minnesota physician february 2011

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T he Institute of Medicine’s landmark report, “To Err is Human,” released in 1999 and followed by several addi- tional reports, made it clear that many patients in the U.S. health care system do not receive the right care or safe care. These reports, along with the patient safety initia- tives by the Joint Commission, the Centers for Medicare & Medicaid Services, and the Institute for Healthcare Improvement, have focused on systems issues and errors, rather than physician incompetence, as the major cause of errors resulting in patient harm. There has been no major study showing sig- nificant physician incompetence in the U.S., but public opinion polls, consumer advocacy groups, health care purchasers, insurers, and managed care organizations nonetheless have called for physicians to be required to regularly demonstrate their competence. At present, most state med- ical boards require physicians to complete a certain number of continuing medical educa- tion (CME) credits and pay a fee to renew their medical license. Physicians are also required to answer a number of questions pertaining to mal- practice cases, disciplinary action taken against them by COMPETENCE to page 10 PRSRT STD U.S. POSTAGE PAID Detriot Lakes, MN Permit No. 2655 Volume XXlV, No. 11 February 2011 Neurobiology of loneliness Meaningful human connection is vital to mental health By Kevin Turnquist, MD T he person who tries to live alone will not succeed as a human being. His heart withers if it does not answer another heart. His mind shrinks away if he hears only the echoes of his own thoughts and finds no other inspiration.” — Pearl S. Buck, novelist How strange that Pearl Buck’s view of loneliness would turn out to be true on a basic neurological level nearly half a century after she wrote these words. For neurobiologists are now learning that loneliness does indeed have profound effects on brain structure and functioning. Human beings are troop pri- mates by nature. Prolonged loneli- ness is antithetical to our primal impulse to be a part of a group. The brain reacts to loneliness as an emer- gency situation. The hormones of our stress response—the glucocorti- coids—are kept at an elevated level. IN THIS ISSUE: Cardiology research Page 20 LONELINESS to page 14 The Independent Medical Business Newspaper Are better tools needed for maintenance of licensure? By Linda Van Etta, MD, FACP, and Jon Thomas, MD, MBA Physician competence

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Health care information for Minnesota doctors Cover: Physician competence by Linda Van Etta, MD, FACP and Jon Thomas, MD, MBA Neurobiology of loneliness by Kevin Turnquist, MD Special focus: Cardiology research

TRANSCRIPT

Page 1: Minnesota Physician February 2011

The Institute of Medicine’s landmarkreport, “To Err is Human,” releasedin 1999 and followed by several addi-

tional reports, made it clear that manypatients in the U.S. health care system donot receive the right care or safe care. Thesereports, along with the patient safety initia-tives by the Joint Commission, the Centersfor Medicare & Medicaid Services, and theInstitute for Healthcare Improvement, have

focused on systems issues and errors, ratherthan physician incompetence, as the majorcause of errors resulting in patient harm.There has been no major study showing sig-nificant physician incompetence in the U.S.,but public opinion polls, consumer advocacygroups, health care purchasers, insurers, andmanaged care organizations nonethelesshave called for physicians to be required toregularly demonstrate their competence.

At present, most state med-ical boards require physiciansto complete a certain numberof continuing medical educa-tion (CME) credits and paya fee to renew their medicallicense. Physicians are alsorequired to answer a numberof questions pertaining to mal-practice cases, disciplinaryaction taken against them by

COMPETENCE to page 10

PRSRTSTDU.S.POSTAGE

PAIDDetriotLakes,MNPermitNo.2655

Volume XXlV, No. 11

February 2011

Neurobiologyof lonelinessMeaningful humanconnection is vitalto mental health

By Kevin Turnquist, MD

The person who tries to live alonewill not succeed as a humanbeing. His heart withers if it

does not answer another heart. Hismind shrinks away if he hears onlythe echoes of his own thoughts andfinds no other inspiration.”

— Pearl S. Buck, novelist

How strange that Pearl Buck’s viewof loneliness would turn out to betrue on a basic neurological levelnearly half a century after she wrotethese words. For neurobiologists arenow learning that loneliness doesindeed have profound effects onbrain structure and functioning.

Human beings are troop pri-mates by nature. Prolonged loneli-ness is antithetical to our primalimpulse to be a part of a group. Thebrain reacts to loneliness as an emer-gency situation. The hormones ofour stress response—the glucocorti-coids—are kept at an elevated level.

IN THIS ISSUE:Cardiology researchPage 20

LONELINESS to page 14

The Independent Medical Business Newspaper

Are better tools needed formaintenance of licensure?

By Linda Van Etta, MD, FACP,and Jon Thomas, MD, MBA

Physiciancompetence

Page 2: Minnesota Physician February 2011

And I did, thanks to Bethesda Hospital, member of HealthEast® Care System.

After a vicious attack fractured her skull and left her in a coma, Tracy Hacker had to learn, not just how to walk again, but also how to be patient with slow, steady progress—a challenge for the energetic horseback rider. Tracy received the full continuum of care available at Bethesda: As an inpatient, brain injury specialists collaborated closely with the respiratory specialty care team. In addition, on-site psychologists aided her progress, with physical medicine and rehabilitative outpatient follow-up services continuing her care. Tracy’s recovery was nothing short of a miracle, and she gives her Bethesda team full credit: “I think it was all the littlest ways they helped me that really made the biggest difference.”

For more information about Bethesda Hospital in St. Paul, Minnesota, visit bethesdahospital.org or call 651-232-2000.

Page 3: Minnesota Physician February 2011

CAPSULES 4

MEDICUS 7

INTERVIEW 8

PROFESSIONAL UPDATE:PHYSICAL THERAPY ANDREHABILITATIONKeeping dancerson their toes 16By Brad R. Moser, MD

PROFESSIONAL UPDATE:PHYSICAL THERAPY ANDREHABILITATIONAftereffects of anepidemic 18By Barbara P. Seizert, MD

WOMEN’S HEALTHVaginal delivery aftercesarean delivery 32By Sarah Manneh, MD

DEPARTMENTS

C O N T E N T S FEBRUARY 2011 Volume XXIV, No. 11

FEBRUARY 2011 MINNESOTA PHYSICIAN 3

Minnesota Physician 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;e-mail [email protected]. We welcome the submission of manuscripts and letters for possible pub-lication. All views and opinions expressed by authors of published articles are solely those of theauthors and do not necessarily represent or express the views of Minnesota PhysicianPublishing, Inc., or this publication. The contents herein are believed accurate but arenot intended to replace legal, tax, business or other professional advice and counsel. Nopart of this publication may be reprinted or reproduced without written permission ofthe publisher. Annual subscriptions (12 issues) are $48.00. Individual issues are $5.00.

PUBLISHER Mike Starnes [email protected]

EDITOR Donna Ahrens [email protected]

ASSOCIATE EDITOR Martha Malan [email protected]

ASSISTANT EDITOR Scott Wooldridge [email protected]

ART DIRECTOR Elaine Sarkela [email protected]

OFFICE ADMINISTRATOR Juline Birgersson [email protected]

ACCOUNT EXECUTIVE John Berg [email protected]

ACCOUNT EXECUTIVE Sharon Brauer [email protected]

TheIndependentMedicalBusinessNewspaper

Physician competence 1Are better tools needed formaintenance of licensure?By Linda Van Etta, MD, FACP, andJon Thomas, MD, MBA

Neurobiology of loneliness 1Meaningful human connection isvital to mental healthBy Kevin Turnquist, MD

FEATURES

www.mppub.com

Nanette LarsonMinnesota Departmentof Corrections

CPR research 20By Keith G. Lurie, MD, andDemetris Yannopoulos, MD

Percutaneously treatingcomplex valve disease 22By Wes Pedersen, MD, VibKshettry, MD, Kevin Harris, MD,Robert Hauser, MD, Ben Sun, MD,and Irvin F. Goldenberg, MD

The ICE Trial 24By Albert Deibele, MD, FACC,FSCAI, FAHA

New technologyextends research 28By Peter Eckman, MD

Improving survivalpost-heart transplant 30By Monica Colvin-Adams, MD, MS

SPECIAL FOCUS: CARDIOLOGY RESEARCH

Exp. Date

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

Please mail, call in or fax your registration by 4/21/2011

MINNESOTA HEALTH CARE ROUNDTABLEMINNESOTA HEALTH CARE ROUNDTABLE

Background and focus:Until recently, when theword wellness came upin organized medicine itwas regularly dismissedas pseudo-science. Ourhealth care deliverysystem, or as many callit “sick care deliverysystem,” evolved in away that doctors werenot paid to keep patientswell and thus wellnessstrangely fell outside thepurview of medicine.Obviously it is better tostay healthy than try tofix complex and some-times avoidable medicalconditions. Selling serv-ices supporting thisapproach was oftencriticized for lack ofrandomized clinical trial

research; inadequate licensing, credentialing, and oversight forpractitioners; and many other concerns. Wellness as an industry,with its wide diversity of methods and approaches, was kept atarm’s length by the medical establishment. Economics have forcedthis to change and now everyone is engaged with using an old toolin new and more collaborative ways for the betterment of all.

Objectives: We will explore the definition of wellness, why todaythere is a wellness revolution, and why doctors now embrace theconcept. Examining multiple collection methodologies and sets ofdata, we will discuss how and why employers are driving this newapproach to health care. We will consider privacy issues and manyother challenges to an already overburdened administrative processposed by collecting and storing individual health care data in placessuch as work sites and health clubs. We will discuss the breadth ofwellness initiatives, their pros and cons, and how they can lower thecost of health care while improving individual health status.

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

Please send me tickets at $95.00 per ticket. Mail orders to MinnesotaPhysician Publishing, 2812 East 26th Street, Minneapolis, MN 55406.Tickets may also be ordered by phone (612) 728-8600 or fax (612) 728-8601.

Name

Company

Address

City, State, Zip

Telephone/FAX

Card #

Signature

Email

The WellnessRevolution

A changing focus in health care

April 28, 20111:00 – 4:00 PM • Duluth Room

Downtown Mpls. Hilton and Towers

Page 4: Minnesota Physician February 2011

4 MINNESOTA PHYSICIAN FEBRUARY 2011

Governor AppointsEhlinger to HeadMDH, Jesson for DHSIn the early days of his adminis-tration, Gov. Mark Daytonchose a public health expert tolead the Minnesota Departmentof Health (MDH) and a healthpolicy lawyer to head theMinnesota Department ofHuman Services (DHS).

Edward Ehlinger, MD, hasled the University of Minne-sota’s Boynton Clinic since1995, and before that worked atthe Minneapolis Department ofPublic Health. In announcingEhlinger’s selection to headMDH on Dec. 31, Dayton notedhis work in public health andhis strong ties to the medicalcommunity. “Dr. Ehlinger’s longexperience in public healthand in leading a key Minnesotahealth facility position him wellto lead the Minnesota Depart-ment of Health and to restoreour state’s former preeminencein national health care initia-tives,” Dayton said.

On Jan. 11, Daytonannounced that Lucinda Jesson,

JD, would be the new commis-sioner of DHS. Jesson is thefounding director of the HealthLaw Institute at HamlineUniversity, and a former deputyattorney general for Minnesota.

“Lucinda Jesson is the rightperson to lead this criticalagency forward,” Dayton said.“Addressing the significant chal-lenges before us requires herexpertise in health policy andlaw, her experience managinglarge organizations, and herability to bring creativity andinnovation to an agency that ison the front lines, workingdirectly with thousands ofMinnesotans.”

Jesson will certainly seechallenges in her new role. DHSprograms represent a large partof the state’s budget, and thedepartment will likely be facedwith funding cuts as Daytonstruggles to address the state’s$6 billion deficit. A pendingMedicaid expansion will switchnearly 100,000 Minnesotansfrom existing state programs toa new program with expandedservices. Officials from the out-going Pawlenty administration

estimated it would take ninemonths to change to the newsystem, but Dayton has setMarch 1 as the start date forthe expanded coverage.

Blue Cross ExpandsOnline Care ServiceTo All MinnesotansBlue Cross and Blue Shield ofMinnesota has expanded itsonline health service to allMinnesotans. The Online CareAnywhere service was firstintroduced one year ago as apilot program serving BlueCross employees, but it hassince been expanded to employ-er groups and is now availableto all Minnesotans at www.onlinecareanywheremn.com.

Online care services arebecoming more common; bothHealthPartners and United-Health Group have introducedonline care options in the pastfew months, but Blue Crossofficials say that their experi-ence gives them an advantage.

“We were really an innova-tor in launching this type ofservice in the Twin Cities,” saysSig Muller, vice president ofbusiness development at BlueCross. “We’ve been in the mar-ket for more than a year nowand it’s really important to us aspart of our mission to providebroader access to health careand help drive down costs.”

The Blue Cross service ismodeled after a traditional doc-tor’s office visit and is staffed byproviders from Fairview HealthServices, including physiciansand nurse practitioners. Userscan connect face to face withproviders via webcam, or canaccess the service by phone.Blue Cross officials stress theconvenience that such a serviceoffers and say consumers havereported saving an hour pervisit with physicians online asopposed to traveling to a clinicin person.

Muller says the averageonline visit lasts 13 minutes andcosts $45. Blue Cross insuranceis accepted or consumers canpay with a credit card.

C A P S U L E S

Attend the 14th Annual ICSI/IHI Colloquium on Health Care Transformation, May 16–18, 2011, Saint Paul RiverCentreLast year’s ICSI/IHI Colloquium achieved record attendance and received rave reviews. This year’s program will equally help you successfully navigate the new health care landscape. The program and pre-conference workshops will focus on “Advancing Accountability, Affordability and the Patient Experience” along three tracks:1. Leadership and Accountability 2. Quality and Safety 3. Patient Engagement/Consumer

Experience

Our Keynoters are:Susan Dentzer, Editor-in-Chief, Health Affairs: Implications and Opportunities in the New Era of Health CareJane Sarasohn-Kahn, THINK-Health: Participatory Health — The New Patient Engagement

Register Early and SaveDon’t miss the Upper Midwest’s most important event to help you thrive today and position your organization for tomorrow. To register and view the preliminary program, go to http://bit.ly/cfBu5h

ICSI/IHIColloquium

Thriving in an Era of Health Care

Reform

Page 5: Minnesota Physician February 2011

FEBRUARY 2011 MINNESOTA PHYSICIAN 5

Minnesota Ranks 6thIn UHG Annual ReportMinnesota is the sixth-healthi-est state in the nation, accord-ing to UnitedHealth Group’sannual “America’s HealthRankings.” The yearly reportfinds that the nation’s overallhealth improved by one per-centage point last year, buthigher rates of uninsurance,along with increases in diabetesand obesity, are among worri-some national trends.

“The rate of gain, whilepositive, is wholly inadequatefor us as a nation. We knowwith certainty that many peoplewill suffer consequences of pre-ventable disease unless westrengthen individual healthi-ness, community by communityacross America,” says ReedTuckson, MD, UHG’s executivevice president and chief of med-ical affairs.

Minnesota has often rankedin the top five states in therankings, but for the past twoyears it has dropped to No. 6.The UHG report says the statehas low rates of prematuredeath and uninsurance, butchallenges remain, includingthe area of public health carefunding and a relatively highrate of binge drinking.

Medica ProgramRanks PhysiciansFor Quality, CostMedica has begun offering aWeb resource that ratesMinnesota physicians by costand quality information.

On Jan. 19 the Minnetonka-based company made itsPremium Designation programavailable to all Medica mem-bers as part of Find a Doctor,Medica’s online provider searchtool. Physicians are rated in azero-to-two-star system: If theymeet quality measures theygain one star; if they also meetcost-efficiency benchmarks theyreceive two stars.

The new ratings are inresponse to demand for moreinformation on health careproviders from consumers,especially large employergroups that buy Medica prod-

ucts, according to Jim Guyn,MD, Medica’s medical directorfor provider relations. “Largernational employers … in a lotof other markets around theUnited States, had the availabil-ity to look at the individualphysicians and they wanted itin this market as well, and thatwas really the motivating factorfor us,” he says. “Cost and qual-ity information down to theprovider level is somethingthat’s going on all over thecountry.”

The program differs from“tiered” products that healthplans in Minnesota have offeredin the past because those earli-er products looked at measure-ments on the clinic or hospitallevel, rather than at individ-ual physician measurements.Tiering also encouraged pro-viders to compete for enrolleesby how they set their rates;the new system measures costefficiency.

Physician groups such asthe Minnesota Medical Asso-ciation have raised questionsabout the fairness of providerratings, but Guyn notes thatthe program’s methodology isrisk-adjusted and says thatMinnesota physicians shouldrank well, based on previousdata.

The measurements arebased on claims data, whichGuyn says is not perfect.However, he says Medica willcontinue to refine the system astime goes on. “A perfect ratingsystem doesn’t exist, but this isprobably the best that’s outthere,” he says.

Dayton Hears OutFoes, Then SignsMedicaid MeasureIn an unusual signing ceremo-ny on Jan. 5, Gov. Mark Daytonsigned an executive orderexpanding Medicaid coveragefor poor Minnesotans and alsolet protesters take the podiumto express their opposition tothe measure.

Signing on to the Afford-able Care Act’s measures for aMedicaid opt-in program was acampaign promise of Dayton’s.

CAPSULES to page 6

Pertussis Vaccination CampaignGet Your ShotsMinnesota is combating a highrate of pertussis. It’s imperativethat physicians and their staffbe immunized.

Physicians and their clinics canjoin the Pertussis VaccinationCampaign to immunize staff,and limit exposure and thepotential to spread pertussisto patients.

Help the Minnesota Academyof Family Physicians Foundationin its campaign to protectpatients, physicians and healthcare workers against pertussis.

To sign up for a free campaign kit foryour clinic, contact Lynn at 952-224-3873or [email protected]. To learn more,visit www.mafp.org/foundation.asp

Page 6: Minnesota Physician February 2011

C A P S U L E S

6 MINNESOTA PHYSICIAN FEBRUARY 2011

The existing stripped-down pro-gram to serve the state’s poorestand sickest residents has beencriticized as inadequate, andonly four hospitals, all in themetro area, are participating inthe program.

At the signing ceremony inthe state Capitol building,Dayton calmed a large crowdand told them that opponentsas well as supporters of themeasure would be allowed tospeak.

Dayton said the Medicaidopt-in measure would providecoverage to 95,000 Minnesotansand create up to 20,000 jobs atno net cost to the state. “Thismoney goes to benefit the low-income recipients, but reallythe dollars themselves go toMinnesota hospitals and doc-tors, nurses, and others whoprovide essential health care toall these citizens and to all ofus,” Dayton said.

Dayton added that healthcare providers had urged himto sign on to the Medicaid opt-in because it would deliver bet-

ter reimbursement rates toproviders and allow more hos-pitals and clinics to treat poorMinnesotans. Both the Minne-sota Medical Association andthe Minnesota HospitalAssociation (MHA) releasedstatements supporting Dayton’sdecision to sign on to theprogram.

“It is important to note thatour poorest residents will nowhave access to primary care,dental care, mental health serv-ices, and an array of other out-patient clinical services on astatewide basis. Physician andpreventive care will now bemore accessible to this popula-tion,” says Lawrence Massa,MHA’s president and CEO.“Even though providers arepaid less than the actual costsof giving care, early Medicaidenrollment of poor single adultswill help ease the burden ofgrowing uncompensated care,which happens when the unin-sured access care in hospitalemergency rooms.”

At the signing ceremony,opponents of the measure ques-tioned whether the state could

afford the long-term costs ofcovering poor Minnesotans andsaid such programs were betterprovided by religious charities.“[This] really puts the state inperil when it comes to cost,”said Twila Brase, president ofthe Citizen’s Council for HealthFreedom. “Once all these peopleare on, it will be difficult to getthem off and it will be expen-sive to the state for the longhaul.”

Sanford Health toExpand ServicesIn MoorheadSanford Health is planning tobuild a new facility and signifi-cantly expand services inMoorhead, officials with theSioux Falls-based systemannounced last week.

While many details have yetto be determined, Sanford haspurchased 24.5 acres for thenew clinic on the southeast partof town, and officials say theproject will be completed in thenext few years.

“The clinic will be uniquelyMoorhead in terms of scale anddesign and will offer an archi-tectural gateway to the commu-nity from the east,” says BrucePitts, MD, Sanford Clinic presi-dent. “We are working closelywith leaders from the city ofMoorhead, Clay County, andour local patients to ensure weare building a facility that willprovide a wide range of servicesto the area for years to come.”

Officials note Sanford’slong-standing commitmentto Moorhead. The MeritCaresystem, which merged withSanford in 2009, opened its firstclinic in the community in 1985and Sanford currently has threefacilities in the area. Its currentclinic is 16,700 square feet, andhas 26,000 patient visits annual-ly, nine providers, and morethan 40 employees.

Capsules from page 5

Upcoming CME Courseswww.cmecourses.umn.edu

Office of Continuing Medical Education 612-626-7600 or 1-800-776-8636 email: [email protected]

2011 CME SPRING COURSESCardiac Arrhythmias: An InteractiveUpdate for Primary CareMarch 25, 2011

12th Annual Lillehei Symposium:Cardiovascular Care for Primary CarePractitionersApril 18 – 19, 2011

“Bridging the Transition to Life afterCancer Treatment”Cancer Survivorship ConferenceApril 29 – 30, 2011

Bariatric Education DayMay 25 – 26, 2011

Workshops in Clinical Hypnosis“Introductory and Advanced Sections”June 2 – 4, 2011

Topics and Advances in PediatricsJune 9 – 10, 2011

Advances in Breast, Endocrine,and Cancer SurgeryJune 16 – 18, 2011

2011 AHRQ National PBRNResearch ConferenceJune 22 – 24, 2011

Global Health TrainingAugust 1 – 26, 2011

UP-COMING FALL 2011COURSES12th Annual Psychiatry ReviewComing in September, 2011

Pediatric Clinical HypnosisSeptember 15 – 17, 2011

Pediatric Trauma SummitSeptember 22 – 23, 2011

Practical DermatologyLate September 2011

Twin Cities Sports MedicineSeptember 30 – October 2, 2011

Transplant Immunosuppression“The Difficult Issues”October 12 – 15, 2011

Internal Medicine Review and UpdateNovember 2 – 4, 2011

ON-LINE CMECOURSESCourses available for CMEcredit.

Reducing Recurrent PretermBirthECG of the WeekThe Reality of Fibromyalgia:Pathways to Diagnosis,Therapy, and Quality of LifeAdult Congenital HeartDisease

All courses are held in theTwin Cities unless noted

Page 7: Minnesota Physician February 2011

Two physicians were recognized for their serv-ice to the community at the annual meetingof Lakeview Hospital medical staff. ElmerKasperson, MD, was recognized for his leader-ship in the surgery department. The awardnoted that Kasperson was instrumental in theinitiation of the surgical residency programaffiliation with the University of Minnesota.Kasperson, a board-certified general surgeon,earned his medical degree from the Universityof Chicago and completed his internship and residency at the Univer-sity of Minnesota. He has been with Stillwater Medical Group since1999. Alan Downie, MD, was recognized for his long commitment to

Lakeview Hospital’s medical staff leadership.He served as surgery department chair for twoyears, followed by eight years on the medicalexecutive committee, including two years aschief of staff. Downie, who practices at Associ-ated Eye Care, completed his medical degreeand residency at Ohio State University. A board-certified ophthalmologist, Downie was initiallyappointed to Lakeview’s active staff in 1995.

Erik Mikkelsen,MD, has joined Children’s Hospital staff andChildren’s Respiratory and Critical Care Special-ists, PA as a pediatric intensivist. Mikkelsenfinished a pediatric critical care fellowship atCincinnati Children’s Hospital in 2010 whilesimultaneously obtaining a master of educationin curriculum and instruction at the Universityof Cincinnati. He attended the Medical College

of Wisconsin-Milwaukeeand completed his pediatric residency at Chil-dren’s Mercy Hospital in Kansas City, Mo.

April Grudell, MD, has joined MinnesotaGastroenterology. She completed her residencyand GI research fellowship training at MayoClinic in Rochester. Subsequently, she com-pleted a clinical gastroenterology/hepatologyfellowship at the University of Michigan in AnnArbor. Grudell is a board-eligible gastroenterolo-

gist with special interest in functional bowel disease and in motilitydisorders, including gastroparesis, post-vagotomy dysmotility, andchronic constipation. She sees outpatients at the practice’s CoonRapids office and is on staff at United Hospital.

Paul Terrill, MD, received the community-nominated Physicianof the Year award for 2010 from the Lake Superior Medical Society.The award is given in recognition of “consistently demonstratingqualities recognized as defining excellence in medical care delivery.”Terrill attended medical school at the University of Minnesota inDuluth and Minneapolis, and completed his residency in familypractice in Duluth. He joined Sawtooth Mountain Clinic in 1991 asa board-certified family practice physician.

James Vodvarka, DO, has joined the St.Luke’s health system as an internal medicinespecialist at Hibbing (Minn.) Family MedicalClinic and Laurentian Medical Clinic, in Moun-tain Iron, Minn. Vodvarka received his doctorof osteopathic medicine degree from the Uni-versity of New England’s College of OsteopathicMedicine in Biddeford, Maine. He completedhis internship at Central Medical Center andHospital in Pittsburgh and his residency in internal medicine atWest Penn Hospital in Pittsburgh. He is board-eligible in internalmedicine.

M E D I C U S

Elmer Kasperson, MD

Alan Downie, MD

April Grudell, MD

James Vodvarka, DO

Erik Mikkelsen, MD

FEBRUARY 2011 MINNESOTA PHYSICIAN 7

2011 HEALTH CARE ARCHITECTURE & DESIGN

HONOR ROLLHONOR ROLLREQUEST FOR NOMINATIONS

2011 HEALTH CARE ARCHITECTURE & DESIGNHONOR ROLL NOMINATION FORM

FACILITY NAME

TYPE OF FACILITY

LOCATION

OWNERSHIP ORGANIZATION

OWNER CONTACT NAME and PHONE

OWNER ADDRESS

CITY, STATE, ZIP

ARCHITECT/INTERIOR DESIGN FIRM

ARCHITECT CONTACT NAME and PHONE

ARCHITECT ADDRESS

CITY, STATE, ZIP

ENGINEER

CONTRACTOR

COMPLETION DATE

TOTAL COST

SQUARE FEET

NUMBER OF COLOR PHOTOS ENCLOSED

NOMINATION PROCEDURE: Send this form or a separate sheet with all the aboveinformation, a project description (150–250 words), and 300 resolution color

8”x10” digital or glossy photographs (no more than eight) to:

Honor RollMinnesota Physician Publishing, Inc.

2812 East 26th Street, Minneapolis, MN 55406

For further information, please phone (612) 728-8600, fax (612) 728-8601or e-mail [email protected].

NOMINATION CLOSING: FRIDAY, MAY 6, 2011

PUBLICATION DATE: JUNE 2011

Seeking Exceptionally Designed Health FacilitiesMinnesota Physician announces ourannual Health Care Architecture &Design Honor Roll.

We are seeking nominations ofexceptionally designed health carefacilities in Minnesota.

The nominees selected for thehonor roll will be featured in the June2011 edition of Minnesota Physician,the region’s most widely read medicalpublication.

Eligible facilities include anystructure designed for patient care:hospitals, individual physician offices,clinics, outpatient centers, etc. Inter-iors, exteriors, expansions, renova-tions, and new structures are alleligible.

In order to qualify for nomination,the facility must have been designed,built or renovated since January 1,2010. It also must be located withinMinnesota (or near the state borderwithin Wisconsin, North Dakota, SouthDakota or Iowa). Color photographsare required.

If you would like to nominate afacility, please fill out the nominationform below and submit the form, threeto eight 300 resolution color photo-graphs, and a brief project descriptionby Friday, May 6, 2011. For moreinformation, call (612) 728-8600.

[Note: Please include a caption for each photo]

Page 8: Minnesota Physician February 2011

� Tell us about the facilities in Minnesota forwhich you oversee health care delivery.

The Department of Corrections has nine prisons,seven male, one female, and one juvenile male.Then we have two boot camps. We have a total ofabout 9,300 offenders. We have five different cus-tody levels, minimum through maximum security.

Each of our prisons has an ambulatory clinic.Most of our sites have at least one practitioneron-site five days per week. Most of our staff arenurses, and the nurses provide a variety of servicesto our offender population including sick call triag-ing, implementing physician standing orders,patient education, medication administration, andmanagement of chronic care. At our female facilityat Shakopee, we also have on-site ob/gyn care,including prenatal care through delivery.

We have two units that are specialty care. OurLinden unit, which is housed at Faribault, providescare for adult males whoneed a close level of monitor-ing, but not necessarily acuteservices. If they’re relativelyable to perform their dailyactivities with minimal assis-tance, they live there.Paraplegics, quadriplegics,and much of our geriatricpopulation live there. We might have some folkswith Alzheimer’s there, coronary artery disease,certainly hypertension.

Our 48-bed transitional care unit at Oak ParkHeights provides a higher level of care. We provideservices such as IV therapy, dialysis services,wound care, pre- and post-surgical care, hospicecare, and management of other complex conditionsthat require intensive nursing intervention.

� Would that facility be considered a hospital?

We consider it a subacute level of care. We don’t dosurgery, so it wouldn’t be considered a hospital inthat respect. We can’t do chemotherapy there, butit provides a very high level of care.

We take offenders who need inpatient hospitalservices or specialty care to community providersfor those kinds of services.

When offenders go off-site, our primary mis-sion is public safety. The prisoners are escorted bytwo officers, and they wear orange jumpsuits, anorange jacket during the winter, and wrist, waist,and ankle shackles.

One last detail about our delivery system isthat we charge our offenders copayments. It’s $3,but for many offenders who are making 50 cents ora dollar an hour, $3 for a copay is pretty hefty.

� Where do you get your providers?

In 1998, the department made a decision to cen-tralize and privatize our health care, and we start-ed contracting with an entity called CorrectionalMedical Services (CMS). They are a correctional

health care management company out of St. Louis,and they provide primary care practitioners andpsychiatrists at the prisons. All our physicians areindependent contractors through our contract withCMS. They contract with community providers forinpatient and outpatient hospital care and specialtycare. CMS provides ancillary services such as phys-ical therapy, optometry, dental care, and all of ourprescription medications come through them.

� How is prisoners’ health care paid for?

My budget for fiscal year 2011 is about $68 millionfor medical, nursing, dental, mental health care,sex offender, and chemical dependency treatment.My budget is entirely state general fund money.We don’t get Medical Assistance, Medicare dollars,Veterans, or Social Security. We do get a little bitof federal grant money for some of our chemicaldependency programming, but it’s mostly state

general fund money.In 1998, the department

made a conscious decision tobe better purchasers of healthcare. Prior to our contractwith CMS, each institutionwas responsible for purchas-ing and managing its ownhealth care. Not only was that

inefficient, but it allowed the offenders to play onephysician against another, because we do a lot oftransferring of our offender population. So thedoctor in Stillwater might say you can have some-thing, and then the offender would be transferredto Moose Lake and they might get the oppositeresponse from the physician up there.

So we centralized health care. We contractedwith CMS, who has the expertise in correctionalhealth care, and we became much better pur-chasers. We started implementing many managedcare principles, for example utilization manage-ment. The implementation of a prescription drugformulary was very helpful.

We continue to look at our community part-ners, the hospitals that we use. We look to them tonegotiate volume discounts. With us, it’s not justthe health care costs, but it’s those security andtransportation costs when we have to send anoffender off-site that impact our budget as well, sowe are trying to figure out what else we can pro-vide on-site.

� Are you affected by rising health care costs?

Certainly we are impacted by rising health carecosts, just like the community. We try to manageour contract with CMS as best we can within thebudget that’s allocated to us. At times we have hadto request a supplemental budget because ofincreased health care costs, but we try to managewith what we have and what the Legislature hasappropriated to us.

Nanette LarsonMinnesota Department

of Corrections

Nanette Larson hasbeen the director of

health services for theMinnesota Departmentof Corrections for more

than 11 years.She is responsible for

the care and well-beingof more than 9,300incarcerated men,

women, and juveniles.Larson has held leader-ship positions in other

state agencies, includingthe Minnesota

Department of Healthand the Office of

Technology, and was theexecutive director forthe Minnesota Health

Care Commission.

Minnesota inmates get health care inside, outside

8 MINNESOTA PHYSICIAN FEBRUARY 2011

I N T E R V I E W

Getting providersto see our offendersin the community is

sometimes challenging.

Page 9: Minnesota Physician February 2011

� What are the most common kinds ofhealth services that prisoners receive?

About 75 percent of the health care that weprovide is primary care. We deal with every-thing that you would see in the community,from upper respiratory infections and sea-sonal influenza to very serious medical con-ditions. We truly deal with everything—can-cer, coronary artery disease—and our popu-lation probably has a higher incidence ofhypertension, diabetes, asthma, and liverissues just because of their high-risk behav-iors. We also have 20 to 25 pregnancies peryear. We pretty much see anything that afamily practice would see.

� What are the biggest challenges in pro-viding health care to this population?

One of our biggest challenges is that theoffenders don’t take very good care of them-selves when they’re on the outside. Probably95 percent of our offenders will be leavingus, so we want to provide them with someeducation to make them a bit more respon-sible for their health care when they get out.

But they don’t have health insurancein coming to us, so whatever primary carethey’ve received has been pretty nonexistentor it’s been through emergency rooms. Manyof them have high-risk behaviors, so chrono-logically they might be 55, but physiological-ly they look more like 65. You’re just dealingwith an older, sicker population. Getting

them to take responsibility for their healthcare decisions is always a challenge.

� Is there a shortage of providers, and howdifficult is it to recruit and retain them?

It is an issue. It’s CMS’s responsibility to dothe recruiting, but it’s our responsibility inpartnership with them to retain them. Wehave a hard time finding psychiatrists, forexample. We are always looking for licensedalcohol and drug counselors or otherlicensed mental health professionals.

We are part of the Federal LoanForgiveness Program for primary care andmental health, so to the extent that we canuse that as the carrot, we like to do that.Going into a prison and working with pris-oners can be a little scary for some folks,but I have to say it’s a very safe place.

One of our unique challenges is thelitigiousness of our population. They liketo write board complaints. I have hadproviders who have never had a board com-plaint until they started working for us.Granted, the board complaints are unsub-stantiated, but nevertheless it’s wearing onthe providers. So dealing with our popula-tion on a day-to-day basis can be very tax-ing, which is one of the retention issues.

� Are the state and federal health carereform laws affecting how care is deliv-ered in the prison setting?

To date, no. There were a number of specificplaces in the health care reform act whereprisoners were excluded, so right now theyare not having an effect. However, some ofthe administrative things like the mandatesfor electronic health record and health infor-mation exchange and e-prescribing will cer-tainly be impacting us and our population.

� What changes would you like to see inthe way health care is provided in prisonfacilities in Minnesota?

I would really like to be able to providemore care on-site. Getting providers to seeour offenders in the community is some-times challenging, because they go off-sitein the orange jumpsuits and the shackles,and then they have to sit in the waitingroom next to Grandma. So to the extentthat we can provide more care on-site, it’sconsistent with our public safety mission,it’s much more convenient for our staffbecause we don’t have to have the officerstaking them off-site. I think it just all aroundwould be better.

We are always challenging ourselvesto try to improve our health care deliverysystem and see where we can do thingsbetter or more efficiently, and to the extentthat we can do it internally, we would wantto do that.

FEBRUARY 2011 MINNESOTA PHYSICIAN 9

Page 10: Minnesota Physician February 2011

a medical staff or professionalsociety, and whether they havebeen diagnosed or are currentlyabusing alcohol or mood-alter-ing drugs. The current debate isfocused on whether these cur-rent requirements for mainte-

nance of licensure (MOL) areenough to assure practicingphysicians are competent.

Defining competence

Licensing and certifying organi-zations often cannot agree on adefinition of physician compe-tence, and there is even lessagreement on what type of test-ing assures competence. Is com-petence the ability to answerknowledge questions on a secure

exam? Or is competence theability to provide safe patientcare that meets the standard ofcare? However, all nationallicensing, certifying, and privi-leging organizations agree onand accept the six competenciesthe Accreditation Council forGraduate Medical Education

(ACGME) expects of new practi-tioners leaving residency:• Patient care• Medical knowledge• Practice-based learning andimprovement

• Interpersonal and communica-tions skills

• Professionalism• Systems-based practice

For decades, U.S. physicianshave been tested using the U.S.

Medical Licensing Examina-tion (USMLE)—the so-called“national boards”—during med-ical school and residency.Successful performance on theUSMLE predicts success at thenext level. After completing resi-dency, many graduates then takea board certification examina-

tion. These exams are given byone of the 24 component boardsof the American Board ofMedical Specialties (ABMS)for allopathic physicians andby the Bureau of OsteopathicSpecialties (BOAS) for osteo-pathic physicians.

Lifetime certificates havebeen granted for most special-ties, though family medicinehas always had a time-limited

certificate that requires a recer-tification exam every decade.Over the past two decades, theother ABMS boards have movedto time-limited board certifica-tion as well, with all 24 boardscompliant as of 2007. Fullimplementation will not occuruntil 2016.

Despite the move to time-limited certificates, the processof recertification varies depend-ing on the specialty. The largerspecialties such as internal med-icine and pediatrics have a moredeveloped and mature process.In internal medicine, a secureexam is required every 10 years.Certificate holders also have tocomplete learning modules andopen-book questions as part ofthis maintenance of certification(MOC) model. The BOAS hasalso moved to this MOC model.Some specialties, such as pathol-ogy, have only recently moved totime-limited certificates, so themajority of certificate holderscurrently hold lifetime certifi-cates. Lifetime certificate hold-ers can elect to participate inMOC, but according to theAmerican Board of Internal

Competence from cover

10 MINNESOTA PHYSICIAN FEBRUARY 2011

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Medicine, one of the 24 compo-nent boards of the ABMS, only 1percent of their lifetime certi-ficate holders have chosen toparticipate. The concern of life-time certificate holders is thatthey might lose their certifica-tion if they fail the test. Whatthey don’t understand is thatthey cannot legally lose theirlifetime certification regardlessof their performance on the test.

Revisiting MOL

In 2003 the Federation of StateMedical Boards (FSMB) con-vened the Special Committeeon Maintenance of Licensure,charged with developing a posi-tion statement on the responsi-bility of state medical boards inensuring physician competenceover the course of his or hercareer. In May 2004, it becameofficial FSMB policy that statemedical boards have a responsi-bility to the public to ensure theongoing competence of physi-cians seeking relicensure.

The Minnesota Board ofMedical Practice (BMP), a mem-ber of the FSMB and the author-ity that licenses and disciplinesphysicians in Minnesota, createda taskforce to study MOL inorder to understand what impli-cations could result from anyrecommendations that mightcome from the FSMB commit-tee. The taskforce consisted ofrepresentatives of the BMP, theMinnesota Medical Association,the dean of the University ofMinnesota Medical School, andrepresentatives of major speci-alty societies, including familymedicine and internal medicine,as well as representatives of theMinnesota Hospital Association,and insurers. Stephen Miller,MD, MPH, then chief executiveofficer of the ABMS, was also amember. The taskforce met reg-ularly from August of 2006through October of 2008 andcontinues to meet ad hoc atpresent; its most recent meetingwas in October 2010.

The Minnesota BMP direct-ed the MOL taskforce to deter-mine whether the currentrequirements for licensingphysicians in Minnesota consti-tute an adequate demonstrationof competency—and if not, torecommend what new require-ments should be added. Any new

requirements would have thefollowing characteristics:• Available to all licensed physi-cians and osteopaths, with alleligible

• Acceptable to the public,regulators, and physicians

• Non-punitive• Not onerous or duplicative ofwhat physicians are alreadydoing

• Not dissuade physicians frompracticing in MinnesotaThe MOL taskforce reviewed

all the existing literature regard-ing maintenance of competency.The board’s computer databasewas also used to compile infor-mation regarding ages and spe-cialty board certification of ourphysician population. We alsolooked at whether the physicianheld a lifetime or a time-limitedcertificate. Speakers were invit-ed to educate taskforce mem-bers about all current CME pro-grams provided in Minnesota.

Some have suggested thatthe easiest requirement toimplement for all physicians todemonstrate their continuingcompetency is to have them par-ticipate in the ABMS MOC pro-gram or the equivalent BOMSprogram for osteopathic physi-cians. ABMS has, until recently,stated that 85 percent of physi-cians in the U.S. hold ABMS cer-tificates. We were surprised,therefore, to find that only 75percent of Minnesota physicianswere board-certified. ABMS hasrecently restated its percentage,now claiming that about 69 per-cent of U.S. physicians areboard-certified through theirorganization.

Only board-certified physi-cians can participate in MOC.ABMS has also stated that thereis robust data showing thatboard certification results inimproved patient outcomes. Ourreview, however, showed that thedata are limited and apply tosingle criteria such as percent-age of patients receiving mam-mograms. No data exist showingthat the MOC program results inimproved patient outcomes.ABMS is working to developsuch data.

Approximately 60 percentof ABMS certificates are cur-rently time-limited, but the per-centage varies widely depending

on the specialty. In Minnesota,we found, most physicians age50 and older hold lifetime boardcertificates and those under age50 have time-limited certificates.However, in several critical spe-cialties that have only recentlyimplemented time-limited cer-tificates, such as pathology andradiology, the vast majority ofphysicians hold lifetime certifi-cates. This could lead to a severeshortage in these specialties ifnew requirements resulted inphysicians electing to leavepractice.

There is concern that aphysician’s knowledge and skillsdecrease the longer he or sheis in practice. This is a majorreason cited for the need forMOL requirements to be morerigorous. The article most com-monly quoted to support thisassertion was written by NiteeshChoudhry, MD, and associatesand published in Annals ofInternal Medicine in 2005. Theauthors did a systematic reviewof the literature. They concludedthat of the 62 papers theyreviewed, 32 showed decreasingperformance with increasing

years on practice for all out-comes assessed. However, theiroutcomes included scores onsecure exams, not just patientoutcomes. Indeed, the only con-sistent negative-associated out-come was with exam scores.Only six of the studies evenlooked at patient outcomesand the results were mixed, withseveral showing no associationwith time in practice.

In an article published inCirculation in 2008, the conclu-sions of Alexander Turchin, MD,and colleagues supported theneed for mandatory recertifica-tion. They looked at intensifica-tion of antihypertensive treat-ment in diabetic patients whoseblood pressure was too high atthe time of an office visit. Only6.9 percent of physicians whohad been board-certified atleast 31 years before the visitincreased or changed the anti-hypertensive medication. Physi-cians who had been board-certi-fied the previous year increasedthe medication 26.7 percent ofthe time. Although this was abetter percentage, nearly 75 per-

FEBRUARY 2011 MINNESOTA PHYSICIAN 11

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COMPETENCE to page 12

Page 12: Minnesota Physician February 2011

cent of patients still did notreceive the proper care for theirblood pressure, even thoughthese physicians were consid-ered very competent based ontheir having passed an ABMSboard certification within theprevious 12 months.

Continuing study

The FSMB special committee onMOL released its draft report forcomment in November 2007.Because the Minnesota taskforcehad been studying MOL andreporting back to the MinnesotaBoard, we were able to providesignificant input to the FSMBduring that feedback period andduring the annual meeting in2008, where the federation votedto adopt the broad principlesdeveloped by the committee.Minnesota was also invited topresent our findings at theFSMB annual meeting in 2009.

In April 2010, the FSMBHouse of Delegates adoptedMaintenance of Licensure asofficial. A MOL ImplementationGroup was convened to developthe steps necessary for a state to

fully implement MOL. The com-ponents of MOL are:• Reflective self-assessment: donethrough self-review tests suchas those associated with MOC,medical society-based, etc.

• Assessment of knowledge andskills: done through MOCsecure exam or peer surveys,performance improvementmodules, participation in SCIPor AMI modules, etc. A secureexam is not required.

• Performance in practice: donethrough 360-degree evalua-tions or other performanceprojects such as CAP, ABMS,AOA, etc.MOL builds on the six com-

petencies of ACGME in a modelof continuous professionaldevelopment.

The FSMB advisory commit-tee has recommended that MOLchanges be “evolutionary, notrevolutionary.” The goal of MOLis not to add another layer ofregulation or to endorse a certi-fying organization. Rather, thegoal is to introduce a frameworkthat gives physicians multipleoptions to meet the require-ments through attestation. For a

board-certified physician with atime-limited certificate, partici-pation in MOC would satisfyMOL. Physicians who are notboard-certified or who have life-time certificates would have avariety of other ways of satisfy-ing MOL without having to takea test. MOL seeks to recognizewhat many dedicated, caring,and conscientious physiciansalready do.

Several states have the regu-latory authority to implementMOL and want to start pilotprojects with FSMB assistance.Several states without the regu-latory authority have expresseda desire to move forward, recog-nizing that they would have tochange their medical practiceacts. Others have sought assis-tance in taking the first steps.

The Minnesota taskforce hasrecommended to the MinnesotaBMP that no changes to licens-ing requirements be made atthis time. The Minnesota Boardand its taskforce will continueto monitor the literature closelyand follow developments at theFSMB and in other memberstates. Without clear evidence

as to what added requirementsfor physicians will result inimproved patient safety and out-comes, it is difficult to choosethe right path or to strongly en-dorse any new path at present.

As the Minnesota Board ofMedical Practice continues toexplore this topic, we welcomefeedback from physicians.Please share your concerns,ideas, and comments by e-mail-ing [email protected].

Linda Van Etta, MD, FACP, was chairof the Minnesota Board of Medical PracticeTaskforce on Continuing Competency andMaintenance of Licensure from 2006 to2009. She is hospital epidemiologist forthe St. Luke’s system, Duluth, and serveson multiple medical staff committees,including the executive committee and thequality committee as well as physician cre-dentialing committee. Jon Thomas, MD,MBA, currently serves as chair of the BMPtaskforce. He sits on the board of directorsof the Federation of State Medical Boardsand is the Federation of State MedicalBoard’s representative to the AmericanBoard of Medical Specialties. Thomas is anotolaryngologist and chief operating officerof Ear, Nose, and Throat Specialty Careof Minnesota PA, and is chief of staff-electat United Hospital in St. Paul.

12 MINNESOTA PHYSICIAN FEBRUARY 2011

Competence from page 11

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May 8, 2011 at Mariucci Arena, University of Minnesota Medicine Buddha Empowerment: A Tibetan Cultural and Spiritual Ceremony Promoting Personal and Societal Healing featuring His Holiness the 14th Dalai Lama9:30 - 11:30 a.m.

Peace Through Inner Peace: A Public Address featuring His Holiness the 14th Dalai Lama2:00 - 3:30 p.m.

May 9, 2011 at University Radisson HotelSecond International Tibetan Medicine Conference: Healing Mind & Body9:00 a.m. - 7:30 p.m. (* His Holiness is not expected to be in attendance.)

2 Days Only, 3 EventsThe Minnesota Visit 2011

For tickets and more information, visit www.dalailama.umn.edu or call 612-624-2345

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One Heart, One Mind, One Universe

A special invitation to health professionals: The Second International Tibetan Medicine ConferenceMay 9, 2011This event will bring to the Twin Cities the foremost practitioners of Tibetan medicine from the Men-Tsee-Khang, the Tibetan Medical Institute of His Holiness the Dalai Lama, in Dharamsala, India. By the end of the conference, participants will be able to meet the following objectives involving Tibetan Medicine:

Examine the relationship between ethics, spirituality, and healing. Investigate participants' own unique constitution. Determine what lifestyle choices to make, based on participants' own constitution.Explain how to heal from the source and develop health through balance.Describe research about Tibetan medicine, as well as propose additional research needed. Apply teachings of Tibetan medicine personally and professionally.

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Page 14: Minnesota Physician February 2011

On an unconscious level, weessentially prepare our bodiesto travel in search of otherhumans.

Those glucocorticoid hor-mones have widespread effectson our brains and bodies. Thestress hormones oppose theactions of insulin. Weight gain,abdominal obesity, and type 2diabetes become more likely. Theresultant abdominal fat secreteshormones of its own, and thosehormones predispose people toanxiety and depression.

Researchers have also dis-covered that lonely people tendto sleep poorly. Adequate sleep isnecessary for the healthy func-tioning of one of the mostimportant brain areas involvedin emotional well-being—thehippocampus. This crucial struc-ture manufactures new braincells every day in response to aprotein called brain-derived neu-rotropic factor (BDNF). Ourantidepressant treatments workthough this pathway.

When people are depressed,their hippocampi may shrink byalmost 20 percent, and recovery

involves building new brain cellshere. In the schizophrenic ill-nesses, the hippocampi are oftensmall and misshapen from birth.Patients with borderline person-ality disorder also commonlyhave malstructured hippocampi,often in response to emotionaltraumas suffered while theirbrains were developing.

We’ve learned that bothpoor sleep and prolonged expo-sure to glucocorticoid hormonesreduce BDNF levels. Interest-ingly, lack of physical exerciseand living in unstimulating envi-ronments have exactly the sameeffect. So if we truly want tooptimize the mental health ofour mentally ill citizens, wemust find ways to provide themwith the things that their brainsrequire on a fundamental level.They need mentally stimulatingactivities, physical exercise,healthy diets, adequate sleep,and freedom from excessivestress hormones. And, most ofall, they need to feel that theyare connected with otherhumans.

Of course, loneliness andsocial isolation are not confined

to people with severe mental ill-nesses. Despite technologicaladvances in communication thatwould have been unimaginable50 years ago, at the same timewe as a population are becom-ing more alone. The tightly knitfamily groupings that havealways typified humans havebeen replaced by casual elec-tronic relationships with relativestrangers. Just because we don’tyet understand the long-termeffects of such changes on ourbrain functioning doesn’t meanthat they aren’t important.

Effects of lonelinessmanifest physically

Non-psychiatric physiciansencounter the effects of loneli-ness on their patients’ physicalhealth all of the time, but theseare not always readily apparent.Common manifestations includedifficulty stabilizing blood sug-ars with conventional diabeticregimens and persistent com-plaints of insomnia. Someclients will abuse alcohol orother drugs in an effort to dealwith the pain of social isolation.And depression itself may pres-

ent in myriad “medical” ways:Unexplained bowel problems,weight loss or gain, fatigue,pain, and heightened anxiety areall commonly encountered.

Busy primary care physi-cians can’t be expected to func-tion as therapists or social work-ers. Yet when patients don’trespond to conventional treat-ments in conventional ways, it’salways wise to inquire whetherthere are psychosocial factors—such as profound loneliness—that might stand as impedi-ments to successful treatment. Atight focus on medication treat-ments alone may result in esca-lating dosages of diabetic meds,sleeping pills, or analgesicswhen the company of other hu-mans is actually what is needed.

Even a casual observer ofour current mental health sys-tem will immediately recognizethat we have a problem here.Many of our clients cannot pro-vide these essential social com-modities for themselves and wehave not, historically, done agood job of helping them inthese areas. Far too many of ourmentally ill people live extremely

14 MINNESOTA PHYSICIAN FEBRUARY 2011

Loneliness from cover

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isolated lives. They have nosense of belonging to a greatercommunity. And their lonelinesscuts them off from one of thesingle healthiest factors for theirbrains: Laughter reduces theeffects of those toxic stresshormones in ways that none ofour medications can replicate.

Creating communities

“What should young people dowith their lives today? Manythings, obviously. But the mostdaring thing is to create stablecommunities in which theterrible disease of lonelinesscan be cured.”

—Kurt Vonnegut, novelist

Like Pearl Buck, KurtVonnegut must have had a realintuitive sense for neurobiology,for creating stable communitiesis exactly what we must accom-plish as a society. There is awidespread tendency to believethat advances in treatment ofthe mentally ill will come in theform of new and improved med-ications, yet the most effectivepills for the major mental ill-nesses have all been around fordecades. The real breakthroughs

in treatment will come, instead,in the form of specially designedliving environments that willprovide our clients with thethings that their brains so vitallyneed, and the things that theyhave such a hard timeobtaining for themselves. Thisis precisely what the nonprofitorganization Touchstone MentalHealth is trying to accomplishwith the creation of its proposedmodel community for thementally ill, the Rising Cedarsfacility.

Rising Cedars will be a 40-unit assisted-living facility forpeople with severe mental ill-nesses. Each client will have anindependent apartment that heor she can call “home,” but con-gregate dining and activities willbe offered as well. Lounges andcommon areas will be set up sothat people will be able to have

privacy when they need it andopportunities for socializationwhen they want it.

On-site medical and psychi-atric care will be combined witha wellness center that will pro-vide a variety of complementarytherapies, groups, educationalactivities, and physical exercise.Work, healthy diets, reliabletransportation, horticulture, andties to existing community sup-ports are all essential elementsof the program. When peopleare in need of increased services,the staff will bring those servicesright to the client’s residence,rather than continually trans-port them back and forth frompsychiatric hospitals based onfluctuations in their clinicalcondition.

This novel program is basedupon principles and ideas thatwere initially elaborated at

www.kevinturnquist.org. Amongthose principles is the common-sense idea that we shouldinvolve our clients directly whenwe are designing housing orsupportive programs for them.Literally hundreds of sugges-tions for the development of thisfacility have been solicited fromclients and staff in Touchstone’sexisting programs. Project forPride in Living, the UrbanWorks architectural firm, andthe University of MinnesotaCollege of Design are helping tocreate a physical environmentthat will be as close to optimalas we can make it.

The hope is that this pro-gram will serve as a template fora new generation of residentialfacilities for the mentally ill andwill ultimately change the waythat severe mental illnesses aretreated for decades to come.

Kevin Turnquist, MD, is a psychiatristat Anoka Metro Regional TreatmentCenter and a consulting and treating psy-chiatrist for the ICRS (Intensive CommunityRehabilitation Services) pilot program atTouchstone Mental Health. This article isadapted from one that appeared inTouchstone’s Winter 2010 Newsletter.

FEBRUARY 2011 MINNESOTA PHYSICIAN 15

Despite technological advances incommunication that would have beenunimaginable 50 years ago, we as apopulation are becoming more alone.

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Page 16: Minnesota Physician February 2011

P R O F E S S I O N A L U P D A T E : P H Y S I C A L T H E R A P Y A N D R E H A B I L I T A T I O N

Minnesota has one ofthe largest dance pop-ulations in the U.S.,

ranking between fourth andsixth nationally. The state’sdance community, encompass-ing about 250 dance studios,schools, companies, and teams,contributes to the overall quali-ty of the Minnesota arts culture.

The art and athletics ofdance place unique demands onits participants, resulting in dis-tinctive injuries and injury ratesin comparison to other athletesin other sports. Complicatingthe injury picture, an estimated30–40 percent of the profession-al dancers in Minnesota and20–30 percent of the amateurdancers are uninsured or under-insured, according to theDance/USA Taskforce onDancer Health (Dance/USA isthe national, nonprofit serviceorganization for professionaldancers).

Dance injury treatment,research, education

Established in 2009, the Minne-sota Dance Medicine Foun-dation (MDM) is a 501(c)(3)

nonprofit organization of dancemedicine professionals dedicat-ed to conducting research andcreating educational initiativesto study dance injuries and pre-vention. MDM’s staff of volun-teers is composed of physiciansand physical therapists whohave had years of experiencetreating dancers. They providemedical care to dancers in addi-tion to conducting research andoffering educational presenta-tions to individual dancers andthe dance community at large.

Medical services. To helpmeet the dance community’sneeds for specialized care,MDM provides complimentaryinjury evaluations and screen-ings to dancers so they can con-tinue to perform without fear of

lacking the funds to get properinstruction and care. MDM’sdance injury clinic is located inthe Cowles Center for Danceand the Performing Arts (for-merly the Minnesota ShubertCenter for Performing Arts),in Minneapolis. The clinic isstaffed by MDM medical profes-sionals, who evaluate dancersfor injury (or potential injury)and answer their questions.

Research and education.MDM conducts research andeducation activities aimed atimproving treatment of dancers’injuries—and helping preventsuch injuries from occurring inthe first place.

Recent studies have shownthat dancers tend to get theirinjury information from theirfriends and teachers, ratherthan a specialized dance medi-cine professional. This is worri-some, as a dancer’s injury thatremains unaddressed can leadto more severe and potentiallycareer-ending injuries. It isessential that an injured dancerget a proper diagnosis thatincludes an evaluation of thedancer’s biomechanics, whichmay have led to the injury.

Misperceptions exist in themedical community as well.A provider may feel that adancer’s injury must not be verysevere because the dancer con-tinues to dance. Yet historically,like other professional athletes,dancers have been taught to“work through the pain”—eventhough doing so can worsen aninjury and cause irreparableharm to the dancer athlete.Medical providers need to beaware of the technique andmovements of the dancer, aswell as the dancer’s dedicationand devotion to the sport, tobetter evaluate and treat thedancer.

To provide dancers withbetter access to more accurateinformation, MDM collaborates

with dancers, dance teachers,choreographers, companies,studios, and schools around thestate in conducting research.The results of their research aredisseminated throughout themedical community to doctors,physical therapists, and athletictrainers through medical jour-nals and educational programs.Current research by MDMincludes a statewide study ofdancer injuries and the injuryrates at all levels of dance anddancer experience. A large pos-terior ankle impingement out-comes study in dancers isalso being done (see sidebar).MDM’s research is aimed atfurther educating the danceand medical community onthe most common injuries andtreatment of those injuries. Inaddition, the research will addto the current national medicalliterature in dance medicine.

Dance medicine, in general,is not well funded, leavingscarce resources dedicatedto research. MDM works toobtain grants through localand national medical fundingsources. This allows MDM tooffer free educational programsto dance companies, studios,and schools throughout thestate. In addition to conductingfree screenings for dancers, theMDM staff lead educationalseminars for dance teachersand choreographers. The aim isto help these organizations pre-vent injury in their dancers andto teach the dancers how toprotect themselves from injury.The seminars or screeningsinclude (but are not limited to):• Teaching dancers and dance

teachers how to apply objec-tive medical criteria to deter-mine when a dancer is “pointeready.”

• Assessing strength and/ormuscular deficits that dancerscan correct to prevent injuryfrom occurring.

• Identifying common injuriesin dancers (or in a particulardance company) and teachingthem how to prevent theseinjuries.

MDM’s dance medicine pro-fessionals also speak on dancemedicine topics at local andnational conferences.

Dance medicine confer-

Keeping dancerson their toes

The Minnesota Dance Medicine Foundation

By Brad R. Moser, MD

16 MINNESOTA PHYSICIAN FEBRUARY 2011

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ence. MDM has conducted anannual dance medicine confer-ence for the past three years.Conference participants haveincluded dancers, dance teach-ers, and choreographers, andpresentations cover aspectsof dance injuries and how toprevent them. MDM conductsa free injury screen to alldancers at the annual confer-ence. Future conferences willbe expanded to include medicalprofessionals who wish to learnmore about these topics.

A growing field

Dancers’ injuries are uniqueand require specialized knowl-edge of the technique andrequirements of dancers inorder to properly diagnoseinjuries (or potential injuries)and return a dancer to activitysafely.

Dance medicine is a youngand growing medical field. Ithas quickly become a subspe-cialty in sports medicine andphysical therapy. It seems possi-ble that special certification pro-grams for these providers couldemerge in the future. Though

research in dance medicine todate is minimal, the large num-bers of dancer athletes in this

sport could benefit fromimprovements in treatmentsupported by research studies.

Minnesota Dance Medicineand the Minnesota DanceMedicine Foundation appreci-ate the need for well-traineddance medicine professionalsto conduct education and dancemedicine research on thesededicated athletes to preventinjury and to further researchin this field. More informationabout Minnesota DanceMedicine is available atwww.mndancemed.org.

Brad R. Moser, MD, is the founderand director of the Minnesota DanceMedicine Foundation, a member of theDance/USA Taskforce on Dancer Health,a dance medicine consultant for manydance companies and studios in the TwinCities, and a sports and dance medicinespecialist at MOSMI–Minnesota Ortho-pedic Sports Medicine Institute in theTwin Cities. He is a member of theInternational Association of DanceMedicine and Science, the PerformingArts Medicine Association, the AmericanMedical Society for Sports Medicine, theAmerican College of Sports Medicine,and the American Academy of FamilyPhysicians.

FEBRUARY 2011 MINNESOTA PHYSICIAN 17

Posterior ankle impingement in the dancer

The following example illustrates the need for improved education ofhealth care professionals treating dancers.

Many times dancers will present to medical providers with acomplaint of “ankle restriction en pointe or relevé”; pain may be asymptom as well in these positions. [In ballet terminology, en pointerefers to performing steps while on the tips of the toes, using a spe-cial blocked shoe; relevé refers to rising from any position to balanceon one or both feet on at least demi-pointe (heels off the floor) orhigher to full pointe, where the dancer is actually balancing on thetop of the toes, supported in pointe shoes.]

In such cases, these dancers are routinely diagnosed withAchilles tendinitis. Dancers can get Achilles tendinitis, especially whenthey have tight heel cords and don’t complete their pliés. However,more often than not the diagnosis lies deeper. Minnesota DanceMedicine estimates that dancers have a higher incidence of posteriorankle impingement than of Achilles tendinitis.

Posterior impingement can be caused by many factors, includinga symptomatic os trigonum, ganglion cyst, synovial hypertrophy,large posterior talar process, or even a stress injury of the talus. Thefirst four of the conditions listed can cause a “mass-like” effect, creat-ing the feeling of restriction in the dancer (impingement); the fifth issimply a feeling of pain en pointe or relevé. Achilles tendinitis doesnot create a feeling of restriction or signs of impingement on exam.

A misdiagnosis of this condition can lead to worsening of theactual injury and subsequently significant time loss from dance. Forthe professional dancer, this could mean demotion or loss of positionwithin a company.

A large posterior ankle impingement outcomes study in dancersis under way at Minnesota Dance Medicine.

Appointments:

Online or Call 651-439-8807

Providing care as 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.SupportingYou.

David Palmer,M.D.& Zawadi’s brother

RussMcGill, OPA-C&Zawadi

multiple moderse aviding carorP innesota and n clinics in Multiple moder onsiniscWesota and

Page 18: Minnesota Physician February 2011

P R O F E S S I O N A L U P D A T E : P H Y S I C A L T H E R A P Y A N D R E H A B I L I T A T I O N

During the 1940s andearly 1950s, the UnitedStates experienced its

worst epidemics of poliomye-litis, most commonly referred toas polio. Nearly 60,000 cases ofparalysis, the vast majority inchildren, and 3,000 deaths werereported in 1952. Polio could betreated but not cured. The treat-ment consisted of bedrest, flu-ids, and, if necessary, mechani-cal help to breathe. Variableamounts of weakness in legs,arms, and swallowing andbreathing muscles remainedafter the resolution of thefebrile illness.

The poliovirus is a humanenterovirus that causes fever,muscle aches and nausea, vom-iting, and diarrhea. Paralysisresults in about 5 percent ofinfected individuals. During theepidemics, an estimated 90 per-cent of individuals who wereinfected with the virus did notappear ill or feel ill in any way,and 5 percent of individuals hadonly gastrointestinal symptoms.The presence of large numbersof asymptomatic individuals

enhanced the spread of the dis-ease. Most cases occurred dur-ing late summer and were asso-ciated with outdoor activitiessuch as swimming pools.

In 1955 came word thatJonas Salk had created a vac-cine to prevent polio, madefrom an inactivated form of thevirus. After the March of Dimessponsored a mass immuniza-

tion campaign, the epidemicended. In 1958, Albert Sabinintroduced an oral vaccineusing live, weakened virus andpolio was gradually extin-

guished in the United Statesand, eventually, most of theworld. Currently, the trivalentinactivated polio vaccine isused in the U.S. and otherdeveloped countries; the oralvaccine is preferred in develop-ing countries because it is inex-pensive, effective, and easy toadminister.

Diagnosing PPS

Most polio patients eventuallyregained much of their functionand went on to lead active lives.In the 1970s and 80s, decadesafter their battle with polio,survivors began to experiencesymptoms, some of which—muscle weakness and some-times pain—were similar tothose of polio. Along with themuscle problems came over-whelming fatigue. Post-poliosyndrome (PPS) was firstdescribed in 1972 and thedescription was further revisedin the 1980s and 1990s.

The diagnostic criteria forpost-polio syndrome are:1) A prior episode of polio-

myelitis with evidence ofresidual motor neuron loss

2) A period of at least 15 yearsafter the acute onset of poliowith neurologic and func-tional stability

3) Gradual (though sometimesabrupt) onset of new weak-ness and abnormal muscle

weakness that persists for atleast one year

4) Exclusion of other medicalconditions that cause similarsymptomsAn estimated 25–50 percent

of polio survivors fit these diag-nostic criteria, depending onhow strictly the criterion of newmuscle weakness is applied. Asthe population ages, more casesare recognized. Risk factors forPPS include age above 12 at thetime of polio, severity of theoriginal paralysis, and greaterextent of recovery from theinitial paralysis. Pain is also afrequent complaint of poliosurvivors but is not necessaryfor the diagnosis of post-poliosyndrome. Post-polio syndromedoes not affect the large major-ity of polio survivors, most ofwhom experience a modestdecline in function and strengthover the years, similar to that ofthe general population after age50, which is 1 percent per year.

Post-polio syndrome is aclinical diagnosis made by care-ful history and physical exami-nation. Studies such as elec-tromyography (EMG) to assessother neurological possibilitiesand the extent of prior polioinvolvement, as well as lab testsfor creatine kinase, a muscleenzyme, may assist in estimat-ing the extent of overuse.

Individuals who recoveredall limb function and have func-tioned normally for years pre-sent a diagnostic challenge.These patients were excludedfrom diagnosis of post-poliosyndrome due to having “nor-mal“ muscle testing on exam.However, it is now known thatthere can be a loss of as muchas 60 percent of the motor unitsat the time of polio and thepatient can and does recoverfull strength on manual muscletesting. This is because thepatients are capable of a one-time maximum contraction, butthe muscle fatigues with contin-ued use. These patients maydescribe fatigue and weaknessand appear to be completelynormal when examined in theoffice. EMG studies, togetherwith medical records of theiracute polio, may assist in diag-nosing these cases.

Aftereffectsof an epidemic

Diagnosing and managingpost-polio syndrome

By Barbara P. Seizert, MD

18 MINNESOTA PHYSICIAN FEBRUARY 2011

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An estimated 25–50 percentof polio survivors fit the diagnostic

criteria for post-polio syndrome.

Page 19: Minnesota Physician February 2011

Treating symptoms of PPS

Fatigue is one of the most com-mon symptoms in any neuro-logical disease, but particularlyin post-polio syndrome.Amantadine, a medication origi-nally used to prevent flu inexposed individuals in the fluepidemics, is used in multiplesclerosis and post-polio syn-drome despite no clearcut evi-dence to support it. Modafanil(brand name Provigil) was stud-ied in a randomized controlledtrial and reported as being ofno benefit (Vasconcelos et al.,Neurology 2007). However, it isstill used, particularly inpatients who also have sleepapnea and daytime sleepiness.

Pacing physical and mentalactivities by imposing rest iseffective. Assessing the qualityof sleep with sleep study to ruleout sleep apnea or other respi-ratory involvement may be ben-eficial. This can occur in poliowithout prior evidence of bul-bar (respiratory and swallow-ing) involvement.

Muscle fatigue and newmuscle weakness have beenstudied most extensively. Both

resistance and cardio types ofexercise have been shown to bebeneficial in restoring strengthand preventing muscle deterio-ration. In a randomized con-trolled trial, polio patients whoreceived strength training withnon-fatiguing exercise threetimes per week at 50 percent ofmaximum resistance showedsignificantly greater improve-ments in strength than controlsassigned to no training (Chan et

al., Muscle Nerve, 2003). Othersmaller, non-controlled studiesalso have reported improve-ments in strength with this typeof program.

Pyridostigmine has beenevaluated in several controlledtrials but has not been shown tosignificantly improve fatigueand is used on an individualbasis. Prednisone has notshown any benefit. Intravenousimmune globulin (IVIG) was

given in two infusions threemonths apart in a randomizedtrial, results of which werereported by Gonzalez et al. inLancet Neurology (2006).Improvement was seen in med-ian muscle strength in a select-ed study, and in a smaller study,statistically significant improve-ment in pain was seen at threemonths. However, there wasno improvement in fatigue orquality of life in either of thesestudies. Additional studies areneeded to support use of thistreatment.

Respiratory and swallow-ing problems can occur in poliosurvivors who had neither prob-lem during their acute polio,or who recovered from themcompletely during the following6–12 months. Treatmentrequires altering diet or eventube feeding if swallow studiesshow aspiration occurring.Aspiration pneumonia orrepeated episodes of bronchitissuggest occult aspiration andindicate need for study. Aboutone-third of post-polio patientshave this problem, and an addi-

FEBRUARY 2011 MINNESOTA PHYSICIAN 19

POST-POLIO to page 38

What causes post-polio syndrome?

The etiology of post-polio syndrome is unknown, but there is supportfor three theories.

The motor neuron—the nerve from the spinal cord to the muscle—is the chief area of loss in polio. Reinnervation, in which the bodycompensates for the loss by sprouting new nerve fibers or axons,leads to increased strength but also enlarges the motor neurons andthe muscle groups they act on. With time, this larger motor unit fails.Overuse or underuse of affected muscles over time has been shownto predispose former polio patients to new weakness. Some of thepreviously reinnervated nerve sprouts and muscle fibers die.

The persistence of poliovirus and its reactivation have beeninvoked to explain neuron loss and have support from tissue cultureand antibody studies in one study, but no other studies since havesupported that finding.

Inflammation and autoimmune-mediated mechanisms in PPSare supported by autopsy study on seven PPS patients. The spinalcord showed inflammation and lymphocyte (cells with antibodies)infiltration along with degeneration of neurons. These changes weremore prominent in patients with progressive weakness.

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Cardiovascular disease,and sudden cardiac arrest(SCA) in particular,

remains the most importantcause of premature death inWestern countries, accountingfor about 400,000 deaths outsidethe hospital and another 400,000deaths inside the hospital peryear in the United States alone.Despite routine cardiopulmon-ary resuscitation (CPR) training,the placement of automaticexternal defibrillators (AEDs)in public places, and increasingawareness of the importance ofearly bystander CPR, only 5–10percent of out-of-hospital SCAvictims leave the hospital, andan even smaller percentage leaveneurologically intact.

Among the factors con-tributing to these poor survival

statistics is the inefficiency ofconventional CPR. CPR alonedelivers only 25 percent of nor-mal blood flow to the brain and15 percent of normal blood flowto the heart. Over the past 20years, working at the Universityof Minnesota in the Depart-ments of Internal Medicineand Emergency Medicine, ourresearch team has focused onstudying the physiology of CPRand developing new principlesand techniques for improvingSCA survival; and it has led tothe development of noninvasivecirculatory enhancement tech-nology to improve circulation inpatients in cardiac arrest.

From concepts to devices

In the 1990s, our NIH-fundedresearch identified the potentialfor modulating intrathoracicpressure for improving cardiacand cerebral blood flow duringCPR. We developed the conceptof using a relatively simpledevice to modify inspiratoryimpedance in order to lowerintrathoracic pressure duringkey parts of the CPR cycle andthereby improve blood flowand survival.

To put the impedancethreshold device (ITD) conceptinto practice, Advanced Circula-tory Systems Inc. was foundedin 1997. Since then, the compa-ny has developed several devicesthat are recommended by thenew 2010 American HeartAssociation CPR guidelines andare widely used by EMTs:• The ResQPOD ITD providesperfusion on demand by regu-lating pressures in the thoraxduring states of hypotension.It selectively prevents unneces-sary respiratory gases fromentering the chest during thechest-wall recoil phrase ofCPR, thereby enhancing refill-ing of the heart with eachrecoil of the chest wall. Thismechanism also lowersintracranial pressure, thus

boosting forward blood flow tothe brain as well. It is FDA-approved for use in the U.S. asa circulatory enhancer device.

• The ResQPump is a hand-helddevice that is placed in thesame position on the sternumas the hands are for standardCPR. It allows rescuers toprovide active decompressionof the chest, thereby assuringproper chest wall recoil andthe creation of a negativeintrathoracic pressure(vacuum) when used with theResQPOD that helps returnblood to the heart.

• The ResQGARD ITD providesa simple and convenient wayto treat hypotension in sponta-neously breathing patients.This device was developed inconjunction with NASA andthe U.S. Army for treatment oflow blood pressure, a problemexperienced by astronautsafter prolonged space flightupon their return to earth anda significant problem for ourwounded soldiers. Inspirationthrough the ResQGARD lowerspressures inside the thorax,drawing more blood back intothe heart and lowering intra-cranial pressures simultane-ously. This device harnessesnormal breathing to increasecirculation.

• More recently, a new group ofdevices has been developed fortreating non-breathing hypo-tensive patients and patientswith head injury based uponthe same physiological con-cepts of the ResQPOD andResQGARD. This group ofdevices lowers intrathoracicpressure after each positivepressure breath. Named theCirQLator and ResQVent, thisnew approach has been usedby anesthesiologists at theUniversity of Minnesota totreat intraoperative hypoten-sion. This approach has alsobeen shown to lower intracra-nial pressure in patients withhead injury.

At the November 2010 meet-ing of the American HeartAssociation, Ralph Frascone,MD, associate professor of emer-gency medicine at the Universityof Minnesota and EMS medicaldirector at Regions Hospital inSt. Paul, presented results of the

CPR researchImproving survival rates for

sudden cardiac arrest

By Keith G. Lurie, MD, and Demetris Yannopoulos, MD

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Cardiovascular diseases,

including stroke, are the

leading cause of death in

Minnesota. Statewide,

they caused 10,656

deaths (28.7 percent of

all deaths) in 2007,

according to the Ameri-

can Heart Association.

This special focus

describes cardiology

research under way in

Minnesota on approaches

to treating sudden car-

diac arrest; percutaneous

treatment of valvular

heart disease; post-heart-

transplant survival; and

optimizing pacemaker

device technology.

S P E C I A L F O C U S : C A R D I O L O G Y R E S E A R C H

Page 21: Minnesota Physician February 2011

first prospective, randomizedclinical trial to demonstrate along-term survival benefit withfavorable neurologic benefitusing CPR devices. The NIH-funded trial compared survivalrates among a control group of813 cardiac arrest patientsreceiving standard CPR to anintervention group of 840 receiv-ing active compression-decom-pression cardiopulmonary resus-citation (ACD CPR) performedusing the ResQPump, with theResQPOD impedance thresholddevice. The study showed that50 percent more patients whoexperienced out-of-hospital car-diac arrest survived after receiv-ing CPR performed with theResQPump and the ResQPODITD as compared to thosereceiving conventional, manualCPR. This research was pub-lished in the Jan. 22, 2011, issueof The Lancet.

These CPR innovations haveresulted in almost doubling ofSCA survival in multicenter clin-ical trials, when the new deviceshave been combined with state-of-the art, high-quality CPR. Themilitary has used this sameapproach for treating soldiersinjured in battle in Iraq andAfghanistan. The importance ofthe findings has been acknowl-edged by NASA, which hasinducted the ResQPOD ITD intothe Space Foundation Techno-

logy Hall of Fame. Trauma spe-cialists are currently evaluatingthis technology to reduce brainswelling after head trauma.

The circulatory system is thehuman body’s transport systemfor life. The consequences ofreduced circulation are severeand burden the health caresystem with billions of dollarsof expenditures on an annualbasis. By enhancing our under-standing of cardiopulmonaryphysiology of the SCA state, ourresearch has helped us developtools and techniques that areproven to improve CPR success.This work is leading to break-throughs in improving surviv-ability after out-of-hospital SCA,and has already saved thousandsof lives. It is anticipated thatthese efforts, in conjunctionwith bystander CPR, AEDs, andtherapeutic hypothermia, willlead to 40–50 percent out-of-hospital SCA resuscitation rates.

We remain actively engagedin CPR research. Most recently,using the devices describedabove in combination with acommonly used vasodilatornamed sodium nitroprusside,we have shown in animals andseveral patients that this newdrug/device combination resultsin improved survival rates, evenafter prolonged periods of car-diac arrest. Larger trials arebeing planned as a result of this

ongoing research.We are on the threshold

for a new era in CPR in whichwe will use systems-basedapproaches that will include

automated CPR devices and newtechniques that optimize circula-tion both during CPR and post-resuscitation. We still have along way to go, but we are defi-nitely making progress.

Keith G. Lurie, MD, is co-director ofthe Cardiac Arrhythmia Center, CentralMinnesota Heart Center, St. Cloud, anda staff cardiologist at St. Cloud Hospital;founder and chief medical officer ofAdvanced Circulatory Systems, Inc.,Roseville; and professor of medicine andemergency medicine at the University ofMinnesota. Demetris Yannopoulos,MD, is an assistant professor of medicineat the University of Minnesota.

The successes described in this article area result of long-standing collaborationwith other members of the University ofMinnesota faculty in the departments ofemergency medicine, pulmonary and criti-cal care medicine, anesthesiology, biomed-ical engineering, and cardiovascular dis-eases, along with collaboration with theU.S. Army Institute for Surgical Research,and investigators at the University ofVirginia, the Medical College of Wisconsin,NASA, the University of SouthernCalifornia, and the University of Cincinnati.The authors have been supported by theMinneapolis Medical Research Foundationat Hennepin County Medical Center.

FEBRUARY 2011 MINNESOTA PHYSICIAN 21

Members of the research team also have activelysupported community education programs to improveSCA survival. Take Heart America (http://takeheartamerica.org/) and Take Heart Minnesota (http://take heartminnesota.org/) are organizations that fosterrecognition of SCA as a health hazard and provideeducation leading to improved knowledge of optimalresuscitation techniques in schools and workplaces.

Recognizing that there is no silver bullet for curingpatients after cardiac arrest, the program is based onpromoting all the intervention guidelines endorsed bythe American Heart Association in 2005. Several inter-ventions included in the Take Heart program have beenpioneered in Minnesota. St. Cloud and three other TakeHeart programs—in Minnesota’s Anoka County; Austin,Texas; and Columbus, Ohio—are pilots for the nationalTake Heart America program. Now plans are underway to expand Minnesota’s programs statewide forTake Heart Minnesota.

Take Heart America aims to dramatically increasethe survival rate of sudden cardiac arrest from 5 per-cent nationwide to more than 20 percent. The overallstrategy is to simultaneously deploy four proven inter-ventions, each of which increases survival from 2 per-centage points to 10 percentage points:• Community-wide CPR/AED education and training.

This involves teaching correct CPR and AED use to allhigh school freshmen and the community at large.

• Deployment of AEDs in strategically positionedlocations—first-responder vehicles, churches, schools,public buildings, shopping centers—to maximizebystander access.

• Comprehensive training for emergency medical prac-titioners and emergency/trauma room personnel withthe latest CPR techniques and a new device called theResQPOD that doubles circulation during CPR. At St.Cloud Hospital and in Anoka County, a device calledthe LUCAS has also been deployed to help automatethe CPR process. Efforts are under way in CentralMinnesota to get ambulance transport companiesto utilize the LUCAS during advanced life-supportprocedures.

• Implementation of specific treatments for post-resuscitation care after successful resuscitation,including therapeutic hypothermia for unconscioussurvivors, aggressive evaluation and treatment withinterventional cardiology techniques and implantablecardioverter-defibrillators, and complete cardiacelectrophysiological evaluation.

According to combined data from Take Heart St.Cloud and Take Heart Anoka, simultaneous implemen-tation of the four interventions has doubled survivabilityfrom all sudden cardiac arrests in St. Cloud and AnokaCounty—from 8.5 percent to 19 percent.

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S P E C I A L F O C U S : C A R D I O L O G Y R E S E A R C H

Transcatheter cardiovascu-lar therapies prior to the21st century witnessed

revolutionary changes in themanagement of coronary andperipheral arterial disease. Overthe past three decades, a highlyinvasive surgical approach hasyielded to less invasive percuta-neous approaches. Transition-ing some of these breakthroughtechnologies into platforms fortreating valvular heart diseasehas ushered in an explosivequest for minimally invasivetreatments of these structuralheart diseases.

The structural complexityof cardiac valve anatomy hascreated technical challenges forworking in three dimensionsthat surpass the challenges oftreating coronary or peripheralartery disease. Concurrent ad-vances in noninvasive imaginghave been essential to the suc-cess of transcatheter modalities,which are carried out in theabsence of direct visualization.

The demand for these revo-lutionary therapies is drivenlargely by current unmet needswithin our growing population

of elderly patients. Valvularheart disease is predominantlydegenerative and, thus, is moreprevalent in the elderly. Patientsin their 70s, 80s, and 90sincreasingly expect enhancedlongevity and quality of life;valvular heart disease adverselyaffects both. Treatment optionstoday are predominantly con-fined to standard open-chest,highly invasive surgicalapproaches, which carryincreased operative morbidityand mortality in elderly pa-tients; hence the need for lessinvasive surgical and trans-catheter approaches. As efficacy

and safety are demonstrated inthese high-risk patient groups,transition to lower-risk groupsis anticipated.

The two predominant valveabnormalities in the adult pop-ulation are aortic stenosis (AS)and mitral insufficiency.

Aortic stenosis

The incidence of aortic stenosisin individuals aged 80 to 90 is5–7 percent and in nonagenari-ans, even higher (10–15 per-cent). Surgical valve replace-ment is a mature and highlysuccessful treatment for aorticstenosis patients and age shouldnever be the basis for exclusion.Nevertheless, operative mortal-ity in octogenarians is 6–8 per-cent and in nonagenarians,12–14 percent. Probably moresignificant is the postoperativemorbidity and prolonged recov-ery. Medical therapy offers littlebenefit for these patients, whohave a 50 percent mortality attwo years from the onset ofsymptoms.

Minneapolis Heart Institute(MHI) at Abbott NorthwesternHospital has focused significantinvestigative effort on the reju-venation of balloon aorticvalvuloplasty (BAV) as an inter-vention with substantial pallia-tive benefit in poor surgicalcandidates. Over the past fiveyears, we have performed ap-proximately 300 aortic valvulo-plasties. Through this uniqueexperience, we have document-ed and published some veryfavorable findings that havecontributed to the reawakeningof aortic valvuloplasty as a goodtreatment option for nonsurgi-cal candidates with severesymptoms.

The mean age in our data-base cohort is ~86 years and

includes a large population ofpatients over 90. Our initialpublished experience in patientsover 90 included 31 patients.The mean age was 93 years, 65percent were female, and 45percent had concurrent coro-nary artery disease. Six patients(19 percent) underwent simulta-neous BAV and coronary stent-ing. The baseline and postoper-ative valve areas were 0.52 cm2

and 0.92 cm2, respectively. NewYork Heart Association (NYHA)functional class improved strik-ingly, from class III/IV to classII. Perioperative mortalityoccurred in only one patient(3 percent). With continuedimprovements in technique,the procedural mortality hasfallen even further in thisgroup, to <2 percent. The pre-dominant limitation of this pro-cedure remains restenosis,which is reported in 42–83 per-cent in five to nine months. Wehave found, however, that thesepatients can be re-dilated seri-ally without increased risk onsubsequent interventions, allow-ing us to extend the period ofquality-of-life enhancement.

The overall incidence ofCAD in patients with severe ASis 40–50 percent. It is thus quitecommon to discover severecoronary stenosis at the time ofcardiac catheterization for BAV.The potential advantage ofoffering a combined procedure,including BAV and simultane-ous percutaneous coronaryintervention (PCI), seems intu-itive but is untested in theseelderly patients. We publishedthe first large experience usingthis approach in our initial 17patients. The mean age was 86.All coronary lesions were treat-ed with stents and included amean of 2.1 lesions and 1.4 tar-get vessels per patient. All butfour patients underwent coro-nary stenting immediately priorto BAV. There were no myocar-dial infarctions, strokes, orprocedural deaths. The proce-dural times with simultaneouscoronary stenting increasedminimally, from 86.2+27.3 to98.8+17.6 minutes. We havenow performed 46 combinedBAV and PCI cases withexcellent results.

We have found BAV to beuseful in “bridging” patients to

Percutaneouslytreating complexvalve disease

Research in a rapidly developing field

By Wes Pedersen, MD, Vib Kshettry, MD,Kevin Harris, MD, Robert Hauser, MD, Ben Sun, MD,

and Irvin F. Goldenberg, MD

22 MINNESOTA PHYSICIAN FEBRUARY 2011

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surgical aortic valve replace-ment (AVR). This approach iscurrently being evaluated byothers in bridging extremelyhigh-risk patients to trans-catheter aortic valve implanta-tion (TAVI). We have now per-formed BAV on 16 patients withprofoundly impaired left ven-tricular function (ejection frac-tion (EF) of <20 percent), whichrepresents an exclusion forentry into current TAVI trialsin the U.S. These patients weresafely dilated without proce-dural mortality. Importantly,50 percent of these patientssubsequently demonstrated animproved EF to >20 percent(mean 26 percent), allowingthem to potentially qualify forTAVI implantation.

Understanding the mecha-nism of aortic valve restenosisfollowing BAV is cellular innature and related to hetero-topic ossification and fibrosis,we conducted a pilot study(Radiation Following Percu-taneous Balloon Aortic Valvulo-plasty to Prevent Restenosis) inhopes of limiting restenosis. Inother clinical settings (e.g.,orthopedic and plastic surgery),external beam radiation deliv-ered post-operatively has beenefficacious in limiting thesehistopathologies. Our initialpublished experience in 20patients using doses rangingfrom 12 Gy to 18 Gy resulted ina 30 percent restenosis in thelow-dose (12 Gy) group and 11percent restenosis in the high-dose (18 Gy) group, which com-pared favorably to the historicalrate of 80 percent. Based onthis, we launched an FDA-approved, multicenter, random-ized, double-blind study evalu-ating the efficacy of localizedexternal beam radiation to theaortic valve following BAV.

Which patients arecandidates for BAV?

Our experience with BAV haspermitted us to advocate forpalliative BAV in appropriatepatients. Candidates shouldinclude those with symptomaticAS and any of the following*:• Bridge to surgical AVR inhemodynamically unstablepatients.

• Increased perioperative risk,STS risk score >10–15 percent.

• Anticipated survival of <3years.

• Age in the late 80s or 90s andprefer BAV over open thoraco-tomy for AVR.

• Severe comorbidities such asporcelain aorta, severe lungdisease, and others for whichthe CV surgeon prefers notto operate.

• Severe and/or disabling neuro-muscular or arthritic condi-tions that would limit postop-erative rehabilitation.

*(STS, Society of Thoracic Surgeons; CV, cardiovascular)

The need for more defini-tive nonsurgical options hasdriven pioneering efforts in thefield of transcatheter aorticvalve implantation. The firstin-man implantation was car-ried out in 2002 by AlainCribier in France. Although twodevices have become commer-cially available in Europe in2007, they are not approved inthe U.S. and can be used onlyunder investigational deviceexemption (FDA-approvedinvestigational trials). The twodevices—the Edwards-SAPIENtranscatheter balloon expend-able valve and the self-expand-ing Medtronic CoreValve—havecombined for a total of nearly20,000 implants worldwide. Asthe technology has improvedand operators have workedthrough their learning curves,the implantation success ratesare now >95 percent. However,complications include adverseperipheral vascular events in2–13 percent, coronary occlu-sion in 0.6 percent, and a strokerate of 2–4 percent.

The first randomized TAVItrial (PARTNER), which our col-leagues at the Mayo Clinic par-ticipated in, was recently com-pleted in the U.S. using theEdwards-SAPIAN balloonexpandable valve. Results in thispatient group, which had beenturned down for conventionalsurgical AVR, were randomizedto TAVI vs. medical therapy. Thefindings demonstrated a robust70 percent reduction in the one-year mortality, from 50 percentto 30 percent, and a highly sig-nificant improvement in qualityof life. We will be participatingwith Mayo Clinic in a secondPARTNER II trial evaluatingthese non-operable patients.

Mitral regurgitation

Mitral regurgitation (MR) iseven more prevalent than ASand significantly more complex,requiring a broad menu of ther-apeutic options to successfullytreat this heterogeneous patientgroup. Mitral valve disorderscausing MR can be divided intotwo groups: primary and sec-ondary. Primary (degenerative)disorders result from abnormal-ities intrinsic to the mitral valveapparatus; secondary (function-al) disorders result from abnor-malities extrinsic to the mitralvalve, most significantly leftventricular dysfunction. Weanticipate transcatheter treat-ments for these diverse disor-ders taking longer to develop inthe absence of the “one size fitsall” approach available forpatients with AS.

The treatment of choice forpatients with severe MR is sur-gical and, whenever possible,repair is preferred over pros-thetic valve replacement. Mini-mally invasive and roboticapproaches are gaining momen-tum but require unique surgicaltalents more commonly avail-

able at higher-volume valve cen-ters of excellence. They primar-ily offer reduced surgical mor-bidity and shortened recoveryperiods.

Transcatheter or percuta-neous treatment approaches forMR thus far have focused onvalve repairs, in contrast to ASapproaches, which have focusedon valve implantation. At pres-ent there are three strategiesfor transcatheter mitral valverepair: 1) edge-to-edge repair,2) coronary sinus deviceimplants, and 3) noncoronarysinus device implants. All arecurrently investigational inthe U.S.

Our center participated inthe landmark EVEREST II trial,a pivotal randomized trialcomparing the percutaneousMitraClip with traditional sur-gery. The MitraClip is a minia-ture clip delivered transvenous-ly from the femoral vein. It ispositioned across the A2-P2scallops of the mitral valveleaflets, creating a “double ori-fice” repair. It is designed tomimic the surgical Alfieri stitch

FEBRUARY 2011 MINNESOTA PHYSICIAN 23

VALVE DISEASE to page 27

Page 24: Minnesota Physician February 2011

S P E C I A L F O C U S : C A R D I O L O G Y R E S E A R C H

Acute coronary syndromesare caused by plaquerupture and thrombosis

leading to ischemia from a new,significant coronary stenosis.Percutaneous coronary inter-vention (PCI) is often a primarytherapy. Prior to the era ofplatelet glycoprotein (GP)IIb/IIIa inhibitors, PCI wasassociated with a major adversecardiac event rate of 10–12percent.

J.E. Tcheng reported in theESPRIT (Enhanced Suppres-sion of the Platelet IIb/IIIaReceptor with IntegrilinTherapy) study that the plateletreceptor GP IIb/IIIa inhibitoreptifibatide improves cardiacoutcomes among patients withPCI by reducing the occurrenceof major adverse cardiac events(ESPRIT investigators, Lancet,2000). Yet despite this improve-ment in outcomes, myocardialinfarction may still complicatePCI in the absence of angio-graphically evident complica-tions. Thrombus, as well as vas-cular debris, may embolize andlead to plugging of the micro-

vasculature, microvascular dys-function, and, eventually,myocardial necrosis.

GP IIb/IIIa antagonists athigh local concentrations mayenhance thrombus disaggrega-tion by disrupting platelet

crosslinking. Indeed, higher lev-els of platelet GP IIb/IIIa recep-tor occupancy using eptifibatidehave been shown to be associ-ated with improved myocardialperfusion among patients with

ST elevation myocardial infarc-tion (Gibson et al., Circulation,2004). Thus, intracoronary (IC)administration of eptifibatidemay result in a very high localconcentration, which may leadto increased levels of platelet

GP IIb/IIIa receptor occupancy,destabilization of platelet aggre-gates, and promotion of throm-bus disaggregation in theepicardial artery and microvas-culature, thereby improvingmyocardial perfusion.

We hypothesized that ICbolus administration of eptifi-batide in an acute coronary syn-drome with stent implantationwould result in higher local lev-els of platelet GP IIb/IIIa recep-tor occupancy (RO) in the coro-nary bed, reduced thrombusburden, and improved measuresof coronary flow.

A single-center prospectivestudy conducted at St. Mary’sMedical Center, Duluth, ran-domized 43 patients who pre-sented with an acute coronarysyndrome from January 2006 toOctober 2007. The ICE (Intra-coronary eptifibatide bolusadministration during percuta-neous revascularization foracute coronary syndromes withevaluation of platelet GPIIb/IIIa receptor occupancy andplatelet function) trial is thefirst randomized trial of intra-coronary eptifibatide.

Methods

All of the 43 patients in the ICEstudy were treated with at least325 mg of aspirin prior to thePCI procedure. A loading doseof clopidogrel 300 mg was

administered immediately aftercompletion of the PCI. Aweight-adjusted heparin regi-men was used to titrate andachieve an activated clottingtime of 200–250 seconds priorto PCI.

A baseline-assessmentmyocardial perfusion wasobtained after administration ofintracoronary adenosine. Thebaseline assessment includedTIMI (thrombolysis in myocar-dial infarction) flow grade(TFG), a standardized measureof epicardial coronary flow; andboth TIMI myocardial perfusiongrade (TMPG) and a correctedTIMI frame count (cTFC), stan-dardized measures of microvas-cular flow. The cTFC measuresthe number of angiographicframes necessary for the bloodto flow with the initial injectionof contrast in the coronary untilthe contrast opacifies the distalvessel. The faster this is accom-plished, the lower the framecount, the better the flow in themicroscopic coronary vessels,and the better the coronary flowto the cardiac muscle.

Treatment subjects (ICarm). The eptifibatide bolus,180 mcg/kg, was administeredover 2 minutes via the guidecatheter. The continuous infu-sion of eptifibatide via a periph-eral vein was started at theonset of the bolus at a rate of2 mcg/kg/min. A second eptifi-batide bolus was administeredvia the guide catheter into thecoronary artery 10 minuteslater.

Control subjects (IV arm).The eptifibatide bolus, 180mcg/kg, was administered via aperipheral vein over 2 minutes.The eptifibatide continuousinfusion rate was 2 mcg/kg/min.A second eptfibatide bolus wasadministered intravenously 10minutes later.

GP IIb/IIIa receptor occu-pancy (RO) study. In the ICarm, coronary sinus andfemoral blood samples wereobtained 30 seconds after thestart of each eptifibatide bolus.In the IV arm, coronary sinusand femoral blood sampleswere obtained 60 seconds afterthe start of each eptifibatidebolus.

The ICE TrialComparing drug delivery pathways in

patients with acute coronary syndrome

By Albert Deibele, MD, FACC, FSCAI, FAHA

24 MINNESOTA PHYSICIAN FEBRUARY 2011

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By changing the route of eptifibatideadministration, microvascular perfusion

can be improved with no additionalassociated costs.

Page 25: Minnesota Physician February 2011

Results

There were no angiographic,electrophysiologic, or otheradverse findings attributable tothe IC administration of eptifi-batide. There were no perfora-tions, pericardial effusions, orclinical evidence for intracar-diac hematomas.

The local platelet GPIIb/IIIa RO in the coronarysinus was significantly higher inthe IC group for both boluses:first bolus 94 percent (±9 per-cent) versus 51 percent (±15percent), p<0.001, and secondbolus 99 percent (±2 percent)versus 91 percent (±4 percent),p=0.001 (Fig. 1). The higherlocal levels of platelet GPIIb/IIIa RO in the IC groupwere associated with animproved post-PCI cTFC medi-an (25th and 75th percentiles)with IC versus IV administra-tion: pre-PCI 36 (16,64) versus31 (23,45), p=0.8, and post-PCI18 (10,22) versus 25 (22,35),p=0.007, respectively.

After adjusting for the pre-PCI cTFC, the IC group had asignificantly better cTFC com-pared to the IV group, p<0.001.The multivariate analysisdemonstrated that, after adjust-ing for the pre-PCI cTFC, theonly factor associated with thepost-procedural cTFC was thefirst bolus platelet GP IIb/IIIaRO in the coronary sinus,p<0.001.

Discussion

This randomized trial of intra-coronary eptifibatide demon-strated a significantly higherlocal platelet GP IIb/IIIa recep-tor occupancy by the antagonisteptifibatide in the coronary bedwith IC versus IV bolus admin-istration. This treatment regi-men was associated withimproved coronary flow andmicrovascular perfusion,demonstrated by improvedcorrected TIMI frame counts.An early high level of localGP IIb/IIIa receptor occupancywith the first bolus administra-tion in the coronary bed wasthe only factor in a multivariateanalysis associated with animproved corrected TIMI framecount.

These beneficial effectsmight be explained by highlocal concentrations of eptifi-

batide, which led to the disag-gregation of thrombi at the rup-tured plaque as well as in themicrocirculation. Since eptifi-batide is a competitive inhibitorof fibrinogen binding to theplatelet GP IIb/IIIa receptor, thepresence of high localized con-centrations of drug may enablethe dissociation of bound fib-rinogen that crosslinked activat-ed platelets to form the occlu-sive thrombus. Hence, micro-vascular perfusion may beimproved by reducing both thenumber as well as the size ofmicroemboli. This mechanismis seen with in-vitro studiesmodeling coronary flow, whichhave shown that eptifibatidedisaggregates thrombi effec-tively at concentrations with anorder of magnitude greater thanthat usually achieved with stan-dard IV administration. (Moseret al., J Cardiovasc Pharmcol,2003).

Furthermore, recent studieshave shown that higher concen-trations of a GP IIb/IIIa antago-nist are necessary to effectivelydisaggregate stable, aged aggre-gates when compared to thosenewly formed thrombi (Speichet al., J Thromb Haemost,2009). The disaggregation ofthrombi may be the mechanismfor the clinical benefit seen inprevious studies.

Improved coronary flowand microvascular perfusionmay have further clinical impli-cations. Previous studies havedemonstrated that lower cor-rected TIMI frame counts havebeen associated with both alower risk of adverse outcomesand a lower risk of inpatientmortality. In the Randomized

Efficacy Study of Tirofiban forOutcomes and Restenosis(RESTORE) trial in the settingof acute coronary syndromes,survivors had a lower cTFCthan patients who died afterPCI (Gibson et al., J Am CollCardiol 1998). Similarly, in thesetting of acute ST elevationmyocardial infarction, the 90-minute cTFC was an independ-ent predictor of in-hospitalmortality OR (odds ratio)=1.21for every 10-frame rise [95 per-cent CI 1.1 to 1.3], p=0.006.

The risk of adverse outcomesdefined by death, recurrent MI,shock, congestive heart failure,or left ventricular ejection frac-tion ≤ 40 percent was 7.9 per-cent for cTFC <20, 15.5 percentfor a cTFC 20–39 and 27.0percent for a cTFC >40, p=0.015(Gibson et al., Circulation,1999).

This study extends previousobservations that have beenreported with another GPIIb/IIIa antagonist, abciximab.IC administration of abciximabduring primary PCI of an STelevation myocardial infarctionhas been associated with adecrease in the infarct size of15.1 percent for IC and 23.4percent for IV, p=0.01, as wellas a decrease in microvascularobstruction as assessed by car-diac magnetic resonance imag-ing (Thiele et al., Circulation,2008).

Conclusions

Intracoronary bolus administra-tion of eptifibatide is superiorto standard intravenous treat-ment in achieving high local

FEBRUARY 2011 MINNESOTA PHYSICIAN 25

FIGURE 1. % GP llb/llla RO by CollectionSite and Bolus

ICE TRIAL to page 26

Page 26: Minnesota Physician February 2011

platelet GP IIb/IIIa receptoroccupancy in the coronary bed,as measured in the coronarysinus, and improved microvas-cular perfusion, as measuredby the corrected TIMI framecount. By changing the routeof eptifibatide administration,microvascular perfusion canbe improved with no additionalassociated costs.

Albert Deibele, MD, FACC, FSCAI,FAHA, is an interventional cardiologistat Essentia Health in Duluth, where he is

chief of hospital-based medical servicesand diagnostics and an active member ofthe cardiology research committee. Hisresearch interests are acute coronarysyndromes and valvular heart disease.

This article is based on a paper thatappeared in the journal Circulation in2010 (Deibele AJ, Jennings LK, Tcheng JE,Neva C, Earhart AD, Gibson CM,Intracoronary eptifibatide bolus adminis-tration during percutaneous revasculariza-tion for acute coronary syndromes withevaluation of platelet GP IIb/IIIa receptoroccupancy and platelet function, the ICETrial, Circulation 2010; 121: 784-791).

26 MINNESOTA PHYSICIAN FEBRUARY 2011

ICE trial from page 25Case presentation for ICE trial

A 54-year-old male with a history of coronary artery diseasepresents with a three-week history of waxing and waning chestdiscomfort radiating to his left arm and associated dyspnea. Theelectrocardiogram is normal, but the cardiac biomarker CK-MB iselevated at 54.6 ng/ml, confirming a non-ST elevation myocar-dial infarction. This patient would be a candidate for the ICE(Intracoronary eptifibatide bolus administration during percuta-neous revascularization for acute coronary syndromes with evalu-ation of platelet GP IIb/IIIa receptor occupancy and platelet func-tion) trial. The angiogram for this patient demonstrated a throm-bus in the distal right coronary artery (Fig. 2). After intracoronaryeptifibatide was administered, there was a significant reductionin the thrombus burden (Fig. 3).

FIGURE 2 (at left). Imageshowing a thrombus inthe distal right coronaryartery of a patient in theICE trial.

FIGURE 3 (at right). Afterintracoronary eptifibatidewas administered to thepatient, there was a sig-nificant reduction in thethrombus burden.

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Page 27: Minnesota Physician February 2011

repair developed by Alfieriand colleagues in Italy in 1991.Leaflets are coapted across theregurgitant orifice and mitralinsufficiency is reduced. It canbe used for both degenerativeand functional MR.

The EVEREST II trialgroup demonstrated theMitraClip at 12 months has aclinical success rate, defined asfreedom from death, >2+ MR,and mitral valve surgery, of 72percent. It achieved statisticalnon-inferiority in comparisonto conventional surgery. Reverseremodeling of the ventriclewas observed in the MitraClipas well as the surgical group.Symptomatic benefit wasobserved in both cohorts,with 98 percent of successfulMitraClip implant patients and88 percent of surgical patientsexperiencing NYHA functionalclass I/II symptoms at 12months. The greatest differencebetween the two groups was inprocedural safety. The rate ofpredefined major adverse eventswas 57 percent in the surgicalcohort compared to 10 percentfor the MitraClip, due largelyto the greater need for bloodtransfusions in the surgicalgroup.

The EVEREST High-Riskregistry was created as a sepa-rate study for nonoperativepatients with severe MR. Thisregistry enrolled 79 patients,the majority of whom had func-tional MR, secondary to under-lying ischemic heart disease. Inaddition, patients were older(average age, 76 years; 68 per-cent >75 years) and more symp-tomatic (89 percent were NYHAclass III or IV) than the ran-domized EVEREST population.We showed that although thepredicted mortality rate for thegroup was 18.2 percent at 30days, the actual mortality ratewas 7.7 percent, with a 76 per-cent one-year survival rate and79 percent of the survivors inNYHA class I or II. In a non-randomized concurrent groupsimilar to the high-risk patientswho were treated medically,there was a survival advantageat one year, with 76.4 percent ofpatients alive in the MitraClipgroup versus 54.7 percent in the

medically treated group. Thesedata support the concept thatnovel percutaneous options arebeneficial, particularly for non-operative patients.

This device has achievedapproval in Europe and is nowunder review by the FDA. Weare participating in an openaccess registry, REALISM, per-mitting the continued evaluationof the MitraClip’s performance.

We also investigated a novelinterventional device, iCoapsys,designed as a ventricular treat-ment approach to patients withfunctional MR. The iCoapsysdevice is designed to acutelyreshape the left ventricle andmitral valve annulus by posi-tioning anterior and posteriorpads on the epicardial surfacethat are tethered together by atransventricular cord. Left ven-tricular and anterior-posteriorannular dimensions are reducedby drawing the pads togetheras the transventricular cord isshortened under transesopha-geal echocardiography guid-ance. MR is reduced by permit-ting improved leaflet coapta-tion. After safety and efficacyhad been demonstrated in asurgical population (open-chest,beating-heart patients), a trans-catheter system was developedfor percutaneous, transpericar-dial delivery. After we demon-strated system feasibility in theanimal model, we successfullyplaced the first percutaneousin-man device at Abbott North-western Hospital in 2008.

A multidisciplinaryteam approach

The development of catheter-based valve implantation andrepair stands not only on theshoulders of a long history ofsurgical valve replacement andrepair, but on recent develop-ments by interventional andimaging cardiologists using per-cutaneous methods. The recentbreakthroughs in transcathetervalve therapy could not havebeen possible without the com-bined efforts of cardiovascularsurgeons and cardiologists.

The future success of thesenovel approaches will requireclose physician collaborationand state-of-the-art “hybrid”surgical rooms. This team

approach will require “doublescrubbing” by interventionalistsand surgeons. The need forcomplex three-dimensionalimaging modalities for preoper-ative assessment as well as on-line guidance will necessitatethe intraprocedural presence ofa cardiac imaging specialist.

We believe valve centers ofexcellence will emerge, permit-ting a highly focused team ofmultiple subspecialists, workingtogether, to manage patientswith complex valve disease.Unique physician skill sets, time,and financial commitment willbe required to develop thesevalve programs at large quater-nary referral centers. The multi-ple treatment options, whichover time will become availableto conventional as well as high-risk patients, will also requireweekly complex valve meetingsto discuss individual patient caremuch like existing tumor boardsin oncology.

Entering a new erain cardiac surgery

The field of transcatheter valvereplacement and repair is devel-oping rapidly. In many respects,it will define the next era in thehighly technical fields of cardi-ology and cardiac surgery.Novel devices are focusing morespecifically on AS and MR valvelesions, which commonly afflictsurgical higher-risk elderlypatients and others with multi-ple comorbidities. As we gainmore experience in managingthese challenging patient sub-sets, these procedures, currentlyin their infancy, will likely betransitioned to more conven-tional surgical candidates.

Wes Pedersen, MD, Vib Kshettry,MD, Kevin Harris, MD, RobertHauser, MD, and Ben Sun, MD,practice at the Minneapolis HeartInstitute Foundation at Abbott North-western Hospital, Minneapolis. IrvinF. Goldenberg, MD, is the directorof the Twin Cities Heart Foundation,Minneapolis.

FEBRUARY 2011 MINNESOTA PHYSICIAN 27

Valve disease from page 23

- Family Medicine(OB)

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Contact Denise Siemers,Physican RecruitmentMercy Medical Center – North IowaPhone: (888) 877-5551 or (641) 428-5551CV to: [email protected]

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S P E C I A L F O C U S : C A R D I O L O G Y R E S E A R C H

The University of Minne-sota has one of the mostactive and successful ven-

tricular-assist device programsin the world for patients withend-stage heart failure. Despitethe fact that we have implantedmore than 500 devices since1995, optimization of devicesettings after implant remains asubjective process that is typi-cally performed at rest. In col-laboration with Shape MedicalSystems in St. Paul, we areworking to study their exercise-based optimization, currentlyused to “tune up” biventricularpacemakers, in the growingpopulation of patients withventricular assist devices.

Background

In the United States, heart fail-ure affects nearly 5 million peo-ple, with more than 500,000new cases diagnosed each year.

Biventricular pacing, alsoknown as cardiac resynchro-nization therapy (CRT), hasbeen an important advance inheart failure care over the pastdecade. Patients with chronicsystolic heart failure and wide

QRS are often eligible for thistreatment, which has beenshown to improve symptoms,reduce mitral regurgitation,promote reverse left ventricularremodeling, and reduce mortal-ity. The benefit is not uniform,and some patients do not reapthe full benefit.

Attempts to optimize devicesettings in order to maximizebenefit are typically guided byclinical experience, and in somecenters, resting echocardiogra-phy. The process usuallyrequires a sonographer, a devicenurse to adjust the pacemaker,and one or two physicians tosupervise the process and inter-pret the results. Consensusregarding the optimal parame-

ters (mitral inflow velocities,left ventricular outflow tractvelocity-time integral as a sur-rogate for cardiac output, andthe like) has not been achieved,and the presence of atrial fibril-lation can add complexity. Fur-thermore, the physiologic differ-ences between rest and exercisesuggest that findings at restmay not apply during exertion.

New technology improvesCRT optimization

To improve risk stratification ofpatients with cardiopulmonarycomplaints, St. Paul-basedShape Medical Systems hasdeveloped the first cardiopul-monary exercise testing sys-tem—called Shape-HF—thatcan be used for CRT optimiza-tion using gas exchange analy-sis as an objective, reproducibleoutcome measure. According toClarence Johnson, presidentand COO of Shape MedicalSystems, “Because patient ven-tilation measurements are sosensitive to changes in CRT set-tings, assessing these changesusing gas exchange parametersduring mild, steady-state exer-cise provides a completelyobjective method for definingacute response to CRT therapy.”

The test takes 15 minutesand involves measuring ventila-tion parameters while thepatient exercises on a treadmillat a very low intensity of onemile per hour with the treadmillset at a 2 percent grade. Thesystem itself includes five com-ponents: a data analyzer, dis-posable patient interface ormask, a pulse oximeter, a com-puter, and a printer. As thepatient exercises at a steady-state heart rate, therapy settingsare adjusted every two minutes,enough time for the adjust-ments to be reflected in ventila-tory physiology. At the end of

the test, during which four tofive therapy settings are tested,a proprietary algorithm ranksthe physiological response toexercise at each setting. Thephysician then reviews theresults and chooses the therapysetting he or she believes ismost appropriate for thepatient.

In the test, Shape-HFmeasures ventilatory efficiency(VE/VCO2) and the partial pres-sure of end-tidal carbon dioxide(PETCO2)—measures that wererecently reported to predictadverse events in patients withheart failure (R. Arena, J Car-diac Failure, 2009)—as well asinspiratory drive and oxygenpulse, a surrogate measure ofcardiac output. With relativelymodest physician oversight,testing is performed with asingle exercise technician.Studies are under way to com-pare exercise-based optimiza-tion to usual care.

Optimizing LVADswith Shape-HF

Researchers at the Universityof Minnesota have been work-ing with the Shape-HF Systemto extend these findings to thegrowing population of patientswho receive left ventricularassist devices (LVADs) forsevere heart failure. Much asfor biventricular pacemakers,clinicians have the ability tochange settings on LVADs.Currently, the optimal devicesettings for a VAD are selectedbased on clinical judgment andresting echocardiography, muchlike CRT optimization. LVADsare much simpler devices, asthe speed is the only parameterthat can be adjusted by a clini-cian, but the parallels to CRToptimization are unmistakable.

Since 2009, our researchteam has been working to de-velop a method of LVAD opti-mization. The concept of LVADoptimization is particularlynovel, as it has only been in thelast few years that outcomeshave improved to the pointwhere survival wasn’t the onlymeasure of interest. With thecurrent generation of smallerLVADs, survival is typically >80percent at one year, and mostpatients return to a high level offunction after recovering from

New technologyextends research

Studying ways to optimizeleft ventricular assist device technology

By Peter Eckman, MD

28 MINNESOTA PHYSICIAN FEBRUARY 2011

Growing multi-specialty group practicein Northern Minnesota is looking fora BC/BE Family Practice Physician,Internal Medicine Physician,Emergency Room Physician,OB/GYN Physician, Urologist as well asan Orthopaedic Surgeon. Join an existinggroup practice and take over existingpractices from departing physicians. GrandItasca Clinic & Hospital in Grand Rapids,Minnesota has recently opened a new stateof the art clinic & hospital. Excellent salaryguarantee with outstanding incomepotential, full benefits and sign-on bonus.Community located in the beautifulnorthern Minnesota lakes area.

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Page 29: Minnesota Physician February 2011

implant. More patients arereturning to work after havingan LVAD implanted, and addi-tional efforts to optimize theirpump function hold promise forfurther improvements in qualityof life for these patients.

Many questions remainunanswered:• Are the best settings the sameat rest and with exercise?

• Should LVADs have a “turbo”button for when patients areactive?

• Does the process of gasexchange-based analysisprovide improvements inoutcomes over usual clinicalcare?

Pacemakers have evolvedsubstantially since EarlBakken’s original invention,which used two dials (pulse rateand output voltage), and nowprovide sophisticated, real-timeevaluation of and response to apatient’s activity level.

Accelerometers andminute ventilationmeasurement areused in modern pace-makers, for example.These real-time physi-ologic measures havehelped integratehuman and machine;it stands to reasonthat LVADs maybenefit from similarefforts.

Although we are30 years behind pace-makers in terms ofthe sophistication of“programming” LVADs, I amhopeful that we’ll be able tocatch up quickly by learningfrom what has already beendone with this treatment [pace-makers and CRT] that has a lotof parallels to LVAD therapy.We are fortunate to have such arobust medical device industryin Minnesota and a rich historyof innovation to emulate. And

collaborating with ShapeMedical Systems on this projecthas been immeasurably easierbecause the device company ishere in town.

This novel project is anexample of the synergy thatcan result from collaborationbetween private industry andclinicians. We believe it high-lights the strengths of both the

University of Minnesota and thestate’s biotechnology businesscommunity.

Peter Eckman, MD, a board-certifiedheart failure and transplant cardiologist,is an assistant professor in the Division ofCardiology at the University of Minnesota,Minneapolis. He is principal investigatorfor the Prospective Observation of ExerciseParameters in Advanced Heart Failurestudy.

FEBRUARY 2011 MINNESOTA PHYSICIAN 29

FIGURE 1. Dennis McGee undergoes a test using the SHAPEsystem as Dr. Peter Eckman observes. (Photo: Steve Rieke)FIGURE 2. The Shape-HF system can also be used forcardiopulmonary evaluation with a step.

Crookston, MN, a strong community of8,000, is located along the Red Lake Riverin the heart of the fertile Red River Valley.Altru Clinic—Crookston is a well-established,collegial medical group with 5 FamilyPractice Physicians, 4 Internists and 3Mid-Level Providers. We have an ongoingpartnership with RiverView Hospital inCrookston that is a 25-bed, critical-accesshospital connected to our clinic. Call is 1:7.

Roseau, MN, which is just 20 minutes frombeautiful Lake of the Woods, is a FamilyPractice clinic consisting of 6 Family PracticePhysicians, 3 Mid-Level Providers and 1Internist. The town of Roseau has over 2,500residents. LifeCare Medical Center is a 25-bed, critical-access hospital just adjacent toour clinic. Our friendly community is safeand welcoming. Call is 1:7.

Altru is a physician-led, not-for-profitintegrated health system that serves a referralpopulation of more than 225,000. More than180 physicians representing 44 specialtiesserve this population base. Altru HealthSystem provides competitive compensation,reviewed annually with specialty-specificindustry data, along with an extensivebenefits package including generous pensionand profit-sharing plans.

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Page 30: Minnesota Physician February 2011

S P E C I A L F O C U S : C A R D I O L O G Y R E S E A R C H

According to the AmericanHeart Association, heartfailure affects 5 million

people. Heart transplantation isnow the definitive cure for end-stage heart failure. Since thefirst heart transplant was per-formed in 1967, there have beennumerous advances in the man-agement of heart transplantrecipients (HTR), immunosup-pressive therapy, monitoringtechniques, and surgical strate-gies. As a result, the mediansurvival of heart transplantrecipients has improved signifi-cantly, to approximately 10–13years, primarily due to improve-ments in short-term survival.Long-term survival, however,is still poor.

Cardiac allograft vasculopa-thy (CAV), a form of coronaryartery disease affecting hearttransplant recipients, is a majorlimitation to long-term successin cardiac transplantation,accounting for up to 30 percentof deaths after five years despitepreventive measures such asstatin therapy and modificationof risk factors (e.g., smoking,obesity, diabetes, dyslipidemia,

hypertension). CAV is clinicallyapparent in 50 percent of HTRat five years; however, intimalthickening, a predictor of CAV,develops earlier and is presentin 58 percent of HTR one yearafter transplant. Ten percent ofpatients die within the first 12months after the diagnosis ofCAV. While some patients diesuddenly, others will developheart failure due to restrictivephysiology. There is no curefor CAV and there are no widelyaccepted treatment strategies.Preventive therapies, such asstatins and aspirin, are usedroutinely and risk factors aremanaged.

Revascularization is for themost part palliative, since CAV

tends to be diffuse in compari-son to native coronary arterydisease. Proliferation signalinhibitors are beneficial inpreventing progression of CAV,but there are no standardizedtreatment strategies based onthis therapy, which is usuallyinitiated after disease has devel-oped. Finally, re-transplant canbe performed in highly selectedindividuals, but this procedureraises an ethical dilemma withregard to organ allocation in apopulation where need greatlyexceeds availability.

Cardiac allograft vasculopathyand endothelial function

The initial event in cardiac allo-graft vasculopathy is theorizedto be a subclinical endothelialcell injury in the graft. Thisinjury causes upregulation ofcytokines, complement, adhe-sion molecules, and growthfactors, creating a state ofinflammation and endothelialactivation and ultimately result-ing in endothelial dysregulation.Cellular and humoral responsesto human leukocyte antigens(HLA) and vascular endothelialcell antigens propagate thisprocess, which ultimately resultsin intimal proliferation anddevelopment of the vascularlesion associated with CAV.

In short, endothelial dys-function precedes the develop-ment of CAV. This has beendemonstrated by Davis and col-leagues, who showed that earlyabnormal coronary responsesto acetylcholine predicted thedevelopment of intimal thicken-ing, the predecessor to CAV, atone year.

Risk factors for CAV

The development of CAV isvariable after transplant and isdetermined by multiple factorsaffecting the transplant recipi-

ent, such as immunologic activa-tion, comorbid conditions, andexposure to cytomegalovirus,as well as “classic” risk factorsfor coronary artery disease,such as hypertension and hyper-lipidemia.

Immunologic risk factors.Ischemia/reperfusion injuryoccurring during removal of thedonor heart, during storage, andafter engraftment in the recipi-ent induces an immunologicresponse that has been shownto cause CAV in an experimentalmodel. Brain death is associatedwith hemodynamic instability,altered loading conditions,decreased coronary perfusion,and apoptosis, resulting inimmune activation and elabora-tion of inflammatory cytokines.

In an animal model, reducedcoronary blood flow and abnor-mal coronary vasomotorresponse to acetylcholine weredemonstrated after brain death.Mehra and colleagues showedthat heart transplant recipientswho received hearts from donorswho died of explosive or trau-matic brain death had signifi-cantly more intimal thickeningand reduced survival.

CAV has been linked withthe duration and number ofepisodes of cellular rejection,as well as with asymptomatichumoral rejection. Donor agegreater than 35 years and trans-plant of a female donor into amale recipient are associatedwith increased intimal thicken-ing on intravascular ultrasound.Finally, cytomegalovirus infec-tion with subsequent eNOS dys-regulation are associated withabnormal coronary endothelialfunction and reduction in sur-vival from CAV.

Classical risk factors.Classic cardiovascular risk fac-tors such as smoking, diabetes,hypertension, obesity, and dys-lipidemia are not uncommon inheart transplant recipients.Ischemic cardiomyopathy is thereason for transplant in approxi-mately 40 percent of recipients.According to data from theInternational Society of Heartand Lung Transplant Registry(2009), 76 percent of transplantrecipients have hypertension atyear one, 27 percent have dia-betes, and 79 percent have

Improving survivalpost-heart transplantResearchers gain insight into mechanisms

of cardiac allograft vasculopathy

By Monica Colvin-Adams, MD, MS

30 MINNESOTA PHYSICIAN FEBRUARY 2011

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hyperlipidemia. At 10 years, 98percent have hypertension, 37percent have diabetes, and 93percent have hyperlidemia.These pre-existing conditionscan be exacerbated by immuno-suppressants, particularlysteroids and calcineurin inhib-itors; however, almost one-thirdof heart transplant recipientsdevelop new hypertension, halfdevelop new hyperlipidemia,and one-fifth develop new dia-betes. These traditional risk fac-tors can increase the risk of CAV.

Challenges in diagnosing CAV

Early detection of CAV is limiteddue to the lack of sensitive diag-nostic studies, variable andsilent clinical presentation, andthe lack of consistent nomencla-ture that imparts prognosticinformation. Coronary angio-gram is used routinely to screenfor CAV, but it is insensitive anddoes not detect disease in up to50 percent of HTR. Many trans-plant centers perform angio-gram yearly to every other yearfor the life of the transplantrecipient, repeatedly exposingthem to nephrotoxic contrast,radiation, and potential compli-cations associated with vascularmanipulation.

While it has not yet beendemonstrated that early detec-tion will improve outcomes, webelieve that early detection willpromote the development ofeffective treatment and preven-tive strategies and thereforehave focused our research onrisk markers and early detectionof CAV and treatment strategiesdesigned to improve endothelialfunction. Our research at theUniversity of Minnesota hasfocused specifically on smallartery elasticity (SAE) and circu-lating endothelial cells as indica-tors of endothelial injury.

Although CAV is likely theend result of multiple processes,including immunological activa-tion, donor injury, genetics andrisk factors of the recipient, andmedications, the end result andthe predecessor of CAV appearsto be endothelial injury, which iscommon to many cardiovascularand inflammatory illnesses andoften a target of therapy. Smallartery elasticity, as measured viathe radial artery, has been

demonstrated to be a prognosticmarker of endothelial function.Diastolic pulse-wave contouranalysis provides informationregarding elasticity of the smalland medium arteries and is asurrogate for endothelial func-tion and cardiac risk. Patientswith coronary artery disease,hypertension, and diabetesdemonstrate a reduction in theoscillatory component of thediastolic waveform, reflectingcapacitance abnormalities in thedistal vessels, or reduced SAE.This reduction in SAE has alsobeen detected in asymptomaticindividuals at risk for cardiovas-cular disease and is associatedwith cardiac events.

Circulating endothelial cellsand endothelial progenitor cellsare, in simplest terms, the repaircells of the human vasculature.When an artery is injured,mature endothelial cells (CEC)are shed from the endothelium,which is re-endothelialized byendothelial progenitor cells(EPC) that are released fromthe bone marrow. These pro-cesses are mediated by a com-plex interaction of cytokines,adhesion molecules, growth fac-tors, endothelial nitric oxide syn-thase (eNOS), and various sig-naling pathways. Both EPC andCEC have been shown to be pre-dictive of cardiovascular eventsand to correlate with risk factorsfor coronary artery disease.Patients with CAD or at riskfor CAD demonstrate decreasedEPC and increased CEC.

Endothelial functionin heart transplant

In our current studies, wesought to determine differencesin endothelial markers betweenheart transplant recipients andnormal, healthy individuals.We also wanted to determine ifthese could be used in futurestudies to evaluate for CAV. Weare beginning to see signs that

heart transplant is associatedwith reduced SAE, that is,increased small artery stiffnessand endothelial dysfunction,and with a high degree of CECactivation. Among other factors,the presence of CAV seems to bea determinant of CEC activationand SAE. Our data to date sup-port evidence that transplant isassociated with endothelial acti-vation and dysfunction; and inour studies, this is manifest asactivated endothelial cells andreduced small artery elasticity.These studies are ongoing.

Future directions

These and other ongoing studiesprovide insight into mechanismsthat are associated with CAV.The tools that we are currentlystudying are clinically applicable

and, we anticipate, can be usedto stratify high-risk patients andserve as therapeutic targets.

Parallel to these exploratorystudies, we are evaluating novelstrategies to prevent CAV. Onesuch study, funded by the Amer-ican Heart Association, targetsthe nitric oxide signaling path-way using a phosphodiesteraseinhibitor. The goal is to treat thefinal common pathway in thepathogenesis of CAV, rather thanthe myriad mechanisms. Thiswill serve our long-term goal ofimproving outcomes after hearttransplantation.

Monica Colvin-Adams, MD, MS, isan assistant professor of medicine at theUniversity of Minnesota Medical School,specializing in advanced heart failure,transplantation, and mechanical circula-tory support. She is currently acting med-ical director of the heart transplant pro-gram. She has participated in multipleclinical research trials in the areas ofadvanced heart failure, heart transplanta-tion, and pulmonary hypertension. Hercurrent research in heart transplantationis funded by the NIH and the AmericanHeart Association.

FEBRUARY 2011 MINNESOTA PHYSICIAN 31

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Page 32: Minnesota Physician February 2011

W O M E N ’ S H E A L T H

Atrial of labor after previ-ous cesarean delivery(TOLAC) provides

women with the possibility ofachieving vaginal delivery aftercesarean delivery (VBAC).VBAC is associated with de-creased maternal risks, shorterrecovery times, and decreasedrisk of complications in futurepregnancies. TOLAC is appro-priate for many women withprevious cesarean sections(C/S), but several factors influ-ence failure/success rates forVBAC. This article reviews therisks and benefits of TOLACand gives a brief overview ofpractice guidelines for manag-ing and counseling patientswith a prior cesarean delivery.

History

In 2007, the U.S. national rateof cesarean deliveries stood atits highest point ever, at 31.1percent, contributing to escalat-ing medical costs. It wasn’talways so: In the 1990s, largeclinical studies documented therelative safety of VBAC, andVBAC rates increased from 18.9percent to 28.3 percent from

1989 to 1996. C/S rates hit anational low of 20.7 percentin 1996.

In the ensuing years, how-ever, as HMOs and third-partypayers encouraged patients tochoose VBAC, physicians werepressured to recommend VBACto unsuitable candidates. Overtime, data regarding complica-tions associated with VBACchanged the medical commu-nity’s attitude regarding its safe-ty. A resultant reversal in prac-tice trends reduced VBAC ratesfrom 55 percent in 2002 to 8.5percent in 2006. Some hospitalsstopped offering TOLAC, prima-rily because of concerns byphysicians and health care insti-tutions over medical liability.

In 2010, the NationalInstitutes of Health (NIH) re-examined the safety of TOLACand VBAC. The NIH ConsensusDevelopment Conference State-ment on Vaginal Birth AfterCesarean: New Insights (http://consensus.nih.gov/2010/vbacstatement.htm), released inMarch 2010, establishes therelative safety for TOLAC andencourages health care organi-zations to facilitate TOLACaccess to all women with aprevious C/S.

Risks of VBAC vs.risks with repeat C/S

The resistance to VBAC mainlyrelates to the risk of uterinerupture or dehiscence, with the

subsequent immediate risk ofmaternal and fetal injury andpossible death.

Uterine rupture occurswhen the prior uterine incisionfrom the previous C/S complete-ly opens and separates. A dehis-cence of the uterine incision isan opening or thin area in theprior incision, but overall theincision remains intact. In bothcases, the risk depends on thetype of incision over the uterus.A low-transverse incision resultsin <1 percent rate of rupture,whereas the rate of rupture fora classical or T-shaped incisionis 4–9 percent. In women whohave had a prior uterine rup-ture, the rate of rupturing againis 6 percent, but it can be ashigh as 32 percent if the previ-ous rupture was in the uppersegment of the uterus. Overallmaternal death rates from thisare less than 1 percent, andfetal rates of death are 0.08percent.

The risks of elective repeatC/S include a higher rate ofbleeding, infection, and overallrecovery time, as it is a major

Vaginal delivery aftercesarean delivery

Practice guidelinesfor counseling patients

By Sarah Manneh, MD

32 MINNESOTA PHYSICIAN FEBRUARY 2011

VBAC to page 34

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abdominal surgery. The rateof maternal death in electiverepeat C/S is 0.01 percent andof fetal death, 0.05 percent,both of which are lower thanfor VBAC. However, especiallyfor those considering largefamilies, VBAC can avoid risksassociated with multiple C/Ssuch as hysterectomy, bowelor bladder injury, the need forblood transfusion, or abnormalimplanting of the placenta.

Who are appropriate candi-dates for TOLAC and VBAC?

The American College ofObstetrics and Gynecology(ACOG) has standardized man-agement and practice guidelinesfor ob/gyns and other providersinvolved in the care of pregnantwomen. The most recent ACOGguideline for VBAC is PracticeBulletin #115, “Vaginal Birthafter Previous Cesarean Deli-very,” published in the August2010 issue of Obstetrics &Gynecology journal. The guide-line identifies risks and benefitsof TOLAC in different clinicalsettings and offers recommen-

dations for counseling womenwho wish to undergo VBAC.

The ACOG guideline alsoincludes recommendationsabout the appropriateness ofTOLAC and VBAC as deliveryoptions. According to the guide-lines, TOLAC and VBAC coun-seling may be considered inwomen who have had:• One previous low-transverseC/S

• Two previous low-transverseC/S (rate of uterine ruptureranges from 0.9 percent to 3.7percent)

• One previous low-transverseC/S and who now has a twinpregnancy and is an appropri-ate candidate for a twin vagi-nal delivery

• A previous C/S with an undoc-umented uterine scar type,unless there is a high clinicalsuspicion of a previous classi-

cal uterine incision• No prior uterine scars fromuterine transfundal surgeryor previous uterine rupture

• Any medical or obstetriccomplication that precludesvaginal deliveryPlanned TOLAC generally

is not recommended in women:• at high risk for complications(e.g., those with a classic orT-incision, prior uterine rup-ture, or extensive transfundaluterine surgery)

• in whom vaginal delivery iscontraindicated (e.g., thosewith placenta previa)

Special considerations

The ACOG guidelines alsoaddress a number of specialcircumstances, described below.

In women who have oneprior low-transverse C/S, are

now pregnant with twins, andare appropriate candidates for atwin vaginal delivery, the rate ofuterine rupture is comparableto the rate for a singleton preg-nancy, and the rate of successis similar.

In women with a diagnosisof fetal macrosomia (defined asfetal birth weight greater than4,000 grams in diabetic womenand 4,500 grams in non-diabeticwomen), the rate of uterine rup-ture is comparable to the ratefor nonmacrosomic births, butthere is an overall lower VBACsuccess rate for macrosomicbirths (50–60 percent). Despitea suspected large baby, aTOLAC should not be ruled outfor these patients.

In women whose pregnan-cies are nearly past 40 weeks’gestation and who have had aprior C/S, the rate of uterinerupture is comparable to C/Sdelivery, but the success rateof VBAC is lower (55 percent).These patients can undergoinduction of their labor safelywith pitocin to establish con-tractions. However, if the cervix

34 MINNESOTA PHYSICIAN FEBRUARY 2011

VBAC to page 36

VBAC from page 32 Potential benefits and risks of bothrepeat C/S and TOLAC should be discussed

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Or fax: 320-255-6436 orTelephone: 320-252-1670, extension 6618

Favorable lifestyle26 days vacationCME days

Competitive salary13 days sick leaveLiability insurance

Interested applicants can mail or email your CV to VAMC

Page 35: Minnesota Physician February 2011

FEBRUARY 2011 MINNESOTA PHYSICIAN 35

Remember graduating from college and passing your MCATs, then spending the next four years of your life getting through classes like clinical epidemiology, neurology and radiology so you could practice medicine? Today’s financially driven managed care environments make having a practice difficult. Hurrying patients in and out of the office to make a quota and going into negotiations to prescribe treatments that don’t coincide with a patient’s policy aren’t practicing medicine. We’d like to prescribe a solution: Move your profession to the United States Air Force. Get back to what’s important — practicing medicine.

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We have part-time and on-call positions available at a variety ofTwin Cities’ metro area HealthPartners Clinics. Evening and weekend shifts are currently available. We are seeking BC/BE full-range family medicine and internal medicine-pediatric(Med-Peds) physicians. We offer a competitive salary and paidmalpractice.

For consideration, apply online at healthpartners.jobs and followthe Search Physician Careers link to view our Urgent Careopportunities. For more information, please contact [email protected] or call Diane at: 952-883-5453; toll-free: 1-800-472-4695 x3. EOE

Family PracticeUrgent Care

NEW POSITIONS:

Dynamic, independent 3 location, single-specialtypractice in northwest Minneapolis suburbs is seekingadditional associates for its Rogers site and has Full Time/Part Time shifts in the Crystal and Rogers Urgent Care.

• Partnership opportunity after 2 years

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• Excellent benefits, 401k/employer paid pension

• Practice at one site/one hospital

• Physician-owned

Please contact or fax CV to:Joel Sagedahl, M.D.

1495 Highway 101 North, Plymouth, MN 55447763-504-6600 • Fax 763-504-6622

Visit our website at www.NWFPC.com

Physician-owned, multi-specialty group practice with 100+ providers, hasan exceptional opportunity for a BC/BE Neurologist to join two others.

You will see patients with a full spectrum of diseasestates and have an opportunity to participate in clinicaltrials.We provide staff and support for EMG, LumbarPunctures, Polysomnograpy, Botox, Occipital Block anda full-time, plus a registered EEG technologist.We offera first year income guarantee with a production incentiveincome thereafter; service area 300,000; great payermix; $6,600 annual CME business allowance; potentialshareholder status after one year; 401(k); profit sharing.

Our picturesque community, population 50,000+ provides a great settingto practice medicine and raise a family plus year-round indoor/outdoorrecreational at nearby lakes and resorts; excellent public and privateschools with award winning academics and sports teams; state university,two colleges, community college, business school with combined enroll-ment of over 18,000; shopping mall with four anchor stores and new retailconstruction. Just over an hour from Minneapolis/St. Paul southern metro;easy access to international airport. No J-1 openings.Contact Dennis Davito, Director of Physician Placement,Mankato Clinic, 1230 East Main Street, P.O. Box 8674, Mankato, MN,56002-8674; phone: 507-389-8654; fax: 507-625-4353;email: [email protected].

www.mankato-clinic.com

Page 36: Minnesota Physician February 2011

remains undilated and requirescervical ripening with medica-tions called prostaglandins,the rate of uterine rupture canincrease by as much as 15–20percent. In contrast, mechanicalmethods to dilate the cervix,such as a Foley bulb or lami-naria, do not increase the rateof uterine rupture.

In a pregnancy where ababy is breech at term andthere is a prior C/S, the physi-cian can offer to turn the babyby pushing on the maternalabdomen (external cephalic ver-sion, or ECV). The rate of suc-cess for ECV is similar to deliv-ery without C/S and the successof VBAC is the same as for non-breech pregnancies.

Some women with priorC/S will require delivery before28 weeks of pregnancy for vari-ous maternal or fetal indica-tions. Prostaglandins can beused, but the decision should beindividualized based on numberof C/S, gestational age, and thewomen’s desire to preserve fer-tility. In the unfortunate settingof a fetal death beyond 28

weeks of pregnancy, mechanicaldilation of the cervix can beused with comparable rates ofuterine rupture and TOLACshould be offered.

Success rates for VBAC

Taking the above factors intoconsideration, appropriate can-didates for TOLAC and VBAChave a rate of success withVBAC of 70–80 percent. If thereason for the first C/S is non-recurring in subsequent preg-nancies (e.g., breech positionor a rapid decrease in the fetalheart rate), VBAC success is10 times greater. If the patienthas had a prior successfulVBAC, success is 10 to 20times greater.

Other factors to considerthat negatively affect the suc-cess of VBAC are maternalobesity, the need for augmenta-tion/induction of labor, and ashort interval of time since the

last C/S (e.g., fewer than 12months).

The ACOG guideline alsonotes that in order to offer aTOLAC safely, the deliveringhospital must offer certainessential services. It is crucialthat a physician capable ofmonitoring and doing an emer-gent cesarean delivery be imme-diately available throughoutactive labor. In addition, imme-diate availability of anesthesiaand personnel for emergent C/Sare necessary.

Counseling patients

Potential benefits and risks ofboth repeat C/S and TOLACshould be discussed withpatients and documented. Thisdiscussion should take placeearly in the prenatal course, toallow for the most time to con-sider all options. Obtaining allprior medical records to docu-ment the type of uterine scar

is important. If other circum-stances arise during the preg-nancy that may change therisks/benefits of TOLAC, theseissues should be re-addressed.Counseling should also considerthe resources available to sup-port women electing TOLAC attheir delivery site.

After appropriate counsel-ing, the decision ultimately isup to the patient. The role ofthe provider is to continue tooffer support and to provide theinformation the patient needsto make the appropriate deci-sions for herself. Any mandateto offer only TOLAC or refuseit would breach the patient’sright to make decisions in herbest interest. Through shareddecision-making with patientsabout TOLAC and VBAC, wemay help reduce the overall rateof cesarean delivery while offer-ing women information aboutthe range of options for a safedelivery.

Sarah Manneh, MD, practices withOakdale Obstetrics & Gynecology.

36 MINNESOTA PHYSICIAN FEBRUARY 2011

VBAC from page 34 In 2007, the U.S. national rateof cesarean deliveries stood at its

highest point ever, at 31.1 percent.

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Page 37: Minnesota Physician February 2011

FEBRUARY 2011 MINNESOTA PHYSICIAN 37

The perfect match ofcareer and lifestyle.

Affiliated Community Medical Centers is a physician ownedmulti-specialty group with 11 affiliate sites located in westernand southwestern Minnesota. ACMC is the perfect match forhealthcare providers who are looking for an exceptional prac-tice opportunity and a high quality of life.Current opportuni-ties available for BE/BC physicians in the following specialties:

• Family Medicine

• General Surgery• Geriatrician/OutpatientInternal Medicine

• Hospitalist

• Infectious Disease• Internal Medicine• Oncology

• OrthopedicSurgery

• Pain Management

• Psychiatry

• Pulmonary/Critical Care

• RadiationOncology

• Rheumatology

For additional information, please contact:

Kari Bredberg, Physician [email protected], 320-231-6366

Julayne Mayer, Physician [email protected], 320-231-5052

www.acmc.com

fairview.org/physiciansTTY 612-672-7300 EEO/AA Employer

Opportunities to fit your lifeFairview Health Services seeks physicians to improve the health of the communities we serve. We have a variety of opportunities that allow you to focus on innovative and quality care. Shape your practice to fit your life as a part of our nationally recognized, patient-centered, evidence-based care team.

Whether your focus is work-life balance or participating in clinical quality initiatives, we have an opportunity that is right for you:

DermatologyEmergency MedicineFamily MedicineGeneral SurgeryGeriatric MedicineHospitalistInternal MedicineMed/Peds

NocturnistOb/GynPalliativePediatricsPeds/Emergency MedicinePsychiatryPulmonology/Critical CareUrgent Care

Visit fairview.org/physicians to explore our current opportunities, then apply online, call 800-842-6469 or e-mail [email protected].

Sorry, no J1 opportunities.

Fairview H

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www.olmstedmedicalcenter.org

Opportunitiesavailable in the

following specialty:

Family MedicineRochester

Northwest Clinic

Family MedicineSt. Charles Clinic

Olmsted Medical Center,a 150-clinician multi-specialty

clinic with 10 outlyingbranch clinics and a 61 bed

hospital, continues to experiencesignificant growth.

Olmsted Medical Centerprovides an excellent opportunityto practice quality medicine in a

family oriented atmosphere.

The Rochester communityprovides numerous cultural,

educational, and recreationalopportunities.

Olmsted Medical Centeroffers a competitive salary

and comprehensivebenefit package.

Send CV to:

OlmstedMedical Center

Administration/Clinician Recruitment

1650 4th Street SE

Rochester, MN 55904

email: [email protected]

Phone: 507.529.6610

Fax: 507.529.6622

EOE

Page 38: Minnesota Physician February 2011

tional one-third have swallow-ing impairments.

Dysphonia, or alteredvoice, may be treated withvoice-strengthening techniquesand by amplification devices.Respiratory symptoms maypresent as subtle changes ofendurance and sleep hypoventi-lation. Early intervention ofnoninvasive respiratory supporthas been shown to be beneficialfor patients with PPS who haverespiratory dysfunction, andmay help avoid invasive treat-ment such as tracheostomy andpermanent positive pressureventilation.

Pain management isaccomplished by bracing, exer-cise, surgery, and medication.Scoliosis, cervical or lumbarstenosis, joint osteoarthritis,knee hyperextension, and me-chanical back pain may occurat earlier ages and present morediagnostic challenges. Previoustendon transfers, ankle fusions,and prior spinal fusions done atthe time of polio may breakdown and require treatment.

Bracing the ankle with acustom-molded, energy-storingcarbon fiber brace is the mostadvanced type of brace for indi-viduals with foot drop and ankleweakness in the calf muscles.It duplicates the push-off of thecalf muscles and can helprestore the architecture of theankle and support knee exten-sion when casted at the appro-priate angle.

Leg length discrepanciesthat patients have tolerated foryears may gradually promoteselective joint overuse in thelonger leg, requiring lifts on theshorter side. Newer, lightweightbraces with “long-leg” bracesthat include the knee can helpcontrol knee hyperextensionand knee extension when thequadriceps are weak.

Preventing falls, particu-larly in Minnesota’s cold cli-mate, is paramount. Castingand immobilization are fre-quently given as the historicalpoint when the symptoms ofweakness and fatigue in post-polio patients first appear. Thismay be due to the loss of regu-

lar weight-bearing and exertionin the limb and overall.

Exercising to improve mus-cle strength can be difficult forindividuals with paralysis ofone or both lower extremities.Warm-water dynamic exercisehas been described as beingespecially applicable to manysuch individuals, and is sooth-ing for painful muscles andeasy on the joints as well(Willen and Sunnerhagen,Arch Phys Med Rehab, 2001).Physical therapists can meetwith patients and adapt a pro-gram that meets patients’ indi-vidual requirements. Groupsof individuals often exercisetogether and create an improm-ptu support group that alsohelps them maintain their exer-cise frequency.

Accepting thechallenges of PPS

The medical community hasobserved that polio survivorstend to demonstrate determina-tion and drive, as well as higherthan average tolerance for pain.These traits have assisted many

of these individuals in takingexcellent care of themselves andpursuing a healthy lifestyle.When confronted with newsymptoms, this group ofpatients tends to accept thechallenge again and fight hardto avoid additional disability.

Sharing information withother survivors in supportgroups is beneficial for somepatients. The book “Polio’sLegacy: an Oral History,” byEdmund J. Sass (UniversityPress of America, 1996), is awell-told recounting of theMinnesota polio experience anddescribes the challenges thatpolio survivors face.

Barbara P. Seizert, MD, specializesin physical medicine and rehabilitationat Sister Kenny Rehabilitation Instituteat Abbott Northwestern Hospital, andChildren’s Hospitals and Clinics ofMinnesota and St. Francis RegionalMedical Center in Shakopee.

38 MINNESOTA PHYSICIAN FEBRUARY 2011

Post-polio from page 19

Dermatology for Primary Care: Beyond the Basics February 26, 2011

25th Annual Family Medicine Today March 10-11, 2011

29th Annual OB/GYN Update April 7- 8, 2011

11th Annual Psychiatry Update: Selected Topics for the Non-Psychiatrist April 29, 2011

Pediatric Fundamental Critical Care Support May 19- 20, 2011

Fundamental Critical Care Support July 14 -15 and October 13 -14, 2011

29th Annual Strategies in Primary Care Medicine September 22- 23, 2011

12th Annual Women’s Health Conference November 4, 2011

Otolaryngology Conference November 18, 2011

33rd Annual Cardiovascular Conference December 1- 2, 2011

Emergency Medicine and Trauma Update Fall 2011

Pediatric Conference Fall 2011

CMEConferences 2011

Education that measurably improves patient care.

imehealthpartners.com952-883-6225

Page 39: Minnesota Physician February 2011

You wouldn’t give a 1-year-old a beer, so why would you give one to an unborn child?

As a physician, it’s your responsibility to let her know: the U.S. Surgeon General Advisory says no amount of alcohol is safe during pregnancy.

Share 049: Zero Alcohol For Nine Months.

www.mofas.org

Page 40: Minnesota Physician February 2011

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