Minnesota Health care News June 2013

Your Guide to Consumer Information

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June 2013 • Volume 11 Number 6

Spinal fusion Nicholas Wills, MD

Fireworks Gary Gosewisch, MD

Hepatitis C Christine Pocha, MD

To learn more, please call the Minnesota Lung Center Research Department.

3 Convenient Locations: Minneapolis (952)852-5324 • Edina (952)852-5274 • Woodbury (952)852-5259

www.minnlung.com

CONTENTS

4 7 8

JUNE 2013 • Volume 11 Number 6

NEWS

PERSPECTIVE Marilee Rose and Joseph Leach, MD

10 QUESTIONS Ann C. Lowry, MD Colon and Rectal Surgery Associates

12

EMERGENCY MEDICINE Fireworks

By Gary Gosewisch, MD, FAAEM

14

18 20

CALENDAR PTSD Awareness Month

22

SURGERY Spinal fusion

24

POLICY Autism and employment

26

RESEARCH Pancreatic cancer

PEOPLE

MMCCOP

10

16

CAREGIVING As loved ones age

TAKE CARE Health care directives

By Kent Wilson, MD, and Sue A. Schettle

30

MINNESOTA HEALTH CARE ROUNDTABLE

By Chris Palmer, RN, and Sharon Roth Maguire, MS, RN, GNP-BC

FORTIETH

SESSION

PUBLIC HEALTH Nail salon safety

By Dirk Halverson, DPM, FACFAS

By Nicholas Wills, MD

By Kelly Thomalla

By Vikas Dudeja, MD, and Selwyn M. Vickers, MD, FACS

INFECTIOUS DISEASE Hepatitis C

By Christine Pocha, MD, PhD, MPH

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

Advanced care planning Addressing end-of-life issues Thursday, October 24, 2013 1:00 – 4:00 PM • Symphony Ballroom Downtown Mpls. Hilton and Towers

Background and focus: For the majority, end-of-life is the most medically managed part of life. With it come complex issues that involve economics, ethics, politics, medical science, resources and more.

Advances in technology are extending life expectancies and require a redefinition of the term “end-of-life.” It now entails a longer time frame than one’s final weeks or hours and debate as to when life is really over. Mechanisms exist to facilitate personal direction around this topic, but there is a need for improved coordination among the entities that provide end-of-life support.

Objectives: We will discuss the significant infrastructure that supports end-of-life care. We will examine the roles of long-term care/assisted living, palliative care, gerontology, and hospice.

We will review the elements that go into creating advanced directives, societal issues that make having them necessary, and the difficulties encountered in bringing them to their current state. We will present a potential road map to optimal utilization of end-of-life support today and how it may best be improved in the future.

Panelists include: Ed Ratner, MD, University of Minnesota Center for BioEthics Suzanne M. Scheller, JD, Elder Law and Advocacy Tom Valdivia, MD, CEO, Luminat Sponsors: Luminat • Scheller Legal Solutions

ART DIRECTOR Elaine Sarkela esarkela@mppub.com OFFICE ADMINISTRATOR MaryAnn Macedo mmacedo@mppub.com ACCOUNT EXECUTIVE Iain Kane ikane@mppub.com

Minnesota Health Care News is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; phone (612) 728-8600; fax (612) 728-8601; email mpp@mppub.com. We welcome the submission of manuscripts and letters for possible publication.

All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc., or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of this publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $36.00. Individual copies are $4.00.

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JUNE 2013 MINNESOTA HEALTH CARE NEWS

3

NEWS

Blue Cross Delays New Payment System For Rural Hospitals Blue Cross and Blue Shield of Minnesota has agreed to delay implementation of a new payment system for rural hospitals.

The new system, which Blue Cross had been rolling out in different parts of the state this spring, caused the Minnesota Hospital Association (MHA) to publicly call for the Bloomingtonbased insurer to slow down implementation of the change.

MHA officials said rural hospitals had complained they could not comply with the changes in time, and some were at risk to lose their contracts with the state’s largest insurer.

The issue raised enough outcry that Minnesota Attorney General Lori Swanson and Minnesota Health Commissioner Ed Ehlinger, MD, met with Blue Cross officials to discuss the matter. State officials seemed particularly concerned about how the

new system would affect critical access hospitals, which are small, rural hospitals that serve outstate areas. After discussion with state officials, Blue Cross announced it was delaying the changes.

Blue Cross released a statement on May 1, saying that it was moving the implementation date for the new payment system to Jan. 1, 2014. The statement added that Blue Cross values critical access hospitals and that it would work with them to implement the new system, including sharing costs of software needed for new reimbursement models.

MHA officials welcomed the announcement that Blue Cross had moved back the implementation date, saying the hospital association agrees that payment models need to change.

STD Cases Increase, MDH Reports A Minnesota Department of Health (MDH) report finds there was a 10 percent increase in the number of reportable sexually

transmitted disease (STD) cases in Minnesota in 2012. Cases of HIV are also on the rise in the state.

The latest STD report says there were 21,465 cases of reportable STDs in 2012 compared with 19,547 cases reported in 2011 and 18,009 cases reported in 2010.

Reportable STDs in Minnesota include chlamydia, gonorrhea, and syphilis.

A second report on HIV cases found an 8 percent rise in such cases in 2012. Health officials say they are concerned the two trends might be related, as STDs can increase HIV transmission. “Some of these STDs can increase HIV transmission or the likelihood of getting infected by two to five times,” notes Minnesota Health Commissioner Ed Ehlinger, MD. MDH officials say HIV testing and the practice of safe sex, along with avoiding sharing needles, can help bring down the number of HIV cases.

“Getting tested for HIV and getting into treatment if infected is an effective prevention strategy,” says Ehlinger. “Those in treatment

can substantially reduce their ability to transmit HIV to their sexual partners.”

Health Plans Report Spending Up in 2012 Spending was up and profits were down for Minnesota health plans in 2012, according to a yearly report from the Minnesota Council of Health Plans (MCHP). Health plans spent $19 billion on health care services, an increase of 7 percent over 2011. Overall, health plans had an operating margin of 1 percent last year.

The MCHP annual report assesses data from private health insurance plans as a whole rather than on an individualized basis.

Health plan results can vary from year to year and company to company. For example, Blue Cross and Blue Shield of Minnesota released a separate statement saying the Eagan-based insurer had a negative operating margin of .06 percent for 2012, while Bloomington-based HealthPartners reported a margin of 4.4 per-

Tick-Borne Disease Specialty Clinic When it comes to your child, getting help early is your priority.

It’s ours too.

Multi-Disciplinary Assessments at St. David’s Center evaluate the needs of the child through: s Psychological Testing s Speech Assessment s Occupational Therapy Evaluation Individual psychological testing and consultation is also available for families with children ages two to six who are already receiving speech or occupational therapy services.

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4

MINNESOTA HEALTH CARE NEWS JUNE 2013

Tick-borne disease can result in disabling consequences that may resist treatment and even diagnosis. We have been successful in the rehabilitation of many patients with unique cases of chronic tick-borne illness.

No medical referral is required.

Charles V. Burton, MD Helen P. Odland, MD For more information, please read Doctor Burton’s report at: www.burtonreport.com To schedule an appointment please call:

Sentinel Medical Associates 514 St. Peter Street, Suite 200 St. Paul 55102

612-287-8781

cent for the same time period.

MCHP officials note that spending for health care services rose $1.3 billion among all plans in 2012, compared with 2011.

Health spending trends have been flat in recent years, possibly because of restrained spending by consumers in a poor economic climate. Increased spending on 2012 care resulted in the lowest operating margins for health plans since 2008, MCHP data shows. “Managed care continues to demonstrate excellent value that allows the state to predict its budget and provide excellent coverage. As the state’s recent value of managed care report showed, Minnesota’s nonprofit health plans continue to outperform plans from across the nation in service, quality, and access to care,� said MHCP executive director Julie Brunner.

Shriners Joins Mayo Network Shriners Hospitals for Children–Twin Cities will join the Mayo Clinic Care Network, officials announced recently. Shriners, a hospital system that provides specialized orthopedic care to children, is the first pediatric hospital to join the network, which provides Mayo Clinic expertise to member hospitals. “The relationship between Shriners and the Mayo Clinic Children’s Center has been a longstanding and rewarding one, and by formalizing our collaboration, we’ll be able to work even more closely together to enhance the care we provide children,� says David Hayes, MD, medical director, Mayo Clinic Care Network.

Estimated 459,000 Minnesotans Eligible For ACA Tax Credits A recent report from Washington, D.C.-based Families USA says more than 459,000 Minnesotans will be eligible for tax credits next year to help pay for health insurance coverage, under health care reforms put in place by the Affordable Care Act (ACA).

The ACA is designed to expand health insurance coverage to many Americans who are currently uninsured or underinsured.

Families USA officials say that under the law, consumers will be eligible for tax credits to purchase health care, determined by a sliding scale based on income.

Those with the lowest incomes will receive the largest tax credits.

Eligibility for tax credits can range as high as $94,200 in annual income for a family of four.

Tax credits will be available to individuals and families purchasing health insurance on the stateĘźs health insurance exchange, MNsure. That online insurance marketplace is scheduled to begin enrollment in October.

The Families USA report says that of the more than 459,000 Minnesotans who will be eligible for new tax credits in 2014, approximately 57 percent will be people with annual incomes between $47,100 and $94,200 for a family of four (the equivalent of incomes between 200 and 400 percent of the federal poverty level).

The report also shows that more than 80 percent of the Minnesotans who will be eligible for the tax credits will be Caucasian, non-Hispanic; about 5 percent of the eligible Minnesotans will be African American, nonHispanic; and about 7 percent of the eligible Minnesotans will be Hispanic. More than 134,000 Minnesotans qualifying for tax credits will come from Hennepin and Ramsey counties.

Families USA officials add that most Minnesotans eligible for premium tax credits will include those 18–34 years of age and those in working families. “The tax credit subsidies are a game-changer: They will make health coverage affordable for huge numbers of uninsured families who would have been priced out of the health coverage and care they need,� says Ron Pollack, executive director of Families USA. News to page 6

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JUNE 2013 MINNESOTA HEALTH CARE NEWS

5

News from page 5

Medical Marijuana Bill Introduced A bipartisan group of legislators has introduced a bill to legalize medical marijuana, saying that the public supports legalizing the drug to help people with serious medical conditions.

At a May 2 press conference at the state capitol, state Rep. Carly Melin (DFL-Hibbing) and Sen. Scott Dibble (DFLMinneapolis) said they would introduce the bill in their respective chambers. Both bills have the maximum number of sponsors allowed: 35 in the House, including 12 committee chairs; and five in the Senate, including two committee chairs. Although nearly all the bill’s co-sponsors are DFL members, one Republican is a cosponsor in both the House and Senate.

At the press conference, citizens talked about benefits of medical marijuana for health care conditions. “A strong majority of Minnesota voters agree it is time

to adopt legislation that allows seriously ill people to use medical marijuana if their doctors believe it will help treat their conditions and ease their suffering,” said Heather Azzi, political director of Minnesotans for Compassionate Care, the advocacy group behind the bill. “People suffering from diseases such as cancer and multiple sclerosis should be able to access medical marijuana safely and use it without fear of being arrested.”

The late introduction of the bill suggests it will not pass this year, but by raising the issue, supporters say they are laying the groundwork for a similar bill in next year’s session.

Organ Donation Support Strong, Study Says Mayo Clinic officials say the results of a new study show more public support for organ donation.

The survey found 84 percent of respondents say they would be

very or somewhat likely to consider donating a kidney or a portion of their liver to a close friend or family member in need. The survey found that 49 percent said they also would consider donating a kidney to someone they have never met, which is often referred to as “Good Samaritan” kidney donation.

“This is really encouraging news,” says Mikel Prieto, MD, surgical director of the kidney and pancreas transplantation programs at Mayo Clinic in Rochester. “As living organ donation becomes more widely known and accepted, and as the safety and surgical proficiency continue to improve, we hope that more people will come forward and offer to help loved ones who need kidney and liver transplants.”

MDH to Change Immunization Rules The Minnesota Department of Health (MDH) has proposed changes to the state’s school immunization rules for Minnesota

Health care for the whole person.

children in child care and grades pre-K–12.

The proposed changes, designed to bring the state up to date with current recommended practices, would require hepatitis A and B vaccination for children enrolling in child care or schoolbased early childhood programs; replace the current seventh-grade tetanus-diphtheria (Td) requirement with a vaccine that also includes pertussis (Tdap); and require secondary students to have meningococcal vaccination beginning in seventh grade.

MDH can approve the changes through its rulemaking authority. If the department is petitioned to hold a public hearing on the changes before May 31, it will hold such a hearing with an administrative judge presiding.

Correction The parasite mentioned in the April 2013 issue’s Perspective essay should have been Naegleria fowleri.

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Acupuncture and Oriental Medicine • Chiropractic • Healing Touch • Massage Therapy • Naturopathic Medicine Nurse Practitioner Services • Physical Therapy • Supplements and lifestyle products Health Clinics

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MINNESOTA HEALTH CARE NEWS JUNE 2013

PEOPLE Heather Bidinger, MMS, PA-C, has been awarded the Minnesota Physician Assistant of the Year Award by the Minnesota Academy of Physician Assistants. Bidinger is the founding and current director of the Master of Physician Assistant Studies program within the Henrietta Schmoll School of Health at St. Catherine Heather Bidinger, MMS, PA-C

Graduate School of Health & Human Services

University, St. Paul.

S. Charles Schulz, MD,

professor and head of the University of Minne-

Advance your career in

sota Department of Psychiatry, will receive the

health & human services

Stanley Dean Award for Research in Schizophrenia in 2014, awarded by The American College of

S. Charles Schulz, MD

SMU offers bachelor completion and master’s programs in the health & human services areas.

Psychiatrists (ACP) to “a group or individual that has made a major contribution to the treatment of schizophrenic disorders.” The award will be presented at the next annual meeting of the ACP in February 2014. Before coming to the University of Minnesota, Schulz founded

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the Schizophrenia Program at the Medical College of Virginia and was the medical director of the Schizophrenia Module at the University of

www.smumn.edu/hhs

Pittsburgh. He has contributed to the National Plan on Schizophrenia Research and, with Carol A. Tamminga, MD, of University of Texas Southwestern Medical School, co-founded the International Congress on Schizophrenia Research.

Karen Sonnenburg, RN, MAHS, has been named a 2012 Nurse of the Year in the “Women’s Health” category by the Minnesota chapter of March of Dimes. Sonnenburg is lead nurse for water births at St. Francis’ Family Birth Place at St. Francis Regional Medical Center, Shakopee, where she program.

Lee Wattenberg, MD, a professor in the Department of Laboratory Medicine and Pathology at the University of Minnesota and a researcher in the Carcinogenesis and ChemopreLee Wattenberg, MD

vention Program at the university’s Masonic

Cancer Center, has been named an American Association for Cancer Research Academy Fellow. The academy honors distinguished scientists whose scientific contributions have resulted in significant innovation and progress in the fight against cancer. Wattenberg is considered the “father of chemoprevention,” having pioneered that field by identifying the protective effects of vitamins A, C, and E and chemicals found in certain vegetables. He continues research to identify agents that can prevent carcinogen-induced lung cancer.

Mark Werner, MD, has joined Medica as its senior vice president and chief clinical and innovation officer. Previously, he was a senior vice president and chief clinical integration officer for Fairview Health Services.

Therese Zink, MD, MPH, a professor in the Department of Family Medicine and Community Health at the University of Minnesota, has received

Mark Werner, MD

Telephone Equipment Distribution (TED) Program

spearheaded development of the water birth

Do you have trouble using the telephone due to hearing loss, speech or physical disability?

If so…the TED Program provides assistive telephone equipment at NO COST to those who qualify.

Please contact us, or have your patients call directly, for more information.

1-800-657-3663 www.tedprogram.org Duluth • Mankato • Metro Moorhead • St. Cloud

the 2013 President’s Award from the Minnesota Academy of Family Physicians in recognition of the numerous activities she is involved in outside her practice. These include serving on the Governor’s Health Reform Task Force from 2011–2012.

The Telephone Equipment Distribution Program is funded through the Department of Commerce Telecommunications Access Minnesota (TAM) and administered by the Minnesota Department of Human Services

JUNE 2013 MINNESOTA HEALTH CARE NEWS

7

PERSPECTIVE

Metro-Minnesota Community Clinical Oncology Program Bringing the advantages of cancer research to the community

T

he Metro-Minnesota Community Clinical Oncology Program (MMCCOP) is a nonprofit research program sponsored by the National Cancer Institute (NCI) and participating hospitals and clinics. This program is one of several CCOPs nationwide and provides people in our community access to the newest therapies available for cancer treatment, management of treatment side effects and disease symptoms, and cancer prevention.

Marilee Rose is director of MMCCOP. Joseph Leach, MD, a medical oncologist with Minnesota Oncology Hematology, PA, is MMCCOP’s principal investigator. MMCCOP’s goal is to provide expertise and resources to develop, implement, and assist in the evaluation of cancer treatment and cancer control clinical trials in cooperation with the National Cancer Institute (NCI) and to improve the incorporation of research results into clinical practice. MMCCOP is currently funded through May 2015.

8

How it works MMCCOP links researchers and community cancer specialists, primary care physicians, and other health care professionals and provides people with the opportunity to participate in NCIapproved national research studies, called clinical trials. Cancer clinical trials are the way we make progress against cancer. Many of the advances in cancer treatment and survival, controlling side effects of cancer treatment, and improvements in cancer prevention were first found to be effective in clinical trials.

participants on NCI-sponsored cancer treatment, prevention, and symptom management protocols. More than 160 physician-investigators participate, representing medical oncology, radiation oncology, surgical oncology, neurosurgery, thoracic surgery, gynecologic oncology, urology, and otolaryngology.

Accomplishments Among MMCCOP’s accomplishments is its role in helping to advance the science of preventing breast cancer. MMCCOP participated in the STAR Study, one of the largest breast cancer prevention clinical trials ever conducted. Across the country, 19,490 postmenopausal women who were at increased risk of developing breast cancer volunteered to participate in the study (584 women were from Minnesota, including 240 women who received care at MMCCOP member sites). Efforts were made to include women of color, and federal funds were available to support the cost of clinic visits for underinsured women.

This clinical trial compared the ability of two drugs, raloxifene and tamoxifen, to prevent women from developing invasive breast cancer.

Participants received either tamoxifen or raloxifene daily for five years and were followed for 81 months. The results of the study helped to clarify that both raloxifene and tamoxifen are good preventive choices for postmenopausal women who are at high risk of developing invasive breast cancer. The long-term follow-up of these study participants provided additional information about the potential side effects of both drugs, Location allowing a better understanding of Minneapolis, Minn. individual risk factors to consider Burnsville, Minn. when choosing the best preventive Edina, Minn. therapy.

The MMCCOP consortium represents an established community program that began in 1979 through an NCI-funded Community Hospital Cancer Program (CHCP) Award. Currently, the consortium represents 21 hospitals and clinics in Minneapolis, St. Paul, and surrounding suburbs as well as Stillwater, Hutchinson, Willmar, New Ulm, and New Richmond, Wis. Consortium members share a common approach and follow established methods of identifying, enrolling, and following Member sites Abbott-Northwestern Hospital Fairview Ridges Hospital Fairview Southdale Hospital Hennepin County Medical Center Hutchinson Community Hospital Lakeview Hospital Mercy Hospital Park Nicollet Health Services New Ulm Medical Center North Memorial Health Care Regions Hospital and Riverside Clinic Rice Memorial Hospital Ridgeview Medical Center St. Francis Regional Medical Center St. John’s Hospital United Hospital Unity Hospital Minnesota Oncology Hematology, PA Westfields Hospital (Cancer Center of Western Wisconsin)

MINNESOTA HEALTH CARE NEWS JUNE 2013

Minneapolis, Minn.

Hutchinson, Minn.

Stillwater, Minn.

Coon Rapids, Minn.

St. Louis Park, Minn.

New Ulm, Minn.

Robbinsdale, Minn.

St. Paul and Minneapolis, Minn.

Willmar, Minn.

Waconia, Minn.

Shakopee, Minn.

Maplewood, Minn.

St. Paul, Minn.

Fridley, Minn.

Maplewood and Woodbury, Minn.

New Richmond, Wis.

Future progress The success of cancer research is made possible through the combined efforts of many individuals.

Participating in a clinical trial contributes to the science for improving cancer care. MMCCOP is currently participating in more than 200 clinical trials, investigating many different types of treatment for adults who have been diagnosed with cancer.

For more information about MMCCOP, visit our website (www. ccopnet.com). For information about a particular cancer, visit the NCI website (www.cancer.gov). To learn more about cancer clinical trials, visit www.clinicaltrials.gov

You call it “reminding mom to take her pills.�

We call it caregiving.

You or someone you know may be a caregiver.

WhatIsACaregiver.org

10 QUESTIONS

Colon and rectal surgery Ann C. Lowry, MD Dr. Lowry is board-certified in colon and rectal surgery and practices with Colon and Rectal Surgery Associates.

What can you tell us about the history of this specialty? In 1899 a specialty named proctology was established, which focused on surgery involving the rectum. After an operation was developed in the early 1900s that combined abdominal and rectal surgery to treat rectal cancer, proctology became colon and rectal surgery. Since then, advances have changed the treatments for colorectal cancer, inflammatory bowel disease (IBD), and disorders of the lower rectum. We now can treat rectal cancer in most patients without needing to give them a permanent colostomy. (A colostomy connects the intestine to an opening in the abdomen; stool exits the body from that opening and collects in a bag that the patient empties.)

Anal cancer now is treated with chemotherapy and radiation, thus avoiding surgery; many colon operations are performed using minimally invasive techniques; and, we can improve the quality of life of patients with bowel incontinence and other problems.

Colorectal cancer is the second-leading killer in the U.S. among people over 50, yet has a good cure rate if detected early. What are its symptoms? Most colorectal cancer does not cause symptoms until late in the course of the disease. The good news is that most colorectal cancer develops in polyps—growths on the lining of the colon—which can be removed during colonoscopy. This is why scheduling regular colonoscopies starting at age 50 is so important. When symptoms do occur, bleeding with bowel movements, a persistent change in bowel habits (either new constipation or diarrhea), and abdominal discomfort are the most common.

What are risk factors for colorectal cancer? More than 90 percent of the time, colorectal cancer is diagnosed in people over 50. Risk increases with age.

A low-fiber, high-fat diet; smoking; and excess alcohol consumption increase risk.

A family history of colorectal cancer or polyps, particularly in an immediate family member, also increases risk. Some specific genetic abnormalities have been identified in certain families who are very likely to develop colorectal cancer. However, most colorectal cancer occurs in people without a family history of it.

How do colorectal surgeons collaborate with other medical specialists? Patients may be referred from primary care physicians for screening for colorectal cancer, for surgery for a known diagnosis, or to obtain a diagnosis. We work with gastroenterologists when patients require collaborative care, such as patients with IBD. We work with medical and radiation oncologists. We work with urologists and urogynecologists to diagnose and treat pelvic floor disorders.

Photo credit: Bruce Silcox

10

MINNESOTA HEALTH CARE NEWS JUNE 2013

What can you tell us about IBD? First, it is important to distinguish between inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS). There are several types of inflammatory bowel disease, but all involve irritation and swelling of the lining of the intestine. It’s often diagnosed in teens and young adults who experience bleeding with bowel movements, abdominal pain, and diarrhea. Diagnosis may be made with X-rays or colonoscopy. Most patients respond to medication but some require surgery. IBS refers to a condition in which people experience

Genetic information is helping viewing the inside of the abdomen on a abdominal discomfort or bloating, constidoctors customize treatment pation, or diarrhea. It is thought that the screen. intestine is sensitive to specific triggers such of colorectal cancer and What are hemorrhoids, and how as foods or stress. No visible abnormality is inflammatory bowel disease. they can be treated? Hemorrhoids are seen with X-rays or colonoscopy, but those clusters of small arteries and veins that may tests are done to be sure of the diagnosis. enlarge with rectal straining. External hemDietary and lifestyle changes, and, sometimes, medication, help peoorrhoids may be painful; internal hemorrhoids may bleed or protrude ple manage symptoms; surgery is not necessary. outside the rectum. However, other conditions may cause the same symptoms, so patients should consult their physician. Many hemorWhat are pros and cons of standard colonoscopy vs. rhoids are managed with diet, warm baths, and ointments. Surgery virtual colonoscopy? Both techniques require bowel preparation may be required for external hemorrhoids. Internal hemorrhoids to clean the colon. Standard colonoscopy involves introducing into often can be treated in the office. the colon a lighted flexible instrument to see the lining. This is usually done with sedation due to possible cramping. Polyps usually can What are the advances in colorectal surgery? Since laparobe removed during the procedure. Virtual colonoscopy involves introscopic surgery is technically challenging for surgery in the pelvis, usducing air into the rectum followed by a scan that allows the radioloing a robotic system controlled by a surgeon seems to be technically gist to see the colon. Because cramping is typically less, no sedation is better. Such technical advances will help us to do more minimally needed. Accuracy is about the same when performed by experienced invasive surgery. Pre-treating certain cancers with chemotherapy and physicians. With the virtual examination there is less risk of injuring radiation before surgery is improving outcomes. Genetic information the colon. However, patients usually require subsequent standard colonoscopy to remove detected polyps. Currently, there may be diffi- is helping doctors customize treatment of colorectal cancer and IBD. New, simple treatments are being developed for bowel incontinence. culty obtaining insurance coverage for virtual colonoscopy.

What advances has laparoscopic surgery made in your field? Because incisions are smaller, patients typically have less pain, shorter hospital stays, and faster recoveries after laparoscopic surgery. To perform this surgery, small incisions are made and the abdomen is filled with carbon dioxide. A camera and surgical instruments are inserted into the abdomen, and the surgeon operates while

How can people promote the health of their colon? A high-fiber, low-fat diet; regular exercise; and avoiding smoking are important. Some evidence suggests that aspirin or other anti-inflammatory medication may reduce the chance of developing polyps or colorectal cancer. Screening colonoscopies reduce the chance of developing colon cancer.

JUNE 2013 MINNESOTA HEALTH CARE NEWS

11

EMERGENCY MEDICINE

Fireworks

O

n the Fourth of July and during the days leading up to the holiday, many people are entertained by the boom, crackle, and exploding color of fireworks displays.

Emergency room doctors, however, deal with the darker side of this tradition.

We see people who have had parts of their fingers blown

By Gary Gosewisch, off, who’ve been MD, FAAEM burned, or both.

These are devastating, lifelong injuries. Not only that, but we also see children who have been poisoned by ingesting fireworks.

According to the Consumer Product Safety Commission, nearly 10,000 people in the U.S. suffer fireworks related injuries every year and

Through the eyes of an ER doctor

nearly half those injured are children. Most of these injuries occur during the “high season” of fireworks, from June 19 to July 19.

Too hot to handle Sparklers are the top firework offender. Ironically, many consider this type of firework to be the safest, and some adults actually allow their children to handle them. But, according to the National Fire Protection Association, the tip of a sparkler or other firework can burn as hot as 1,200 degrees. This is hotter than boiling water or burning wood, hot enough to melt glass—and hot enough to cause third-degree burns. Bottle rockets are also a major cause of fireworks-related visits to the emergency room.

Types of injuries The most common fireworkscaused injuries that send people to the emergency room are: • Eye damage, including blindness • Burns to skin on the body and face • Poisoning • Hand and foot wounds Eye damage A tear, or abrasion, of the cornea is the most common eye injury caused by fireworks. Researchers have found that these injuries occur when tiny shards of unspent explosive debris spray onto the eye. Those injured in this way should not rub the eye. Doing so can cause chemical burns or injure the eye even further.

If there is a foreign object in the eye, do not try to remove it.

Instead, go to your doctor to have it properly and safely removed.

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MINNESOTA HEALTH CARE NEWS JUNE 2013

If there does not appear to be an object in the eye, flushing the eye is the best immediate treatment.

Afterward, you can use over-thecounter eye care products designed to help soothe irritation.

Flushing the eye Tilt the person’s head over the sink.

Gently pull down the lower lid to encourage the person to open his or her eyes as wide as possible. Slowly pour lukewarm water over the eye.

Flush for up to 15 minutes, checking every five minutes to see if the object has been flushed out. If the object is not removed by flushing, seek medical attention.

Burns First, determine the severity of the burn. If the burn is not deep and covers an area smaller than the size of the person’s palm, it can be treated at home. However, if the burn is on the face, genitals, or major joints, the person should see a doctor.

Second, to decide if you should seek medical care, you’ll also need to determine the type of burn: • Superficial or first-degree The tip of a burns result in sparkler or other reddened skin without blisfirework can ters. These burn as hot as types of burns 1,200 degrees. can be treated at home.

Poisoning Fireworks contain toxic chemicals such as potassium nitrate, white phosphorus, barium chlorate, and arsenic. They’re often packaged in in pretty, colorful packages that can look like candy to a child. Because swallowing any amount of fireworks can be harmful, keep them out of the reach of children and animals.

If your child ingests fireworks, call 911 or poison control immediately to determine immediate steps to take, which may include a trip to the emergency room. You can reach poison Sparklers are control at: (800) 222-1222.

Hand and foot wounds

the top firework offender.

These are the most common fireworks-caused injuries. They typically happen when fireworks explode while being lit, including cases in which someone lights a firework while holding it.

To treat these types of wounds: • Apply direct pressure to the wound until bleeding stops.

• Clean the injured area with warm water and soap.

• Apply antibiotic ointment and a sterile bandage.

• Apply ice on top of the bandage and elevate the wounded area to reduce swelling.

• If a finger or part of a finger has been blown off, collect the severed part and place it in a dry plastic bag. Put the bag on ice and transport it and the injured person to the hospital Fireworks safety to page 34

• Partial-thickness or second-degree burns cause reddened skin with blisters. It’s best to have a doctor assess this type of burn.

• Full-thickness or third-degree burns are characterized by white or charred skin. See a doctor immediately. The area loses sensation to pain and touch and often needs a skin graft to heal properly and to lessen serious scarring.

Remember: how you decide to treat a burn depends on its size and location. If you are unsure how to treat it, check with your doctor.

Cover the burn with a sterile dressing or a clean, dry washcloth or towel during the trip to see your doctor.

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Call 952-920-8644 www.vivifydietrehab.com JUNE 2013 MINNESOTA HEALTH CARE NEWS

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TA K E C A R E

Health care directives

Y

ou hit your head and are in a coma, unable to communicate your choices about medical care. The prognosis is that you are profoundly brain damaged and will be unable to communicate or provide any self-care for the rest of your life.

Who would speak for you if you were unable to speak for yourself?

Without a directive …

Wrenching family struggles can unfold at the bedside of a loved one when relatives have conflicting ideas about how they think the patient would want his or her situation handled. “I have witnessed, far too many times, families who struggle to come to consensus on what types of treatment to give their loved one. If they only knew what their loved one would want! Many families are forever changed because consensus is not obtained. As an ICU [intensive care unit] physician, I can give them my best advice but ultimately, the family members must make the call. Advance care plan-

ning can greatly enhance the ease with which this final stage unwinds,” observes David Bonham, MD, who practices with St. Paul Lung Clinic.

As the U.S. population ages and medicine becomes more adept at prolonging life, famiBy Kent Wilson, MD, lies may increasingly find themselves thrust and Sue A. Schettle into the position of having to make decisions about loved ones’ health care. Although life-prolonging treatment is available for most medical conditions, its benefits may be questionable. It may buy a patient extra time, but may diminish a patient’s quality of life by imposing additional physical discomfort and hospitalization. It may also burden a patient and family with debilitating financial cost.

Patients who want all avenues for health care to be pursued on their behalf have a right to receive that care.

Patients also have the right not to have all avenues of care pursued. Those choices, and all those in between, can be specified in a document called a health care directive. This document ensures that a patient’s wishes are respected and makes medical decision-making easier for all concerned.

Make your wishes known

What is a health care directive?

A health care directive is a written document that spells out instructions you make for your future health care. This document is also referred to as an advance health care directive and an advance directive. It specifies a person, called a health care agent, who has agreed to act as your surrogate decision maker in health-related matters if you are unable to communicate your wishes.

Do I really need one?

Research published in 2010 in the New England Journal of Medicine reported that patients who participated in advance care planning with their health care providers and their health care agents were more likely to have decisions made at the end of their lives that upheld the care preferences they had specified in their health care directives. For example, cancer patients who discussed care preferences with their oncologists were more likely to receive end-of-life care that honored their preferences. In contrast, those who did not have such discus-

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MINNESOTA HEALTH CARE NEWS JUNE 2013

sions tended to receive aggressive care, and reported a worse quality of life.

How do I get a health care directive?

Everyone over the age of 18 should complete a health care directive and update it periodically.

Health care directive forms are free; multiple online sources as well as your doctor can provide one. One online source is www.honoringchoices.org. Click on the “Resources & Links” tab, locate “Advance Care Directives” at the top of the page, and click on “Honoring Choices Health Care Directive.”

When should I construct a health care directive?

Everyone over the age of 18 should complete a health care directive and update it periodically, as well as assign a health care agent and backup agent. Review and update the directive whenever any of the following “Five D’s” occur: when you start a new decade of life; when you experience a divorce or other major family change; when you are diagnosed with a serious health condition; when you experience a significant deterioration of an existing health condition, especially one that makes you unable to live on your own or is predicted to do so; and whenever a loved one dies. The death of a loved one forces families to confront end-of-life concerns and reminds them to update or create a health care directive. It’s also important to update your directive if you select a different health care agent.

What topics should a health care directive cover?

The health care directive form itself walks you through topics and decisions that might need to be made on your behalf, such as whether or not you want to be resuscitated if you stop breathing.

By filling out the health care directive, you state the treatment you want to have in certain medical situations. In addition, the directive should contain the name and contact information of your health care agent. It is a good idea to invite a second person to be a backup agent, whose contact information should also be in the directive.

The form asks you to state your overall health care goals in terms that Health can be as simple or detailed as you care wish. This enables your health care agent to make decisions for you in directive unanticipated scenarios. forms

are free.

can discuss medical scenarios in which difficult decisions may arise.

What should I do with the directive?

Give a copy of your directive to your physicians, every hospital or clinic from which you receive service, family members, clergy, lawyer, and your health care agent and backup agent. Some people carry a copy of their directive when they travel. Keep a copy at home in an easily accessible place. It may be a good idea to give a copy to a trusted neighbor. Keep a copy at work in case you require emergency medical treatment there.

Make decision-making easier

When Terry Traudt’s father and father-in-law died, “There were no painful or divisive family decisions to be made at the time of … their deaths,” she recalls. Both men had made their end-of-life desires known to their families. “In hindsight, I’m so grateful that we participated in these conversations, in spite of the overwhelming temptation to say, ‘Dad, please don’t talk that way,’ or, ‘I don’t want to think about that!’ In honor of these wonderful men, I have completed a health care advance directive and made my own end-of-life wishes known to members of my immediate family and friends. I encourage others to do the same.”

Kent Wilson, MD, is the medical director of Honoring Choices Minnesota.

Sue A. Schettle is the chief executive officer of the Twin Cities Medical Society and the project director for Honoring Choices Minnesota (www.honoringchoices.org). Terry Traudt is a volunteer ambassador for Honoring Choices Minnesota.

What does a health care agent do?

Being a person’s health care agent means making the decisions that the person would make if he or she were able to speak for himself or herself. These decisions may be about end-of-life care. The patient trusts you to follow his or her wishes. An agent must be 18 or older but need not be a family member.

How can I prepare to be a health care agent?

Interview the person who chose you as their agent; understand his or her wishes for future medical care. It can be helpful to talk with professionals who help people make medical decisions. These include advance-care planning facilitators, who are based primarily in clinical settings. Other sources of helpful information include hospital chaplains, social workers, and spiritual leaders. All are experienced at supporting people who need to make decisions on behalf of others and JUNE 2013 MINNESOTA HEALTH CARE NEWS

15

CAREGIVING

As loved ones age How do you know when it’s time to offer help?

By Chris Palmer, RN, and Sharon Roth Maguire, MS, RN, GNP-BC

Supporting Our Patients.

Supporting Our Partners.

Supporting You. In 2008, Tanzanian missionaries brought little Zawadi Rajabu to the U.S. to seek treatment for her two severely clubbed feet. A physician referred Zawadi to Dr. Mark T. Dahl of St. Croix Orthopaedics. Using the Ilizarov Method, Dr. Dahl surgically changed the course of Zawadi’s feet and her life.

Dr. David Palmer and Russ McGill, OPA-C, recently traveled to Tanzania on another of their frequent medical missionary trips. They dedicated an entire day to checking in on their partner’s patient.

To their delight, they were greeted by 6-year-old Zawadi her face aglow, her healed feet dancing toward them.

David Palmer, M.D. & Zawadi’s brother Russ McGill, OPA-C & Zawadi

Appointments:

Online or Call 651-439-8807 Providing P roviding care care at at multiple mu ultiple moder modern n clinics in Minnesota Minne esota and Wisconsin Wisconsin

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MINNESOTA HEALTH CARE NEWS JUNE 2013

O

ne of the hardest things we will ever have to face is watching our loved ones age. When our parents or grandparents become ill, lose mobility, or experience mental decline, we want to step in and help them in any way we can. Not surprisingly, though, aging people often resist help from their family.

They want to show they are still self-sufficient and able-minded, and they don’t want to feel as though they are being “checked on” or handled with kid gloves. It can be understandably upsetting for them to feel as though they are losing independence and freedom, even if they know it is in their own best interests. In addition, changes in an elder’s physical or mental abilities may occur so gradually that adult children may not realize that Mom or Dad is not handling the challenges of daily life until a crisis occurs.

Should you step in?

Due to resistance from elders, family members tend to wonder: Am I doing the right thing by offering help? Does Mom or Grandma really need my help, or am I being overbearing? Questions such as these can prevent people from stepping in and making tough judgment calls when it comes to older relatives’ welfare.

The situation can be further complicated because aging individuals often try to appear as capable as possible and may hide pertinent information. Your loved ones might not tell you about a slip in the shower or a loss of vision, not only because it might be scary to share that information out loud, but because they worry about what your reaction will be. “I don’t want you to Aging people worry,” Mom assures you. But deep often resist down, you know something is not quite right and it’s impossible not to spend help from sleepless nights worrying about her. their family.

In order to help put your mind at ease and help yourself decide if you should step in and offer help, consider the following signs that your aging loved ones may no longer be able to adequately take care of themselves.

Signs to watch for 1. Medication mismanagement. A loved one’s confusion over medication management is cause for serious concern. Forgetting to take medication or taking double doses can have life-threatening repercussions. This is one of the most important signs to look for because medication mismanagement can contribute to worsening confusion and a host of other adverse health outcomes, including full-blown medical crises.

While daily pillboxes and alarms can help remind someone when it is time to take medication, these tools can do only so much.

In order to help your aging loved one understand how serious this issue is, consider accompanying him or her on a doctor’s visit and

Confusion over medication management is one of the most important signs to look for.

asking the doctor to discuss the crucial importance of taking medication correctly. Information delivered by a professional who is not a family member is sometimes easier to accept than the same information delivered by a relative. Medication mismanagement is also important to address because it can indicate memory loss, which adversely affects other areas of functioning.

2. Changes in driving. Physical and mental decline can keep elders from doing the things they normally do, including driving a car. If your loved ones are missing doctor’s appointments or family occasions, this might be a sign they are in need of extra care. This can be a tricky issue, because sometimes even when aging loved ones truly shouldn’t be driving, they don’t easily accept that fact. Instead, they may insist on continuing to drive, which puts themselves and everyone else on the road in danger. Elders can have driving skills evaluated by contacting their local AAA chapter.

3. Financial mismanagement. Signs that aging family members are unable to take care of their financial obligations can include piles of unsorted mail, bills piling up, or phone messages from debt As loved ones age to page 19

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. Be ac tive minutes for 30 every da y . Eat le ss salt . If yo uh diabetesave your bloo, keep sugar lo d w

This campaign was was adopted adoopted from from the Minnesota Minnesota Stroke Stroke Partnership.

Par tnership.

JUNE 2013 MINNESOTA HEALTH CARE NEWS

17

June Calendar 8

11

11

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Health Fair Mighty Fortress International and Excell Academy for Higher Learning present Restoration Health: Refresh, Revive & Restore. This health fair will feature health screenings and seminars with health professionals. Free. Call Nancy at (763) 535-9096 for more information.

Register at www.eventbrite.com Saturday, June 8, 10 a.m.–3 p.m., Excell Academy for Higher Learning, 6500 Zane Ave. N. #107, Minneapolis Recovery Night The Emily Program Foundation hosts Recovery Night, where speakers share their stories of hope and success in recovering from eating disorders. Speakers include Emily Program staff, former clients, and community members. Free. Call (651) 379-6134 for more information.

Tuesday, June 11, 6:30–8 p.m., The Emily Program Foundation, 2265 Como Ave., St. Paul Stop Smoking Allina Health offers Introduction to Tobacco Cessation, a class to help employees, volunteers, patients, and community members stop smoking. Held the second Tuesday of every month. Free. Call (612) 863-1648 to register or for more information.

Tuesday, June 11, 5–6 p.m., Abbott Northwestern Hospital, Conference Rm. E1220, 800 E. 28th St., Minneapolis Premenopausal Bleeding Lakeview Health presents Abby Heller, MD, as she discusses the different causes of heavy bleeding in premenopausal women.

Learn about the types of tests you can expect from your doctor, and the treatment available. Free. Call (651) 430-4697 to register or for more information.

Thursday, June 13, 6:30–7:30 p.m., Lakeview Hospital, 927 Churchill St. W., Stillwater Varicose Vein Screenings Park Nicollet Vascular Surgery offers free varicose vein screenings from board-certified surgeons. The surgeons will inspect

PTSD Awareness Month Have you or someone you know been through combat, lived through a disaster, or experienced any other traumatic event? After a trauma or life-threatening event, it is common to have reactions like upsetting memories of the event, increased jumpiness, or trouble sleeping. If these reactions persist or worsen, you may have Post-traumatic Stress Disorder (PTSD).

In 2011, Veterans Affairs (VA) provided mental health services to 1.3 million veterans, in large part for PTSD. June has been designated PTSD Awareness Month to help slow the spread of this disorder.

To further raise awareness, VA created AboutFace, a tool that allows the public to learn about PTSD from veterans who have personally experienced the disorder.

Experience AboutFace at www.ptsd.va.gov/aboutface While many people go through trauma at some point in their lives, not all get PTSD. Whether or not you get PTSD can depend on: • How intense the trauma was or how long it lasted • If you were injured or lost someone important to you • How close you were to the event • How strong your reaction was • How much you felt in control of events • How much help and support you got after the event If you believe you may have PTSD, contact your health provider. Treatments are available, and you and your provider can pick the best one for you. For more information on PTSD, visit www.ptsd.va.gov any visible, bulging veins in your legs and recommend a course of action. Free. Call (952) 993-2651 to schedule a screening.

Monday, June 17, 3:30–4:30 p.m., Park Nicollet Heart and Vascular Center, Vascular Surgery Clinic, 3rd Flr., 6500 Excelsior Blvd., St. Louis Park

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Dealing with Addiction Minnesota Organization for Fetal Alcohol Syndrome (MOFAS) offers this support

group for caregivers of adults affected by prenatal alcohol exposure and those dealing with chemical dependency issues.

Free. Call Sue at (651) 917-2370 for more information.

Wednesday, June 19, 10–11:30 a.m., Ring Mountain Creamery, Reserved Private Rm., 1965 Cliff Lake Rd., Eagan

19–23

Camp, Camp Revolution One Heartland offers Camp, Camp Revolution, a camp for youth ages 13–18 identifying as LGBTQ. Youth explore issues in the LGBTQ community and how to face them. Pricing determined by family income. Contact Jill at (888) 545-6658 for more information. Register at www.oneheartland.org Wednesday-Sunday, June 19–23, One Heartland Center, 26001 Heinz Rd., Willow River, MN

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Lupus Support The Lupus Foundation of Minnesota offers this support group for individuals impacted by lupus. Come learn about the unique services and resources available close to home. Free. Call Maria at (763) 3237155 to register or for more information.

Wednesday, June 26, 6–7:30 p.m., Anoka City Hall, Committee Rm., 2015 First Ave. N., Anoka

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National HIV Testing Day National HIV Testing Day is June 27th of each year. This day was created in 1995 to promote HIV testing and early diagnosis. For free drop-in HIV testing, visit the Minnesota AIDS Project. Call MAP AIDSLine at (612) 373-2437 if you would prefer an appointment.

Thursday, June 27, 10 a.m.–12:30 p.m., Minnesota AIDS Project–Twin Cities, 1400 Park Ave., Minneapolis

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

America's leading source of health information online 18

MINNESOTA HEALTH CARE NEWS JUNE 2013

As loved ones age from page 17

couch your conversation in love, rather than anger or guilt. In broaching the topic of their diminishing driving abilities, for example, say something like, “I notice you seem to have a hard time seeing things lately, even when you are wearing your glasses. I love you so much and I want you to be safe, and it really scares me to think about you behind the wheel of a car. Can we talk about this?” Instead of forcing a decision on them, empower your loved ones to make their own. You likely will find that their resistance and anger decrease as a result.

collectors. If you notice these signs, it may be time to have your loved one’s cognitive status and medication regimen evaluated. This may detect health-related concerns that interfere with the ability to manage finances.

4. Messy home. Physical challenges, pain, or depression may limit someone’s ability to clean and organize. This will be apparent if your loved ones don’t maintain their home to their usual standards. Dishes in the sink, spoiled food in the refrigerator, piles of dirty laundry, and extreme clutter are indicators, especially if the person is usually neat and orderly. If they stop caring for cherished possessions such as a pet or prized houseplants, this also can be a sign that they could benefit from help.

Changes in personal care are similar indicators. If you notice your loved one has not been bathing or showering as often as usual, it might be because of physical hardship, depression, or memory loss. Consider other signs as well. Does your loved one struggle to make meals or forget to turn off the oven?

Easing the aging process

Couch your conversation in love, rather than anger or guilt.

How to step in

While it can be difficult to step up and insist that your parent or grandparent consider outside help, it ultimately may be the most loving and considerate thing you can do for them. Aging is never easy, but if families approach it with honesty, kindness, and empathy, the process can be much smoother for everyone involved.

Chris Palmer, RN, is director of nursing at BrightStar Care of West Metro, Minneapolis, which provides in-home assistance. Sharon Roth Maguire, MS, RN, GNP-BC, is senior vice president, quality and clinical operations, at BrightStar Care.

Try to have an honest, nonaccusatory talk with your elders about your concerns. Make sure to

When Alzheimer’s disease touches your life, turn to us.

The Alzheimer's Association can help.

The Alzheimer’s Association Minnesota-North Dakota Chapter is the premier source of information, support and hope for those with Alzheimer’s disease, their families and caregivers; and offers a broad range of programs and services state-wide, including: • 24/7 Information Helpline – 1.800.272.3900 • Family and Community Education • Support groups • Care Consultation • Professional Education • Advocacy • Research • Medic Alert® + Safe Return®

Make the first call for help 24/7 Information Helpline—1.800.272.3900 Visit us online - www.alz.org/mnnd

JUNE 2013 MINNESOTA HEALTH CARE NEWS

19

PUBLIC HEALTH

N

ail salon safety should concern anyone who visits a salon. If a salon follows improper hygiene procedures, clients are at significant risk of several types of infection.

Here’s what a consumer should look for and ask about to determine if a salon is following appropriate procedures.

License

Nail salon safety Avoiding infections

First, look for the salon’s license, which should be displayed clearly in a public area of the establishment. If it’s not visible, ask to see it. The Minnesota Board of Cosmetologist Examiners (BCE) is responsible for licensing salons statewide, so a license must indicate that it was issued by the board. Licenses are issued for three-year periods and the date of expiration should be clearly indicated on the license. The board is also responsible for inspecting salons and for enforcing salon rules and regulations.

The BCE website (www.bceboard.state.mn.us) details requirements for licensure. While a license does not guarantee that a salon follows appropriate procedures, it provides a measure of reassurance because it indicates that the salon is open to inspection. It’s also prudent to visit this website to see if any disciplinary actions have been taken against a given salon before using the salon’s services. The BCE website states, “Disciplinary action is public information and is posted on the BCE Board website under Complaints & Enforcement Action.”

Hygiene

By Dirk Halverson, DPM, FACFAS

Thousands of Minnesotans live with foot pain You don’t have to

Second, assess the general appearance of the salon. Is it clean? If nail dust and nail clippings are easily visible in the client treatment area, it is safe to assume that the salon is not cleaning adequately. This is your first indication that you should find a new salon.

Do the nail technicians themselves have a clean personal appearance? Do they use gloves when providing nail care? Gloves minimize the chance that an infection from one client will be passed to another.

However, this only works if gloves are changed after each and every client. If you notice that technicians are not changing gloves between clients, seek another salon.

Another procedure to observe is the hand-washing practices of the technicians. Hands should be washed before and after every client, after the technician discards a used pair of gloves. If you do not observe this level of hand washing, it is in your best interest to visit another salon.

Equipment

Free foot screening— acting early could save your limb or your life.

Call today: 612-788-8778 Clinics conveniently located all around Twin Cities

Dirk Halverson, DPM FACFAS

www.midwestpodiatrycenters.com 20

Third, observe and ask about procedures to disinfect and sterilize tools and work surfaces. Note if tools that are not in use are left out in the area of nail care or if they are put away. It is important for them to be stored so that they do not become contaminated. It is also the law; the BCE website specifies that instruments that are not being used must be in a closed container. Porous tools such as wooden nail files or pumice stones should be used on only one person and then discarded.

Note how the soaking tub is disinfected. You should see that the basin is totally drained and that disinfectant is placed in the tub and left in place for 10 minutes. If the tub is a whirlpool-type tub, the whirlpool should be operated for 10 minutes with the disinfectant in the water, then drained and disinfected as above. This procedure is Nail salon safety to page 33

MINNESOTA HEALTH CARE NEWS JUNE 2013

JUNE 2013 MINNESOTA HEALTH CARE NEWS

21

SURGERY

Spinal fusion Stabilizing the spine to improve quality of life

By Nicholas Wills, MD

O

ne of the first things I hear from my patients is, “I don’t need a spinal fusion, do I?” The answer is nearly always ‘no.’ But, for properly selected patients, spinal fusion and the relief of nerve compression it provides can make a profound improvement in quality of life. “Properly selected patients” are those for whom nonsurgical treatment has not alleviated pain and other symptoms of nerve compression.

Sciatica—pain in the buttocks and legs—that co-occurs with spinal instability is the compression-caused symptom most successfully treated by fusion. Very rarely, spinal fusion is done to remove a degenerative disc in order to treat back pain produced by the disc, which is the cushion between the vertebrae. Fusion for degenerative disc disease is not as successful as fusion for instability.

What is fusion?

The definition of spinal fusion is the surgical joining of two or more vertebrae so that motion no longer occurs between them.

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MINNESOTA HEALTH CARE NEWS JUNE 2013

Vertebrae are some of the bones that make up your spine, and in a healthy spine, a certain amount of movement among vertebrae is necessary. That’s what allows someone driving a car to look over his or her shoulder before changing lanes, and allows a bicyclist to bend forward over the handlebars.

Causes Too much vertebral movement, however, can put pressure on the nerves, and that’s what fusion can address. This procedure is typically performed to treat the excess movement of the vertebrae that creates instability or potential instability of the spine, called spondylolisthesis. (Spondylo means spine; listhesis means slip).

Spondylolisthesis can cause nerves to become compressed, which can produce symptoms that include pain; reduced control of muscles; numbness, tingling, or other sensory changes; weakness; and, in some cases, paralysis.

Spondylolisthesis can be caused by multiple factors although it is frequently associated with spinal stenosis, which can happen as a result of normal aging. Stenosis is a narrowing of the spinal canal, which is the space within the spinal column that houses the spinal cord and the roots of nerves that branch off from the cord. As the canal narrows, the cord and nerves within it have less room and may eventually become compressed by the surrounding bones.

Factors that contribute to spinal stenosis include arthritis, which can deform and thicken bones so that they protrude into the spinal canal, thus narrowing the space within it. Spondylolisthesis also can be caused by degeneration of the vertebrae. This may result from agerelated wear and tear, trauma, or longEvery surgeon term use of bone-thinning medications is a little such as prednisone.

Before surgery

different in her or his preferred methods of rehabilitation.

Once a patient and his or her surgeon agree that surgery is necessary, a patient who smokes should stop smoking, since smoking increases the risk of surgical complications and can impede the bone healing necessary for successful fusion.

Patients should see a primary physician for a medical examination to make sure they are in optimal health for the coming surgery.

Left. Titanium screws and rods on each side of this patient’s neck stabilize vertebrae after laminectomy and fusion.

Below. Seen from the patient’s right side, titanium screws and rods stabilize neck vertebrae after laminectomy and fusion.

During surgery Spinal fusion encompasses several phases. First, the surgeon meticulously repositions muscles away from the bones of the spine; muscles are put back in place later in the procedure. The next phase is a procedure called a laminectomy, which creates more room for the nerves within the spinal canal.

Decompression of the nerves is the most important aspect of the surgery because nerve compression is the source of the pain that drives most patients to seek medical care.

Laminectomy This phase of the surgery involves cutting a space in the back of those vertebrae that are crowding the spinal cord and nerves.

The bone that is cut out is sometimes used with spacers between vertebrae to help stabilize the vertebrae. This is kept in place by hardware installed during the next phase of the surgery.

Fusion

Fusion may sound scary at first, [but] for properly selected patients it can remarkably improve their quality of life.

Once nerves and the spinal cord are no longer compressed, the fusion phase of the procedure begins. Fusion is necessary to stabilize the spine so that the opening made to decompress the nerves remains permanently open.

In most cases, special titanium screws are placed in the unstable bones of the spine and are connected to each other with titanium rods. Screws and rods together serve as an internal cast that holds bones in place while they knit themselves together, just as a broken arm is placed in an external cast while it heals. Unlike an external cast, screws and rods are permanent.

Many people believe that fusion only involves screws and rods, but the most important aspect of it is the

way the bones are handled. The key to getting the bones to heal is to trick the body into thinking the bones are broken by scuffing the bone.

After surgery Initial recovery is the most difficult part of the fusion procedure and typically includes a short hospital stay. Patients should expect the area that was operated on to be very painful immediately after surgery. This is managed by pain medication. Hospital staff help the patient get up and walk soon after surgery, which is very important to avoid formation of blood clots and to get the muscles of the low back and legs moving—the key to recovery for fusion performed on the low back and helpful for regaining health no matter where fusion is performed.

By six weeks after surgery, a patient’s health usually has significantly improved and stabilized. There is not a standard protocol for postoperative rehabilitation. Each patient’s speed of recovery is individual and every surgeon is a little different in her or his preferred methods of rehabilitation. The only therapy I ask my patients to do for the first three months is to walk, so they can regain strength in their legs. Physical therapy for low-back strengthening begins around three months after low-back fusion. Physical therapy begins around six weeks after fusion in the neck area, and within three months for fusion done mid-back.

Even though a fusion may sound scary at first, for properly selected patients it can remarkably improve their quality of life.

Nicholas Wills, MD, is a board-certified spine surgeon who practices with Summit Orthopedics.

In the next issue..

• Eating disorders • Genetic counseling • Stroke rehabilitation JUNE 2013 MINNESOTA HEALTH CARE NEWS

23

POLICY Autism spectrum disorder

Autism and employment Breaking through barriers

By Kelly Thomalla

A

ccording to the U.S. Department of Labor, the general population’s unemployment rate is 7.6 percent, while the unemployment rate for people with disabilities, including those with autism, is 12.3 percent. The Social Security Administration reports that only about 6 percent of adults with autism work full time.

The American Academy of Pediatrics estimates that roughly half a million individuals with autism will reach adulthood during the next decade. Although it may be challenging for someone with autism to get hired, there are strategies that can help.

Autism spectrum disorder (ASD) is a lifelong developmental disability that ranges widely in the severity of its symptoms.

People with autism may be unable to care for themselves, or they may have highfunctioning autism, hold down a full-time job, and live independently. What is common across the spectrum of this disorder is that it affects essential human behaviors such as social interaction, self-regulation, and the ability to establish relationships with others.

The Centers for Disease Control and Prevention reports that ASD occurs in one of every 50 individuals, making it the fastest growing developmental disability in Minnesota. ASD is five times more prevalent in males than in females and knows no racial, ethnic, or social boundaries.

Challenges Brian Paulson has autism and owns an accounting firm. He has spent the 17 years he’s worked at the firm climbing to the top, but not without challenges.

“One barrier I experienced was other people looking down their noses at me because they thought I was weird or different,” Paulson says.

“This was due to the fact that I am on the spectrum, but others don’t always know that.”

Paulson notes that despite being challenged socially, he interviews well. “I am good at memorizing how to act during an interview,” he explains. Once he was hired, Paulson says, he wasn’t comfortable revealing his autism diagnosis. Because he didn’t need onthe-job accommodations, he chose not to disclose it.

Ben Van Heel is a graphic artist with autism who works in grocery retail. He notes that employers aren’t always willing to take a risk on someone with an autism diagnosis. “If an employer understood that I am a detail-oriented person, that it just takes me a little bit longer to learn a process, they would know that I have a lot to offer,” he says.

Van Heel obtained his current position by working through a job-training program for adults where his assigned job coach helped him refine his search to areas of interest to him. His job coach saw the opening at a grocer and suggested that Van Heel apply.

24

MINNESOTA HEALTH CARE NEWS JUNE 2013

Interviews

client questions him and when he assesses a potential employee. “For me, being interviewed by someone or interviewing someone else does not come easily or naturally,” he says. “But playing a part or acting out a role does come easily. When I interview, I’m acting out how I think an interview should go.”

Candidates should prepare for job interviews by learning about the employer beforehand; mapping the route to and from the employer; and practicing answers to possible interview Once you’re hired questions. Before the interDisclosing an ASD diagnosis to a supervisor may be view, individuals should ask important if and when an employee needs workfriends or family for assistance in preparing place accommodation to be successful on the job. for it. This includes being coached to provide conThe Americans with Disabilities Act requires reacise answers and to ask questions that show interIdentifying sonable accommodation, which is any modification est in the company. or adjustment to a job or work environment that a mentor for Dress and personal appearance are important, enables a qualified applicant or employee with a understanding as is a strong handshake and making eye contact. disability to perform essential job functions. There Candidates should ask their supporters to videoworkplace norms is no single list of accommodations for people with tape them in a mock interview to learn which ASD in the workplace because there is no uniform is helpful. interview skills need to be improved. description of the behaviors they may exhibit. The Whether or not a potential employee chooses employee needs to tell the supervisor what accomto disclose his or her diagnosis during the employment process is a modations are necessary for himself or herself. personal decision. An individual who chooses to disclose should be It’s important for employees with ASD to practice workplaceprepared to answer questions about autism and to discuss any needappropriate behaviors even if they don’t come easily. This includes ed workplace accommodations. Accommodations may include havbeing on time, maintaining good attendance, engaging in appropriing a colleague assigned as a mentor; a work schedule for organizaate small talk, greeting people, asking questions to clarify job expection; and dimmed lights, earplugs, and a clutter-free workstation to tations, understanding the business culture, being aware of others’ reduce sensory overstimulation. nonverbal communication, regulating personal behavior, and knowPaulson notes that the interview process isn’t easy. As a business Autism and employment to page 29 owner, he experiences both sides of interviewing: when a potential

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RESEARCH

Pancreatic cancer Recent advances offer hope

By Vikas Dudeja, MD, and Selwyn M. Vickers, MD, FACS Pancreatic cancer is the fourth most common cause of cancer deaths in the U.S. Nationwide, in 2012 more than 44,000 people were diagnosed with pancreatic cancer and more than 37,000 patients lost their lives to it. Well-known Americans who have died of this disease include the actor Patrick Swayze, the astronaut Pancreas Sally Ride, and Olympic and championship basketball coach Chuck Daly.

In Minnesota, about 600 people succumb to it each year.

Many factors contribute to these abysmal outcomes. Since the pancreas is situated deep in the abdomen, patients with this disease typically do not have many symptoms early on. This leads to patients not seeking medical help until late in the course of disease. By that time, in more than

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80 to 90 percent of patients the disease is so advanced that it cannot be treated by surgical removal of the pancreas, which is the only curative treatment currently available.

Furthermore, pancreatic cancer is one of the most aggressive cancers known to humankind. Even though it is the ninth most frequently diagnosed cancer, it is the fourth-leading cause of death from cancer. Less than 6 percent of patients are alive five years after diagnosis. Research to develop better methods of early diagnosis and treatment is of paramount importance to improve these dismal outcomes.

outcome for patients with pancreatic cancer remains dismal.

Encouraging results

Recently, some major breakthroughs have been made in the laboratory of Ashok Saluja, PhD, and Selwyn M. Vickers, MD, in the Department of Surgery at the University of Minnesota. Research in this laboratory Recently, found that “heat shock protein-70� (HSP70), a prosome major tein that protects the body from stress-induced injury, breakthroughs is overproduced in pancreatic cancer and that decreashave been ing the level of this protein in pancreatic cancer cells leads to the death of the cancer cells. These results led made. to a search for drugs that could decrease levels of Improving diagnosis HSP70 in human pancreatic cancer cells and thus Given that more than 80 percent of patients with pancreatic cancer could be used as a therapy against pancreatic cancer. do not seek medical help until their disease is so advanced that it is Fortunately, such a compound was identified in nature. not amenable to surgery, an attempt has been made to discover Triptolide, a compound extracted from the Chinese plant novel biomarkers that could help diagnose pancreatic cancer sooner. Tripterygium wilfordii, was found to decrease the production of Due to the low incidence of pancreatic cancer, screening in the genHSP70. Crude extracts of this plant have been used as medicine in eral population is unlikely to be cost effective at this time.

China for hundreds of years to treat autoimmune and inflammatory Furthermore, no ideal screening option is available. CA 19-9, a pro- diseases, including rheumatoid arthritis. Studies in the Saluja/Vickers laboratory showed that giving triptolide to mice that had pancreatic tein detected in serum, has been widely used but it is neither sensicancer decreased HSP70 levels in the cancer cells, leading to the tive (since it is not elevated in all patients with pancreatic cancer) death of those cells. This compound has been tested extensively in nor specific (its elevation can be observed in many other pancreatic, animal models of pancreatic cancer and has shown encouraging liver, and biliary diseases).

Other proteins, including mesothelin and MIC-1 (macrophage Pancreatic cancer to page 28 inhibitory cytokine), are being investigated as potential biomarkers.

If research determines that these proteins can be detected at increased levels in people who have early-stage pancreatic cancer, it might be possible to develop a diagnostic test that uses these proteins to detect the disease earlier than is currently possible.

Earlier diagnosis would lead to earlier Patients with treatment, which could improve life this disease expectancy.

typically do not have many symptoms early on.

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wherever you are!

Improving treatment

Currently, the standard of care for patients who have pancreatic cancer that can be removed is to perform surgery, followed by chemotherapy and, in some cases, radiation, to eliminate any stray cancer cells that remain in the body. Research data suggest that postoperative chemotherapy and radiation (i.e., chemoradiation) improves patients’ survival from between 11 months and 15 months without chemoradiation to about 20 months.

Poor outcomes despite surgery and chemoradiation have led researchers and clinicians to evaluate other drugs and treatment strategies. One approach is to target the mechanism by which cells in the pancreas become cancerous, i.e., the pathogenesis of pancreatic cancer. Clinical trials of various drugs targeting pathogenesis have produced an increase in survival of between two weeks and several months in patients whose cancer is metastatic (i.e., has spread beyond the pancreas). Despite these advances, the overall

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Pancreatic cancer from page 27

results. Research published in 2007 in the scientific journal Cancer Research shows that triptolide at very low dosage decreases the growth and metastasis of tumors in mice that have pancreatic cancer.

Furthermore, this therapy is without many of the adverse side effects associated with chemotherapy and radiation.

From lab to clinic

Pancreas

For more information about pancreatic cancer, visit www.pancan.org

One of the original limitations in using triptolide in humans was that it did not dissolve in water. This was a problem because in order to administer it in clinics, the drug needed to be dissolved in water so that it could be injected. This has been circumvented by synthesis, at the University of Minnesota, of a water-soluble derivative named Minnelide. This novel, patented compound has been tested comprehensively in the Saluja/Vickers laboratory, with results published in the journal Science Translational Medicine (2012). These results showed that Minnelide was effective against pancreatic cancer in mice in experiments designed to represent the range of human clinical scenarios.

For example, in one study Minnelide was administered to mice whose tumors were very big and metastatic, to mimic the usual case of patients who are not diagnosed until their pancreatic cancer is advanced and has spread to other organs. In other studies, Minnelide was administered to mice that had pancreatic tumors until the tumors disappeared, and then the drug was discontinued

and the animals were observed to see if the tumors came back.

Results from all of the studies were extremely encouraging: Minnelide was highly effective at shrinking tumors and extending the lifespan of the mice. In many animals, the tumors disappeared completely and did not return, even after treatment was stopped. Our research team is waiting for approval of the federal Food and Drug Administration to test this drug in humans. It is expected that clinical trials evaluating Minnelide in humans will begin in 2013.

We are very hopeful that Minnelide will change the face of pancreatic cancer.

Research continues

Pancreatic cancer is difficult to treat. In addition, the national advocacy organization Pancreatic Cancer Action Network reports that the number of deaths from pancreatic cancer is rising and that it is projected to become the second most frequent cause of death from cancer by 2020. Although some headway has been made, this disease still has a poor prognosis. This can be changed only through research to discover tools for early diagnosis and improved treatment.

Vikas Dudeja, MD, is a chief resident in the Department of Surgery at the University of Minnesota. Selwyn M. Vickers, MD, FACS, is a surgical oncologist and gastrointestinal surgeon at University of Minnesota Medical Center, Fairview. He is also Jay Phillips Professor and chairman, University of Minnesota Department of Surgery, and the associate director of University of Minnesota Masonic Cancer Center.

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MINNESOTA HEALTH CARE NEWS JUNE 2013

Autism and employment from page 25

ing how and when to adjust manners to fit the situation. Often, identifying a mentor for understanding workplace norms is helpful.

According to Barb Luskin, PhD, LP, Mental Health Services therapist at the Autism Society of Minnesota, finding a mentor varies depending on the employee and the situation. She recommends using the following script with a potential colleague-mentor: “I know I miss a lot of social cues and others often misunderstand me. You seem to be good with social cues and I wondered if you would be willing to help me.”

When approaching a supervisor for assistance in identifying a mentor, Luskin recommends the following: “I know I miss a lot of social cues and others often misunderstand me. I am wondering if there is someone in the office who could help me with this by being a mentor. I am afraid I don’t know how to ask someone for help, and I would appreciate it if you could ask someone for me.”

Dr. Luskin notes that script wording can be changed to fit the employee’s need.

Expect adjustment Because people with ASD may appear to be disability-free, their coworkers may be puzzled when interacting with someone who may have a different way of communicating and processing information and who may prefer to work alone. Co-workers may therefore per-

It’s important for people with ASD to interact with co-workers and not to isolate themselves. ceive colleagues who have ASD as unfriendly or rude. Employees with ASD should not be discouraged if it takes a while to feel accepted by coworkers.

One individual with ASD described his position within a law enforcement group, in which camaraderie was very important. “It took me a long time to feel accepted—I had to work hard,” he recalls. “When they gave me a hard time at the beginning, I had to realize it was a rite of initiation. I sometimes had trouble figuring out whether they were attacking me personally or just trying to help me fit in.”

It’s important for people with ASD to interact with co-workers and not to isolate themselves. The resulting benefits will be worth far more than just a paycheck.

Kelly Thomalla is the director of communications for the Autism Society of Minnesota (AuSM). Established in 1971, AuSM is a nonprofit organization committed to education, advocacy, and support to enhance the lives of those affected by autism from birth through retirement. AuSM also offers an employment guide for individuals seeking employment, and experts to help guide adults with autism through the steps of a successful employment process. For more information, visit www.ausm.org

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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:

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JUNE 2013 MINNESOTA HEALTH CARE NEWS

29

INFECTIOUS DISEASE “Hepatitis” means inflammation of the liver. The liver is an important organ for processing food into energy and nutrients and for removing harmful substances from the blood. When the liver is inflamed, it may have difficulty performing its job. Hepatitis C is one of several types of liver inflammation.

Hepatitis C

What is it?

The silent epidemic

By Christine Pocha, MD, PhD, MPH

Hepatitis is usually caused by a virus. In the U.S., the most common types of viral hepatitis are hepatitis A, hepatitis B, and hepatitis C (HCV). Alcohol use, toxins, some medications, and certain medical conditions also can cause hepatitis.

The hepatitis C virus was identified in 1989 and a blood test to detect it was developed in 1990. More than 80 percent of HCV infections become chronic, leading to liver disease and, sometimes, liver failure. Liver failure due to hepatitis C is the leading cause of liver transplantation in the U.S. The Centers for Disease Control and Prevention (CDC) estimates that 4 million people in this country have chronic HCV infection, and more than 200 million people worldwide have it. Liver disease, liver cancer, and deaths from hepatitis C are on the rise.

Public health threat This makes HCV one of the greatest public health threats of this century. There are already many more people infected with HCV than with HIV, the virus that causes AIDS. Some

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MINNESOTA HEALTH CARE NEWS JUNE 2013

people are infected with both viruses, which increases the risk of liver damage. In 2011, the Minnesota Department of Health estimated that 36,000 people in Minnesota were currently infected with HCV or had been exposed to it.

Since symptoms of hepatitis C infection are typically mild in the disease’s early stages, it is rarely diagnosed There are early during the disease. Often, already many hepatitis is not recognized until more people it has progressed to a chronic stage, by which time it has infected with caused the severe liver damage HCV than that produces noticeable sympwith HIV. toms. Because it takes about 20–30 years for infection to progress to symptomatic liver disease, the true impact of this disease on infected populations does not appear for decades. For this reason, chronic hepatitis C is often referred to as the “silent epidemic.”

Research has shown that more than 75 percent of adults infected with the virus are baby boomers, who are five times more likely to be infected with hepatitis C than members of other generations.

That’s why the CDC recommends that baby boomers—anyone born from 1945 through 1965— get tested for hepatitis C. Risk factors

Diagnosis Detecting past exposure. The virus is diagnosed by blood tests; the most common screening test detects antibody that a person’s body made in an effort to combat the virus. HCV antibodies become detectable seven to 10 weeks after exposure and stay positive for the rest of that person’s life. If this test is positive, it means that the person was exposed to the virus in the past. Most people exposed to the virus have a chronic infection, as the body does not eradicate the virus on its own very well.

Detecting current infection. Blood tests performed to confirm the current presence of the virus in a person’s body are called polymerase chain reaction (PCR) tests. These sensitive tests detect the virus and quantify how much of it is in a person’s body. While test results do not correlate with the severity of chronic infection, they help predict success of treatment: A person who has a higher number of virus particles (viral load) is less likely to be cured of chronic infection than someone with a lower viral load.

If testing confirms the virus is present, the next step is to evaluate the extent of liver damage. This includes lab tests to measure liver function, and other tests that can give information about the severity of inflammation and scarring of the liver, called fibrosis. Sometimes, a liver biopsy and/or imaging studies such as ultrasound or computed tomography are necessary to clarify the severity of damage. The degree of damage is an important guide to determine if treatment is necessary.

If the virus is not eradicated within six months, the infection becomes chronic, and treatment is needed to eradicate it because Hepatitis C to page 32

You are at risk for HCV if you: • Ever injected intravenous drugs, shared needles, or used contaminated equipment associated with drug use • Received a blood transfusion or solid organ transplant such as a kidney, liver, or heart before 1992, or were treated for clotting problems with a blood product manufactured before 1987 • Have occupational exposure to blood (dental hygienists, etc.)

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• Had sexual contact with multiple partners • Used intranasal street drugs • Had tattoos or body piercings (this risk is small) Hepatitis C virus is not spread by: • Breastfeeding • Sneezing or coughing • Hugging and casual contact • Food, water, or sharing eating utensils/drinking glasses Symptoms

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31

liver damage caused by hepatitis C. It is not known what constitutes a safe amount of alcohol to consume per day or per week. If consuming some alcohol easily leads to consuming more alcohol, it may be best to abstain altogether.

There is no vaccine to prevent HCV. The only way to stop the spread of HCV is to avoid direct contact with infected blood. This means no sharing of needles, razors, or toothbrushes; practicing safe sex; using clean needles and equipment for tattoos or body piercings; and wearing gloves if touching someone’s blood is unavoidable.

Hepatitis C from page 31

chronic infection can lead to scarring of the liver, liver cancer, liver failure, and other complications, such as bleeding from the gastrointestinal tract.

Treatment Treatment lasts between six and 12 months and consists of weekly injections of pegylated interferon (an immune system stimulant) and daily pills of ribavirin, an anti-viral drug. Two new drugs, boceprevir and telaprevir, were approved by the Food and Drug Administration in 2011 to treat some cases of chronic hepatitis C virus infection. Both drugs attack HCV directly to keep it from growing and are in a new drug group called HCV protease inhibitors. These two drugs can’t get rid of the virus by themselves, but either one, used in combination with pegylated interferon and ribavirin (often called PEG/riba), increases the chance of curing HCV to between 70 percent and 90 percent.

However, this medication regimen does not work for all people with HCV and has serious side effects.

Get tested Hepatitis C treatment is changing rapidly. Over the next few years newer medications will become available that are more effective at eradicating the virus, have fewer side effects, and shorten treatment duration. It is anticipated the new treatments will be remarkably better than the present treatments. This makes it very important to be tested for hepatitis C if you have symptoms and/or were born between 1945 and 1965, and to schedule follow-up care if hepatitis C is diagnosed.

It is very important to be tested for hepatitis C if you were born between 1945 and 1965.

Living with hepatitis C People with HCV should live a healthy lifestyle; get vaccinated for hepatitis A and B, which can co-occur with HCV and cause damage in their own right; follow up with their doctor regularly; and avoid drugs and alcohol. Alcohol has been shown to speed the rate of

Christine Pocha, MD, PhD, MPH, is a board-certified gastroenterologist and assistant professor of medicine at the University of Minnesota, and leads the Hepatitis C Center of Excellence of the Minneapolis Veterans Affairs Healthcare System.

Minnesota

Health Care Consumer May 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 May survey.

1. It is important to me to have one (or more) designated

2. It is important to involve family members in discussions

individual(s) to make health-care related decisions should I become unable to communicate my wishes.

about making one’s wishes for end-of-life care known should one become unable to communicate them.

80

80

70

65.79% Percentage of total responses

Percentage of total responses

70 60 50 40

28.95%

30 20 10 0

2.63% Strongly agree

Agree

No opinion

0% Disagree

50

80

40

34.21%

30 20

40 30

26.32%

20

15.79% 7.89%

10

No opinion

0.0%

0.0%

Disagree

Strongly disagree

36.84%

30 25

21.05% 18.42%

20 15

13.16% 10.53%

10 5

10

32

Agree

have advanced care directives.

50.0%

Percentage of total responses

50

0

2.63% Strongly agree

35

60

40

20

5. I feel that Medicare recipients should be required to

65.79% Percentage of total responses

Percentage of total responses

70

31.58% 30

0

Strongly disagree

were clearly questionable (may buy time but diminish quality of ife and impose additional physical discomfort).

50 40

10

2.63%

4. I would decline life-prolonging treatment if its benefits 3. It is important to me to have the option to decline expensive end-of-life diagnostic procedures.

65.79%

60

Strongly agree

Agree

0.0%

0.0%

0.0%

No opinion

Disagree

Strongly disagree

MINNESOTA HEALTH CARE NEWS JUNE 2013

0

0.0% Strongly agree

Agree

No opinion

Disagree

Strongly disagree

0

Strongly agree

Agree

No opinion

Disagree

Strongly disagree

It is important to ask a salon about its disinfectant procedures.

Nail salon safety from page 20

necessary to eliminate fungal spores. These spores are difficult to kill, so proper disinfecting and sterilization is vital. If you ask a salon employee about these procedures and observe any hesitation in the answer, consider another nail salon for your treatment. Suction screens used in pedicure baths and soaking tubs should be disposable and replaced after each client, since bacteria can become trapped in the screens.

Finally, nail care should be comfortable and relaxing. Pain or bleeding during a salon procedure means it is likely that tissue is being damaged and that the nail technician is being too aggressive. In some cases, such as treatment of an ingrown toenail, discomfort is to be expected, but that treatment should be performed by a podiatrist or other medical profession and not in a salon.

to nail salons because they have a chronic ingrown nail problem. If you have a chronic problem with ingrown nails, seek advice from a physician or a podiatrist. There are techniques that can permanently correct ingrown nails.

Skin infections occur when tools are not sterilized properly between patients or when the technician is too aggressive with a treatment. Cuticles protect the nail bed, so they should never be cut away; cutting them exposes the nail bed to infection. People preparing to visit a nail salon should never shave their legs or toes during the 24 hours before their appointment. Shaving can cause minor breaks in the skin that make it easier for any bacteria in the area to cause an infection.

Complications

Use common sense

A common complication that can appear after a visit to a nail salon is a fungal infection of the nail. Symptoms of this type of infection vary. It can appear as a white patch on top of the nail; the nail can be thickened and appear yellow or brown; or the nail can look black.

Fungal infections of the nail are treatable but there is no cure that is 100 percent effective.

Other common complications include ingrown nails and skin infections. Ingrown nails happen as a result of cutting nails improperly. Symptoms typically include pain when the corner of the nail is touched, redness, and sometimes drainage, and most commonly occur one to three weeks after the nail was trimmed. Many individuals go

Most nail salons operate safely. Nonetheless, it is important to ask a salon about its disinfectant procedures and to make sure technicians use good hygiene, that the salon is clean and orderly, and that treatment does not cause pain or bleeding. Even if the salon follows these procedures it is possible to get an infection or an ingrown nail, but it is much less likely. Using common sense and asking a few questions go a long way toward preventing infections from your nail salon.

Treatment

Dirk Halverson DPM, FACFAS, is a board-certified podiatric surgeon at the Richfield, Blaine, St. Anthony, and Brooklyn Park offices of Midwest Podiatry Centers, which is also located in Cottage Grove and Roseville.

Minnesota

Health Care Consumer Association

SM

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

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JUNE 2013 MINNESOTA HEALTH CARE NEWS

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Fireworks safety from page 13

immediately.

• See your doctor right away for a deep wound that you cannot clean thoroughly or if the wound shows signs of infection. These signs include pus, swelling, surrounding skin that is red and/or warm, a bad smell, or red streaks radiating away from the wound.

If your child ingests fireworks, call 911 or poison control immediately.

Prevention

• Never place any part of your body directly over a fireworks device when lighting the fuse. Light one firework at a time and always back up to a safe distance immediately after lighting it. That means 25–40 feet for fountains and ground-based fireworks and 75–100 feet for fireworks that shoot into the sky.

• Keep a bucket of water handy in case something catches on fire.

• Never try to relight or handle malfunctioning fireworks. Instead, soak them in water for 24 hours. Then place the fireworks in a bag and return them to where you bought them or your local fire station for safe disposal.

Most methods of fireworks injury prevention are common sense. Unfortunately, alcohol and a festive attitude can get in the way of following important safety guidelines when it comes to enjoying fireworks. In a perfect world, we would leave fireworks displays up to the professionals.

But for those who insist on lighting fireworks themselves, follow these important precautions:

Play it safe If fireworks are part of your holiday tradition, play it safe. The alternative is spending the holiday in an emergency room. It’s better to enjoy the oohs and aahs of a fireworks display on the Fourth of July than to ooh and aah in pain while being treated for a serious fireworks-caused injury.

• Never use illegal fireworks.

• Never allow young children to play with or ignite fireworks. Keep children far away and supervised when fireworks are being lit.

Gary Gosewisch, MD, FAAEM, is board-certified in emergency medicine and is the CEO of The Urgency Room in Woodbury, Eagan, and Vadnais Heights.

• If fireworks are packaged in brown paper … stay away. This can be a sign that the fireworks were made for professional displays and that they could pose a danger to consumers.

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

34

MINNESOTA HEALTH CARE NEWS JUNE 2013

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

Important Patient Information This is a BRIEF SUMMARY of important information about Victoza®. This information does not take the place of talking with your doctor about your medical condition or your treatment. If you have any questions about Victoza®, ask your doctor. Only your doctor can determine if Victoza® is right for you.

WARNING During the drug testing process, the medicine in Victoza® caused rats and mice to develop tumors of the thyroid gland. Some of these tumors were cancers. It is not known if Victoza® will cause thyroid tumors or a type of thyroid cancer called medullary thyroid cancer (MTC) in people. If MTC occurs, it may lead to death if not detected and treated early. Do not take Victoza® if you or any of your family members have MTC, or if you have Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).

This is a disease where people have tumors in more than one gland in the body.

What is Victoza® used for?

• Victoza® is a glucagon-like-peptide-1 (GLP-1) receptor agonist used to improve blood sugar (glucose) control in adults with type 2 diabetes mellitus, when used with a diet and exercise program.

• Victoza® should not be used as the first choice of medicine for treating diabetes.

• Victoza® has not been studied in enough people with a history of pancreatitis (inflammation of the pancreas).

Therefore, it should be used with care in these patients.

• Victoza is not for use in people with type 1 diabetes mellitus or people with diabetic ketoacidosis. ®

• It is not known if Victoza® is safe and effective when used with insulin.

Who should not use Victoza®?

• Victoza should not be used in people with a personal or family history of MTC or in patients with MEN 2. ®

• Victoza® may cause nausea, vomiting, or diarrhea leading to the loss of fluids (dehydration). Dehydration may cause kidney failure. This can happen in people who may have never had kidney problems before. Drinking plenty of fluids may reduce your chance of dehydration.

• Like all other diabetes medications, Victoza® has not been shown to decrease the risk of large blood vessel disease (i.e. heart attacks and strokes).

What are the side effects of Victoza®?

• Tell your healthcare provider if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath while taking Victoza®. These may be symptoms of thyroid cancer.

• The most common side effects, reported in at least 5% of people treated with Victoza® and occurring more commonly than people treated with a placebo (a non-active injection used to study drugs in clinical trials) are headache, nausea, and diarrhea.

• Immune system related reactions, including hives, were more common in people treated with Victoza® (0.8%) compared to people treated with other diabetes drugs (0.4%) in clinical trials.

• This listing of side effects is not complete. Your health care professional can discuss with you a more complete list of side effects that may occur when using Victoza®.

What should I know about taking Victoza® with other medications?

• Victoza® slows emptying of your stomach. This may impact how your body absorbs other drugs that are taken by mouth at the same time.

Can Victoza® be used in children?

• Victoza® has not been studied in people below 18 years of age.

Can Victoza® be used in people with kidney or liver problems?

• Victoza® should be used with caution in these types of people.

Still have questions?

What is the most important information I should know about Victoza®?

• In animal studies, Victoza® caused thyroid tumors. The effects in humans are unknown. People who use Victoza® should be counseled on the risk of MTC and symptoms of thyroid cancer.

• In clinical trials, there were more cases of pancreatitis in people treated with Victoza® compared to people treated with other diabetes drugs. If pancreatitis is suspected, Victoza® and other potentially suspect drugs should be discontinued. Victoza® should not be restarted if pancreatitis is confirmed. Victoza® should be used with caution in people with a history of pancreatitis.

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

FOR TYPE 2 DIABETES

Victoza® helped me take my blood sugar down…

and changed how I manage my type 2 diabetes.

Victoza® helps lower blood sugar when it is high by targeting important cells in your pancreas—called beta cells.

While not a weight-loss product, Victoza® may help you lose some weight.

And Victoza® is used once a day anytime, with or without food, along with eating right and staying active.

Model is used for illustrative purposes only.

Indications and Usage: Victoza® is an injectable prescription medicine that may improve blood sugar (glucose) in adults with type 2 diabetes when used along with diet and exercise.

Victoza® is not recommended as the first medication to treat diabetes. Victoza® is not insulin and has not been studied in combination with insulin. Victoza® is not for people with type 1 diabetes or people with diabetic ketoacidosis.

It is not known if Victoza® is safe and effective in children. Victoza® is not recommended for use in children.

Important Safety Information: In animal studies, Victoza® caused thyroid tumors—including thyroid cancer—in some rats and mice. It is not known whether Victoza® causes thyroid tumors or a type of thyroid cancer called medullary thyroid cancer (MTC) in people which may be fatal if not detected and treated early. Do not use Victoza® if you or any of your family members have a history of MTC or if you have Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). While taking Victoza®, tell your doctor if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath. These may be symptoms of thyroid cancer.

Inflammation of the pancreas (pancreatitis) may be severe and lead to death. Before taking Victoza®, tell your doctor if you have had pancreatitis, gallstones, a history of alcoholism,

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

or high blood triglyceride levels since these medical conditions make you more likely to get pancreatitis.

Stop taking Victoza® and call your doctor right away if you have pain in your stomach area that is severe and will not go away, occurs with or without vomiting, or is felt going from your stomach area through to your back. These may be symptoms of pancreatitis.

Before using Victoza ®, tell your doctor about all the medicines you take, especially sulfonylurea medicines or insulin, as taking them with Victoza® may affect how each medicine works.

Also tell your doctor if you are allergic to any of the ingredients in Victoza®; have severe stomach problems such as slowed emptying of your stomach (gastroparesis) or problems with digesting food; have or have had kidney or liver problems; have any other medical conditions; are pregnant or plan to become pregnant. Tell your doctor if you are breastfeeding or plan to breastfeed.

It is unknown if Victoza® will harm your unborn baby or if Victoza® passes into your breast milk.

Your risk for getting hypoglycemia, or low blood sugar, is higher if you take Victoza® with another medicine that can cause low blood sugar, such as a sulfonylurea. The dose of your sulfonylurea medicine may need to be lowered while taking Victoza®.

Victoza® may cause nausea, vomiting, or diarrhea leading to dehydration, which may cause kidney failure. This can happen in people who have never had kidney problems before.

Drinking plenty of fluids may reduce your chance of dehydration.

The most common side effects with Victoza® include headache, nausea, and diarrhea. Nausea is most common when first starting Victoza®, but decreases over time in most people. Immune system-related reactions, including hives, were more common in people treated with Victoza® compared to people treated with other diabetes drugs in medical studies.

Please see Brief Summary of Important Patient Information on next page.

If you need assistance with prescription drug costs, help may be available. Visit pparx.org or call 1-888-4PPA-NOW. You are encouraged to report negative side effects of prescription drugs to the FDA. Visit fda.gov/medwatch or call 1-800-FDA-1088.

Victoza® is a registered trademark of Novo Nordisk A/S. © 2011 Novo Nordisk 0611-00003312-1 August 2011

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

Non-insulin • Once-daily