Minnesota Physician February 2011 by Minnesota Physician Publishing

Volume XXlV, No. 11

February 2011

The Independent Medical Business Newspaper

Neurobiology of loneliness Meaningful human connection is vital to mental health By Kevin Turnquist, MD

he person who tries to live alone will not succeed as a human being. His heart withers if it does not answer another heart. His mind shrinks away if he hears only the echoes of his own thoughts and finds no other inspiration.” — Pearl S. Buck, novelist

By Linda Van Etta, MD, FACP, and Jon Thomas, MD, MBA

he Institute of Medicine’s landmark report, “To Err is Human,” released in 1999 and followed by several additional reports, made it clear that many patients in the U.S. health care system do not receive the right care or safe care. These reports, along with the patient safety initiatives by the Joint Commission, the Centers for Medicare & Medicaid Services, and the Institute for Healthcare Improvement, have

COMPETENCE to page 10

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Are better tools needed for maintenance of licensure?

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competence

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focused on systems issues and errors, rather than physician incompetence, as the major cause of errors resulting in patient harm. There has been no major study showing significant physician incompetence in the U.S., but public opinion polls, consumer advocacy groups, health care purchasers, insurers, and managed care organizations nonetheless have called for physicians to be required to regularly demonstrate their competence. At present, most state medical boards require physicians to complete a certain number of continuing medical education (CME) credits and pay a fee to renew their medical license. Physicians are also required to answer a number of questions pertaining to malpractice cases, disciplinary action taken against them by

How strange that Pearl Buck’s view of loneliness would turn out to be true on a basic neurological level nearly half a century after she wrote these words. For neurobiologists are now learning that loneliness does indeed have profound effects on brain structure and functioning. Human beings are troop primates by nature. Prolonged loneliness is antithetical to our primal impulse to be a part of a group. The brain reacts to loneliness as an emergency situation. The hormones of our stress response—the glucocorticoids—are kept at an elevated level. LONELINESS to page 14

IN THIS ISSUE:

Cardiology research Page 20

6aa > lVciZY lVh id Zi WVX` ^c i]Z hVYYaZ V\V^c# And I did, thanks to Bethesda Hospital, member of HealthEast® Care System.

After a vicious attack fractured her skull and left her in a coma, Tracy Hacker had to learn, not just how to walk again, but also how to be patient with slow, steady progress—a challenge for the energetic horseback rider. Tracy received the full continuum of care available at Bethesda: As an inpatient, brain injury specialists collaborated closely with the respiratory specialty care team. In addition, on-site psychologists aided her progress, with physical medicine and rehabilitative outpatient followup services continuing her care. Tracy’s recovery was nothing short of a miracle, and she gives her Bethesda team full credit: “I think it was all the littlest ways they helped me that really made the biggest difference.” For more information about Bethesda Hospital in St. Paul, Minnesota, visit bethesdahospital.org or call 651-232-2000.

CONTENTS

FEBRUARY 2011 Volume XXIV, No. 11

FEATURES Physician competence Are better tools needed for maintenance of licensure?

MINNESOTA HEALTH CARE ROUNDTABLE

By Linda Van Etta, MD, FACP, and Jon Thomas, MD, MBA

Neurobiology of loneliness Meaningful human connection is vital to mental health

By Kevin Turnquist, MD

DEPARTMENTS CAPSULES

MEDICUS

INTERVIEW

PROFESSIONAL UPDATE: PHYSICAL THERAPY AND REHABILITATION Keeping dancers on their toes 16 By Brad R. Moser, MD

PROFESSIONAL UPDATE: PHYSICAL THERAPY AND REHABILITATION Aftereffects of an epidemic 18

Nanette Larson Minnesota Department of Corrections

By Barbara P. Seizert, MD

WOMEN’S HEALTH Vaginal delivery after cesarean delivery

By Sarah Manneh, MD

SPECIAL FOCUS: CARDIOLOGY RESEARCH CPR research

The ICE Trial

By Keith G. Lurie, MD, and Demetris Yannopoulos, MD

By Albert Deibele, MD, FACC, FSCAI, FAHA

Percutaneously treating complex valve disease 22

New technology extends research

By Wes Pedersen, MD, Vib Kshettry, MD, Kevin Harris, MD, Robert Hauser, MD, Ben Sun, MD, and Irvin F. Goldenberg, MD

By Peter Eckman, MD

Improving survival post-heart transplant

By Monica Colvin-Adams, MD, MS

The Independent Medical Business Newspaper

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

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

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

The Wellness Revolution

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

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

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FEBRUARY 2011 MINNESOTA PHYSICIAN

CAPSULES

Governor Appoints Ehlinger to Head MDH, Jesson for DHS In the early days of his administration, Gov. Mark Dayton chose a public health expert to lead the Minnesota Department of Health (MDH) and a health policy lawyer to head the Minnesota Department of Human Services (DHS). Edward Ehlinger, MD, has led the University of Minnesota’s Boynton Clinic since 1995, and before that worked at the Minneapolis Department of Public Health. In announcing Ehlinger’s selection to head MDH on Dec. 31, Dayton noted his work in public health and his strong ties to the medical community. “Dr. Ehlinger’s long experience in public health and in leading a key Minnesota health facility position him well to lead the Minnesota Department of Health and to restore our state’s former preeminence in national health care initiatives,” Dayton said. On Jan. 11, Dayton announced that Lucinda Jesson,

JD, would be the new commissioner of DHS. Jesson is the founding director of the Health Law Institute at Hamline University, and a former deputy attorney general for Minnesota. “Lucinda Jesson is the right person to lead this critical agency forward,” Dayton said. “Addressing the significant challenges before us requires her expertise in health policy and law, her experience managing large organizations, and her ability to bring creativity and innovation to an agency that is on the front lines, working directly with thousands of Minnesotans.” Jesson will certainly see challenges in her new role. DHS programs represent a large part of the state’s budget, and the department will likely be faced with funding cuts as Dayton struggles to address the state’s $6 billion deficit. A pending Medicaid expansion will switch nearly 100,000 Minnesotans from existing state programs to a new program with expanded services. Officials from the outgoing Pawlenty administration

ICSI/IHI

Colloquium Thriving in an Era of Health Care Reform

MINNESOTA PHYSICIAN FEBRUARY 2011

estimated it would take nine months to change to the new system, but Dayton has set March 1 as the start date for the expanded coverage.

Blue Cross Expands Online Care Service To All Minnesotans Blue Cross and Blue Shield of Minnesota has expanded its online health service to all Minnesotans. The Online Care Anywhere service was first introduced one year ago as a pilot program serving Blue Cross employees, but it has since been expanded to employer groups and is now available to all Minnesotans at www. onlinecareanywheremn.com. Online care services are becoming more common; both HealthPartners and UnitedHealth Group have introduced online care options in the past few months, but Blue Cross officials say that their experience gives them an advantage.

Attend the 14th Annual ICSI/IHI Colloquium on Health Care Transformation, May 16–18, 2011, Saint Paul RiverCentre Last year’s ICSI/IHI Colloquium achieved record attendance and received rave reviews. This year’s program will equally help you successfully navigate the new health care landscape. The program and pre-conference workshops will focus on “Advancing Accountability, Affordability and the Patient Experience” along three tracks: 1. Leadership and Accountability 2. Quality and Safety 3. Patient Engagement/Consumer Experience

“We were really an innovator in launching this type of service in the Twin Cities,” says Sig Muller, vice president of business development at Blue Cross. “We’ve been in the market for more than a year now and it’s really important to us as part of our mission to provide broader access to health care and help drive down costs.” The Blue Cross service is modeled after a traditional doctor’s office visit and is staffed by providers from Fairview Health Services, including physicians and nurse practitioners. Users can connect face to face with providers via webcam, or can access the service by phone. Blue Cross officials stress the convenience that such a service offers and say consumers have reported saving an hour per visit with physicians online as opposed to traveling to a clinic in person. Muller says the average online visit lasts 13 minutes and costs $45. Blue Cross insurance is accepted or consumers can pay with a credit card.

Our Keynoters are: Susan Dentzer, Editor-in-Chief, Health Affairs: Implications and Opportunities in the New Era of Health Care Jane Sarasohn-Kahn, THINK-Health: Participatory Health — The New Patient Engagement Register Early and Save Don’t miss the Upper Midwest’s most important event to help you thrive today and position your organization for tomorrow. To register and view the preliminary program, go to http://bit.ly/cfBu5h

Minnesota Ranks 6th In UHG Annual Report Minnesota is the sixth-healthiest state in the nation, according to UnitedHealth Group’s annual “America’s Health Rankings.” The yearly report finds that the nation’s overall health improved by one percentage point last year, but higher rates of uninsurance, along with increases in diabetes and obesity, are among worrisome national trends. “The rate of gain, while positive, is wholly inadequate for us as a nation. We know with certainty that many people will suffer consequences of preventable disease unless we strengthen individual healthiness, community by community across America,” says Reed Tuckson, MD, UHG’s executive vice president and chief of medical affairs. Minnesota has often ranked in the top five states in the rankings, but for the past two years it has dropped to No. 6. The UHG report says the state has low rates of premature death and uninsurance, but challenges remain, including the area of public health care funding and a relatively high rate of binge drinking.

Medica Program Ranks Physicians For Quality, Cost Medica has begun offering a Web resource that rates Minnesota physicians by cost and quality information. On Jan. 19 the Minnetonkabased company made its Premium Designation program available to all Medica members as part of Find a Doctor, Medica’s online provider search tool. Physicians are rated in a zero-to-two-star system: If they meet quality measures they gain one star; if they also meet cost-efficiency benchmarks they receive two stars. The new ratings are in response to demand for more information on health care providers from consumers, especially large employer groups that buy Medica prod-

ucts, according to Jim Guyn, MD, Medica’s medical director for provider relations. “Larger national employers … in a lot of other markets around the United States, had the availability to look at the individual physicians and they wanted it in this market as well, and that was really the motivating factor for us,” he says. “Cost and quality information down to the provider level is something that’s going on all over the country.” The program differs from “tiered” products that health plans in Minnesota have offered in the past because those earlier products looked at measurements on the clinic or hospital level, rather than at individual physician measurements. Tiering also encouraged providers to compete for enrollees by how they set their rates; the new system measures cost efficiency. Physician groups such as the Minnesota Medical Association have raised questions about the fairness of provider ratings, but Guyn notes that the program’s methodology is risk-adjusted and says that Minnesota physicians should rank well, based on previous data. The measurements are based on claims data, which Guyn says is not perfect. However, he says Medica will continue to refine the system as time goes on. “A perfect rating system doesn’t exist, but this is probably the best that’s out there,” he says.

Pertussis Vaccination Campaign Get Your Shots Minnesota is combating a high rate of pertussis. It’s imperative that physicians and their staff be immunized. Physicians and their clinics can join the Pertussis Vaccination Campaign to immunize staff, and limit exposure and the potential to spread pertussis to patients. Help the Minnesota Academy of Family Physicians Foundation in its campaign to protect patients, physicians and health care workers against pertussis. To sign up for a free campaign kit for your clinic, contact Lynn at 952-224-3873 or foundation@mafp.org. To learn more, visit www.mafp.org/foundation.asp

Dayton Hears Out Foes, Then Signs Medicaid Measure In an unusual signing ceremony on Jan. 5, Gov. Mark Dayton signed an executive order expanding Medicaid coverage for poor Minnesotans and also let protesters take the podium to express their opposition to the measure. Signing on to the Affordable Care Act’s measures for a Medicaid opt-in program was a campaign promise of Dayton’s.

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CAPSULES to page 6 FEBRUARY 2011

MINNESOTA PHYSICIAN

CAPSULES

Capsules from page 5

ter reimbursement rates to providers and allow more hospitals and clinics to treat poor Minnesotans. Both the Minnesota Medical Association and the Minnesota Hospital Association (MHA) released statements supporting Dayton’s decision to sign on to the program. “It is important to note that our poorest residents will now have access to primary care, dental care, mental health services, and an array of other outpatient clinical services on a statewide basis. Physician and preventive care will now be more accessible to this population,” says Lawrence Massa, MHA’s president and CEO. “Even though providers are paid less than the actual costs of giving care, early Medicaid enrollment of poor single adults will help ease the burden of growing uncompensated care, which happens when the uninsured access care in hospital emergency rooms.” At the signing ceremony, opponents of the measure questioned whether the state could

The existing stripped-down program to serve the state’s poorest and sickest residents has been criticized as inadequate, and only four hospitals, all in the metro area, are participating in the program. At the signing ceremony in the state Capitol building, Dayton calmed a large crowd and told them that opponents as well as supporters of the measure would be allowed to speak. Dayton said the Medicaid opt-in measure would provide coverage to 95,000 Minnesotans and create up to 20,000 jobs at no net cost to the state. “This money goes to benefit the lowincome recipients, but really the dollars themselves go to Minnesota hospitals and doctors, nurses, and others who provide essential health care to all these citizens and to all of us,” Dayton said. Dayton added that health care providers had urged him to sign on to the Medicaid optin because it would deliver bet-

afford the long-term costs of covering poor Minnesotans and said such programs were better provided by religious charities. “[This] really puts the state in peril when it comes to cost,” said Twila Brase, president of the Citizen’s Council for Health Freedom. “Once all these people are on, it will be difficult to get them off and it will be expensive to the state for the long haul.”

Sanford Health to Expand Services In Moorhead Sanford Health is planning to build a new facility and significantly expand services in Moorhead, officials with the Sioux Falls-based system announced last week. While many details have yet to be determined, Sanford has purchased 24.5 acres for the new clinic on the southeast part of town, and officials say the project will be completed in the next few years.

“The clinic will be uniquely Moorhead in terms of scale and design and will offer an architectural gateway to the community from the east,” says Bruce Pitts, MD, Sanford Clinic president. “We are working closely with leaders from the city of Moorhead, Clay County, and our local patients to ensure we are building a facility that will provide a wide range of services to the area for years to come.” Officials note Sanford’s long-standing commitment to Moorhead. The MeritCare system, which merged with Sanford in 2009, opened its first clinic in the community in 1985 and Sanford currently has three facilities in the area. Its current clinic is 16,700 square feet, and has 26,000 patient visits annually, nine providers, and more than 40 employees.

Upcoming CME Courses www.cmecourses.umn.edu Office of Continuing Medical Education U 612-626-7600 or 1-800-776-8636 U email: cme@umn.edu

2011 CME SPRING COURSES Cardiac Arrhythmias: An Interactive Update for Primary Care March 25, 2011

ON-LINE CME COURSES

“Bridging the Transition to Life after Cancer Treatment” Cancer Survivorship Conference April 29 – 30, 2011

12th Annual Psychiatry Review Coming in September, 2011 Pediatric Clinical Hypnosis September 15 – 17, 2011

Courses available for CME credit. s Reducing Recurrent Preterm Birth s ECG of the Week s The Reality of Fibromyalgia: Pathways to Diagnosis, Therapy, and Quality of Life s Adult Congenital Heart Disease

Bariatric Education Day May 25 – 26, 2011

Pediatric Trauma Summit September 22 – 23, 2011

All courses are held in the Twin Cities unless noted

Workshops in Clinical Hypnosis “Introductory and Advanced Sections” June 2 – 4, 2011

Practical Dermatology Late September 2011

12th Annual Lillehei Symposium: Cardiovascular Care for Primary Care Practitioners April 18 – 19, 2011

Topics and Advances in Pediatrics June 9 – 10, 2011 Advances in Breast, Endocrine, and Cancer Surgery June 16 – 18, 2011

2011 AHRQ National PBRN Research Conference June 22 – 24, 2011

MINNESOTA PHYSICIAN

Global Health Training August 1 – 26, 2011

UP-COMING FALL 2011 COURSES

Twin Cities Sports Medicine September 30 – October 2, 2011 Transplant Immunosuppression “The Difficult Issues” October 12 – 15, 2011 Internal Medicine Review and Update November 2 – 4, 2011

FEBRUARY 2011

MEDICUS

Two physicians were recognized for their service to the community at the annual meeting of Lakeview Hospital medical staff. Elmer Kasperson, MD, was recognized for his leadership in the surgery department. The award noted that Kasperson was instrumental in the initiation of the surgical residency program affiliation with the University of Minnesota. Kasperson, a board-certified general surgeon, Elmer Kasperson, MD earned his medical degree from the University of Chicago and completed his internship and residency at the University of Minnesota. He has been with Stillwater Medical Group since 1999. Alan Downie, MD, was recognized for his long commitment to Lakeview Hospital’s medical staff leadership. He served as surgery department chair for two years, followed by eight years on the medical executive committee, including two years as chief of staff. Downie, who practices at Associated Eye Care, completed his medical degree and residency at Ohio State University. A boardcertified ophthalmologist, Downie was initially appointed to Lakeview’s active staff in 1995. Alan Downie, MD Erik Mikkelsen, MD, has joined Children’s Hospital staff and Children’s Respiratory and Critical Care Specialists, PA as a pediatric intensivist. Mikkelsen finished a pediatric critical care fellowship at Cincinnati Children’s Hospital in 2010 while simultaneously obtaining a master of education in curriculum and instruction at the University of Cincinnati. He attended the Medical College Erik Mikkelsen, MD of Wisconsin-Milwaukee and completed his pediatric residency at Children’s Mercy Hospital in Kansas City, Mo. April Grudell, MD, has joined Minnesota Gastroenterology. She completed her residency and GI research fellowship training at Mayo Clinic in Rochester. Subsequently, she completed a clinical gastroenterology/hepatology fellowship at the University of Michigan in Ann April Grudell, MD Arbor. Grudell is a board-eligible gastroenterologist with special interest in functional bowel disease and in motility disorders, including gastroparesis, post-vagotomy dysmotility, and chronic constipation. She sees outpatients at the practice’s Coon Rapids office and is on staff at United Hospital. Paul Terrill, MD, received the community-nominated Physician of the Year award for 2010 from the Lake Superior Medical Society. The award is given in recognition of “consistently demonstrating qualities recognized as defining excellence in medical care delivery.” Terrill attended medical school at the University of Minnesota in Duluth and Minneapolis, and completed his residency in family practice in Duluth. He joined Sawtooth Mountain Clinic in 1991 as a board-certified family practice physician. James Vodvarka, DO, has joined the St. Luke’s health system as an internal medicine specialist at Hibbing (Minn.) Family Medical Clinic and Laurentian Medical Clinic, in Mountain Iron, Minn. Vodvarka received his doctor of osteopathic medicine degree from the University of New England’s College of Osteopathic Medicine in Biddeford, Maine. He completed James Vodvarka, DO his internship at Central Medical Center and Hospital in Pittsburgh and his residency in internal medicine at West Penn Hospital in Pittsburgh. He is board-eligible in internal medicine.

REQUEST FOR NOMINATIONS

2011 HEALTH CARE ARCHITECTURE & DESIGN

HONOR ROLL NOMINATION CLOSING: FRIDAY, MAY 6, 2011 PUBLICATION DATE: JUNE 2011

Seeking Exceptionally Designed Health Facilities Minnesota Physician announces our annual Health Care Architecture & Design Honor Roll. We are seeking nominations of exceptionally designed health care facilities in Minnesota. The nominees selected for the honor roll will be featured in the June 2011 edition of Minnesota Physician, the region’s most widely read medical publication. Eligible facilities include any structure designed for patient care: hospitals, individual physician offices, clinics, outpatient centers, etc. Interiors, exteriors, expansions, renovations, and new structures are all eligible.

In order to qualify for nomination, the facility must have been designed, built or renovated since January 1, 2010. It also must be located within Minnesota (or near the state border within Wisconsin, North Dakota, South Dakota or Iowa). Color photographs are required. If you would like to nominate a facility, please fill out the nomination form below and submit the form, three to eight 300 resolution color photographs, and a brief project description by Friday, May 6, 2011. For more information, call (612) 728-8600.

2011 HEALTH CARE ARCHITECTURE & DESIGN HONOR ROLL NOMINATION FORM FACILITY NAME TYPE OF FACILITY LOCATION OWNERSHIP ORGANIZATION OWNER CONTACT NAME and PHONE OWNER ADDRESS CITY, STATE, ZIP ARCHITECT/INTERIOR DESIGN FIRM ARCHITECT CONTACT NAME and PHONE ARCHITECT ADDRESS CITY, STATE, ZIP ENGINEER CONTRACTOR COMPLETION DATE TOTAL COST SQUARE FEET NUMBER OF COLOR PHOTOS ENCLOSED [Note: Please include a caption for each photo] NOMINATION PROCEDURE: Send this form or a separate sheet with all the above information, a project description (150–250 words), and 300 resolution color 8”x10” digital or glossy photographs (no more than eight) to: Honor Roll Minnesota Physician Publishing, Inc. 2812 East 26th Street, Minneapolis, MN 55406 For further information, please phone (612) 728-8600, fax (612) 728-8601 or e-mail comments@mppub.com.

FEBRUARY 2011

MINNESOTA PHYSICIAN

INTERVIEW

Minnesota inmates get health care inside, outside ■ Tell us about the facilities in Minnesota for

which you oversee health care delivery.

Nanette Larson Minnesota Department of Corrections Nanette Larson has been the director of health services for the Minnesota Department of Corrections for more than 11 years. She is responsible for the care and well-being of more than 9,300 incarcerated men, women, and juveniles. Larson has held leadership positions in other state agencies, including the Minnesota Department of Health and the Office of Technology, and was the executive director for the Minnesota Health Care Commission.

The Department of Corrections has nine prisons, seven male, one female, and one juvenile male. Then we have two boot camps. We have a total of about 9,300 offenders. We have five different custody levels, minimum through maximum security. Each of our prisons has an ambulatory clinic. Most of our sites have at least one practitioner on-site five days per week. Most of our staff are ■ How is prisoners’ health care paid for? nurses, and the nurses provide a variety of services to our offender population including sick call triag- My budget for fiscal year 2011 is about $68 million for medical, nursing, dental, mental health care, ing, implementing physician standing orders, sex offender, and chemical dependency treatment. patient education, medication administration, and My budget is entirely state general fund money. management of chronic care. At our female facility We don’t get Medical Assistance, Medicare dollars, at Shakopee, we also have on-site ob/gyn care, Veterans, or Social Security. We do get a little bit including prenatal care through delivery. of federal grant money for some of our chemical We have two units that are specialty care. Our Linden unit, which is housed at Faribault, provides dependency programming, but it’s mostly state general fund money. care for adult males who In 1998, the department need a close level of monitormade a conscious decision to Getting providers ing, but not necessarily acute be better purchasers of health services. If they’re relatively to see our offenders care. Prior to our contract able to perform their daily in the community is with CMS, each institution activities with minimal assiswas responsible for purchassometimes challenging. tance, they live there. ing and managing its own Paraplegics, quadriplegics, health care. Not only was that and much of our geriatric inefficient, but it allowed the offenders to play one population live there. We might have some folks physician against another, because we do a lot of with Alzheimer’s there, coronary artery disease, transferring of our offender population. So the certainly hypertension. doctor in Stillwater might say you can have someOur 48-bed transitional care unit at Oak Park thing, and then the offender would be transferred Heights provides a higher level of care. We provide to Moose Lake and they might get the opposite services such as IV therapy, dialysis services, response from the physician up there. wound care, pre- and post-surgical care, hospice So we centralized health care. We contracted care, and management of other complex conditions with CMS, who has the expertise in correctional that require intensive nursing intervention. health care, and we became much better pur■ Would that facility be considered a hospital? chasers. We started implementing many managed We consider it a subacute level of care. We don’t do care principles, for example utilization management. The implementation of a prescription drug surgery, so it wouldn’t be considered a hospital in formulary was very helpful. that respect. We can’t do chemotherapy there, but We continue to look at our community partit provides a very high level of care. ners, the hospitals that we use. We look to them to We take offenders who need inpatient hospital negotiate volume discounts. With us, it’s not just services or specialty care to community providers the health care costs, but it’s those security and for those kinds of services. transportation costs when we have to send an When offenders go off-site, our primary misoffender off-site that impact our budget as well, so sion is public safety. The prisoners are escorted by we are trying to figure out what else we can protwo officers, and they wear orange jumpsuits, an vide on-site. orange jacket during the winter, and wrist, waist, and ankle shackles. One last detail about our delivery system is that we charge our offenders copayments. It’s $3, but for many offenders who are making 50 cents or a dollar an hour, $3 for a copay is pretty hefty. ■ Where do you get your providers?

In 1998, the department made a decision to centralize and privatize our health care, and we started contracting with an entity called Correctional Medical Services (CMS). They are a correctional

health care management company out of St. Louis, and they provide primary care practitioners and psychiatrists at the prisons. All our physicians are independent contractors through our contract with CMS. They contract with community providers for inpatient and outpatient hospital care and specialty care. CMS provides ancillary services such as physical therapy, optometry, dental care, and all of our prescription medications come through them.

MINNESOTA PHYSICIAN FEBRUARY 2011

■ Are you affected by rising health care costs?

Certainly we are impacted by rising health care costs, just like the community. We try to manage our contract with CMS as best we can within the budget that’s allocated to us. At times we have had to request a supplemental budget because of increased health care costs, but we try to manage with what we have and what the Legislature has appropriated to us.

■ What are the most common kinds of

health services that prisoners receive? About 75 percent of the health care that we provide is primary care. We deal with everything that you would see in the community, from upper respiratory infections and seasonal influenza to very serious medical conditions. We truly deal with everything—cancer, coronary artery disease—and our population probably has a higher incidence of hypertension, diabetes, asthma, and liver issues just because of their high-risk behaviors. We also have 20 to 25 pregnancies per year. We pretty much see anything that a family practice would see. ■ What are the biggest challenges in pro-

viding health care to this population? One of our biggest challenges is that the offenders don’t take very good care of themselves when they’re on the outside. Probably 95 percent of our offenders will be leaving us, so we want to provide them with some education to make them a bit more responsible for their health care when they get out. But they don’t have health insurance in coming to us, so whatever primary care they’ve received has been pretty nonexistent or it’s been through emergency rooms. Many of them have high-risk behaviors, so chronologically they might be 55, but physiologically they look more like 65. You’re just dealing with an older, sicker population. Getting

them to take responsibility for their health care decisions is always a challenge. ■ Is there a shortage of providers, and how

difficult is it to recruit and retain them? It is an issue. It’s CMS’s responsibility to do the recruiting, but it’s our responsibility in partnership with them to retain them. We have a hard time finding psychiatrists, for example. We are always looking for licensed alcohol and drug counselors or other licensed mental health professionals. We are part of the Federal Loan Forgiveness Program for primary care and mental health, so to the extent that we can use that as the carrot, we like to do that. Going into a prison and working with prisoners can be a little scary for some folks, but I have to say it’s a very safe place. One of our unique challenges is the litigiousness of our population. They like to write board complaints. I have had providers who have never had a board complaint until they started working for us. Granted, the board complaints are unsubstantiated, but nevertheless it’s wearing on the providers. So dealing with our population on a day-to-day basis can be very taxing, which is one of the retention issues. ■ Are the state and federal health care

reform laws affecting how care is delivered in the prison setting?

To date, no. There were a number of specific places in the health care reform act where prisoners were excluded, so right now they are not having an effect. However, some of the administrative things like the mandates for electronic health record and health information exchange and e-prescribing will certainly be impacting us and our population. ■ What changes would you like to see in

the way health care is provided in prison facilities in Minnesota? I would really like to be able to provide more care on-site. Getting providers to see our offenders in the community is sometimes challenging, because they go off-site in the orange jumpsuits and the shackles, and then they have to sit in the waiting room next to Grandma. So to the extent that we can provide more care on-site, it’s consistent with our public safety mission, it’s much more convenient for our staff because we don’t have to have the officers taking them off-site. I think it just all around would be better. We are always challenging ourselves to try to improve our health care delivery system and see where we can do things better or more efficiently, and to the extent that we can do it internally, we would want to do that.

FEBRUARY 2011

MINNESOTA PHYSICIAN

Competence from cover a medical staff or professional society, and whether they have been diagnosed or are currently abusing alcohol or mood-altering drugs. The current debate is focused on whether these current requirements for mainte-

exam? Or is competence the ability to provide safe patient care that meets the standard of care? However, all national licensing, certifying, and privileging organizations agree on and accept the six competencies the Accreditation Council for Graduate Medical Education

Medical Licensing Examination (USMLE)—the so-called “national boards”—during medical school and residency. Successful performance on the USMLE predicts success at the next level. After completing residency, many graduates then take a board certification examina-

In Minnesota, most physicians age 50 and older hold lifetime board certificates and those under age 50 have time-limited certificates. nance of licensure (MOL) are enough to assure practicing physicians are competent. Defining competence

Licensing and certifying organizations often cannot agree on a definition of physician competence, and there is even less agreement on what type of testing assures competence. Is competence the ability to answer knowledge questions on a secure

(ACGME) expects of new practitioners leaving residency: • Patient care • Medical knowledge • Practice-based learning and improvement • Interpersonal and communications skills • Professionalism • Systems-based practice For decades, U.S. physicians have been tested using the U.S.

tion. These exams are given by one of the 24 component boards of the American Board of Medical Specialties (ABMS) for allopathic physicians and by the Bureau of Osteopathic Specialties (BOAS) for osteopathic physicians. Lifetime certificates have been granted for most specialties, though family medicine has always had a time-limited

certificate that requires a recertification exam every decade. Over the past two decades, the other ABMS boards have moved to time-limited board certification as well, with all 24 boards compliant as of 2007. Full implementation will not occur until 2016. Despite the move to timelimited certificates, the process of recertification varies depending on the specialty. The larger specialties such as internal medicine and pediatrics have a more developed and mature process. In internal medicine, a secure exam is required every 10 years. Certificate holders also have to complete learning modules and open-book questions as part of this maintenance of certification (MOC) model. The BOAS has also moved to this MOC model. Some specialties, such as pathology, have only recently moved to time-limited certificates, so the majority of certificate holders currently hold lifetime certificates. Lifetime certificate holders can elect to participate in MOC, but according to the American Board of Internal

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Revisiting MOL

In 2003 the Federation of State Medical Boards (FSMB) convened the Special Committee on Maintenance of Licensure, charged with developing a position statement on the responsibility of state medical boards in ensuring physician competence over the course of his or her career. In May 2004, it became official FSMB policy that state medical boards have a responsibility to the public to ensure the ongoing competence of physicians seeking relicensure. The Minnesota Board of Medical Practice (BMP), a member of the FSMB and the authority that licenses and disciplines physicians in Minnesota, created a taskforce to study MOL in order to understand what implications could result from any recommendations that might come from the FSMB committee. The taskforce consisted of representatives of the BMP, the Minnesota Medical Association, the dean of the University of Minnesota Medical School, and representatives of major specialty societies, including family medicine and internal medicine, as well as representatives of the Minnesota Hospital Association, and insurers. Stephen Miller, MD, MPH, then chief executive officer of the ABMS, was also a member. The taskforce met regularly from August of 2006 through October of 2008 and continues to meet ad hoc at present; its most recent meeting was in October 2010. The Minnesota BMP directed the MOL taskforce to determine whether the current requirements for licensing physicians in Minnesota constitute an adequate demonstration of competency—and if not, to recommend what new requirements should be added. Any new

requirements would have the following characteristics: • Available to all licensed physicians and osteopaths, with all eligible • Acceptable to the public, regulators, and physicians • Non-punitive • Not onerous or duplicative of what physicians are already doing • Not dissuade physicians from practicing in Minnesota The MOL taskforce reviewed all the existing literature regarding maintenance of competency. The board’s computer database was also used to compile information regarding ages and specialty board certification of our physician population. We also looked at whether the physician held a lifetime or a time-limited certificate. Speakers were invited to educate taskforce members about all current CME programs provided in Minnesota. Some have suggested that the easiest requirement to implement for all physicians to demonstrate their continuing competency is to have them participate in the ABMS MOC program or the equivalent BOMS program for osteopathic physicians. ABMS has, until recently, stated that 85 percent of physicians in the U.S. hold ABMS certificates. We were surprised, therefore, to find that only 75 percent of Minnesota physicians were board-certified. ABMS has recently restated its percentage, now claiming that about 69 percent of U.S. physicians are board-certified through their organization. Only board-certified physicians can participate in MOC. ABMS has also stated that there is robust data showing that board certification results in improved patient outcomes. Our review, however, showed that the data are limited and apply to single criteria such as percentage of patients receiving mammograms. No data exist showing that the MOC program results in improved patient outcomes. ABMS is working to develop such data. Approximately 60 percent of ABMS certificates are currently time-limited, but the percentage varies widely depending

on the specialty. In Minnesota, we found, most physicians age 50 and older hold lifetime board certificates and those under age 50 have time-limited certificates. However, in several critical specialties that have only recently implemented time-limited certificates, such as pathology and radiology, the vast majority of physicians hold lifetime certificates. This could lead to a severe shortage in these specialties if new requirements resulted in physicians electing to leave practice. There is concern that a physician’s knowledge and skills decrease the longer he or she is in practice. This is a major reason cited for the need for MOL requirements to be more rigorous. The article most commonly quoted to support this assertion was written by Niteesh Choudhry, MD, and associates and published in Annals of Internal Medicine in 2005. The authors did a systematic review of the literature. They concluded that of the 62 papers they reviewed, 32 showed decreasing performance with increasing

2011 Winter Conference

Medicine, one of the 24 component boards of the ABMS, only 1 percent of their lifetime certificate holders have chosen to participate. The concern of lifetime certificate holders is that they might lose their certification if they fail the test. What they don’t understand is that they cannot legally lose their lifetime certification regardless of their performance on the test.

years on practice for all outcomes assessed. However, their outcomes included scores on secure exams, not just patient outcomes. Indeed, the only consistent negative-associated outcome was with exam scores. Only six of the studies even looked at patient outcomes and the results were mixed, with several showing no association with time in practice. In an article published in Circulation in 2008, the conclusions of Alexander Turchin, MD, and colleagues supported the need for mandatory recertification. They looked at intensification of antihypertensive treatment in diabetic patients whose blood pressure was too high at the time of an office visit. Only 6.9 percent of physicians who had been board-certified at least 31 years before the visit increased or changed the antihypertensive medication. Physicians who had been board-certified the previous year increased the medication 26.7 percent of the time. Although this was a better percentage, nearly 75 perCOMPETENCE to page 12

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MINNESOTA PHYSICIAN

Competence from page 11 cent of patients still did not receive the proper care for their blood pressure, even though these physicians were considered very competent based on their having passed an ABMS board certification within the previous 12 months. Continuing study

The FSMB special committee on MOL released its draft report for comment in November 2007. Because the Minnesota taskforce had been studying MOL and reporting back to the Minnesota Board, we were able to provide significant input to the FSMB during that feedback period and during the annual meeting in 2008, where the federation voted to adopt the broad principles developed by the committee. Minnesota was also invited to present our findings at the FSMB annual meeting in 2009. In April 2010, the FSMB House of Delegates adopted Maintenance of Licensure as official. A MOL Implementation Group was convened to develop the steps necessary for a state to

fully implement MOL. The components of MOL are: â&#x20AC;˘ Reflective self-assessment: done through self-review tests such as those associated with MOC, medical society-based, etc. â&#x20AC;˘ Assessment of knowledge and skills: done through MOC secure exam or peer surveys, performance improvement modules, participation in SCIP or AMI modules, etc. A secure exam is not required. â&#x20AC;˘ Performance in practice: done through 360-degree evaluations or other performance projects such as CAP, ABMS, AOA, etc. MOL builds on the six competencies of ACGME in a model of continuous professional development. The FSMB advisory committee has recommended that MOL changes be â&#x20AC;&#x153;evolutionary, not revolutionary.â&#x20AC;? The goal of MOL is not to add another layer of regulation or to endorse a certifying organization. Rather, the goal is to introduce a framework that gives physicians multiple options to meet the requirements through attestation. For a

board-certified physician with a time-limited certificate, participation in MOC would satisfy MOL. Physicians who are not board-certified or who have lifetime certificates would have a variety of other ways of satisfying MOL without having to take a test. MOL seeks to recognize what many dedicated, caring, and conscientious physicians already do. Several states have the regulatory authority to implement MOL and want to start pilot projects with FSMB assistance. Several states without the regulatory authority have expressed a desire to move forward, recognizing that they would have to change their medical practice acts. Others have sought assistance in taking the first steps. The Minnesota taskforce has recommended to the Minnesota BMP that no changes to licensing requirements be made at this time. The Minnesota Board and its taskforce will continue to monitor the literature closely and follow developments at the FSMB and in other member states. Without clear evidence

as to what added requirements for physicians will result in improved patient safety and outcomes, it is difficult to choose the right path or to strongly endorse any new path at present. As the Minnesota Board of Medical Practice continues to explore this topic, we welcome feedback from physicians. Please share your concerns, ideas, and comments by e-mailing comments@mppub.com. Linda Van Etta, MD, FACP, was chair of the Minnesota Board of Medical Practice Taskforce on Continuing Competency and Maintenance of Licensure from 2006 to 2009. She is hospital epidemiologist for the St. Lukeâ&#x20AC;&#x2122;s system, Duluth, and serves on multiple medical staff committees, including the executive committee and the quality committee as well as physician credentialing committee. Jon Thomas, MD, MBA, currently serves as chair of the BMP taskforce. He sits on the board of directors of the Federation of State Medical Boards and is the Federation of State Medical Boardâ&#x20AC;&#x2122;s representative to the American Board of Medical Specialties. Thomas is an otolaryngologist and chief operating officer of Ear, Nose, and Throat Specialty Care of Minnesota PA, and is chief of staff-elect at United Hospital in St. Paul.

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

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The Minnesota Visit 2011 His Holiness the 14th Dalai Lama

A special invitation to health professionals: The Second International Tibetan Medicine Conference May 9, 2011 This event will bring to the Twin Cities the foremost practitioners of Tibetan medicine from the Men-Tsee-Khang, the Tibetan Medical Institute of His Holiness the Dalai Lama, in Dharamsala, India. By the end of the conference, participants will be able to meet the following objectives involving Tibetan Medicine: Examine the relationship between ethics, spirituality, and healing. Investigate participants' own unique constitution. Determine what lifestyle choices to make, based on participants' own constitution. Explain how to heal from the source and develop health through balance. Describe research about Tibetan medicine, as well as propose additional research needed. Apply teachings of Tibetan medicine personally and professionally.

etan Ame Tib r

Minnesota of

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

un n Fo dation ica

Loneliness from cover On an unconscious level, we essentially prepare our bodies to travel in search of other humans. Those glucocorticoid hormones have widespread effects on our brains and bodies. The stress hormones oppose the actions of insulin. Weight gain, abdominal obesity, and type 2 diabetes become more likely. The resultant abdominal fat secretes hormones of its own, and those hormones predispose people to anxiety and depression. Researchers have also discovered that lonely people tend to sleep poorly. Adequate sleep is necessary for the healthy functioning of one of the most important brain areas involved in emotional well-being—the hippocampus. This crucial structure manufactures new brain cells every day in response to a protein called brain-derived neurotropic factor (BDNF). Our antidepressant treatments work though this pathway. When people are depressed, their hippocampi may shrink by almost 20 percent, and recovery

involves building new brain cells here. In the schizophrenic illnesses, the hippocampi are often small and misshapen from birth. Patients with borderline personality disorder also commonly have malstructured hippocampi, often in response to emotional traumas suffered while their brains were developing. We’ve learned that both poor sleep and prolonged exposure to glucocorticoid hormones reduce BDNF levels. Interestingly, lack of physical exercise and living in unstimulating environments have exactly the same effect. So if we truly want to optimize the mental health of our mentally ill citizens, we must find ways to provide them with the things that their brains require on a fundamental level. They need mentally stimulating activities, physical exercise, healthy diets, adequate sleep, and freedom from excessive stress hormones. And, most of all, they need to feel that they are connected with other humans. Of course, loneliness and social isolation are not confined

to people with severe mental illnesses. Despite technological advances in communication that would have been unimaginable 50 years ago, at the same time we as a population are becoming more alone. The tightly knit family groupings that have always typified humans have been replaced by casual electronic relationships with relative strangers. Just because we don’t yet understand the long-term effects of such changes on our brain functioning doesn’t mean that they aren’t important. Effects of loneliness manifest physically

Non-psychiatric physicians encounter the effects of loneliness on their patients’ physical health all of the time, but these are not always readily apparent. Common manifestations include difficulty stabilizing blood sugars with conventional diabetic regimens and persistent complaints of insomnia. Some clients will abuse alcohol or other drugs in an effort to deal with the pain of social isolation. And depression itself may pres-

ent in myriad “medical” ways: Unexplained bowel problems, weight loss or gain, fatigue, pain, and heightened anxiety are all commonly encountered. Busy primary care physicians can’t be expected to function as therapists or social workers. Yet when patients don’t respond to conventional treatments in conventional ways, it’s always wise to inquire whether there are psychosocial factors— such as profound loneliness— that might stand as impediments to successful treatment. A tight focus on medication treatments alone may result in escalating dosages of diabetic meds, sleeping pills, or analgesics when the company of other humans is actually what is needed. Even a casual observer of our current mental health system will immediately recognize that we have a problem here. Many of our clients cannot provide these essential social commodities for themselves and we have not, historically, done a good job of helping them in these areas. Far too many of our mentally ill people live extremely

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isolated lives. They have no sense of belonging to a greater community. And their loneliness cuts them off from one of the single healthiest factors for their brains: Laughter reduces the effects of those toxic stress hormones in ways that none of our medications can replicate. Creating communities

“What should young people do with their lives today? Many things, obviously. But the most daring thing is to create stable communities in which the terrible disease of loneliness can be cured.” —Kurt Vonnegut, novelist

Like Pearl Buck, Kurt Vonnegut must have had a real intuitive sense for neurobiology, for creating stable communities is exactly what we must accomplish as a society. There is a widespread tendency to believe that advances in treatment of the mentally ill will come in the form of new and improved medications, yet the most effective pills for the major mental illnesses have all been around for decades. The real breakthroughs

Despite technological advances in communication that would have been unimaginable 50 years ago, we as a population are becoming more alone. in treatment will come, instead, in the form of specially designed living environments that will provide our clients with the things that their brains so vitally need, and the things that they have such a hard time obtaining for themselves. This is precisely what the nonprofit organization Touchstone Mental Health is trying to accomplish with the creation of its proposed model community for the mentally ill, the Rising Cedars facility. Rising Cedars will be a 40unit assisted-living facility for people with severe mental illnesses. Each client will have an independent apartment that he or she can call “home,” but congregate dining and activities will be offered as well. Lounges and common areas will be set up so that people will be able to have

privacy when they need it and opportunities for socialization when they want it. On-site medical and psychiatric care will be combined with a wellness center that will provide a variety of complementary therapies, groups, educational activities, and physical exercise. Work, healthy diets, reliable transportation, horticulture, and ties to existing community supports are all essential elements of the program. When people are in need of increased services, the staff will bring those services right to the client’s residence, rather than continually transport them back and forth from psychiatric hospitals based on fluctuations in their clinical condition. This novel program is based upon principles and ideas that were initially elaborated at

www.kevinturnquist.org. Among those principles is the commonsense idea that we should involve our clients directly when we are designing housing or supportive programs for them. Literally hundreds of suggestions for the development of this facility have been solicited from clients and staff in Touchstone’s existing programs. Project for Pride in Living, the Urban Works architectural firm, and the University of Minnesota College of Design are helping to create a physical environment that will be as close to optimal as we can make it. The hope is that this program will serve as a template for a new generation of residential facilities for the mentally ill and will ultimately change the way that severe mental illnesses are treated for decades to come. Kevin Turnquist, MD, is a psychiatrist at Anoka Metro Regional Treatment Center and a consulting and treating psychiatrist for the ICRS (Intensive Community Rehabilitation Services) pilot program at Touchstone Mental Health. This article is adapted from one that appeared in Touchstone’s Winter 2010 Newsletter.

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PROFESSIONAL

U P D AT E :

Dance injury treatment, research, education

Established in 2009, the Minnesota Dance Medicine Foundation (MDM) is a 501(c)(3)

AND

R E H A B I L I TAT I O N

The Minnesota Dance Medicine Foundation By Brad R. Moser, MD

nonprofit organization of dance medicine professionals dedicated to conducting research and creating educational initiatives to study dance injuries and prevention. MDM’s staff of volunteers is composed of physicians and physical therapists who have had years of experience treating dancers. They provide medical care to dancers in addition to conducting research and offering educational presentations to individual dancers and the dance community at large. Medical services. To help meet the dance community’s needs for specialized care, MDM provides complimentary injury evaluations and screenings to dancers so they can continue to perform without fear of

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THERAPY

Keeping dancers on their toes

innesota has one of the largest dance populations in the U.S., ranking between fourth and sixth nationally. The state’s dance community, encompassing about 250 dance studios, schools, companies, and teams, contributes to the overall quality of the Minnesota arts culture. The art and athletics of dance place unique demands on its participants, resulting in distinctive injuries and injury rates in comparison to other athletes in other sports. Complicating the injury picture, an estimated 30–40 percent of the professional dancers in Minnesota and 20–30 percent of the amateur dancers are uninsured or underinsured, according to the Dance/USA Taskforce on Dancer Health (Dance/USA is the national, nonprofit service organization for professional dancers).

PHYSICAL

MINNESOTA PHYSICIAN FEBRUARY 2011

lacking the funds to get proper instruction and care. MDM’s dance injury clinic is located in the Cowles Center for Dance and the Performing Arts (formerly the Minnesota Shubert Center for Performing Arts), in Minneapolis. The clinic is staffed by MDM medical professionals, who evaluate dancers for injury (or potential injury) and answer their questions. Research and education. MDM conducts research and education activities aimed at improving treatment of dancers’ injuries—and helping prevent such injuries from occurring in the first place. Recent studies have shown that dancers tend to get their injury information from their friends and teachers, rather than a specialized dance medicine professional. This is worrisome, as a dancer’s injury that remains unaddressed can lead to more severe and potentially career-ending injuries. It is essential that an injured dancer get a proper diagnosis that includes an evaluation of the dancer’s biomechanics, which may have led to the injury. Misperceptions exist in the medical community as well. A provider may feel that a dancer’s injury must not be very severe because the dancer continues to dance. Yet historically, like other professional athletes, dancers have been taught to “work through the pain”—even though doing so can worsen an injury and cause irreparable harm to the dancer athlete. Medical providers need to be aware of the technique and movements of the dancer, as well as the dancer’s dedication and devotion to the sport, to better evaluate and treat the dancer. To provide dancers with better access to more accurate information, MDM collaborates

with dancers, dance teachers, choreographers, companies, studios, and schools around the state in conducting research. The results of their research are disseminated throughout the medical community to doctors, physical therapists, and athletic trainers through medical journals and educational programs. Current research by MDM includes a statewide study of dancer injuries and the injury rates at all levels of dance and dancer experience. A large posterior ankle impingement outcomes study in dancers is also being done (see sidebar). MDM’s research is aimed at further educating the dance and medical community on the most common injuries and treatment of those injuries. In addition, the research will add to the current national medical literature in dance medicine. Dance medicine, in general, is not well funded, leaving scarce resources dedicated to research. MDM works to obtain grants through local and national medical funding sources. This allows MDM to offer free educational programs to dance companies, studios, and schools throughout the state. In addition to conducting free screenings for dancers, the MDM staff lead educational seminars for dance teachers and choreographers. The aim is to help these organizations prevent injury in their dancers and to teach the dancers how to protect themselves from injury. The seminars or screenings include (but are not limited to): • Teaching dancers and dance teachers how to apply objective medical criteria to determine when a dancer is “pointe ready.” • Assessing strength and/or muscular deficits that dancers can correct to prevent injury from occurring. • Identifying common injuries in dancers (or in a particular dance company) and teaching them how to prevent these injuries. MDM’s dance medicine professionals also speak on dance medicine topics at local and national conferences. Dance medicine confer-

Posterior ankle impingement in the dancer The following example illustrates the need for improved education of health care professionals treating dancers. Many times dancers will present to medical providers with a complaint of “ankle restriction en pointe or relevé”; pain may be a symptom as well in these positions. [In ballet terminology, en pointe refers to performing steps while on the tips of the toes, using a special blocked shoe; relevé refers to rising from any position to balance on one or both feet on at least demi-pointe (heels off the floor) or higher to full pointe, where the dancer is actually balancing on the top of the toes, supported in pointe shoes.] In such cases, these dancers are routinely diagnosed with Achilles tendinitis. Dancers can get Achilles tendinitis, especially when they have tight heel cords and don’t complete their pliés. However, more often than not the diagnosis lies deeper. Minnesota Dance Medicine estimates that dancers have a higher incidence of posterior ankle impingement than of Achilles tendinitis. Posterior impingement can be caused by many factors, including a symptomatic os trigonum, ganglion cyst, synovial hypertrophy, large posterior talar process, or even a stress injury of the talus. The first four of the conditions listed can cause a “mass-like” effect, creating the feeling of restriction in the dancer (impingement); the fifth is simply a feeling of pain en pointe or relevé. Achilles tendinitis does not create a feeling of restriction or signs of impingement on exam. A misdiagnosis of this condition can lead to worsening of the actual injury and subsequently significant time loss from dance. For the professional dancer, this could mean demotion or loss of position within a company. A large posterior ankle impingement outcomes study in dancers is under way at Minnesota Dance Medicine.

ence. MDM has conducted an annual dance medicine conference for the past three years. Conference participants have included dancers, dance teachers, and choreographers, and presentations cover aspects of dance injuries and how to prevent them. MDM conducts a free injury screen to all dancers at the annual conference. Future conferences will be expanded to include medical professionals who wish to learn more about these topics. A growing field

Dancers’ injuries are unique and require specialized knowledge of the technique and requirements of dancers in order to properly diagnose injuries (or potential injuries) and return a dancer to activity safely. Dance medicine is a young and growing medical field. It has quickly become a subspecialty in sports medicine and physical therapy. It seems possible that special certification programs for these providers could emerge in the future. Though

research in dance medicine to date is minimal, the large numbers of dancer athletes in this

Minnesota Dance Medicine and the Minnesota Dance Medicine Foundation appreciate the need for well-trained dance medicine professionals to conduct education and dance medicine research on these dedicated athletes to prevent injury and to further research in this field. More information about Minnesota Dance Medicine is available at www.mndancemed.org. Brad R. Moser, MD, is the founder and director of the Minnesota Dance Medicine Foundation, a member of the Dance/USA Taskforce on Dancer Health, a dance medicine consultant for many dance companies and studios in the Twin Cities, and a sports and dance medicine specialist at MOSMI–Minnesota Orthopedic Sports Medicine Institute in the Twin Cities. He is a member of the International Association of Dance Medicine and Science, the Performing Arts Medicine Association, the American Medical Society for Sports Medicine, the American College of Sports Medicine, and the American Academy of Family Physicians.

sport could benefit from improvements in treatment supported by research studies.

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uring the 1940s and early 1950s, the United States experienced its worst epidemics of poliomyelitis, most commonly referred to as polio. Nearly 60,000 cases of paralysis, the vast majority in children, and 3,000 deaths were reported in 1952. Polio could be treated but not cured. The treatment consisted of bedrest, fluids, and, if necessary, mechanical help to breathe. Variable amounts of weakness in legs, arms, and swallowing and breathing muscles remained after the resolution of the febrile illness. The poliovirus is a human enterovirus that causes fever, muscle aches and nausea, vomiting, and diarrhea. Paralysis results in about 5 percent of infected individuals. During the epidemics, an estimated 90 percent of individuals who were infected with the virus did not appear ill or feel ill in any way, and 5 percent of individuals had only gastrointestinal symptoms. The presence of large numbers of asymptomatic individuals

U P D AT E :

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AND

R E H A B I L I TAT I O N

Aftereffects of an epidemic Diagnosing and managing post-polio syndrome By Barbara P. Seizert, MD

enhanced the spread of the disease. Most cases occurred during late summer and were associated with outdoor activities such as swimming pools.

tion campaign, the epidemic ended. In 1958, Albert Sabin introduced an oral vaccine using live, weakened virus and polio was gradually extin-

An estimated 25â&#x20AC;&#x201C;50 percent of polio survivors fit the diagnostic criteria for post-polio syndrome. In 1955 came word that Jonas Salk had created a vaccine to prevent polio, made from an inactivated form of the virus. After the March of Dimes sponsored a mass immuniza-

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guished in the United States and, eventually, most of the world. Currently, the trivalent inactivated polio vaccine is used in the U.S. and other developed countries; the oral vaccine is preferred in developing countries because it is inexpensive, effective, and easy to administer. Diagnosing PPS

Most polio patients eventually regained much of their function and went on to lead active lives. In the 1970s and 80s, decades after their battle with polio, survivors began to experience symptoms, some of whichâ&#x20AC;&#x201D; muscle weakness and sometimes painâ&#x20AC;&#x201D;were similar to those of polio. Along with the muscle problems came overwhelming fatigue. Post-polio syndrome (PPS) was first described in 1972 and the description was further revised in the 1980s and 1990s. The diagnostic criteria for post-polio syndrome are: 1) A prior episode of poliomyelitis with evidence of residual motor neuron loss 2) A period of at least 15 years after the acute onset of polio with neurologic and functional stability 3) Gradual (though sometimes abrupt) onset of new weakness and abnormal muscle

weakness that persists for at least one year 4) Exclusion of other medical conditions that cause similar symptoms An estimated 25â&#x20AC;&#x201C;50 percent of polio survivors fit these diagnostic criteria, depending on how strictly the criterion of new muscle weakness is applied. As the population ages, more cases are recognized. Risk factors for PPS include age above 12 at the time of polio, severity of the original paralysis, and greater extent of recovery from the initial paralysis. Pain is also a frequent complaint of polio survivors but is not necessary for the diagnosis of post-polio syndrome. Post-polio syndrome does not affect the large majority of polio survivors, most of whom experience a modest decline in function and strength over the years, similar to that of the general population after age 50, which is 1 percent per year. Post-polio syndrome is a clinical diagnosis made by careful history and physical examination. Studies such as electromyography (EMG) to assess other neurological possibilities and the extent of prior polio involvement, as well as lab tests for creatine kinase, a muscle enzyme, may assist in estimating the extent of overuse. Individuals who recovered all limb function and have functioned normally for years present a diagnostic challenge. These patients were excluded from diagnosis of post-polio syndrome due to having â&#x20AC;&#x153;normalâ&#x20AC;&#x153; muscle testing on exam. However, it is now known that there can be a loss of as much as 60 percent of the motor units at the time of polio and the patient can and does recover full strength on manual muscle testing. This is because the patients are capable of a onetime maximum contraction, but the muscle fatigues with continued use. These patients may describe fatigue and weakness and appear to be completely normal when examined in the office. EMG studies, together with medical records of their acute polio, may assist in diagnosing these cases.

What causes post-polio syndrome? Treating symptoms of PPS

Fatigue is one of the most common symptoms in any neurological disease, but particularly in post-polio syndrome. Amantadine, a medication originally used to prevent flu in exposed individuals in the flu epidemics, is used in multiple sclerosis and post-polio syndrome despite no clearcut evidence to support it. Modafanil (brand name Provigil) was studied in a randomized controlled trial and reported as being of no benefit (Vasconcelos et al., Neurology 2007). However, it is still used, particularly in patients who also have sleep apnea and daytime sleepiness. Pacing physical and mental activities by imposing rest is effective. Assessing the quality of sleep with sleep study to rule out sleep apnea or other respiratory involvement may be beneficial. This can occur in polio without prior evidence of bulbar (respiratory and swallowing) involvement. Muscle fatigue and new muscle weakness have been studied most extensively. Both

The etiology of post-polio syndrome is unknown, but there is support for three theories. The motor neuron—the nerve from the spinal cord to the muscle— is the chief area of loss in polio. Reinnervation, in which the body compensates for the loss by sprouting new nerve fibers or axons, leads to increased strength but also enlarges the motor neurons and the muscle groups they act on. With time, this larger motor unit fails. Overuse or underuse of affected muscles over time has been shown to predispose former polio patients to new weakness. Some of the previously reinnervated nerve sprouts and muscle fibers die. The persistence of poliovirus and its reactivation have been invoked to explain neuron loss and have support from tissue culture and antibody studies in one study, but no other studies since have supported that finding. Inflammation and autoimmune-mediated mechanisms in PPS are supported by autopsy study on seven PPS patients. The spinal cord showed inflammation and lymphocyte (cells with antibodies) infiltration along with degeneration of neurons. These changes were more prominent in patients with progressive weakness. resistance and cardio types of exercise have been shown to be beneficial in restoring strength and preventing muscle deterioration. In a randomized controlled trial, polio patients who received strength training with non-fatiguing exercise three times per week at 50 percent of maximum resistance showed significantly greater improvements in strength than controls assigned to no training (Chan et

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al., Muscle Nerve, 2003). Other smaller, non-controlled studies also have reported improvements in strength with this type of program. Pyridostigmine has been evaluated in several controlled trials but has not been shown to significantly improve fatigue and is used on an individual basis. Prednisone has not shown any benefit. Intravenous immune globulin (IVIG) was

given in two infusions three months apart in a randomized trial, results of which were reported by Gonzalez et al. in Lancet Neurology (2006). Improvement was seen in median muscle strength in a selected study, and in a smaller study, statistically significant improvement in pain was seen at three months. However, there was no improvement in fatigue or quality of life in either of these studies. Additional studies are needed to support use of this treatment. Respiratory and swallowing problems can occur in polio survivors who had neither problem during their acute polio, or who recovered from them completely during the following 6–12 months. Treatment requires altering diet or even tube feeding if swallow studies show aspiration occurring. Aspiration pneumonia or repeated episodes of bronchitis suggest occult aspiration and indicate need for study. About one-third of post-polio patients have this problem, and an addiPOST-POLIO to page 38

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CPR research

Cardiovascular diseases, including stroke, are the

Improving survival rates for sudden cardiac arrest

leading cause of death in Minnesota. Statewide, they caused 10,656

CARDIOLOGY

By Keith G. Lurie, MD, and Demetris Yannopoulos, MD

deaths (28.7 percent of all deaths) in 2007, according to the American Heart Association. This special focus describes cardiology research under way in Minnesota on approaches to treating sudden cardiac arrest; percutaneous treatment of valvular heart disease; post-hearttransplant survival; and optimizing pacemaker device technology.

ardiovascular disease, and sudden cardiac arrest (SCA) in particular, remains the most important cause of premature death in Western countries, accounting for about 400,000 deaths outside the hospital and another 400,000 deaths inside the hospital per year in the United States alone. Despite routine cardiopulmonary resuscitation (CPR) training, the placement of automatic external defibrillators (AEDs) in public places, and increasing awareness of the importance of early bystander CPR, only 5–10 percent of out-of-hospital SCA victims leave the hospital, and an even smaller percentage leave neurologically intact. Among the factors contributing to these poor survival

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statistics is the inefficiency of conventional CPR. CPR alone delivers only 25 percent of normal blood flow to the brain and 15 percent of normal blood flow to the heart. Over the past 20 years, working at the University of Minnesota in the Departments of Internal Medicine and Emergency Medicine, our research team has focused on studying the physiology of CPR and developing new principles and techniques for improving SCA survival; and it has led to the development of noninvasive circulatory enhancement technology to improve circulation in patients in cardiac arrest. From concepts to devices

In the 1990s, our NIH-funded research identified the potential for modulating intrathoracic pressure for improving cardiac and cerebral blood flow during CPR. We developed the concept of using a relatively simple device to modify inspiratory impedance in order to lower intrathoracic pressure during key parts of the CPR cycle and thereby improve blood flow and survival. To put the impedance threshold device (ITD) concept into practice, Advanced Circulatory Systems Inc. was founded in 1997. Since then, the company has developed several devices that are recommended by the new 2010 American Heart Association CPR guidelines and are widely used by EMTs: • The ResQPOD ITD provides perfusion on demand by regulating pressures in the thorax during states of hypotension. It selectively prevents unnecessary respiratory gases from entering the chest during the chest-wall recoil phrase of CPR, thereby enhancing refilling of the heart with each recoil of the chest wall. This mechanism also lowers intracranial pressure, thus

boosting forward blood flow to the brain as well. It is FDAapproved for use in the U.S. as a circulatory enhancer device. • The ResQPump is a hand-held device that is placed in the same position on the sternum as the hands are for standard CPR. It allows rescuers to provide active decompression of the chest, thereby assuring proper chest wall recoil and the creation of a negative intrathoracic pressure (vacuum) when used with the ResQPOD that helps return blood to the heart. • The ResQGARD ITD provides a simple and convenient way to treat hypotension in spontaneously breathing patients. This device was developed in conjunction with NASA and the U.S. Army for treatment of low blood pressure, a problem experienced by astronauts after prolonged space flight upon their return to earth and a significant problem for our wounded soldiers. Inspiration through the ResQGARD lowers pressures inside the thorax, drawing more blood back into the heart and lowering intracranial pressures simultaneously. This device harnesses normal breathing to increase circulation. • More recently, a new group of devices has been developed for treating non-breathing hypotensive patients and patients with head injury based upon the same physiological concepts of the ResQPOD and ResQGARD. This group of devices lowers intrathoracic pressure after each positive pressure breath. Named the CirQLator and ResQVent, this new approach has been used by anesthesiologists at the University of Minnesota to treat intraoperative hypotension. This approach has also been shown to lower intracranial pressure in patients with head injury. At the November 2010 meeting of the American Heart Association, Ralph Frascone, MD, associate professor of emergency medicine at the University of Minnesota and EMS medical director at Regions Hospital in St. Paul, presented results of the

The Take Heart program Members of the research team also have actively supported community education programs to improve SCA survival. Take Heart America (http://takeheart america.org/) and Take Heart Minnesota (http:// take heartminnesota.org/) are organizations that foster recognition of SCA as a health hazard and provide education leading to improved knowledge of optimal resuscitation techniques in schools and workplaces. Recognizing that there is no silver bullet for curing patients after cardiac arrest, the program is based on promoting all the intervention guidelines endorsed by the American Heart Association in 2005. Several interventions included in the Take Heart program have been pioneered in Minnesota. St. Cloud and three other Take Heart programs—in Minnesota’s Anoka County; Austin, Texas; and Columbus, Ohio—are pilots for the national Take Heart America program. Now plans are under way to expand Minnesota’s programs statewide for Take Heart Minnesota. Take Heart America aims to dramatically increase the survival rate of sudden cardiac arrest from 5 percent nationwide to more than 20 percent. The overall strategy is to simultaneously deploy four proven interventions, each of which increases survival from 2 percentage points to 10 percentage points: • Community-wide CPR/AED education and training. This involves teaching correct CPR and AED use to all high school freshmen and the community at large.

first prospective, randomized clinical trial to demonstrate a long-term survival benefit with favorable neurologic benefit using CPR devices. The NIHfunded trial compared survival rates among a control group of 813 cardiac arrest patients receiving standard CPR to an intervention group of 840 receiving active compression-decompression cardiopulmonary resuscitation (ACD CPR) performed using the ResQPump, with the ResQPOD impedance threshold device. The study showed that 50 percent more patients who experienced out-of-hospital cardiac arrest survived after receiving CPR performed with the ResQPump and the ResQPOD ITD as compared to those receiving conventional, manual CPR. This research was published in the Jan. 22, 2011, issue of The Lancet. These CPR innovations have resulted in almost doubling of SCA survival in multicenter clinical trials, when the new devices have been combined with stateof-the art, high-quality CPR. The military has used this same approach for treating soldiers injured in battle in Iraq and Afghanistan. The importance of the findings has been acknowledged by NASA, which has inducted the ResQPOD ITD into the Space Foundation Techno-

• Deployment of AEDs in strategically positioned locations—first-responder vehicles, churches, schools, public buildings, shopping centers—to maximize bystander access. • Comprehensive training for emergency medical practitioners and emergency/trauma room personnel with the latest CPR techniques and a new device called the ResQPOD that doubles circulation during CPR. At St. Cloud Hospital and in Anoka County, a device called the LUCAS has also been deployed to help automate the CPR process. Efforts are under way in Central Minnesota to get ambulance transport companies to utilize the LUCAS during advanced life-support procedures. • Implementation of specific treatments for postresuscitation care after successful resuscitation, including therapeutic hypothermia for unconscious survivors, aggressive evaluation and treatment with interventional cardiology techniques and implantable cardioverter-defibrillators, and complete cardiac electrophysiological evaluation. According to combined data from Take Heart St. Cloud and Take Heart Anoka, simultaneous implementation of the four interventions has doubled survivability from all sudden cardiac arrests in St. Cloud and Anoka County—from 8.5 percent to 19 percent.

logy Hall of Fame. Trauma specialists are currently evaluating this technology to reduce brain swelling after head trauma. The circulatory system is the human body’s transport system for life. The consequences of reduced circulation are severe and burden the health care system with billions of dollars of expenditures on an annual basis. By enhancing our understanding of cardiopulmonary physiology of the SCA state, our research has helped us develop tools and techniques that are proven to improve CPR success. This work is leading to breakthroughs in improving survivability after out-of-hospital SCA, and has already saved thousands of lives. It is anticipated that these efforts, in conjunction with bystander CPR, AEDs, and therapeutic hypothermia, will lead to 40–50 percent out-ofhospital SCA resuscitation rates. We remain actively engaged in CPR research. Most recently, using the devices described above in combination with a commonly used vasodilator named sodium nitroprusside, we have shown in animals and several patients that this new drug/device combination results in improved survival rates, even after prolonged periods of cardiac arrest. Larger trials are being planned as a result of this

ongoing research. We are on the threshold for a new era in CPR in which we will use systems-based approaches that will include

automated CPR devices and new techniques that optimize circulation both during CPR and postresuscitation. We still have a long way to go, but we are definitely making progress. Keith G. Lurie, MD, is co-director of the Cardiac Arrhythmia Center, Central Minnesota Heart Center, St. Cloud, and a staff cardiologist at St. Cloud Hospital; founder and chief medical officer of Advanced Circulatory Systems, Inc., Roseville; and professor of medicine and emergency medicine at the University of Minnesota. Demetris Yannopoulos, MD, is an assistant professor of medicine at the University of Minnesota. The successes described in this article are a result of long-standing collaboration with other members of the University of Minnesota faculty in the departments of emergency medicine, pulmonary and critical care medicine, anesthesiology, biomedical engineering, and cardiovascular diseases, along with collaboration with the U.S. Army Institute for Surgical Research, and investigators at the University of Virginia, the Medical College of Wisconsin, NASA, the University of Southern California, and the University of Cincinnati. The authors have been supported by the Minneapolis Medical Research Foundation at Hennepin County Medical Center.

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ranscatheter cardiovascular therapies prior to the 21st century witnessed revolutionary changes in the management of coronary and peripheral arterial disease. Over the past three decades, a highly invasive surgical approach has yielded to less invasive percutaneous approaches. Transitioning some of these breakthrough technologies into platforms for treating valvular heart disease has ushered in an explosive quest for minimally invasive treatments of these structural heart diseases. The structural complexity of cardiac valve anatomy has created technical challenges for working in three dimensions that surpass the challenges of treating coronary or peripheral artery disease. Concurrent advances in noninvasive imaging have been essential to the success of transcatheter modalities, which are carried out in the absence of direct visualization. The demand for these revolutionary therapies is driven largely by current unmet needs within our growing population

FOCUS:

Research in a rapidly developing field By Wes Pedersen, MD, Vib Kshettry, MD, Kevin Harris, MD, Robert Hauser, MD, Ben Sun, MD, and Irvin F. Goldenberg, MD of elderly patients. Valvular heart disease is predominantly degenerative and, thus, is more prevalent in the elderly. Patients in their 70s, 80s, and 90s increasingly expect enhanced longevity and quality of life; valvular heart disease adversely affects both. Treatment options today are predominantly confined to standard open-chest, highly invasive surgical approaches, which carry increased operative morbidity and mortality in elderly patients; hence the need for less invasive surgical and transcatheter approaches. As efficacy

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and safety are demonstrated in these high-risk patient groups, transition to lower-risk groups is anticipated. The two predominant valve abnormalities in the adult population are aortic stenosis (AS) and mitral insufficiency. Aortic stenosis

The incidence of aortic stenosis in individuals aged 80 to 90 is 5–7 percent and in nonagenarians, even higher (10–15 percent). Surgical valve replacement is a mature and highly successful treatment for aortic stenosis patients and age should never be the basis for exclusion. Nevertheless, operative mortality in octogenarians is 6–8 percent and in nonagenarians, 12–14 percent. Probably more significant is the postoperative morbidity and prolonged recovery. Medical therapy offers little benefit for these patients, who have a 50 percent mortality at two years from the onset of symptoms. Minneapolis Heart Institute (MHI) at Abbott Northwestern Hospital has focused significant investigative effort on the rejuvenation of balloon aortic valvuloplasty (BAV) as an intervention with substantial palliative benefit in poor surgical candidates. Over the past five years, we have performed approximately 300 aortic valvuloplasties. Through this unique experience, we have documented and published some very favorable findings that have contributed to the reawakening of aortic valvuloplasty as a good treatment option for nonsurgical candidates with severe symptoms. The mean age in our database cohort is ~86 years and

includes a large population of patients over 90. Our initial published experience in patients over 90 included 31 patients. The mean age was 93 years, 65 percent were female, and 45 percent had concurrent coronary artery disease. Six patients (19 percent) underwent simultaneous BAV and coronary stenting. The baseline and postoperative valve areas were 0.52 cm2 and 0.92 cm2, respectively. New York Heart Association (NYHA) functional class improved strikingly, from class III/IV to class II. Perioperative mortality occurred in only one patient (3 percent). With continued improvements in technique, the procedural mortality has fallen even further in this group, to <2 percent. The predominant limitation of this procedure remains restenosis, which is reported in 42–83 percent in five to nine months. We have found, however, that these patients can be re-dilated serially without increased risk on subsequent interventions, allowing us to extend the period of quality-of-life enhancement. The overall incidence of CAD in patients with severe AS is 40–50 percent. It is thus quite common to discover severe coronary stenosis at the time of cardiac catheterization for BAV. The potential advantage of offering a combined procedure, including BAV and simultaneous percutaneous coronary intervention (PCI), seems intuitive but is untested in these elderly patients. We published the first large experience using this approach in our initial 17 patients. The mean age was 86. All coronary lesions were treated with stents and included a mean of 2.1 lesions and 1.4 target vessels per patient. All but four patients underwent coronary stenting immediately prior to BAV. There were no myocardial infarctions, strokes, or procedural deaths. The procedural times with simultaneous coronary stenting increased minimally, from 86.2+27.3 to 98.8+17.6 minutes. We have now performed 46 combined BAV and PCI cases with excellent results. We have found BAV to be useful in “bridging” patients to

surgical aortic valve replacement (AVR). This approach is currently being evaluated by others in bridging extremely high-risk patients to transcatheter aortic valve implantation (TAVI). We have now performed BAV on 16 patients with profoundly impaired left ventricular function (ejection fraction (EF) of <20 percent), which represents an exclusion for entry into current TAVI trials in the U.S. These patients were safely dilated without procedural mortality. Importantly, 50 percent of these patients subsequently demonstrated an improved EF to >20 percent (mean 26 percent), allowing them to potentially qualify for TAVI implantation. Understanding the mechanism of aortic valve restenosis following BAV is cellular in nature and related to heterotopic ossification and fibrosis, we conducted a pilot study (Radiation Following Percutaneous Balloon Aortic Valvuloplasty to Prevent Restenosis) in hopes of limiting restenosis. In other clinical settings (e.g., orthopedic and plastic surgery), external beam radiation delivered post-operatively has been efficacious in limiting these histopathologies. Our initial published experience in 20 patients using doses ranging from 12 Gy to 18 Gy resulted in a 30 percent restenosis in the low-dose (12 Gy) group and 11 percent restenosis in the highdose (18 Gy) group, which compared favorably to the historical rate of 80 percent. Based on this, we launched an FDAapproved, multicenter, randomized, double-blind study evaluating the efficacy of localized external beam radiation to the aortic valve following BAV. Which patients are candidates for BAV?

Our experience with BAV has permitted us to advocate for palliative BAV in appropriate patients. Candidates should include those with symptomatic AS and any of the following*: â&#x20AC;˘ Bridge to surgical AVR in hemodynamically unstable patients. â&#x20AC;˘ Increased perioperative risk, STS risk score >10â&#x20AC;&#x201C;15 percent.

â&#x20AC;˘ Anticipated survival of <3 years. â&#x20AC;˘ Age in the late 80s or 90s and prefer BAV over open thoracotomy for AVR. â&#x20AC;˘ Severe comorbidities such as porcelain aorta, severe lung disease, and others for which the CV surgeon prefers not to operate. â&#x20AC;˘ Severe and/or disabling neuromuscular or arthritic conditions that would limit postoperative rehabilitation. *(STS, Society of Thoracic Surgeons; CV, cardiovascular)

The need for more definitive nonsurgical options has driven pioneering efforts in the field of transcatheter aortic valve implantation. The first in-man implantation was carried out in 2002 by Alain Cribier in France. Although two devices have become commercially available in Europe in 2007, they are not approved in the U.S. and can be used only under investigational device exemption (FDA-approved investigational trials). The two devicesâ&#x20AC;&#x201D;the Edwards-SAPIEN transcatheter balloon expendable valve and the self-expanding Medtronic CoreValveâ&#x20AC;&#x201D;have combined for a total of nearly 20,000 implants worldwide. As the technology has improved and operators have worked through their learning curves, the implantation success rates are now >95 percent. However, complications include adverse peripheral vascular events in 2â&#x20AC;&#x201C;13 percent, coronary occlusion in 0.6 percent, and a stroke rate of 2â&#x20AC;&#x201C;4 percent. The first randomized TAVI trial (PARTNER), which our colleagues at the Mayo Clinic participated in, was recently completed in the U.S. using the Edwards-SAPIAN balloon expandable valve. Results in this patient group, which had been turned down for conventional surgical AVR, were randomized to TAVI vs. medical therapy. The findings demonstrated a robust 70 percent reduction in the oneyear mortality, from 50 percent to 30 percent, and a highly significant improvement in quality of life. We will be participating with Mayo Clinic in a second PARTNER II trial evaluating these non-operable patients.

Mitral regurgitation

Mitral regurgitation (MR) is even more prevalent than AS and significantly more complex, requiring a broad menu of therapeutic options to successfully treat this heterogeneous patient group. Mitral valve disorders causing MR can be divided into two groups: primary and secondary. Primary (degenerative) disorders result from abnormalities intrinsic to the mitral valve apparatus; secondary (functional) disorders result from abnormalities extrinsic to the mitral valve, most significantly left ventricular dysfunction. We anticipate transcatheter treatments for these diverse disorders taking longer to develop in the absence of the â&#x20AC;&#x153;one size fits allâ&#x20AC;? approach available for patients with AS. The treatment of choice for patients with severe MR is surgical and, whenever possible, repair is preferred over prosthetic valve replacement. Minimally invasive and robotic approaches are gaining momentum but require unique surgical talents more commonly avail-

able at higher-volume valve centers of excellence. They primarily offer reduced surgical morbidity and shortened recovery periods. Transcatheter or percutaneous treatment approaches for MR thus far have focused on valve repairs, in contrast to AS approaches, which have focused on valve implantation. At present there are three strategies for transcatheter mitral valve repair: 1) edge-to-edge repair, 2) coronary sinus device implants, and 3) noncoronary sinus device implants. All are currently investigational in the U.S. Our center participated in the landmark EVEREST II trial, a pivotal randomized trial comparing the percutaneous MitraClip with traditional surgery. The MitraClip is a miniature clip delivered transvenously from the femoral vein. It is positioned across the A2-P2 scallops of the mitral valve leaflets, creating a â&#x20AC;&#x153;double orificeâ&#x20AC;? repair. It is designed to mimic the surgical Alfieri stitch VALVE DISEASE to page 27

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RESEARCH

The ICE Trial

cute coronary syndromes are caused by plaque rupture and thrombosis leading to ischemia from a new, significant coronary stenosis. Percutaneous coronary intervention (PCI) is often a primary therapy. Prior to the era of platelet glycoprotein (GP) IIb/IIIa inhibitors, PCI was associated with a major adverse cardiac event rate of 10–12 percent. J.E. Tcheng reported in the ESPRIT (Enhanced Suppression of the Platelet IIb/IIIa Receptor with Integrilin Therapy) study that the platelet receptor GP IIb/IIIa inhibitor eptifibatide improves cardiac outcomes among patients with PCI by reducing the occurrence of major adverse cardiac events (ESPRIT investigators, Lancet, 2000). Yet despite this improvement in outcomes, myocardial infarction may still complicate PCI in the absence of angiographically evident complications. Thrombus, as well as vascular debris, may embolize and lead to plugging of the micro-

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Comparing drug delivery pathways in patients with acute coronary syndrome By Albert Deibele, MD, FACC, FSCAI, FAHA vasculature, microvascular dysfunction, and, eventually, myocardial necrosis. GP IIb/IIIa antagonists at high local concentrations may enhance thrombus disaggregation by disrupting platelet

ST elevation myocardial infarction (Gibson et al., Circulation, 2004). Thus, intracoronary (IC) administration of eptifibatide may result in a very high local concentration, which may lead to increased levels of platelet

By changing the route of eptifibatide administration, microvascular perfusion can be improved with no additional associated costs. crosslinking. Indeed, higher levels of platelet GP IIb/IIIa receptor occupancy using eptifibatide have been shown to be associated with improved myocardial perfusion among patients with

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GP IIb/IIIa receptor occupancy, destabilization of platelet aggregates, and promotion of thrombus disaggregation in the epicardial artery and microvasculature, thereby improving myocardial perfusion. We hypothesized that IC bolus administration of eptifibatide in an acute coronary syndrome with stent implantation would result in higher local levels of platelet GP IIb/IIIa receptor occupancy (RO) in the coronary bed, reduced thrombus burden, and improved measures of coronary flow. A single-center prospective study conducted at St. Mary’s Medical Center, Duluth, randomized 43 patients who presented with an acute coronary syndrome from January 2006 to October 2007. The ICE (Intracoronary eptifibatide bolus administration during percutaneous revascularization for acute coronary syndromes with evaluation of platelet GP IIb/IIIa receptor occupancy and platelet function) trial is the first randomized trial of intracoronary eptifibatide. Methods

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All of the 43 patients in the ICE study were treated with at least 325 mg of aspirin prior to the PCI procedure. A loading dose of clopidogrel 300 mg was

administered immediately after completion of the PCI. A weight-adjusted heparin regimen was used to titrate and achieve an activated clotting time of 200–250 seconds prior to PCI. A baseline-assessment myocardial perfusion was obtained after administration of intracoronary adenosine. The baseline assessment included TIMI (thrombolysis in myocardial infarction) flow grade (TFG), a standardized measure of epicardial coronary flow; and both TIMI myocardial perfusion grade (TMPG) and a corrected TIMI frame count (cTFC), standardized measures of microvascular flow. The cTFC measures the number of angiographic frames necessary for the blood to flow with the initial injection of contrast in the coronary until the contrast opacifies the distal vessel. The faster this is accomplished, the lower the frame count, the better the flow in the microscopic coronary vessels, and the better the coronary flow to the cardiac muscle. Treatment subjects (IC arm). The eptifibatide bolus, 180 mcg/kg, was administered over 2 minutes via the guide catheter. The continuous infusion of eptifibatide via a peripheral vein was started at the onset of the bolus at a rate of 2 mcg/kg/min. A second eptifibatide bolus was administered via the guide catheter into the coronary artery 10 minutes later. Control subjects (IV arm). The eptifibatide bolus, 180 mcg/kg, was administered via a peripheral vein over 2 minutes. The eptifibatide continuous infusion rate was 2 mcg/kg/min. A second eptfibatide bolus was administered intravenously 10 minutes later. GP IIb/IIIa receptor occupancy (RO) study. In the IC arm, coronary sinus and femoral blood samples were obtained 30 seconds after the start of each eptifibatide bolus. In the IV arm, coronary sinus and femoral blood samples were obtained 60 seconds after the start of each eptifibatide bolus.

Results

There were no angiographic, electrophysiologic, or other adverse findings attributable to the IC administration of eptifibatide. There were no perforations, pericardial effusions, or clinical evidence for intracardiac hematomas. The local platelet GP IIb/IIIa RO in the coronary sinus was significantly higher in the IC group for both boluses: first bolus 94 percent (Âą9 percent) versus 51 percent (Âą15 percent), p<0.001, and second bolus 99 percent (Âą2 percent) versus 91 percent (Âą4 percent), p=0.001 (Fig. 1). The higher local levels of platelet GP IIb/IIIa RO in the IC group were associated with an improved post-PCI cTFC median (25th and 75th percentiles) with IC versus IV administration: pre-PCI 36 (16,64) versus 31 (23,45), p=0.8, and post-PCI 18 (10,22) versus 25 (22,35), p=0.007, respectively. After adjusting for the prePCI cTFC, the IC group had a significantly better cTFC compared to the IV group, p<0.001. The multivariate analysis demonstrated that, after adjusting for the pre-PCI cTFC, the only factor associated with the post-procedural cTFC was the first bolus platelet GP IIb/IIIa RO in the coronary sinus, p<0.001. Discussion

This randomized trial of intracoronary eptifibatide demonstrated a significantly higher local platelet GP IIb/IIIa receptor occupancy by the antagonist eptifibatide in the coronary bed with IC versus IV bolus administration. This treatment regimen was associated with improved coronary flow and microvascular perfusion, demonstrated by improved corrected TIMI frame counts. An early high level of local GP IIb/IIIa receptor occupancy with the first bolus administration in the coronary bed was the only factor in a multivariate analysis associated with an improved corrected TIMI frame count. These beneficial effects might be explained by high local concentrations of eptifi-

FIGURE 1. % GP llb/llla RO by Collection Site and Bolus

batide, which led to the disaggregation of thrombi at the ruptured plaque as well as in the microcirculation. Since eptifibatide is a competitive inhibitor of fibrinogen binding to the platelet GP IIb/IIIa receptor, the presence of high localized concentrations of drug may enable the dissociation of bound fibrinogen that crosslinked activated platelets to form the occlusive thrombus. Hence, microvascular perfusion may be improved by reducing both the number as well as the size of microemboli. This mechanism is seen with in-vitro studies modeling coronary flow, which have shown that eptifibatide disaggregates thrombi effectively at concentrations with an order of magnitude greater than that usually achieved with standard IV administration. (Moser et al., J Cardiovasc Pharmcol, 2003). Furthermore, recent studies have shown that higher concentrations of a GP IIb/IIIa antagonist are necessary to effectively disaggregate stable, aged aggregates when compared to those newly formed thrombi (Speich et al., J Thromb Haemost, 2009). The disaggregation of thrombi may be the mechanism for the clinical benefit seen in previous studies. Improved coronary flow and microvascular perfusion may have further clinical implications. Previous studies have demonstrated that lower corrected TIMI frame counts have been associated with both a lower risk of adverse outcomes and a lower risk of inpatient mortality. In the Randomized

Efficacy Study of Tirofiban for Outcomes and Restenosis (RESTORE) trial in the setting of acute coronary syndromes, survivors had a lower cTFC than patients who died after PCI (Gibson et al., J Am Coll Cardiol 1998). Similarly, in the setting of acute ST elevation myocardial infarction, the 90minute cTFC was an independent predictor of in-hospital mortality OR (odds ratio)=1.21 for every 10-frame rise [95 percent CI 1.1 to 1.3], p=0.006.

The risk of adverse outcomes defined by death, recurrent MI, shock, congestive heart failure, or left ventricular ejection fraction â&#x2030;¤ 40 percent was 7.9 percent for cTFC <20, 15.5 percent for a cTFC 20â&#x20AC;&#x201C;39 and 27.0 percent for a cTFC >40, p=0.015 (Gibson et al., Circulation, 1999). This study extends previous observations that have been reported with another GP IIb/IIIa antagonist, abciximab. IC administration of abciximab during primary PCI of an ST elevation myocardial infarction has been associated with a decrease in the infarct size of 15.1 percent for IC and 23.4 percent for IV, p=0.01, as well as a decrease in microvascular obstruction as assessed by cardiac magnetic resonance imaging (Thiele et al., Circulation, 2008). Conclusions

Intracoronary bolus administration of eptifibatide is superior to standard intravenous treatment in achieving high local ICE TRIAL to page 26

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MINNESOTA PHYSICIAN

FIGURE 2 (at left). Image showing a thrombus in the distal right coronary artery of a patient in the ICE trial. FIGURE 3 (at right). After intracoronary eptifibatide was administered to the patient, there was a significant reduction in the thrombus burden.

Case presentation for ICE trial A 54-year-old male with a history of coronary artery disease presents with a three-week history of waxing and waning chest discomfort radiating to his left arm and associated dyspnea. The electrocardiogram is normal, but the cardiac biomarker CK-MB is elevated at 54.6 ng/ml, confirming a non-ST elevation myocardial infarction. This patient would be a candidate for the ICE (Intracoronary eptifibatide bolus administration during percutaneous revascularization for acute coronary syndromes with evaluation of platelet GP IIb/IIIa receptor occupancy and platelet function) trial. The angiogram for this patient demonstrated a thrombus in the distal right coronary artery (Fig. 2). After intracoronary eptifibatide was administered, there was a significant reduction in the thrombus burden (Fig. 3).

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MINNESOTA PHYSICIAN FEBRUARY 2011

ICE trial from page 25 platelet GP IIb/IIIa receptor occupancy in the coronary bed, as measured in the coronary sinus, and improved microvascular perfusion, as measured by the corrected TIMI frame count. By changing the route of eptifibatide administration, microvascular perfusion can be improved with no additional associated costs. Albert Deibele, MD, FACC, FSCAI, FAHA, is an interventional cardiologist at Essentia Health in Duluth, where he is

chief of hospital-based medical services and diagnostics and an active member of the cardiology research committee. His research interests are acute coronary syndromes and valvular heart disease. This article is based on a paper that appeared in the journal Circulation in 2010 (Deibele AJ, Jennings LK, Tcheng JE, Neva C, Earhart AD, Gibson CM, Intracoronary eptifibatide bolus administration during percutaneous revascularization for acute coronary syndromes with evaluation of platelet GP IIb/IIIa receptor occupancy and platelet function, the ICE Trial, Circulation 2010; 121: 784-791).

Valve disease from page 23 repair developed by Alfieri and colleagues in Italy in 1991. Leaflets are coapted across the regurgitant orifice and mitral insufficiency is reduced. It can be used for both degenerative and functional MR. The EVEREST II trial group demonstrated the MitraClip at 12 months has a clinical success rate, defined as freedom from death, >2+ MR, and mitral valve surgery, of 72 percent. It achieved statistical non-inferiority in comparison to conventional surgery. Reverse remodeling of the ventricle was observed in the MitraClip as well as the surgical group. Symptomatic benefit was observed in both cohorts, with 98 percent of successful MitraClip implant patients and 88 percent of surgical patients experiencing NYHA functional class I/II symptoms at 12 months. The greatest difference between the two groups was in procedural safety. The rate of predefined major adverse events was 57 percent in the surgical cohort compared to 10 percent for the MitraClip, due largely to the greater need for blood transfusions in the surgical group. The EVEREST High-Risk registry was created as a separate study for nonoperative patients with severe MR. This registry enrolled 79 patients, the majority of whom had functional MR, secondary to underlying ischemic heart disease. In addition, patients were older (average age, 76 years; 68 percent >75 years) and more symptomatic (89 percent were NYHA class III or IV) than the randomized EVEREST population. We showed that although the predicted mortality rate for the group was 18.2 percent at 30 days, the actual mortality rate was 7.7 percent, with a 76 percent one-year survival rate and 79 percent of the survivors in NYHA class I or II. In a nonrandomized concurrent group similar to the high-risk patients who were treated medically, there was a survival advantage at one year, with 76.4 percent of patients alive in the MitraClip group versus 54.7 percent in the

medically treated group. These data support the concept that novel percutaneous options are beneficial, particularly for nonoperative patients. This device has achieved approval in Europe and is now under review by the FDA. We are participating in an open access registry, REALISM, permitting the continued evaluation of the MitraClip’s performance. We also investigated a novel interventional device, iCoapsys, designed as a ventricular treatment approach to patients with functional MR. The iCoapsys device is designed to acutely reshape the left ventricle and mitral valve annulus by positioning anterior and posterior pads on the epicardial surface that are tethered together by a transventricular cord. Left ventricular and anterior-posterior annular dimensions are reduced by drawing the pads together as the transventricular cord is shortened under transesophageal echocardiography guidance. MR is reduced by permitting improved leaflet coaptation. After safety and efficacy had been demonstrated in a surgical population (open-chest, beating-heart patients), a transcatheter system was developed for percutaneous, transpericardial delivery. After we demonstrated system feasibility in the animal model, we successfully placed the first percutaneous in-man device at Abbott Northwestern Hospital in 2008. A multidisciplinary team approach

The development of catheterbased valve implantation and repair stands not only on the shoulders of a long history of surgical valve replacement and repair, but on recent developments by interventional and imaging cardiologists using percutaneous methods. The recent breakthroughs in transcatheter valve therapy could not have been possible without the combined efforts of cardiovascular surgeons and cardiologists. The future success of these novel approaches will require close physician collaboration and state-of-the-art “hybrid” surgical rooms. This team

approach will require “double scrubbing” by interventionalists and surgeons. The need for complex three-dimensional imaging modalities for preoperative assessment as well as online guidance will necessitate the intraprocedural presence of a cardiac imaging specialist. We believe valve centers of excellence will emerge, permitting a highly focused team of multiple subspecialists, working together, to manage patients with complex valve disease. Unique physician skill sets, time, and financial commitment will be required to develop these valve programs at large quaternary referral centers. The multiple treatment options, which over time will become available to conventional as well as highrisk patients, will also require weekly complex valve meetings to discuss individual patient care much like existing tumor boards in oncology.

Entering a new era in cardiac surgery

The field of transcatheter valve replacement and repair is developing rapidly. In many respects, it will define the next era in the highly technical fields of cardiology and cardiac surgery. Novel devices are focusing more specifically on AS and MR valve lesions, which commonly afflict surgical higher-risk elderly patients and others with multiple comorbidities. As we gain more experience in managing these challenging patient subsets, these procedures, currently in their infancy, will likely be transitioned to more conventional surgical candidates. Wes Pedersen, MD, Vib Kshettry, MD, Kevin Harris, MD, Robert Hauser, MD, and Ben Sun, MD, practice at the Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis. Irvin F. Goldenberg, MD, is the director of the Twin Cities Heart Foundation, Minneapolis.

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he University of Minnesota has one of the most active and successful ventricular-assist device programs in the world for patients with end-stage heart failure. Despite the fact that we have implanted more than 500 devices since 1995, optimization of device settings after implant remains a subjective process that is typically performed at rest. In collaboration with Shape Medical Systems in St. Paul, we are working to study their exercisebased optimization, currently used to “tune up” biventricular pacemakers, in the growing population of patients with ventricular assist devices.

Background

In the United States, heart failure affects nearly 5 million people, with more than 500,000 new cases diagnosed each year. Biventricular pacing, also known as cardiac resynchronization therapy (CRT), has been an important advance in heart failure care over the past decade. Patients with chronic systolic heart failure and wide

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RESEARCH

New technology extends research Studying ways to optimize left ventricular assist device technology By Peter Eckman, MD

QRS are often eligible for this treatment, which has been shown to improve symptoms, reduce mitral regurgitation, promote reverse left ventricular remodeling, and reduce mortality. The benefit is not uniform, and some patients do not reap the full benefit. Attempts to optimize device settings in order to maximize benefit are typically guided by clinical experience, and in some centers, resting echocardiography. The process usually requires a sonographer, a device nurse to adjust the pacemaker, and one or two physicians to supervise the process and interpret the results. Consensus regarding the optimal parame-

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Contact: Gail Anderson (218) 999-1447 gail.anderson@granditasca.org. 28

CARDIOLOGY

MINNESOTA PHYSICIAN FEBRUARY 2011

ters (mitral inflow velocities, left ventricular outflow tract velocity-time integral as a surrogate for cardiac output, and the like) has not been achieved, and the presence of atrial fibrillation can add complexity. Furthermore, the physiologic differences between rest and exercise suggest that findings at rest may not apply during exertion. New technology improves CRT optimization

To improve risk stratification of patients with cardiopulmonary complaints, St. Paul-based Shape Medical Systems has developed the first cardiopulmonary exercise testing system—called Shape-HF—that can be used for CRT optimization using gas exchange analysis as an objective, reproducible outcome measure. According to Clarence Johnson, president and COO of Shape Medical Systems, “Because patient ventilation measurements are so sensitive to changes in CRT settings, assessing these changes using gas exchange parameters during mild, steady-state exercise provides a completely objective method for defining acute response to CRT therapy.” The test takes 15 minutes and involves measuring ventilation parameters while the patient exercises on a treadmill at a very low intensity of one mile per hour with the treadmill set at a 2 percent grade. The system itself includes five components: a data analyzer, disposable patient interface or mask, a pulse oximeter, a computer, and a printer. As the patient exercises at a steadystate heart rate, therapy settings are adjusted every two minutes, enough time for the adjustments to be reflected in ventilatory physiology. At the end of

the test, during which four to five therapy settings are tested, a proprietary algorithm ranks the physiological response to exercise at each setting. The physician then reviews the results and chooses the therapy setting he or she believes is most appropriate for the patient. In the test, Shape-HF measures ventilatory efficiency (VE/VCO2) and the partial pressure of end-tidal carbon dioxide (PETCO2)—measures that were recently reported to predict adverse events in patients with heart failure (R. Arena, J Cardiac Failure, 2009)—as well as inspiratory drive and oxygen pulse, a surrogate measure of cardiac output. With relatively modest physician oversight, testing is performed with a single exercise technician. Studies are under way to compare exercise-based optimization to usual care. Optimizing LVADs with Shape-HF

Researchers at the University of Minnesota have been working with the Shape-HF System to extend these findings to the growing population of patients who receive left ventricular assist devices (LVADs) for severe heart failure. Much as for biventricular pacemakers, clinicians have the ability to change settings on LVADs. Currently, the optimal device settings for a VAD are selected based on clinical judgment and resting echocardiography, much like CRT optimization. LVADs are much simpler devices, as the speed is the only parameter that can be adjusted by a clinician, but the parallels to CRT optimization are unmistakable. Since 2009, our research team has been working to develop a method of LVAD optimization. The concept of LVAD optimization is particularly novel, as it has only been in the last few years that outcomes have improved to the point where survival wasn’t the only measure of interest. With the current generation of smaller LVADs, survival is typically >80 percent at one year, and most patients return to a high level of function after recovering from

FIGURE 1. Dennis McGee undergoes a test using the SHAPE system as Dr. Peter Eckman observes. (Photo: Steve Rieke) FIGURE 2. The Shape-HF system can also be used for cardiopulmonary evaluation with a step. implant. More patients are returning to work after having an LVAD implanted, and additional efforts to optimize their pump function hold promise for further improvements in quality of life for these patients. Many questions remain unanswered: • Are the best settings the same at rest and with exercise? • Should LVADs have a “turbo” button for when patients are active? • Does the process of gas exchange-based analysis provide improvements in outcomes over usual clinical care? Pacemakers have evolved substantially since Earl Bakken’s original invention, which used two dials (pulse rate and output voltage), and now provide sophisticated, real-time evaluation of and response to a patient’s activity level.

Accelerometers and minute ventilation measurement are used in modern pacemakers, for example. These real-time physiologic measures have helped integrate human and machine; it stands to reason that LVADs may benefit from similar efforts. Although we are 30 years behind pacemakers in terms of the sophistication of “programming” LVADs, I am hopeful that we’ll be able to catch up quickly by learning from what has already been done with this treatment [pacemakers and CRT] that has a lot of parallels to LVAD therapy. We are fortunate to have such a robust medical device industry in Minnesota and a rich history of innovation to emulate. And

collaborating with Shape Medical Systems on this project has been immeasurably easier because the device company is here in town. This novel project is an example of the synergy that can result from collaboration between private industry and clinicians. We believe it highlights the strengths of both the

University of Minnesota and the state’s biotechnology business community. Peter Eckman, MD, a board-certified heart failure and transplant cardiologist, is an assistant professor in the Division of Cardiology at the University of Minnesota, Minneapolis. He is principal investigator for the Prospective Observation of Exercise Parameters in Advanced Heart Failure study.

Family Medicine w/ OB Opportunities in 2 Wonderful Rural Locations Altru Health System is seeking Family Practitioners to join our existing and thriving practices in Crookston, MN and Roseau, MN. Crookston, MN, a strong community of 8,000, is located along the Red Lake River in the heart of the fertile Red River Valley. Altru Clinic—Crookston is a well-established, collegial medical group with 5 Family Practice Physicians, 4 Internists and 3 Mid-Level Providers. We have an ongoing partnership with RiverView Hospital in Crookston that is a 25-bed, critical-access hospital connected to our clinic. Call is 1:7.

Altru is a physician-led, not-for-profit integrated health system that serves a referral population of more than 225,000. More than 180 physicians representing 44 specialties serve this population base. Altru Health System provides competitive compensation, reviewed annually with specialty-specific industry data, along with an extensive benefits package including generous pension and profit-sharing plans.

Roseau, MN, which is just 20 minutes from beautiful Lake of the Woods, is a Family Practice clinic consisting of 6 Family Practice Physicians, 3 Mid-Level Providers and 1 Internist. The town of Roseau has over 2,500 residents. LifeCare Medical Center is a 25bed, critical-access hospital just adjacent to our clinic. Our friendly community is safe and welcoming. Call is 1:7.

Contact: Kerri Hjelmstad, Physician Recruiter Altru Health System PO Box 6003 Grand Forks, ND 58201-6003 1-800-437-5373 Fax: 701-780-6641 khjelmstad@altru.org www.altru.org

www.altru.org FEBRUARY 2011

MINNESOTA PHYSICIAN

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ccording to the American Heart Association, heart failure affects 5 million people. Heart transplantation is now the definitive cure for endstage heart failure. Since the first heart transplant was performed in 1967, there have been numerous advances in the management of heart transplant recipients (HTR), immunosuppressive therapy, monitoring techniques, and surgical strategies. As a result, the median survival of heart transplant recipients has improved significantly, to approximately 10–13 years, primarily due to improvements in short-term survival. Long-term survival, however, is still poor. Cardiac allograft vasculopathy (CAV), a form of coronary artery disease affecting heart transplant recipients, is a major limitation to long-term success in cardiac transplantation, accounting for up to 30 percent of deaths after five years despite preventive measures such as statin therapy and modification of risk factors (e.g., smoking, obesity, diabetes, dyslipidemia,

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CARDIOLOGY

Improving survival post-heart transplant Researchers gain insight into mechanisms of cardiac allograft vasculopathy By Monica Colvin-Adams, MD, MS

hypertension). CAV is clinically apparent in 50 percent of HTR at five years; however, intimal thickening, a predictor of CAV, develops earlier and is present in 58 percent of HTR one year after transplant. Ten percent of patients die within the first 12 months after the diagnosis of CAV. While some patients die suddenly, others will develop heart failure due to restrictive physiology. There is no cure for CAV and there are no widely accepted treatment strategies. Preventive therapies, such as statins and aspirin, are used routinely and risk factors are managed. Revascularization is for the most part palliative, since CAV

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tends to be diffuse in comparison to native coronary artery disease. Proliferation signal inhibitors are beneficial in preventing progression of CAV, but there are no standardized treatment strategies based on this therapy, which is usually initiated after disease has developed. Finally, re-transplant can be performed in highly selected individuals, but this procedure raises an ethical dilemma with regard to organ allocation in a population where need greatly exceeds availability. Cardiac allograft vasculopathy and endothelial function

The initial event in cardiac allograft vasculopathy is theorized to be a subclinical endothelial cell injury in the graft. This injury causes upregulation of cytokines, complement, adhesion molecules, and growth factors, creating a state of inflammation and endothelial activation and ultimately resulting in endothelial dysregulation. Cellular and humoral responses to human leukocyte antigens (HLA) and vascular endothelial cell antigens propagate this process, which ultimately results in intimal proliferation and development of the vascular lesion associated with CAV. In short, endothelial dysfunction precedes the development of CAV. This has been demonstrated by Davis and colleagues, who showed that early abnormal coronary responses to acetylcholine predicted the development of intimal thickening, the predecessor to CAV, at one year.

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RESEARCH

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Risk factors for CAV

The development of CAV is variable after transplant and is determined by multiple factors affecting the transplant recipi-

ent, such as immunologic activation, comorbid conditions, and exposure to cytomegalovirus, as well as “classic” risk factors for coronary artery disease, such as hypertension and hyperlipidemia. Immunologic risk factors. Ischemia/reperfusion injury occurring during removal of the donor heart, during storage, and after engraftment in the recipient induces an immunologic response that has been shown to cause CAV in an experimental model. Brain death is associated with hemodynamic instability, altered loading conditions, decreased coronary perfusion, and apoptosis, resulting in immune activation and elaboration of inflammatory cytokines. In an animal model, reduced coronary blood flow and abnormal coronary vasomotor response to acetylcholine were demonstrated after brain death. Mehra and colleagues showed that heart transplant recipients who received hearts from donors who died of explosive or traumatic brain death had significantly more intimal thickening and reduced survival. CAV has been linked with the duration and number of episodes of cellular rejection, as well as with asymptomatic humoral rejection. Donor age greater than 35 years and transplant of a female donor into a male recipient are associated with increased intimal thickening on intravascular ultrasound. Finally, cytomegalovirus infection with subsequent eNOS dysregulation are associated with abnormal coronary endothelial function and reduction in survival from CAV. Classical risk factors. Classic cardiovascular risk factors such as smoking, diabetes, hypertension, obesity, and dyslipidemia are not uncommon in heart transplant recipients. Ischemic cardiomyopathy is the reason for transplant in approximately 40 percent of recipients. According to data from the International Society of Heart and Lung Transplant Registry (2009), 76 percent of transplant recipients have hypertension at year one, 27 percent have diabetes, and 79 percent have

hyperlipidemia. At 10 years, 98 percent have hypertension, 37 percent have diabetes, and 93 percent have hyperlidemia. These pre-existing conditions can be exacerbated by immunosuppressants, particularly steroids and calcineurin inhibitors; however, almost one-third of heart transplant recipients develop new hypertension, half develop new hyperlipidemia, and one-fifth develop new diabetes. These traditional risk factors can increase the risk of CAV. Challenges in diagnosing CAV

Early detection of CAV is limited due to the lack of sensitive diagnostic studies, variable and silent clinical presentation, and the lack of consistent nomenclature that imparts prognostic information. Coronary angiogram is used routinely to screen for CAV, but it is insensitive and does not detect disease in up to 50 percent of HTR. Many transplant centers perform angiogram yearly to every other year for the life of the transplant recipient, repeatedly exposing them to nephrotoxic contrast, radiation, and potential complications associated with vascular manipulation. While it has not yet been demonstrated that early detection will improve outcomes, we believe that early detection will promote the development of effective treatment and preventive strategies and therefore have focused our research on risk markers and early detection of CAV and treatment strategies designed to improve endothelial function. Our research at the University of Minnesota has focused specifically on small artery elasticity (SAE) and circulating endothelial cells as indicators of endothelial injury. Although CAV is likely the end result of multiple processes, including immunological activation, donor injury, genetics and risk factors of the recipient, and medications, the end result and the predecessor of CAV appears to be endothelial injury, which is common to many cardiovascular and inflammatory illnesses and often a target of therapy. Small artery elasticity, as measured via the radial artery, has been

Cardiac allograft vasculopathy (CAV), a form of coronary artery disease affecting heart transplant recipients, is a major limitation to long-term success in cardiac transplantation. demonstrated to be a prognostic marker of endothelial function. Diastolic pulse-wave contour analysis provides information regarding elasticity of the small and medium arteries and is a surrogate for endothelial function and cardiac risk. Patients with coronary artery disease, hypertension, and diabetes demonstrate a reduction in the oscillatory component of the diastolic waveform, reflecting capacitance abnormalities in the distal vessels, or reduced SAE. This reduction in SAE has also been detected in asymptomatic individuals at risk for cardiovascular disease and is associated with cardiac events. Circulating endothelial cells and endothelial progenitor cells are, in simplest terms, the repair cells of the human vasculature. When an artery is injured, mature endothelial cells (CEC) are shed from the endothelium, which is re-endothelialized by endothelial progenitor cells (EPC) that are released from the bone marrow. These processes are mediated by a complex interaction of cytokines, adhesion molecules, growth factors, endothelial nitric oxide synthase (eNOS), and various signaling pathways. Both EPC and CEC have been shown to be predictive of cardiovascular events and to correlate with risk factors for coronary artery disease. Patients with CAD or at risk for CAD demonstrate decreased EPC and increased CEC. Endothelial function in heart transplant

In our current studies, we sought to determine differences in endothelial markers between heart transplant recipients and normal, healthy individuals. We also wanted to determine if these could be used in future studies to evaluate for CAV. We are beginning to see signs that

heart transplant is associated with reduced SAE, that is, increased small artery stiffness and endothelial dysfunction, and with a high degree of CEC activation. Among other factors, the presence of CAV seems to be a determinant of CEC activation and SAE. Our data to date support evidence that transplant is associated with endothelial activation and dysfunction; and in our studies, this is manifest as activated endothelial cells and reduced small artery elasticity. These studies are ongoing. Future directions

These and other ongoing studies provide insight into mechanisms that are associated with CAV. The tools that we are currently studying are clinically applicable

and, we anticipate, can be used to stratify high-risk patients and serve as therapeutic targets. Parallel to these exploratory studies, we are evaluating novel strategies to prevent CAV. One such study, funded by the American Heart Association, targets the nitric oxide signaling pathway using a phosphodiesterase inhibitor. The goal is to treat the final common pathway in the pathogenesis of CAV, rather than the myriad mechanisms. This will serve our long-term goal of improving outcomes after heart transplantation. Monica Colvin-Adams, MD, MS, is an assistant professor of medicine at the University of Minnesota Medical School, specializing in advanced heart failure, transplantation, and mechanical circulatory support. She is currently acting medical director of the heart transplant program. She has participated in multiple clinical research trials in the areas of advanced heart failure, heart transplantation, and pulmonary hypertension. Her current research in heart transplantation is funded by the NIH and the American Heart Association.

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WOMEN’S

trial of labor after previous cesarean delivery (TOLAC) provides women with the possibility of achieving vaginal delivery after cesarean delivery (VBAC). VBAC is associated with decreased maternal risks, shorter recovery times, and decreased risk of complications in future pregnancies. TOLAC is appropriate for many women with previous cesarean sections (C/S), but several factors influence failure/success rates for VBAC. This article reviews the risks and benefits of TOLAC and gives a brief overview of practice guidelines for managing and counseling patients with a prior cesarean delivery. History

In 2007, the U.S. national rate of cesarean deliveries stood at its highest point ever, at 31.1 percent, contributing to escalating medical costs. It wasn’t always so: In the 1990s, large clinical studies documented the relative safety of VBAC, and VBAC rates increased from 18.9 percent to 28.3 percent from

H E A LT H

Vaginal delivery after cesarean delivery Practice guidelines for counseling patients By Sarah Manneh, MD

1989 to 1996. C/S rates hit a national low of 20.7 percent in 1996. In the ensuing years, however, as HMOs and third-party payers encouraged patients to choose VBAC, physicians were pressured to recommend VBAC to unsuitable candidates. Over time, data regarding complications associated with VBAC changed the medical community’s attitude regarding its safety. A resultant reversal in practice trends reduced VBAC rates from 55 percent in 2002 to 8.5 percent in 2006. Some hospitals stopped offering TOLAC, primarily because of concerns by physicians and health care institutions over medical liability.

In 2010, the National Institutes of Health (NIH) reexamined the safety of TOLAC and VBAC. The NIH Consensus Development Conference Statement on Vaginal Birth After Cesarean: New Insights (http:// consensus.nih.gov/2010/vbac statement.htm), released in March 2010, establishes the relative safety for TOLAC and encourages health care organizations to facilitate TOLAC access to all women with a previous C/S. Risks of VBAC vs. risks with repeat C/S

The resistance to VBAC mainly relates to the risk of uterine rupture or dehiscence, with the

subsequent immediate risk of maternal and fetal injury and possible death. Uterine rupture occurs when the prior uterine incision from the previous C/S completely opens and separates. A dehiscence of the uterine incision is an opening or thin area in the prior incision, but overall the incision remains intact. In both cases, the risk depends on the type of incision over the uterus. A low-transverse incision results in <1 percent rate of rupture, whereas the rate of rupture for a classical or T-shaped incision is 4–9 percent. In women who have had a prior uterine rupture, the rate of rupturing again is 6 percent, but it can be as high as 32 percent if the previous rupture was in the upper segment of the uterus. Overall maternal death rates from this are less than 1 percent, and fetal rates of death are 0.08 percent. The risks of elective repeat C/S include a higher rate of bleeding, infection, and overall recovery time, as it is a major VBAC to page 34

Allina Hospitals & Clinics in Minnesota/Western Wisconsin Allina Hospitals & Clinics is known for its clinical quality, and an award-winning EMR. At Allina, physician leadership and involvement drive our success. The Clinic and Community Division features the Allina Medical Clinic, Aspen Medical Group, and Quello Clinics, as well as Home and Community Services. Our clinics, as well as our 11 hospitals, are located in the Twin Cities metro area, throughout Minnesota, and in western Wisconsin.

Full- or part-time urban, suburban, and rural openings are available in the following specialties: • Allergy • Dermatology • Emergency Medicine • Endocrinology • Family Medicine • General Surgery • Geriatrics (including Medical Director) • Hospitalist • Internal Medicine • Internal Medicine/Pediatrics • Neurology • Obstetrics Hospitalist • Obstetrics & Gynecology • Orthopedic Surgery • Pain Management • Perinatology • Physical Medicine & Rehab (Cancer Rehab & SCI) • Psychiatry • Psychology • Urgent Care • Urology

Allina offers a competitive benefits and salary package. For more information, please contact: Kaitlin Osborn Allina Physician Recruitment Toll-free: 1-800-248-4921 Email: Kaitlin.Osborn@allina.com Fax: 612-262-4163 Website: allina.com/physiciancareers

“A Hospital for Heroes” Working with and for America’s Veterans is a privilege and we pride ourselves on the quality of care we provide. In return for your commitment to quality health care for our nation’s Veterans, the VA offers an incomparable benefits package. They all come together at the Sioux Falls VA Medical Center. • Physician (ENT)

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Practice Well. Live Well.

Occupational Medicine

Lake Region Healthcare is located in a magnificent, rural, and family-friendly setting in Minnesota lakes country where we aim to be the state’s preeminent regional health care partner. Our award winning patient care and uncommon medical specialties set us apart from other regional health care groups. Lake Region’s physicians and their families also enjoy an unmatched quality of professional and personal life. Current opportunities including competitive salary and benefit packages available for BE/BC physicians are: • Internal Medicine • Internal Medicine • Pediatrics • Pediatrics

• Family Medicine • Urology • Family Medicine • General Surgery • Psychiatrist • General Surgery

For more information contact

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Immediate full time opportunity to join our growing occupational health practice. Seeking BC/BE physician with occupational health background, but open to primary care physician with interest in an exciting sub-specialty. As a NorthWorks provider, enjoy a wide variety of Occupational Medicine challenges. From acute injury care to health and safety in the workplace, your days will be filled with interesting cases. NorthWorks provides clinical and on-site services to our clients. Join an experienced team of occupational medicine Specialists practicing unfettered by HMO or Medicare restrictions. For more information, please contact John Capouch, CEO 4080 W. Broadway, Suite 200 Robbinsdale, MN 55422

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Join Our Prestigious Upper Midwest Group Practice Sanford Health is currently seeking BC/BE Family Medicine physicians to join staff at several of its primary care clinics. Good call arrangements and modern well-established community hospitals. OB is desired but not required. Sanford offers competitive salary and comprehensive benefits, paid malpractice and a generous relocation allowance. Excellent practice opportunities exist in communities located in the “Heart of Minnesota” lake country including Sanford Clinics in: • Bemidji • Cass Lake • Detroit Lakes

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Each community features its own unique personality and a variety of community and cultural activities, including year-round indoor and outdoor recreational activities and sporting events. To learn more, contact: Kathryn Norby, Physician Recruiter Sanford Health Physician Placement Phone: (701) 280-4851 • Fax: (701) 280-4136 Email: Kathryn.Norby@sanfordhealth.org AA/EOE

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MINNESOTA PHYSICIAN

Potential benefits and risks of both repeat C/S and TOLAC should be discussed early in the prenatal course, to allow for the most time to consider all options.

VBAC from page 32 abdominal surgery. The rate of maternal death in elective repeat C/S is 0.01 percent and of fetal death, 0.05 percent, both of which are lower than for VBAC. However, especially for those considering large families, VBAC can avoid risks associated with multiple C/S such as hysterectomy, bowel or bladder injury, the need for blood transfusion, or abnormal implanting of the placenta. Who are appropriate candidates for TOLAC and VBAC?

The American College of Obstetrics and Gynecology (ACOG) has standardized management and practice guidelines for ob/gyns and other providers involved in the care of pregnant women. The most recent ACOG guideline for VBAC is Practice Bulletin #115, “Vaginal Birth after Previous Cesarean Delivery,” published in the August 2010 issue of Obstetrics & Gynecology journal. The guideline identifies risks and benefits of TOLAC in different clinical settings and offers recommen-

dations for counseling women who wish to undergo VBAC. The ACOG guideline also includes recommendations about the appropriateness of TOLAC and VBAC as delivery options. According to the guidelines, TOLAC and VBAC counseling may be considered in women who have had: • One previous low-transverse C/S • Two previous low-transverse C/S (rate of uterine rupture ranges from 0.9 percent to 3.7 percent) • One previous low-transverse C/S and who now has a twin pregnancy and is an appropriate candidate for a twin vaginal delivery • A previous C/S with an undocumented uterine scar type, unless there is a high clinical suspicion of a previous classi-

cal uterine incision • No prior uterine scars from uterine transfundal surgery or previous uterine rupture • Any medical or obstetric complication that precludes vaginal delivery Planned TOLAC generally is not recommended in women: • at high risk for complications (e.g., those with a classic or T-incision, prior uterine rupture, or extensive transfundal uterine surgery) • in whom vaginal delivery is contraindicated (e.g., those with placenta previa) Special considerations

The ACOG guidelines also address a number of special circumstances, described below. In women who have one prior low-transverse C/S, are

now pregnant with twins, and are appropriate candidates for a twin vaginal delivery, the rate of uterine rupture is comparable to the rate for a singleton pregnancy, and the rate of success is similar. In women with a diagnosis of fetal macrosomia (defined as fetal birth weight greater than 4,000 grams in diabetic women and 4,500 grams in non-diabetic women), the rate of uterine rupture is comparable to the rate for nonmacrosomic births, but there is an overall lower VBAC success rate for macrosomic births (50–60 percent). Despite a suspected large baby, a TOLAC should not be ruled out for these patients. In women whose pregnancies are nearly past 40 weeks’ gestation and who have had a prior C/S, the rate of uterine rupture is comparable to C/S delivery, but the success rate of VBAC is lower (55 percent). These patients can undergo induction of their labor safely with pitocin to establish contractions. However, if the cervix VBAC to page 36

St. Cloud VA Medical Center is accepting applications for the following full or part-time positions:

• Internal Medicine With more than 200 providers, Prevea Health offers expertise in nearly every specialty, with advanced specialties that are not found anywhere else in Northeast Wisconsin. Our patients have their choice of care at 18 locations, as well as their choice of three hospitals: St. Mary's and St. Vincent Hospitals in Green Bay and St. Nicholas Hospital in Sheboygan. At Prevea Health we believe that we're all part of one family, and that the best health care starts with a trusted relationship—someone who is there for the patient, whatever their health care needs. If that sounds right for you, we invite you to join our family. Prevea offers a very competitive salary and benefit program including: • 4 weeks vacation/CME • Malpractice, health, life, (6 weeks as shareholder) dental and disability insurance • And much more! • Relocation assistance • 401(k) and retirement plan Opportunities are currently available in: *note if no site listed – opportunity is for Green Bay (J-1 Visa Waiver not available) Cardiology (Sheboygan) Geriatrics Pediatrics Family Medicine Gyn Oncology Pediatric (Green Bay, Sheboygan) Ophthalmology Hospitalist Dermatology Psychiatry Internal Medicine Emergency Medicine Pulmonology/ Neurology Sleep Medicine Endocrinology Orthopedic Hand Rheumatology Gastroenterology Orthopedic Spine Contact Information

Dolly Willems, Physician Recruitment Green Bay, WI

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MINNESOTA PHYSICIAN FEBRUARY 2011

• Geriatrician

(St. Cloud, Brainerd)

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(St. Cloud)

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(St. Cloud)

Position available in Internal Medicine or Family Practice for one-time disability assessments (compensation and pension exams) US Citizenship required or candidates must have proper authorization to work in the US. Physician applicants should be BC/BE. Applicant(s) selected for a position may be eligible for an award up to the maximum limitation under the provision of the Education Debt Reduction Program. Possible relocation bonus. EEO Employer.

Excellent benefit package including: Favorable lifestyle 26 days vacation CME days

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Interested applicants can mail or email your CV to VAMC Sharon Schmitz (Sharon.schmitz@va.gov) 4801 Veterans Drive, St. Cloud, MN 56303 Or fax: 320-255-6436 or Telephone: 320-252-1670, extension 6618

Urgent Care Minneapolis/St. Paul

NO ONE GOES THROUGH MEDICAL SCHOOL We have part-time and on-call positions available at a variety of Twin Cities’ metro area HealthPartners Clinics. Evening and weekend shifts are currently available. We are seeking BC/BE full-range family medicine and internal medicine-pediatric (Med-Peds) physicians. We offer a competitive salary and paid malpractice. For consideration, apply online at healthpartners.jobs and follow the Search Physician Careers link to view our Urgent Care opportunities. For more information, please contact diane.m.collins@healthpartners.com or call Diane at: 952-883-5453; toll-free: 1-800-472-4695 x3. EOE

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TO PR AC TICE INSUR ANCE.

Remember graduating from college and passing your MCATs, then spending the next four years of your life getting through classes like clinical epidemiology, neurology and radiology so you could practice medicine? Today’s financially driven managed care environments make having a practice difficult. Hurrying patients in and out of the office to make a quota and going into negotiations to prescribe treatments that don’t coincide with a patient’s policy aren’t practicing medicine. We’d like to prescribe a solution: Move your profession to the United States Air Force. Get back to what’s important — practicing medicine.

NEW POSITIONS:

Family Practice Urgent Care Dynamic, independent 3 location, single-specialty practice in northwest Minneapolis suburbs is seeking additional associates for its Rogers site and has Full Time/ Part Time shifts in the Crystal and Rogers Urgent Care. • • • • •

Partnership opportunity after 2 years Competitive salary with incentives Excellent benefits, 401k/employer paid pension Practice at one site/one hospital Physician-owned

Please contact or fax CV to: Joel Sagedahl, M.D. 1495 Highway 101 North, Plymouth, MN 55447 763-504-6600 • Fax 763-504-6622

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Physician-owned, multi-specialty group practice with 100+ providers, has an exceptional opportunity for a BC/BE Neurologist to join two others. You will see patients with a full spectrum of disease states and have an opportunity to participate in clinical trials. We provide staff and support for EMG, Lumbar Punctures, Polysomnograpy, Botox, Occipital Block and a full-time, plus a registered EEG technologist. We offer a first year income guarantee with a production incentive income thereafter; service area 300,000; great payer mix; $6,600 annual CME business allowance; potential shareholder status after one year; 401(k); profit sharing. Our picturesque community, population 50,000+ provides a great setting to practice medicine and raise a family plus year-round indoor/outdoor recreational at nearby lakes and resorts; excellent public and private schools with award winning academics and sports teams; state university, two colleges, community college, business school with combined enrollment of over 18,000; shopping mall with four anchor stores and new retail construction. Just over an hour from Minneapolis/St. Paul southern metro; easy access to international airport. No J-1 openings. Contact Dennis Davito, Director of Physician Placement, Mankato Clinic, 1230 East Main Street, P.O. Box 8674, Mankato, MN, 56002-8674; phone: 507-389-8654; fax: 507-625-4353; email: ddavito@mankato-clinic.com.

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FEBRUARY 2011

MINNESOTA PHYSICIAN

In 2007, the U.S. national rate of cesarean deliveries stood at its highest point ever, at 31.1 percent.

VBAC from page 34 remains undilated and requires cervical ripening with medications called prostaglandins, the rate of uterine rupture can increase by as much as 15–20 percent. In contrast, mechanical methods to dilate the cervix, such as a Foley bulb or laminaria, do not increase the rate of uterine rupture. In a pregnancy where a baby is breech at term and there is a prior C/S, the physician can offer to turn the baby by pushing on the maternal abdomen (external cephalic version, or ECV). The rate of success for ECV is similar to delivery without C/S and the success of VBAC is the same as for nonbreech pregnancies. Some women with prior C/S will require delivery before 28 weeks of pregnancy for various maternal or fetal indications. Prostaglandins can be used, but the decision should be individualized based on number of C/S, gestational age, and the women’s desire to preserve fertility. In the unfortunate setting of a fetal death beyond 28

weeks of pregnancy, mechanical dilation of the cervix can be used with comparable rates of uterine rupture and TOLAC should be offered. Success rates for VBAC

Taking the above factors into consideration, appropriate candidates for TOLAC and VBAC have a rate of success with VBAC of 70–80 percent. If the reason for the first C/S is nonrecurring in subsequent pregnancies (e.g., breech position or a rapid decrease in the fetal heart rate), VBAC success is 10 times greater. If the patient has had a prior successful VBAC, success is 10 to 20 times greater. Other factors to consider that negatively affect the success of VBAC are maternal obesity, the need for augmentation/induction of labor, and a short interval of time since the

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MINNESOTA PHYSICIAN FEBRUARY 2011

last C/S (e.g., fewer than 12 months). The ACOG guideline also notes that in order to offer a TOLAC safely, the delivering hospital must offer certain essential services. It is crucial that a physician capable of monitoring and doing an emergent cesarean delivery be immediately available throughout active labor. In addition, immediate availability of anesthesia and personnel for emergent C/S are necessary. Counseling patients

Potential benefits and risks of both repeat C/S and TOLAC should be discussed with patients and documented. This discussion should take place early in the prenatal course, to allow for the most time to consider all options. Obtaining all prior medical records to document the type of uterine scar

is important. If other circumstances arise during the pregnancy that may change the risks/benefits of TOLAC, these issues should be re-addressed. Counseling should also consider the resources available to support women electing TOLAC at their delivery site. After appropriate counseling, the decision ultimately is up to the patient. The role of the provider is to continue to offer support and to provide the information the patient needs to make the appropriate decisions for herself. Any mandate to offer only TOLAC or refuse it would breach the patient’s right to make decisions in her best interest. Through shared decision-making with patients about TOLAC and VBAC, we may help reduce the overall rate of cesarean delivery while offering women information about the range of options for a safe delivery. Sarah Manneh, MD, practices with Oakdale Obstetrics & Gynecology.

Fairview Health H Servicees Opportunities O pportunities es to fit yyour our life Fairview H Fairview Health ealth SServices ervices seeks physicians to impr improve ove the health of the wee serve. opportunities allow communities w serve. We We have havve a vvariety ariety of oppor tunities that allo w innovative care. yyou ou to focus on inno vative and d quality car e. SShape hape yyour our practicee to partt of our nationally fit yyour our life as a par tionally recognized, recognized, patient-centered, patient-centerred, caree team. evidence-based car participating Whether yyour our focus is work-life work-life fe balance or par ticipating in clinical cal initiatives, wee hav havee an opportunity quality initiativ es, w opportunity that is right for yyou: ou: Dermatology Dermatology Emergency Medicine E mergency M edicine Medicine FFamily amily M edicine General G eneral Surgery Surgery y Geriatric G eriatric Medicine Medicine Hospitalist H ospitalist IInternal nternal Medicine Medicine Med/Peds M ed/Peds

Nocturnist N octur nist Ob/Gyn O b/Gyn Palliative P alliative Pediatrics P ediatrics Peds/Emergency Medicine P eds/Emergency M edicine Psychiatry P sychiatry y Pulmonology/Critical Care P ulmonology/Critical C are e Urgent Care U rgent C are

Visit fair fairview.org/physicians view w.orrg/physicians to explor exploree our curr current ent oppor opportunities, tunities, nities, then apply online, call 800-842-6469 42-6469 or e-mail rrecruit1@fairview.org. ecruit1@fairview iew w.orrg. Sorry, Sorr ry, no n J1 oppor opportunities. tunities.

fair view.org /physicians fairview.org/physicians TTTY T Y 612-672-7300 612- 672-730 0 EEEO/AA EO/A A Employer E m p l oye r

The perfect match of career and lifestyle. Affiliated Community Medical Centers is a physician owned multi-specialty group with 11 affiliate sites located in western and southwestern Minnesota. ACMC is the perfect match for healthcare providers who are looking for an exceptional practice opportunity and a high quality of life. Current opportunities available for BE/BC physicians in the following specialties: • Family Medicine • General Surgery • Geriatrician/ Outpatient Internal Medicine • Hospitalist

• Infectious Disease • Internal Medicine • Oncology • Orthopedic Surgery • Pain Management

For additional information, please contact: Kari Bredberg, Physician Recruitment karib@acmc.com, 320-231-6366 Julayne Mayer, Physician Recruitment mayerj@acmc.com, 320-231-5052 www.acmc.com

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• Psychiatry • Pulmonary/ Critical Care • Radiation Oncology • Rheumatology

Opportunities available in the following specialty: Olmsted Medical Center, a 150-clinician multi-specialty clinic with 10 outlying branch clinics and a 61 bed hospital, continues to experience significant growth.

Family Medicine Rochester Northwest Clinic

Family Medicine St. Charles Clinic

Olmsted Medical Center provides an excellent opportunity to practice quality medicine in a family oriented atmosphere. The Rochester community provides numerous cultural, educational, and recreational opportunities.

Send CV to: Olmsted Medical Center Administration/Clinician Recruitment 1650 4th Street SE Rochester, MN 55904

Olmsted Medical Center offers a competitive salary and comprehensive benefit package.

email: egarcia@olmmed.org Phone: 507.529.6610 Fax: 507.529.6622 EOE

MPP, Inc. • 2812 East 26th Street • Minneapolis, MN 55406 • www.mppub.com

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MINNESOTA PHYSICIAN

Post-polio from page 19 tional one-third have swallowing impairments. Dysphonia, or altered voice, may be treated with voice-strengthening techniques and by amplification devices. Respiratory symptoms may present as subtle changes of endurance and sleep hypoventilation. Early intervention of noninvasive respiratory support has been shown to be beneficial for patients with PPS who have respiratory dysfunction, and may help avoid invasive treatment such as tracheostomy and permanent positive pressure ventilation. Pain management is accomplished by bracing, exercise, surgery, and medication. Scoliosis, cervical or lumbar stenosis, joint osteoarthritis, knee hyperextension, and mechanical back pain may occur at earlier ages and present more diagnostic challenges. Previous tendon transfers, ankle fusions, and prior spinal fusions done at the time of polio may break down and require treatment.

Bracing the ankle with a custom-molded, energy-storing carbon fiber brace is the most advanced type of brace for individuals with foot drop and ankle weakness in the calf muscles. It duplicates the push-off of the calf muscles and can help restore the architecture of the ankle and support knee extension when casted at the appropriate angle. Leg length discrepancies that patients have tolerated for years may gradually promote selective joint overuse in the longer leg, requiring lifts on the shorter side. Newer, lightweight braces with “long-leg” braces that include the knee can help control knee hyperextension and knee extension when the quadriceps are weak. Preventing falls, particularly in Minnesota’s cold climate, is paramount. Casting and immobilization are frequently given as the historical point when the symptoms of weakness and fatigue in postpolio patients first appear. This may be due to the loss of regu-

CME

Conferences 2011

lar weight-bearing and exertion in the limb and overall. Exercising to improve muscle strength can be difficult for individuals with paralysis of one or both lower extremities. Warm-water dynamic exercise has been described as being especially applicable to many such individuals, and is soothing for painful muscles and easy on the joints as well (Willen and Sunnerhagen, Arch Phys Med Rehab, 2001). Physical therapists can meet with patients and adapt a program that meets patients’ individual requirements. Groups of individuals often exercise together and create an impromptu support group that also helps them maintain their exercise frequency. Accepting the challenges of PPS

of these individuals in taking excellent care of themselves and pursuing a healthy lifestyle. When confronted with new symptoms, this group of patients tends to accept the challenge again and fight hard to avoid additional disability. Sharing information with other survivors in support groups is beneficial for some patients. The book “Polio’s Legacy: an Oral History,” by Edmund J. Sass (University Press of America, 1996), is a well-told recounting of the Minnesota polio experience and describes the challenges that polio survivors face. Barbara P. Seizert, MD, specializes in physical medicine and rehabilitation at Sister Kenny Rehabilitation Institute at Abbott Northwestern Hospital, and Children’s Hospitals and Clinics of Minnesota and St. Francis Regional Medical Center in Shakopee.

The medical community has observed that polio survivors tend to demonstrate determination and drive, as well as higher than average tolerance for pain. These traits have assisted many

Dermatology for Primary Care: Beyond the Basics February 26, 2011

25th Annual Family Medicine Today March 10 - 11, 2011

29th Annual OB/GYN Update April 7- 8, 2011

11th Annual Psychiatry Update: Selected Topics for the Non-Psychiatrist April 29, 2011

Pediatric Fundamental Critical Care Support May 19- 20, 2011

Fundamental Critical Care Support July 14 - 15 and October 13 - 14, 2011

29th Annual Strategies in Primary Care Medicine September 22- 23, 2011

12th Annual Women’s Health Conference November 4, 2011

Otolaryngology Conference November 18, 2011

33rd Annual Cardiovascular Conference December 1- 2, 2011 Education that measurably improves patient care.

imehealthpartners.com 952-883-6225

Emergency Medicine and Trauma Update Fall 2011

Pediatric Conference Fall 2011

MINNESOTA PHYSICIAN FEBRUARY 2011

You wouldnâ&#x20AC;&#x2122;t give a 1-year-old a beer, so why would you give one to an unborn child? As a physician, itâ&#x20AC;&#x2122;s your responsibility to let her know: the U.S. Surgeon General Advisory says no amount of alcohol is safe during pregnancy. Share 049: Zero Alcohol For Nine Months.

www.mofas.org

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