Volume XXV, No. 11
February 2012
The Independent Medical Business Newspaper
Aiming high
Improving health, patient experience while lowering costs By Paul Youngquist, MD
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Clinical reasoning models
MODELS to page 10
PAID
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ediatric physical therapists (PTs) throughout the state of Minnesota, in collaboration with parents and physicians, make multiple decisions each day that affect the quality of children’s lives as well as the life of their patients’ families. These professionals provide therapy to children with a variety of neuromuscular and musculoskeletal diagnoses based on the patient/client management model put forth by the American Physical Therapy Association (APTA) and develop their clinical decisions based on the clinical reasoning
PRSRT STD U.S. POSTAGE
By David Chapman, PT, PhD
model developed by Hawkins et al. Each of these models is reviewed below. The patient-client management model developed by the APTA is shown in Figure 1 on page 10. This model encourages the therapist to complete a thorough examination of the child that involves: 1) obtaining a detailed medical and developmental history; 2) performing a review of the child’s cardiopulmonary, musculoskeletal, neuromuscular, and integumentary systems; and 3) selecting and administering appropriate tests and measures that will provide the data needed to confirm the
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Managing pediatric physical therapy
cynic might wonder whether the Institute of Healthcare Improvement’s (IHI) Triple Aim for health care—to improve health and patient experience while lowering health care costs—might be an oxymoron. But my work at Mercy Hospital in Coon Rapids (one of the 11 hospitals in Allina Health System) on two initiatives to prevent hospitalacquired infections has convinced me that those three aims are not only simultaneously achievable but interconnected. At Mercy, which provides care to approximately 2,400 critical patients each year, two of the most common hospitalacquired infections— IN THIS ISSUE: ventilator-associated Rehab and pneumonia (VAP) and physical therapy central-line associated Page 20 bloodstream infections (CLABSI)—have been virtually eliminated. There have been no cases of CLABSI for more than three years and only one case of VAP per year. These results recently garnered Mercy AIMING HIGH to page 12
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CONTENTS
FEBRUARY 2012 Volume XXV, No. 11
FEATURES Clinical reasoning models Managing pediatric physical therapy
1
MINNESOTA HEALTH CARE ROUNDTABLE
By David Chapman, PT, PhD
Aiming high 1 Improving health, patient experience while lowering costs
T H I R T Y- S E V E N T H
SESSION
By Paul Youngquist, MD
DEPARTMENTS CAPSULES
4
MEDICUS
7
INTERVIEW
8 Arjun Sharma, MD, FACC, FACP, FRCPC
NEUROLOGY New approaches, rooted in experience
16
By Thaddeus Walczak, MD
By Jon T. O’Neal, MD, MPH, FACOEM
Boston Scientific
PROFESSIONAL UPDATE: CARDIOLOGY From “no options” to new options 14 By Mohammad Sarraf, MD, Rachel E. Olson, RN, Theresa L. Arndt, RN, Jay H. Traverse, MD, and Timothy D. Henry, MD
DERMATOLOGY A psoriasis update for nondermatologists
Controlling the cost of care Thursday, April 19, 2012 26
By Mitchell Bender, MD
PAIN MEDICINE Pain and palliative care for children 32 By Stefan J. Friedrichsdorf, MD
SPECIAL FOCUS: REHAB AND PHYSICAL THERAPY Improving COPD care By Chris Wendt, MD, and Cynthia Isaacson
18
Specialty pharmacy
OCCUPATIONAL MEDICINE Return-to-work determinations 22
Cancer rehabilitation and survivorship
20
By Nancy Hutchison, MD
The Independent Medical Business Newspaper
1:00 – 4:00 PM • Duluth Room Downtown Mpls. Hilton and Towers
Background and focus: Medications treating chronic and/or life-threatening diseases are frequently new products, which are often more expensive than generic or older, branded products that treat similar conditions. The term specialty pharmacy has come to be associated with these medications. Exponents claim the new technology improves quality of life and lowers the cost of care by reducing hospitalizations. Opponents claim the higher per-dose cost spread over larger populations does not justify the expense.
The cost of research, both failed and successful, is reflected in product pricing. Current federal guidelines allow generic equivalents marketplace access based on the patent date, not the release date, of a product. This considerably narrows the window in which costs of advances may be recovered. A further complicating dynamic involves the payers. Physician reimbursement policies sometimes reward utilizing lower-cost “proven” products and cast those prescribing highercost products as “over-utilizers,” placing them in lower-tiered categories of reimbursement and patient access. Objectives: We will discuss the issues that guide the early adoption of new pharmaceutical therapies and how they relate to medical devices. We will examine the role of pharmacy benefit management in dealing with the costs of specialty pharmacy. We will explore whether it is penny-wise but pound-foolish to restrict access to new therapies and what level of communication within the industry is necessary to address these problems. With the baby boomers reaching retirement age, more people than ever will be taking prescription medications. As new products come down the development pipeline, costs and benefits will continue to escalate. We will provide specific examples of how specialty pharmacy is at the forefront of the battle to control the cost of care.
www.mppub.com PUBLISHER Mike Starnes mstarnes@mppub.com EDITOR Donna Ahrens dahrens@mppub.com ASSOCIATE EDITOR Janet Cass jcass@mppub.com ASSISTANT EDITOR Scott Wooldridge swooldridge@mppub.com
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FEBRUARY 2012 MINNESOTA PHYSICIAN
3
CAPSULES
Mayo’s Research Honored By Science Magazine Mayo Clinic research on aging was recently selected by the journal Science as one of the top 10 groundbreaking scientific achievements of 2011. Mayo officials note that the clinic’s study on eliminating the effects of aging in mice received worldwide attention when it was published in Nature in November. In the study, researchers showed that the animal-based research could help humans delay or prevent the onset of age-related disorders and disabilities by eliminating senescent cells: cells that have become “deadbeat” and are no longer dividing. “Our discovery demonstrates that, in our body, cells are accumulating that cause these agerelated disorders and discomforts,” says Jan van Deursen, PhD, the Vita Valley Professor of Cellular Senescence at Mayo Clinic. “Therapeutic interventions to get rid of senescent cells or block their effects may repre-
sent an avenue to make us feel more vital, healthier, and allow us to stay independent for a much longer time.” Researchers say the work is an important step in the quest to improve health span— not necessarily living a longer life, but a healthier, more productive one.
Minnesota Health Systems Join ACO Project Three Minnesota health systems have been named as part of a pilot program to roll out accountable care organizations (ACOs), a key component of the health reforms passed as part of the Affordable Care Act (ACA). The Minnesota systems participating in the Pioneer ACO initiative are Allina Hospitals and Clinics, Fairview Health Services, and Park Nicollet Health System. Nationally, 32 health organizations were chosen to take part in the program. According to U.S. Health and Human Services (HHS)
Secretary Kathleen Sebelius, the new program will encourage primary care physicians, specialists, hospitals, and other caregivers to provide better, more coordinated care for Medicare recipients. Officials say the Pioneer ACOs could save up to $1.1 billion in health care costs over five years. The ACO model has been discussed and debated throughout the health-care reform process, and the new program is a further step to bring the concept to reality on a large scale. HHS officials say the initiative will test the effectiveness of different payment models as systems move from paying for volume to paying for the value of care provided. The Pioneer ACO program will feature robust quality measurements, freedom of choice in choosing providers, and a coordinated approach to care. The Minnesota systems chosen for the program are among the largest in the state, and serve large populations in the metro area. Minnesota systems also have the advantage
of being familiar with health reform innovations such as coordinated care, since such concepts are already being tested throughout the state. “Fairview Health Network is very well positioned to serve as a Pioneer ACO, says Dave Moen, MD, president of Fairview Physician Associates, “because we have already made tremendous progress with implementing new care delivery models and care coordination processes. Our patients will enjoy better care and a better experience.”
ACS Reports Declines in Cancer Mortality Cancer mortality rates continue to decline both nationally and in Minnesota, according to new data from the American Cancer Society (ACS). The group’s annual cancer statistics report shows that between 2004 and 2008, cancer death rates decreased by 1.8 percent per year in men and by
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MINNESOTA PHYSICIAN FEBRUARY 2012
mortality rates. In Minnesota, the cancer society data show that African American men have a 13 percent higher cancer incidence rate than nonHispanic white men and a 42 percent higher mortality rate. Harvin says that more than ethnicity, socioeconomic factors are playing a role in these findings. “It’s not really about the race of the person, it’s more about access to health care,” he says. “They don’t get the same treatment; they don’t have health insurance. It’s more socioeconomic.”
HealthPartners Changes Policy For Back Pain Patients HealthPartners is changing the way it covers back surgery, providing a new program designed to help enrollees make decisions about the best course of treatment for spinal problems. Officials with the Bloomington-based health plan say that patients with back pain or spinal issues can be confused by the range of treatment choices available, and that some may seek surgical solutions when there are other options that would provide similar or better outcomes at a lower cost. “With low back pain or spine pain, because there’s such variation, there are options,” says Thomas Marr, MD, HealthPartners’ medical director of clinical relations. He adds that patients simply aren’t getting good guidance about what their choices are. “We’ve heard over and over again from primary care physicians that they don’t know where to send these patients, so they send them to surgeons.” Under the new approach, primary care physicians will refer patients with spinal issues to a designated medical spine center, where a specialist will discuss the best options with patients. Specialists approved for the program will be rehabilitation physicians, occupational medicine physicians, or sports medicine physicians who meet certain standards, including a multispecialty approach that CAPSULES to page 6
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Lindquist & Vennum PLLP is pleased to welcome Paul C. Thissen as a Partner to the firm’s Health Law Practice Group. Paul was recognized as one of the 100 most influential Minnesotans in Health Care by Minnesota Physician. He has wide-ranging legal experience, representing large and small companies in commercial disputes, gaining several victories in the Minnesota appellate courts. Paul also serves in the Minnesota House of Representatives. He was first elected in 2002 to serve south Minneapolis and Richfield. He is currently the Minority Leader in the Minnesota House. He previously served as chair of the Health Policy and Oversight Committee. In 2006, Paul was selected as one of the Twin Cities’ “Forty Under 40” top professionals by the Minneapolis/ St. Paul Business Journal and was named one of the Twin Cities “Best Brains” by Minneapolis/St. Paul Magazine.
Paul C. Thissen
Paul is active in pro bono work and has served on the Minnesota Justice Foundation’s board of directors and founded the Access for Persons with Disabilities Program. He is active in several community organizations. Minneapolis Denver lindquist.com
Telephone Equipment Distribution (TED) Program
1.6 percent per year in women. Overall cancer incidence rates for men have also declined, by 0.6 percent per year nationally. Cancer incidence rates in women were stable during those four years. The incidence and mortality rates for cancer in Minnesota have shown similar declines in recent years, officials with the Minnesota chapter of ACS say. The overall cancer mortality rate in Minnesota decreased by 1.6 percent a year between 2000 and 2007. After adjusting for population growth and aging, the overall cancer mortality rate in Minnesota was 15 percent lower in 2007 than it was 20 years earlier, with cancer mortality declining 17 percent in men and 15 percent among women. According to Lou Harvin, public relations manager for the Minnesota chapter of ACS, although it takes time to collect data for cancer illness and death, improving trend lines have been consistent. He says that better treatments have played a role, along with improved screening rates. Harvin notes that one reason that men’s incidence and death rates have declined more than women’s is that men are quitting smoking at higher rates. The data show that cancer remains the No.1 killer of Minnesotans. The report estimates that in this state, cancer will account for more than 9,000 deaths in 2012. Harvin says that although the ongoing reduction in smoking among the general population is making significant improvement in cancer numbers, other health trends could reverse the gains that anticancer groups have been seeing. “We continue to see Americans and Minnesotans becoming more overweight and obese,” he says. “We know that one-third of cancers are directly related to nutrition, exercise, and general eating habits. There is a good chance that 10 years from now, we could see these numbers going backward.” Another area of concern is the racial and ethnic disparities seen in cancer incidence and
Do you have patients with trouble using their telephone due to hearing loss, speech or physical disability? If so…the TED Program provides assistive telephone equipment at NO COST to those who qualify. Please contact us, or have your patients call directly, for more information.
1-800-657-3663 www.tedprogram.org Duluth • Mankato • Metro Moorhead • St. Cloud The Telephone Equipment Distribution Program is funded through the Department of Commerce Telecommunications Access Minnesota (TAM) and administered by the Minnesota Department of Human Services
FEBRUARY 2012
MINNESOTA PHYSICIAN
5
CAPSULES
Capsules from page 5 includes physical therapy and psychology. Marr says the inclusion of psychologists is important because for many patients, pain management has a psychological element. HealthPartners officials say that under the program, there will be 102 centers available in Minnesota and Wisconsin. The specialists at the centers will provide evaluations within 10 working days for most referrals; more urgent cases will be sent directly to surgeons. According to Marr, the new system is based on a successful program in Grand Rapids, Mich., implemented by Priority Health. That program found high patient satisfaction while reducing the number of spine surgeries by 25 percent. Marr notes that it will be the patient’s decision whether or not to pursue a surgical treatment for a spinal issue. “This is not a gatekeeper model,” he says. “The main goal is for the patient to know what all of their options are.”
Forum Addresses Challenges to Independent Practice Independent medical practices face daunting challenges, from obtaining competitive contract rates to lacking lobbying clout to complying with multiple state and federal requirements for data collection. These and other aspects of independent medical practice were discussed at a forum held Jan. 11 in Bloomington. The forum, sponsored by the Midwest Independent Practice Association (MIPA), a partnership of private-practice physicians, drew more than 50 medical group administrators, physicians, and other staff from independent medical practices. Speakers from six Minnesota health care organizations discussed legislative issues, payment and other policy issues, health-care reform efforts, and other topics of interest to independent practices. John English, MD, MIPA board chairman, opened the
2012 CME Courses
meeting by noting that independent medical practices need to differentiate themselves from larger, systems-run physician groups, and urged them to join in efforts to promote and expand independent medical practice “to make independent [practice] a worthy cause and something to fight for.” English described the current initiative by the Minnesota Medical Association (MMA) regarding independent medical practices as “a tremendous plus” for such practices. The MMA has established a ninemember committee of independent physicians to work on defining the term “independent practice,” determine how many physicians in Minnesota can be considered independent practitioners, identify major challenges they face, and prioritize their top three concerns. The MMA will then help devise strategies to meet the needs of this group of physicians.
UCare Announces P4P Results for 2011 UCare paid more than $2.8 million in financial incentives to care systems and clinics as part of its 2011 pay-for-performance (P4P) program. Officials with the Minneapolis-based health plan say UCare’s P4P system rewards providers in Minnesota and western Wisconsin for good performance in a range of quality measurements. “UCare’s Pay-for-Performance program rewards providers of all sizes for providing UCare members with outstanding or improved care that is measured using key quality-ofhealth criteria,” says Russ Kuzel, MD, senior vice president and chief medical officer of UCare. “Clinics and care systems are rewarded for their diligence and accomplishments in improving our members’ health with early detection and preventive care practices, and managing their chronic conditions.”
www.cmecourses.umn.edu
(All courses in the Twin Cities unless noted)
Care Across the Continuum: A Trauma & Critical Care Conference May 11, 2012
SPRING COURSES Urology for Primary Care March 15, 2012
Global Health Training May 14-28, 2012
Lillehei Symposium April 5-6, 2012
Advanced Pediatric Dermatology May 18, 2012
Cardiac Arrhythmias April 13, 2012 Integrated Care Conference: Integrating Behavioral Health into the Health Care Home April 13, 2012
Intensive Care Unit (ICU) Team Training April 23-25, 2012 North Central Chapter Infectious Diseases Society of America (NCCIDSA) Annual Meeting April 28, 2012
Bariatric Education Conference May 23-24, 2012 Workshops in Clinical Hypnosis May 31-June 2, 2012 Topics & Advances in Pediatrics June 7-8, 2012
FALL COURSES
ONLINE COURSES (CME credit available) For more information: www.cme.umn.edu/online U Fetal Alcohol Spectrum Disorders (FASD) U Global Health (7 Modules), to include: - Introduction to Health Care for Immigrant and Refugee Populations - Parasitic Infections - Travel Medicine
Psychiatry Review September 2012 National Pediatric Hypnosis Training Institute (NPHTI) September 20-22, 2012 Twin Cities Sports Medicine October 5-6, 2012 Practical Dermatology October 2012
Office of Continuing Medical Education 612-626-7600 or 1-800-776-8636 email: cme@umn.edu
Promoting a lifetime of outstanding professional practice
6
MINNESOTA PHYSICIAN
FEBRUARY 2012
MEDICUS
William Payne, MD
William Payne, MD, has been named medical director of LifeSource, a Minneapolis-based organ and tissue donation organization. Payne was instrumental in the formation of the organization in 1987 and has served on the LifeSource board of directors since the group began. Payne has stepped down from his role as surgical director of the adult liver transplant program at the University of Minnesota Medical Center, Fairview, but will continue to see patients at
the U of M. Christopher Wenner, MD, has been recognized by the Regional Extension Center for Health Information Technology (REACH) for his leadership in the nationwide transition toward electronic health records (EHR). Wenner, a solo family physician in Cold Spring, is one of the first providers in Minnesota to attest to meaningful use for the Medicare EHR Incentive Program. Wenner will receive one of the first incentive payments in Minnesota made under the Medicare and Medicaid EHR Incentive Programs. Medicare and Medicaid incentive payments are available to eligible professionals and hospitals when they adopt, implement, upgrade, or demonstrate meaningful use of a certified electronic health record. Six physicians have recently joined Duluthbased Essentia Health. Nancy Rova, MD, has joined the Family Medicine Department at the group’s Lakewalk Clinic and Proctor Clinic. She completed a family practice internship at the Nancy Rova, MD University of Minnesota’s North Memorial Hospital. Brett Carlson, MD, has joined Essentia Health’s Heart & Vascular Center. Carlson completed an internal medicine residency at Hennepin County Medical Center in Minneapolis and a cardiology fellowship with the Geisinger Health System in Danville, Pa. Charity Wip, MD, has joined Brett Carlson, MD Essentia Health–St. Mary’s Medical Center as a trauma surgeon. Wip did a fellowship in burn surgery at the Keck School of Medicine at the University of Southern California, and completed a general surgery internship at Wright State University’s Department of SurCharity Wip, MD gery in Dayton, Ohio. Joseph Signorelli, MD, and Xan Courville, MD, have joined the Orthopedics Department at Essentia Health’s Duluth Clinic. Signorelli studied joint replacement in his fellowship, at Harvard’s Brigham and Women’s Hospital in Boston, and his residency, at Dartmouth’s Hitchcock Medical Center in Lebanon, N.H. Courville Joseph Signorelli, MD is an orthopedic surgeon who specializes in ankle and foot surgeries. She completed a surgical internship and orthopedic surgery residency at Dartmouth's Hitchcock Medical Center, and completed a fellowship in foot and ankle surgery at the University of Utah in Salt Lake City. Ayad Jindeel, MD, has joined Xan Courville, MD Essentia Health’s Heart and Vascular Center in Duluth. Jindeel is a vascular medicine specialist, worked as an assistant clinical professor at the University of California-Los Angeles, and was on the faculty at Harbor-UCLA for six years. Before that, he was an internist for seven years at Kaiser in California. He completed his residency at Kaiser San Francisco, graduated from medical school in Mosul, Iraq, and is board-certified in internal medicine.
REQUEST FOR NOMINATIONS
2012 HEALTH CARE ARCHITECTURE & DESIGN
HONOR ROLL NOMINATION CLOSING: MONDAY, APRIL 30, 2012 PUBLICATION DATE: JUNE 2012
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 2012 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, 2011. 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 Monday, April 30, 2012. For more information, call (612) 728-8600.
2012 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 2012
MINNESOTA PHYSICIAN
7
INTERVIEW
Pursuing innovation, maintaining safety ■ Tell us a little about the history of Boston
Scientific.
Arjun Sharma, MD, FACC, FACP, FRCPC Boston Scientific Arjun Sharma, MD, FACC, FACP, FRCPC, is a cardiac electrophysiologist and a senior medical director at Boston Scientific. He has 25 years of clinical experience in academic and private practice, and has worked in the past as a consultant and advisor for a number of companies, including Medtronic and St. Jude Medical. Sharma has been involved with more than 50 clinical trials involving pharmaceuticals and implantable devices. He has submitted six patents as a co-inventor with Boston Scientific.
8
In the building we’re in right now, this originally started right here in the Twin Cities as Cardiac Pacemakers Incorporated back in the 1970s. It was then bought by Eli Lilly and then subsequently became Guidant. In 2006, Boston Scientific acquired Guidant, so that is a very brief history of this particular facility in the pacemaker area. In terms of Boston Scientific’s history as a whole, one of the key acquisitions, going back, was the acquisition of Scimed, based in Maple Grove now, which makes coronary and other stents. The company has acquired a number of other divisions. There is pain modulation, a neurological area, peripheral vascular, women’s, and urology. In the last year, we have had several acquisitions of products that haven’t yet made it to the market, but we are always looking to go forward in a positive way.
has, as a result, been a very limited role for physicians in overseeing a lot of medical devices. However, our company has been very proactive in involving physicians with the engineers to make sure that the products we are making are appropriately designed and safe for patient use. ■ Recent laws have limited or regulated access
to physicians from both drug companies and medical device manufacturers. Has this new trend created barriers to physicians being educated about new products?
I think we’re very early into some of these legislations and I think time will tell what sort of potential bad or unintended effects might occur. I described how complicated our devices are, and it is true that the avenues to teaching physicians about these new developments, once they’re already out in practice, have become very limited. My question is, how do you keep people up to date on some of these very ■ It’s interesting that the specific details? I don’t think It takes a great deal history of the company anybody has quite come to reflects the boom of of planning and foresight grips with how to do that. I medical device companies think the assumption has to estimate what these here in the Twin Cities. been made that all of these products are relatively simiIt certainly has, but I think uptake rates will be for lar and that one doesn’t need what is so fascinating is how product-specific training, but these different therapies. much of our company is I am concerned that as we go right here in the Twin Cities. forward over a longer period That fits with what I think of time and these products diverge in their specific the general perception is, that the Twin Cities are details, it’s going to become harder and harder for one of the most important areas in the entire world physicians to keep up with these details. in terms of medical device development. Another unintended effect is the cost of documentation and legal fees that we generate to make ■ Tell us about your role at Boston Scientific. sure that we’re keeping up with all the changes in I’m a cardiac electrophysiologist, which is a bit of the regulations that occur on a yearly basis. For a a mouthful, but that means that I’m first a cardiosole practitioner, that’s a huge deal. logist and then secondly I’ve subspecialized in the It’s difficult because obviously the people that area of the electricity of the heart. are writing the regulations are not practitioners, so I first joined the company in terms of safety, there are those unintended effects. I think most of and now I’m working on the medical director side, us realize that we need to drive towards the most which probably is a little bit more recognizable to cost-effective health care as we go forward. physicians in practice, because what I do primarily now is provide clinical expertise to our groups in clinical trials, and I oversee some of the safety events that occur in the clinical trials. During testing and clinical trials, the FDA may have medical questions, in which case the team might bring me in to discuss those questions. At the end of the studies, I am involved with the tabulation of the data and sometimes with presentation to the FDA as well. The safety aspect of my role is probably something that physicians in practice are less aware of. In the pharmaceutical industry, hiring physicians in a safety role has been going on for a long time, but in the medical device industry, the devices are usually designed and build by engineers, and are so technically advanced that they are beyond the scope of understanding of most physicians. There
MINNESOTA PHYSICIAN FEBRUARY 2012
■ Charges over kickbacks in the medical device
industry have resulted in multimillion-dollar payments. Why has this issue continued to be a problem? Well, first of all, I don’t know if it is continuing to be a problem, in the sense that the things that you and I see in the press are usually things that occurred quite some time ago, and the legal process is a slow one. I think that many of the changes that have been made will hopefully prevent that from happening again. Certainly our company is all in favor of making sure that this sort of thing doesn’t happen. I would expect that you would be seeing anything like that going forward.
■ Studies have shown that when a new
device or drug comes to market, it takes seven years to become widely used. What is the reason for this time lag? There are a number of different things that can contribute. Medical guidelines more and more are driving how physicians practice. By the very nature of the guidelines, they tend to slow down innovation and uptake of new types of procedures. Of course, reimbursement plays a role, since both Medicare and third-party payers tend not to want to pay for anything new that they haven’t budgeted for. So we see that there is a financial disincentive to using new therapies. During that period of time you still have to support the regulatory side, the quality side, and the sales and the marketing, even though you may have a lower volume of sales. It takes a great deal of planning and foresight to estimate what these uptake rates will be for these different therapies. If you have some really long-shot types of treatments, they may not actually go to the market because companies have to be much more conservative in terms of the risks that they take. Patents only last for a finite period of time. If there is a certain therapy where it will take 10 or 15 years before it gets used a lot, that will be hard for people to invest in as the first player. It might be better to be the second player in a
situation like that because then you can take advantage of the leaders having broken that barrier to use—which is discouraging, because if you are a patient, you would like to have the latest and best treatment.
vide more devices to the other parts of the world.
■ Has the global recession had an impact
I know that when I was in practice, I was very busy, just like most of your readers are. When something unintended or unexpected occurs, it’s very hard for the physician in practice to know what he’s supposed to do with that information. I would definitely urge your readers to try to learn about reporting—reporting to the FDA, for example, if there is an unintended drug effect or device effect, because that’s really one of the main ways of making sure that their voice is heard and that patients get better products going forward. That’s what drives product improvement. When we hear back from physicians about various experiences with products, we can use that information to make better products for patients going forward. Within the company, we report everything we hear per regulations, but physicians are not covered by the same regulations, yet their voice is actually the most important Companies like Boston Scientific are putting into place better physician reporting and hospital reporting systems, to make sure that we see what really is going on out there in the world.
on the medical device field? Yes. Sales are down. I think that is public knowledge because all the companies, Medtronic, St. Jude, and Boston Scientific, report their quarterly earnings, and there is no doubt that inside the U.S., in particular, in the area of pacemakers, defibrillators, and stents, there hasn’t been the growth that was occurring in the previous decade. There are many reasons for this, but I think that the timing in relationship to the recession is no doubt there. However, the question is whether this is really a global recession, because we still see other economies that are continuing to expand. One of the consequences of this is that we are looking at other markets that are growing, and as a result Boston Scientific is actively going into China, India, Brazil, areas where the economies are growing more rapidly than here. That is going to be our bigger source of growth in the near future. Of course, with a large number of people employed here in Minnesota, that benefit will accrue back here in part as well; so it’s a win-win situation to be able to pro-
■ What can physicians in general do to
help research and innovation in the medical device field?
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Engaging Patients, Accelerating Change, Improving Value
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Models from cover presence or absence of impaired body functions and structures, activity and participation limitations, and environmental and personal factors
The physical therapist considers additional services this child and family may need. that may affect the course of therapy for this child. The examining therapist then develops her clinical judgments based on the information and data obtained during the examination. During this evaluation process, the physical therapist also considers what additional services this child and her family may need. Both the examination data and the evaluation process enable the therapist to develop a physical therapy diagnosis. This process allows the pediatric PT to develop a realistic prognosis that is
based on specific intervention strategies (e.g., gait training, neuromuscular reeducation, strength training), as well as the frequency, intensity, and duration of the physical therapy services needed to meet the child’s treatment goals. All of these steps are typically completed during the initial physical therapy visit with the child and her parent/caregiver. The therapist summarizes this information in an evaluation note that is then sent to the referring physician for review. Skilled physical therapy interventions are implemented next at the frequency, intensity and duration agreed upon by the parent, therapist, and physician. Periodically, depending on the child’s needs, patient progress, and regulatory requirements, the physical therapist will complete a reexamination of the child to verify progress as well
DIAGNOSIS Both the process and the end result of evaluating examination data, which the physical therapist organizes into defined clusters, syndromes, or categories to help determine the prognosis (including the plan of care) and the most appropriate intervention strategies.
PROGNOSIS (including plan of care) Determination of the level of optimal improvement that may be attained through intervention and the amount of time required to reach that level. The plan of care specifies the interventions to be used and their timing and frequency.
EVALUATION A dynamic process in which the physical therapist makes clinical judgments based on data gathered during the examination. This process also may identify possible problems that require consultation with or referral to another provider.
EXAMINATION The process of obtaining a history, performing a systems review, and selecting and administering tests and measures to gather data about the patient/client. The initial examination is a comprehensive screening and specific testing process that leads to a diagnostic classification. The examination process also may identify possible problems that require consultation with or referral to another provider.
OUTCOMES Results of patient/client management, which include the impact of physical therapy interventions in the following domains: pathology/pathophysiology (disease, disorder, or condition); impairments, functional limitations, and disabilities; risk reduction/ prevention; health, wellness, and fitness; societal resources; and patient/client satisfaction.
as reveal impairments and/or functional limitations that may require additional intervention or other types of services. The physical therapist is also responsible for developing appropriate outcomes for each patient. Outcomes in physical therapy are best thought of as the anticipated result(s) of therapy and are usually designed to reflect the direct interventions provided to the child and her family by the treating physical therapist.
Clinical reasoning model
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To successfully implement patient-client management, pediatric physical therapists frequently rely on the clinical reasoning model mentioned above. Figure 2 illustrates the model of clinical reasoning developed by Hawkins et al., which is based on universal structures of thought. It contains eight specific elements and can be reviewed beginning at the top of this circular model and progressing in a clockwise direction. Initially, the physical therapist identifies the purpose of her clinical reasoning. The therapist accomplishes this by answering the question, “What
INTERVENTION Purposeful and skilled interaction of the physical therapist with the patient/client and, if appropriate, with other individuals involved in care of the patient/client, using various physical therapy procedures and techniques to produce changes in the condition that are consistent with the diagnosis and prognosis. The physical therapist conducts a reexamination to determine changes in patient/ client status and to modify or redirect intervention. The decision to reexamine may be based on new clinical findings or on lack of patient/client progress. The process of reexamination also may identify the need for consultation with or referral to another provider.
FIGURE 1. The elements of patient-client management. Adapted from the American Physical Therapy Association “Guide to Physical Therapist Practice.” APTA, 2001. is the objective of my clinical reasoning?” or completing the statement, “The purpose of my clinical reasoning is to …” For example, when a PT works with a young infant with lumbar or sacral spina bifida (SB), one purpose of her clinical reasoning may be to find a method(s) to increase the number of times the baby moves and/or kicks her legs. The second element of this approach encourages the pediatric PT to identify the specific clinical question that needs to be answered or problem to be solved. In the case of a young infant with lumbar or sacral SB, the clinical question may be, “How can I help this child move and kick her legs more often?” because the clinical problem to be addressed is that this young infant with lumbar or sacral SB is not moving her legs very often. Recognizing our clinical assumptions is the third ele-
ment of this model. An important and often challenging task for every clinician is to selfidentify her clinical assumptions. Further, each therapist needs to confront how these assumptions may shape her point of view or perspective as she continues to treat infants and children with movementrelated diagnoses. In the example of a baby with SB, the therapist may assume that if the infant moves and kicks her legs more, she will strengthen the muscles needed to walk and the neural connections that support those movements, and that this may help her learn to walk earlier in life than she might have without increasing the number of leg movements she generates prior to walking. Each therapist perceives her patient(s) from a certain point of view. Thus, she is challenged to reflect on questions such as these: • What is my point of view? • What weaknesses exist within my point of view? • What other points of view should I consider?
Clinical Implications & Consequences that which follows logically, results
Clinical Interpretation & Inference conclusions, solutions
Clinical Concepts theories, definitions, laws, principles, models
Purpose of Clinical Reasoning goal, objective, function
Elements of Clinical Reasoning
Clinical Information data, facts, evidence, observations, reasons
• What are the strengths and weaknesses of these other perspectives? By engaging in this reflective process, the therapist prevents herself from becoming complacent and facilitates her ability to treat her patients in an explicit, transparent, and consciously competent manner that can be easily understood by the child’s parent or caregiver.
FIGURE 2. The elements of clinical reasoning. Adapted from Hawkins, D., et al., “The Thinker’s Guide to Clinical Reasoning.” Dillon Beach, Cal.: The Foundation for Critical Thinking Press, 2010.
Clinical Question at Issue problem, issue
Clinical Assumptions presuppositions, axioms, what is taken for granted
Clinical Point of View frame of reference, perspective, orientation
The fifth element of this clinical reasoning model allows the therapist to actively consider data that may be relevant to this particular child’s needs, as well as reflect on the following questions: Is my reasoning based on relevant data? Do I have enough data to reach a valid conclusion? Both of these questions move the therapist’s clinical reasoning forward and enable the
therapist to provide services that are evidence-guided. Next, the therapist asks herself what concepts and theories are shaping her clinical reasoning. In the SB example referred to above, the therapist may “see” these infants through the lens of dynamic systems theory (DST), basic concepts of functional anatomy, biomechanics, neuroanatomy, and her years of clinical experience working with infants with SB. For example, a key concept of DST is that children demonstrate new movement skills in real time as a result of the interactions of all of their multiple subsystems, e.g., muscles, joints, CNS, movement experiences, and nutritional status. Although this may be the clinician’s perspective, she remains responsible for asking whether she is applying these ideas clearly, precisely, MODELS to page 38
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Aiming high from cover an Outstanding Leadership Award from the U.S. Department of Health and Human Services (HHS) and the designation of “Mentor Hospital” from IHI. Eliminating these infections has required changes in complex clinical practices as well as a strong focus on unit culture and teamwork. “Bundled” interventions to eliminate VAP and CLABSI
Research shows that both VAP and CLABSI lead to higher mortality rates. When patients do survive, they endure pain and suffering, time in the intensive care unit (ICU), and expense. For example, Mercy data show that eliminating CLABSI resulted in a total of 96 fewer days in the ICU for our patients treated between 2007 and 2010. Preventing VAP has saved approximately $18,000 per patient. For all of these reasons, the federal Affordable Care Act has set challenging goals for eliminating hospital-acquired infections. Solid evidence now supports the use of bundles—inter-
ventions implemented as a group—to eliminate VAP and CLABSI. The VAP bundle has several key elements: • Head-of-bed elevation to reduce aspiration pneumonia; • Daily sedation vacations and readiness-to-wean assessments, which ensure patients are weaned off ventilators as soon as possible; • Peptic ulcer disease prophylaxis to suppress acid that may contribute to aspiration of gastric secretions; and • Deep vein thrombosis prophylaxis to prevent thrombotic complications that would extend a patient’s stay in the ICU. Two CLABSI prevention bundles, including best practices for insertion and maintenance of the central line, were implemented. The insertion bundle includes hand hygiene practices, maximal 2 percent chorhexedine gluconate solution for insertion and site care, and optimal catheter site selection. The line maintenance bundle includes re-siting of the central line if the patient arrives with a line in the femoral
artery or if insertion was initially completed without sterility; daily, documented review of line necessity; daily bathing of patients with a CHG-impregnated cloth; and standardized site care, line maintenance, and hub-scrubbing practices. Culture and teamwork interventions
At Mercy, the key to success has been not just the infection-reducing clinical practices but also the culture and teamwork practices that help engage all clinicians in doing the work. One of Mercy’s first steps was to develop partnerships with the multidisciplinary team to help them drive and support the work. This involved making a clear, compelling, evidence-based case that this initiative would improve the quality of care for patients. Several interventions were particularly helpful in spurring partnerships with physicians. • Consultative and direct roles on clinical action teams (CAT teams). These unit-based teams of direct-care staff drove much of the work to accom-
plish our goals. Intensivists and pulmonologists directly participated on CAT teams in a consultative role. Teams’ activities were reported to the Critical Care Quality Improvement Committee, which includes a trauma surgeon, hospitalist, emergency medicine physician, and intensivists who reviewed and provided input on the approaches that the teams recommended. The CAT teams reviewed the scientific literature, implemented evidencebased improvements, and then “hard-wired” the best practices they recommended into work flows. These teams acted as a feedback mechanism where group members could bring up what wasn’t working and strategies could be developed to address areas of weakness. • Leadership support. When physicians have received a clear, evidence-based case for why new interventions will improve care quality but their actions still are not in line with the new interventions, leadership help is needed to remove these barriers. At
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Mercy, when a new clinician comes in, information on the clinician-developed infection prevention practices is provided. If the clinician’s documentation or practices do not align with the CLABSI bundle, the medical director sends a letter inviting that colleague to partner with the ICU in following the CLABSI initiative, thereby improving care excellence. If the clinician doesn’t respond to written and verbal coaching, an entry can be made in the clinician’s credentialing file, which affects the provider’s application for reappointment. • A focus on interventions that help teams do it right for every patient, every time. Clinician support also requires that new interventions be developed and tested in the most efficient way possible. At Mercy, many interventions are hard-wired into the system through preprinted order sets and validated at daily multidisciplinary rounds. New interventions are introduced via rapid-cycle change, in which small tests of change
are performed and then implementation is expanded if the new process improves patient care. The SBAR communication tool (SBAR stands for situation, background, assessment, and recommendation) helps structure the communication with clinicians and leaders in order to gain support for new initiatives. Reaching this level of success has not happened quickly but over the course of many years. Complex, multistep process changes usually aren’t performed perfectly in the beginning. Coaching has helped smooth out implementation of new process changes, and peer coaching by trained colleagues helps provide immediate, bedside feedback. A critical event analysis of every harmful event is conducted to learn from each of our failures. This involves a review of the patient’s risk factors, clinical course, evidence of following best practices, and the root cause of the infection. Specific bullet points, addressing what was done right and what could be improved, are shared
widely and are posted in areas that staff members, patients, and family members can access. Celebrating success
One of the most overlooked ways to motivate staff members who are implementing complex changes in the way they perform care is to celebrate what is going right. There are many low-cost, simple ways to reinforce and build upon progress. At Mercy, those have ranged from a pancake breakfast for staff members to administrative staff time offered for writing articles about our progress. These articles celebrated our work and helped us develop new allies. For example, articles about our progress were published through the Allina system and resulted in these interventions expanding into new Allina units and hospitals. Articles also were published in national medical journals, allowing us to add our knowledge to a national conversation about infection prevention. Data now show that Mercy has achieved the triple aim of improving care and patient ex-
perience of ICU care while eliminating the costs that hospitalacquired infections can add to patients’ medical bills. The cultural change that has occurred as part of these initiatives has had an impact on other parts of the work environment as well. Data from Allina-wide 2010 and 2011 “safety culture” surveys, which are validated and benchmarked through the Agency for Healthcare Research and Quality, revealed that Mercy’s ICU “safety culture” ranks in the top 10 percent of U.S. hospitals. These achievements have helped us exceed Minnesota and HHS quality measure thresholds and have helped establish Mercy Hospital’s overall quality performance, which ranks in the top 10 percent of Minnesota hospitals. Most important, thanks to our teams’ dedication to this pursuit, patients have experienced less suffering, fewer hospital days, lower costs, and higherquality care during their ICU experiences. Paul Youngquist, MD, is an intensivist at Mercy Hospital in Coon Rapids.
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n estimated 10 million to 12 million people in the United States have angina pectoris, and approximately 400,000 new cases are diagnosed each year. Angina is the initial sign of coronary artery disease (CAD) in 50 percent of patients, is debilitating in many patients, and results in a significant burden on the health care system in the U.S. As the population ages and mortality of patients with acute coronary syndrome declines, more patients are living longer with CAD. This has led to an increase in the number of patients who have exhausted the usual therapeutic options, including medical therapy, percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery. These patients with “refractory angina pectoris” are often referred to as “no option” patients. In an attempt to provide options for these challenging patients we developed the OPTions In Myocardial Ischemic Syndrome Therapy (OPTIMIST) program at the Minneapolis
U P D AT E :
From “no options” to new options Renewed hope for patients with severe CAD By Mohammad Sarraf, MD, Rachel E. Olson, RN, Theresa L. Arndt, RN, Jay H. Traverse, MD, and Timothy D. Henry, MD
Heart Institute (MHI) at Abbott Northwestern Hospital in Minneapolis. A number of unique, clinically approved therapies as well as novel
research trials are available in the OPTIMIST clinic with the goal of improving the quality of life in this challenging population of patients.
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At the heart of the program is an individualized treatment plan for each patient. Every patient meets with a select group of nurses and cardiolo-
Despite their high risk and complex heart disease, only about 3 percent of OPTIMIST patients die per year—a rate similar to age-matched patients without heart disease.
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gists to determine the best treatment suitable for that individual. We carefully review the patient’s current and past medical problems, including previous revascularization, anti-anginal medication, and risk-factor modification, as well as the most recent stress test and coronary angiogram. After reviewing the conventional medical and surgical options, we consider a number of unique treatment options, including cutting-edge research trials. Currently, the OPTIMIST program is following more than 1,400 patients with refractory angina. Our results indicate that more than 90 percent of these patients will have improved symptoms and quality of life. Novel medications
There are a number of novel pharmacologic options for treatment of refractory angina in Europe and Asia, yet only one has U.S. Food and Drug Administration (FDA) approval for treatment of chronic angina in the U.S. Ranolazine (Ranexa) is an extended-release tablet that modulates the metabolic activity of the heart in favor of reducing the oxygen consumption. More importantly, it does not affect the hemodynamic parameters, and thus can be used safely in
patients with marginal blood pressure and/or heart rate. In a study from our OPTIMIST clinic presented at the American College of Cardiology meeting in March 2011, we observed significant improvement in 80 percent of patients with refractory angina, when ranolazine was added to their previous medications, but at 1 year only 60 percent of patients remained on the medications, primarily due to cost and side effects. It is noteworthy that another supplemental therapeutic option in these patients is Larginine (8–10 g daily), available as an over-the-counter supplement. Small studies have shown symptom improvement in patients with refractory angina. Enhanced external counterpulsation (EECP)
A noninvasive procedure, EECP is a precisely timed diastolic pressure augmentation to improve the coronary perfusion. It includes three pairs of pneumatic cuffs that are placed on the patient’s calves, thighs, and buttocks. The compressions are synchronized with the patient's electrocardiogram, and the cuffs inflate sequentially from the calves up and then deflate in a manner to augment circulation to the heart (see Fig. 1). Patients undergo 35 one-hour sessions over seven weeks. EECP leads to substantial improvement in symptoms for 75 percent to 80 percent of patients by increasing recruitment of myocardial collaterals, improving endothelial function and the release of nitric oxide, proangiogenic cytokines, and circulating stem cells. EECP is FDA-approved for patients with class 3–4 angina who are not candidates for revascularization, and is covered by most major insurance companies. Angiogenesis and cell therapy
Patients with severe CAD frequently have naturally occurring collaterals stimulated by ischemia. Since patients with refractory angina have severe CAD not amenable to further CABG surgery and/or PCI procedures, protein and gene therapies were initially used to enhance this natural process of
angiogenesis in the heart. While these initial efforts were promising, more convincing results have emerged recently by using the patient’s own stem cells, injected directly into the heart, to stimulate the growth of collateral vessels, bypassing the diseased segment of the heart and increasing its blood supply. Unfortunately, much of the media coverage regarding stem cells has focused on ethical and political concerns related to use of embryonic stem cells. In the meantime, cardiology research with adult stem cells has progressed dramatically, using both autologous (patient’s own cells) and allogeneic (cells from young, healthy donors) stem cells. Nearly 300 patients have been treated at the Minneapolis Heart Institute at Abbott Northwestern (one of five National Institutes of Healthsupported Cardiovascular Stem Cell Centers) using a wide variety of cells and methods of delivery for refractory angina, acute myocardial infarction, CHF, and peripheral arterial disease. In particular, the use of CD 34+ stem cells in patients with refractory angina have yielded very positive results. In a double-blind, placebocontrolled trial published in Circulation Research (August 2011), patients treated with CD 34+ stem cells had an improvement of more than two minutes in the time they were able to spend exercising on a treadmill, and had nearly 15 fewer episodes of chest pain a week. These positive results were sustained for at least two years. Based on these promising results, several new clinical trials are under way to illuminate the best approach for stem cell therapy in these challenging patients. Neurostimulation
Spinal cord stimulation (SCS) uses a percutaneously implanted electrical stimulator to deliver mild electrical signals to the
Improving symptoms, quality of life
FIGURE 1: Mechanism of action of enhanced external counterpulsation (EECP). (With permission from www.iprogressivemed.com/therapies/eecp.html)
area of the spinal cord that corresponds to the location of a patient’s angina. By modulating the pain pathways in the spinal cord, SCS can improve control of the pain symptoms, including angina. With this therapy, patients have fewer episodes of angina pectoris, as well as improved blood flow. It is believed that through modulation of the neural pathways, the autonomic trafficking of the heart will shift in favor of reducing the myocardial oxygen consumption. This approach has been successfully tested in patients with refractory angina. Currently, it is an approved therapy in these patients in Europe.
from nonischemic to ischemic territories. The coronary sinus occluder is a percutaneous implantable device designed to establish coronary sinus narrowing and to elevate coronary sinus pressure. The results of small, randomized, open-label trials are promising, and a larger phase II trial is underway.
In summary, patients are living longer despite severe blockages in their coronary arteries. Despite their high risk and complex heart disease, only about 3 percent of OPTIMIST patients die per year— a rate similar to agematched patients without heart disease. Therefore, the major focus is to improve the patient’s symptoms and quality of life. Fortunately, the number of options for “no-option” patients is growing and provides renewed hope for patients with severe CAD. Mohammad Sarraf, MD, is a cardiology fellow at the University of Minnesota, Minneapolis; Rachel E. Olson, RN, and Theresa L. Arndt, RN, are staff at the Minneapolis Heart Institute Foundation, Minneapolis; and Jay H. Traverse, MD, and Timothy D. Henry, MD, are staff at the Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis.
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Transmyocardial revascularization (TMR)
TMR is a surgical technique that creates tiny channels in the myocardium with a specialized laser. The idea is that formation of small channels may stimulate angiogenesis and also decrease the sensation of pain from the nerve endings of the heart. Although TMR has been approved by the FDA both alone and in conjunction with CABG, the complexity of patient selection has limited its widespread use. Recently we began using minimally invasive TMR delivered robotically.
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mentor who kindled my interest in epilepsy had some favorite sayings that I still hear echoing in the recesses of my subconscious from time to time. “Seizures are not like fractures,” she would say, “and they are not like appendicitis. When you treat seizures you are not treating something you can see or feel, you are treating a story.” Then again: “Epilepsy is not a seizure or even a collection of seizures. Epilepsy is a process that has potential to change a person over time and you have to deal with this if you want to really help a person.” I remember reacting the way most eager trainees react: nodding my head, trying to appear interested, but thinking to myself, “What is she talking about? And why won’t she talk about something that can be defined, quantified, and examined in a proper scientific study?” More than 20 years later, I am beginning to understand. And hard scientific data of the sort I craved as a beginner are beginning to demonstrate three
New approaches, rooted in experience Science begins to catch up with what we’ve long known about epilepsy By Thaddeus Walczak, MD
basic ideas that experienced practitioners treating epilepsy had always known: • Precise diagnosis is critical in epilepsy, but it is not always easy to achieve. • Persistent epilepsy is associated with significant comorbidities that often affect quality of life more than the seizures. Diagnosing and treating these is just as important as treating the seizures. • Aggressive treatment reduces seizures and may also reverse or prevent the development of comorbidities. Each of these keys to diagnosing and treating epilepsy is discussed below.
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Diagnosing epilepsy
Precise diagnosis is critical in epilepsy but it is not always easy to achieve. A person presenting with a potential seizure presents with a story rather than with a physical sign or a test result. More so than with most other disease entities, diagnosis of seizure depends on the description of what happened to the patient. It is even more challenging than usual because much of the time the patient is impaired during the event. The clinician is left with the patient’s recollections of what happened before and after the seizure. An observer history is probably the most useful piece of historical information but requires some detective work by a person experienced in the many clinical manifestations that epileptic seizures can take. Neuroimaging is critical to exclude intracranial lesions that may be causing the epilepsy, but we must remember that not all imaging is created equal. Magnetic resonance imaging (MRI) detects potentially epileptogenic lesions far more often than CT scanning. Epilepsydirected magnetic resonance imaging with sequences sensitive for mesial temporal sclerosis, cavernomas, and cortical dysplasia is more useful still and should be pursued if initial imaging is unremarkable and seizures are not controlled. Electroencephalography (EEG) is even more critical but some experience is necessary to interpret results correctly. First, specific findings such as epileptiform spikes and sharp waves are highly associated with epilepsy but many other abnormalities are nonspecific. Determining whether any given waveform is epileptiform is a subjective call and depends on the
experience of the interpreter. Unfortunately, “overreading” of EEGs and subsequent incorrect diagnoses of epilepsy are still common and often cause unnecessary distress. Second, diagnostic utility of EEG is dependent on the sampling time (duration of recording). The epileptiform spikes and sharp waves highly associated with epilepsy are not always present and may not appear during a routine hourlong study. This is not uncommon; almost half of people with seizures recorded in our unit will not have epileptiform sharp waves or spikes after multiple EEGs. Therefore, a normal EEG cannot rule out epilepsy. Finally, continuous videoEEG recording can overcome these limitations. Longer recording times increase opportunities to record diagnostic findings. More importantly, the events of interest can actually be recorded with EEG and video. This allows an unambiguous determination of whether or not the events are epileptic. Recording characteristic events with video-EEG monitoring is the only way to be sure that the events in question are epileptic. This may not always be necessary, but it is essential if seizures do not respond to treatment. Why is accurate diagnosis so important? Because accurate diagnosis determines treatment and allows realistic assessment of prognosis. If diagnosis is uncertain, treatment becomes a series of shots in the dark. Many physicians do not realize that up to one-quarter of people with seizures not responding to medications do not have seizures at all but, rather, other types of attacks that superficially mimic seizures and are often psychiatrically based. Obviously, treating with antiseizure medications in this situation is a recipe for frustration. Even if the diagnosis of epilepsy is certain, the type of epilepsy syndrome will determine the best treatment. This has been illustrated in several class I studies reported in the last several years. The SANAD trial demonstrated convincingly that valproate was more effective for primary generalized tonic-clonic seizures than lamot-
rigine or topiramate (Marson AJ, et al., Lancet 2007). Another major trial reported that ethosuximide was more effective for absence seizures than lamotrigine and better tolerated than valproate (Glauser TA, et al., N Engl J Med 2010). Further studies demonstrate that rufinamide and soon-to-be-released clobazam are two very effective options for the multiple refractory seizure types in the Lennox Gastuat syndrome while most other antiseizure medications donâ&#x20AC;&#x2122;t help (Glauser TA, et al., Neurology 2008; Sperling MR, et al., Epilepsia 2004). The bottom line is that correct epilepsy syndrome diagnosis increasingly points to specific medications that are most likely to be effective. The old approach of starting a familiar medication and hoping for the best is no longer the best way to treat our patients. Treating comorbidities
Persistent epilepsy is associated with significant comorbidities that often affect quality of life more than the seizures. Diagnosing and treating these is just as important as treating the seizures. Significant medical conditions strongly associated with ongoing epilepsy include depression and suicide, sudden unexplained death, poor bone health, and impaired fertility. The story of the association between epilepsy and depression is particularly interesting. For many years practitioners knew that major depression occurred in approximately one-third of people with severe epilepsy, three to four times more frequently than in the general population. This was not considered particularly surprising; after all, this group had struggled unsuccessfully with a stigmatizing medical condition and usually sustained many social losses. However, in the last decade it became clearer that both depression and suicide were more common in people at the time of their first seizure than in control groups. Several years ago, Hesdorffer and colleagues demonstrated that people with depression alone are more likely to experience a new onset seizure over time than people
who are not depressed (Hesdorffer DC, et al., Epilepsia 2011). The notion that the depression-prone brain is also seizure-prone has led to the idea that anomalies in serotonin receptors and serotonin trafficking may be responsible for both conditions, and this idea is being actively pursued. However this plays out, it is increasingly clear that the relationship between epilepsy and depression is real and goes both ways. Uncontrolled seizures usually do not occur every day, but untreated depression affects a person more or less continuously. Multiple studies have shown that quality of life in epilepsy is affected more by a personâ&#x20AC;&#x2122;s mood than by the effect of the seizures. People with epilepsy should therefore be screened for depression and treated if appropriate. A few medications such as levetiracetam and the barbiturates can trigger depression, and this should be considered as a possible cause. Practitioners are often wary of initiating antidepressant medications in people with epilepsy because of concerns that psychotropic drugs will lower seizure threshold. In fact, this is quite rare. There is reasonable evidence that clozapine, chlomipramine, and buproprion at doses higher than 300 mg per day may increase seizure tendency. Other psychotropic medications are very unlikely to trigger seizures. Several antidepressants (fluoxetine, citalopram, imipramine) have actually shown some antiseizure efficacy. Aggressive treatment
Aggressive treatment reduces seizures and may also reverse or prevent the development of comorbidities. After diagnosis, seizures should be treated with an antiseizure medication appropriate for the patientâ&#x20AC;&#x2122;s seizure type, and medication doses should be increased until seizures are controlled or unacceptable side effects occur. If two appropriate antiseizure medications do not control seizures, referral to confirm diagnosis and consider more aggressive treatment such as resective epilepsy surgery is appropriate. This approach is now standard of care and us-
ually will result in reasonable seizure control. The good news is that recent studies report that aggressive treatment also appears to reverse or prevent epilepsy comorbidities. Long-term follow-up of the large, multicenter epilepsy surgery trial cohort demonstrates that both depression and anxiety improve following successful epilepsy surgery and that this benefit is maintained through five years after the operation. Analysis of the same cohort reveals that successful surgery decreases mortality. A very recent meta-analysis of more than 20,000 patients with medically intractable epilepsy found that risk of sudden death decreases substantially after addition of a new medication even if multiple previous medications have not completely controlled seizures (Ryvlin P, et al., Lancet Neurology 2011). There are many medications and treatment options for epilepsy and the scientific evidence increasingly supports the traditional idea that neither the physician nor the patient should give up.
Our mentors were right
Comprehensive care addressing both seizures and comorbidities will be challenging in the current health care environment. Physicians are pressed daily by increased patient demands, too much information, too little time, and too few resources. It may seem too much to approach a potentially dangerous condition like epilepsy in a new way. Nonetheless, the hard scientific data increasingly show that the intuitions of our older, mentor clinicians were on target: Defining the epilepsy as precisely as possible upfront and treating it as a process is the best way to get our patients better. Collaborative relationships with epilepsy centers (there are four level-4 centers in Minnesota) and leveraging potential benefits of electronic medical records will be important. We are hopeful that we can harness the current emphasis on systems, organization, and pathways to truly make our patients better. Thaddeus Walczak MD, is a neurologist/epileptologist with MINCEP Epilepsy Care in Minneapolis.
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MINNESOTA PHYSICIAN
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Physical therapy and rehabilitation serve a
FOCUS:
R E H A B I L I TAT I O N
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PHYSICAL
Improving COPD care Care coordination and pulmonary rehabilitation
wide range of patients and treat a variety of health problems and
By Chris Wendt, MD, and Cynthia Isaacson
chronic conditions. In addition to the cover story on pediatric physical rehabilitation, this month’s special focus looks at rehabilitation for patients with chronic obstructive pulmonary disease and the growth of the field of physical medicine and rehabilitation in addressing the unique needs of cancer survivors.
D
ecreasing hospital readmissions related to chronic obstructive pulmonary disease (COPD) is a hot topic in Minnesota. Starting Oct. 1, 2014, Medicare will begin withholding reimbursements for COPD hospital readmission within 30 days of an initial admission, putting pressure on hospital systems to start looking at how their systems of care might need restructuring to prevent early readmissions. Some Minnesota health insurance plans began withholding reimbursements in October 2011, making the issue all the more pertinent. Even though this appears to be a hospital issue, COPD readmission provides an opportunity for all physicians to look at frequently missed opportunities to
improve the lives of people with COPD using care coordination and pulmonary rehabilitation. In 2008, chronic obstructive pulmonary disease (COPD) became the third leading cause of death in the U.S. More than 12 million Americans have been diagnosed with COPD, and an estimated 12 million have yet to be diagnosed. The Lancet reported in September 2011 that 25 percent of people age 35 and older will develop COPD in their lifetime, making the risk of developing COPD greater than the risk of developing heart failure, breast cancer, or prostate cancer. COPD readmissions
Of course, the best way to prevent a readmission is to prevent a first admission. Studies have
THERAPY
demonstrated that optimized medications, annual influenza immunizations, and, in some cases, an outpatient, managedcare program focusing on patient education with early outpatient treatment of exacerbations can prevent exacerbations and, therefore, prevent hospital admissions. Since 2005, the American Lung Association in Minnesota (ALA in Minnesota) has monitored the scope of COPD in Minnesota. According to 2008 data from the organization’s scope of COPD data, approximately 63 percent of Minnesotans with COPD see a family physician or internist for managing their COPD; 65 percent of COPD patients have seen a specialist at least once; 39 percent have been in the emergency department (ED); and 23 percent have been hospitalized. These findings illustrate that providers across the spectrum of health care have a hand in managing COPD. Primary and specialist care is a pivotal area of preventing hospitalizations and promoting
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A patient’s perspective good disease management while ED physicians and hospitalists treat major exacerbations and must determine the root of the exacerbation: Is the patient’s medication optimized to prevent exacerbations? Is the patient compliant and taking the medication properly with good technique? Are external factors, such as affordability of medication, creating barriers to optimal care? Does the patient need more education about this chronic disease? Care coordination teams
The most efficient and effective way physicians and health care systems can assure coordination of care across transitions among health care settings is to develop a care coordination team. An ideal team might include a lead physician and program coordinator, along with a rehabilitation specialist, dietician/nutritionist, social worker, physical therapist, occupational therapist, psychologist, and chaplain. Upon discharge of a COPD patient under circumstances where hospitalists provide inpatient care and the primary care provider is not involved during hospitalization, the hospitalist should contact the patient’s primary care physician and make certain that the patient leaves with a care plan that includes a scheduled follow-up visit, guideline-based medication for the disease stage, home oxygen prescription when required, referral to smoking cessation and pulmonary rehabilitation whenever available, and education for the patient’s caregivers at home. Each member of the care coordination team needs to determine how services will be continued once the patient leaves the hospital and is transferred back to the primary care team. This type of follow-up after inpatient care is important to effectively communicate about a patient’s health. Such transitions require communication, and time, as well as the desire and incentive to provide the best care possible. Pulmonary rehabilitation
While appropriate medication therapy has been demonstrated
By Robert Munson I would be sure to let pulmonologists know that rehab is beneficial to all who have compromised lungs—if only to reassure them that they are not alone and that being proactive in self-care is a necessity. It certainly is not only for those who are in a serious health situation. Actually, it can be very beneficial for those who do not have seriously compromised lungs, as it gives patients tools to enhance their lives. From personal experience, I can say that having COPD or any lessening of ability to breathe can be a depressing and emotionally frightening experience for a patient. Being able to take in and expel air is taken for granted until one is not able to do this. The science of lung function is one thing—the emotional aspect of not being able to do life activities in the same way is quite another. COPD patients need the science to know what is happening. They need emotional support in order to adjust to this change in their lives. Pulmonary rehabilitation is a step in this direction, but I think there needs to be a holistic approach to patient care. Robert Munson is a COPD patient and a board member of the American Lung Association in Minnesota. to decrease exacerbations, pulmonary rehabilitation can improve quality of life. Pulmonary rehabilitation encourages patients in groups and individually to learn more about their disease; often this in-depth education is just not possible during a regular clinic visit. Pulmonary rehabilitation is a critical piece in the coordinated care process and instrumental in educating patients. Pulmonary rehabilitation helps improve patients’ daily life activities through respiratory therapy, physical therapy, nutrition science education, social work involvement, and social and emotional support. Topics covered in pulmonary rehab are tailored to fit each patient’s needs to achieve realistic goals and long-term success. Recent studies suggest that pulmonary rehabilitation may reduce health care costs through shorter hospital stays and decreased utilization of health care resources, making pulmonary rehabilitation an effective treatment when combined with optimal medical management in COPD. Pulmonary rehabilitation helps patients “become more confident in their everyday living,” says Shanna Watrin, director of respiratory therapy at Mercy Hospital in Moose Lake, Minn. Sue Strohman, a respiratory therapist with Essentia Health in Duluth, agrees. “Patients develop better physical condition, know more about their disease and how to manage it, as well as coping strategies.
They are empowered.” Pulmonary rehabilitation poses many challenges for patients. Committing to an exercise program is one of them. “The biggest challenge is getting de-conditioned patients to believe that they can participate in moderate exercise in class and at home,” says Carla Knippenburg, coordinator of the pulmonary rehab program at Lakeview Hospital in Stillwater.
“They often feel discouraged, depressed, and even scared.” Continuing with their exercise program after completion of the program is key to long-term success. Many studies demonstrate that functional improvements after pulmonary rehabilitation diminish after 12 to 18 months if these activities are not sustained. Sandie Stegeman, who co-heads the pulmonary rehab program at North Memorial Hospital in Robbinsdale, notes that “the biggest challenge for our patients is to continue their exercises at home.” In addition to attendance and follow through, other common barriers include patient referral to pulmonary rehab and access to a program. Access to pulmonary rehab is still a concern across the state, but even where programs are available to patients, they are often underutilized. A reported 66 percent of COPD patients say they have never been offered pulmonary rehabilitation, according to the ALA in Minnesota. COPD CARE to page 25
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SPECIAL
T
FOCUS:
here are approximately 12 million cancer survivors in the United States. Most people undergoing cancer treatment survive; recent statistics indicate that long-term survival for many cancers approaches 70 percent. However, the effects of cancer treatment leave many cancer survivors with physical limitations and diminished quality of life. Cancer rehabilitation addresses quality-of-life deficits that include physical as well as psychosocial dysfunction. All must be addressed for survivors to resume optimal life and health. Physical medicine and rehabilitation (PMR) physicians have unique skills for evaluating and treating functional impairments due to chronic medical conditions. Minnesota is fortunate in having a strong PMR presence in many communities. Cancer rehabilitation is emerging as a subspecialty of PMR, with training to address the acute and chronic effects of cancer treatment. Cancer surgery, chemotherapy, hormonal therapy, biologic
R E H A B I L I TAT I O N
PHYSICAL
Cancer rehabilitation and survivorship A medical subspecialty improves life, health of cancer survivors By Nancy Hutchison, MD
agents, radiation therapy, and stem cell transplants all have specific sequelae that affect function and are amenable to rehabilitation. PMR cancer rehabilitation MDs use evidencedbased tools to anticipate and evaluate debilitating effects of cancer treatments and implementing strategies for maximizing function and recovery of cancer survivors. The PMR cancer rehabilitation MD works with a team to develop and coordinate the complex rehabilitation care of cancer survivors. In the last 15 to 20 years, rehabilitation therapies (e.g., physical, occupational, speech) have become so specialized that oncology and primary care
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physicians may not know which type of therapist can best treat the physical effects of cancer treatments. For example, rehabilitation therapists may specialize in lymphedema, balance and neuropathy, cognitive effects of cancer treatment, physical reconditioning, pelvic floor dysfunction, or swallowing disorders. Cancer rehabilitation physicians are familiar with the network of rehabilitation therapists throughout the state and region. Even a one-time visit to a PMR cancer rehab MD can help cancer patients find the best cancer therapy providers in their area to carry out an individualized program of recovery from the effects of cancer treatment. Since many health plans have therapy caps, it is important that cancer survivors be referred to the correct team of therapists to maximize recovery and minimize out-of-pocket expense. A documented need for cancer rehabilitation
The American College of Surgeons Commission on Cancer (CoC) accredits many hospitals in the U.S. The CoC has been a pioneer in recognizing the importance of rehabilitation as an essential part of cancer care; indeed, the CoC mandates cancer rehabilitation as a requirement for accreditation. Yet, despite the general awareness that rehabilitation is good for cancer survivors, many clinicians do not know how to find effective services or refer patients to them. For example, some providers may be under the impression that a community-based exercise program (cancer fitness) is the same as cancer rehabilitation. However, a significant number of cancer survivors cannot proceed directly
THERAPY
from cancer treatment to community-based exercise because of the severity of deconditioning or physical deficits that must be treated first. In addition, many exercise facilities and trainers are unfamiliar with the medical complexity of cancer survivors. The American Cancer Society (ACS) and the American College of Sports Medicine (ACSM) have teamed up to establish a certification (ACSM/ACS Certified Cancer Exercise Trainer) for exercise professionals who desire to work with cancer patients. Even so, the cancer survivor with physical deficits, pain, fatigue, and debility will need rehabilitation first. The Institute of Medicine (IOM) report “From Cancer Patient to Cancer Survivor: Lost in Transition” (National Academies Press, 2005) documented that many patients finish cancer treatment with medical, psychosocial, financial, occupational, and functional deficits that are not adequately addressed. The report established the new paradigm that survivorship is a distinct phase of cancer care, with specific concerns that must be addressed by the medical community. To achieve this goal, cancer survivors need a survivorship care plan. Since the IOM report was published, many oncology providers have implemented this recommendation: “Provide a comprehensive summary and follow-up plan (survivorship care plan) to survivors.” Most of the initial survivorship care plans have been geared toward medical surveillance; they are just beginning to address the other aspects of physical chronic illness related to cancer. To address this latter aspect of a survivor care plan, oncology and primary care providers will need to link with cancer rehabilitation providers. The IOM report’s other recommendations include developing tools to identify and manage late effects of cancer treatment; implementing quality assurance programs to ensure quality of life assessment and follow-up; educating health care providers; improving interdisciplinary care
Cancer rehab: A case study Mrs. X is a 50-year-old woman undergoing radiation therapy for breast cancer. She had a mastectomy and axillary node dissection followed by chemotherapy with adriamycin, cytoxan, and taxol and now is getting herceptin. She will be placed on a hormonal agent in the future. During radiation therapy, she tells her providers that she has severe pain shooting down her arm and it feels swollen. Instead of assuming she has lymphedema and referring her to a lymphedema therapist, the providers refer her to a PMR cancer rehab physician, to address the cause of the pain and determine whether she has lymphedema or another condition that mimics lymphedema. At the visit with the PMR cancer rehab physician, Mrs. X is found to have a combination of chemotherapy-induced peripheral neuropathy, axillary web syndrome from the surgery (axillary node dissection), and shoulder bursitis from the position for radiation therapy. She also has severe insomnia, and cognitive and fatigue complaints are affecting her ability to perform daily functions. She worries that she will not be able to function when she returns to her job. The PMR cancer rehab physician asks Mrs. X about her energy and exercise. Mrs. X says she used to exercise regularly, but now she “crashes” when she gets home, has gained 25 pounds since starting cancer treatment, and feels as if she is sinking into depression, as she has no idea how to reverse this downward spiral. She thought she would be looking forward to finishing her cancer treatment, but now she is afraid that this is her “new normal” and she “will have to live with it.” She doesn’t want to go to a gym because she is concerned about lymphedema and pain and feels embarrassed by the changes in coordination of survivor services; improving access for diverse groups; and eliminating job and insurance discrimination affecting cancer survivors. Care coordination and networking
PMR cancer rehabilitation MDs seek to network with the oncology community to coordinate cancer survivor services, just as we do for other major chronic disabling conditions such as polio, spinal cord injury, stroke, brain injury, musculoskeletal conditions, and chronic pain. Our current systems of health care and health care education have not done enough to break down the medical silos that impede patients’ access to cancer rehabilitation and survivorship care. Most health professionals are not trained to evaluate for rehabilitation and survivorship concerns of cancer patients. Even when problems are identified, there is a gap in methods of referral to effective services. The many barriers include timing, access, cost,
her body. She has no current evidence of swelling in the arm, but has sensory changes mimicking a feeling of swelling. She doesn’t know what to tell her employer, as she does not know what to expect for recovery. The PMR cancer rehab MD offers a plan to roll out over several weeks to months and reassures Mrs. X that her recovery plan will take on the various concerns in a prioritized fashion. The doctor also gives Mrs. X a trial of gabapentin for neuropathic pain and a referral for acupuncture, and refers her to a physical therapist or occupational therapist with specific expertise in the management of shoulder and arm problems of breast cancer survivors. The PMR cancer rehab MD places Mrs. X into a protocol for surveillance for lymphedema, which she does not currently have but is at risk for developing. After radiation therapy, once she is feeling better, she will follow up with the PMR cancer rehab MD, who will recommend fitness and weight-loss protocols. Specific evidencedbased exercise protocols have been shown to reduce the risk of developing lymphedema and osteoporosis as well as improve fatigue, quality of life, and weight management. At subsequent follow-up visits, the cancer rehab MD helps Mrs. X find a way of exercising that addresses her fears and concerns, and also refers her to a healing coach. If the insomnia, cognitive, and fatigue problems do not resolve, she will be referred to a therapist who specializes in strategies for addressing cognitive deficits after cancer. She may also need a referral to a mental health professional for treatment of depression. The PMR cancer rehab MD assesses Mrs. X’s vocational demands and develops a return-to-work strategy with her employer.
psychosocial support, healthy behavior change, and collaboration with oncology supportive care and integrative medicine. Mary Vargo, MD, a cancer rehabilitation PMR specialist, discussed these issues in an excellent article in the June 2008 issue of the Journal of Clinical Oncology. The goal of the PMR cancer rehabilitation physician is to provide the platform and “onestop shop” to access the most appropriate, cost-effective, and conveniently located rehabilitative and survivorship care plan for patients. Cancer rehabilitation services are generally covered by insurance. The physician visit is covered according to the patient’s insurance care network. The PMR cancer rehab physician can then help the patient find covered rehabilitative services in his or her locale, as well as assist with return-to-work resources, disability assessment, psychosocial supports, referral to integrative medicine interventions, and fitness resources for transition to self-management
and healthy lifestyle. The case study described in the sidebar demonstrates how this expertise can benefit both patients and their physicians. In response to the need for cancer rehabilitation, programs such as Oncology Rehab Partners’ STAR (Survivorship Training and Rehabilitation) Certification are being developed to meet the need for education and training of medical professionals and to assist cancer centers and rehabilitation providers in developing their own programs and training. As the number of cancer survivors continues to grow, PMR cancer rehabilitation MDs will play an essential role in helping to return these patients to a high quality of life. Nancy Hutchison, MD, is medical director of cancer rehabilitation and lymphedema at the Sister Kenny Rehabilitation Institute/Virginia Piper Cancer Institute, Minneapolis. She is a board-certified physical medicine and rehabilitation specialist and a certified lymphedema therapist.
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O C C U PAT I O N A L
Return-to-work determinations
N
early 3.1 million nonfatal workplace injuries and illnesses were reported by private-industry employers in 2010. The vast majority of these injured or ill workers were treated and returned to work by primary care providers. While some providers are occupational medicine specialists (i.e., physicians who are residency-trained or board-certified in occupational and environmental medicine), any physician who sees a patient who has a work-related medical problem can be considered an occupational medicine provider (OMP), and any physician who sees an ill or injured patient that works will need to make a return-to-work determination, even if the problem was not work-related. Occupational medicine providers have two main goals: 1. To treat and prevent injuries and illnesses in workers. 2. To return workers to work. The first goal is straightforward: We all learn about evaluating, diagnosing, and treating injuries and illnesses in medical
MEDICINE
Simple concepts to deal with a complicated process By Jon T. O’Neal, MD, MPH, FACOEM school. Prevention of workrelated injuries and illnesses is taught in occupational and environmental medicine residency programs. There are currently
OEM is from the American Board of Preventive Medicine. The second goal is more elusive, as most OMPs do not receive much, if any, training
The No. 1 factor identified in chronic low-back pain cases is not lifting, bending, or conditioning. It’s job dissatisfaction. only about 25 residencies in occupational and environmental medicine (OEM) in the U.S., and one of the oldest and largest programs is based at HealthPartners in St. Paul and affiliated with the University of Minnesota School of Public Health. Board certification in
related to returning workers to work. I learned about returning workers to work through the school of hard knocks, picking it up from experienced OMPs, employers, and employees. Below are 10 basic concepts that physicians should keep in mind in making return-to-work determinations.
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1. It’s not the physician’s duty to take someone out of work. Our duty is to prevent and treat injuries and illnesses, and to make recommendations to employers about activities workers can safely perform without hurting themselves or others. I prefer the term “activity restrictions” to “work restrictions,” because activity restrictions can also apply to activities away from work (for a nurse with low back pain, recommending “no lifting more than 50 pounds, no bending or stooping” is much more helpful than recommending “no working as a nurse”). Activity restrictions can be also used both at work and at home. 2. The physician’s duty is to safely return workers to work. Employers look to occupational medicine providers to place activity restrictions on workers that will allow them to return to work safely. We treat the worker first, then make recommendations about activity restrictions and duty status.
3. It’s the employer’s responsibility to take workers out of work. Taking someone out of work is an administrative decision, not a medical decision. Here’s how it works: The OMP recommends activity restrictions, and then the employer determines whether modified duty is available that conforms to those restrictions. 4. If appropriate modified duty is not available, the employer sends the worker home. The employer pays the OMP to treat the worker and then make activity restriction recommendations. The employer makes the decision to send a worker home if no modified duty is available that fits the OMP’s restrictions. For most providers, this is a major paradigm shift. We’re used to excusing patients from school or work because of routine illnesses. That’s our duty, to prevent our patients from infecting others and to allow patients to have adequate rest, treatment, and recuperation. However, in occupational medicine we see only work-related illnesses and injuries, and very rarely do ill workers infect others with occupational illnesses. An exception might be occupationally acquired and active tuberculosis; but even then, after initial treatment these workers may be returned to work rapidly with adequate respiratory precautions. Certainly, after some major work-related trauma, workers will need time to recuperate at home. But unless you’re recommending strict bedrest, you should make activity restriction recommendations rather than sending a worker home. For example, someone with a broken leg may have the following restrictions: “sitting job only, no prolonged walking or standing, elevate leg, no stairs, no climbing, may use wheelchair, no driving.” Many companies can easily accommodate these restrictions by allowing a worker to answer the phone or do computer work. Of course, a worker who uses a jackhammer won’t be going back to the same job— but the employer still makes the determination about keeping an employee at work, based upon
what type of work and accommodations are available. When a doctor sends a worker home, it’s a lost duty day. Companies track worker safety by counting injuries and lost duty days. Injury reporting is pretty simple; however, lost duty days are tracked by the actual days an employee is out of work. The day a worker is injured does not count as a lost duty day. If a doctor takes a worker out of work, however, the next lost workday is a lost duty day. In the workplace, bonuses for safety officers and human resources personnel may be based on decreasing the number of lost duty days per year. Thousands of dollars of safety bonuses for a plant or group of workers with the best safety record may be at stake when workers are taken out of work. 5. Be as precise and detailed as possible with activity restrictions, and adjust restrictions for the job. By asking workers what activities they do at their job, you can easily modify activity restrictions. I don’t say “no working at heights” to reception-
Occupational medicine providers do not receive much, if any, training related to returning workers to work. ists while they’re on medications that cause drowsiness, and I usually don’t say “no operating hazardous equipment” for secretaries. However, I might recommend those restrictions for building maintenance personnel on medications that cause drowsiness. I often specify “no repetitive use of” or “avoid bending and stooping” instead of the absolute “no,” in order to allow workers to quickly return to some type of duty. If I think a worker should be sent home, I place significant and multiple restrictions on the worker. I often don’t know the workplace that well and may not know what modified duty is available. The supervisor may send someone home who has only a simple activity restriction, such as no lifting more than 40 pounds, but that’s the employer’s decision. Employers understand it’s their decision to send work-
ers home, and will be disappointed in physicians who don’t understand this. 6. Educate the workers. Employees think it’s the doctor’s decision to send them home. They’re wrong. A good OMP will educate the employee. I anticipate employees’ anger (“My back hurts, I expect you to send me home!”) and tell them outright that it’s their supervisor’s decision. Yes, some employees get mad. But it’s the employer who pays the bills and watches productivity; and for every irate employee who is sent safely back to work with appropriate restrictions, there’s a satisfied employer that knows their employees were provided good occupational medicine care— and will send more employees your way. Also, quite often, employers will know about the problem employees you have to deal with—because they’ve been
dealing with them themselves. 7. Never compromise your medical treatment. Occupational medicine is not just about the typical straight-line physician/patient relationship you learned in medical school— it’s actually about a triangular physician/patient/company relationship. The word “occupational” in occupational medicine should remind you to think about this other invested player—the company (employer). After you’ve attended to the patient/employee, you should think about the company, and unless you’ve worked closely with the company you won’t know all sides of the story. I think about the problem from the employee’s perspective, and I think about the problem from the employer’s perspective; but even after that, I don’t do what’s best for the employee and I don’t do what’s best for the employer—I do what’s best for the patient. I don’t have major problems with employers or employees, because I don’t compromise my medical treatRETURN-TO-WORK to page 24
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St. Cloud VA Health Care System is accepting applications for the following full or part-time positions: • Anesthesiologist (St. Cloud) • Associate Chief, Primary and Specialty Medicine (Internist-St. Cloud) • Dermatology (St. Cloud)
• Internal Medicine/ Family Practice (Alexandria, Brainerd, St. Cloud, Montevideo) • Medical DirectorExtended Care & Rehab (IM or Geriatrics) (St. Cloud) • NP/PA (Montevideo)
• Disability Examiner (IM or FP) (St. Cloud)
• Podiatrist (St. Cloud)
• ENT (St. Cloud)
• Psychiatrist (Brainerd, St. Cloud)
• General Surgeon (St. Cloud) • Geriatrician (Nursing Home-St. Cloud) • Hematology/Oncology (St. Cloud)
• Radiologist (St. Cloud) • Urgent Care Provider (MD, PA or NP) • Weekend Medical Officer of the Day (IM or FP) (fee for service appointment, St. Cloud)
US Citizenship required or candidates must have proper authorization to work in the US. J-1 candidates are now being accepted for the Hematology/Oncology positions. 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
Competitive salary
26 days vacation
13 days sick leave
CME days
Liability insurance
Interested applicants can mail or email your CV to VAHCS
St.Health Cloud VA Care System Brainerd | Montevideo | Alexandria
Sharon Schmitz (Sharon.schmitz@va.gov) 4801 Veterans Drive, St. Cloud, MN 56303 Or fax: 320-654-7650 or Telephone: 320-252-1670, extension 6618
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MINNESOTA PHYSICIAN FEBRUARY 2012
Return-to-work from page 23 ment, and I don’t get caught in employee-employer battles. 8. Do not get caught in administrative battles. Explain to employees that it’s your responsibility to provide medical treatment and return them safely to work, and it’s the company’s responsibility to find them appropriate modified duty. Avoid taking on the role of the employer in finding modified duty. For example, if you ask an injured worker if he could answer the phone or type at a computer and he answers, “That’s not available,” you can reply, “How do I know that? It’s your supervisor’s call.” I also explain to workers that the activity restrictions apply to both the home and the workplace. The problem is usually not that OMPs don’t know how to diagnose or treat; it’s that they don’t know how to appropriately manage work restrictions. Providers are taught to develop a bond with their patients and they may be concerned that this bond will be broken if they send someone back to work. Do you give your patients narcotic painkillers every time they ask? Of course not. Again, do what’s best for your patients. 9. Rapidly and safely returning to work is best for the worker. Every recent study indicates that returning injured workers back to work rapidly is beneficial. Pilots who survive aviation accidents and are returned quickly to the cockpit, as well as soldiers with battlefield stress who are returned quickly to combat, fare the best both physically and psychologically. Though those are extreme examples, the same holds for the more typical worker. Keeping someone out of work for routine low-back pain increases their chance of developing a “disabled” personality, and the longer the employee is out of work, the greater the chance of long-term disability. Returning a worker to work places the worker back with his or her peers, keeps the person productive, contributes to a feeling of well-being and increased
self-worth, and decreases the risk of psychological disability. But be realistic about human nature, and realize that inevitably some employees will try to use medical excuses to get a new job or disability pay. (Note: The No. 1 factor identified in chronic low-back pain cases is not lifting, bending, or conditioning. It’s job dissatisfaction.) Of course, there are exceptions. You don’t want to rapidly return a worker with occupationally induced asthma to work. It may take weeks to fully evaluate significant work-related asthma, and, unfortunately, sometimes workers with asthma can never go back to their same job or workplace. 10. Assume the worker is the most valuable employee in the company. Unless you know the workplace intimately, you won’t know the importance of one particular employee being at work. Suppose you’re the president of the company, and a team from New York is making a profitable multimillion dollar takeover bid that day. Would you send yourself home with a sprained ankle? Of course not. Again, you must let the supervisor/employer make the decision about the importance of someone being at work with restrictions or being sent home. In closing, the two main goals of occupational medicine providers—to treat and prevent injuries and illnesses, and to return workers to work safely— seem simple. But in occupational medicine, nothing is as simple as it seems. If you keep in mind the occupational medicine triangle of the provider, the worker, and the company, and follow the 10 basic concepts presented above, you’ll be able to make effective and appropriate return-to-work determinations, and help keep your patients that work healthy and working. Jon T. O’Neal, MD, MPH, FACOEM, is the residency director of the HealthPartners Occupational Medicine program in St. Paul.
COPD care from page 19 Some doctors are hesitant to send their patients for pulmonary rehabilitation. Robert Munson of Maple Grove, a board member of the ALA in Minnesota, says that his pulmonologist “was not sure if I needed the rehab [because] I am a conscientious patient and motivated in self-care. He did not refer me to the program until I requested that I be placed in it.” Mercy Hospital’s Watrin encourages physicians to refer all COPD patients for pulmonary rehab: “You never know when that one patient [the physician] thinks will not do it goes to class and gets the most out of it.” Stegeman asks physicians to “not wait until end stage to send them; send them earlier so we can do more with them.” Transportation can also present a barrier to attending pulmonary rehabilitation. All the respiratory therapists interviewed cited transportation for retired patients as a significant barrier to regular attendance. Time off from work was cited as
the biggest barrier for COPD patients under the age of 65. In addition to physical improvements, both respiratory therapists and patients cite the importance of pulmonary rehabilitation in meeting patients’ emotional needs. Pulmonary rehabilitation encourages regular exercise, good breathing techniques, and improved nutrition and disease management skills and addresses depression, which affects up to 40 percent of those with COPD. Annette Sadler, a COPD patient from the Methodist Hospital Pulmonary Rehabilitation program at in St. Louis Park, says that “the emotional piece was hardest for me—accepting that I now have a label of a progressive disease.” Robbie Crannick, a respiratory therapist at Mercy Hospital in Robbinsdale, explains to her patients that “they just may have to do things differently.” She says that in rehab sessions, patients learn to cope with their shortness of breath and may find out that their limitations are not as great as they had feared. Jessica Oman, the direc-
tor of pulmonary rehab at St. Cloud Hospital, encourages family member to lend patients “a lot of emotional support … to keep [patients] working toward goals.” Support groups provide ways for patients to learn more about their disease and meet other people who are also dealing physically and emotionally with similar problems. “During support group, members share experiences to help each other successfully manage their disease and improve their quality of life. It is reassuring for them to hear how others walking in their shoes cope with the day-today issues of living with lung disease,” says Cheryl Sasse, director of the ALA in Minnesota and Better Breathers Clubs support group facilitator. Overall, pulmonary rehabilitation program directors say that most of their patients feel they should have done pulmonary rehabilitation years earlier. They note that patients who complete pulmonary rehab feel they are in better health than when they started the program,
and many successfully implement lifestyle changes such as better diet, smoking cessation, coping techniques, stress management, and exercise. Time to make changes
It is time to start making changes for COPD care. Encourage care coordination; talk to the providers where your COPD patients are admitted to encourage better care transitions, and let them know you remain involved in your patient’s care. In addition, find out where the nearest pulmonary rehabilitation program is and how you can make such a program available to your patients. Your patients will thank you, and your readmission rates will decline. Chris Wendt, MD, is section chief of pulmonary medicine at the Veterans Administration Medical Center, Minneapolis. Cynthia Isaacson is manager of respiratory health for the American Lung Association in Minnesota.
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D E R M AT O L O G Y
P
soriasis is among the most common chronic skin diseases, affecting approximately 2 percent of the world’s population. It is thought to be an inflammatory process affecting the skin due, in part, to a dysregulation of the cutaneous immune system. Psoriasis affects children and adults of all ethnic and socioeconomic groups and comprises a significant percentage of a general medical dermatologic practice. Often, psoriasis flares in the autumn and winter, particularly in more northern climates with limited sunlight exposure. Patients complain of itching, flaking, and discomfort. Qualityof-life assessments of psoriasis patients reveal high rates of embarrassment, daily discomfort, and interference with personal relationships. Studies show psoriasis severity to be related to compromised employment, income levels, self-esteem, and social withdrawal.
Types of psoriasis
Plaque psoriasis is the most common form of psoriasis, com-
26
A psoriasis update for non-dermatologists Therapy advances have revolutionized patient management By Mitchell Bender, MD
prising 85 percent to 90 percent of psoriatic cases. It is characterized by erythematous, thickened plaques with a fine silvery (micaceous) scale and is usually seen on the scalp, elbows, knees, and sacral back. Moist affected areas, such as the axillae, groin folds, genitalia, and intergluteal cleft, show erythematous papules and plaques, often with little to no scale. When the nails are affected, there is pitting (fine stippled appearance of the nail plate surface) or a yellow discoloration of the nail plate, which is often confused with fungal infection. Histologically, plaque-type psoriasis is characterized by a hyperplastic epithelium and
MINNESOTA PHYSICIAN FEBRUARY 2012
stratum corneum, the result of an increased mitotic rate of epithelial cells (keratinocytes). There is an intense dermal inflammatory infiltrate of neutrophils, dermal dendritic cells, and T cells. Neutrophils and T lymphocytes are also found in the epidermis. The dermal blood vessels become tortuous and engorged, resulting in the thickened and red scaling plaques seen clinically. The increased epithelial cell mitotic rate is due to cytokines produced by both the inflammatory cells and the keratinocytes themselves. Dermal dendritic cells, Th17 and Th1 helper T cells, and keratinocytes produce a variety of cytokines, including tumor necrosis factor alpha (TNFalpha), interleukins -1, -6, -12, -17, -22, -23, and interferons. The discovery of these immunologic abnormalities has led to advances in therapy and a greater understanding of other chronic inflammatory diseases such as arthritis and inflammatory bowel disease. Guttate psoriasis is often found in adolescents and young adults and is frequently associated with infection, particularly streptococcal pharyngitis. The term guttate is derived from the Latin word guttata, meaning water droplet, a reminder of the 5-mm to 10-mm erythematous scaling papules most concentrated on the chest, abdomen, back, and extremities. When this form of psoriasis is identified, clinicians should search for underlying infection, such as streptococcal pharyngitis, dental abscesses, and perianal streptococcal infections in children. Appropriate antibiotic management is indicated. This form of psoriasis usually responds well to narrow-band ultraviolet B phototherapy and is the author’s
treatment of choice. Patients may or may not go on to develop chronic plaque-type psoriasis after an episode of guttate psoriasis. Pustular psoriasis may be limited to the palms and soles (also called palmar–plantar pustulosis) or may be generalized. The generalized form can be associated with joint pain, fever, and leukocytosis. It has been seen with Crohn’s disease treated with anti-TNF-alpha drugs such as adalimumab (Humira). TNF-alpha has both inflammatory and anti-inflammatory properties, and blockade of TNF-alpha function may result in inflammatory processes such as generalized pustular psoriasis, a multiple sclerosis-like spinal neuropathy, paradoxical flares of cutaneous psoriasis, and a lupus erythematosus-like cutaneous and systemic reaction. Generalized pustular psoriasis can also result from the withdrawal of systemic corticosteroids; for this reason, systemic corticosteroids should be avoided in cutaneous psoriasis therapy if possible. The pustules in both the localized palmar-plantar and generalized varieties are sterile; therefore, systemic antibiotic therapy is ineffective. Generalized erythrodermic psoriasis is characterized by intense erythema, usually with scale involving the entire cutaneous surface. It must be considered in the differential diagnosis of generalized erythroderma, which includes medication reaction, severe atopic dermatitis, pityriasis rubra pilaris, and the leukemic phase of cutaneous T-cell lymphoma (Sézary syndrome). This form can produce serious systemic problems such as high-output cardiac failure in the elderly, shaking chills, and cutaneous pain and itching. Therapy includes topical corticosteroids, continuous wet dressings, and search for underlying infection. Recalcitrant cases may require therapy with infliximab or cyclosporin. Immunopathology of psoriasis
A thorough review of this subject is beyond the scope of this article; readers are referred to PSORIASIS to page 30
FEBRUARY 2012
MINNESOTA PHYSICIAN
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Victoza® (liraglutide [rDNA origin] injection) Rx Only BRIEF SUMMARY. Please consult package insert for full prescribing information. WARNING: RISK OF THYROID C-CELL TUMORS: Liraglutide causes dose-dependent and treatment-duration-dependent thyroid C-cell tumors at clinically relevant exposures in both genders of rats and mice. It is unknown whether Victoza® causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as human relevance could not be ruled out by clinical or nonclinical studies. Victoza® is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Based on the findings in rodents, monitoring with serum calcitonin or thyroid ultrasound was performed during clinical trials, but this may have increased the number of unnecessary thyroid surgeries. It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate human risk of thyroid C-cell tumors. Patients should be counseled regarding the risk and symptoms of thyroid tumors [see Contraindications and Warnings and Precautions]. INDICATIONS AND USAGE: Victoza® is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Important Limitations of Use: Because of the uncertain relevance of the rodent thyroid C-cell tumor findings to humans, prescribe Victoza® only to patients for whom the potential benefits are considered to outweigh the potential risk. Victoza® is not recommended as first-line therapy for patients who have inadequate glycemic control on diet and exercise. In clinical trials of Victoza®, there were more cases of pancreatitis with Victoza® than with comparators. Victoza® has not been studied sufficiently in patients with a history of pancreatitis to determine whether these patients are at increased risk for pancreatitis while using Victoza®. Use with caution in patients with a history of pancreatitis. Victoza® is not a substitute for insulin. Victoza® should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis, as it would not be effective in these settings. The concurrent use of Victoza® and insulin has not been studied. CONTRAINDICATIONS: Victoza® is contraindicated in patients with a personal or family history of medullary thyroid carcinoma (MTC) or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). WARNINGS AND PRECAUTIONS: Risk of Thyroid C-cell Tumors: Liraglutide causes dosedependent and treatment-duration-dependent thyroid C-cell tumors (adenomas and/or carcinomas) at clinically relevant exposures in both genders of rats and mice. Malignant thyroid C-cell carcinomas were detected in rats and mice. A statistically significant increase in cancer was observed in rats receiving liraglutide at 8-times clinical exposure compared to controls. It is unknown whether Victoza® will cause thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as the human relevance of liraglutide-induced rodent thyroid C-cell tumors could not be determined by clinical or nonclinical studies [see Boxed Warning, Contraindications]. In the clinical trials, there have been 4 reported cases of thyroid C-cell hyperplasia among Victoza®-treated patients and 1 case in a comparator-treated patient (1.3 vs. 0.6 cases per 1000 patient-years). One additional case of thyroid C-cell hyperplasia in a Victoza®-treated patient and 1 case of MTC in a comparator-treated patient have subsequently been reported. This comparator-treated patient with MTC had pre-treatment serum calcitonin concentrations >1000 ng/L suggesting pre-existing disease. All of these cases were diagnosed after thyroidectomy, which was prompted by abnormal results on routine, protocol-specified measurements of serum calcitonin. Four of the five liraglutide-treated patients had elevated calcitonin concentrations at baseline and throughout the trial. One liraglutide and one non-liraglutide-treated patient developed elevated calcitonin concentrations while on treatment. Calcitonin, a biological marker of MTC, was measured throughout the clinical development program. The serum calcitonin assay used in the Victoza® clinical trials had a lower limit of quantification (LLOQ) of 0.7 ng/L and the upper limit of the reference range was 5.0 ng/L for women and 8.4 ng/L for men. At Weeks 26 and 52 in the clinical trials, adjusted mean serum calcitonin concentrations were higher in Victoza®-treated patients compared to placebo-treated patients but not compared to patients receiving active comparator. At these timepoints, the adjusted mean serum calcitonin values (~ 1.0 ng/L) were just above the LLOQ with between-group differences in adjusted mean serum calcitonin values of approximately 0.1 ng/L or less. Among patients with pre-treatment serum calcitonin below the upper limit of the reference range, shifts to above the upper limit of the reference range which persisted in subsequent measurements occurred most frequently among patients treated with Victoza® 1.8 mg/day. In trials with on-treatment serum calcitonin measurements out to 5-6 months, 1.9% of patients treated with Victoza® 1.8 mg/day developed new and persistent calcitonin elevations above the upper limit of the reference range compared to 0.8-1.1% of patients treated with control medication or the 0.6 and 1.2 mg doses of Victoza®. In trials with ontreatment serum calcitonin measurements out to 12 months, 1.3% of patients treated with Victoza® 1.8 mg/day had new and persistent elevations of calcitonin from below or within the reference range to above the upper limit of the reference range, compared to 0.6%, 0% and 1.0% of patients treated with Victoza® 1.2 mg, placebo and active control, respectively. Otherwise, Victoza® did not produce consistent dose-dependent or time-dependent increases in serum calcitonin. Patients with MTC usually have calcitonin values >50 ng/L. In Victoza® clinical trials, among patients with pre-treatment serum calcitonin <50 ng/L, one Victoza®-treated patient and no comparator-treated patients developed serum calcitonin >50 ng/L. The Victoza®-treated patient who developed serum calcitonin >50 ng/L had an elevated pre-treatment serum calcitonin of 10.7 ng/L that increased to 30.7 ng/L at Week 12 and 53.5 ng/L at the end of the 6-month trial. Follow-up serum calcitonin was 22.3 ng/L more than 2.5 years after the last dose of Victoza®. The largest increase in serum calcitonin in a comparator-treated patient was seen with glimepiride in a patient whose serum calcitonin increased from 19.3 ng/L at baseline to 44.8 ng/L at Week 65 and 38.1 ng/L at Week 104. Among patients who began with serum calcitonin <20 ng/L, calcitonin elevations to >20 ng/L occurred in 0.7% of Victoza®-treated patients, 0.3% of placebotreated patients, and 0.5% of active-comparator-treated patients, with an incidence of 1.1% among patients treated with 1.8 mg/day of Victoza®. The clinical significance of these findings is unknown. Counsel patients regarding the risk for MTC and the symptoms of thyroid tumors (e.g. a mass in the neck, dysphagia, dyspnea or persistent hoarseness). It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate the potential risk of MTC, and such monitoring may increase the risk of unnecessary procedures, due to low test specificity for serum calcitonin and a high background incidence of thyroid disease. Patients with thyroid nodules noted on physical examination or neck imaging obtained for other reasons should be referred to an endocrinologist for further evaluation. Although routine monitoring of serum calcitonin is of uncertain value in patients treated with Victoza®, if serum calcitonin is measured and found to be elevated, the patient should be referred to an endocrinologist for further evaluation. Pancreatitis: In clinical trials of Victoza®, there were 7 cases of pancreatitis among Victoza®-treated patients and 1 case among comparator-treated patients (2.2 vs. 0.6 cases per 1000 patient-years). Five cases with Victoza® were reported as acute pancreatitis and two cases with Victoza® were reported as chronic pancreatitis. In one case in a Victoza®-treated patient,
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MINNESOTA PHYSICIAN
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pancreatitis, with necrosis, was observed and led to death; however clinical causality could not be established. One additional case of pancreatitis has subsequently been reported in a Victoza®-treated patient. Some patients had other risk factors for pancreatitis, such as a history of cholelithiasis or alcohol abuse. There are no conclusive data establishing a risk of pancreatitis with Victoza® treatment. After initiation of Victoza®, and after dose increases, observe patients carefully for signs and symptoms of pancreatitis (including persistent severe abdominal pain, sometimes radiating to the back and which may or may not be accompanied by vomiting). If pancreatitis is suspected, Victoza® and other potentially suspect medications should be discontinued promptly, confirmatory tests should be performed and appropriate management should be initiated. If pancreatitis is confirmed, Victoza® should not be restarted. Use with caution in patients with a history of pancreatitis. Use with Medications Known to Cause Hypoglycemia: Patients receiving Victoza® in combination with an insulin secretagogue (e.g., sulfonylurea) may have an increased risk of hypoglycemia. In the clinical trials of at least 26 weeks duration, hypoglycemia requiring the assistance of another person for treatment occurred in 7 Victoza®-treated patients and in two comparator-treated patients. Six of these 7 patients treated with Victoza® were also taking a sulfonylurea. The risk of hypoglycemia may be lowered by a reduction in the dose of sulfonylurea or other insulin secretagogues [see Adverse Reactions]. Renal Impairment: Victoza® has not been found to be directly nephrotoxic in animal studies or clinical trials. There have been postmarketing reports of acute renal failure and worsening of chronic renal failure, which may sometimes require hemodialysis in Victoza®-treated patients [see Adverse Reactions]. Some of these events were reported in patients without known underlying renal disease. A majority of the reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration [see Adverse Reactions]. Some of the reported events occurred in patients receiving one or more medications known to affect renal function or hydration status. Altered renal function has been reversed in many of the reported cases with supportive treatment and discontinuation of potentially causative agents, including Victoza®. Use caution when initiating or escalating doses of Victoza® in patients with renal impairment. Macrovascular Outcomes: There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with Victoza® or any other antidiabetic drug. ADVERSE REACTIONS: Clinical Trials Experience: Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The safety of Victoza® was evaluated in a 52-week monotherapy trial and in five 26-week, add-on combination therapy trials. In the monotherapy trial, patients were treated with Victoza® 1.2 mg daily, Victoza® 1.8 mg daily, or glimepiride 8 mg daily. In the add-on to metformin trial, patients were treated with Victoza® 0.6 mg, Victoza® 1.2 mg, Victoza® 1.8 mg, placebo, or glimepiride 4 mg. In the add-on to glimepiride trial, patients were treated with Victoza® 0.6 mg, Victoza® 1.2 mg, Victoza® 1.8 mg, placebo, or rosiglitazone 4 mg. In the add-on to metformin + glimepiride trial, patients were treated with Victoza® 1.8 mg, placebo, or insulin glargine. In the add-on to metformin + rosiglitazone trial, patients were treated with Victoza® 1.2 mg, Victoza® 1.8 mg or placebo. Withdrawals: The incidence of withdrawal due to adverse events was 7.8% for Victoza®-treated patients and 3.4% for comparatortreated patients in the five controlled trials of 26 weeks duration or longer. This difference was driven by withdrawals due to gastrointestinal adverse reactions, which occurred in 5.0% of Victoza®-treated patients and 0.5% of comparator-treated patients. The most common adverse reactions leading to withdrawal for Victoza®-treated patients were nausea (2.8% versus 0% for comparator) and vomiting (1.5% versus 0.1% for comparator). Withdrawal due to gastrointestinal adverse events mainly occurred during the first 2-3 months of the trials. Tables 1, 2 and 3 summarize the adverse events reported in ≥5% of Victoza®-treated patients in the six controlled trials of 26 weeks duration or longer. Table 1: Adverse events reported in ≥5% of Victoza®-treated patients or ≥5% of glimepiride-treated patients: 52-week monotherapy trial All Victoza® N = 497 Glimepiride N = 248 (%) (%) Adverse Event Term Nausea 28.4 8.5 Diarrhea 17.1 8.9 Vomiting 10.9 3.6 Constipation 9.9 4.8 Upper Respiratory Tract Infection 9.5 5.6 Headache 9.1 9.3 Influenza 7.4 3.6 Urinary Tract Infection 6.0 4.0 Dizziness 5.8 5.2 Sinusitis 5.6 6.0 Nasopharyngitis 5.2 5.2 Back Pain 5.0 4.4 Hypertension 3.0 6.0 Table 2: Adverse events reported in ≥5% of Victoza®-treated patients and occurring more frequently with Victoza® compared to placebo: 26-week combination therapy trials Add-on to Metformin Trial All Victoza® + Placebo + Glimepiride + Metformin N = 724 Metformin N = 121 Metformin N = 242 (%) (%) (%) Adverse Event Term Nausea 15.2 4.1 3.3 Diarrhea 10.9 4.1 3.7 Headache 9.0 6.6 9.5 Vomiting 6.5 0.8 0.4 Add-on to Glimepiride Trial All Victoza® + Placebo + Glimepiride Rosiglitazone + Glimepiride N = 695 N = 114 Glimepiride N = 231 (%) (%) (%) Adverse Event Term Nausea 7.5 1.8 2.6 Diarrhea 7.2 1.8 2.2
Victoza® (liraglutide [rDNA origin] injection) Rx Only BRIEF SUMMARY. Please consult package insert for full prescribing information. WARNING: RISK OF THYROID C-CELL TUMORS: Liraglutide causes dose-dependent and treatment-duration-dependent thyroid C-cell tumors at clinically relevant exposures in both genders of rats and mice. It is unknown whether Victoza® causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as human relevance could not be ruled out by clinical or nonclinical studies. Victoza® is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Based on the findings in rodents, monitoring with serum calcitonin or thyroid ultrasound was performed during clinical trials, but this may have increased the number of unnecessary thyroid surgeries. It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate human risk of thyroid C-cell tumors. Patients should be counseled regarding the risk and symptoms of thyroid tumors [see Contraindications and Warnings and Precautions]. INDICATIONS AND USAGE: Victoza® is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Important Limitations of Use: Because of the uncertain relevance of the rodent thyroid C-cell tumor findings to humans, prescribe Victoza® only to patients for whom the potential benefits are considered to outweigh the potential risk. Victoza® is not recommended as first-line therapy for patients who have inadequate glycemic control on diet and exercise. In clinical trials of Victoza®, there were more cases of pancreatitis with Victoza® than with comparators. Victoza® has not been studied sufficiently in patients with a history of pancreatitis to determine whether these patients are at increased risk for pancreatitis while using Victoza®. Use with caution in patients with a history of pancreatitis. Victoza® is not a substitute for insulin. Victoza® should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis, as it would not be effective in these settings. The concurrent use of Victoza® and insulin has not been studied. CONTRAINDICATIONS: Victoza® is contraindicated in patients with a personal or family history of medullary thyroid carcinoma (MTC) or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). WARNINGS AND PRECAUTIONS: Risk of Thyroid C-cell Tumors: Liraglutide causes dosedependent and treatment-duration-dependent thyroid C-cell tumors (adenomas and/or carcinomas) at clinically relevant exposures in both genders of rats and mice. Malignant thyroid C-cell carcinomas were detected in rats and mice. A statistically significant increase in cancer was observed in rats receiving liraglutide at 8-times clinical exposure compared to controls. It is unknown whether Victoza® will cause thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as the human relevance of liraglutide-induced rodent thyroid C-cell tumors could not be determined by clinical or nonclinical studies [see Boxed Warning, Contraindications]. In the clinical trials, there have been 4 reported cases of thyroid C-cell hyperplasia among Victoza®-treated patients and 1 case in a comparator-treated patient (1.3 vs. 0.6 cases per 1000 patient-years). One additional case of thyroid C-cell hyperplasia in a Victoza®-treated patient and 1 case of MTC in a comparator-treated patient have subsequently been reported. This comparator-treated patient with MTC had pre-treatment serum calcitonin concentrations >1000 ng/L suggesting pre-existing disease. All of these cases were diagnosed after thyroidectomy, which was prompted by abnormal results on routine, protocol-specified measurements of serum calcitonin. Four of the five liraglutide-treated patients had elevated calcitonin concentrations at baseline and throughout the trial. One liraglutide and one non-liraglutide-treated patient developed elevated calcitonin concentrations while on treatment. Calcitonin, a biological marker of MTC, was measured throughout the clinical development program. The serum calcitonin assay used in the Victoza® clinical trials had a lower limit of quantification (LLOQ) of 0.7 ng/L and the upper limit of the reference range was 5.0 ng/L for women and 8.4 ng/L for men. At Weeks 26 and 52 in the clinical trials, adjusted mean serum calcitonin concentrations were higher in Victoza®-treated patients compared to placebo-treated patients but not compared to patients receiving active comparator. At these timepoints, the adjusted mean serum calcitonin values (~ 1.0 ng/L) were just above the LLOQ with between-group differences in adjusted mean serum calcitonin values of approximately 0.1 ng/L or less. Among patients with pre-treatment serum calcitonin below the upper limit of the reference range, shifts to above the upper limit of the reference range which persisted in subsequent measurements occurred most frequently among patients treated with Victoza® 1.8 mg/day. In trials with on-treatment serum calcitonin measurements out to 5-6 months, 1.9% of patients treated with Victoza® 1.8 mg/day developed new and persistent calcitonin elevations above the upper limit of the reference range compared to 0.8-1.1% of patients treated with control medication or the 0.6 and 1.2 mg doses of Victoza®. In trials with ontreatment serum calcitonin measurements out to 12 months, 1.3% of patients treated with Victoza® 1.8 mg/day had new and persistent elevations of calcitonin from below or within the reference range to above the upper limit of the reference range, compared to 0.6%, 0% and 1.0% of patients treated with Victoza® 1.2 mg, placebo and active control, respectively. Otherwise, Victoza® did not produce consistent dose-dependent or time-dependent increases in serum calcitonin. Patients with MTC usually have calcitonin values >50 ng/L. In Victoza® clinical trials, among patients with pre-treatment serum calcitonin <50 ng/L, one Victoza®-treated patient and no comparator-treated patients developed serum calcitonin >50 ng/L. The Victoza®-treated patient who developed serum calcitonin >50 ng/L had an elevated pre-treatment serum calcitonin of 10.7 ng/L that increased to 30.7 ng/L at Week 12 and 53.5 ng/L at the end of the 6-month trial. Follow-up serum calcitonin was 22.3 ng/L more than 2.5 years after the last dose of Victoza®. The largest increase in serum calcitonin in a comparator-treated patient was seen with glimepiride in a patient whose serum calcitonin increased from 19.3 ng/L at baseline to 44.8 ng/L at Week 65 and 38.1 ng/L at Week 104. Among patients who began with serum calcitonin <20 ng/L, calcitonin elevations to >20 ng/L occurred in 0.7% of Victoza®-treated patients, 0.3% of placebotreated patients, and 0.5% of active-comparator-treated patients, with an incidence of 1.1% among patients treated with 1.8 mg/day of Victoza®. The clinical significance of these findings is unknown. Counsel patients regarding the risk for MTC and the symptoms of thyroid tumors (e.g. a mass in the neck, dysphagia, dyspnea or persistent hoarseness). It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate the potential risk of MTC, and such monitoring may increase the risk of unnecessary procedures, due to low test specificity for serum calcitonin and a high background incidence of thyroid disease. Patients with thyroid nodules noted on physical examination or neck imaging obtained for other reasons should be referred to an endocrinologist for further evaluation. Although routine monitoring of serum calcitonin is of uncertain value in patients treated with Victoza®, if serum calcitonin is measured and found to be elevated, the patient should be referred to an endocrinologist for further evaluation. Pancreatitis: In clinical trials of Victoza®, there were 7 cases of pancreatitis among Victoza®-treated patients and 1 case among comparator-treated patients (2.2 vs. 0.6 cases per 1000 patient-years). Five cases with Victoza® were reported as acute pancreatitis and two cases with Victoza® were reported as chronic pancreatitis. In one case in a Victoza®-treated patient,
pancreatitis, with necrosis, was observed and led to death; however clinical causality could not be established. One additional case of pancreatitis has subsequently been reported in a Victoza®-treated patient. Some patients had other risk factors for pancreatitis, such as a history of cholelithiasis or alcohol abuse. There are no conclusive data establishing a risk of pancreatitis with Victoza® treatment. After initiation of Victoza®, and after dose increases, observe patients carefully for signs and symptoms of pancreatitis (including persistent severe abdominal pain, sometimes radiating to the back and which may or may not be accompanied by vomiting). If pancreatitis is suspected, Victoza® and other potentially suspect medications should be discontinued promptly, confirmatory tests should be performed and appropriate management should be initiated. If pancreatitis is confirmed, Victoza® should not be restarted. Use with caution in patients with a history of pancreatitis. Use with Medications Known to Cause Hypoglycemia: Patients receiving Victoza® in combination with an insulin secretagogue (e.g., sulfonylurea) may have an increased risk of hypoglycemia. In the clinical trials of at least 26 weeks duration, hypoglycemia requiring the assistance of another person for treatment occurred in 7 Victoza®-treated patients and in two comparator-treated patients. Six of these 7 patients treated with Victoza® were also taking a sulfonylurea. The risk of hypoglycemia may be lowered by a reduction in the dose of sulfonylurea or other insulin secretagogues [see Adverse Reactions]. Renal Impairment: Victoza® has not been found to be directly nephrotoxic in animal studies or clinical trials. There have been postmarketing reports of acute renal failure and worsening of chronic renal failure, which may sometimes require hemodialysis in Victoza®-treated patients [see Adverse Reactions]. Some of these events were reported in patients without known underlying renal disease. A majority of the reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration [see Adverse Reactions]. Some of the reported events occurred in patients receiving one or more medications known to affect renal function or hydration status. Altered renal function has been reversed in many of the reported cases with supportive treatment and discontinuation of potentially causative agents, including Victoza®. Use caution when initiating or escalating doses of Victoza® in patients with renal impairment. Macrovascular Outcomes: There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with Victoza® or any other antidiabetic drug. ADVERSE REACTIONS: Clinical Trials Experience: Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The safety of Victoza® was evaluated in a 52-week monotherapy trial and in five 26-week, add-on combination therapy trials. In the monotherapy trial, patients were treated with Victoza® 1.2 mg daily, Victoza® 1.8 mg daily, or glimepiride 8 mg daily. In the add-on to metformin trial, patients were treated with Victoza® 0.6 mg, Victoza® 1.2 mg, Victoza® 1.8 mg, placebo, or glimepiride 4 mg. In the add-on to glimepiride trial, patients were treated with Victoza® 0.6 mg, Victoza® 1.2 mg, Victoza® 1.8 mg, placebo, or rosiglitazone 4 mg. In the add-on to metformin + glimepiride trial, patients were treated with Victoza® 1.8 mg, placebo, or insulin glargine. In the add-on to metformin + rosiglitazone trial, patients were treated with Victoza® 1.2 mg, Victoza® 1.8 mg or placebo. Withdrawals: The incidence of withdrawal due to adverse events was 7.8% for Victoza®-treated patients and 3.4% for comparatortreated patients in the five controlled trials of 26 weeks duration or longer. This difference was driven by withdrawals due to gastrointestinal adverse reactions, which occurred in 5.0% of Victoza®-treated patients and 0.5% of comparator-treated patients. The most common adverse reactions leading to withdrawal for Victoza®-treated patients were nausea (2.8% versus 0% for comparator) and vomiting (1.5% versus 0.1% for comparator). Withdrawal due to gastrointestinal adverse events mainly occurred during the first 2-3 months of the trials. Tables 1, 2 and 3 summarize the adverse events reported in ≥5% of Victoza®-treated patients in the six controlled trials of 26 weeks duration or longer. Table 1: Adverse events reported in ≥5% of Victoza®-treated patients or ≥5% of glimepiride-treated patients: 52-week monotherapy trial All Victoza® N = 497 Glimepiride N = 248 (%) (%) Adverse Event Term Nausea 28.4 8.5 Diarrhea 17.1 8.9 Vomiting 10.9 3.6 Constipation 9.9 4.8 Upper Respiratory Tract Infection 9.5 5.6 Headache 9.1 9.3 Influenza 7.4 3.6 Urinary Tract Infection 6.0 4.0 Dizziness 5.8 5.2 Sinusitis 5.6 6.0 Nasopharyngitis 5.2 5.2 Back Pain 5.0 4.4 Hypertension 3.0 6.0 Table 2: Adverse events reported in ≥5% of Victoza®-treated patients and occurring more frequently with Victoza® compared to placebo: 26-week combination therapy trials Add-on to Metformin Trial All Victoza® + Placebo + Glimepiride + Metformin N = 724 Metformin N = 121 Metformin N = 242 (%) (%) (%) Adverse Event Term Nausea 15.2 4.1 3.3 Diarrhea 10.9 4.1 3.7 Headache 9.0 6.6 9.5 Vomiting 6.5 0.8 0.4 Add-on to Glimepiride Trial All Victoza® + Placebo + Glimepiride Rosiglitazone + Glimepiride N = 695 N = 114 Glimepiride N = 231 (%) (%) (%) Adverse Event Term Nausea 7.5 1.8 2.6 Diarrhea 7.2 1.8 2.2
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Psoriasis from page 26 the following excellent review article: Nestle FO, Kaplan DH, and Barker J, Psoriasis NEJM 2009; 361: 496-509. However, I wish to emphasize several key points. The pivotal players in the immunopathology of psoriasis are the dermal dendritic cells, bone marrow-derived macrophages that come to reside in the dermis of the skin. These antigen-processing cells presumably present epidermal cell antigens to T cells. Activated dermal dendritic cells also secrete interleukins -12 and -23, a process that facilitates naïve T cells developing into Th1 and Th17 helper cells. Th1 and Th17 helper T cells are key players in cutaneous psoriasis and are prime targets for newer pharmacologic therapy. TNF-alpha also plays an important role in this process. Psoriatic skin lesions are characterized by an overproduction of TNF-alpha by T cells, keratinocytes, dendritic cells, and Langerhans cells.
Concentration of TNF-alpha is higher in psoriasis lesions compared to normal skin or the skin of normal patients. This higher concentration diminishes with successful therapy of psoriasis, and the decline parallels clinical improvement. TNF-alpha induces the expression of a variety of adhesion molecules, resulting in the recruitment of inflammatory cells into psoriatic skin. TNF-alpha also induces production of matrix metalloproteinases in joints affected by psoriatic arthritis, causing cartilage degradation. Thus, TNFalpha plays a key role in both psoriatic cutaneous and joint disease and is a prime target for biologic therapy. Associated comorbidities
Moderate to severe psoriasis has important systemic comorbidities, including increased risk of metabolic syndrome and myocardial infarction. The latter is thought to be due to circulating inflammatory factors that damage endothelial cells. Endothelial cell damage, in addition to other risk factors (e.g., hyper-
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tension, smoking, obesity, dyslipidemia), potentiates the formation of atheromatous plaque. Thus, effective therapy of moderate to severe psoriasis may have beneficial effects on adverse cardiovascular events and should be incorporated into a prevention program that includes weight reduction for obese patients, control of hypertension, management of dsylipidemia, and smoking cessation. Therapeutics
The understanding of the immunopathology of psoriasis has led to exciting advances in therapy, several of which are described below. Ultraviolet phototherapy has been used for decades for psoriasis therapy. Broadband ultraviolet phototherapy (290 nm–320 nm wavelength) in conjunction with coal tar is known as Goeckerman therapy, honoring the Mayo Clinic dermatologist who initiated its use. Identification of the most effective segment of this band of light as 308–311 nm has led to the creation of ultra-efficient narrowband UV bulbs, with peak wavelength output at 311 nm, and has helped lead to the clinical use of the 308-nm excimer laser. These two devices are highly effective in treating psoriasis and are also used to treat other cutaneous diseases such as vitiligo and cutaneous T-cell lymphoma, patch stage (mycosis fungoides). Ultraviolet therapy has multiple helpful biological/therapeutic effects on psoriatic skin, including apoptosis of lymphoid cells and dendritic cells. The systemic retinoid acitretin (Soriatane) is used as monotherapy for plaque-type and pustular palmar-plantar psoriasis, and in combination with narrow-band UVB for generalized moderate to severe plaquetype psoriasis. Approximately 85 percent to 90 percent of severe psoriatic patients can be greatly improved or cleared with acitretin and narrow-band UVB therapy. There are certain caveats. Acitretin is a potent teratogen and is fat soluble, remaining in fat for years. Therefore, it should not be given to women
of child-bearing potential. Other side effects include cheilitis, dry skin, xerophthalmia, nasal mucositis, and hypertriglyceridemia. The side effects are usually quite manageable if the dose is kept at or below 25 mg per day. The biologic agents are the most exciting addition to the therapeutic armamentarium. The TNF-alpha agonists can be divided into two categories: monoclonal antibodies (adalimumab [Humira] and infliximab [Remicade]) and fusion proteins (etanercept [Enbrel]). The monoclonal antibodies may be chimeric, meaning they are partly human and partly murine (infliximab), or fully human (adalimumab). Etanercept is a fusion protein composed of the human TNF-alpha receptor and the FC portion of lgG. Infliximab is given intravenously; etanercept and adalimumab are administered via subcutaneous injection, performed by the patient, at home. Etanercept is indicated for treatment of rheumatoid arthritis, psoriatic arthritis, moderate to severe cutaneous psoriasis, juvenile rheumatoid arthritis, and ankylosing spondylitis. Infliximab is used to treat rheumatoid and psoriatic arthritis, Crohn’s disease, and moderate to severe cutaneous psoriasis. Adalimumab is used for rheumatoid and psoriatic arthritis, Crohn’s disease, ankylosing arthritis, and moderate to severe cutaneous psoriasis. It has been found to be effective in juvenile rheumatoid arthritis. All three agents interfere with the function of TNF-alpha and are effective in psoriatic therapy. Possible side effects include activation of latent tuberculosis, increased risk of upper respiratory infection, and, perhaps, herpes zoster and development of a lupus erythematosus-like syndrome. There is a questionable increased risk of lymphoma with these agents. This is difficult to calculate because rheumatoid arthritis has a severalfold increase in lymphoma compared to the normal population, while psoriasis has a 2.5 times increased risk. Therapy with TNF-alpha-
blocking drugs has been associated with rare cases of new onset or exacerbation of demyelinating diseases (e.g., multiple sclerosis, transverse myelitis, optic neuritis, seizure disorder), so these drugs should not be used to treat patients with a history of demyelinating disease. Infliximab may be associated with infusion reactions, which occur in approximately 3.8 percent of patients. Live viral vaccines should not be administered to patients receiving antiTNF-alpha drugs. The newest member of the biologic therapy group is ustekinumab (Stelera). It is a fully human monoclonal antibody against interleukins -12 and -23, key players in psoriasis. Interleukin -12 promotes the population of Th1 cells in psoriatic lesions, while interleukin -23 promotes the Th17 cell population. Ustekinumab’s clinical effect on plaque-type psoriasis is dramatic, with the majority of patients demonstrating marked improvement or complete clearance. Ustekinumab is administered subcutaneously and must
Studies show psoriasis severity to be related to compromised employment, income levels, self-esteem, and social withdrawal. be administered by a provider. Two injections are given 30 days apart and then every 12 weeks, for greater patient convenience (etanercept is given every week, adalimumab every two weeks, infliximab every six to eight weeks). Ustekinumab has been used for only three years, so its longterm safety is unknown. Side effects include possible increased risk of infection and a theoretical risk of malignancy. A rare neurological complication, posterior reversible encephalopathy syndrome, has been described in ustekinumab-treated patients and has been seen in patients treated with cyclosporine, tacrolimus, and interferon alpha. The relationship to ustekinumab is unclear, and longer experience will be necessary for clarification. Though
ustekinumab is not FDAapproved for therapy of psoriatic arthritis, in my experience it improves joint pain and stiffness in psoriatic patients. There have been several reports of increased risk of myocardial infarction with the use of ustekinumab. Interleukin -12 or -23 may have a protective effect against atheroma formation within blood vessels. Therefore, it may be prudent to screen possible candidates for ustekinumab for cardiovascular risk factors. Some clinicians advocate the use of low-dose aspirin in such patients. More experience will be needed before this risk can be accurately assessed.
Limited psoriasis often can be controlled with topical therapy. Moderate to severe psoriasis is much more challenging and has a 15 percent to 25 percent associated risk of inflammatory arthritis and a risk of major adverse cardiovascular events 2.5 times higher than the risk for the general population. Advances in therapy— narrow-band UVB, acitretin, and the biologic agents—have revolutionized patient management. The biologic agents have had a profound impact on management of psoriatic and rheumatoid arthritis. They may also have a major impact on the adverse cardiovascular events that afflict many of our psoriatic patients. Mitchell Bender, MD, practices with Dermatology Specialists PA and is an adjunct clinical faculty member in the Department of Dermatology at the University of Minnesota Medical School, Minneapolis.
A global health issue
Psoriasis is a major global health issue, thought to affect 125 million people worldwide.
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The Northwest Wisconsin Region of Mayo Clinic Health System has more than 300 physicians representing a wide range of medical specialties in a community healthcare setting. We are a respected and financially secure organization with strong emphasis on high quality care and patient satisfaction. A Mayo One emergency medical helicopter is based in Eau Claire, offering surrounding communities access to the area’s only verified Level II trauma center. Our current opportunities include: Dermatology Oncology Emergency Medicine Orthopedic Surgery – General, Sports, & Trauma Endocrinology Palliative Care Family Medicine Pathology General Surgery PM & R Hospitalist Psychiatry – Adult Internal Medicine Rheumatology Neurology Urology Neurosurgery If you wish to learn more or to express interest in this position, please contact: Cyndi Edwards/Christie Blink by phone (800-573-2580); email edwards.cyndi@mayo.edu or blink.christie@mayo.edu
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PAIN
E
ach year more than 38,000 children in the U.S. die from a terminal medical condition. Most of those children suffer unnecessarily because many physicians might be afraid to use powerful drugs on children, or they are simply not yet trained in pain and palliative care. Central to any team entrusted to help a child heal, pediatric pain and palliative care is part of a holistic, interdisciplinary approach to caring for child and family—no matter what the diagnosis. The pain and palliative care program at Children’s Hospitals and Clinics of Minnesota is one of only a few centers of its kind in the country. Our care team is trained specifically to treat and relieve children’s pain and other distressing symptoms, such as nausea, fatigue, and loss of appetite. Just as importantly, we work with family members to help them ease their child’s pain and, if their child passes away, we help families though the grief and bereavement process.
Orthopaedic Surgery Opportunity Live in Beautiful Minnesota Resort Community
MEDICINE
Pain and palliative care for children Control of pain and related symptoms helps children endure treatment By Stefan J. Friedrichsdorf, MD
Live as long as possible as well as possible
Pediatric pain and palliative care is sometimes misconstrued as simply hospice care for children. While hospice-type care is part of what we do, pediatric palliative care provides solace for children of all ages who are suffering from a life-threatening or life-limiting condition— regardless of whether curative treatments succeed or fail. With an integrated pain and palliative care program, care is provided within a continuum, from acute, chronic, or complex pain and symptom management to palliative care and hospice care. Palliative care is not “giving up.” Most often, it involves
Two BC/BE Orthopaedic Surgeons wanted to join four orthopaedic surgeons at Sanford Bemidji Orthopaedics Clinic in Bemidji, Minnesota. Part of an 85-physician, multi-specialty group practice and 118 bed acute care hospital. 1:6 call anticipated. Competitive compensation/benefits package, paid malpractice, relocation assistance and more. Sanford Health of Northern Minnesota has 1,450+employees and is part of Sanford Health system based in Fargo, ND and Sioux Falls, SD. Bemidji, Minnesota, located in northwestern Minnesota, is a beautiful resort community offering exceptional schools, a state university, and yearround cultural activity as well as great access to the outdoors for year-round recreation activity. To learn more about this excellent practice opportunity contact: Kathie Lee, Director Physician Placement Phone: 701-280-4887 Fax: 701-280-4136 Email: Kathie.Lee@sanfordhealth.org AA/EOE
management of pain and distressing symptoms in children, helping them to endure their treatment and to heal. These treatments usually occur in the hospital or clinic setting, but for children with life-limiting conditions, treatment is moved to the home when appropriate. The goal of a pediatric pain and palliative care program should be to help a child live as long as possible as well as possible. One baby boy our program cared for was diagnosed with a genetic disorder soon after birth that had caused major developmental defects in many of his organs. Sadly, most children diagnosed with this particular defect die within the first month of life. After his diagnosis, both his parents and his providers noticed that he was almost constantly in some form of discomfort, often writhing in pain. The boy’s doctors suggested a pain medication, but his parents resisted, fearing it would interfere with their child’s ability to eat and grow stronger so that he could have the heart surgery he needed. Still, in order to meet certain developmental milestones, the boy needed to have his pain properly managed. After agreeing to the medication, his parents felt comforted by the fact that, when their son did die a few months later, he was not suffering. In fact, when children’s distressing symptoms are aggressively managed—commonly with opioids and/or benzodiazepines—they live longer and with a better quality of life. No needless pain
For a parent, there are few things worse than watching one’s child in pain. At
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Children’s, we have a philosophy of “no needless pain.” Often, this includes the use of drugs, usually in combination with nonpharmacological therapies such as massage or music therapy, hypnosis, or acupuncture. Distraction is also an oftused technique: During a painful procedure, we may encourage the child to blow bubbles, or we may use guided imagery to focus the mind on something positive. Even something as simple as the human touch can comfort a child. Drugs and other techniques are often used in concert, but each child’s case is unique. The one universal aspect of pain and palliative care is that treatment is most successful when approached early and aggressively. Helping children and families live well
Pain is a complex and unique experience that affects all areas of a child’s life. Whether the pain is caused by a chronic illness or has an unknown cause, it can affect relationships, school, family life, and everyday responsibilities. In 2003, our team cared for a boy who was being treated for leukemia. As a result of his treatment, he developed a very rare side effect—chronic pain that sidelined him from living his adolescent years properly. Despite daily medications, the boy became severely disabled by the pain. He needed a wheelchair and missed many days of school. His family turned to our department for help. After his evaluation, the boy had regular appointments at our pediatric pain clinic where he learned to use alternative therapies like biofeedback and self-hypnosis. The team also prescribed physical therapy, including aquatic therapy. By the time school began in the fall of 2007, he was able to start his freshman year of high school without a wheelchair and without strong pain medications. Now, he rarely misses a day of school, can enjoy his favorite activities, and is no longer limited by his pain. PEDIATRIC PAIN to page 34
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Live in the relaxed lake country of Mille Lacs and practice medicine where you will make a difference. We’re looking for a Family Physician to join us at Mille Lacs Health System in Onamia, Minnesota. Loan forgiveness options may be available. Contact: Fern Gershone: fgershone@mlhealth.org or Dr. Tom Bracken: tbracken@mlhealth.org
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Five myths about pediatric palliative care Pediatric pain from page 32 Another boy in our program, who died at the age of 12, described his care this way: “Palliative care no longer means helping children die well, it means helping children and their families to live well and then, when the time is certain, to help them die gently.” One care team
When patients and families have their first visit with the pain and palliative care team in our clinic, they are greeted by an interdisciplinary team that usually includes a nurse, social worker, physical therapist, psychologist, and pediatric pain and palliative care specialist. This active and total approach to care embraces physical, emotional, social, and spiritual elements to healing. By including the whole team on the initial interview, the family does not have to repeat the pain narrative, which is often a painful and taxing experience, more than once. At the end of the evaluation, the team meets and makes
Myth: The death of a child in the U.S. is a rare event. Fact: Fifty thousand or more children die each year, more than 15,000 of them due to a life-limiting disease. Myth: Pediatric palliative care is only for children with cancer. Fact: Cancer causes only a about a quarter of the deaths in children due to life-limiting conditions. Myth: Pediatric palliative care starts when curative treatment stops and/or when a child is close to dying, and ends at death. Fact: Pediatric palliative care starts at diagnosis of life-threatening or life-limiting disease and continues through the trajectory of the illness. Myth: Parents have to choose between “fighting for a cure” or “giving up.” Fact: Life-saving care and excellent symptom relief can and should be provided simultaneously. Myth: Pediatric palliative care is the same as “doing nothing.” Fact: Even when the underlying condition can not be cured, sophisticated medical technology can be used to control symptoms and improve a child’s quality of life. recommendations for immediate follow-up with the same evaluating providers and with other pediatric specialty areas as needed. No matter what the recommendation, the next steps focus on enhancing the quality of life for the child and supporting the family. This may include management of distressing symptoms, provision of respite, and care throughout the child’s medical journey.
Resources for providers
On average, a pediatric physician receives six or fewer hours of training in pain management. In contrast, veterinarians receive almost 100 hours of training; in fact, in Oregon pain management is a mandatory part of clinical practice in veterinary medicine. Sadly, this is not the case in pediatric institutions. This continues to be an important gap to fill to ensure that we are treating our chil-
A Diverse and Vital Health Service
dren’s pain properly. In an effort to advance the state of the art of pain and palliative care, Children’s volunteered in 2003 to develop a centralized pediatric resource center for the state of Minnesota in conjunction with its hospice and palliative care programs. The Children’s Institute for Pain and Palliative Care offers training, consultation, and technical assistance to providers in Minnesota, Wisconsin, North Dakota, South Dakota, and Iowa. To date, the institute has trained more than 1,000 providers, and has hosted practicum visitors from many U.S. states and from overseas. Primary care and referring physicians can tap into the Children’s Institute in a variety of ways. They can call a member of our care team for advice on caring for a particularly complex patient or conduct an official phone consult. Physicians may refer a patient to us for outpatient services or hospital admission. Our care team provides training at clinics and PEDIATRIC PAIN to page 36
Boynton Health Service
Welcome to Boynton Health Service >ŽĐĂƚĞĚ ŝŶ ƚŚĞ ŚĞĂƌƚ ŽĨ ƚŚĞ dǁŝŶ ŝƟĞƐ ĂƐƚ ĂŶŬ ĐĂŵƉƵƐ͕ ŽLJŶƚŽŶ ,ĞĂůƚŚ ^ĞƌǀŝĐĞ ŝƐ Ă ǀŝƚĂů ƉĂƌƚ ŽĨ ƚŚĞ hŶŝǀĞƌƐŝƚLJ ŽĨ DŝŶŶĞƐŽƚĂ ĐŽŵŵƵŶŝƚLJ͕ ƉƌŽǀŝĚŝŶŐ ĂŵďƵůĂƚŽƌLJ ĐĂƌĞ͕ ŚĞĂůƚŚ ĞĚƵĐĂƟŽŶ͕ ĂŶĚ ƉƵďůŝĐ ŚĞĂůƚŚ ƐĞƌǀŝĐĞƐ ƚŽ ƚŚĞ hŶŝǀĞƌƐŝƚLJ ĨŽƌ ŶĞĂƌůLJ ϵϬ LJĞĂƌƐ͘ /ƚ͛Ɛ ŽƵƌ ŵŝƐƐŝŽŶ ƚŽ ĐƌĞĂƚĞ Ă ŚĞĂůƚŚLJ ĐŽŵŵƵŶŝƚLJ ďLJ ǁŽƌŬŝŶŐ ǁŝƚŚ ƐƚƵĚĞŶƚƐ͕ ƐƚĂī͕ ĂŶĚ ĨĂĐƵůƚLJ ƚŽ ĂĐŚŝĞǀĞ ƉŚLJƐŝĐĂů͕ ĞŵŽƟŽŶĂů͕ ĂŶĚ ƐŽĐŝĂů ǁĞůůͲďĞŝŶŐ͘ ŽLJŶƚŽŶ͛Ɛ ŽƵƚƐƚĂŶĚŝŶŐ ƐƚĂī ŽĨ ϮϱϬ ŝŶĐůƵĚĞƐ ďŽĂƌĚ ĐĞƌƟĮĞĚ ƉŚLJƐŝĐŝĂŶƐ͕ ŶƵƌƐĞ ƉƌĂĐƟƟŽŶĞƌƐ͕ ƌĞŐŝƐƚĞƌĞĚ ŶƵƌƐĞƐ͕ D Ɛͬ>WEƐ͕ ƉŚLJƐŝĐŝĂŶ ĂƐƐŝƐƚĂŶƚƐ͕ ĚĞŶƟƐƚƐ͕ ĚĞŶƚĂů ŚLJŐŝĞŶŝƐƚƐ͕ ŽƉƚŽŵĞƚƌŝƐƚƐ͕ ƉŚLJƐŝĐĂů ĂŶĚ ŵĂƐƐĂŐĞ ƚŚĞƌĂƉŝƐƚƐ͕ ƌĞŐŝƐƚĞƌĞĚ ĚŝĞƟƟĂŶƐ͕ ƉŚĂƌŵĂĐŝƐƚƐ͕ ƉƐLJĐŚŝĂƚƌŝƐƚƐ͕ ƉƐLJĐŚŽůŽŐŝƐƚƐ͕ ĂŶĚ ƐŽĐŝĂů ǁŽƌŬĞƌƐ͘ KƵƌ ŵƵůƟĚŝƐĐŝƉůŝŶĂƌLJ ŚĞĂůƚŚ ƐĞƌǀŝĐĞ ŚĂƐ ďĞĞŶ ĐŽŶƟŶƵŽƵƐůLJ ĂĐĐƌĞĚŝƚĞĚ ďLJ , ƐŝŶĐĞ ϭϵϳϵ͕ ĂŶĚ ǁĂƐ ƚŚĞ ĮƌƐƚ ĐŽůůĞŐĞ ŚĞĂůƚŚ ƐĞƌǀŝĐĞ ƚŽ ŚĂǀĞ ĞĂƌŶĞĚ ƚŚŝƐ ĚŝƐƟŶĐƟŽŶ͘ ƩĞŶĚŝŶŐ ƚŽ ŽǀĞƌ ϭϬϬ͕ϬϬϬ ƉĂƟĞŶƚ ǀŝƐŝƚƐ ĞĂĐŚ LJĞĂƌ͕ ŽLJŶƚŽŶ ,ĞĂůƚŚ ^ĞƌǀŝĐĞ ƚĂŬĞƐ ƉƌŝĚĞ ŝŶ ŵĞĞƟŶŐ ƚŚĞ ŚĞĂůƚŚ ĐĂƌĞ ŶĞĞĚƐ ŽĨ h ŽĨ D ƐƚƵĚĞŶƚƐ͕ ƐƚĂī͕ ĂŶĚ ĨĂĐƵůƚLJ ǁŝƚŚ ĐŽŵƉĂƐƐŝŽŶ ĂŶĚ ƉƌŽĨĞƐƐŝŽŶĂůŝƐŵ͘
Gynecologist/Clinical Supervisor ŽLJŶƚŽŶ ,ĞĂůƚŚ ^ĞƌǀŝĐĞ ŝƐ ƐĞĞŬŝŶŐ Ă 'LJŶĞĐŽůŽŐŝƐƚ ƚŽ ƐĞƌǀĞ ĂƐ ůŝŶŝĐĂů ^ƵƉĞƌǀŝƐŽƌ ĨŽƌ ƚŚĞ tŽŵĞŶ͛Ɛ ůŝŶŝĐ͘ dŚĞ ůŝŶŝĐĂů ^ƵƉĞƌǀŝƐŽƌ ǁŝůů ĞŶƐƵƌĞ ƐƚĂī ĂĚŚĞƌĞŶĐĞ ƚŽ ƌĞůĞǀĂŶƚ ƌĞŐƵůĂƟŽŶƐ͕ ĂƐƐƵƌĞ ŚŝŐŚĞƐƚ ƉƌŽĨĞƐƐŝŽŶĂů ĂŶĚ ĞƚŚŝĐĂů ƐƚĂŶĚĂƌĚƐ͕ ĂŶĚ ǁŽƌŬ ǁŝƚŚ ƚŚĞ ŝƌĞĐƚŽƌ ĂŶĚ ŚŝĞĨ DĞĚŝĐĂů KĸĐĞƌ ŝŶ ĨŽƌŵƵůĂƟŶŐ ůŽŶŐ ƌĂŶŐĞ ƉůĂŶŶŝŶŐ ĂŶĚ ƉŽůŝĐŝĞƐ͘ ƐŵĂůů ƉĞƌĐĞŶƚĂŐĞ ŽĨ ƟŵĞ ǁŝůů ďĞ ƐƉĞŶƚ ƉƌŽǀŝĚŝŶŐ ĐůŝŶŝĐĂů ĂŶĚ ƚĞĂĐŚŝŶŐ ƐĞƌǀŝĐĞƐ ĨŽƌ ƚŚĞ ĐĂĚĞŵŝĐ ,ĞĂůƚŚ ĞŶƚĞƌ KďͲ'LJŶ ĞƉĂƌƚŵĞŶƚ ĂŶĚ hŶŝǀĞƌƐŝƚLJ ŽĨ DŝŶŶĞƐŽƚĂ WŚLJƐŝĐŝĂŶƐ͘ dŚŝƐ ƉŽƐŝƟŽŶ ŽīĞƌƐ Ă ĐŽŵƉĞƟƟǀĞ ƐĂůĂƌLJ ĂŶĚ Ă ŐĞŶĞƌŽƵƐ ĂĐĂĚĞŵŝĐ ƐƚĂƚƵƐ ƌĞƟƌĞŵĞŶƚ ƉůĂŶ͘ WƌŽĨĞƐƐŝŽŶĂů ůŝĂďŝůŝƚLJ ĐŽǀĞƌĂŐĞ ŝƐ ƉƌŽǀŝĚĞĚ͘ ƉƉůLJ ŽŶͲůŝŶĞ Ăƚ ŚƩƉƐ͗ͬͬĞŵƉůŽLJŵĞŶƚ͘ ƵŵŶ͘ĞĚƵ ĂŶĚ ƌĞĨĞƌĞŶĐĞ ƌĞƋƵŝƐŝƟŽŶ ŶƵŵďĞƌ 176093͘ dŽ ůĞĂƌŶ ŵŽƌĞ͕ ƉůĞĂƐĞ ĐŽŶƚĂĐƚ ,ŽƐĞĂ KũǁĂŶŐ͕ ,ƵŵĂŶ ZĞƐŽƵƌĐĞƐ ŝƌĞĐƚŽƌ ;ϲϭϮͿ ϲϮϲͲϭϭϴϰ͕ ŚŽũǁĂŶŐΛďŚƐ͘ƵŵŶ͘ĞĚƵ͘ dŚĞ hŶŝǀĞƌƐŝƚLJ ŽĨ DŝŶŶĞƐŽƚĂ ŝƐ ĂŶ ƋƵĂů KƉƉŽƌƚƵŶŝƚLJ͕ ĸƌŵĂƟǀĞ ĐƟŽŶ ĚƵĐĂƚŽƌ ĂŶĚ ŵƉůŽLJĞƌ
ϰϭϬ ŚƵƌĐŚ ^ƚƌĞĞƚ ^ ͻ DŝŶŶĞĂƉŽůŝƐ͕ DE ϱϱϰϱϱ ͻ ;ϲϭϮͿ ϲϮϱͲϴϰϬϬ ͻ ǁǁǁ͘ďŚƐ͘ƵŵŶ͘ĞĚƵ
34
MINNESOTA PHYSICIAN FEBRUARY 2012
Psychiatrist 40 Hour Work Week The Federal Medical Center, Rochester, MN, is an accredited Joint Commission medical and behavioral health referral center for the Federal Bureau of Prisons.
The perfect match of career and lifestyle.
Psychiatrists work closely with a multi-disciplinary team consisting of health care, mental health care, social work, rehabilitation services, and correctional professionals to provide diagnostic and treatment services to federal inmates.
Affiliated Community Medical Centers is a physician owned multispecialty 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: • ENT • Family Medicine • General Surgery • Geriatrician/ • Outpatient Internal Medicine
• Hospitalist • Infectious Disease • Internal Medicine • OB/GYN • Oncology • Orthopedic Surgery
The Federal Bureau of Prisons, Health Services Division, is committed to providing evidence-based medical and psychiatric treatment and has a national impact through the development of comprehensive medical and psychiatric clinical guidelines.
• Psychiatry • Pediatrics • Pulmonary/ Critical Care • Radiation Oncology • Rheumatology
The Federal Bureau of Prisons offers a competitive salary and benefits package. The Federal Bureau of Prisons is an Equal Opportunity Employer.
For additional information, please contact:
Kari Bredberg, Physician Recruitment karib@acmc.com, (320) 231-6366
Contact: Lynn Platte, Assistant Human Resource Manager
Julayne Mayer, Physician Recruitment mayerj@acmc.com, (320) 231-5052
lplatte@bop.gov or call (507) 424-7521 www.acmc.com
Urgent Care
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. 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.
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.
Family Medicine Rochester Northwest Clinic Rochester Southeast Clinic St.Charles Clinic Internal Medicine Southeast Clinic Occupational Medicine Southeast Clinic Dermatology Southeast Clinic
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
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
healthpartners.com
www.olmstedmedicalcenter.org ©
FEBRUARY 2012 MINNESOTA PHYSICIAN
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Pediatric pain from page 34 hospitals both nationally and internationally, and we are regularly asked to speak on the topic of pain and palliative care. The institute also offers the annual weeklong Pediatric Pain Master Class, which includes training and hands-on learning opportunities. Attended mostly by doctors and nurse practitioners, the master class gives a broad overview of how to manage acute, chronic, and procedural pain in children, using both medication and nonpharmacological methods such as distraction, guided imagery, and even blowing bubbles. Practitioners from 12 different countries attended the master class in 2011. In addition, the institute offers one- and two-year physician fellowships and has recently begun work with outlying care centers to provide education via video conference. Limited access to a necessary service
Only a few generations ago, it was not uncommon for infants
and children to die. Today, thankfully, mortality rates in the developed world have plummeted. While comprehensive, state-ofthe-art palliative care for adults is fast becoming the norm, access to and availability of palliative care for the majority of children with life-threatening conditions is still lacking. In the U.S. and in most other countries worldwide, the vast majority of infants, children, and teenagers with advanced illness who are near the end of life do not have access to interdisStefan Friedrichsdorf, MD, tends to ciplinary pediatric palliative a young patient in the NICU at care services either in their Children’s – Minneapolis. community or at the nearest hospital. children heal faster. At State-of-the-art manageChildren’s, this is part of the ment of pain and distressing day-to-day activity of our hospisymptoms in children requires tal system, and we see patients the integration of pharmacofrom all different areas, not just logy, medical interventions, those children suffering from and rehabilitation with complecancer or terminal illness. mentary nonpharmacological For example, if we are seeand supportive therapies. We ing a child for something like have found that treating even stitches, there is usually no the mildest kinds of pain helps need for heavy sedation, but
A Diverse and Vital Health Service Welcome to Boynton Health Service
guiding them through a pleasant visualization to distract them from the procedure helps to lessen the pain and take their mind off the procedure. In the case of surgery, where the child will be in the hospital for a number of days, managing that child’s pain on a daily basis is crucial. Techniques like therapeutic massage and guiding them through deep breathing exercises help lessen the pain. Our positive experience in pediatric palliative care was recently supported in a randomized, controlled trial involving adults. This 2010 groundbreaking study, published in the New England Journal of Medicine, found that adults with advanced lung cancer who received palliative care in addition to standard cancer therapy not only had a better quality of life and less depression, but also lived longer than those who received only standard cancer therapy. Stefan J. Friedrichsdorf, MD, is medical director of the Department of Pain Medicine, Palliative Care and Integrative Medicine at Children’s Hospitals and Clinics of Minnesota.
Boynton Health Service
Physician
>ŽĐĂƚĞĚ ŝŶ ƚŚĞ ŚĞĂƌƚ ŽĨ ƚŚĞ dǁŝŶ ŝƟĞƐ ĂƐƚ ĂŶŬ ĐĂŵƉƵƐ͕ ŽLJŶƚŽŶ ,ĞĂůƚŚ ^ĞƌǀŝĐĞ ŝƐ Ă ǀŝƚĂů ƉĂƌƚ ŽĨ ƚŚĞ hŶŝǀĞƌƐŝƚLJ ŽĨ DŝŶŶĞƐŽƚĂ ĐŽŵŵƵŶŝƚLJ͕ ƉƌŽǀŝĚŝŶŐ ĂŵďƵůĂƚŽƌLJ ĐĂƌĞ͕ ŚĞĂůƚŚ ĞĚƵĐĂƟŽŶ͕ ĂŶĚ ƉƵďůŝĐ ŚĞĂůƚŚ ƐĞƌǀŝĐĞƐ ƚŽ ƚŚĞ hŶŝǀĞƌƐŝƚLJ ĨŽƌ ŶĞĂƌůLJ ϵϬ LJĞĂƌƐ͘ /ƚ͛Ɛ ŽƵƌ ŵŝƐƐŝŽŶ ƚŽ ĐƌĞĂƚĞ Ă ŚĞĂůƚŚLJ ĐŽŵŵƵŶŝƚLJ ďLJ ǁŽƌŬŝŶŐ ǁŝƚŚ ƐƚƵĚĞŶƚƐ͕ ƐƚĂī͕ ĂŶĚ ĨĂĐƵůƚLJ ƚŽ ĂĐŚŝĞǀĞ ƉŚLJƐŝĐĂů͕ ĞŵŽƟŽŶĂů͕ ĂŶĚ ƐŽĐŝĂů ǁĞůůͲďĞŝŶŐ͘
ŽLJŶƚŽŶ ,ĞĂůƚŚ ^ĞƌǀŝĐĞ ŚĂƐ ĂŶ ŝŵŵĞĚŝĂƚĞ ŽƉĞŶŝŶŐ ĨŽƌ Ă ĨƵůůͲƟŵĞ ƉŚLJƐŝĐŝĂŶ ƚŽ ƉƌŽǀŝĚĞ ƐĞƌǀŝĐĞƐ ŝŶ ƚŚĞ WƌŝŵĂƌLJ ĂƌĞ ĂŶĚ hƌŐĞŶƚ ĂƌĞ ůŝŶŝĐƐ͘ ĂŶĚŝĚĂƚĞƐ ƐŚŽƵůĚ ĞŶũŽLJ ǁŽƌŬŝŶŐ ŝŶ Ă ĐŽůůĞŐĞ ŚĞĂůƚŚ ĞŶǀŝƌŽŶŵĞŶƚ ǁŝƚŚ Ă ůĂƌŐĞ ĂŶĚ ĚŝǀĞƌƐĞ ƉŽƉƵůĂƟŽŶ ŽĨ ƐƚƵĚĞŶƚƐ ĂŶĚ ƐƚĂī͘
ŽLJŶƚŽŶ͛Ɛ ŽƵƚƐƚĂŶĚŝŶŐ ƐƚĂī ŽĨ ϮϱϬ ŝŶĐůƵĚĞƐ ďŽĂƌĚ ĐĞƌƟĮĞĚ ƉŚLJƐŝĐŝĂŶƐ͕ ŶƵƌƐĞ ƉƌĂĐƟƟŽŶĞƌƐ͕ ƌĞŐŝƐƚĞƌĞĚ ŶƵƌƐĞƐ͕ D Ɛͬ>WEƐ͕ ƉŚLJƐŝĐŝĂŶ ĂƐƐŝƐƚĂŶƚƐ͕ ĚĞŶƟƐƚƐ͕ ĚĞŶƚĂů ŚLJŐŝĞŶŝƐƚƐ͕ ŽƉƚŽŵĞƚƌŝƐƚƐ͕ ƉŚLJƐŝĐĂů ĂŶĚ ŵĂƐƐĂŐĞ ƚŚĞƌĂƉŝƐƚƐ͕ ƌĞŐŝƐƚĞƌĞĚ ĚŝĞƟƟĂŶƐ͕ ƉŚĂƌŵĂĐŝƐƚƐ͕ ƉƐLJĐŚŝĂƚƌŝƐƚƐ͕ ƉƐLJĐŚŽůŽŐŝƐƚƐ͕ ĂŶĚ ƐŽĐŝĂů ǁŽƌŬĞƌƐ͘ KƵƌ ŵƵůƟĚŝƐĐŝƉůŝŶĂƌLJ ŚĞĂůƚŚ ƐĞƌǀŝĐĞ ŚĂƐ ďĞĞŶ ĐŽŶƟŶƵŽƵƐůLJ ĂĐĐƌĞĚŝƚĞĚ ďLJ , ƐŝŶĐĞ ϭϵϳϵ͕ ĂŶĚ ǁĂƐ ƚŚĞ ĮƌƐƚ ĐŽůůĞŐĞ ŚĞĂůƚŚ ƐĞƌǀŝĐĞ ƚŽ ŚĂǀĞ ĞĂƌŶĞĚ ƚŚŝƐ ĚŝƐƟŶĐƟŽŶ͘
dŚĞ ƋƵĂůŝĮĞĚ ĂƉƉůŝĐĂŶƚ ŵƵƐƚ ďĞ D^ ďŽĂƌĚ ĐĞƌƟĮĞĚͬĞůŝŐŝďůĞ ĂŶĚ ŚĂǀĞ ƚƌĂŝŶŝŶŐ ĂŶĚͬŽƌ ĞdžƉĞƌŝĞŶĐĞ ŝŶ ĂŶ ŽƵƚƉĂƟĞŶƚ ƉƌĂĐƟĐĞ ĂŶĚ ƵƌŐĞŶƚ ĐĂƌĞ͘ <ŶŽǁůĞĚŐĞ ŽĨ ĞůĞĐƚƌŽŶŝĐ ŚĞĂůƚŚ ƌĞĐŽƌĚƐ ǁŽƵůĚ ďĞ ďĞŶĞĮĐŝĂů͘ dŚŝƐ ƉŽƐŝƟŽŶ ŽīĞƌƐ Ă ĐŽŵƉĞƟƟǀĞ ƐĂůĂƌLJ͕ D ŽƉƉŽƌƚƵŶŝƟĞƐ͕ ĂŶĚ Ă ŐĞŶĞƌŽƵƐ ĂĐĂĚĞŵŝĐ ƐƚĂƚƵƐ ƌĞƟƌĞŵĞŶƚ ƉůĂŶ͘ WƌŽĨĞƐƐŝŽŶĂů ůŝĂďŝůŝƚLJ ĐŽǀĞƌĂŐĞ ŝƐ ƉƌŽǀŝĚĞĚ͘
ƩĞŶĚŝŶŐ ƚŽ ŽǀĞƌ ϭϬϬ͕ϬϬϬ ƉĂƟĞŶƚ ǀŝƐŝƚƐ ĞĂĐŚ LJĞĂƌ͕ ŽLJŶƚŽŶ ,ĞĂůƚŚ ^ĞƌǀŝĐĞ ƚĂŬĞƐ ƉƌŝĚĞ ŝŶ ŵĞĞƟŶŐ ƚŚĞ ŚĞĂůƚŚ ĐĂƌĞ ŶĞĞĚƐ ŽĨ h ŽĨ D ƐƚƵĚĞŶƚƐ͕ ƐƚĂī͕ ĂŶĚ ĨĂĐƵůƚLJ ǁŝƚŚ ĐŽŵƉĂƐƐŝŽŶ ĂŶĚ ƉƌŽĨĞƐƐŝŽŶĂůŝƐŵ͘
dŽ ůĞĂƌŶ ŵŽƌĞ͕ ƉůĞĂƐĞ ĐŽŶƚĂĐƚ ,ŽƐĞĂ KũǁĂŶŐ͕ ,ƵŵĂŶ ZĞƐŽƵƌĐĞƐ ŝƌĞĐƚŽƌ͕ Ăƚ (612) 626-1184, hojwang@bhs.umn.edu ƉƉůLJ ŽŶůŝŶĞ Ăƚ ŚƩƉƐ͗ͬͬĞŵƉůŽLJŵĞŶƚ͘ƵŵŶ͘ĞĚƵ and reference ƌĞƋƵŝƐŝƟŽŶ ŶƵŵďĞƌ 175782͘ dŚĞ hŶŝǀĞƌƐŝƚLJ ŽĨ DŝŶŶĞƐŽƚĂ ŝƐ ĂŶ ƋƵĂů KƉƉŽƌƚƵŶŝƚLJ͕ ĸƌŵĂƟǀĞ ĐƟŽŶ ĚƵĐĂƚŽƌ ĂŶĚ ŵƉůŽLJĞƌ͘
ϰϭϬ ŚƵƌĐŚ ^ƚƌĞĞƚ ^ ͻ DŝŶŶĞĂƉŽůŝƐ͕ DE ϱϱϰϱϱ ͻ ;ϲϭϮͿ ϲϮϱͲϴϰϬϬ ͻ ǁǁǁ͘ďŚƐ͘ƵŵŶ͘ĞĚƵ
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MINNESOTA PHYSICIAN FEBRUARY 2012
Emergency Medicine Emergency Practice Associates has immediate full-time, part-time and locums opportunities at our sites in:
Hibbing Little Falls Park Rapids Alexandria Austin For more information contact Tina Dalton or Mike Coulter at 800-458-5003, email:
recruiting@epamidwest.com or visit our website at
www.epamidwest.com
Your Emergency Practice Partner
Practice Well. Live Well.
Lake Region Medical Group is seeking a full-time Certified Physician Assistant to join our Lake Region Healthcare team of 3 orthopedic surgeons; providing care in a multi-specialty clinic with 50+ providers.We are looking for a hardworking, conscientious individual committed to providing quality care to our patients as we develop our Orthopedic Center of Excellence.
Duties will include new and follow-up patient visits, assisting with surgery, post-op visits and hospital rounds in our 108 –bed community based hospital.The ideal candidate will have 2-5 years experience in orthopedics. We offer a competitive salary with a healthy benefit package. For more information contact Barb Miller, Physician Recruiter bjmiller@lrhc.org • (218) 736-8227
712 Cascade St. S., Fergus Falls, MN 736-8000 • (800) 439-6424
Lake Region Healthcare is an Equal Opportunity Employer. EOE
www.lrhc.org
Chief Medical Officer Rice Memorial Hospital has an outCandidates submit a cover standing opportunity for the right letter and resume to: person to serve as its Chief Medical Michael Schramm, CEO Officer (CMO). Rice Memorial Hospital Reporting directly to the CEO, this 301 SW Becker Avenue Willmar, MN 56201 senior executive will be responsible for leading the medical staff in the planRice provides a competining, facilitating and implementing of tive salary and generous programs to enhance physician effecbenefit package. To learn tiveness, quality of practice, clinical more see our website at integration and patient satisfaction. www.ricehospital.com The CMO will be line administrator for physician services within the Emergency Department and is expected to provide direct patient care at least four shifts per month in the Emergency Room. The position requires an MD or DO with a license to practice medicine in the State of Minnesota; as well as a minimum of seven years of clinical experience and at least two years of physician leadership experience. An MBA or Masters degree in public health is desirable. Located in the lakes region two hours west of the Twin Cities, Rice Memorial Hospital is the state’s largest municipal hospital, providing a vast array of services to the residents of west central Minnesota, including high-tech diagnostics, rehabilitation, long-term care, DME, mental health, dialysis, radiation oncology and hospice. Rice recently completed a $52 million building and renovation project.
Internal Medicine?
Yup.
Family Medicine?
NEW clinic in Mahtomedi, MN?
Internal and Family Medicine Opportunities Stillwater Medical Group is an 90+ provider multi-specialty group practice affiliated with Lakeview Hospital. For more than 50 years we have been providing comprehensive healthcare services in the St. Croix Valley, just east of the Twin Cities metro area. Internal and Family Medicine Physician Opportunities: Stillwater Medical Group has exciting new Internal and Family Medicine Physician opportunities at our NEW Mahtomedi, MN clinic opening Fall 2012! Additional opportunities also available in Stillwater, MN. Mahtomedi, MN? (Ma-toe-me-dye) So what if you can’t pronounce it? We can help with that. Mahtomedi is located in Washington County, on the east shore of White Bear Lake. Residents appreciate the community’s small town charm, lakeside flavor, and close proximity to the Twin Cities Metropolitan Area. In addition, the Mahtomedi School District and other area colleges offer excellence in education. For further information please contact: Patti Lewis, Director Human Resources 1500 Curve Crest Blvd, Stillwater MN (651) 275-3304, plewis@lakeview.org stillwatermedicalgroup.com
We’ll make it all better.
FEBRUARY 2012 MINNESOTA PHYSICIAN
37
Overview of pediatric physical therapy Pediatric physical therapy assists in early detection of health problems as well as the diagnosis, treatment, and management of infants, children, and adolescents with a variety of injuries, disorders, and diseases that affect the muscles, bones, and joints. Treatments focus on improving gross and fine motor skills, balance and coordination, strength and endurance as well as cognitive and sensory processing and integration. Children treated by pediatric physical therapists have a wide range of diagnoses, including: • • • • • • • •
Cancer Cerebral palsy Chronic pain Developmental delay Autism spectrum disorder (ASD) Genetic syndromes Hemophilia Developmental coordination disorder
Models from page 11 and appropriately. Without this type of deeper, ongoing reflection, therapists risk simply becoming technicians. The seventh element of this model prompts the therapist to consider whether or not the clinical data support her perceptions and conclusions regarding the effect of her physical therapy interventions. This element also encourages the
• • • • • •
Traumatic brain injury Juvenile arthritis Stroke Torticollis Pediatric obesity Orthopedic injuries or conditions
apy? And which outcomes are most probable, given the examination data she collected and the evaluation process she completed with a given child? In conclusion, pediatric physical therapists generally follow a clinical reasoning process or model that enables them to effectively manage their patients’ care as well as document the impact of their interventions on each child’s impairments and limitations. The most effective pediatric physical therapists also communicate well with the child’s family and
therapist to “triangulate” her inferences by considering whether they are consistent or not, as well as assess what other reasonable inferences may be considered regarding a given child’s case. The final element of this clinical reasoning model challenges pediatric therapists to consider the implications and consequences of her clinical reasoning. For instance, what are the likely outcomes of ther-
physician(s) as they interweave their treatment strategies with an ongoing process of selfreflection and assessment regarding the impact of their work. David Chapman, PT, PhD, is an assistant professor in the Doctor of Physical Therapy Program at St. Catherine University, St. Paul. He has practiced as a physical therapist with inpatient and outpatient adult and pediatric patients. as well as in the acute rehabilitation setting. This article is adapted from a presentation by the author at the Minnesota APTA Fall Conference, held in Duluth, Minn., in 2011.
An important and often challenging task for every clinician is to self-identify his or her clinical assumptions.
continuing medical education 26th Annual Family Medicine Today
March 8-9, 2012
30th Annual OB/GYN Update
April 12-13, 2012
Psychiatry Update for Primary Care
April 19-20, 2012
• Child and Adolescent Mental Health • Adult Mental Health
Pediatric Fundamental Critical Care Support
April 19, 2012 April 20, 2012
May 3-4 and November 8-9, 2012
Fundamental Critical Care Support 30th Annual Strategies in Primary Care Medicine Midwestern Region Burn Conference
July 19 -20, 2012 September 20-21, 2012 October 10-12, 2012
• Pre-Conference Workshops – Burn Rehabilitation: The Bridge to Recovery – The Pathway to Improving Outcomes for Pediatric Burn Injuries (includes simulation-based learning)
Optimizing Mechanical Ventilation
education that measurably improves patient care 38
MINNESOTA PHYSICIAN FEBRUARY 2012
October 10, 2012 October 10, 2012
October 26-28, 2012
healthpartnersIME.com
You wouldnâ&#x20AC;&#x2122;t give a 3-year-old a drink, 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
MEDICAL OFFICE FOR LEASE Several space options metro-wide Existing or build to suit Gardenview Medical Building, St. Paul
Southdale Medical Center, Edina
Physicians Building, Edina
High Pointe Health Campus, Lake Elmo
2800 Medical Building, Minneapolis
Southdale Medical Center Exp., Edina
Ritchie Medical Place, St. Paul
Midtown Medical Building, Minneapolis
6405 Medical Building, Edina
www.davisrealestatemn.com
Mark A. Davis mdavis@davisrealestatemn.com 612.341.3242
Jill K. Rasmussen, CCIM, SIOR jrasmussen@davisrealestatemn.com 612.341.3247