Volume XXVl, No. 4
July 2012
The Independent Medical Business Newspaper
Reducing readmissions Minnesota’s RARE Campaign
By Kathy Cummings, RN; Tania Daniels, PT, MBA; and Janelle Shearer, MA, BSN, RN
A
By Marie Manthey, MNA, FRCN, FAAN, PhD (hon.)
NURSING to page 10
PAID
Evolving relationships and education
S
PRSRT STD U.S. POSTAGE
changing role of nursing
ome things never change: Every year, a Gallup poll asks the public to rank more than 20 professions on ethics, honesty, and trustworthiness, and every year, nursing is No. 1 (except for 2001, when that spot went to firefighters). However, while the public’s positive perception of the nursing profession remains unchanged, the role that nurses play has changed dramatically over the past 20 years, as the settings in which nurses work and the ways in which they help patients have expanded. As the role of nurses has changed, so have the relationships between physicians and nurses. The traditional “handmaiden” concept of
Detriot Lakes, MN Permit No. 2655
The
cross the United States, hospitals and other health care organizations are working to reduce avoidable hospital readmissions, following national priorities set by the Centers for Medicare & Medicaid Services (CMS) and the Affordable Care Act. Minnesota health care leaders recognized the need to improve, since nearly one in five Medicare patients discharged from Minnesota hospitals is readmitted within 30 days. Eighteen states have lower readmission rates. Minnesota hospitals, health plans and other health care organizations intensified their efforts to reduce avoidable readmissions starting in 2009. To combine and build upon this work and accelerIN THIS ISSUE: ate improvement statewide, three health Orthopedics care organizations colPage 20 laborated to create the RARE (Reducing Avoidable Readmissions Effectively) Campaign. READMISSIONS to page 12
SMOKER SUPPORT PERSON STUDY Do you see smokers in your clinical practice who would like to quit but are not quite ready? Do you see nonsmokers in your practice who are concerned about a smoker?
Please invite these patients to learn about a new research study. The Smoker Support Person Study will enroll more than 1,000 non-smokers to help their friends and loved ones quit smoking. • Participants will receive free guidance and tools to help a smoker move towards quitting.
r Improve smoking cessation programs around the country
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Not onlyparticipation will you becould helping patients, but their but your meanyour bringing the entire country one step closermean to kicking its smoking addiction. participation could bringing the entire country one step closer to kicking itsatsmoking addiction. Call 1-800-957-2950 or email us supportpersonstudy@mayo.edu
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MC4106-159
CONTENTS
JULY 2012 Volume XXVI, No. 4
FEATURES The changing role of nursing Evolving relationships and education
1
By Marie Manthey, MNA, FRCN, FAAN, PhD (hon.)
Reducing readmissions Minnesota’s RARE Campaign
1
By Kathy Cummings, RN; Tania Daniels, PT, MBA; and Janelle Shearer, MA, BSN, RN
DEPARTMENTS CAPSULES
4
MEDICUS
7
INTERVIEW
8 Aaron Friedman, MD University of Minnesota Medical School
MEDICINE AND THE LAW Legislative wrap-up 14 By H. Theodore Grindal, JD, and Nate Mussell, JD
ALZHEIMER’S DISEASE Uncovering clues to memory loss
ALZHEIMER’S DISEASE A national plan for Alzheimer’s
18
By Carla Zbacnik
PROFESSIONAL UPDATE: NEUROLOGY Pacemakers for pain 24 By Peter Pahapill, MD
BEHAVIORAL HEALTH ADHD across the lifespan
28
By Elizabeth Reeve, MD
PATIENT PERSPECTIVE When the “vulnerable” adult is you
32
By Jen Kirchen, LSW
16
By Adine D. Stokes, Kirstin Stokes Smith, and Karen H. Ashe, MD, PhD
PATIENT PERSPECTIVE A stroke at 15
36
By Judy McMillan and Michael McMillan
SPECIAL FOCUS: ORTHOPEDICS Advances in stem cell therapy By J. Chris Coetzee, MD
20
Chronic recurring ortho problems
22
By Angela Voight, MD
The Independent Medical Business Newspaper
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Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; phone (612) 728-8600; fax (612) 728-8601; email mpp@mppub.com. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc., or this publication. The contents herein are believed accurate but are not intended to replace legal, tax, business or other professional advice and counsel. No part of this publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 issues) are $48.00. Individual issues are $5.00.
JULY 2012 MINNESOTA PHYSICIAN
3
C APSULES
Supreme Court Ruling Lets Health Law Largely Stand On June 28, the Supreme Court issued its long-awaited ruling on President Obama’s Affordable Care Act (ACA). The 5–4 decision largely let stand the ACA’s health care reforms. The court upheld the key provision known as the individual mandate, which requires virtually all citizens to buy health care insurance. That provision is considered by many to be the pillar of health care reform legislation. In addition, the court let stand the ACA’s major expansion of the government-funded Medicaid program. However, the ruling allows states to choose whether or not to expand their Medicaid programs, without facing the financial penalties the law called for. Minnesota commissioners Lucinda Jesson of Human Services, Mike Rothman of
Commerce, and Ed Ehlinger of Health, released a statement calling the ruling “an affirmation of the reform efforts currently underway in Minnesota to improve health and lower the cost of care. The ruling signifies real progress and important protection for citizens across Minnesota: affordable insurance for small business, young people can stay on their parents insurance until age 26, and guaranteed coverage for those with pre-existing conditions.".
Sanford Begins Work On Thief River Falls Medical Center Sanford Health has broken ground on a new medical center in Thief River Falls. The 137,000-square-foot Sanford Thief River Falls Medical Center is expected to be finished by fall 2014. Plans for the $60 million project were announced last fall. “This project illustrates Sanford Health’s delivery on
a promise made to the Thief River Falls community and for the people throughout northwestern Minnesota,� says Chris Harf, CEO, Sanford Thief River Falls. The project will include a new, 25-bed critical access hospital with birthing units, intensive care beds, emergency rooms, and operating rooms. Services include dialysis, behavioral health, chemotherapy, radiology, surgery, lab, family medicine, obstetrics and gynecology, pediatrics, cardiac rehabilitation, and nutrition.
Pediatric Psychiatric Drug System Created By DHS The Minnesota Department of Human Services (DHS) has created a system that will encourage physicians to check with Mayo Clinic experts when prescribing psychotropic medications for children. The service is referred to as “collaborative psychiatric consultation,� and will be required
for fee-for-service patients in the state’s Medical Assistance (MA) program. However, the state is encouraging all pediatricians and primary care providers who prescribe psychotropic drugs for children to use the service, regardless of whether providers are public or private. “We are pleased to join with the Mayo Clinic to provide better mental health care to all Minnesota children, especially children served by the Medical Assistance program,� says Human Services Commissioner Lucinda Jesson. “This new psychiatric consultation service holds the promise of improved access and quality of care as well as greater efficiency, so resources can be focused on appropriate treatment.� Experts have been concerned by overuse and inappropriate use of psychotropic drugs among children. They point to studies that show over 60 percent of all children receiving psychotropic medications were not receiving specialized mental health services. The Minnesota program
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will receive a two-year state and federal investment of $1.7 million, which will be offset by reduced costs for inpatient hospitalizations and medications in the state’s MA program, DHS officials say. Beginning in August, the Mayo Clinic and its partners will operate a call center Monday through Friday from 7 a.m. to 7 p.m. A licensed social worker will answer calls and determine the most appropriate response. When possible, callers will be connected with existing services in the caller’s home community, and calls can be routed to psychiatrists who have qualifications specific to the situation. “For the first time in the state’s history, this new program will enable child psychiatrists and social workers across leading health care systems to function as an integrated team,” says Peter Jensen, MD, a professor of psychiatry at Mayo Clinic. “We’re truly working together to help Minnesota’s primary care physicians deliver quality health care to their children with mental health needs.”
Essentia Completes Construction of Clinic in Aurora Duluth-based Essentia Health has completed a $4.5 million construction and remodeling project in Aurora, moving that community’s clinic to a site adjacent to Essentia HealthNorthern Pines hospital. “We’ve built a modern and well-equipped medical campus for our patients and community,” says Northern Pines administrator Laura Ackman. “Bringing the facilities together helps provide better care and more convenience for patients and their families.” The new clinic will feature 13,000 square feet of space, along with new technology and upgraded equipment. The clinic and hospital will share a new registration area as well as a new and expanded laboratory and radiology suite. The clinic has 12 exam rooms and space for minor medical procedures. Another $200,000 project cre-
ated a new waiting area for surgical patients and their families, officials note.
New Applications For Public Programs Available Online The Minnesota Department of Human Services (DHS) has streamlined its application for public assistance programs. People applying for public health plans can now simultaneously apply for other programs, and vice versa. The ApplyMN form is available online at applymn.dhs. mn.gov, and will allow state residents to fill out a single online application for a range of programs. “ApplyMN is an easy, secure way for Minnesotans in need to apply for assistance from more than one program,” said Human Services Commissioner Lucinda Jesson. “This will streamline the application process, increase administrative efficiencies, and is an important step in our effort to make government easier to navigate.” DHS officials say close to 61,000 Minnesotans apply each month for health care and other human services programs. The new online form is a “smart application” that asks applicants questions and can show them what programs they are eligible for. Although paper applications will still be available, experts say there are several advantages to using the online approach. “ApplyMN will be a useful tool for clients to be able to fill out an application on the Internet and immediately submit it, and not have to incur the cost of driving to the county office to turn in a paper application or return it by mail,” says Khou Vue, SNAP outreach specialist at Second Harvest Heartland. “It will greatly benefit clients who don’t have a means of transportation and are in dire need of the services.” CAPSULES to page 6
KNOW the 10 SIGNS EARLY DETECTION MATTERS
1
Memory loss that disruptss daily life.
6
New problems with word wordss in speaking or writing.
2
Challenges in planning orr solving problems.
7
Misplacing things and losing lossing the ability to retrace steps. steps.
3
Difficulty completing familiar famiiliar tasks at home, at work orr at leisure.
8
Decreased or poor judgment. judgm ment.
9
Withdrawal from work or social activities.
4
Confusion with time or place. plaace.
5
Trouble understanding Trouble visual images and spatial relationships.
10
Changes in mood and personality.. personality
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MINNESOTA PHYSICIAN
5
C APSULES Capsules from page 5
Mayo, Medica Agreement Allows Increased Coverage Mayo Clinic and Medica have announced a new agreement that will allow residents from 22 counties in southern Minnesota to purchase individual and family health plans. Medica already had an arrangement with Mayo Clinic that allowed those on employerbased health plans in-network coverage at Mayo facilities. The new arrangement will allow the growing individual market segment to purchase Medica products that feature Mayo providers in their networks. Medica enrollees may be seen at any Mayo Health System facility and the Mayo Clinic campus in Rochester. “This agreement with Medica gives southern Minnesota residents in these 22 counties access to a new competitive health-care coverage option,” says John Noseworthy, MD, Mayo Clinic president and CEO. “We wel-
come the opportunity to serve Medica members in this region of the state.” Officials with the two organizations note that the new arrangement is an incentivebased system that will reimburse Mayo Clinic providers based on how well the system manages the population’s health overall. “We know that the health care system needs to improve the way care is delivered and the way it is paid,” says David Tilford, Medica president and CEO. “This arrangement with Mayo Clinic provides the impetus for change through its focus on more efficient and effective delivery of care and a better understanding of the true costs of care. It takes on the fundamental issues facing the health care industry today: how to improve quality and patient experience while reducing cost.” Medica officials say there are currently 5,000 to 10,000 Medica enrollees in southeastern Minnesota. With the expanding market for individual products, the company expects substantial growth in the number of
enrollees in that area, they add. Dannette Coleman, Medica vice president for individual and family business, claims the new health insurance products for individuals will be very affordable when compared to similar products on the market.
Planned Parenthood Praises Defeat of Measure 3 Planned Parenthood of Minnesota, North Dakota, South Dakota was one of the groups cheering the recent defeat in North Dakota of a constitutional amendment regarding religious liberty. “Measure 3” would have given individuals a constitutional right to follow their religious beliefs regardless of law or regulation, unless government could provide a compelling interest for their compliance. The measure was defeated by a 64 percent to 36 percent margin. The amendment came at a time when some individuals and organizations have cited reli-
gious beliefs as a reason for neither distributing nor providing health insurance coverage for birth control pills or procedures. Opponents of the amendment argue that the measure was unnecessary and could have unintended consequences. In a statement, Sarah Stoesz, president of the Planned Parenthood Minnesota, North Dakota, South Dakota Action Fund, hailed the vote. “Tonight, North Dakotans—with a strong and clear ‘No’ vote—affirmed that religious liberty is securely protected in the U.S. Constitution. Measure 3 was divisive, unnecessary, and could have had dangerous consequences. Tonight’s vote protects state laws against child abuse or neglect; laws against domestic violence; laws that affect access to health care, including birth control; and laws that ensure equal opportunity in the workplace.” Supporters of the measure noted that they had raised awareness of the issue and said they would continue to work for the protection of religious freedom.
Supporting Our Patients. Supporting Our Partners. Supporting You. In 2008, Tanzanian missionaries brought little Zawadi Rajabu to the U.S. to seek treatment for her two severely clubbed feet. A physician referred Zawadi to Dr. Mark T. Dahl of St. Croix Orthopaedics. Using the Ilizarov Method, Dr. Dahl surgically changed the course of Zawadi’s feet and her life. Dr. David Palmer and Russ McGill, OPA-C, recently traveled to Tanzania on another of their frequent medical missionary trips. They dedicated an entire day to checking in on their partner’s patient. To their delight, they were greeted by 6-year-old Zawadi her face aglow, her healed feet dancing toward them.
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MINNESOTA PHYSICIAN
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MEDICUS Three psychiatrists from Minnesota were among 17 nationwide honored by the National Alliance of Mental Illness (NAMI) at its annual conference in Philadelphia. The annual Exemplary Psychiatrist Awards recognize psychiatrists who go the extra mile in providing care, reducing the stigma surrounding mental illness, and working in their communities to provide public education and advocacy. The three Minnesotans selected for the award were Ivan Sletten, MD, from Stillwater; Scott Crow, MD, from Minneapolis (University of Minnesota Medical School, Department of Psychiatry); and David Einzig, MD, from St. Paul (Children’s Physician Network). The MetLife Foundation recently named Clifford R. Jack Jr., MD, the recipient of a 2012 Award for Medical Research in Alzheimer’s Disease. Jack is a professor of radiology and the Alexander Family Professor of Alzheimer’s Disease Research at Mayo Clinic, Rochester. Jack, who has developed and applied imaging methodologies to determine and track the stages of Alzheimer’s disease, was honored for his work as an innovator in clinical studies of brain structure in the disease. Jack also recently accepted the 2012 Gold Medal Award from the International Society for Magnetic Resonance in Medicine in recognition of his major research contributions to the field of magnetic resonance. Min Hyung Kim, MD, an internal medicine specialist, has joined the ACMC–Marshall clinic. She graduated from the Sungkyunkwan University School of Medicine, Seoul, Korea, and recently completed her residency at Englewood Hospital in Min Hyung Kim, MD Englewood, N.J. The Minnesota Hospital Association (MHA) recently honored two physicians at its annual awards ceremony. Terry Pladson, MD, received the Stephen Rogness Distinguished ServTerry Pladson, MD ice Award. Pladson, who is president and CEO of CentraCare Health System, St. Cloud, has worked in health care for more than three decades. In addition to recognizing his stewardship of CentraCare, the award cited his support for the nursing program at the College of St. Benedict, St. Joseph, Minn., and for the development of the St. Cloud State University Nursing Program. Steve Mulder, MD, received the Patient Safety Leadership Award. Mulder is president and CEO of Hutchinson Area Health Care and has been inSteve Mulder, MD volved in patient safety initiatives both within that organization and on a statewide level. He is the immediate past chair of the MHA’s Patient Safety Committee and also serves on MHA’s Physician Leadership Council and its Registry Advisory Council. The Minnesota Psychiatric Society (MPS) recently announced its annual awards. Gloria Segal Medical Student Awards went to Nisha Fernandes, MD, Chaitanya Pabbati, MD, and Julie Shekunov, MD. The awards are presented annually to fourth-year medical students who demonstrate excellence in the care of psychiatric Elizabeth Reeve, MD patients, show outstanding performance during pre-clinical and clinical rotations in psychiatry, and high enthusiasm for the profession of psychiatry. Elizabeth Reeve, MD, a HealthPartners physician at Regions Hospital, was named 2012 Psychiatrist of the Year. The 2012 Distinguished Service Award went to Michael Farnsworth, MD, of the Blue Earth Health System in Mankato. George Dawson, MD, a staff psychiatrist at Hazelden Foundation in Center City, received the MPS Presidential Service Award. The 2012 Paul Wellstone Advocacy Award, named in honor of the late Minnesota senator, went to the Marty and Gloria Segal family.
MINNESOTAHEALTH HEALTH CARE ABLE MINNESOTA CAREROUNDT ROUNDTABLE
T H I R T Y- E I G H T H
SESSION
Background and Focus The recent Supreme Court ruling on the Affordable Care Act clears the way for implementation of Health Insurance Exchanges. States have the option of creating their own exchange or joining one created by the federal government by January 2014. A Health Insurance Exchange would provide consumers a place to compare and shop for health insurance coverage. In Minnesota this idea was first proposed as part of the Assuring they are meaningful Pawlenty administration’s health care reform task force, Thursday, November 1, 2012 and Gov. Dayton is a strong 1:00 – 4:00 PM • Duluth Room supporter of creating a stateDowntown Mpls. Hilton and Towers run program. Though simple and compelling at first brush, creating a consumer-accessible, “apples to apples” website for comparing health insurance costs is challenging and very complex.
Health Insurance Exchanges:
Objectives We will define what a health care insurance exchange is and, considering the detailed and proprietary design of health insurance coverage, how it can be meaningful. Health insurance policies contain terms like “medically necessary,” “investigative,” “cosmetic,” “not medically necessary” and “contract/benefit exclusion”—all terms that are defined differently by different insurers. This alone makes it virtually impossible for anyone to compare plans effectively. Further, networks of providers vary, depending on whether you choose the “bronze,” “silver,” “gold,” or “platinum” option within a given insurer, as will access to hospital-based facilities, DME providers, and ancillary services. Throw in features like “deductibles,” “co-insurance,” “maximum out-of-pocket expenses,” “formulary design” and “covered preventive services,” and you have a bewildering mathematical matrix. We will offer suggestions as to how an insurance exchange can address these issues and provide a meaningful, consumer-friendly comparison service.
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JULY 2012
MINNESOTA PHYSICIAN
7
I N TE R VI E W
Medical education at a tipping point ■ As dean of the Medical School at the U of M,
what are some of your most important duties? There are three really important components. We have a responsibility to train and educate the next generation of practicing physicians. We also have a responsibility to develop new science and new treatments. And lastly, as part of both of those, we provide care. The Dean of the Medical School office is a place where those three things are organized. We have to be the place that thinks about not only how do you get it done today, but what is it going to look like five years from now. Aaron Friedman, MD U of M Medical School Aaron Friedman, MD, has been vice president for health sciences at the University of Minnesota and dean of the University of Minnesota Medical School since January 2011. Prior to leading the medical school, Friedman was the head of the university’s Department of Pediatrics. Friedman also served as pediatricianin-chief at the University of Minnesota Amplatz Children’s Hospital. Before coming to the U of M in 2008, he led pediatric departments at Brown Medical School in Rhode Island and the University of Wisconsin-Madison. Friedman is a member of the board of directors of the American Board of Pediatrics, serving as chair in 2008, and is active in the American Academy of Pediatrics.
■ The Minnesota Legislature has cut funding
for the Medical Education and Research Cost (MERC) program. How is that affecting medical education programs in Minnesota?
■ Every medical school has controversies. What is
I think that the impact is just now being understood; because of the nature of the way the program worked, the changes are really coming to I think we need to be reasonably analytical—so it bear this calendar year. I think this is a serious does help not only to understand the history but problem. The reason I say that is that we are a to understand the agendas. Controversy, as I see it, state that relies on producing a lot of our health occurs because there is a disagreement about the care workforce ourselves. If we look at the physigoals and not just the means. There really is a cians who are here in the state, the pharmacists basic and, I would say, principled difference who are in the state, dentists—those are all people between what the university feels is its responsibilwho we primarily train [at the U of M]. ity and what some citizens feel the state should be The MERC funding was engaged in. I think that is a very, very important in allowfundamental difference. We are a state that ing trainees to spend time in ■ The U of M not only does across the state. relies on producing a communities medical research, but partMERC funds really were used ners with companies bringlot of our health care to offset costs that both the students and the training sites ing therapies to market. workforce ourselves. had during a training period. What ethical issues arise We slashed them in half, not to from these partnerships? mention the MERC funds that I think that one of the issues that the university has were provided directly to activities inside the Twin had, and one that the vice president for research at Cities, which were completely eliminated. the university has been working diligently on, is The cuts that we have experienced have been the issue of contractual relationships. These are transferred to those communities. We have already things like intellectual property, understanding been told, “We will not take your trainees.” This what happens to discoveries when discoveries go to has been a hard thing for them to tell us, because market and are quite successful, how the university many of the communities feel that they have an shares in those, and so forth. opportunity to show themselves off to trainees— These issues have really taken up an enormous those are the people who will come back and work amount of time. The university now is looking at in those communities. We have to understand that streamlining the approach and making it easier we are not going to fill that in by getting people for our faculty and others to work together, to be from someplace else in the United States. I think it able to move things through the system in a more is a big, big problem, and I personally think that timely fashion, and, frankly, to be more user we as a health care workforce have to make this friendly across the board. Now, the reason to think abundantly clear to our legislature and to our govabout that is not just because it would be nice to ernor. have more of these arrangements. It is because at your philosophy for dealing with them?
the end of the day, what the people who are working on this are most interested in is bringing improvements to the marketplace. That is why the medical device companies for many, many years were most successful here in the United States. ■ We have had some big successes come out of
the U of M. Exactly. However, I think we have to be careful because we are losing that edge as we tie ourselves up in these contractual knots. It is an issue. We have to be careful about the conflicts of interest;
8
we have to be sure that what we are bringing to market is actually safe for patients. At the same time, we have to recognize that we also have to be as effective and as efficient as possible in making those things happen. This is an issue across the nation and involves the FDA and other programs, because we are all concerned that we are not really being as effective as we can be.
MINNESOTA PHYSICIAN JULY 2012
■ Health care reforms continue on both the state
and federal level. What effect are such reforms having on the U of M’s mission to educate physicians? Right now we have not made any sort of significant change. We have been doing planning, but there are just too many balls in the air to be firm about what change we will need to make. I think that health care financing of the reform is going to have a couple of interesting impacts on training, assuming they go through. I think some
of these may occur even if something significant happens to the Affordable Care Act. First of all, one of the things that we are hearing very plainly from provider groups and so forth is that nurses, doctors, pharmacists have to be better able to work in teams than they are now. We are about to engage in what I think will be a very interesting conversation with providers in the Twin Cities area about the notion that this is not about just paying a doctor or just paying a pharmacist; this is paying a team to take care of a patient population. Another is what our workforce is going to look like—what would actually change in terms of the ratio of primary care to specialty care and so forth. Lastly, Twin Cities Public Television is doing a series right now on Honoring Choices. End-of-life care is a huge component of our overall medical bill. I think this sort of larger cultural conversation about areas where medical care becomes very expensive is important. We not only must have a medical conversation, but a community conversation about how we do this and how we do it differently, if we think we are not doing well now. ■There have also been reforms to how
long residents and medical students can be on-shift as part of their training. Can you comment on whether that has had
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the desired affect of reducing medical errors? That is a really interesting question. My understanding is that there is now a small amount of information that is trying to examine this question specifically, and has not demonstrated much impact in reduction of hours, as far as its impact on medical errors. We made an assumption that if people spent less time on call, they would make fewer errors, based on the notion in other professions that this is when you start seeing an increase in mistakes. The interesting question there is the change was made on the basis of these other professions. So far, I think the preliminary data do not suggest the change has resulted in any kind of significant decrease in medical errors. That may be because a lot of the errors do not have to do with fatigue, but [rather] they have to do with other things like handoffs. â– So when one provider is handing off a
patient to another provider, there might be communication problems or something forgotten? Exactly. That is an interesting point. One of the things that may have happened inadvertently is we decreased the number of hours that an individual would spend on shift but increased the number of handoffs. Maybe—
and this has not been demonstrated—we have not seen much of a change because these changes have offset each other. ■Newly minted doctors emerge with
staggering debt; however, that is only a fraction of the actual cost to train them. How can we continue to produce competent physicians? I think this is an overall education question, which is not just about medical school but also about higher education in general. If we are really going to have the programming that we have had in the past, or even something approaching it—do we really believe that a system that just turns over more and more of the cost to the student as tuition? Is that really viable long term? I think we may be at a tipping point. We are certainly at that transition point where a generation ago there was a more community-based argument about common good and about the need to have this education and the willingness of the population as a whole to be part of the solution. Today there is a sense that these are really individual decisions and individuals should bear the cost. I do not believe in the long term that it is in our interest, especially in places like Minnesota, to make this solely an individual burden. I don’t think this is a viable longterm approach.
%AR .OSE 4HROAT 3PECIALTY#ARE TAKES PLEASURE IN ANNOUNCING
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Nursing from cover nursing has given way to more of a partnership model that includes several types of clinicians on a care team. While this change may result in some overlap or blurring of boundaries between the two professions, a distinction that helps differentiate them is that physicians are responsible for treating illness and disease, while nurses are responsible for health promotion and for facilitating the most effective human response to the disease and treatment. Many factors are driving this evolution in the role of nurses and their relationship with physicians: • System restructuring that has changed settings of care from mostly hospital units to ambulatory centers and even homes • Patients’ increased use of the Internet • Emphasis on preventive care and care of chronic disease • Demographic changes, e.g., longer life span resulting in a growing population of fragile elderly
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• Increased complexity of care delivery, requiring larger care teams and care coordination • Cost of health care • Payment models based on patient satisfaction rather than traditional fee-for-service or DRGs. These factors have contributed to a greater breadth of nursing services, as evidenced by role expansion in the areas of care coordination, informatics, specialty nursing, patient advocacy, and nursing research (particularly in health management). And it may happen that nurses will assume ever more independent decision-making responsibility in parallel with ongoing efforts to deliver medical care more efficiently. Statistics released in January 2012 by the Centers for Disease Control and Prevention show that nationally, the percentage of hospital outpatient department visits during which a patient saw an APRN or
MINNESOTA PHYSICIAN JULY 2012
The traditional “handmaiden” concept of nursing has given way to more of a partnership model that includes several types of clinicians on a care team. physician assistant increased significantly from 1999 to 2009, the most recent decade for which such data are available. Changes in nursing education
Expansion in nursing roles has been accompanied by changes in nursing education. Settings of education, curriculum content, and length and levels of education have all changed over the past few decades. Until the 1960s, nursing education was in a hospitalbased program that typically prepared nurses to work in hospitals implementing doctors’ orders: checking and recording patient temperatures, bringing medication to the bedside, handing a surgeon the requested tool during surgery, and so on. That began to change in the 1970s when nursing education shifted from hospital-based programs to academic settings. Now, advanced academic degrees prepare nurses to assume roles involving greater responsibility and an increasing degree of independent decision-making. These degrees include a PhD in nursing, which requires postgraduate academic study and prepares a nurse to conduct research and to teach. Other graduate programs educate clinical nurse specialists, nurse midwives, and nurse practitioners, to name a few “advanced practice” roles. For example: • Clinical nurse specialists typically work with patients who have multiple complex diagnoses, as advisers and consultants to caregivers in various settings. • Patient advocate/coach roles are increasing as patients become more involved in their own care decisions. This often involves assessing the patient’s level of knowledge and involvement, making sure the patient’s information is correct,
and guiding patients through the process of owning their health. • Nurse practitioners provide primary care involving diagnosis and treatment of individuals with long-term chronic disease, or individuals with minor symptoms. • Health coaches are often advanced practice nurses who work in corporations, community clinics, and insurance companies to proactively improve health within a specific population. • Many nurse practitioners and nurse midwives work in partnership with physicians in office practices, handling the situations they are prepared to handle, and thus freeing the physician to handle more complex problems. A recent development in graduate education programs among all clinical professions is the doctorate level programs. As in pharmacy, physical therapy, and other medical professions, nurses are now being prepared for advanced practice in DNP (doctor of nursing practice) programs, earning a doctor of nursing degree. This is now the highest level of preparation for individuals in advanced nursing practice. Nurses and doctors: evolving relationships
This brings us to one of the more dramatic role changes medical professionals are currently experiencing: the traditional physician/nurse dynamic. Relationships between these two key members of the health care team have a long and interesting history. As doctors and nurses have worked side by side for decades, their roles have evolved from a dominant-subordinate model to the current, more collaborative partnership model, especially in ICUs and other highly complex care situations.
Hospital-based internists and experienced bedside nurses are reporting a strong need for better communication and collaboration. System redesign recognizes the need for improved coordination of patient care as organizational complexity becomes more challenging. Fortunately, this recognition has stimulated some innovative programs in education as well as in practice, several of which are described below. Academic courses. Many academic health centers are designing and implementing required courses in interdisciplinary communication that will extend throughout the students’ program. The University of Minnesota has developed a program called Foundations for Interprofessional Communication and Collaboration (www. ahc.umn.edu/1health/phase1/ fipcc/home.html). In the fall semester of 2011, 850 students were divided into 72 groups of 12 and met in various classrooms for six 2.5-hour sessions on Friday afternoons, facilitated by 72 volunteer health professionals from a variety of professions. The students were from medicine, nursing, dentistry, pharmacy, veterinary medicine, and lab sciences. The class was the first part of a three-phase program designed to: • Increase students’ awareness of various disciplines • Immerse students in interprofessional collaboration and teamwork • Help students master advanced skills in interprofessional collaboration and teamwork The first phase of the program provided structured opportunities to identify relationship issues, to examine stereotypical beliefs, and to see the value of healthy teamwork. One particularly interesting session involved developing an understanding of similarities and differences among the various codes of ethics of each profession. Medical professional conferences. Another opportunity for developing collaboration pathways among professionals is through conferences. Each of
four Ways of Knowing conferences (www.lifesciencefoun dation.org/prwaysconversations. html), co-sponsored by the University of Minnesota Center for Spirituality & Healing and the Life Science Foundation, has attracted 100–180 attendees
“The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the neces-
Gallup poll findings about the nursing profession. Because whatever the setting and role in which nurses function, nurses have the knowledge, skill, position, and ability to interact with patients in a way that alleviates pain, increases comfort, and
Expansion in nursing roles has been accompanied by changes in nursing education. from many disciplines. Outside speakers presented research and experiences on a wide variety of topics common to all traditional and non-traditional health providers and practitioners. In addition, each daylong session included “table talk� as an important element of the program. Individuals from different disciplines frequently commented on the value of interacting with each other around topics of common interest, in a venue other than the workplace. Nursing salons. For several years, nurses have been meeting in homes using a semi-structured conversational format to informally discuss issues regarding their nursing practice or profession issues. Attendees consider these “nursing salon� conversations very helpful in processing some of the complex issues that cause nurses to experience incredible stress; they sometimes even use the word “healing� to describe the outcome of the salon sessions. Word-of-mouth marketing is credited with expanding this idea to many cities and states, and professional journals periodically carry positive articles about this development. There has been discussion about starting physician-nurse conversation sessions, and plans are underway to start one this fall. Information about local salons is available on my blog, www. mariesnursingsalon .wordpress.com/.
sary strength will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible.� While nursing roles have evolved since Henderson’s time, what isn’t changing is the reality of patient vulnerability. Whenever our health is involved, and especially when we are diagnosed with a condition requiring treatment, the universal human response is to feel vulnerable. This vulnerability is, in my opinion, the true explanation of the
decreases the feeling of vulnerability. And that is the privilege of nursing. Marie Manthey, MNA, FRCN, FAAN, PhD (hon.), received the first honorary PhD awarded by the University of Minnesota School of Nursing, given in recognition of her contributions to the advancement of the nursing field. She is one of only four U.S. nurses to have been elected a member of the United Kingdom’s Royal College of Nursing, and is a member of the American Academy of Nurses. She is the founder of Creative Health Care Management, a Minneapolis consulting firm specializing in the organization and delivery of health care.
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What’s next?
Pioneering nursing theorist Virginia Henderson (1897–1996) offered this classic definition of nursing:
&ROM THE #OURTROOM TO &R O M T H E #O U R T R O O M T O TTHE #APITOL ¸ HE #APITOL ¸ JULY 2012
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Readmissions from cover The campaign was launched in July 2011 under the leadership of three operating partners: the Institute for Clinical Systems Improvement (ICSI), a quality improvement organization that brings diverse stakeholders together to tackle complex health care issues; the Minnesota Hospital Association (MHA), which represents the state’s hospitals; and Stratis Health, an independent nonprofit that leads collaboration and innovation in health care quality and safety, and serves as the Medicare quality improvement organization for Minnesota. Supporting partners are the Minnesota Medical Association, MN Community Measurement, and VHA Upper Midwest. The operating partners set aggressive goals for the RARE Campaign, based on the “Triple Aim” of optimizing health, care, and costs: • Population health: Prevent 4,000 avoidable readmissions within 30 days of discharge and reduce by 20 percent the overall readmissions rate from
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the 2009 base by Dec. 31, 2012. • Care experience: Recapture 16,000 nights of patients’ sleep in their own beds (based on an average four-day hospital stay X 4,000 avoided readmissions); improve 5 percent on the Hospital Consumer Assessment of Healthcare Providers and Systems survey questions on discharge. • Affordability of care: Save an estimated $30 million for commercially insured patients, with additional savings for Medicare patients (based on per-readmission costs of $8,000 to $13,000). To date, 80 hospitals, accounting for more than 80 percent of the state’s readmissions, are participating in the campaign along with 70 community partners that are committed to helping prevent avoidable readmissions across the continuum of care. To join the campaign, hospitals agreed to reduce their avoidable readmissions by 20 percent based on their Potentially Preventable Readmissions (PPR) 2009 benchmark figures provided by the MHA.
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Contributors to avoidable readmissions
Each participating hospital conducted an organizational assessment to identify drivers of its readmissions and to help the hospital select the interventions that would accelerate improvement. Based on all the organizational assessments submitted, the main gaps can be grouped into the following areas: Discharge planning: This area has the most opportunity for improvement, with hospitals indicating that tools, templates, and technical assistance would help them improve all aspects of the discharge process. Some of the most pressing needs are for standardized discharge summaries, interagency referrals, and improved communication with primary clinics. Assessment and measurement: Ranking second as a barrier is assessment and measurement, especially how data is measured, tracked, and analyzed so it can be used effectively to identify improvement opportunities. Help also is needed to develop effective tools and scorecards, particularly in the medication reconciliation process. Patient education: Patient education is an area ripe for improvement, including development of standardized materials written in plain language to facilitate patient teaching early in their hospitalization. Other focus areas are engaging patients at their literacy level, using teach-back techniques, better end-of-life conversations, and a simpler teaching system for medication management. Staff education: Many participating hospitals advocate training staff to use teach-back and train-the-trainer techniques for maximum effectiveness and efficiency. Additional needs include education for long-term care and skilled nursing facility staff. IT/Electronic health records: Hospitals are dealing with challenges related to electronic health records (EHRs), including multiple systems that don’t “talk” to each other and output that is not easily understood and patient-friendly.
Collaboration and bestpractice sharing: The assessments identified a pressing need for better collaboration across care settings and disciplines, more opportunities for best practice sharing, and finding ways to involve family members and caregivers in support of the patient. The RARE operating partners provide resource consultants, learning opportunities and tools in the following five areas to help hospitals address their gaps: • Comprehensive discharge planning • Medication management • Patient and family engagement • Transition care support • Transition communications Hospitals also can participate in three learning collaboratives to help address the five key areas: • Care Transition Intervention, provided by Eric Coleman, MD, MPH, of the University of Colorado, and his team • Project RED (Re-Engineered Discharge), developed by Boston University Medical Center. • Safe Transitions, piloted in 2011 by 13 Minnesota hospitals under the direction and support of the MHA; 27 hospitals are now participating. These collaboratives offer a structured improvement process and an array of activities with recognized experts to help staff from different hospitals interact and learn from each other. Acting on assessments
Steve Bergeson, MD, medical director of quality for Allina Health, found that participating in the RARE Campaign has expanded Allina’s readmissions focus beyond patients with the three conditions identified by CMS as top causes of readmissions: heart failure, acute myocardial infarction, and pneumonia. “The PPR methodology helped us learn about additional populations experiencing avoidable readmissions including patients younger than the Medicare population, and patients with specific medical and surgical diagnoses,” Bergeson noted. “We were
surprised at how quickly some of these patients return to our hospitals. The RARE PPR data has helped individual Allina hospitals to focus on the reasons patients are returning.” Completing the organizational assessment helped Allina Health identify a new infrastructure to support the full range of performance improvement (PI) required to analyze and interpret data and facilitate improvement teams. The interdisciplinary PI teams are designing new care processes to ensure that transitions are repeatable and reliable for all Allina patients, including: Discharge disposition: Create standardized clinical assessment tools, documented in the EHR, to plan the transition of care after hospitalization. The discharge package: Redesign the package of written instructions given to the patient at discharge with concise and relevant information to promote patient self-management following hospitalization. Provider transitions: Create consistent and reliable communication between Allina’s inpatient and all outpatient providers at the time of discharge to ensure the care plan started in the hospital is continued in the post-hospitalization setting. Readmission predictive model: Create a predictive model to help clinicians identify patients who could benefit from a transition conference about resources available for the next level of care. Allina realized it needed to empower its patients to manage their own health care. It chose to participate in the Care Transitions Intervention (CTI) collaborative because CTI focuses on skills transfer and helping patients achieve their personal goals by taking charge of their own health care. They implemented CTI as a pilot program on a targeted population based on past readmissions in one rural and one metro Allina hospital. Allina has discovered the following challenges as it pilots CTI: • Patients may agree while in the hospital to participate in the program, but by the time they get home they’ve changed
their mind. CTI’s consultants continue to work with the Allina coaches on ways to better engage patients while they are still in the hospital. • It is important to contact the patient as soon as possible after discharge to schedule the in-home visit. Allina is using its EHR systems to ensure the coach is notified when an eligible patient is discharged. • It is common for care transition coaches to have other responsibilities, as they do at Allina. As the pilot moves forward, Allina plans to have its coaches spend more of their time in the CTI intervention. Bergeson noted that they’re seeing great collaboration and have a coaching team that is very engaged and believes strongly in the CTI program. “The plan is to show a steady gain in number of patients coached, and the decision has been made to extend the pilot,” he added. At the other end of the spectrum is Glencoe Medical Clinic. Continuity of care is simplified somewhat because the small critical access hospital has a clinic and long-term care facility all located at one site. Glencoe doesn’t admit many critically ill patients, which reduces the possibility of potential readmissions, and its readmission rate was low even before joining the RARE campaign. But that doesn’t mean there isn’t room for improvement, according to internist Bryan Fritsch, DO, Glencoe’s physician champion for the campaign. “The most surprising discovery to come out of our assessment was how fractured, nonstandardized, and varying our discharge process is from patient to patient,” Fritsch said. “Each physician seemed to have their own way of doing things, and that led to confusion among the nurses about what is expected.” Glencoe chose Project RED to streamline and improve its medication reconciliation process, improve patient education throughout the hospital stay, and ensure better follow-up at discharge. This collaborative supports hospital teams as they implement strategies to improve
patient safety and reduce hospital readmissions by focusing on processes related to discharge planning. “We found things that we can improve to help us cut down on follow-up phone calls from patients, medication confusion, and gaps in lab follow-up,” Fritsch commented. Fritsch noted that it was initially challenging to implement Project RED. “There has been a lot of work by the nurses and also by the pharmacists, and it wasn’t easy to get everyone together for rounds, but it has been worth it. Now all the key players know the plan for the patient, and that can only be a good thing for everyone involved.” Early results and going forward
Work begun before the launch of RARE and six months since has prevented 1,915 avoidable readmissions through 2011. Hospitals receive their individual PPR data quarterly so they can monitor progress, and the operating partners can determine how best to help individual hospitals progress toward their goals.
As the campaign continues, enthusiasm, and commitment remain very high. For example, nearly 200 representatives from participating hospitals and community partners recently gathered for a day of learning and sharing best practices. Many participating hospitals and community partners note the value of the operating partners combining efforts, helping them focus on five key areas known to prevent avoidable readmissions, and providing resource consultants and programs that accelerated progress. All the groups participating in this statewide, collaborative effort are looking forward to achieving the goal of ensuring Minnesotans spend 16,000 more nights in their own beds. Kathy Cummings, RN, is project manager at the Institute for Clinical Systems Improvement. Tania Daniels, PT, MBA, is vice president of patient safety at the Minnesota Hospital Association. Janelle Shearer, MA, BSN, RN, is program manager at Stratis Health.
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M E D I C I N E A N D TH E L AW
T
he 2012 legislative session brought a welcome change in the health care world as the focus shifted away from budget-cutting measures and left physicians and other health providers unharmed. The state’s first budget surplus since 2007, coupled with a general unease over redistricting and the fall elections, made for a very quiet legislative session on a number of issues including health care. The political posturing started before the legislative session got underway, following the release in early December of the November budget forecast. Though many had expected the state to be in the red with a $500 million deficit, the budget forecast showed a surplus of $876 million. The real budget work began in late February, after the release of the revised budget forecast and the release of the new legislative maps. The February forecast brought more good news, showing an additional $323 million surplus on top of the earlier surplus of $876 million.
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A quiet session Health care reform still an open question By H. Theodore Grindal, JD, and Nate Mussell, JD
However, the nearly $1.3 billion surplus disappeared quickly, having been required to refill the state’s budget reserve account and the state’s cash flow account. After those dollars were spent, there was little money left over to even think about repairing some of the difficult health care cuts from 2011. Any remaining dollars after restoring the budget reserves and cash flow account went to begin repaying the school-aid payment shift that had been used as a budget-balancing mechanism the last couple of legislative sessions. At this point, no additional surplus is forecasted for the next biennium; instead, the forecast in February projected a $1.1 billion deficit. However, as the tax receipts trickle in over the summer months, and if the economy
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recovers somewhat, this budget number could move in a more positive direction heading into the 2013 session. HHS Omnibus Budget Bill
The added benefit of a budget surplus meant there was no need to institute significant cuts in health and human services (HHS), as had been the case going back multiple legislative sessions. The 2012 HHS Omnibus Budget Bill proved to be relatively noncontroversial and moved through the process with relative ease this session. The bill budgeted about $23 million for health and human services, much of which came from a payback by the state’s HMOs. Going back to the 2011 session, Gov. Dayton had announced several changes to how the state was operating its Prepaid Medical Assistance Program (PMAP), particularly as it related to price transparency in the program. One of the changes required that for a oneyear period, any profits accrued above 1 percent by the HMOs in PMAP had to be returned to the state. All told, the state received a total payback of $73 million: $31 million from Medica, $25 million from Health Partners, $9 million from Blue Cross, and $8 million from UCare. After returning just over half the funds to the federal government and allocating a portion to the Health Care Access Fund, the Legislature was left with around $27 million. In the end, only about $11 million of those funds was allocated towards the HHS budget. House and Senate leadership allocated the remaining funds towards a tax-relief package, which the governor ultimately vetoed twice. Rep. Jim Abeler (R–Anoka), chairman of the Health and Human Services Finance Committee, and Sen. David Hann (R–Eden Prairie), chairman of the Senate Health and
Human Service Policy and Finance Committee, used the monies in their budget to restore a few of the cuts made in the 2011 budget that had been priorities of the governor’s supplemental budget. The restored money included $5.9 million for a delay in the cut for personal care attendants who were relatives of the patient, and $4.6 million for restoration of cancer and dialysis treatment coverage for Emergency Medical Assistance patients. However, funding cuts from the 2011 session to the Medical Education and Research Costs (MERC) program were not restored; early in the 2012 session, the governor had identified restoring money to that program as a priority. The omnibus bill also contained a few health-care policy items worth noting, most of which proved noncontroversial or had been worked out during the conference committee. These included legislative authority to conduct audits of PMAP in conjunction with the legislative auditor; a study of the effectiveness of managed care in public programs; a study of for-profit HMOs in Minnesota; a study of the Emergency Medical Assistance program; and a study of privacy in patient medical records. Medicaid investigation of PMAP funds
One issue that garnered increasing attention throughout the session centered on the state’s Prepaid Medical Assistance Program and questions about the more than $3 billion spent annually on the program. Over the past two legislative sessions, questions about the PMAP program have slowly boiled to the surface. Previous legislatures had brought forward legislation to create risk pools and legislation to eliminate health plan management of PMAP entirely and move to a direct-contracting arrangement, as a couple of other states have done. This session, the issue surfaced in a bill calling for independent thirdparty audits of the health plans and the rate-setting in PMAP done by the Department of Human Services (DHS).
A couple of months into the session, it came to light through media reports and during testimony by Human Services Commissioner Lucinda Jesson that the federal government was reportedly investigating the ratesetting process the state had previously used in the PMAP program. There appeared to be questions about whether the state had intentionally inflated the rates in the Medical Assistance program (which receives federal matching funds) in order to make up for losses being sustained in the General Assistance Medical Care (GAMC) program, which was funded through state dollars only. Following the coverage of the issue on the state level, congressional leaders in Washington, D.C., began to look further into some of the unanswered questions as well, going as far as holding a hearing in late April at which Commissioner Jesson was requested to testify. While little more has come to light since mid-session, this issue is unlikely to disappear anytime soon and will continue to bear watching over the coming months, to see whether any adverse action will be taken against the state and whether anything emerges from the congressional oversight that will have an impact on the state’s Medical Assistance program going forward. Physician oversight and Board of Medical Practice
Another contentious issue that arose this session, in large part due to some press coverage, dealt with the question of whether the Board of Medical Practice (BMP) was properly overseeing and disciplining physicians. In an interesting twist, this issue came before the legislative Sunset Advisory Commission largely as a result of their reviewing all state board activity over the interim months last fall. The question that went back and forth in half a dozen legislative committees dealt with whether a health care provider’s malpractice settlements should be posted on a public website. After considerable opposition
Unease about the current structure of the Provider Peer Grouping reporting eventually prompted the passage of legislation this session. from providers across the state, the malpractice language was stripped from the final bill, leaving only judgments, adverse privileging actions, and felony convictions to be posted on the BMP’s public website for notification for consumers. Provider Peer Grouping
Since its inception, the concept of provider peer grouping has come under heavy scrutiny from physicians, clinics, and hospitals. The Provider Peer Grouping (PPG) program was a major piece of the Health Care Reform bill passed by the 2008 Legislature. Many of the concerns raised about the program stem from questions about the effectiveness and accuracy of the reporting cost and quality data as a tool by which to measure providers. Last fall, hospitals around the state became the first set of providers to have their peer grouping data released. The release of the data to hospitals brought the concerns of the past two years to the forefront, as there were considerable questions about both the accuracy of the data and the ability of hospitals to review the data. In January, Health Commissioner Ed Ehlinger preemptively put the release of further provider data on hold until more accurate measures could be devised. Despite the delay, unease about the current structure of the PPG reporting eventually prompted the passage of legislation this session. The hospital and provider communities, in conjunction with the health plans and the Department of Health, put together a bill that made changes to the program. The bill creates an advisory committee that will be involved in selection of quality measures and other technical decisions and will make recommendations about how the data will be disseminated to the public. The bill
also extends the timeline on review of the data from 90 to 120 days. Health insurance exchange and the ACA
The biggest health care issue nationally got little attention locally this session. Outside of initial discussions in the House and Senate HHS committees on the activities of the Governor’s Health Insurance Exchange Task Force, the only legislative activity on the exchange occurred when Sen. Hann gave the insurance exchange bill a hearing in his committee late on a Monday evening—only to vote the bill down along party lines. Although relatively little was discussed in public, there was no doubt that many legislators were awaiting a final decision by the U.S. Supreme Court on the con-
stitutionality of the Accountable Care Act (ACA) before embracing some of the reforms in that bill. [Ed.’s note: The Supreme Court handed down its decision on June 28; see news item on page 6.] Thus, following a rather quiet session, much of what happens between now and the start of the 2013 Legislative session will be dictated by the Supreme Court’s decision. Gov. Dayton and his administration will continue to move forward with their task forces and broader health reform efforts. At this point, however, the questions of both the fall elections and the future of federal health care reform in Minnesota remain open. Depending on the answers to these questions, the 2013 legislative session could shape the health care environment in Minnesota for years to come. H. Theodore Grindal, JD, and Nate Mussell, JD, are with the Minneapolis law firm of Lockridge Grindal Nauen PLLP. They provide legal and government relations services to health care providers.
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ALZHEIMER’ S D ISEASE
A
lzheimer’s disease affects about 5.4 million people in the United States today, at an annual cost of $183 billion. The challenge to physicians and researchers is that without prevention, Alzheimer’s disease will affect three times as many people by 2050 and will be the most costly of all illnesses. Working partnerships between the medical and research communities are vital to the continued growth and advancement of Alzheimer’s research. At the N. Bud Grossman Center for Memory Research and Care at the University of Minnesota (www.memory.umn.edu), our aim is to translate our research findings into therapies that can stem the loss of memories and lives. The center combines clinical care, including research opportunities for patients and their families, with translational research while maintaining a strong focus on basic science, the foundation of our research.
Basic research: Laying the groundwork
Although memory loss is the cardinal symptom of Alzheimer’s, the pathophysiological mechanisms leading to cognitive deficits are poorly understood. It is difficult to address this problem in human studies and impossible in cultured cells. Therefore, animal models are needed to elucidate the molecular mechanisms leading to dementia. Beginning in the early 1990s, our research team focused on developing genetically engineered research mice that model the earliest, asymptomatic phase of the disease and on understanding how amyloid-β and tau proteins impair memory and cognition. In 1996 our team developed the Tg2576 mouse model, an Alzheimer’s disease–like mouse in which researchers could observe both memory loss and plaques. In the earliest, asymptomatic phase of Alzheimer’s, just as in the Tg2576 mice, there is memory loss but not the cell death that characterizes later stages of the disease.
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Uncovering clues to memory loss U of M center links dementia research with clinical application By Adine D. Stokes, Kirstin Stokes Smith, and Karen H. Ashe, MD, PhD Discovery and identification of a protein molecule that is a key player in the progress of Alzheimer’s disease, known as Aβ* (pronounced A-beta star), has produced promising findings. Aβ* is a specific protein molecule in the brain that is a soluble member of the class of Aβ proteins that show up
experiments have shown that neither the plaques nor the tangles, on their own, cause memory loss or neurodegeneration. We are now studying tau, the protein that ends up clumped into neurofibrillary tangles, to isolate which form of that class of protein is the cause of cell death during Alzheimer’s dis-
The pathophysiological mechanisms leading to cognitive deficits are poorly understood. Therefore, animal models are needed to elucidate the molecular mechanisms leading to dementia. clumped into amyloid plaques. These plaques, along with neurofibrillary tangles, are the two main hallmarks of Alzheimer’s disease. Our team isolated Aβ* as the memory-impairing agent in mice modeling Alzheimer’s disease by applying a method familiar from the study of infectious disease, Koch’s postulate: 1) Establish that the suspect organism is present in diseased, but not in healthy subjects, 2) Isolate and culture the pure organism. We purified Aβ* from our Tg2576 mouse model of Alzheimer’s disease, then injected it into the brains of healthy, young rats, who then demonstrated memory loss through their behavior; as the protein dissipated, memory function returned. This gives hope that eliminating Aβ* or blocking its effects may cure Alzheimer’s disease. Prior to this, conventional thinking was that the amyloid plaques and neurofibrillary tangles caused the memory loss and brain cell death found in Alzheimer’s disease. However,
MINNESOTA PHYSICIAN JULY 2012
ease. Pinning down what happens in the brain to cause Alzheimer’s disease provides hope for treatments to stop the disease during the earliest, asymptomatic phase of the disease. The Tg2576 mouse model of pathological aging and preclinical Alzheimer’s disease has been sent to more than 100 laboratories around the world and has been used to generate more than 500 publications. At least 200 of these publications have demonstrated the beneficial effects of various interventions, several of which are now being tested in humans with Alzheimer’s disease. Continuing research: Toward a vision of prevention
The key to winning the fight against Alzheimer’s disease is rooted in research focused on preventing rather than curing the disease. It’s been proven that once symptoms present themselves, irreversible brain damage already has occurred. Staving off the onset of Alzheimer’s is vital
to securing a future with fewer families and individuals affected by this disease and the legacy of related health problems for both those with the illness and those who care for them. The current challenge facing our research team—and the Alzheimer’s research and medical community at large—is transforming research findings into a workable human solution. A wide gap remains between a memory-impairing molecule in a mouse model and a prescription at a local pharmacy. We aim to bridge that gap. During the coming years, we hope to find new ways to use information gained from our studies in mice to test strategies to prevent Alzheimer’s disease in humans. To accomplish this, we have begun to collaborate across disciplines, as basic scientists, with neurologists, neuropsychologists, radiologists, epidemiologists, and health policy experts. This new interdisciplinary collaboration will promote significant advances in brain disease and will eventually lead to new methods to study, understand, and prevent this disease. At the heart of the N. Bud Grossman Center for Research and Care lies a unique opportunity to save the wisdom and memories of more than 10 million Americans. The medical and research community can contribute substantially to the eradication of Alzheimer’s disease by preventing illness in people who would otherwise develop this devastating form of dementia. Adine Stokes, LSW, is director of outreach and engagement for the N. Bud Grossman Center for Memory Research and Care at the University of Minnesota, Minneapolis. Kirstin Stokes Smith is a copywriter at Mobile Social WordCraft. Karen H. Ashe, MD, PhD, is the director of the N. Bud Grossman Center for Memory Research and Care. She is a professor in the University of Minnesota Medical School, where she holds the Edmund Wallace and Anne Marie Tulloch Chairs in Neurology and Neuroscience. Ashe was recognized by the Alzheimer's Association with a Lifetime Achievement Award in 2010 for her achievements in advancing Alzheimer’s research; in the same year, she was inducted into the Institute of Medicine.
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leep is an essential part of life. This should come as no surprise since humans spend about a third of their life in the state of sleep. However, it has only been over the past several decades that we as physicians are finally realizing how important sleep is. The first medical sleep centers opened in the 1970s. Sleep medicine only became a board-certified subspecialty through the American Board of Medical Specialties in 2007. Sleep influences almost all aspects of our health and society. Epidemiological data demonstrate increased mortality in patients who report on average either very short or very long sleep times. Acute sleep deprivation results in problems with concentration, increased accident risk, metabolic dysregulation including decreased leptin and increased ghrelin levels which have been proposed to result in weight gain and obesity. REM behavioral disorder, a disease in which patients act out their dreams, can be a precursor to the eventual development of neurodegenerative processes such as Parkinson's disease. Parasomnia behaviors are common and sleep walking defenses are now being used in the legal arena. The number of individuals who work the graveyard shift continues to increase with the demands of a global economy. Good, refreshing sleep, or lack thereof, is becoming more important than ever. Obstructive sleep apnea (OSA), a disorder in which patients intermittently pause while breathing during sleep, is probably the most recognized sleep disorder by physicians today. There is increasing evidence of serious health consequences of untreated OSA. OSA has been associated with the worsening of multiple diseases: glycemic control in diabetes is worse, ejection fraction in heart failure is lower, daytime blood pressures are increased, inflammatory cytokine levels are elevated, progression of atherosclerotic disease is accelerated, the incidence of stroke is higher, atrial fibrillation is more common, a number of coagulation factors are activated, and mortality rates from cancer are higher. Snoring, excessive daytime sleepiness, fatigue, insomnia, observed apneic episodes, and gasping arousal's are all symptoms of OSA; however, some patients complain of no symptoms at all -- especially if they have no bed partner. The gold standard treatment for OSA is noninvasive positive airway pressure ventilation, although other treatments exist such as mandibular advancement devices, positional therapies, certain surgeries, and nasal expiratory positive airway pressure devices. A common sleep complaint presented to many physicians is insomnia. Insomnia is reported in up to 26% of individuals monthly and is estimated to cost the US economy $63 billion annually. Insomnia is a disease that is quite complex and thus can be frustrating for many physicians and patients. In many patients, insomnia is strongly associated with psychiatric disease and in fact is one of the strongest predictors of relapse of depression. Long-standing insomnia typically has strong con-
Eric Hernandez, M.D., Ph.D. is a neurologist at the Noran Neurological Clinic and a board certified sleep specialist at the Noran Clinic Sleep Center.
ditioned components and maladaptive behavioral responses which propagate the disease making insomnia frequently refractory to medical treatment. To complicate matters, many medications and diseases can also cause insomnia. There are also sleep-related breathing disorders, sleep-related movement disorders, and circadian rhythm disorders which can all cause or masquerade as insomnia. Effective treatment for insomnia includes appropriate time in bed restrictions, stimulus control techniques, sleep hygiene counseling, possible screening for underlying sleep disorders, and lastly medication management. In fact, cognitive behavioral therapy for insomnia (a behavioral approach) is more effective than medications for insomnia in long-term studies. At the other end of the spectrum, excessive daytime sleepiness (EDS) is a cause of injury and poor quality of life. EDS is increasingly becoming a problem in society today. In fact, 4 out of 5 Americans consume caffeine to compensate for sleep deprivation and caffeine is the second most traded commodity in the world behind oil. EDS has been implicated in one out of every five motor vehicle accidents in the United States. It only takes 5 seconds to drive into oncoming traffic after falling asleep at the wheel. This is a serious enough issue that governmental regulatory agencies are beginning to screen individuals with commercial driver’s licenses for sleep disorders. Almost everyone who wakes up to an alarm clock is at least partially sleep deprived. Although the most common reason for EDS is sleep deprivation, sedating medications, sleep disordered breathing, nocturnal movement disorders, central nervous system hypersomnia disorders, and circadian rhythm disorders can also cause EDS. Appropriate treatment for EDS depends greatly on identifying the cause and may involve noninvasive positive airway pressure ventilation, stimulants, medication adjustment, sleep hygiene counseling, or circadian adjustment. The terms "night owl" and “early bird" are proof that society recognized circadian rhythm disorders long before the medical profession had names for
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them. One way to understand a circadian rhythm disorder is to picture your patient in a constant state of jetlag. Our circadian rhythm is genetically determined by the human periodicity and clock genes. Less recognized and quite possibly more prevalent in contemporary society is shift work sleep disorder in which individuals are working during their normal sleep period and are trying to sleep during times where they are normally awake. As expected, this can result in insomnia, hypersomnia, increased workplace error, worse quality of life and injury. There is mounting evidence that circadian rhythm disorders cause more than just insomnia and hypersomnia but are also related to other medical disorders. Experimental data indicates that a number of human metabolic pathways are strongly linked to our endogenous circadian clock. In contrast, some hormones are secreted only during certain stages of sleep. Circadian misalignment has been associated with diabetes and cardiovascular disease. Night shift workers who have worked more than 5 years have an increased risk of coronary heart disease. There is growing evidence that to stay healthy, people not only have to get a sufficient amount of restorative sleep but that they have to get it at the correct biologic time. Sleep is essential for good health and quality of life. Physicians need to be diligent about screening patients for sleep disorders since these disorders are 1) common, 2) associated with poor quality of life, 3) complicate a number of medical and psychiatric disorders, and 4) are treatable. Getting adequate amounts of good, restorative sleep is more than just simply putting a mask on a patient to help them breathe when they sleep. The Noran Neurological Clinic Sleep Center is more than just a sleep lab. We are an accredited sleep center staffed by fellowship trained, boardcertified sleep physicians and technicians. With locations in Minneapolis and Blaine, we are easily accessible to much of the twin cities’ metropolitan area. Here at Noran, we clinically evaluate patients and decide on the appropriate sleep testing needed which includes polysomnography, electroencephalography, multiple sleep latency testing, multiple wakefulness testing, actigraphy and imaging. We sit down with patients after testing and personally review the actual studies with them to help them understand their diseases better. We then formulate comprehensive treatment strategies and follow up with them to resolve their sleep complaints and disorders. As board certified sleep physicians, we are qualified to treat patients for all sleep disorders including but not limited to OSA, insomnia, hypersomnia, and RLS. As board certified neurologists we add the extra expertise in movement disorders, nocturnal seizures, parasomnia behaviors, circadian disorders, as well as neurodegenerative and neuromuscular diseases. When you send a patient to the Noran Clinic Sleep Center you are engaging a well-trained, courteous team of professionals dedicated to helping your patient with his or her sleep needs. JULY 2012
MINNESOTA PHYSICIAN
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ALZHEIMER’ S D ISEASE
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or too many individuals with Alzheimer’s and their families, the system has failed them, and today we are unnecessarily losing the battle against this devastating disease. Individuals with Alzheimer’s disease are high users of government-funded health care programs, and federal leadership specific to Alzheimer’s has the potential to both lower costs and improve care for these individuals. Leadership from the federal government has helped lower the number of deaths from major diseases such as HIV/AIDS, heart disease, and stroke. By making Alzheimer’s a priority, we have the potential to replicate this success. The Alzheimer’s Association advocates at the state and federal levels for legislation that has the potential to improve the lives of people affected by Alzheimer’s. By recruiting advocates from across the country and encouraging them to raise their voices in support of those with Alzheimer’s, we’re building a movement unlike any we’ve seen before. As a result, we are
“I slept in comfort and woke up with a
A national plan for Alzheimer’s Taking a collaborate approach to address growing needs By Carla Zbacnik
seeing movement both nationally and locally. National Alzheimer’s Project Act (NAPA)
In January 2011, President Obama signed landmark legisla-
strategy. A key result of NAPA is the first-ever national plan, which was released in May 2012. That plan includes a stated commitment by President Obama for an Alzheimer’s research investment of $130 million and $26
The National Alzheimer’s Project Act (NAPA) lays the foundation for a national Alzheimer’s strategy. tion, the National Alzheimer’s Project Act (NAPA) (Public Law 111-375), which lays the foundation for a national Alzheimer’s
million to support people with Alzheimer’s and their families. It recommends optimizing existing resources, supporting public-
private partnerships, and transforming our national approach to Alzheimer’s by acting from a single comprehensive vision. The law also created an Advisory Council on Alzheimer’s Research, Care, and Services to assist in coordinating the work of federal agencies as well as in developing and evaluating the plan. The council will allow patient advocates, health care providers, state health departments, Alzheimer’s researchers, and health associations to participate in the evaluation and strategic planning process. Ronald Petersen, MD, Cadieux director of the Mayo Clinic Alzheimer’s Disease Research Center, chairs the NAPA advisory council and Alzheimer’s Association president and CEO Harry Johns is an advisory council member. Through its annual review process, NAPA will, for the first time, enable Congress and the American people to answer this simple question: Did we make satisfactory progress this past year in the fight against Alzheimer’s? NAPA ensures stra-
plan.”
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Alzheimer’s Association tegic planning and alignment of Alzheimer’s related work and it recognizes that the Alzheimer’s crisis is no longer emerging— it has arrived. Statewide collaboration
The rise of Alzheimer’s in Minnesota will bring enormous cost and burden to individuals with the disease, their families, caregivers, employers, communities, and the state. The rapidly increasing prevalence of Alzheimer’s disease and its implications for Minnesota raise an urgent call for us to prepare our systems and communities for the spiraling needs related to the disease. To more fully understand and address the mounting Alzheimer’s crisis in Minnesota, the 2009 Minnesota Legislature called on the Minnesota Board on Aging to establish the Alzheimer’s Disease Working Group (ADWG) to study the status of Alzheimer’s disease in Minnesota and make recommendations for changes that will prepare the state for the future. In response, ADWG
The Alzheimer’Association is the leading voluntary health organization in Alzheimer care, support and research. Our mission is to eliminate Alzheimer’s disease through the advancement of research; to provide and enhance care and support for all affected; and to reduce the risk of dementia through the promotion of brain health. Our vision is a world without Alzheimer’s disease. • 24/7 Information Helpline at (800) 272-3900 • www.alz.org/mnnd developed a set of priority recommendations, which it delivered to the Minnesota Legislature in January 2011. “Prepare Minnesota for Alzheimer’s 2020” is a statewide collaboration of medical, aca-
recommendations as a springboard for action. “Prepare Minnesota for Alzheimer’s 2020” seeks to accomplish its vision through five principal avenues:
“Prepare Minnesota for Alzheimer’s 2020” is a statewide collaboration of medical, academic, community, government, business, and nonprofit stakeholders. demic, community, government, business, and nonprofit stakeholders across Minnesota seeking to transform the medical and long-term care systems and communities, using the ADWG
1. Detect the disease early and provide quality care. 2. Sustain caregivers with information, support, and resources.
3. Equip communities to support their residents who are touched by the disease. 4. Raise awareness and engage community in taking action. 5. Invest in interventions that reduce the cost curve of Alzheimer’s disease. Organized under a unique collaborative structure, Prepare Minnesota for Alzheimer’s 2020 is intended to foster collective ownership and accountability for furthering its vision. No single organization owns, funds, or controls the initiative. Instead, the vision and goals are furthered through collective contributions of more than 130 participants, including over 30 nonprofit, governmental and private sector organizations. To learn more or share information on research, best practices, and other topics that may foster fulfillment of the goals, visit www .collective actionlab.com. Carla Zbacnik is marketing director of the Alzheimer’s Association MinnesotaNorth Dakota.
Secure HIPAA-Compliant Communications for Healthcare At Revation Systems, we work with organizations and practices like yours to help you better connect and communicate with your patients and other caregivers. Our secure, HIPAA-compliant, cloud-based LinkLive Healthcare platform enables cost-effective voice, high definition video, text chat, and email through an easy-to-use unified solution that eliminates costly and capital-intensive on-premise equipment. Healthcare Solutions include: • Care coordination with any caregiver • Virtualizing in-house language services • Accountable Care communications • Web-enabled medical contact centers • And many more! • Virtual provider visits • Virtualized medicine therapy management LinkLive Healthcare is a subscription service that is easy to configure and use, has very low operating costs, and virtually no capital costs. Contact us today to see how we can help you better connect and communicate. For more information, please contact Dave Hemler dhemler@revation.com 612.216.3110
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MINNESOTA PHYSICIAN
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S P E C I A L F O C U S : O R TH O P E D I C S This month’s special focus articles discuss research on foot and ankle injuries. Stem cell therapy has shown promise in treating complicat-
Advances in stem cell therapy Salvage of complicated nonunions in foot and ankle surgery By J. Chris Coetzee, MD
ed nonuions following fusion surgery on the ankle joint, as a means of avoiding amputation or the need for repeated autologous bone harvesting. Though far more
C
omplicated nonunions continue to be one the most challenging problems for orthopedic surgeons. These nonunions come in different varieties, including relatively “simple� cases that start
The most challenging nonunion cases are usually related to high-energy trauma with poor-quality bone and a compromised tissue envelope. Most of these cases would have involved multiple attempts ini-
common, recurring Achilles tendinopathy and plantar fasciitis can be difficult to treat, and high-level evidence of
A prospective randomized multicenter study is comparing autologous bone graft to allograft/stem cells for ankle joint fusions.
treatment efficacy is still lacking.
off as a straightforward fusion, and two or three surgeries later are still not healed.
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MINNESOTA PHYSICIAN JULY 2012
tially at fracture healing, as well as later fusion attempts. Charcot neuroarthropathy in diabetics can be comparable in complexity. Some of these cases can result in severe destruction of bone that can leave a patient with a severely deformed and compromised foot. Without adequate salvage options, too many patients end up with amputations. The most common complicated nonunions occur in the ankle joint, whether subtalar or any of the mid- and forefoot joints. Conventional approaches to salvage of such complicated nonunions include stable fixation with autologous bone graft to stimulate healing and to fill bone voids. Autograft bone has long been the gold standard for surgical procedures requiring the restoration of bony anatomy. The obvious primary advantage of autograft bone is that it is readily available and should have a population of live cells. The disadvantage is the inevitable donor site morbidity. In many situations, however, the quality of autologous bone is inferior. In older individuals there may be limited cells, and many disease processes can
compromise the activity of cells as well. And even with the living cells, not all fusions heal. Alternatives to traditional autologous grafts
Once an autologous graft fails, the treatment options are limited. It is possible to use an external fixator and do a bone transport from a distant healthy area, but this is very time- and labor intensive, with multiple potential complications. An alternative is to use manufactured osteogenetic protein (OP), an implantable bone putty that stimulates natural bone healing by actively recruiting stem cells from the surrounding tissue and blood supply. Two OP products, OP1 (osteogenic protein 1) and Infuse (osteogenic protein 7) are commercially available, but both have issues unique to the use of a single OP. There have been several reports of major inflammatory responses and at times excessive heterotopic bone formation with subsequent nerve compression. Over the past 10 years, research has focused on additional methods in these situations to avoid, in some cases, the need for an amputation— or, in simplest form, as an alterative to the need for repeated autologous bone harvesting. A suitable alternative could be allograft tissue with a living cell population. However, it was necessary to first confirm that there were adequate amounts of bone morphogenetic protein (BMP) contents in allograft cancellous bone. The BMPs are needed for osteoinduction. Studies showed that allograft cancellous bone and allograft cortical bone had equal amounts of BMPs. UCLA researchers showed in 2002 that human adipose tissue has an abundance of multipotent stem cells (Zuk P et al., 2002, Molecular Biology of the Cell 13:12). It was postulated that, due to the ready supply of adipose tissue, it might be the ideal source of the multipotent cells if combined with allograft cancellous bone. Cancellous bone was then harvested from a donor, dem-
Trying the stem-cell approach
With this background in mind, it was decided to use this stem cell compound in a few desperate cases as a final-ditch effort before a below-the-knee amputation (BKA) for complex hindfoot nonunions. The initial patients were referred for consultations for BKAs, and the stem-cell option was offered as an alternative. [It is obviously not an option in all traumatized legs. In some cases there is so much tissue, vascular, or nerve damage that getting the bone to heal will still not leave the patient with a functional limb.] A standard revision approach is used by removing all fibrous nonunion tissue, as well as any bone that appears avascular. The defects are then filled with the allograft/stem cell strips and allograft added to fill defects. The extent of fusion is evaluated with a CT scan between three and six months. The initial results were pretty remarkable, and we could show that several of these very complex nonunions went on to heal within six months (see Fig. 1). Current research
Building on the anecdotal success of our initial research, our practice is currently leading a prospective randomized multi-
FIGURE 1A is an example of an ankle fracture that was treated with an open reduction and internal fixation but went on to severe arthritis. It is already noted at six months that there is no joint space left.
FIGURE 1B shows a severe deformity after two failed attempts at an ankle fusion were done elsewhere. The patient was advised to have a below-the-knee amputation and was seen for a second opinion and consultation for a possible amputation.
center study comparing autologous bone graft to allograft/ stem cells for fusions. The study began in 2011 and involves three research centers. Even in the best hands, standard, first-time subtalar fusions have a reported nonunion rate of about 8 percent. It was therefore felt this would be the ideal study group. To make the study as clean as possible, fairly strict inclusion and exclusion criteria are followed to avoid anything that would skew the results in any way. Patients are informed and, if they agree, consented for the study. They are then randomized to either autologous graft or allograft/stem cells. CT scans are done at six months to evaluate the extent of fusion in both groups. We are about halfway through the study, but at this point the results look very favorable. Of specific note, there has not been a single adverse response or reaction to the graft to date. That includes no excessive or unusual inflammation, wound healing issues, or rejection of the graft. It is also important to know that these cells don’t appear to cause any host reaction response and no antirejection drugs are needed.
FIGURE 1C shows the fusion salvaged with a revision fixation and an AlloStem graft. This went on to a stable construct that allowed the patient to return to fairly normal activities.
An interesting observation was that the early healing signs on X-rays can be deceiving, and this was initially troublesome. With the autologous group, signs of healing could be seen
Telephone Equipment Distribution (TED) Program
ineralized, and prepared in cubes or strips. Adipose tissue was recovered from the same donor and mesenchymal stem cells (or MSCs, bone-marrowderived cells that give rise to a variety of tissues) were collected through centrifugation. The MSCs were then combined with the allograft strips and cryopreserved. Several studies showed significant osteogenic activity and in vitro osteogenesis with bone allograft combined with adult human adipose-derived mesenchymal stem cells. In vitro studies also showed well-organized bone formation similar to normal bone healing. Early clinical experience showed very promising results with adipose-derived stem cells combined with partially demineralized matrix (AlloStem, developed by AlloSource).
FIGURE 1. Case example of an ankle fracture in a diabetic patient who developed Charcot neuroarthropathy and mal-/nonunion of the ankle.
fairly early on, but, per protocol, a CT scan was only done at six months. With the allograft/stem cell group the initial healing could look suspect, especially if there was a void to start with. The obvious explanation for this observation is that the allograft was demineralized during the preparation phase— and without minerals, the graft is not visible on plain X-rays. It takes several months for the host to mineralize the graft before the bone healing looks solid on plain X-rays. If this study provides the same or better results with stem cells, it will open a whole new avenue for management of complex primary as well as revision fusions. It might also be ideal for patients where autologous harvesting is not in their best interest, if there are limited harvest resources due to previous procedures, or if the harvestable bone quality of the patient is inferior. J. Chris Coetzee, MD, is an orthopedic foot and ankle surgeon with Minnesota Sports Medicine Institute, a division of Twin Cities Orthopedics.
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 JULY 2012
MINNESOTA PHYSICIAN
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S P E C I A L F O C U S : O R TH O P E D I C S
C
hronic tendon injuries, frequently referred to as overuse injuries, are estimated to represent up to 50 percent of all sports-related injuries. In response to the high rates of injury, Injury Prevention journal published an editorial in 2003 titled “Can we afford to exercise, given current injury rates?” The question should be, how can we afford not to exercise? Although the number of hours spent exercising is a risk factor for chronic tendon injuries, other risk factors include obesity, sedentary lifestyle, weakness of core muscles, and improper training techniques. Chronic tendon injuries result from improper load management, whether the issue is too big a load (obesity), too much time with a certain amount of load (standing on your feet all day), or too frequent a load without adequate rest (overtraining). Tendon injuries have commonly been referred to as “tendinitis.” However, it is becoming clear that these are not inflam-
Chronic recurring ortho problems Achilles tendinopathy and plantar fasciitis By Angela Voight, MD
matory injuries; rather, they are chronic degenerative conditions. The tendon tissue becomes disorganized, hypercellular, and hypervascular, leading to pain and weakness in the tendon. These changes are a universal response regardless of the site of injury. Some of the more common sites of tendon injury include the patellar tendon, Achilles tendon, plantar fascia, hamstrings, iliotibial band, lateral epicondyle, and rotator cuff. Given the frequency of these injuries, it is essential that primary care doctors know how to treat common tendinopathies and get patients back to exercise as safely and quickly as possible. This article focuses on Achilles tendinopathy and plantar fasci-
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itis and the evidence-based treatment of these injuries. Achilles tendinopathy
Achilles tendinopathy presents with pain at the Achilles 2–6 cm proximal to the insertion of the tendon onto the calcaneus. This is referred to as midportion Achilles tendinopathy (MAT). A less common site of injury is at the insertion of the Achilles onto the calcaneus, known as insertional Achilles tendinopathy (IAT). According to the Clinical Journal of Sports Medicine in 2009, the treatment with the best evidence for effectiveness in Achilles tendinopathy is eccentric exercise. In eccentric exercise, the muscle fibers lengthen as they contract, and the contraction is used to lower the load gently rather than letting it drop. The original eccentric exercise protocol for the Achilles was described by Alfredson in 1998. He had 15 patients do heel drops off a step, using both feet to raise up on the step and then using only the injured foot to lower back down into dorsiflexion. Patients did 3×15 reps, twice a day, seven days a week, for 12 weeks. After the 12-week training period, all patients were back at their preinjury levels with full running activity. The same protocol has been studied numerous times since then with good results. However, it has been found to be less effective in IAT, though a British Journal of Sports Medicine study in 2008 found that 67 percent of patients had good results if they did eccentric exercises without going into dorsiflexion. Complete rest has often been prescribed for chronic Achilles tendinopathy, but a study in the American Journal of Sports Medicine in 2007 found that patients who did eccentric exercise and continued their
normal running and jumping activities had similar improvement in pain and function to those who rested and did eccentric exercises. The patients who continued their activities were instructed to only do activity up to 5/10 pain level. A Cochran Review in 2001 looked at common treatments for Achilles tendinopathy and found that NSAIDs provide short-term relief in the first two to three weeks of symptoms. Heel pads have insufficient evidence to recommend for or against their use. A meta-analysis in Sports Medicine in 2012 evaluated Kinesio taping in treatment and prevention of injuries and found a small benefit. Topical glyceryl trinitrate has been studied as an off-label treatment for chronic Achilles tendinopathy. A randomized, double-blind, placebo-controlled trial in the Journal of Bone and Joint Surgery of America 2004 showed that patients with MAT had significantly reduced pain with activity, reduced night pain and had improved functional measures. The dose used was 1.25 mg/24 hrs (one-fourth of a 5-mg nitro patch). The patch was used continuously on the location of greatest pain for 12 to 24 weeks. A newer treatment that has been touted by several professional athletes is platelet-rich plasma (PRP) therapy, in which a patient’s blood is centrifuged and the concentrated platelets are injected into the injured tendon. The concentrated growth factors are thought to aid in tissue repair and healing. A randomized, clinical trial in JAMA 2010 compared eccentric exercises combined with either a PRP injection vs. a saline injection and found no greater improvement in pain and activity. Plantar fasciitis
Plantar fasciitis is characterized by pain at the origin of the plantar fascia on the medial calcaneal tubercle. Patients may describe pain with prolonged standing, pain with exercise, or pain with the first steps in the morning. Risk factors include pes planus deformity as well as pes cavus feet. Excessive running, a sedentary lifestyle, and
occupations requiring prolonged standing/walking have all been associated with plantar fasciitis. Common treatments such as rest, activity modification, stretching, and NSAIDs have shown short-term improvement, but there are few studies to support the benefit of these individual treatments used alone. Orthotics have been shown to be beneficial in plantar fasciitis. A 2008 Cochrane review found that over-the-counter orthotics are just as effective as custom foot orthotics for pain reduction. Night splints have also been shown to improve plantar fasciitis pain, but noncompliance is common due to discomfort and difficulty sleeping. Soft-tissue modalities, including deep myofascial massage and Graston techniques (using stainless steel tools to palpate affected areas and treat adhesions or scar tissue), have only anecdotal evidence of benefit yet are often included as part of a comprehensive physical therapy program. Iontophoresis is a treatment for plantar fasciitis that uses
Chronic tendon injuries result from improper load management. electrical pulses to cause absorption of topical medication, such as dexamethasone, into the soft tissues. A randomized, doubleblind, placebo-controlled trial in the American Journal of Sports Medicine in 1997 found that iontophoresis combined with traditional physical therapy modalities provided immediate reduction in symptoms in the first two weeks, but no significant difference was seen at one month of treatment. Extracorporeal shock-wave therapy (ESWT) has FDA approval for treating plantar fasciitis lasting more than six months. It is thought to work by inducing inflammation with lowenergy shock waves. A systematic review and meta-analysis in the BMC Musculoskeletal Disorders in 2005 found conflicting evidence for the efficacy of ESWT, with the highest-quality studies showing no benefit. Multiple types of injections have been used for plantar fasci-
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Common conditions but difficult to treat
itis, the most common being corticosteroid injections. The American Family Physician in 2011 found that corticosteroid injections have a level B evidence rating for effectiveness (i.e., inconsistent or limited-quality patient-oriented evidence). A prospective randomized study in the Journal of American Podiatric Medical Association in 2009 compared autologous blood injection, lidocaine needling, triamcinolone injection, and triamcinolone needling, and found superior results in both triamcinolone groups. Platelet-rich plasma (PRP) and stem cell injections have been studied ways to induce a healing response by injecting growth factors and pluripotent cells into the damaged tendon. However, these treatments are still considered investigational due to lack of evidence for effectiveness. The risk for plantar fascia rupture with injection is estimated to be 1.5 percent.
Chronic tendinopathies are very common but remain difficult conditions to treat. Two conditions, Achilles tendinopathy and plantar fasciitis, have been studied extensively yet still have level B evidence, at best, for treatment. For the Achilles, eccentric exercises have the most evidence for effectiveness. Both the Achilles and plantar fascia can be treated with ice, NSAIDs, stretching, relative rest, and physical therapy. For Achilles tendinopathy, heel lifts and topical glyceryl trinitrate have been used with some degree of success. Plantar fasciitis can be treated with over-the-counter orthotics and night splints. Newer injection treatments, such as platelet-rich plasma and stem cells, are being studied but are still considered investigational. Angela Voight, MD, practices at Summit Orthopedics in Woodbury and Eagan and specializes in sports medicine.
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P R O F E S S I O N A L U P D AT E : N E U R O L O G Y
C
hronic pain, defined as pain that persists for more than three months, is one of the biggest medical health problems in the developed world. It affects about one out of four Americans and has been estimated to represent more than $500 billion per year in health care costs and lost productivity. Disability and poor quality of life in chronic pain sufferers are thought to be worse than cancer or heart disease, and account for higher costs than the other two diseases combined. Chronic neuropathic pain is a form of pain that results from injury to the nervous system that has happened some time ago, damaging the nerves and altering the normal function of the nervous system, long after the injury has occurred. This is in contrast to acute nociceptive pain, in which the nervous system is working properly, letting you know through your nociceptors about new tissue irritation, impending injury, or actual injury (e.g., bone fracture, bruise, sciatica).
Pacemakers for pain Spinal cord stimulation systems By Peter Pahapill, MD While management and treatment of acute nociceptive pain is reasonably good and responsive to opioids, chronic neuropathic pain sufferers have a less robust response to opioids, creating an enormous emotional and financial burden to sufferers, caregivers, and society. In addition, patients with chronic pain often experience depression and anxiety that exacerbate the negative emotional state characterized by the pain sensation and create a vicious cycle of escalating pain and depression. Neuromodulation
Neuropathic pain can be more amenable to neuromodulation approaches, which essentially involve an intervention that interfaces on some level with a person’s nervous system and modifies functions so as to
affect benefit. Neuromodulation is a field of science, medicine, and bioengineering that encompasses implantable and nonimplantable technologies which act upon the neural interface. It is the fastest-growing medical field today worldwide, both in number of procedures performed and number of indications for these procedures. With continued innovation, neuromodulation stands to become one of the greatest sources of therapeutic intervention ever, in terms of number of people treated and overall contribution to quality of life. An estimated 10 million people in the U.S. today, including about 150,000 in Minnesota, would qualify for an approved neuromodulation implant. However, only 1 percent to 10 percent of potential candidates are aware
that such therapies are available to them. Awareness of neuromodulation therapies remains a great challenge for the field. Present-day examples of neuromodulation devices include deep brain stimulators for Parkinson’s disease and tremors, chemical pumps for spasticity and pain, vagal nerve stimulators for epilepsy, and sacral nerve stimulators for urinary incontinence and retention. Perhaps the most common, and the focus of the discussion below, are spinal cord stimulators (SCS) for chronic pain. SCS technology
Development of epidural electrical stimulation began in the mid-1960s. The new therapy involved placing a lead with electrodes over the spine and creating an electrical current with a power source. Since the first successful application in 1967, used to treat a patient with neuropathic cancer pain, advances have included development of multi-contact leads, improved computer modeling, totally implantable generators,
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MINNESOTA PHYSICIAN JULY 2012
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rechargeable systems, miniaturization, and, perhaps most importantly, the development of prospective controlled studies. More than a quarter of a million patients worldwide have received SCS pain therapy systems since the 1970s. SCS technology is derived from that of cardiac pacemakers and shares many of the same characteristics. Electrodes on the lead provide a source of delivery of the current, which can be closely controlled and modified. A spinal stimulation system generates mild electrical pulses and sends them to nerves along the patient’s spinal cord. These electrical signals are thought to mask the transmission of pain perception, replacing them with a gentle massaging sensation. The leads are connected to a subcutaneous generator that contains a power source and a computer-programming platform, which controls current, pulse width, amplitude, frequency, and electrode array to shape the electrical field. The therapeutic stimulation is completely reversible and adjustable.
TABLE 1. Assessing the likelihood that SCS can provide good long-term pain control. Limited Good response response to SCS to SCS
Patient/Pain characteristic
Limb pain (arm or leg) Axial pain (back or neck) Neuropathic pain Nociceptive pain Constant pain Periodic, mechanical pain Deep, aching, burning Sharp, stabbing Dermatomal distribution Non-dermatomal Known biological cause of nerve injury Unknown cause Pain for less than 1–2 years Pain for more than 2–5 years Addiction history Secondary pain issues Ongoing psychosis/behavioral disorders Patient selection for SCS
Goals of SCS therapy are at least a 50 percent level of pain relief, improvement in quality of life and function, and a decrease in pain medications. Strict selection of patients who might qualify for spinal stimulation therapy is crucially important for long-term outcomes.
++++ + ++++ + ++++ + ++++ + ++++ + ++++ + ++++ + + + +
It is important to understand that SCS is used to help in overall management of a chronic pain disease state (as in treating hypertension or diabetes) but does not provide a cure. Longterm good outcomes are successful only with proper patient selection and commitment to subsequent management of the
therapy by a dedicated team of health care providers and the patient. An implantable neuromodulation system is indicated for spinal cord stimulation as an aid in management of chronic, intractable pain of the trunk and/or limbs. Under the direction of their chronic pain physician, patients should try the most conservative approaches first, such as NSAIDs, opioids, and neuropathic pain medications (Neurontin, Cymbalta, Lyrica, etc.), injections, and physical therapy. After these modalities, including only a brief course of opioids, have failed, SCS should be considered immediately, to avoid escalating, chronic opioid use. There should be no contraindications such as active infection at the site of the implant or systemically; no untreated bleeding disorders; and no psychological contraindications such as suicidal thoughts, delusions, or untreated psychosis. SCS is not a treatment for drug abuse; addicPAIN to page 26
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Pain from page 25 tion issues should be addressed prior to implant when possible. The most relevant issues in patient selection are patient characteristics and the disease state causing the pain syndrome. Table 1 summarizes the different patient and pain characteristics and the likelihood that SCS can provide good long-term pain control. However, because most patients have mixed pain patterns that require both SCS and additional treatments of muscle, joint, and visceral pain, a screening trial is essential. Trial of SCS
The three- to eight-day trial duplicates the definitive procedure and offers the most meaningful prognostic sign that the SCS will succeed or fail. Once a patient is deemed a good candidate to be considered for a trial of SCS, neuropsychological clearance is required. The trial of stimulation involves placing a test lead wire into the space with a needlebased approach. This is no more involved than an epidural
steroid injection—only instead of medicine, an electrode is placed through the needle. The lead wire is then connected to an external power source that delivers stimulation similar to a fully implanted system. This is a brief outpatient procedure done with some sedation and no general anesthesia. After the trial period, the wire electrode is simply removed in the office. If the trial is successful (a combination of greater than 50 percent pain relief with improved function, mood, sleeping pattern, and reduction of pain medication intake during the trial), the patient can decide whether to go on to add the spinal stimulation therapy to the overall chronic pain treatment plan. SCS implant
Once a patient has passed a trial and wishes to go on to a permanent implant, either a wire electrode is re-inserted through a needle or, preferably, a paddle or plate electrode is implanted. The paddle electrode has a number of advantages over a wire elec-
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MINNESOTA PHYSICIAN JULY 2012
trode. Its only disadvantage is that a small open incision and laminotomy is required for its insertion (instead of through a needle). However, it typically is a brief procedure in an outpatient setting with sedation and no general anesthesia. The patient goes home without an externalized wire but with an implanted battery, with the system being entirely under the skin. Once implanted, the system can be adjusted at home or office. The effects are completely reversible and adjustable. Common uses of SCS in the U.S.
Use of SCS is well established in many disease settings, two of which are discussed below. SCS for failed back/neck surgery syndrome. The most common reason for use of SCS in the in U.S. is nerve pain following failed back/neck surgery or progress of disease after previous spine surgery. In this not uncommon scenario, patients continue to have pain and disability with a low quality of life despite anatomically successful
decompressive spine surgery, such as cervical or lumbar discectomy, laminectomy, and/or spinal fusions. In many cases, when a spine surgery fails to provide pain relief in the trunk, back, neck, arms, or legs, an additional spine surgery is recommended. There are few alternatives to this additional surgery when the goal is to relieve residual or new nerve compression and weakness, but the outcomes often are very limited when it is performed primarily to reduce pain. In this setting, SCS has been shown to be effective for radicular neuropathic limb pain (axial back/neck pain is more of a challenge). Prospective randomized studies in patients who are candidates for a second spinal surgery have shown that they do better with SCS with regard to pain reduction, health care use, crossover to additional therapies, and long-term costs. Given the high cost of a primary complex spine surgery, it is reasonable to consider SCS as a primary treatment option for patients whose odds of a good
outcome with additional spinal surgery are uncertain. A screening trial of SCS can be used to predict outcome, in contrast to a very invasive re-operation where the results are irreversible and uncertain. SCS for complex regional pain syndrome. SCS has also shown good results in treating complex regional pain syndrome (CRPS), also called reflex sympathetic dystrophy (RSD). This neuropathic pain syndrome leads to loss of function and severe pain, with tremendous expense to society. The goals of SCS in this population include pain relief, improved blood flow in those who have vasoconstriction, global satisfaction, and increased ability to tolerate physical rehabilitation. Achieving these goals will lead to a reduction in muscle atrophy, preservation of movement, and maintenance of strength via physical therapy and home exercise. The success of SCS for CRPS is well supported by robust statistical studies. The level of evidence for utilizing SCS for neuropathic pain relief
in CRPS is at the highest levels, according to peer review criteria. In a prospective randomized trial of SCS plus physical therapy vs. physical therapy alone, the group with SCS had significantly better outcomes up to two years later. A common thread in all studies regarding SCS for chronic pain is the importance of moving forward with SCS therapy early in the course of the disease. Studies have shown that the risk of failure of SCS increases about 10 percent to 15 percent for every year of delay; there is less than a 50 percent chance of success with SCS after a patient has experienced chronic pain for more than five years. Therefore, it is best to offer SCS within one to two years of the onset of the patient’s chronic pain syndrome. Risks and complications
As for other surgical procedures, implantation of SCS systems can be associated with complications. The vast majority of devices are placed and maintained without complications
but, when they do occur, the most common complications are lead fracture or migration and infection. Of these complications, the most common problem is lead migration, with the incidence being much less for paddle electrodes. Lead fracture appears to be the second most common complication. Infection as a potential complication of SCS appears to range from 2 percent to 10 percent. Early identification and aggressive treatment of superficial wound infections may prevent more extensive infection and help avoid expensive loss of the device. Dural puncture, spinal cord and nerve injury from trauma, and bleeding are extremely rare (and, in my experience, even less with paddle implants); avoiding general anesthetic helps reduce the risk of such injuries. Rejection of the device is rare. Achieving best results
Another complication, which I think is underestimated, is loss of continuity of care. Unfortunately, it happens fairly
often that patients complete the screening trial and are implanted, and then the implanting physicians have less interest in continued management. This is why it is critical that patients be assessed and managed by a committed and experienced team of SCS neuromodulators. The best long-term results with SCS therapy are achieved when it is provided by a pain center accredited by the American Academy of Pain Management, within a multimodality, multidisciplinary chronic pain program in which all members of the health care team are committed to managing patients with SCS therapies for the long term. The program should also be involved in teaching and research, perform large volumes of procedures, and include experience with all aspects of emergent technologies, with equal and unbiased relationships with the different companies that provide the implants. Peter Pahapill, MD, is a neurosurgeon with United Neurosurgery Associates in St. Paul.
Health Care that Starts with You! Join a truly mission-driven organization! Independent, nonproďŹ t UCare is recognized as one of the Minnesota’s leading health plans. We provide more than 285,000 members across Minnesota and western Wisconsin with the health coverage plans and services they need to maintain and improve their health. The innovative coverage we create makes a difference for Medicare-eligible individuals, individuals and families enrolled in Minnesota Health Care Programs, such as MinnesotaCare and Medical Assistance, and disabled adults with special health care needs. UCare is growing in size, membership, products, geographic coverage, and employees. We’re an organization that’s going places. Be part of a team that cares about you, be part of UCare.
Associate Medical Director The Associate Medical Director will oversee the health care needs of the membership in products and assist with the administration of medical services for all members. Provide professional leadership and direction for the development, implementation and maintenance of assigned quality improvement, credentialing, operational, utilization review, and case management activities of the health plan. Work collaboratively with other plan functions that interface with medical management such as Health Care Economics, Provider Relations and Contracting, Health Promotion, Compliance and the Pharmacy Department. Provide support to staff in activities requiring physician oversight.
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This position has some exibility for our selected candidate to choose a full-time or parttime work schedule. QualiďŹ ed candidates will be license in Minnesota as a Doctor of Medicine (MD or DO), possess Board CertiďŹ cation in a specialty recognized by the American Board of Medical Specialties (ABMS) and 3 years of medical practice experience with knowledge and advocacy of primary care. Experience with Managed care, practice guidelines and outcome data analysis preferred. Our ideal candidate will have pediatric experience to meet the needs of our membership. To learn more about UCare and apply online, visit us at:
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B E H AV I O R A L H E A LT H
S
usan came in with three kids in tow and talking on her cell phone. I heard the family’s arrival long before they came into the office. I glanced at the clock: She was 45 minutes early for her appointment, which meant she must have forgotten what time to be here. Her oldest son, 15-year-old Sam, was here for his routine six-month ADHD visit. When they came in, the two youngest kids immediately started bickering over who was going to play with which toy. Sam busied himself on his cell phone, managing to send several text messages before he even sat down. Susan quickly pulled out Sam’s recent report card and expressed her dismay: three A’s, a C, and a D. Sam was a bright, competent student, but his report card did not always show it. Sam chimed in that his poor grades were “because the class is boring and I don’t like the teacher.” Susan wondered if a medication change would “solve the problem.” I wondered if Susan had followed up on my previous
ADHD across the lifespan Overview of symptoms, diagnosis, and treatment By Elizabeth Reeve, MD
suggestions to have an evaluation for her own symptoms. This family’s visit is a textbook example of ADHD through the lifespan.
The ability to focus and attend turns out to be a delicate balance among environment, motivation, and neurotransmission. A disorder of attention regulation
Attention deficit hyperactivity disorder (ADHD), described by Scottish-born physician Alexander Crichton in 1798 and labeled by George Still, MD, in 1902, has historically been
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thought of as a disorder of childhood. We now know that 40 percent to 60 percent of ADHD children will grow up to be ADHD adults. Unfortunately,
MINNESOTA PHYSICIAN JULY 2012
only 5 percent to 10 percent of adults receive treatment for their symptoms. Given the ongoing shortage of mental health providers, this makes ADHD a disorder that is most often treated in the offices of primary care providers. The current version of the American Psychiatric Association’s “Diagnostic and Statistics Manual” (DSM-IV-TR), used by clinicians to define mental health disorders, identifies three types of ADHD: the inattentive subtype, the hyperactive/ impulsive subtype, and the combined subtype. Individuals need to have six symptoms in one category to meet the diagnostic threshold for the inattentive or hyperactive subtypes, and six symptoms in each category to meet criteria for the combined subtype (see sidebar on p. 29). Symptoms must be present before the age of 7 and cause dayto-day functional impairment. In addition, a diagnosis of ADHD requires that the symptoms cannot be better explained by the presence of another disorder. For example, children with autism often struggle with focus and inattention. Since these symptoms can be accounted for by the autism, they do not count toward a separate diagnosis of ADHD. The DSM-V, which is expected to be released in 2013,
will make changes to the diagnostic criteria for ADHD. It is anticipated that only four symptoms in a category will be needed for people over the age of 17 and that the age threshold will be raised from 7 years to 12 years. There is also a plan to include examples of more agespecific and developmentally relevant symptoms, something that has long been criticized as lacking in previous versions of the DSM. Biologically, ADHD is best thought of as a disorder of attention regulation rather than a disorder of inattention. We all have heard frustrated parents lament the fact that their child (or perhaps their spouse) can focus “when they want to.” How can a disorder of “inattention,” they ask, allow someone to play four hours of video games without making eye contact with another human being the entire time? The ability to focus and attend turns out to be a delicate balance among environment, motivation, and neurotransmission. Placed in different environments or given certain motivators, we all have variations in our attention spans. This explains why it takes us three days to organize and complete our tax forms every April—and only a few minutes to arrange for a babysitter and get ready to go out when offered free tickets for our favorite sports team’s game. Proper attention relies on three aspects of brain function: arousal and alertness, processing, and memory. Processing includes focusing, filtering, and inhibition; memory includes both access and retrieval. ADHD may be clinically evident if any of these functions are significantly impaired, although typically a person with ADHD has impairment in more than one of these areas. The neurotransmitter norepinephrine is primarily used for arousal and alertness and the neurotransmitter dopamine is essential for interest, filtering, and sustaining attention over time. Interestingly, dopamine is also the “pleasure” neurotransmitter. This may explain the propensity for some ADHD persons to be thrill seekers.
DSM-IV Criteria for ADHD (adapted from Centers for Disease Control and Prevention, ADHD website, www.cdc.gov/ncbddd/adhd/diagnosis.html) Either A or B: A. Six or more of the following symptoms of inattention have been present for at least six months to a point that is inappropriate for developmental level: Inattention • Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities. • Often has trouble keeping attention on tasks or play activities. • Often does not seem to listen when spoken to directly. • Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions). • Often has trouble organizing activities. • Often avoids, dislikes, or doesn’t want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework). • Often loses things needed for tasks and activities (e.g., toys, school assignments, pencils, books, or tools). • Is often easily distracted. • Is often forgetful in daily activities. B. Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least six months to an extent that is disruptive and inappropriate for developmental level: Diagnosis
Making an ADHD diagnosis depends on clinical data. While formal testing from a psychologist or neuropsychologist is often sought, it is not always necessary. Adjunctive data from reliable resources is essential to confirm symptoms and proceed with treatment. Rating scales are readily available online. The Vanderbilt ADHD Rating Scales provide useful data on children and adolescents. This rating scale provides not only ADHD symptoms data but also screening questions for symptoms related to mood, anxiety, and oppositionality. The ASRS, Adult ADHD Self Report Scales, are useful for patients out of high school. Developed through the World Health Organization, these scales are accessible on the Internet at no cost to providers. It is important to try to gain information from more than one source other than the patient. For adult patients, this can be a challenge. Consideration should be given to having patients bring
Hyperactivity • Often fidgets with hands or feet or squirms in seat when sitting still is expected. • Often gets up from seat when remaining in seat is expected. • Often excessively runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless). • Often has trouble playing or doing leisure activities quietly. • Is often “on the go” or often acts as if “driven by a motor”. • Often talks excessively. Impulsivity • Often blurts out answers before questions have been finished. • Often has trouble waiting one’s turn. • Often interrupts or intrudes on others (e.g., butts into conversations or games). Based on these criteria, three types of ADHD are identified: IA. ADHD, Combined Type: if both criteria IA and IB are met for the past six months IB. ADHD, Predominantly Inattentive Type: if criterion IA is met but criterion IB is not met for the past six months IC. ADHD, Predominantly Hyperactive-Impulsive Type: if criterion IB is met but criterion IA is not met for the past six months.
in old school report cards, or to allowing communication with a spouse, significant other, or employer if possible. Because of the comorbidity of ADHD with substance abuse, adult patients can present a challenge. Faced with a new patient in a primary care office who claims a history of ADHD but may be abusing substances, primary care providers may feel overwhelmed and unsure of how to proceed. Prescribing potentially abusable and addicting medications for treatment is not recommended. However, continued undertreatment can lead to further life impairment and perpetuate the cycle of dysfunction and suboptimal performance. This conundrum leads us to our final question: How should we treat ADHD? Treatment
Before discussing treatment options, it is important to understand why we treat. The potential psychosocial impact of ADHD is significant. Statistically, people with
ADHD are at risk for increased mental health comorbidities, higher rates of substance abuse, decreased income, underemployment, lower educational achievement, and greater interpersonal conflict. During childhood and adolescence, ADHD increases the risk for earlyage smoking, substance abuse, lower high school graduation rates, and increased teen pregnancy. In some studies, comorbidity for substance abuse is as high as 70 percent for adults with ADHD. The personal impact of ADHD changes family life. Parents of children with ADHD are more likely to miss work, often due to the need to go to school to pick up a child after a crisis. Children with ADHD have more frequent visits to the emergency room, more bike accidents, and, in later teen years, more motor vehicle accidents. On a day-to-day ADHD to page 30
Practice Well. Live Well. Lake Region Healthcare is located in a magnificent, rural, and family-friendly setting in Minnesota lakes country where we aim to be the state’s preeminent regional health care partner. Our award winning patient care and uncommon medical specialties set us apart from other regional health care groups. Lake Region’s physicians and their families also enjoy an unmatched quality of professional and personal life. Current opportunities including competitive salary and benefit packages available for BE/BC physicians are: • Dermatologist • Family Medicine • Emergency Medicine
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For more information contact Barb Miller, Physician Recruiter bjmiller@lrhc.org • (218) 736-8227
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ADHD from page 29 basis, family conflict in homes with ADHD children can be significant and disruptive. Treatment is broken into two primary categories: pharmaceutical and nonpharmaceutical. Because the evidence tends to point to greater efficacy for pharmaceutical interventions, that is the focus in this article. Keep in mind, however, that nonpharmaceutical approaches, particularly behavioral approaches focusing on time management, organization, impulse control, and prioritization, do have benefit and should be incorporated into the overall treatment strategy for all patients. Pharmacologic treatments for ADHD focus on medications that affect the function of norepinephrine and dopamine. Medications fall into two major groups, the stimulants and the nonstimulants. Stimulant medications. Stimulants readily available include methylphenidate, mixed amphetamine salts, and dextroamphetamine products. Each
Biologically, ADHD is best thought of as a disorder of attention regulation rather than a disorder of inattention. has equal likelihood of working. Drug choice should be made based on desired length of action, cost, and individual patient history. All stimulants are potentially abusable, although shortacting stimulants are far more likely to be misused or abused than long-acting formulations. Potential side effects include appetite suppression with weight loss, height suppression, motor or vocal tics, mild tachycardia, mild increase in blood pressure, headaches, insomnia, irritability, and stomach upset. The premorbid presence of tics is not a contraindication to trying stimulant medications; studies show that only about 30 percent of patients with preexisting tics show exacerbation with medications. Previous cardiac concerns have not proven to be significant on re-analysis of data, and current recommendations do not support baseline EKG testing for
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all patients taking stimulants. Height and weight must be monitored at every visit. While weight loss is common and most often insignificant, height suppression should be monitored, and if it is severe, medication discontinuation should be considered. Nonstimulant medications. Nonstimulant options include atomoxetine and the alpha-2 adrenergic agonists clonidine and guanfacine. Both of the latter are now available in longacting, brand-name, FDAapproved formulations. Unlike stimulants, which can be stopped and started abruptly with no impact on efficacy, nonstimulants need to be taken daily and take weeks to work at full efficacy. Because they are not controlled substances, prescribing them is easier and less cumbersome.
In patients who are partial responders to one class of medications, co-prescribing a stimulant and a nonstimulant is common practice and well tolerated by most patients. A common, undertreated disorder
ADHD is a common but still often undertreated disorder. Pharmacologic and behavioral interventions have increased, making options for treatment broader. The long-term outcome of untreated ADHD can impact work, home, and family. Practitioners are encouraged to recognize ADHD as a lifetime disorder that has changes in its manifestations as a patient ages but continues to need, and respond to, treatment. Elizabeth Reeve, MD, is a child and adolescent psychiatrist at Regions Hospital’s Child and Adolescent Psychiatric Clinic in. St. Paul and a past president of the Minnesota Psychiatric Association. She was named 2012 Psychiatrist of the Year by the Minnesota Psychiatric Association.
Freedom to Care and Freedom to Thrive with Allina Hospitals & Clinics
Clockwise-Top Left: Joanie Larkin, NP, Sam Gupta, MD, MPH, Liz Burns, NP, Dana Matthews, BSN, MBA, Margaret Hilgemann, NP, Dan Morehouse, MD, RVT, Kim Nguyen, PA-C, Jackie Windschill, RDMS, RVT, RPhS, Peg Guthrie, MD, Tammy Vittorio, NP, Tanya Black, NP
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We make a difference in the lives of our patients, our staff, and our communities. Physicians can focus on patient care and can professionally thrive in Allina, and the result is the quality of care for which we are known. We are based in Minneapolis, and have comprehensive services throughout Minnesota and in western Wisconsin. Become a part of the Allina team, joined together with a common purpose and uncommon caring. For more information, please contact: Kate Steiner, Allina Physician Recruitment Toll-free: 1-800-248-4921 | Fax: 612-262-4163 Email: kate.steiner@allina.com Website: allina.com/jobs EOE
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Urgent Care We have part-time and on-call positions available at a variety of Twin Cities’ metro area HealthPartners Clinics. Evening and weekend shifts are currently available. We are seeking BC/ BE full-range family medicine and internal medicine pediatric (Med-Peds) physicians. We offer a competitive salary and paid malpractice. For consideration, apply online at healthpartners.jobs and follow the Search Physician Careers link to view our Urgent Care opportunities. For more information, please contact diane.m.collins@ healthpartners.com or call Diane at: 952-883-5453; toll-free: 1-800-472-4695 x3. EOE
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Internal Medicine?
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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
Orthopaedic Surgery Opportunity Live in Beautiful Minnesota Resort Community
An immediate opportunity is available for a BC/BE orthopedic surgeon in Bemidji, MN. Join three board certified orthopedic surgeons in this beautiful lakes community. Enjoy practicing in a new Orthopedic & Sport Medicine Center, opening spring 2013 and serving a region of 100,000. Live and work in a community that offers exceptional schools, a state university with NCAA Division I hockey and community symphony and orchestra. With over 500 miles of trails and 400 surrounding lakes, this active community was ranked a “Top Town” by Outdoor Life Magazine. Enjoy a fulfilling lifestyle and rewarding career. To learn more about this excellent practice opportunity contact: Celia Beck, Physician Recruiter Phone: (218) 333-5056 Fax: (218) 333-5360 Email: Celia.Beck@sanfordhealth.org AA/EOE - Not subject to H1B Caps
We’ll make it all better.
JULY 2012 MINNESOTA PHYSICIAN
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PAT I E N T P E R S P E C T I V E
A
fter 15 years of serving vulnerable adults as a licensed social worker, I became a vulnerable adult myself as a result of a stroke at age 36. My life was turned upside down. No more carpool for my daughters or work deadlines; the stroke left me unable to walk, talk, or even eat. Medical professionals who embrace the compassion necessary to make a difference in the lives of stroke survivors are the most beneficial in recovery. But what happens when the patient is you? Eight years ago, I met the man of my dreams and together we have made a family of our own with my children from a previous marriage. I am like any other working mom: I get the kids off to school, go to work, have meetings, and hurry home from work and make dinner for my family.
An “average day” takes a frightening turn
Nov. 16, 2010, was an average day. After dinner, I headed to the high school to volunteer my
When the “vulnerable adult” is you A stroke survivor’s journey By Jen Kirchen, LSW
time coaching my daughter’s volleyball team. That night I was assisting with volleyball tryouts. There were multiple groups of girls
The EMT took one look at me and told the doctor I was having a stroke. She knew from experience; she was a stroke survivor. She said we needed to get to the hospital as soon as possible. trying out for the volleyball club, and as we were waiting for the next group to finish and come to our station, I noticed the sudden onset of numbness in my right
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hand. I thought the cause might have been a pinched nerve in my shoulder since I had been tossing so many volleyballs for the drill. I rubbed my hand, think-
MINNESOTA PHYSICIAN JULY 2012
No .7
2007
ing the feeling would go away, and it tingled. I decided to go out into the hall and get a drink of water, hoping to shake it off. Upon attempting to reenter the gym, I went to grab the door handle and my right hand didn’t work; it had gone totally limp. I was terrified! I opened the door with my left hand and called out to one of the other coaches. She came out and asked what was wrong. By that time, my hand had gone limp and my speech had started to go. I thought, “This is a stroke,” but I couldn’t tell her since my speech was limited. She asked if I needed to go to the doctor and I said yes. She transported me to urgent care. Within an hour of the onset of my first symptom, my whole right side was paralyzed and I was essentially mute. I lay on the gurney and just sobbed. My husband arrived a short time later and was stunned. The doctor, who thought I was having an anxiety attack, asked my husband if he wanted to drive me to the hospital. My husband refused. He knew something was really wrong and asked the doctor to call an ambulance. The EMT took one look at me and told the doctor I was having a stroke. She knew from experience; she was a stroke sur-
vivor. She said we needed to get to the hospital as soon as possible. With that, I was loaded into the ambulance and transported to the hospital, lights and sirens wailing. I lay there thinking that life as I knew it was over. I feared living in a nursing facility for the rest of my life. The EMT, knowing firsthand what I was going through, recognized my racing thoughts and reassured me that although it wasn’t going to be easy, I could do it. I made the decision to recover. At the hospital, I was given a clot-busting drug (tPA), with the hope of restoring blood flow to the part of my brain that was deprived. If I hadn’t recognized that something was wrong and gotten medical help in time, I may not have been able to benefit from tPA. Timing is important, as tPA must be administered within three hours of the first symptom of stroke. I made it with a half-hour to spare. Aftermath: connecting with others
I received occupational, physical, and speech therapy at the hospital. By the time I was discharged on Nov. 23 (the day after my 37th birthday), I was able to walk on the treadmill, fry an egg, and talk in full sentences. Since my release from the hospital, it’s been confirmed that I have a genetic condition that predisposes me to clotting. Initially doctors thought that was the reason for my stroke. Thanks to a hematologist who was hesitant to prescribe Coumadin to someone so young and active, I went to the Mayo Clinic for a second opinion. It was there that they discovered a venous malformation in my brain. The Mayo neurologist I saw said he had seen only three cases like mine result in stroke in his 20 years of practicing medicine. There were many challenges in my rehabilitation, and a great deal of hard work, but I am now about 95 percent fully functional. I still have a bit of trouble with my speech and numbness in my right hand, but I have returned to work, can play VULNERABLE to page 34
Sioux Falls VA Health Care System “A Hospital for Heroes” Working with and for America’s Veterans is a privilege and we pride ourselves on the quality of care we provide. In return for your commitment to quality health care for our nation’s Veterans, the VA offers an incomparable benefits package. They all come together at the Sioux Falls VA Health Care System.
• Orthopedic Surgeon
• Cardiologist
• Emergency Department Physician
• Pulmonologist
• Chief of Primary Care and Specialty Medicine • Urologist
• Physiatrist • Endocrinology • ENT • Hospitalist
• Psychiatrist
• Pathologist
• Radiologist
• Neurologist
To be a part of our proud tradition, contact:
Human Resources Mgmt. Service P O Box 5046 Sioux Falls SD 57117 605-333-6852
www.siouxfalls.va.gov
In the heart of the Cuyuna Lakes region of Minnesota, the medical campus in Crosby includes Cuyuna Regional Medical Center, a critical access hospital and clinic offering superb new facilities with the latest medical technologies. Outdoor activities abound, and with the Twin Cities and Duluth area just a short two hour drive away, you can experience the perfect balance of recreational and activities.. cultural activities EEnhance nhance yyour our professional professional life life in in an an eenvironment nvironment that that provides provides exciting exciting practice practice Northwoods oopportunities pportunities iinn a bbeautiful eautiful N orthwoods ssetting. etting. welcomes TThe he Cuyuna Cuyuna Lakes Lakes rregion egion w elcomes you. you.
We invite you to explore our opportunities in: • Family Medicine • Emergency Medicine • Hospitalist • Orthopaedic PA
Contact: Todd Todd o Bym Bymark, ark, tbymark@cuyunamed.org tbymark@cuyunamed.org www.cuyunamed.oorg (866) 270-0043 / (218) 546-4322 | www.cuyunamed.org
Family Medicine St. Cloud/Sartell, MN
Look for the friendly doctor in a MN based physician staffing service ...
We are actively recruiting exceptional part-time or full-time BC/ BE family medicine physicians to join our primary care team in Sartell, MN. This is an out-patient only opportunity and does not include labor and delivery or hospital call and rounding. Our current primary care team includes family medicine, adult medicine, OB/ GYN and pediatrics. Previous electronic medical record experience is preferred, but not required. We use the Epic electronic medical record system at all of our clinics and admitting hospitals. Our HealthPartners Central Minnesota Clinics – Sartell moved into a new primary care clinic in the summer 2010. We offer a competitive salary, an excellent benefit package, a rewarding practice and a commitment to providing exceptional patientcentered care. St. Cloud/Sartell, MN is located just one hour north of the Twin Cities and offers a dynamic lifestyle in a growing community with a traditional appeal. Apply on-line at healthpartners.jobs or contact diane.m.collins@ healthpartners.com or call Diane at 800-472-4695 x3. EOE
healthpartners.com
Physicians: • Let us do your scheduling & credentialing • Paid Malpractice • Physician Friendly • Choose where and when you want to work • Competitve Rates • Courteous Staff
Clients: • Prevent loss of revenue • BC/BE physicians • Competitive rates • Quality coverage • Malpractice coverage paid by us
P-763-682-5906/F-763-684-0243 michelle@whitesellmedstaff.com www.whitesellmedstaff.com
JULY 2012 MINNESOTA PHYSICIAN
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Stroke facts Vulnerable from page 32 volleyball again, and have run my first 5K. I feel very lucky to be alive! My family has never been the traditional kind. I was raised by my mother, grandmother, and grandfather, none of whom I am currently in contact with. I have always relied on friends as my chosen family throughout the years. My family and friends supported me unconditionally during my stroke experience. There were countless hours spent at my bedside, meals delivered, hugs given, and overall encouragement. I soon realized how much I meant to people and how much they cared about me. I can definitely say I have the greatest people in the world surrounding me and participating in my life. Still, after my stroke, I felt disconnected from friends and family who didn’t understand what I was going through. I sought out a young adult stroke group, hoping to identify with survivors that had been through the same thing. I formed some great friendships, but the loca-
• Stroke is a leading cause of death in the United States. • Stroke occurs every 40 seconds in the United States. Every four minutes, someone dies of stroke. • Approximately 5 percent of all deaths in Minnesota are due to stroke. • Stroke is the fourth-leading cause of death in Minnesota behind cancer, heart disease, and unintentional injury. • In 2009, Minnesotans incurred more than $367 million in charges for inpatient hospitalizations due to stroke. • In 2010, the estimated cost of stroke in the United States was $53.9 billion. This total includes the cost of health care services, medications, and lost productivity. For more information, visit the website of the Minnesota Stroke Association: www.strokemn.braininjurymn.org/. tion and time limited my continued participation after I went back to work. One day during one of my speech therapy appointments, a speech pathologist at Fairview said it would be really great if we had a younger stroke group there in the south metro. The staff at Fairview Ridges offered to donate the space and, since I had a social work background training and experience, they thought it would be a perfect fit for me to facilitate the group. Seven months after my stroke, I started the Fairview
A Journey of Opportunity After Hours (Walk In Care) Family Medicine, Med/Peds or Pediatrics Physicians
If work / life balance is important enjoy these Part-time and Casual positions currently available at four of our established clinics: Maplewood Clinic, Woodbury Clinic, Grand Avenue Clinic and Stillwater Clinic. Weeknight and weekend hours, 4 or 8-hour shifts. Benefit eligibility at .5 FTE. HealthEast® Care System, the largest non-profit health care organization in the Twin Cities’ East Metro area, is dedicated to offering physicians the professional journey that works best for them.
Ridges Young Adult Support Group in Burnsville. We currently meet for an hour once a month and discuss topics related to stroke. We have also added a “children of stroke survivors” group that meets separately at the same location during the same time as the adult group. Additionally, I volunteer at Sister Kenny Rehabilitation unit, which is the very unit in which I did my inpatient rehab. I find it very rewarding to give back, offering encouragement to current stroke patients.
Through my experience I have become active in the Minnesota Stroke Association. In 2011, I raised $1,500 for the Strides for Stroke walk and had over 30 friends and family members walk with me on my team, “Jen’s Journey.” I hope to do the same this year. I also contributed my story to the “Stroke Matters” spring 2012 newsletter, with the intent of helping others through sharing my experience. My journey is full of great examples of how the hard work and the dedication of medical professionals lead to my amazing recovery. From the EMT who offered those initial words of encouragement to the hematologist who just didn’t feel comfortable prescribing Coumadin, the medical staff involved in my case never gave up. One final comment: It is important to make people aware of the symptoms of stroke and to seek immediate medical assistance if they suspect they are having a stroke. Stroke can happen at any age, and time is of the essence. Jen Kirchen, LSW, lives in Apple Valley.
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
Your career journey starts here! For more information visit our website or contact Michael Griffin, Manager of Physician/Provider Recruitment at 651-232-2227 or 702-595-3716 (Cell), or email mjgriffin@healtheast.org. EOE
712 Cascade St. S., Fergus Falls, MN 736-8000 • (800) 439-6424 www.healtheast.org/careers www .healtheast.orrg/careers
Lake Region Healthcare is an Equal Opportunity Employer. EOE
www.lrhc.org
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MINNESOTA PHYSICIAN JULY 2012
Minneapolis VA Health Care System Great place to work, great place to live. You are invited to be part of the Department of Veterans Affairs that has been leading change in the health care sector.The Minneapolis VA is a 341-bed tertiary care medical center affiliated with the University of Minnesota. Our patient population and case mix is challenging and exciting, providing care to veterans and active-duty personnel.The Twin Cities area offers excellent living and cultural opportunities. Opportunities for full-time and part-time physicians are available in the following positions: • Deputy Chief of Staff • Chief of Surgery/Director of Specialty Care Service Line • Compensation & Pension (Occupational Medicine) • Gastroenterologist
• Orthopedic Surgeon – Total Joint/Spine • Spinal Cord Injury Physician applicants should be BC/BE. Possible recruitment bonus. Interested applicants should email CV to: Brittany Sierakowski, HRMS • brittany.sierakowski@va.gov Fax 612-725-2287 • Telephone 612-629-7873
Opportunities available in the following specialties:
The Rochester community provides numerous cultural, educational, and recreational opportunities. Olmsted Medical Center offers a competitive salary and comprehensive benefit package.
• Infectious Disease • Internal Medicine • Med/Peds Hospitalist • OB/GYN • Oncology • Orthopedic Surgery
• Psychiatry • Pediatrics • Pulmonary/ Critical Care • Radiation Oncology • Rheumatology
For additional information, please contact:
Kari Bredberg, Physician Recruitment karib@acmc.com, (320) 231-6366
Julayne Mayer, Physician Recruitment mayerj@acmc.com, (320) 231-5052
www.acmc.com
EEO Employer
Olmsted Medical Center provides an excellent opportunity to practice quality medicine in a family oriented atmosphere.
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
• General Internal Medicine • Internal Medicine/Family Practice – Rice Lake and Chippewa Falls, WI
Olmsted Medical Center, a 150-clinician multi-specialty clinic with 9 outlying branch clinics and a 61 bed hospital, continues to experience significant growth.
The perfect match of career and lifestyle.
Family Medicine Rochester Northwest Clinic Wanamingo Clinic Chatfield Clinic Dermatology Southeast Clinic Child Psychiatry Southeast Clinic Hospitalist OMC Rochester Hospital Emergency Medicine OMC Rochester Hospital Send CV to:
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
Olmsted Medical Center Administration/Clinician Recruitment 1650 4th Street SE
www.epamidwest.com
Rochester, MN 55904 email: egarcia@olmmed.org Phone: 507.529.6610 Fax: 507.529.6622
www.olmstedmedicalcenter.org
EOE
Your Emergency Practice Partner JULY 2012 MINNESOTA PHYSICIAN
35
PAT I E N T P E R S P E C T I V E
I
A stroke at 15
t all started when …
Michael
I remember it was a typical day; I had a pretty good breakfast that morning. I rode to school with my brother and everything was normal.
Michael’s story of his “silent disability” By Judy McMillan and Michael McMillan
Judy Judy (Michael’s mother)
Michael has very little memory of the day, but he does recall earlier that morning he was sitting in the locker room school and started to feel dizzy. Michael
I walked through the gym hoping a teacher would be available because I knew something was wrong. I just didn’t know what. When I got to my locker, I needed a friend to help me open it because I couldn’t see the combination. I was very confused and by the time I got to class, the teacher knew something was wrong. He sent me to the nurse and as I was walking up the stairs, I dropped my books. That must have been when it happened.
Michael experienced a complicated migraine, which started in the basilar artery. Normally, in a migraine, the blood vessel constricts but with Michael, the vessel started to pulse and pushed into the cerebellum and hypothalamus. Doctors referred to it as a stroke caused by complicated migraine. I had just pulled in the driveway at work when my cell phone rang. It was the nurse from Michael’s high school. Michael wasn’t feeling well and they thought he should go home. They told me he was very tired and seemed “out of it.” When I arrived at the school, there was an ambulance outside. It never dawned on me that it was for Michael. When I got to the door, they told me not to be alarmed
but they were just being cautious. I ran to the nurse’s office to find Michael lying on a cot, his left eye was wandering off, he would not respond even though several people were calling his name and rubbing his chest. I began calling his name and he looked at me with the most distant stare. The people in the office asked me if he could be on drugs or had consumed alcohol. It was 8:30 in the morning, he was a three-sport athlete, and I was sure that he had not ever used drugs or alcohol. He was only 15 years old. The paramedics decided they needed to take him to the emergency room. Michael
I don’t remember much in the nurse’s office and I don’t remember anything about the ambulance ride. Judy
Psychiatric Nurse Practitioner Location: St. Louis Park, MN Schedule: Open to Full-time or Part-time, Regular About Us: The Emily Program was voted #1 Top Midsize Workplace in 2011 by the Star Tribune. Established in 1993 in St. Paul, The Emily Program has outpatient and residential facilities at offices throughout the Twin Cities metro, Duluth and Seattle, WA, and is a leader in innovative treatment for people with eating disorders. About the Position: The psychiatric nurse practitioner is responsible for providing direct client service. He/she will work with other Emily Program clinicians in providing comprehensive treatment to the client. Conducts client assessments; evaluates and assesses clients’ need or options for medication management, prescribes medications, and monitors on a regular basis. Qualifications: • Board Certified in the state of MN and hold a valid state registration or license as specified. • Passion for working with clients with eating disorders. • Related clinical experience/education in the assigned program(s) of care. To Apply: Email cover letter, resume and salary requirements to careers@emilyprogram.com The Emily Program is an Equal Opportunity Employer (EOE).
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MINNESOTA PHYSICIAN JULY 2012
When Michael arrived at the hospital he was unconscious. The emergency room staff was convinced that Michael had been using drugs or alcohol even though the test results came back negative. The doctor and nurses tried different pain stimuli, but Michael did not respond. At one point they put straight ammonia into his nostrils and he did not respond. They did a CT scan, which showed no concerns. We asked for an MRI, but we were told it wasn’t warranted. The doctor came to us and told us that he believed it was psychological and Michael was looking for attention. I said, “Then I’m putting him in acting school because he is really good!” A nurse took us aside and talked about pseudoseizures and then they sent him home. When we got home, Michael initially seemed a little better but as the evening progressed, we became very concerned with Michael’s increasingly strange and disoriented behavior. He
would shove food in his mouth. He took a whole box of candy and put it all in his mouth at one time; he tried texting his friends and it was all nonsense. He insisted that I call Joe Mauer to come and see him. “He is such a nice guy, I know he will come and see me if he knows I am sick,” Michael mumbled. Concerned by his behavior and questioning the results from the emergency room, we took him to his pediatrician, who immediately had us go to Gillette Children’s Hospital, where his stroke was finally diagnosed. It affected the hypothalamus and the cerebellum. His right side was weak, he had a left-field cut, and his speech was difficult to understand. He slept most of the time but when he was awake he was confused and disoriented. I remember finally getting up the courage to tell Michael what had happened. After I explained to him that he had had a stroke, he cried and asked if he would ever get better and then fell back asleep. When he woke up, I sat by him, waiting for him to ask me more difficult questions but instead he asked, “Why am I here?” This happened three more times over the course of several days. Little did we know that his memory was going to remain an issue for a long time. Michael
I was homebound from school for the next three months. I began PT, OT, and speech therapy to regain the physical effects of the stroke but the piece that none of us were planning on was the cognitive limitations. Since the stroke, I have sensory issues, my memory is bad, and I get overwhelmed and anxious easily. I have trouble with impulse control. My organizational and executive functions skills are low. My neurologist reports that I have “frontal lobe behaviors.” Because I don’t have any physical limitations —with the exception of a hand tremor if I become overly fatigued or I am required to do a lot of writing or typing—many people think I am “all better.” My disability is labeled a “silent disability.” STROKE to page 38
FAMILY PRACTICE w/OB
St. Cloud VA Health Care System
Crookston, MN and Roseau, MN
is accepting applications for the following full or part-time positions:
• Country Lifestyle.... Urban Technology • Dedicated Team Approach • Competitive Salary & Benefits Idylic Practice Opportunities located in family friendly communities. Leave the hassle and bustle of the city behind. Contact: Kerri Hjelmstad, Physician Recruiter Altru Health System PO Box 6003 Grand Forks, ND 58201-6003 1-800-437-5373 Fax: 701-780-6641 khjelmstad@altru.org
www.altru.org
• Associate Chief, Primary & Specialty Medicine (Internist-St. Cloud) • Chief, Primary & Specialty Medicine (Internal Medicine) (St. Cloud)
• Internal Medicine/ Family Practice (Alexandria, Brainerd, St. Cloud, Montevideo) • Medical DirectorExtended Care & Rehab (IM or Geriatrics) (St. Cloud)
• Dermatologist (St. Cloud)
• NP/PA (Montevideo)
• Disability Examiner (IM or FP) (St. Cloud)
• Psychiatrist (Brainerd, St. Cloud)
• ENT (St. Cloud)
• Radiologist (St. Cloud)
• Geriatrician (Nursing Home-St. Cloud)
• Urgent Care Provider (MD: IM/FP/ER) (St. Cloud)
• Hematology/Oncology (St. Cloud)
NEW POSITIONS:
Family Practice Urgent Care Dynamic, independent 3 location, single-specialty practice in northwest Minneapolis suburbs is seeking additional associates for its Rogers site and has Full Time/ Part Time shifts in the Crystal and Rogers Urgent Care. • • • • •
Partnership opportunity after 2 years Competitive salary with incentives Excellent benefits, 401k/employer paid pension Practice at one site/one hospital Physician-owned
Please contact or fax CV to: Joel Sagedahl, M.D. 5700 Bottineau Blvd., Crystal, MN 55429 763-504-6600 • Fax 763-504-6622
Visit our website at www.NWFPC.com
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
JULY 2012 MINNESOTA PHYSICIAN
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Stroke from page 36 Judy
Devastated by the realization that my 15-year-old son would be living with the effects of a stroke, I began to search the Internet for resources. I found the Minnesota Stroke Association and contacted them for information. What I received was extreme support, resources, and education. Our family has participated in the Strides for Stroke Walk the past two years and plan to make it a yearly event. Michael also attended the Strike Out Stroke event with the Minnesota Twins and last year received the greatest thrill. He was asked to throw out the first pitch. We feel so fortunate to have found wonderful support services such as the Minnesota Stroke Association, the Brain Injury Association of Minnesota, National Stroke Association, and PACER. Michael
My overall high school experience has been difficult. I am now on an IEP (individualized
education program) and receive special education services at school. However, I have been accused of “milking the system” by teachers who have told my parents that they think I am “comfortable in the forgetting mode.” My coaches, much like my teachers, thought that I was looking for special treatment or not giving it my best. Before the stroke, I was a three-sport athlete and even though I was able to participate again in football, baseball, and wrestling, my athletic performance was not the same. I actually was on the receiving end of bullying from the football and wrestling coach. I was told I was “no good” and referred to as “a person like you.” I am looking forward to graduating and starting a new chapter. My goal of attending a four-year college is on hold for now due to my cognitive challenges, but I plan to attend a community college and get my Paraprofessional Educator Certification so I can work with students who are having the
same type of issues that I have experienced. As my abilities improve, I hope to someday become a special education teacher. I also am taking an EMT course at our community college while in high school. Hopefully, someday I can help others—and, this time, be able to recall the ambulance ride. Judy
Michael is motivated to get the word out that strokes can occur at any age and the cognitive disabilities or “silent disabilities” are just as devastating as the physical limitations. He will be an amazing teacher. As a parent, you only want the best for your child. Seeing him struggle physically, rise above it, and then be destroyed emotionally by the insensitive, heartless comments of people you hoped would be there for support is devastating. I am so proud that Michael has been able to turn the things that have happened into a positive. On this journey to recovery, we have met several other teens that have had strokes. They, too, were misdiagnosed initially. This
is alarming and concerning and raises the issue of educating health care professionals, at all levels, that a teen who is displaying disorientation, unconsciousness, and speech difficulties may not be using drugs or alcohol. Once those test results come back negative, it is important to go the next step and do an MRI to determine if the person has suffered a stroke or some other type of brain injury. Michael continues to amaze us. His strength and determination have made him the wonderful person he is today. Michael has a verse framed in his room that best describes who he has become: “But it isn’t about how hard you hit. It’s about how hard you can get hit and keep moving forward. How much you can take and keep moving forward.” –Rocky Balboa, in the movie “Rocky” Judy McMillan and Michael McMillan live in Oakdale, Minn.
continuing medical education 30th Annual Strategies in Primary Care Medicine
September 20-21, 2012
• Post-Conference Activities – Basic Life Support for Health Care Providers – Recertification – ABIM Maintenance of Certification Learning Session
Midwestern Region Burn Conference
October 11-12, 2012
• Pre-Conference Workshops – Burn Rehabilitation: The Bridge to Recovery – The Pathway to Improving Outcomes for Pediatric Burn Injuries (includes simulation-based learning) • Post-Conference ABLS Provider Course
Optimizing Mechanical Ventilation 13th Annual Women’s Health Conference Pediatric Fundamental Critical Care Support Emergency Medicine and Trauma Update: Beyond the Golden Hour 34th Annual Cardiovascular Conference
education that measurably improves patient care 38
MINNESOTA PHYSICIAN JULY 2012
October 10, 2012
October 13, 2012
October 26-28, 2012 November 2, 2012 November 8-9, 2012 November 15, 2012 December 13-14, 2012
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You wouldn’t give a 4-year-old a drink, so why would you give one to an unborn child? As a physician, it’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.
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