Your Guide to Consumer Information
January 2013 â€˘ Volume 11 Number 1
CPR Demetris Yannopoulos, MD
Winter eye injuries Y. Ralph Chu, MD
Beta-blockers Ashley Crowl, PharmD
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JANUARY 2013 • Volume 11 Number 1
PERSPECTIVE Clarence Jones Southside Community Health Service
DRUG CLASSES Beta-blockers By Ashley Crowl, PharmD, and Jean Moon, PharmD
CALENDAR Birth Defects Prevention Month T H I R T Y- N I N T H
POLICY A national plan for Alzheimer’s By Susan J. Spalding
PUBLIC HEALTH Cardiac arrest and CPR
INFECTIOUS DISEASE Shingles
NEPHROLOGY Urinary incontinence
CARDIOLOGY Premature ventricular contractions
John T. Chow, MD, FACE Endocrinology Clinic of Minneapolis
OPHTHALMOLOGY Winter eye injuries
NUTRITION Fatty acids and your health
By Y. Ralph Chu, MD
MINNESOTA HEALTH CARE ROUNDTABLE
By Demetris Yannopoulos, MD, and Kim Harkins, NREMT
By Christina Weber, PharmD
By Christopher W. Boelter, MD
By Pierce Vatterott, MD
By Heidi Greenwaldt, MS, RD, LD, CNSC
www.mppub.com PUBLISHER Mike Starnes firstname.lastname@example.org
Background and focus: The next step in health care reform involves the patient becoming more actively engaged with staying healthy. New physician reimbursement models reward improved population health but bring new dynamics into the exam room. Incorporating patient attitude and lifestyle Creating measures that work choices into health care delivery is Thursday, April 25, 2013 necessary, but how 1:00 – 4:00 PM • Duluth Room Downtown Mpls. Hilton and Towers should it be done? Creating conceptual and empirical clarity around this question may be best addressed by the term Patient Activation Measure (PAM).
Objectives: We will examine the development of PAM, what it means and how it works. We will explore patient engagement methods that have been successful and the role of health insurance companies and employers in this process. We will explore how PAM may be used across the continuum of care and whose job it will be to implement and track these measures. We will discuss the challenges that are inherent within the concept of PAM and how it may realize its best potential.
EDITOR Donna Ahrens email@example.com ASSOCIATE EDITOR Janet Cass firstname.lastname@example.org ASSISTANT EDITOR Scott Wooldridge email@example.com ART DIRECTOR Elaine Sarkela firstname.lastname@example.org
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Please mail, call in or fax your registration by 04/18/2013 JANUARY 2013 MINNESOTA HEALTH CARE NEWS
State Ranks 12th In Preventing Youth from Smoking
DFL Likely to Move Quickly to Implement ACA
A report on funding for tobacco prevention finds that Minnesota ranks 12th nationally in funding programs aimed at preventing youth from smoking and at helping smokers quit. The annual report by the Campaign for Tobacco-Free Kids says that Minnesota currently spends $19.6 million a year on tobacco prevention and cessation programs, which is 33.6 percent of the $58.4 million recommended by the U.S. Centers for Disease Control and Prevention (CDC). Officials with the campaign point out that Minnesota will collect $535 million in revenue this year from the 1998 tobacco settlement and tobacco taxes, but will spend just 3.7 percent of it on tobacco prevention programs. The campaign is calling for state lawmakers to raise the cigarette tax and increase funding for antismoking programs.
The road is clear for implementation of the Affordable Care Act (ACA) in Minnesota, with new DFL majorities in the state House and Senate. The Nov. 6 election that saw Barack Obama re-elected as president also brought the House and Senate under DFL control. With DFL Gov. Mark Dayton in charge of the executive branch, the 2012 election resulted in DFL control of both houses and the governorship for the first time since 1990. The election seems to settle the question of whether the ACA would be fully put into place, although opposition to the sweeping health reform law remains. According to Rep. Tom Huntley, who for the past two years has been the ranking DFL member of the House Human Services Finance committee and also serves on the Health and
Human Services Reform committee, the new DFL majorities in the Legislature will join with Dayton to move forward quickly on issues such as health insurance exchanges, Medicaid expansion, and state health-care payment reforms. “We’re not going to agree with the governor on every comma and semicolon, but overall, we have a very similar view on where we need to go,” Huntley says. “All three groups want to move ahead with the ACA, so I think that will be done.” The state is facing federal deadlines for designing the health insurance exchanges, a central part of the ACA. Exchanges will provide coverage for individuals currently without insurance and for small businesses that have not been able to offer health plans to employees. Last spring the Republican-led Legislature declined to work on preparing for the exchanges, despite being urged to do so by health care and business leaders.
Huntley says the looming federal deadlines are a concern but expressed confidence that the new Legislature and the Dayton administration would find a way to complete work on the exchanges. “We have very difficult timelines that we’re going to have to try to meet,” Huntley says. “I think that we will get some flexibility from the federal government, but … there’s going to be a lot of work done between now and Jan. 1.”
MDH Report Looks at Teen Health Measurements A new report by the Minnesota Department of Health (MDH) finds that in most areas, teens are doing well in health measurements when compared with the 1990s. “The Health and Well-Being of Minnesota’s Adolescents of Color and American Indians: A Data Book” was released in early December 2012. The report looks
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at students 12 to 19 years old from all racial and ethnic groups. It finds that overall, teens have experienced substantial declines in rates of smoking cigarettes, binge drinking, sexual activity, hitting or beating up another person, carrying a weapon on school property, drinking pop, and riding in a car without a seat belt. Officials say that although adolescents of color have made progress in some areas, there is a persistent wellness gap between white adolescents in the state and adolescents of color and Native Americans. The report also notes that the number of Native American adolescents and adolescents of color in Minnesota has doubled since 1990, with one-quarter of Minnesota’s public school students currently being students of color or Native Americans. “This teen fact book shows that efforts in some targeted areas have been working to protect adolescents of color and American Indians, but it also shows that much more needs to be done,” says Ed Ehlinger, MD, Minnesota commissioner of health. “With its increasing diversity, Minnesota cannot thrive without creating more opportunities for improving the health of these teens who will be tomorrow’s leaders, innovators, workers, business owners, and parents.” The report says Native American children and those of color are more likely to start off with economic and educational disadvantages that put them at greater risk regarding drugs, teen pregnancy, stress, violence, and other unhealthy experiences. Poverty rates are three to five times higher among Native American adolescents and those of color compared to white adolescents; failure to graduate on time is two to three times higher. Because of these factors, children in communities of color experience poor health more often than white adolescents, MDH officials say. “Parents know what puts their children at risk—lack of healthy activities, drugs, tobacco, alcohol, auto accidents, and unsafe people and environments,” Ehlinger says.
“We plan to use these data to work with our community partners to achieve the goal of making sure that all the children in Minnesota have an equal opportunity for success.”
Health Reformers Celebrate 20 Years of MinnesotaCare Some of the top health reform advocates from the past two decades helped celebrate the 20th anniversary of MinnesotaCare on Nov. 27 in St. Paul. The event at the Minnesota History Center noted the history of the legislation, passed in 1992, that established Minnesota’s ground-breaking health insurance program for Minnesotans who did not have health insurance coverage. The program was designed for people not poor enough for existing public programs but who still could not purchase health insurance, officials note. “The enactment of MinnesotaCare 20 years ago is certainly worth celebrating and remembering,” said Amy Crawford, regional director of Children’s Defense Fund–Minnesota (CDF-MN), and one of the event’s hosts. “This landmark piece of legislation provided critical health care coverage for hundreds of thousands of Minnesotans who had previously been caught in the health insurance dilemma—they earned too much for Medical Assistance but couldn’t afford coverage in the private market. MinnesotaCare contributed to Minnesota’s reputation as a national model for providing health care to its citizens.”
Article Discusses Difficult Decisions At End of Life A recent article in Mayo Clinic Proceedings takes on the issue of end-of-life care and the tough discussions that families and providers face over continuing care. In the article, two Mayo Clinic experts, Christopher Burkle, MD,
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News to page 6 JANUARY 2013 MINNESOTA HEALTH CARE NEWS
News from page 5 JD, and Jeffre Benson, MD, look at recent controversial cases that involve end-of-life decisions, and then outline several steps that families can take to ease the difficulties of discussing such decisions. “Health care professionals in the United States have struggled with the importance of maintaining patient autonomy while attempting to practice under the guidance of treatments based on beneficial care,” says Burkle, the study’s lead author. The authors say the first key element is early and clear communication between families and providers. Secondly, they recommend choosing objective surrogates to represent patients who cannot represent themselves. Lastly, the article says when providers and patients or their representatives cannot agree on end-of-life care, turning to a third party may be necessary. They note that the Joint Commission has required hospitals to establish procedures for considering ethical
issues, and many hospitals have ethics committees to resolve such issues.
Essentia Provides Life Jackets, Safety Education to Youth Duluth-based Essentia Health has announced that it is again partnering with Kohl’s Department Stores and the Kohl’s Cares program to provide life jackets and safety education programs to children in northeast Minnesota and northwest Wisconsin. Since 2006, officials say, Kohl’s has donated more than $257,000 to Essentia Health’s St. Mary’s Children’s Hospital for safety education and events to help keep kids safe. On May 24, 2012, Essentia staff worked with Kohl’s to give away 1,300 life jackets to children. Kohl’s and Essentia will team up again to give away life jackets on June 13, 2013. In addition, an injury prevention nurse from St. Mary’s Trauma
Program will be visiting nine schools in the Duluth community to share information about water safety. Students at the schools will receive water safety education materials to bring home and share with their family.
MDH Program Aims To Make Homes Safer and Healthier Minnesota Department of Health (MDH) is introducing a new plan for making homes safer and healthier. The Minnesota Healthy Homes Strategic Plan (HH Plan) calls for a community-based approach to creating healthier living spaces. State officials say threats such as lead poisoning, asthma, radon, carbon monoxide, and problems due to moisture or poor ventilation are some of the things that make homes less safe. “Unsafe, unhealthy housing makes people sick and costs us all money,” says MDH Commissioner Ed Ehlinger, MD. “Our objective is
to reduce illness and its related costs by reducing hazards before they become a problem.” The HH Plan is a joint effort of MDH and the Minneapolis-based Sustainable Resources Center (SRC). Officials from the two groups note that federal funding for areas such as lead poisoning prevention have been cut, and say they are trying to create a community-based partnership that takes a comprehensive approach to home health and safety. “Instead of focusing on individual problems in a piecemeal fashion, this approach requires us to look at the big picture,” says SRC Executive Director Dan Newman. “That includes the way homes are built, laws and policies that relate to housing, and things that residents can do themselves to lower their health risks. We believe that this approach will be more efficient and have a greater positive impact on human health than focusing on individual risks one at a time.”
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Peter Dehnel, MD, with its Benjamin Rush Award for Citizenship and Community Service. Dehnel is a practicing pediatrician in Minneapolis and is also medical director for utilization management at Blue Cross and Blue Shield of Minnesota. In the early 2000s, Dehnel testified before legislators and local community leaders about the Peter Dehnel, MD
dangers of secondhand smoke to children.
His efforts led to city ordinances that banned smoking in several cities and a county in the Minneapolis area, and later led to a statewide smoking ban in 2007. As current president of the Twin Cities Medical Society, Dehnel works with state healthy living programs to reduce childhood obesity. He has also partnered with the National Initiative for Children’s Healthcare Quality and the American Academy of Pediatrics to develop information for physicians to use in working with families to help their children lead healthier lives. Erin Sullivan Sutton, assistant commissioner of Children and Family Services for the Minnesota Department of Human Services (DHS), was honored by the North American Council on Adoptable Children for her work on behalf of children and families across Minnesota at the 2012 Voices from the Heart Gala on Nov. 17 in West St. Paul, coinciding with National Adoption Day. As assistant commis-
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sioner, Sullivan Sutton is responsible for overseeing programs and policies that promote economic stability, child safety and permanency, child care, child support, and successful transition for immigrant families. Working for DHS since 1987, she has developed a reputation as an
The Telephone Equipment Distribution Program is funded through the Department of Commerce Telecommunications Access Minnesota (TAM) and administered by the Minnesota Department of Human Services
articulate champion of children’s issues in the community and the Minnesota Legislature. Sullivan Sutton was also the past president and is current executive committee member of the National Association of Public Child Welfare Administrators, while serving on numerous task forces with the Minnesota Judicial Branch promoting permanent families for children when they cannot safely return to their birth parents.
Taking cholesterol medication? Do you also have heart disease or risk factors for heart disease?
John Finnegan, PhD, dean of the University of Minnesota School of Public Health, has been named chair of the board of directors of the Association of Schools of Public Health (ASPH).
John Finnegan, PhD
Finnegan has more than 25 years’ experience in public health research, specializing in public health, community campaigns, and the role of mass media in health behavior and social change. ASPH is the only organization representing the Council on Education for Public Health-accredited schools of public health and programs seeking accreditation as schools of public health. The March of Dimes has honored Barbara Bor with its 2012 Distinguished Nurse of the Year Award, in recognition of her dedication to preventing infection. The nomination for Bor, who is the infection prevention coordinator at Gillette Children’s Specialty Healthcare in St. Paul, cited her ability to unite many disciplines in a concerted
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effort to promote patient safety through infection prevention. More than 300 nurses from across the state were nominated for the awards by patients, colleagues, friends, and family. The full list of the 15 nurses honored at the March of Dimes nurse recognition event is available at www.marchofdimes.com/minnesota/news_10004.html.
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JANUARY 2013 MINNESOTA HEALTH CARE NEWS
Bringing health care to the “Q”mmunity Helping to bridge the gap between underserved communities and primary care
n May 2011, Southside Community Health Service’s outreach department was chosen from among several submitted proposals to receive UCare’s newly retired mobile dental vehicle. The 37-foot-long Winnebago was still in great condition, and UCare believed that, in the hands of the right organization, the vehicle could continue to be of use to the community.
Clarence Jones Southside Community Health Service
Clarence Jones is community outreach director for Southside Community Health Service, a Federally Qualified Health Center established in 1971. Southside has provided medical, dental, and vision services to the uninsured and underinsured in south Minneapolis and Stillwater for more than 30 years. The organization strongly believes in the importance of reaching out to the community to improve access to primary health care and to reduce health disparities. Southside’s mission is to earn the right to serve the community and to encourage community members to engage in their own health.
Collaboration Collaboration is an integral part of Southside’s outreach success with “Q”mmunity. We believe that in order to earn the right to serve the community, we must work in partnership with that community to address public health issues that it identifies as important. Therefore, Southside only brings “Q”mmunity to locations and events to which we have been invited. And we share this mobile medical unit with other community organizations so that they can use it for outreach as well.
Southside was honored to receive this donated vehicle. Because we already had a mobile dental unit, we decided to transform UCare’s vehicle into one that would provide mobile medical services and health education to “Q”mmunity is staffed by people in the community, Southside employees, plus some of whom did not “Q”mmunity volunteer and paid public receive regular—or any— health nurses from the provides primary health medical care. Today, the Minnesota Visiting Nurse donated vehicle, now screening services. Agency and the Minnesota renamed the “Q”mmunity Black Nurses Association, Mobile Medical Unit for its U of M medical students, community focus and commitment to “quick” and and staff from other Federally Qualified Health “quality” service, has a private exam room and Centers such as NorthPoint Health and Wellness space in which staff and volunteer health person- Center, Neighborhood Health Source, and Open nel provide a variety of free preventive health Cities. services. On the road to better health Services In the summer of 2012, the “Q”mmunity Mobile These services include checking blood pressure, cholesterol, and glucose. This can alert the person being tested to the need to modify diet and exercise in order to reduce the risk of developing stroke, diabetes, and other chronic health conditions. It helps people who already know they have diabetes to monitor their condition, and alerts people who aren’t aware that they have diabetes that their blood glucose levels are high enough to require medical follow-up. “Q”mmunity also offers BMI testing, which assesses whether or not someone is obese and could benefit from education about obesity’s health risks. In addition, “Q”mmunity provides HIV/STD testing, vaccines, child/teen checkups, clinical breast exams, referrals for mammograms, and patient education. These services express the vision that Southside has for “Q”mmunity: to help bridge the gap that often exists between underserved communities and primary care. “Q”mmunity provides primary health screening services as well as information about additional services and resources that are available. Our goal is to connect patients to a medical home, inform uninsured patients about health care programs that are available to them, help keep people out of emergency rooms, and emphasize the importance of having a primary care doctor.
MINNESOTA HEALTH CARE NEWS JANUARY 2013
Medical Unit provided health screenings to more than 2,000 individuals in the Twin Cities metro area and provided resources and educational materials to more than 8,000 individuals in the same area. One of our success stories took place on a day in May 2012, when the “Q”mmunity Mobile Unit was providing screening services at the YMCA in north Minneapolis, sponsored that day by HealthFair11. A woman without health insurance who had just moved to the area stopped by to have her blood pressure checked, and found that it was alarmingly high—so high that she was at risk of suffering an immediate stroke if she walked home. Staff from the Minnesota Visiting Nurse Agency and the Minnesota Black Nurses Association called an ambulance and helped the woman get to a local hospital. A few months later at another event in north Minneapolis, the same woman came back to the “Q”mmunity Mobile Unit to thank the staff for saving her life that May day. She also told the staff that since then, she had acquired a primary care doctor and was making significant lifestyle changes to improve her health. This story and many others like it are the reasons that Southside is so committed to its outreach efforts and the work of the “Q”mmunity Mobile Medical Unit.
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JANUARY 2013 MINNESOTA HEALTH CARE NEWS
Endocrinology, what’s new? John T. Chow, MD, FACE Dr. Chow is board-certified in internal medicine and endocrinology. He trained at the Mayo Clinic in Rochester and practices at the Endocrinology Clinic of Minneapolis in Edina. What does an endocrinologist do? Endocrinologists diagnose and treat disorders involving hormones—substances produced in glands throughout the body that carry messages from those glands to tissues or organs. Hormoneproducing glands include the pituitary, thyroid, parathyroids, pancreas, adrenals, ovaries, and testes. These glands have wide-ranging functions, so endocrinologists treat a broad range of medical conditions. How did the field get started? Hormones were extracted from human urine in China as early as 200 BC. In the early 1900s, a substance in the blood was found to stimulate pancreatic secretions. This substance, secretin, was the first specifically defined hormone. The first hormone replacements were used to treat diseases such as diabetes and hypothyroidism. When would someone consult an endocrinologist? Typically, a referral is made by a primary care provider. Many endocrine disorders, including diabetes, hypothyroidism, and osteoporosis, can be diagnosed and managed initially by primary care providers. Consulting an endocrinologist becomes appropriate if a patient has difficulty achieving treatment goals, such as a diabetic patient controlling blood glucose levels. Disorders such as thyroid cancer, pituitary gland dysfunction, and adrenal tumors involve complex evaluation and treatment and warrant early evaluation by an endocrinologist. What should we know about vitamin D? Vitamin D is a hormone produced by the body with sun exposure, and is also absorbed from foods and supplements. Historically, it was thought of primarily as essential to bone health. However, recent studies suggest effects ranging from cancer prevention to heart disease treatment. Research on vitamin D’s effects is a hot topic in medicine now. There is not yet consensus on how much vitamin D is needed in the daily diet.
MINNESOTA HEALTH CARE NEWS JANUARY 2013
The current recommended daily allowance (RDA) of vitamin D is 600 International Units (IU) for adults, though most experts would suggest that 1000–2000 IU is a good daily target from diet and supplement intake. Vitamin D requirements also depend on a person’s exposure to sunlight and his or her skin pigment. Please tell us about metabolic syndrome. This refers to several factors that increase the risk for heart disease, stroke, and type 2 diabetes when they occur simultaneously in the same person. Someone with metabolic syndrome has at least three of the following factors: increased waist circumference, high triglycerides (which carry fat in the blood), low HDL (good cholesterol), high blood pressure, and high fasting glucose (meaning you start the day with a higher than normal amount of sugar in your blood). “Metabolic syndrome” is a controversial term. Knowing there is an association between risk factors can prompt someone with one factor to look for other factors. This could help prevent and manage disease, especially diabetes and cardiovascular disease. But some experts feel that lumping these factors together as a syndrome does not predict disease better than assessing each factor separately. What can you tell us about thyroid problems? They’re very common. The thyroid produces hormones that control the body’s metabolic rate; these hormones are associated with body weight and energy levels. Common disorders include hypothyroidism and hyperthyroidism, which are frequently due to autoimmune Photo credit: processes. In hypothyroidism, the thyroid Bruce Silcox underproduces hormones, and an affected person may feel fatigued, cold, inexplicably gain weight, and have dry skin, among other symptoms. A person with hyperthyroidism pro-
Consulting an endocrinolo-
in the U.S. Early adoption of diet and exerduces an excess of thyroid hormones, and, gist becomes appropriate if cise programs—paramount in weight loss due to a higher than normal metabolism, efforts—can slow or prevent the devastating may experience insomnia, fast heart rate, a patient has difficulty complications of diabetes. Once these comunintended weight loss, and sweating, achieving treatment goals. plications occur, little can be done to reverse among other symptoms. Hypothyroidism is typically managed with medications. Hyperthe disease process. thyroidism treatment may involve medications, iodine radiation pills, What have been the most dramatic advancements in or surgery. endocrinology during the last decade? Improved insulin Thyroid nodules, or growths within the thyroid, are also common, pumps and continuous glucose sensors rank among many major steps particularly in women; half of women have at least one thyroid nodforward. Insulin pumps, which infuse a precise amount of insulin ule by age 50. Approximately 5 percent of persons with thyroid nodinto a diabetic person’s body constantly throughout a day, have been ules develop thyroid cancer, but prognosis is generally good, particuaround for decades. New pumps are easier to wear, and provide flexlarly in younger patients and in those with small cancers. ibility in how insulin is distributed for a given person’s diet and activHelp us understand prediabetes. Prediabetes means that you ity level. Insulin dosing through shots or a pump can be optimized by are at increased risk for developing diabetes. This is sometimes called using an additional device called a continuous glucose sensor, which “impaired fasting glucose” or “impaired glucose tolerance.” Research continuously relays information about blood glucose levels. that studied thousands of adults at risk for developing diabetes Are treatment advances on the horizon for people with showed that improvements in lifestyle factors such as diet and exercise endocrine conditions? Research and development continue to reduced the risk of prediabetes progressing to diabetes by over half. improve technology for insulin pumps and continuous glucose senWhat is the most important thing you wish patients knew sors. Eventually, an artificial pancreas could theoretically incorporate about type 2 diabetes? “An ounce of prevention is worth a pump and sensor technology to completely automate a person’s diapound of cure.” With diabetes, we are primarily concerned about betes management, correcting small problems so they do not turn complications that can occur due to toxic effects of high blood gluinto big ones; that’s the “holy grail.” Genetic tests are being introcose levels on blood vessels. These effects typically progress from duced to help predict the aggressiveness of thyroid cancer, thus allowharming small blood vessels to harming large blood vessels. Small ing physicians to individually tailor cancer treatments. And osteoblood vessel disease can damage eyes, kidneys, and nerves. Large porosis drugs in development are designed to have the same degree of blood vessel disease produces heart disease, the leading cause of death fracture prevention as current drugs, without some of the side effects.
Chemical dependency in older adults is hard to recognize We help them live a healthier life Alcohol and drug abuse by seniors often goes unnoticed because of isolation and loneliness. As a result, the older adult continues to suffer in silence. Senior Helping Hands is a program of St. Cloud Hospital Recovery Plus and a recognized national leader providing support and services to stop the suffering. Senior Helping Hands serves individuals age 55 and older. Services • Outreach service and consultation with family or concerned persons • Evaluation and assessment for chemical dependency and/or mental health issues completed by qualified professionals • Volunteer support for older adults who are chemically dependent • Support from peer volunteer counselors for older adults with mental health issues Programs Older Adult Chemical Dependency Primary Treatment Program A comprehensive program that involves physical/psychosocial/chemical use assessments performed by professionals trained in chemical dependency and mental health, including a full time Medical Director who is an addictionist. The program provides a slow pace, holistic approach to recovery. Transportation and temporary housing are available if needed.
Contact Us 713 Anderson Ave., St. Cloud, MN 56303 (320) 229-3762 • (800) 742-HELP toll-free www.centracare.com (Search: Senior Helping Hands)
JANUARY 2013 MINNESOTA HEALTH CARE NEWS
Winter eye injuries
ccording to the American Academy of Ophthalmology, more than 40 percent of eye injuries each year— about 40,000—are related to sports or recreational activities. Among high-risk winter sports are those that include a ball, puck, stick, or racquet and those involving body contact. Think hockey, basketball, football, and racquetball. Extremely high-risk sports are those that involve body contact and traditionally lack eye protection, such as wrestling and martial arts. Outdoor winter activities such as snowmobiling, skiing, and sledding also pose a risk. Case in point: Bryan Berard, a former professional ice hockey defenseman. During a game in 2000, an opponent’s stick clipped Berard’s right eye, causing devastating damage. Berard endured seven surgeries and was told by doctors he was lucky he didn’t lose his vision completely. Types of injury
Enjoy winter sports—safely By Y. Ralph Chu, MD
There are three types of eye injuries most common in winter sports: blunt trauma, corneal abrasion, and sunburn. Blunt trauma is the most serious. Known as an orbital blowout fracture, it is a break in the bones surrounding the eye. Typically caused by significant force or trauma to the eye from a puck or a kick or elbow in the face, this type of injury is a medical emergency. Surgery is sometimes needed to heal broken bones or in cases where the retina has detached from the eyeball. Bruising or “black eyes” are less serious forms of this injury.
WHO’S GOT BETTER MOVES ON THE DANCE FLOOR, YOU OR ME? Every day is a reason for a person with Down syndrome to smile. And find joy in things the rest of us often overlook. To learn more about the richness of knowing or raising someone with such an enthusiasm for life, call your local Down syndrome organization. Or visit ndsccenter.org today. It is the mission of the Down Syndrome Association of Minnesota to provide information, resources and support to individuals with Down syndrome, their families and their communities. We offer a wide range of services, programs and materials at no charge. If you are interested in receiving one of our information packets for new or expectant parents, please email Kathleen@dsamn.org or For more information please call:
(651) 603-0720 • (800) 511-3696 12
MINNESOTA HEALTH CARE NEWS JANUARY 2013
©2007 National Down Syndrome Congress
even on overcast days. (UV radiation travels through clouds.) If damage does occur, symptoms may be relieved by artificial tears and cool wet compresses on the eyes. Sunburned eyes will heal in one to three days if treated promptly. Sufferers who wear contact lenses should remove them and wear sunglasses until symptoms improve. When to seek treatment With any eye injury, certain symptoms require immediate attention: • Pain lasts for more than a few hours or is severe • Vision is blurred or you have vision loss • You feel like there is something in your eye that you can’t remove • The eye is unusually red • Pain that went away after treatment returns If a small object is stuck in the eye: • Always wash your hands before examining the eye.
Anyone outdoors in winter should wear sunglasses.
Blunt trauma requires immediate medical attention. Corneal abrasion. People who suspect corneal abrasion should see their eye doctor right away, even if the pain goes away. Scratches from this type of injury can make you more susceptible to infection, because bacteria and fungi can enter the eye through a scratch in as few as 24 hours. This type of infection can cause blindness, especially if the object that scratched the eye was dirty or contaminated. Rubbing the eye only makes the situation worse, and a patch over the eye may allow bacteria to grow. Corneal abrasion is typically treated with antibiotic eye Scratches can drops or ointment and possibly make you more steroid or anti-inflammatory eye drops to reduce inflammation and susceptible to the risk of scarring. Your eye care infection. professional may use anesthetic eye drops to relieve initial pain, but these drops are not a long-term remedy, as they will interfere with healing. Over-the-counter eye drops can reduce pain and sensitivity to light, as will sunglasses. UV radiation damage. Prevention is the best treatment for this, which is why anyone outdoors in winter should wear sunglasses,
• Do not touch, rub, or press the eye. If the patient is a child, keep the child from doing so. • Never try to manually remove a foreign body from the eye because you risk scratching the cornea. Instead, try flushing it out. This technique is safe if done properly. Winter eye injuries to page 30
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Corneal abrasion occurs when something scratches or pokes the eye. This can happen if a basketball player’s finger scratches another player’s eye as they both jump to rebound a ball. It can also be caused by a branch that snaps into the eye of a skier or snowmobile rider; one of my patients experienced this when a stick flew into his eyes as he rode an ATV. Corneal abrasions can be very uncomfortable and cause severe sensitivity to light. Sunburn. Skiers, snowmobilers, and others who spend time outdoors in the winter need to be aware of radiation injury that occurs when the eye is exposed to too much ultraviolet (UV) light from the sun. UV radiation damage to the eye, or ultraviolet keratitis, is similar to sunburn of the skin because damage accumulates according to exposure. Damage happens faster at extreme elevations on snow because the snow reflects light upward and into the eyes. The risk of this type of injury, or “snow blindness,” is very high under these conditions. The injury isn’t usually noticed until several hours after exposure, when symptoms include watery eyes and a painful, sand-inthe-eyes sensation.
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JANUARY 2013 MINNESOTA HEALTH CARE NEWS
Fatty acids and your health
ot all fat is bad. Fatty acids, which are produced when fat is broken down during normal metabolism, are an important part of a healthy diet because the body uses them in many ways that promote health. Now, before you start pouring extra butter over your popcorn and ordering deep-fried chicken and french fries—all of which contain an overabundance of unhealthy fats in addition to fatty acids—continue reading to find out why fatty acids are a valuable part of a healthy diet and which foods contain them.
Multiple benefits, many sources By Heidi Greenwaldt, MS, RD, LD, CNSC
What fatty acids do Fatty acids play many roles, including being used for energy by most types of cells and aid-
ing the absorption of vitamins A (eyesight), D (calcium absorption), E (anti-aging), and K (blood clotting). They also support cell membrane development and function. Essential fatty acids are called “essential” because they cannot be produced by the body and thus must be obtained from food or supplements. The two main classes of essential fatty acids are omega-3 and omega-6. Omega-3 fatty acids. The main benefit of omega-3s is anti-inflammatory. Since inflammation has been implicated in heart disease, cancer, and arthritis, omega-3s may reduce the risk of developing these conditions. Omega-3s are also believed to
Now accepting new patients
A unique perspective on cardiac care Preventive Cardiology Consultants is founded on the fundamental belief that much of heart disease can be avoided in the vast majority of patients, and significantly delayed in the rest, by prudent modification of risk factors and attainable lifestyle measures.
Elizabeth Klodas, M.D., F.A.S.C.C is a preventive cardiologist. She is the founding Editor in Chief of CardioSmart for the American College of Cardiology www.cardiosmart.org, a published author and medical editor for webMD. She is a member of several national committees on improving cardiac health and a frequent lecturer on the topic.
We are dedicated to creating a true partnership between doctor and patient working together to maximize heart health. We spend time getting to know each patient individually, learning about their lives and lifestyles before customizing treatment programs to maximize their health. Whether you have experienced any type of cardiac event, are at risk for one, or
are interested in learning how to prevent one, we can design a set of just-for-you solutions. Among the services we provide • One-on-one consultations with cardiologists • In-depth evaluation of nutrition and lifestyle factors • Advanced and routine blood analysis • Cardiac imaging including (as required) stress testing, stress echocardiography, stress nuclear imaging, coronary calcium screening, CT coronary angiography • Vascular screening • Dietary counseling/Exercise prescriptions
To schedule an appointment or to learn more about becoming a patient, please contact: Preventive Cardiology Consultants 6545 France Avenue, Suite 125, Edina, MN 55435 phone. 952.929.5600 fax. 952.929.5610 www.pccmn.com
MINNESOTA HEALTH CARE NEWS JANUARY 2013
Amount of omega-3 fatty acids in foods
support development and functioning of the 1 ounce of walnuts/about 14 shelled walnut halves contain 2.6 grams nervous system, including playing a crucial role in of omega-3 fatty acid brain function. They may enhance mood and memory as 1 ounce of flax seeds/3 Tbsp. of ground flax seed/2 Tbsp. whole flax well. These positive effects on the nervous system are found seed = 1.8 grams. Ground flax seed is better than whole seed because in adults as well as in children. the body uses it more readily. Whole seeds should be ground or chewed thoroughly to facilitate the body’s access to omega-3s inside In addition to benefiting cognitive and behavioral develthe seeds. opment in children, omega-3 fatty acids have been shown to 4 ounces of canned mackerel or salmon = 2.2 grams benefit children’s visual development. Because the subtype 4 ounces of fresh or frozen salmon, cooked = 1.7 grams of omega-3 called DHA occurs naturally in breast milk, some infant formula and toddler foods are fortified with 1 Tbsp. canola oil = 1.3 grams DHA. Although some studies report that children benefit 1 Tbsp. soybean oil = 0.9 grams from these enriched foods, other studies have shown no 4 ounces of fresh or frozen cod, cooked = 0.6 grams benefit. Currently, the American Academy of Pediatrics does 4 ounces of fresh or frozen scallops, cooked = 0.5 grams not have a position on DHA-enriched food. ½ cup dry soybeans, cooked = 0.5 grams EPA is another omega-3 subtype. Studies have shown 4 ounces of canned tuna, drained = 0.3 grams that increasing dietary intake of both 1 ounce of pecans / about 20 shelled pecan halves = 0.3 grams EPA and DHA can decrease the risk of heart disease in several ways: by lowering the amount of fats mends eating fish high in omega-3s at least in the blood called twice a week. For someone who already has triglycerides, by heart disease, the AHA recommends conreducing inflammasuming a daily total of tion, and by lowering 1 gram of a combination of EPA and DHA blood pressure. ALA is considfrom fish or a supplement, contingent upon approval by that perered the third subtype of omega-3 because it is partially converted son’s health care provider. to EPA and DHA in the body. Fatty acids and your health to page 34 Omega-6 fatty acids. Like omega-3s, this subtype is used by the body as an energy source and is incorporated into cell membranes and nerve cells. However, excess consumption of omega-6s can lead to increased inflammation. Since the typical American diet contains about 20 times more omega-6s than is ideal, consider replacing corn oil and vegetable oil, which contain omega-6s, with oils rich in omega-3s, such as canola oil and soybean oil. Sources Since omega-3 and omega-6 fatty acids cannot be produced in the body, they must be obtained regularly from food or supplements. However, be sure to discuss all supplements with your health care provider before you begin taking them. Food. Omega-6s are found only in plants, as is the omega-3 subtype ALA. Omega-3 subtypes EPA and DHA are found in abundance in coldwater fish like salmon, herring, mackerel, sardines, and trout. While the greatest health benefits of omega-3s come from EPA and DHA in fish, omega-3s are also found in flax, pumpkin, and chia seeds and in walnuts. Consider eliminating items from your diet that have little or no omega-3 fatty acids, such as corn oil and vegetable oil, and replacing them with omega-3-rich oils such as canola or soybean oil. Since research shows that consuming omega-3 fatty acids promotes heart health, the American Heart Association (AHA) recom-
Consuming omega-3 fatty acids promotes heart health.
JANUARY 2013 MINNESOTA HEALTH CARE NEWS
eta-blockers make the heart’s job easier by making it beat more slowly and less forcefully. This reduces the heart rate and lowers blood pressure for the estimated 1 billion patients worldwide that currently use this class of medication. Reasons for use Most people use beta-blockers to treat high blood pressure, also called hypertension. An estimated 50 million Americans have this condition, which increases the risk of heart attack, heart failure, stroke, kidney disease, loss of vision, and difficulty thinking and remembering. The culprit that causes each of these effects is a narrowing of the arteries, which are blood vessels that direct blood from the heart to the rest of the body.
High blood pressure is most likely to develop in people over 55 and in those who are diabetic, smoke tobacco, drink too much alcohol, experience too much stress, and are overweight. Symptoms usually are not detected, which is why hypertension is known as the silent killer, but may include dull headaches, dizziness, and nosebleeds. If symptoms do appear, it’s generally after blood pressure has already become dangerously elevated and serious damage to internal organs already has occurred. That’s why it’s important to have routine medical checkups that include having your blood pressure checked. By Ashley Crowl, PharmD, Free blood pressure checks may be and Jean Moon, PharmD available at local fire stations and community health fairs, but free blood pressure readings from machines in stores may not be accurate. If you check your blood pressure yourself, whether by using a machine in a store or with a blood pressure cuff at home, be sure to be seated for five minutes with your feet flat on the floor before taking the blood pressure reading.
Lowering blood pressure since the 1960s
How do they work? The 16 beta-blockers approved by the U.S. Food and Drug Administration (FDA) affect the body in different ways. Some affect the heart; some, the kidney.
Living with gout? Keep enjoying life’s simple pleasures.
Heart effects Some slow the heart by slowing its muscle contractions. Others dilate arteries, creating an effectively wider-diameter artery. This reduces blood pressure within arteries in the same way water pressure in a garden hose is reduced when the water flows through a hose with a wider diameter. Kidney effects Beta-blockers that affect the kidney prevent sodium (salt) and water from being retained in the blood. This effect, plus beta-blockers’ ability to widen arteries, keeps blood pressure within a normal range. Other uses
Gout is the most common form of inﬂammatory arthritis in men and affects millions of Americans. In people with gout, uric acid levels build up in the blood and can lead to an attack, which some have described as feeling like a severe burn. Once you have had one attack, you may be at risk for another. Learn more about managing this chronic illness at www.goutliving.org
MINNESOTA HEALTH CARE NEWS JANUARY 2013
In addition to being used to treat high blood pressure, heart failure, atrial fibrillation, and coronary artery disease, beta-blockers can help patients who have suffered a heart attack. They help improve exercise tolerance and life expectancy for these people. They’ve been found useful for non-cardiac conditions too. One is glaucoma, which leads to increased fluid pressure inside the eye and can cause blindness if untreated. Beta-blockers administered as eye drops successfully treat glaucoma by reducing pressure inside the eye.
Beta-blockers reduce the fast heart rate that can be a symptom of hyperthyroidism. They are also used to reduce certain types of neurological tremors and to reduce anxiety. Propranolol, for example, is a beta-blocker that helps calm some people who fear public speaking. It has also been shown to help reduce the frequency and severity of migraine headaches. Side effects Many patients tolerate beta-blockers well, but some may experience side effects. As with most blood pressure medications, patients may feel dizzy or lightheaded if they stand up too quickly. This symptom, if it occurs, generally does so soon after the patient starts taking the drug and usually goes away after a week or two. Another side effect is fatigue. Less common side effects are diarrhea, constipation, gas, heartburn, increased weight gain from retaining water, and swollen legs. Patients who experience weight gain or swollen legs should contact their doctor to rule out congestive heart failure. In rare cases, betablockers may cause nightmares or difficulty sleeping. Lastly, male patients using certain beta-blockers may experience impotence. Fortunately, beta-blockers do not require lab tests to ensure that they are working effectively and safely. Typically, patients have their blood pressure and pulse checked one to two weeks after initiating therapy to make sure the drug is working appropriately and that the patient is tolerating the medication. People taking beta-blockers should never abruptly stop taking them unless advised to do so by their health care provider, as that can create unwanted side effects. It may take up to four weeks for a beta-blocker to exert its maximal effect. Patients using this class of medication typically have frequent follow-ups with their health care providers to be sure that their blood pressure is under control.
Hypertension is known as the silent killer.
Contraindications There are a few specific populations for whom beta-blockers are either not recommended or for whom these medications should be used with additional caution. Patients who have controlled asthma and who use beta-blockers need to be aware that these drugs can increase the potential for an asthma attack because of their potential for constricting airways. This occurs since both beta-blockers and albuterol inhalers affect the same part of the nervous system. Patients with chronic obstructive pulmonary disease (COPD), however, typically can tolerate beta-blocker therapy but should monitor their breathing frequently while taking this medication. While beta-blockers can be used by elderly people, health care providers typically wait to prescribe them to this age group until after other therapies have been tried and found unsuccessful. This is due to the fact that a significantly lowered heart rate from beta-blockers can pose a risk to elderly people. Diabetic patients who use beta-blockers need to monitor their blood sugar levels extra closely because these drugs can increase fast-
ing blood sugar levels, mask the signs of low blood sugars, or both. Beta-blockers also have been found to increase triglycerides (a type of fat in the blood) and HgA1C levels (which indicate the amount of sugar in a personâ€™s blood). Neither side effect is desirable in someone whose diabetes is uncontrolled. However, beta-blockers still can be an appropriate medication for patients with diabetes who are monitored closely by their health care providers. Use of beta-blockers by patients with psychiatric illness should be considered cautiously, because these drugs can make depression worse. Lastly, beta-blockers appear to be less effective in African Americans. These patients typically will be prescribed other classes of blood pressure medications before trying beta-blockers. Effective treatment Although medically supervised changes in lifestyle and diet can effectively lower blood pressure to a healthy range in some patients, other patients may benefit from the additional help provided by medication. For them, beta-blockers can effectively reduce hypertension with few, if any, side effects. But regardless what medications may be prescribed to treat a patientâ€™s high blood pressure, that patient will likely need to eat a healthier diet that contains minimal salt and will need to exercise most days of the week, limit alcohol intake, quit smoking, and lose weight. Ashley Crowl, PharmD, is a pharmaceutical care leadership resident in the U of M College of Pharmacy Ambulatory Care Residency Program and practices at Broadway Family Medicine, Minneapolis. Jean Moon, PharmD, is a clinical faculty member and an assistant professor in the U of M College of Pharmacy and practices at North Memorial Family Medicine Residency Program/Broadway Family Medicine, Minneapolis.
Cholesterol Do you know your numbers?
Ask your doctor
The h Goodd = HDL Cholesterol: Keep it high The Bad = LDL Cholesterol: Keep it low The Ugly = too much cholesterol can lead to heart attack and stroke Visit www.heart.org for more information about cholesterol and heart health
Minnesota Diabetes & Heart Health Collaborative
The Minnesota Diabetes and Heart Health Collaborative: Working together to keep you informed
www.mn-dc.org JANUARY 2013 MINNESOTA HEALTH CARE NEWS
January Calendar 12–13
Healthy Life Expo MediaMax presents the Healthy Life Expo. This two-day event will feature free seminars, health screenings, and samples. Admission is $6 or free with a nonperishable food donation to Twin Cities Food Drive. Call (612) 335-6025 for more information. Saturday and Sunday, Jan. 12–13, 10 a.m.–5 p.m., Minneapolis Convention Ctr., Ballroom, 1301 2nd Ave. S., Minneapolis
Celiac Disease Support Celiac Disease Foundation Twin Cities Chapter offers this support group for those affected by celiac disease and gluten intolerance. Come discuss questions and concerns about the gluten-free lifestyle or share your own food experiences. For more information, contact Lynn at (952) 443-2626. Tuesday, Jan. 15, 6:30–8 p.m., Chanhassen Library, 7711 Kerber Blvd., Chanhassen ALS Caregiver Support ALS Association offers a support group for the caregivers of those with Lou Gehrig’s disease. Free. RSVP is required. To RSVP or for more information, contact Jennifer at (888) 672-0484 or email@example.com. Wednesday, Jan. 16, 7–8 p.m., ALS Association MN/ND/SD Chapter Office, Union Plaza Bldg., 333 Washington Ave. N., Ste. 105, Minneapolis Alzheimer’s Caregiver Support Alzheimer’s Association offers this group for the caregivers of those suffering from early onset Alzheimer’s, MCI, or related disorders. To register, visit www.meetup.com. For more information, contact Denise at firstname.lastname@example.org. Thursday, Jan. 17, 7–9 p.m., Houlihan’s, 6601 Lyndale Ave. S., Richfield Hope for Recovery Workshop National Alliance on Mental Illness Minnesota offers a workshop for those with mental illness and an accompanying family member. Learn about the mental
health system, potential treatments, strategies, and resources. Free; lunch not provided. Register at www.eventbrite.com. Call (651) 645-2948 for more information. Saturday, Jan. 19, 9 a.m.–3 p.m., Bethlehem Lutheran Church, 4100 Lyndale Ave. S., Minneapolis
Birth Defects Prevention Month Did you know that one in 33 babies is born with a birth defect? While birth defects are not entirely preventable, there are steps any woman who is pregnant or may become pregnant can take to reduce the risk: • Take a daily multivitamin with at least 400 micrograms of folic acid. Folic acid helps the baby develop a healthy spine in the first trimester. Folic acid is recommended for women in their teens through childbearing years, since enough folic acid needs to be in the body before a woman gets pregnant. • Don’t drink alcohol or smoke tobacco. No amount of these is safe during pregnancy, so it is best not to consume any. • Talk to your doctor about any medicines you may be taking. Some medications can increase the risk of heart defect. • If you have diabetes, keep your blood sugar under control. Very high blood sugar levels can increase the chances of pregnancy complications, of having an extra large baby, and of having a baby who will be at increased risk for childhood obesity and diabetes. • Maintain a healthy weight, both before and after pregnancy. Obesity can increase the chances of having a baby with a congenital heart defect. • Get vaccinated. Before becoming pregnant, talk to your doctor about whether your vaccinations are up to date. If you will be pregnant during the flu season, be sure to get the flu shot. • Know your family history. Genetic factors can increase the chances of having a baby with a heart defect. If this is the case, ask your doctor for a referral to a genetic counselor. For more information, visit the National Birth Defects Prevention Network website at www.nbdpn.org.
18 Early Pregnancy Class Regina Medical’s Family Birthing Center presents a class on early pregnancy. Free. Fathers/labor coaches encouraged to attend. Call (651) 480-4175 to register. Friday, Jan. 18, 6:30–8:15 p.m., Regina Medical Ctr., First Floor Classroom, 1175 Nininger Rd., Hastings
Lupus Support Group The Lupus Foundation of Minnesota offers this support group for those affected by lupus. Come share personal stories, educational materials and resources, and socialize with others who understand. For more information, contact Judy at (952) 8314722 or Arlene at (952) 881-8558. Monday, Jan. 21, 7–8:30 p.m., Christ the King Lutheran Church, 8600 Fremont Ave. S., Bloomington
Hidden Disabilities The University of Minnesota hosts a panel discussion on the prevalence of disabilities. Learn about the challenges and opportunities of living with hidden disabilities. Free. Call Anne at (612) 625-9973 for more information. Friday, Jan. 25, 1:30–3 p.m., University of Minnesota, Elmer L. Andersen Library, Rm. 120, 222 21st Ave. S., Minneapolis
Affordable Care Act (ACA) The U of M presents Sara Rosenbaum, JD, discussing the ACA’s future in today’s political climate. Learn about challenges facing this act before it’s implemented in 2014. Free. Call Martha at (612) 625-2948 for more information. Thursday, Jan. 31, 11:30 a.m.–1 p.m., University of Minnesota, Coffman Memorial Union Theater, 300 Washington Ave S.E., Minneapolis
Send us your news: We welcome your input. If you have an event you would like to submit for our calendar, please send your submission to MPP/Calendar, 2812 E. 26th St., Minneapolis, MN 55406. Fax submissions to (612) 728-8601 or email them to mmacedo@ mppub.com. Please note: We cannot guarantee that all submissions will be used. CME, CE, and symposium listings will not be published.
America's leading source of health information online 18
MINNESOTA HEALTH CARE NEWS JANUARY 2013
You call it â€œreminding mom to take her pills.â€?
We call it caregiving.
You or someone you know may be a caregiver. WhatIsACaregiver.org
A national plan for Alzheimer’s For too many individuals with Alzheimer’s and their families, the system has failed them. Fortunately, progress is being made both nationally and in Minnesota.
lzheimer’s is a progressive, fatal brain disease, and the number of Minnesotans who have it is projected to increase from an estimated 98,000 people in 2010 to 200,000 by 2050. This is not just an “old person’s disease.” While the number of individuals with Alzheimer’s disease and other dementias is expected to double among those age 75–84 and triple for those over age 85, younger-onset Alzheimer’s, which occurs in people under age 65, is also increasing and accounts for 10 percent of all individuals with dementia. The cost of caring for all Minnesotans afflicted by Alzheimer’s is expected to increase, too, to $20 billion dollars per year. That’s nearly two-thirds of the current state budget.
National Alzheimer’s Project Act (NAPA)
National progress was made in January 2011, when President Obama signed into law landmark legislation, the National Alzheimer’s Project Act (NAPA). This laid the foundation for a national Alzheimer’s strategy. A key result of NAPA is the first-ever national plan, which A collaborative approach was released in May 2012. That plan includes a stated commitment addresses growing needs by President Obama to an Alzheimer’s research investment of $130 million and an investment By Susan J. Spalding of $26 million to support people with Alzheimer’s and their families. The plan recommends optimizing existing resources, supporting public-private partnerships, and transforming our national approach to Alzheimer’s by acting from a single comprehensive vision. NAPA also created the Advisory Council on Alzheimer’s Research, Care and Services. This council’s job is to help coordinate the work of federal agencies as well as to help develop and evaluate the national plan. The council allows patient advocates, health care providers, state health departments, Alzheimer’s researchers, and health associations to participate in the evaluation and strategic planning process. Ronald Petersen, MD, PhD, director of the Mayo Clinic Alzheimer’s Disease Research Center, chairs the council, and the Alzheimer’s Association president and CEO is a council member. Through an annual review process, NAPA will enable Congress and the American people to answer this simple question each year: At a Clare Bridge® community, communityy, we care for those who have been n touched Did we make satisfactory progress against Alzheimer’s during the by With home-like by Alzheimer’s Alzheimer’s and and dementia. dementia. W ith innovative innovative activities, activities, h ome-like past year? environments environments aand nd professional professional staff, staff, Clare Clare Bridge Bridge communities communities deliver deliver highhigh-
Everyone cares about
quality, Wee aalso understand quality, full-time full-time care. c are . W lso ccare are eenough nough tto ou nderstand tthe he ffull ull iimpact mpact of of this this disease, disease, from from its its destruction destruction of of the the memory memory to to the the challenges challenges and and difficulties it poses for families and an nd loved ones. And we respond accordingly. acccordingly. That’s why a Clare Bridge community comm munity is special. If your family has been touched toucheed by Alzheimer’s, call or visit your you ur nearest www.brookdaleliving.com. Clare Bridge community or log onto o We do more than th han care. We understand.
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MINNESOTA HEALTH CARE NEWS JANUARY 2013
State progress Progress was made on the state level when the 2009 Minnesota Legislature asked the Minnesota Board on Aging to establish the Alzheimer’s Disease Working Group (ADWG) to study the status of Alzheimer’s disease in Minnesota and to make recommendations for changes that would prepare the state for the future. The ADWG’s recommendations are now law and require the state to regularly collect information about: • Rates and results of cognitive screening statewide • Rates of Alzheimer’s and other dementia diagnoses statewide
• Types of care and treatment plans prescribed statewide This law also calls for cost analyses to be done regarding: • Earlier identification of Alzheimer’s and other dementias • Improved support of family caregivers • Improved collaboration between medical care providers and community-based supports
Alzheimer’s Association The Alzheimer’s Association is the world’s leading voluntary health organization in Alzheimer’s care, support, and research. Our mission is to eliminate Alzheimer’s disease through the advancement of research; to provide and enhance care and support for all affected; and to reduce the risk of dementia through the promotion of brain health. Our vision is a world without Alzheimer’s disease.
resources that help communities understand each of the key elements of a dementia capable community. Help is available
Alzheimer’s disease brings enormous cost and burden to individuals who have it, their families, 24/7 Information Helpline at (800) 272-3900 caregivers, employers, communiwww.alz.org/mnnd ties, and the state. The rapidly increasing prevalence of this disease in Minnesota and its Statewide collaboration implications for the state raise an urgent call for us to prepare The ADWG continued its commitment to assure the implementation our health care and support systems and our communities for the of the recommendations by establishing a collaborative organization spiraling needs related to this disease. For more information about ACT on Alzheimer’s and how called ACT on Alzheimer’s (formerly called Prepare Minnesota for it can help your community, visit www.collectiveactionlab.com Alzheimer’s 2020). /content/act-alzheimers. This statewide collaboration of medical, academic, community, government, business, and nonprofit stakeholders seeks to transform medical and long-term care systems and communities via five goals:
Susan J. Spalding is executive director of the Alzheimer’s Association Minnesota-North Dakota.
1. Detect Alzheimer’s early and provide quality care. 2. Sustain caregivers with information, support, and resources. 3. Equip communities to support their residents who are affected by the disease. 4. Raise awareness and engage communities in taking action.
The cost of caring for all Minnesotans afflicted by Alzheimer’s is expected to increase to $20 billion dollars per year.
5. Invest in interventions that reduce future costs of Alzheimer’s. No single organization owns, funds, or controls ACT on Alzheimer’s. Instead, its vision and goals are furthered by more than 150 participants, including more than 50 nonprofit, governmental, and private-sector organizations. Communities ACT One goal of ACT on Alzheimer’s is to help communities become “dementia capable.” Alzheimer’s A dementia capable community is one that is informed about Alzheimer’s; is safe for and is a respectful of individuals with the disease, progressive, their families, and caregivers; and provides supportive options that foster quality of life. fatal Currently, ACT on Alzheimer’s is working brain with five self-defined communities—St. Paul disease. Neighborhood Community, Walker area (Northern Lakes area), St. Louis Park/ Hopkins, the Twin Cities Jewish community, and the Willmar area (West Central Coalition)—and will soon launch a Dementia Capable Community Toolkit statewide. This toolkit helps communities implement four key action steps. The first step involves building a team interested in acting together to facilitate change. A strong team is needed to undertake the other three action steps: assessing a community’s dementia capability, analyzing where a community has opportunities for improvement, and developing and acting on a plan for the community to become more dementia capable. To support these action steps, the toolkit provides
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JANUARY 2013 MINNESOTA HEALTH CARE NEWS
PUBLIC HEALTH What is cardiac arrest?
Cardiac arrest and CPR You can make a difference By Demetris Yannopoulos, MD, and Kim Harkins, NREMT
Cold weather makes many things work harder, like furnaces and car batteries. Hearts, too. So it shouldn’t be surprising that cardiac arrests increase in Minnesota during the winter months by approximately 9 percent.
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Cardiac arrest is not the same as heart attack. A heart attack is often preceded by observable symptoms and occurs when blood is blocked from circulating through the heart. It is a plumbing problem that may require a trip to the emergency room. In contrast, a cardiac arrest is sudden, typically happens without observable symptoms, and occurs when a regular heartbeat suddenly changes to a lethal rhythm. This is an electrical problem requiring immediate action. The obvious indicator of cardiac arrest is someone who suddenly collapses and loses consciousness (passes out). There are various causes of cardiac arrest, including having had a heart attack. The increase in cardiac arrest (and in heart attacks) during the winter may be because arteries constricted by the cold are narrower than usual, so the heart must work harder to pump blood through them. This extra work can intensify existing symptoms such as chest pain and shortness of breath, symptoms that may have gone unnoticed during warmer months. And of course, shoveling snow, navigating slippery surfaces, and wearing heavy clothing put additional strain on the heart. Minnesota Resuscitation Consortium Working to improve survival for people who suffer cardiac arrest is the Minnesota Resuscitation Consortium, based at the University of Minnesota. We collect data on cardiac arrest to assess how often it occurs, who is likely to have it, different ways of managing it, and outcomes. Funded by the Medtronic Foundation’s Heart Rescue Project, we partner with organizations across the state to collect data and to coordinate efforts to improve bystander programs, pre-hospital care, care in the hospital, and recovery after cardiac arrest. Cardiac arrests Minnesota has a strong system of increase in care for cardiac arrest. Statewide survival rates are as high as 13 percent, Minnesota compared with the national average of during the 8 percent. But we can do better.
MINNESOTA HEALTH CARE NEWS JANUARY 2013
The American Heart Association states that performing cardiopulmonary resuscitation (CPR) on someone who has just had cardiac arrest can double, and possibly triple, that person’s chances of survival. One way to increase the survival rate is by encouraging bystanders to perform CPR and by increasing public access to
Resources defibrillators, also called automated external defibrillators (AEDs). While surveys show that almost 70 percent of Minnesotans have some knowledge of CPR, our current bystander CPR rate is only about 30 percent. That means that only one of every three people performs CPR on someone who suffers cardiac arrest. We aim to teach every Minnesotan to provide this lifesaving help. Learning CPR Learning CPR is much easier than in the past. People who require a CPR training card to prove completion of a CPR course for their employment should take a traditional CPR class. However, people who want to learn this skill in order to feel comfortable reacting in an emergency can benefit from shorter training that teaches compression-only CPR, also called hands-only CPR. This method differs from traditional CPR by eliminating mouth-to-mouth breathing. The rescuer only needs to recognize that an emergency has occurred, call 911, and begin pushing down hard and fast in the center of the patient’s chest. Studies have shown that this can be as effective as the traditional method of CPR during the early stages of rescue. However, recommended CPR technique for children and infants still includes mouth-to-mouth breathing and traditional CPR training. Nonetheless, if a person is unsure or unwilling to breathe for the patient, compression-only CPR is worthwhile, as it provides some benefit until help arrives. Winter CPR tips Performing CPR in colder weather is more stressful on your body, so continue to call for help after you start CPR. If bystanders offer to help but say they don’t know CPR, you can easily show them where to put their hands and coach Learning them while you rest. CPR is much In winter, someone who has collapsed from a cardiac arrest may be wearing easier than extra layers of clothing. These layers can in the past. hamper efforts to locate the proper site for hand placement. Layers also act as a cushion between your hands and the patient’s chest, making compressions less effective. Unzip the patient’s jacket and lift up his or her sweater to clear away as much bulky clothing as possible from the chest. Don’t worry about the patient getting cold; providing that person with a heartbeat is more important. During CPR, your compressions are the heartbeat.
Visit the Save-a-Life simulator at www.heartrescuenow.com www.mrc.umn.edu minute. Singing the 1980s disco song “Staying Alive” can help maintain the beat. 5. Continue compressions until help arrives or until someone applies an AED. If an AED is applied, follow the voice prompts and continue CPR. You may hear some cracking noises as you compress the chest, but don’t be alarmed. Often, this just means that cartilage is loosening from the breastbone. However, even if a rib does break during CPR, it can be repaired and will heal. This is a much better option than the alternative. If you are concerned about causing harm by doing CPR, remember: If you do something, the chance of survival increases. Do nothing, and the chance of survival significantly decreases. Be prepared While many people may never need to perform CPR, knowing the basic steps and attending a training session may save a life. Cardiac arrest can happen to anyone, any place, anytime. Be prepared: Learn CPR. Demetris Yannopoulos, MD, is an associate professor of medicine in the University of Minnesota’s cardiovascular division and is the medical director of the Minnesota Resuscitation Consortium. Kim Harkins, NREMT (nationally registered emergency medical technician), is the consortium’s program manager.
Follow these steps to provide CPR: 1. Call 911 if a person suddenly collapses and you can’t get a response from him or her. 2. Position the person on his or her back. Place your hands, one on top of the other, on the center of the chest. Your hands should be on the lower half of the breastbone. 3. Push down so that the person’s chest is compressed at least 2 inches in depth. 4. Compress the chest repeatedly and quickly, at least 100 times per JANUARY 2013 MINNESOTA HEALTH CARE NEWS
Shingles Painful, but potentially preventable By Christina Weber, PharmD
eople who have had chickenpox are at risk of developing a painful skin rash called shingles later in life. That’s because the same varicella zoster virus that causes the red, itchy spots of chickenpox also causes shingles. Once a person has had chickenpox, the virus moves from the skin into his or her nervous system, where it may stay inactive for decades. Sometimes, though, the virus becomes reactivated, although it’s not yet understood why or how this happens. When it does, the virus moves from the nerves back into the skin and causes shingles. According to the Centers for Disease Control and Prevention (CDC), 99.5 percent of people over the age of 40 have had chickenpox. This means that virtually everyone over the age of 40 carries the varicella zoster virus in his or her body. One-third of the people in this age group are likely to develop shingles, with those odds increasing after age 60. In fact, almost half of people between the ages of 50 and 85 develop this condition, for an estimated one million cases each year. Symptoms
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MINNESOTA HEALTH CARE NEWS JANUARY 2013
The first symptoms include a feeling of tingling, itching, or burning skin that can start one to five days before a rash is visible. Once the rash appears, it usually starts on one side of the mid-back, close to the waistline. It may also appear on the upper back, shoulder, or the face. Sometimes the rash appears in more than one of those areas, but rarely in all three. Additional symptoms may range from fever and chills to headaches and an upset stomach. After the rash goes away, blisters may develop in the same area. These typically dry up and disappear within two to four weeks, although scarring may result. When the rash and blisters are present, they can be extremely painful and sensitive to even slight pressure. Sometimes pain continues after the rash and blisters have healed completely. This condition is called postherpetic neuralgia and is a common complication of shingles. As many as 13 percent of people over 60 years old who have had shingles are at risk for this. Ongoing pain from this condition can last many months or even years. Additional complications of shingles include pneumonia, balance problems, a brain infection called encephalitis, a blood infection known as sepsis, deafness and other hearing problems, and vision loss that can include blindness. Vision or hearing loss may happen if shingles appears on the face or in the eye. Treatment
Shingles can be diagnosed by a physical exam. Since treatment must be started within 72 hours after the rash appears in order to be effec-
tive, contact your health care provider as soon as you notice the rash or any of the skin sensations of shingles. Antiviral medications are available that reduce shingles’ duration and severity. Your health care provider may also prescribe medication to help with itching and general pain. To relieve itching, try placing wet compresses or calamine lotion on the rash and take baths using a bath product that contains colloidal oatmeal. Get plenty of rest, especially if you have a fever. Do not touch or scratch the rash or blisters, and keep the affected area clean. Wash and disinfect all washcloths, towels, clothing, blankets, and sheets before reusing them, and put disposable items in the trash. Transmission
The virus that causes shingles is highly contagious and can cause chickenpox in someone who has never had it or who hasn’t been vaccinated against it. Transmission occurs from person to person by direct contact or through the air on droplets produced by coughing or sneezing. People who have not previously had chickenpox or those with weakened immune systems should avoid contact with those who have shingles. This is especially important for women who are planning to become pregnant, are pregnant, or who are breastfeeding; infants and premature infants (even if the mother was vaccinated); people with cancer or HIV/AIDS; people who have received a bone marrow or solid organ transplant; and those who are taking steroids. All of them are at greater risk of developing a severe case of chickenpox.
shingles ranges from $112 to $525. The average cost of vaccination depends on a person’s individual medical insurance, but ranges from $165 to $300. Medicare Part D covers the cost of the shingles vaccine; Medicare Parts A and B do not provide coverage. Ask your insurance provider or Medicare Part D plan if there is a copayment associated with shingles vaccination. Vaccination works
According to a study of more than 75,000 people, published Jan. 12, 2011, in the Journal of the American Medical Association, vaccina-
The single best way to prevent shingles is to get vaccinated. tion was effective in preventing shingles more than 50 percent of the time. The shingles vaccine also reduced the chance of having postherpetic neuralgia by roughly 67 percent. Shingles is serious. Not only can it be very painful, it can cause complications that have long-term health consequences, such as postherpetic neuralgia, hearing loss, and blindness. The CDC recommends that adults over age 60 get the shingles vaccine to significantly lower their risk of contracting this illness. Christina Weber, PharmD, manages one of four Walgreens pharmacies in Bloomington.
According to the CDC, the single best way to prevent shingles is to get vaccinated with the herpes zoster vaccine, also known as the shingles vaccine. The vaccine is approved for people 50 and older and is recommended by the CDC for people 60 and older. Even people who do not remember having had chickenpox as a child should get vaccinated against shingles since they could contract it if they become infected by the varicella zoster virus. Since shingles can recur, the best way to protect against recurrence is to be Medicare vaccinated, even if you already have had Part D shingles. The vaccine can be administered after the rash and subsequent blisters have covers the healed. It is not given to people while they cost of the are currently experiencing shingles or shingles postherpetic neuralgia. vaccine. The shingles vaccine is available at pharmacies such as Walgreens and at many doctors’ offices. Before you receive the shingles vaccine, check with your health care professional to see if you are allergic to any of the vaccine’s ingredients and if your immune system is strong enough for it. Do not get this vaccine if you are pregnant or breastfeeding. Once you’ve been vaccinated, check the area around the injection site daily. If you see a skin reaction that looks like the chickenpox, keep the injection site covered until it heals and contact your health care provider with any questions. Other reactions to the vaccine may include soreness, swelling, itching, and headache. Cost
Research from the Agency for Healthcare Research and Quality shows that the cost of treating an unvaccinated person who develops JANUARY 2013 MINNESOTA HEALTH CARE NEWS
rinary incontinence, or involuntary loss of urine, affects an estimated 200 million men and women worldwide. It’s a common and embarrassing problem that many people hesitate to discuss with their doctor because of the unfortunate misconception that a person “just has to live with it” as a normal condition associated with aging. However, this is not the case. Although aging muscles in the bladder and urethra are a contributing factor, excess weight, smoking, and conditions such as diabetes and kidney disease increase the risk of incontinence. Fortunately, for most types of urinary incontinence there are multiple surgical and nonsurgical treatments—some as simple as lifestyle modification.
Urinary incontinence Embarrassing but treatable By Christopher W. Boelter, MD
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MINNESOTA HEALTH CARE NEWS JANUARY 2013
Assessment The first step in treatment is an initial office visit for assessment. Patient and physician jointly determine the treatment plan that will work best for each individual. This phase of treatment typically includes completing a survey of past medical history, symptom severity, and any treatments the patient may have already tried. Additionally, urinalysis, imaging such as X-rays or ultrasound, a post-void bladder scan, bladder function testing, and a pelvic exam may be performed. Patients may also be asked to maintain a voiding diary that records how often they pass urine and under what conditions. Assessment provides information that categorizes a patient’s incontinence as stress, urge, or mixed urinary incontinence. These terms refer to the presumed cause(s) of the condition, which helps determine the next step. Types and treatment Stress incontinence is a sudden leakage of urine due to an increase in abdominal pressure that is caused by coughing, sneezing, laughing, or physical activity. Various surgical and nonsurgical options have been shown to dramatically improve or even cure this type of incontinence. The first step in exploring these options involves strengthening the pelvic floor with biofeedback-guided exercise. This physical therapy strengthens pelvic muscles that support the bladder (the organ that collects urine) and the urethra (the tube through which urine exits the body). During biofeedback, small sensors are placed on or near the muscles being targeted. By monitoring the results, a nurse is able to coach the patient to learn how to perform Kegel exercises, which strengthen pelvic muscles. Eighty percent of patients who learn to properly exercise their pelvic muscles report decreased or cured incontinence. Additionally, patients are instructed to make lifestyle adjustments that may include modifying fluid intake; weight loss; tobacco Patient cessation; and avoiding bladder irritants such and as caffeine, alcohol, carbonation, and certain physician acidic foods. Patients may also be instructed to monitor bowel habits, since a constipated jointly bowel can press on the bladder. If these conserdetermine vative measures do not produce noticeable the improvement, surgery is another option. This treatment may involve placement of a small sling to support the urethra. Between 90 percent and 95 plan. percent of patients experience relief of symptoms through this surgical procedure. Urge incontinence is commonly referred to as “overactive bladder.” It is often described as the “Gotta go!” feeling. Sometimes, treatment is as simple as decreasing intake of substances that can irritate the bladder muscle, such as coffee, caffeine, and chocolate. There are also medications that treat urge incontinence. These are called anticholinergics and are available as a tablet, patch, or gel. Physical therapy and biofeedback can be helpful treatment for urge incontinence, especially if the pelvic floor muscles are weak. If
these conservative measures fail, surgical options include sacral neuromodulation. This minimally invasive therapy, also known as InterStim, targets communication between the brain and the nerves that control the bladder and bowel. If those nerves do not communicate properly, the bladder and bowel will not function properly. By stimulating these nerves with a mild electric current, the neurostimulator helps the bowel and bladder to work properly. To determine if this treatment is appropriate for a given patient, evaluation is done using a peripheral nerve evaluation test . During this
Excess weight, smoking, and conditions such as diabetes and kidney disease increase the risk of incontinence. simple procedure, mild electrical stimulation of the nerves near the base of the spine is performed using a temporarily implanted small wire and an external neurostimulator. If this therapy is found to be effective, a permanent internal system can be implanted. Eighty percent to 90 percent of InterStim patients find this therapy to significantly improve their symptoms. Although stress and urge are the most common forms of incontinence, there are additional forms. Overflow incontinence is characterized by frequent dribbling of urine. This can be evaluated with an office test called a bladder scan, which determines how well the bladder empties. If the bladder Urinary incontinence to page 28
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Urinary incontinence from page 27
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empties incompletely, it may be related to one of several neurologic conditions, an enlarged prostate, prior surgery, or pelvic organ prolapse. Pelvic organ prolapse can be a contributing factor to incontinence in females. This occurs when organs such as the bladder or vagina slip, or prolapse, from their normal position. This can happen because the muscles and ligaments that hold pelvic organs in place become weak or stretched from childbirth, menopause, or surgery. This condition can be corrected conservatively or surgically. One nonsurgical treatment uses a device called a pessary, or “incontinence ring.” The pessary is inserted into the vagina to reduce the size of the prolapsed areas. This often improves urinary incontinence and reduces pelvic pain and pressure. One of the surgical procedures that can be used to correct pelvic organ prolapse is called a sacrocolpopexy and involves implanting a piece of soft mesh to support pelvic organs that have slipped out of their normal position.
It’s a common and embarrassing problem that many people hesitate to discuss with their doctor.
Mixed incontinence refers to the situation in which someone leaks urine due to both stress and urge incontinence. In mixed incontinence, the bladder is overactive and the pelvic floor muscles tend to be underactive. A treatment plan is developed by addressing the symptoms in order of dominance. Ask your doctor
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MINNESOTA HEALTH CARE NEWS JANUARY 2013
Urologists often hear hesitations such as, “It’s not that bad, I can live with it” or, “I need to take care of my family first.” Hesitation is understandable, but I encourage people to speak with their doctors and seek treatment. Don’t let urinary incontinence keep you from living life to its fullest. Treatments are available and your doctor can help. Christopher W. Boelter, MD, is a managing partner at Adult and Pediatric Urology (APU) and treats patients at APU’s Sartell and Buffalo locations. He has special interests in urological cancers and women’s health, as well as in laparoscopic and minimally invasive surgery.
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People who ride snowmobiles should wear goggles that are made for that sport and have polarized lenses that allow the rider to adjust to bright sunlight. These goggles should also have a layer of fog protection so that vision is not impaired while out on the trail. When fitting growing children and teens for goggles, remember to check periodically that the goggles continue to fit properly. Ill-fitting frames can obstruct peripheral vision and can actually put the wearer at greater risk of being hit by a ball or object from the side. Make sure that padding inside the sides of the goggle rests flush with the face and the eyes.
Winter eye injuries from page 13
How to flush the eye Tilt the person’s head over a basin or the sink. Gently pull down the lower lid to encourage the person to open his or her eyes as wide as possible. Slowly pour lukewarm water over the eye. Flush for up to 15 minutes, but check every five minutes to see if the object has been flushed out. If you can’t remove the object by flushing, seek medical attention. Protective gear While 40,000 sports-related eye injuries per year is an alarming number, the good news is that 90 percent of those injuries can be avoided. It’s as simple as investing in quality protective gear appropriate to the sport. Sports goggles are a sensible choice for people who play racquetball and basketball, and some even fit inside hockey or football helmets. Select goggles made of polycarbonate, an impact-resistant lens material that protects eyes from fast moving balls, pucks, hockey sticks, footballs, etc. You can also find polycarbonate lenses with built-in UV protection, which are useful for outdoor sports.
Protection is crucial
People who ride snowmobiles should wear goggles that are made for that sport.
It goes without saying that eye protection is crucial to preventing injury and lasting damage to your eyes. Doctors consider former hockey player Berard lucky for not losing his sight. It’s an eyeopening lesson for us all. Y. Ralph Chu, MD, is medical director and founder of Chu Vision Institute, Bloomington, a member of the Sports Ophthalmic Society of the Americas and the American Society of Cataract and Refractive Surgeons, and an adjunct associate professor of ophthalmology at the University of Minnesota Medical School, Minneapolis.
Health Care Consumer December survey results ... Each month, members of the Minnesota Health Care Consumer Association are invited to participate in a survey that measures opinions around topics that affect our health-care delivery system. There is no charge to join the association, and everyone is invited. For more information, please visit www.mnhcca.org. We are pleased to present the results of the December survey.
1. Employer-sponsored programs designed to lower my insurance costs by monitoring my compliance with medical advice violate my privacy. 28.9%
Percentage of total responses
5 Strongly agree
4. When the human resources department of an employer has access to medical information about an employee, it is a violation of health-care data privacy. 50
5.3% 0.0% Strongly agree
MINNESOTA HEALTH CARE NEWS JANUARY 2013
30 20 10
15 10 5.3%
5 Strongly agree
15 10 5
0.0% Strongly agree
47.4% Percentage of total responses
Percentage of total responses
Percentage of total responses
5. It is acceptable for a wellness program provided through an employer to have access to my medical records.
3. It violates my rights for an employer to collect information about my personal health status that is typically part of a medical record collected by a physician. 50.0%
2. Employer-sponsored programs that penalize/ reward employees for meeting health status standards violate employee rights.
Percentage of total responses
5.3% Strongly agree
Health Care Consumer Association
Welcome to your opportunity to be heard in debates and discussions that shape the future of health care policy. There is no cost to join and all you need to become a member is access to the Internet.
Members receive a free monthly electronic newsletter and the opportunity to participate in consumer opinion surveys.
â€œA way for you to make a differenceâ€? JANUARY 2013 MINNESOTA HEALTH CARE NEWS
Premature ventricular contractions When your heart skips a beat By Pierce Vatterott, MD
aybe you’re lying in bed, ready to fall asleep, or having a quiet moment during the day when you feel your heart skip a beat. It may feel like you want to cough, or just an odd feeling in your chest. This sensation is called a premature ventricular contraction (PVC). You may ask, “What is it? Is it a sign of heart disease? Is it serious?” What are PVCs?
PVCs are incorrectly timed contractions of the heart muscle, are not necessarily serious, and do not necessarily indicate the presence of heart disease. Most people experience PVCs at some time in their lives; random sampling of the population reveals that about one in 200 healthy young adults have them. These contractions become more common with age, especially in people with heart disease. In young, healthy individuals and in others without heart disease, PVCs are benign and require treatment only if someone has many of them and/or if they affect a patient’s quality of life or heart function. In patients with heart disease, a PVC originates from damaged, injured, or stressed heart tissue. Why do PVCs occur?
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MINNESOTA HEALTH CARE NEWS JANUARY 2013
A PVC is caused by a spontaneous electrical impulse produced by one or more cells in the lining of the heart. This impulse can be triggered by many factors, including adrenaline that surges in response to emotional or physical stress, dehydration, or certain stimulants, including caffeine. Certain abnormalities in heart structure, such as a blocked blood vessel or a faulty valve, can trigger PVCs directly, as can damaged heart tissue. Low blood levels of the electrolytes potassium or magnesium can stimulate PVCs and can be caused by kidney disease or by loss of body fluids due to diarrhea, vomiting, and some medications such as diuretics (water pills). Abnormal thyroid function and some medications can also cause PVCs. The connection between a spontaneous electrical impulse and an incorrectly timed contraction of heart muscle is that heartbeats require teamwork between a mechanical system (muscle) and an electrical system. In a normal heartbeat, the electrical system first activates the upper part of the heart to contract and pump and then activates the lower part. A PVC interrupts this sequence by causing the lower part to beat first. It is this out-of-sequence beat that causes symptoms. Diagnosis The occasional PVC presents little risk and needs no evaluation. PVCs should be evaluated if they affect quality of life, occur in someone who passes out for no known reason, or occur in someone with a family history of heart disease or who had relatives that died suddenly at a young age. The first step in diagnosis is typically for a health care provider to order a test called a simple 12-lead ECG (also called EKG). Depending on the patient’s history and exam, there may be additional tests such as a 24-hour ECG monitor called a Holter monitor, an exercise stress test, an echocardiogram (a picture of the heart via ultrasound), and/or a heart MRI, which is another procedure that
the major blood vessels of the produces a picture of the groin. The catheters are then heart. threaded from the groin into the Sometimes, the intermitheart. tent nature of PVCs makes Then, sophisticated recording diagnosis a challenge. In these of the heart electrical system is percases, the patient wears a FIGURE 1. Three-dimensional map of a patient’s heart electrical formed to locate the origin of the long-term monitor called an system, showing origin of PVCs in red. This patient was cured by PVCs. Once the heart tissue reevent monitor and activates it a single ablation at this site. Picture courtesy of the author. sponsible for producing PVCs has whenever symptoms occur, in been located, it is eliminated by order to record the heart burning a small portion of it, one just a few millimeters wide and a rhythm at that time. few millimeters deep. (See Fig. 1.) This ablation involves such a In people known to have damaged heart muscle or in whom small loss of tissue that it rarely affects heart function. Years of testing detects heart damage, PVCs can predict more serious events. technology and procedural advancements have made this technique PVCs themselves can weaken heart muscle if roughly 20 percent or practical, successful, and low risk. more of someone’s total daily heartbeats consist of PVCs. Treatment Treatment depends on a patient’s risk or if the condition affects quality of life. If your physician tells you that your PVCs are not dangerous, then choosing to have treatment is a quality-of-life decision. This typically includes lifestyle changes such as decreasing or eliminating caffeine and alcohol, improving rest and dietary habits, and decreasing stress. Abnormalities in heart structure that cause PVCs can be detected and, if possible, remedied. If your doctor is concerned about your PVCs, referral to a cardiologist or cardiac electrophysiologist is appropriate. This specialist will assess your risk based on your history, exam, and tests. If heart damage is found, Most it will be addressed.
people experience PVCs at some time in their lives.
Pierce Vatterott, MD, is a cardiologist at United Heart and Vascular Clinic, St. Paul, specializing in heart rhythm abnormalities. His major interests are ablation of lower heart rhythm abnormalities, extraction of failed or infected pacemaker and ICD leads, and genetic disorders of the heart that cause heart rhythm disorders.
Lifestyle Therapy for PVCs typically begins by reversing lifestyle factors such as diet and stress. If symptoms persist, using medication is generally the next step. Medication
The first medication that is usually tried is a beta-blocker, which can help quiet the heart. Some individuals benefit from overthe-counter omega-3 fish oil supplements. Stronger heart rhythm medicines are available but can be ordered only by a specialist and should be used with caution. Surgery PVCs that occur so frequently that they diminish an individual’s quality of life and/or decrease heart function can be remedied by a procedure called ablation. Only 1 percent to 2 percent of patients require this. In this procedure, which is performed in the hospital, a cardiac electrophysiologist places small tubes called catheters into JANUARY 2013 MINNESOTA HEALTH CARE NEWS
Fatty acids and your health from page 15
Ways to increase omega-3 consumption
Supplements. If you take supplements to obtain fatty acids, be sure to read the label to ensure you are receiving the correct amount of omega-3s. Many products on the market direct users to take two capsules each day, with each capsule containing 500 milligrams of omega-3 fatty acids. Unfortunately, many people incorrectly assume they are meeting AHA advice by taking this daily total of 1,000 milligrams (1 gram) of omega-3 fatty acids.
• Consume cold-water fish at least two times per week. • Increase intake of walnuts. Ways to accomplish this: – Sprinkle on top of salad. – Add to oatmeal. – Crush and use as a coating for chicken and fish instead of bread crumbs. • Increase intake of flax seed. – Sprinkle ground flax seed on yogurt.
The two main classes of essential fatty acids are omega-3 and omega-6.
– Add a tablespoon of ground flax seed to recipes for pancakes and baked goods. • Use canola or soybean oil instead of vegetable or corn oil. • Snack on roasted soybeans.
However, upon closer inspection of the supplement label, you will find the specific amounts of the EPA and DHA in the product. For example, one omega-3 fatty acid supplement contains 500 milligrams of omega-3 fatty acids per capsule, composed of 180 milligrams of EPA, 120 milligrams of DHA, and 200 milligrams of ALA. To meet the AHA’s recommendation of 1 gram of EPA and DHA, you would actually need to consume four capsules of this product per day instead of the two suggested in the directions. Consult your pharmacist if you’re unsure whether or not you’re consuming the recommended amount of omega-3s.
• Consume grass-fed beef instead of grain-fed beef; omega-3 content of the meat is higher in the former. • Purchase eggs from chickens fed a diet rich in omega-3. Certain brands advertise this on the egg carton. • Choose products fortified with omega-3. Those currently available include butter, margarine, salad dressing, cereal, peanut butter, and bread. Heidi Greenwaldt, MS, RD, LD, CNSC, is a registered and licensed dietitian, and is the spokesperson for the Minnesota Academy of Nutrition and Dietetics.
Supporting Our Patients. Supporting Our Partners. Supporting You. In 2008, Tanzanian missionaries brought little Zawadi Rajabu to the U.S. to seek treatment for her two severely clubbed feet. A physician referred Zawadi to Dr. Mark T. Dahl of St. Croix Orthopaedics. Using the Ilizarov Method, Dr. Dahl surgically changed the course of Zawadi’s feet and her life. Dr. David Palmer and Russ McGill, OPA-C, recently traveled to Tanzania on another of their frequent medical missionary trips. They dedicated an entire day to checking in on their partner’s patient. To their delight, they were greeted by 6-year-old Zawadi her face aglow, her healed feet dancing toward them.
David Palmer, M.D. & Zawadi’s brother Russ McGill, OPA-C & Zawadi
Online or Call 651-439-8807 Providing P roviding care care at at multiple mu ultiple moder modern n clinics in Minnesota Minne esota and Wisconsin Wisconsin
MINNESOTA HEALTH CARE NEWS JANUARY 2013
• Serious low blood sugar (hypoglycemia) may occur when Victoza® is used with other diabetes medications called sulfonylureas. This risk can be reduced by lowering the dose of the sulfonylurea.
Important Patient Information This is a BRIEF SUMMARY of important information about Victoza®. This information does not take the place of talking with your doctor about your medical condition or your treatment. If you have any questions about Victoza®, ask your doctor. Only your doctor can determine if Victoza® is right for you. WARNING During the drug testing process, the medicine in Victoza® caused rats and mice to develop tumors of the thyroid gland. Some of these tumors were cancers. It is not known if Victoza® will cause thyroid tumors or a type of thyroid cancer called medullary thyroid cancer (MTC) in people. If MTC occurs, it may lead to death if not detected and treated early. Do not take Victoza® if you or any of your family members have MTC, or if you have Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). This is a disease where people have tumors in more than one gland in the body. What is Victoza® used for? • Victoza® is a glucagon-like-peptide-1 (GLP-1) receptor agonist used to improve blood sugar (glucose) control in adults with type 2 diabetes mellitus, when used with a diet and exercise program. • Victoza® should not be used as the first choice of medicine for treating diabetes. • Victoza® has not been studied in enough people with a history of pancreatitis (inflammation of the pancreas). Therefore, it should be used with care in these patients. • Victoza is not for use in people with type 1 diabetes mellitus or people with diabetic ketoacidosis. ®
• It is not known if Victoza® is safe and effective when used with insulin. Who should not use Victoza®? • Victoza should not be used in people with a personal or family history of MTC or in patients with MEN 2. ®
• Victoza® may cause nausea, vomiting, or diarrhea leading to the loss of fluids (dehydration). Dehydration may cause kidney failure. This can happen in people who may have never had kidney problems before. Drinking plenty of fluids may reduce your chance of dehydration. • Like all other diabetes medications, Victoza® has not been shown to decrease the risk of large blood vessel disease (i.e. heart attacks and strokes). What are the side effects of Victoza®? • Tell your healthcare provider if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath while taking Victoza®. These may be symptoms of thyroid cancer. • The most common side effects, reported in at least 5% of people treated with Victoza® and occurring more commonly than people treated with a placebo (a non-active injection used to study drugs in clinical trials) are headache, nausea, and diarrhea. • Immune system related reactions, including hives, were more common in people treated with Victoza® (0.8%) compared to people treated with other diabetes drugs (0.4%) in clinical trials. • This listing of side effects is not complete. Your health care professional can discuss with you a more complete list of side effects that may occur when using Victoza®. What should I know about taking Victoza® with other medications? • Victoza® slows emptying of your stomach. This may impact how your body absorbs other drugs that are taken by mouth at the same time. Can Victoza® be used in children? • Victoza® has not been studied in people below 18 years of age. Can Victoza® be used in people with kidney or liver problems? • Victoza® should be used with caution in these types of people. Still have questions?
What is the most important information I should know about Victoza®? • In animal studies, Victoza® caused thyroid tumors. The effects in humans are unknown. People who use Victoza® should be counseled on the risk of MTC and symptoms of thyroid cancer. • In clinical trials, there were more cases of pancreatitis in people treated with Victoza® compared to people treated with other diabetes drugs. If pancreatitis is suspected, Victoza® and other potentially suspect drugs should be discontinued. Victoza® should not be restarted if pancreatitis is confirmed. Victoza® should be used with caution in people with a history of pancreatitis.
This is only a summary of important information. Ask your doctor for more complete product information, or • call 1-877-4VICTOZA (1-877-484-2869) • visit victoza.com Victoza® is a registered trademark of Novo Nordisk A/S. Date of Issue: May 2011 Version 3 ©2011 Novo Nordisk 140517-R3 June 2011
FOR TYPE 2 DIABETES
Victoza® helped me take my blood sugar down…
and changed how I manage my type 2 diabetes. Victoza® helps lower blood sugar when it is high by targeting important cells in your pancreas—called beta cells. While not a weight-loss product, Victoza® may help you lose some weight. And Victoza® is used once a day anytime, with or without food, along with eating right and staying active.
Model is used for illustrative purposes only.
Indications and Usage: Victoza® is an injectable prescription medicine that may improve blood sugar (glucose) in adults with type 2 diabetes when used along with diet and exercise. Victoza® is not recommended as the first medication to treat diabetes. Victoza® is not insulin and has not been studied in combination with insulin. Victoza® is not for people with type 1 diabetes or people with diabetic ketoacidosis. It is not known if Victoza® is safe and effective in children. Victoza® is not recommended for use in children. Important Safety Information: In animal studies, Victoza® caused thyroid tumors—including thyroid cancer—in some rats and mice. It is not known whether Victoza® causes thyroid tumors or a type of thyroid cancer called medullary thyroid cancer (MTC) in people which may be fatal if not detected and treated early. Do not use Victoza® if you or any of your family members have a history of MTC or if you have Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). While taking Victoza®, tell your doctor if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath. These may be symptoms of thyroid cancer. Inflammation of the pancreas (pancreatitis) may be severe and lead to death. Before taking Victoza®, tell your doctor if you have had pancreatitis, gallstones, a history of alcoholism,
If you’re ready for a change, talk to your doctor about Victoza® today.
or high blood triglyceride levels since these medical conditions make you more likely to get pancreatitis. Stop taking Victoza® and call your doctor right away if you have pain in your stomach area that is severe and will not go away, occurs with or without vomiting, or is felt going from your stomach area through to your back. These may be symptoms of pancreatitis. Before using Victoza ®, tell your doctor about all the medicines you take, especially sulfonylurea medicines or insulin, as taking them with Victoza® may affect how each medicine works. Also tell your doctor if you are allergic to any of the ingredients in Victoza®; have severe stomach problems such as slowed emptying of your stomach (gastroparesis) or problems with digesting food; have or have had kidney or liver problems; have any other medical conditions; are pregnant or plan to become pregnant. Tell your doctor if you are breastfeeding or plan to breastfeed. It is unknown if Victoza® will harm your unborn baby or if Victoza® passes into your breast milk. Your risk for getting hypoglycemia, or low blood sugar, is higher if you take Victoza® with another medicine that can cause low blood sugar, such as a sulfonylurea. The dose of your sulfonylurea medicine may need to be lowered while taking Victoza®.
Victoza® may cause nausea, vomiting, or diarrhea leading to dehydration, which may cause kidney failure. This can happen in people who have never had kidney problems before. Drinking plenty of fluids may reduce your chance of dehydration. The most common side effects with Victoza® include headache, nausea, and diarrhea. Nausea is most common when first starting Victoza®, but decreases over time in most people. Immune system-related reactions, including hives, were more common in people treated with Victoza® compared to people treated with other diabetes drugs in medical studies. Please see Brief Summary of Important Patient Information on next page. If you need assistance with prescription drug costs, help may be available. Visit pparx.org or call 1-888-4PPA-NOW. You are encouraged to report negative side effects of prescription drugs to the FDA. Visit fda.gov/medwatch or call 1-800-FDA-1088. Victoza® is a registered trademark of Novo Nordisk A/S. © 2011 Novo Nordisk 0611-00003312-1 August 2011
To learn more, visit victoza.com or call 1-877-4-VICTOZA (1-877-484-2869).
Non-insulin • Once-daily