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June 2012 • Volume 10 Number 6

Appendicitis Kevin Bjork, MD

Genetic research Warren Regelmann, MD

Dialing 911 Darlene Pankonie, ENP


You call it “reminding mom to take her pills.�

We call it caregiving.

You or someone you know may be a caregiver. WhatIsACaregiver.org


CONTENTS

4 7 8

JUNE 2012 • Volume 10 Number 6

NEWS

PEOPLE

PERSPECTIVE Marianne Keuhn, MBA March of Dimes

10

10 QUESTIONS

16 18 20

SURGERY Appendicitis

22

HOSPITALS Health care chaplains

24

BEHAVIORAL HEALTH Transcranial magnetic stimulation

Darlene Pankonie, ENP Dialing 911

By Kevin Bjork, MD

CALENDAR Extreme heat precautions TAKE CARE Wound care By Renee Montes, RN, CWOCN, and Julie Roskamp, RN, CWOCN

By Helen Wells O’Brien, MEd, MDiv, BCC (Board Certified Chaplain)

By Abraham Verjovsky, MD

12

MEDICAL RESEARCH Genetic research and cystic fibrosis By Warren Regelmann, MD

14

RARE DISEASES Alport syndrome By Clifford E. Kashtan, MD, FASN

26 28

PALLIATIVE CARE The healing power of art By Megan Hatch

MEN’S HEALTH Benign prostatic enlargement By William M. Kaylor, MD

32

PUBLIC HEALTH Minnesota Board of Nursing By Shirley A. Brekken, RN, MS

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

To CHANGE your life (For the better)

ART DIRECTOR Elaine Sarkela esarkela@mppub.com BUSINESS DEVELOPMENT DIRECTOR Juline Birgersson jbirgersson@mppub.com ACCOUNT EXECUTIVE Iain Kane ikane@mppub.com

Advisory Board: Minnesota Medical Association (MMA), Minnesota Hospital Association (MHA), Minnesota Medical Group Management Association (MMGMA), Buyers Health Care Action Group (BHCAG), Minnesota Business Partnership (MBP), Minnesota Healthcare Network (MHN), Advocates for Marketplace Options for Mainstreet (AMOM), Minnesota HomeCare Association (MHCA), Minnesota Physician-Patient Alliance (MPPA), Physicians Service Network (PSN), Minnesota Center for Rural Health, and Minnesota Council of Health Plans. 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.

Contact: Sentinel Medical Associates Laser Center Gallery Professional Building 514 St. Peter, Suite 220 St. Paul MN 55102

Ph: 651.294.3232 www.sentinelasercenter.com

JUNE 2012 MINNESOTA HEALTH CARE NEWS

3


NEWS

Swanson Report Hits Accretive Practices, Fairview Cuts Ties Attorney General (AG) Lori Swanson released a report in April on debt collection practices by Fairview Health Services and Chicago-based Accretive Health, saying the companies crossed a line in trying to collect payments from patients. The AG began investigating Accretive’s practices last summer, after a stolen laptop created a security breach for Fairview and North Memorial Hospital. Both health systems had contracts with Accretive for various administrative services. Swanson later filed a lawsuit against Accretive, alleging numerous violations of state and federal laws. The new report publicly discloses examples of what Swanson says were deceptive and illegal practices. “Accretive has hidden its true identity from patients, aggressively and illegally attempted to collect debts from patients, improp-

erly used patient health information to collect debts, and failed to follow basic laws regarding the registration and conduct of its collectors,” the report says. In the days following the report’s release, Fairview cut ties with Accretive. In response to Swanson’s allegations, Accretive issued a statement disputing the charges and filed a motion for the suit to be dismissed.

HHS Omnibus Bill Fixes Cuts from Last Year As the legislative session approached its end in late April, Gov. Mark Dayton signed the Health and Human Services (HHS) omnibus bill, restoring $18 million in funding to a range of services that were cut in last year’s budget. Dayton called the HHS omnibus bill one of the great accomplishments of the session. He praised leaders from both parties and agency heads for working together. “It’s an extraordinary

t a P

– UCare member St. Louis Park, MN

accomplishment, especially in the context of some of the other difficulties we’ve had this session in working together in a cooperative, bipartisan way,” he said. Dayton noted that additional funds were available to address some of the HHS shortfalls because of the work of Department of Human Services Commissioner Lucinda Jesson, who negotiated a cap on profits from state health plans for the private insurers that administer them. “That’s what generated $43 million, which will not only pay for the $18 million [in health and human services] but provides $25 million for purposes still under discussion,” Dayton said. Officials at the bill-signing ceremony on April 30 said the new law builds on previous reforms and fixes some unintended problems caused by last year’s protracted efforts to balance the state’s budget. “There were a few gaps, which we solved with a little bit of money that the commissioner was able to yield with some good management,” says Rep.

Jim Abeler, chair of the House Human Services Finance committee. “So many people count on our services … there’s a lot to be proud of, and we did it in a collaborative way.” Some of the provisions included in the HHS bill included language that increases payments for personal care attendants, restores funding for treatments such as dialysis and chemotherapy for people on Emergency Medical Assistance, and the funding of an autism study. The omnibus bill did not address cuts to Medical Education Research Costs or physician reimbursements for the state’s Medical Assistance program. One the most talked-about health care proposals, independent audits of state health plans, was included in the final legislation, but its implementation will be delayed until 2014, with the first report expected in 2015. David Feinwachs, a former health care executive who has been the most public champion of health plan audits over the past

D

iscover UCare for Seniors , the simple, affordable health plan that provides great benefits at a great price — just what you’d expect from health care that starts with you. SM

Visit: UCareplans.org to access rates, plan details, and more.

Call: (toll free) 1-877-523-1518 (TTY) 1-800-688-2534, 8 a.m. to 8 p.m. daily.

UCare Minnesota and UCare Wisconsin, Inc. are health plans with Medicare contracts. © 2011, UCare H2459 H4270_081211_4 CMS File & Use (08172011) 4

MINNESOTA HEALTH CARE NEWS JUNE 2012


two years, was critical of the delay. “If we all agree there’s something wrong, why are we waiting three years?” he asked. “If they were serious about it, it would be happening now.”

Mayo Study Shows Dramatic Rise in Skin Cancer Mayo Clinic researchers are seeing a dramatic rise in skin cancer, especially among people under 40, according to a new study. In the April issue of Mayo Clinic Proceedings, researchers reported that the incidence of melanoma increased eightfold among young women and fourfold among young men. The study looked at cancer rates between 1970 and 2009. “We anticipated we’d find rising rates, as other studies are suggesting, but we found an even higher incidence than the National Cancer Institute had reported using the Surveillance, Epidemiology, and End Result database, and in particular, a dramatic rise in women in their 20s and 30s,” says lead investigator Jerry Brewer, MD, a Mayo Clinic dermatologist. The researchers speculate that the use of indoor tanning beds is a key culprit in the rising cancer rate in young women. “A recent study reported that people who use indoor tanning beds frequently are 74 percent more likely to develop melanoma, and we know young women are more likely to use them than young men,” Brewer says. Although the risks from tanning beds are well known, Brewer adds, young women continue to use them. “The results of this study emphasize the importance of active interventions to decrease risk factors for skin cancer and, in particular, to continue to alert young women that indoor tanning has carcinogenic effects that increase the risk of melanoma,” he says. The study contained some positive news: Researchers found mortality rates from the disease have improved over the years,

likely due to early detection of skin cancer and prompt medical care. “People are now more aware of their skin and of the need to see a doctor when they see changes,” Brewer says. “As a result, many cases may be caught before the cancer advances to a deep melanoma, which is harder to treat.”

Researcher Says Cost Can Influence Medical Decisions A new study from a University of Minnesota researcher suggests that higher out-of-pocket costs for health services, such as copays and deductibles, may lead families to cut back on needed health care treatments for children. Pinar Karaca-Mandic, PhD, an assistant professor with the U of M School of Public Health, followed 8,834 privately insured patients from across the United States whose children were prescribed medication for asthma control. Her report, published in the Journal of the American Medical Association, looked at how the trend of rising out-ofpocket costs for health coverage affected medical decisions in those families. “We found that among children age 5 to 18 years, children whose families paid more out-ofpocket toward asthma-control medications used their medications less often,” she said. “And, at the same time, these children were more likely to get hospitalized for asthma. We didn’t find this effect for younger children, which perhaps reflects that parents are less sensitive to costs for these younger children, whose asthma is typically more severe.” At a time when health plans are reporting healthy profits, due in part to decreased utilization by enrollees, some experts have raised concerns about the impact of shifting higher costs to consumers. Karaca-Mandic says her study shows the trend could impact health care delivery overall. “The result is these children aren’t getting the medicine they News to page 6

MINNESOTA HEALTH CARE ROUNDTABLE

T H I R T Y- S E V E N T H

SESSION

Specialty pharmacy Controlling the cost of care Thursday, June 7, 2012 1:00 – 4:00 PM • Symphony Ball Room Downtown Mpls. Hilton and Towers

Background and focus: Medications treating chronic and/or life-threatening diseases are frequently new products, which are often more expensive than generic or older, branded products that treat similar conditions. The term specialty pharmacy has come to be associated with these medications. Exponents claim the new technology improves quality of life and lowers the cost of care by reducing hospitalizations. Opponents claim the higher per-dose cost spread over larger populations does not justify the expense.

The cost of research, both failed and successful, is reflected in product pricing. Current federal guidelines allow generic equivalents marketplace access based on the patent date, not the release date, of a product. This considerably narrows the window in which costs of advances may be recovered. A further complicating dynamic involves the payers. Physician reimbursement policies sometimes reward utilizing lower-cost “proven” products and cast those prescribing higher-cost products as “over-utilizers,” placing them in lowertiered categories of reimbursement and patient access.

Objectives: We will discuss the issues that guide the early adoption of new pharmaceutical therapies and how they relate to medical devices. We will examine the role of pharmacy benefit management in dealing with the costs of specialty pharmacy. We will explore whether it is penny-wise but pound-foolish to restrict access to new therapies and what level of communication within the industry is necessary to address these problems. With the baby boomers reaching retirement age, more people than ever will be taking prescription medications. As new products come down the development pipeline, costs and benefits will continue to escalate. We will provide specific examples of how specialty pharmacy is at the forefront of the battle to control the cost of care. Panelists include: N Sara Drake RPh, MPH, MBA, Pharmacy Program Manager, Minnesota Department of Human Services N Alan H. Heaton, PharmD, RPh, Director, Pharmacy Management, UCare N Daniel Johnson, MEd, Vice President of Public Policy, National Multiple Sclerosis Society N Timothy Stratton, PhD, BCPS, FAPhA, Professor, College of Pharmacy, UMD N Gene Stringer MD, Stillwater Medical Group

Sponsors include: Daiichi Sankyo • Novartis 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 #

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JUNE 2012 MINNESOTA HEALTH CARE NEWS

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News from page 5 need, which can spell serious long-term trouble for them,” she said. “The results signal one of the true impacts of rising insurance costs.” She added that children, families, and schools should be educated on the importance of asthma care and the potential lifelong implications of medication under-use.

MDH Website Provides Information On Infant Hearing The Minnesota Department of Health (MDH) has combined its online resources about infant hearing issues into one new website, officials announced recently. The new site is for parents, providers, and other professionals looking for resources from the agency’s Early Hearing Detection and Intervention (EHDI) program for infants and children. Parents of children who have hearing loss or who may develop hearing loss can learn about the

EHDI program at the new site, www.improveehdi.org/mn. The site will provide parents with information on identification and intervention about hearing loss, and help them find specialists and education resources. Providers can access material about best practices, screening processes, support for patients, and training materials.

Health Plans Saw A Profitable 2011 Minnesota health plans saw their most profitable year in more than half a decade in 2011, according to figures released recently by the Minnesota Council of Health Plans (MCHP). The MCHP’s annual financial report shows that health plans in the state overall had an operating margin of 1.8 percent, the highest margin in the past six years, with $19.8 billion of premium revenue. Plans paid $17.7 billion for medical care, with health care spending up 1.8 percent over 2010. Health plans in the state saw

a slowdown in how much they spent per enrollee, MCHP says. In 2011, per-enrollee spending increased 0.4 percent, compared with a 2.6 percent increase per enrollee in 2010. The largest increases in spending were outpatient care at hospitals, spending on medical goods, and spending at skilled nursing facilities, all of which saw double-digit spending increases in 2011. Spending for hospitalized patients, prescription drugs, and physician services decreased in 2011. The report finds that enrollment in plans sponsored by large employers grew nearly 2.4 percent, to 2.2 million. At the same time, group coverage for small companies of 50 or fewer employees declined. More than 14,000 Minnesotans employed by small companies lost coverage in 2011. Enrollment in Medicare plans grew by nearly 10 percent, to 438,927 enrollees. Overall, enrollment in the seven health insurance companies that make up MCHP increased to 4.3 million, up 1.4 percent.

One of the more notable developments for health plans in the past year was the agreement between plans and the state of Minnesota to cap the profits on Medicaid and MinnesotaCare products that private plans administer for the state. With concerns rising in the Legislature that plans were not being transparent enough about the taxpayerfunded revenues they gained from public programs, health plans agreed to return profits over 1 percent for 2011. The result is that plans will return a little more than $73 million to the state. That amount will be shared with the federal government, which splits the funding for Medicaid with states.

Correction: In the April 2012 edition, an article titled “Massage Therapy” contained the incorrect statement, “Massage therapists practicing in Minnesota must pass a state licensure test ...” The state of Minnesota does not require massage therapists to have a license.

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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

6

MINNESOTA HEALTH CARE NEWS JUNE 2012


PEOPLE Charlotte Roehr, MD, and Michele Brezinski, MD, have joined Courage Center Physicians Associates. Roehr will see patients at Courage Center Golden Valley and at Courage Center Burnsville. A board-certified physical medicine and rehabilitation physician, Roehr is also board-certified in EMG with a special emphasis in working with clients with brain injury and ALS. In addition to Charlotte Roehr, MD

her medical practice, Roehr

has been an assistant professor at the University of Minnesota Medical School, Minneapolis. Brezinski comes to the Courage Center from the Park Nicollet Health System. A board-certified family practice and integrative medicine physician, Brezinski will see patients in the Golden Valley clinic and

Michele Brezinski, MD

will do inpatient consultation in the Transitional Rehabilitation Program. Monica Mahon has been named client experience liaison at AgeWell, an Edina-based comMonica Mahon

pany that offers health care services for seniors.

Previously she was a life care navigator at the company. In her new role, Mahon’s main responsibility will be coaching caregivers in the field in their relationships with clients and families. Mahon is a social worker with more than 15 years’ experience working in a wide range of settings including long-term care, housing, transitional care unit,

MOVE YOUR CAREER IN HEALTHCARE AHEAD.

and home care. Two local executives were honored by the Women’s Health Leadership Trust at its annual forum and awards ceremony in April. Shirley Weis, vice president and chief administrative office at Mayo Clinic, was awarded the Trusted Senior Leader Award, and Julie Faulhaber, senior director at Medica State Public Programs, was given the Emerging Leader Award. The Trust was founded in 1979 to expand women’s leadership roles as an influential force in the health care community and to provide a support system for women in health-care leadership roles. Thomas Kottke, MD, and Courtney Jordan Baechler, MD, MS, have been named physician co-chairs for the Twin Cities

At Nebraska Methodist College, we help professionals expand their skills and advance their careers in healthcare. We offer fully accredited degree programs online in Nursing, Health Promotion and Medical Practice Management. Now there is a way to earn your degree that is both flexible for your busy lifestyle and respected by healthcare employers everywhere. Give your career a boost. Call us today!

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individuals, and organizations working to reduce obeThomas Kottke, MD

sity among children and

adults. Kottke is a cardiologist and medical director for evidence-based health at HealthPartners. Baechler is vice president of the Penny George

Courtney Jordan Baechler, MD, MS

Institute for Health and Healing, where she leads efforts to expand the institute’s scope to more broadly include prevention and health promotion. She is a cardiologist and continues to see patients at United Heart & Vascular Clinic in St. Paul. Benjamin Kuhse, CPO, joined the staff of St. Croix Orthopaedics Orthotics Center in May. Kuhse, a certified prosthetic and orthotic

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practitioner, has several years of experience providing patient care for children and adults and also holds a BS degree in biomechanical engineering from Marquette University, Milwaukee, Wis. JUNE 2012 MINNESOTA HEALTH CARE NEWS

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PERSPECTIVE

March of Dimes leads the way So that every baby is born healthy

M

Marianne Keuhn, MBA March of Dimes

Marianne Keuhn, MBA, is the state director of programs and public affairs at the March of Dimes, a national foundation whose mission is to improve the health of babies by preventing birth defects, premature birth, and infant mortality. The March of Dimes is working toward the day when all babies will be born healthy. Get involved today at www. marchofdimes.com

8

ore than four million babies are born each year in the United States and March of Dimes aims to help each one. This organization grew out of President Franklin D. Roosevelt’s personal struggle with polio, which led him to create the National Foundation for Infantile Paralysis in 1938, when polio was on the rise. Now known as March of Dimes, the foundation established a polio patient aid program and funded research for vaccines that effectively ended the U.S. polio epidemic.

5. Get a medical checkup. 6. Eat healthfully and maintain your optimal weight. 7. Do something active every day. 8. Avoid exposure to chemicals and other harmful substances at work and at home. 9. Learn to lower stress.

Before you get pregnant 1. Plan when you want to have a baby. 2. Use a reliable form of birth control until you’re ready to get pregnant. 3. Take a multivitamin pill that contains 400 micrograms of folic acid every day to help reduce the risk of neural tube defects. 4. Stop smoking, drinking alcohol, and taking illegal drugs.

deliver for at least 39 weeks. The baby’s brain, lungs, and liver are still developing during the last few weeks of pregnancy. Eyes and ears are developing too, which is why babies born too early are more likely to have vision and hearing problems later in life. Bottom line? When mom is healthy during pregnancy, she gives her baby the best chance of being born healthy and full-term.

During pregnancy 1. Go to all your prenatal care checkups. 2. Tell your provider about any chronic health conditions you have and any medications Mission enlarges you take. Its original mission accomplished, the foundation 3. Tell your provider about your pregnancy and turned its focus to preventing birth defects and family history. infant mortality. March of Dimes has led the way to discover genetic causes of birth defects, pro- 4. Take a prenatal vitamin containing folic acid every day. mote newborn screening, and educate medical professionals and the public about best practices 5. Don’t smoke, drink alcohol, use illegal drugs, or abuse prescription medicines. for healthy pregnancy. We have supported research for surfactant therapy 6. Eat healthy foods. to treat respiratory distress in 7. Do something active every neonates (newborns) and helped Babies born even day. initiate a system of regional 8. Stay away from chemicals a few weeks early are neonatal intensive care units for that could hurt a growing premature and sick babies. Our at risk of severe baby. efforts to encourage women to 9. Take good care of your health problems. take folic acid before and during teeth and get regular dental pregnancy dramatically reduced checkups. the incidence of babies born with neural tube defects, which are brain and Learn signs of preterm labor 1. Contractions that make your belly tighten up spine defects caused by folic acid deficiency. like a fist every 10 minutes or more often. Combating prematurity 2. Change in the color of your vaginal discharge, Babies born even a few weeks early are at risk of or bleeding from your vagina. severe health problems and lifelong disabilities, 3. The feeling that your baby is pushing down. and every year, more than half a million babies This is called pelvic pressure. are born too soon in the United States. Premature birth costs society more than $26 billion a year 4. Low, dull backache. and takes a high toll on families. Alarmingly, our 5. Cramps that feel like your period. country’s premature birth rate has risen by 36 per- 6. Belly cramps with or without diarrhea. cent over the last 25 years. Since 2003, March of If your pregnancy is healthy, it’s best to stay Dimes has worked to combat this trend through pregnant for at least 39 weeks our Prematurity Campaign, an intensive, multiYou might not have a choice about when to have year campaign that helps women have full-term, a baby. If there are problems with your pregnancy healthy babies. or your baby’s health, you may need to have your How can a woman increase her likelihood of a baby earlier. But if you have a choice and you’re healthy full-term pregnancy? planning to schedule your baby’s birth, wait to

MINNESOTA HEALTH CARE NEWS JUNE 2012


A philosophy of caring is good. A history of it is better. Caring. It would be nice if you could see it, like an amenity. Or tour it, like an apartment. But you can’t. All we can do is give you our definition: Caring is believing that everyone is someone who deserves to feel loved and valued, and be treated with dignity. That’s not just something we say. As the nation’s largest not-forprofit provider of senior care and services, it’s what we’ve been doing for almost 90 years.

www.good-sam.com

To learn more about our communities in Minnesota, call 1-888-GSS-CARE.

The Evangelical Lutheran Good Samaritan Society provides housing and services to qualified individuals without regard to race, color, religion, sex, disability, familial status, national origin or other protected statuses according to federal, state and local laws. All faiths or beliefs are welcome. Copyright © 2010 The Evangelical Lutheran Good Samaritan Society. All rights reserved. 10-G2016


10 QUESTIONS

& Darlene Pankonie, ENP Darlene Pankonie, ENP, is the 911 communications center manager for the Washington County sheriff’s office and has been in the 911 communications field for more than 18 years. Pankonie is a member of the Association of Public-Safety Communication Officials (APCO) and holds the National Emergency Number Association (NENA) certification of ENP, Emergency Number Professional. Organization and authority for the 911 emergency response system is more complicated than people think. Please tell us how it works. Minnesota has emergency response dispatch centers that are run by state government, county government, municipal government, or joint powers agreements between municipal governments, county governments, or a combination of governments. Examples of Minnesota dispatch centers that are joint power agreements are the Dakota Communications Center and the Red River Regional Dispatch Center in the Fargo/Moorhead area. The structure of a given 911 center dictates how many and which police, fire, and EMS response agencies are dispatched by that center’s staff. Some 911 centers dispatch a single police department while others dispatch multiple police, fire, and EMS agencies. The location from which the 911 call originates dictates which dispatch center gets the call. What protocols do 911 operators use in fielding health-care related calls? 911 dispatch centers can opt to provide emergency medical dispatch (EMD) protocols. EMD protocols allow a 911 dispatcher to triage a patient’s symptoms in order to determine the appropriate priority for an EMS response. The protocols also give a 911 dispatcher instructions for the patient or bystanders to follow before EMS responders arrive. These instructions can help prevent further harm and help bystanders provide appropriate first aid. In a health-related situation, what guidelines should a person use in deciding whether or not to call 911? Above all, no one should be afraid to call 911. The 911 dispatcher will ask questions to determine the best response for the situation. Anyone who wants an ambulance should call 911. What information should a 911 caller be prepared to tell the dispatcher? The first thing a 911 dispatcher needs from every caller is the location of the emergency because help cannot be started without it. Callers should never assume that the 911 dispatcher automatically knows the caller’s location. If the address is not known, be prepared to answer questions from the 911 dispatcher that will help determine the location. Secondly, callers should provide the number they are calling from and any other phone number that is relevant, to enable a callback if needed. Thirdly, be prepared to explain the nature of the emergency so that appropriate responders can be dispatched.

Photo credit: Bruce Silcox

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MINNESOTA HEALTH CARE NEWS JUNE 2012

What kind of data can you share about health-care related calls that result in transportation to the emergency room versus situations resolved on-site by emergency responders? Paramedics and other emergency responders assess a situation and treat according to EMS guidelines. There are some medical emergencies that can be resolved without transportation. EMS agency guidelines along with the paramedic’s expertise and the patient’s desires determine if transportation to a medical facility via an ambulance is required.


No one should be afraid to call 911.

How is a 911 caller involved in decision making about where they are taken by emergency transportation? Paramedics let the patient decide which hospital they would like to be transported to for treatment. This is often based on a patient’s insurance and his or her primary physician. Patients in need of specialized care that is not offered at their hospital of choice will be advised by the paramedic to go to a more appropriate hospital. Tell us about the problems cell phones pose to the 911 system? The traditional landline (wired) phone was the primary calling device for many years. Now, the cell phone (wireless) is the primary device used to call 911. 911 centers are seeing around 70 percent of their calls coming from cell phones. The biggest difference between the two types of phones is that landline phones are linked to a specific address and cell phones are transient. Most 911 centers can map a cell phone to a general area, but it is not 100 percent accurate. Therefore, 911 callers using a cell phone MUST know their address or location. How will the 911 system adapt as communication technology continues to evolve? The existing enhanced 911 (E911) system was designed for the traditional landline phone. Because wireless and Voice over Internet Protocol (VoIP) devices are now the preferred method for personal communications, a transition from the existing E911 to a modern Internet Protocol

(IP)-based system utilizing high speed data connectivity is taking place. This transition is called NG911 (Next Generation 911). Minnesota has begun the transition to a NG911 network. The hope for NG911 is that it will serve as a network capable of utilizing the data capabilities of modern devices such as text and video messaging. What do you want people to know about using the 911 system in a medical emergency? Try to remain calm. The 911 dispatcher will assist the caller in getting the address of the emergency and the nature of the emergency, and will provide appropriate assistance until emergency responders arrive. What is the best advice you could give to a layperson to handle a medical emergency? The most critical medical emergency is a person in cardiac arrest. I would encourage people to learn cardiopulmonary resuscitation (CPR). In the past, giving mouth-to-mouth resuscitation may have deterred some people from learning CPR. However, hands-only CPR for the layperson is now being taught and has been found to be highly effective. Also be mindful that many public settings now have an automatic external defibrillator (AED) readily available. AED devices have simple audio and visual commands. They are designed so a bystander can easily open the device and follow instructions that could result in saving a life.

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MEDICAL RESEARCH

Genetic research and cystic fibrosis Improved treatment today, hope for the future By Warren Regelmann, MD

In January 2012, treatment of inherited diseases took a giant leap forward when the Food and Drug Administration approved Kalydeco, a drug that improves the lives of people with cystic fibrosis (CF). CF is an inherited chronic disease affecting the lungs and digestive system of about 30,000 children and adults in the United States and is

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MINNESOTA HEALTH CARE NEWS JUNE 2012

the most common inherited life-limiting disease among Caucasians. Kalydeco, also known by its generic name of Ivecaftor, will very likely improve and prolong the lives of CF patients. For them, this drug represents a major advance. However, this new drug is exciting not only because it offers CF patients an improved quality of life but because it shows that research targeting a specific genetic defect can lead to more effective treatment of inherited diseases. The nature of the problem CF is caused by mutations in any of the many CFTR genes that produce CFTR proteins. (CFTR stands for Cystic Fibrosis Transmembrane Conductance Regulator.) Mutation produces a defective CFTR protein that causes the body to produce extremely thick, sticky mucus. CF mucus clogs the lungs and leads to life-threatening lung infections, obstructs the pan-


creas, and stops natural enzymes from helping the body break down and absorb food, which leads to an inability to maintain a healthy weight. Until the discovery of Ivecaftor, CF treatment focused on controlling airway infections that produce the disease’s hallmark symptoms of cough, mucus production, shortness of breath, and pancreatic insufficiency that causes weight loss. These are downstream effects of a defective CFTR protein that has lost much of its function. Ivecaftor is the first drug to restore function to that protein. For patients who have the defective CFTR protein that responds to Ivecaftor, this drug, given as a tablet, restores normal movement of mucus out of the airway. As a result, microbes trapped in CF mucus have less time in the airway to reproduce and therefore attract fewer inflammatory cells. This decreases coughing, mucus production, and shortness of breath, and allows patients to gain and maintain much-needed weight. How was it determined that this particular CFTR protein was abnormal in some CF patients and how did we find a drug to fix it? Unraveling the mystery In the 1950s, CF patients were found to have much more sodium chloride (salt) in their sweat than unaffected people. Studying families affected by CF revealed the disease’s pattern of inheritance (autosomal recessive). Knowing how CF is inherited allowed our research to determine with precision the gene that was mutated in CF families. This, in turn, made it possible to identify the protein that this mutated CFTR gene produced. Subsequently, we confirmed that cells from the lining of CF patients’ sweat ducts, airways, or gut showed abnormal functioning of the mutated protein. Why is this protein important? Normally, it moves chloride from inside airway-, gut-, and duct-lining cells to outWe are on side the cells. However, the mutated CFTR the verge protein in CF patients does not move of slowing enough chloride. Consequently, chloride and possibly stays in the sweat, resulting in the overly salty sweat characteristic of CF. stopping the

progression of the lung disease.

More drugs will be discovered and developed for inherited diseases.

Cystic Fibrosis Center and at other institutions around the world. These tests showed that Ivecaftor decreased patients’ sweat chloride concentrations toward a normal level. Most importantly, this drug increased airflow through patients’ airways and they gained a healthy amount of weight Improved treatment today, hope for the future

What sets Ivecaftor’s discovery and development apart from the usual path of drug development is that it focused on a specific protein whose role in disease was discovered based on an understanding of genes and how they are inherited. It is the way more drugs will be discovered and developed for inherited diseases that today are poorly treatable. We are currently testing another drug that may produce similar improvement in CF patients who have a different mutation in the CFTR gene. With the help of patients with CF who participate in these clinical trials, we are on the verge of slowing and possibly stopping the progression of the lung disease that shortens the lives of most CF patients. Warren Regelmann, MD, is an associate professor of pediatric pulmonology and infectious diseases at the University of Minnesota, where he is director of the Pediatric Pulmonary Division and CF Center. The CF Center is supported by grants from the Cystic Fibrosis Foundation and is one of 13 Translational and Therapeutic Development Centers funded to carry out early-phase clinical trials of new therapies. He studies how inflammation destroys airways and what can be done about it.

From research to drug

Once the defective chloride-moving protein was identified, drugs that could theoretically make it behave more normally could be synthesized. Better yet, it was now possible to test thousands of drugs already available for treatment of other diseases for their effectiveness on cultured cells that contained the abnormal CFTR protein. This testing was accomplished by Vertex Pharmaceuticals with start-up funding from the Cystic Fibrosis Foundation. Vertex developed a rapid screening method and applied it to the already-synthesized drugs, testing them for their effect on chloride flow from inside the cell to outside it. Ivecaftor was one drug that was found to work. After preliminary safety testing, Ivecaftor’s effect was tested for safety and effectiveness in humans at the University of Minnesota JUNE 2012 MINNESOTA HEALTH CARE NEWS

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RARE DISEASES

What is Alport syndrome?

Alport syndrome Diagnosis and treatment By Clifford E. Kashtan, MD, FASN

Alport syndrome is an inherited disease of the kidney, inner ear (cochlea), and eye that affects approximately 30,000 to 60,000 people in the United States. Alport syndrome is caused by genetic mutations that result in abnormal type IV collagen proteins. Because type IV collagen proteins play important structural and functional roles in the kidney, cochlea, and eye, abnormalities in these proteins lead to kidney disease, deafness, and specific eye changes. The age when symptoms appear and the severity of those symptoms are influenced by a person’s gender and the type of mutation that the person has. The risk of passing Alport syndrome to offspring depends on the genetic type of Alport syndrome in the family. The form called “Xlinked” is most common, while autosomal recessive and autosomal dominant forms are less prevalent. Some people have type IV collagen mutations without having symptoms, but are capable of passing the mutation to offspring. Symptoms

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MINNESOTA HEALTH CARE NEWS JUNE 2012

People with Alport syndrome always have impaired kidney function; many also have deafness and abnormalities of the eyes. Kidney symptoms. The hallmark symptom of this condition is the presence of blood in the urine (hematuria). Boys with this syndrome always have hematuria, which first appears in early childhood. Girls with Alport syndrome may have this symptom always, intermittently, or never. The hematuria of Alport syndrome is usually microscopic, meaning it can only be detected with a microscope or a urine dipstick. However, children with Alport syndrome sometimes have brown, pink, or red urine for several days when they have a cold or the flu. Urine that looks like this can be frightening, but is not harmful. It is called “gross hematuria” and eventually goes away on its own. As boys with Alport syndrome get older, they begin to show additional signs of kidney disease, such as protein in the urine (proteinuria) and high blood pressure. These symptoms are often present by the time the boys are teenagers. Girls with Alport syndrome usually do not have proteinuria and high blood pressure until much later in life, although occasionally these symptoms appear in childhood or adolescence. Alport syndrome causes progressive damage to the kidneys through the gradual replacement of normal kidney structures by scar tissue, a process known as fibrosis. All boys with the form of this disease called X-linked Alport syndrome eventually develop kidney failure. There is a 50 percent likelihood that males with any form of this syndrome will need dialysis or kidney transplantation by age


25. In some families, kidney failure does not develop until the regular evaluation of the child’s hearing should begin when he or she is about 8 years of age. patient is 40 to 50 years of age. Most girls with X-linked Alport syndrome do not develop kidFuture treatment ney failure although as women with Alport syndrome age, their risk Animal models of Alport syndrome in mice and dogs are being used of kidney failure increases. Approximately 90 percent of females to study the mechanisms of kidney injury in this disease and to test who have this disease have microscopic hematuria, which can lead potential therapies. Although there is currently no proven treatment to renal failure later in life. All boys and girls with the form of this for Alport syndrome, animal studies suggest several promising disease called autosomal recessive Alport syndrome develop kidney potential treatments. failure, usually by their teens or young adult years. Potential drug treatments that may be able to delay or prevent Deafness is an important feature of Alport syndrome. About 80 the development of kidney failure exist, but need to be evaluated percent of affected boys develop deafness at some point in their lives, often by adolescence. Fortunately, hearing aids are usually very effective in boys with Alport-caused deafness. The hallmark symptom of this Girls with the disease may also develop deafness, but do so less frequently than boys and usually later in life. The condition is blood in the urine. deafness of Alport syndrome is not improved by kidney transplantation. through clinical trials. Large registries of Alport families have been Eye symptoms. About 15 percent of men with Alport syndrome established in the United States and Europe, making it possible to have an abnormality in the shape of the lens of their eye that is develop clinical trials to test these promising treatments for Alport called anterior lenticonus. This is a bulging of the lens, which may syndrome. cause problems with vision and lead to cataract formation. Some people with Alport syndrome have abnormal pigmentation of the Clifford E. Kashtan, MD, FASN, is professor of pediatrics and director of the Division of Pediatric Nephrology in the Department of Pediatrics at the retina, but this does not result in any abnormalities of vision. Diagnosis The diagnosis of Alport syndrome is based on careful evaluation of the patient’s symptoms, blood and urine tests, family history, tissue biopsies, and genetic tests. In some people with hematuria, it is difficult to determine whether they have Alport syndrome or a related condition known as Thin Basement Membrane Nephropathy because these conditions can have very similar symptoms, especially in children. In these cases, the true diagnosis may not become clear until years later. However, it is possible to diagnose Alport syndrome using genetic testing that involves sequencing certain genes, a procedure that is commercially available in the United States. Genetic testing for Alport syndrome is usually covered by health insurance, but may involve a substantial copay.

Alport syndrome causes progressive damage to the kidneys.

Current treatment

Currently, there is no treatment proven to prevent the development of kidney failure in people with Alport syndrome, so it is very important for people with this condition to schedule regular checkups with their nephrologist. This allows the effects of this disease, such as hypertension, to be identified early and treated. Many nephrologists prescribe specific antihypertensive medications that are thought to slow down the scarring process in diseased kidneys and have a low occurrence of major side effects. The best treatment when end-stage kidney failure is approaching is kidney transplantation, which has a very high success rate in these cases. Hearing should also be monitored. To determine if a child with Alport syndrome needs help detecting sounds,

University of Minnesota Medical School and Amplatz Children’s Hospital. He is executive director of the Alport Syndrome Treatments and Outcomes Registry (ASTOR), www.med.umn.edu/peds/astor/home.html.

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SURGERY

F

or an organ that has no known function, the appendix certainly keeps surgeons busy. Approximately 500,000 people in this country have their appendix removed each year for treatment of acute appendicitis, making this condition the most common acute abdominal problem treated by surgeons in the United States. Men have a lifetime risk for this condition of 8.5 percent compared with a 6.5 percent risk for women. There does not seem to be a genetic correlation for appendicitis. Causes

To understand what causes appendicitis, it helps to know that the appendix is a hollow structure attached to the first portion of the large intestine (cecum). The appendix may serve as a reservoir for bacteria normally present in a healthy gut. While the exact causes of appendicitis are not well understood, one common cause is the presence of a fecalith, or small fecal stone, that obstructs the opening between the appendix and cecum, leading to bacterial overgrowth in the appendix. Obstruction may also be caused by kinking of the cecum, parasites, or overgrowth of lymphatic tissue near the appendix’s attachment to the cecum. Younger people normally have more lymphatic tissue at this site than do older

appendix

Appendicitis Symptoms, diagnosis, and treatment By Kevin Bjork, MD

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It can be a individuals, which is felt to be the reason that the whereas a negative ultrasound usually requires furmost common age range for developing appendicitis ther imaging. The use of CT scanning in the diagchallenge to is 10 to 20, although appendicitis affects people nosis of appendicitis has become common practice. diagnose MRI is seldom used due to the time required for of all ages. appendicitis. the examination and its expense but is as sensitive The reason that obstruction of the appendix is as CT and also avoids radiation exposure. undesirable is that it increases pressure within the organ and decreases the blood supply to the wall of the appendix. Appendicitis during pregnancy Bacterial invasion or gangrene may then occur, which can lead to a Appendicitis can be difficult to diagnose during pregnancy because perforated (ruptured) appendix. Perforation, in turn, can cause either peritonitis (infection that spreads throughout the abdomen) or the mother’s enlarged uterus displaces the appendix from its usual site and because the stretching of pelvic ligaments that occurs during an abscess, which is contained by the tissues adjacent to the appenpregnancy can cause right lower abdominal pain. Further complicatdix. Twenty-five percent of patients with acute appendicitis perfoing diagnosis is the fact that normal pregnant females often have an rate within the first 24 hours after onset of symptoms and 65 percent do so within the first 48 hours. Between 10 percent and 15 per- elevated white blood cell count along with nausea, vomiting, indigestion, and bowel/bladder irregularity. cent of patients with appendicitis have a milder case of chronic or Ultrasound is generally the initial imaging study used to evalurecurring appendicitis that is symptomatic but does not proceed ate a pregnant woman for possible appendicitis because it avoids directly to perforation. radiation exposure and can examine other pelvic structures. In addiSymptoms tion to ultrasound, MRI may be used to diagnose appendicitis durSymptoms of early appendicitis are nonspecific: mid-abdominal ing pregnancy as can CT, using a modified CT protocol to decrease discomfort, nausea, indigestion, and decreased appetite. Midradiation exposure. Appendicitis and the surgery for it can lead to abdominal pain that miscarriage, which is more likely to happen if appendicitis occurs moves to the right during the first trimester of pregnancy. lower abdomen is a Appendicitis Treatment hallmark of typical affects people Recommended treatment of appendicitis is generally surgical appendicitis. By this of all ages. time, the pain is gener- removal of the appendix, or appendectomy, which has not been ally more severe, worsAppendicitis to page 19 ens with movement or jarring, and may be accompanied by fever, increased nausea with vomiting, and bowel or bladder changes. Diagnosis

Diagnosis is primarily based on patient history and physical examination. A physician will check to see if there is localized tenderness in the patient’s right lower abdomen, pain in the right lower abdomen after tapping on the patient’s left lower abdomen, and a lab test showing an elevated white blood cell count. A urinalysis to evaluate for urinary tract infection or urinary stones may be performed, as well as a pregnancy test in women of childbearing age. It can be a challenge to diagnose appendicitis because its symptoms are similar to those of many other abdominal conditions. These include diverticulitis, inflammation of the last portion of the small intestine before it enters the colon, malignancy, inflammation of the lymph nodes near the bowel, and gynecologic conditions such as ectopic pregnancy, pelvic inflammatory disease, or ovarian cysts. In addition, diagnosis can be more difficult in the very young, the elderly, women of childbearing age, patients with diabetes and/or obesity, and patients with decreased immune function, such as those receiving chemotherapy. If a diagnosis of appendicitis is not clear based on symptoms, radiologic testing may be helpful. A plain abdominal X-ray may show a fecalith or slowing of the bowel near the appendix. If more advanced imaging is needed, ultrasound has the advantage of being readily available and inexpensive and is a way to avoid radiation exposure. A positive ultrasound that shows appendicitis is helpful,

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June Calendar 6

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Circle of Parents This parent support group helps to improve parenting skills and strengthen family relationships. The weekly group meetings provide opportunities for parents to exchange ideas in safe and supportive surroundings. To learn more, call Prevent Child Abuse Minnesota at (651) 523-0099. You may also email pcamn@pcamn.org or visit www.pcamn.org. Wednesday, June 6, 9:30–10:30 a.m., Medica Skyway Senior Ctr., 950 Nicollet Mall, Ste. 290, Minneapolis "Think Outside the Box" Creative Housing Summit Searching for housing for yourself or a loved one with a disability? This free summit features an informational panel with a family- and self-advocate, county representatives, and an attorney. RSVP requested by June 4th. Please call The Arc at (952) 920-0855 for more information. Monday, June 11, 5:30–8:30 p.m., Ridgedale Library, 12601 Ridgedale Dr., RHR Rm., Minnetonka Free Varicose Vein Screening Do visible or bulging veins in your legs cause pain, swelling, or cramping? Our board-certified vascular surgeons will inspect your legs and recommend a potential course of action. Medicare/Medicaid patients are not eligible due to federal regulations. To schedule, call (952) 993-2651. Wednesday, June 13, 1–2:30 p.m., Methodist Hospital, 6500 Excelsior Blvd., Heart and Vascular Ctr. 3rd Fl., St. Louis Park Governor Dayton’s Task Force on the Prevention of School Bullying Attend this public listening session and share your experiences about school bullying. Help make Minnesota's schools safer for all youth. For more information, call (651) 582-8200 or visit www.education.state.mn.us/ Monday, June 18, 10 a.m.–noon, Minn. Dept. of Education, 1500 Highway 36 W., Roseville

Extreme heat precautions From 1979 to 2003, more people in the U.S. died from extreme heat than from hurricanes, lightning, tornadoes, floods, and earthquakes combined—despite the fact that most heat-related deaths and illnesses are preventable. Signs and symptoms of heat exhaustion include dizziness, thirst, fatigue, headache, nausea, visual disturbances, weakness, anxiety, confusion, and vomiting. Untreated heat exhaustion can progress to heatstroke, which can be fatal. Heat stroke includes an extremely high body temperature (above 103°F); red, hot, and dry skin; rapid breathing; racing heart rate; headache; nausea; confusion; and unconsciousness. While everyone is susceptible to illnesses due to extreme heat, people with preexisting medical conditions, the very young (younger than 5 years old), the elderly (older than 65), the poor and homeless, and obese individuals are especially vulnerable. The National Weather Service issues heatrelated advisories, watches, and warnings. For updates, stay tuned to your local television or radio station, visit the Internet, or look for information that may be distributed as a flyer or posted in your community. The following steps can help reduce the risk of health problems during an extreme heat event. • Use air conditioning or spend time in air-conditioned locations. • Take a cool bath or shower. • Minimize direct exposure to the sun. • Limit your time outdoors as much as possible; take frequent breaks if you must be outside. • Stay hydrated—drink water or nonalcoholic fluids. • Wear loose-fitting, light-colored clothes. • Check on your neighbors, friends, and family members—especially those who are older and/or have health issues. • Do not leave children or pets unattended in a vehicle, even with the windows rolled down, for even a few minutes. For more resources for responding to heatrelated events, visit www.health.state. mn.us/divs/climatechange/extremeheat.html

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Better Breathers Club NEW! Talking with others who understand COPD, asthma, pulmonary fibrosis, or lung cancer has a positive impact on your health. Family members, friends, and support persons are welcome. No fee. Contact Carla Knippenberg at (651) 430-4530 or email cknippenberg@lakeview.org. Wednesday, June 20, 1–3 p.m., Lakeview Hospital, 927 Churchill St. W., Stillwater

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Sleepless in Minnesota: Insomnia and Shift Work Disorder Learn helpful hints and possible courses of treatment for insomnia and common sleep disorders experienced by shift workers. To register, please call Fairview On Call at (612) 672-7272. Thursday, June 21, 6–7:30 p.m., Fairview Brooklyn Park Clinic, 10000 Zane Ave. N., Brooklyn Park

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Grandparenting: What Has Changed? Discover your new role as a grandparent and the latest changes in infant care, methods of feeding, and home, car, and toy safety. Aunts and uncles are welcome too! To register, call (320) 229-5139. Monday, June 25, 6:30–8:30 p.m., CentraCare Health Plaza, 1900 CentraCare Cir., Hughes Mathews Rm., St. Cloud

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Connections4Concussions This youth-led support group offers encouragement, support, and education to young people dealing with concussions and mild traumatic brain injuries (mTBI). Parents and caregivers are welcome also. Meetings are held the fourth Tuesday of each month. For more information, email: connections4concussions@yahoo.com Tuesday, June 26, 6–7 p.m., Penn Lake Library, 8800 Av. S., Bloomington

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 jbirgersson@ 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 JUNE 2012


Appendicitis from page 17

include increased pain, swelling, redness, warmth of the skin around the incision, and/or purulent drainage from the incision. Symptoms of an abscess in the abdomen include increased abdominal or pelvic pain, bladder symptoms, or unexplained fever. If a wound infection or abscess within the abdomen occurs, it generally happens between five and 14 days after surgery. A post-appendectomy patient who suspects the presence of any of these symptoms should contact his or her physician immediately.

shown to change digestion or bowel function or to cause any other adverse effects. Removal may be done directly through an incision over the appendix—“open” technique—or laparoscopically. The choice of open versus laparoscopic technique is generally based on the surgeon’s preference. The advantages of laparoscopy are that it is a less invasive procedure and involves smaller incisions, decreased risk of wound (incision) infection, and potentially less postoperative pain, hospital stay, and recovery time. However, there is an increased cost of the procedure itself due to the additional instrumentation required. Advantages of a laparoscopic approach are minimal for pediatric and thin patients who have typical symptoms of appendicitis. A laparoscopic approach is especially useful if the diagnosis is in question, in obese individTreatment of uals where a larger incision may be necessary, in the elderly, and in diabetics, who appendicitis is generally have an increased risk of developing a surgical removal. wound infection after surgery. Potential complications

Timing of surgery

After appendicitis is diagnosed, preparations are made for surgical removal. This generally includes pain management, hydration and addressing any significant medical issues that may complicate the anesthesia, procedure or recovery. In at least one review of 32,000 adults having appendectomy for acute appendicitis, published in 2010 in Archives of Surgery, there did not appear to be adverse outcomes related to a delay in surgery. It is generally felt to be safe for patients diagnosed with appendicitis late at night to have their appendix removed the following morning. Kevin Bjork, MD, is a board-certified general surgeon and past president of the Minnesota Surgical Society. He practices with the Stillwater Medical Group.

The two most common complications after appendectomy are infection of the incision and development of an abscess within the abdomen. Symptoms of an infected incision

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TA K E C A R E

Y

our skin is not only your largest organ, it multitasks to keep you healthy. It protects you from many bacteria, viruses, and chemicals, as well as from ultraviolet radiation, excessive fluid loss, and the bumps and kicks of daily life. It keeps you cooler in the summer and warmer in the winter. Sensation in your skin prevents you from touching that hot stove, yet comforts you when holding your loved one’s hand. The top layer of your skin, the epidermis, is quite thin and can rejuvenate itself. Injury to this layer is shallow, usually pink, and painful because nerves are exposed. Injury to it heals without a scar. A deeper injury that extends through the second layer of skin, the dermis, can expose fat tissue, muscle, or bone, and will heal with scar tissue because the dermis does not rejuvenate itself. Scar tissue is not as strong as original skin so it may be reopened by a less severe injury than it took to produce the original wound.

Types of wounds

Wound care

What you can do and when to get help By Renee Montes, RN, CWOCN, and Julie Roskamp, RN, CWOCN

Wounds are classified as either acute or chronic. Acute wounds are generally caused by trauma or surgery. They progress through a predictable, rapid process of healing that in an otherwise relatively healthy person produces a durable closure within a matter of weeks. Chronic, or nonhealing wounds, do not progress through the reparative process as expected and typically fail to produce tissue integrity within three months after injury. Most chronic wounds are associated with diabetes, constant pressure on the skin (“bedsores”), or ischemia, which refers to an insufficient oxygen supply to the tissue that can be associated with coronary heart disease and certain other conditions. Chronic wounds can also be associated with venous stasis, or blood pooling. This condition often occurs in the legs and is commonly associated with such conditions as chronic congestive heart failure, kidney disease, and varicose veins. Chronic wounds produce enormous health care expenditures, estimated to total more than $3 billion per year. It is important to notify your physician for follow-up if you think you have a chronic wound. Your doctor will determine if you need to consult a specialist such as a surgeon, vascular clinic, dermatologist, infectious disease specialist, or a wound clinic, and/or receive further skilled assessment and care from home care nurses.

Managing acute wounds At some time in your life you likely will have an acute laceration, such as a cut from a sharp object. First, apply pressure to the wound to stop the bleeding. If it doesn’t stop or slow within 10 minutes or if you are losing a large amount of blood, call 911 or go to your nearest emergency room. Do not be alarmed by a manageable amount of bleeding; bleeding and subsequent clotting initiate the natural healing process. Blood brings to the wound the cells that fight infection and build and strengthen new tissue. Once bleeding has stopped, run water or soap and water over the open wound to thoroughly clean it and the surrounding skin. Usually, no other cleanser is necessary. Do not use hydrogen peroxide, as it can damage tissue. Antiseptic ointment may be applied and used short term until the wound is covered by a scab or light pink skin and a bandage is no longer necessary. If wound edges

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MINNESOTA HEALTH CARE NEWS JUNE 2012


do not touch each other, pull them together with a butterfly bandage or sterile strip to promote faster healing. Over-the-counter liquid products are available that help wound edges stick together to promote healing. Keep the wound clean and protected from bacteria in the environment, some of which are resistant to conventional antibiotic treatment. An effective way to do this is to cover it with a clean dressing, which creates a healing environment and inhibits the growth of bacteria in the wound bed. Clean, dry gauze usually suffices, or you can ask your physician or wound specialist to help you find a dressing that’s right for you. Don’t be alarmed if you see signs of minor inflammation that last approximately three days. Signs may include redness, swelling, and a pale pink, yellow, or clear fluid that drains from the wound.

When to get help Consult your physician or get emergency care if: • the laceration is so deep that you can see fat, muscle, or bone. • you haven’t had a tetanus shot in the last five years or can’t remember the last time you had one. • the wound site feels partially or completely numb. • you have diabetes.

Do not use hydrogen peroxide, as it can damage tissue.

• there is increasing redness around the wound or you observe red streaks radiating from the wound; increased swelling, tenderness, thick pus, or a bad smell; or if the surrounding skin feels warmer than usual. These are signs of infection. • the wound isn’t healing or improving over time.

Speaking of time, you may be wondering how long it will take to heal your wound. That is the million-dollar question, because the length of time varies with each person and wound. Factors that can substantially delay wound healing are stress, both physical (such as preexisting disease) and psychological; smoking; diabetes; neuropathies; certain medications such as systemic steroids and chemotherapeutic drugs; obesity; malnutrition; infection; and increasing age.

can improve your ability to heal. And always wash your hands with soap and water before caring for your wound. Dieting while you have a wound is not recommended. You need adequate amounts of protein; carbohydrates; polyunsaturated fatty acids; vitamins A, C, and E; zinc; magnesium; copper; iron; arginine; and glutamine to develop strong tissue. Because skin is the first line of defense against infection, that defense is compromised while your wound heals. Therefore, a healthy diet is additionally important during this time in order to support your immune system. Supplemental nutrients may be necessary depending on the size of your wound and your current nutritional status, but consult a nutritionist or have your physician check your nutritional status before supplementing.

Wounds happen Wounds happen, but there is a lot you can do at home to encourage an acute injury to heal. A chronic wound, however, should be followed closely by a medical professional knowledgeable about current standards of care in wound healing. The good news is that once a chronic wound heals, there are specific self-care routines that can help prevent the wound from reoccurring. Julie Roskamp, RN, CWOCN, and Renee Montes, RN, CWOCN, are certified wound, ostomy, and continence nurses and co-owners of Twin City Wound and Ostomy Associates.

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How to heal faster Although you cannot change your age, there are steps you can take to help your body heal faster. Manage or lower your life stressors where possible. Minimize smoking. Better yet, stop smoking. Cigarette smoke contains carbon monoxide, which decreases the amount of oxygen available to your cells and constricts blood vessels that carry oxygen to the wound to help it heal. Secondhand smoke inhibits healing as much as smoking itself. Keep blood glucose levels below 180 if you’re diabetic. Consult your physician to review your medications that may hinder healing. Keep your weight within normal limits; if you are overweight, even a small weight loss

www.mppub.com JUNE 2012 MINNESOTA HEALTH CARE NEWS

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H O S P I TA L S

Health care chaplains Support during difficult times By Helen Wells O’Brien, MEd, MDiv, BCC (Board Certified Chaplain)

A diagnosis of

Cancer is overwhelming news.

It raises many questions few of us are prepared to answer, such as: • How can I take time off from work? • Can I get help paying bills? • What is the difference between a health care directive and a power of attorney? • Can I keep my health insurance even if I lose my job? • And many others. If you or a loved one is facing cancer, we are here to help.

We are a nonprofit organization funded entirely through grants and donations. Your tax-deductible donations are welcome.

We provide free cancer related legal information on a wide range of topics.

Please visit our web site to find out more: www.cancerlegalline.org

The other day, I visited the hospital room of a young patient who has had multiple surgeries. He and I have established a rapport; when he is in pain, he simply extends his hand for me to hold. Sometimes, he asks me to pray for him. But I didn’t expect the question he asked the other day. He said he had gotten a fortune cookie with the message: Courage comes through suffering. “What do you think about that?” he said. “What do YOU think about that?” I said, trusting he had his own opinion. “Well, I think it’s not always true.” We had a good talk. We named all the ways suffering can make us feel: helpless, bitter, sad, mad, bewildered, alone. I asked this wise child how he managed to keep his spirits up in the face of suffering. He replied that he is thankful for his friends and his dogs, for those to whom he feels connected, and for those who surround him when he is suffering. Help for everyone Many people have similar questions when they receive a diagnosis, live with a chronic condition, or support a gravely ill or injured loved one. That’s where a health care chaplain can help. These chaplains are ordained clergy trained to provide spiritual care to people of any religion as well as to those who profess no religion. Additional clinical training and expertise in health care issues enable health care chaplains to help people articulate the personal beliefs and values that inform their health care decisions, and to help people think through options in the process of medical decision-making. Many needs, multiple roles Chaplains may also serve as go-betweens if, for example, a patient’s religious practice and standard hospital practice seem at odds or family members disagree about what’s best for a loved one. Health care chaplains support participation of a patient’s spiritual leaders and spiritual practices that promote healing, comfort, and spiritual well-being. Health care chaplains also: • Provide comfort and care as people adjust to new realities regarding their health or their loved one’s health. • Respond to spiritual distress, helping people talk about and perhaps resolve spiritual or religious problems, thus improving health and adjustment. • Obtain holy texts for those who request them, reading from them upon request. • Provide and participate in blessings, rituals, and prayers as requested.

educate.inform.empower

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MINNESOTA HEALTH CARE NEWS JUNE 2012

Spirituality is acknowledged as an important aspect of healing.

• Care for those who are seriously ill or dying, and for their families.


Advance care planning • Provide pastoral counseling and bereavement care for those coping with loss and grief. Some clinics and many hospitals and long-term care facilities have health care chaplains on staff. Ask a staff nurse, physician, or social worker to make a referral. There is usually a chaplain on call in hospitals for emergency situations.

Honoring Choices: Health-care directive forms and other resources www.honoringchoices.org Consider the Conversation: DVD and discussion guide www.considertheconversation.org “Hard Choices for Loving People: CPR, Artificial Feeding, Comfort Care, and the Patient with a Life-Threatening Illness,” by Hank Dunn, www.hardchoices.com

Scenarios The following hypothetical scenarios illustrate some of the situations in which health care chaplains function. Fred is an 83-year-old widower with diabetes who was doing yard work when he suffered a stroke that left him with severe brain damage and an uncertain prognosis. He is unconscious and connected to mechanical ventilation by a breathing tube. The doctor recommends surgical procedures to insert both a tracheotomy tube and a feeding tube. Because Fred did not fill out a health care directive—written instructions that specify how he wants health care decisions handled if he cannot speak for himself—the decision to proceed with these procedures can only be made by Fred’s adult children. They recall their father talking about “being ready to go when the time comes,” but don’t know what to do.

There is usually a chaplain on call in hospitals.

A chaplain can listen compassionately as Fred’s children talk about their father, his hopes and dreams, and what treatments he may or may not have wanted in his current situation. Compassionate listening helps them think through options such as palliative and hospice care, provides grief care as they face the possible loss of their surviving parent, and helps them wrestle with these important decisions on their father’s behalf.

Sue and Linda’s 86-year-old mother, Alice, fell and broke her hip and subsequently developed pneumonia. When she is conscious, she is very confused. The physician recommends transferring Alice to intensive care and connecting her to a ventilator that provides mechanical ventilation. However, before her fall, Alice filled out a health care directive stating she never wants to be “dependent on a breathing machine.” Sue believes her mother would want the opportunity to recover from pneumonia via temporary ventilator assistance. Linda believes her mother wouldn’t want a breathing machine for any reason and remembers her mother saying something about pneumonia being the way people used to die naturally.

A chaplain can help Neal and Mai articulate their spiritual beliefs that inform decisions regarding what is best for their son. In addition, a chaplain can help them identify practices from their religious tradition that promote healing and hope and suggest ways to integrate those with accepted hospital practice, thus facilitating communication and understanding between parents and the surgeon. In the midst of difficult times In the midst of difficult times for patients, families, and staff, health care chaplains provide support with compassion and respect, promoting healthy environments where spirituality is acknowledged as an important aspect of healing and hope. Helen Wells O’Brien, MEd, MDiv, BCC, has served since 1998 as a staff chaplain for Regions Hospital and Gillette Children’s Specialty Healthcare and is a member of Gillette Children’s palliative care consultative team.

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A chaplain could mediate a discussion between the sisters to resolve their conflicting understanding of Alice’s wishes. Chaplains can also advocate for a care conference at which families, doctors, and palliative care providers discuss a loved-one’s condition and treatment options. At the sisters’ request, a chaplain can invite Alice’s rabbi to attend the conference for support. Neal and Mai are told by a surgeon that their son needs surgery, but are frightened of putting their son through surgical pain and risk. Plus, their spiritual tradition maintains that opening the body exposes the soul to grave danger. However, they don’t want to offend the surgeon by declining surgery.

7301 Babcock Trail East, Inver Grove Heights, MN 55077 651-457-2500 • 1-800-275-2500 www.glassingflorist.com

JUNE 2012 MINNESOTA HEALTH CARE NEWS

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

Transcranial magnetic stimulation Suzanne and Caroline are typical of patients t 45, Suzanne had suffered from anxiety suffering from treatment resistant depression, or and depression her entire life, although she TRD. Their depression is lifelong and overpowering, was not clinically diagnosed until early and they have found antidepressants completely adulthood. The married mother of two had been or partially ineffective. And over the years, they on and off antidepressant therapy for nearly lost hope of ever finding relief or truly enjoying 20 years, but recently had found her depression By Abraham their lives. so disabling that she could barely interact with Verjovsky, MD family and friends or continue her work as a dental Competing treatments’ side effects hygienist. The downsides of antidepressants are well known. Aside from their Caroline described her life as a “pernicious hell” of voices in her slow and often inconsistent efficacy, they are associated with the head, unshakable despondency, and daily thoughts of suicide. risk of many side effects: insomnia, anxiety, weight gain, fatigue, Decades of talk therapy, meditation, and antidepressant drugs had bowel complications, sexual dysfunction, and others. The primary failed to lift her black cloud of depression, and at age 50, the maralternative has been electroconvulsive therapy (ECT). ECT has been ried mother of two teenage daughters was actively fantasizing about dramatically refined over the years and is taking her own life. highly effective and safe for TRD patients, but it, too, carries the risk of side effects. It requires general anesthesia and, in many patients, causes significant confusion and memory loss. The sad fact is that many people with major depression never seek Hospital and Clinics treatment, partly because of concerns about treatment options and side effects. Over the past two years, however, Suzanne and Caroline and thousands like them have found relief from their condition through a newly available technology called transcranial magnetic stimulation (TMS). TMS was approved by the Food and Drug Offering comprehensive and integrated psychiatric Administration (FDA) in 2008 based on studies proving its efficacy services including inpatient and outpatient care. in treating depression. The American Psychiatric Association includes TMS in its treatment guidelines for major depression.

A

Breakthrough treatment for depression

TMS was approved by the FDA in 2008.

Edina E diina d Mapl p e Grove Grove v Maple W oo o odbury Woodbury Free F ree Needs Ne eds Assessments Assessments 888-9-Prairie 8 88-9-Prairie prairie-care.com prairie-care.com A University University Of Minnesota Minne esota Medical School Affiliate Affi filiate

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MINNESOTA HEALTH CARE NEWS JUNE 2012

How it works

TMS is an outpatient, noninvasive procedure that requires no anesthesia. It uses highly focused magnetic pulses to directly stimulate neurons (a type of cell) in the part of the brain that controls mood. The pulses are delivered by a coil positioned on the scalp, and the pulses pass through the skull and penetrate 2 to 3 centimeters into the targeted area. The pulses cause the patient’s neurons to restore the normal release of neurotransmitters such as serotonin, which relays signals to the brain that regulate how a person feels. During this procedure, the patient experiences a tapping sensation on the skull that has been described as sounding like a woodpecker. This sensation can be irritating until the patient becomes accustomed to it, but is rarely painful. A typical course of TMS treatment requires a total of 20 to 30 daily sessions. The patient has


one session each day of the workweek, for four to six weeks. Each treatment lasts 37 minutes.

insurance companies have covered at least part of the cost after a lengthy cycle of appeals, denial letters, and more appeals. As a result, doctors have been slow to make the initial investment in the equipment. But as TMS technology advances and insurers and physicians become more familiar with this procedure, I expect it to become a major influence on depression treatment in the future.

Precautions

There are some precautions in the use of this treatment. Patients with implanted metal devices in or around the head should not be treated, but dental implants are not generally a problem. TMS should be used with caution in patients with implanted pacemakers or cardioverter/defibrillators (ICDs).

Here, a treatment coil is shown positioned for NeuroStar TMS therapy. Courtesy Neuronetics, Inc., Malvern, Pa.

Results

The impact on the patient is often immediately evident. Some describe it as a “light switch” clicking on. Two days before beginning TMS therapy, Caroline wrote in her journal that she was vividly imagining “a glass or two of wine, a very sharp razor, and lots of blood.” After her first two TMS treatments, her journal entry began, “Feel great!!!! … HAVE ENERGY!” Research on TMS has shown that one in two patients experience significant improvement in their symptoms, and one in three achieve remission. In my own clinical experience, there has been dramatic improvement in 85 percent to 90 percent of my patients. Anecdotal reports from TMS providers around the United States indicate a similar success rate. TMS is proving itself a valuable breakthrough for patients whose lives are being impacted, or even endangered, by intractable depression. A patient typically is referred by a primary care physician or psychiatrist to a TMS-provider for treatment with this procedure. After completing a course of treatment, the patient returns to the referring physician, ideally in far better shape to handle whatever other medical challenges lie ahead. Use during pregnancy

TMS is also a resource for pregnant patients with depression. Women of reproductive age make up a significant percentage of patients with depression, outnumbering men almost two to one, and the hormonal changes of pregnancy can significantly exacerbate depression symptoms. But because late-term antidepressant use increases the risk of birth defects, women must often stop taking their antidepressants just when they need them the most. TMS, however, is safe for both mother and fetus.

Major influence

It has already had a major influence on my patients. The voices tormenting Caroline faded after a few treatments and have not returned. Her occasional depressive episodes are milder and of much shorter duration. She is medication-free and no longer has thoughts of suicide. “TMS pulled me from the abyss,” she wrote recently, “and I believe the change is permanent.” Suzanne believes, quite simply, that TMS saved her life. She continues daily antidepressant medication, but is dramatically more functional—and happy. “I have never felt better in my life,” she writes. Abraham Verjovsky, MD, is board-certified by the American Board of Psychiatry and Neurology, has been in private practice for over 20 years, and currently sees patients in his Edina office.

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“TMS pulled me from the abyss.”

Insurance

Caroline and Suzanne learned about TMS online, but the word isn’t truly out yet, with fewer than 400 physicians nationwide regularly using this therapeutic procedure. The barrier to faster and more widespread adoption of the technology is cost. Health insurance doesn’t cover TMS, so most patients must spend $8,000 or more out-of-pocket for a full course of treatment. Some

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PA L L I AT I V E C A R E Mandala by Richard Bonk at the Penny George Institute for Health and Healing at Unity Hospital. Cancer patients in art classes at Penny George Institute make mandalas called Power Shields.

Art

The healing power of A necessary part of medicine By Megan Hatch

A

s an oncologist, David King, MD, talks with many cancer patients in his office at the Virginia Piper Cancer Institute on the Unity Hospital campus in Minneapolis. The conversations typically start with treatment protocols and what patients can expect. But the conversation often takes another turn when patients ask about the impressive artwork hanging on the wall. The abstract acrylic painting, which covers the entire wall above the doctor’s desk, looks like it could be a sea or a forest. King explains that it’s called “Reflections on

Consider TMS for your depression Transcranial Magnetic Stimulation (TMS) is a safe, painless treatment for depression and associated mood disorders without the use of medications. Dr. Craig Vine is now offering TMS treatment at Psych Recovery for treatment for depression. He received his board certification from the American Board of Psychiatry and Neurology. For more information on TMS, call our office or visit our website.

Psych Recovery, Inc.

2550 University Ave W, Ste 229N St. Paul, MN 55114

651-645-3115 TMS: 651-294-3410 www.psychrecoveryinc.com

26

MINNESOTA HEALTH CARE NEWS JUNE 2012

Gunflint Lake” and that he bought it at the annual Art-A-Whirl that’s held each spring in northeast Minneapolis. Coincidentally, the artist, Peggy Thompson, is also a chaplain at Unity Hospital. Focusing on the painting might seem like a nice diversion from the difficult talk about cancer treatment. In fact, it’s not an accident, but rather the result of a purposeful program at Allina Hospitals & Clinics to infuse the power of art—both visual art and music—in the healing process. King observes that the arts often help optimize a patient’s condition to better tolerate the many side effects of chemotherapy and radiation. “The placebo effect is an example of how the mind can be a powerful force in the healing process. Healing does not just happen on a physical level and the arts help engage patients in the healing process on a psychological, emotional, and mental level,” he says. Allina is part of a national trend in health care facilities to implement arts programs as a core strategy to alleviate pain and to improve care and patient satisfaction. About 50 percent of hospitals in the United States have arts programs, according to the Center for Health Design, based in Concord, Calif. Allina developed a healing arts policy two years ago for its 11 hospitals and nearly 100 clinics. Allina’s healing arts program is modeled on an initiative begun seven years ago at the Penny George Institute for Health and Healing, which is based at Abbott Northwestern Hospital in Minneapolis. The vision was to use patient and public areas at the Penny George Institute as exhibit spaces for local artists. New exhibits of original art are installed monthly, with related interactive arts programming open to patients, staff, and community members. Choy Leow, director of Allina design and construction, developed a healing arts policy that embraces nature as a primary subject and emphasizes regional artists. The exhibits are part of what has grown to be the largest hospital-based integrative medicine program in the nation. Unlike alternative medicine, which is used in place of conventional medicine, the Penny George Institute’s integrative services are offered in conjunction with traditional Western medicine for both inpatient and outpatient care. Pain relief

Last year, Allina published the first study showing that nontraditional therapies relieve pain among a broad cross-section of hospitalized patients by as much as 50 percent. Results of the study were published in the March 5, 2010 issue of the Journal of Patient Safety. The study included 1837 cardiovascular, medical, surgical, orthopedics, spine, rehabilitation, oncology, and women’s health


Using murals as a therapeutic distraction

patients at Abbott Northwestern. The treatments resulted in a significant decrease in pain included nonpharmaceutical services: music and intensity, pain quality, and anxiety. art therapy, and mind-body therapies designed to elicit the relaxation response, including acupuncture, massage therapy, and healing touch. The study aspects of the hospital. expands on earlier studies that focused on the effectiveness of inteThose surveyed reported that inside patient rooms, interior grative therapies in managing pain in cancer or surgical patients. design—including visual art—was the most satisfying feature. “Western medicine is highly skilled at treating illness and disOutside patient rooms, hospital interior design—again, including ease with procedures,” says Lori Knutson, RN, BSN, HN-BC, execvisual art—was second only to maintenance as an environmental utive director of the Penny George Institute. “Effective health care source of patient satisfaction. acknowledges the difference between curing and healing and the Researchers noted that when former patients were talking therapeutic properties of the creative process.” about their hospital rooms, they often commented on the artwork. Positive distraction and symptom management Historically, environmental design in health care has focused on trying to minimize negative factors in the environment such as noise, light, and the risk of infection. In the past few decades, however, the focus has changed to how hospitals can create and reinforce positive experiences. Designers have recognized that environmental factors can also provide a positive distraction, allowing patients to shift attention away from negative factors in the health care environment and toward more restorative aspects from the nonmedical world. A 2006 review of scientific literature published in the Journal of Perinatology examined the role of positive distraction as a means of mitigating stress for patients and caregivers in neonatal intensive care units. The review found that the environmental variables that are most commonly known to contribute to positive distraction are visual art, access to nature, and music. Results of a study published in the March 2003 issue of the medical journal Chest showed that adult patients in a procedure room reported better pain control when they were exposed to a nature scene and heard nature sounds broadcast from the ceiling. Using murals as a therapeutic distraction resulted in a significant decrease in pain intensity, pain quality, and anxiety reported The arts by burn patients in a 1992 study published help engage in the Journal of Burn Care & Rehabilipatients in tation. Breast cancer patients reported the healing reduced anxiety, fatigue, and distress during chemotherapy when they were exposed to process on a psychological, virtual reality intervention displaying underwater scenes, in a 2003 study published in emotional, CyberPsychology and Behavior Journal.

and mental level.

Patient and staff satisfaction

Healing arts programs in health care are also gaining favor as a way to improve patient satisfaction. The Centers for Medicare & Medicaid Services, headquartered in Baltimore, has published patient satisfaction scores since 2008. In 2012, Medicare will up the ante by basing reimbursement in part on patient satisfaction scores. In addition to improving patient outcomes, research has also shown that art can increase patient satisfaction. A 2002 study of six different hospitals owned by Intermountain Health Care in Utah sought to determine the extent to which environmental sources played a role in overall patient satisfaction. The nearly 400 patients interviewed by telephone shortly after hospital discharge were asked questions about their level of satisfaction with six environmental

While patients and the public are the primary reasons many hospitals have arts programs, 55 percent of the programs surveyed by the Center for Health Design also focus on using the arts to reduce stress and burnout among staff members, a significant problem in health care. The visual arts can facilitate cultural competence as well: Artwork from different cultures can sensitize providers, contribute to an inclusive environment, and serve as a form of crosscultural communication. As the role of visual art in health care evolves from art as decoration to art as a core component of healing environments, growing research is expected to firmly establish evidence-based design and provide a scientific basis for visual art as a necessary part of medicine. Megan Hatch is clinic manager and arts program coordinator at Allina’s Penny George Institute of Health and Healing at Abbott Northwestern Hospital, Minneapolis.

Living with gout? Keep enjoying life’s simple pleasures.

Gout is the most common form of inflammatory arthritis in men and affects millions of Americans. In people with gout, uric acid levels build up in the blood and can lead to an attack, which some have described as feeling like a severe burn. Once you have had one attack, you may be at risk for another. Learn more about managing this chronic illness at www.goutliving.org

JUNE 2012 MINNESOTA HEALTH CARE NEWS

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MEN’S HEALTH

Benign prostatic enlargement

T

he prostate is a small gland that is located just below a man’s bladder and surrounds the urethra, the tube that carries urine away from the bladder. Benign prostatic enlargement (BPE) is a noncancerous growth of this gland that affects 25 percent of men by age 55 and 80 percent of men by age 80. Historically, 30 percent of men will require a surgical procedure for treatment of BPE during their lifetime. Factors that increase the risk of BPE include aging, obesity, diabetes, and the presence of elevated prostate specific antigen (PSA) in the blood.

Symptoms

Do you have it? What to do next By William M. Kaylor, MD

Because an enlarged prostate gland presses against the urethra, the first symptoms of BPE involve changes in the flow of urine. These include a weak stream, difficulty starting the stream, and a stream that stops and starts repeatedly. As the prostate enlarges further, urination may become more frequent during the day and at night. Severe symptoms of BPE may include a sudden urge to urinate that can be followed by involuntary leakage of urine, called urinary incontinence. This leakage is the result of a bladder that doesn’t empty well or thick-

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:

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MINNESOTA HEALTH CARE NEWS JUNE 2012

©2007 National Down Syndrome Congress


ened bladder muscle that spasms. Late complications of BPE include urinary tract infections, kidney failure, and bladder stones, which form in the bladder as a result of poor emptying. Diagnosis

An evaluation for BPE usually starts with the patient’s primary care physician, who takes a thorough medical history and performs a complete physical exam that includes a digital rectal exam of the prostate. Patients will usually be asked to provide a urine sample for urinalysis and a blood sample will be drawn to check the level of PSA, a protein produced by the prostate gland. Common causes of elevated PSA include BPE, prostate inflammation, and prostate cancer. The primary care physician refers a patient to a urologist if any tests are abnormal or if symptoms do not improve with treatment. In the urologist’s office, a patient will be asked to complete a questionnaire called the American Urological Association Symptom Score. This questionnaire asks the patient to score the severity of seven urinary symptoms on a scale of one to five to determine whether symptoms are mild, moderate, or severe. Then, a bladder ultrasound is performed to determine how well the patient empties his bladder. This identifies the occasional patient who underestimates his symptoms and retains a significant amount of urine in the bladder after urinating, a situation called urinary retention. The urologist usually repeats the digital rectal exam and recommends a PSA if it has not been checked during the preceding six to 12 months. PSA can be falsely elevated if performed immediately after the digital rectal exam, within 48 hours after ejaculation, and occasionally, after bicycle riding. Although the U.S. Preventive Services Task Force recently issued a statement recommending against using the PSA test for prostate cancer screening, urologists believe PSA is a critically important test in evaluating urinary symptoms and distinguishing between benign and malignant prostate obstruction. Further testing may be indicated for men with neurologic disease, diabetes, urinary retention, or urinary incontinence. These patients often require urodynamic tests that measure the bladder’s capacity to hold and expel urine and can distinguish between weak bladder muscle and prostate obstruction. These tests are done in the office and take about 20 minutes to perform. Finally, the urologist may examine the urethra, prostate, and bladder using a flexible telescope. This procedure, called cystoscopy, is performed in the doctor’s office under local anesthesia and lasts less than a minute.

diminished DHT, the prostate shrinks in size and patients experience symptom relief within six to 12 months. Alpha blockers and phosphodiesterase inhibitors can be used alone or in combination with each other. Jalyn is a relatively new medication that combines the alpha-blocker Tamsulosin with the phosphodiesterase inhibitor Avodart. All BPE medications must be taken daily and continued long term to be effective. Side effects

Thirty percent of Alpha-blockers can cause dizziness, stuffy men will require nose, runny nose, and a surgical procedure. problems with ejaculation. They can also affect the eyes and may complicate otherwise standard cataract surgery. Men must inform their eye specialist when taking alpha-blockers. Phosphodiesterase inhibitors can cause decreased libido in 5 percent of men and breast enlargement or sensitivity in 1 percent. Two major U.S. studies published in 2003 and 2010 showed that Finasteride and Avodart reduce the incidence of the more common, less aggressive form of prostate cancer by 25 percent but increase the incidence of the more aggressive form of prostate cancer from 0.5 percent to 1 percent. However, most urologists do not feel a true risk exists. Instead, they believe the increased number of aggresBenign prostatic enlargement to page 30

Treatment

Men who have mild BPE symptoms, empty their bladders well, and have minimal enlargement of the prostate gland as assessed by a digital rectal exam, should see their urologist yearly unless symptoms change. Moderate and severe BPE symptoms require medication, thermotherapy, or surgery. Medication

Medicines used to treat BPE include a class of drugs called alphablockers (examples are Terazosin, Tamsulosin, Uroxatrol, and Rapaflo) and another class called phosphodiesterase inhibitors (Finasteride and Avodart). Alpha-blockers relax prostate muscles, improve urinary flow, reduce urinary frequency, and are effective within days of starting treatment. Phosphodiesterase inhibitors block the production of a chemical in the prostate called dihydrotestosterone (DHT). With JUNE 2012 MINNESOTA HEALTH CARE NEWS

29


Benign prostatic enlargement from page 29

sive prostate cancers is due to a difference in detection. In other words, aggressive cancers that may go undetected in untreated prostate glands are more easily detected in glands that have been reduced in size by Finasteride or Avodart. Thermotherapy

Men whose symptoms do not improve with medication, who have side effects from it, or who do not wish to take medication the rest of their lives, are excellent candidates for procedures that selectively destroy excess prostate tissue using heat. One procedure is transurethral microwave thermotherapy (TUMT), which uses microwave energy to heat and destroy prostate tissue. The other, formerly called transurethral needle ablation of the prostate, is now known as Prostiva RF. Prostiva RF delivers lowlevel radio frequency energy directly into the prostate to destroy excess tissue. Both procedures are performed in the doctor’s office using local anesthesia and mild sedation. Each takes less than one hour to complete, causes minimal bleeding, and has less than a 1 percent risk of causing urinary incontinence and erection problems. TUMT and Prostiva RF have been proven effective in patients with severe BPE symptoms, large prostate size, and significant urinary retention. Surgery

Procedures performed in a hospital include transurethral vaporization of the prostate (TUVP), transurethral incision of the prostate (TUIP), transurethral resection of the prostate (TURP),

and open prostatectomy. The patient’s surgeon selects a given procedure based on such factors as the size and configuration of the patient’s prostate gland. TUVP currently requires general or spinal anesthetic, may require overnight hospitalization, and uses a laser or a bipolar electrode to destroy excess prostate tissue. TUVP offers excellent results and less bleeding compared with TURP and open prostatectomy. TUIP makes one or two small cuts in the prostate gland to improve urine flow and correct other BPE-related symptoms. Compared with other surgical procedures, TUIP is simpler to do and has fewer complications. TURP removes excess prostate tissue and has been considered the gold standard of care for relieving BPE-related obstruction. However, thermotherapy and laser vaporization have become more popular alternatives because they pose fewer risks. Open prostatectomy removes excess prostate tissue, requires an abdominal incision, a longer hospitalization, and is generally reserved for men who have extremely large prostates or have BPE and a large bladder stone. Nonsurgical, nonpharmaceutical management

For the patient who has severe health problems and whose enlarged prostate gland significantly obstructs his bladder, surgery may not be the best option. Such patients can be managed with techniques to empty the bladder such as intermittent catheterization, permanent catheters, or urethral stents. William M. Kaylor, MD, has been practicing urology in Minneapolis for 23 years and is a partner with Urologic Physicians, P.A.

Minnesota

Health Care Consumer May survey results ... Association

30

24.3%

20 10

5.4% Strongly agree

Agree

No opinion

8.1% 2.7% Disagree

Strongly disagree

MINNESOTA HEALTH CARE NEWS JUNE 2012

Percentage of total responses

25 18.9%

20 15

10.8%

10.8% 10

40 30

0

0

Strongly agree

Agree

Does not apply

Disagree

Strongly disagree

24.3%

20 10

10.8%

Strongly agree

Agree

No opinion

8.1% Disagree

51.4%

64.9%

50 40 27.0%

30 20 10

5.4% 0.0% Strongly agree

Agree

No opinion

Disagree

50 40 32.4% 30 20 13.5% 10

2.7% Strongly disagree

5.4% Strongly disagree

5. I feel there should be more consumer protection around the issue of collections for health care costs. 60

60

0

50

5

Percentage of total responses

30

51.4% 27.0%

80 Percentage of total responses

Percentage of total responses

40

60

32.4%

4. Collection activity that provides an outside party access to any portion of my medical history is a violation of my patient privacy rights.

70

50

0

35 30

Percentage of total responses

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 May survey.

3. I feel it compromises my relationship with my doctor when payment issues come before diagnosis and treatment issues. 59.5% 60

2. Demanding payment for health care services before they are provided should not be allowed.

1. I feel I have been unfairly pressured to make payments for health care-related services.

0

0.0% Strongly agree

Agree

No opinion

Disagree

2.7% 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

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“A way for you to make a difference� JUNE 2012 MINNESOTA HEALTH CARE NEWS

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PUBLIC HEALTH

Minnesota Board of Nursing The Board of Nursing’s mission is to protect the public’s health and safety by providing reasonable assurance that the persons who practice nursing are competent, ethical practitioners with the necessary knowledge and skills appropriate to their title and role. History The state Legislature established the Board of Nursing in 1907 to protect the public’s health and welfare by overseeing and ensuring the safe practice of nursing in Minnesota. This is a significant responsibility. The board comprises 16 members appointed by the governor: eight registered nurses, four practical nurses, and four public members, each serving a four-year term. Today, there are over 112,000 licensed nurses in Minnesota. The board holds nurses accountable for conduct based on legal, ethical, and professional standards. It achieves its mandate of public protection by promoting these standards and issuing licenses to qualified individuals to practice nursing. Once a license is issued, the board’s

responsibility continues by monitoring licensees’ compliance with state laws and taking action against the licenses of nurses who exhibit unsafe nursing practice and present a risk of harm to the public. Services The Board of Nursing regulates nursing practice through the following service areas. • Credentialing: licenses registered nurses, licensed practical nurses, advanced practice registered nurses, and public health nurses.

Protecting the public By Shirley A. Brekken, RN, MS

• Education: ensures nursing schools prepare a sufficient nursing workforce to practice nursing safely and competently.

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MINNESOTA HEALTH CARE NEWS JUNE 2012


• Discipline/complaint resolution: investigates complaints and takes action against nurses, including removing nurses from practice who present a risk to patient safety.

Disciplinary action

Whether or not there is sufficient evidence impacts the board’s ability to act. If it does take action, the board often requires remedial education and monitoring of the • Nursing practice standards: interprets laws and nurse’s practice by way of an agreement between the nurse rules related to nursing practice and establishes and the board, called a Stipulation and Consent Order. nursing performance guidelines so that employTerms of an order may include requiring the nurse to take ers and consumers can make informed decisions a continuing education course or meet with a nurse regarding the performance of nursing services. who is an expert in the area of nursing practice of concern, periodic performance reports from a super• Data: verifies the license of a nurse for employThere are vising registered nurse, and/or reports from a treating ers and consumers and over 112,000 professional. The nurse may continue to practice provides nurse informaunder this conditional or limited license as long as the tion for purposes of emerlicensed nurses nurse is compliant with the order. gency preparedness, a in Minnesota. In some particularly egregious cases, when the pending nurse shortage, risk of harm to the public is high, the board and workforce planning. takes immediate action before providing Submitting a complaint the nurse with a hearing. For example, While the vast majority of the board received a report alleging a nurses are safe, ethical, caring Minnesota nurse had communicated with practitioners, there are several individuals via Internet chat rooms instances in which a nurse does and encouraged them to commit suicide. not meet the expected standard of care or violates the law. The board issued an Order of Temporary The board requests that complaints be submitted in writing and Suspension. Subsequently, a hearing was conducted and the nurse’s acknowledges receipt of complaints by letter, with the complainant’s license was revoked. identity kept confidential. Each complaint is reviewed to determine Another example of rapid action by the board involved a nurse if it is jurisdictional to the board. That means that the board first who was authorized to practice nursing in Minnesota based on decides whether or not the allegations, if proven true, could Minnesota Board of Nursing to page 34 provide grounds for disciplinary action as provided in the Nurse Practice Act. Investigating a complaint Once a complaint is determined to be jurisdictional, board staff may gather additional information from the complainant or obtain written records, such as employment records, medical records, and court records. Sometimes, a field investigation is conducted by an investigator from the Minnesota Attorney General’s office. The board often requests a written response to allegations from the nurse in question. Following an investigation, the board may determine that no action is warranted and the complaint may be dismissed. If action is warranted, the complaint proceeds through the disciplinary process and may result in removal of the nurse’s authority to practice or in other disciplinary action. During this investigative and decisionmaking period, nurses who have complaints against them are provided with all due processes according to Minnesota law. In 2011, the board dealt with more than 2,400 complaints. Many complaints come from employers, other nurses, or, in smaller numbers from patients or family members. They usually fall into the categories of substandard nursing care, chemical dependency and diversion of medications, and other types of unprofessional and unethical conduct. Examples of substandard care include failure to adhere to infection control procedures, inaccurate or insufficient documentation, or not performing a treatment correctly. Suspected diversion of medications may be raised if a patient does not get adequate pain relief. A nurse who records a procedure he or she did not perform may be disciplined for unethical conduct.

In the next issue..

• Drug shortages • Childhood wellness • Rehabilitation after knee replacement JUNE 2012 MINNESOTA HEALTH CARE NEWS

33


Minnesota Board of Nursing from page 33

licensure in Wisconsin and previous employment at a Minnesota facility (hospital A). The board learned the nurse had been arrested after attempting to siphon morphine from the intravenous pump of a hospital patient at a different Minnesota facility (hospital B). The nurse was not employed by hospital B but dressed and acted in a manner to appear to be an employee. Within four days of being notified, the board issued a Cease and Desist order that prevented the nurse from practicing nursing at any facility in Minnesota. Subsequently, the board was informed the nurse had been terminated by hospital A due to allegations of diversion of controlled substances. The board reported the incident to the Wisconsin Board of Nursing for possible action against the nurse’s license in that state. In a third case, a hospital alleged to the board that a The vast majority nurse diverted a controlled substance from intravenous of nurses are safe, medication bags of hospital ethical, caring patients. The report alleged that the nurse substituted practitioners. saline (a saltwater solution) for the controlled substances, contaminating the bags in the process. This resulted in patients receiving diluted medication and becoming infected. In addition to reporting the matter to the board, the hospital contacted the Minnesota Department of Health for assistance in investigating the infectious disease outbreak, as well as law enforce-

ment once diversion became suspected. Recognizing the likelihood of a protracted criminal investigation and prosecution, the board contacted the nurse to offer a Stipulation to Cease Practicing Nursing. This stipulation is a public agreement between the nurse and the board whereby the nurse agrees to refrain from practice for the duration of the agreement, and the board agrees to suspend disciplinary proceedings pending the outcome of the criminal matter. Such agreements protect the public by removing a nurse’s ability to practice until the merits of an allegation can be determined. Complain effectively The Board of Nursing takes its role of protecting the public seriously. If anyone has questions regarding the practice and education of nurses or if there is reason to believe a nurse has violated the law, contact: Minnesota Board of Nursing 2829 University Ave. SE, Suite 200 Minneapolis MN 55414 www.nursingboard.state.mn.us (612) 617-2277 Shirley A. Brekken, RN, MS, has served as executive director of the Minnesota Board of Nursing since her appointment in 1999.

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

Appointments:

Online or Call 651-439-8807

Providing P roviding care care aatt mul multiple tiple moder modern n clinics in M Minnesota innesota and W Wisconsin isconsin

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MINNESOTA HEALTH CARE NEWS JUNE 2012


• 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 June 2012  

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