Inside

New Prostate Cancer Treatment Based on Your Patients’ Genetics

Complications of Opioid Therapy

That Tiny, Tricky Thyroid

When in Doubt, Sit Them Out

Battling Obesity

FRAX: Realizing Its Strengths Depends on Recognizing Its Limitations

Barrett’s Esophagus

Coming Events

RoundsTHE LATEST NEWS FOR PRIMARY CARE PHYSICIANS FROM CLEVELAND CLINICSuMMER 2013

The Affordable Care Act (ACA) tossed the ball to primary care physi-cians (PCPs), tasking them with the unprecedented responsibilities of keeping people well and more aggressively managing those with chronic diseases.

“We are moving from a reactive to a proactive model,” says David L. Longworth, MD, Chairman of the Medicine Institute. “Our focus has shifted to coordinating the care of higher-risk, resource-consuming patients to keep them out of emergency rooms and hospitals. We must also promote wellness, so healthy people do not develop chronic diseases such as diabetes, hypertension and obesity.”

QuarTerback fOr care

At the core of this new model is the patient-centered medical home (PCMH), a team-based model of care in which providers operate at top of license and manage individuals as well as a population of patients. In this model, the PCP serves as each patient’s personal caregiver and is supported by other team members. Within this team is an RN who helps coordinate and proactively manage the minority of complex medical patients with chronic diseases, including those with heart failure, diabetes, renal disease, hypertension and COPD. Also included are patients who have been recently hospitalized or seen in the emergency room. Although these patients may represent a relatively small percentage of a PCP’s total patient popula-tion, they tend to consume a disproportionate amount of time, energy and resources.

cOnTinueD On back cOver

The Primary Care Physician: Quarterback for Care

Services for Physicians

REFERRING PHYSICIAN CENTER AND HOTLINE

Cleveland Clinic’s Referring Physician Center has established a 24/7 hotline — 855.REFER.123 (855.733.3712) — to streamline access to our array of medical services. Contact the Referring Physician Hotline for information on our clinical specialties and services, to schedule and confi rm patient appointments, for assistance in resolving service-related issues, and to connect with Cleveland Clinic specialists.

PHYSICIAN DIRECTORY

View all Cleveland Clinic staff online at clevelandclinic.org/staff.

TRACK YOUR PATIENT’S CARE ONLINE

DrConnect is a secure online service providing real-time information about the treatment your patient receives at Cleveland Clinic. Establish a DrConnect account at clevelandclinic.org/drconnect.

CRITICAL CARE TRANSPORT WORLDWIDE

Cleveland Clinic’s critical care transport teams and fl eet of vehicles are available to serve patients across the globe.

• To arrange for a critical care transfer, please call 216.448.7000 or 866.547.1467 (see also clevelandclinic.org/criticalcaretransport).

• For STEMI (ST elevated myocardial infarction), acute stroke, ICH (intrace-rebral hemorrhage), SAH (subarachnoid hemorrhage) or aortic syndrome transfers, call 877.379.CODE (2633).

OUTCOMES DATA

View clinical Outcomes books from all Cleveland Clinic institutes at clevelandclinic.org/outcomes.

CLINICAL TRIALS

At any given time, we offer thousands of clinical trials for qualifying patients. Visit clevelandclinic.org/clinicaltrials.

CME OPPORTUNITIES: LIVE AND ONLINE

Cleveland Clinic’s Center for Continuing Education’s website offers convenient, complimentary learning opportunities. Physicians can manage CME credits using the myCME.com web portal. Visit ccfcme.org.

EXECUTIVE EDUCATION

Cleveland Clinic has two education programs for healthcare executive leaders — the three-day Executive Visitors’ Program and the two-week Samson Global Leadership Academy immersion program. Visit clevelandclinic.org/executiveeducation.

SAME-DAY APPOINTMENTS

Cleveland Clinic offers same-day appointments to help your patients get the care they need, right away. Have your patients call our same-day appointment line, 216.444.CARE (2273).

About Cleveland Clinic

Cleveland Clinic is an integrated healthcare delivery system with local, national and international reach. At Cleveland Clinic, more than 3,000 physicians and researchers represent 120 medical specialties and subspecialties. We are a nonprofi t academic medical center with a main campus, eight community hospitals, more than 75 northern Ohio outpatient locations (including 16 full-service family health centers), Cleveland Clinic Florida, Cleveland Clinic Lou Ruvo Center for Brain Health in Las Vegas, Cleveland Clinic Canada, Sheikh Khalifa Medical City and Cleveland Clinic Abu Dhabi.

In 2013, Cleveland Clinic was ranked one of America’s top 4 hospitals in U.S. News & World Report’s annual “America’s Best Hospitals” survey. The survey ranks Cleveland Clinic among the nation’s top 10 hospitals in 14 specialty areas, and the top in heart care for the 19th consecutive year.

24/7 ReferralsReferring Physician Hotline

855.REFER.123

(855.733.3712)

Hospital Transfers

800.553.5056

On the Web at

clevelandclinic.org/refer123

Stay Connected to Cleveland Clinic

Overtreatment of prostate cancer is one of the most significant issues in men’s health today. Limited avail-able information leads more than 90 percent of low-risk patients to undergo immediate treatment, despite having less than a 3 percent chance of their low-risk disease progressing to become deadly. But now, a new genetic-based test can help determine which of your patients truly need treatment.

The OncOType DX prOsTaTe TesT

Developed at Cleveland Clinic, the Oncotype DX Prostate Cancer Test can more accurately determine how aggressive a patient’s cancer is — and whether surgery or radiation therapy is necessary.

“For slow-growing, low-risk prostate cancers, active surveil-lance may be a better option — when cancer is monitored with periodic clinic visits and prostate-specific antigen tests and repeat biopsies every year or two,” explains Glickman Urological & Kidney Institute Chairman Eric A. Klein, MD.

The new test helps identify more men who can opt for active surveillance — and men whose cancer is actually more aggressive than originally thought.

WhaT The TesT measures

Oncotype DX measures the expression levels of 17 genes across four biological pathways to predict a man’s prostate cancer aggressiveness.

Its results create a Genomic Prostate Score (GPS), ranging from 0 to 100. This score, combined with other factors, helps further determine prostate cancer risk before starting treatment.

By adding the individualized biological information, Dr. Klein says, more men with low-risk disease can confidently choose active surveillance and be spared unnecessary treatment and possible life-altering side effects, such as incontinence and impotence.

hOW We DevelOpeD The TesT

We conducted studies evaluating 700 patients at Cleveland Clinic with manufacturer Genomic Health. Working with our pathologists, Cristian Magi-Galluzzi, MD, and Sarah Falzarano, MD, we identified genes important in both low- and high-grade tumors.

“In doing this, we tackled key challenges in assessing pros-tate cancer risk, including the problem of tumors being too varied to fully interpret their risk from one patient to another,” Dr. Klein says. “With Oncotype DX, we can improve risk assessment at diagnosis and choose the most appropriate treatment options.”

We were able to measure and analyze gene expression in prostate cancer tissue samples from radical prostatectomy and very small needle biopsy specimens, Dr. Klein says.

“Our final analysis found the expression of 17 genes could be converted to a reproducible GPS to accurately predict disease aggressiveness of the entire prostate before considering treat-ment options.”

sTuDy TO valiDaTe Our finDings

University of California at San Francisco researchers validated our findings in another study of 395 patients, adding the biological information revealed by the GPS. They significantly increased the number of patients identified as having very low-risk disease, making them appropriate for active surveil-lance, from 5 to 10 percent to 26 percent.

Specifically, more than one-third of patients originally classified as low risk based on clinical measures were identi-fied by GPS as very low risk and could confidently choose active surveillance.

Also, patients requiring more aggressive treatment were iden-tified. About 10 percent of patients originally classified as very low or low risk by clinical factors were identified by the test as having more aggressive disease, which would more appropriately be considered for immediate treatment. n

Our urologists can order the Oncotype DX for your patients, analyze the GPS report, meet with them to discuss the implications and help them decide on the best options. Call 855.REFER.123.

New Prostate Cancer Treatment Based on Your Patients’ Genetics

clevelandclinic.org/rounds 3

Complications of Opioid Therapy: More to the Story than Abuse and Addiction

When it comes to aviation, the flight time and landing are as important as the takeoff. This same principle holds true for opioid therapy.

“Too often, pain management specialists see new patients who have already ‘taken off’ on opioid therapy without a flight plan,” explains the Pain Management Department’s Benjamin Abraham, MD. “They have no established goals, so they don’t know how to determine if the therapy is working. They have no idea when therapy should end or how they will ‘land.’ Some have no understanding of the challenges they may encounter along the way.”

At Cleveland Clinic, our Pain Management Department can work with you to head off side effects of opioid therapy in your patients before they cause major complications.

a mulTiTuDe Of pOTenTial effecTs

Of course, one of the biggest challenges with opioid therapy is risk of abuse and addiction. In the past decade, the number of U.S. deaths from painkillers, including opioids, has qua-drupled to nearly 15,000 annually.

But abuse and addiction aren’t the only concerns. Opioid therapy can cause other unwelcome side effects:

Immunosuppression. Opioids have long been proven to weaken the immune system. While it may not become clinically significant for years, immune function declines in every opioid user.

With no tried-and-true way to boost immune function, it’s best to reduce the dosage or discontinue use when possible, such as for patients with nonmalignant pain.

Androgen deficiency. Opioid-induced androgen deficiency is an issue for both men and women. Symptoms include erectile dysfunction (ED), reduced libido, fatigue, hot flashes, menstrual irregularities, low energy, weight gain and depres-sion — and more serious complications, such as infertility and osteoporosis.

Opioid-Induced Side Effects and Potential Treatments

Side effect Potential treatment

ImmunosuppressionReduce opioid dose or discontinue

Androgen deficiencyTestosterone replacement therapy

ConstipationStool softeners and laxatives; methylnaltrexone for severe cases

HyperalgesiaReduce opioid dose; rotate to methadone

DepressionReduce opioid dose; antidepressants

Cleveland CliniC Rounds4

It is diffi cult to defi nitively pinpoint whether these symptoms are caused by opioids and how soon they may follow opioid initiation. However, it can take about one month after dis-continuing opioids for testosterone and estrogen to reset and for weight gain and ED to begin reversing. Changes such as reduced bone density may take longer.

If discontinuing opioid use isn’t preferred, androgen replace-ment therapy can be used, although it sometimes triggers other medical concerns in women.

Constipation. Constipation can set in almost immediately, after only a day or two of opioid use.

For the most part, stool softeners and laxatives are effective management tools. In severe cases, such as patients with long-term opioid use, there is methylnaltrexone. This mu-opioid receptor antagonist selectively reverses opioid-induced constipation without reversing pain relief. Once this two-dose subcutaneous injection relieves the severe constipation and removes bowel obstruction, the patient can resume using stool softeners and laxatives.

Hyperalgesia. Evidence of increased pain resulting from opioid use has been observed since the 19th century, but hyperalgesia’s onset and severity remains relatively unstudied.

In general, opioid-induced hyperalgesia is managed by reducing the dosage or rotating to another opioid, such

as methadone. However, methadone’s dosage is diffi cult to adjust, and signifi cant side effects include risk of heart arrhythmia and respiratory depression.

Depression. About 10 percent of patients using opioids develop depression. Again, a direct cause and effect is diffi -cult to determine because depression occurs for other reasons. If a patient cannot be transitioned off opioids, antidepressants are standard adjunctive therapy.

cOmplicaTiOns nOT limiTeD TO lOng-Term use

These conditions aren’t limited to patients with long-term opioid use or overuse. They can occur in all patients and even with short-term use. Many effects occur immediately — within fi ve minutes for some instances of hyperalgesia. And they can occur within properly managed therapeutic doses.

“That’s why it’s critical to prescribe opioids only when other treatments and analgesics have proven ineffective,” Dr. Abraham says. “At that time, physicians should establish expectations, set goals for each patient and then actively monitor them. Our team can consult with physicians to fi nd the most effective — and safest — solutions.” n

If you would like to consult with our Pain Management physicians about opioid management strategies, call 216.444.PAIn (7246).

“Too often, pain management specialists see new patients who have already ‘taken off’ on opioid therapy without a fl ight plan…”

clevelandclinic.org/rounds 5

That Tiny, Tricky ThyroidThyroid disease doesn’t always cause symptoms, which can make it challenging to diagnose. Here’s what you need to know about three common thyroid disorders.

Most primary care physicians know how to recognize and treat symptomatic hypothyroidism, the most common thyroid disorder. But hyperthyroidism and thyroid nodules, as well as asymptomatic hypothyroidism, present challenges that leave more room for error.

“The diagnosis and treatment of these less-common diseases is less straightforward,” says Christian Nasr, MD, Medical Director of Cleveland Clinic’s Thyroid Center.

hyperThyrOiDism: a Disease WiTh sysTemic impacT

Patients with hyperthyroidism may experience a racing heart, excessive sweating and other symptoms of a metabolism in overdrive. Eye symptoms (pain and blurred vision) are also common. These symptoms may begin up to two years before hyperthyroidism begins, or up to two years after. Severe symp-toms, such as bulging eyes, occur in only about 10 percent.

Referral to an endocrinologist ensures that these patients receive a comprehensive evaluation and care, including con-sults with cardiology or ophthalmology, when needed.

The diagnosis is made with a radioactive iodine uptake scan, which should be ordered before the patient is sent to an endocrinologist. Pregnant women and women of childbear-ing age are exceptions. “These patients may have gestational hyperthyroidism or a high-risk pregnancy and should be referred without testing,” says Dr. Nasr, who collaborates with Cleveland Clinic maternal-fetal medicine specialists to evaluate pregnant patients.

Hyperthyroidism may be treated with medication to slow thyroid output or elimination of the thyroid with radioactive iodine or surgery. Older patients may benefit from a beta-blocker to relieve palpitations and tachycardia and to protect the stressed heart.

ThyrOiD nODules: cancerOus Or benign?

As many as one-third of women have one or more thyroid nodules, of which 5 to 15 percent are malignant.

Most nodules are painless. They may be discovered by pal-pating the neck during routine physical examination. However, most are diagnosed incidentally on imaging studies. Patients with large nodules may feel or see a lump in the neck. Some nodules can cause compressive symptoms, such as difficulty swallowing or breathing.

“Nodules most often do not affect thyroid function. Even in the presence of symptoms such as fatigue and weight gain, many patients with thyroid nodules are euthyroid,” says Thyroid Center Surgical Director Joyce Shin, MD.

A nodule’s size and characteristics determine the need for fine-needle aspiration biopsy. The thyroid is removed if the nodule is diagnosed as, or is suspected of being, malignant or causes compressive symptoms.

“It is helpful, but not necessary, to obtain a thyroid ultrasound before referring a patient, as this is performed in the office during the patient’s initial consultation. There is usually no need for other tests, such as a CT or thyroid uptake scan,” says Dr. Shin.

asympTOmaTic hypOThyrOiDism

Sometimes, hypothyroidism is a subclinical, biochemical finding. A TSH test is usually sufficient to detect hypothy-roidism, but a T4 level is needed when pituitary disease is suspected. “TSH alone cannot be trusted, and a T3 test is unnecessary. A low T3 does not diagnose hypothyroidism,” says Dr. Nasr. n

Call 855.REFER.123 to refer a patient to Cleveland Clinic’s Thyroid Center.

We’ve increased our endocrine surgery services into the region, with surgeons available for patient consults at our Twinsburg, Willoughby Hills, Solon, and Independence family health centers.

Truth or bunk?Thanks to unsubstantiated theories published on the Internet, it is increasingly common for patients with normal TSH and T4 levels to question whether they might be hypothyroid. “It does not make scien-tific sense!” says Dr. Nasr.

Cleveland CliniC Rounds6

When in Doubt, Sit Them OutA look at House Bill 143: Ohio’s return-to-play law

This spring, House Bill 143, Ohio’s return-to-play law for young athletes, went into effect to protect young athletes from serious and potentially permanent harm by promoting education and proper treatment of concussions. Here’s what you should know about this new law — and what it means for managing concussion patients in your practice.

The basic cOmpOnenTs

The law contains three elements:• Preseason education of athletes, parents and coaches

on the signs and symptoms of concussions• Removal of young athletes suspected of having a concus-

sion from a game or practice and not permitting return to play on the same day

• A licensed healthcare professional must clear young athletes to return to play

Why Was h.b. 143 neeDeD?

Richard Figler, MD, a sports health physician at Cleveland Clinic Sports Health and team physician for Solon High School and John Carroll University, says the law stems from several high-profile events across the nation in which mild traumatic brain injuries, or concussions, in young athletes may have been prevented if recognized and treated earlier.

managing cOncussiOn paTienTs

Concussion symptoms can be physical, cognitive and emo-tional and can impact sleep patterns. Dr. Figler says primary care physicians play a key role in appropriately identifying, diagnosing and managing cases.

“Individuals still manifesting signs and symptoms of concus-sion are not allowed to return to play,” he says. “We want the athlete to return to his or her normalcy before being allowed to return to play.”

The Acute Concussion Evaluation (ACE) form from the Centers for Disease Control and Prevention provides physi-cians with evidence-based protocols for initial evaluation and diagnosis of suspected mild traumatic brain injury. The ACE also can be used to track symptom recovery over time.

“From a primary care physician standpoint of managing con-cussions, what we found to be most effective is relative rest,” Dr. Figler says. “The main point to drive home with patients

is don’t push through symptoms; that typically will delay overall recovery. When in doubt, sit them out.”

eviDence-baseD resOurces

Cleveland Clinic Concussion Center was formed to prevent concussions in athletes of all ages and skill levels, minimize their long-term effects when they do occur, and further research to improve tomorrow’s care. The center brings together a multidisciplinary team of primary care sports medicine physicians, neurologists, neurosurgeons, neuropsy-chologists, certified athletic trainers, vestibular therapists, physical therapists, pediatricians, radiologists, neuro-ophthal-mologists and researchers.

Together, they use an evidence-based approach to customize care for athletes, which includes baseline testing, accurate and prompt diagnoses, symptom management, recovery mon-itoring and help returning to play as soon as safely possible.

The Concussion Center is leading the way in mild traumatic brain injury care path development across multiple institutes

— Orthopaedic & Rheumatologic, Pediatric, Neurological — and Emergency Services. Care paths are evidence-based care models, embedded in the electronic medical record to guide clinicians through the care process for a specific condition. The aim is to reduce harmful or needlessly expensive practice variation and ensure evidence-based care.

“If we can arm physicians with educational material and outcome data, or information that eventually could be trans-mitted to the clinician, that will help us improve continuity of care. And when used with an evidence-based protocol such as the Concussion Care Path, it holds the promise of taking much of the guesswork out of concussion manage-ment for athletes and helping guide therapy over time,” says Concussion Center Director Jay Alberts, PhD. n

To refer a patient to the Cleveland Clinic Concussion Center, call 855.REFER.123.

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Healthy Expectations

About one-third of women of reproductive age in the United States are obese. Not only is maternal obesity associated with adverse perinatal outcomes (see box below), but it is directly linked to childhood obesity. Maternal obesity also escalates healthcare expenses — from additional offi ce visits and ultrasounds to additional days spent in the hospital due to complications.

The Ob/Gyn & Women’s Health Institute’s new maternal obesity program is specifi cally designed to help women optimize their weight before pregnancy and continue on a healthy path during pregnancy and after delivery.

“You wouldn’t run a long-distance race without training for it,” says Jeffrey Chapa, MD, Head of Maternal-Fetal Medicine at Cleveland Clinic. “It’s the same kind of thing with pregnancy. Pregnancy puts a signifi cant strain on a woman’s body for nine months. Studies show that getting healthy beforehand can make a world of difference.”

Patients frequently feel there is nothing they can do about their weight, says Dr. Chapa. “My goal is to encourage women to say, ‘Look, I can try to do something to lower my risk of complications.’ ”

Healthy Expectations

About one-third of women of reproductive age in the United States are obese. Not only is maternal obesity associated with adverse perinatal outcomes (see box below), but it is directly linked to childhood obesity. Maternal obesity also escalates healthcare expenses — from additional offi ce visits and ultrasounds to additional days spent in the hospital due to complications.

The Ob/Gyn & Women’s Health Institute’s new maternal obesity program is specifi cally designed to help women optimize their weight before pregnancy and continue on a healthy path during pregnancy and after delivery.

“You wouldn’t run a long-distance race without training for it,” says Jeffrey Chapa, MD, Head of Maternal-Fetal Medicine at Cleveland Clinic. “It’s the same kind of thing with pregnancy. Pregnancy puts a signifi cant strain on a woman’s body for nine months. Studies show that getting healthy beforehand can make a world of difference.”

Patients frequently feel there is nothing they can do about their weight, says Dr. Chapa. “My goal is to encourage women to say, ‘Look, I can try to do something to lower my risk of complications.’ ”

The risks of doing nothing

Risks to obese expectant mothers:

• Preeclampsia

• Gestational diabetes

• Large babies

• Complications following vaginal delivery or cesarean section

Risks to the child:

• Stillbirth

• Prematurity

• Birth defects

• Obesity in childhood

• Diabetes

Battling Obesity New programs for expectant mothers, children and adolescents

at Cleveland Clinic, we’re committed to halting the obesity epidemic that began in the 1980s and contin-ues to sweep across our nation without signs of stopping. Here is a look at two innovative programs we offer — to help expectant mothers and children and adolescents in your practice.

70% Increase in obesity among pregnant women in U.S. from 1994 to 2003

CLEVELAND CLINIC ROUNDS8

The risks of doing nothing

Risks to the child:

• Stillbirth

• Prematurity

• Birth defects

• Obesity in childhood

• Diabetes

hOW DOes iT WOrk?

Patients are seen during a 60-minute shared medical appoint-ment, led by obesity medicine physician Karen Cooper, DO, and a registered dietitian, with other women who face similar weight challenges before, during or after pregnancy. This helps patients hear answers to questions they may not have asked and learn more than they would have on their own.

Before pregnancy — Dr. Cooper will explain, in a group setting, how your patients can improve their health to increase fertility and reduce the risks of miscarriage. Our registered dietitian calculates each patient’s BMI and shows her how to eat right to achieve her weight loss goals.

During pregnancy — Our staff will explain how much weight patients should gain — and how weight affects pregnancy outcomes. Your patients’ BMI will be calculated and patients will receive practical meal-planning tips.

After pregnancy — If a new mother gained excessive weight during pregnancy, Dr. Cooper will evaluate her and determine which food choices and exercise plan she needs to achieve a healthier weight. Our registered dietitian will offer tips on making easy, healthy family meals. And the team will help your patients understand portion control and how to quickly decipher food labels to make healthy choices for themselves and their families.

While conversations about weight are tough ones to have with patients, Dr. Chapa says patients tend to be a bit more receptive when the end goal is the health of their child or child-to-be.

“It’s not to make people feel bad. It’s to say, ‘Look, these are the risks that are out there. Because if there was something else that would adversely affect the health of your child, wouldn’t you want to know about it? And it is so clear that excess weight impacts the health of your kid going forward.”

Your patients can schedule an appointment with our maternal obesity program by calling 216.444.6601.

Be Well Kids Clinic

We all want kids to be healthy. Yet more than 30 percent of American children and teens are overweight or obese. The reason for concern has little to do with appearance and every-thing to do with health: This generation of children is likely to be the first to die sooner than their parents.

Behind the shorter life span are profound health problems that begin in childhood, says Cleveland Clinic Children’s pediatrician Sara Lappé, MD.

For obese and overweight kids and teens ages 2 through 20, Cleveland Clinic Children’s new Be Well Kids Clinic offers help from a team including Dr. Lappé; pediatric GI specialist Naim Alkhouri, MD; Kari Gali, CNP; pediatric psychologist Eileen Kennedy, PhD; and Andrea Rumschlag, RD, CSP, LD.

hOW DOes iT WOrk?

During a one-and-a-half-hour evaluation, one of our medical experts will review the child’s medical, family and diet history. A physical exam will be performed, and lab tests will be ordered. The child’s health status will be explained to his or her parents, and a few goals will be set. The family will also meet with a registered dietitian, who will assess the child’s eating habits, discuss healthy alternatives and explain how to keep a food journal.

The families will have follow-ups monthly, both individually and with other families in a group session with the entire Be Well Kids Clinic team. Any kids with weight-related medical complications are seen by Cleveland Clinic Children’s special-ists, including:

• Endocrinologists for diabetes, thyroid problems or PCOS

• Sleep medicine specialists for sleep apnea

• Pulmonologists for asthma or apnea

• Nephrologists for hypertension

• Cardiologists for high cholesterol or lipids

300,000Number of American deaths attributed to obesity each year

clevelandclinic.org/rounds 9

Battling Obesity continued

“A lot of families see overweight and obesity as an insurmount-able problem,” says Dr. Lappé. “They feel overwhelmed by everything they need to change. But small changes really add up. Every parent can make these changes to get their kids — and the whole family — healthier.”

To prevent long-term medical problems, it’s best to get started young, Dr. Lappé notes. “Prevention is the best approach,” she says. “Obese kids create more fat cells than healthy-weight kids as they grow — up until early adolescence. Because of this, they have more diffi culty losing weight when they are older.”

You can refer a child to the Be Well Kids Clinic by calling 216.448.6000.

The main threat at any age? Protecting hearts.

Even those who are mildly obese face an increased risk of early death from heart disease. Obesity has become one of the most important reversible causes of heart disease. When a person loses weight, his or her risk factors for heart disease nearly always improve. Obesity is both preventable and treat-able, but few patients are successful in the long run.

“Excess body weight means that the heart has to do more work,” says Cleveland Clinic cardiac surgeon Marc Gillinov, MD. “A normal heart in an obese person is like a Volkswagen engine in a Mack truck,” Dr. Gillinov says. “Responding to the excess work requirement, the heart undergoes structural changes, including a thickening of its walls, an increase in the size of the chambers, and unfavorable alterations in heart function.”

When it comes down to it, weight loss hinges on the simple equation of calories taken in minus calories burned. Encourage your patients not to be fooled by fads that promise quick weight loss. We suggest targeting weight loss of one to two pounds per week.

Here is a look at what Cleveland Clinic heart experts recom-mend to their patients for healthy weight loss:

Exercise — Only 13 percent of American men and 9 percent of American women report exercising vigorously for 10 minutes or more fi ve times or more a week. The vast majority of Americans never break a sweat.

“A lot of families see overweight and obesity as an insurmount-able problem,” says Dr. Lappé. “They feel overwhelmed by everything they need to change. But small changes really add up. Every parent can make these changes to get their kids — and the whole family — healthier.”

To prevent long-term medical problems, it’s best to get started young, Dr. Lappé notes. “Prevention is the best approach,” she says. “Obese kids create more fat cells than healthy-weight kids as they grow — up until early adolescence. Because of this, they have more diffi culty losing weight when they are older.”

You can refer a child to the Be Well Kids Clinic by calling 216.448.6000.

The main threat at any age? Protecting hearts.

Even those who are mildly obese face an increased risk of early death from heart disease. Obesity has become one of the most important reversible causes of heart disease. When a person loses weight, his or her risk factors for heart disease nearly always improve. Obesity is both preventable and treat-able, but few patients are successful in the long run.

“Excess body weight means that the heart has to do more work,” says Cleveland Clinic cardiac surgeon Marc Gillinov, MD. “A normal heart in an obese person is like a Volkswagen engine in a Mack truck,” Dr. Gillinov says. “Responding to the excess work requirement, the heart undergoes structural changes, including a thickening of its walls, an increase in the size of the chambers, and unfavorable alterations in heart function.”

When it comes down to it, weight loss hinges on the simple equation of calories taken in minus calories burned. Encourage your patients not to be fooled by fads that promise quick weight loss. We suggest targeting weight loss of one to two pounds per week.

Here is a look at what Cleveland Clinic heart experts recom-mend to their patients for healthy weight loss:

Exercise — American women report exercising vigorously for 10 minutes or more fi ve times or more a week. The vast majority of Americans never break a sweat.

Health problems caused by childhood obesity

These problems were practically unheard of in kids just a few decades ago:

• Type 2 diabetes

• Hypertension

• High cholesterol

• Sleep apnea

• Fatty liver disease

• Polycystic ovarian syndrome

30% Percentage of our nation’s population that is obese

CLEVELAND CLINIC ROUNDS10

What type and how much? For heart health, at least 30 minutes of exercise per day, five days a week is best. Aerobic exercise should include brisk walking at a minimum, but fun alternatives can include basketball, Frisbee and bicycling. If patients are able, encourage them to do vigorous exercise to break a sweat. Using a heart rate monitor is generally unnecessary. Two days of resistance exercise, light weights or machines, should be added per week.

Diet — There are hundreds of diet books and thousands of websites that promise to deliver the diet for your patient’s heart health. Our best heart diet is summed up in one word: Mediterranean.

We recommend the Mediterranean diet — rich in fresh fruits and vegetables, whole-grain products, fish and olive oil — to our patients. This is the only diet whose long-term impact has been studied in randomized, controlled trials. A study recently published in the New England Journal of Medicine found that about 30 percent of heart attacks, strokes and deaths from heart disease can be prevented in high-risk patients if they switch to a Mediterranean diet. So, compared with other diets, it comes out the clear winner.

Talk to your patients about the importance of controlling calories, watching portion sizes, never finishing an entire restaurant meal, using smaller bowls and plates at home and avoiding sugar-sweetened beverages.

What about patients who are obese but do not have changes in lipids, blood pressure or other standard risk factors? Recent studies in this group demonstrate they face an increased risk of developing heart disease when compared with metabolically healthy people of normal weight.

The message is clear: Excess weight is a real and independent risk factor for heart disease even when other standard risk factors are absent. Patients should not be lulled into a false sense of security if their weight is high but their cholesterol is normal.

What should we recommend for patients when diet and exercise fail? If a patient is severely overweight (usually a BMI of at least 35) and has major health issues related to obesity, bariatric surgery should be a consideration. Bariatric surgery not only improves cardiovascular health, but also improves sleep apnea, gastroesophageal reflux, asthma and depression

— translating to a longer life.

In a Swedish study of more than 4,000 obese individuals, those who had bariatric surgery saw their risk of dying over an 11-year period reduced by nearly 30 percent. An American study demonstrated this improved survival was attributable to reduced risks of death from coronary heart disease, diabetes and cancer.

To refer a patient to any of our heart specialists at the Miller Family Heart & Vascular Institute, call 855.REFER.123.

What are the components of the Mediterranean diet?

PlAnT FOODS: fresh fruits and vegetables, beans, nuts, seeds, legumes, whole grains

OlIVE OIl

POulTRY: moderate amounts

FISH: moderate amounts

EGGS: fewer than 4 per week

DAIRY: low-fat offerings, moderate consumption of cheese and yogurt

WInE: moderate consumption with meals, usually red

VERY lITTlE RED MEAT

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Case Study

A 65-year-old white woman presented for osteoporosis evalu-ation. She had been treated with a bisphosphonate for three years immediately following menopause (ages 52 to 55). She had a lumbar spine T-score of – 2.3 and a femoral neck T-score of – 2.2. Her current bone density showed a significant decline of 8.6 percent in the spine and 7.0 percent in the hip when compared with her bone density three years earlier. Laboratory tests did not reveal a secondary cause for low bone mass and bone loss. She was taking adequate calcium and vitamin D and walked for exercise four times a week.

Her 10-year absolute fracture risk based on the FRAX® tool was 1.9 percent for hip fracture and 10.0 percent for major osteoporotic fractures. Current National Osteoporosis Foundation guidelines recommend treatment if the 10-year fracture risk is 3 percent or greater for the hip or 20 percent or greater for a major osteoporotic fracture (hip, spine, wrist or humerus). Even though our patient’s fracture risk was below treatment thresholds, she was started on a bisphosphonate.

using fraX in yOur pracTice

The FRAX tool is helpful for guiding treatment decisions for patients with osteoporosis in your practice. But with FRAX, as with all tools, understanding its strengths as well as its limitations is essential to making appropriate treatment decisions.

Chad Deal, MD, Director of the Center for Osteoporosis and Metabolic Bone Disease in the Department of Rheumatic and Immunologic Diseases, explains why the devil’s in the details.

“The limitations are often called FRAX caveats,” Dr. Deal explains. “In the case of our patient above, the most impor-tant limitation is that the FRAX model does not adjust for patients with rapid bone loss. Allowing this patient to con-tinue losing bone at a rate of 7 to 8 percent every three years would result in increasing fracture risk over time.

“This is a case when treatment for prevention is appropriate in spite of her FRAX-generated 10-year fracture risk being below the National Osteoporosis Foundation treatment threshold.”

The sidebar (above right) lists clinical risk factors considered in FRAX. Many of these risk factors are dichotomous, involv-ing a yes/no response (see screenshot on next page). Yet in the real world these risk factors are more nuanced and complex. As a result, Dr. Deal says, the dichotomous nature of some variables can result in either over- or underestima-tion of fracture risk. The risks for fracture in the FRAX model are averages in a large population of patients. Here are just a few examples of why FRAX needs to be skillfully utilized:

Fracture history. A patient with one vertebral fracture has a fivefold increase in fracture risk, while a patient with two ver-tebral fractures has a twelvefold increase in risk. Despite this difference, FRAX allows previous fracture to be reported only as “yes” or “no” with no adjustment for multiple fractures or for fracture site.

Smoking and alcohol use. FRAX assigns the same risk to a patient regardless of whether she smokes one pack a day or two packs a day or whether her alcohol use is three or six units daily. Moreover, “no” is the technically accurate entry for “current smoking” for a patient who quit a 40-year smoking habit six months ago, yet this leaves the skeletal effects of decades of smoking totally uncaptured.

Glucocorticoid use. The same increase in fracture risk is assigned by FRAX for a patient on 60 mg of prednisone for temporal arteritis as for a patient who was on 5 mg of pred-nisone for three months five years ago.

Rheumatoid arthritis. The severity of rheumatoid arthritis is likely to affect fracture risk (severe disease having a greater effect than mild disease), yet FRAX does not account for disease severity.

FRAX: Realizing Its Strengths Depends on Recognizing Its Limitations

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Risk Factors Considered in FRAX — not Always So Straightforward

History of previous fracture

Hip fracture in a parent

Current smoking

Glucocorticoid use (≥ 5 mg/d of prednisolone [or equivalent] for ≥ 3 months at any time)

Secondary osteoporosis (used when risk is based on body mass index, not bone mass)

Alcohol use ≥ 3 units a day

Femoral neck bone mineral density in g/cm2

Confirmed diagnosis of rheumatoid arthritis

Race/ethnicity (used in U.S.)

Age, height, weight

Family and personal fracture history. Family history of osteoporosis is represented only by parental hip fracture, not by spine fracture or other fracture types. Although personal history is represented by both fracture types, many spine fractures are asymptomatic and are thus not included in the FRAX calculation unless X-rays are reviewed or ordered.

OTher limiTaTiOns

Additionally, the FRAX model does not include some factors that affect fracture risk, such as bone turnover and falls, Dr. Deal says. The model is also hip-centric; when lumbar spine density is lower than hip density, the model will underesti-mate fracture risk. “FRAX-hip” might be a more precise name for the tool. Moreover, the model’s output — 10-year fracture risk — is absolute, with no confidence intervals. Whereas FRAX may assign a patient a risk of 19 percent, fracture risk (and life) is not so exact, and a standard deviation around the estimate would be welcome.

A final limitation, and one with relevance to our case study patient, is that FRAX is designed for use in treatment-naïve

patients, with no guidance for a patient who took a bisphos-phonate five or 10 years ago or who took estrogen but discontinued two years ago.

sTill a valuable TOOl — if useD apprOpriaTely

The purpose of reviewing all the limitations of FRAX is to help you wield this tool in an appropriate manner, not to negate its importance.

“The FRAX tool is a significant advance in global case finding of patients at increased risk for fracture, compared with other methods available for predicting fracture risk before FRAX was introduced in 2008,” Dr. Deal notes. “FRAX is a great starting point for assessing fracture risk, but its usefulness in guiding treatment decisions for individual patients depends, like the usefulness of all tools, on the knowledge and skill of the user.” n

Still have questions about using FRAX and want to consult with one of rheumatologists? Call 855.REFER.123.

clevelandclinic.org/rounds 13

Barrett’s EsophagusA conversation with Prashanthi Thota, MD Head, Center of Excellence for Barrett’s Esophagus

Who’s affected? The true prevalence of Barrett’s esophagus is unknown, but the National Institutes of Health estimates that it affects 1.6 to 6.8 percent of people. Men develop Barrett’s esopha-gus two times more often than women do, and white men are more likely to develop the condi-tion than men of other races.

Who should be referred for evaluation? Patients who have the following risk factors need to be referred for an endoscopy:

•Male

•White

•50s or older

•Obese

•Heartburnformorethanfiveyears

•Family history of esophageal cancer

What follow-up is needed for Barrett’s patients in your practice? When managing Barrett’s patients, it’s critical to underscore the impor-tance of continuing treatment — even if they don’t have any symptoms. Patients with Barrett’s requiremedicationtocontroltheacidreflux.

Barrett’s patients also need to return for surveil-lance endoscopies periodically, depending on their degree of dysplasia.

Need more help? Long a high-volume center for treating Barrett’s, Cleveland Clinic’s Digestive Disease Institute recently established a Barrett’s CenterofExcellence.Thisnewcenterfeaturesexperiencedgastroenterologists,GIpathologists

and thoracic surgeons — all with a special interest in Barrett’s esophagus and early esopha-geal cancer.

Our team offers the latest ablation treatments, including radiofrequency, cryotherapy and endoscopic resection for those with high-grade (and selected cases of low-grade) dysplasia. We’re also using an innovative technology, narrow-band imaging, to improve Barrett’s diag-nosis and are investigating the potential role of optical coherence tomography for screening and surveillance. n

To refer a patient or consult with experts from our Barrett’s Center of Excellence, call 855.REFER.123.

Prashanthi Thota, MD, of Cleveland Clinic Digestive Disease Institute’s Department ofGastroenterologyandHepatology,specializes in Barrett’s esophagus and complexendoscopicproceduresfortreat-ment of Barrett’s esophagus.

DiAgnosis:

Cleveland CliniC Rounds14

Coming Events

CME Opportunities: live and Online — Cleveland Clinic’s Center for Continuing Education’s website, ccfcme.org, offers convenient, complimentary learning opportunities, from a virtual textbook of medicine (Disease Management Project) and a medical newsfeed refreshed daily to myCME, a system for physicians to manage their CME portfolios. Many live CME courses are hosted in Cleveland, an economical option for business travel.

Genetics Education symposium: Genetics & Genomics: Roadmap for Clinical Practice

sept. 5, 2013

InterContinental HotelCleveland, OhioRegister at ccfcme.org/genetics

HIV for Primary Care Conference

Oct. 11, 2013

Cleveland Clinic Administrative CampusBuilding #3, AuditoriumBeachwood, OhioRegister at ccfcme.org/hivpc

Lung Summit: Advances in Pulmonary Medicine, Critical Care Medicine and Mechanical Ventilation

sept. 25-27, 2013

InterContinental Hotel Cleveland, Ohio Register at ccfcme.org/lungSummit

8th annual Obesity summit: Science and Practice of Obesity Management

Oct. 16-17, 2013

InterContinental Hotel Cleveland, Ohio Register at ccfcme.org/go-obesity

2013 Primary Care Women’s Health: Essentials and Beyond

Oct. 3-4, 2013

Landerhaven by Executive CaterersMayfi eld Heights, Ohio Register at ccfcme.org/women

5th Annual Practical Management of Acute Stroke

sept. 27, 2013

Global Center for Health Innovation and Cleveland Convention CenterCleveland, Ohio Register at ccfcme.org/AcuteStroke13

Diabetes and the Heart

Oct. 21-22, 2013

InterContinental Hotel Cleveland, Ohio Register at ccfcme.org/DiabetesHeart

2013 Cardiology for the Primary Care Physician

Oct. 25, 2013

Cleveland Clinic Administrative CampusBuilding #3, AuditoriumBeachwood, Ohio Register at ccfcme.org/PrimaryCardio

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The Cleveland Clinic Foundation9500 Euclid Ave. / AC311Cleveland, OH 44195

Referring Physician Guide Now Available

In response to popular demand, Cleveland Clinic now offers a hard-copy staff directory for referring physicians. It lists Cleveland Clinic’s specialists by location and specialty and includes their practice interests and contact information. You can get regular updates as new specialists join or leave Cleveland Clinic. The binder format makes it easy to add or remove pages. To get your Cleveland Clinic Referring Physician Guide, call our Referring Physician Hotline at 855.REFER.123 (855.733.3712) or visit clevelandclinic.org/refer123.

In football, the quarterback calls the shots but relies on a team to carry out his instructions. In the PCMH, the PCP is the quarterback who is supported by the care coordinator and others to deliver care to an entire population. Rather than leaving the responsibility for obtaining care solely in patients’ hands, the nurse care coordinator runs interference. If a patient has been recently hospitalized, or has been in and out of the emergency department, the nurse follows up and pulls the patient in to see the PCP. If the patient has a chronic disease, the nurse coordinator ensures that the patient makes and keeps appointments with the PCP.

Studies have shown this proactive approach reduces the uti-lization of costly services and lowers the cost of care. It also undoubtedly makes patients happier; quality of life polls con-tinue to reinforce patients’ desire to stay out of the hospital.

Since the new law provides PCPs with a fi nancial incentive to manage patient care proactively, the staff must understand the game plan and work as a team.

“It’s much easier to quarterback a team that is oriented toward a single goal than to run with the ball and try to reach the goal by yourself,” says Dr. Longworth. n

The Primary Care Physician: Quarterback for Care continued from cover

ROUNDS | sUMMER 2013 | THE LATEST NEWS FOR PRIMARY CARE PHYSICIANS FROM CLEVELAND CLINIC

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