P.O. Box 3026Cedar Rapids, IA 52406-3026

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A1Healthcare to go iTriage mobile healthcare app

A2Laparoscopic partial nephrectomy Robotic surgery increases positive outcomes for kidney cancer patients

A5St. Luke’s Work Well Solutions New satellite clinic opens at Jones Regional Medical Center

A7Behavioral health Mental health wellness in chronic illness management

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In this issueHealthcare to goDeveloped by two ER physicians, iTriage is a healthcare app that empowers people to make better healthcare decisions, with information such as:

• Symptoms,diseasesand medical procedures.

• LocationsofERs,urgentcare clinics, doctor’s offices and pharmacies anywhere.

• ERwaittimesandturn-by-turn GPSdirections.

Use a QR code scanner

• OpenyourpreferredQRcode scanner.

• Pointyourphonecameraat theQRcodebelowandscanit.

• Followtheinstructions for installation.

iPhone, iPod Touch, iPad, and iTunes are registered trademarks of Apple Inc. Android is a trademark of Google, Inc. BlackBerry is a registered trademark of Research in Motion Limited.

Download manually

iPhone®, iPod touch®, iPad™: Download at iTunes®. Android™: Download at the Android Market.

BlackBerry®, Palm and others:Use your phone’s browser to visit iTriageHealth.com/get-mobile to access the app’s mobile version. At home: desktops and laptopsVisit iTriageHealth.com.

To learn more about iTriage, log on to stlukescr.org or go to iTriageHealth.com■

Download iTriage for your mobile device one of two ways:

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Kidney cancer cure: robotic laparoscopic partial nephrectomy

Robotic surgery techniques and earlier diagnoses increase positive outcomes for kidney cancer patients.

Surgicalremoval(nephrectomy)isacurative method for kidney cancer, as the disease does not respond well to chemotherapy or radiation treatments. The trend towards earlier diagnosis when a tumor is smaller makes a partial nephrectomy (removalofonlythediseasedportionofthekidney)amoreviableoption than removing the entire kidney(totalnephrectomy).Thisallows better preservation of overall renal function, which is especially important in patients with diabetes or hypertension.

“While there is not a maximum size criteria that determines whether a partial nephrectomy

“ In addition to three-dimensional viewing, another advantage of the da Vinci system is that the surgeon can view both the patient’s ultrasound and anatomy simultaneously on one screen for precise, coordinated information.”

Jon Rippentrop, MD, Physicians’ Clinic of Iowa, P.C. Department of Urology and St. Luke’s medical director of Minimally Invasive Surgery

can be performed as opposed to a total nephrectomy, a partial nephrectomy is usually reserved for smaller masses,” said Rippentrop. “In addition, the mass must be in a favorable location in the kidney; if it is too close to the center of the kidney(i.e.renalhilum),apartialnephrectomy may not be an option for a patient.”

Along with earlier diagnoses, the increasingly positive outcomes for kidney cancers can also be credited to newer surgical techniques such as robotic surgery. A partial nephrectomy using traditional open surgery methods involves

Kidney cancer represents approximately three percent of all adult cancers in the United States.AccordingtotheAmericanCancerSociety,about58,000new cases are diagnosed in adults and children each year and it’s estimatedthat13,000peoplediefrom the disease annually. Kidney cancer occurs most often in people betweentheagesof50and70,andaffects men almost twice as often as women.

According to Jon Rippentrop, MD, Physicians’ Clinic of Iowa, P.C., Department of Urology and St.Luke’smedicaldirectorofMinimallyInvasiveSurgery,renaltumors are increasingly being found incidentally. In fact, a study conductedfrom1982until1997demonstrated a shift in the reason for diagnosis of renal cancer. In 1982,13percentofrenalcancerswerefoundincidentally.By1997,this number had increased to 59percent(LucianiLG,CestariR, Tallarigo C. Incidental renal cell carcinoma – age and stage characterization and clinical implications.Urology2000;56(1):58-62.)

Rippentrop sees this shift happening in his own practice: “Typically a patient is found to have a renal mass during an evaluation of another problem, although some patients still present with the classic triad of flank pain, hematuria and weight loss. Thankfully, with an early diagnosis, there exists the possibility of renal preservation,” said Rippentrop.

Open kidney surgery incision da Vinci surgery incisions

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making a large incision across the flank through multiple layers of muscle. This results in persistent pain, amultiple-daystayinthehospitaland prolonged recovery at home after discharge.

Rippentrop has been performing roboticlaparoscopicpartialnephrec-tomies incorporating the da Vinci® roboticsystemsince2008.Thesystem has been used in laparoscopic cases for several years, but has recently been applied to renal surgery with an impressive level of success.

“Increasingly, the da Vinci robotic system’sadvantagesofthethree-dimensional viewing and precise wristed instruments, is allowing a minimally invasive approach to select renal tumors,” said Rippentrop. “This has the benefit of less pain, quicker recovery and preservation of a maximum of functional renal tissue.”

Inadditiontothree-dimensionalviewing, another advantage of the da Vinci system is the surgeon can view both the patient’s ultrasound and anatomy simultaneously on one screen for precise, coordinated information.

A partial nephrectomy using the da Vinci surgical system begins with fourtoseven.5cmto1cmincisionsthrough which a small camera and working instruments are placed. The renal mass can generally be seen using the da Vinci’s optical system, however, if the cancer is located deeper in the kidney, a laparoscopic ultrasound device can be used to identify the location and size of tumor. The device can also determine the amount of blood flow to the diseased area and to the entire kidney.

Oncetherenalmassisindentified,the blood supply to the organ is temporarily stopped so the surgery can be performed with minimal bleeding. The cancer is then removed, along with a margin of normal tissue. The da Vinci system’s operative controlsandthree-dimensional

magnification also create greater precision for the reconstruction portion of the surgery once the diseased tissue has been removed.

Time is a challenge when performing a partial nephrectomy. Because blood flow is restricted during the procedure, the tumor removal and kidney reconstruction ideally is completed in less than

“To be able to perform each phase of the procedure – dissection, excision and reconstruction – with efficiency and precision is remarkable.”Jon Rippentrop, MD, Physicians’ Clinic of Iowa, P.C.Department of Urology and St. Luke’s medical director of Minimally Invasive Surgery

thirty minutes in order to preserve normal kidney function.

Rippentrop credits the capabilities of the da Vinci robotic system in the rise of positive outcomes for kidney cancer patients. “To be able to perform each phase of the procedure – dissection, excision and reconstruction – with efficiency and precision is remarkable.”

Case Report:A72-year-oldfemalepatientwasreferred to Jon Rippentrop, MD, Physicians’ Clinic of Iowa, P.C., DepartmentofUrologyandSt.Luke’smedical director of Minimally Invasive Surgery.Shepresentedwithleftlowerquadrant abdominal pain. A CT scan obtained by her family physician demonstrated diverticulitis, as well asa2.5centimeterleftsolidrenalmass. Her symptoms cleared with antibiotics.

After considering her treatment options:totalnephrectomy(eitheropenorlaparoscopic)oranopenpartial nephrectomy, the patient electedtoundergoarobotic-assistedlaparoscopic partial nephrectomy.

Her tumor was identified and only the affected portion of the kidney was removed, successfully maintaining the vast majority of her renal function and keeping blood loss to a minimum. Postoperatively, she began a regular diet and ambulating the day of surgery and was discharged home thedayaftersurgery.Finalpathologydemonstrated a renal cell carcinoma with negative margins and she underwent no further therapy. Followuphasdemonstratedhertoremain tumor free in both kidneys.

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To learn more about St. Luke’s robotics program, contact Janna Petersen at 319/369-7224.

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St. Luke’s Work Well opens

new clinic at Jones Regional Medical Center

TroyOverholt,director,St.Luke’sWorkWellSolutions,saidthenewclinicopenedMarch2andiscurrentlystaffedwithaboard-certified occupational medicine physician, Mark Taylor and a nurse from the Cedar Rapids Work Well Clinic.

threeyears.OncethenewJonesRegional Medical Center was completedinsummer2010,workto make the clinic operational begantomoveforward.Overholtsaid choosing the location was key: “We already do business with some clients in the Monticello and Anamosa areas, and with the new critical access hospital, this was a really good fit for the community andSt.Luke’s,”saidOverholt. BeinglocatedbetweenSt.Luke’sinCedarRapidsandFinleyHospitalin Dubuque has also been a positive factor. “We are able to make services more accessible to more

people with this location,” said Overholt.“Andit’sbeenarealbonus being able to work with the occupational medicine program at Finley.”FinleyandSt.Luke’sareboth affiliates of the Iowa Health System.

The Work Well Center at Jones Regional Medical Center is openWednesdaysfrom12:30-3:30p.m.forpre-employmentphysicals.

For more information about Work Well Solutions, contact Troy Overholt at 319/369-8153.

St. Luke’s Work Well Solutions recently opened a new satellite clinic at Jones Regional Medical Center in Anamosa.

WorkWellSolutionspartnerswithmorethan400localcompanies to serve business health needs. The Work Well Clinic provides servicesexclusivelyforwork-relatedinjuriessuchas:

•Physicals •Wellnessscreenings •Workers’compensationtreatment •Drugscreenings •Vaccinations

Mark Taylor, MDBoard-certified occupational

health physician

Troy Overholt, directorSt. Luke’s Work Well Solutions

“We are able to make services more accessible to more people with this location.”

“Currentlyweofferpre-employment physicals and have plans to offer more services such as employee ‘fit for duty’ exams andinjurycare,”saidOverholt.Employment drug screening is provided through the lab at Jones Regional Medical Center. “We hope to soon coordinate clinic hours with times that best suit the employers in the area and offer a comprehensive set of services to cover their occupational health needs.”

AccordingtoOverholt,asatelliteclinic has been in the plans for

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“ If a patient was being treated for cancer but not for co-occurring diabetes, it would seem ridiculous; yet that is happening with patients who have both a mental illness and another chronic condition.”

Kent Jackson, director St. Luke’s Behavioral Health Services

As the largest behavioral health provider in the state, the mental health professionals at St. Luke’s treat hundreds of patients each year, from children to the elderly.

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Mental health wellnessin chronic illness management

KentJackson,directorofSt.Luke’sBehavioralHealthServices,saysone of the most important trends he is witnessing in the behavioral health field is the recognition of a co-occurrenceofchronicphysicaland mental health issues.

“Research is uncovering that not only is the mind like the rest of the body, but the wellness of one can impact the wellness of the other,” said Jackson.

“There was a time when the argument of the chicken or the egg would come up in relation to mental health and physical illness: did hypertension cause the anxiety or did the anxiety cause the hypertension; the mental health side was generally secondary,” said Jackson. “We now know each illness can greatly impact the other, so it’s imperative we look beyond the cause and effect aspect and treat both equally. If a patient was being treated for cancer but notforco-occurringdiabetes,itwould seem ridiculous; yet that is

happening with patients who have both a mental illness and another chronic condition.”

Jackson highlights depression as a mental illness, which can impact an individual’s physical health. Because depression has been shown to weaken the immune system, a depressed individual becomes more susceptible to physical disorders.Studiesshowpeoplewith depression are four times as likely to die within six months of a heart attack.

The statistics also hold true for those with more severe and persistent mental illness such as schizophrenia:asmanyas75percent of those individuals also have a serious physical illness such as high blood pressure, diabetes, respiratory and heart problems.

The cost of careWith medical deductibles and co-paysontheriseformanypatients, Jackson says it’s possible

recognizing and treating mental healthconditionsthatco-existwith physical issues can work proactively to rein in healthcare costs.

“Studiesindicatepatientssufferingfrom depression use healthcare services three times more often thannon-depressedpatientsandmake seven times more visits to the Emergency Room,” said Jackson.

Infact,accordingtotheSubstanceAbuseandMentalHealthServicesAdministration(SAMHSA),ameta-analysisof91studiesfoundwith active behavioral health treatment, patients diagnosed with a mental disorder had a reduced overallmedicalcostof17percent,while controls who did not receive behavioral treatment increased an averageof12.3percent.

Insurance concernsAlso at issue has been the polarizing of physical healthcare from mental healthcare by medical health insurers, who in the past

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Reduced need for medical visits as a result of treatment for depression

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separated each. Until recently, many health insurance plans failed to provide as much – if any – coverage for mental health or substance abuse services as they did for other healthcare. However, asweepinglaw-ThePaulWellstoneand Pete Domenici Mental Health Parity and Addiction Equity Act of2008-mandatesparityformental health and substance abuse services in private health insurance and was enacted into law in January2010.

Jackson said while the new legislation has numerous loopholes yet to be worked out, it is a move in the right direction. “The parity bill is a start in recognizing mental illness as a disease just as important and as treatable as physical illnesses such as diabetes and hypertension,” said Jackson.

A new path to treatmentJackson believes the movement to coordinate treatment for both physical and mental illness should begin by offering mental health services at general or family practice offices, as that’s where nearlytwo-thirdsofpatientsgowhen they have a mental health concern.

“A national survey found 32percentofundiagnosed,asymptomatic adults would likely turn to their primary care physician to help with mental health issues while only four percent would initially approach a mental health professional,” said Jackson. “This is really not ideal.” He said while general practitioners can be helpful in some behavioral health cases, patients generally are treated for mental health issues

more efficiently when they visit a professional specifically trained in mental health.

Jackson believes the stigma of mental illness is a major reason many people avoid a mental health professional. Many contact family physicians, who treat over half of all behavioral health patients in this country. With more common disorders this is generally acceptable, but with more complex disorders it may be problematic in terms of clinical outcomes and it may delay treatment with a mental health provider. An ideal model

of care would involve grouping services together, such as placing behavioral health specialists in family practices. “If we begin to bundleservicestogether-generalpractitioners with mental health professionals, patients would feel comfortable in their choices and could be treated more effectively and efficiently,” said Jackson.

To learn more about Behavioral Health Services at St. Luke’s, contact Kent Jackson at 319/369-8356.

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Six months after depression treatment

Six months before depression treatment