Minnesota Health care News April 2013

April 2013 • Volume 11 Number 4

Bladder cancerGregory Hanson, MD

Donated bloodJeffrey McCullough, MD

Children’seyesightJill Schultz, OD

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Minnesota Health Care News is published once a month by Minnesota Physician Publishing, Inc. Ouraddress is 2812 East 26th Street, Minneapolis, MN 55406; phone (612) 728-8600; fax (612) 728-8601;email [email protected]. 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 donot necessarily represent or express the views of Minnesota Physician Publishing, Inc., or thispublication. The contents herein are believed accurate but are not intended to replace med-ical, legal, tax, business, or other professional advice and counsel. No part of this publica-tion may be reprinted or reproduced without written permission of the publisher. Annualsubscriptions (12 copies) are $36.00. Individual copies are $4.00.

APRIL 2013 MINNESOTA HEALTH CARE NEWS 3

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PUBLISHER Mike Starnes [email protected]

EDITOR Donna Ahrens [email protected]

ASSOCIATE EDITOR Janet Cass [email protected]

ASSISTANT EDITOR Scott Wooldridge [email protected]

ART DIRECTOR Elaine Sarkela [email protected]

OFFICE ADMINISTRATOR MaryAnn Macedo [email protected]

ACCOUNT EXECUTIVE Iain Kane [email protected]

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APRIL 2013 • Volume 11 Number 4

HEMATOLOGYDonated bloodBy Jeffrey McCullough, MD

CALENDARDistracted Driving Awareness Month

OPHTHALMOLOGYChildren’s eyesightBy Jill Schultz, OD, FAAO,FCOVD

PUBLIC HEALTHFish consumption guidelinesBy Deborah Durkin, MPH

COMMUNITY CAREGIVERSBy Scott Wooldridge

7 PEOPLE

NEWS4C O N T E N T S

820

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PERSPECTIVE

10 QUESTIONS

POLICY“I know I need to improvemy health—but how?”By Naomi Hertsgaard, MPH, andWilliam Nersesian, MD, MHA

UROLOGYBladder cancerBy Gregory Hanson, MD, FACS,and Basir Tareen, MD, FACS

Glenn Nemec, MD

Monticello Clinic

VicLiengswangwong,MD

MinnesotaOncology

Exp. Date

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

Please mail, call in or fax your registration by 04/18/2013

MINNESOTA HEALTH CARE ROUNDTABLE MINNESOTA HEALTH CARE ROUNDTABLE

Background and focus:The next step in health carereform involves the patientbecoming more activelyengaged with stayinghealthy. New physician reim-bursement models rewardimproved population healthbut bring new dynamics intothe exam room. Incorpor-ating patient attitude andlifestyle choices into healthcare delivery is necessary, but how should it be done?Creating conceptual andempirical clarity around thisquestion may be best ad-dressed by the term PatientActivation Measure (PAM).

Objectives: We will examinethe development of PAM,what it means and how it

works. We will explore patient engagement methods that have beensuccessful and the role of health insurance companies and employ-ers in this process. We will explore how PAM may be used across thecontinuum of care and whose job it will be to implement and trackthese measures. We will discuss the challenges that are inherentwithin the concept of PAM and how it may realize its best potential.

Panelists include:

� Vivi-Ann Fischer, DC, Chief Clinical Officer, Chiropractic Care of Minnesota, Inc.

� Laura Gandrud, MD, Children's Hospitals and Clinics of MN,Diabetes and Endocrinology

� Peter Mills, MD, CEO, nGage Health

� William Nersesian, MD, MHA, Chief Medical Officer, Fairview Physician Associates

� Pam Van Zyl York, MPH, PhD, RD, LN, MDH Health Promotion and Chronic Disease Division

Sponsors: ChiroCare • nGage Health

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

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Patient engagement

Creating measures that work

$3.6 Billion Spent On Community Care,Report FindsThe Minnesota Hospital Associ-ation (MHA) reports that its mem-bers spent more than $3.6 billionon programs that benefit theircommunities, including treatmentfor patients unable to pay for care.

According to the CommunityBenefit Report, spending for com-munity services was up 7 percentover the amount spent in 2010.The report looks at spending thatcovers shortfalls in governmentreimbursement; uncompensatedcare for patients; and spending foreducation, public health, andother community programs.

Uncompensated care contin-ues to be a driver of communityspending for hospitals. Charitycare (defined as cases wherepatients cannot pay for services)and bad debt (defined as patientswho don’t pay their share of ahospital bill that’s partially paid byinsurance), totaled $509.5 millionin 2011, MHA says. This is an

increase of 2.6 percent over 2010.Ongoing reforms at both the

state and federal level could helphospitals with uncompensatedcare, officials with MHA say. “Asnonprofits, hospitals and healthsystems provide access to care topatients—regardless of their abil -ity to pay—24 hours a day, sevendays a week,” says LawrenceMassa, MHA president and CEO.“That’s why Minnesota hospitalssupport the expansion ofMedicaid to provide insurancecoverage to more Minnesotansand the creation of a Minnesota-based insurance exchange toinsure more Minnesotans.”

However, government payersare also part of the communitycost equation, the report says. In2011, there was nearly a 26 per-cent increase in the differencebetween actual costs of providingcare and what hospitals were paidby the government for Medicaidservices. “State and federal gov-ernment payments to Minnesotahospitals and health systems forMedicaid and Medicare patients

were nearly $1.5 billion below theactual costs of providing the care,”the report says.

In addition, the report findshospitals in Minnesota spent $1.3billion in 2011 on public healthservices, education, and health-care workforce development;research to develop new and better treatments and find curesfor disease; community buildingactivities; and donations to otherlocal nonprofits.

Transitional CareFacilities PlannedAllina Health System is partneringwith two long-term care providersto create a new model of transi-tional care that allows patients tomove from hospital care to arehabilitative care setting beforemoving back home.

Minneapolis-based Allina isworking on the new model withDuluth-based Benedictine HealthSystem (BHS) and PresbyterianHomes & Services (PHS), basedin Roseville. Officials say two ini-

tial projects are in the works: atransitional care center on thecampus of Unity Hospital inFridley, to be managed by BHS;and a similar center at Allina’sWestHealth facility in Plymouth,to be managed by PHS.

The new model will seek toprovide advanced rehabilitationand recovery services at locationsthat feature comfortable, spa-likesettings. In addition to easing theprocess of moving from a hospitalsetting back home, officials saythe approach will reduce theamount of rehospitalization forpatients.

“As health care reform movesforward, our communities willneed new approaches to ensuringthat after people leave the hospi-tal they receive the care they needto make a successful transitionback home and don’t end up backin the hospital,” says KennethPaulus, president and chief execu-tive officer of Allina Health. “Bybringing together the acute careand rehabilitation expertise of ourthree organizations, we will be

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able to forge new paths that easethe transition from hospital tohome.”

The organizations have along-term goal of making brandedcenters available on a franchisebasis. Officials say the collabora-tion of organizations that provideskilled nursing facilities and long-term care with the clinical expert-ise of an organization such asAllina will allow for integrated,seamless care.

Allina officials estimate theWestHealth facility will cost $17million; the Unity facility is pro-jected to cost $15 million.

Lawmakers PassMedicaid ExpansionA measure that would expand thestate’s Medicaid program wasapproved by the state Legislatureand signed by Gov. Mark Daytonin February.

The bill, HF 9/SF 5, officiallyadopts a Medicaid expansion forMinnesota under the AffordableCare Act (ACA). It will also changehow eligibility for the program iscalculated from Minnesotans’income.

The expansion will movethousands of impoverishedMinnesotans from primarily state-based programs to Medicaid cov-erage, which is run jointly by thestate and federal government.Under the new ACA rules, the fed-eral government will pick up 100percent of coverage costs forchildless adults earning less than$15,414 annually for the first fewyears after expansion officiallybegins Jan. 1, 2014. After thatdate, the federal government willfund 90 percent of those costs.

Rep. Thomas Huntley (DFL-Duluth), chair of the House Healthand Human Services Finance committee, says the bill willincrease the number of insuredMinnesotans by approximately35,000. “It will result in a surplusin the Minnesota budget becausethe feds are picking up a lot ofpeople that we already pay [for],”says Huntley. “In addition to that,it brings in about $1.7 billion ofextra federal money into the statethat will all go to health care

providers and hospitals and thosesorts of things. It’s a huge eco-nomic impact and it saves thestate money and it increases thenumber of insured in the state.”

Gov. Mark Dayton alreadysigned the state up for an earlyversion of Medicaid expansion.Dayton and DFL leaders havebeen pushing to complete the lat-est bill under ACA deadlines. TheMinnesota Department of HumanServices estimates that the combi-nation of early and full expansionof Medicaid eligibility will save thestate more than $1 billion duringthe 2011–2015 fiscal period.

Supporters say the bill willbring down costs by reducinguncompensated hospital emer-gency room care for poorMinnesotans. Those costs haveburdened hospitals in the stateand often are passed on to insur-ance companies, resulting in pre-mium increases.

Flu Shots OK forPregnant Women,Study Finds A new study by HealthPartnersInstitute for Education andResearch says that pregnantwomen who receive flu shots arenot any more likely to experiencehealth complications than thosewho do not receive shots.

The study was published Feb. 6 in Obstetrics & Gynecology,the official publication of theAmerican College of Obstetriciansand Gynecologists.

Using national data from systems such as HealthPartners in Minnesota and Wisconsin, the Kaiser Permanente HealthSystem in the western U.S., andMarshfield Clinic in Wisconsin, thestudy included 75,906 vaccinatedand 147,992 unvaccinated preg-nant women between ages 14 and49. The women were matched byage, site, and pregnancy start dateto observe any health events asso-ciated with the flu shot. Theresearchers found that receipt ofthe vaccine during pregnancy wasnot associated with an increasedrisk of the complications studied,

News to page 6APRIL 2013 MINNESOTA HEALTH CARE NEWS 5

The Freedom Medicare planSwitch your Medicare plan. Not your clinic.

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You’ll likely be covered no matter where you go with a HealthPartners Freedom plan. Shop and compare health plans at healthpartners.com/medicare

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including allergic reactions, cellulitis, and seizures within thefirst three days; or cases ofGuillain-Barré syndrome, opticneuritis, transverse myelitis, orBell’s palsy within the first 42days.

“We’ve been recommendingthat women at all stages of preg-nancy get a seasonal flu vaccinefor years, but concerns regardingits safety have remained,” saysJim Nordin, MD, MPH, the study’slead author and a pediatricianwith HealthPartners in St. Paul. “I hope this study will reassurewomen and their health careproviders about the safety of theinfluenza vaccination.”

MNCM Report Looks at QualityMeasurementsMinnesota CommunityMeasurement (MNCM) hasreleased its ninth annual HealthCare Quality Report, which looksat 2012 performance data in 21

clinical quality measures forhealth care clinics and hospitalsthroughout the state.

Among the report’s findingsare improvements in several areassuch as diabetes care and colorec-tal cancer screening. The reportalso looked at two new areas:cesarean delivery rates andimmunizations for adolescents.

The report finds that 26 per-cent of births to first-time mothersin Minnesota are by cesareandelivery, a rate that some expertssay is higher than it needs to be.Although the MNCM report doesnot address whether individualoperations are appropriate, thereport does show that cesareandelivery rates vary widely in thestate. The percentage of cesareanbirths to first-time mothers at allmedical groups ranged from 14percent to 51 percent.

Improvements in perform-ance data included the number ofpatients getting optimal diabetescare, the number of children get-ting follow-up treatment afterbeing prescribed ADHD medica-tion, better rates of remission for

patients with depression, a 4 per-cent increase in the number ofMinnesotans receiving colorectalscreening, and a 7 percentincrease in the number of childrenup to date on immunizations.

MNCM officials say they areworking on including cost meas-urements in future reports, andthat the group plans to report data on total cost of care meas-urements this year. The group isalso working with the MinnesotaDepartment of Health on astatewide way to measure patientexperience of care. Results fromthat research will be posted onlinethis summer, officials say.

The full report for 2012 can befound at www.mncm.org

North MemorialMakes HealthGrades’Best Hospitals ListNorth Memorial Medical Center inRobbinsdale was named amongHealthGrades’ America’s 50 BestHospitals last week. The yearly listrecognizes hospitals that have

risk-adjusted mortality and com-plication rates low enough toplace them in the top 1 percent ofall hospitals nationwide.

North Memorial was joinedby St. Luke’s Hospital in Duluth onthe HealthGrades list of America’s100 Best Hospitals, which recog-nizes the top 2 percent of hospi-tals in the nation. In addition, theMinneapolis/St. Paul metro areawas listed 9th in the nation forhaving the lowest overall averagerisk-adjusted in-hospital mortalityrates among major cities.

“The America’s BestHospitals distinction provides ameasure of confidence for con-sumers,” says Evan Marks, execu-tive vice president of informaticsand strategy for HealthGrades.“Each hospital’s exceptional per-formance reflects a dedicationand approach to qual ity whichhas been evidenced across theorganization and has beendemonstrated consistently interms of superior clinical out-comes.”

News from page 5


Alcohol and drug abuse by seniors often goes unnoticed because of isolation and loneliness. As a result, the older adult continues to suffer in silence. Senior Helping Hands is a program of St. Cloud Hospital Recovery Plus and a recognized national leader providing support and services to stop the suffering. Senior Helping Hands serves individuals age 55 and older.

Services• Outreach service and consultation with family or concerned persons• Evaluation and assessment for chemical dependency and/or mental health

issues completed by qualified professionals• Volunteer support for older adults who are chemically dependent• Support from peer volunteer counselors for older adults with mental health issues

ProgramsOlder Adult Chemical Dependency Primary Treatment ProgramA comprehensive program that involves physical/psychosocial/chemical use assessments performed by professionals trained in chemical dependency and mental health, including a full time Medical Director who is an addictionist. The program provides a slow pace, holistic approach to recovery. Transportation and temporary housing are available if needed.

Chemical dependency in older adults is hard to recognizeWe help them live a healthier life

Contact Us713 Anderson Ave., St. Cloud, MN 56303(320) 229-3762 • (800) 742-HELP toll-free

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Pat Pulice, director of Fraser Center of Autism Excellence, recently

received an Outstanding Service Award from the Minnesota Associa -

tion for Children’s Mental Health. The award recognizes individuals who

have shown extraordinary achievement and/or leadership in the field of

children’s mental health. Pulice has more than 30 years of experience

working with children on the autism spectrum. She provides program

development, resources, and continuity of intervention at Fraser, a

Minnesota nonprofit serving children and adults with special needs.

Pulice also served on the state’s Autism Spectrum Disorder Task Force

and has provided testimony to the state legislature over the years

regarding the needs of children on the autism spectrum and their fami-

lies. She is now consulting with Fairview Hospital system to increase

hospital staff knowledge and skills so they can work more effectively

with children and youth who are severely affected by autism.

John Manion, MD, has received the 2013 Trustee of the Year Award

from Aging Services of Minnesota. The Trustee of the Year Award hon-

ors individuals whose volunteer leadership as a board member has

benefited their older adult services organization and enhanced the

work environment of its employees and the quality of life of the sen-

iors it serves. Since 1994, Manion has served on the board of directors

at Saint Therese, a nonprofit that provides senior care services and

housing in the Twin Cities metro area. He estab-

lished a palliative care unit at Saint Therese, the

first of its kind in the upper Midwest.

Hennepin County Medical Center (HCMC)

has announced the hiring of several physicians.

Jackie Kawiecki, MD, has joined HCMC’s Physical

Medicine and Rehabilitation Clinic. She is a diplo-

mate of the American Board of Physical Medicine

and Rehabilitation for both physical medicine and

rehabilitation, as well as spinal cord injury medi-

cine. Kawiecki treats rehabilitation of spinal cord

injury, stroke, brain injury, trauma, cerebral palsy,

and amputees. She has a special interest in spas-

ticity management, botox injection, and phenol

nerve block procedures. Paul Nystrom, MD, has

joined HCMC’s Department of Emergency

Medicine. Nystrom went to medical school at the

University of Iowa and completed his emergency

medicine residency at HCMC. Nystrom has a special interest in tactical

EMS and has worked with the Chula Vista, Cal., Police Department

SWAT Team, the Drug Enforcement Agency, the Brooklyn Park, Minn.,

Police Department SWAT Team, and the Hennepin County Weapons

of Mass Destruction Team. He is an EMS Fellow in the Department

of Emergency Medicine. Gaurav Guliani, MD,

has joined HCMC’s Neurology Department.

Guliani attended medical school at the University

of Illinois in Chicago, and completed a residency

in neurology at the University of Minnesota and

a fellowship in neuromuscular medicine and

electromyography at Washington University in

St. Louis. Guliani’s clinical interests include

nerve and muscle diseases, headache, palliative

care in neurological diseases, immune diseases of the nervous sys-

tem, brachial plexus injuries, and motor neuron disease. He is a princi-

pal and co-investigator in ALS clinical research trials at the Berman

Center for Research in Minneapolis.

P E O P L E


Jackie Kawiecki, MD

Gaurav Guliani, MD

Paul Nystrom, MD

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Glenn Nemec, MDMonticello Clinic

Glenn Nemec, MD,is a board-certified

family physicianwith Monticello

Clinic. He has prac-ticed in Monticellofor 25 years and is a member of the MinnesotaAcademy of

Family Physicians. In 2008, theMinnesota

Pollution ControlAgency began a10-year cycle ofintensively moni-toring an average

of eight water-sheds each year.This monitoring

includes lakewater chemistry,stream chemistry,and biology, such

as fish popula-tions. The resulting

data help deter-mine if lakes meet

the standards for public health,recreation, and

aquatic life.

o jump in the lake! As temperatures rise,this is a way of life for many people inthe land of 10,000 lakes. But what dan-

gers lurk in the water?

Waterborne illness

In Minnesota, public sanitation has rendered seri-ous waterborne illness virtually extinct; there isgenerally far more danger from accidental drown-ing than there is from any microorganism. Thisdoes not mean that you should enter any body ofwater with total abandon. But it should reassureyou that even if you do contract a waterborne ill-ness, you likely will live to complain about it.

There are rare exceptions to this rule and lastyear’s deaths from Nocardia make that point.Nocardia is a parasite that lives in shallow, warm,stagnant water that tends tohave algae growing on top ofit. Nocardia can enter thebody through the mouth andnose and travel to the nerv-ous system. There, it causes asevere and difficult-to-treatform of meningitis, which isinflammation of the membranes that cover thebrain and spinal cord. Avoiding such bodies ofwater and not getting water in your nose or mouthare the only ways to prevent infection. Althoughthis infection occurs rarely, and primarily in peo-ple with weakened immune systems, it’s a goodidea to avoid water that has algae growing on it.

The much more common and relatively harmlessillnesses that can be contracted during recrea -tional water use fall into two general categories,diarrheal illness and swimmer’s itch. The latter isoften wrongly called “chiggers,” which is a re lateddisease contracted in grassy areas.

Diarrheal illness. The typical cause of diarrheafrom a waterborne source is viruses from animalsand humans. If someone swallows virus-infectedwater, these viruses multiply in the person’s intes-tine and cause a usually short-lived case of diar-rhea. Occasionally, diarrhea is caused by a para-site called Giardia. This pest lives in some animalsand is flushed by rain into the water system fromanimal droppings. It also can be transmitted in thestool of a human infected with it. It causes alonger-lasting watery diarrhea that can be accom-panied by bloating, gas, loss of appetite, nausea,stomach cramps, vomiting, and fever.

Someone whose diarrhea has lasted more than 10days, who has other accompanying symptoms,

and who recently has been in a natural body ofwater should consult a physician. Giardia is treat-able with certain antibiotics, but in the vast major-ity of healthy people it goes away by itself withintwo to six weeks. The best prevention is to avoidgetting water in the nose and mouth and to neverswallow water from natural bodies of water.

Swimmer’s itch is caused by parasitic microsco -pic worms that live in water snails and waterfowlfound in calm, shallow, warm water. When theparasites leave the snails and swim in an attemptto find waterfowl to infect, they may accidentallypenetrate human skin. That person’s immunesystem reacts to the parasite and causes small,intensely itchy red bumps. Some of the itchinessis relieved by over-the-counter antihistaminesand cortisone creams, but mostly you just have

to wait it out. Avoiding calm,shallow, warm water is theonly prevention. Toweling offvigorously after leaving thewater helps reduce the risk ofswimmer’s itch by dislodgingthe parasites from the skin.

Minimize risk

• Don’t swallow water or get water in your mouthwhile swimming; spit it out.

• Shower after swimming.

• Do not go in the water when you have diarrhea.You can pass Giardia or viruses in your stool andcontaminate water.

• Take kids on frequent bathroom breaks; waitingto hear “I have to go” may mean that it’s too late.

• Change diapers in changing rooms, not next tothe water.

• Wash hands after changing diapers.

The best way to minimize exposure to all water-borne illness in Minnesota is to confine recre-ational water activities to higher-quality bodies ofwater. You can find these waters by checking theMinnesota Pollution Control Agency’s website,which posts water quality assessments. However,since not all Minnesota waters have beenassessed yet, follow this guideline: The clearer thewater, the safer it is.

Water quality information on specific lakes and rivers in the state can be found atcf.pca.state.mn.us/water/watershedweb/datasearch/waterSearch.cfm

Recreational waterborne illnessCome on in, the water’s fine—if you take precautions

P E R S P E C T I V E

G

Never swallow water from natural bodies

of water.


You call it

“reminding mom to take her pills.”

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

We call it caregiving.

Dr. Liengswangwong is board-certified in radiation oncology and practices atMinnesota Oncology-Maplewood Cancer Center.

What is radiation oncology? Radiation oncology combines principles ofphysics and biology. It uses ionizing radiation, either alone or in combination withtreatments from other medical specialties, to treat cancers and certain benign dis-eases such as heterotopic ossification, in which bony material sometimes grows insoft tissues following bone injury or surgery involving bone.

How do diagnostic radiology and radiation oncology differ? Althoughradiologists and radiation oncologists are both certified by the American Board ofRadiology, diagnostic radiology—imaging and diagnosing medical conditions—andradiation oncology are different specialties that require different training. Radiationoncologists undergo specialized residency training for at least five years after gradu-ating from medical school, followed by fellowship training in radiation oncology.

How do radiation oncologists interact with other medical specialists?Patients are referred to radiation oncologists by physicians in different specialities,so that we can evaluate whether radiation treatment will benefit the patient. We work closely with primary care physicians, surgeons, internists, gynecologists, medical oncologists, radiologists, pathologists, medical geneticists, and other cancerspecialists to ensure patient-centered care and optimal outcomes.

What is brachytherapy? It is one way to deliver radiation treatment.Brachytherapy involves placing sealed radioactive sources inside the patient’s body,close to or in contact with the cancer. This technique allows delivery of a high doseof radiation safely to the treatment target area over a short period of time, whileminimizing radiation exposure to healthy tissue. It has been used extensively totreat, for example, prostate cancer, certain gynecological cancers, breast cancer, ocu-lar melanoma (retinoblastoma), and certain benign conditions such as age-relatedmacular degeneration. At the completion of treatment, the radioactive sources areremoved. One exception to removal is permanent prostatic seed implant, in whichradioactive sources are purposely left inside a patient’s prostate.

How does CyberKnife work? This delivers stereotactic irradiation in highlyprecise, narrow beams of high-dose radiation to the target tissue while minimizingradiation to surrounding normal tissue. X-ray beams are delivered via a robotic armthat moves around the patient. Accuracy is monitored during delivery by using asophisticated computerized imaging system. This technique makes it possible totreat certain cancers that formerly were treatable only by risky surgery. Comparedwith traditional surgery, stereotactic radiation treatment is less invasive and affordsgreater precision. These advantages can reduce the length of a patient’s hospital stayand the cost of treating certain conditions. These advantages are also true of otherequipment used for stereotactic radiosurgery and stereotactic radiotherapy, such asGamma Knife, linear accelerator SRS/SRT, and tomotherapy equipment.

What clinical trials are being conducted in radiation oncology? Onecurrent area of research investigates the most effective way to combine radiation


1 0 Q U E S T I O N S

Photo credit: Bruce Silcox

Radiation oncologyVic Liengswangwong, MD

and novel chemotherapeutic agents. Anotherarea of research focuses on reducing sideeffects of cancer treatment. One example ofwork in this area involves assessing the poten-tial protective effects of memantine (a medica-tion for Alzheimer’s patients) in preservingmemory and brain function in patients whoreceive whole brain irradiation for brain tumors.

Experts predict a shortage of radiation oncologists by2020. How do you explain this? Between 2010 and 2020, thetotal number of patients receiving radiation therapy is expected toincrease by 22 percent, while the number of full-time radiation oncol-ogists is expected to increase by only 2 percent. The probable reasonfor the expected increase in patients is the ongoing change in demo-graphics in this country. Since the number of people age 65 years andolder will increase, so will the need for cancer care.

What should patients of childbearing age know aboutradiation therapy and fertility? In females, cancer treatmentcan cause impaired fertility and premature menopause in severalways. Radiation treatment to the pelvic area can lead to prematureovarian failure and decreased numbers of eggs. It can cause uterinefibrosis and damage to the endometrium (the lining of the uterus),thereby interfering with embryo implantation. Radiation treatment tothe brain can disrupt hormonal pathways, resulting in a loss of fertil-ity. Irradiation also can result in infertility in male cancer survivorsby causing an inability to ejaculate or to have an erection necessaryfor intercourse. It also can damage the testes, leading to abnormalsperm or a low sperm count. Strategies for fertility preservation in

females include surgically repositioning theovaries away from areas of radiation treat-ment before starting treatment and bankingembryos, eggs, and ovarian tissue. Options formales include banking sperm and testicular tis-sue and shielding the testicles during radiationtreatment. All patients of reproductive age

who will undergo cancer treatment capable of damaging the repro-ductive system are candidates for fertility preservation.

Are advances on the horizon in radiation oncol ogy?Advances in prostate cancer treatment may come from current clini-cal trials of novel radiation treatment using radium-223 chloride formen who have prostate cancer that has spread to their bones despitehormonal treatment or chemotherapy. Research into radiation treat-ment for benign disease, such as epimacular brachytherapy for wetage-related macular degeneration, also holds promise.

Please share a success story. One of my patients was found to have breast cancer spreading to her brain about a year after shecompleted chemotherapy, mastectomy, and radiotherapy for lo callyad vanced breast cancer. She had surgery to remove that cancer andsubsequent radiation treatment. I continue seeing her for follow-up,and she has been cancer-free for the past seven years. She retur ned tofull-time teaching; enjoys her friends, her husband, and their school-aged children; and is active in her commun ity. No reward to physi-cians is more valuable than the privilege to care for and heal patientswho, as a result of medical care, are able to live joyful and produc-tive lives.


No reward to physicians is more valuable than the

privilege to care for and heal patients.

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At 31, Travis weighed 308 pounds. But it wasn’tuntil his friends dropped him from their plans fora fishing trip that Travis started to think seriously

about what his weight was doing to his relationships andability to enjoy life.

When Deborah’s first grandchild was born,Deborah knew she finally had to do something abouther pack-a-day smoking habit if she wanted to see littleHailey grow up. But she didn’t know where to start.

BarriersResearch has shown that lifestyle behaviors suchas inactivity and eating a poor diet promote

obesity and type 2 diabetes. These, in turn, con-tribute to seven of the top 10 causes of death inthe U.S., including heart disease. Strategies andtools to change these behaviors come at us fromall angles: doctors, television, magazines, andwebsites. Even so, the number of people withobesity and type 2 diabetes continues to rise. Ifwe know our unhealthy habits threaten ourcurrent or future health, why don’t we change?

Perhaps that’s because we traditionallyhave viewed our health care providers likeour car mechanics: We expect them to fix ourhealth problems for us. We want to hear theequivalent of “take two aspirin and call mein the morning.” This way of thinking puts

the responsibility for our health and wellness on the doctor insteadof on us.

Providers offer expertise, but they can’t make behavior changesfor us. Increasingly, they are trying new ways to help us reach ourhealth goals. Instead of “take two aspirin,” health care providers areinviting us to participate in our own care. Here are three ways wecan accept this invitation and become engaged and effective inachieving lasting health.

Find motivationWe naturally visit health care professionals when something iswrong. We might walk away with diagnoses such as high choles-terol, prediabetes, or obesity. For some of us, simply hearing thesewords prompts action but for others, such diagnoses lack meaning.Deborah’s doctor had urged her for years to quit smoking. Yet untilshe saw her first grandchild, Deborah did not feel motivated tochange her habit. Many of us can relate to Deborah. We might notbe motivated by our doctors’ words like “overweight,” “shortness ofbreath,” or “knee pain.” But we might respond to exclusion from anactivity with friends or knowing we might not see our grandchildrengrow up.

One way to find the motivation to change behavior is to reflecton our values. We all value something: relationships, independence,sports, work, competition, the outdoors, volunteering, and mobility,among others. To make lasting change, it helps to associate our val-ues with our behaviors. Deborah connected something she values—fam ily—to her smoking habit and realized that smoking threatenedto rob her of time with her family.

P O L I C Y

© 2013 Minnesota Diabetes & Heart Health Collaborative

Eat more fruits, vegetables & whole grains and less fat

Be active 30 minutes a day, 5 times a week

Don’t smoke

Eat smaller portions and lose 10 pounds if you are overweight

Watch your blood pressure and cholesterol

Talk to your doctor about all serious health problems in your family tree

www.mn-dc.org

Is diabetesin your family tree?

“I know I need to improve my

health—but how?”Patient engagement

By Naomi Hertsgaard, MPH, and William Nersesian, MD, MHA

Focus on what you can doFor most of us, unhealthy behaviors develop over time and, like-wise, take time to change. We often give up trying to change ourbehaviors before we get very far because of personal barriers suchas self-doubt and fear of change. Finances, competing responsibili-ties, or a lack of support from those around us can further com-pound our barriers. We fixate on our deficiencies and fallprey to “all or nothing” thinking. If we can’t even runaround one block, why bother? Travis blamed his inactivityon his weight; it hurt to run around his block.

To combat this self-defeating attitude, it helps to identifysmall, incremental changes we know we can make. Instead ofrunning around the block, Travis decided he could walkaround one block each day without feeling pain. After two weeks ofwalking around one block each day without pain, he increased hiswalk to two blocks a day.

Unless we tell our providers what changes we believe we canmake, they might expect more of us than we realistically canachieve. Instead of nodding his head as his provider tells him toexercise, Travis can share the small changes he is ready to make.Together, he and his provider can create a plan. Small changes,made consistently over weeks and months, generate change and lead to success.

Build supportive relationshipsRecognizing your motivation and identifying small changes you canmake are first steps. Enlisting the support of a health care provider,friend, coworker, neighbor, or community group can help you stickwith your plan.

Finding a supportive provider is just as important as finding ahairdresser you are happy with or an accountant you trust. Payingattention to how you feel when you are with your provider will helpyou determine if you can work as a team or not. Can you ask ques-

tions? Is your provider asking you ques-tions? Can you be honest, and not sugarcoat your answers about whetherand how you can make a change?Responding “no” to these questionsmeans it is time to shop around for anew provider or to have a candid discus-sion with an existing one. Look for aprovider who wants to know you, to listen to you, and who is committed topartnering with you.

Loved ones and community groupsalso can support us as we make positivelifestyle changes. Examples include faith-based organizations, community centers,

local gyms, friends, family, neighbors, or even online communities. After several weeks of walking around his neighborhood, Travis

decided to join a community gym where his neighbor worked out.Because Travis planned to meet the neighbor twice a week at thegym, he was less likely to skip his workouts. Similarly, Deborahpaired up with a coworker who also was motivated to quit smok-ing. They agreed to check in with one another whenever either onewanted a cigarette, which helped each one control the urge tosmoke.

Start with a single step When we open our eyes to the resources and people around us, wesee that we are not alone in our struggles. We might even discoverthat we can help others on their journeys to health and wellness.When searching for support among friends or in your communities,follow the same rules as when looking for a provider: How do you

feel? Can you be honest? Do those around you want to worktogether?

The journey toward enjoying improved health starts with a single step, followed by small, incremental steps. To make that firststep, discover your motivation. To stay on track, focus on smallchanges over time and build supportive relationships to help your-self make those changes. Travis and Deborah, with the help of others, are taking steps to plan and shape their future health—andso can you.

Naomi Hertsgaard, MPH, is a quality data analyst at Fairview PhysicianAssociates. William Nersesian, MD, MHA, is a pediatrician with a back-ground in public health. He is currently chief medical officer at FairviewPhysician Associates.


It helps to identify small, incremental changes we know

we can make.

If we knowour unhealthy

habits threaten ourcurrent or

future health,why don’t we

change?


What did Hubert Humphrey, JackLemmon, and Telly Savalas allhave in common? All three died

of bladder cancer. Bladder cancer occurs when the normal

lining of the urinary tract changes intoabnormal cells that grow out of control toform a mass called a tumor, which typicallyforms inside the bladder.

This disease is one of the most expensivecancers in the U.S., with nearly$3 billion spent annually on itsdiagnosis and treatment. It’s alsothe fourth most common cancerin men, and the second mostcommon cancer of the urinarytract for both men and women,in this country. In 2011, approximately69,250 people were diagnosed with bladdercancer in the U.S. and an estimated 14,990people died from it.

Despite the often aggressivenature of this disease and its relatively common occurrence,there is insufficient publicaware ness of it. This is unfor -tunate, because greater aware-ness of symptoms could lead toearlier detection and improvedsurvival.

Symptoms

The most common symptom isblood in the urine. Blood canmake urine appear red, pink, ordark brown. Eighty percent to90 percent of patients diagnosedwith bladder cancer report see-ing blood in their urine for sixmonths before consulting aphysician.

Additional symptoms caninclude pain during urination,increased urinary frequency,pain in the pubic region, fatigue,weight loss, and fevers. How -ever, for most patients diag-nosed with bladder cancer, theonly symptom is blood in theirurine.

Any blood in your urinemeans that you should consult a physician promptly. Too often, apatient’s delay in contacting a physician delays treatment that hasthe potential to cure the cancer.

Risk factors

Smoking causes half of bladder cancer cases in both men andwomen. In fact, the most common cause of bladder cancer is to bacco exposure, whether from smoking or secondhand smoke.Current smokers and people exposed to smoke are four to five times more likely to develop this disease than people who havenever smoked. In addition, patients exposed to certain dyes, petrol -eum products, diesel fumes, hair spray, and printing presses are athigher risk. A family history of bladder cancer also increases risk.

Diagnosis

Diagnosis starts by ruling out other reasons that a patient mighthave bloody urine. These include urinary tract infections, kidneystones, and some prostate disorders, most of which are benign. Ifthese causes are ruled out, patients are referred to a urologist. Thisis a specialist who addresses medical disorders related to theprostate, bladder, kidneys, and testicles.

For a patient who has blood in the urine, a urologist will oftenperform an imaging test of the kidneys to detect abnormalities.(Urine is produced in the kidneys.) This test is typically an ultra-sound or CT scan.

The urologist may also examine the inside of the bladder via aprocedure called a cystoscopy. This involves inserting a narrow flex-ible tube into the bladder through the urethra, the anatomical struc-

U R O L O G Y

A diagnosis of

Canceris

overwhelmingnews.

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Know the symptomsBy Gregory Hanson, MD, FACS,

and Basir Tareen, MD, FACS

Bladder cancer

cystoscope

ture though which urine leaves the body. Attached tothe tube is a fiber optic camera called a cystoscope.This procedure is relatively painless, is performed inthe doctor’s office with a local anesthetic, and usuallylasts less than a minute.

The advantage of this procedure is that while theurologist is looking at the inside of the bladder, tissuesamples from any suspicious-looking areas can besnipped out using a tool attached to the cystoscope.Samples are then sent to a pathologist to help make the diagnosis.

Treatment

The method of treatment depends on whether the cancer is a lessaggressive or more aggressive variety. The less aggressive varietyoccurs 60 percent to 70 percent of the time, is found only in the lin-ing of the bladder, and can be managed by removing the tumor viacystoscope. These tumors often come back, but, if they do, can bemanaged by the same cystoscopic removal method. Recurringtumors of this type typically will not grow deeper into the bladder.

Approximately 40 percent of bladder cancers are the moreaggressive variety and have invaded deeper layers of the bladder bythe time they are diagnosed. These more aggressive tumors carry asignificant risk of spreading to different parts of the body. They aretypically treated with a cystectomy (removal of the entire bladder)and, in some cases, with chemotherapy or radiation. Even withaggressive treatment, the five-year survival rate for advanced blad-der cancer is only about 60 percent to 70 percent.

Cystectomy is a surgical procedure that involves removing thebladder and surrounding lymph nodes as well as reconstructing away for urine to exit the body. This procedure traditionally has been

done through a large incision thatextends from the belly button downto the pubic bone. More recently,however, surgeons have begun per-forming it using a robotically assistedlaparoscope, which allows the proce-dure to be performed through a smallincision in the abdomen. The advan-tages of this laparoscopic approachinclude less blood loss, less pain, and,

sometimes, a shorter hospital stay. Urine collection. After a cystectomy, some patients elect to col-

lect their urine in an artificial external bladder. This is a bag called aurostomy, which is attached to the outside of the patient’s abdomenand fits under the patient’s clothing. Urine is rerouted from the kid-ney through a small portion of the intestine and into the bag, whichis emptied periodically by the patient.

Other patients are candidates for a new internal bladder con-structed from a piece of their intestine. Urine from this neobladderexits the body through the patient’s urethra just as it did before surgery.

Prevention

If bladder cancer is found early, many patients can live long, pro-ductive lives after diagnosis. However, bladder cancer has one of thehighest risks of recurrence of any malignancy, so patients who arediagnosed with it should have regular cystoscopic exams in theirurologist’s office to ensure that the cancer has not returned.

Patients who want to decrease their risk of devel-oping bladder cancer should reduce their exposure totobacco by quitting smoking if they smoke and byavoiding secondhand smoke whether or not theysmoke. Risk is also reduced by limiting or avoidingexposure to chemicals found in petroleum products,diesel fuel, pesticides, and aerosolized chemicals such as those used with printing presses and those inhair spray.

In addition, studies suggest that increasing daily fluid intakemay help reduce bladder cancer risk. Diet may play a protective role as well, according to a 2008 study commissioned by the WorldHealth Organization. The study reported that certain fruits and vegetables may help reduce the risk of bladder cancer. These includeyellow-orange vegetables, citrus fruit, and cruciferous vegetablessuch as broccoli.

Bloody urine? See your physician

Bladder cancer is a significant medical problem in the U.S., espe -cially among the elderly. Quit smoking, reduce your environmentalexposure to chemicals, consult your doctor if you have a family history of this disease, and see a physician at the first sign of bloodin your urine.

Gregory Hanson, MD, FACS, and Basir Tareen, MD, FACS, are board-certified urologists with Metro Urology in Minneapolis/St. Paul. Both arefellowship-trained in urologic oncology and co-chair the Metro UrologyCancer Committee.


The most common cause

of bladder cancer istobacco

exposure.

Any blood inyour urine

means that youshould consult

a physicianpromptly.


Donated bloodWe often hear about the need to donate blood after anatural disaster has occurred, but in truth, there isalways a need for blood. In Minnesota, 700–800units of blood are used each day. (A unit equals abouttwo cups.) It’s used in emergency rooms to help keeptrauma victims from bleeding to death, and to helpcancer patients, burn victims, surgical patients, new

mothers who may have lost bloodduring delivery, and people whoseown blood functions improperly.One unit of donated blood cansave three lives.

What is it?

Blood is a complex mixture of aliquid called plasma and several

kinds of cells, including red cells and platelets. Afterblood is collected it is separated into the three bloodproducts used most frequently: red cells, plasma, andplatelets.

Red cells carry oxygen to tissues and are oftenused by patients who lose blood during surgery.Plasma contains proteins, nutrients, and clotting factors that help prevent and stop bleeding. It is used

H E M A T O L O G Y

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McCullough, MD

The University of Minnesota School of Public

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most frequently by people with trauma, burns, or blood diseases.Platelets help blood clot. Donated platelets are often used by

people who have either low numbers of their own platelets or non-functioning platelets, since either situation predisposes them to bleedduring chemotherapy, bone marrow transplantation, major surgery,liver disease, or severe trauma. Platelets also contain growth factorsthat help repair damaged body tissue.

All of these components have a short shelf life. Red cells can berefrigerated for up to 42 days. Platelets cannot tolerate cold and arestored at room temperature but only for five days before they mustbe discarded. Plasma can be frozen for one year.

Most patients do not need whole blood replacement. Therefore,separation of donated blood into components allows physicians tochoose the specific component that is best for each patient. Forinstance, a patient who loses one or two units of blood during sur-gery needs red cells to improve his or her blood’s oxygen-carryingcapacity. Such a person usually does not have a deficiency ofplatelets or clotting factors and, thus, does not need to have thoseblood components replaced. Those components can be used byother patients, such as those who have lost blood to trauma orthose undergoing cancer chemotherapy. Chemotherapy sometimesnecessitates platelet transfusion to prevent bleeding. In contrast, atrauma patient receiving a large number of transfusions and whoneeds replacement of clotting proteins would receive plasma.

Blood collection

Of the roughly 15 million units of blood collected annually in theU.S., 10 percent is collected in hospitals. The nonprofit organizationAmerican Red Cross collects approximately 40 percent. The remain-ing 50 percent of the U.S. blood supply is collected by other non-profits and by for-profit organizations. Blood is considered a drug,

so it and the organizations that collectand provide it are regulated by the fed-eral Food and Drug Administration.

Before giving blood, potentialdonors are asked confidential questionsto determine whether donation is safe forthem and whether their blood mightpose risks for recipients. Questions iden-tify donors who may have exposure toblood-transmissable diseases such as hep-atitis and malaria or behaviors thatcould put them at risk for HIV, the virusthat causes AIDS. Blood is collected bysingle-use needles and containers.

Collection usually takes about 5–7 minutes, after which donors areoffered fluids such as juice to replace the amount of donated blood.That amount represents only about 10 percent of an average adult’sblood and is quickly regenerated by the body.

Blood can also be collected by apheresis, a process in which the donor is connected to a machine that separates his or her blood into components called platelets and plasma, and returnsmost of the blood to the donor. Either collection method takes 45minutes to an hour.

Blood safety

Improvement in the safety of donated blood is one of the mostimpressive and gratifying advances in medicine during the last

30 years. It’s been accomplished by refiningprotocols to acquire a more extensive donorhistory before collection to screen out poten-tial donors who pose health risks, and byimproved laboratory testing of collectedblood. As a result, transfusion-transmitteddisease occurs only a handful of times annu-ally in the U.S.

Donated blood under-goes extensive testing toassure that it is safe. It istested for HIV virus,which causes AIDS; hepa-titis; syphilis; and anotherHIV-like virus. Testing foradditional infectious agents is performed onblood destined for transfusion into certainpatients. One such agent is cytomegalovirus,which typically produces no symptoms whenit infects a healthy adult but can cause seri-ous disease in immunosuppressed patientssuch as those undergoing transplants.

Complications of receiving donatedblood, in addition to transmissible disease,include fever, bacterial contamination of theblood product, and allergic reactions due toblood group incompatibility. Strategies are


Do you have trouble using the telephone dueto hearing loss, speech or physical disability?

If so…the TED Programprovides assistive telephoneequipment at NO COST to those who qualify.

Please contact us, or have your patients call directly, for more information.

1-800-657-3663www.tedprogram.org

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

Duluth • Mankato • Metro Moorhead • St. CloudTe

lepho

ne E

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ent

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ED)

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Donated blood to page 34

One unit of donatedblood cansave three

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Donated blood undergoes extensive testing to assure that

it is safe.

11 Widowed SupportPark Nicollet presents a support group foryoung widowed people. If you have lost aspouse, partner, fiancé, or fiancée, comeand receive support from peers and griefcounselors. Free. Call (952) 993-6165 toregister or for more information.Thursday, Apr. 11, 6:30–7:45 p.m., Park Nicollet Frauenshuh Cancer Ctr.,3931 Louisiana Ave. S., St. Louis Park

16 Advance Care PlanningLakeview Health presents Advance CarePlanning for Minnesotans. This class willhelp you assess goals, values, and beliefsabout end-of-life care. Learn how to pick a surrogate decision maker and talk withyour loved ones. To register or for moreinformation, call (651) 430-4697.Tuesday, April 16, 1–2 p.m., LakeviewHospital, 927 Churchill St. W., Stillwater

18 Cancer Legal SeminarCancer Legal Line presents Chris Wheaton,Esq., and Brea Buettner-Stanchfield, Esq.,discussing cancer survivors’ financial con-cerns and dealing with creditors. Free.Call (651) 472-5599 to register or formore information.Thursday, April 18, 6:30–8 p.m., Angel Foundation, 700 3rd St. S., Ste. 106W, Minneapolis

20 Women’s Health Fair West 7th Community Center’s Women’sHealth Fair offers health screenings; learnabout health and wellness throughout thelifespan. Free. Call (651) 298-5493 to find out more.Saturday, April 20, 10 a.m.–1 p.m., West 7th Community Ctr., 265 Oneida St., St. Paul

21 Free Health Screenings Medtronic and Shiloh Missionary Baptist Church offer blood pressure, glucose, and cholesterol screening to the public.Free. Call Kelly at (770) 367-3150 to find out more.Sunday, April 21, 9:30–11:30 a.m., Shiloh Missionary Baptist Church,501 W. Lawson Ave., St. Paul

25 Disability Day Join Minnesota Brain Injury Alliance for Disability Day at the Capitol. Tell the story of your disability to legislators and advo-cate for the support you need. Call (800) 669-6442 to register and for information.Thursday, April 25, 10 a.m.–1 p.m.,Minnesota State Capitol, 75 Rev. Dr.Martin Luther King Jr. Blvd., St. Paul

25 Exercise With AutismMinnesota Life College presents a class for people with autism. Learn tai chi, yoga, and meditation techniques to help cope with stress. Free. Register atwww.eventbrite.com. Call (612) 869-4008for more information.Thursday, April 25, 6:30–7:30 p.m.,Southdale YMCA, 7355 York Ave. S., Edina

26 Health Disparities Roundtable University of Minnesota presents“Engaging Communities in Public HealthResearch, Practice, and Policy,” a round-table discussion featuring Byllye Avery,MEd, Amy Jo Schulz, PhD, and the LatinoVoices program. Free. Register online atwww.sph.umn.edu/details/course/11309/ Friday, April 26, 9 a.m.–12 p.m.,Coffman Memorial Union, 300 Washington Ave. S.E., Minneapolis

May 1 Caregiver SupportFamilyMeans and Stillwater MedicalGroup present a support group for care-givers of those with memory loss. Free.Call Lisa at (651) 789-4004 for moreinformation or to register.Wednesday, May 1, 1–3 p.m.,FamilyMeans, Desch Rm., 1875Northwestern Ave. S., Stillwater

May 6 Disability Trends University of Minnesota presents LindaMartin (RAND Corp.) discussing disabilityand chronic conditions among olderAmericans from 1997–2010. Free. Call (612) 626-5818 for information ordisability accommodations.Monday, May 6, 12:15 p.m.–1:15 p.m.,50 Willey Hall, MPC Seminar Rm., 225 19th Ave. S., Minneapolis

Send us your news:We welcome your input. If you have an event youwould like to submit for our calendar, please sendyour submission to MPP/Calendar, 2812 E. 26thSt., Minne apolis, MN 55406. Fax submissions to(612) 728-8601 or email them to [email protected]. Please note: We cannot guaranteethat all submissions will be used. CME, CE, andsymposium listings will not be published.

America's leading source of health

information online

Did you know that 18 per-cent of injury crashes in2010 were reported as dis-traction-affected crashes?Distracted driving is anyactivity that could divert aperson’s attention awayfrom driving, such as text

messaging, using a cell phone, eating anddrinking, or even adjusting the radio.

By far the most dangerous of these distractions is text messaging, since itrequires visual, manual, and cognitiveattention from the driver. Sending or read-ing a text takes a driver’s eyes off the roadfor 4.6 seconds, which at 55 mph, equalsabout the length of a football field. Textmessaging while driving is illegal inMinnesota.Though 16 percent of all distracted driving crashes involve drivers under 20years old, all drivers benefit from limitingdistractions in their vehicles. Commit todriving phone-free, and turn your cellphone off when you turn on the ignition.For more information on distracted driv-ing, including how you can take thepledge for safer roads, visit: www.distraction.gov

23 Driving RefresherSt. Cloud State University offers a four-hourdriving refresher course for ages 55 andup. Learn defensive driving tips and the lat-est changes in laws and vehicle technology.$20 fee. Call (888) 234-1294 or visitwww.mnsafetycenter.org to register.Tuesday, Apr. 23, 9 a.m.–1 p.m., Apple Valley Senior Ctr.,14601 Hayes Rd.,Apple Valley

Distracted Driving Awareness Month


April Calendar

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-for-profit provider of senior care and services, it’s what we’ve been doing for almost 90 years.

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

www.good-sam.com


O P H T H A L M O L O G Y

Children’s eyesightHealthy eyes = better learning

By Jill Schultz, OD, FAAO, FCOVD

Vision is the primary way we absorbinformation and learn, with over 20different visual skills needed for ade-quate visual development. This criti-cal sense develops as infants exploretheir world, and, as a child grows,visual information is integrated withgross motor, fine motor, tactile, andother skills. Healthy vision allows us

to identify objects and patterns, and to process what we see.Poor visual skills make learning difficult, and untreatedvision problems can put children at risk for academic under-achievement and behavior problems.

When vision development goes awryVision problems are common during childhood. Risk factorsinclude premature birth; complicated birth and delivery;developmental delays; certain inherited conditions; or a preg-nant mother’s smoking, exposure to smoke, or certain med-ications during pregnancy.

Unlike other common childhood conditions such asspeech delays or poorly aligned teeth, vision issues are usu -ally not noticeable. Adults assume that children see the waythe adults see. Children with vision problems don’t realizethat anything is amiss, and therefore don’t indicate that any-thing’s wrong.

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Many parents assume their child has adequatevision if the child passes a vision screening. What par-ents may not realize is that screenings only assess dis-tance vision. Screenings do not detect all visual disor-ders, nor a child’s visual functioning at close distance.It’s especially important to check visual functioning atclose distance since that is used for “near work” such as

reading and computer use, and thusis vital for classroom activity.

Vision, learning, and behaviorBecause vision and learning are inti-mately connected, students withvisual problems can be misdiagnosedas having learning disabilities such

as ADHD or dyslexia. For example, children who havelearning-related visual problems cannot sustain atten-tion to near work at school and may become bored ormisbehave. They may be misdiagnosed as havingADHD because children with ADHD sometimes alsohave difficulty sustaining attention to classwork.

Symptoms of vision problemsAlthough most vision problems often have no obvioussigns, the following symptoms can indicate a visionproblem and warrant a comprehensive vision exam -ination.

• A child loses her place when reading

• Avoiding reading or other near work

• Poor attention, especially during near tasks or reading

• Tilting or turning the head to see

• History of ADD/ADHD or learning difficulties

• History of receiving physical or occupational therapy

• Below-average school performance

• Poor or inconsistent performance in sports

• Frustration during homework or school tasks

• Headaches, blurred vision, or double vision

Common vision problems These symptoms can be caused by one or more of the following con-ditions, all of which are treatable or curable if detected early.

Refractive error encompassesnearsightedness, farsightedness, andastigmatism. Each of these conditionscan cause blurred vision that can beimproved with glasses or contactlenses. In some cases, if this conditionis not corrected, 20/20 vision will failto develop in one or both eyes, fine

motor skill development can be delayed, or both. Amblyopia, or “lazy eye,” describes the condition in which one

eye is not capable of seeing 20/20, even with the help of glasses.Scientists once believed that amblyopia could not be treated after achild had reached the age of 6–8 years, but now we know that thiscondition can be improved at older ages, even in adulthood.

Strabismus, or “crossed eyes,” can cause amblyopia if untreated. Eye tracking requires that the eyes move together with exquisite

precision. This allows the eyes to move along the lines of print in abook and to make quick and accurate shifts from far to near. Poortracking skills produce poor reading skills.

Focusing, or accommodation, is the ability to maintain a clearview of something at different distances. This is needed for readingand writing, as well as for rapidly and efficiently changing visual clar-ity from distance to near, such as when sitting at a desk and copyingsomething written on the board. Visual focus is also needed to sustainvisual attention. Poor focusing skills can lead to blurred vision,headaches, and avoidance of reading.

Eye teaming is the ability to keep a target single, a skill used fre-quently in reading. The closer the target, the more your eyes have toturn to keep it single. If the eyes are not accurately teaming, it takesmore effort to process visual information. Faulty teaming can reducevisual attention, negatively impact spatial judgment, and can causecrossed or wandering eyes. Poor teaming skills are common and havebeen associated with ADD and ADHD. Many studies demonstratethe effectiveness of vision therapy to improve eye teaming.

Post-concussion vision syndrome. Most individuals who experi-ence a concussion have visual disturbances afterward. Commonvision symptoms after concussion include headache, avoidance ofreading, light sensitivity, double vision, blurred vision, and dizziness.Early identification and treatment of these problems can lead to bet-ter outcomes and faster recovery.

Delayed visual processing. Some children struggle with readingand early learning because they do not have adequately developedvisual processing skills. Symptoms may include poor letter recogni-


Did you know?• Diabetic retinopathy can be controlled and

diabetic patients need regular eye exams to

maintain vision and good eye health.

• Diabetes Type ll can also cause vision changes.

• Glaucoma must be diagnosed in early stages in

order to prevent vision loss.

• All children entering school need a comprehen-

sive eye exam, because vision screenings do not

detect a number of eye disorders.

• To maintain eye health, everybody from babies

to boomers to older adults needs a regular eye

exam by a family eye doctor.

To locate an optometrist near you and find comprehensive information about eye health visit

http://Minnesota.aoa.org

Minnesota Optometric Association

Doctors on the frontline of eye and vision care

Children’s eyesight to page 25

Vision issues are

usually not noticeable.

Resources www.covd.orghttp://minnesota.aoa.org/www.pavevision.orgwww.infantsee.org

Physicians and other health experts recommend that people of all ages eatfish twice a week. Yet, we also know

that most fish are contaminated with mer -cury and that some fish are contaminatedwith additional chemicals. Isn’t this contra-dictory? Why should we eat fish if it’s con-taminated with chemicals?

Why eat fish?

Mounting scientific evidence shows that eat-ing fish low in mercury and other contami-nants—particularly fish rich in omega-3fatty acids, like sardines and salmon—isgood for the health of adults and for thegrowth and development of babies and chil-dren. Consumption of fish by adults hasbeen strongly linked to a lower risk of car-diovascular disease. Other research indicates

lower risk of stroke, depression, age-relatedmental decline, and improved arthritis symp-toms, among many other benefits. In babiesand children, omega-3 fatty acids from fishpromote brain growth and development. Inseveral studies, mothers who ate fish whilethey were pregnant gave birth to babies whohad better eyesight and higher scores oncognitive tests as infants and at age fourthan babies whose mothers did not eat fish.Other studies have shown that eating fishduring pregnancy may result in newbornswith higher birth weights and may help pre-vent premature births.

However, you can’t tell by tasting,smelling, or looking at a fish whether it iscontaminated with chemicals, nor theamount of mercury or other chemicals itmay contain. That’s why the Minnesota

P U B L I C H E A L T H


Fish consumptionguidelinesWhich fish, and how much fish, is safe to eat?

By Deborah Durkin, MPH

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Department of Health (MDH) providesSafe-Eating Guidelines. MDH uses monitor-ing results from fish caught in Minnesota todetermine how much Minnesota-caught fisha person can eat without risking too muchexposure to contaminants. MDH also

provides Safe-EatingGuidelines for pur-chased fish based oninformation from thefederal governmentand other sources.

How to choose fish

Whether you eat fish that are caught inMinnesota, canned tuna, fresh fish from thegrocery store, or fish at a restaurant, MDHsafe-eating guidelines help you choose fishthat maximize health benefits and minimizepotential risk from chemical contaminants.

Statewide guidelines cover all fishcaught or purchased in Minnesota. For peo-ple who want information about a particu-lar Minnesota lake or river where they liketo fish, there are site-specific guidelines.

Site-specific guidelines provide detailedinformation on fish found in approximately1,500 Minnesota lakes, rivers, and streams

where fish have been tested for chemicals.Con sumption advice for fish from these tes -ted waters may be the same or slightly dif-ferent from statewide advice, so it’s a goodidea to check site-specific guidelines if youfish the same waters frequently.

Guidelines for mothers and children

Within each set of guidelines—statewide andsite-specific—there is more restrictive advicedesigned to protect babies and young chil-dren. This is necessary because even smallamounts of mercury can damage a brainthat is just starting to form or grow.Consequently, developing fetuses and chil-dren under age 15 are at greatest risk frommercury contamination.

Pregnant women should be extra carefulabout the fish they eat because pregnantwomen provide nutrition for their babies

Fish consumption guidelines to page 24

Safe Eating Guidelines for Minnesota-caught fish:

Pregnant Women, Women WhoCould Become Pregnant, Children Under Age 15

1 serving/week of any Minnesota-caught:

• Bullhead • Crappie• Sunfish • Yellow perch

AND ALSO 1 serving/monthIn addition to fish from the groupabove, you can also have 1 servingeach month of Minnesota-caught: • Bass• Catfish• Northern pike smaller than 30 inches• Walleye smaller than 20 inches• Other Minnesota species

Do Not Eat Minnesota-caught:• Muskellunge• Northern pike longer than 30 inches• Walleye longer than 20 inches

Safe Eating Guidelines forMinnesota-caught fish: Men, BoysAge 15 and Older, and Women Not

Planning to Become Pregnant

No more than 4 servings/week ofMinnesota-caught:

• Bullhead • Crappie• Sunfish • Yellow perch

OR 1 serving/week of Minnesota-caught:

• Bass • Catfish• Northern pike • Walleye• Other Minnesota species

Don’t beafraid toeat fish.

In the next issue...

• Foodborne illness• COPD• Viatical insurance


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before birth. Because mercury takes time toleave the mother’s body, women who mightalready be pregnant or who plan to becomepregnant should follow the same guidelinesas pregnant women. While it is healthful forpregnant women and children to eat fish,they should be careful to eat fish that arelow in mercury, and to consume that fishaccording to the recommended guidelines.

Resources

All of the MDH safe-eating guidelines can be found on the MDH website atwww.health.state.mn.us/divs/eh/fish/Site-specific safe-eating guidelines are also on the Minnesota Department ofNatural Resources (DNR) LakeFinder atwww.dnr.state.mn.us/lakefind/index.htmlTo learn more, order the following materials

online or toll-free by phone; they are pro -vided free of charge and free from shippingcharges.

• Eat Fish Often? A Minnesota Guide toEating Fish: Health-based advice on eatingfish from lakes and rivers in Minnesota

• A Family Guide to Eating Fish: Safe-eatingguidelines for fish from Minnesota watersand fish bought in restaurants and stores(in English and Spanish)

• Talk about Fish and Way of Eating Fish:Hmong-language video explains how tochoose fish low in mercury.

• Eat Smaller Fish magnet reminds you thatsmaller fish typically have lower levels ofcontaminants.

Order online at:www.health.state.mn.us/divs/eh/fish/forms/index.html or by telephone at (651) 201-4911/(800) 657-3908; press 1.

You can also email Fish Advisory ProgramOutreach Coordinator Deborah Durkin([email protected]).

Wise consumption nets benefits

Scientific evidence continues to grow: Eating fish low in mercury and other con-taminants, particularly fish that is rich inomega-3 fatty acids, is good for adult healthand for the growth and development ofbabies and children.

Don’t be afraid to eat fish. Eat fish lowin contaminants every week to get all of itshealth benefits while lowering your expo-sure to mercury and other contaminants.

Deborah Durkin, MPH, is the fish advisory pro-gram outreach coordinator within the SiteAssessment and Consultation Unit of theMinnesota Department of Health.

Fish consumption guidelines from page 23


Choose fish that maximize health benefits and minimize potential risk from chemical contaminants.

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tion; difficulty grasping the concept of right and left;letter reversals, such as interpreting b as d; and failureto recognize patterns or familiar words or objects.These skills can be learned.

Enhance your child’s vision • Play! Visual skills are learned through motor activi-

ties and experience, so play catch or roll a ball withyour child. Expose your child to real, three-dimen-sional objects so he or she learns how to focus theeyes at different distances. Television and videogames do not teach this skill.

• Healthy eyes and vision need a nutritious diet thatincludes vitamins A, C, D, and E, as well as theessential fatty acids EPA and DHA.

• Wear sunglasses. Eighty percent of sun damageoccurs before 18 years of age. Sunglasses should bepolarized and protect against UVA, UVB, and UVCrays.

• Wear sports glasses, which can help prevent the600,000 sports-related eye injuries that occur eachyear.

• Educate children about risks associated with sharpobjects near their eyes. Select toys carefully and seekimmediate professional care after any eye injury.

Comprehensive vision examinationUnlike a screening, a comprehensive vision examinationassesses eyesight, eye health, and how the eyes focusand work together during near work. Because mostvision conditions have no obvious signs or symptoms, acomprehensive exam by an eye doctor trained in visualdevelopment is needed to identify problems that couldimpact the future potential of the child. The AmericanOptometric Association recommends all childrenreceive their first eye examination between 6 and 12months of age, at 3 years, before kindergarten, andevery one to two years thereafter.

Good vision promotes full potentialBecause visual skills are learned, they can be developed.Possible treatment options include glasses, contact lenses, patching one eye, vision therapy, and, in rarecases when other efforts have been exhausted, surgery.Vision therapy is similar to speech, physical, and occu-pational therapy in that it treats deficient visual skills.Many children notice great improvement in school andsports performance after this therapy—good visualskills help children reach their full potential.

Jill Schultz, OD, FAAO, FCOVD, is board-certified in visiontherapy and visual development. She serves on the Children’s

Vision Committee of the Minnesota Optometric Association and practices atBright Eyes Vision Clinic in Otsego and Minnetonka.

Children’s eyesight from page 21

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“On Wednesday night there was a magnitude4.5 earthquake. We only felt it as a slight vibra-tion where we were, but it very understand-ably caused a lot of concern.”

So goes an entry in the blog “ProjectOrtho: From Hennepin to Haiti,” which chroni-cles the work of Patrick Yoon, MD, and otherproviders from Hennepin County MedicalCenter (HCMC) as they provide health careservices in Haiti. Orthopedists from HCMChave been traveling to Haiti on a regular basissince a January 2010 earthquake devastatedthat country.

The severity of that earthquake, its effecton Haiti’s infrastructure and economy, and the

country’s severe poverty have combined to cre-ate ongoing demand for volunteer health careexperts such as the HCMC providers.

“There’s absolutely a need,” Yoon says.“There’s been a shift from taking care of theacute injuries from the quake to taking care ofsome of the long-term sequelae and complica-tions of injuries, for example,nonhealing bones and chronicinfections.”

HCMC providers have beentraveling to Haiti about twice ayear, Yoon says, working primar -ily out of Hospital Adventisted’Haiti, in the town of Carrefour.On his trip in March 2012, Yoonsays his team saw a mix of condi-tions, including chronic infectionsdue to injuries from the quake,congenital deformities in chil-dren, and acute broken bones,which he notes is a commonproblem in a city with manyroads that are still in bad shape.

The Adventist hospital islocated 20 miles outside Haiti’scapital of Port-au-Prince, and is

considered a large hospital, with approximat ely70 beds. Yoon notes that the hospital has anumber of issues that would give U.S. physi-cians pause but which are not unusual for aHaitian facility. These include power shortages,sanitation issues, and a staff that is overworkedand underpaid.

Since his first trip in July 2010, Yoon hascollaborated with Tom Slater, a surgical techni-cian from HCMC who also participated in theHaiti mission trips, to blog about the team’sexperience of providing health care in Haitiafter the earthquake. The blog providesremarkable insights into the experiences of theAmerican health care workers. Providers writeabout looking out over tent cities of injuredHaitians and their families, choking on air thickwith smoke from trash fires, or hunkeringdown to weather out hurricanes that furthercomplicate their efforts to deliver health care.

The topics can be relatively lighthearted aswell, such as when the bloggers note the tem-porary loss of Internet service because the hos-pital didn’t pay its bill, or compare notes onlocal food, or write of enjoying their trips tolocal orphanages. (“Every Haitian kid I see isthe absolute cutest kid ever ... until I see thenext one,” one provider writes.)

“It’s a way to process what we’ve beenthrough,” Yoon says of the blog. “A lot oftimes you have very strong emotions that canoccur with all the stress of working 17-, 18-hour days under what can be sometimes veryhectic conditions. It’s a way to digest it and Iguess vent in a way so that you don’t keep itall bottled up inside. There are oftentimesemotional moments where there are patientsyou can’t save or who’ll never walk again. It’s a

way to process all that and dealwith it in our own way.”

Yoon says the blog, whichoften features photographs ofproviders and patients alike, hasdrawn a following back home inMinnesota, including followerson Facebook. “It’s somewhateducational to let them knowhow bad people have it downthere in a country that’s reallynot very far away at all,” he says.“We try to not just treat patientsas numbers, but [also show]faces to put with the names andshow that these are humanbeings, no better than you orme, just the same as us, thathave had horrible things happento them and need help.”

Making a difference in

C O M M U N I T Y C A R E G I V E R S 2 0 1 3

Blogging from the epicenter


“There arepatients you can’t

save or who’llnever walk again.”

Patrick Yoon, MD

MRecognizingMinnesota’s volunteer physicians

Each year, Minnesota

Physician Publishing

honors physicians

who have volunteered

medical services in

recent years. Through

volunteer medical

activities that span

the globe, Minnesota’s

volunteer physicians

have provided medical

care and medical

education while

expanding cross-

cultural skills and

understanding. Their

compassion, commit-

ment, and generosity

reflect deeply held

values of Minnesota’s

medical community.

By Scott WooldridgeAssistant editor

Minnesota PhysicianPublishing

Our team resting at night after a long day in the OR.


For the past seven years, S. Jafar Hasan, MD,an ophthalmologist with Edina Eye Physiciansand Surgeons, has offered free eye-care clinicson a bimonthly basis. He says he was motiv -ated to launch the clinics primarily by seeingthe number of people without access to goodhealth care.

Hasan notes that doing something assimple as providing glasses can make atremendous difference to people with poorvision. “Getting a pair of glasses can reallychange someone’s life, so it’s a really easything to do, with a big reward,” he says. Thefree clinics screen for basic eye conditionsand provide eye exams. Hasan says Edina Eyeprovides eyeglass prescriptions at a signifi-cant discount for patients of the free clinic.

Hasan has also been involved with BigBrothers, Big Sisters organization, and hasworked with local schools to provide preven-tive eye care to children. He says he’s alwayshad an interest in helping others. “My father is a social worker, so he just kind of ingrainedthat in me.”

Hasan, who is Muslim, says his religioninfluences his community work. “We’re taught

to give back, and that’s what I’m trying todo,” he says. Hasan and some colleagues started Muslim Physicians of Minnesota a fewyears ago. “Basically our goal is to provideaccess to health care and education for allpeople, not just Muslims; our goal is to incor-porate everybody,” he says.

The group provides health care services athealth fairs and educational seminars, and at

Day of Dignity, an annual community eventsponsored by the Masjid An-Nur mosque andIslamic Relief USA. Day of Dignity has beenheld on Minneapolis’ north side in Octoberthe past two years.

Hasan says the annual event allows groupslike his to reach out to the community. “It’skind of an open house for people who don’t

have access to many social services,” he says.“They’ll have financial people there, nursesgiving out flu shots. We had a booth there,not just for eye care; we had a cardiologist,blood pressure screenings, cholesterol screen-ings, and other things.”

According to Hasan, Muslim Physicians ofMinnesota has a membership of approximately200 people, which includes health care work-ers other than physicians. He says the grouphas been trying to raise its visibility and theresponse has been good so far. In addition tothe eye clinics he provides, the group alsosponsors primary care and pediatric clinics atdifferent locations around the Twin Cities.

“The other thing we’re working on now isoutreach to try and get mentors for students,particularly Somali students,” he says. “Manyof them don’t have [mentors] in the commu-nity if they’re interested in the medical field.”

Hasan hopes to begin offering his eye cli -nic on a monthly basis, in response to increas-ing demand. “There’s definitely a need,” hesays. “There are more and more people with-out access to good health care. There’s been apretty significant backlog of people needingeye care.”

Giving back

“ We’re taught togive back, andthat’s what I’m trying to do.”Jafar Hasan, MD

Caregivers to page 28

n Minnesota and the world

Call to get help with: Planning for long-term care Remaining independent in your community Arranging for in-home services Getting help from state agencies Becoming involved in your community

Understanding Medicare

p with

A One Stop Shop for Minnesota Seniors



Many physician volunteers go on medical missions that involve travelingfrom developed nations to relatively impoverished regions. Jerry Kobrin,MD, along with his wife Hilary Stecklein, MD, have worked to preparethousands of people from a poor region of Africa to travel to new,healthier lives in Israel.

Kobrin and Stecklein are both physicians with HealthPartners;Kobrin is an ophthalmologist and Stecklein, a pediatrician. They haverecently been working with Jewish Healthcare International (JHI) on anongoing project that has relocated thousands of Ethiopian Jews. TheEthiopians have been working with the Israeli government since the1980s to relocate members of this ethnic minority to Israel, a processcalled aliyah. According to JHI officials, the Israeligovernment is planning to relocate the approximately8,000 Jews remaining in Ethiopia to Israel by 2015.

As part of that effort, Kobrin and Stecklein trav-eled last June to Gondar, Ethiopia, a region wheremany Ethiopian Jews are located. The two doctorsprovided physicals and medical screenings for indi-viduals who were scheduled for aliyah. Health issuessuch as tuberculosis and malnutrition are not uncom-mon, and the Israeli government, along with JHI, isworking to make sure that the emigrants are rela -tively healthy and have up-to-date medical records.

Kobrin says the program identifies those with themost pressing medical needs and treats them, usu -ally at a local hospital. “It all depends on the urg -ency,” he says. “It could be a minor thing like dentalcare. We can alert the authorities so the proper ap -pointments are made. If it’s an urgent situation, wecan make sure they’re taken care of and healthyenough to go.” Physicians with JHI also give lectures

and provide training at the medical school in Gondar, in an effort toleave a self-sustaining medical legacy behind, Kobrin notes.

Northern Ethiopia is beautiful, Kobrin says, not the desert that onemight expect. “The northern region is mountainous and quite green,actually. It has a fascinating history and very warm and friendly people.”

However, he adds, the people of northern Ethiopia are often quiteimpoverished, with most working as subsistence farmers. “It’s very hardfor them to scratch out a living there,” Kobrin says. Emigrating to Israelgives them a future of new opportunities, he says, but the transition isnot easy. He says the Ethiopian emigrants are “terrified and excited. It’sa whole new life for them. It’s like going to another planet.”

To help with that, JHI and the Israeli government have instituted anumber of programs to educate emigrants and help them with language

training and other acclimation issues. JHI’s programto identify health conditions and create medicalrecords is part of those transition efforts, Kobrin says.

The JHI program, he says, “… tries to identifymedical problems early and pay attention to thetypes of medical conditions these people are bringingwith them. It’s like going back 2,000 years on theclock. In developed countries, you don’t see rampantmalnutrition, malaria, tuberculosis. With the help ofthe medical university there, when we identify some-one who is really sick, we can provide them with careto get them on their feet again so they can be healthyenough for the journey.”

Kobrin, who worked with JHI on earlier medicalmissions to Eastern Europe, says the work with Jewspreparing for aliyah was very fulfilling. “It was won-derful to get back to the basics. It was very heart-warming working side-by-side with my spouse,” hesays. “These are gentle people, very appreciative,and it was wonderful to help them start a new life.”

Starting a new life

“It’s like going back 2,000 years on the clock.”

Jerry Kobrin, MD, and Hilary Stecklein, MD

Read usonlinewherever you are!

www.mppub.com

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Margit Bretzke, MD, has been part of a small, Minneapolis-based med-ical mission to Guatemala for the past eight years. The organization,Medical Teams Serving Guatemala, sends teams of surgeons and otherproviders for a total of three weeks (one week for every team) each fallto the city of Antigua, west of Guatemala’s capital, Guatemala City.There, the teams provide treatment for Guatemalans who otherwisewould have little hope of being seen by a surgeon.

Bretzke says the trips have been something that she has enjoyedsharing with her family. Her husband, Jeff Hanson, MD, has an exten-sive history of working in community clinics in Minneapolis as a familypractice physician, and her son, Peter, has been on sev-eral trips, starting when he was 10 years old. She notesthat Peter has always helped out with jobs associatedwith the Catholic church where the mission is based.

“One year he helped inoculate chickens; he helpedbuild prefab houses that they would send into the moun-tains for people. He and Jeff would do language school,”she says. “Peter actually had the opportunity to come intothe operating room a couple times just to see what thatwas like.” When asked if the experience had left animpression on Peter, Bretzke laughs. “Yes, he’s real clearthat he doesn’t want to go into medicine.” She adds thatwhile visits to the operating room were rare, children ofproviders have often come on the missions and havealways gotten a lot out of the trips.

“It’s a really good experience,” she says. “They real-ize how lucky they are in the United States. We’vealways wanted our son to think globally, and this helps,to do things like this and understand what people are upagainst.”

The patients served by the mission come from allaround the region, and stay at a local facility while recov-

ering from surgery. Bretzke says the surgical team does five to sixcases a day, with restrictions due to lack of supplies and medical sup-port. “We have to do the kind of surgeries that keep people in the hospi-tal maybe one or two nights, that aren’t going to need an intensive careunit, that are unlikely to need a blood transfusion.”

Even within those limits, there are many serious conditions to treat.“They can be like the biggest hernias you’ve ever seen; the gallbladder’salways hard, but people have had these issues for years and years andhaven’t had access to health care,” she says. “The other thing that isalways so remarkable to us is that they don’t require much for pain. Ithink these people live with a lot of pain in their lives, and they’re just sohappy to have things taken care of. You’ll send them home with ibupro-

fen and that’s it. They never complain, and they may haveto walk 10 miles. It’s just remarkable.”

Despite having to operate in less than ideal condi-tions, Bretzke says the surgeons who participate in themission enjoy the trip and often will chip in extra money tohelp fund the mission. “You can have a lot of fun, and youlearn,” she says. “Most surgeons, I think, are thrill seekersin one way or another. You’re doing things really out ofyour comfort zone. You’re not sure about your equipment,always; you’re not sure what you’re going to find.”

Bretzke says that another program that has becomeimportant to her is the Common Hope initiative, whichgives providers on the mission the opportunity to helpsponsor a Guatemalan child’s education. “The deal is thatCommon Hope will continue to support this child as longas they stay in school. A lot of people who have gonedown there ended up doing this,” she says. “Every yearwe visit the family. That last day you’re not operating; mostpeople go visit the child they’re helping support. That isunbelievably powerful, to get to know that family.”

Outside the comfort zone


“Most surgeons, I think, are thrill

seekers in one way or another.”

Margit Bretzke, MD


Appointments:

Online or Call 651-439-8807

Providing care at multiple modern clinics in Minnesota and Wisconsin

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.

Supporting Our Patients.Supporting Our Partners.Supporting You.

David Palmer, M.D.& Zawadi’s brother

Russ McGill, OPA-C& Zawadi

mute aviding carorP

innen clinics in Multiple moder

onsiniscWesota and

Aaron Johnson, MD, has seen firsthand how important building trust iswhen U.S. providers undertake medical missions in impoverished areasof Mexico and Guatemala. Johnson, who has been traveling to commu-nities in those countries for four years with Minnesota Doctors forPeople (MDP), knows the troubled history of the region, which hasseen political corruption, crime, and civil war.

“There’s always been that trust piece; they have a hard time know-ing who to trust,” says Johnson, a family practice physician from UnitedHospital District in Blue Earth. “In Chiapas, I noticed when we weredown there last year, people came back to us and said,‘Yeah, we remember your group.’ That’s huge, becausethe indigenous Indians there have a fair amount of dis-trust and they’re not sure they should even talk to you,let alone let you look in their mouth or at their back. Justbreaking down those barriers is progress. But it’s slow.”

Johnson says it helps that his group works closelywith local providers and hospitals, especially inGuatemala where MDP has a longer history, to providesupplies and support. “We try to do as much teaching aswe can,” he says. “It’s more than just going down andthrowing Band-Aids on; we’re actually trying to help thelocal parishes and communities, and local individual[caregivers]. Some of them are the equivalent of an RN,and for a lot of stuff, they would be very qualified tomanage things like high blood pressure.”

A typical trip for Johnson and the other MDPproviders lasts from seven to 10 days. Physicians andmedical staff see up to 60 patients a day, usually atmakeshift clinics set up in remote villages. He recalls onevisit from last year’s trip, when they arrived in a smalltown and started seeing patients in the early afternoon.

“People were already lined up outside of the building, which waskind of their community center, but it was really kind of the equivalentof a barn. There were three incandescent light bulbs down the lengthof this room, which was probably 35 feet,” Johnson says. “So we justkind of set up makeshift partitions, and each provider had one lightbulb above us. We went until about midnight. There were just so manypeople there that had walked to this little town, which was a big townfor them, but still a pretty small place. So we just kept seeing people.”

Johnson says the providers see a wide range of conditions, fromdiabetes, to infections, to muscle strains. In some cases, they performminor surgeries. With chronic conditions, such as diabetes, they can

offer only limited help. Other conditions are easier todeal with. “We see a lot of parasite-type stuff, which isone of the things we can actually treat, so it’s fairlyrewarding,” he says. “We can give them a three-daycourse of anti-worm medicine and know it’s going to betaken care of. Doesn’t mean that they’re not going toget it again; but at least you can treat it.”

The missions can be eye-opening, Johnson notes, asthe MDP teams regularly encounter conditions veryrarely seen in the U.S. “There’s lots of really bizarrepathology that you’d see in a textbook in a medicalschool—rheumatic heart disease, for example. Mostpeople go through medical school and their practiceand [never see it], unless it’s in a 90-year old, a truerheu matic heart murmur. You’ll hear it in 20-, 30-, 40-year-olds all the time down there.”

Johnson adds that the experience is both emotion -ally draining and, at the same time, invigorating. “Itkind of takes you back to why most individuals want tobe a nurse or a doctor,” he says. “It takes you back tothe basic level of just being able to help somebody.”

A mission of trust

“We see a lot of parasite-type stuff,

which is one of the things we

can actually treat.”Aaron Johnson, MD



Every day is a reason for a person with Down

syndrome to smile. And find joy in things the rest

of us often overlook. To learn more about the rich-

ness of knowing or raising someone with such an

enthusiasm for life, call your local Down syndrome

organization. Or visit ndsccenter.org today.

It is the mission of the Down Syndrome Association of Minnesota to provide information, resources and support to individuals with Down syndrome, their families and their communities. We offer a wide range of services, programs andmaterials at no charge. If you are interested in receiving one of our information packets for new or expectant parents, please email [email protected] or

For more information please call:

(651) 603-0720 • (800) 511-3696©2007 NationalDown SyndromeCongress

WHO’S GOT BETTER MOVES ON THEDANCE FLOOR, YOU OR ME?

Richard Hart, MD, has a long history of medical missions and commu-nity work to his credit. The St. Cloud pediatrician’s latest recognitionwas being named the recipient of the 2012 Caduceus Award from St. Cloud’s CentraCare Health Foundation.

The Caduceus award recognizes physicians who have made a com-mitment of $10,000 or more to support the mission of improvinghealth and health care in central Minnesota. Winners are selected bytheir peers in the medical community. Officials with CentraCare notethat Hart was instrumental in forming a program developed by St. Cloud State University that created care plans for severely disabledchildren.

The award also highlighted Hart’s long history ofmedical missions, such as work with HELPS International,an Addison, Texas–based charitable foundation thatworks with nongovernmental organizations to providehealth care, education, economic development, andother services to impoverished areas.

Hart recalls working with HELPS in the ‘90s, when heparticipated in medical missions to rural communities inGuatemala. “It was about a 10-hour or 12-hour bus ridethrough the tropical forest,” he says. “We had to taketwo buses, because if one would get stuck, the secondone would be able to pull the first bus out.”

Closer to home, Hart’s work with St. Cloud StateUniversity brought together school specialists, psycholo-gists, public health officials, and pediatricians to addressthe needs of disabled children in local schools. “We tookchildren who were having a great deal of difficulty in theschool system,” he says. “We spent half a day evaluatingeach student and tried to come up with a care plan thatwould work. We did get some feedback. We had some

very good successes, and we had some that didn’t work so well.”More recently, Hart has been working with the March of Dimes on

projects such as “Healthy Babies Are Worth the Wait,” a programencouraging expectant mothers to carry babies to 39 weeks. March ofDimes officials note that some births are being scheduled earlier than39 weeks for nonmedical reasons, and they warn of health problemsthat can come from early deliveries.

Hart says that he and his wife, Patricia, a neonatal nurse practition-er who serves on the March of Dimes state board, strongly support theHealthy Babies program. “A lot of maturation of the fetus occurs in thelast few weeks [before birth],” he says. “Before 37 weeks, there can bea significant number of problems, and before 39 weeks, they don’t

have their full nutrition. They’re still prone to jaundiceand other problems that can show up a little bit later.”

With his history of community service and volunteerwork for medical missions, Hart says he appreciates thevolunteering spirit of health care providers in the St. Cloud area. “There’s a lot of local interest in volun-teering for a variety of programs,” he says. “We’re noton as big a scale as the bigger programs in the TwinCities, but we’re finding more and more people [whovolunteer].”

Hart also says his experience suggests that physi-cians and health care groups should pay attention to thefeedback they receive from communities they serve.“From a volunteer standpoint, that becomes the mostimportant thing,” he says. “Rather than us decidingwhat we’re going to do, see where the patients or fami-lies demonstrate a need—then you can help them outwith that specific need.”

“There’s a lot of local interest in

volunteering for a variety of programs.”

Richard Hart, MD

Committed to community service



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Last spring, Hani Ahmed, MD, returned to Somalia, a country she hadleft 23 years earlier as a child. Ahmed volunteered in 2012 with theAmerican Refugee Committee (ARC) to work for a month at a hospitalin the capital of Mogadishu. The timing was not perfect: Somalia wassuffering from a famine and some of the worst factional fighting inrecent years.

Ahmed’s coworkers at Hennepin County Medical Center (HCMC)were not eager to see her travel into a war zone. “My program directorwas concerned; I remember her saying, ‘We want you to be safe,’”Ahmed says. “I really pushed for it. I felt I had to do it.”

It’s not hard to understand her director’s concern.Ahmed described having trouble sleeping at night due tomortar shells overhead. She heard gunshots on a dailybasis. Minneapolis-based ARC provided her with an armedescort and evacuation insurance.

“There was a lot of violence when I was there,”Ahmed recalls. “Driving through the city, we had to wear bulletproof vests every day and a helmet because of possible stray bullets. You couldn’t go anywhere atnight. You had this constant sense of agitation; you justcouldn’t really relax.”

The hospital where she worked, Benadi Children’sHospital, had also been marked by war. She describes afacility lacking in supplies and run by a handful of youngdoctors just out of medical school. “Probably some of myearliest reactions were shock and despair,” she says.“Especially the first two weeks; it was really overwhelmingto take in how bare it was. There was no monitoringequipment of any kind. There were times when therewere no physicians. All the medications were locked in acabinet because they could be sold in the market. We justhad the absolute minimum of everything we needed.”

In addition to treating patients, Ahmed, an internal medicine resident at HCMC, worked to educate some of the hospital staff thatlacked medical training. She taught staff to take vital signs and docu-ment medication for patients. She set up an isolation ward for tubercu-losis patients. “I had to learn to do as much as I could with as little possible,” she says. “Those kinds of experiences make you realize whatis a priority.”

Despite the lack of resources and the dangerous state of the city,Ahmed describes the experience as tremendously rewarding. “I can’tthink of any better feeling,” she says. “It was overwhelming when I

went there, but when I left I felt very happy.” She saidthe knowledge that she could make a real difference wasone reason why she pushed to go to Mogadishu. “BeingSomali myself, I knew the biggest impact I was going tomake was going to be in a place like Somalia,” she says.“I speak the language. The people are my people. I feltlike I could just do so much more.”

Ahmed says she plans to return to Somalia, probablyin 2014. She notes that the security situation is improvingand that the country is now more politically stable.

In the meantime, Ahmed is raising funds for ARC andsharing her story with other health care providers and thecommunity. She is talking with Somali physicians aboutthe possibility of regular trips to the country and of send-ing equipment and money to hospitals like BenadiChildren’s Hospital. To help with fundraising, she hasdeveloped a slideshow of pictures she took during hermission. “The concern of donors is always whethermoney is going to reach the people in need,” she says. “Ithink seeing pictures from the ground, they see firsthandwhat ARC is doing. They see exactly what the sort ofneed is and how much need there is.”

“We had to wearbulletproof vestsevery day and a

helmet because ofstray bullets.”

Hani Ahmed, MD


Mogadishu Spring


Health Care ConsumerAssociation

Minnesota

Each month, members of the Minnesota HealthCare Consumer Association are invited to participate in a survey that measures opinionsaround 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 March survey.

Pe

rce

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Strongly

agree

Does not

apply

Agree Disagree Strongly

disagree

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10

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35.29%

50%

0%

11.76%

2.94%

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Strongly

agree

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disagree

0

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14.71%

2.94%

50%

26.47%

5.88%

2. I get most of my health care advice from a medical doctor.

1. I trust the professional advice of my medical doctor.

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disagree

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8.82%

2.94%

58.82%

29.41%

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Strongly

agree

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disagree

0

5

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14.71%

23.53%

5.88%

38.24%

17.65%

5. I, or a member of my family, have requested specificmedication and been unable to receive it because itwas not covered by my health insurance.

Pe

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disagree

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26.47%

8.82%

50%

14.71%

3. I have had trouble following the instructions of mymedical doctor.

March survey results ...

4. I, or a member of my family, have had difficulty fillingprescriptions due to drug shortages.

“A way for you to make a diff erence”

Join now.

SM

Welcome to your opportunity to be heard in debates and discussions that shape the futureof health care policy. There is no cost to joinand all you need to become a member is access to the Internet.

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

www.mnhcca.org

Health Care ConsumerAssociation

Minnesota


used to minimize these complications and to make sure that donorand recipient blood are compatible.

Transfusion alternatives

During the past 25 years, medicine has learned that patients do verywell with less blood than was previously believed necessary. There -fore, transfusion now is done less frequently. In addition, strategiesto avoid transfusion are used increasingly. These include operatingroom machines that recover a patient’s blood lost during surgeryand return it to the patient.

Patients planning a surgical procedure that may involve transfu-sion can donate blood for their own use. However, this is not doneoften because:

• Donor blood is extremely safe.

• Medical reasons such as anemia (insufficient oxygen in the blood)may make self-donation dangerous for the patient.

• A limited amount of blood can be self-donated, potentially replac-ing only part of the need.

• Storing self-donated blood costs more than using publicly donatedblood.

• Complications can arise from transfusion of a patient’s ownblood. Self-donation is rarely recommended by surgeons.

Ongoing need

Since efforts to develop a blood substitute have been unsuccessfuland since all blood components have a short shelf life, donation of this life-giving substance continues to be vitally important. To donate or to learn more, visit www.redcross.org or call (800) 733-2767.

Jeffrey McCullough, MD, is a professor in the Department of LaboratoryMedicine and Pathology at the University of Minnesota, where he holds theAmerican Red Cross chair in transfusion medicine in the medical school.He has served as the scientific director of the St. Paul Regional Red CrossBlood Service since 1992.

Donated blood from page 17

Transfusion now is done less frequently,and strategies to avoid transfusion

are used increasingly.


Elizabeth Klodas, M.D.,F.A.S.C.C is a preventive

cardiologist. She isthe founding Editor inChief of CardioSmartfor the American

College of Cardiologywww.cardiosmart.org,a published author

and medical editor forwebMD. She is a member

of several nationalcommittees on improving

cardiac health and afrequent lecturer on

the topic.

Preventive Cardiology Consultants isfounded on the fundamental belief thatmuch of heart disease can be avoidedin the vast majority of patients, andsignificantly delayed in the rest, by prudentmodification of risk factors and attainablelifestyle measures.

We are dedicated to creating a true part-nership between doctor and patient workingtogether to maximize heart health. Wespend time getting to know each patientindividually, learning about their lives andlifestyles before customizing treatmentprograms to maximize their health.

Whether you have experienced any typeof cardiac event, are at risk for one, or

are interested in learning how to preventone, we can design a set of just-for-yousolutions.

Among the services we provide

• One-on-one consultations withcardiologists

• In-depth evaluation of nutrition andlifestyle factors

• Advanced and routine blood analysis

• Cardiac imaging including (as required)stress testing, stress echocardiography,stress nuclear imaging, coronary calciumscreening, CT coronary angiography

• Vascular screening

• Dietary counseling/Exercise prescriptions

Now accepting new patients

A unique perspective on cardiac care

To schedule an appointment or to learn more about becominga patient, please contact:

Preventive Cardiology Consultants6545 France Avenue, Suite 125, Edina, MN 55435

phone. 952.929.5600 fax. 952.929.5610 www.pccmn.com

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®isaglucagon-like-peptide-1(GLP-1)receptoragonistusedtoimprovebloodsugar(glucose)controlinadultswithtype2diabetesmellitus,whenusedwithadietandexerciseprogram.

• Victoza®shouldnotbeusedasthefirstchoiceofmedicinefortreatingdiabetes.

• Victoza®hasnotbeenstudiedinenoughpeoplewithahistoryofpancreatitis(inflammationofthepancreas).Therefore,itshouldbeusedwithcareinthesepatients.

• Victoza®isnotforuseinpeoplewithtype1diabetesmellitusorpeoplewithdiabeticketoacidosis.

• ItisnotknownifVictoza®issafeandeffectivewhenusedwithinsulin.

Who should not use Victoza®?

• Victoza®shouldnotbeusedinpeoplewithapersonalorfamilyhistoryofMTCorinpatientswithMEN2.

What is the most important information I should know about Victoza®?

• Inanimalstudies,Victoza®causedthyroidtumors.Theeffectsinhumansareunknown.PeoplewhouseVictoza®shouldbecounseledontheriskofMTCandsymptomsofthyroidcancer.

• Inclinicaltrials,thereweremorecasesofpancreatitisinpeopletreatedwithVictoza®comparedtopeopletreatedwithotherdiabetesdrugs.Ifpancreatitisissuspected,Victoza®andotherpotentiallysuspectdrugsshouldbediscontinued.Victoza®shouldnotberestartedifpancreatitisisconfirmed.Victoza®shouldbeusedwithcautioninpeoplewithahistoryofpancreatitis.

• Seriouslowbloodsugar(hypoglycemia)mayoccurwhenVictoza®isusedwithotherdiabetesmedicationscalledsulfonylureas.Thisriskcanbereducedbyloweringthedoseofthesulfonylurea.

• Victoza®maycausenausea,vomiting,ordiarrhealeadingtothelossoffluids(dehydration).Dehydrationmaycausekidneyfailure.Thiscanhappeninpeoplewhomayhaveneverhadkidneyproblemsbefore.Drinkingplentyoffluidsmayreduceyourchanceofdehydration.

• Likeallotherdiabetesmedications,Victoza®hasnotbeenshowntodecreasetheriskoflargebloodvesseldisease(i.e.heartattacksandstrokes).

What are the side effects of Victoza®?

• Tellyourhealthcareproviderifyougetalumporswellinginyourneck,hoarseness,troubleswallowing,orshortnessofbreathwhiletakingVictoza®.Thesemaybesymptomsofthyroidcancer.

• Themostcommonsideeffects,reportedinatleast5%ofpeopletreatedwithVictoza®andoccurringmorecommonlythanpeopletreatedwithaplacebo(anon-activeinjectionusedtostudydrugsinclinicaltrials)areheadache,nausea,anddiarrhea.

• Immunesystemrelatedreactions,includinghives,weremorecommoninpeopletreatedwithVictoza®(0.8%)comparedtopeopletreatedwithotherdiabetesdrugs(0.4%)inclinicaltrials.

• Thislistingofsideeffectsisnotcomplete.YourhealthcareprofessionalcandiscusswithyouamorecompletelistofsideeffectsthatmayoccurwhenusingVictoza®.

What should I know about taking Victoza® with other medications?

• Victoza®slowsemptyingofyourstomach.Thismayimpacthowyourbodyabsorbsotherdrugsthataretakenbymouthatthesametime.

Can Victoza® be used in children?

• Victoza®hasnotbeenstudiedinpeoplebelow18yearsofage.

Can Victoza® be used in people with kidney or liver problems?

• Victoza®shouldbeusedwithcautioninthesetypesofpeople.

Still have questions?

Thisisonlyasummaryofimportantinformation.Askyourdoctorformorecompleteproductinformation,or

• call1-877-4VICTOZA(1-877-484-2869)

• visitvictoza.com

Victoza® is a registered trademark of Novo Nordisk A/S.

DateofIssue:May2011Version3

©2011NovoNordisk140517-R3June2011

Victoza® helped me take my blood sugar down…

Model is used for illustrative purposes only.

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.

If you’re ready for a change, talk to your doctor about Victoza® today.

FOR TYPE 2 DIABETES

To learn more, visit victoza.com or call 1-877-4-VICTOZA (1-877-484-2869).

Non-insulin • Once-daily

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,

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

Documents

Minnesota Health care News April 2013