Minnesota Health care News October 2013 by Minnesota Physician Publishing

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October 2013 â&#x20AC;˘ Volume 11 Number 10

Hypoglycemia David Weinstein, MD

Thyroid disease John Chow, MD

Concussion in youth Armantina Malvarez Espinosa, MD

CO NTENTS

4 7 8

OCTOBER 2013 • VOLUME 11 NUMBER 10

18 20

NEWS

PEOPLE

PERSPECTIVE Stella WhitneyWest, CEO NorthPoint Health & Wellness Center

10 12

10 QUESTIONS Rebeca Barroso, CNM, DNP HealthEast Care

ENDOCRINOLOGY Thyroid disease

By John T. Chow, MD, FACE

TAKE CARE

POLICY

22 24 26 30

CALENDAR

MINNESOTA HEALTH CARE ROUNDTABLE

SPECIAL FOCUS: DIABETES Feet and diabetes By Dirk Halverson, DPM, FACFAS

Hypoglycemia

By David A. Weinstein, MD, MMSc

Medication management

By Jessica M. Swearingen, PharmD, BCPS, and Kandace M. Schuft, PharmD

Somalis and type 1 diabetes

By Muna Sunni, MBBCh, and Antoinette Moran, MD

NEUROLOGY

Concussion in youth

By Armantina Malvarez Espinosa, MD, and Brionn K. Tonkin, MD

10 Ways to avoid colds By Daron Gersch, MD

Growing deeper roots By Rep. Kim Norton

FORTIETH

SESSION

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

Background and focus: For the majority, end-of-life is the most medically managed part of life. With it come complex issues that involve economics, ethics, politics, medical science, and more. Advances in technology are extending life expectancies and require a redefinition of the term “end-of-life.” It now entails a longer time frame than one’s final weeks or hours, and provokes debate as to when life is really over. Mechanisms exist to facilitate personal direction around this topic, but there is a need for improved coordination among the entities that provide end-of-life support.

Objectives: We will discuss the significant infrastructure that supports end-of-life care. We will examine the roles of long-term care/assisted living, palliative care, gerontology, and hospice. We will review the elements that go into creating advanced directives, including societal issues that make having them necessary, and the difficulties encountered in bringing them to their current state. We will present a potential road map to optimal utilization of end-of-life support today and how it may best be improved in the future. Panelists include: ◆ Ed Ratner, MD, University of Minnesota Center for Bioethics ◆ Suzanne M. Scheller, Esq., Scheller Legal Solutions, LLC

www.mppub.com PUBLISHER Mike Starnes | mstarnes@mppub.com SENIOR EDITOR Donna Ahrens | dahrens@mppub.com

◆ Cheryl Stephens, PhD, MBA, President, CEO, Community Health Information Collaborative ◆ Tomás Valdivia, MD, MS, CEO, Luminat ◆ Maggie O'Connor, M.D., Facilitator, Sacred Art of Living & Dying

Sponsors: Community Health Information Collaborative Luminat • Scheller Legal Solutions

ASSOCIATE EDITOR Janet Cass | jcass@mppub.com ASSISTANT EDITOR Jennifer Holingsworth-Barry | jhb@mppub.com ART DIRECTOR Alice Savitski | asavitski@mppub.com OFFICE ADMINISTRATOR Amanda Marlow | amarlow@mppub.com ACCOUNT EXECUTIVE Iain Kane | ikane@mppub.com Minnesota Heath 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 are opinions expressed by authors of published articles are solely those of the authors and do publications. 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 the publication may be reprinted or reproduced within written permission of the publisher. Annual subscriptions (12 copies) are $36.00/ Individual copies are $4.00.

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

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Please mail, call in or fax your registration by 10/17/2013

2013 OCTOBER MINNESOTA HEALTH CARE NEWS

NEWS

Immunization law changes The Office of Administrative Hearings has determined that the Minnesota Department of Health (MDH) has the authority to adopt revisions to the state’s school and child care immunization law, saying that the proposed rules are needed and reasonable. The changes, which go into effect September 2014, will affect children that are in school (K-12), in child care, or enrolled in early childhood programs. New requirements for children enrolling in child care and school-based early childhood programs include hepatitis A and B vaccinations, and changing the age for the first varicella (chickenpox) immunization from 18 months to 15 months. Changes for school-age children require secondary students to get a meningococcal vaccination

beginning in seventh grade, and replacement of the current seventh-grade tetanusdiphtheria vaccine with one that also includes pertussis (DTaP). Additionally, the timing of the polio and DTaP vaccines will change to meet current medically accepted standards. In late June, Laurel Ries, MD, chair of the Minnesota Medical Association’s Public Health Committee, and Robert Jacobson, MD, a Mayo Clinic physician and president of the Minnesota Chapter of the American Academy of Pediatrics, spoke in favor of the proposed changes before an administrative law judge. MDH officials say the updates will bring Minnesota up to date with current recommendations from the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices.

MINNESOTA HEALTH CARE NEWS OCTOBER 2013

Lyme disease underreported According to the Centers for Disease Control and Prevention, Lyme disease affects about 300,000 Americans annually, 10 times the number of cases that are documented. In Minnesota, the number of reported Lyme disease cases is between 1,000 and 1,300 each year, with rates growing steadily since the 1980s. Epidemiologist Dave Neitzel, MS, of the Minnesota Department of Health, estimates that the state’s total number of cases is three to four times higher than the number that has been documented. “It really is a wake-up call for us,” says Jeff Bender, DVM, MS, a professor at the University of Minnesota School of Veterinary Medicine and the School of Public Health, who studies how Lyme disease is

passed from infected deer ticks to humans. “We need to be thinking how to be more aware of it, diagnose it, encourage prevention.” According to officials, 13 states, including Minnesota, account for 96 percent of Lyme disease cases.

Patient clinic experience surveyed Results have been released from more than 230,000 patients surveyed regarding their health care experience at 651 primary and specialty clinics across Minnesota in 2012. A 2008 state health reform law requires clinics to report their performance on a standard set of quality measures. The nonprofit Minnesota Community Measurement partnered with the Minnesota Department

of Health to collect and report data. The next report is expected in 2015. Patients rated clinics based on access to care and on interaction and communication with physicians and office staff. Twenty-six clinics scored above statistical averages in all categories. Ninety percent of patient respondents gave high marks for physician communication skills. This measure included questions concerning knowledge of patients’ medical history, ability to explain things in an understandable manner, listening skills, and whether physicians spent enough time with the patient. Ninety-two percent reported that clinic office staff were respectful and helpful. Many clinics scored lower on access to care. Patients were asked how often they were able to secure appointments when needed and how often they saw their provider within 15 minutes of a scheduled appointment. Only 60 percent of patients said they experienced top-level access to care. “Having these data be there, transparent and available, will help (patient choice) of clinics,” says Minnesota Commissioner of Health, Ed Ehlinger, MD. “For providers, this information creates a statewide benchmark that they can use to learn about their strengths and weaknesses, to help them improve the quality of care and the patient experience.” Eventually, this information will be integrated into the MNsure online health insurance exchange system, according to officials. To see scores, visit www. mnhealthscores.com. The next report is expected in 2015.

Childhood obesity drops

According to new research published by the U.S. Centers for Disease Control and Prevention (CDC), 18 states, including Minnesota, have experienced a decline in obesity rates of low-income preschoolers. The new data came from the CDC’s Pediatric Nutrition Surveillance System. Researchers analyzed height and weight measurements from almost 12 million low-income children, age two to four years, between 2008 and 2011. In Minnesota, the rate fell from 13.4 percent in 2008 to 12.6 percent in 2011. Overall, obesity rates declined at least slightly in 18 states. Nineteen states did not show a significant change, and three states showed an increase. Ten states were not included in the report due to changes in how they track height and weight. “Now, for the first time, we’re seeing a significant decrease in childhood obesity” nationally, says Thomas Frieden, CDC director.

Law proposed to prevent fatal overdoses State Sen. Chris Eaton (DFLBrooklyn Center) will propose a bill in the next legislative session that would offer legal immunity to people who seek emergency services for someone suffering an overdose and would increase access to naloxone, a drug that can revive someone who has overdosed on an opiate, say officials. Fourteen states and the District of Columbia already have similar laws in place, and 16 states have passed laws allowing wider distribution of naloxone, according to the Network for Public Health Law.

It’s always

PERSONAL to us.

Personalized Assisted Living goes a long way toward optimizing the daily quality of life for our residents. If you have a loved one that needs a friendly environment with a personalized care plan designed just for them, call or visit a Brookdale Community near you. Because caring for our residents is what we do, and it’s always personal to us.

To learn more, visit us online at brookdale.com

Alzheimer’s Association is a registered service mark of Alzheimer’s Disease and Related Disorders Association, Inc. ALL THE PLACES LIFE CAN GO is a trademark of Brookdale Senior Living Inc., Nashville, TN, USA. ®Reg. U.S. Patent and TM Office MNM3-RES20-0813 LMM

How will health care reform change your life? A little. A lot. Or not at all. We can help you understand how it affects you and your family. Visit medica.com/reform. Or call 1-855-HCR-8588. And do your thing.

Gavin Bart, MD, director Concussion in youth to page 32

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2013 OCTOBER MINNESOTA HEALTH CARE NEWS

Concussion in youth from page 31

of the Division of Addiction Medicine at Hennepin County Medical Center, says consideration of the law comes at a critical time, as Minnesota has seen a dramatic increase in overdoses in the last seven years.

Guardians can end life support A new ruling by the Minnesota Court of Appeals is a game changer for an important end-of-life issue. Guardians now have the authority to disconnect a ward’s life-support systems without approval by the state. The decision will have implications for many of the more than 12,000 Minnesotans currently under guardianship. “Although courts are experienced in making reasoned

and impartial decisions, doctors and medical ethics committees have the most appropriate knowledge and expertise to evaluate the potential for a ward’s long-term recovery and quality of life and advising a guardian on end-of-life decision-making,” Judge Natalie Hudson wrote in her decision. “Imposing a requirement for additional court involvement in this process would be inconsistent with the Supreme Court’s recognition of a private, medically based model of decision-making.” Previously, the district court had ruled that guardians had the power to consent to medical treatment on behalf of those under their care, but not the authority to terminate life support. That ruling came in 2012 in the case of Jeffers Tschumy, a 57-yearold man who suffered from diabetes, effects from a stroke, and partial paralysis from a spinal infection.

MINNESOTA HEALTH CARE NEWS OCTOBER 2013

Tschumy had been living in a group home, under the care of a state appointed guardian, since 2008. When he choked and suffered severe brain damage in 2012, doctors said he had little hope for recovery. With no known family, and no health care directive, the hospital filed a motion asking a judge allow Tschumy to be removed from life support by clarifying that his guardian had the power to make the decision, or by issuing the order from the court. Life-support termination was authorized, but the guardian’s request for power as the decision-maker was denied.

Pediatric mental health center planned The Washburn Center for Children is constructing a new, $24.5 million facility west of

downtown Minneapolis. The state-of-the-art center will replace the center’s current location, and will double its size in response to a growing need in the community for children’s mental health services. More space and natural light will create an environment more conducive to healing, officials say. An additional $2.5 million in donations is needed to fund the project, designed as a safe, healing place for children suffering from mental health conditions such as anxiety, depression, and abuse, says executive director Steve Lepinksi. Construction on the new building is expected to be completed by fall of next year.

PEOPLE Christine Larsen, MD, a board-certified ophthalmologist specializing in glaucoma treatment, has joined Twin Cities-based Minnesota Eye Consultants. She completed medical school and residency at the University of Nebraska Medical Center, Omaha, and a fellowship in glaucoma at the University of Wisconsin, Madison.

Brad Linden, MD

Bradley Linden, MD, has joined Pediatric Surgical Associates, Minneapolis. Board-certified in pediatric and general surgery, he earned his medical degree and completed his residency at the University of Minnesota and completed his fellowship at Boston Children’s Hospital. Linden previously served as director of minimally invasive pediatric surgery at Harvard Medical School and founded and directed the bariatric surgery program at Boston Children’s Hospital.

James Peters, MD, board-certified in sports medicine and family medicine, has joined Sports & Orthopaedic Specialists, part of Allina Health. Peters earned a medical degree from Rush Medical College, Chicago, and completed residencies at the University of Minnesota. Most recently, he cared for patients at Fairview Sports and Orthopedic Care, which he founded. Aby Z. Philip, MD, board-certified in internal medicine, has joined the Cancer Center at Essentia Health-St. Joseph’s Medical Center, Brainerd, as an oncologist. Philip earned his medical degree from Government Medical College in Thiruvananthapuram, India. He served a residency in internal medicine and a fellowship in hematology and oncology at the University of Connecticut Health Care Center in Farmington, Conn.

Aby Z. Philip, MD

Nico Pronk, PhD, HealthPartners’ vice president and chief science officer, has been selected by the nonprofit, Edina-based Health Enhancement Research Organization (HERO) to receive its Mark Dundon Research Award. The peer-nominated award recognizes Pronk’s overall body of work to promote research that advances the science of employee health management. In his role at HealthPartners, Pronk addresses the gap between scientific evidence of effectiveness and practical application of health solutions, and how health resources may be most effectively applied to various settings, such as the workplace, the clinic, and the community. Steven Senica, MD, board-certified in obstetrics and gynecology, has joined the Essentia Health Baxter Specialty Clinic as an obstetrician-gynecologist and also will see patients at Good Beginnings OB Clinic at Essentia Health St. Joseph’s Medical Center, Brainerd. Senica earned a medical degree from Loyola University Stritch School of Medicine and completSteven Senica, MD ed a residency in obstetrics and gynecology at Loyola University Medical Center, both in Maywood, Ill.

Health care reform answers, plain and simple. Find out how health care reform will affect you at medica.com/reform. Or call 1-855-HCR-8588. And do your thing.

Daniel Weisdorf, MD, board-certified in hematology and medical oncology, has been appointed director of the Division of Hematology, Oncology and Transplantation in the University of Minnesota Department of Medicine. Weisdorf received his medical degree from the University of Chicago Medical School, completed an internal medicine residency at Michael Reese Hospital, Chicago, and completed a fellowship in hematology and medical oncology at the University of Minnesota. 2013 OCTOBER MINNESOTA HEALTH CARE NEWS

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PERSPECTIVE

Northside Fresh Transforming the food environment in North Minneapolis

N Stella Whitney-West NorthPoint Health & Wellness Center Stella WhitneyWest is CEO of NorthPoint Health & Wellness Center (www. northpointhealth. org). Northside Fresh grew from a 2009 contract between NorthPoint and Blue Cross Blue Shield of Minnesota. NorthPoint focuses on four primary areas: 1. Improve community health 2. Increase use of primary care, instead of emergency services, as the point of entry into the health care system 3. Advance social determinants of health as an evidenced-based approach to improve the ability of the people we serve to attain full health and wellness potential 4. Achieve health equity for those we serve by addressing barriers to access and utilization of quality, affordable health care.

orthside Fresh is a coalition of more than 30 partners representing more than 100 residents and other community members in North Minneapolis. Residents of this neighborhood experience some of the highest racial/ethnic health disparities in the state, including higher rates of diabetes, heart disease, and obesity than the general population.

measured through reduced rates of obesity, diabetes, or heart disease.

In 2012, NorthPoint Health & Wellness Center created a new strategic plan to affect all of these determinants of health. One strategy builds on continued work toward transforming the food environment through the efforts of Northside Fresh. We aim to transform the food environment through collective impact.

together systematically is an example of what the Stanford Social Science Review terms “collective impact,” and has been widely promoted as a promising practice for improving community health and reducing health disparities. There is tangible evidence of progress in North Minneapolis, including more community and residential gardens, more—and affordable—produce at corner stores, and three new farmers’ markets that accept EBT payment.

Rather, we are working to change the conditions from which these health disparities arise. Signs that we are moving in the right direction include self-reported stronger and new relationships among community organizations working to improve access to healthy foods; consistent Although many of these health community messaging and disparities are preventable We are working to change communication across partner through diet and exercise, it is organizations about local difficult to achieve those behav- the conditions from which opportunities and the benefits ioral changes through clinical of healthy eating; and the health disparities arise. interventions alone. Research extent to which the coalition literature is clear: Multiple factors interact to has worked and is working toward a shared impact the health of individuals and populations, vision, shared measures of success, and new including policy, social factors, health services, opportunities for economic development through individual behavior, and biology/genetics healthy food entrepreneurship. (HealthyPeople.gov, 2012). This model of multisector organizations working

How it works The Northside Fresh partnership completed a comprehensive food assessment under the direction of a community advisory committee. The study included a survey of more than 300 community members, several key-informant interviews, and five culture-specific focus groups. Using these data, Northside Fresh created and implemented a strategic plan for transforming the food environment. Currently, the Northside Fresh coalition is organized into four community action teams focused on changing policies, providing community programming and youth development, systematic communications on the benefits of healthy eating, creating physical changes to the community through urban agriculture, economic development and continuous coalition improvement. The coalition recently formed an operations team to provide administrative leadership. Funds from Blue Cross and Blue Shield of Minnesota are used to support implementation of work and evaluation plans created by each of the teams, composed primarily of North Minneapolis residents. Accomplishments Working upstream to affect policies, systems, and the environment that affect health outcomes recognizes a broad health context from which evidence of success is derived, often through nonclinical indicators. Within Northside Fresh, we do not expect to see immediate returns as

MINNESOTA HEALTH CARE NEWS OCTOBER 2013

Sustainability Sustainability of this work has been a priority since day one. First, we have built an infrastructure for continuing the work by creating action and operations teams, with work and evaluation plans along with budgets. Second, throughout the past five years Northside Fresh has received organizational, communications, and collaboration capacity-building technical assistance through Blue Cross. Third, partner organizations have institutionalized Northside Fresh activities into existing positions so that the work can carry on as organizational norms. Finally, the coalition has created a three-year fund development plan, which it is implementing by submitting proposals to private and public funding agencies. Achievements of Northside Fresh continue to unfold. Effort to influence systems, policies, and environment that affect clinical outcomes in diabetes, obesity, and heart disease is a long-term commitment requiring a substantial paradigm shift. Northside Fresh leaders and participants recognize the substantial value that multiple community partners bring together to address complex community problems that affect health outcomes. We seek to co-create a better future by entering into and caring for purposeful long-term relationships that will contribute to the health and well-being of members of the community.

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Bell Bladder Control Tea for Women #4b Satisfaction guaranteed (see box) for incontinence and control.* This inexpensive, pleasant tasting herbal combination tea is safe and effective. Put an end to embarrasments and discomfort. Support the bladder and urinary tract with these all natural ingredients. Tastes great hot or cold !* <I wish I had found this tea sooner! A family member told me that she used the Bell Tea for Women #4b with positive results. What a wonderful product. It also worked for me. Australia P. Rodriguez, Rego Park, NY.* < Plan to keep taking it as long as I live! One of the clerks in my local health food store recommended the Bladder Control Tea #4b. I was very skeptical. What a surprise it worked! 5 days after starting the tea I noticed a major improvement and it is continually getting better each day. I plan to keep taking it for as long as I live. Thank you! Frances Baird, 87, Venice, FL.*< Exercises didn’t help! After drinking the Bell Tea for Women #4b my life is far less stressful especially when I am at work. Thanks for such an amazing product! Marilyn Sallows, 53, Fort McMurray, AB*<Tea represents truth in advertising! Being a skeptic, I ordered this Bladder Control Tea for Women as a more or less last resort, after trying everything else in the last 5 years. It worked better than I hoped for. Thank you for this great product, and above all, for truth in advertising. Marina Rosa, 57, Las Vegas, NV *

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100% Truthful testimonials with full name and towns. Real people you can call, if you want more reassurance. More testimonials on the Bell website. No money is paid for testimonials. * These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure or prevent any disease. <AVAILABLE IN MINNEAPOLIS: Nutrition City 2108 Lyndale Ave. S; Pharmalife of MN Pharmacy 1200 Nicollet Mall; Your Natural Choice 11670 Wayzata Blvd; Present Moment Herbs & Books 3546 Grand Ave. S; Natural Healing Store 3728 Nicollet Ave; <ST. PAUL: Great Health Nutrition 1360 University Ave; Blomberg Pharmacy 1583 N. Hamline Ave; Setzer Pharmacy 1685 Rice St; <BLOOMINGTON: Nutrition Plus 609 W. 98th St; Bloomington Drug 509 W. 98th St; <COKATO: Dan & Becky's Market 5636 Oliver Ave. SW; <COLUMBIA HEIGHTS: Great Health Nutrition 5192 Central Ave NE; <COON RAPIDS: Nutrition City 113 85th Ave. N; <LAKEVILLE: Erickson Drug 20751 Holyoke Ave. W; <MANKATO: HY-Vee Stores 2010 Adams St; <MAPLEWOOD: Healthy Food & Healthy Ways 3001 White Bear Ave. N; Nutrition City 3035 White Bear Ave. N; <MINNETONKA: Nutrition Plus 13181 Ridgedale Dr; <OWTONNA Hy Vee 1620 S. Cedar Ave; <PARK RAPIDS: 3rd Street Market 120 West 3rd St; <PEQUOT LAKES: Seeds of Sommer 4464 Main St; <ST. CLOUD: Inez Naturway Foods 3715 - 3rd St. N; <WEST ST. PAUL: Great Health Nutrition1668 S. Robert St; <WAYZATA: Healthy Foods & Healthy Ways 1133 Wayzata Blvd.

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10 QUESTIONS

Midwifery Rebeca Barroso, CNM, DNP

Dr. Barroso practices as a clinical nurse-midwife at HealthEast Care, St. Paul; teaches nurse-midwifery at Frontier Nursing University in Hyden, Kentucky, the oldest such U.S. program in continuous existence; and is immediate past co-chair of the American College of Nurse-Midwives Minnesota Affiliate. She has attended approximately 3,000 births over the course of nearly 40 years.

How long has midwifery existed? The earliest available pictorial accounts of human birth include a female attendant, the midwife, caring for a birthing woman. Ancient texts include midwives in significant societal roles in and outside the birth room. What training is required to be a nurse-midwife? The individual must be a registered nurse (RN) and have earned at least a masterâ&#x20AC;&#x2122;s degree from an institution of higher learning accredited by the Accreditation Commission for Midwifery Education, which, in turn, is recognized by the U.S. Department of Education. Formal education must meet the Core Competencies for Basic Midwifery Practice as defined by the American College of Nurse-Midwives. The student must acquire advanced classroom and clinical skills in both nursing and midwifery. A clinical practicum under the guidance of licensed certified nurse-midwives (CNMs) is required. After completing the specified program of studies, the graduate must pass a national board exam administered by the American Midwifery Certification Board, the credentialing body for U.S. nurse-midwives. Upon passing the exam, the candidate is credentialed as a CNM and is eligible to apply for licensure to her/his stateâ&#x20AC;&#x2122;s regulatory agency. In Minnesota, nurse-midwives are regulated as advanced practice nurses through the Minnesota Board of Nursing. The CNM credential is recognized, and the practice is regulated, in all 50 states and U.S. territories. Please describe the differences between a nurse-midwife-attended birth and a physician-managed one. At the present time, nurse-midwives recognize two models of birth attendance. The first is the

MINNESOTA HEALTH CARE NEWS OCTOBER 2013

technological model that is provider-defined and seeks to optimize outcomes through the use of appropriate interventions. The second is the midwifery model that is woman-centric and seeks to support the normal physiologic body processes. In the midwifery model, interventions occur only when the normal processes are not optimally functioning. There are physicians who support the midwifery model and nurse-midwives who are advocates on behalf of the technological model. For example, eating and drinking are determined by hospital policies, not by the physicians or the nurse-midwives. Some physicians and midwives who are advocates of eating and drinking work in hospital environments where this is not allowed. Likewise, some physicians who are aghast at the thought of women drinking and eating during labor work at institutions/hospitals where eating and drinking are not only allowed but also promoted by the nurses. What are some reasons that a woman chooses a nurse-midwife? The relationship between the woman and her nurse-midwife is generally less formal than the relationship between the woman and her physician. The nurse-midwifeâ&#x20AC;&#x2122;s focus is that of helping the woman help herself. Nurse-midwives see the woman as the primary health care provider for her family. Besides providing care related to pregnancy, labor, birth, and the postpartum period, nurse-midwives provide well-woman care from adolescence through menopause and beyond. Nurse-midwives attend to well-woman annual exams, reproductive health issues, and minor primary health and gynecological concerns. Although the ruling out of pathology is not overlooked, time is spent on education and counseling in order to promote optimal health of the woman, her baby, and her family.

What are some issues that have arisen as The nurse-midwife’s focus collaborate with other licensed health care providers and institutions, developing and maintaining collea result of childbirth having become such a gial interprofessional relationships. In nurse-midis that of helping the medically managed process? wife formal education and clinical training, the The seduction of technology has led to current woman help herself. mechanism of consultation, co-management, and Cesarean rates, which are excessive according transfer of care to the physician as warranted by the to established national and international safety woman’s or the fetus’ condition is embedded as a parameters. Unnecessary Cesareans lead to increased crucial component of providing safe care. Both nurse-midwives and physimaternal and infant morbidity. On the other hand, the use of routine episiotomy (a surgical cut to enlarge the vaginal opening at the time of birth) cians work toward the same end, sometimes collaboratively and sometimes continues to decrease. Moreover, the rate of electively induced labor has now independently of each other. been reduced by nationwide efforts to decrease infant morbidity by avoiding elective inductions before term gestation. What changes have you observed in your specialty during the time you’ve been delivering care? Changes have been paradoxical. There has been a sustained move toward How do global perceptions toward childbirth vary? the support of physiologic birth along with increased use of constantly Whereas the physician is the predominant birth attendant in the United evolving technologies. Waterbirth facilities are now offered in many hospital States, there are many countries in Western Europe where the midwife is settings. Licensed freestanding birth centers are increasing, as is the number the expected attendant unless there are problems that warrant physician of women wanting to access them. Both waterbirth and freestanding birth expertise. centers have been demonstrated to be safe. As the number of physician colleagues who accept these trends supportive of physiologic birth grows, Please share some history of nurse-midwifery in Minnesota. the divide between nurse-midwives and physicians is becoming smaller. Nurse-midwives have practiced in Minnesota since 1971. There are presently over 270 nurse-midwives licensed in the state in more than 100 separate practices. Through established legislation, Minnesota nurse-midwives practice in all birth settings. We have prescription-writing privileges; qualify for insurance company reimbursement; and carry our own malpractice insurance. Nurse-midwives now have practice privileges at most Twin Cities area hospitals that offer maternity care. Minnesota nurse-midwives are not required to have written collaborative agreements with their consulting physicians. Nurse-midwife-attended births in Minnesota have steadily increased over the last 40 years. Eleven percent of Minnesota births are now attended by nurse-midwives. How do nurse-midwives and physicians collaborate? Nurse-midwives work within the larger health care system and, as such,

What does the future hold for nurse-midwifery? The number of nurse-midwives needs to grow. There is a projected shortage of primary care physicians and surgeons looming on the not-too-distant horizon. Already, almost half of U.S. counties lack an obstetrician. Nurse-midwife care has been repeatedly shown to be safe, cost-effective, and satisfying to those served. The Western European model (one that has far better outcomes than those of the United States), where there are many more midwives and far fewer obstetricians, may become a necessity. The American Congress of Obstetricians and Gynecologists has formally recognized the need for obstetricians to partner with nurse-midwives as we move toward closer collaboration.

2013 OCTOBER MINNESOTA HEALTH CARE NEWS

E N D O C R I N O LO GY

Thyroid disease Seek prompt diagnosis By John T. Chow, MD, FACE

isorders of thyroid function produce a wide spectrum of symptoms and can be difficult to diagnose. For instance, symptoms such as dry skin and cold intolerance may be overlooked as the winter months approach. Palpitations and shakiness may be interpreted as an anxiety disorder. For some people, however, these are the first indicators of thyroid disease. The thyroid The thyroid, a butterfly-shaped gland in the lower neck, secretes hormones that primarily regulate the body’s ability to control energy utilization and storage. Hypothyroidism is a term that reflects low levels of thyroid hormone, while hyperthyroidism describes elevated hormone levels.

Tick-Borne Disease Specialty Clinic Tick-borne disease can result in disabling consequences that may resist treatment and even diagnosis. We have been successful in the rehabilitation of many patients with unique cases of chronic tick-borne illness. No medical referral is required.

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

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

612-287-8781 12

MINNESOTA HEALTH CARE NEWS OCTOBER 2013

Causes Most thyroid disorders occur due to an autoimmune condition, which means that the body is attacking itself. When people have such a condition, there is frequently a predisposition in the family to develop autoimmune disease. In the case of hypothyroidism, this autoimmune process is called Hashimoto’s disease. In hyperthyroidism, this is called Graves’ disease. Hashimoto’s disease causes hypothyroidism because the body’s ongoing attack against its own thyroid eventually causes enough damage to the thyroid to impair production of its main hormones, thyroxine (T4) and triiodothyronine (T3). Graves’ disease causes hyperthyroidism because the immune system inadvertently stimulates the thyroid to produce too much T4 and T3. Rarely, people are born with a nonfunctional thyroid or no thyroid at all (congenital hypothyroidism). Hypothyroidism can also occur due to the effects of radiation, iodine (both low and high levels), as well as some medications, such as amiodarone and lithium. Hyperthyroidism also can occur independent of autoimmune disease, as nodules (growths) in the thyroid can sometimes produce too much thyroid hormone. Inflammation of the thyroid, which can occur after infection or after pregnancy, can cause temporary hyperthyroidism. Exposure to iodine, such as with supplements containing iodine or intravenous contrast for radiologic studies, can trigger hyperthyroidism. Furthermore, overtreatment of hypothyroidism with thyroid hormone can cause hyperthyroidism. Symptoms Hypothyroidism The symptom that most commonly triggers an evaluation is fatigue. Weight gain, cold intolerance, constipation, dry skin, coarse/thin hair, and brittle nails are also common in this condition. Other symptoms include depression, fluid retention, muscle weakness, slowed heart rate, and memory problems. Women may have heavy or irregular periods. There is evidence that Hashimoto’s disease/ hypothyroidism causes infertility and miscarriage when it is

Most thyroid disorders occur due to an autoimmune condition.

The degree of symptoms can vary markedly from person to person. For instance, some individuals with mild hypothyroidism as shown by blood tests can have quite severe symptoms, whereas others with extraordinarily abnormal thyroid blood test results can be seemingly without any symptoms.

Hyperthyroidism As with hypothyroidism, hyperthyroidism can cause a wide variety of symptoms. These symptoms are caused by a speeding-up of the metabolism: The heart beats faster (called tachycardia), the gut moves faster (causing more frequent bowel movements), and weight can rapidly decline despite a normal or increased appetite. Other typical symptoms include fatigue, muscle weakness, heat intolerance/ sweating, tremors, anxiety, shortness of breath, insomnia, reduced menstrual flow, and increased urinary frequency. Untreated hyperthyroidism can lead to heart arrhythmias, as well as loss of bone density, which itself can lead to osteoporosis. People with Graves’ disease can have inflammation of the muscles around the eyes. This can cause the classic Graves’ symptom of bulging eyes. People with hyperthyroidism also may have a gritty feeling in their eyes, which may be particularly pronounced in cigarette smokers. Diagnosis If you have typical symptoms of thyroid dysfunction, ask your doctor for thyroid testing. Given the wide range of symptoms of hypothyroidism and hyperthyroidism, detection of these disorders could be delayed for years if symptoms were the sole indication for testing. Therefore, thyroid screening is typically performed beginning at age 35 and every five years thereafter, which is the schedule for routine health screenings that is recommended by the U.S. Preventive Services Task Force. People with a family history of autoimmune thyroid disease should request more frequent screening. Over- and under-functioning thyroid glands are diagnosed with blood tests that identify the relationship of thyroid hormones T4 and T3 to the thyroid-stimulating hormone TSH, which is made by the pituitary gland in the brain. The relationship of the pituitary gland and the thyroid is similar to that of a thermostat and a furnace. Much as a furnace is turned on or off depending on the home’s temperature, thyroid hormone is produced to keep up with the body’s metabolic demands. The pituitary gland secretes TSH at steady levels to stimulate the thyroid to produce a consistent amount of thyroid hormone. If the thyroid is not efficient at making T4 and T3 hormones, TSH levels increase to push the thyroid to increase production. If there is too much T4 and T3 made, the pituitary shuts off TSH in an attempt to restore a balanced hormone state. Treatment Hypothyroidism Most patients with hypothyroidism are initially diagnosed by a primary care provider. Standard treatment is to replace thyroid hormone with levothyroxine, a synthetic form of T4. Primary care

providers typically refer a thyroid patient to an endocrinologist if the patient’s blood levels of thyroid hormone are unstable despite medication adjustments. Women who are planning for pregnancy or who are pregnant may be referred, especially if they have a family history of Hashimoto’s disease or hypothyroidism, given the association of that condition with infertility and miscarriage. Hyperthyroidism Although many patients with hypothyroidism can be managed by primary care providers, hyperthyroidism is more typically managed by endocrinologists. This is due to the wider spectrum of diseases that cause hyperthyroidism, as well as the more complicated treatment this condition may require. Treatments typically include thioamide medications that block thyroid hormone production, an iodine radiation pill that destroys thyroid function, and surgery to remove the thyroid. Address symptoms No matter which symptoms someone has, it’s important to consult a physician about them. Timely diagnosis and treatment can provide a marked improvement in quality of life.

John T. Chow, MD, FACE, is board-certified in internal medicine and endocrinology and practices at the Endocrinology Clinic of Minneapolis in Edina.

Telephone Equipment Distribution (TED) Program

undertreated. Thus, hypothyroidism is occasionally detected during a fertility evaluation or following a miscarriage.

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

2013 OCTOBER MINNESOTA HEALTH CARE NEWS

TAKE CARE

Ways to avoid

colds

Simple steps, big impact By Daron Gersch, MD

very winter, something comes to Minnesota that we all dread. It is not the 10-degree-below-zero days or even the snow. It is the common cold. The threat of a runny nose, sore throat, and cough is enough to make anyone shiver.

missed annually by children because of colds. In my small practice in central Minnesota, we see several hundred people each year who have the common cold. Here are 10 things you can do to help lower your chances of getting it and spreading it.

A study done by the University of Michigan Health System reported that the overall cost of the common cold in the United States is about $40 billion a year. Of that, $4.4 billion is spent on over-the-counter and prescription medications, $7.7 billion on doctor visits, and close to $20 billion in work days missed. The study also reported that about 189 million school days are

1. Wash your hands. This may seem like common sense, but most people do not wash their hands enough. During cold and flu season (usually mid-December to mid-April), we should wash our hands several times a day. Most viruses are spread by touching contaminated objects such as doorknobs, other people’s cellphones, or public keyboards, and then touching our own face. The proper way to wash your hands is to use soap and water and to spend about 20 seconds lathering before rinsing. Hand sanitizers are not as effective, but are an option when you are somewhere you can’t wash. According to the federal Centers for Disease Control and Prevention, handwashing is the single best thing you can do to decrease your chance of getting sick.

In the next issue...

• Heart attack prevention • Obtaining home care • Winter biking

MINNESOTA HEALTH CARE NEWS OCTOBER 2013

2. Eat healthfully. Eating dark green vegetables has been shown to provide nutrients that help your body fight off colds. During cold and flu season, try to get at least two helpings of dark green vegetables daily. Also, an apple a day just might help keep the doctor away. There is an antioxidant called quercetin in apples that may help boost the immune system. Finally, people who regularly eat breakfast have been shown to have a lower rate of infections. 3. Get enough sleep. Getting a good night’s sleep can boost your defenses against a cold. One study showed that people who got fewer than seven hours of sleep a night were two to three times more likely to get a cold than those who got eight hours or more. Sleep efficiency is also important. If you sleep the whole night through, you

are less likely to get ill than someone who wakes up several times a night. 4. Use tissues. When you cough or sneeze, use a tissue to cover your mouth and nose and then throw it away. After you throw the tissue away, wash your hands before you touch anything. If you don’t have a tissue, cough or sneeze into the crook of your arm. Never sneeze into your hands. 5. Oral hygiene. Studies show that gargling three times a day lowers your chance of getting a cold by as much as 30 percent. You do not need to gargle with mouthwash, as most of these studies were done with plain water. It is felt that gargling is helpful by removing viruses from the back of the throat before they can become established. 6. Stay hydrated. Drinking lots of fluids like water, juice, decaffeinated tea and coffee, clear broth, and sports drinks can help you to both fight off a cold and fight a cold once you have it. Drinking keeps mucous thinner, which makes it easier for your body to remove the mucous and any viruses trapped in it. Avoid drinking alcohol and caffeinated drinks (coffee, tea, sodas), which dehydrate you.

with your doctor first to make sure it is safe for you.

If you do come down with a cold … you may recover faster if you rest at home.

10. Stay home if you are ill. People feel obligated to show up for work and school. However, if you do come down with a cold, you might want to think about taking a couple of days off. We are not as productive while we are sick, going to work or school when ill increases the chance of infecting others, and you may recover faster if you rest at home. Common questions • W hat about getting a flu shot? Shouldn’t that be among the 10 things to do? No, because the common cold and the flu are caused by two different types of viruses. While it is very important to get your flu vaccine to help protect you from influenza—a very serious and sometimes fatal respiratory infection—it does not help the common cold. • Should I ask my doctor for antibiotics? No. Antibiotics are used to fight bacterial infections. Since the common cold is caused by a virus, antibiotics do nothing for a cold. By following these simple steps, you can significantly lower your chances of getting the common cold. Take care and good luck. Daron Gersch, MD, is board-certified in family medicine and sees patients at Albany (Minn.) Area Hospital And Medical Center. MSA - MN Healthcare July 2013.pdf

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7. Skip shaking hands. Viruses are very good at clinging to our hands, and some people aren’t good at washing their hands. Don’t be rude, but opting out of a handshake can lower your chance of spreading and getting a cold. If you can’t avoid a handshake, keep your hands away from your face after the handshake and wash them as soon as is politely possible. 8. Consider vitamin D. Vitamin D not only helps keep your bones strong, it is also necessary for a strong immune system. We naturally get vitamin D from a chemical reaction in our skin when exposed to sunlight. However, during a Minnesota winter the sun is at too low an angle to make this vitamin (not to mention that most of our skin is covered). It’s advisable for adults to take 1,000–2,000 mg of vitamin D daily during the winter months, but check with your doctor before taking this. Several recent studies have shown that vitamin C and echinacea do nothing for a cold. 9. Exercise. Exercise helps to strengthen your immune system. It can also help to relieve stress, which weakens the immune system. People should get about 30 minutes of exercise four times a week. If you are new to exercising, start slowly and gradually build up. If you are over 50 years old and are going to start an intensive exercise program, visit 2013 OCTOBER MINNESOTA HEALTH CARE NEWS

POLICY

Destination Medical Center initiative looks to Minnesota’s future By Rep. Kim Norton

n May, the Minnesota Legislature voted to support a unique public-private partnership that will enable Mayo Clinic to grow in Minnesota and further establish our state as a global medical destination. This opportunity, called Destination Medical Center (DMC), is slated to present significant direct benefits to the state, including thousands of jobs and billions in new tax revenues, and to anchor Minnesota’s status and leadership in health and biosciences for generations to come. Founded in 1854 by Dr. William W. Mayo, Mayo Clinic

When it comes to your child, getting help early is your priority.

has deep roots in Minnesota. As the state’s largest private employer, with 43,000 Minnesota workers, Mayo Clinic is responsible for $9.8 billion in economic impact and $1.5 billion in tax revenues for our state annually. After conducting an extensive analysis of emerging opportunities and challenges in health care, Mayo officials determined that in the coming years, two or three institutions around the world will emerge as global destinations for the highest quality health care. Mayo competitors such as Cleveland Clinic, Johns Hopkins, and Massachusetts General, as well as entities in Europe and Asia, are making significant strategic moves and investments in order to replicate the “Mayo model” and to attempt to surpass Mayo as a global destination medical center in order to capture the significant economic benefits generated by “high-value” medical spending. In many cases, government is partnering with medical institutions to accelerate and help finance their expansion in order to generate the significant direct and indirect economic benefits of high-quality jobs, imported spending, and new tax revenues. Mayo Clinic has made the strategic business decision to defend its global position and be one of those destination medical centers. More importantly, Mayo has decided that its global DMC will be right here in Minnesota.

It’s ours too. Our Pediatric Therapies partner with families to help children gain skills and improve functioning through: • Occupational Therapy • Speech and Language Therapy • Feeding Therapy • Music Therapy

Learn more:

stdavidscenter.org/therapies 952.548.8700

The Destination Medical Center plan The Destination Medical Center plan includes approximately $3.5 billion in new Mayo-financed capital investments on its Rochester campus over the next 20 years. Mayo Clinic is prepared to make a massive private investment in additional physicians and staff, new medical buildings, technology, clinical and wellness services, and the other enhancements needed to meet the growing needs of its patients and effectively compete and retain its position as one of the world’s top medical centers. These capital improvements will require state and local support to improve the public infrastructure that supports the level of patient, visitor, and employee growth created by this major expansion. The initiative is expected to create 35,000 to 45,000 new jobs

MINNESOTA HEALTH CARE NEWS OCTOBER 2013

in Rochester and statewide over 20 years, including 14,000 to 16,000 new jobs at Mayo Clinic alone. Many of the jobs created by the DMC initiative will be high paying and sustainable, including positions in medicine, medical research, and biomedical engineering. In addition, a broad spectrum of jobs will be created when private investors bring in businesses to complement the growth. The DMC plan is expected to spark an additional $2 billion in private investment to support the additional patient traffic and visitor experience in Rochester, and to generate approximately $3 billion in new tax revenues to the state and local governments over 20 years. Additionally, the plan will aggressively work to retain, in Minnesota, the new businesses and jobs that emerge from Mayo Clinic’s extensive medical research. The DMC plan has five core objectives: • Sustaining Rochester and Minnesota as a global medical destination that offers patients a welcoming, comfortable, and engaging environment in which to receive the most advanced medical care in the world • Establishing Rochester as a magnet community that will attract the most promising students and sophisticated health care professionals, thinkers, and educators from around the globe

has developed into a major partner for the city of Rochester and the Mayo Clinic. These new investments, in combination with increases in state investments in pre-K, K–12, and higher education, will help educate a quality workforce focused on science, technology, engineering, and math, and will train health care employees for the future. From vision to reality Taking the DMC concept from vision to reality in Minnesota will require a modest level of public investment for infrastructure and other public facilities to support this significant private investment. The city of Rochester alone simply could not finance the necessary infrastructure, and the private market simply wouldn’t assume the burden of these costs. A large group of stakeholders, including Mayo Clinic, developed the DMC downtown master plan in concert with local government and identified Investments in projects like what improveDestination Medical Center ments will be needed to will drive our state’s high-tech, accommodate modern economy. this growth. Based on this concept, state and local resources would be harnessed to support road and highway improvements, public transportation investments, wastewater treatment facilities designed to handle an Growing deeper roots to page 34

• Leveraging Mayo Clinic’s presence in Minnesota to ignite institutional and commercial research in an environment that encourages shared knowledge, partnerships, medical advancements, and innovation • Creating experiences of hope, health, and hospitality for every person, every day • Providing the ideal patient, companion, visitor, citizen, and community experience to become the world’s premier destination medical community The initiative offers significant benefits to Rochester, southeast Minnesota, and the state. The economic impact from drawing new patients and visitors to Rochester and Minnesota each year will benefit Olmsted County and the state as a whole, significantly boosting our state’s economy by creating thousands of new jobs and billions in new tax revenues. This initiative also means that medical professionals who relocate to Rochester will have the opportunity to practice medicine in a cutting-edge setting with an even higher quality of life. For visiting patients, Mayo Clinic’s investment still will mean great medical care, but with an improved experience. For the community, it will mean sustainable, carefully planned growth that will continue to provide jobs, yet keep our cost of living within reason for lifetime residents. In addition, the DMC initiative supports the continued growth and development of the University of Minnesota–Rochester (UMR). In recent years UMR, with its unique niche approach to education, 2013 OCTOBER MINNESOTA HEALTH CARE NEWS

October Calendar National Down Syndrome Awareness Month

National Depression Screening Day

Held annually during Mental Illness Awareness Week in October, National Depression Screening Day raises awareness and screens people for depression and related mood and anxiety disorders. Screening for Mental Health (SMH) offers National Depression Screening Day programs for the military, colleges and universities, community-based organizations, and businesses. If you are concerned about yourself or someone you love, visit SMH for anonymous online depression screening (www. HelpYourselfHelpOthers.org).

Infant Massage

Minnetonka Community Education hosts this infant massage class, taught by a pediatric physical therapist and certified infant massage instructor. Participants are encouraged to bring their infant and learn the benefits of infant massage techniques. Recommended for parents with children from birth to crawling stage. Free. To sign up, call (952) 401-6800.

Tuesday, Oct. 15, 6–7 p.m., 4584 Vine Hill Rd., MCEC Room, Excelsior

Lowering Diabetes Risk Naturally

Valley Natural Foods offers Achieving Wellness: An Introduction to Lowering Your Diabetes Risk Naturally. This class will teach a holistic approach to lowering lifetime risk for type 2 diabetes through healthy eating, exercise, supplementation, and stress relief, and will explain key prediabetes health numbers. Free for members of a Twin Cities food co-op, $5 for non-members. Register online at valleynaturalfoods.com/education or call (952) 891-1212 x221.

In 1984, President Ronald Reagan signed a resolution proclaiming October as National Down Syndrome Awareness Month. The movement began as a campaign founded by the National Down Syndrome Society to spread knowledge and dispel myths about this genetic disorder and the people whose lives it affects. Down syndrome occurs when a person is born with a full or partial extra copy of chromosome 21, usually resulting in delays in physical, intellectual, and language development. It is the most common human chromosome abnormality, affecting one in 691 babies born in the U.S., or about 6,000 babies each year, according to the Centers for Disease Control and Prevention. In 1910, children with Down syndrome had a life expectancy of nine years. With recent medical advances, up to 80 percent of people affected live to at least age 60. As life expectancy increases, more people across the nation are interacting with individuals with Down syndrome, making the need for widespread public education and acceptance clear.

Parenting a Child with Special

Needs Workshop

PACER presents this free, educational workshop: Planning for the Journey of Parenting a Child with Special Needs. Come learn helpful and insightful strategies for raising a child with special needs. Topics include gaining a hopeful and positive outlook, setting high expectations, and using strengths and resilience. Visit www.pacer.org/workshops or call (952) 838-9000 to register.

Tuesday, Oct. 15, 6:30–8:30 p.m. Valley Natural Foods, 13750 County Rd. 11, Burnsville

Heart Transplant Support Group

Allina Health offers this support group for individuals currently on a heart transplant waiting list and their loved ones. The free group sessions offer support and education for people coping with issues related to waiting for a transplant and life changes after the procedure. To sign up, call (612) 775-5007.

Thursday, Oct. 17, 12–1 p.m., Abbott Northwestern Hospital, 800 E. 28th St., Minneapolis

Monday, Oct. 7, 6:30–8:00 p.m., PACER Center, 8161 Normandale Blvd., Bloomington

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

MINNESOTA HEALTH CARE NEWS OCTOBER 2013

Prostate Cancer Education and Support

North Memorial Hospital hosts this free monthly educational support group for men from all phases of a prostate cancer diagnosis. Come for discussion and camaraderie and learn more about managing life with prostate cancer. Support persons are welcome.

Wednesday, Oct. 23, 5:30–7 p.m., North Memorial Outpatient Center, Oak Room, 3435 West Broadway, Robbinsdale

Chronic Conditions Workshop

The Live Well with Chronic Conditions Workshop comprises six sessions that teach problem-solving and strategies for living with chronic conditions. Learn new techniques that can be applied to everyday life. Open to people affected by chronic conditions, and their friends, family members, and caregivers. Free. Other dates and locations are available in the metro area. To register or for more information, call Jennifer at (651) 280-4685.

Friday, Oct. 25, 1–3:30 p.m. East Shore Place Apartments 805 Wildwood Rd., Mahtomedi

Advanced Care Planning

Park Nicollet hosts these free Advanced Care Planning Group Classes for those who are ready to begin the planning process. Come learn how to select a health care agent, start a family conversation, and complete a health care directive. Time will be allowed for questions and individual help. Classes are offered monthly and registration is required. Call (952) 993-3454 or register online at (www.parknicollet.com).

Wednesday, Oct. 30, 1–2:30 p.m., Park Nicollet Clinic, Senior Services Conference Room, 3850 Park Nicollet Blvd., St. Louis Park

Nov. 9

Brain Injury Conference

The Minnesota Brain Injury Alliance hosts this free conference for individuals affected by a brain injury and their loved ones. Workshops and sessions focus on innovations in brain injury care, therapy, and rehabilitation. To sign up or for more information, call (800)-669-6442.

Saturday, Nov. 9, 8:30 a.m.–12:00 noon, North Como Presbyterian Church, 965 Larpenteur Ave. W., Roseville

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

We call it caregiving.

You or someone you know may be a caregiver. WhatIsACaregiver.org 2013 OCTOBER MINNESOTA HEALTH CARE NEWS

SPECIAL FOCUS: DIABETES

ymptoms in the feet are often the first indication patients have that they are diabetic. These symptoms can develop very gradually and may be difficult to identify at first. Some indicators that suggest you may have diabetes include wounds that either don’t heal or that take a long time to heal; infections that don’t go away or that occur frequently; and numbness, tingling, cramping, or burning sensations that often start in the toes.

How feet are affected Circulation Diabetes decreases circulation, an effect noted most in small blood vessels located far from the heart, including those in the fingers, toes,

and feet. When blood flow to one of these areas is decreased, tissue in that area loses its strength and can be injured more easily due to the lack of nutrition that blood flow would normally bring. Once injured, the tissue takes longer to heal or may not heal at all because inadequate blood flow keeps it from receiving necessary blood-borne nutrients. And, since skin is the primary barrier to infection, a nonhealing wound has a greater chance of becoming infected. If you see a slow-healing or nonhealing wound anywhere on the body, but particularly on the foot or a lower limb, contact a physician to make sure you do not have diabetes. Nervous system

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MINNESOTA HEALTH CARE NEWS OCTOBER 2013

The effect of diabetes on nerves can lead to a condition referred to as peripheral neuropathy, which most commonly produces symptoms in the feet, but also in the hands and lower legs. These symptoms, including tingling, burning, cramping, and numbness, often start in the toes and can have either a gradual or a rapid onset. Because peripheral neuropathy can lead to abnormal nerve function, a person with this condition has a delayed or absent reaction to pain. For example, people with peripheral neuropathy who touch a hot stove or who puts their feet in overly hot water to soak them may not realize their skin is in contact with something too hot until the resulting tissue damage has become serious, making it likely that an open sore will develop. Immune system The immune system is depressed in someone who has diabetes, making it harder to fight off infections. Consequently, diabetics are at increased risk of developing an open sore, or ulcer, on their feet. In fact, the federal Centers for Disease Control and Prevention estimates that 15 percent of people with diabetes will have at least one foot ulcer during their lives. If an ulcer becomes infected it may lead to serious, irreversible consequences. An estimated 5 percent of diabetics in the U.S. will have part or all of one foot amputated during their lifetime. Worse, five years after the initial amputation, up to 51 percent of them will require a second amputation, studies show.

According to government research in 2006, more than 65,000 amputations that year were related to diabetes. Regular foot examinations have been shown to reduce the risk of ulcers by 85 percent.

Foot care Control blood sugar. It’s the most important thing people can do to protect their feet when they have diabetes. Keeping your blood sugar under control slows the development of circulatory, neurologic, and immune problems and may help you avoid them. Controlling your blood sugar will also help slow damage to your kidneys and eyes, two other areas of the body that are greatly affected by diabetes. Check your feet daily. This is a must for all diabetic patients. Many potentially serious problems can be averted by this simple, two-minute activity. Look at the entire foot, including the sole and between the toes. If it is difficult to look at the bottoms of your feet, place a mirror on the floor or have someone else in your family examine them. Symptoms of possible problems include redness, callouses, areas of drainage, or open sores. The best time to check your feet is during your daily foot-care routine.

be considered diabetic. Prediabetes is serious nonetheless, since it increases the risk of developing diabetes.

Regular foot examinations have been shown to reduce the risk of ulcers by 85 percent.

Additional risk factors for developing this disease include being overweight, getting older, having a family history of diabetes, and physical inactivity. Ethnicity plays a role, too, with higher rates of diabetes found among Native Americans, African Americans, Hispanics, and Asians.

Diabetes is not a disease to be taken lightly. If you are prediabetic, now is the time to change your lifestyle to prevent diabetes. Losing weight, increasing exercise, and adopting healthy eating habits are critical. One study of 3,000 prediabetic adults showed a 71 percent reduction in their risk of developing full-fledged diabetes after they implemented and maintained these changes.

Clean your feet daily to minimize the risk of infection. Dry your feet thoroughly, since excess moisture between the toes promotes fungal infections and resulting breakdown of the skin.

If you are already diabetic, listen to what your doctor tells you. Make any necessary changes to your lifestyle, make sure to care for your feet daily, visit your doctor on a routine basis, and contact your doctor if you observe worrisome signs on your feet.

Keep the skin on the feet from drying and cracking to help prevent infection. Use moisturizing cream on a daily basis. Care should be taken not to get cream between the toes, as this area usually does not need extra moisture.

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

Toenails. Proper nail trimming is very important for the diabetic patient. Many foot infections that have led to amputation have started with improperly trimmed nails. Trim toenails straight across; do not round the corners. If you experience problems such as ingrown nails, seek medical care. Most insurance plans will cover this for diabetic patients, as study after study has indicated that professional treatment of nail problems significantly reduces foot infections. Wear properly fitting shoes to help prevent open sores from developing. Shoes should not feel tight in any area. When you put on a pair of new shoes, check your feet for redness after a few hours. Redness indicates pressure points and may mean the shoe is not fitting properly. New shoes should be broken in slowly over several weeks. Many insurance companies cover diabetic shoes and inserts if deemed medically necessary. Insurance typically requires that you have a prescription for shoes and inserts, and that a physician treating you specifically for diabetes sign a form to certify your need for them.

Many insurance companies cover diabetic shoes and inserts.

Take action

Diabetes is a serious problem. According to the American Diabetes Association, approximately 25.8 million Americans have diabetes, and an estimated 7 million of them are undiagnosed. An estimated 79 million Americans are prediabetic, which means that they have a higher than normal blood sugar level that is not high enough to

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2013 OCTOBER MINNESOTA HEALTH CARE NEWS

SPECIAL FOCUS: DIABETES

Hypoglycemia Tips for prevention and management By David A. Weinstein, MD, MMSc

im Larson knew he needed to drink something sweet. Fast. He remembers the agitation, the rising anxiety, shakiness, heart palpitations, and sweatiness that preceded his lunge for the fridge. But he never made it.

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Had it not been for the arrival of friends soon after he lost consciousness, Jim would not be alive to talk about his hypoglycemia, a manageable but potentially deadly condition.

What is it? Like everyone with type 1 and type 2 diabetes, Jim is at high risk for hypoglycemia, in which the level of sugar that normally exists in the blood falls to dangerously low levels. A normal blood sugar level in a fasting person ranges between 70 milligrams and 100 milligrams per deciliter. When that level drops below 50, the brain is not getting the sugar it needs as an energy source. This can set off a progression of disastrous events: loss of mental function, loss of consciousness, seizures, and death. Fatal car accidents in which a diabetic driver lost consciousness, fatal falls from ladders—these accidents and more have resulted from hypoglycemia.

Causes The difficulty for many diabetes patients, including Jim, is that hypoglycemia is very often a side effect of the insulin they take every day to stay alive. Here’s how to understand this apparent contradiction: • A nondiabetic person produces insulin, which ushers dietary sugar (which the body turns into a sugar called glucose) into the body’s cells, where it’s used for energy. • Diabetics take insulin because their pancreas doesn’t produce enough of it, or because their cells are not receptive to it.

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• Too much insulin can cause the blood sugar level to drop too low, resulting in hypoglycemia. • A low blood sugar level also can occur if diabetics eat less than they normally do (consuming less sugar) or exercise more than

MINNESOTA HEALTH CARE NEWS OCTOBER 2013

they normally do (using up more glucose). Alcohol abuse and certain medications can trigger a serious drop in blood sugar as well.

A daily discipline

The delicate interplay of food, medication, and exercise requires calculations and adjustments throughout the day.

This delicate interplay of food, medication, and exercise requires calculations and adjustments throughout the day for those at risk of hypoglycemia. Although every person’s body and metabolism is different, Jim’s daily routine is a good example of a regimen that includes strict adherence to a doctor’s advice and a healthy dose of personal responsibility: I wake up at 5 o’clock every morning, and the first thing I do when I sit up in bed is test my blood sugar and administer my medications. For breakfast, lunch, and dinner, I count the carbs I’m going to eat and balance them with protein. I drink water. I don’t use alcohol. If I need to get my blood sugar up in a hurry, I take a bite of baker’s chocolate. I always have apples, oranges, and bananas handy. Every three hours or so, I test my blood sugar, and if I need insulin, I take it. If I exercise—lift weights or go for a long walk—I make sure that my blood sugar is 120 so I don’t find myself getting anxious about how my body is operating. I carry my blood-testing equipment with me all the time in a little satchel, along with snacks, in case I need to get my blood sugar up fast. I check my blood sugar after exercising, and if it’s down to 70 or 80, I eat some fruit and recheck a little while later to make sure it’s gone back up. At night when I go to bed, I make sure my blood sugar is 130 or 140. If I wake up in the middle of the night, I’ll check my blood sugar. I always want to know where it’s at. Daily dietary recommendations that help avoid hypoglycemia include high-quality protein (fish, poultry, lean meats, and eggs); vegetables (especially dark, leafy greens); and high-fiber foods (raw, unsalted nuts as well as legumes, whole fruits, and oats). Avoid foods such as processed meats and artificial sweeteners.

While you sleep You might have noticed that Jim’s daily regimen includes monitoring his blood sugar right before he goes to bed, and any time he wakes up during the night. Even if it’s 2:00 or 3:00 in the morning, rather than putting his head back on the pillow, Jim tests his blood sugar. This habit helps him head off what’s known as “nocturnal hypoglycemia.” Symptoms of this can include waking with a headache, damp sheets, and nightmares. Parents of children with diabetes often check their children during the night for symptoms. Studies are under way to develop insulin and dietary regimens that will help prevent nocturnal hypoglycemia. Researchers are working to develop monitoring devices that can alert and awake the wearers of those devices if their blood sugar level falls too low.

diabetes since he was in his 40s. He has survived four hypoglycemic episodes, and they are experiences he doesn’t want to repeat.

“You wake up with a sense of exhaustion, tension, and depression,” he says. “It takes a long time to recover—about three full days— and each time it happens, it takes longer to recover.” As a registered member of the Sisseton Wahpeton Oyate of the Lake Traverse Reservation, Jim is acutely aware of the risk of diabetes among Native Americans. Compared with the general population, they are more than twice as likely to be diagnosed with diabetes and almost twice as likely to die from its complications. When Jim reads the Sisseton obituaries and sees that someone has died of “complications from diabetes,” he has learned that this often means that the person died of hypoglycemia. Hypoglycemia’s lethal potential brings an understanding of what he needs to do to take care of himself, Jim says. “It’s learning not to play a game that you’ll lose.” David A. Weinstein, MD, MMSc, is the director of the Glycogen Storage Disease Program and a professor of pediatric endocrinology at the University of Florida College of Medicine, Gainesville. Dr. Weinstein serves as an adviser to Diabetes Sentry Products, Inc., a medical device company based in Orono, Minn.

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SPECIAL FOCUS: DIABETES

Medication management Store properly for maximum benefit By Jessica M. Swearingen, PharmD, BCPS, and Kandace M. Schuft, PharmD

o you know that storing medication properly can make the difference between life and death? Excessive sunlight, humidity, and temperature can alter a medication’s characteristics, decreasing its strength or potency. Some medications, including insulin, can lose their potency if frozen or exposed to high temperatures.

Doctors on the frontline of eye and vision care

The importance of correct storage increases as colder weather approaches. This is especially true for snowboarders and others who carry insulin with them while outdoors for long periods of time during the winter. The same is true for diabetics traveling to visit relatives for the holidays, and for those enjoying warmer climates this winter, whose insulin may be exposed to extreme heat. Many medication labels say, “Store at room temperature,” but what does this really mean? And what should you do with medication when temperatures reach extremes?

Did you know?

Ideal storage

• Diabetic retinopathy can be controlled and diabetic patients need regular eye exams to maintain vision and good eye health. • Diabetes Type ll can also cause vision changes. • Glaucoma must be diagnosed in early stages in order to prevent vision loss. • All children entering school need a comprehensive eye exam, because vision screenings do not detect a number of eye disorders. • To maintain eye health, everybody from babies to boomers to older adults needs a regular eye exam by a family eye doctor. To locate an optometrist near you and find comprehensive information about eye health visit

Temperature

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MINNESOTA HEALTH CARE NEWS OCTOBER 2013

Controlled room temperature is ideal for most medications. The United States Pharmacopoeia, which regulates pharmacy policies and procedures, defines controlled room temperature as one maintained between 68°F and 77°F. In most cases it’s considered safe to use medication exposed to temperatures slightly outside this range, as long as it’s not for 24 hours or longer. Medication exposed to temperatures at or below freezing (32°F) or above 104°F for any length of time may be unsafe or ineffective. Check the package insert for specific storage requirements for each of your medications. Humidity Keep medication in a dry place, i.e., one with low humidity. “Low humidity” means conditions that don’t exceed 40 percent average relative humidity. It’s best not to keep medication in a bathroom where a shower or bathtub are used regularly, nor in a kitchen cabinet near a dishwasher or sink.

Diabetes Medication Oral

Manufacturer Storage Recommendations Ideal Storage

Acceptable Range

Additional Comments

Light

Pioglitazone (Actos)

Store at 25° C (77°F)

Range of 15–30°C (59–86°F)

Keep tightly closed; protect from light, moisture, humidity

In addition to protecting medication from humidity and temperature extremes, protect it from direct sunlight. Do not store medication on windowsills. The best places to store medication are where the home is coolest, possibly a hallway linen closet, the basement, or a room without windows.

Glipizide (Glucotrol)

Store at 25° C (77°F)

Range of 15–30°C (59–86°F)

Protect from moisture & humidity

Metformin (Glucophage)

Store at 20°C–25°C (68°F–77°F)

Range of 15–30°C (59–86°F)

Keep tightly closed & protect from light

Sitagliptin (Januvia)

Store at 20°C–25°C (68°F–77°F)

Range of 15–30°C (59–86°F)

Glyburide (Micronase)

Store at 20°C–25°C (68°F–77°F)

Range of 15–30°C (59–86°F)

Glimepiride (Amaryl)

Store at 20°C–25°C (68°F–77°F)

Range of 15–30°C (59–86°F)

Keep medication in its original packaging when possible. However, if you use a pillbox or other container to help organize your medication and make it easier to remember to take it, make sure to store the pillbox in a cool, dry place away from direct sunlight.

Outdoors

Injectable

Ideal Storage

Insulin Lispro (Humalog)

Unopened: Refrigerator, 2–8°C (36–46°F)

Insulin Glargine (Lantus)

Unopened: Refrigerator, 2–8°C (36–46°F)

Insulin Aspart (Novolog)

Unopened: Refrigerator, 2–8°C (36–46°F)

Insulin Detemir (Levemir)

Unopened: Refrigerator, 2–8°C (36–46°F) in original carton to protect from light

Opened: 28 days @ room temp Opened: 28 days @ room temp Opened: 28 days @ room temp

Acceptable Range

Keep tightly closed & protect from light

Additional Comments

Not greater than 30°C (86°F)

Do not freeze, protect from direct heat & light

Not greater than 30°C (86°F)

Do not freeze

Not greater than 30°C (86°F)

Do not freeze

Not greater than 30°C (86°F)

Do not freeze, protect from direct heat & light

Not greater than 30°C (86°F)

Do not freeze, protect from excessive heat & sunlight

Not greater than 30°C (86°F)

Do not freeze, protect from light

Opened: 42 days @ room temp Liraglutide (Victoza)

Unopened: Refrigerator, 2–8°C (36–46°F), away from cooling element Opened: 30 days @ room temp

Exenatide (Byetta)

Unopened: Refrigerator, 2-8°C (36-46°F) Opened: 30 days @ room temp

If you’re spending a winter day Pramlintide (Symlin) Unopened: Refrigerator, 2-8°C (36-46°F) Not greater than 30°C (86°F) outdoors and away from home, Opened: 30 days @ room temp protect insulin and testing kits from freezing. Tuck them in an Medication management to page 29 inner coat pocket or wrap them in a spare pair of socks or hat carried in a fanny pack or backpack. Juice boxes, gels, and other snacks that might freeze can be carried the same way. If winter recreation takes you to high elevations, check the altitude limitations of your meter and test strips. Altitude information is in the insert of the package containing your meter.

Do not freeze, protect from light

It’s also important to protect insulin when you spend a hot day outdoors and away from home. Some options that help keep medication cool include individual insulin cooler wallets and mini portable refrigerators. These refrigerators may be helpful if you are away from home for longer than a day.

On the road Before traveling, make sure you consider unique situations you may encounter that can affect proper medication storage. For example, baggage holds on airplanes are not temperature controlled and, depending on the outside temperature, can reach high or low temperature extremes. If you plan to fly, it’s best to carry your medication on the plane with you or to pack it in your carry-on luggage. Also, be aware that it may be easier to pass through airport screening if medications are kept in their original containers with pharmacy labels. If you carry medication in a pillbox, allow for extra screening time.

Sunlight, humidity, and temperature can alter a medication’s characteristics.

If you are driving, don’t store 2013 OCTOBER MINNESOTA HEALTH CARE NEWS

SPECIAL FOCUS: DIABETES

Somalis and type 1 diabetes Bridging cultures, empowering patients By Muna Sunni, MBBCh, and Antoinette Moran, MD

ccording to recent census data, Minnesota is the state with the largest number of Somalis, an ethnic group that emigrated from its home in Somalia, East Africa, when civil war erupted in that country in the 1990s. Minnesota pediatric endocrinology clinics have seen relatively large numbers of Somali children with type 1 diabetes in the last decade.

Type 1 diabetes

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Type 1 diabetes is the most common type of diabetes in children. It is an autoimmune disease in which the body does not make insulin, which the body needs in order to use glucose for energy. Glucose is a sugar found in food, especially carbohydrates. The reason that type 1 diabetics are unable to use glucose is that their pancreatic cells that produce insulin are attacked and destroyed by their own immune system. Consequently, glucose accumulates in a type 1 diabetic’s bloodstream in high amounts. This gives rise to this disease’s hallmark symptoms of excessive thirst and urination, weight loss, and fatigue. The only treatment for type 1 diabetes is to inject insulin, which keeps glucose from accumulating and helps the body use glucose for energy. Inheriting certain genes puts an individual at risk for developing type 1 diabetes. Blood can be tested to see if a person carries these genes. Further, people with type 1 have proteins in their blood that indicate that diabetes’ autoimmune process is occurring. These proteins, called autoantibodies, can be tested to prove that any diabetes that is present is type 1.

Background research Very little information is available on Somali children who have diabetes. If pediatric diabetes does occur in Somalia (which is likely), it is rarely diagnosed because the health care system there is in total disarray and most diabetic children probably die without ever getting the right diagnosis. A small study of Somali immigrants in Helsinki, Finland (Pediatric Diabetes, 2012), described diabetes as being common in this population, and reported worse diabetes control among Somali pediatric patients with type 1 diabetes compared with Finnish

patients in the same clinic. The study also described genetic and antibody profiles of those Somali patients that were typical of type 1 diabetes.

Knowing how much carbohydrate is in food and drink is vitally important for a type 1 diabetic.

Current research The University of Minnesota (U of M) Division of Pediatric Endocrinology is leading a study to better understand type 1 diabetes in Somali children in the Twin Cities. Conducted at the U of M Amplatz Children’s Hospital and at Children’s Hospitals and Clinics of Minnesota, this study aims to understand cultural and religious beliefs of families of Somali children with diabetes through a survey, and to compare their diabetes control to that of the general pediatric diabetes clinic population at both hospitals. One of the study’s goals is to determine if Somali children with diabetes have the same genetic risk of diabetes as children of other ethnicities in the United States. Another goal is to determine if Somali children have the same diabetes autoantibodies as other U.S. children. A third goal is to use this population’s cultural and religious beliefs to create culturally specific educational material that improves Somalis’ ability to manage type 1 diabetes.

almost all type 1 diabetes in Somali children. On the other hand, it may be that most Somalis have this gene, whether or not they have diabetes. To sort this out, we are planning to test Somali children and adults who do not have diabetes and who do not have a close relative (child, sister, brother, or parent) with type 1 diabetes. If we find this gene only in Somalis with diabetes, it may help us predict who is at risk. Preliminary results from 19 families show that most of them accept the diagnosis of type 1 diabetes, do not believe it could have been prevented, are comfortable using insulin as prescribed, and, in general, avoid adding traditional remedies. Diabetes education provided by the researchers has been very well received. However, we discovered that there are no resources for estimating the carbohydrate content of commonly eaten traditional Somali foods. Of concern, we also found that Somali children with diabetes have worse control of their blood sugar level compared with their non-Somali peers who have diabetes, particularly among adolescents.

Future research This study establishes groundwork for future pediatric diabetes research projects at the U of M. One project now underway aims to improve participants’ ability to self-manage their disease by more accurately estimating the Somalis and type 1 diabetes to page 28

Participants Eligibility criteria • Participants who have diabetes and are 19 years old or younger • Somali origin (at least one parent must be Somali) Recruitment Participants are recruited with the assistance of Somali interpreters at the U of M pediatric diabetes clinic, in the community, and at the pediatric diabetes clinic at Children’s Hospitals and Clinics of Minnesota. Participation Somali interpreters help participating families fill out surveys that explore how families of children with diabetes view the disease, their understanding of the disease, their ability to cope, and their suggestions for improving care. Surveys and other study documents are in both English and Somali. Participating children are also asked to provide a blood sample. Blood samples are analyzed for the presence of diabetes genes and autoantibodies.

Preliminary results Our preliminary data have produced a somewhat surprising finding. Eighteen of the 19 children tested so far carry one specific gene that has been associated with diabetes but is found in only about 25 percent of U.S. people with type 1 diabetes, including African Americans. This may suggest that a very specific gene is responsible for 2013 OCTOBER MINNESOTA HEALTH CARE NEWS

Somalis and type 1 diabetes from page 27

carbohydrate content of what they eat and drink. Knowing how much carbohydrate is in food and drink is vitally important for a type 1 diabetic because it tells that person how much insulin to inject when eating or drinking something that contains carbohydrates. The higher a food’s carbohydrate content, the higher someone’s blood sugar level is after eating that food. If the blood sugar level gets too high, that person may go into a coma. Unfortunately, currently available resources for determining carbohydrate content are based on a Western diet, while many Somali families still cook traditional Somali dishes. Many of these dishes contain large amounts of carbohydrates (millet, rice, beans, and corn). This makes estimating carbohydrate content a difficult task in the absence of culturally appropriate references. We are developing materials to address this need.

If the blood sugar level gets too high, [a diabetic] person may go into a coma.

Another project aims to identify the main factors that contribute to worse diabetes control

in Somali adolescents compared with other teens. Identifying those factors will allow remedies to be developed to improve Somalis’ diabetes control and, ultimately, their long-term health. Diabetes education is well received in this population, paving the way for providing additional culturally specific education. Developing culturally specific tools and resources to support Somali families’ efforts in managing their children’s diabetes complements medical treatment. Involving Somalis themselves in developing these tools and in research nurtures their sense of accountability, ownership, and initiative, traits that have proven successful for other populations that tackle diabetes. Muna Sunni, MBBCh, is a board-certified pediatrician and a board-eligible pediatric endocrinologist at the University of Minnesota Amplatz Children’s Hospital, Minneapolis. She leads the study described in this article. Antoinette Moran, MD, is a board-certified pediatric endocrinologist and division chief of the pediatric endocrinology division at the University of Minnesota Amplatz Children’s Hospital, Minneapolis. Acknowledgment This research would not be possible without the efforts of community members, interpreters, and Somali students and families who volunteered to become actively involved.

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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Medication management from page 25

medication in the trunk or leave it in the car for long periods of time. Instead, carry medication with you. You should also consider the temperature and humidity of your destination. For example, if you travel to a tropical area of high humidity, it’s best to store your medication in an air-conditioned area. If you are staying in an area without air conditioning and expect high temperatures, it may be possible to store medication in a refrigerator, but always discuss that option with your pharmacist first. Another option may be to store medication indoors near a vent or fan.

Detecting damage

Find storage recommendations here 1. Medication package insert 2. Your local pharmacist 3. www.fda.gov 4. www.diabetes.org

It’s important to know that not all damage caused by extreme temperature and other storage conditions is visible to the naked eye. During times of excessive heat or cold, pay close attention to out-of-the-ordinary symptoms or side effects you experience

from your medication. Also pay attention to unusual characteristics of the medication: discoloration, crumbling, or separation. If medication sticks together or feels moist to the touch, it may have been exposed to too much humidity.

Do not store medication on windowsills.

If you’re unsure If you think your medication may have been affected by humidity, extreme temperature, or direct sunlight, the first step is to ask your pharmacist what he or she recommends. Based on that conversation, the next step may be to call your insurance company to request replacement medication. If medication needs to be replaced but your insurer won’t do so, request replacement from the manufacturer, whose toll-free number should be on the package insert or the medication container. Jessica M. Swearingen, PharmD, BCPS, is a clinical pharmacy manager at Unity Hospital, Fridley, part of Allina Health. Kandace M. Schuft, PharmD, is a pharmacy practice resident at Unity Hospital.

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2013 OCTOBER MINNESOTA HEALTH CARE NEWS

NEUROLOGY

Concussion in youth

Know the symptoms

By Armantina Malvarez Espinosa, MD, and Brionn K. Tonkin, MD

oncussion in America is a growing concern, particularly among our youth. This is a serious condition and is a form of traumatic brain injury (TBI), the leading cause of death and disability among children and young adults. In Minnesota, nearly 14,000 brain injuries occur annually. Approximately 4,400 of those are in youth age 17 and younger, with the largest group being ages 10â&#x20AC;&#x201C;12. More than 75 percent of those injuries are mild TBI. What is concussion? Concussion is a pathophysiological process that affects the brain and is induced by biomechanical forces. You do not need to lose con-

sciousness to have a concussion. Symptoms are subjective, and concussion is typically not detected by imaging techniques such as a CT scan or MRI. It is important to know concussion is not always caused by a direct blow to the head, because a blow to the body can produce impact that travels to the brain. Sports According to the federal Centers for Disease Control and Prevention, an estimated 3.8 million sports-related concussions occur each year in the United States, and it is estimated that as many as 40 percent of youth athletes who sustain a concussion return to play sooner than they should. Sports-related concussions are now the second-leading cause of TBI among people 15 to 24 years of age. Activities associated with the greatest estimated number of TBIrelated emergency department visits are bicycling, football, playground activities, basketball, and soccer.

Concussion is not always caused by a direct blow to the head.

Minnesota law requires any youth athlete who participates in any athletic activity (public and private) and who has a suspected concussion to be removed from play and to not resume participation until cleared by an appropriate, trained health care professional. This legislation was fueled largely by the recent and alarming number of professional and collegiate athletes who have dealt with chronic problems related to concussions. The law also mandates coaches receive training about concussion.

It may be beneficial for an athlete to have a neurocognitive test before beginning sports. This establishes baseline functioning that

MINNESOTA HEALTH CARE NEWS OCTOBER 2013

A blow to the body can produce impact that travels to the brain.

can be compared with post-concussion functioning. Some athletes intentionally perform poorly on a baseline test in hopes they will appear to have normal cognitive functioning if they have to take a post-injury test. Although there are not good data on this phenomenon, there are controls, checks, and balances built into the testing to identify people who may be trying to score poorly.

A baseline test is not essential, and the most important thing is to correctly diagnose a concussion and to not return an athlete to play before all symptoms are resolved. Symptoms It is important to know the symptoms of concussion, as they are often unrecognized and therefore untreated. Symptoms fall into three areas: • Physical: Headaches, dizziness, visual changes, sleep alterations, balance problems, fatigue, sensitivity to bright lights or loud noises, feeling dazed or “foggy” • Behavioral: Irritability, anxiety, more emotional than usual, symptoms of depression • Cognitive: Slowed reaction times; difficulty with word-finding; difficulty multitasking; trouble with memory, attention, or concentration Any combination of these symptoms following an impact to the body or head should raise suspicion of a concussion and prompt further medical evaluation.

milestone.

Adolescents Adolescents participate in many recreational activities and a variety of sports. They may downplay or deny having symptoms because they want to continue their usual activities. Signs may be complaints of headache, sleeping more than usual, falling grades, or changing social patterns. Concussion that has lasting effects in this group can cause challenges in their demanding schedules, schoolwork, and sports schedules and changes in their peer relationships. Treatment For pediatric patients of all ages, the primary treatment for concussion is cognitive and physical rest. While treatment is individualized for each person, this could mean staying home from school, not participating in extracurricular events, and avoiding activities that involve visual and auditory stimulation, such as texting, playing video games, shopping in a noisy mall, and watching movies. Recovery For most patients, 80 percent of symptoms disappear within one month, although recovery may take longer in younger patients. The 10 percent to 20 percent of youth whose symptoms persist past one month benefit from treatment provided by a team that may

Concussion in youth to page 32

Diagnosis A diagnosis of concussion is made by a combination of reported and observed symptoms and physical examination. At this time there is no single test that definitively diagnoses concussion; it remains a clinical diagnosis. In younger children, concussion is harder to diagnose because younger children cannot tell us their symptoms. The importance of evaluating any head injury in very young children cannot be overestimated. For babies and younger children, the most frequent causes of TBI include falls, car accidents, bicycle crashes, and inflicted injuries from physical abuse. Symptoms to watch for in babies and young children include: • Crying, fussy, irritable behavior; difficult to console • Rubbing of head (presumably due to headache) • Excessive sleeping • Vomiting • Change in eating patterns • Problems with coordination If you suspect your child has had a concussion, consult your pediatrician or the nearest medical facility immediately.

Some features from concussion may not be recognized until much later, such as when a child is not meeting a developmental 2013 OCTOBER MINNESOTA HEALTH CARE NEWS

Concussion in youth from page 31

Call 911 if your child has any symptoms:

second-impact syndrome.

include physicians; physical, occupational, or speech therapists; and psychologists or neuropsychologists. There is a small role for medication for some patients. Importantly, school and athletic accommodations may be needed and should be coordinated by the physician and team treating the youngster. Feedback from parents and child is critical and invited for appropriate implementation and relevancy of accommodations. However, someone who has suffered a concussion should be symptom-free in all areas before resuming his or her usual activities. For school-age children, this includes a successful return to school and recreational activities. Return to athletics is recommended only after the athlete remains symptom-free during the course of several levels of increasing exertion monitored by a trained professional experienced in concussion recovery, such as an athletic trainer, physical therapist, or physician. The danger of returning to play too soon is that the person may suffer another concussion while still recovering from the first one. This can lead to a serious and potentially fatal condition called

Prevention Prevention is the only “cure” for concussion-caused TBI. Wear appropriate safety restraints in motorized vehicles. Never, ever shake a baby. Wear appropriate, well-fitting helmets for sports and recreational activities. (There is currently no evidence that mouth guards or certain helmets prevent concussion.)

• Severe, uncontrollable headache • Vomiting • So sleepy you cannot get him or her awake • Altered or loss of consciousness (fainting)

Youth and adolescent concussion is a growing concern in America. Recent studies have shown that repeated concussion can have a severe impact on a person’s physical, cognitive, and emotional health. Prevention is best, but if your child sustains a blow to the head or body and shows symptoms of concussion, prompt identification and management is critical to prevent long-term problems.

• Not moving one side of the body • Seizure • One eye’s pupil larger than the other (The pupil is the round center of the eye.) • Clear or bloody fluid coming from ears or nose

Armantina Malvarez Espinosa, MD, is a pediatric neurologist at Hennepin County Medical Center (HCMC) and co-medical director of HCMC’s Pediatric Brain Injury Program. Brionn K. Tonkin, MD, is a staff physiatrist at HCMC and an adjunct assistant professor at the University of Minnesota specializing in traumatic brain injuries and musculoskeletal injuries.

September Survey results... 1. I understand the information MNsure has made available about purchasing health insurance.

50 44%

40 30

26%

20 13% 9%

10 0

Strongly agree

26%

35 30

26%

20 15 9%

0% Strongly agree

Agree

No Disagree Strongly opinion disagree

MINNESOTA HEALTH CARE NEWS OCTOBER 2013

26%

30%

30 25

26%

22%

20 15

13%

0% Strongly agree

Agree

No Disagree Strongly opinion disagree

17%

15 10 5 0% Strongly Agree agree

No Disagree Strongly opinion disagree

5. I plan to purchase health insurance through MNsure.

35%

26%

No Disagree Strongly opinion disagree

5 0

Agree

Percentage of total responses

39%

30%

4. I feel that the money being spent to promote and educate around MNsure utilization is being well managed.

Percentage of total responses

3. I feel the process of how companies were chosen to be part of MNsure has been made adequately public.

2. I am concerned that no new insurance providers are available through MNsure.

Percentage of total responses

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 September survey.

30 26%

26%

22%

Agree

No Disagree Strongly opinion disagree

20 15 10 5 0

4% 0% Strongly agree

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.

“A way for you to make a difference” SEPTEMBER 2013 MINNESOTA HEALTH CARE NEWS 2013 OCTOBER MINNESOTA HEALTH CARE NEWS

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the city—a significant investment for a community its size. Rochester and Mayo Clinic are committed to moving Minnesota’s economy forward. Making investments in projects like Destination Medical Center will drive our state’s high-tech, modern economy.

Growing deeper roots from page 17

influx of new taxpayers and visitors, storm water management, and electrical utility enhancements. The DMC finance plan outlined in the bill is very low risk for the state, but offers a high return to Minnesota. The plan does not direct public dollars to pay for Mayo Clinic’s buildings or facilities. Instead, a formula based on new private capital investments will be used to determine the release of direct state support and local taxing opportunities for public infrastructure, but only after the private investment is made. The plan requires proof of investment by Mayo Clinic and the private sector before financing of any public investments is approved. There are investments we leave to the private markets and those we rightfully expect government to make on behalf of everyone. Mayo Clinic came to the Capitol during the 2013 legislative session not asking for a check, but rather, seeking commitment from the State of Minnesota to provide support for a strong, long-term partnership with the city of Rochester and Olmsted County to provide normal government services that could accommodate significant private growth. Rochester already has committed to spending $339 million during this period to help improve infrastructure in

The Minnesota Legislature approved a $585 million funding package for Mayo’s DMC plan on May 20. The state’s long-term investment in Rochester will complement Mayo Clinic’s offer of unprecedented private investment and the strong commitment from local business and government partners. The legislative debate about the Destination Medical Center initiative was not simply about whether we supported Mayo Clinic’s future in Minnesota, but whether we wanted a Minnesota that invests in a skill-based economy and high-quality jobs. All in all, it was not such a tough decision. Rep. Kim Norton represents District 25B (Rochester) in the Minnesota House of Representatives. She is vice-chair of the House Health and Human Services Finance committee.

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 OCTOBER 2013

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