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July 2013 • Volume 11 Number 7

Eating disorders Jillian Lampert, PhD

Dental therapy Karl Self, DDS

Stroke rehabilitation Bruce Idelkope, MD


Eating disorders are complex, and it’s not always obvious if and when to seek help. If you think you or someone you care about may be struggling with an eating disorder, the experts at Melrose Center can help you find answers.

952-993-6200

parknicollet.com/melrose

Thousands of lives restored


CONTENTS

4 7 8

JULY 2013 • Volume 11 Number 7

16

NEWS

PERSPECTIVE Robert O. Fisch, MD

20

HEALTH CARE ARCHITECTURE 2013 Honor Roll SPECIAL FOCUS: STROKE REHABILITATION

Beau Crabb, MS, CGC

HEALTH PROFESSIONS Dental therapy By Karl Self, DDS, MBA

14

18

CALENDAR Minority Health Awareness Month

10 QUESTIONS

Children’s Hospitals and Clinics of Minnesota

12

MINNESOTA HEALTH CARE ROUNDTABLE

By Jillian G. Lampert, PhD, RD, LD, MPH, FAED

PEOPLE

University of Minnesota, emeritus

10

BEHAVIORAL HEALTH Eating disorders

COMPLEMENTARY MEDICINE Utilizing alternative care

26

Stroke rehabilitation

28

When the “vulnerable adult” is you

30

By Bruce Idelkope, MD, and Alexander Zubkov, MD, PhD, FAHA

By Jen Kirchen, LSW

A stroke at 15 By Judy McMillan and Michael McMillan

By Charles Sawyer, DC

FORTIETH

SESSION

Advance care planning Addressing end-of-life issues Thursday, October 24, 2013 1:00 – 4:00 PM • Symphony Ballroom Downtown Mpls. Hilton and Towers

Background and focus: For the majority, end-of-life is the most medically managed part of life. With it come complex issues that involve economics, ethics, politics, medical science, and more. Advances in technology are extending life expectancies and require a redefinition of the term “end-of-life.” It now entails a longer time frame than one’s final weeks or hours, and provokes debate as to when life is really over. Mechanisms exist to facilitate personal direction around this topic, but there is a need for improved coordination among the entities that provide end-of-life support.

Objectives: We will discuss the significant infrastructure that supports end-of-life care. We will examine the roles of long-term care/assisted living, palliative care, gerontology, and hospice. We will review the elements that go into creating advanced directives, including societal issues that make having them necessary, and the difficulties encountered in bringing them to their current state. We will present a potential road map to optimal utilization of end-of-life support today and how it may best be improved in the future. Panelists include:

www.mppub.com PUBLISHER Mike Starnes mstarnes@mppub.com EDITOR Donna Ahrens dahrens@mppub.com ASSOCIATE EDITOR Janet Cass jcass@mppub.com ASSISTANT EDITOR Scott Wooldridge swooldridge@mppub.com

 Ed Ratner, MD, University of Minnesota Center for Bioethics  Suzanne M. Scheller, JD, Elder Law and Advocacy  Cheryl Stephens, PhD, MBA, President, CEO, Community Health Information Collaborative  Tomás Valdivia, MD, MS, CEO, Luminat Sponsors: Community Health Information Collaborative Luminat • Scheller Legal Solutions

ART DIRECTOR Elaine Sarkela esarkela@mppub.com OFFICE ADMINISTRATOR Arshia Sandozi asandozi@mppub.com ACCOUNT EXECUTIVE Paula Abramson pabramson@mppub.com ACCOUNT EXECUTIVE Iain Kane ikane@mppub.com Minnesota Health Care News is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; phone (612) 728-8600; fax (612) 728-8601; email mpp@mppub.com. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc., or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of this publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $36.00. Individual copies are $4.00.

Please send me tickets at $95.00 per ticket. Mail orders to Minnesota Physician Publishing, 2812 East 26th Street, Minneapolis, MN 55406. Tickets may also be ordered by phone (612) 728-8600 or fax (612) 728-8601. Name Company Address City, State, Zip Telephone/FAX Card #

Exp. Date

 Check enclosed  Bill me  Credit card (Visa, Mastercard, American Express, or Discover)

Signature Email

Please mail, call in or fax your registration by 10/17/2013

JULY 2013 MINNESOTA HEALTH CARE NEWS

3


NEWS

Cancer Researchers Seek Volunteers The Masonic Cancer Center at the University of Minnesota is seeking volunteers for a cancer study that requires input from the general public. The research is sponsored by the American Cancer Society and is part of its Cancer Prevention Study-3 (CPS-3). The study helps scientists better understand the genetic, environmental, and lifestyle factors that cause or prevent cancer. Officials note that previous such studies have provided valuable data on cancer, including helping researchers understand the link between smoking and lung cancer. Participation in the CPS-3 is easy, officials say. Participants take a survey, have their waist measured, and provide a small blood sample. “It’s amazing to imagine a future without cancer,” says Douglas Rausch, MD, medical director of the Comprehensive

Cancer Center at Hennepin County Medical Center (HCMC), one of many locations where people can enroll for the study. “This is a great opportunity to be part of a study that just might produce the information needed to eliminate this widespread, life-threatening, and deadly disease.” More information is available at www.cancermw.org/cps3 /TwinCities/TwinCities.html

Health Groups Pleased with Legislative Session The 2013 legislative session was a momentous one for the health care community in Minnesota. Public programs were expanded, a major new health insurance model was established, the tobacco tax saw a large hike, and funding was increased for health care providers. Health care organizations expressed satisfaction that policymakers had worked to address the concerns of providers during the session.

The early part of the session saw lawmakers working to implement provisions of the Affordable Care Act (ACA) that had been stymied last year, when the Republican-led Legislature was unwilling to endorse the ACA. With the Legislature controlled by the DFL in 2013, Medicaid expansion was signed into law on Feb. 19, ensuring that 35,000 additional Minnesotans would have access to Medicaid. The Legislature then tackled health insurance exchanges, another key provision for expanding health insurance coverage to uninsured Americans. The Dayton administration had moved forward with planning for the exchange, but legislation was needed to set up the new insurance model. Officials estimate that with the passage of the exchange in early March, 300,000 currently uninsured Minnesotans will find coverage. Ultimately, 1.3 million state residents could eventually benefit from the new exchange. According to Dave Renner, director of Minnesota Medical

Association’s department of state and federal legislation, his group saw progress on nearly all its priorities. “This was a very successful session,” Renner says. In addition to Medicaid expansion and the insurance exchanges, Renner points to funding increases for medical education and the funding for health prevention measures like the State Health Improvement Program. “Tobacco continues to be the No. 1 preventable cause of death and disease; obesity adds to significant health risks in a number of areas,” he says. “If we can start addressing those issues, we will go a long way toward keeping people out of the doctor’s office and out of the hospital.” Lawmakers also approved a 20-year, $455 million program to create a Destination Medical Center with Rochester’s Mayo Clinic. The funding is designed to make Mayo Clinic competitive with other large urban health centers such as Cleveland Clinic and Baltimore’s Johns Hopkins Hospital.

The Public Is Cordially Invited To an informative interactive conference with national and local medical leaders. Date: Saturday, August 10, 2013 Time: 8:30 am - 4:30 pm Place: Hubert Humphrey School of Public Affairs Conference Room University of Minnesota Minneapolis, MN Cost: $25.00 (lunch provided) Registration: http://tinyurl.com/lajk4uo Or call Dave Racer at 651-705-8583, Ext 1.

Learn how Direct Pay Medical/Professional Practices provide affordable, quality healthcare to you and your family: • Gain better access to your doctor and know what your care will cost. • Hear real-life stories of practicing physicians and surgeons who have transitioned from third-party insurance practices to a direct pay model. • Learn why many physicians, surgeons and other health care professionals are moving to direct pay practices.

Learn first hand from MDs who are already in Direct Pay Practice: Jane Orient, MD Tucson, AZ

Chris Foley, MD Minneapolis, MN

Gerard Gianoli, MD Baton Rouge, LA

Juliette Madrigal, MD Marble Falls, TX

Robert Sewell, MD Dallas, TX

James Eelkema, MD Burnsville, MN

Lee Beecher, MD St. Louis Park, MN

Adam Harris, MD San Antonio, TX

Lee Hieb, MD Lake City, IA

Susan Wasson, MD Osakis, MN

Merlin Brown, MD Edina, MN

Plus Twila Brase (CCHF) and Authors: Lee Kurisko, MD Ralph Weber & Dave Racer, Mlitt

Sponsored by the Association of American Physicians and Surgeons (AAPS) and the Minnesota Physician and Patient Alliance (MPPA)

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MINNESOTA HEALTH CARE NEWS JULY 2013


Rep. Eric Paulsen is calling for new legislation to promote the use of health savings accounts (HSAs) and flexible spending accounts (FSAs). Paulsen, who represents Minnesota’s 3rd District, says the federal government should simplify regulations around the health insurance models and do away with the “use it or lose it” rule that prevents FSA funds from rolling over from one year to the next. “With health care costs on the rise, Congress should be taking steps to make it easier for Americans to save, not limit their options,” Paulsen says. “HSAs and FSAs are a great way for seniors to plan for expenses that Medicare won’t cover and for families to plan for health expenses like braces or glasses. I am proud to introduce a common sense bill that helps Minnesotans retain control of their own health care needs.” Paulsen’s Family and Retirement Health Investment Act would make a number of changes to current HSA/FSA rules, including removing restrictions on HSA/FSA dollars used to purchase overthe-counter drugs; allowing HSAqualified plans more flexibility in covering prescription medications for chronic illnesses, diseases, and conditions; allowing individuals to roll over up to $500 from their FSA account; and expanding the definition of qualified medical expenses.

NAMI, HealthPartners Partner to Reduce Mental Illness Stigma HealthPartners is working with the National Alliance on Mental Illness (NAMI) to reduce the stigma associated with mental illness. HealthPartners, along with its Regions Hospital in St. Paul and NAMI, is launching a public information campaign called “Make It OK,” which seeks to encourage people to talk openly about mental illness and to ask for help.

“Mental illnesses touch us all, affecting people from every walk of life,” said Mary Brainerd, HealthPartners president and CEO. “Here in Minnesota, one in five people experience a mental illness each year. Most people live with the symptoms of a mental illness for up to 10 years before seeking treatment, largely due to the stigma. Together, we are working to change that and make it okay to ask for help.” The campaign will include radio and television commercials and print ads and the website, www.makeitok.org. The coalition began offering education and coaching sessions for business and community groups in June.

Study Finds Minnesota Seniors Healthiest in U.S. Minnesota is the healthiest state in the nation for seniors, a new report from United Health Foundation says. The foundation, a division of Minnetonka-based UnitedHealth Group, released its study on May 29 and found that Minnesota, Vermont, New Hampshire, Massachusetts, and Iowa are the top five states for seniors’ health. The state with the lowest ranking for senior health is Mississippi. “The America’s Health Rankings Senior Report is a comprehensive portrait of senior health designed to inspire new, effective solutions that meet the health care needs of this rapidly expanding demographic,” says Reed Tuckson, MD, senior advisor to United Health Foundation. “We are measuring senior health in order to help improve it. States with healthy seniors have a combination of positive personal behaviors and community support, which demonstrate that improving senior health will only come about by acting on individual, family, community, and state levels.” The report finds that Minnesota’s strengths include high rates of annual dental visits,

Telephone Equipment Distribution (TED) Program

Bill Seeks Flexibility For HSAs, FSAs

Do you have trouble using the telephone due to hearing loss, speech or physical disability? If so…the TED Program provides assistive telephone equipment at NO COST to those who qualify. Please contact us, or have your patients call directly, for more information.

1-800-657-3663 www.tedprogram.org Duluth • Mankato • Metro Moorhead • St. Cloud

The Telephone Equipment Distribution Program is funded through the Department of Commerce Telecommunications Access Minnesota (TAM) and administered by the Minnesota Department of Human Services

Tick-Borne Disease Specialty Clinic Tick-borne disease can result in disabling consequences that may resist treatment and even diagnosis. We have been successful in the rehabilitation of many patients with unique cases of chronic tick-borne illness. No medical referral is required.

Charles V. Burton, MD Helen P. Odland, MD For more information, please read Doctor Burton’s report at: www.burtonreport.com To schedule an appointment please call:

Sentinel Medical Associates 514 St. Peter Street, Suite 200 St. Paul 55102

612-287-8781

News to page 6 JULY 2013 MINNESOTA HEALTH CARE NEWS

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News from page 5 prescription drug coverage that the report finds reasonably comprehensive, relatively high availability of home health care workers, and a low rate of seniors at risk of hunger. Minnesota’s ranking also reflects a large number of seniors who report being in very good or excellent health. The study says that among the challenges in Minnesota is a low percentage of seniors with a personal doctor or health care provider. The report notes that Minnesota’s senior population is expected to grow nearly 55 percent between 2015 and 2030.

Stroke Numbers in State Remain Steady, MDH Says The Minnesota Department of Health (MDH) has released data showing that the incidence of stroke in Minnesota has held steady over the past eight years, while costs for treating strokes continue to rise.

Stroke was the third-leading cause of death in Minnesota as of 2010, state data show. MDH officials say that since 2005, the number of stroke hospitalizations has remained between 11,000 and 12,000 a year. They note that during the same time, the total number of hospitalizations for heart attack declined almost 15 percent from a high of 9,740 in 2005. Hospitalization data from 2011 show 11,570 hospitalizations for stroke for that year. The total inpatient charges for these hospitalizations were $414.1 million, an increase of $47 million in just two years. As part of raising awareness about stroke, MDH is educating Minnesotans about the warning signs of stroke and promoting prevention as well. “The reality of stroke is that if you’re having one, you need to get to the hospital fast,” says Ed Ehlinger, MD, Minnesota commissioner of health. “Our goal is for Minnesota to do a better job of managing blood pressure, cholesterol, smok-

When it comes to your child, getting help early is your priority.

ing, and other risk factors for stroke, so people never have to experience this life-threatening emergency." MDH officials say one key strategy to help prevent stroke hospitalizations is for doctors and providers to deliver a heightened level of care to patients who have experienced a transient ischemic attack (TIA) or a “mini-stroke.” After a TIA, patients are at a higher risk for full-blown stroke, officials say, and should work with providers to explore treatment options such as aggressively controlling their blood pressure, taking blood-thinning medications, stopping smoking, and avoiding heavy drinking.

Community Health Clinics to Receive More Funding Community health centers in Minnesota will get more funding from the federal government as part of the Affordable Care Act (ACA), as the new law begins

providing coverage to more Minnesotans. Such clinics traditionally have served a high percentage of uninsured Americans. Federal and state officials say more than $1.6 million will be available to support the 16 federally designated community health centers in Minnesota. “Health centers have extensive experience providing eligibility assistance to patients, are providing care to 181,389 individuals in Minnesota communities, and are well-positioned to support enrollment efforts,” says Health and Human Services Secretary Kathleen Sebelius. “Investing in health centers for outreach and enrollment assistance provides one more way the Obama administration is helping consumers understand their options and enroll in affordable coverage.” The new funds will allow centers to hire new staff, train existing staff, and conduct community outreach events and other educational activities.

Elder and Advocacy Services I am passionate about being an advocate for the elderly and disabled, including in maltreatment, injury and wrongful death claims.

It’s ours too. Our Pediatric Therapies partner with families to help children gain skills and improve functioning through: s Occupational Therapy s Speech and Language Therapy s Feeding Therapy s Music Therapy

Learn more:

stdavidscenter.org/therapies 952.548.8700

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MINNESOTA HEALTH CARE NEWS JULY 2013

Other services include: • nursing home litigation • health care agent appointments • elder abuse and neglect • elder mediation • nursing home resident rights • estate planning • speaker

Please contact: Suzanne M. Scheller, Esq. Scheller Legal Solutions LLC 6312 113th Place North Champlin, MN 55316

763.647.0042 suzy@schellerlegalsolutions.com

www.schellerlegalsolutions.com


PEOPLE Judith A. Jerde, RN, senior nursing project coordinator with HealthPartners, has been named this year’s CDC Childhood Immunization Champion for Minnesota by the federal Centers for Disease Prevention and Control (CDC). The award acknowledges individuals whose extraordinary efforts help improve immunizations among children from birth to age two. Jerde’s work helped increase the percentage of children age 18–23 months who were up to date on vaccinations following a HealthPartners clinic visit from approximately 80 percent before 2012 to 84.7 percent at the end of 2012. Kristine Matson, MD, a board-certified pediatrician, has joined the staff at PACE Pediatrics Clinic’s West St. Paul site; PACE is part of Children’s Hospitals and Clinics of Minnesota. Matson earned her medical Kristine Matson, MD

degree in 1983 from Sanford

School of Medicine of the University of South Dakota and completed a residency in pediatrics at Fairview University Medical Center. She has worked as a pediatrician in the Northfield area for the past 16 years. Ronald C. Peterson, MD, PhD, a professor in the Department of Neurology at the Mayo Clinic and the director of the Mayo Clinic Alzheimer’s

Ronald C. Peterson, MD, PhD

Disease Research Center, testified before the Senate Special Committee on Aging regarding the status of the National Alzheimer’s Project Act, which is legislation that aims to treat Alzheimer’s disease

H2462_68051_CMS AAccepted H2462_68051_CMS ccepted 55/18/2013. /18/2013. PPlan lan pperformance erformance SStar tar RRatings atings are are assessed assessed each each year year aand nd m ay cchange hange ffrom rom oone ne yyear ear ttoo may tthe he next. next. He althPartners iiss a hhealth ealth pplan lan w ith a M edicare contract. contract.   HealthPartners with Medicare © 2013 HealthPartners HealthPartners ©2013

effectively by 2025. In his testimony, Peterson addressed such points as the potential burden and cost of Alzheimer’s disease on the health care system, current research that shows the benefits of early care and treatment for the disease, and the crucial need for funding. Lipi Ramchandani, MD, MS, has joined Hennepin County Medical Center’s (HCMC) St. Anthony Village Clinic. She graduated from Grant Medical College, Mumbai, India, and completed family medicine residency training at the University of Minnesota, North Memorial Program. Ramchandani Lipi Ramchandani, MD, MS

Prevent Pre vent strokes. strokess. Lower your your risk ttoday. oday.

earned a master’s degree in clinical research from the

University of Minnesota School of Public Health in 2008. Andrew H. Schmidt, MD, an orthopedic surgeon at HCMC, has begun his term as president of the Orthopaedic Trauma Association, elected by his peers who are voting members of that international organization.

Andrew H. Schmidt, MD

Richard Sveum, MD, an allergy specialist with Park Nicollet Clinic, has received the Lifetime Achievement Award from the American Lung Association in Minnesota. Sveum is a member of the health charity’s Leadership Board, the medical board for the Lung Association’s Camp

oking . Stop sm r blood . Keep you low e pressur r . Keep you ol low r choleste

. Be ac tive minutes for 30 every da y . Eat le ss salt

. If yo uh diabetesave your bloo, keep sugar lo d w

Superkids program, and the board of the American Lung Association of the Upper Midwest. Sveum is also a clinical professor in pediatrics and medicine at the University of Minnesota Medical School.

This campaign was was adopted adoopted from from the Minnesota Minnesota Stroke Stroke Partnership. Par tnership.

Richard Ziegler, PhD, has assumed the position of executive director of the Essentia Institute of Rural Health. Ziegler has more than 25 years of administrative experience, including serving as dean of the University of Minnesota Medical School, Duluth. JULY 2013 MINNESOTA HEALTH CARE NEWS

7


PERSPECTIVE

Resilience Developing the ability to cope with adversity

R

esilience. As a doctor, my first thought is to define this word in a way that relates to physical health. In appendicitis, for example, the body is usually physically resilient enough to withstand the cure, which is surgery. But life has taught me that resilience also relates to the mind and spirit.

Robert O. Fisch, MD University of Minnesota Medical School

Robert O. Fisch, MD, is emeritus professor of pediatrics at the University of Minnesota Medical School. He is also an internationally exhibited painter; a collection of his paintings with accompanying text was published in 1994 as “Light From the Yellow Star—A Lesson of Love from the Holocaust.” For more information, visit www.yellowstar foundation.org. Additional books by Dr. Fisch include “The Metamorphosis to Freedom,” “Dear Dr. Fisch: Children’s Letters to a Holocaust Survivor,” and “Fisch Stories— Reflections on Life, Liberty and the Pursuit of Happiness.”

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• Take care of your health by eating a healthy diet and getting enough sleep and regular exercise. Do not use substances that can mask stress, such as alcohol and drugs. • See the absurd in apparently bleak situations and take humor seriously. That may seem contradictory, but it is part of the wisdom of the Buddhist pillar, “Let things go.” This comes into play when, from time to time, we all find ourselves at a crossroad where we can choose a positive outlook or a negative outlook.

Positive outlook Born in Hungary, I survived a Nazi concentration camp and came to the U.S. in 1957. I have been a Jew under Fascism, a bourgeois under Communism, a rebel defeated in an uprising, a Choices refugee among the free, and a have-not amid The outlook we choose determines whether plenty. In spite of many traumatic and life-threat- we travel a positive or negative road. That, in turn, ening experiences, personal tragedies, and determines our quality of life. A negative road depressions, having resilience saved me. leads to fear, hopelessness, and despair, mingled Resilience allows a person with envy, resentment, to find something good in a and anger. That outlook bad experience. For exampoisons our thoughts, See the absurd in ple, you can learn to be spoils personal relationapparently bleak situations more humane as a result ships, and does not allow a of experiencing inhumane and take humor seriously. person to have a productreatment. tive and enjoyable life. Resilience plays an imporChoosing a positive road, tant part in everyday life. It helps people survive however, leads to hope and breeds a courage that and even thrive in spite of circumstances they is enriched by generosity and empathy. This route cannot control, such as being laid off or a loved encompasses an acceptance of our limitations one’s death. It enables the resilient person to cope and an appreciation of the impermanence of our by envisioning a future beyond his or her current existence. Once we accept our limitations, relahardship. People who haven’t learned how to han- tionships and experiences become more precious dle adversity may dwell on problems instead of and fulfilling. Each taste, smell, and sight brings focusing on finding solutions to those problems. us pleasure. The joys and sorrows we share with They may also rely on unhealthy coping mecha- fellow human beings renew our strength and nisms such as overeating and other forms of sub- affirm our desire to make the most of the gift of stance abuse. life. We become more outgoing, unselfish, more constructive, and more creative. Fostering resilience Fortunately, it is possible to develop resilience. We are changed for the better in all physical and Consciously deciding to have a positive outlook mental respects. fosters resilience and the health benefits that have Resilience breeds resilience been scientifically shown to derive from it. These Whatever happens to us and whoever we are, benefits include reduced stress and a reduced risk we should enjoy every minute as a gift. We should of heart disease, anxiety, and depression. In order look for the good in every situation and in every to cultivate a positive outlook, practice these individual, create good where we can, and keep behaviors: smiling. • Don’t keep problems to yourself; talk about your challenges with supportive people. • Make time for yourself every day to relax. Some people do this by listening to music, petting a dog, or carving out time to be alone.

MINNESOTA HEALTH CARE NEWS JULY 2013


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Bell products are available at the above store locations, on our website or call us with Visa or Mastercard. S & H $9.95.

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Bell uses 100% Truthful testimonials. Real people who want the power to tell everybody about their relief. of nature to No money is paid for testimonials. Many more help put life testimonials on our website. back into * These statements have not been evaluated by the Food and Drug your Administration. This product is not intended to diagnose, treat, cure lifestyle or prevent any disease. JULY 2013 MINNESOTA HEALTH CARE NEWS

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10 QUESTIONS

Making sense of genetic information Beau Crabb, MS, CGC Mr. Crabb is a board-certified genetic counselor at Children’s Hospitals and Clinics of Minnesota. Genetic counseling is a relatively new field; what can you tell us about its history? Genetic counseling is the process of helping people understand and adapt to the medical, psychological, and familial implications of genetic contributions to disease. This process integrates interpretation of family and medical histories to assess the chance of disease occurrence or recurrence, education about inheritance, testing, management, prevention, resources, and research. Genetic counseling’s goal is to promote informed choices and adaptation to a risk or condition. The first class of master’s degree genetic counselors graduated from Sarah Lawrence College in 1971. Eight years later, genetic counselors formed a professional society, the National Society of Genetic Counselors (NSGC). There are currently more than 2,700 NSGC members. What training and certification are required to be a genetic counselor? Genetic counselors are health professionals with specialized graduate degrees and experience in the areas of medical genetics and counseling. Counselors enter the field from a variety of disciplines, including biology, genetics, nursing, psychology, public health, and social work. A genetic counseling degree is a twoyear master’s degree that combines coursework and clinical experience. Following graduation, genetic counselors take board-certification tests; becoming a certified genetic counselor (CGC) is required for most genetic counseling positions. Counselors must recertify every five to 10 years. Some states have additional requirements and a genetic counseling licensing program. Minnesota does not yet have a law establishing licensure requirements, but efforts are underway to create one. What are some of the reasons a person would see a genetic counselor? There are a variety of reasons. Someone who is pregnant or considering childbearing and is concerned about the health of the baby might see a genetic counselor in a prenatal clinic. When a person is concerned that they, their child, or a family member has a genetic or inherited condition, they might visit a genetic counselor in a specialty or pediatric clinic to discuss diagnostic testing options. Families with a history of developmental disability, birth defects, and/or mental retardation often see a genetic counselor to learn their testing options or recurrence risks. Sometimes, genetic counselors see individuals with a family history of cancer who would like to know if there is a genetic explanation for that history.

Photo credit: Bruce Silcox

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MINNESOTA HEALTH CARE NEWS JULY 2013

Does insurance typically cover the cost of genetic counseling? Insurance typically covers the cost of a genetic counseling visit, especially when referred by a physician specialist. The amount of coverage provided for genetic tests varies widely, depending on what type of insurance someone has. Genetic counselors coordinate testing, verify insurance coverage, and advocate for their patients to obtain coverage for recommended testing. Many people have concerns about the potential for discrimination based on genetic testing results. Luckily, the Genetic Information Nondiscrimination Act (GINA) was passed in 2008 and prohibits dis-


Genetic counseling’s goal crimination in health coverage and employDeferring predictive genetic testing of minors ment based on genetic information. for adult-onset conditions is recommended is to promote informed Where do genetic counselors work? whenever possible. The decision to test, when choices and adaptation to Genetic counselors work in a variety of setthe test is not anticipated to impact medical tings, including university medical centers, management in the near term, is made on a a risk or condition. case-by-case basis. Deferring predictive genprivate and public hospitals/medical facilities, etic testing until a child becomes an adult and diagnostic laboratories, pharmaceutical comcan choose whether or not to test preserves a child’s autonomy. panies, not-for-profit organizations, and government organizations and agencies. We work in multiple specialty areas, including prenatal, What is a challenge facing the field? Insurance coverage for cardiovascular disease, cancer, metabolic disease, neurology, pediatrecommended genetic testing is highly variable, and genetic testing is rics, infertility, and genomic medicine. Increasing demand for genetic inherently a costly endeavor. Counselors frequently have to deal with expertise means genetic counselors are working in administration, the frustration of families who cannot afford to pay for testing outresearch, public and professional education, Internet companies and of-pocket and whose insurance companies denied testing. websites, public health, laboratory support, public policy, and consulting. How does someone access a genetic counselor? Most What are some of the ways a genetic counselor interacts with physicians? Most genetic counselors work closely with a physician in a specialty clinic. Many specialist physicians refer their patients to genetic counselors, including obstetrician/gynecologists, primary care physicians, oncologists, gastroenterologists, neurologists, cardiologists, ophthalmologists, and pulmonologists.

patients get a referral from either their primary care provider or a specialist. Genetic counselors are happy to speak with patients prior to referral to determine if a genetic counseling visit is warranted. Two websites help patients find a genetic counselor: the NSGC website (www.nsgc.org) and the Minnesota-specific genetic counselor association (www.mygenepool.org).

Tell us about some biomedical ethics issues raised by the field of genetic counseling? One recurring theme is the ethical concept of autonomy. For example, parents may request that their minor child be tested for an adult-onset genetic condition that runs in the family so they can prepare for the future. Genetic counselors guide families through the process of deciding whether to test.

What does the future of genetic counseling hold? The race is on to offer whole-genome sequencing on a clinical basis. While this is an exciting prospect, it also increases the likelihood of having ambiguous results and incidental findings. Genetic counselors will play a critical role in helping families process the immense amount of information that these new tests will provide.

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JULY 2013 MINNESOTA HEALTH CARE NEWS

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HEALTH PROFESSIONS Scope

Dental therapy If you don’t know what dental therapy is, you’re not alone. It’s fairly new to the U.S., although the profession originated in New Zealand during the 1920s, when otherwise fit men were rejected for military service in World War I because of the poor condition of their teeth. Today, more than 50 countries utilize some form of dental therapy, including Australia, Canada, Netherlands, and the UK. In 2011, Minnesota became the first U.S. state to license dental therapists, and it is the first state to offer training for this profession.

New profession aims to ease health care shortages By Karl Self, DDS, MBA

Graduate School of Health & Human Services

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MINNESOTA HEALTH CARE NEWS JULY 2013

A dental therapist is a midlevel dental practitioner whose responsibilities overlap those of dental hygienists and dentists. Dental therapists work under the supervision of a licensed dentist to provide basic dental services, including some that were previously available only from a dentist. Minnesota law allows dental therapists to provide preventive and restorative care, as well as limited minor surgical dental care. This includes taking X-rays, applying fluoride, placing sealants, and delivering oral health care instructions and disease prevention education. For example, a dental therapist can restore teeth by drilling out cavities and placing permanent fillings and can stabilize broken teeth by placing temporary crowns. (Only a dentist may place a permanent crown.) With additional master’s-level training and 2,000 hours of clinical practice, a licensed dental therapist may take an examination for certification as an advanced dental therapist. This certification allows a dental therapist to practice in collaboration with a dentist but without on-site supervision, which makes it possible to offer dental services at such sites as schools and nursing homes. Other countries that utilize dental therapists report that the quality of dental therapists’ work is the same as that provided by dentists.

Training To work as a dental therapist in Minnesota requires graduation from a dental therapy educational program approved by the Minnesota Board of Dentistry and successful performance on the state licensure examination. There are currently two approved training programs in the state. The University of Minnesota School of Dentistry offers a 28-month full-time program; Metropolitan State University and Normandale Community College collaboratively operate a 26-month full-time program. Students at the School of Dentistry take most of their courses alongside dentistry and dental hygiene students, an environment that models the working relationship in a general dental practice. They also participate in interprofessional learning experiences such as clinical rotations within the community and volunteer service events. This collegial approach to education ensures a solid educational and clinical preparation, and promotes collaboration between the various dental professions, a single standard of care for patients, and a smooth transition from education into professional employment after graduation.


The first classes of dental therapists in the U.S. graduated in 2011 from both the School of Dentistry and Metropolitan State; 27 students are now in the educational pipeline. Currently, 25 licensed dental therapists, including one advanced dental therapist, practice in the state, working in a variety of urban and rural settings that include community clinics, large group practices, nonprofit clinics, and private practices that reach out to the underserved.

Addressing current problems Dental therapy was created specifically to extend dental care to underserved areas. Minnesota state law specifies that dental therapists must practice in “settings that serve low-income, uninsured, and underserved patients, or in a dental health professional shortage area.” In 2011, 56 of Minnesota’s 87 counties were designated as complete or partial dental health professional shortage areas. This shortage is predicted to increase as more Minnesota dentists get closer to retirement. According to the Minnesota Department of Health, the average age of a dentist in 2010 was 54 years, compared with an average age of 47 a decade earlier. And the average age of a dentist in rural Minnesota is even older (57). A recent survey found that roughly 60 percent of all Minnesota dentists between the ages of 55 and 65 plan to retire within the next 10 years. These statistics highlight the point that even as our state’s population continues to increase, the number of dentists in the state may start to decline. Add to that the reality that some people lack dental care because of financial concerns, and that it costs less for a dental therapist to deliver services than for a dentist to do so, and it becomes clear that adding dental therapists to the ranks of dental care providers can make it easier for Minnesotans to find and afford dental care.

Minnesota is on the cutting edge of innovation in oral health care delivery.

Growing need

This is important because untreated oral diseases usually do not get better. They typically become more serious, more painful, and more difficult to treat. Nationally, almost 2.5 million days of work and more than 51 million school hours are lost each year to oral illness. Equally disturbing is that the rate of cavities among U.S. children 2–5 years of age has recently increased. Even worse is that in our state, the tooth-decay rate among children is higher than the national average: 55 percent of Minnesota thirdgraders have at least one cavity, compared with 53 percent of sameaged children nationwide. Data from New Zealand and other countries in which dental therapy has an established history have shown that access to dental therapists can reduce the rate of cavities, especially in children, by increasing access to dental care. Minnesota has a growing number of people who have identified oral health care as their most important unmet need, because they either cannot afford the care or cannot find a dentist to provide it. Benefits of having a dental therapist on an oral health care team include increasing a dental clinic’s efficiency and capacity to care for

Dental therapy was created specifically to extend dental care to underserved areas.

a greater number of underserved patients, as well as freeing dentists to devote more time to complex treatment needs.

Model for the country

Other states are following our lead. The Maine legislature heard testimony from Leon Assael, DDS, dean of the University of Minnesota School of Dentistry, as it considered legislation this past spring to license dental therapists. (The proposed Maine law had not been voted on as this issue went to press.) Approximately 20 other states across the U.S. are currently considering licensing dental therapists. Minnesota is on the cutting edge of innovation in oral health care delivery. We expect to see dental therapy become more widespread in this state and in the nation during the next five years as the public and dentists become more aware of the improved access to care made possible by this new category of health care provider. As John Powers, DDS, a dentist with Main Street Dental Care in Montevideo, notes, “In the [time] we’ve had a dental therapist, we have seen a lot of families get turned around in terms of their oral health because of the fact that the dental therapist is seeing them.” Karl Self, DDS, MBA, is a clinical associate professor and the director of the Division of Dental Therapy at the University of Minnesota School of Dentistry.

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www.midwestpodiatrycenters.com JULY 2013 MINNESOTA HEALTH CARE NEWS

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C O M P L E M E N TA RY M E D I C I N E

Utilizing alternative care A growing trend By Charles Sawyer, DC Consumers are increasingly turning to health care providers who historically have not been members of mainstream medicine. In 2008, the National Center for Complementary and Alternative Medicine and the National Center for Health Statistics released findings from a 2007 National Health Interview Survey, reporting that nearly 40 percent of Americans use some type of complementary or alternative health care treatment. Among the providers of this treatment are chiropractic doctors and a group of alternative medicine providers that includes acupuncturists, massage therapists, naturopathic doctors, and other practitioners who until recently cared for patients largely outside of mainstream medicine. Do new treatment methods work? Recent research supports the effectiveness of these new methods. A randomized clinical trial published in the January 2012 issue of Annals of Internal Medicine studied three groups of patients who

sought treatment for relief of neck pain. One group was treated with spinal manipulation performed by chiropractic doctors, a second group did neck exercises at home, and the third group received only medication. Researchers found that patients who received chiropractic treatment and patients who did neck exercises at home had better long-term relief of neck pain than patients who received only medication. These results are notable because neck pain affects nearly 75 percent of people in American at some point in their lives. Neck pain is one of the most frequent reasons for trips to primary care doctors, prompting millions of visits every year, according to a 2007 report in the medical journal Spine.

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MINNESOTA HEALTH CARE NEWS JULY 2013


Give permission

prescribed by other health care providers. Another study supporting the value of using an alternative to all of your Keeping all your providers “in the loop� type of care was reported in October 2012 in JAMA Internal health care about all your treatments promotes better Medicine. In this study, researchers analyzed data from 29 cliniand more efficient health care. cal trials that assessed acupuncture as a treatment to reduce providers to chronic pain. The study compared share your What does the future hold? pain reduction in patients who As our health care system continues to medical received real acupuncture with that in patients who information with evolve, patients can expect to see new models of integrative care. We should all received sham, or fake, one another. become more knowledgeable about imporacupuncture. Fifty percent tant health issues, especially things we can of the patients who received do ourselves to become and stay healthy. One thing we can do is to acupuncture reported decreased incorporate a good diet with an appropriate number of calories, more pain, compared with 30 percent of exercise, and less stress into our busy lives. Patients should ask their the patients who received sham health care providers for help in making healthy life choices. acupuncture. The study concluded Second, talk to your medical doctor about the care you may be that acupuncture was effective for the receiving from your other health care professionals and give permistreatment of chronic pain. sion to all of your health care providers to share your medical inforNew models of care mation with one another. As more health care providers use electronIn the Twin Cities, several sites host health professionals from differic medical records, this sharing will become increasingly efficient and ent disciplines who blend new, evolving methods of care with tradiwill ultimately lead to better care coordination. tional medical treatment in an integrative approach to health care. Finally, for consumers who will be eligible to obtain health coverage on Minnesota’s new health insurance exchange, MNsure, beginExamples include the Penny George Institute for Health and Healing ning in 2014, individual purchasers should shop for health insurance at Abbott Northwestern Hospital in plans that include adequate access to services they feel have value, Minneapolis and the Whittier Clinic including new methods of care. and Parkside Alternative Medicine Clinic, both operated by Charles Sawyer, DC, is the senior vice president at Northwestern Health Hennepin County Medical Sciences University in Bloomington. Center. The health clinics at Northwestern Health Sciences University (NWHSU) already provide and continue to develop an integrative model of health care. NWHSU has health care providers from multiple fields in one clinic, making it easier for them to confer with one another about a given patient and making easier for patients to access more than one provider during the same visit. Another significant leader in the integrative health movement is the Center for Spirituality and Healing at the University of Minnesota, which educates health professionals about this new model of care. Insurance coverage

Nearly 40 percent of Americans use some type of complementary or alternative health care treatment.

Not all services provided in integrative health settings are covered by health insurance. Nonetheless, patients are increasingly electing to pay more out of pocket because they see the value in alternative clinical approaches that complement or may even substitute for conventional medical care. Many advocacy groups are aggressively pressing health insurers to include better coverage for alternative clinical treatments. It is important that everyone involved in your health be aware of all treatments you receive. Each of your health care providers needs all of your health information in order to make informed treatment plans. This also helps one health care provider to avoid inadvertently prescribing medication that could interact adversely with medication

Do you still believe losing weight will change your emotional need for food?

You need emotional eating rehab. Call 952-920-8644 www.vivifydietrehab.com JULY 2013 MINNESOTA HEALTH CARE NEWS

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B E H AV I O R A L H E A L T H

Eating disorders Life threatening but treatable By Jillian G. Lampert, PhD, RD, LD, MPH, FAED

I

was on a plane recently when my seatmate asked me what I do for a living. This is always a loaded question, and I am sometimes tempted to say: “I sell shoes at Macy’s.” It is not because I don’t love my work or that I am ashamed of what I do. In fact, just the opposite is true. The work I do every day is incredibly important and I love it; it helps people heal from devastating illnesses and it saves lives. The reason I hesitate to share my profession is that I can predict what will happen when I tell someone that I work in the eating disorder field. More often than not I hear some variation of “I wish I had an eating disorder,” as if eating disorders are harmless and represent a great new weight-loss program. I try to remain calm as I explain that eating disorders are serious illnesses that can be life threatening. There are many myths and misconceptions about eating disorders. Increasing awareness about these illnesses is of great importance.

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MINNESOTA HEALTH CARE NEWS JULY 2013


Widespread problem

Causes, risks

It is estimated that more than 14 million people in the U.S. suffer from eating disorders, with over 200,000 sufferers in Minnesota. Eating disorders are not an adolescent phase, they are not behavior problems, and they are not a choice. Eating disorders are not about vanity and they are not limited to young girls who wish to be thin. You cannot tell if someone has an eating disorder by looking at him or her because people with eating disorders range from being dramatically underweight to being dramatically overweight. Eating disorders do not discriminate. They affect all ages, impacting children as young as elementary school age and adults well into their 60s and 70s. Eating disorders occur across gender, socioeconomic status, ethnicity, and race. They often go undiagnosed until they are very serious. It is not uncommon for someone who has an eating disorder to have a cooccurring illness like anxiety, depression, post-traumatic stress disorder, or substance abuse.

Eating disorders are biopsychosocial in nature. This means that they are brain disorders that involve abnormal activity in the brain and are influenced by personality characteristics, genetics, and culture. We also know that we live in a culture obsessed with appearance, weight, shape, and food. Living in this culture of thinness gives most people a distorted idea about the importance of size and shape and gives the impression that there is one “right” size that must be attained to be happy, successful, accomplished, appreciated, and loved. We know that dieting can be a gateway for developing an eating disorder despite decades of medical research showing that calorie-restrictive dieting seldom contributes to overall health and is rarely effective for permanent weight loss.

Eating disorders are brain disorders.

Complex illnesses Eating disorders are serious, complicated, complex illnesses that affect all systems in the body. People who struggle with eating disorders experience severe disturbances in eating behavior, such as extreme reduction of calorie intake, purging behaviors, binge eating, and/or extreme distress about body weight and shape. The American Psychiatric Association categorizes eating disorders as follows: • Anorexia nervosa • Bulimia nervosa

Here is a simple self-scoring tool that can help you decide if you or someone you care about may at risk for developing an eating disorder: • Do you feel like you sometimes lose or have lost control over how you eat? • Do you ever make yourself vomit because you feel uncomfortably full? Eating disorders to page 19

• Binge eating disorder • Eating disorder not otherwise specified (EDNOS) Anorexia nervosa is characterized by an intense fear of gaining weight and the relentless pursuit of thinness. People who struggle with anorexia nervosa are unable to maintain a healthy weight and often see themselves as overweight even when they are starved or malnourished. Anorexia nervosa has the highest mortality rate of any psychiatric illness; people with this disease are up to 12 times more likely to die as a result of their illness compared with those without anorexia nervosa. Bulimia nervosa is characterized by recurrent and frequent episodes of eating large amounts of food followed by behaviors that compensate for the eating binge, such as purging, fasting, laxative abuse, and/or excessive exercise. The person who struggles with bulimia nervosa feels out of control, fears weight gain, and is typically intensely unhappy with her or his size and shape. People with bulimia nervosa can appear as if they are maintaining a normal weight and cannot be identified by outward appearance. Binge eating disorder is characterized by recurrent binge eating episodes during which the person feels out of control over his or her eating. The person suffering from this disorder binge eats without the purging, laxative abuse, or other behaviors used to compensate for the binge eating to rid the body of food. There is a great deal of shame, guilt, and self-loathing associated with binge eating disorder. Eating disorder not otherwise specified (EDNOS) is a diagnosis for someone who does not meet the strict criteria for anorexia, bulimia, or binge eating disorder, although EDNOS is no less serious or life threatening. JULY 2013 MINNESOTA HEALTH CARE NEWS

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July Calendar 11

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Navigating Cancer Lakeview Health presents Finding Your Way through Cancer, a four-week series for individuals and families dealing with a cancer diagnosis. Free. This series meets Thursday evenings (July 11, 18, 25, and Aug. 1). Each week will address a different issue. Call (651) 430-4697 to register or for more information. Thursday, July 11, 7–8:15 p.m., Lakeview Hospital, 927 Churchill St. W., Stillwater Ability Support Group We ‘R’ Able offers this group for people with a variety of health challenges. Come, share stories, and offer encouragement to others. Donation of $1 per meeting is encouraged. For transportation needs, call Heartland Express at (763) 689-8131. For more information, call Loreli at (320) 358-1220. Wednesday, July 17, 1:30–2 p.m., Chisago County Senior Ctr., 38790 6th Ave. N., North Branch New Parent Support Allina Health offers this support group for new parents and their infants, birth to six months old. Come learn from an ECFE (Early Childhood Family Education) instructor about feeding, development, sleeping patterns, and childcare options. Free. Call (763) 506-1275 to register or for more information. Monday, July 22, 1–2:30 p.m., Unity Hospital, Auditorium, 550 Osborne Rd., Fridley Brain Injury Class Minnesota Brain Injury Alliance offers Brain Injury Basics: Adjustment to Brain Injury. Learn about life changes expected as a result of brain injury and how to handle the road ahead. $5 donation appreciated from individuals with brain injury or their families. For more information or to register, call (612) 378-2742. Thursday, July 25, 6–8 p.m., Education Ctr., Minnesota Brain Injury Alliance, 34 13th Ave. N.E., Ste. B001, Minneapolis

Minority Mental Health Awareness Month The U.S. House of Representatives proclaimed July as National Minority Mental Health Awareness Month in 2008. This proclamation was made in honor of Bebe Moore Campbell to help carry out her goal of spreading mental health awareness and eliminating the stigma of mental illness among multicultural communities. Herself a sufferer of mental illness, Campbell was an accomplished author, advocate, and co-founder of the National Alliance on Mental Illness (NAMI) Urban Los Angeles. She said in 2005 that America needed a national campaign to remove the stigma of mental illness—especially a campaign targeted toward African-Americans. Three years later, two years after her death, the awareness month was born. One in four adults and one in 10 children in every community are affected by mental illness, so spreading awareness is essential in reducing the stigma associated with it. If you or someone you know has a mental illness, recovery is possible. For support groups and more information on mental illness, visit NAMI Minnesota at www.namihelps.org

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Get to Know NAMI NAMI Minnesota offers this free class to teach the community about its organization. Come hear firsthand from staff and volunteers about their work in the community, and learn about the classes and programs offered. For more information or to register, contact Kay at (651) 645-2948 x113. Tuesday, July 9, 11:30 a.m.–12:30 p.m., NAMI Minnesota, 800 Transfer Rd., Ste. 31, St. Paul

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World Hepatitis Day July 28 is World Hepatitis Day. Immunization Action Coalition (IAC) offers access to essential information on hepatitis B, including links to CDC vaccination recommendations, patient and staff handouts, and other resources. Visit the IAC to learn about vaccinations and hepatitis at www.immunize.org

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Assistive Technology PACER Center offers a free assistive technology (AT) class for children with disabilities and their parents. Live web-streaming available. Call (800) 537-2237 for more information. Register at www.pacer.org Wednesday, July 31, 6:30–8:30 p.m., PACER Center, 8161 Normandale Blvd., Bloomington

Aug.1

Eating Disorder Support The St. Cloud Hospital Behavioral Health Clinic offers this support group for friends and family of those suffering from eating disorders. Come learn about different eating disorders, and get tips on how to make mealtime less stressful. Free. Call Bette at (320) 229-4918 for more information. Thursday, Aug. 1, 4:30–6 p.m., CentraCare Health Plaza, Leonard, Street & Deinard Rm., 1900 CentraCare Cir., St. Cloud

Aug.1

Pre-K Eye Exam Day Minnesota Optometric Association has named August 1 “Pre-K Eye Exam Day.” Unlike vision screenings, eye exams check for eye function disorders and astigmatism. One-time, free eye exams will be offered to children entering kindergarten. For a full list of participating providers, check http://minnesota.aoa.org

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 asandozi@ 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 JULY 2013


Eating disorders from page 17

• Do you believe yourself to be fat, even when others say you are too thin? • Does food or thoughts about food dominate your life? • Do thoughts about changing your body or your weight dominate your life? • Have others become worried about your weight? In this informal survey, two or more “yes” answers strongly indicate the presence of disordered eating. Symptoms Early warning signs of an eating disorder include:

seek treatment that will lead to recovery. One of the most important things support persons can do is to educate themselves about eating disorders. The more you know, the better you will be at supporting someone you care for. Treatment Because eating disorders are so complex, no single type of treatment can successfully address every person’s needs. Typically, treatment for an eating disorder involves an outpatient team of professionals. This can include a therapist, dietitian, medical doctor, psychiatrist, and others. Sometimes, treatment includes a longer-term stay in an inpatient or residential treatment program. Family and friends are a very important part of the team.

• Skipping or avoiding meals or situations where food is present • Avoiding specific foods or food groups • Withdrawal from family and friends • Preoccupation with weight, body size and shape, or specific aspects of appearance • Unexpected shifts in weight • Obsessing over calorie intake and calories burned via exercise If you recognize these signs in yourself or someone you know, it may be time to seek professional assessment. It is hard to know how to approach someone who may be struggling with an eating disorder, but remember that support can help the person recognize the problem and

One of the most important messages to anyone struggling with an eating disorder is that recovery is possible.

Recovery One of the most important messages to anyone struggling with an eating disorder is that recovery is possible. There is help and there is hope. Recovery can take a while and it can be hard, but full recovery happens! Studies show that, with good treatment, up to 75 percent of people can make a full and lasting recovery. Jillian G. Lampert, PhD, RD, LD, MPH, FAED, is a dietitian and senior director for The Emily Program, a comprehensive eating disorder treatment program with multidisciplinary outpatient and inpatient treatment facilities throughout Minneapolis/St. Paul and Duluth.

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)

JULY 2013 MINNESOTA HEALTH CARE NEWS

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health care architecture honor roll

M

innesota Physician’s 2013 Health Care Architecture Honor Roll recognizes six outstanding projects completed in the past year. This year’s Honor Roll projects include new clinic and hospital construction, remodeled spaces, and facility expansions in urban, suburban, and greater Minnesota. The medical services range from routine clinic visits to specialized care. Populations served include the standard patient rosters typically seen in family medicine clinics, as well as specialized groups—such as new mothers and their babies, and children and adolescents needing individualized psychotherapeutic care. One urban facility remodeled an existing space that previously housed a book retailer. Seeking to provide a welcoming environment, many of the projects incorporate elements from nature and feature eye-catching artwork. Minnesota Physician Publishing thanks all those who participated in the 2013 honor roll.

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MINNESOTA HEALTH CARE NEWS JULY 2013


St. Luke’s Medical Office Building A Type of facility: Medical office building/parking structure Location: Duluth Client: Ventas, Inc. Architect/Interior design:

Amberwing Type of facility: Child, adolescent, and young adult mental health and chemical dependency treatment center

Location: Duluth Client: Miller-Dwan Foundation Architect/Interior design: John Ivey Thomas Assoc., architect; Kitchi Gammi Design, interior design Engineer: SEH, civil; Northland Consulting Engineers, LLP, structural; The Design Group, mechanical/electrical Contractor: Johnson Wilson Constructors Completion date: August 2012 Total cost: $6.2 million Square feet: 25,883 sf Amberwing–Center for Youth & Family Well-Being, built by the Miller-Dwan Foundation with more than $6 million in charitable gifts, provides individualized psychotherapeutic care for young people and their families. Amberwing was designed specifically to reduce the stress and stigma of mental health and chemical dependency care. Located on six wooded acres in the heart of Duluth, the facility’s central atrium and four treatment wings reflect the welcoming warmth of a North Woods lodge. Each wing is anchored by a family-friendly kitchen and gathering area surrounded by separate rooms for educational therapy, talk therapy, play therapy, a classroom, and a living room-like space for family meetings. A separate wing designed for alternative therapies offers music, art, drama, occupational therapy, recreation, and movement therapy to enhance therapeutic outcomes.

An imaginative lobby, a community meeting area, a spiritual center, a treatment space for infant and toddlers, and a professionally staffed parent and family resource center make up the heart of Amberwing, encouraging the community to enter. The wooded outdoors, which is connected to a 16-acre federal park, allows for nature walks in the spring and summer, outdoor games, and snowshoeing in the winter. The building includes an outdoor deck and a strategically designed outdoor gathering space to integrate nature into Amberwing’s treatment programming. Left: A wooden, ribbed canoe suspended from the ceiling of the lobby, along with earth tones and comfortable design touches, carries out the facility’s theme of a welcoming North Woods lodge. Top: The fireplace room provides a cozy space for youth and families to relax. Bottom inset: The facility, built in a restful wooded area, is near a 16-acre federal park.

Erdman; DSGW Architects, design consultant Engineer: Erdman Contractor: Erdman

Completion date: August 2012 Total cost: $25 million Square feet: 175,000 sf St. Luke’s Campus Building A was built for the fast-changing climate of health care, with an eye to the future. The top floor of the fivefloor medical office building is home to six of St. Luke’s specialty clinics: Gastroenterology, Neurosurgery, Orthopedics and Sports Medicine, Pediatrics, Physical Medicine & Rehab, and Plastic Surgery. Patient exam rooms, procedure rooms, casting rooms, physician offices, lab, digital tomographic X-ray suites, a physical therapy room, and separate waiting areas for the pediatric and plastic surgery clinics are found on the fifth floor. The main patient waiting area and a number of the patient exam rooms offer beautiful views of Lake Superior. The fourth floor is currently unoccupied, offering room for expansion. The clinical space on the fourth and fifth floors comprises 70,600 square feet of the total 175,000-square-foot structure. The lower three levels offer enclosed, climate-controlled parking for 219 patient and employee vehicles.

Top: Nurses’ station Right: Lobby Bottom: Entrance to Medical Building A


HONOR ROLL

2 013 Mother Baby Center Type of facility: Hospital Location: Minneapolis Client: Joint venture between Children’s Hospital and Clinics of Minnesota and Abbott Northwestern Hospital Architect/Interior design: HDR Architecture, Inc. Engineer: Palanisami & Associates, Inc., structural; HDR Architecture, Inc., mechanical/electrical Contractor: Knutson Construction Completion date: January 2013 Total cost: $36.7 million Square feet: 75,000 sf, new; 22,000 sf, remodeled

Left: The signature entrance allows for a celebratory family experience.

Left Inset: Rooms with a birthing tub provide moms with a variety of birthing options. Top: The exterior façade captures the welcoming spirit of the Mother Baby program through color and creative forms.

The Mother Baby Center combines Children’s Hospitals and Clinics of Minnesota’s excellence in neonatal care with Abbott Northwestern Hospital’s renowned obstetrical program, enabling mothers, babies, and families to stay together and experience the highest level of coordinated care. The four-story facility is nestled between Abbott Northwestern and Children’s with a skyway that connects the two. The new facility has capacity for 5,000 births each year. It offers a comprehensive approach to care, beginning at prenatal care and continuing through obstetrics, perinatology, labor and delivery, neonatology, and pediatrics. Combining a comforting spa-like atmosphere with state-of-the-art clinical technology, the Mother Baby Center achieves an environment that balances function with the needs of families before, during, and after childbirth. The facility includes a maternal assessment center; 13 labor and delivery rooms; two 24-bed postpartum units; an 11-bed high-risk antepartum unit; a 24-room/31-bed special care nursery; and three operating rooms, including an integrated operating room for highly complex cases that is 150 feet from Children’s level III/IV NICU. The Mother Baby Center has live telemedicine capabilities, allowing the center to extend its expertise beyond its physical location and advise providers at other birth centers in the region.

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

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Online or Call 651-439-8807 Providing P roviding care care at at multiple mu ultiple modern modern clinics in M Minnesota inne esota and W Wisconsin isconsin

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MINNESOTA HEALTH CARE NEWS JULY 2013


Hazelden Center for Youth and Families Type of facility: Addiction treatment facility Location: Plymouth Client: Hazelden Foundation Architect/Interior design: HGA Architects and Engineers Engineer: HGA Contractor: Knutson Construction Co. Completion date: October 2013 Total cost: $22,865,900 Square feet: 50,000 sf The Hazelden project consists of a 50,000square-foot expansion and a 50,000-square-foot renovation of an addiction treatment facility for teens and young adults, ages 14–25, in Plymouth. It is nestled within a residential neighborhood surrounded by beautiful woodland along the north shore of Medicine Lake, next to Three Rivers park grounds. The expansion comprises a new, two-story 32-bed resident unit, gymnasium with rock-climbing walls and attached fitness room, a serene meditation area, a large auditorium, an outpatient clinic, and numerous group and training rooms. The existing resident units/dormitories, the medical service unit, and the kitchen/dining area also are being transformed to mirror the elegance of the newly completed addition. In January, Hazelden began serving patients in the new building with great enthusiasm. Employees and clients alike are highly satisfied with their brand-new space.

Landscaping is underway to enhance their experience even more with a beautiful water feature, labyrinth, fire pit, and amphitheater. The entire project is scheduled to be complete this fall. Top: Family waiting area Inset: Entrance to the facility, which is nestled within a residential neighbor-

hood surrounded by beautiful woodland along the north shore of Medicine Lake in Plymouth

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HONOR ROLL

2 013 This medical clinic was built in the renovated space formerly occupied by a book retailer. The two-story interior underwent many renovations, including skylights and patient-friendly touches (no more weighing patients in the public hallways). The exterior was also updated to include heated sidewalks by the main entrance, so patrons don’t run the risk of slipping and falling.

HealthEast Midway Clinic Type of facility: Outpatient internal medical clinic Location: St. Paul Client: MSP/University Medical, LLC Architect/Interior design: HGA Architects and Engineers Engineer: Anderson-Urlacher PA Contractor: Welsh Construction Completion date: April 2012 Total cost: $5.5 million Square feet: 23,000 sf

The location was very attractive to HealthEast and real estate developer MSP on many levels. Located on the corners of Hamline and University Avenues, the new Midway clinic is centrally located between Minneapolis and St. Paul. Neighbors like Super Target, Herberger’s, and Walmart make it a destination location for patrons. It is also located two blocks from where the Central Corridor light rail will be, making it convenient for those patrons reliant on public transit. This successful conversion of a retail space into a medical building will serve the needs of patients, providers, and HealthEast Care System extremely well. Top: Floor-to-ceiling windows provide plenty of light in the waiting room. Inset: The new facility’s location, near a number of retail stores and two blocks from the Central Corridor light rail (now under construction), make it convenient to patrons.

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MINNESOTA HEALTH CARE NEWS JULY 2013


Riverwood Healthcare Center Type of facility: Critical access hospital (renovation) Location: Aitkin Client: Riverwood Healthcare Center Architect/Interior design: HDR Architecture Engineer: Paulson & Clark Engineering, Inc. Contractor: Kraus-Anderson Construction Co. Completion date: June 2013 Total cost: Withheld at owner’s request Square feet: 24,365 sf (renovated) Riverwood Healthcare Center is an independent, integrated hospital and clinic facility serving Aitkin county and nearby communities in northern Minnesota. Renovation in 2012–2013 included remodeling of patient, specialty treatment, pharmacy, waiting areas, and staff amenities—all accomplished without interruption to clinic or hospital services. Included was conversion of 11 existing patient rooms to single patient rooms; new labor and delivery unit; relocated emergency room and intensive care unit; remodeled rehab space; addition of five infusion bays for chemotherapy and other medication therapies; and relocation of pharmacy, respiratory therapy, diabetes education, and wound care. In addition, renovation created a new support services addition, which houses medical records, human resources, and other services, bringing all Riverwood employees in Aitkin into one location. Infection controls were implemented in each phase. Other renovation work included utility and site improvements (grading, curb/gutter, courtyard pavers, landscaping) and additional parking. The expansion effort also facilitated an economic boost, creating 18 new positions at the hospital and generating 130 new construction jobs with a payroll of approximately $6 million for the duration of construction. A

number of subcontractors were hired from Aitkin as well as the surrounding area, providing regional economic impact. Top: Remodeled nurses’ station Bottom: Riverwood Healthcare Center entrance at dawn

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NEUROLOGY

S Stroke rehabilitation Patients and specialists work together to maximize potential By Bruce Idelkope, MD, and Alexander Zubkov, MD, PhD, FAHA

troke is a neurological condition that happens when a blood vessel to the brain is blocked. This blockage deprives brain tissue of the oxygen and glucose that the brain needs to function and which is delivered by blood. This is one of the leading causes of disability and death among adults. It often occurs in individuals who have hypertension, diabetes, hyperlipidemia (excess fat in the blood), obesity, heart disease, sedentary lifestyles, and who smoke; stroke is also seen in less common medical conditions. Stroke affects a broad spectrum of individuals in all age groups. An increasingly sedentary lifestyle and poor diet are increasing the number of young patients who suffer a stroke. When stroke occurs, damage happens within seconds. Medical attention can reduce damage once a stroke is identified, but must be delivered to the person who had the stroke within a few hours after onset of stroke symptoms in order to produce noticeable benefit. After untreated stroke damage has been present for 24 hours, any deficit is often permanent. It’s vital to recognize stroke symptoms and to get medical help immediately by calling 9-1-1. What does a stroke do?

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When an area of the brain is deprived of oxygen, a central area of dead cells results. These cells are surrounded by a ring of cells that were oxygen deprived but are not dead, which are surrounded by another ring of cells rendered nonfunctional by the sudden shock of oxygen deprivation and resultant swelling. Each of these two areas surrounding the area of cell death has some capacity to recover and may spontaneously restore some brain function. In addition, other areas of the brain have some capacity to compensate for the area damaged by the stroke. Most recovery happens in the first three to six months after a stroke, but recovery may continue to occur for many years. The extent of the injury relates to the size of the brain damage. Injury can be minor, as in a transient ischemic attack, or major, with blockage of large vessels damaging a large area of the brain. Recovery potential

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MINNESOTA HEALTH CARE NEWS JULY 2013

Predicting recovery is complicated and often uncertain early after a stroke. The functional deficits of a stroke depend entirely upon the blood vessel(s) involved and what part of the brain it nourished, because each part of the brain manages a specialized function. For example, there is a specific area responsible for speaking and a different one for comprehending the spoken word. Separate areas on each side of the brain control motor and sensory functions of limbs, and there are specific areas for reading, writing, language, memory, problem solving, balance, walking, coordination, and many more functions. Blockage of larger blood vessels generally predicts greater injury. Injury to the dominant hemisphere, which controls speech and language, is more difficult to recover from than injury to the right hemisphere because the dominant half affects our ability to understand speech. The dominant hemisphere is usually the left hemisphere in all right-handed and in most left-handed individuals. Other factors affecting recovery include age, previous stroke history, co-occurring


Stroke symptoms—Act FAST medical conditions (especially diabetes), and family support. Nonetheless, there is always recovery potential that rehabilitation aims to maximize. The recovery process

CALL 9-1-1 immediately if you see any of these stroke symptoms • Face: Ask the person to smile. Does one side of the face droop? • Arms: Ask the person to raise both arms. Does one drift down? • Speech: Ask the person to repeat a simple sentence. Is the speech slurred or odd? • Time: Call 9-1-1 immediately if you observe one or more of these symptoms.

Stroke rehabilitation focuses on maximizing recovery and restoring independence, and typically occurs in stroke rehabilitation centers. These centers are separate from the acute Other common stroke symptoms care hospitals where strokes are initially diagnosed and • Sudden numbness or weakness of the face, arm, or leg, especially on treated. The type of stroke and the expectations for recovery one side of the body drive the selection of the best-suited rehabilitation site: acute • Sudden confusion; trouble speaking or understanding stroke rehabilitation centers, subacute stroke rehabilitation • Sudden trouble seeing in one or both eyes centers, or skilled nursing rehabilitation facilities. In an acute • Sudden trouble walking, dizziness, loss of balance or coordination center, aggressive therapy is often undertaken twice daily for • Sudden severe headache with no known cause 10–21 days until the patient’s degree of recovery allows the individual to go home to continue therapy as an outpatient. Adapted from Minnesota Stroke Association, www.strokemn.org In a subacute setting, less intensive therapies are applied for function in that hand compared with patients who relied on their several months until the patient can continue therapy as an outpahealthy hand for daily tasks. tient. In a skilled nursing setting, expectation for recovery is low and does not depend on the intensity of therapy, so patients in this setting Bruce Idelkope, MD, is the medical director of the Minneapolis Clinic of receive limited therapy while awaiting spontaneous brain recovery. Neurology Rehabilitative Services Department, and is an associate professor Multidisciplinary effort All three approaches to rehabilitation involve a multidisciplinary team that includes the patient’s neurologist, nursing staff, speechlanguage pathologists, physical therapists, occupational therapists, psychologists, social workers, recreational therapists, nutrition specialists, and other specialties as needed. Speech-language pathologists address language, communication, and swallowing problems, as well as general cognitive function. Physical therapists help patients maximize their mobility and balance. Occupational therapists help patients relearn self-care techniques and improve cognition. Psychologists focus primarily on the patient’s mood and the amount of effort the patient invests in rehabilitation. Recreational therapists help patients learn or relearn ways to engage in hobbies. Nutritionists address any needed dietary adaptations and healthy lifestyles. Social workers handle discharge planning and family support. Each specialist assesses effects of the stroke and what type of therapy will best help the patient attain independent, functional living. The team determines a treatment plan that incorporates all the specialties. This team also meets regularly with the medical and nursing team to measure and modify its collective approach, as well as to communicate with the family and other concerned individuals.

of neurology at the University of Minnesota Medical School. Alexander Zubkov, MD, PhD, FAHA, is the medical director of the Fairview Southdale Hospital Stroke Program, an adjunct associate professor of neurology at the University of Minnesota Medical School, and practices with the Minneapolis Clinic of Neurology.

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Rehabilitation is not limited to a few hours with a therapist.

Determination maximizes recovery It is very important to understand that rehabilitation is not limited to a few hours with a therapist. We encourage our patients to follow the exercises they are prescribed, including daily stretching exercises. It is important to do so because these exercises stimulate the brain and retrain it. It takes determined, diligent effort and perseverance on the part of the patient in order for his or her brain to learn how to compensate for damage. This effort pays off. One study showed that constant efforts to use a stroke-weakened hand resulted in much greater improvement in

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PAT I E N T P E R S P E C T I V E

When the

“vulnerable adult” is you A stroke survivor’s journey By Jen Kirchen, LSW

A

fter 15 years of serving vulnerable adults as a licensed social worker, I became a vulnerable adult myself as a result of a stroke at age 36. My life was turned upside down. No more carpool for my daughters or work deadlines; the stroke left me unable to walk, talk, or even eat. Medical professionals who embrace the compassion necessary to make a difference in the lives of stroke survivors are the most beneficial in recovery. But what happens when the patient is you?

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MINNESOTA HEALTH CARE NEWS JULY 2013

Eight years ago, I met the man of my dreams and together we have made a family of our own with my children from a previous marriage. I am like any other working mom: I get the kids off to school, go to work, have meetings, and hurry home from work and make dinner for my family. An average day takes a frightening turn

Nov. 16, 2010, was an average day. After dinner, I headed to the high school to volunteer my time coaching my daughter’s volleyball team. That night I was assisting with volleyball tryouts. There were multiple groups of girls trying out for the volleyball club, and as we were waiting for the next group to finish and come to our station, I noticed the sudden onset of numbness in my right hand. I thought the cause might have been a pinched nerve in my shoulder since I had been tossing so many volleyballs for the drill. I rubbed my hand, thinking the feeling would go away, and it tingled. I decided to go out into the hall and get a drink of water, hoping to shake it off. Upon attempting to reenter the gym, I went to grab the door handle and my right hand didn’t work; it had gone totally limp. I was terrified! I opened the door with my left hand and called out to one of the other coaches. She came out and asked what was wrong. By that time, my hand had gone limp and my speech had started to go. I thought, “This is a stroke,” but I couldn’t tell her since my speech was limStroke can ited. She asked if I needed to go to the dochappen at tor and I said yes. She transported me to any age, urgent care. Within an hour of the onset of my first and time symptom, my whole right side was parais of the lyzed and I was essentially mute. I lay on essence. the gurney and just sobbed. My husband arrived a short time later and was stunned. The doctor, who thought I was having an anxiety attack, asked my husband if he wanted to drive me to the hospital. My husband refused. He knew something was really wrong and asked the doctor to call an ambulance. The EMT took one look at me and told the doctor I was having a stroke. She knew from experience; she was a stroke survivor. She said we needed to get to the hospital as soon as possible. With that, I was loaded into the ambulance and transported to the hospital,


lights and sirens wailing. I lay there thinking that life as I knew it was over. I feared living in a nursing facility for the rest of my life. The EMT, knowing firsthand what I was going through, recognized my racing thoughts and reassured me that although it wasn’t going to be easy, I could do it. I made the decision to recover. At the hospital, I was given a clot-busting drug (tPA), with the hope of restoring blood flow to the part of my brain that was deprived. If I hadn’t recognized that something was wrong and gotten medical help in time, I may not have been able to benefit from tPA. Timing is important, as tPA must be administered within three hours of the first symptom of stroke. I made it with a half-hour to spare.

Help fight against stroke • Stroke is a leading cause of death and long-term disability in the U.S. • Each year, more than 790,000 Americans experience a stroke and almost 130,000 Americans die as a result of stroke. • Stroke occurs every 40 seconds in the U.S. Every four minutes, someone dies of stroke. • Approximately 5 percent of all deaths in Minnesota are due to stroke, making it the third-leading cause of death in Minnesota behind cancer and heart disease. • Women are at higher risk for stroke. Nationwide, 425,000 women experience stroke each year, 55,000 more than men. • In 2011, the estimated cost of stroke was $38.6 billion in the U.S. and was more than $387 million in Minnesota. This total includes the cost of health care services, medications, and lost productivity. • For more information, visit the Minnesota Stroke Association’s website (www.strokemn.org).

Aftermath: connecting with others I received occupational, physical, and speech therapy at the hospital. By the time I was discharged on Nov. 23 (the day after my 37th birthday), I was able to walk on the treadmill, fry an egg, and talk in full sentences. Since my release from the hospital, it’s been confirmed that I have a genetic condition that predisposes me to clotting. Initially doctors thought that was the reason for my stroke. Thanks to a hematologist who was hesitant to prescribe Coumadin to someone so young and active, I went to the Mayo Clinic for a second opinion. It was there that they discovered a venous malformation in my brain. The Mayo neurologist I saw said he had seen only three cases like mine result in stroke in his 20 years of practicing medicine.

There were many challenges in my rehabilitation, and a great deal of hard work, but I am now about 95 percent fully functional. I still have a bit of trouble with my speech and numbness in my right hand, but I have returned to work, can play volleyball again, and have run my first 5K. I feel very lucky to be alive! My family has never been the traditional kind. I was raised by my mother, grandmother, and grandfather, none of whom I am currently in contact with. I have always relied on friends as my chosen family throughout the years. My family and friends supported me unconditionally during my stroke experience. There were countless hours spent at my bedside, meals delivered, hugs given, and overall When the “vulnerable adult” is you to page 34

WHO’S A BIGGER BASEBALL FAN, YOU OR ME? You’ll find that people with Down syndrome have a passion for knowledge and learning that can rival anyone you’ve met before. To learn more about the rewards of knowing or raising someone with Down syndrome, contact your local Down syndrome organization. Or visit www.dsamn.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

©2007 National Down Syndrome Congress JULY 2013 MINNESOTA HEALTH CARE NEWS

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PAT I E N T P E R S P E C T I V E

It all started when …

books. That must have been when it happened.

Michael I remember it was a typical day; I had a pretty good breakfast that morning. I rode to school with my brother and everything was normal. Judy (Michael’s mother) Michael has very little memory of the day, but he does recall earlier that morning he was sitting in the locker room school and started to feel dizzy.

A stroke at 15 Michael

Michael’s story of his “silent disability” By Judy McMillan and Michael McMillan

I walked through the gym hoping a teacher would be available because I knew something was wrong. I just didn’t know what. When I got to my locker, I needed a friend to help me open it because I couldn’t see the combination. I was very confused and by the time I got to class, the teacher knew something was wrong. He sent me to the nurse and as I was walking up the stairs, I dropped my

In the next issue.. • Retinal tears • Compulsive gambling • Affording long-term care 30

MINNESOTA HEALTH CARE NEWS JULY 2013

Judy Michael experienced a complicated migraine, which started in the basilar artery. Normally, in a migraine, the blood vessel constricts but with Michael, the vessel started to pulse and pushed into the cerebellum and hypothalamus. Doctors referred to it as a stroke caused by complicated migraine. I had just pulled in the driveway at work when my cell phone rang. It was the nurse from Michael’s high school. Michael wasn’t feeling well and they thought he should go home. They told me he was very tired and seemed “out of it.” When I arrived at the school, there was an ambulance outside. It never dawned on me that it was for Michael. When I got to the door, they told me not to be alarmed but they were just being cautious. I ran to the nurse’s office to find Michael lying on a cot. His left eye was wandering off, and he would not respond even though several people were calling his name and rubbing his chest.


I began calling his name and he looked at me with the most distant stare. The people in the office asked me if he could be on drugs or had consumed alcohol. It was 8:30 in the morning, he was a three-sport athlete, and I was sure that he had not ever used drugs or alcohol. He was only 15 years old. The paramedics decided they needed to take him to the emergency room. Michael

Doctors referred to it as a stroke caused by complicated migraine.

I don’t remember much in the nurse’s office and I don’t remember anything about the ambulance ride. Judy When Michael arrived at the hospital he was unconscious. The emergency room staff was convinced that Michael had been using drugs or alcohol even though the test results came back negative. The doctor and nurses tried different pain stimuli, but Michael did not respond. At one point they put straight ammonia into his nostrils and he did not respond. They did a CT scan, which showed no concerns. We asked for an MRI, but we were told it wasn’t warranted. The doctor came to us and told us that he believed it was psychological and Michael was looking for attention. I said, “Then I’m putting him in acting school because he is really good!” A nurse took us aside and talked about pseudoseizures and then they sent him home. When we got home, Michael initially seemed a little better, but as the evening progressed, we became very concerned with Michael’s increasingly strange and disoriented behavior. He would shove food in his mouth. He took a whole box of candy and put it all in his mouth at one time; he tried texting his friends and it was all nonsense. He insisted that I call Joe Mauer to come and see him. “He is such a nice guy, I know he will come and see me if he knows I am sick,” Michael mumbled. Concerned by his behavior and questioning the results from the emergency room, we took him to his pediatrician, who immediately had us go to Gillette Children’s Hospital, where his stroke was finally diagnosed. It affected the hypothalamus and the cerebellum. His right side was weak, he had a left-field cut, and his speech was difficult to understand. He slept most of the time, but when he was awake he was confused and disoriented. I remember finally getting up the courage to tell Michael what had happened. After I explained to him that he had had a stroke, he cried and asked if he would ever get better and then fell back asleep. When he woke up, I sat by him, waiting for him to ask me more difficult questions but instead he asked, “Why am I here?” This happened three Strokes more times over the course of several days. Little did we know that his memory was can occur at any age. going to remain an issue for a long time.

Because I don’t have any physical limitations—with the exception of a hand tremor if I become overly fatigued or I am required to do a lot of writing or typing—many people think I am all better. My disability is labeled a “silent disability.” Judy

Devastated by the realization that my 15-year-old son would be living with the effects of a stroke, I began to search the Internet for resources. I found the Minnesota Stroke Association and contacted them for information. What I received was extreme support, resources, and education. Our family has participated in the Strides for Stroke Walk the past two years and plan to make it a yearly event. Michael also attended the Strike Out Stroke event with the Minnesota Twins and last year received the greatest thrill: He was asked to throw out the first pitch. We feel so fortunate to have found wonderful support services such as the Minnesota Stroke Association, the Brain Injury Association of Minnesota, National Stroke Association, and PACER. Michael

My overall high school experience has been difficult. I am now on an IEP (individualized education program) and receive special education services at school. However, I have been accused of “milking the system” by teachers who have told my parents that they think I am “comfortable in the forgetting mode.” A stroke at 15 to page 32

Michael I was homebound from school for the next three months. I began PT, OT, and speech therapy to recover from the physical effects of the stroke, but the piece that none of us were planning on was the cognitive limitations. Since the stroke, I have sensory issues, my memory is bad, and I get overwhelmed and anxious easily. I have trouble with impulse control. My organizational and executive functions skills are low. My neurologist reports that I have “frontal lobe behaviors.” JULY 2013 MINNESOTA HEALTH CARE NEWS

31


A stroke at 15 from page 31

My coaches, much like my teachers, thought that I was looking for special treatment or not giving it my best. Before the stroke, I was a three-sport athlete and even though I was able to participate again in football, baseball, and wrestling, my athletic performance was not the same. I actually was on the receiving end of bullying from the football and wrestling coach. I was told I was “no good” and referred to as “a person like you.” I am looking forward to graduating and starting a new chapter. My goal of attending a four-year college is on hold for now due to my cognitive challenges, but I plan to attend a community college and get my Paraprofessional Educator Certification so I can work with students who are having the same type of issues that I have experienced. As my abilities improve, I hope to someday become a special education teacher. I also am taking an EMT course at our community college while in high school. Hopefully, someday I can help others—and, this time, be able to recall the ambulance ride.

Because I don’t have any physical limitations … many people think I am all better.

Judy Michael is motivated to get the word out that strokes can occur at any age and that the cognitive disabilities or silent disabilities are just as devastating as the physical limitations. He will be an amazing teacher. As a parent, you only want the best for your child. Seeing him struggle physically, rise above it, and then be destroyed emotion-

ally by the insensitive, heartless comments of people you hoped would be there for support is devastating. I am so proud that Michael has been able to turn the things that have happened into a positive. On this journey to recovery, we have met several other teens that have had strokes. They, too, were misdiagnosed initially. This is alarming and concerning and raises the issue of educating health care professionals, at all levels, that a teen who is displaying disorientation, unconsciousness, and speech difficulties may not be using drugs or alcohol. Once those test results come back negative, it is important to go the next step and do an MRI to determine if the person has suffered a stroke or some other type of brain injury. Michael continues to amaze us. His strength and determination have made him the wonderful person he is today. Michael has a verse framed in his room that best describes who he has become: “But it isn’t about how hard you hit. It’s about how hard you can get hit and keep moving forward. How much you can take and keep moving forward.” –Rocky Balboa, in the movie “Rocky” Michael is now 19. He has no physical limitations but although he continues to deal with cognitive challenges, he is in college and has found tools to help him be successful. He volunteers for the Minnesota Stroke Association as a speaker to raise awareness of pediatric stroke (www.strokemn.org).

Minnesota

Health Care Consumer June survey results ... Association

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 June survey.

97.06%

100

50

Percentage of total responses

Percentage of total responses

41.18%

80 60 40 20

40 30 23.53% 20 14.71% 10 2.94%

Yes

32.35%

0

No

genetic screening.

35

20 14.71% 8.82% %

10 2.94% 0

32

Strongly agree

Agree

No opinion

Disagree

Strongly disagree

MINNESOTA HEALTH CARE NEWS JULY 2013

Disagree

41.18%

20.59% 20 11.76%

10 5 0

No opinion

50

32.35%

25

15

Agree

40 30 20

26.47% 17.65% 11.76%

10

2.94% Strongly agree

Agree

No opinion

Disagree

Strongly disagree

Strongly disagree

passing on a serious illness, it would significantly impact my decision to have children.

Percentage of total responses

23.53%

Percentage of total responses

Percentage of total responses

30

Strongly agree

5. If genetic mapping indicated I was at high risk of

30

40

17.65%

2.94%

4. I feel it is important to provide newborn infants with

50.00%

50

procedures if genetic counseling placed my risk of developing a serious illness in a high percentile.

genetic counselor.

0

3. Genetic mapping should be a required part of any medical record.

2. I would support the idea of radical preventive medical

1. I, or someone in my family, have seen a

2.94% 0

Strongly agree

Agree

No opinion

Disagree

Strongly disagree


Minnesota

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.

SM

Members receive a free monthly electronic newsletter and the opportunity to participate in consumer opinion surveys.

www.mnhcca.org

Join now.

“A way for you to make a difference� JULY 2013 MINNESOTA HEALTH CARE NEWS

33


When the “vulnerable adult” is you from page 29

I thought, “This is a stroke,” but I couldn’t tell her since my speech was limited.

encouragement. I soon realized how much I meant to people and how much they cared about me. I can definitely say I have the greatest people in the world surrounding me and participating in my life. Still, after my stroke, I felt disconnected from friends and family who didn’t understand what I was going through. I sought out a young adult stroke group, hoping to identify with survivors that had been through the same thing. I formed some great friendships, but the location and time limited my continued participation after I went back to work. One day during one of my speech therapy appointments, a speech pathologist at Fairview said it would be really great if we had a younger stroke group there in the south metro. The staff at Fairview Ridges offered to donate the space and, since I had a social work background and experience, they thought it would be a perfect fit for me to facilitate the group. Seven months after my stroke, I started the Fairview Ridges Young Adult Support Group in Burnsville. We currently meet for an hour once a month and discuss topics related to stroke. We have also added a “children of stroke survivors” group that meets separately at the same location during the same time as the adult group.

Additionally, I volunteer at Courage Kenny Rehabilitation Institute, which is the very place at which I did my inpatient rehab. I find it very rewarding to give back, offering encouragement to current stroke patients. Through my experience I have become active in the Minnesota Stroke Association. In 2011, I raised $1,500 for the Strides for Stroke walk and had over 30 friends and family members walk with me on my team, “Jen’s Journey.” I participated in the walk in 2012 and 2013 walks as well. I also contributed my story to the “Stroke Matters” spring 2012 newsletter, with the intent of helping others through sharing my experience. My journey is full of great examples of how the hard work and the dedication of medical professionals lead to my amazing recovery. From the EMT who offered those initial words of encouragement to the hematologist who just didn’t feel comfortable prescribing Coumadin, the medical staff involved in my case never gave up. One final comment: It is important to make people aware of the symptoms of stroke and to seek immediate medical assistance if they suspect they are having a stroke. Stroke can happen at any age, and time is of the essence.

Jen Kirchen, LSW, lives in Apple Valley.

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

34

MINNESOTA HEALTH CARE NEWS JULY 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


Minnesota Health care News July 2013