Minnesota Health care News May 2012 by Minnesota Physician Publishing

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May 2012 â&#x20AC;˘ Volume 10 Number 5

Cholesterol and statins Gene Stringer, MD

Corneal transplants Omar Awad, MD

Adolescent gynecology Suja Roberts, MD

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CONTENTS

4 7 8

MAY 2012 • Volume 10 Number 5

18 20

NEWS

PEOPLE

PERSPECTIVE

PATIENT TO PATIENT Bone marrow transplant By Karen Lorentz, RN

WOMEN’S HEALTH Adolescent gynecology By Suja Roberts, MD

May 2012 • Volume 10 Number 5

Cholesterol and statins Gene Stringer, MD

Corneal transplants

Minnesota Department of Health

Nancy A. Hutchison, MD, CLT-LANA

DRUG CLASSES Controlling cholesterol with statins By Gene C. Stringer, MD

Omar Awad, MD

Adolescent gynecology Suja Roberts, MD

10 QUESTIONS

Sister Kenny Rehabilitation Institute and Virginia Piper Cancer Institute

FREE

Your Guide to Consumer Information

Raiza M. Beltran, MPH

WOUND CARE Pressure ulcers By Julibeth Petter-Lauren, PhD, RN, CNS, and Laura Kenney, MSN, RN, CNP, CWOCN, CFCN

PUBLIC HEALTH Twin Cities Obesity Prevention Coalition By Jennifer J. Anderson, MA

23 26 28

CALENDAR National Celiac Disease Awareness Month

INFECTIOUS DISEASE Cytomegalovirus: A disabling virus in babies

OPHTHALMOLOGY Corneal transplant By Omar Awad, MD, FACS

ONCOLOGY Ovarian cancer By Paul Haluska, MD, PhD

By Mark R. Schleiss, MD

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

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

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MAY 2012 MINNESOTA HEALTH CARE NEWS

NEWS

Uninsured Rate Remains High, State Report Says Despite better economic times, uninsured rates in Minnesota remain high, officials with Minnesota Department of Health (MDH) say. The MDH report finds that the uninsured rate for Minnesotans remained at 9.1 percent in 2011, unchanged since 2009. In the 2009 report, data showed the rate of uninsured people in Minnesota increased, from 7.2 percent in 2007. That followed an upward trend since 2001, when the uninsured rate was 6.1 for state residents. An estimated 490,000 Minnesotans were uninsured in 2011, compared to 480,000 Minnesotans in 2009 and 374,000 in 2007. MDH says approximately 70,000 children were without health coverage in 2011. Officials say the report indicates that the state has not recovered from the losses in health

insurance coverage sustained during the recession. According to the report, the fact that uninsured rates have stayed the same despite an improved economy suggests that jobs being created do not offer insurance, or that some employers are dropping coverage for existing workers. In addition, the report finds a decline in the number of people who choose to enroll in employer-sponsored health plans—perhaps an indication that health insurance is becoming too expensive for some Minnesotans. Another concern is the number of people uninsured for an entire year, a group sometimes called “long-term uninsured.” Officials say those numbers are increasing. “For the first time in 2011, the all-year uninsured accounted for more than half— 51.1 percent—of [the uninsured], up from 44.3 percent in 2009, potentially representing a trend toward more long-term uninsurance that deserves to be monitored closely,” the report says.

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– UCare member St. Louis Park, MN

A more positive trend is found in coverage of young adults, MDH officials say. “If there is one bit of good news in the research findings, it is that young adults ages 18 to 25 saw a decline in their uninsured rate in 2011,” says Stefan Gildemeister, director of the Health Economics Program at MDH. “For the first time in years, young adults saw an increase in coverage through an employer.” Officials say implementation of the federal Affordable Care Act (ACA), which allows young adults to remain on their parents’ insurance through age 26, may be contributing to the increase in coverage for this demographic.

Mayo Clinic, CentraCare Announce New Partnership Mayo Clinic and CentraCare’s Coborn Cancer Center announced a new relationship last week, with the St. Cloud-based cancer center becoming the first mem-

ber of the Mayo Clinic Cancer Care Network. The move formalizes existing ties between the two organizations, officials say, and will give both physicians and patients more access to Mayo specialists and resources. As part of the new Mayo Clinic Cancer Care Network, officials say Coborn Cancer Center will have access to unique Mayo services and tools, including AskMayoExpert, a state-of-the-art resource that allows providers to use Mayo Clinic's evidence-based disease management protocols, clinical care guidelines, treatment recommendations, and reference materials for a variety of medical conditions. CentraCare physicians will also be able to use eConsults, which will allow them to connect with a Mayo expert to get input on specific questions regarding cancer treatment. The arrangement seems similar to one announced nearly a year ago with Altru Health System, the Grand Forks, N.D.based health system. As with that

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MINNESOTA HEALTH CARE NEWS MAY 2012

arrangement, officials have stressed that the new relationship between Mayo Clinic and Coborn Cancer Center is not an acquisition or merger.

Poison Center Marks 40th Year The Hennepin Regional Poison Center (HRPC) is marking its 40th anniversary of helping state residents. Established in 1972 at Hennepin County Medical Center (HCMC), the center responds to more than 50,000 calls a year concerning poison emergencies and related questions. Officials with HCMC note that the service began with one woman, Alice Lange (aka Poison Alice), who pioneered HRPC with a telephone and index cards. Lange received 70 calls in her first month; today, the center fields 4,600 calls monthly. “Back in 1972 some of the typical calls were similar to today—kids eating iron tablets, or someone accidentally splashing cleaning solution in his or her eyes,” says Jon Cole, MD, medical director of HRPC. “As new chemicals, interactions, and trends in usage are being thought of everyday, there’s never a dull moment in our work. And unfortunately, in addition to accidental exposures, intentional exposure to chemicals like methamphetamine and bath salts is increasing. Last year 1,963 of the calls we received were related to people purposefully exposing themselves to a chemical to obtain a high.” The program is one of 57 U.S. Poison Centers accredited by the American Association of Poison Control Centers. Officials say the service is able to provide quick instructions to people in their homes in 92 percent of all calls received, resolving possible poisoning questions and preventing unnecessary visits to emergency departments. This preventive step is estimated to save the state $26 million annually in health care costs.

St. Cloud Pharmacy To Take Back Old Prescriptions A HealthPartners pharmacy in St. Cloud is offering to take back unused prescription drugs from residents and dispose of them in an environmentally friendly manner. The free service is being offered to help reduce the risk of accidental poisonings and unintended drug use. By disposing of the drugs properly, officials say, the program will ensure that chemicals do not end up in surface water or groundwater resources. “We want to make it as easy as possible for people in the St. Cloud area to safely dispose of unused medicine, said Diane Dalzell, pharmacy manager for HealthPartners Central Minnesota Clinics. “Proper disposal helps reduce the risk of accidental poisoning, it helps limit prescription medicine abuse, and it keeps drugs from entering our groundwater supply.” The program is available for all non-narcotic drugs: by law, pharmacies are not allowed to take back controlled substances including Vicodin, Valium, codeine, Oxycodone, and others. Individuals wishing to dispose of controlled substances are asked to contact the Stearns County Sheriff Department.

North Memorial Designated Top 50 Hospital North Memorial Medical Center in Robbinsdale is the only Minnesota hospital to be designated one of the top 50 in the nation by HealthGrades, a Denver, Colo.based health information company. In addition to North Memorial’s recognition, Fairview Southdale in Edina and St. Luke’s Hospital in Duluth made HealthGrades’ 100 Best Hospitals list. North Memorial officials say to make the list of 50 best hospitals in the nation, hospitals had to

MINNESOTA HEALTH CARE ROUNDTABLE

T H I R T Y- S E V E N T H

SESSION

Specialty pharmacy Controlling the cost of care Thursday, June 7, 2012 1:00 – 4:00 PM • Symphony Ball Room Downtown Mpls. Hilton and Towers

Background and focus: Medications treating chronic and/or life-threatening diseases are frequently new products, which are often more expensive than generic or older, branded products that treat similar conditions. The term specialty pharmacy has come to be associated with these medications. Exponents claim the new technology improves quality of life and lowers the cost of care by reducing hospitalizations. Opponents claim the higher per-dose cost spread over larger populations does not justify the expense.

The cost of research, both failed and successful, is reflected in product pricing. Current federal guidelines allow generic equivalents marketplace access based on the patent date, not the release date, of a product. This considerably narrows the window in which costs of advances may be recovered. A further complicating dynamic involves the payers. Physician reimbursement policies sometimes reward utilizing lower-cost “proven” products and cast those prescribing higher-cost products as “over-utilizers,” placing them in lowertiered categories of reimbursement and patient access.

Objectives: We will discuss the issues that guide the early adoption of new pharmaceutical therapies and how they relate to medical devices. We will examine the role of pharmacy benefit management in dealing with the costs of specialty pharmacy. We will explore whether it is penny-wise but pound-foolish to restrict access to new therapies and what level of communication within the industry is necessary to address these problems. With the baby boomers reaching retirement age, more people than ever will be taking prescription medications. As new products come down the development pipeline, costs and benefits will continue to escalate. We will provide specific examples of how specialty pharmacy is at the forefront of the battle to control the cost of care. Panelists include: N Sara Drake RPh, MPH, MBA, Pharmacy Program Manager, Minnesota Department of Human Services N Alan H. Heaton, PharmD, RPh, Director, Pharmacy Management, UCare N Daniel Johnson, MEd, Vice President of Public Policy, National Multiple Sclerosis Society N Timothy Stratton, PhD, BCPS, FAPhA, Professor, College of Pharmacy, UMD N Gene Stringer MD, Stillwater Medical Group

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News to page 6 MAY 2012 MINNESOTA HEALTH CARE NEWS

News from page 5 post very low risk-adjusted mortality and complication rates. In addition, North Memorial was ranked No. 1 in Minnesota for treatment of stroke and best in the region for overall cardiac services. “We are extremely proud of being one of the top 50 hospitals in the nation and the only hospital in Minnesota to be recognized,” says Andy Cochrane, president of hospital operations and CEO of the Maple Grove Hospital. “We completely acknowledge that this achievement is a result of the innovative and dedicated employees and physicians who provide care at North Memorial Medical Center. North Memorial has been recognized for seven years in a row. This doesn’t happen without an exceptional and consistent commitment to teamwork, quality, and safe care of our patients by all of our nurses, physicians, allied professionals, leadership, and staff at North Memorial.”

HealthPartners, Children’s Fight Childhood Obesity HealthPartners and Children’s Hospitals and Clinics of MInnesota are joining forces to fight childhood obesity and improve coordination of health care for families, officials recently announced. The new initiative will focus on managing and preventing childhood obesity through education and programming in communities and clinics in the metro area. HealthPartners is currently working with Minneapolis and St. Paul public schools through its yumPower campaign, which aims to build healthy eating habits among elementary schoolaged youth. Officials with HealthPartners and Children’s say the two groups will also collaborate on standardizing and coordinating care to create a seamless experience for children and their families. “At Children’s we’re always looking for ways to improve the

experience for patients and families,” says Alan Goldbloom, MD, president and CEO of Children’s of Minnesota. “At the same time, we know the best way to take care of kids is to keep them out of the hospital to begin with. Tackling childhood obesity and improving our care coordination together with HealthPartners helps us with both of these goals.”

Eagan Resolution Takes on Nutrition, Healthy Lifestyles The City of Eagan has passed the state’s first Healthy Eating Active Living resolution, which promotes healthy lifestyle and nutritional activities in that community. The idea for the resolution comes from the Twin Cities Obesity Prevention Coalition (TCOPC), a community-based coalition of organizations, physicians, and individuals committed to improving public health by advocating active lifestyles and healthy nutritional choices. The

group is funded by Blue Cross and Blue Shield of Minnesota. Resolutions such as Eagan’s are one of several strategies the coalition is promoting. “I think I can speak for all our physician members when applauding the Eagan City Council and Mayor Mike Maguire for their leadership and foresight in laying down a foundation for the future health and wellness of Eagan residents,” says Peter Dehnel, MD, president of the Twin Cities Medical Society and physician advocate for TCOPC. Among the specific steps called for in the resolution are: advocating for the continued sustainability of existing healthy eating and active living offerings; investigating additional policies and practices within the built environment, or the places where people live, work, eat, and play; identifying efforts to provide access to healthy foods for residents; and encouraging efforts to improve employee wellness among cityoperated worksites.

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MINNESOTA HEALTH CARE NEWS MAY 2012

PEOPLE Marna Canterbury, MS, RD, has been named director of community health and wellness at the Lakeview Foundation. She will lead the Lakeview Foundation’s Children’s Health and Wellness Initiative, which aims to improve physical fitness and nutrition for children in the St. Croix Valley, working with schools, businesses, health providers, and other community stakeholders. Marna Canterbury, MS, RD

Canterbury brings more than 25 years of experi-

ence in population health improvement, health and nutrition communications, social marketing, and program evaluation to her new position. She previously was executive director of the United Way of Washington County–East and led health improvement efforts within health systems, foundations, and health plans, including HealthPartners. The Minnesota Cancer Alliance has announced the addition of eight new members: Ruth Bachman, University of Minnesota Masonic Cancer Center Community Advisory Board; Ken Bence, Medica; Sirad Warfa Osman, New American Community Services; Kris Rhodes, American Indian Cancer Foundation; Marilee Rose, Metro Minnesota Community Clinical Oncology Program; Denise Blumberg-Tendel, Susan G. Komen for the Cure–Minnesota Affiliate; Dai Vu, Individual Member; and Lindy Yokanovich, Cancer Legal Line. Anna Leininger, MS, CGC, a certified genetic counselor at Minnesota Oncology, is part of a national team recently awarded the 2012 Cancer SIG Grant Award by the National Society of Genetic

Anna Leininger, MS, CGC

MOVE YOUR CAREER IN HEALTHCARE AHEAD.

Counselors. Leininger is the only team member from Minnesota. The grant funds development of a new resource guide; “Parents’ Disclosure of BRCA Results to Their Pre-teens and Adolescents: Development of a Resource Guide.” (BRCA1 and BRCA2 genes are associated with high lifetime risks of developing breast and ovarian cancers.) The publication will provide a structural framework for planning and guiding the disclosure of familial BRCA mutations to their children at an age-appropriate level, offering straightforward ways to express complex terms and concepts associated with genetics and cancer. Leininger provides genetic risk evaluation services at Minnesota Oncology’s Woodbury clinic and the Maplewood Cancer Center.

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Michael Wolfson, MD, has joined North Memorial Clinic, Camden. He cares for a broad spectrum of medical conditions such as high blood pressure, diabetes, heart disease, and preventive medicine/ healthy living and has a particular interest in perimenopause and menopause. Wolfson, who is board-certified in internal medicine and

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a fellow of the American College of Physicians, completed medical school and residency at Rush University in Chicago. Rich Schlueter has joined Richfield-based Newman Long-Term Care as a long-term care insurance specialist. Previously, he spent 14 years with a financial planning firm, most recently as vice president of insurance services and manager Rich Schlueter

of central planning services. Schlueter has earned

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certifications as a chartered life underwriter, chartered financial consultant, fellow of the Life Office Management Association, and certified financial planner. MAY 2012 MINNESOTA HEALTH CARE NEWS

PERSPECTIVE

Free screening for breast and cervical cancer Reducing barriers to health care

hen Blaine resident Debra Johnson first noticed a lump in her left breast, she was shocked. At 40 years of age, Johnson considered herself a healthy woman. She did not smoke cigarettes, rarely drank alcohol, ate fruits and vegetables, and exercised regularly.

Raiza M. Beltran, MPH Minnesota Department of Health Raiza Beltran, MPH, is a health program representative for the Sage Screening Program at the Minnesota Department of Health. Sage is a statewide comprehensive breast and cervical cancer control program that is funded through the Centers for Disease Control. This program's primary objective is to increase the number of underserved Minnesota women screened for breast and cervical cancer. Beltran earned a journalism degree from the University of Minnesota and a master’s degree in community health education from the University of Minnesota School of Public Health. She has written for various publications on the health and social

And there was yet another unexpected situation: Having returned to Minnesota to care for her ailing mother, Johnson found herself without health insurance. Fearful of the cost she would incur for simply seeing a doctor, she sought help from the Neighborhood Involvement Program (N.I.P.) Community Clinic in the Uptown area of Minneapolis. The clinic enrolled Johnson in the Sage Screening Program, a Minnesota Department of Health (MDH) program that provides uninsured or underinsured women with free screening for breast cancer and cervical cancer. Sage

Don’t wait Sage has diagnosed and treated approximately 1,900 women for breast and cervical cancer, including Johnson, who was diagnosed with breast cancer in 2008. Now celebrating her fourth year as a breast cancer survivor, Johnson is an advocate of breast cancer screening and educates other women about the importance of early detection of breast cancer. “Don’t wait because you’re afraid. It may be frightening to go through what I went offers through, but it’s better than not being here at all,” she points transportation and out.

Relief from worry Through Sage, Johnson interpreter services. received a breast exam, mamHow to get help mogram, and Pap smear at the This year, according to the N.I.P. clinic at no cost. The clinic American Cancer Society, an doctor recommended additional diagnostic imag- estimated 4,110 women in Minnesota will be diaging and a biopsy, all of which were covered by nosed with breast cancer; an estimated 600 Sage. “It was a relief not to have to worry about women in the state will die from the disease next medical bills while getting the test results,” she year. Annual mammography reduces death from recalls. breast cancer by detecting the disease in its earliJohnson is one of nearly 135,000 women screened by the Sage program since its inception in 1991. “We think there are many women who are not receiving these life-saving screening tests because they have no insurance or their insurance has deductibles or copayments that they cannot meet. Sage can help,” says Jonathan Slater, PhD, chief of cancer control at MDH.

est stages when it is most easily treated. Women seeking eligibility information about the free mammogram and Pap test program and women who want to make an appointment for a free mammogram and Pap test should call Sage at (888) 6-HEALTH [(888) 643-2584)]. Mention promo code MHN1 when you call and you may qualify for a $20 incentive.

Statewide help With a statewide network of more than 450 health care providers that provide free screening, Sage successfully reaches underserved populations that include women in rural communities and women from diverse racial and ethnic groups. In addition to screening, Sage offers transportation and interpreter services for participants who otherwise would miss or cancel their screening appointments. “Whether it is taking time off from

To find a provider near you that offers free screening, visit www.health.state.mn.us/divs/hpcd/ccs/ screening/sage.

issues that face minority and immigrant communities in Minnesota.

work, lack of child care, or other competing priorities, women often encounter barriers that prevent them from taking care of themselves and their health. Sage is committed to reducing these barriers and improving breast and cervical cancer screening rates in Minnesota,” says Christina Nelson, recruitment and evaluation manager for Sage.

MINNESOTA HEALTH CARE NEWS MAY 2012

Sage offers additional services at no cost to eligible Minnesota residents including SagePlus, a heart-health screening program, and SageScopes, a colorectal-cancer screening program. Sage also offers tobacco cessation tools in conjunction with Minnesota QUITPLAN Services.

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10 QUESTIONS

& Nancy Hutchison, MD, CLT-LANA Nancy Hutchison, MD, CLT-LANA, is a board-certified physiatrist and is the medical director of cancer rehabilitation at the Sister Kenny Rehabilitation Institute and the Virginia Piper Cancer Institute in Minneapolis. She works with teams of rehabilitation therapists at Sister Kenny Rehabilitation Institute and Sister Kenny Sports and PT Centers. Please tell us what physical medicine and rehabilitation encompasses. Physical medicine and rehabilitation (PMR) is also known as physiatry. The name derives from the Greek: physikos (physical) and iatreia (art of healing). Our goal is to improve function and quality of life by addressing prevention, diagnosis, and treatment of conditions that lead to reduced function. Physiatry requires four years of medical school and four years of residency, leading to board certification. Physiatrists have formal training in neurology, orthopedics, and rheumatology as well as the psychosocial aspects of illness. Just like other physicians, physiatrists diagnose illness and prescribe treatments. Some physiatrists also perform fluoroscopic-guided spine injections, or chemodenervations, to manage pain and reduced function, and may also perform electrodiagnostic testing. Rehabilitation is at the heart of our specialty. What are the most common interactions a PMR physician has with other physicians? Typically, a physician refers a patient to a physiatrist because an injury or chronic illness has led to the patientâ&#x20AC;&#x2122;s impaired function, reduced activity, or pain. We create a vocational rehabilitation plan for the patient, determine what someone is physically capable of doing in the workplace, and suggest how the workplace environment and/or the physical demands of the job can be adapted for that patient. People such as professional athletes or musicians are sometimes referred to us because they have lifestyles that may lead to injury. How does PMR interact with allied health professionals such as physical therapists? Physiatrists work as part of a team that includes traditional allied health professionals such as physical therapists (PT), occupational therapists (OT), and speechlanguage pathologists (SLP), along with chiropractors, psychologists, and complementaryintegrative therapists. Physiatrists prioritize and coordinate interventions for optimal recovery by combining nonsurgical interventions with rehabilitation therapies and individualized fitness interventions. What are the most common conditions that you treat? Physiatrists treat neurologic and musculoskeletal conditions of children and adults such as spinal cord injury, brain injury, arthritis, stroke and non-surgical management of spine conditions. We also treat patients with any medical condition that impairs function, mobility, and life skills, including cancer and cardiopulmonary conditions. Physiatrists also work in a preventive capacity to reduce the impact of illness and repetitive stress activities.

Photo credit: Bruce Silcox

MINNESOTA HEALTH CARE NEWS MAY 2012

Please tell us about the work you do with cancer survivors. Many patients finish cancer treatment with medical, psychosocial, financial, occupational, and functional deficits that are not adequately addressed. Survivorship is a distinct phase of cancer care with specific concerns that must be addressed by the medical community. I consult with patients to address the functional aspects of survivorship care. Surgery, chemotherapy, and radiation therapy affect physical function. I prescribe treatments that reduce a patientâ&#x20AC;&#x2122;s

“

”

We work in a complementary, holistic way with other care providers.

functional decline, ameliorate symptoms, and enhance recovery. Interventions may or many not require rehabilitation therapy. I may also refer a patient who is a cancer survivor to other support opportunities. I also treat lymphedema, which is limb swelling that is a common side effect of cancer treatment. PMR’s unique approach to lymphedema combines therapy and compression garments with exercise and weight management. What have been the most significant advances in your field over the last 10 years? Physiatry has developed expertise in the diagnosis and nonsurgical management of pain and reduced function using procedures such as chemodenervations, which allow the patient to progress into therapy or to exercise to improve function. Another advance is that recent research in cancer rehabilitation documents the importance of activity before, during, and after cancer treatment. A third advance is the team approach to patient care that PMR developed, which is now standard in all medical specialities.

What do you see coming in the next 10 years? Increasing lifespan means that more people are living with the functional impairments of chronic illness. Geriatric research shows that medical frailty and debility lead to disability, and while losing independence is a personal loss, it also costs society. PMR research is creating tools that foster independence, including some that use robotics and telemedicine.

Some people may lack access to a physiatrist or don’t know that PMR exists. What can you tell us about this? PMR care may be covered by insurance. Patients and health care providers should seek rehabilitation care from institutions that have strong multidisciplinary therapy teams and CARF or STAR accreditation so that patients receive a team approach to rehabilitation care. What are some of the most significant improvements you have seen in patients who have received PMR? • A man with pancreatic cancer was too weak to walk but, after rehabilitation, was able to walk his daughter down the aisle and dance at her wedding.

• A woman treated for head and neck cancer could not eat solid food. After rehabilitation, she went on a cruise where she was able to eat a variety of foods from the buffet. • A woman with severe leg lymphedema after gynecologic cancer was able to wear regular shoes and exercise again after lymphedema therapy and rehabilitation. What would you like people to know about PMR? PMR benefits patients by working to prevent, diagnose, and treat conditions that impair function. Physiatry does not compete with primary care, physical therapy, chiropractic, or any other discipline. We work in a complementary, holistic way with other care providers. Our unique multispecialty and psychosocial training make us a partner in the survivorship care of oncology patients.

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MAY 2012 MINNESOTA HEALTH CARE NEWS

DRUG CLASSES

Controlling cholesterol with statins

Rewards and risks By Gene C. Stringer, MD

Editor’s Note: This article is the first in an ongoing series on prescription drug classes. Drug classes are a way of categorizing medicines and are determined by the U.S. Food and Drug Administration. A class is typically defined by the primary active chemical ingredient or structure of the drugs in it or by the type of health condition it treats. The two most basic drug classes are over-the-counter (OTC) drugs and prescription drugs. Prescription drugs are divided into several classes: statins, ACE inhibitors, beta blockers, steroids, etc. This series will provide information on several of the most commonly prescribed drug classes.

holesterol is a waxy material found in certain foods and also produced naturally by your body. It circulates in your blood for a variety of applications, including being used as a building block for many hormones. Sometimes, though, you produce more of cholesterol’s “LDL” component—low-density lipoprotein—than you need. That’s not healthy, since high LDL levels in your blood increase the risk of cardiovascular disease. This type of disease includes heart disease and stroke, and accounts for more than one-third of all deaths in the United States.

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

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

MINNESOTA HEALTH CARE NEWS MAY 2012

Multiple costs, multiple treatments High LDL levels are costly in economic terms as well as in loss of human life: The total cost of cardiovascular disease in the U.S. was estimated at $444 billion in 2010. The same year, the federal government’s Centers for Disease Control and Prevention contributed $56.2 million to 41 states, including Minnesota, to fund programs designed to combat heart disease and to prevent stroke. These programs are based in part on evidence that preventing and controlling high levels of LDL play a significant role in promoting cardiovascular health. (In contrast to LDL, the cholesterol component called high-density lipoprotein, or HDL, confers cardiovascular protection; so one way that reducing LDL promotes health is by increasing the relative amount of HDL in your blood.) Preventive programs have the potential to help Minnesotans. According to Minnesota High Cholesterol 2011—an analysis of Minnesotans’ health published in 2011 by Minnetonka-based United Health Foundation—nearly 67 percent of adults who have high levels of the LDL cholesterol component don’t have those levels under control. This means that their LDL levels could be dangerously high or even rising. One main goal of preventive programs in Minnesota is to help the overall population achieve better control of LDL cholesterol levels. One way to accomplish this is to use statins, a class of drugs that lowers cholesterol levels. Multiple generic and brand-name statins are available, which differ in terms of their interactions with other drugs, potency, risks, and efficacy. All statins work the same way in the body and help many patients reach their cholesterol goals, possibly more effectively than any other cholesterol-lowering medication. But, as with any drug, there may be a price to pay in terms of risks and side effects. If your cholesterol is too high, the best thing you can do is to become educated about your decision to take or not to take statins, and to work with your health care provider to achieve your desired cholesterol level.

Statins block the body’s production of cholesterol.

How do statins work? Statins block the body’s production of cholesterol. The recommendation before taking any statin is that you first try a strict regimen of diet and exercise to get your cholesterol under control. If lifestyle modifications are not enough to reduce your cholesterol to optimal levels, your doctor may decide to prescribe a statin for you. The dose you are prescribed will vary depending on which statin is prescribed and the degree to which you need to lower your cholesterol. Statins and lifestyle In addition to taking a statin, you need to be prepared to make some lifestyle changes that may include dieting, exercising, coping with stress, and quitting smoking. Treating high cholesterol with lifestyle changes and statin medication is a long-term commitment and is something you will probably need to continue indefinitely. Unlike an antibiotic that you stop taking after you have finished your prescription and feel better, a statin is something you continue to refill and

take in order to keep your cholesterol under control. If you stop taking your statin medication, your cholesterol levels will likely start to get out of control once again. An exception to this long-term commitment might occur if someone lowers his or her cholesterol—and keeps it lowered—by making substantial improvement to diet and exercise routines. In that case, the physician might discontinue the statin, but always consult a physician before discontinuing any cholesterol medications. Side effects and risks

If you are prescribed a statin and you are likely to be on that statin for the rest of your life, it is good for you to know the side effects and risks associated with this class of drugs. The most common side effect associated with taking statins is muscle pain. The way you feel this muscle pain may be different from the way someone else feels it. The pain could vary from a sensation of tired muscles and mild discomfort to severe pain that makes it difficult to perform daily activities such as climbing stairs. There is also a very rare risk of developing rhabdomyolysis, a side effect causing permanent muscle damage that can lead to life-threatening kidney failure. Anyone taking a statin should report muscle pain promptly to his or her physician. Controlling cholesterol with statins to page 16

Health care …naturally The clinics of Northwestern Health Sciences University offer natural health care solutions at three Twin Cities locations. We also partner to provide free services at community clinics. • Acupuncture and Oriental medicine • Chiropractic • Healing touch • Massage therapy • Naturopathic medicine • Nursing practitioner services Many services are covered by health insurance. Visit our website or call to find out more about locations, hours and services:

nwhealth.edu/patients • 952-885-5444

MAY 2012 MINNESOTA HEALTH CARE NEWS

WOUND CARE

Pressure ulcers Prevention tips By Julibeth Petter-Lauren, PhD, RN, CNS, and Laura Kenney, MSN, RN, CNP, CWOCN, CFCN

Remember “bedsores,” those reddened, sometimes open wounds grandma developed on her skin when confined to her bed with pneumonia? We watched them persist until grandma’s pneumonia got better and she was able to get out of bed. What are pressure ulcers? Now called pressure ulcers, these wounds develop as a result of persistent unrelieved pressure on the skin. Pressure reduces blood flow to the skin, and without enough blood to supply oxygen and nutrients to that tissue, the tissue begins to break down and a sore or ulcer begins to form. The ulcer may become deep and develop dying tissue. If the ulcer is not treated, the dying tissue continues to decay, may become infected, and may ultimately necessitate surgery. It’s important to prevent these pressure ulcers from forming, not only to avoid infection but because they’re painful and can lead to additional complications, costly medical care, and, possibly, longer hospitalization.

2012 MN Parkinson’s Disease Forum Coming together for “Parkinson’s Friendly Communities TM”

Monday, June 11th Tuesday, June 12th

8:30am - 4:30 pm 8:30 am -3:30 pm

(Registration and continental breakfast 7:30-8:30 both days)

McNamara Event Center, University of Minnesota

This conference is open to anyone who wants to learn more about Parkinson’s Disease (PD).You do not have to have PD or even know anyone with PD to be welcome. A newly diagnosed person can learn about the variety of treatment options and services in the area or join in an exercise class or support group. Someone who has lived with PD for a while can learn about participating in medical research or how to contact policy-makers to ensure research gets proper funding. Caregivers can get information on how to better care for themselves and how to utilize support services.

MINNESOTA HEALTH CARE NEWS MAY 2012

Topics will include: • Early-Mid-Late Stage PD: Common Symptoms, Treatments & Complementary Therapies • Sleep Issues in Parkinson’s Disease • Impulse-Control Issues • Avoiding Caregiver Burnout • The role of Exercise in PD • And many others

Reservation is required, space is limited $15 per person for one day, $25 for both days For more information call 763-545-1272 www.parkinsonmn.org/events/forum

Signs that a pressure ulcer may be forming include skin that blisters, becomes increasingly red and does not turn temporarily white in response to gentle pressure, and ultimately forms an open sore.

by asking nursing staff if the patient may sit in a chair when guests visit instead of staying in bed.

Causes Pressure can come from prolonged lying or sitting in the same position, from medical devices that rest against the skin, or from any object that causes enough pressure to reduce the blood flow to the skin for a prolonged period of time. People at risk for developing pressure ulcers include: • Full-time wheelchair users • People who need assistance to move part of their body due to paralysis or other conditions • Those with diminished blood flow due to diabetes, vascular disease, or other reasons

Eat well. Nutrition plays a key role in healing. An ill or injured body often requires a more nutritious diet than a healthy one. Proper nutrition can be a problem if the patient feels nauseated or is in pain, too weak to eat, or unconscious. In such cases, hospital nutritionists and dieticians recommend nutritional options that provide the necessary supplements. You can help improve your family member’s nutritional status by asking hospital staff to suggest what food you might bring from home for the patient. Sometimes familiar food comforts patients and encourages them to eat. Before bringing any food to the hospital, however, discuss your plans with hospital staff. If a patient is malnourished pre-hospital, it is more challenging and critical to address nutritional needs. A patient who is severely underweight and exhibits signs of poor nutrition has a significantly increased risk of developing pressure ulcers. Addressing nutritional needs at home is extremely important for families with an elderly, immobile, or ill family member.

Act early to prevent a potential sore from getting worse.

• People who have fragile skin caused by aging, corticosteroid use, or chronic health conditions • Anyone with urinary or bowel incontinence • Malnourished people Keep an eye on these areas The most common areas for pressure ulcers to occur are over bony prominences, areas of the body where bones are closer to the skin’s surface and where there isn’t much padding underneath the skin. Areas at highest risk for developing pressure ulcers include heels, ankles, elbows, shoulder blades, back, back of the head, and the sacrum and coccyx, which are the bony bumps at the middle and top of the buttocks. Pressure between the bone and a mattress or medical device compresses the skin and underlying tissues. This reduces blood flow to the tissues, resulting in skin breakdown. Sometimes breakdown occurs over the course of several days, but depending on the health and condition of the patient, may begin within hours after the onset of prolonged pressure. If you suspect that you or a loved one has a pressure ulcer, contact your health care provider. Also, if you provide care for someone with a suspected pressure ulcer who is being admitted to a hospital or other care facility, notify a nurse or physician immediately upon admission so that treatment can be started right away to prevent the wound from decaying further.

Manage chronic illness. Chronic medical conditions such as heart disease, diabetes, and cancer increase the risk of pressure ulcers. These conditions may decrease the body’s ability to circulate blood and hence to supply tissues with oxygen and nutrients. Caring Pressure ulcers to page 17

Prevention Change position. Address all aspects of medical care to avoid a pressure ulcer, whether the patient is in the hospital or at home. Hospital personnel encourage patients to reposition themselves frequently, and will assist patients if they cannot move themselves. Moving relieves pressure and allows blood flow to return to the tissues. While visiting a loved one in the hospital, encourage the patient to move. Support hospital staff in their efforts to frequently turn and reposition the patient. If moving the patient causes pain or nausea, the care team will relieve the patient’s discomfort before attempting to reposition him or her in bed, walking with him or her in the hallway, or moving the patient to a chair. Visitors can participate in this ulcer-prevention/healing process by walking in the hallway with a patient who is able to walk, and MAY 2012 MINNESOTA HEALTH CARE NEWS

Controlling cholesterol with statins from page 13

Statins may also cause digestive problems, rashes, flushing, headaches, and nausea. In addition, precautions exist for coadministration of statins with some common medications, including erythromycin (an antibiotic), niacin (vitamin B3), and amlodipine (also called Norvasc, a calcium channel blocker used to treat high blood pressure and angina). Plus, studies of different statins have suggested their use may predispose patients to develop diabetes. Research published in the January 2012 issue of Archives of Internal Medicine reported an approximately 50 percent increase in the incidence of new-onset type 2 diabetes among postmenopausal women taking a statin. Therefore, patients taking statins should consult their providers about dose, duration of therapy, and their risk of developing diabetes. However, these risks can be moderated by taking other medications along with statins. One such medication is Welchol, which can be taken in conjunction with any dose of any statin. Welchol lowers hemoglobin A1C in adult patients with type 2 diabetes—in other words, it lowers the elevated blood sugar that is one characteristic of type 2 diabetes. Welchol also reduces the amount of statin needed by lowering LDL and raising HDL levels. Before adding any medication to moderate statins’ side effects, however, consult your pharmacist and physician to make sure you are not taking your statin with other medication that could be causing side effects. Lowering the dose of a statin almost always decreases its side effects,

but the decision to change the dose or add a medication should be made only by your physician. Take control When you get ready to make decisions about your cholesterol, the first thing to do is to consult your physician. There are many options out there, and statins are known to be the most effective prescription therapy for lowering cholesterol. With that effectiveness comes the price of some side effects and risks. Balance those risks by taking care of yourself with diet and exercise, and by asking your physician about additional medications, such as Welchol, that can be used with a statin to minimize its risks. Overall, the best way to approach using statins to control cholesterol is to weigh the options, benefits, and risks of statin therapy, and to work with your physician to decide what works best for you. Then you’ll be equipped with information and ready to take control of the road to your cholesterol goals. Gene C. Stringer, MD, is board-certified in family medicine and practices with the Stillwater Medical Group.

Always consult a physician before discontinuing any cholesterol medications.

Now accepting new patients

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

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

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

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

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

MINNESOTA HEALTH CARE NEWS MAY 2012

Pressure ulcers from page 15

for a patient with a chronic medical condition requires increased efforts to improve mobility, turning and repositioning the patient, keeping heels up off the mattress, keeping the patient dry, and inspecting under devices. Devices such as lines, tubes, pressure stockings, and splints all may cause pressure ulcers. Managing pressure at home, in the hospital, or in a long-term care facility is extremely important for chronically ill patients. Keep skin dry. Moisture weakens the skin and inhibits healing. A patient who is sweaty or unable to control bladder or bowel movements has an increased risk of developing skin breakdown and ulcer formation. After incontinent patients urinate or have a bowel

movement, the area should be thoroughly cleansed and dried. If skin is moist under a device, this too, increases the risk of skin breakdown and pressure ulcer formation. Therefore, a hospital’s health care team needs to inspect a patient’s skin for signs of potential skin breakdown and act early to prevent a potential sore from getting worse, even for patients who are up and walking around. Get help Seek immediate medical attention if you observe any of these signs of infection in or around a pressure ulcer. • A bad smell comes from the ulcer. • The ulcer changes color to yellow, gray, or black. • Drainage from the ulcer becomes cloudy, green, or pus-like, or increases in volume. • Skin near the ulcer is red and painful. • Skin near the ulcer feels warmer than usual. Inspect every inch, every patient, every day

Heart disease, diabetes, and cancer increase the risk of pressure ulcers.

MINNESOTA HEALTH CARE NEWS MAY 2012

At Regions Hospital, nurses specializing in wound care work as part of a multidisciplinary team to prevent pressure ulcers. Our health-care team motto is: “We inspect every inch, every patient, every day.” For those of you caring for loved ones at home, this can be your motto too. Julibeth Petter-Lauren, PhD, RN, CNS, is director of practice and education at Regions Hospital, St. Paul. Laura Kenney, MSN, RN, CNP, CWOCN, CFCN, is an adult nurse practitioner certified in wound, ostomy, and continence, and works at Regions Hospital.

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

Bone marrow transplant

he worst day of my life started with a simple preschool screening exam in July 1996. I was planning to send my 3-year-old son, Bob, to preschool in a few weeks, but a simple hemoglobin test would derail that plan. Bob’s hemoglobin was low, but not low enough to send out alarms—yet. We were to return three weeks later for a retest. Three weeks later The retest results changed our lives forever. I knew by the look on our doctor’s face that the news we were about to receive was bad, and it was. Bob’s hemoglobin was very low and so were his platelets. As a nurse, I knew this probably meant he had leukemia. I started to cry. We went directly from the doctor’s office to the hospital, where Bob began chemotherapy that evening. The next few days were an emotional rollercoaster. We were told there are two types of leukemia, “good” acute lymphocytic leukemia (ALL), which generally responds to chemotherapy, and “bad” acute myelogenous leukemia (AML), which is generally much less responsive to treatment. Initially, we were told that Bob had ALL. I remember getting that news and jumping up and down with joy that he had the good type. Except he didn’t.

A little boy’s second chance at life By Karen Lorentz, RN

Only one hope A biopsy of Bob’s bone marrow showed he had a form of the bad type of leukemia that is rare in children, called acute myelogenous leukemia with chromosomal disorder monosomy 7. This type of leukemia isn’t usually cured by chemotherapy. Bob’s only hope for survival was to have his own diseased marrow replaced by a transplant of healthy marrow. For some patients, marrow can be donated by a close relative, but Bob’s only sibling at the time was his adopted brother from South Korea, and there wasn’t a match. (To “match” means that donor and recipient are genetically similar enough for donor marrow to be accepted by the recipient’s body. Donation doesn’t harm donors, who regenerate what they donate.) Parents rarely match offspring. In fact, the chance of finding a match within a family is only about 30 percent. That means two-thirds of patients need an unrelated donor. Potential unrelated donors are listed in a national registry of people who are willing to donate, located in Minneapolis and maintained by the nonprofit National Marrow Donor Program. Be The Match Registry finds lifesaving matches for patients who require an unrelated bone marrow transplant. As soon as Bob was diagnosed, his oncologist set the wheels in motion to find an unrelated match. Bob was very fortunate that a good match was found quickly. Many people are not as lucky. The transplant took place in March 1997. It was a very rough time for our family; we didn’t leave Bob’s room at University of Minnesota/Fairview Hospital for 60 days. He came home on May 9, 1997—a wonderful Mother’s Day gift! A stranger donates

MINNESOTA HEALTH CARE NEWS MAY 2012

Bob’s donor was Debbie, a woman who had participated in a college campus marrow drive 10 years earlier. The sample she donated at that time was characterized and its description was

Since donating, Debbie has become a cherished friend of Bob’s family. Here, she and Bob enjoy her visit to his family’s Minnesota home in November 2011. saved in the registry in case it matched a potential recipient in the future. When the registry called her 10 years later to donate marrow on Bob’s behalf, she readily agreed. We met her after his transplant, but there is simply no way we can thank her enough, ever. I remember well when Debbie was asked why she donated and she replied, “You don’t have to be smart, pretty, or rich; you just have to be there!” I am so glad she was there for Bob. A perfect stranger, willing to donate some of her cells to save a life. How amazing! Donating marrow changed Debbie’s life as well as Bob’s. Formerly a geologist, she changed careers and is now a transplant coordinator for patients undergoing bone marrow transplants. What is bone marrow? Bone marrow occupies the space inside our large bones and is full of stem cells that produce blood components that keep us alive: white blood cells, red blood cells, platelets, and others. Blood-forming stem cells are also in blood from the umbilical cord but are NOT the embryonic stem cells that are a controversial topic often in the news. Umbilical cord stem cells and embryonic stem cells are different. According to the National Marrow Donor Program, every year, more than 10,000 patients in the United States are diagnosed with life-threatening diseases such as leukemia or lymphoma. For them, marrow or umbilical cord blood from an unrelated donor may be their best or only hope for a cure. They depend on the National Marrow Donor Program’s Be The Match Registry to find an unrelated donor or umbilical cord blood. How donation works There are three ways to donate to save the life of someone who needs unrelated stem cells to put in their bone marrow. The donation method is determined by the doctor according to what is best for the patient. The first method is by bone marrow extraction, which is done in the hospital under general anesthesia and is usually a one-day procedure. This is how Debbie donated and afterward, she said, it felt mildly uncomfortable, as though she had fallen on her bottom and bruised herself. She said she wouldn’t hesitate to do it again. A second method is by a procedure called peripheral blood stem cell collection, which is much like giving blood. These donors take a stem cell-stimulating drug a few days before donating. This boosts

Donation doesn’t harm the donor.

the number of stem cells in their blood. Then, their blood is collected, passed through a machine that filters out and collects the stem cells, and the remainder of the blood is returned to the donor. (The donor regenerates stem cells.) This procedure lasts about six to eight hours while the donor sits. Some people catch up on their reading or watch TV during this procedure. A third way to provide stem cells is for a woman to donate the umbilical cord after she gives birth. (The cord is normally discarded as medical waste.) Cord blood contains stem cells that produce blood cells in bone marrow; cord stem cells are different from human embryonic stem cells.

Donating marrow changed Debbie’s life as well as Bob’s. Happy ending It’s been 15 years since Bob’s transplant. He is healthy and happy and pursuing a career in music. It’s been a long journey, full of sorrow as well as joy—made possible by a kind stranger whose selfless act saved the life of a little boy, and by Be The Match Registry, which made the miracle match that gave Bob a second chance at life. To read other patient stories and find out how you can save a life, please visit www.bethematch.org. Karen Lorentz, RN, is a registered nurse, mother of three, and a volunteer courier who transports bone marrow and stem cells for the National Marrow Donor Program.

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

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

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

EXERTstudy.org MAY 2012 MINNESOTA HEALTH CARE NEWS

WOMEN’S HEALTH

Adolescent gynecology

f you are a parent of young daughter, you may be dreading her preteen years due to the changes about to take place and some of the challenging times that can occur during puberty. However, there is no need to panic. Parents who prepare for this transitional time and keep the lines of communication open will be better equipped to guide their daughters through this process. Earlier puberty

During the past two decades, girls have started entering puberty at much younger ages than in past generations. Many of us over 40 may remember the onset of puberty at around age 12 or 13. Today, girls begin to experience the early signs of puberty—growth spurts, breast buds, underarm and pubic hair—as early as

Preparing for the journey ahead

age 9. Menstruation is also beginning at a younger age than in previous generations. This trend in physical maturation can be attributed in part to a change in diet. Improved nutrition is thought to cause early-onset puberty in females, although other factors, such as genetics, also contribute. The role of processed food with increased fatty content and the presence of hormones and chemicals in the environment have been debated as causes, although unsupported by scientific data. Other environmental and lifestyle factors may also play a role. Whatever the reasons, the fact is that puberty is occurring earlier for today’s girls, which requires parents to take note and prepare so they can be there for their young daughters. That first conversation

Many parents wonder when to initiate a conversation with their young daughter about the changes she can anticipate. Every situation is unique depending on the maturity of the girl, what she may be hearing from her friends, or particular questions she may be asking. While there is no magical age, the earlier this conversation begins the better. A good guideline is to start the conversation when a girl is between the ages of 9 and 11. That allows both the girl and her parents to be prepared for upcoming bodily changes. She’ll be aware of what to expect and won’t be caught off guard. These early conversations between a parent and young daughter don’t need to be overly explicit. The goal is to provide enough information so that the girl understands that the changes happening with her body are completely normal and knows she can reach out to her parents as questions arise. A helpful book that gently introduces puberty in an age-appropriate way is “The Care & Keeping of You” (Schaefer, V., 1998, American Girl). In addition to providing some basic facts, the book has a positive tone and illustrations that convey topics that may be embarrassing for girls or their parents to bring up.

By Suja Roberts, MD

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

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

MINNESOTA HEALTH CARE NEWS MAY 2012

Probably the single most frightening aspect of puberty for girls, menstruation is likely to begin when girls are between the ages of 9 and 15. While the exact timing cannot be predicted, many girls start to menstruate about a year or so after they start to develop breasts and grow pubic hair. The most helpful thing parents can do is to make sure their daughter has enough information and sanitary supplies so she is not caught off guard when she menstruates for the first time.

Resources First gynecologist visit

• “The Care & Keeping of You,” Schaefer, V., 1998, American Girl.

Pediatricians and family physicians are great resources for providing guidance as girls enter the beginning stages of puberty. However, to help your daughter feel more comfortable with the changes taking place in her body, it is a good idea to introduce her to a gynecologist when she is between the ages of 13 and 15, or earlier if she starts menstruating before age 13. Annual visits should be scheduled from then onward. A physical exam will be done either at the initial visit or at one of the subsequent visits. This does not mean girls at this age should get a pelvic exam or Pap smear at their first visit. The recommended age for a Pap smear is now 21, even if the girl has been sexually active. However, if there is a concern about a sexually acquired infection or abnormal puberty, such as very early or delayed onset of menstruation, a pelvic exam will be necessary. It is important for parents not only to be aware of normal puberty, but also to recognize possible indicators of abnormal puberty, such as delayed or early onset of physical changes. Abnormal changes could be due to an underlying medical condition requiring evaluation and treatment. A girl’s early visits with a gynecologist are about establishing a relationship of trust and talking about healthy lifestyle habits that range from eating well and exercise to sexual health. Girls may feel more comfortable asking sensitive or embarrassing questions about their body or sex, and getting advice and insight, from a non-parent.

• HPV information: www.cdc.gov/vaccines • Mayo Clinic website: www.mayoclinic.com/health/ tween-and-teen-health/MY00393 The preteen years are a good time to discuss body weight and educate girls about body mass index (BMI). Body mass index is a measure of weight in relation to height and the most practical way to estimate if a person is underweight, at a healthy weight, or overweight. A normal BMI is between 19 and 25. Schools may address this in the classroom but parents can provide additional guidance and serve as role models for establishing healthy eating habits and adopting an exercise routine. Since accidents are a leading cause of death among teenagers, now is also the time to reinforce safe habits such as wearing a seatbelt; using a helmet when biking, skiing, or snowboarding; and avoiding texting while driving. Puberty doesn’t have to be a traumatic experience for parents or their daughters. When handled with love and care, it can be an exciting time that strengthens bonds within families and helps girls transition to happy, strong, and confident young women.

It is important to know some facts about HPV.

Suja Roberts, MD, is board-certified by the American College of Obstetrics and Gynecology and practices with Clinic Sofia, which has offices in Edina and Maple Grove.

HPV vaccination Because human papillomavirus (HPV) is spread through sexual contact, the topic of how to properly protect teenagers and the appropriate age to vaccinate against HPV remains sensitive. First, it is important to know some facts about HPV. There are more than 100 different types of HPV. More than half of sexually active men and women are infected with HPV at some point in their lives. Many do not even realize it, because most HPV infections don’t cause symptoms. Some types of HPV can cause genital warts; others lead to cervical cancer in women. The Centers for Disease Control and Prevention advises that girls and boys get vaccinated for HPV between the ages of 11 and 12 before they are sexually active. This three-dose vaccine provides protection against four common types of HPV. Parents should ask their pediatrician or family doctor for more information or visit www.cdc.gov/vaccines to download a vaccination information sheet that outlines risks and benefits of the HPV vaccine.

Puberty doesn’t have to be a traumatic experience.

Communication is key Above all, the key to getting through this transitional time for parents and their daughters is to keep the conversation going during preteen years. Beyond body changes and the inevitable discussions around sexual health that will come in later years, it is important to introduce other topics that will be increasingly important throughout the teen years.

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

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

PUBLIC HEALTH

Twin Cities Obesity Prevention Coalition Obese:

Combating a menace By Jennifer J. Anderson, MA

That single word describes the clinical health status of one-third of U.S. adults. In Minnesota alone, 24.8 percent of adults are obese and another 38 percent are classified as overweight according to the Minnesota Department of Health. These two groups combined means that 62 percent of all Minnesotans are in a dangerous weight category. Even more worrisome is the rapid rate at which the number of obese Minnesotans has been increasing. While Minnesota’s incidence currently stands at 24.8 percent of the population, it was less than 15 percent in 1990. Bottom line? Our obesity has almost doubled in the past 20 years. According to the American Medical Association, obesity nationwide will reach an alarming level if left unchecked. Increasing along with obesity is the incidence of devastating health consequences associated with it. These include coronary heart disease, type 2 diabetes, hypertension, stroke, liver and gallbladder disease, sleep apnea, respiratory problems, and even certain cancers. Most troubling of all is that if nothing is done to combat the growing incidence of obesity, the most recent generation of Americans will be the first generation in the history of the nation that will not Twin Cities to page 22

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MINNESOTA HEALTH CARE NEWS MAY 2012

May Calendar 8

Talking with Your Doctor about Lyme Disease Elizabeth Maloney, MD, is presenting on medical decision-making to help improve communication with your doctor regarding the diagnosis of Lyme disease and options for treatment. You will be able to create a personalized, evidence-based treatment plan that works. For more information, visit www.mnlyme.com. Tuesday, May 8, 6:30–8 p.m., First Lutheran Church, 4000 Linden St., White Bear Lake Women’s-Only Cardiac Support Group For women living with heart disease, join other women to discuss experiences, strategies for heart-healthy living, and solutions to the challenges. Each week, guest speakers and featured topics will teach ways to improve heart health. Free, but please register in advance. Call Susan White at (612) 775-3074. Monday, May 14, 6:30–8 p.m., Minneapolis Heart Institute, 920 E. 28th St., Lower Level, Minneapolis Legal Issues for Cancer Survivors: Protections Against Abusive Debt Collection Practices If you have been diagnosed with cancer, or know someone who has, the Cancer Legal Line is available as a resource to you, confidentially and free of charge. Christopher Wheaton of Barry, Slade & Wheaton, LLC will be presenting. Please register by calling (651) 472-5599. Tuesday, May 15, 6:30–8 p.m., Wescott Library, 1340 Wescott Rd., Eagan Charlas sobre Lupus/Chat about Lupus Spanish speaking group Las Charlas de Lupus se realizan mensualmente y son una oportunidad para quienes padecen lupus (u otras condiciones crónicas,) y las personas que los asisten para conectarse con otros y conversar de temas relacionados con la salud y el diario vivir con una afección crónica. Contact Gustavo Taberna Community Outreach Coordinator, at gtaberna@ lupusmn.org or (952) 746-5151. For additional support groups, visit

National Celiac Disease Awareness Month Did you know that 3 million Americans have celiac disease, but only about 5 percent of them are accurately diagnosed? Blood tests are the first step in a diagnosis of celiac disease. A doctor will order the tests to measure your body’s response to gluten. Celiac disease is an autoimmune digestive disease that damages the finger-like villi of the small intestine and interferes with absorption of nutrients from food. What does this mean? Essentially the body is attacking itself every time a person with celiac consumes gluten, which is found in wheat, barley, and rye. Accurately diagnosing celiac disease can be quite difficult largely because the symptoms often mimic those of other diseases, including irritable bowel syndrome, Crohn’s disease, ulcerative colitis, diverticulosis, intestinal infections, chronic fatigue syndrome, and depression. Some people may experience no symptoms at all. The only treatment for celiac disease is a lifelong gluten-free diet. Despite these restrictions, people with celiac disease can eat a well-balanced diet with a variety of foods, including gluten-free bread and pasta. Many gluten-free products are now made with potato, rice, soy, or bean flour. In addition, plain meat, fish, fruits and vegetables do not contain gluten, so celiacs can eat as much of these foods as they like. For more information and resources visit the National Foundation for Celiac Awareness (NFCA) at www.CeliacCentral.org or call (215) 325-1306. Talk with your health care professional about specific health concerns. 12 Anoka County Celiac Support Group We meet the second Saturday of each month. Bring your questions, ideas, and a gluten-free treat, along with the recipe to share. Contact Margaret “Mike” Douville at (763) 421-3656 or Sandy Carroll at (763) 427-6965. Saturday, May 12, 10 a.m.–noon, Grace Lutheran Church, 13655 Round Lake Blvd., Andover For information about additional adult and children support groups, visit www .northlandceliacs.fastmail.fm/support.html

www.lupusmn.org. Friday, May 18, 6–7:30 p.m., Lupus Foundation of Minnesota, 2626 E. 82nd St., The Atrium Ste. 315, Bloomington

Hope and Optimism After Stroke Please join us for StrokeWise in a Day 2012. Presentations include “Bad Day, Baffled Day, Beautiful Day,” intimacy and sexuality after stroke, physical changes during recovery from stroke, and an adventure of healing and hope. Lunch is included. Stay for the prize drawings! $25/person. Call (952) 993-6789 to register. Saturday, May 19, 8 a.m.–2 p.m., Methodist Hospital, 6500 Excelsior Blvd., Heart & Vascular Ctr., Ground Floor Auditorium, St. Louis Park

Living Well: Spirituality Tom Allen, BS, spiritual director, Loyola Spirituality Center, will share a perspective from many spiritual practices that support people with dementia and their care partners. This free seminar will present strategies to meet challenges and losses, and to live well with the dementia diagnosis. For more information, contact samantha.moy @alz.org or call (952) 857-0546. Tuesday, May 22, 7–8 p.m., Mount Zion Temple, 1300 Summit Ave., Margolis Hall, St. Paul

Arthritis Pain Management This presentation focuses on arthritis symptoms and causes, different types of arthritis (there are more than 100), and pain management and control. There is no charge to attend. Please register in advance by calling (651) 298-5493. Friday, May 25, 10:15–11 a.m., West 7th Community Ctr., 265 Oneida St., St. Paul

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

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

Twin Cities from page 24

live longer than their parents. That’s very disturbing, considering that this nation has always prided itself on leaving its children a better and more secure future. Causes Multiple factors contribute to the increasing number of overweight and obese Minnesotans. It’s easy to point a finger at personal responsibility or lack of willpower, but in reality, the choices individuals make are largely influenced by the social and built environment in which they live, work, play, and socialize. If you live in a community with inadequate sidewalks or nonexistent bike lanes, how can you or your children walk or bike safely? If you don’t have adequate park space or access to indoor facilities for year-round physical activity, how can you expect to move your body 30 minutes per day as recommended by the federal government’s Centers for Disease Control (CDC)? And if the nearest source of food is a gas station, how can you easily add fresh fruits and vegetables to your family’s plate, given that such outlets typically don’t sell fresh produce? America, including Minnesota, has largely become a sedentary society in the last 20 years. At the same time, it has become overly reliant on

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MINNESOTA HEALTH CARE NEWS MAY 2012

less healthy foods. Television and computer screen time has increased; physical education classes and even recess have often been eliminated from the school day; highly processed foods loaded with salt and fat are common both in the home and in many schools; and sugar-sweetened beverages have become a dietary staple rather than the treat they once were. Response In the summer of 2010, the physicians of the Twin Cities Medical Society (TCMS) rated obesity the No. 1 health issue in their practices. They were determined to do something about the obesity epidemic, and in November 2010, TCMS staff created the Twin Cities Obesity Prevention Coalition (TCOPC), a community-based coalition of organizations, physicians, and concerned individuals committed to improving public health by advocating on behalf of healthy eating and active-living strategies in metro-area communities. “The mission of the Twin Cities Medical Society is that we exist to connect, represent, and engage physicians in improving the practice of medicine, policy development, and public health initiatives. That mission is at the core of our efforts with the obesity prevention coalition,” says TCMS President Peter Dehnel, MD. The coalition includes 22 physician members of the TCMS who are passionate about addressing the obesity epidemic. Their work with the coalition includes educating the public about the benefits of a healthy, active lifestyle and meeting with elected officials to talk about the dangers of obesity. They also serve as spokespersons for passing healthy community resolutions, one of the cornerstones of TCOPC efforts. Resolving to improve Resolutions are designed to positively impact a community and improve the health of its residents. Each resolution is tailored to an individual community, not as a “one size fits all” recommendation. For example, a resolution might call for supporting increased community access to school facilities for physical activity and nutrition education; comprehensive school-level campaigns to promote healthy behaviors that include healthy eating and increasing the time allotted for physical activity during the school day; implementing “walking school buses” to encourage elementary school students and their parents to walk to school with other kids and parents; partnerships with businesses to promote workplace health and wellness; increasing the number of farmers markets and community gardens; or efforts to promote healthy eating habits among families. Each resolution is designed to be malleable so that it can be tailored to meet a given community’s specific needs and used as a blueprint for action rather than just as a proclamation by that community’s mayor. “An effective or ideal resolution will include policy goals that allow a community to plan long-term around improving the health of all residents and the environments in which they live, work, play, and socialize,” explained Dehnel in a 2011 coalition partner meeting.

The TCOPC expects between six and nine communities to craft and approve city-specific resolutions in 2012. The city of Eagan is poised to vote this spring on a resolution that will support the development and sustainability of community gardens and farmers markets; encourage electronic benefits transfer (EBT) and Supplemental Nutrition Assistance Program (SNAP) access at all licensed farmers markets; and support efforts to implement a healthy food and beverage policy for city meetings and facilities, including city-operated food and beverage vending machines.

In addition to the TCMS, current members of the Twin Cities Obesity Prevention Coalition include Catalyst, a statewide group of young people who promote health; American Heart Association; American Diabetes Association; Bloomington Public Health; APPEAL for Health; Neighborhood Health Source; American Cancer Society; Welcyon Fitness; Rainbow Health Initiative; Blue Cross and Blue and Shield of Minnesota; Burnsville Eagan Savage Public School District 191; and Minnesota Public Health Association. For more information about the coalition, visit www.metrodoctors.com

Economic, physical health Sue Schettle, TCMS CEO, notes that the coalition’s efforts make sense not only from the standpoint of improving public health but also as a way to control the exploding costs associated with the obesity epidemic. This epidemic costs $1.3 billion dollars annually in increased health care costs. If the upward trend in obesity rates continues, it could cost Minnesotans an additional $3.7 billion dollars by 2020. “We can’t afford to do nothing,” says Schettle. “Passing a healthy community resolution allows cities to implement healthy community policies and encourages businesses, nonprofit organizations, public entities, individuals, and other interested community members to participate in a community-wide effort to reverse the rise in obesity rates. A resolution with policy goals provides for a continuous plan of action the city can build on year after year.”

Making healthy easy In 2012, the goal of the coalition is not only to pass communitybased resolutions but also to connect and engage with communities to start the conversation about ways to increase opportunities for citizens to enjoy a healthy, active lifestyle. “Every day across Minnesota, communities work together to rally around issues that impact local residents. The issue of obesity shouldn’t be any different,” Schettle pointed out at TCMS’ annual board dinner in January 2012. “The bottom line is that if we are going to combat the obesity epidemic, we need to make the healthy choice the easy choice at the community level. But people can’t make that choice if it’s not available.” Jennifer J. Anderson, MA, is a project coordinator at the Twin Cities Medical Society.

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OPHTHALMOLOGY result can be blurred or hazy vision, distortion of images, and even blindness. Corneal transplants have an excellent track record of remedying these problems.

Corneal transplant Century-old remedy for multiple symptoms By Omar Awad, MD, FACS

irst performed more than 100 years ago, corneal transplants are among the most straightforward and successful of all transplant procedures. More than 50,000 of them are performed each year in the United States. This procedure involves replacing all or part of the cornea, which is the transparent tissue that covers the eye. The cornea performs much of the focusing for the eye but when it is not working properly, the

Hospital and Clinics

MINNESOTA HEALTH CARE NEWS MAY 2012

Reasons for transplant Causes of impaired corneal functioning include inherited conditions, damage from trauma or infection, and age. Aging affects the innermost layer of the cornea, or endothelium, which contains pump cells that keep the cornea from swelling. Pump cells are necessary because the cornea receives nutrients from fluid inside the eye that naturally travels into the cornea. After nutrients are extracted, these cells pump excess water back out. Endothelium pump cells are gradually lost as people age, and they don’t regenerate. This loss happens at an earlier age and a faster rate in Fuchs’ endothelial dystrophy, an inherited condition. Fuchs’ is a slowly progressive corneal disease that typically affects both eyes and appears more often in women than in men. Although it may be detected in people during their 30s and 40s, it generally does not affect vision until age 50 to 70. Early symptoms of Fuchs’ dystrophy include waking up with blurred vision that gradually clears during the day. This occurs because the cornea is normally thicker in the morning since it is swollen with fluids it retains during sleep and which evaporate during the day once the eyes are open. However, as Fuchs’ dystrophy progresses, corneal swelling and blurred vision persist throughout the day. A loss of endothelial pump cells can also be caused by inflammation and as a postoperative complication of eye surgery. If enough pump cells are lost or damaged, the cornea may start to swell, resulting in blurred vision. Another part of the cornea that can develop a need for transplantation is the stroma, one of the cornea’s outer layers and its thickest part. It comprises almost 90 percent of the cornea and provides structural strength. This strength is important because the cornea must be rigid enough to maintain the eyeball’s shape, yet flexible enough to accommodate blinking and eye rubbing. The stroma’s structural integrity is affected in keratoconus, the condition in which the cornea’s shape becomes progressively more cone-like and warped as the stroma becomes increasingly thinner. This distorts vision and can eventually scar the cornea. The cause of keratoconus is unknown, but the condition is associated with excessive eye rubbing. The cornea may also require transplantation if it has become excessively scarred or cloudy from degenerative conditions such as pellucid marginal degeneration, other inherited corneal dystrophies, or injury. Corneal infections, particularly those associated with contact lens use, can scar the cornea.

Types of transplant Corneal transplants are among the most straightforward and successful of all transplant procedures because the cornea is easily accessible to the surgeon and has no blood vessels. There are two basic types of transplant. One replaces the full thickness of the cornea. The other selectively replaces either the inner or outer layer of the cornea.

Finding transplantable corneas Corneal transplants depend on donated corneas. Minnesota Lions Eye Bank obtains and distributes donated eye tissue for use in corneal transplants, medical research, and medical education. To find out how your corneas can restore sight and renew life after you no longer need them, visit www.mnlionseyebank.org.

Full thickness Traditionally, corneal transplantation required replacing the cornea’s full thickness. This procedure is still done when necessary and is called a penetrating keratoplasty (PK). In this procedure, the central part of the cornea is removed using a trephine, which is similar to a very small cookie cutter. The donor cornea is then sutured (sewn) into place. This surgery lasts about one to two hours, is performed in an operating room, and the patient goes home afterward. It may take up to one year before sutures can be removed but they are thinner than a human hair and do not cause irritation. Recovery of vision can also take many months and patients may have a significant change in eyeglass prescription or may require contact lenses posttransplant. Partial thickness Techniques developed in recent years permit transplanting either inner or outer layers of the cornea. These partial thickness transplants have the general name of lamellar keratoplasty. More specific names are given to these procedures depending on which layer is transplanted. Endothelial keratoplasty (EK) replaces the inner layer of the patient’s cornea with a donated inner layer that contains endothelial pump cells. EK might be performed for a patient with corneal swelling caused by malfunctioning or insufficient numbers of endothelial pump cells, as in Fuchs’ dystrophy. In this procedure, surgery is performed through a very small incision on the side of the eye. It involves Corneal removing the patient’s damaged tissue from the inner part of the transplants cornea, placing the inner part of the have an donor cornea into the patient’s eye, and moving the donated layer into excellent position using an air bubble. track record. The bubble holds the partial transplant in place, so there are no sutures in the transplant. Pumping action of the new cells causes the transplant to completely adhere and reduces corneal swelling. The bubble is absorbed by the eye within a few days. Endothelial keratoplasties heal much faster than penetrating keratoplasties. An EK wound is far less likely to rupture if the eye subsequently suffers an injury during or after healing because the EK incision is significantly smaller than the one used for PK. And, since EK preserves the outer parts of the patient’s cornea, this procedure may not change the patient’s eyeglass prescription as signifi-

cantly as a full-thickness transplant would. Deep anterior lamellar keratoplasty (DALK) replaces damaged stroma while preserving the patient’s inner corneal layers. Since the inner layers are kept intact, the eye is not completely opened during the surgery, which enhances the safety of this procedure. The patient’s own endothelial cells are also preserved, which reduces the chance of transplant rejection. DALK sutures may be removed sooner than those used for PK.

Reduce your risk Although corneal transplant is a safe and commonly performed surgery, it’s prudent to reduce the risk of eventually needing it. To do so, see your eye doctor regularly to detect any conditions at an early stage, wear eye protection when using tools, follow established protocol if you use contact lenses, and contact your doctor promptly about eye infections, especially if you wear contact lenses. Omar Awad MD, FACS, is a board-certified ophthalmologist who specializes in corneal diseases, cataracts, and refractive surgery. Dr. Awad performs corneal transplants at the Phillips Eye Institute in Minneapolis and practices with Awad Eye Care, LLC, in St. Paul and with LasikPlus in Maple Grove, Edina, and Oakdale.

In the next issue.. • Benign prostate enlargement • Appendicitis • Cystic fibrosis MAY 2012 MINNESOTA HEALTH CARE NEWS

ONCOLOGY

Recognize the symptoms By Paul Haluska, MD, PhD

Ovarian cancer

It was in the middle of a busy holiday season when Joy Wetzel started feeling uncomfortable. The 57-year-old Golden Valley woman frequently felt bloated and could only eat a small amount before feeling a sense of reflux in her throat. And, in addition to being constipated, she felt short of breath when she sat back in a chair. Concerned about her breathing difficulties, Joy decided to visit her local urgent care clinic. There, she received a diagnosis of reflux with the recommendation to take antacids. While visiting family a few weeks later, Joy’s sister became alarmed at Joy’s discomfort and insisted she visit a doctor again. She immediately set up Joy with an appointment with her own physician, who examined her, performed blood tests, and called later that day to recommend Joy have a CT scan when she returned home.

The CT scan Joy had once she was back in Minnesota revealed somber news: A large mass suggested the presence of ovarian cancer.

Early detection For many women, the road to a diagnosis of ovarian cancer is similar to Joy’s experience: symptoms that are bothersome, but can be attributed to more common causes. Presumptive diagnoses such as gastric reflux, irritable bowel syndrome, and chronic constipation often delay appropriate diagnosis. Less than 20 percent of ovarian cancer patients are diagnosed at an early stage. And while survival rates for women with ovarian can-

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.

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MINNESOTA HEALTH CARE NEWS MAY 2012

Reduce your risk cer continue to improve, the Although ovarian cancer is not preventable, there are risk-reducers. disease continues to be the fifth• Having children can reduce a woman’s risk. leading cause of cancer-related • The use of birth control pills for five or more years has been proven to death among women and is the reduce risk by 50 percent. deadliest gynecologic cancer. • Some studies show that breastfeeding reduces risk. Once referred to as a “silent • Tubal ligation reduces risk. killer,” research now shows that • For high-risk women, surgical removal of the ovaries and fallopian tubes can dramatically reduce risk. This procedure is called salpingoovarian cancer does have a voice, oophorectomy (RRSO). if a woman and her physician listen closely and are aware of the symptoms. Unlike the Pap test for cervical cancer, right move although all too often, many women are not referred to there is no ovarian cancer-screening test for the general public. this type of specialist. That’s why it is crucial for women to be aware of the four If ovarian cancer is suspected, it is important that a gynecologic main symptoms of ovarian cancer: oncologist perform the surgery that determines the extent of the suspected cancer and removes it, a procedure called “debulking.” This • Bloating specialist is a surgeon trained in the complex debulking techniques • Pelvic or abdominal pain that remove as much of the cancer as possible, which makes subse• Difficulty eating or feeling full quickly while eating quent chemotherapy treatment more effective and improves survival • Increased urinary frequency or a feeling of urinary urgency odds. This specialist can also prescribe chemotherapy. Experts advise that a woman who experiences any of these four Multiple studies have shown that an ovarian cancer patient’s symptoms daily for more than a few weeks should take action and chance of survival is significantly improved when debulking is pervisit her health care provider. At this visit, a thorough examination is formed by a gynecologic oncologist. One analysis found that women suggested, including a rectal-pelvic examination, a transvaginal ultrawhose surgeries were performed by gynecologic oncologists were 45 sound, and a CA125 blood test, which measures the amount of a percent more likely to have their cancer completely assessed and to protein in the blood that can indicate ovarian cancer. have a 25 percent reduction in death from ovarian cancer than women whose debulking surgeries were done by general gynecologists The role of the gynecologic oncologist or other physicians who weren’t gynecologic oncologists. Once the CT scan suggested that Joy had ovarian cancer, her care was transferred to a gynecologic oncologist. This was exactly the

A diagnosis of

Cancer is overwhelming news.

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

Ovarian cancer to page 34

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INFECTIOUS DISEASE

Cytomegalovirus A disabling virus in babies

C How to prevent transmission By Mark R. Schleiss, MD

ytomegalovirus (CMV) infection in an otherwise relatively healthy adult generally isn’t serious. Prenatal infection of a developing fetus with CMV, however, is a major cause of long-term disability. In fact, infection acquired prior to birth, known as congenital CMV, is the leading nongenetic cause of hearing loss in children. CMV can also cause mental retardation, cerebral palsy, seizure disorders, and developmental delay. Indeed, congenital CMV causes more mental retardation in children than Down syndrome and fetal alcohol syndrome combined. Yet, despite the common nature of this infection and its serious consequences, there is little public awareness of CMV, particularly among women of childbearing age. Fortunately, there are steps adults can take to reduce the risk of transmitting this virus.

Adult symptoms Most people become infected with CMV during the course of their lifetime, although usually without symptoms. Rarely, a mild mononucleosis-like illness occurs, producing enlarged lymph nodes, low-grade fever, and a sore throat. Since these symptoms are mild and nonspecific, medical attention is seldom sought. Consequently, infection is rarely diagnosed. But once someone is infected with CMV, he or she remains infected for life. Infection occurs through close contact with infected bodily fluids, including urine, saliva, blood, and breast milk, and can also be sexually transmitted. Newborn symptoms If a pregnant woman becomes infected, she probably won’t realize it because she’ll likely be asymptomatic. However, the virus can infect

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

(651) 603-0720 • (800) 511-3696 30

MINNESOTA HEALTH CARE NEWS MAY 2012

the developing fetus. Injury to the developing fetus appears to be most severe, particularly to the brain, when the mother becomes infected during the first trimester of pregnancy. Infection acquired in the womb retards intrauterine growth, resulting in a small-for-gestational-age baby. It can also cause widespread organ damage to the fetus, including injury to the liver, bone marrow, lungs, kidneys, retina, brain, and the cochlea, which is part of the internal ear. Infected infants may be born with a rash, jaundice, enlargement of the liver and spleen, microcephaly (unusually small head), and hearing loss. Most infants with congenital CMV have no symptoms at birth, but are at risk for developmental problems later in childhood. Long-term disabilities due to congenital CMV can include seizures, cerebral palsy, mental retardation, and developmental delay. These disabilities are more common in infants whose symptoms (particularly microcephaly) are noted at birth. Other neurodevelopmental results, including behavior disorders and autism, may be caused by congenital CMV. Hearing loss may be the only manifestation of congenital CMV. Approximately 10 percent to 15 percent of infants with congenital CMV will be born with or develop hearing loss that can range from mild loss in one ear to profound deafness in both ears. Some children who eventually lose their hearing due to CMV have normal hearing at birth, so their hearing impairment is not detected until later in childhood. In fact, most babies with congenital CMV who become deaf from CMV have normal hearing at birth and pass their newborn hearing screen. That is why relying on newborn hearing screening alone fails to detect most congenital CMV-related hearing loss, and why it is so important to schedule regular checkups with your baby’s pediatrician. Make sure your baby's hearing and language milestones develop normally, especially if there is concern about possible CMV infection. Treatment Currently, there is no proven treatment for CMV-infected pregnant women that reduces the likelihood of infection and injury to the fetus. Since most maternal and fetal infections are asymptomatic and therefore not clinically recognized, administration of treatment, even if it were available, would be problematic. Treatment for infected newborns, however, is available. Newborns with CMV symptoms at birth appear to benefit from treatment with the antiviral drug ganciclovir, which has a modest impact on the likelihood and severity of hearing loss. However, this drug has potentially serious side effects and should be used only under close medical supervision by a health care provider experienced in managing them. Hearing loss that progresses despite antiviral therapy can be corrected by cochlear implantation. Infants with congenital CMV often require multidisciplinary evaluation and ongoing monitoring by audiologists, otolaryngologists, ophthalmologists, child neurologists, and developmental pediatricians. Radiological studies, including CT or MRI imaging of the brain, can help delineate the extent of infection and predict prognosis. Infected children do not require special isolation procedures, nor should they be excluded from group day care. Pregnant health care providers may care for CMV-infected children, provided they use

The majority of infected babies do not show symptoms at birth. appropriate precautions to prevent transmission. Diagnosis CMV infection is best diagnosed in the infected newborn by examining the baby’s blood, saliva, and urine for the presence of the virus. One dilemma that arises in diagnosing congenital CMV is that fact that the majority of infected babies do not show symptoms at birth, so there are no clinical clues that would trigger diagnostic studies. These asymptomatic infants are nonetheless at risk for the consequences of CMV infection, particularly hearing loss, and could benefit from early antiviral treatment, close monitoring, and early intervention for any hearing impairment that develops. Currently, newborns are not routinely screened for the presence of CMV. Cytomegalovirus to page 32

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Information for pregnant women: www.cdc.gov/cmv/risk/preg-women.html

Cytomegalovirus from page 31

A potential solution to this dilemma was addressed in a study of Minnesota babies, reported December 2009 in Pediatric Infectious Diseases Journal. This study compared the amount of CMV in blood samples from newborns that failed their newLearn born hearing test with blood from those that passed their hearing test. There was a tenfold increase in congenital CMV infection in the infants who failed their hearing test, compared with the newborns that had normal hearing. Since blood samples in this study were anonymous, it wasn’t possible to track the babies’ health to see if these findings predicted long-term outcomes of the newborns’ hearing. A 2011 legal decision makes it difficult to use newborn blood samples in future congenital CMV research in Minnesota, although there are active screening research programs in other states. Screening for the presence of CMV in pregnant women during pregnancy is routine in some European countries, although the American Congress of Obstetricians and Gynecologists does not currently recommend it. Pregnant women who are concerned they may have recently been exposed to CMV should contact their obstetrician. Prevent transmission CMV is not transmitted by casual contact or inhalation. Key to preventing transmission is to avoid exposure to infectious bodily fluids: Urine, saliva, vaginal secretions, and semen are major sources of this virus. For pregnant women, the two most common exposures to

Infection prevention guidelines: www.cdc.gov/cmv/prevention.html Parent support groups: www.cmvfoundation.org www.stopcmv.org www.averysjourney.com

CMV are through sexual contact and through contact with the urine of young children with CMV infection, particularly children who attend group day care. Transmission from young children to adults can occur through activities such as diaper changing, nose wiping, and feeding. Prevent transmission by thoroughly washing hands following diaper changes, feeding, nose wiping, and handling children’s toys. Care providers and parents should not share food, drinks, or utensils with young children. A child’s pacifier or toothbrush should not be placed into an adult caregiver’s mouth. Several potential CMV vaccines are currently being tested, although none are licensed yet. However, with increased public awareness, people can make behavioral changes that can reduce the risk of congenital CMV infection. Mark R. Schleiss, MD, is a professor of pediatrics at the University of Minnesota Medical School, the director of the school’s Division of Infectious Diseases and Immunology, the associate chair for research in the Department of Pediatrics, and an attending physician in infectious diseases at Amplatz Children’s Hospital, Minneapolis.

Minnesota

Health Care Consumer April survey results... Association

1. I, or a member of my family, has had rehabilitation services and or physical therapy prescribed by a physician.

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 April survey.

3. What percentage of these services were covered by your insurance? 34.0%

Percentage of total responses

40 17.0%

20 0

Yes

0.0% Partially covered

Not covered

Does not apply

MINNESOTA HEALTH CARE NEWS MAY 2012

6.4% 0.0% Strongly agree

Agree

Disagree

Strongly disagree

42.6%

23.4%

21.3%

17.0%

25.5%

5. I was satisfied with the quality of care where these services were provided.

6.4% Strongly agree

Percentage of total responses

17.0%

Mostly covered

44.7%

19.1%

Fully covered

51.1%

83.0%

29.8%

30 Percentage of total responses

100

4. I felt I needed more treatment/visits than my insurance was willing to cover.

Percentage of total responses

2. I felt the outcome of these services was positive.

40 31.9% 30 20

17.0% 8.5%

4.3% Agree

Disagree

Strongly disagree

Does not apply

0.0% Strongly agree

Agree

Disagree

Strongly disagree

Does not apply

Minnesota

Health Care Consumer Association

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

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

www.mnhcca.org

Join now.

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

Ovarian cancer from page 29

Survival rates for women with ovarian cancer continue to improve.

Fortunately for Minnesota women, there are many gynecologic oncologists here, currently located primarily in the Rochester and Twin Cities metro areas. A woman with suspected ovarian cancer who needs surgery will most likely have surgery in one of these two locations, but can receive followup care in her community or at multiple sites. The Women’s Cancer Network website has a “Find a Doctor” feature at www.wcn.org, where visitors can search for a gynecologic oncologist by ZIP code.

Risk factors Because hereditary breast and ovarian cancer account for at least 10 percent of ovarian cancer cases, women with a history of breast or ovarian cancer in their families should talk with their provider or a licensed genetic counselor to determine if they should be tested for these mutations and what steps they may be able to take to reduce their risk of ovarian cancer. Lynch syndrome, associated with an increased risk for colon, uterine, and ovarian cancer, is another hereditary condition that may be detected via genetic counseling. Women who know they have Lynch syndrome or the gene mutations known to cause breast and ovarian cancer, called BRAC1 and BRAC2, may also want to use genetic counseling to assess ways to reduce their cancer risk.

Resources An ovarian cancer diagnosis can be a frightening time for women and their families. Thankfully, there are resources available in Minnesota to support them.

The Minnesota Ovarian Cancer Alliance (MOCA) is a key resource for ovarian cancer patients. A statewide nonprofit comprising a network of more than 800 survivors and 45,000 supporters and volunteers, MOCA offers support groups, educational resources, and other services for women with ovarian cancer and their families. MOCA also provides ovarian cancer research funding to Minnesota researchers and medical education programs to medical students, nurse practitioners, and other health providers. The MOCA website, www.mnovarian.org, is another resource.

Hopeful future There is great reason for women to have hope after receiving a diagnosis of ovarian cancer. Medical advances, increased awareness of symptoms, and the increasing referral of women with symptoms to gynecologic oncologists mean that today, more women than ever are living long, full lives after diagnosis. Joy, who celebrates 11 years of survivorship this year, has made it her mission to inform women and the medical community about ovarian cancer symptoms by volunteering with MOCA. Like so many others, Joy hopes that increased awareness of ovarian cancer will improve the lives of other Minnesota women. Paul Haluska, MD, PhD, is an associate professor of oncology at the Mayo Clinic and a member of MOCA’s medical advisory board. Dr. Haluska treats ovarian cancer patients, conducts trials of new treatments for ovarian cancer, and conducts research to develop and individualize treatment for patients with ovarian cancer.

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

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

MINNESOTA HEALTH CARE NEWS MAY 2012

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

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

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

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

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

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

FOR TYPE 2 DIABETES

Victoza® helped me take my blood sugar down…

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

Model is used for illustrative purposes only.

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

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

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

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

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

Non-insulin • Once-daily