer: AECOM Contractor: Henry Carlson Co. Completion date: March 2012 Total cost: Confidential per owner request Square feet: 205,000 sf Thirty years after the Sanford Health heart program began, the hospital sought to consolidate the programs of Sanford Clinic Health Partners and Sanford Clinic Cardiac, Thoracic, and Vascular Surgery to make quality heart care available to patients in a single convenient location. Attached directly to Sanford USD Medical Center, the new Sanford Heart Hospital means even more convenience for patients and their families. The 205,000-square-foot building is directly connected to the main lobby of the existing medical center and connects underground to the parking ramp. The new hospital houses physician offices, outpatient testing, surgical services, cath labs, and consultation services. It also includes 58 inpatient beds, cardiovascular operating rooms, a hybrid operating room, and clinic and outpatient services. Patient rooms are safe, secure, state-of-the-art living spaces that promote rest and healing. A range of amenities and technologic updates ensure that patients have everything they need to heal. Rooms are sized to accommodate acuity-adaptable care, which allows patients to remain in

Photography by Dana Wheelock

Top: Interior of Sanford Heart Hospital Inset: Hybrid operating room

the same room from admission to discharge. In addition, art, long known to comfort and soothe the human spirit and body, is incorporated here. Art has been shown to influence the speed of recovery and to provide distraction for patients and families during challenging times. The hospital features 130 works of art by regional artists, further connecting the new hospital to the community it serves.

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

MS = dreams lost. dreams rebuilt. What does MS equal to you? Join the Movement® at MSsociety.org JULY 2012 MINNESOTA HEALTH CARE NEWS

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Completion date: June 2011 Total cost: Building shell, $3.5 million;

Allina Medical Clinic–Ramsey Type of facility: Outpatient medical clinic Location: Ramsey Client: Allina Medical Clinic Architect/Interior design: bdh+young Engineer: Krech, O’Brien, Mueller & Associates Inc., structural; Gilbert Mechanical, mechanical; Clark Engineering, civil; Hunt Electric, electrical Contractor: Kraus-Anderson Construction Co.

tenant, $2.3 million Square feet: 25,682 sf A new Allina outpatient medical clinic is part of Ramsey’s town center development. The patient-centered clinic design includes family exam rooms to accommodate family members and patient education functions. Designers also focused on simplifying patient flow and wayfinding, increasing natural light with skylights, and providing walk-up and self-check options. The project also incorporates sustainable elements: solar power; renewable building materials such as bamboo veneer, brick, and stone sourced regionally; low-VOC paints; and high-efficiency mechanical systems. Top: Designers created centralized care team stations that incorporate natural light. Bottom inset: Sustainable elements include solar power, renewable and regional materials, and high-efficiency mechanical systems. Top inset: The new Allina outpatient clinic is part of Ramsey’s town center development.

Hospital and Clinics

Living with gout? Keep enjoying life’s simple pleasures.

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

MINNESOTA HEALTH CARE NEWS JULY 2012

Allina: J.A. Wedum Residential Hospice House Type of facility: Independent hospice care facility Location: Brooklyn Park Client: Allina Architect/Interior design: Mohagen Hansen Architectural Group Engineer: Dunham Associates Contractor: D.J. Kranz Construction Completion date: February 2012 Total cost: $3.7 million Square feet: 19,000 sf Hospice care can be provided in whatever setting a patient calls home. This could be in a private home, a variety of nursing facilities, or a residential hospice. Upwards of 30 percent to 40 percent of patients receive their hospice care in a residential setting, and most people say that they would want to spend their last days at home. Yet, more than 50 percent of patients are dying in hospitals. Therefore, Allina, with a sizable donation from the J.A. Wedum Foundation, set out to build a residential hospice house. Upon entering the facility, family members are greeted with warm colors, a rich wood archway, and pillars similar to what one would find in a model home. As an alternative to hospice care provided in a patient’s home or a hospital, it was important that this facility offer all of the comforts of home. The house has 12 private rooms, each with a private bath and attached patio. Each room also has a comfortable sofa sleeper, for a family member who wishes to spend the night. Also located within the house are two large family rooms that are perfect for spending quiet time with friends and family outside a resident’s room; a large reflection room; a children’s play area; full kitchen; and dining room. Visitors immediately sense the beauty and warmth of the building as they enter the facility.

Top: Comfortable family room for patients and their families Bottom: Exterior view of hospice house front entry from circular drive

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Crystal Medical Center Type of facility: Medical office building Location: Crystal Client: The Davis Group Architect/Interior design: bdh+young Engineer: Krech, O’Brien, Mueller & Associates Inc. Contractor: Timco Construction Completion date: February 2012 Total cost: $11.2 million Square feet: 44,865 sf

The new Crystal Medical Center is a Class A multi-tenant facility in the growing community of Crystal, Minn. The goal of the development was to create a project that was mutually beneficial to the community and would attract tenants by designing a strong project identity to complement and enhance the surrounding area. The rentable 44,865-square-foot two-story building is constructed of brick, glass, and metal accent panels and includes a prominent covered patient drop-off canopy at the main entrance. A number of design features were introduced into the project that closely align with the sustainable principles of the LEED Reference Guide for Green Building Design and Construction. Interior design features include highly finished clinic suites with soft lighting, modern carpet and flooring, solid surface counters, and customdesigned patient exam and procedure rooms. The building has prime visibility and easy access from the newly reconstructed Highway 81 and Bass Lake Road. This busy intersection provides tenants with excellent signage opportunities and 220 surface parking stalls on-site. Currently, there are three suites available to new tenants, totaling a little more than 9,000 square feet. The building is home to Northwest Family Physicians, Nova Care, and Crystal Imaging, and brings a variety of quality health care services to the community. The medical center has brought this community closer together by providing all of these services under one roof, making one-stop medical care available to patients.

Top: Main front-entry lobby Bottom: View of stone and brick facade at the main entry to the building

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

(651) 603-0720 • (800) 511-3696 30

MINNESOTA HEALTH CARE NEWS JULY 2012

What Washington is doing from page 13

tees so that these committees can help boost medical innovation by reducing regulatory burdens that unnecessarily delay beneficial new medical products from reaching patients. The Medical Device Regulatory Improvement Act aims to reform the review and approval process for innovative medical treatments. Medicare Part D When new treatments become available, we also need to make sure that patients can afford them. One way to reduce prescription drug costs is to focus on the Medicare Part D prescription drug program that was created in 2003. The Government Accountability Office found that between 2000 and 2008, the prices of more than 400 brand-name drugs increased by at least 100 percent, and in many cases, by as much as 500 percent. As a result of these rising prices, many patients are forced to split pills, skip doses, or not fill their prescriptions at all. Meanwhile, Medicare patients in private plans cost taxpayers about 15 percent more than those covered under traditional government programs. With the health care reform law, we did succeed in narrowing the dreaded “doughnut hole,” which had been extremely costly for some seniors. But the Medicare Part D law (which passed before I was in the Senate) still prohibits Medicare from directly negotiating lower drug prices from pharmaceutical companies. Yet, on the other hand, the Veterans Administration (VA) medical system is allowed to negotiate. As a result,

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it is able to use its bulk purchasing power to secure significantly lower drug prices. In fact, by one estimate, if Medicare were allowed to do what the VA does, it would save taxpayers nearly $20 billion per year in lower drug prices. That’s $200 billion over 10 years that could be applied to reducing the federal budget deficit. Ever since I arrived in the Senate, I have supported legislation that would allow Medicare to negotiate lower drug prices. And last year, I introduced the Medicare Prescription Drug Price Negotiation Act to give that authority to the Department of Health and Human Services. The economic reality is that, sooner rather than later, we must do something to reduce the federal budget deficit and rein in Medicare costs. One sure way to do that is by negotiating lower prices for drugs purchased through Medicare Part D. America continues to provide the highest quality, most technically advanced health care in the world. But our physicians, pharmacists, and patients shouldn’t have to worry about having access to the medication that is necessary for care. Above all, they deserve peace of mind that essential life-saving medications will be there for them when needed. To follow the progress of these bills and other health care legislation, go to the website of the U.S. Senate (www.senate.gov/) or the U.S. House of Representatives (www.house.gov/). U.S. Sen. Amy Klobuchar, (D-Minn.), was elected to the U.S. Senate in 2006.

Public Health Certificate in Clinical Research The University of Minnesota School of Public Health offers a program for people who work with research clinical applications on human beings but who do not have an advanced degree in clinical research. Coursework is conveniently offered online and the program can be completed in six terms.

www.sph.umn.edu/programs/certificate/cr JULY 2012 MINNESOTA HEALTH CARE NEWS

This interaction builds the child’s language and intelligence as much as it creates important moments between parent and child that are filled with kindness and attention and promote mental health.

Childhood wellness from page 19

120 The maximum temperature hot water should reach in a water heater. Anything higher will scald infants and children. 2 Twice a year, parents should replace the batteries in their smoke alarms and carbon monoxide monitors. Test each new battery to ensure it works. Parents should make sure each bedroom has a smoke alarm and each level of the house has a carbon monoxide monitor.

Resources

0 Zero is the number of miles an hour a car should be traveling if the driver is on the phone or texting or if any of the occupants is not in a seat restraint. Children should be in rear-facing car seats until they reach age 2 or weigh 20 pounds. Children should be in car seats until they weigh 40 pounds and Children in booster seats until they should ride are age 8 and are taller than in the rear of 4 feet 9 inches. Children should the car until ride in the rear of the car until they are 13 years old. they are 13

years old.

Reach Out and Read is a national nonprofit effort promoting literacy and school readiness in young children. Its 97 programs across Minnesota serve more than 67,000 children annually and distribute nearly 120,000 children’s books each year, free of charge. To find a program near you, to volunteer, or to donate books or funds, visit www.reachoutandread. org/whereweare/site_list.aspx

Reading’s benefits 1 One more number: Read to

your child at least once each day. Minnesota’s Reach Out and Read Program recommends reading to children starting at 6 months of age at least once a day, every day.

Numbers to thrive by

Minnesota is the land of 10,000 lakes and is home to 1,284,063 children, according to the 2010 Census. There are a few other numbers parents should know to keep their children well. From five fruits and vegetables each day to one book every night, these numbers can refocus attention on what parents can do to help children thrive. Robert M. Jacobson, MD, FAAP, is president-elect of the Minnesota chapter of the American Academy of Pediatrics, a father of four, a professor of pediatrics in the Mayo Clinic College of Medicine, and a primary care pediatrician in the Employee and Community Health Initiative at Mayo Clinic in Rochester.

Minnesota

Health Care Consumer June survey results ... Association

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 June survey.

48.9% 40.0%

20 8.9% 2.2% 0

0.0%

Very Supportive No Unsupportive Very supportive unsupportive opinion

MINNESOTA HEALTH CARE NEWS JULY 2012

Percentage of total responses

28.9%

25 20 15.6%

15 8.9%

8.9%

5 0

35 30

46.7%

15 10

6.7% 2.2% Very Supportive No Unsupportive Very supportive unsupportive opinion

5. I feel increased government intervention into the food and beverage industry is necessary to improve population health.

46.7%

44.4%

20 10 2.2% Agree

26.7%

24.4%

Very Supportive No Unsupportive Very supportive unsupportive opinion

Strongly agree

40.0%

37.8%

4. Nutritional content and impact on my health play an important part in my decisions about how I spend money on food.

Percentage of total responses

3. How supportive are you of requiring products that contain genetically modified foods to be identified as such on packaging?

2. How supportive are you of imposing restrictions on fast food advertising similar to those placed on tobacco and alcohol?

1. How supportive are you of imposing additional tax on high-sugar-content soft drinks?

No opinion

40 30 24.4% 20

15.6%

13.3%

4.4% 0.0% Disagree

Strongly disagree

2.2% 0

Strongly agree

Agree

No opinion

Disagree

Strongly disagree

Minnesota

Health Care Consumer Association

Welcome to your opportunity to be heard in debates and discussions that shape the future of health care policy. There is no cost to join and all you need to become a member is access to the Internet.

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

www.mnhcca.org

Join now.

â&#x20AC;&#x153;A way for you to make a differenceâ&#x20AC;? JULY 2012 MINNESOTA HEALTH CARE NEWS

Smoking and oral health from page 21

The combined effect of this decrease in blood cells and blood flow is poor healing. Not surprisingly, according to the International Journal of Prosthodontics (2006), patients who were smokers at the time of dental implant surgery had a significantly higher implant failure rate than nonsmokers. Smokers are encouraged to stop smoking prior to oral procedures to decrease the risk of postoperative complications and unsatisfactory results. In addition, according to the Journal of Canadian Dental Association (2007), current smokers are more likely to report sensitivity of teeth to hot or cold temperatures, toothaches, and pain in the mouth or face. Smoking is also highly associated with halitosis and loss of taste, and can increase the incidence of black hairy tongue.

Smokers are encouraged to make a conscious decision to quit.

importance of routine exams, including an oral cancer screening; regular cleanings from a dental hygienist; and meticulous oral hygiene at home. A thorough oral hygiene home care plan includes brushing, flossing, and oral cancer self-examinations every six months. During a self-exam, check for: â&#x20AC;˘ Sores around the face, neck, or mouth. â&#x20AC;˘ Frequent bleeding inside the mouth. â&#x20AC;˘ White, red, or dark patches on the palate, tongue, gums, and all other surfaces inside the mouth. â&#x20AC;˘ Lumps or bumps on lips, gums, and all other areas in the facial region. Contact your dentist right away if you find any sores, bleeding, lumps, bumps, or discolored patches in or on your face, neck, or mouth. Smoking is bad for you and your mouth.

Give yourself a break

Laura Howley, DDS, graduated from the University of Minnesota School of Dentistry, completed a general practice residency at Meriter Hospital in Madison, Wis., and practices with Associated Dentists in St. Paul.

Given the overwhelming evidence of tobaccoâ&#x20AC;&#x2122;s negative effects on systemic and oral health, smokers are encouraged to make a conscious decision to quit. If quitting is not an option, the dental profession stresses the

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MINNESOTA HEALTH CARE NEWS JULY 2012

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

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

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

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

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

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

FOR TYPE 2 DIABETES

Victoza® helped me take my blood sugar down…

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

Model is used for illustrative purposes only.

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

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

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

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

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

Non-insulin • Once-daily