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The Great Prostate Cancer Challenge

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HEALTH SYSTEM

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Contentsi HIGHDEsERTPULsE

COVER STORY

FACT TO FALLACY 8 FROM Why do new medical studies so often prove the old studies wrong?

FEATURE BEYOND ANTIDEPRESSANTS

30 Working with new therapies to stimulate the brain. DEPARTMENTS

7 UPDATES What's new since we last reported. DOES SHE DO IT? 14 HOW Evidence shows Deputy District Attorney Mary Anderson likes working out. BEACH VOLLEYBALL 18 SNAPSHOT: Sand courts, open for play. GET READY: GEOCACHING 20 The search is its own reward.

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Then there's the treasure.

THE JOB: MISSION MEDICINE 24 ON Bend surgeonmoves to operate in Kenya. GEAR: THE GREAT WHEEL DEBATE 28 GET 26ers and 29ers face off. SORTING IT OUT: WELL-CHILD VISITS Not just for infants anymore.

OF KNOWLEDGE: POP QUIZ 53 BODY How long can you expect to live? VOICE: APERSONAL ESSAY 54 ONE Running with dad.

COVER PHOTO: ROB KERR;COVER DESIGN: ANDY ZEIGERT CONTENTS PHOTOS,FROMTOP: SUBMITTED, PETEERICKSON, ANDYTULLIS (2)

HIGH DESERT PULSE • SUMMER/FALL 2012

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EARNED WITH GUTS. WORN WITH P RIDE.

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09.22.12 BEND, OR - 2501 /1251 RELAY OPTIONS AVAILABLE THE EVOLUTION OF TRIATHLON. LeadmanTri is not about fortune or fame. The elite triathletes who race it are after one thing — the buckle. Finish in under 11hours and you' ll earn one. Do it in under 9 and you' ll take home the big one. But make no mistake, anyone who crosses the finish line gets bragging rights. For the fortunate few who earn a LeadmanTri buckle, it tells the world all about your race — and you don't have to say a word. Learn more at LeadmanTri.corn.

LIFETIME FOUNDATION

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In the Spring/Summer 2011 issue, we told you about efforts to study the collection of microbes living in the human body, known as the microbiome (" The War Within" ). This summer, the first major ef fort to describe the microbiome was completed and published. The Human Microbiome Project, as it was called, involved hundreds of scientists and volunteers who collected bacteria living on a normal,

healthy human body with the hope of gaining a baseline picture of Iuywy yyyyyyyyu

Chest radiation can increase cancer risks The Summer/Fall 2011 issue explored the higher risk of cancer faced by those who have undergone cancer treatment (" Living with the Cure" ). New data released at the 2012 American Society of Clini cal Oncology found that women who received chest radiation for childhood cancer face a similar risk of breast cancer to those who have genetic mutations known as BRCA I or 2. "While most women are aware that hereditary mutations can in crease their risk of breast cancer, few are aware that radiation to the chest can also increase this risk, including the women who them selves were treated," said Dr. Chaya Moskowitz, a biostatistician with Memorial Sloan-Kettering Cancer Center in New York and lead author of the study. "It's not just survivors of Hodgkin lymphoma who are at risk of developing breast cancer, but survivors of other childhood cancers typically treated with more moderate doses of radiation." The Children's Oncology Group recommends that women who re ceived 20 grays of radiation exposure during their treatment start mam mography as early as age 25 or eight years after treatment, whichever is later. The Sloan-Kettering research suggested women who received 10 grays or more could also benefit from early breast cancer screening.

the number of microbes that call us home. What they found was astonishing. There are more than 10,000 species of microbes that inhabit the human ecosystem, making up several pounds of each person's body weight. Moreover, the scien tists found that each person contains millions of microbial genes compared toa mere 22,000 human genes. These microbes, the sci entists think, perform a variety of functions in the body, including

some very beneficial ones such as helping with digestion. They now plan to study the microbiome further to see if different microbes are present in people with certain diseases.

— Betsy Q. Cliff

Alternative donor screening protocols Since we reported on the blood donation pipeline and concerns

over a shrinking pool of blood donors (" Blood Relations," Winter/ Spring 201 2), officials from the U.S. Department of Health and Human Services signaled they were exploring alternatives to the lifetime ban

on gay men donating blood. The agency issued a request for propos als on how to design pilot studies that could test alternative screening protocols and was reviewing the comments submitted. In June, 62 members of Congress signed a letter supporting the agency's con sideration of other approaches, and urged HHS to explore ways to differentiate between gay men engaging in high-risk sexual activity and those who pose little or no risk to the blood supply.

— Markian Hawryluk

P LEASE W E L C O M E . . .

DR.JACK E. BERNDT, MD Pain Management Specialist to Central Oregon DR. BERNDT is a board cerufied Anesthesiologist and certified in age management medicine.

Pinnac e patn center 1693 SW Chandler Ave. Ste. 260, Bend, OR 97702

W W HIGH DESERT PULSE • SUMMER IFALL 2012

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INN AC

DR. BERNDT has joined the Central Oregon office of Pinnacle Pain Center where he is practicing in comprehensive pain management medicine. Dr. Berndt's approach includes interventional spine and joint procedures and multi-modality medical management. DR BERNDT is nou accepting neu patients by physician referrals. You can reach his office at:

541 525 5565

P AI

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Cover story

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Howisit that medical researchers can be so often misled or so easily mistaken that they conclude that drugs, treatments orinterventions work when they really don't? For one, it's the nature ofmedical research. BY MARKIAN HAWRYLUK

n the 1990s, research conclusively showed that when patients had a sudden blockage of a coronary artery resulting in a heart at tack, the best course of action was to clear the blockage with a tiny balloon and to implant a stent, a small mesh tube used to prop open clogged arteries. The treatment was better than clot-busting drugs at restoring blood flow to the heart, resulting in more patients surviving heart attacks and fewer patients left with debilitating heart failure. The intervention was so effective at saving lives that doctors began to use stents for other patients who weren't in the throes of a heart at tack. Why wait until a heart attack happened? A stent could keep arter ies from getting completely blocked in the first place, they reasoned. By the early 2000s, doctors were implanting about a quarter of a mil lion stents each year, 85 percent of them in patients who weren't having a heart attack. Patients needed only complain of chest pain upon exer tion or have a scan that showed narrowed arteries — even if they didn' t have any symptoms — and doctors would recommend a stent. But in 2007, a randomized controlled trial known by the acronym COURAGE found that individuals with stable heart disease did no better after a $15,000 stent implantation than they did taking medi cations that prevented chest pain and protected the heart and blood vessels. Somehow a treatment that carried more risk and a higher cost for patients with no additional benefit had become standard practice until better research proved otherwise. Doctors will tell you they' re scientists. Trained in biology and chemistry, schooled in the analysis of statistics and the scientific method, they act on the basis of research, implementing the find ings of rigorously controlled medical studies that provide decisive evidence about the best course of treatment. Yet there's a growing realization even among doctors themselves that medical research isn't nearly as reliable as we'd like to think. Over the past decade, concerns have emerged that half, maybe

HIGH DESERT PULSE • SUMMER/FALL 2012

more, of published medical research findings could be flat wrong. This realization comes at a time when the push to adhere to proven strategies, to rein in doctors from freelancing in the care of patients, is being inextricably woven into the fabric of the medi cal system. There is at the same time a concern that the tapestry of medicine has more than a few loose threads. Last year, three physicians from the University of Chicago and Northwestern University reviewed the 212 original articles published

in a single year of the New England Journal of Medicine, arguably the most prestigious medical journal in the world. Slightly more than half of the articles published a claim about some medical treatment, whether newly proposed or established practice. And of those, 13 percent over turned what was previously considered standard medical practice. Of the 35 studies that tested one of the established clinical practices — things doctors routinely do now — 16 confirmed the practice and 16 contradicted it. The remaining three studies were inconclusive. "They' re no more accurate than a flip of a coin," said Dr. Vinay Prasad, one of the researchers who conducted the review. Prasad maintains that much of medical practice is unproven. "We don't know if it works or if it doesn't work, but it came into practice for a lot of reasons," he said. "It seemed to make sense, and it became so ingrained in the culture that we do it every day. From time to time, people have had the courage to test some really well established truths or the sacred cows of medicine."

Occasionally they find out what we had been doing for years was instituted in error. "It wasn't wrong like 'It was fine years ago, and we have some thing better.' It was wrong in the sense that it was no better than what came before it, and no better than doing nothing," Prasad said. "We call that medical reversal." At best, a reversal means that patients have been getting ineffective treatment, accepting all the potential risks and side effects without re alizing any benefits. At worst, it means that patients are being harmed

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Cover story(WHY MOST MEDICAL RESEARCHISWRONG

Coffee and panereatie eaneer A1981 study in the New England Journal of Medicine linked coffee to a higher risk of pancreatic cancer. The researchers, who were gastroenterologists, had identified patients in the hospital with pancreatic cancer and then asked them how much coffee they had consumed on a daily basis. The doctors then asked their other patients how much coffee they drank. Those with pancreatic cancer drank much more coffee. The flaw; Pancreatic cancer generally has few symptoms until its latter stages. So patients continued to live normal lifestyles — including drink ing coffee — until they were hospitalized. The gastroenterologists'other hospitalized patients, however, were mainly those with chronic gut con ditions, who hadn't been able to tolerate coffee for years.

tion a study has garnered, good or bad, and of the impact a research article has had on the field. loannidis found that 45 of the 49 most-cited studies had a positive finding. Of those 45, the conclusions of 16 percent were contradicted by later studies. Another 16 percent were found to have overstated the benefit. Less than half — 44 percent — of the most high-impact

findings were confirmed by subsequent research. "He hit the nail on the head," Prasad said. "If we think of all the ques tions that could be asked, isn't it shocking that what is published is con sistently 70 to 80 percent positive findings? It's too good to be true."

The nature of research How is it that medical researchers can be so often misled or so easily mistaken that they conclude that drugs, treatments or inter ventions work when they really don' t? For one, it's the nature of

medical research. Most people think of research as being like the discovery of peni by the treatment or by the lack of an alternate treatment that could have saved their lives.

Challenging the status quo No single researcher has challenged the status quo of medical research more than Dr. John loannidis, a Greek researcher now at Stanford University in Palo Alto, Calif. It was loannidis' groundbreak ing 2005 article, "Why Most Published Research Findings are False," that has served as a clarion call for skeptics challenging the medical research establishment. loannidis maintains that up to 90 percent of research is flawed. It is a shocking statement for many — as much today as when he first raised the issue seven years ago — but it's based on more than just the num

bers of medical reversals. There's a simple logic behind the claim as well. Consider a researcher trying to uncover a treatment for a condi tion. There are an infinite number of possible interventions, but only a handful that might actually work. We might grant a researcher the benefit of the doubt, that he or she is likely to limit the research to the interventions that are scientifically plausible. Perhaps that would re duce the odds of finding something that works to one in a thousand, or one in a hundred. Are researchers so good at picking effective in terventions that they could be right in more than half of their cases? Yet that's exactly the scenario playing out in published medical

research. The vast majority of published research findings show a positive effect; that is, the study proved a treatment worked. It's just the opposite of what would have been expected. And that wasn't just the impact of the marginal studies published in little-known journals that had little impact on medical practice. loannidis looked at studies that been cited more than 1,000 times by the authors of other research. Citations are a reflection of the atten

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cillin: It either works or it doesn' t. It either cures the disease or it doesn' t. There's little doubt. Some discoveries are still like that. The discovery of the drug Gleevac by researchers at Oregon Health 8 Sci ence University in the late 1990s, for example, changed the progres sion of chronic myelogenous leukemia from a disease with a 30 per cent survival rate to one that nearly 90 percent of patients survive. But Gleevac-type breakthroughs are few and far between. Most research deals with more subtle effects, incremental changes in risk that might not show a benefit until years into the future. Say you' re an average 45-year-old man. You have a 1.4 percent chance of having a heart attack or stroke by age 80. Your doctor prescribes a drug that research suggests will cut your risk of a heart attack in half. Even if your doctor could follow you for 35 years until you turned 80, there would be no way to know whether the drug truly prevented a heart attack or you were never going to have one anyway. Was it the drug or diet, exercise and genetics that kept you from having a heart attack? Only one in 71 of those 45-year-old men will have a heart attack or stroke. If the drug works, more than 140 men would have to be treated to prevent a single heart attack. It's only when doctors can compare a large number of patients taking the drug to a large number of patients not taking the drug, and see the difference in heart attack rates, that they can link the drug to a benefit. Even then the doctors would have to be sure that there weren't other important differences between the groups that led to more heart attacks in the group not taking the drug. "We see this over and over again," said Dr. Roger Chou, scien tific director for the Oregon Evidence-Based Practice Center, which reviews the quality of evidence behind various medical tests and treatments. "When you' re looking at complex things like health, and

SUMMER/FALL 2012 • HIGH DESERTPULSE

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you' re trying to isolate the effects of a single component — say your diet — it's very difficult. And it's difficult because there are so many other factors that affect health; our ability to control for these other factors is often limited."

Psychology of medicine It's not enough for researchers to show that people get better af ter treatment. They must show that the treatment is the reason pa tients got better by designing studies that rule out the effects of all those other factors. When patients improve, the natural inclination is to believe the treatment made the difference. But medical research is fraught with complexities that can mislead us. For one, the patient may have gotten better due to the natural pro

gression of the illness. Many conditions — such as a cold or the flu — are self-limiting. Eventually the body's immune system gets the upper hand and clears the body of the virus or bacteria causing the sickness. But patients often seek treatment when their symptoms are at their worst. They get a treatment and begin to feel better, con cluding it's the treatment that changed the course of their disease. But in reality, they may have recovered just as quickly on their own. Patients also tend to get better just because they' re being studied, a phenomenon known as the Hawthorne effect. It's named after a fa mous series of studies in the 1920s and 1930s at the Western Electrical Company's Hawthorne Works in Chicago. Researchers were testing what working conditions would improve productivity. When they tried brighter lights, productivity went up. When they tried dimming the lights, productivity went up. Whatever they tried, productivity went up. When they concluded their study and left, productivity dropped. The same happens in health care. Patients who get a lot of atten tion from doctors doing research tend to do better. It's similar to the placebo effect. Giving patients a sugar pill with no medicine in it sometimes has a therapeutic effect just because pa tients believe they are getting a medication. Particularly when stud ies use a subjective measure — such as reducing pain — it's easy for researchers to be misled. Over the years, dozens of interventions — spinal manipulation,

Vioxx and heart risk Vioxx was introduced in 1999 and quickly became a popular drug to treat arthritis and chronic pain. A randomized clinical trial funded by Merck showed the drug was safer than naproxen because it caused less internal bleeding and other gastrointestinal side effects. The flaw; While Vioxx did cause less bleeding than naproxen, the 2000 study comparing the two drugs showed a higher number of heart at tacks and strokes among those taking Vioxx. Merck published the find ings anyway touting the reduced risk of bleeding. To explain away the higher risk ofcardiac events, Merck said that naproxen must protect against heart attacks and strokes, a previously unrecognized effect of the drug. It was another four years before an independent study highlighted the higher cardiac risk and forced the company to pull the drug from the market. By that time, more than 2 million patients had taken Vioxx, producing annual sales of 52.5 billion.

cedure, in which doctors went through the same process with pa tients, taking them into the surgery room and inserting a needle but injecting no cement. Two trials found the sham procedure had the same rate of relieving pain as the actual procedure. "It is just a reliance on (knowledge of the disease) without any real clinical trials," said Dr. Adam Cifu, an internist at the University of Chicago Medical School. "We' ve done this to a few people and they feel better, so we' re going to do it. That makes no sense. That's what we were doing 300 years ago with snake oil. This person got better, so it must work. That's just wrong."

Study design

Researchers try to prevent these types of missteps by including a control group of patients, similar in every way to the test subjects, except that they don't get the intervention. But even in controlled studies, there are plenty of pitfalls. Medical research is subject to the influence of various factors that can intentionally or unintentionally bias the results. In some cases, it's the way patients are recruited for epidural blocks, exercise programs, fusion surgery — have all been the trials or how they are assigned to receive the intervention or be shown to be effective for treating lower back pain in about 80 per in the control group, a problem known as selection bias. In one fa cent of cases. On the other hand, 80 percent of lower back pain re mous case, a nurse who felt sorry for sicker patients assigned them to solves on its own within six to seven weeks. More recently, spine the treatment group, while steering healthier patients to the placebo surgeons took a shine to vertebroplasty, a procedure in which a ce group. Not surprisingly, the treatment group had much worse results. ment was injected into spinal vertebrae with compression fractures. Better study design can help. The most reliable type of research is Again, 80 percent of patients got better. the large, double-blind, randomized controlled trial, where patients "This is a procedure that was very enthusiastically taken up. There are randomly assigned to either the treatment or the control group, were neurosurgeons here in Portland where you could call them and and neither the test subjects nor those treating them know which get the patient in the next day," Chou said. group is which. And when these types of trials are significantly Then in 2009, doctors tested vertebroplasty against a fake pro large, they rule out findings that might be due to chance, rather than

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Cover story(WHY MOST MEDICAL RESEARCHISWRONG

Avandia and heart risk ' '" Approved in 1999, Avandia was marketed as a safer, more effective way to treat diabetes. The drug was approved on the basis of studies that showed it was effective at lowering blood sugar levels of those with Type 2 diabetes. It quickly became the best-selling diabetes drug. The flaw; In 2007, a researcher from the Cleveland Clinic analyzed data posted online by ClaxoSmithKline, Avandia's manufacturer, as part of a legal settlement over a case involving a different drug. The analysis showed that patients taking Avandia had a 43 percent higher risk of heart problems than those taking other medications or a placebo. Much of the research that showed a higher risk had never been pub lished. Avandia remains on the market, but under strict restrictions.

to treat symptoms of menopause but to protect them against future heart attacks and death. But two RCTs, one in 1998 and the second in 2002, conclusively proved that giving women estrogen increased, not decreased, their risk of heart attacks. The entire debacle became the poster child for the unreliability of observational studies. "If you think about why observational studies go wrong, there' s probably nothing better than the Nurses Health Study example," Cifu

said. "The two groups are clearly different. The people who chose to

a real effect. While randomized controlled trials, or RCTs, aren't infallible, they have the highest batting average of any type of study. The findings

take estrogen made all sorts of other healthy choices." It was only in hindsight that researchers identified what went wrong. Some critics have argued that the researchers made a huge blunder in deciding not to factor in the socioeconomic status of the nurses in the study. Those who chose hormone replacement ther apy, it was later discovered, were better off financially than those who did not. And other studies have linked financial status with bet ter health outcomes. The researchers, however, believed they didn' t need to adjust for income. After all, these were all nurses and seem

of large, well-designed RCTs hold up 85 percent of the time.

ingly should have similar income levels.

But RCTs are difficult and expensive to conduct, and because they start with the intervention being tested, it can take years if not de cades to get meaningful results. Instead, researchers have opted for study designs that are easier, faster and less expensive, but at the cost of reliability. When researchers turn to observational studies — where they ob serve what is happening rather than setting the parameters of the study themselves — their findings hold only 20 percent of the time. The problem in observational studies is that the researchers aren' t setting up the experiment. Other people — the test subjects them selves or their doctors — are deciding whether a patient gets a treat ment or not. Researchers can try to create a control group by finding individuals who are similar in every conceivable way to those who got the treatment, but who didn't get the treatment being studied. But the approach is ripe for selection error. There's no way to ensure there's only one difference between the groups. "Observational studies are great at outlining the prognosis of a certain group, a certain cohort with a disease, and they generally give us really good information about the treatment that these peo ple are getting," Cifu said. "But we' ve been burned on those, dating back to the Nurses Health Study with estrogen replacement. We' ve been burned on those a lot." The Nurses Health Study enrolled more than 120,000 female regis tered nurses in 1976, and the surveyed them every two years about their diet, lifestyle and health. One of the major findings of the study was that women who took hormone replacement therapy reduced their risk of a heart attack by two-thirds. On the basis of the finding in 1985, thousands of women were prescribed hormones, not only

Page 12

"It's easy to go back later and say we should have adjusted for that, but these were very smart people who said, 'We adjusted for the 20 to 30 other things we thought were important,'" Chou said. "It's so difficult to know ahead of time what you' re doing is wrong." Most nutritional studies are observational, simply because it's so difficult to get two groups of people to eat the exact same thing. Some nutritional studies have attempted to do this by confining pa tients to a hospital and providing them with all their meals. But you couldn't conduct a study like that long enough to provide meaning ful results over a lifetime of dietary choices. Additionally, you'd have the problem that when the control group isn't eating something, they must eat something else, introducing a second variable to the study. Increasingly, observational studies are conducted by analyzing databases, looking for associations between behaviors or medica tions and certain outcomes. These types of studies can suggest a link between two things, but can't prove a causal connection. It' s why so many vitamin studies have failed to show any benefit. An ob servational study crunches the data and finds that people who con sume lots of a particular type of vitamin have a lower risk of heart disease or cancer. But once the notion is tested in an randomized controlled trial, no effect is found. Last year, two separate groups of researchers analyzed the same da tabase of patients taking medications for osteoporosis to see if the drugs raised the risk of cancer. Neither group knew the other was conducting the same research. Despite dealing with the same group of patients and the same outcome, they came up with the opposite conclusions. One study, published in the British Medical journal, identified patients

SUMMER/FALL 2012 • HIGH DESERTPULSE

with cancer, then looked back to see how many of them had taken the

drugs. The other study, published in the Journal of the American Medi cal Association, identified patients who were taking the drugs, then matched them with a similar group of patients who weren't taking the

drug and counted up how many cancers occurred in each group. The first study found that those with cancer were nearly twice as likely to have filled at least 10 prescriptions for oral bisphosphonates than a control group of patients who did not have cancer. The second found little difference in the risk of cancer between the two groups. "Those are cheap, simple things to do," Cifu said. "You don't have to recruit patients and you don't have to get someone to fund them."

While well-designed RCTsare considered the gold standard, the only type of study that can prove a causal connection, their difficulty has led researchers to cut corners. It could take decades for a trial to determine whether a heart drug prevents heart attacks and saves lives. Instead, researchers rely on surrogate endpoints, such as lowering cholesterol

or high blood pressure. High cholesterol and blood pressure have been shown to increase the risk of heart attacks. Such changes can show up in weeks or months rather than years or decades. Last year, researchers from the medical schools at the University

of California, Los Angeles, and Harvard analyzed all of the random ized medication trials published in the six most influential medical journals over a two-year period. They found that 37 percent used such surrogate markers. "Patients and doctors care less about whether a medication low ers blood pressure than they do about whether it prevents heart at tacks and strokes or decreases the risk of premature death," said Dr. Michael Hochman, the lead author of the study. "Similarly, patients don't care if a medication prevents deaths from heart disease if it leads to an equivalent increase in deaths from cancer." Yet the researchers found that 27 percent of studies measured

Appendectomy and selection bias A randomized controlled trial published in 1996 in the World Journal of Surgery found that laparoscopic appendectomy had similar out comes to open appendectomy, but had lower infection rates and a shorter recovery time. The flaw; It was later discovered that the researchers'attempts at randomizing patients to one group or the other were circumvented by thes taf fcarryingout the study. When a patient required an ap pendectomy, staff members were to pull an envelope at random from a stack, and open it to determine whether the patients should get laparoscopic or open surgery. The trial ran as designed during the day, but at night, staff had to wake the attending surgeon if a laparoscopic surgery was required. The staff members were hesitant to call on those surgeons in the middle of night — particular those with difficult personalities. So the staffcame up with a simple solution. When they didn't want to wake the surgeon, they held the envelopes up to the light, finding one that assigned the patient in question to an open procedure. That meant patients with worse cases who couldn't wait till the morning tended to get open procedures, while those who could wait till the morning tended to get laparoscopic surgery.

at stake in pharmaceutical research. A new drug's patent protection starts at the moment the patent is filed, starting the clock for a lim ited window before generic competition can eat into the company's profits. But it may take additional time for the company to secure market approval from the Food and Drug Administration. The short er the research phase, the more the company can profit. In many cases, those motivations have led not just to unreliable stud ies, but to outright fraud. In 2004, Warner-Lambert, a pharmaceutical company that had been purchased by Pfizer, pled guilty to violating

only whether a drug prevents a single type of death. Dr. Danny McCormick, a Harvard Medical School professor and co rules regarding marketing of unapproved uses of the epilepsy drug author of the analysis, said that studies using surrogate markers or disease-specific mortality data were much more likely to be funded by pharmaceutical companies or other commercial ventures. Some 45 percent of industry-funded studies relied on surrogate endpoints, compared with 29 percent of those with no commercial funding. "It may be easier to show that a commercial product has a benefi cial effect on a surrogate marker like blood pressure than on a hard outcome like heart attacks," McCormick said. "In fact, studies in our analysis using surrogate outcomes were more likely to report posi tive results than those using hard outcomes like heart attacks."

The business of research The higher use of less-reliable study designs by pharmaceutical manufacturers is perhaps not surprising given the billions of dollars

HIGH DESERT PULSE • SUMMER/FALL 2012

Neurontin. A subsequent class-action suit led to the release of 8,000 pages of corporate documents describing how pharmaceutical compa nies can skew the research to make their drugs look more effective. The strategies included companies writing research articles on be half of researchers, quashing the publication of negative research and changing the parameters of the study after seeing the results. Perhaps what was most concerning about the Neurontin case was that the actions the company took were only illegal because they pro

moted unapproved, or off-label, uses of the drug. Had the company used the same strategies to promote the approved use of the drug, it would have been fair game. Equally frightening was that most of the players involved considered the tactics standard practice. "What's great about the Neurontin case was that the report became Continued on Page 47

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Deschutes County prosecutor Mary Anderson once thought of exercise ';-:,'as, work but pdw;-. t

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or much of Mary Anderson's life, exercising was just another thing on the to-do list. She regularly logged her time on the elliptical between rais ing two sons and working long hours as a Deschutes County prosecu tor. She watched the scale to make sure her weight stayed in check. "In the past, working out was a chore," she said recently. "I went to the gym to do cardio. I never really liked it." Then about four years ago, Anderson's perception of exercise changed. Friends coaxed her to try new activities with them. She began sampling sports like hors d'oeuvres from a platter. Today the Central Oregon native is as busy as ever — Anderson, 42, became the county's chief deputy district attorney in 2011 and is But now, not only does she eagerly await that next workout, she also seeks out new athletic challenges. In the past two years, she has run

Page 14

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BY HEIDI HAGEMEIER PHOTOS BY PETE ERICKSON

a single mom.

several half-marathons and in June completed a grueling race featuring military-style obstacles.

The diff erence,she said,has been finding sports she loves and doing them with family and friends. "Now it's more of a reward," she said. "My friends are there and we encourage each other. It's my social time."

Learning to love exercise Musing recently over tea and half an almond croissant, Anderson said she played tennis in high school, but at that age she was really more into her family's horses than sports. Anderson said she approached exercise as something she had to do for health and calorie control. Then a friend asked her to join an indoor soccer team. She noticed that exercise became play. The real turning point, she said, was in 2008. Another friend in vited her to Bikram yoga, a form of yoga in which the room's tem perature is cranked up over 100 degrees.

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doing my time," she said.

not who's first or a competition, because everyone is helping every

body else."

Taking on new challenges

It encouraged her to try more and do more. Last year, a third friend asked her to try out a learn-to-run class. Although she admits running still isn't her first preference, she signed up to spend time

Anderson regularly squeezes in exercise at lunch or after work with colleagues from the Deschutes County District Attorney's Office. Or she meets her dad, Alex Robertson, who at 65 is also into CrossFit. with her pal. She talks of her workout partners as teammates; they motivate Now, Anderson's passions are stand-up paddleboarding — which and encourage each other, as well as hold each other accountable. she calls a great core workout — and CrossFit. In a town of elite athletes, Anderson laughs at the idea that she is CrossFit is often done in a gym setting and focuses on strength doing anything special. Yet in the past several years, she has taken and conditioning. It goes for high intensity, varying exercises on some tough athletic challenges. throughout the workout to target different areas of the body. Brandi Shroyer, a friend, running partner and fellow county pros Anderson started a little more than a year ago and said she is ecutor, described Anderson as a "very strong athlete." "I think Mary approaches working out just like she does every hooked on the combination of intense training and camaraderie. "I'm going to sound like one of the people who has drunk the Kool-Aid, thing else," Shroyer said. "She's committed, she's a hard worker, she but CrossFit has changed my perspective on working out," she said. works well with the team and she has fun." "It's the most supportive community of people," she added. "It' s Anderson accomplished last year's goal of running her first half

HIGH DESERT PULSE • SUMMER /I ALL 2012

Page 15

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f marathon, the Happy Girls Half Marathon. This year it was the Tough Mudder in Van couver, B.C.: a 10-plus-mile race punctuated

by 25 obstacles designed by British special forces that involve climbing, swimming and

hauling. While the distance isn't terribly long, it takes on average at least three hours to complete. And each course is different. An

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Mary Anderson, bottom right, celebrates wi th her teammates after finishing the Tough Mudder obstacle course racein Vancouver, BC.,in June.Anderson isjoined by,from leftto rightin the back row: Brandi Shroyer, Sarah Foreman, Stacy Neil, Kandy Gi es, Brigid Turner, Jenn Potts and Katie Clason. Kari Hathorn sits with Andersonin the front. The women helped each other throughout the course and finished together.

•

ing a log. One obstacle called the Arctic En ema required racers to plunge into water so cold that ice chunks floated on top. "The cold water obstacles were shock ing," she said. "In the middle of one there's a wall, so you had to go under. It was so cold I couldn't breathe, I couldn't talk. "You get out and you start running again and within a few minutes you don't even re member that you were in cold water." Yet the point of th e event, Anderson said, is the essence of what she loves about

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How does she doit? lMARY ANDERSON

working out: It's about pulling together and team spirit. Everyone helps each other. She and her eight teammates finished the race

together in roughly three-and-a-half hours. "We killed the obstacles," she said. "I was so proud of us. We had so much fun and we were so happy when we were done."

sion gets called to crime scenes in the middle of the night. She said she tries to reserve one day a week in which she doesn't work at all. These pressures make working out with friends all the more im portant: It's Anderson's stress relief and social life. So she squeezes it in at lunch with colleagues, on a weekend morning with a girlfriend and even at times includes her children. Max sometimes does Cross Fit with her — she said even though he doesn't work out regularly,

Friends say Anderson is fit and competitive, regularly pushing herself to the limit. But she does it with good humor. Colin Richards, owner and head coach at Bend's CrossFit All-Ter he can easily top his mom in the gym. rain, was her team's personal trainer for the Tough Mudder. He said She likes to get in four sessions a week, yet she doesn't beat her Anderson was the ringleader in getting the team together and kept self up if she can only manage one. Asked if she mountain bikes, she them coordinated and motivated through six months of training. smiled and said, "I do socially."

They did aerobic and anaerobic training, with plenty of legwork, running and weight-bearing resistance moves. "When she shows up it might seem like it's a 75 percent day, and then she gets going and she goes for it 100 percent," he said. "It's very hard for her to not go 100 percent. She really loves to push herself."

Maintaining balance

"People shouldn't be so hard on themselves," she said. "If you miss a workout, no big deal." These days, she rarely gets on a scale. "Now I have different goals," she said. "It's all about what I can do, what I can lift, what workout I can complete." She advises people to try new sports — at some point, something

might click.

"If you aren't looking forward to what you' re doing," she said, For all the intensity, Anderson's attitude about exercise remains "then you shouldn't be doing it." laid back. She takes that stance in part because of her busy life. When her boys are with her, Anderson said she makes them the For the next challenge, she's talking with her teammates about priority. Max is 15 and Charlie is 11. doing another race, perhaps a second Tough Mudder. Anderson's job is normally less than 50 hours a week but once in And she's excited. "I hope I never have to do time on an elliptical again." • awhile can push into 60 or 70 hours. Like all prosecutors, she on occa

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Snapshot ~ BEAcH voLLEYBA LL

PHOTO BY PETE ERICKSON

on Bardeschewski, of Portland (left), and Matt Greenleaf, of Bend, wait for the spike by Ben Tustin, of Bend, during a tournament at the beach volley ball courts in Bend's Old Mill District. The four sand courts — located just south of the Les Schwab Amphitheater — are open for play throughout the summer except during tournaments or league play. The courts are free to use during open play, but can be rented in advance for guaranteed access. Contact: www.bendbeachvolleyball.corn.

Page 18

SUMMER/FALL 2012

• HIGH DESERT PULSE

Page19

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Nearly 10,000 geocaches hide in Central Oregon. What are you waiting for?

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r SUMMER/FALL 2012• HIGH DESERTPULSE

Resources

• Checkout the following websites for more information on GPS units; www.g psinformation.net or shop.geocaching.corn • Several localorganizations periodically offer classes on how to operate GPS units. For information contact Central Oregon Community College Community Learning: noncredit.cocc.edu, emailceinfo@cocc.edu or 541-383-7270 REI: www.rei.corn/stores/96 or 541-385-0594

jagged terrain without trails, guided by the

GPS devicein the palm ofm y hand. It was one of my first trips geocaching, a sport that requires a healthy dose of brain and at times some brawn. It involves using longitude and latitude coordinates plugged into a GPS device to find a

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owning and learning how to operate a GPS enabled device. From there, just about the only limitation is enthusiasm. "I like doing the more adventurous ones," Brown said. "Ones that take me to a place % I' ve never been before, ones that are re

ally beautiful, ones where I have some thing to figure out."

den in the wild. But what I was fast learning is geocaching can be about more than that. The GPS delivered us to an island in the lava, home to a handful of ancient junipers

A new pursuit

I Geocaching blossomed in the wake of a

major development. On May 2, 2000, the U.S.government with gnarled, lichen-covered limbs and pon removed what is called "selective availabil derosa pines standing as sentinels. Ahead ity." Blake Miller, a GPS expert who teaches lay the Cascades coated in white. It was ob-~ courses for Central Oregon Community Col vious why this cache is named "Forest in the lege Community Learning, said until then, Flow." the government had deliberately scrambled The man who designed the cache, Bend satellite signals. It did so to make GPS units resident Judson Brown, smiled as we experi less accurate for average citizens out of con enced our "ah-ha" moment. cern that the technology might be used for This was definitely about the journey. criminal activity. "Look at that," he said, appreciating the President Bill Clinton ordered selective view. "It's like a little garden in the lava. Most availability removed as soon as the military people don't even know it's out here." developed ways to selectively block GPS Geocaching is a relatively new outdoor transmissions in the event of a national se pursuit, and it's perhaps one of the most curity threat. versatile. As on this day, it can require miles The change improved GPS accuracy for of hiking over terrain guaranteed to bring the general public by tenfold overnight. Mill on a sweat. Or it can be as mild as a stroll er said it was the difference between accu through a city park. L racy within about 300 feet to about

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BY HEIDI HAGEMEIER PHOTOS BY ANDY TULLIS

ven in the cool June morning, the

Caches can be as big as an ammo

black lava flow through the Newberry

can or as small as a button-size mag net stuck to a rail. They can include puzzles and riddles that would con

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heating up.

That same month, according to the dominant website for geocach ers, Geocaching.corn, Oregon resi clent Dave Ulmer wanted to test the new GPS accuracy. He hid a container in the woods

I was starting to sweat while leading a found the Sphinx. Or they might be simple small band over razor-sharp rock and deep enough to charm young children. fissures in the volcanic landscape. Lava And geocaching can be enjoyed year outside Portland, including a logbook and Butte, with its visitor center, roads and trails, round, since caches are hidden everywhere pencil, .

loomed to the southeast and U.S. Highway 97 not far beyond it. Yet we traveled slowly ~ t h r o ugh what seemed like wilderness, over

HIGH DESERT PULSE • SUMMER/FALL 2012

from national forests to urban Bend to the desert. Getting into geocaching is as simple as

•

He broadcasted the idea and container coordinates online. Within days several peo ple had found it and reported back on their

Page 21

Get ready IGEQCACHING

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experiences. Soon others were replicating the experiment, hiding their own caches.

Geocaching.cornemerged by September of that year. Then there were 75 caches; now more than I million are hidden all over the world. The website has been the sport's hub ever since. Participants use the site to find out about caches, report their experiences and relate the norms of the pastime to newcomers.

Getting started When getting going, the first step is to pick acache at Geocaching.corn. There are now nearly 10,000 caches hidden within 100 miles of Bend. Each cache has descriptions listed on Geo caching.corn determined by its creator. One description characterizes the difficulty of the find and another the difficulty of the terrain. A third shows the size of the cache. There is

also a map showing general location, a com ment section for feedback from other geo cachers and other pertinent information.

The rules of geocaching are relatively sim ple: Don't move the cache. Only place caches on land where you have permission. Don't al ter the landscape in any way. Share what you learn online with the geocaching community. There is an array of cache types out there. For a traditional cache, the coordinates pro vide the exact location of a container with at minimum a logbook to sign and date. Some larger containers also hold trinkets ranging from small toys to tools. Geocache culture allows for taking an item as long as it's replaced with an item of equal or greater

value. A nano- or micro-cache is a tiny container that holds only a logsheet. There are others: Multi-caches include several "waypoints" on the journey — spots to be found that offer coordinates of the next destination — before

Page 22

reaching the cache. Then there those that contain puzzles, riddles or math problems to solve to get the cache's coordinates~ Some caches can be found relativel y

quickly. It's worth doing a few simple ones when starting out.

Searching the lava

terrain or obstacles. "The key thing when you get a GPS is to get out and use it and develop that~uscle

memory," he said. Geocachers alsogre urged to

respect private property and to leave no trace on their outings. In fact, permission from the property owners, from private individuals to

]

As we slowly moved through the lava, I reguarly stopped to shift my eyes between my feet and the GPS unit. But the device pro vides the most accurate data when moving, so my pauses would cause us to go in the wrong direction. Also, even the most expensive GPS device is only so good. As I sought one of the three waypoints on this adventure, the device told me I was getting warmer until I was about 20 feet away. Beyond that radius, it couldn' t pinpoint the destination. "That's when geo-sense takes over," Brown said, advising me to switch from using the de vice to using my senses. I thought about the clue — get to the base of a lone, large ponder osa pine — scanned the landscape and scram bled across the lava to the most likely spot. Brown, a math and science teacher at Sev en Peaks School and longtime outdoor rec reationist, went from geocaching novice to creating his own caches within a few years.

those responsible for public lands, is a require ment of creating a cache.

Enjoying the journey A geocache need not be in the wild,how ever. In fact, it can prompt a new perspec tive in a crowd.

On a sunny day near Farewell Bend Park, Bend resident Jen Michaelson, her two sons,

ages 16 and 11, and her dog climbed through brush toward the cliffs above the trail in

search of a cache. Runners, bikers and dog walkers zipped by, but none saw this view of river and trees from 30 feet above. Michaelson said she always wears pants

and sturdy shoes when geocaching, since the whole point is often to leave the trail be hind. She also carries water, a spare GPS unit, extra batteries and a snake bite kit — which she has never used but considers essential.

The Michaelsons go out as a family — she

He stumbled across geocaching online and

is presently attempting to seek a cache a

decided to give it a try. After logging a num ber of caches, creating them seemed a natu ral extension. "One of the things that I like about it is it' s forced me to explore," he said. "I get away from the crowds."

day foran entire year.They have found caches embedded in rocks, fake bolts and

Sincegeocaching by design leads offthe beaten path, Miller advised that people read their GPS device manuals and know how they work before heading out. Geocachers need to know the device well enough to get back to the car or trailhead, particularly if the most direct route is not possible due to

magnets.

Michaelson said she enjoys the challenge of a find. "Every once in a while you' re digging around and you can't find it," she said, "but

you never give up." And since people are constantly creating new ones, there is always a fresh pursuit. "We have been tosome beautifulplaces geocaching," she said. "It always leaves you excited." •

SUMMER/FALL 2012• HIGH DESERTPULSE

Judson Brown seeks a clue to finding a geocache on anisland ofgreenin the lava. Below, from left, he finds the container, g examines the clue with GPS coordinates and discovers the cache. I. ' l 'irr RS .,

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Tech savvy Geocachers useGlobal Positioning Satellite, or GPS, technology to find objects with latitude and longi tude coordinates. EachGPSdevice receives signals broadcast by satellites. A device needs signals from at least three satellites at a time to calculate its genera I location and four to get an accurate fix that includes altitude, time, longitude and latitude. A GPSdevice can range in price from 580 to 5500. Some now come with geocaching-specific features. Also, some GPS-enabled smartphones and apps can

be used for geocaching. Several features to consider when looking to buy aGPS device include: • Basemaps.Abasemapisa basicsetofmapdata included with a GPS device, principally road maps of major highways and city streets. VariousGPSdevice brands offer more detailed map data for a price. Buying detailed topographicmaps is highlyrecom mended by Geocaching.corn. • Memory.Detailed maps can use alot of memory on your device. Higher-end devicesusually accept a memory card for additional storage.

• Channels.Multiple channels help the device find satellites more quickly and accurately. Most units to day have 12channels. • Interface.Many newer units have a USBport to make it easy to connect to your computer to down load cache data. • Power source.Most units are powered by AA, AAA or lithium batteries. Some can plug into an external source, like a cigarette lighter. • Water-resistant. Look for a device that is at least water-resistant.

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Dr Michael Mara, center and his wife, Ann, talk with their friend Robert Andrews, of Bend, during a going-away party for them at 10 Barrel Brewing Co. in Bendin June.

Bend surgeon Michael Mara will teach doctors in Kenya for five years BY MARKIAN HAWRYLUK

itting in a luxurious hotel room in Maui on Jan. 12, 2010, Dr. Michael Mara switched on the flatscreen television. He was there with his wife, Ann, to celebrate their shared birthday the next day. The images that flickered on the screen changed the de meanor of their trip. A massive earthquake had hit Haiti, killing more than 300,000 and injuring 300,000 more.

"It just broke my heart," he said. "All those people were dying for

Page 24

the lack of an orthopedic surgeon." It was a turning point for the Maras, a critical event that pushed them toward a journey they had always talked about. By the end of the year, the Bend surgeon had resigned from his job at Desert Orthopedics and committed to a five-year post teaching orthopedic surgery at a missionary hospital in Kenya. "We' ve always kind of had the idea that that was a possibility for us, and then kind of gradually, that urge got stronger and stronger, where I kind of felt I was in the wrong place," Mike Mara said. The Maras had met in Africa in 2001. Mike was in Tanzania teaching

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Dr. Michael Mara holds a Haitian boy during a medical mission to the earthquake-ravaged countryin 2010.

hand surgery for six weeks, while Ann was doing missionarywork. under tarps. A million people ...

Mike had heard about Ann, and took a six-hour bus ride to attend a Les s then two miles from the hospital where he operated, 200,000 Thanksgiving Day party thrown by a friend in the Peace Corps,know- H a itians were buried in a mass grave."They had to get rid of the ing she would be there as well. He left Africa two weeks later, but soon b o d ies for infection control," he said. caught up with Ann in her native Ireland. The two married in 2003 But M ike also saw profound hope in the patients he treated. "There were people who were thanking God for what they do and he convinced Ann they should return to Bend, closing the dealby telling her it doesn't really snow all that much in Central Oregon. have, very actively, very vocally in just the worst setting I can imag ine," he said. "It was incredibly moving to be able to Ruse accomplished, Mike resumed his practice at Desert Orthopedics, but always had in the back of his go into a situation like that and just love people. You' re On mind the idea of returning to Africa. Although special fixing their bones but you' re also just there for them." izing in hand surgery, he continued to take trauma and If there was any lingering doubt it was time to move ollow the Maras' orthopedic cases at the hospital, anticipating a need on, the Haiti trip sealed it. ntureon their blo9, "It was a huge thing. If there'saway I can do that for for those skills if he went abroad again. Ann worked "' r9 for The Justice Conference, a two-day annual event to my career, why would I not do that?" he said. "I came promote dialogue around issues such as human traf home and the die was cast." ficking, slavery, poverty and AIDS. Ann, meanwhile, took no convincing. "I' ve been waiting for nine They settled into the community, buying a house near DrakePark, years," she said. "I was ready." and had two children, Michael, now 7, and Jane, 5. In December, the two spent an evening talking and praying But dreams of returning to Africa continued to simmer. about their decision. There would never be a perfect time to go, When Mike returned from Maui in 2010, he signed on with a re- a n d o nce their kids got older, it would be much more compli lief effort in Haiti. About a month before he was due to arriv e, the c a ted to uproot their lives. The next day, Mike told Pat Hansen, hospital where he was to operate was shut down due to ra mpant t h e CEO at Desert Orthopedics, he was leaving and planned to go infections. The entire building had to be decontaminated and they t o A f rica. told him there was no point in coming. Not to be deterred, hefound Hans en replied, "What took you so long?" another hospital at which he could work. Mike, 48, will teach orthopedic surgery at the Kijabe Hospital, a mis "I'd seen it before in other countries. I'd seen that kind of s uffer- s i on hospital with more than 100 beds on the edge of the Great Rift ing, but not to that magnitude," he said. "Lots of people whowere V a lley, some 30 miles northwest of Nairobi. It's a teaching hospital and injured and nobody to take care of them." he will help train 15 mostly Kenyan doctors — a few Somalis, some The conditions were staggering. Millions of displaced peoplewere S u danese — who have completed medical school and two years of living in tent cities that "stretched to the horizon," he said. "It was a d d itional training. Each year, three new doctors are admitted to the people living like rats. People who had jobs and education and all f i v e-year program at the hospital to become orthopedic surgeons. "There's 40 orthopedic surgeons for 40 million people in Kenya. We of a sudden there's no clean water, no sewage facilities, just living

HIGH DESERT PULSE • SUMMER/FALL 2012

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On thejoh(MISSION MEDICINE

have 20 orthopedic surgeons in Bend," Mike said. "I could go over there and work day and night and not make a dent. If we train Kenyans in orthopedic surgery, we can start to make a dent there." Successful surgery requires a sterile operating environment, an esthesia and the proper equipment. The hospital may not be up to Western standards but it's close, Mike said. "Sterility and anesthesia are nearly the equivalent of what we have here at St. Charles or the Bend Surgery Center," he said. "The main limitations are senior leadership and equipment. It's very much mak ing do, MacGyvering, making the best of what you have."

to be crushed under the weight of it all. I think you have to be happy with small victories." If the Maras had any doubts about their chosen path, they were dispelled by a chance encounter at Antioch Church in Bend. A fellow parishioner introduced the Maras to his son and daughter-in-law, who had just returned from Africa, where they had been working at the hospital in Kijabe. He, a dentist, and she, an obstetrician, were there with their two young children. "We just dove on them," Mike said. "We pulled every detail from them." The demand for care is overwhelming. Most of the people who Then a year ago, Mike went to Kijabe to meet the surgeons and come to the hospital are trauma patients. Traffic accidents are com the staff, and work there for two weeks. "He called me and said, 'The only reason I'm coming home is you mon, seat belts and air bags are not. Pedestrians, especially children, are frequently hit by cars. About 20 percent of his case load will be and the kids,'" Ann recalled. children with birth defects, a consequence of the nutritional chal Their kids are equally excited about the trip. Michael has told his lenges in the region. father he wants to get a spear for hunting. "What are you going to And because it's a mission hospital, which turns away no one, hunt?" Mike asked him. "Fruit," he replied. the vast majority of patients will be poor. Kijabe does attract a fair amount of wealthier Kenyans as well, drawn to the high quality of Jane wants a pet giraffe. "They' ve grown up with the idea of moving, because they know care provided at the hospital or seeking care when the doctors or that's where Mummy and Daddy met and where they fell in love," nurses at government-run hospitals go on strike. "I think the biggest challenge is going to be avoiding despair," Ann, 39, said. "I think we' ve raised them with a sense of adventure." Mike said. "The problems are so bad and so insurmountable, if you The Maras' colleagues in Bend are sad to see them leave, but know go in with the idea that you' re going to fix everything, you' re going the opportunity to help the less fortunate will make them happy.

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SUMMER/ EALL201 2• HIGH DESERTPULSE

Hansen called Mike the "heart and soul" of Desert Orthopedics. "He leads with his heart, not his mind," he said. "If the people were honest and willing on their side, there's nothing Dr. Mara wouldn' t do for them."

road about as far as I can go down it," he said. "It was all right, there was nothing wrong. But I knew there had to be more to life." The Maras believe their good fortune, skills and ability to help people are blessings that come with responsibility. "My role is to steward those gifts. I don't own those gifts. I don' t Mike willingly gave up two days each month — and the payments that came along with that — to volunteer at the Volunteers in Medi own the money. I don't own the ability to do orthopedics," Mike said. "I don't feel like, 'The great white doctor is here.' It's more like, 'Wow, cine clinic in Bend. "We live off of people's goodwill," said Dr. Jim Ritzenthaler, co-medical it's really humbling to be the tip of the spear, to be able to make a director of the VIM clinic. "And Dr. Mara, as long as I' ve been here, has difference.'" probably been one of our great contributors, especially given that his The organization that he will be working with in Kijabe re contributions were in the context of a full-time practice." quires them to raise the money they will need for day-to-day Dr. Randall Jacobs, an urgent-care physician with Bend Memorial living expenses. They were not permitted to pay for any of the Clinic and a close friend of the Maras, said he wasn't surprised the trip themselves, or even to book a flight until the money had Maras decided to move, although he was a little stunned to hear it been raised.

was for five years. "They are motivated in two ways," he explained. "One is just a heart to serve, for those that don't have access to the resource that he can provide. And number two, they' re both very strong Christian people, and they have really resonated and accepted the call to go

"We' ve been fundraising since January and we have over 55 fami lies who have come alongside, who are pledging a monthly amount," Ann said. "Anywhere from, our lowest is $10 a month, to $1,000 a month."

Those families have pledged to support them not only financially serve, and (they' re) giving up a lot of their potential personal things, but spiritually as well. like wealth and security." Mike said his world view has changed a lot since he first became

a physician. "I used to have a really fancy car, a fancy house. I went down that

The Maras have committed to being in Kijabe for five years and say they have no idea what they will do at the end of that time. "We don't have a plan B yet," Mike said. "We' ll just go and see what

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Page 27

Getgeori THEGREATwHEELDEBATE

egggg 11

BY HEIDI HAGEMEIER PHOTO BY PETE ERICKSON

he great wheel debate — long sim

mering among bike geeks — has made its way to the weekend war riors: Which to buy, 26 or 29? Twenty-six-inch wheels have been the standard for mountain bikes since Gary Fish er pedaled his cruiser off-road in the 1970s. But 29-inch wheels, in evolution for the

past decade, have now come of age. Shops across the region are filled with new 29er mountain bikes. The best bike for you, experts say,

depends on how you ride.

Want adrenaline? Go 26. Riding rocks, roots and tight de scents? Travis Lucas, a former Mountain

Bike World Cup mechanic and avid biker, says stick to the 26.

The 26er is lighter, usually by a few pounds, and therefore more manueverable on technical trails. The shorter diameter also means the wheels are sturdier, which mat ters when taking big drops. 'You get into technical kinds of rocky, slip pery situations and you see those people

Page 28

Jeff Clausen 29-inch rider:

A29erju"st rolls overstuffeaslerungues,tionably Some ofthe things that wiljlostle you or throw you offa 26er will not even fazeyou on a29er." SUMMER/FALL 2012

walking their bikes down," Lucas said of 29 riders. Another word continually pops up with the 26: Fast. Less weight means it starts and stops faster. 'You' ll learn skills on a 26er that you can't really learn

on a 29er," said Jeff Clausen, a biking aficionado who owns 26ers and a 29er. "I make it a point every season to go out on every bike once. I'm like, 'Wow, this thing

is like a hummingbird on cocaine.'"

Want all-in-one? Go 29. Those who own just one bike might want to make it a 29er. The smooth, less technical riding of Central Oregon lends itself to a 29er. The bike acts as if it has a bit more suspension, smoothing out obstacles. Compare rolling over a root with a skateboard wheel versus a truck tire — the smaller tire just can't absorb as much

shock. The 29er also makes for comfortable uphill

Travis Lucas 26-inch rider:

climbs, as it grips trails well and doesn't lose as much momentum on bumps and rocks. Clausen says the extra weight of a 29er need not be an issue, even though it entails a bit more exertion. "The average person can just downshift as long as you

have a good selection of gears," he said.

'A29is great for getting from A to 8fast. But a26is a lot more tun on thosespotsin between. It does wheelies,it' s more playful. I'd rather ride mybike than drive my bike." HIGH DESERTPULSE

And $600 to$2,000 can buy a decent front suspen sion 29er that can serve multiple purposes. "If you' re trying to use your one bike for more than one purpose — commute on your mountain bike and ride trails — I think it makes sense," Lucas said. •

Page 29

Mike, a22-year-oldstudentat the UniversityofOregon, said he has babbleddepression since he wasin middle school Talk therapy has helped, but Mike hopes to stop taking antidepressants someday. In June, Mike received transcranial magnetic stimulation therapy, one ofseveral new treatments doctors are using as an alternative to drugs, at Samaritan Mental Health Outpatient Servicesin Corvallis. The therapyis delivered daily over 5-6 weeks.Each 40-minute sessioninvolves 3000 magnetic pulses delivered to specific areas of the brain.

•

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Treating depression ~NEwTEcHNIQUEs

Doctors go straight to the brain with new treatments BY ANNE AURAND PHOTOS BY JOHN KLICKER

evolving landscape of depression treatment, intended for patients who have severe, disabling depression that other treatments haven' t

helped. n a midweek afternoon in June, Mike, a 22-year-old col lege student from Eugene, reclined in what looked like a dentist's chair. He dug an iPhone from his jeans pocket and held it on his thigh, settling in for his 18th treatment of transcranial magnetic stimulation — magnetic pulses into his brain intended to treat major depression. Megan Hogland, the TMS technician at Samaritan Mental Health in

Corvallis, secured a padded bar against the right side of Mike's head

Antidepressant medications are the front-line weapon against

depression, along with psychotherapy, also known as talk therapy, and in extreme cases, electroconvulsive therapy, which electrically induces seizures in the brain. But those methods are either only moderately effective or come with health risks and undesirable side effects.

Dissatisfaction with antidepressants

to immobilize it. She aligned the casing of the machine's magnetic coil directly over his dorsolateral prefrontal cortex — the left front part of his brain, thought to be involved with mood regulation. Then she activated the treatment from a computer screen. When the magnetic pulses started hammering on his skull, the de vice sounded like a machine gun. Mike wore earplugs to protect his

In 2010, antidepressants were the second most commonly prescribed class of drugs in the U.S., according to IMS Health, a health-care information company. Antidepressants alter important neurotransmitters — chemicals such as serotonin, dopamine and norepinephrine that brain cells use to communicate — that are as sociated with mood. hearing. Ten pulses clicked for four seconds. Then a silent, 26-sec Antidepressant use along with psychotherapy can cure many peo ond rest interval. Then the next 10-pulse series. This repeated for 40 ple, but there's still a significant population for whom those treatments don't work, according to Dr. George Keepers, chair of the Oregon Health minutes. "It's like a woodpecker on your head," said Mike, who preferred 8 Science University psychiatry department. "Even if you do everything right with (antidepressants and psy not to have his last name used. "Uncomfortable, but bearable." TMS is a non-invasive therapy that doesn't require the patient to use chotherapy) you have a large number of people ... about 30 percent anesthesia or pain medications. The rapid-fire magnetic pulses feel like ... who do not get over it," Keepers said. "We' re not satisfied with how our current treatments work," he hot, deep zaps. They are not painful, but are intense and annoying. The stimulation can trigger twitches in the facial muscles or make a body said. sweat, especially the first time. It's a relief when it's over, Mike said. Besides, antidepressants can bring their own set of problems. A The Food and Drug Administration approved TMS in 2008 for the group of researchers who examined previous studies on the ben treatment of major depressive disorder in patients for whom antide efits and effects of antidepressant medications concluded that their pressant medications didn't work. Samaritan Mental Health in Cor benefits don't typically outweigh their risks. "We need to be much more cautious about the widespread use vallis started providing the treatment in 2010 and is the only facility in Oregon to offer it. of these drugs," said Paul Andrews, an evolutionary biologist at Mc TMS is just one of a handful of cutting-edge approaches in the Master University in Canada and lead author of the article published

HIGH DESERT PULSE • SUMMER/FALL 2012

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Treating depression( NEW TECHNIQUES

recently in the online journal Frontiers in

Psychology. Studies have shown that antidepressants can create problems with digestion and sex ual stimulation and function. They can also cause abnormal bleeding and stroke. Most people who take antidepressants experi ence sideeffects such as headaches, night sweats, nausea, agitation, dry mouth or con stipation. Studies have shown associations between antidepressant use and h igher rates of death than among non-users. Despite a growing dissatisfaction with an tidepressants, their use has been steadily in creasing. In the United States, doctors wrote about 264 million prescriptions for antide pressants in 2011, according to IMS Health.

What is depression?

Transeranial magnetic stimulation therapy A modern and milder variant of electroconvulsive therapy, non-invasive TMS uses magnetic pulses to stimulate parts of the brain thought to be involved with mood regulation. A magnetic transmission penetrates the skull to a shallow depth in a focused area. It induces electrical currents through brain circuits to connected, deeper regions of the brain. The current activates a massive release of serotonin, dopamine and norephinephrine — neurotrans mitters whose imbalances are linked to major depressive disorder. The outcome is similar to that of antidepressant medications, but to more specific areas of the brain and without unwanted systemic effects of drugs. 6 Prefrontal cortex Concentration, pleasure, interests, mental fatigue

Major depression, also known as clinical depression or unipolar depression, goes beyond ordinary ups and downs, becoming 6 Anterior cingulate

6 Thalamus Sensory perception, sleep cycles 0 Amygdala Guilt, suicidality, worthlessness,mood

cortex a serious medical condition and health con Guilt, suicidality, cern that interferes with someone's ability to Q Hippocampus worthlessness function in life. Emotions, memories Experts believe that major depression is 0 Striatum 0 Brainstem Physical fatigue, neurotransmitter caused by a combination of genetic, biologi centers pleasure, interests cal, environmental and psychological factors. It's considered a disorder of the brain, and 0 Hypothalamus Mood, pleasure most theories suggest that neurotransmitter Sources: "Mechanism of Action,"courtesy Neuronetics, the manufacturer of the transcra nial magnetic stimulation treatment system; chemicals are out of balance in a depressed Dr George Keepers, chair of the Oregon Health 8r Science university psychiatrydepartment

person. Keepers said that during episodes of de pression, a brain functions differently. Re searchers have measured a decrease in met abolic activity in various regions of the brain when a person is depressed. Medications, psychotherapy and electroconvulsive thera py can reverse those metabolic changes. Even the experts don't definitively under stand all the mechanisms behind depression, Keepers said. But it is known that a strong genetic predisposition coupled with stress or traumatic events can greatly increase a person's risk, he said. People with one varia tion of the serotonin transporter gene, for example, are more prone to the develop ment of depression under stress, said Keep

ers. A genetically predisposed person who lost a parent at a young age is more likely to develop depression than one who didn' t lose the parent. Absent the trauma or stress, that person's risk might have matched the

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ANDYZEIGERT

rest of the population that does not have the gene variant. Depression can feel different to every in dividual who has it.

said bad things happened to him. He has

and therapyhave "knocked the edge off,"he

he'sin urgent need ofa safe place,he checks

said, but have never resolved it.

himself into Sage View Psychiatric Center at St. Charles Bend. When told about transcranial magnetic stimulation, he said it sounded like some thing he might be willing to try.

post-traumatic stress disorder. He declined to provide specific details. "For me, I think depression is irreversible. I' ve resigned myself to the fact that it's going For James Hayes, of Redmond, it's physi cal. He hurts all over, he said, and he car to be a monkey on my back for the rest of ries with him a pervasive, intense feeling of my life," he said. being down. At 61, Hayes has spent most He has thought about suicide, and his of his life feeling depressed and about 30 adult sons have at times removed his guns years actively trying to treat it. Medications from hishome. Every now and then, when

Hayes' life was probably a perfect storm for depression. He said many of his relatives

have been diagnosed with major depression and bipolar disorder, which is characterized by more extreme mood swings. This sug gests a genetic component. He also had a

"I keep telling myself I should be able to overcome this, but I am acknowledging that

tough childhood in Texas, during which he I can't on my own," he said.

SUMMER/ I ALL 201 2• HIGH DESERTPULSE

Major depressive disorder: beyond the blues

You would give anything

Clinically-diagnosed major depressive disorder, or major depres sion, according to the National Institutes of Mental Health, is char acterized by a combination of symptoms thatinterfere with a person's ability to work, sleep, study, eat, and enjoy once pleasurable activities. Aboutone in 10 adults,or 10 percent of adults in the United States, deals with depression, according to the Centers for Disease Control and Prevention. Oregon's rates are slightly lower, with between 7 percent and 8 percent of adults having it. It'smore common in women than in men.Most who experience it need treatment to heal.

for your family.

Give theme less radiation and more peace of mind.

Major depression, such as what Hayes experiences, is different than grief or sadness. "A significant part of what we see is grief and loss — loss of a loved one, loss of health function. That can lead to symptoms (of

major depression)," said Brian Evans, a licensed psychologist with the St. Charles Sleep Center in Bend who specializes in mental health patients whose depression is a component of a medical

illness. "It's important to tease out: Is it grief? Or depression? That may affect treatment. We don't want to medicalize a normal life process of grieving," Grief doesn't call for antidepressant medica tions or brain stimulation, but more likely, some kind of therapy to teach the coping skills required to process the grief.

"Depressed people feel worthless, have awful self-esteem," Ev ans said. "That's not the case with grief. But unresolved grief can turn into full-on depression."

Stimulating the brain The prevalence and severity of depression, coupled with dis satisfaction about medications available to treat it, has opened the door to new methods of treating the brain, an electrochemi

cal organ. Some of the newer approaches — TMS, vagus nerve stimula tion and deep brain stimulation — are gentler derivatives of their

predecessor, electroconvulsive therapy, which has been used for decades. Brain stimulation techniques, generally speaking, produce a massive release of serotonin, dopamine and norepinephrine into the brain. "When you stimulate the brain electrically — with a big seizure or a milder one over a longer period of time — you are causing the neurons in the brain to do a bunch of things, one of which is to produce a lot of neurotransmitters all at once," Keepers said. The result is similar to that of antidepressant medications, but

more focused. Electroconvulsive therapy, a well-tested treatment, comes with a high success rate — 70 to 80 percent — but also with some harsh side effects. It was first developed in 1938. Known as "shock" therapy, it garnered a negative reputation, but the procedure has improved

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Treating depression( NEW TECHNIQUES

extra $1,750. Mike said he was lucky — his quickly improving depression. In electroconvul parents' insurance helped. sive therapy, a patient is both sedated and given He stumbled upon TMS while searching over the years and is comparatively effective in

a muscle relaxant while electrical currents pass through electrodes on the head, causing a sei zure in the brain that typically lasts less than a minute. Patients undergo this treatment about three times a week for a couple of weeks. But side effects can include severe memory loss, headaches, upset stomach and muscle aches. Transcranial magnetic stimulation, such as that performed at Samaritan in Corval lis, is a modern variant of electroconvulsive therapy, but without the seizure, the side ef fects, hospitalization or anesthesia, Keepers said. Instead of electrical currents, magnetic pulses penetrate to a shallow depth and in duce an electrical current in the brain. The stimulation goes to a more specific region than in electroconvulsive therapy. Only 11 patients have completed the treat ment protocol — five to six weeks of daily, 40-minute sessions — of TMS treatment at Samaritan. Three more people were in treat ment this summer. Dr. Scott Babe, who spe

Where to get help Feeling depressed? Need help? Concerned about a friend? Crisis hotlines and information: • Deschutes County Behavioral Health: 541-322-7500 •Oregon Suicide and Crisis hotline; www.suicidehotlines.corn/oregon. html This site offers emergency phone numbers for various towns across the state. In Central Oregon; 1-888-232-7192.

the Internet for an alternative to antidepres sant drugs, which hadn't eradicated his de pression and came with undesirable side ef fects. He was unwilling to try electroconvul sive therapy because of its potential to erase memory. So he spent several weeks this summer driving between Eugene and Cor vallis daily for the treatment. It was worth it, he said, "because depressionaffects the whole realm of life and it sucks having it.

You' ll go to such lengths (to resolve it)." Originally from Alaska, Mike said he's felt depression and indifference since middle R

school. I didn't want to do much," he said. R I had no ambition, motivation." It's become more severe recently, since he's been in col lege. It degenerates his mood and shatters his attention span. When it's really bad, his memory falters. The effects of TMS are cumulative. The treatment takes time. About halfway into Mike's treatment, family members told him cializes in general psychiatry and psycho his mood seemed better. As he faced finals somatic medicine for Samaritan Health Ser in June, he said he felt more confident than vices and is the main doctor in Oregon now usual. Once completed, he said finals had providing transcranial magnetic stimulation gone well. therapy, said he believes TMS is underused After the multi-week treatment protocol R because most insurance companies still con ended, Mike said, TMS helped and I feel sider it experimental and won't pay for it. much better." Out of pocket, it costs $9,085 for five weeks, Since the treatment is so new, long-term and for those who need a sixth week, an effectsare yet unknown.

Studies on TMS suggest that it's as effec tive as antidepressants, said Babe. As with patients who first try a new antidepressant, TMS patients have about a 30 percent chance of beingcured and about a 50 percent chance of some measure of improvement, he said.

Other new techniques Another rarely used treatment is called vagus nerve stimulation. It is performed at OHSU. A device called a pulse generator is surgically implanted under the skin in the upper left chest. A wire connects the genera tor to the vagus nerve, which runs from the brainstem through the neck, down the side of thechest and to the abdomen. The gen erator sends continual, regular, brief electrical pulses to the nerve, which reaches areas of the brain that control mood, sleep and more.

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vagus nerve stimulation was found to alter neurotransmitters associated with depres sive symptoms. In 2005, the FDA approved it to treat patients who had severe and re curring depression that hadn't been helped by other treatments. It remains controver sial, according to the National Institutes of Mental Health, because studies on its ef fectivenesshave been mixed. Some insur ance companies, such as Regence BlueCross BlueShield, consider it "investigational" and not medically necessary for the treatment of depression, and therefore don't cover it. The cost of the device and its implantation can

of sending pulses to the heart, the currents hit small, targeted areas in the brain that

be around $25,000.

risky. There's a chance of bleeding in the

OHSU was one site of a big study on the effectiveness of vagus nerve stimulation. About 25 "very sick patients," the type for whom electroconvulsive therapy was not effective, got implants several years ago, Keepers said. About a quarter of the patients

brain, or stroke or infection. The stimulation can create disorientation, unwanted mood

are dysfunctional in depression and mood disorders. Deep brain stimulation is used on an experimental basis only and is the subject of current trials. Some small tri als have shown promising results, and re searchers are hopeful that this might be

something that can help people for whom other treatments have failed. Scientists believe that the pulses help "re set" malfunctioning brain areas, according to the National Institutes of Mental Health. As with any type of brain surgery, it' s

changes or sleeping problems. It's likely that

Deep brain stimulation In deep brain stimulation, electrodes are surgically implanted in areas of the brain involved with depression and other mood disorders. They are controlled by a generator implanted in the chest. Stimulation is Electrode continuous and its

frequency and level is customized to the individual. DBS is available on an experimentalbasis only. A few small studies suggest promising results for treating depression.

improved dramatically, he said.

hoarseness and breathing and swallowing problems. Another technique is deep brain stimu lation, in which electrodes are surgically implanted in the brain and controlled by a generator implanted in the chest. It works somewhat like a pacemaker, except instead

Pulse generator ~

When time is of the essence: Different drugs

suicidal," he said. And it has drawbacks; be cause thedevice affectsa nerve in the neck, it can cause discomfort in the neck or throat,

Source: National Institutes of Mental ffealth

other side effects haven't yet been identi fied, and long-term benefits and side effects are unknown.

This therapy takes time to work. "It's not a life-saving treatment for someone who is

Prob 1

ANDY ZEIGERT

Normally, patients take antidepressants for weeks before they start to work. TMS and vagus nerve stimulation also take time to be effective. So researchers are looking for better ways to save the severely depressed patient who is suicidal, someone who can' t afford to wait a few weeks to see if any par ticular type of treatment might help.

mental but showing some promise is ket

amine, which is approved by the FDA as an anesthetic. It's also a recreational club drug, sometimes called Special K, which can be

found in powder, pill or liquid forms.

Ketamine has been used on battlefields and in emergency rooms as an anesthetic, with injections of about 2 milligrams at a One drug therapy that's purely experi Continued on Page 50

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c are t e a m

a n y t i m e , a n y w h er e .

V isit our new w e b s ite and get co nn ected to y ou r h e al th . Bend Upper Mill 541.389.7741 Bend Eastside. 541.318.4249 Sisters 541.549.9609 H IG H L A K E S H E A L T H C A R E . C O M HIGH DESERT PULSE • SUMMER/FALL 2012

H ea lt h

C are Page35

Kristi Nix, a pediatrician with

MosaicMedicalinBend, gives Dakota House, 7, a regular well-child checkup in June.

Assessing development from sleep to sociability, wellness visits provide a safety net for kids and a sense of security for their parents BY ANNE AURAND PHOTO BY ANDY TULLIS

for potential problems that a parent might not realize exist, such as vision problems, heart murmurs and high cholesterol.

The recommended frequency of well-child visits varies from clinic arring illness or injury, many children stop seeing their pedia to clinic, but generally, children without underlying health problems tricians regularly when they no longer need routine vaccines,

should go annually between ages 2 and 5 and at least every other

around age 6.

year during grade school. Visits should be annual again during pu berty and adolescence, when children experience more physical,

"With older kids, parents can see they' re running around and know they can tell you when things are wrong. So parents are less

emotional and social changes, according to Kim Wollmuth, a pedia

concerned. And kids get busy. Well-child checkups get low on the trician at Central Oregon Pediatric Associates. list," said Kristi Nix, a pediatrician with Mosaic Medical in Bend. But local pediatricians and national organizations recommend school-aged children continue to visit a health-care provider regularly to monitor everything from physical health to social development.

Well-child checkups A well-child checkup is a visit to a doctor in the absence of an ill ness or injury. Such visits provide opportunities for doctors to screen

Page 36

At well-child visits, doctors can screen for anxiety and depression,

and discuss sleep habits, healthy eating, school performance and risks for sports injuries. Immunizations get updated. School-aged

kids may be checked for cholesterol levels, and adolescent girls may need to be checked for anemia after menstruation begins. Doctors review growth and development over time. Obesity and weight-related complications are more prevalent these

days, and they start young. Nix said she sees kids as young as 4 who

SUMMER/ FALL 201 2• HIGH DESERTPULSE

Recommended eheekup schedule The American Academy of Pediatrics developed this ambitious "Bright Futures" guideline, considered a gold standard for health supervision. In the past, many insurance companies covered one checkup every two years for school-aged children and teens. Newer policies are now required by the Patient Protection and Affordable Care Act to cover checkups according to this preventive health care schedule, said Kim Wollmuth, a pediatrian at Central Oregon Pediatric Associates. A well-child checkup includes: • To be performedQ Risk assessment to be performed, action to follow if positive

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are at risk for high cholesterol and diabetes. In Central Oregon, 24 per relieved it wasn't an injury and didn't need treatment. cent of kids are overweight by eighth grade, with 10 percent of them Sports physicals falling into the obese category, Nix said. "Obesity sneaks up on families quietly," she said. "Our perception Well-child checkups are more comprehensive than sports physi

of how kids should look has changed so we don't often look at an cals, which are required biannually for children from seventh grade at-risk kid and feel like he's got a weight problem. We are all used up who join extracurricular school sports programs. Sports physi to looking at heavy kids." Ongoing height and weight checks are cals require a medical provider to clear the child to play a sport important, she said. But another less tangible benefit of regular checkups, both pedia tricians said, is establishing a relationship with a doctor. "If a child comes in for annual visits, they have less anxiety and more comfort with doctors, so when I start asking about sex and drugs in adolescence, there is at least an expectation that we' ll go over issues like that. I feel like that enhances adolescent care," Nix said.

after examining the patient's cardiovascular and musculoskeletal health. But sports physicals are not a substitute for more inclusive well

child checks, which delve deeper than the question of the child' s

ability to play, Wollmuth said. Some athletes participate in convenient, mass sports physical clinics that rotate kids through various health stations, Wollmuth Bend mom Rachel Schaedler takes her six children, who range in said. Screening questions are asked about prior injuries, asthma, age from 15 months to 19 years, for annual checkups to see how fainting, concussions, seizures and family history of heart disease much they' ve grown and if everything is on track. or sudden death. Sometimes orthopedic and cardiac care special "I just think it's important. You might find something," she said. ists are involved. But, she said, this method provides a snapshot For example, her 13-year-old daughter Larissa Maguire had pain in time. Care providers don't usually have a patient's records or and swelling in her right knee one day when she was running. She growth charts to review. happened to have a well-child checkup scheduled at Mosaic Medical For those who get routine well-child checks, making an additional the next day, so Schaedler suggested Larissa talk to a doctor about sports physical appointment is not necessary. "When you get a well it there. Turned out it was a common knee condition that goes away child check, ask for a sports physical as part of it," Nix said. "It's just with time. a form to fill out. We' ve done everything we need to for sports physi "It's always nice to know, 'Oh, that's why,'" Schaedler said. She was cal in a well-child checkup. Bring a form or make sure we have it."•

HIGH DESERT PULSE • SUMMER/FALL 2012

Page 37

AOVERTISINGSUPPLEMENT

2 012 C E N T RA L O R E G O N

Your

S o u r c e f o r Lo c a l H e a l t h S e r v i c e s a n d Ex p e r t M e d i c a l P r o f e s s i o n a l s To list your medical office andyor physicians in the PULSE/Connections Medical Directory contact...

Lorrain e S t a r o d u b , A c c o u n t E x e c u t i v e ( H e a l t h Bc M e d i c a l ) • 5 4 1 . 6 1 7 . 7 8 5 5 l •

• •

•

••

•

A 119 N RopeStreet • Sisters

541-588-6119

DermaSpa at Bend Dermatology

2705 NE Conners Drive• Bend

541-330-9139

Bend Memorial Clinic

Locations in Bend StRedmond

541-382-4900

1099 NE Watt Way• Bend

541-385-4717

ADULT FOSTER CARE

Absolute Serenity Adult Foster Care

AESTHETIC SERVICES ALLERGY IAASTHMA

ALZHEIMERS IA DEMENTIA CARE Clare Bridge Brookdale Senior Livt 'ng

wwwab s oluteserenity.info

www.bendderm.corn www . bendmemorialclinic.corn www. brookdaleli ving.corn

ASSISTED LIVING

Brookside Place

3550 SWCanalBlvd •Redmond

541-504-1600

BEHAVIORAL HEALTH

St. Charles Behavioral Health

2542 NE Courtney Drive• Bend

541-706-7730

CANCER CARE

St. Charles Cancer Center

Locations in Bend StRedmond

541-706-5800

www. s tcharleshealthcare.org

Locations in Bend StRedmond

541-382-4900

www . bendmemorialclinic.corn

2500 NE Neff Road• Bend

541-706-6900

www .heartcentercardiology.corn

2500 NE Neff Road• Bend

541-388-1636

www. s tcharleshealthcare.org

2GOO NENeffRoad • Bend

541-382-4900

www . bendmemorialclinic.corn

CARDIOLOGY

Bend Memorial Clinic

CARDIOLOGY

The Heart Center

CARDIOTHORACIC SURGERY S t . Charles Cardiothoracic Surgery COSMETIC SERVICES

Bend Memorial Clinic

COUNSELING & WELLNESS

J u n i per Mountain Counseling gt Wellness

DERMATOLOGY

ENDOCRINOLOGY

334 NE Irving Ave, Ste 102 • Bend

541-617-0377

ww wjunipermountaincounseling.corn

Sisters Denture Specialties

I GI E Cascade• Sisters

541-549-0929

www. r aordenturecenter.corn

Bend Dermatology Clinic

FAMILY MEDICINE

www.bendderm.corn

2747 NE Conners Drive• Bend

541-382-5712

Bend Memorial Clinic

2GOO NENeffRoad • Bend

541-382-4900

www . bendmemorialclinic.corn

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

www . bendmemorialclinic.corn

Endocrinology ServicesNW Bend Memorial Clinic

FAMILY MEDICINE

www.ccliving.corn www. s tcharleshealthcare.org

St. Charles Family Care in Bend

2084 NW Professional Court• Bend

541-317-56oo

Locations in Bend, Redmond StSisters

541-382-4900

www . bendmemorialclinic.corn

29G5 NE ConnersAve, Suite 127 • Bend

541-706-4800

www. s tcharleshealthcare.org

St. Charles Family Care in Prineville

1103 NE ElmStreet • Prineville

541-447-6263

www. s tcharleshealthcare.org

St. Charles Family Care in Redmond

211 NWinarchAvenue• Redmond

541-548-2164

www. s tcharleshealthcare.org

G15 ArrowleafTrail• Sisters

541-549-1318

www. stcharleshealthcare.org

St. Charles Family Care in Sisters

FAMILY PRACTICE

High Lakes Health Care

GASTROENTEROLOGY

Bend Memorial Clinic

GASTROENTEROLOGY

GastroenterologyofCentral Oregon

GENERAL DENTISTRY

Coombe and Jones Dentistry

GENERAL SURGERY

Surgical Associates of the Cascades

GENE RALSURGERY,RARIAYRICSAVEINCARE Advanced Specialty Care

Locations in Bend StSisters

541-389-7741

www . highlakeshealthcare.corn

1501 NE Medical Center Drive• Bend

541-382-4900

www . bendmemorialclinic.corn

2450 Mary Rose Place, Ste 210• Bend

541-728-0535

www. gastrocentraloregon.corn www.c o ombe-jones.corn

774 SW Rimrock Way• Redmond

541-923-7633

1245 NW 4th Street, Ste 101 • Redmond

541-548-7761

www.cosurgery.corn

2084 NE Professional Court• Bend

541-322-5753

1245 NW 4th Street, Ste 101 • Redmond

541-548-7761

St. C h arles Home Health Services

2500 NE Neff Road• Bend

541-706-7796

Partners In Care

2075 NE Wyatt Ct.• Bend

541-382-5882

Mountain View Hospital

470 NE 'A" Street• Madras

541-475-3882

www. s tcharleshealthcare.org www. stcharleshealthcare.org

GENERALSURGERY & OBESITY CARE

Cascade Obesity and General Surgery

HOME HEALTH SERVICES

HOSPICE/HOME HEALTH HOSPITAL

www .advancedspecialtycare.corn www.cosurgery.corn www. s tcharleshealthcare.org www.partnersbend.org

www, mvhd, org

HOSPITAL

Pioneer Memorial Hospital

1201 NE Elm St• Prineville

541-447-6254

HOSPITAL

St. Charles Bend

2500 NE Neff Road• Bend

541-382-4321

HOSPITAL

St. Charles Redmond

1253 NE Canal Blvd• Redmond

541-548-8131

www. stcharleshealthcare.org

HOSPITAL I ST

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

www . bendmemorialclinic.corn

1501 NE Medical Center Drive• Bend

541-382-4900

www . bendmemorialclinic.corn

Locations in Bend StRedmond

541-382-4900

www . bendmemorialclinic.corn

HYBERBARIC OXYGENTHERAPY Bend Memorial Clinic IMAGING SERVICES

Bend Memorial Clinic

IMMEDIATE CARE

St. Charles Immediate Care

INFECTIOUS DISEASE

Bend Memorial Clinic

2GOO NENeffRoad • Bend

541-706-3700

www. s tcharleshealthcare.org

1501 NE Medical Center Drive• Bend

541-382-4900

www . bendmemorialclinic.corn

2 012 CE N T RA L O R E G O N •

OVERTISINGSUPPLEMENT

M E D I CA L D I RECTORY B

INTEGRATED MEDICINE

Center for Integrated Medicine

INTERNAL MEDICINE

Bend Memorial Clinic

INTERNAL MEDICINE

High Lakes Health Care Upper Mill

INTERNAL MEDICINE

Internal Medicine Associates of Redmond

INTERNAL MEDICINE

Redmond Medical Clinic

LASIK

91G SW17th St, Ste 202 • Redmond

541-504-0250

ww w .centerforintegratedmed.corn

Bend Eastside 8/Westside

541-382-4900

www . bendmemorialclinic.corn

929 SW Simpson Ave• Bend

541-389-7741

www . highlakeshealthcare.corn www.imredmond.corn

23GNW Kingwood Ave • Redmond

541-548-7134

1245 NW 4th Street, Ste 201• Redmond

541-323-4545

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

www . bendmemorialclinic.corn

MEDICAL CLINIC

Bend Memorial Clinic

ooos w Mr.o„l I 5 • 8 otw r/ 541-382-4900

www . bendmemorialclinic.corn

MEDICAL CLINIC

Bend Memorial Clinic

1501 NEMedical Center Dr • Bend (East) 541-382-4900

www . bendmemorialclinic.corn

MEDICAL CLINIC

Bend Memorial Clinic

231 East CascadesAve• Sisters

541-382-4900

www . bendmemorialclinic.corn

MEDICAL CLINIC

Bend Memorial Clinic

8G5 SWVeterans Way• Redmond

541-382-4900

www . bendmemorialclinic.corn www . bendmemorialclinic.corn

NEPHROLOGY

Bend Memorial Clinic

Locations in Bend, Redmond 8/ Sisters

541-382-4900

NEUROLOGY

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

www . bendmemorialclinic.corn

541-382-3344

www.t h ecenteroregon.corn

NEUROSURGERY NUTRITION

The Center: Orthopedic 8/ Neurosurgical Care8/Researd/ L o c a tions in Bend 8/ Redmond

Bend Memorial Clinic

OBSTETRICS &GYNECOLOGY E ast Cascade Women's Group, P.C. OBSTETRICS &GYNECOLOGY S t. Charles OB /GYN - Redmond OCCUPATIONAL MEDICINE OCCUPATIONAL MEDICINE

Ben d Memorial Clinic

Locations in Bend, Redmond 8/ Sisters

541-382-4900

www . bendmemorialclinic.corn ww w .eastcascadewomensgroup.corn

2400 NE Neff Road, Ste A• Bend

541-389-3300

213 NW Larch Ave,Suite B• Redmond

541-526-6635

www. s tcharleshealthcare.org

Locations in Bend 8/Redmond

541-382-4900

www . bendmemorialclinic.corn

541-382-3344

www.t h ecenteroregon.corn

The C e nter:Orthopedic 8/Neurosurgical Care@Researd/ L o c a tions in Bend 8/ Redmond

ONCOLOGY - MEDICAL

Bend Memorial Clinic

Locations in Bend 8/Redmond

541-382-4900

www . bendmemorialclinic.corn

OPHTHALMOLOGY

Bend Memorial Clinic

Locations in Bend 8/Redmond

541-382-4900

www . bendmemorialclinic.corn

OPTOMETRY

Bend Memorial Clinic

Locations in Bend 8/Redmond

541-382-4900

www . bendmemorialclinic.corn

ORTHOPEDICS

Desert Orthopedics

Locations in Bend 8/Redmond

541-388-2333

www. d esertorthopedics.corn

ORTHOPEDICS

541-382-3344

www.t h ecenteroregon.corn

2200 NENeffRoad,Suite302 • Bend

541-388-3978

ww wdeschutesosteoporosiscentercom

2500 NE Neff Road• Bend

541-706-5880

www. s tcharleshealthcare.org

1230 NE 3rd Street, Suite A-174• Bend

541-389-6600

www.d entistryforkidz.corn

The Center: Orthopedic 8/ Neurosurgical Care8/Researd/ L o c a tions in Bend 8/ Redmond

OSTEOPOROSIS

Deschutes Osteoporosis Center

PALLIATIVE CARE

St. Charles Advanced Illness Management

PEDIATRIC DENTISTRY

Dentistry For Kidz

PEDIATRIC DENTISTRY

Deschutes PediatricDentistry

1475SWChandlerAve, Ste202• Bend

541-389-3073

www.d eschuteskids.corn

PEDIATRICS

Bend Memorial Clinic

1080 SWMt. Bachelor Dr • Bend (West)

541-382-4900

www . bendmemorialclinic.corn

20G5 NE Williamson Court, Suite B • Bend

541-382-0287

Locations in Bend 8/Redmond

541-388-2333

PHARMACY PHYSICAL MEDICINE PHYSICAL MEDICINE

I V/ C I

I I*

Desert Orthopedics

541-382-3344

www.t h ecenteroregon.corn

1501 NE Medical Center Drive• Bend

541-382-4900

www . bendmemorialclinic.corn

2275 NE Doctors Dr¹3 ti 33GSWCyber Dr Ste107

541-382-5500

www .alpinephysicaltherapy.corn

404 NE PennAvenue • Bend

541-318-7041

Offices in Bend, Redmond 8/ Prineville

541-388-2881

Locations in Bend 8/Redmond

541-382-4900

The Center: Orthopedic 8/ Neurosurgical Care8/Researd/ L o c a tions in Bend 8/ Redmond

PHYSICAL MEDICINE/REHABILITATION

Bend Memorial Clinic

PHYSICAL THERAPY

Alpine Physical Therapy gt Spine Care

PHYSICAL THERAPY

Healing Bridge Physical Therapy

PODIATRY

Cascade Foot Clinic

PULMONOLOGY

Bend Memorial Clinic

PULMONOLOGY

St. Charles Pulmonary Clinic

RADIOLOGY

Central Oregon Radiology Associates, P.C.

REHABILITATION RHEUMATOLOGY RHEUMATOLOGY

DeschutesRheumatology

www.homecareiv.corn www. d esertorthopedics.corn

www.healingbridge.corn www . bendmemorialclinic.corn

Locations in Bend 8/Redmond

541-706-7715

14GO NE Medical Center Dr • Bend

541-382-9383

www. s tcharleshealthcare.org

St. Charles Rehabilitation Center

Locations in Bend 8/Redmond

541-706-7725

www. s tcharleshealthcare.org

Bend Memorial Clinic

Locations in Bend 8/Redmond

541-382-4900

www . bendmemorialclinic.corn

www.corapc.corn

2200 NENeffRoad,Suite 302 • Bend

541-388-3978

Bend Memorial Clinic

Locations in Bend 8/Redmond

541-382-4900

SLEEP MEDICINE

St. Charles Sleep Center

Locations in Bend 8/Redmond

541-706-6905

www. s tcharleshealthcare.org

SURGICAL SPECIALIST

Bend Memorial Clinic

Locations in Bend 8/Redmond

541-382-4900

www . bendmemorialclinic.corn

URGENT CARE

Bend Memorial Clinic

UROLOGY

Urology Specialists of Oregon

VASCULAR SURGERY

Bend Memorial Clinic

VEIN SPECIALISTS

Inovia Vein Specialty Center

Locations inBend(East 8/West) 8/ Redmond 541-382-4900 2084 NE Professional Court• Bend

541-322-5753

1501 NE Medical Center Drive• Bend

541-382-4900

2200 • E Neff Road, Ste 204• Bend

541-382-8346

/ www . bendmemorialclinic.corn

www . bendmemorialclinic.corn ht t/p/usof : or.praxismedicalgroup.com www . bendmemorialclinic.corn www.bendvein.corn

2 012 CE N T RA L O R E G O N •

ADAM WILLIAMS, MD

•

M E D I CA L D I RECTORY

•

Bend Memorial Clinic

STEPHEN ARCHER, MF, FACS Advanced Specialty Care

•

OVERTISINGSUPPLEMENT

•

541-382-4900

www . bendmemorialclinic.corn

2084NEProfessional Court• Bend

541- 3 2 2-5753

www . advancedspecialtycare.corn

Bend Eastside 8 Redmond

PHILIP B.ANDERSON, MD

St. Charles Behavioral Health

2542 • E Courtney Dr • Bend

541-706-7730

www.stcharleshealthcare.org

KAREN CAMPBELL, PILD

St. Charles Behavioral Health

2542 • E Courtney Dr • Bend

541-706-7730

www.stcharleshealthcare.org

RYAN C. DIX, PsyD

St. Charles Family Care

1103 • E Elm Street, Ste C• Prineville

541-447-6263

www.stcharleshealthcare.org

BRIAN T. EVANS, PsyD

St. Charles Behavioral Health

2542 • E Courtney Dr •

541-706-7730

www.stcharleshealthcare.org

EUGENE KRANZ, PILD

St. Charles Behavioral Health

2542 • E Courtney Dr •

541-706-7730

www.stcharleshealthcare.org

SONDRA MARSHALL, PILD

St. Charles Behavioral Health

2542 • E Courtney Dr •

541-706-7730

www.stcharleshealthcare.org www.stcharleshealthcare.org

NATHAN OSBORN, MD

St. Charles Behavioral Health

2542 • E Courtney Dr • Bend

541-706-7730

MIKALA SACCOMAN, PILD

St. Charles Behavioral Health

2542 • E Courtney Dr • Bend

541-706-7730

www.stcharleshealthcare.org

LEAH SCHOCK, PILD

St. Charles Behavioral Health

2542 • E Courtney Dr • Bend

541-706-7730

www.stcharleshealthcare.org

REBECCA SCRAFFORD, PsyD

St. Charles Behavioral Health

2542 • E Courtney Dr • Bend

541-706-7730

www.stcharleshealthcare.org

KIMBERLY SWANSON, PILD

St. Charles Behavioral Health

2542 • E Courtney Dr • Bend

541-706-7730

www.stcharleshealthcare.org

•

JEAN BROWN, PA-C

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

www.bendmemorialclinic.corn

RICK KOCH, MD

Bend Memorial Clinic

Bend Eastside 8 Redmond

541-382-4900

www.bendmemorialclinic.corn

GAVIN L.NOBLE, MD

Bend Memorial Clinic

Bend Eastside 8 Redmond

541-382-4900

www.bendmemorialclinic.corn

STEPHANIE SCOTT, PA-C

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

www.bendmemorialclinic.corn

JASON WEST, MD

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

www.bendmemorialclinic.corn

•

JOHN D. BLIZZARD, MD

St.Charles Cardiothoracic Surgery

2500 • E Neff Road• Bend

541-388-1636

www.stcharleshealthcare.org

DARIN CLEMENT, PA-C

St.Charles Cardiothoracic Surgery

2500 • E Neff Road• Bend

541-388-1636

www.stcharleshealthcare.org

541-388-1636

www.stcharleshealthcare.org

541-388-1636

www.stcharleshealthcare.org

541-388-1636

www.stcharleshealthcare.org

CARL E. MILLER, PA-C

St.Charles Cardiothoracic Surgery

2500 • E Neff Road• Bend

ANGELO A. VLESSIS,MD

St.Charles Cardiothoracic Surgery

2500 • E Neff Road• Bend

TIMOTHY J.ZERGER, PA-C

St.Charles Cardiothoracic Surgery

2500 • E Neff Road• Bend

JASON M.KREMER,DC,CCSP, CSCS Wellness Doctor

1345 NW Wall St, Ste 202• Bend

541- 3 1 8-1000

www. b endwellnessdoctor.corn

MICHAEL R. HALL, DDS

1563 NW Newport Ave• Bend

541-3 8 9 -0300

www .centraloregondentalcenter.net

1016 NW Newport Ave• Bend

541-389-1107

Central Oregon Dental Center

BRADLEY E. JOHNSON, DMD C o n temporary Family Dentistry •

wwwc ontemporaryfamilydentistrycorn

•

ALYSSA ABBEY, PA-C

Bend Memorial Clinic

2600 NE Neff Road• Bend

541-382-4900

www . bendmemorialclinic.corn

ANGELA COVINGTON, MD

Bend Memorial Clinic

2600 NE Neff Road• Bend

541-382-4900

www . bendmemorialclinic.corn

541-678-0020

ww w.centraloregondermatology.corn

541-382-4900

www . bendmemorialclinic.corn

541-382-4900

www . bendmemorialclinic.corn

541-382-4900

www . bendmemorialclinic.corn

MARK HALL, MD

CentralOregon Dermatology

JAMES M. HOESLY, MD

Bend Memorial Clinic

2600 NE Neff Road• Bend

GERALD E. PETERS,MD, DS (ttohs)

Bend Memorial Clinic

2600 NE Neff Road• Bend

ANN M. REITAN, PA-C(ttohs)

Bend Memorial Clinic

2600 NE Neff Road• Bend

MARY F. CARROLL, MD

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

54 1 -382-4900

www. bendmemorialclinic.corn

RICK N.GOLDSTEIN, MD

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

www.bendmemorialclinic.corn

TONYA KOOPMAN, MSN, FNP-BC Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

www.bendmemorialclinic.corn

I•

388 SW Bluff Dr• Bend

' •

•

PATRICK MCCARTHY, MD

Endocrinology ServicesNW

2084 NW Professional Court• Bend

541-317-5600

n/a

TRAVIS MONCHAMP, MD

Endocrinology ServicesNW

2084 NW Professional Court• Bend

541-317-5600

n/a

2 012 CE N T RA L O R E G O N

M E D I CA L D I RECTORY

OVERTISINGSUPPLEMENT

CAREY ALLEN, MD

St. Charles Family Care

1103 NE Elm Sueet• Prineville

541-447-6263

www . stcharleshealthcare.org

HEIDI ALLEN, MD

St. Charles Family Care

1103 NE Elm Sueet• Prineville

541-447-6263

www.stcharleshealthcare.org

211 NW Larch Avenue• Redmond

541-548-2164

www . stcharleshealthcare.org

THOMAS L. ALLUMBAUGH, MD St. Charles Family Care KATHLEEN C. ANTOLAK, MD

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

ww w .bendmemorialclinic.corn

SADIE ARRINGTON, MD

Bend Memorial Clinic

865 SW Veterans Way• Redmond

541-382-4900

ww w .bendmemorialclinic.corn

JOSEPH BACHTOLD, DO

St. Charles Family Care

61 5 Arrowleaf Trail• Sisters

541-549-1318

www .stcharleshealthcare.org

EDWARD BIGLER, MD

High Lakes Health CareUpper Mill

JEFFREY P.BOGGESS, MD

Bend Memorial Clinic

BRANDON W. BRASHER, PA-C SHANNON K. BRASHER, PA-C

929 SW Simpson Avenue• Bend

541-389-7741J

.I ikkl k k k k «

1080 SW Mt. Bachelor Drive• Bend

541-382-4900

ww w .bendmemorialclinic.corn

St. Charles Family Care

1103 NE Elm Sueet• Prineville

541-447-6263

www . stcharleshealthcare.org

St. Charles Family Care

1103 NE Elm Sueet• Prineville

541-447-6263

www . stcharleshealthcare.org

MEGHAN BRECKE, DO

St. Charles Family Care

29G5 NE ConnersAve, Suite 127 • Bend

541-706-4800

www . stcharleshealthcare.org

NANCY BRENNAN, DO

St. Charles Family Care

29G5 NE ConnersAve, Suite 127 • Bend

541-706-4800

www . stcharleshealthcare.org

WILLIAM C.CLARIDGE, MD

St. Charles Family Care

211 NW Larch Avenue• Redmond

541-548-2164

www . stcharleshealthcare.org

MATTHEW CLAUSEN, MD

St. Charles Family Care

29G5 NE ConnersAve, Suite 127 • Bend

541-706-4800

www . stcharleshealthcare.org

LINDA C. CRASKA, MD

St. Charles Family Care

1103 NE Elm Sueet• Prineville

541-447-6263

www . stcharleshealthcare.org

AUDREY DAVEY, MD

Bend Memorial Clinic

Bend Eastside SkWestside

541-382-4900

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AMY DELOUGHREY, PA-C

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

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JAMES K. DETWILER, MD

St. Charles Family Care

211 NW Larch Avenue• Redmond

541-548-2164

www . stcharleshealthcare.org

MAY S. FAN, MD

Bend Memorial Clinic

231 East Cascades Avenue• Sisters

541-382-4900

ww w .bendmemorialclinic.corn

JAMIE FREEMAN, PA-C

High Lakes Health CareUpper Mill

929 SW Simpson Avenue• Bend

541-389-7741

www.highlakeshealthcare.corn

MARK GONSKY, DO

St. Charles Family Care

29G5 NE ConnersAve, Suite 127 • Bend

541-706-4800

www.stcharleshealthcare.org

STEVEN GREER, MD

St. Charles Family Care

61 5 Arrowleaf Trail• Sisters

541-549-1318

www.stcharleshealthcare.org

ALAN C. HILLES, MD

Bend Memorial Clinic

Redmond Sk Sisters

541-382-4900

www.bendmemorialclinic.corn

PAMELA J. IRBY, MD

St. Charles Family Care

211 NW Larch Avenue• Redmond

541-548-2164

www.stcharleshealthcare.org

MAGGIE J. KING, MD

St. Charles Family Care

1103 NE Elm Sueet• Prineville

541-447-6263

www.stcharleshealthcare.org

PETER LEAVITF, MD

St. Charles Family Care

29G5 NE ConnersAve, Suite 127 • Bend

541-706-4800

www.stcharleshealthcare.org

CHARLOTTE LIN, MD

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

www.bendmemorialclinic.corn

STEVE MANN, DO

High Lakes Health Care UpperMill

929 SW Simpson Avenue• Bend

541-389-7741

www.highlakeshealthcare.corn

JOE T.MC COOK, MD

St. Charles Family Care

211 NW Larch Avenue• Redmond

541-548-2164

www.stcharleshealthcare.org

LORI MCMILLIAN, FNP

Redmond Medical Clinic

1245 NW 4th Street, Ste 201• Redmond

541-323-4545

n/a

EDEN MILLER, DO

High Lakes Health Care Sisters

354 W Adams Avenue• Sisters

541-549-9609

www.highlakeshealthcare.corn

KEVIN MILLER, DO

High Lakes Health Care Sisters

354 W Adams Avenue• Sisters

541-549-9609

www.highlakeshealthcare.corn www.highlakeshealthcare.corn

929 SW Simpson Avenue• Bend

541-389-7741

DANIEL J. MURPHY, MD

211 NW Larch Avenue• Redmond

541-548-2164

www.stcharleshealthcare.org

SHERYL L. NORRIS, MD

211 NW Larch Avenue• Redmond

541-548-2164

www.stcharleshealthcare.org

1247 NE Medical Center Drive• Bend

541-318-4249

www.highlakeshealthcare.corn www.bendmemorialclinic.corn

JESSICA MORGAN, MD

AUBREY PERKINS, FNP

High Lakes Health Care Upper Mill

High Lakes Health Care East

JANEY PURVIS, MD

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

KEVIN REUTER, MD

High Lakes Health Care East

1247 NE Medical Center Drive• Bend

541-318-4249

www.highlakeshealthcare.corn

DANA M. RHODE, DO

Bend Memorial Clinic

1080 SW Mt. Bachelor Drive• Bend

541-382-4900

www.bendmemorialclinic.corn

HANS G. RUSSELL, MD

Bend Memorial Clinic

Bend Eastside SkWestside

541-382-4900

www.bendmemorialclinic.corn

ERIC J. SCHNEIDER, MD

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

www.bendmemorialclinic.corn

CINDY SHUMAN, PA-C

Bend Memorial Clinic

1080 SW Mt. Bachelor Drive• Bend

541-382-4900

www.bendmemorialclinic.corn

JENNIFER SURBER, MD

High Lakes Health Care East

1247 NE Medical Center Drive• Bend

541-318-4249

www.highlakeshealthcare.corn

EDWARD M. TARBET, MD

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

www.bendmemorialclinic.corn

JOHN D. TELLER, MD

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend ~ 541-382-4900

www.bendmemorialclinic.corn

2 012 CE N T RA L O R E G O N

OVERTISINGSUPPLEMENT

M E D I CA L D I RECTORY

St . Charles Family Care

211 NW Larch Avenue• Redmond 5 4

LISA URI, MD

High Lakes Health Care Upper Mill

929 SW Simpson Avenue• Bend

541-389-7741

www.highlakeshealthcare.corn

MARK A. VALENTI, MD

St. Charles Family Care

211 NW Larch Avenue• Redmond

541-548-2164

www.stcharleshealthcare.org

THOMAS A. WARLICK, MD

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

www.bendmemorialclinic.corn

High Lakes Health Care East

1247 NE Medical Center Drive• Bend

541-318-4249

www.highlakeshealthcare.corn

1103 NE Elm Sueet• Prineville

541-447-6263

www.stcharleshealthcare.org

BILL WIGNALL, MD BRUCE N. WILLIAMS, MD

DAVID KELLY, MD '

St. Charles Family Care

High Lakes Health Care Upper Mill •

929 SW Simpson Avenue• Bend 5

1- 5 4 8-2164

www.stcharleshealthcare.org

NATHAN R. THOMPSON, MD

41- 3 8 9-7741

www.highlakeshealthcare.corn

•

RICHARD H. BOCHNER, MD

I Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

www.bendmemorialclinic.corn

ELLEN BORLAND, MS, RN, CFNP Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

www.bendmemorialclinic.corn

ARTHUR S. CANTOR, MD

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

www.bendmemorialclinic.corn

HEIDI CRUISE, PA-C, MS

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

www.bendmemorialclinic.corn

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

www.bendmemorialclinic.corn

SIDNEY E. HENDERSON III, MD

Be nd Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

www.bendmemorialclinic.corn

SANDRA K. HOLLOWAY, MD

Ben d Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

www.bendmemorialclinic.corn

450 Mary Rose Place, Ste 210• Bend

541-728-0535

www.gastrocentraloregon.corn

1501 NE Medical Center Drive• Bend

541-382-4900

www.bendmemorialclinic.corn

J T

GLENN KOTEEN, MD

GastroenterologyofCentral Oregon

MATTHEW WEED, MD

Bend Memorial Clinic

CHRISTY ENGLAND, PA-C

Advanced Specialty Care

2084 NE Professional Court• Bend

541-322-5753

w w w.advancedspecialtycare.corn

NICOLLE O' NEIL, PA-C

Advanced Specialty Care

2084 NE Professional Court• Bend

541-322-5753

w w w.advancedspecialtycare.corn

NGOCTHUY HUGHES, DO, PC

Ca s cade Obesity and General Surgery

1245 NW 4th Street, Ste 101 • Redmond 54 1 -548-7761

JOHN R. ALLEN, MD

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

www.bendmemorialclinic.corn

LAURIE D'AVIGNON, MD

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

www.bendmemorialclinic.corn

GINGER L.DATTILO, MD

Bend Memorial Clinic

1501 NE MedicalCenter Drive• Bend

541-382-4900

www.bendmemorialclinic.corn

MATTHEW DAVEY, MD

Bend Memorial Clinic

1501 NE MedicalCenter Drive• Bend

541-382-4900

www.bendmemorialclinic.corn

BENJAMIN ENGLAND, MD

Bend M emorial Clinic

1501 NE MedicalCenter Drive• Bend

541-382-4900

www.bendmemorialclinic.corn

MICHAEL GOLOB, PA-C

Bend Memorial Clinic

1501• E Medical Center Drive• Bend

541-382-4900

www.bendmemorialclinic.corn

ADRIAN KRUEGER, PA-C

Bend Memorial Clinic

1501• E Medical Center Drive• Bend

541-382-4900

www.bendmemorialclinic.corn

SUZANN KRUSE, PA-C

Bend Memorial Clinic

541-382-4900

www.bendmemorialclinic.corn

PHONG NGO, MD

Bend Memorial Clinic

J 1501• E Medical Center Drive• Bend T 1501• E Medical Center Drive• Bend

541-382-4900

www.bendmemorialclinic.corn

DEONA J. WILLIS, FNP-C

Bend Memorial Clinic

1501• E Medical Center Drive• Bend

541-382-4900

www.bendmemorialclinic.corn

LAURIE D'AVIGNON, MD

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend 541 -382-4900

www.bendmemorialclinic.corn

JON LUTZ, MD

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend 541 -382-4900

www.bendmemorialclinic.corn

JENESS CHRISTENSEN, MD

High L akes Health Care Upper Mill

•

www.cosurgery.corn

929 SW Simpson Avenue• Bend

541-389-7741

www.highlakeshealthcare.corn

929 SW Simpson Avenue• Bend

541-389-7741

ww w .highlakeshealthcare.corn

JOHN CORSO, MD

High Lakes Health Care Upper Mill

CELSO A.GANGAN, MD

Redmond Medical Clinic

1245 NW 4th Street, Ste 201• Redmond

541-323-4545

MICHAEL N. HARRIS,MD

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

ANNE KILLINGBECK, MD

Internal Medicine Associates of Redmond

ANITA D.KOLISCH, MD

Bend Memorial Clinic

MATTHEW R. LASALA, MD

Bend Memorial Clinic

23G NW Kingwood Ave• Redmond

541-548-7134

Bend Eastside St Redmond

541-382-4900

1501 NE Medical Center Drive• Bend ~ 541-382-4900

/ www .bendmemorialclinic.corn

www.imredmond.corn www .bendmemorialclinic.corn

www.bendmemorialclinic.corn

2 012 CE N T RA L O R E G O N MADELINE LEMEE, MD

M E D I CA L D I RECTORY

High Lakes Health Care Upper Mill

T T T T

MARY MANFREDI, MD

High Lakes Health Care Upper Mill

929 SW Simpson Avenue• Bend

541-389-7741

OVERTISINGSUPPLEMENT

www.highlakeshealthcare.corn

541- 3 8 9-7741

www.highlakeshealthcare.corn

KAREN L. OPPENHEIMER, MD B end Memorial Clinic

1080 SW Mt. Bachelor Drive• Bend

541-382-4900

www.bendmemorialclinic.corn

H. DEREK PALMER, MD

Redmond Medical Clinic

1245 NW 4th Street, Ste 201• Redmond

541-323-4545

n/a

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

www.bendmemorialclinic.corn

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

54 1 - 382-4900

www.bendmemorialclinic.corn

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

54 1 - 382-4900

www.bendmemorialclinic.corn

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

54 1 - 382-4900

www.bendmemorialclinic.corn

A. WADE PARKER, MD MATTHEW REED, PA-C M. SEAN ROGERS, MD DAN SULLIVAN, MD •

•

929 SW Simpson Avenue• Bend

•

CAROL A. CRAIG, NNP

St. Charles Medical Group - Neonatology

2500 • E Neff Road• Bend

541-382-4321

www.stcharleshealthcare.org

JOHN 0. EVERED, MD

St. Charles Medical Group - Neonatology

2500 • E Neff Road• Bend

541-382-4321

www.stcharleshealthcare.org

SARAH E. JAMES, NNP

St. Charles Medical Group - Neonatology

2500 • E Neff Road• Bend

541-382-4321

www.stcharleshealthcare.org

JAMES MCGUIRE, MD

St. Charles Medical Group - Neonatology

2500 • E Neff Road• Bend

541-382-4321

www.stcharleshealthcare.org

St. Charles Medical Group - Neonatology

2500 • E Neff Road• Bend

541-382-4321

www.stcharleshealthcare.org

Ben d Memorial Clinic

Bend Eastside Sa Redmond

541-382-4900

www.bendmemorialclinic.corn

RUSSELL E. MASSINE, MD, FACP Bend Memorial Clinic

Bend Eastside Sa Redmond

541-382-4900

www.bendmemorialclinic.corn

Bend Memorial Clinic

Bend Eastside Sa Redmond

541-382-4900

www.bendmemorialclinic.corn

Bend Eastside Sa Redmond

541-382-4900

www.bendmemorialclinic.corn

FREDERICK J. RUBNER, MD '

•

MICHAEL E. FELDMAN, MD

ROBERT V.PINNICK, MD

Bend Memorial Clinic

MOLLY TILLEY,MD '

•

FRANCENA ABENDROTH, MD B end MemorialClinic

1501 NE Medical Center Drive• Bend

54 1 - 382-4900

www.bendmemorialclinic.corn

CRAIGAN GRIFFIN, MD

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

54 1 - 382-4900

www.bendmemorialclinic.corn

RICHARD KOLLER, MD

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

54 1 - 382-4900

www.bendmemorialclinic.corn

The Center: Or/hopedic gr Neurosurgical CaregrResearda

Locations in Bend Sa Redmond

541-3 8 2-3344

www.thecenteroregon.corn

The Center: Or/hopedic gr Neurosurgical CaregrResearda

Locations in Bend Sa Redmond

541-3 8 2-3344

www.thecenteroregon.corn

RAY TIEN, MD BRAD WARD, MD

Bend Eastside Sa Redmond

541-382-4900

www.bendmemorialclinic.corn

J S L GI I * O B /GRN

213 NW Larch Ave, Ste A• Redmond

541-526-6635

www.stcharleshealthcare.org

St. Charles OB/GYN

213 NW Larch Ave, Ste A• Redmond

541-526-6635

www.stcharleshealthcare.org

The Center: Or/hopedic gr Neurosurgical CaregrResearda

Locations in Bend Sa Redmond

541-382-3344

www.thecenteroregon.corn

The Center: Or/hopedic gr Neurosurgical CaregrResearda

Locations in Bend Sa Redmond

541-382-3344

www.thecenteroregon.corn

Locations in Bend Sa Redmond

541-706-5800

www.stcharleshealthcare.org

Bend Eastside Sa Redmond

541-382-4900

www.bendmemorialclinic.corn

ANNIE WILLIAMSON, RD, LD •

B e nd Memorial Clinic

•

WILLIAM H. BARSRDW, MD AMY B. MCELROY, FNP

JAMES NELSON, MD LARRY PAULSON, MD •

•

ROB BOONE, MD

St. Charles Cancer Center

THEODORE A. BRAICH, MD

Ben d Memorial Clinic

CORA CALOMENI, MD

St. Charles Cancer Center

Locations in Bend Sa Redmond

541-706-5800

www.stcharleshealthcare.org

SUSIE DOEDYNS, FNP

St. Charles Cancer Center

Locations in Bend Sa Redmond

541-706-5800

www.stcharleshealthcare.org

STEVE KORNFELD, MD

St. Charles Cancer Center

Locations in Bend Sa Redmond

541-706-5800

www.stcharleshealthcare.org

BILL MARTIN, MD

St. Charles Cancer Center

Locations in Bend Sa Redmond

541-706-5800

www.stcharleshealthcare.org

LAURIE RICE, ACNP

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

www.bendmemorialclinic.corn

WILLIAM SCHMIDT, MD

Bend Memorial Clinic

Bend Eastside Sa Redmond

541-382-4900

www.bendmemorialclinic.corn

HEATHER WEST, MD

Bend Memorial Clinic

1501 NE Medical Center Drive• Bend

541-382-4900

www.bendmemorialclinic.corn

2 012 CE N T RA L O R E G O N •

•

M E D I CA L D I RECTORY

OVERTISINGSUPPLEMENT

•

LINYEE CHANG, MD

St. Charles Cancer Center

2500 • E Neff Road• Bend

541-70 6 -7733

www. s tcharleshealthcare.org

TOM COMERFORD, MD

St. Charles Cancer Center

2500 • E Neff Road• Bend

541-70 6 -7733

www. s tcharleshealthcare.org

2500 • E Neff Road• Bend

541-70 6 -7733

www. s tcharleshealthcare.org

~ Bend Eastside, Westside th Redmond

541-382-4900 ~

ww w.bendmemorialclinic.corn

RUSS OMIZO, MD •

St. Charles Cancer Center

•

BRIAN P.DESMOND, MD

~ Bend Memorial Clinic

THOMAS D. FITZSIMMONS,MD,MPH Bend Memorial Clinic

Bend Eastside, Westside th Redmond

54 1 - 382-4900

www. bendmemorialclinic.corn

ROBERT C. MATHEWS, MD

Ben d Memorial Clinic

Bend Eastside, Westside th Redmond

54 1 - 382-4900

www. bendmemorialclinic.corn

SCOTT T.O'CONNER, MD

Bend Memorial Clinic

Bend Eastside, Westside th Redmond

54 1 - 382-4900

www. bendmemorialclinic.corn

DARCY C. BALCER, OD

Bend Memorial Clinic

Bend Eastside th Westside

541-382-4900

www.bendmemorialclinic.corn

LORISSA M. HEMMER, OD

Bend Memorial Clinic

Bend Eastside th Westside

541-382-4900

www.bendmemorialclinic.corn

•

KEITH E. KRUEGER, DMD, PC Keith E. Krneger, DMD, PC • '

• '

•

AARON ASKEW, MD

1475 SW Chandler, Ste 101• Bend

541 - 6 17-3993

www.d r keithkrueger.corn

•

Desert Orthopedics

Locations in Bend th Redmond

541-388-2333

www.desertorthopedics.corn

ANTHONY HINZ, MD

The Center: Ouhopedic gr Neurosurgical CaregrReseardr Locations in Bend th Redmond

541-382-3344

www.thecenteroregon.corn

JEFFREY P.HOLMBOE, MD

The Center: Ouhopedic gr Neurosurgical CaregrReseardr Locations in Bend th Redmond

541-382-3344

www.thecenteroregon.corn

JOEL MOORE, MD

The Center: Ouhopedic gr Neurosurgical CaregrReseardr Locations in Bend th Redmond

541-382-3344

www.thecenteroregon.corn

KNUTE BUEHLER, MD

The Center: Ouhopedic gr Neurosurgical CaregrReseardr Locations in Bend th Redmond

541-382-3344

www.thecenteroregon.corn

MICHAEL CARAVELLI, MD

Th e C e nter:Ouhopedic@NeurosurgicalCaregr Researdr Locations in Bend th Redmond

541-382-3344

www.thecenteroregon.corn

541-388-2333

www.desertorthopedics.corn

541-382-3344

www.thecenteroregon.corn

541-388-2333

www.desertorthopedics.corn

• '

Desert Orthopedics

JAMES HALL, MD

The Center: Ouhopedic gr Neurosurgical CaregrReseardr Locations in Bend th Redmond

ROBERT SHANNON, MD • '

• '

Desert Orthopedics

MICHAEL RYAN, MD • '

• '

' ' •

Locations in Bend th Redmond ' I

Desert Orthopedics

1303 • E Cushing Dr, Ste 100• Bend

54 1 -388-2333

www.desertorthopedics.corn

Desert Orthopedics

1303 • E Cushing Dr, Ste 100• Bend

541-388-2333

www. d esertorthopedics.corn

Desert Orthopedics

1303 • E Cushing Dr, Ste 100• Bend

541-388-2333

www. d esertorthopedics.corn

GREG HA, MD KATHLEEN MOORE, MD • '

Locations in Bend th Redmond

• '

J J

TIMOTHY BOLLOM, MD

Locations in Bend th Redmond

541-382-3344

www.thecenteroregon.corn

1315 NW 4th Street• Redmond

541-388-2333

www.desertorthopedics.corn

The Center: Ouhopedic gr Neurosurgical CaregrReseardr

Locations in Bend th Redmond

541-382-3344

www.thecenteroregon.corn

The Center: Ouhopedic gr Neurosurgical CaregrReseardr

Locations in Bend th Redmond

541-382-3344

www.thecenteroregon.corn

54 1 - 388-2333

www.desertorthopedics.corn

Locations in Bend thRedmond

541-382-3344

www.thecenteroregon.corn

KENNETH HANNINGTON, MD D esert Orthopedics

Locations in Bend thRedmond

541-388-2333

www.desertorthopedics.corn

SOMA LILLY, MD

Locations in Bend thRedmond

541-382-3344

www.thecenteroregon.corn

Locations in Bend th Redmond

541-388-2333

www.desertorthopedics.corn

541-382-3344

www.thecenteroregon.corn

BRETT GINGOLD, MD SCOTT T.JACOBSON, MD BLAKE NONWEILER, MD • '

• '

Desert Orthopedics

J. J

The Center: Ouhopedic gr Neurosurgical CaregrReseardr

MICHAEL MARA, MD

Desert Orthopedics

JAMES VERHEYDEN, MD •

1303 • E Cushing Dr, Ste 100• Bend

MICHAEL COE,MD

•

Desert Orthopedics

CARA WALTHER, MD • '

The Center: Ouhopedic gr Neurosurgical CaregrReseardr

•

Th e C e n ter: OuhopedicNeurosurgi gr cal Care@Researdr Locations in Bend th Redmond

• :

MOLLY OMIZO, MD

•

Deschntes Osteoporosis Center

2200 NENeffRoad,Suite302•Bend

sosteoporosiscentercom ( 541-388-3978 (wwwdeschute

2 012 CE N T RA L O R E G O N

M E D I CA L D I RECTORY

OVERTISINGSUPPLEMENT

LISA LEWIS, MD

Partners in Care

2075 • E Wyatt Ct • Bend

541-382-5882

www.partnersbend.org

RICHARD J. MAUNDER, MD

St. Charles Advanced Illness Management

2500 • E Neff Road • Bend

541-706-5885

www.stcharleshealthcare.org

LAURA K. MAVITY, MD

St.Charles Advanced Illness Management

250 0 • E Neff Road • Bend

541-706-5885

www.stcharleshealthcare.org

1475 SW Chandler Ave, Ste• Bend

541 - 3 8 9-3073

www.deschuteskids.corn

1475 SW Chandler Ave, Ste• Bend

541 - 3 8 9-3073

www.deschuteskids.corn

1230 • E Third St, Ste A-174• Bend

54 1 - 389-6600

www.d entistryforkidz.corn

1080 SW Mt. Bachelor Drive• Bend

541-382-4900

www. bendmemorialclinic.corn

1080 SW Mt. Bachelor Drive• Bend

541-382-4900

www. bendmemorialclinic.corn

1080 SW Mt. Bachelor Drive• Bend

541-382-4900

www. bendmemorialclinic.corn

211 NW Larch Ave• Redmond

541-548-2164

www. s tcharleshealthcare.org

Bend Memorial Clinic

1080 SW Mt. Bachelor Drive• Bend

541-382-4900

www. bendmemorialclinic.corn

Bend Memorial Clinic

1080 SW Mt. Bachelor Drive• Bend

541-382-4900

www. bendmemorialclinic.corn

211 NW Larch Ave• Redmond

541-548-2164

www. s tcharleshealthcare.org

1080 SW Mt. Bachelor Drive• Bend

541-382-4900

www. bendmemorialclinic.corn

Desert Orthopedics

Locations in Bend Sa Redmond

541-388-2333

www.desertorthopedics.corn

High Lakes Health Care Upper Mill

929 SW Simpson Avenue• Bend

541-389-7741

www.highlakeshealthcare.corn

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Cover story(WHY RESEARCHISWRONG ' •

•

Continued from Page 13 public. In that report, you see a long list of different strategies that can be used to corrupt the evidence base," said Dr. Mark Helfand, director of the Oregon Evidence Based Practice Center and editor of the journal Medical Decision Making."But we have this problem that we don't know how common those are and we don' t know when they' re there or not, so they undermine confidence in virtually all of the literature." Helfand said there is often little a jour nal can do to prevent researchers from gaming the system. A research article

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other journals combined." Journal editors cannot know whether authors are holding back on research that shows no effect, submitting only those studies that support the intervention, or whether they changed their study proto cols midway through to have their intend ed research findings match the data. "Somebody can get a broker to look at 20, 30 data sets and find the one that' s going to be the most agreeable to the hy pothesis," Helfand said. "They can actu ally ask people who study the data sets to help them find a match to the data set that they' re more likely to get a positive result in." Helfand's journal has a reputation for

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"There are so many models now for getting things out into journals, includ ing some models that border on vanity press," Helfand said. "We' re competing

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Cover story(WHY MOST MEDICAL RESEARCHISWRONG

Class 1C antiarrythmaties and CAST In the 1970s, doctors noticed that if patients having heart attacks had a

certain type of rhythm disturbance, they were more prone to dying. A new class of drugs called Class 1Cantiarrythmatics were developed to stop those abnormal rhythms. The flaw; Doctors believed these drugs helped because they were successful in altering heart rhythms, but they really didn't know whether the treatment saved lives. Once the Cardiac Arrhythmia Sup pression Trial was conducted, it became clear that the treatment in creased the risk of death. The case study is widely cited as a key driver in the push for evidence-based medicine.

single studies, even if they' re large randomized controlled trials, that should in an instant change practice," she said. 'You have to sort of pro ceed with caution before you' re going to try this at home, so to speak." Single studies may deal with a very specific subgroup of patients or may work because all the parameters can be tightly controlled in a research setting. Out in the real world, the findings may not be as

broadly applicable. And with the growing recognition of the unre liability of medical research, physicians are becoming much more

hesitant to change practice on the basis of single study. It leaves practicing physicians in the tenuous position of knowing that what is considered sound practice one day could be overturned now in an environment where at a lot of journals, if anyone decides to the next. look at that paper, it's going to get published." Dr. Bruce McLellan, an interventional cardiologist with Heart Cen Getting research published helps residents get fellowships, fel ter Cardiology in Bend, said that the COURAGE reversal, for example, lows get faculty positions and faculty get more funding. had less of an impact in Bend because local cardiologists hadn't been "We live in a world where there is incentive at every step of train as quick to implant stents in patients with stable coronary disease. "What I saw when I was in fellowship, patients would come in and ing for people to produce marginal research," Prasad said. "There' s 162,000 journals out there, so crappy science is going to get pub if they had a reasonably good story for angina, they went straight lished somewhere. They have to fill their pages." to the cath lab," he said. "It made me really appreciate my partners The vetting that journals do may help to categorize the reliability and the practice in Bend because we all try to follow guideline-based of results. Authors with better studies may shoot for publication in medicine." the top journals, such as the New England Journal of Medicine or the At the same time, McLellan can recall plenty of cases where es Journal of the American Medical Association. If they can't get them tablished medical practice turned out to be wrong. Three decades published there, they try for less prestigious publications. ago, he said, the drug digoxin was considered standard treatment "There's a big filter," said Dr. Christine Laine, editor of the Annals of for atrial fibrillation. Now doctors know that the heart will return to Internal Medicine. "We' re only publishing 6 to 8 percent of the origi normal rhythms on its own just as often as with the drug. "If we go back 10 or 15 years, did we have good data to say that nal research articles that we get. But the large majority of papers we

reject do get published somewhere."

we were saving lots of lives by raising HDL significantly? No, we really

Laine said she believes that misconduct by researchers, such as that described in the Neurontin case, contributes only a small portion to the problem of unreliability of research. In some cases, researchers might simply be so enthusiastic about their findings that they overlook

didn't have that," McLellan said. "It was scientifically reasonable, and it was low risk for the patient, and then later, information comes out and you find out that it didn't work." He believes that may just be the way medicine must evolve; better information, better research contantly improving physicians' under standing of the best way to treat patients.

methodological flaws or oversell the significance of their findings. "I think what the public doesn't understand is that there are very few

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Clutching at flaws "I'm OK with that. That's the progression of medicine," he said. "And that's what keeps it interesting." Clinicians who are working to implement the findings of medical research into rec ommendations of how to treat patients are now conducting systematic reviews. Rather than basing a decision on a single study or even an accounting of how studies sup port or refute a finding, systematic reviews gauge the reliability of the evidence. "A systematic review evaluates the qual ity of the individual studies, sees whether or not they can be combined to look at a treatment effect or an effect's size, so that enables someone to get a better ap preciation of what a body of literature about a specific question can tell us," said Dr. Jean Slutsky, director of the Center for Outcomes and Evidence at the Agency for

breakthroughs, not the mundane stud ies that show no effect. When research ers published an independent systematic review of the effectiveness of Neurontin for treating pain, one of the off-label uses the company got caught promoting, the researchers concluded it was effective based on the findings published at the time. It was only after the lawsuit that the reviewers determined the company was stacking the deck. There's no way to tell how many other systematic reviews are

agency whose mission is to improve the quality, safety, efficiency and effective ness of health care. "Oftentimes that' s more valuable than looking at individual studies alone." Nonetheless, it's often difficult for re searchers to know whether they' re look ing at the entire picture or not. Medical journals suffer from both reporting bias where researchers don't bother to report the studies that don't support their case — and from publication bias — where journals want to publish new and exciting

Laine acknowledges that a publication bias may exist, that journals are more likely

based on similarly flawed data. "The experience over the last I 5 years with one episode after another of finding out that evidence that we were relying on is not ev erything that should be there means that sort of narrow reliance on the published literature can't be trusted," Helfand said. "This pres

ents a very big problem for evidence-based Healthcare Research and Quality, a federal medicine."

to publish eye-popping sensational conclu sions than the systematic reviews that rep resent a rehashing of past research. But she also maintains that same standard should apply to critics of medical research, such as loannidis. "There's a certain amount of sensation alism in being able to publish studies that say 'It's all wrong,' too," Laine said. "So I think you have to have balance of both sides.

Ideally whenbetter medical researchtrumps flawed findings, doctors will quickly abandon the discredited treatments. But studies suggest doc tors tend to stick to what they believed was true, despite evidence to the contrary. Dr. John loannidis, anexpert in evaluating medical research, looked at three findings from obser vational studies; that vitamin E protects against heart disease,that beta-carotene protects against cancer and that hormone replacement prevents Alzheimer's disease.All three garnered wide atten tion after they were published and all three were later refuted by randomized controlled trials. Nonetheless, doctors continued to cite, even de fend, the refuted research f Eightyearsafter it was disproved, halfof the pub lished articles on vitamin Estill claimed the vitamin protected against heait disease. Adecade after the beta-carotene benefit for cancer preven tion was debunked, few studies still cited the original evidence supporting a protective effect. Instead, articles that claimed the treat ment was effective simply didn't mention the contradicting study. Researchers continued to argue that estrogen could prevent Alzheimer' s disease three years after a randomized con trolled trial showed no benefit. "We encountered almost any source of bias,genu ine diversity, and biological reasoning invoked to defend the original observations," loannidis wrote in the Journal of the American Medical Association in 2007."While some or even many of these coun terarguments may be valid, this isalso consistent with a belief that is defended at all cost."

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Treating depression( NEW TECHNIQUES

Continued from Page 35

time, said Gerard Sanacora, director of the Yale Depression Research Program and a professor of psychiatry at Yale University. In clinical trials that study its effects on depres sion, about one-quarter of that amount of ketamine —.5 milligrams — is injected over a 40-minute period. The response is almost immediate. The

Different forms of depression

chemical of the drug?"

What is known is that ketamine works on the glutamate system in the brain — a different set of neurotransmitters than the serotonin, dopamine and norepinephrine targeted by other treatments, said Sanacora. drug has produced a mood-altering effect It appears to act on a specific glutamate re within hours of injection, although relief is ceptor, the NMDA receptor. He said 60 to 80 often temporary. percent of the brain's neurons use glutamate Ketamine infusions are currently experi as the primary neurotransmitter. It's difficult mental and used only as a "rescue" treatment, to develop drugs for this system because Keepers said. A pain specialist in Oregon has if something were to go wrong, the effects treated patients this way, although Keepers would behuge.Too much could cause sei would not say who or where. zures or an undesired anesthesia effect, he "The drug is used in anesthesia frequently said. but not approved for depression. Some evi There's still much to learn about how the dence supports it but we haven't seen long drug works. "We don't think it's just working on the term studies," Keepers said. How does it work on the brain? "We really glutamate system," Sanacora said. "It also don't know. It's a different chemical system seems to kick off another response that has in the brain," he said. "What the antidepres some benefit. The drug itself is gone from sant effect is coming from we don't know. the body in a number of hours, yet the bene

Psychotic depression:Severe depres sion plus some form of psychosis, delusions or hallucinations. Postpartum depression:10 to 15 percent of women experience this after giving birth, when hormonal and physical changes pile on top of the overwhelming responsibility ofcaring for a new baby. Seasonal affective disorder:Cha racter ized by winter onset, when there is less natural sunlight. Bipolar disorder, or manic-depressive illness:Characterized by cycling mood changes, from extreme highs to extreme lows. Sources: National Institutes of Mental ffealth, Oregon ffealth 8r Science University, American Psychiatric Association

•

An alteration of consciousness? The intoxi cation it produces? Or a fundamental neuro

•

• •

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Home Health

Page 50

SUMMER/FALL 2012 • HIGH DESERT PULSE

Depressionsymptoms to watch out for fits seem to last longer ... days to a month." Sanacora said it would be dangerous to try to buy ketamine on the street and self administer outside of a medically supervised situation. Too much could kill a person. It's a similar anesthetic to the drug that was found

to the pharmacology of depression. Results

that, there may be another new approach to medicating depression.

Gehrig's syndrome and is also being studied as a treatment for depression and anxiety. "These are not miracle cures. They look ex tremely interesting but there's so much more research that needs to be done before they are taken," Sanacora said. (Patients interested in ongoing trials can visit clinicaltrials.gov)

Researchers don't know which drug will be "the one," but all this work gives new direction

•Persistent sad, anxious, or empty feelings •Loss of interest in activities once previ ously enjoyed •Excessive crying •Increased restlessness and irritability •Difficulty concentrating, remembering details and making decisions •Decreased energy and fatigue •Thoughts of death or suicide •Increased feelings of guilt, worthlessness, irritability, helplessness, hopelessness or pessimism •Weight and/or appetite changes •Insomnia, early-morning wakefulness, or excessive sleeping •Socia I withdrawal •Aches and pains or digestive problems that don't ease with treatment

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to have killed pop star Michael Jackson. Ketamine is one of several drugs being researched. Others, by names such as AZD 6765 and CP 101606, may not cause the same level of perceptual alterations as ket amine — the very effects that make it prime for abuse as a street drug. Another drug that targets the glutamate system, riluzole, is ap proved by the FDA for the treatment of Lou

If you have at least five of these symptoms daily for at least two consecutive weeks, consult a physician or mental health professional:

from ongoing trials will be available in a cou ple of years, he said. A couple of years after

There are many theories and disagree ments about what creates and what resolves

depression, said Evans, the psychologist from St. Charles. In his experience, cognitive be havioral therapy — examining and retraining thinking patterns — has good outcomes, and medications can help some people. But the best improvements come from people who are ready to put in time and effort, he said.

For example: • Exercise. Evans is not the only local psy

chologist who believes physical exercise should be a primary treatment for depression. "Physical activity can treat insomnia and chron ic pain, which can create depression. Sleep and exercise is where I start," Evans said. Physical activity wa s a ssociated with

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Treating depression( NEW TECHNIQUES

lower rates of depression in one large study from Sweden. Other studies published in peer-reviewed scientific j o urnals showed that exercise reduced depression symptoms. It's believed that aerobic exercise has a neu

rochemical effect on the body's stress hor mones, painkillers and mood elevators. "I call exercise a behavioral antidepressant," Evans said. But many patients are not inter ested in it, and most medical professionals

don't emphasize it. He can't explain why. Perhaps because "we tend to over-com plicate things," he said. "It's well accepted

but not well applied." • Meditation. The practice is also be

coming a primary approach, Evans said. Medical professionals "have packaged a 2,500-year-old pschyo-technology" into •

•

• •

•

s •

something Western patients can digest. Used in many hospitals, it might be called "mindfulness-based stress reduction" and include meditation, yoga or tai chi. "It has wonderful results in treating real depres sion. This is a hot thing. It's been gaining traction in the last five years," Evans said. • Light therapy. "One of best, evi dence-based treatments that is relatively unknown but effective is light therapy," Evans said. "It's cheap, effective and safe." (But it's not always recommended

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•

sion," Evans said. • I

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esearch suggests that living a long and healthy life is partly dependent on genetics and partly on lifestyle. Do you know what factors

impact life expectancy? Take this quiz. After all, puzzles and games are supposed to keep your aging mind sharp.

What is the current life expectancy in the U.S.? A. 72.3 years B. 75.7 years C. 78.5 years D. 79 years

If you are now 65, how many more years canyou expect to live? A. 10 years B. 13.5 years C. 19 years D. 27 years

True or false: That means most people will die in their 70s.

Which contributes more to premature deaths, alcohol use or salt intake?

Which of the following behaviors contributes most to premature deaths in America?

Which of the following has been shown to shorten life expectancy?

A. Obesity

A. Running marathons

B.Smoking

B.Living alone

C. Accidents D. Lack of exercise

C. Prostate cancer screening D. Beer

If all Americans maintained a healthy weight with good diet and exercise, as well as not smoking, how many cancer deaths could be avoided? A. 10 percent B. 44 percent C. 62 percent D. 0 percent — nothing can prevent cancer.

According to the CensusBureau, in 2010, the U.S. had an esti mated 72,000 centenarians. How many will we have by 2050 when baby boomers start to hit the century mark? A. 95,000 B. 120,000 C. 300,000 D. 600,000

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Page 53

One voice ~ApERs oNALEssAY Ir

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U nnin wit BY DAVID JASPER

a But by then, I'd swapped Nikes for Vans, run

ning for skateboarding. If Dad was disappointed, mong my earliest memories is one where I'm running with my father. I'm maybe 7,

he never let on.

Growing up, my friends and I thought he looked he's in his early 40s. We' re running along like Tarzan. He'd always been a tan and fit firefight side a canal in a field near our Miami home. Running seemed to be something anyone could

PETE ERICKSON

DavidJasperisa featuresreporterat The Bulletin. Below, he's seen at a late 1970s racein Miami with his father, Larry Jasper.

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er, but in the early '90s he began a losing battle with basal cell carcinoma. By 2000, he lost control do, even me. Soon, I had my own pair of Nikes and of half his face. In 2003, he lost an ear. When the was running regularly, mostly because my dad cancer returned, Dad didn't want more radiation. was a runner. What boy that age doesn't want to It spread to his other organs. He slowly wasted

be right by his dad's side, doing what he's doing?

away, taking several bad falls in the process.

He started running in the early '60s, long before the jogging boom. I don't know why he started, and I can't ask now. He died in 2010. He ran for four decades,untilhe became too weak from cancer. Back when we ran together, he'd often run ahead to get in more of a workout — bye, Dad! — then double back. I was always relieved to see him return. When w e neared home, he'd say,"Ready to pour iton?"and we'd sprint by the last few houses before ours. I had no idea what I was doing, but I'd read something about the value of stretching, so I stretched. Thus he nicknamed me "Stretch." I soon ran the first of many 10Ks. Dad usu ally started the races with me. After a mile or so,

He kept running for a while, until he took a spill off a sidewalk. That was the end of running for him. He'd often sit doubled over, which he said eased the chronic shoulder pain from that fall. One visit home, I drove the car while he sat hunched in the passenger seat. I reached over to give an en

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Before he died, he wrote down stories from his life, including an anecdote about how, even in his later years, he loved to take off his shoes and run barefoot through grass.

On the flight home from his funeral, I began

reading "Born to Run," a book about how we as he'd take off at his own pace — bye, Dad! — and I a species are truly built to run. I'd been right as a wouldn't see him again until the finish line. boy: Anyone can run, and probably should. He ran the Orange Bowl Marathon annually and did Inspired, I started running a bit during daily a few ultramarathons, including a 62-miler, and one in walks with the dog. Over time, some 35 years af which runners circled an outdoor track for 24 hours. ter I first ran with my dad, the dormant runner in I ran two half-marathons. I can't remember the me re-emerged. I now run 2-4 miles several times first, but the second left more of an impression a week, farther some weekends. — I came in dead last. The worst of it was, I'd even Often during runs, my thoughts turn to my cheated, shaving a short distance off by turning dad. Maybe I'm just more aware of his influence, or it's the endorphins talking, but it feels as if I' ve one block before the official turnaround. I thought I was so far behind it'd be just Dad somehow erasedthe distance between us,as ifhe waiting at the finish, but then I heard an announcer knows I'm running again. say my name over a loudspeaker. To my surprise, The truth is I' ll never again see him running back horror and guilt, there was still a crowd around, toward me. Yet by running, something that was so and everyone was cheering for me. important to him, I feel closer to him anyway. I didn't race much after that. Around 1980, I I pick up the pace as I head for home. And when dropped out of a too-hot summer 10K. I ran a last one I reach the corner, I always pour it on past the last in 1983, just to see if I still could. It was staged at a mall few houses. built over the field where I'd first run with my dad. Bye, Dad.

Page 54 : "

couraging pat on his once-muscled shoulder. The phrase "skin and bones" gained new meaning.

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If and your family fro sun amagz

We e love l our sun here but u Cen entral Oregon has one of the highest es rates of newmelanoma a di iagnoses an in thecountry Melanomaisisth e most deadly form ofskincancer. Babies ab and children are e much much more sensitive n an adults.• Just one e bli stering sunbur n in childho oo dmorethandoublesa person'schancesof develo oping melanomalater in life. Staycovvered.Apply sunscreengenerousl wear protective cloth o ing and avoidexce ce n a m and4pm.

For more infformation about protectin f- l y f - m . k . - - . r , please contact St. aries Family Care in Bend at 541-706-4800 or visit StCharlesHea IthC a r e.org. aa

St. Charles

y~yf C~e St fCharles CANCER CENTER