Douwe Rienstra, MD

Educational Activities

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2009

June 19, 2009 Lynne P. Taylor, MD, of the Virginia Mason Medical Center, outlined methods of detecting, diagnosing and helping people with dementia and their families. Dementia affects about half of people who reach the age of 85. We always need to consider that depression, vitamin B12 deficiency, environmental toxins, or other reversible problems may cause dementia.

About 80 percent of people with dementia have Alzheimer's disease and/or vascular (blood vessel) changes. Most of the rest have Lewy body dementia, which can be differentiated on clinical grounds or by a PET scan. While there is an advertising campaign claiming that normal-pressure hydrocephalus is a common and treatable cause, Dr Taylor finds this to be less common and less treatable than the ads suggest.

Kristoffer Rhoads, PhD, reviewed the tests used to assess mental function in people who have or might have dementia. The tests are lengthy and expensive.

June 12, 2009 William Traverso, MD, and Vincent J. Picozzi Jr., MD of Virginia Mason Medical Center reviewed advances in the treatment of pancreatic cancer.

Many factors influence survival after cancer of the pancreas develops. The Virginia-Mason team leads the nation and world in the success in treatment, which is based on some new ideas in the 1990's which turned out to be correct, along with attention to detail to ensure that patients escape the various complications of treatment.

June 5, 2009 Nancy Tipton, MD, gynecologist at the Virginia Mason Clinic, reviewed the new guidelines for cervical cancer screening. Cervical cancer is caused by certain high-risk strains of HPV, the human papilloma virus. Just about all women become infected with some type of HPV when they become sexually active, and most clear the infection within 12 to 18 months. Those that remain infected with a high-risk strain may develop cancer of the cervix. Since no surveillance occurs for this illness in much of Africa, cervical cancer kills many women there.

Begin pap tests about 3 years after initiation of sexual activity. If you do a pap sooner, there is a good chance you will find HPV, and there is a good chance she is in process of clearing this on her on, so you are best to leave her alone until the age of 30. Even later in life, when HPV has caused microscopic cancer on the cervix, around half of that cancer will disappear on her own.

May 29, 2009 Christopher Porter, MD, of the Virginia Mason Medical Center reviewed screening and treatment of prostate cancer. Although PSA helps us find prostate cancer earlier, argument continues as to whether this helps people. PSA is a normal protein that liquifies semen and vaginal fluids, and can rise in both normal people and in those with early prostate cancer.

May 22, 2009 Tom McCormick, MD, of the Virginia Mason Medical Center discussed some of the dilemmas we face in modern medicine. For example, we may have questions of how aggressively to treat a dying man, and family members disagree as to what the patient's wishes would be in this situation. Or, a tiny premature baby is dying; how aggressive should we be? Or, a man wakes up from an accident. He has such a severe spine injury that he cannot move his arms or legs. He asks that respirator be disconnected, but the doctors know that 90% of people who have some time to adjust to such an injury find life sweet, and are glad they are alive.

Dr McCormick reviewed the methods used to resolve these and other difficult questions.

May 15, 2009 John G. Hunter, MD, the Chair of the Department of Surgery at the Oregon Health & Science University in Portland, Oregon titled his talk "Beyond Checklists, Time Outs and Antibiotics: The True Elements of Performance Enhancement in Medicine" Researchers and insurers are more and more able to track outcomes of surgery and other medical care. Individual patient results are collected for individual physicians and institutions as well. Results are compared between institutions and over time. That way if outcomes begin to degrade, investigation can be made as to why, and corrective measures applied.

May 8, 2009 John J. O'Shea, MD, the Scientific Director of the National Institute of Arthritis and Musculoskeletal and Skin Diseases, has studied and researched the immune system for decades in his role as a rheumatologist (specialist in arthritis-type illnesses.)

Many people know that certain forms of arthritis result from the immune system attacking our own tissues. O'Shea studies the details. These details include about 180 chemicals the white blood cells of the immune system use to talk to each other. These chemicals, called cytokines, allow the various elements of the immune system to coordinate their efforts to correctly identify life-threatening invaders.

May 1, 2009 Michael Gluck, MD reviewed the treatment of pancreatitis, a truly serious illness. An important element of treatment is to identify and drain abscesses that form in the pancreas. These are tricky to identify and difficult to drain. A major medical center skilled in this may save the individual's life.

April 3, 2009 Anne M. Mahoney, MD, in the Section of Pulmonary and Critical Care Medicine at the Virginia Mason Medical Center reviewed lung diseases in the elderly.

March 20, 2009 David H. Robinson, MD of the Virginia Mason Medical Center reviewed stroke and transient ischemic attack. People with a TIA should be evaluated immediately for carotid stenosis, because if they have greater than 50% narrowing, they are at high risk for CVA within the next weeks and months. He discussed diagnosis and methods to prevent permanent loss of function.

March 13, 2009 Douglas D. Backous, MD, specialist in Otology, Neurotology and Skull Based Surgery at the Virginia Mason Medical Center pointed out that hearing loss occurs more frequently than we commonly think, and produces more harm than we commonly think.

A 35 decibel hearing loss significantly impairs communication and function. About 33% of people with dementia will function better when impaired hearing is addressed. In a Canadian evaluation of about 200 adverse events in hospitalized patients, about 20% were directly due to inability of the patient to hear. Hearing screening improved health more than did screening for depression or cholesterol.

Only 25% of people who could benefit from hearing aids have them. Primary physicians appropriately treat hearing loss only half the time, and those who do have hearing aids often do not have them fitted or maintained properly.

We physicians need to be better at communicating with people with hearing loss.

March 6, 2009 Thomas A. Preston, MD, of the University of Washington spoke on the Washington Death with Dignity Bill. Following that, several physicians debated the issues and answered questions.

February 27, 2009 Christopher M. Bernards, MD, an anesthesiologist at the Virginia-Mason Clinic reviewed the effect of opioids on people with sleep apnea.

February 20, 2009 Mic Oreskovich, MD, Medical Director and CEO of the Washington Physicians Health Program discussed methods for physicians to become emotionally healthier. As a surgeon, he recalls every complication, but doesn't recall the procedures that went perfectly. Physicians, in fact, are haunted by failure. Perfectionistic, physicians are much more likely to commit suicide, male physicians at 2.4 times the usual rate, female physicians at 5 times the rate of their non-physician sisters.

Most physicians grew up in homes where love was given for accomplishment. Physicians tend to see things as black and white, with no ambiguity. They are relatively unable to express feelings, and rely on work and effort to reach objectives. They hesitate to delegate or lose control, and tend to be neglectful of self and others, and to delay gratification. Physicians suffer from self-doubt, guilt, and an exaggerated sense of responsibility.

Physicians tend to work long hours. They do not accept that fear is an acceptable emotion. Given their knowledge of drugs and access to them, they are much more prone to substance abuse. Of the 22,000 practicing MDs, DOs, and PAs in Washington state, about 8% are troubled by burnout, fatigue, marital problems, finance difficulties, and other severe stresses. Oreskovich estimates that about 2 or 3% are affected by substance abuse or emotional distress that interferes to some degree with their ability to practice.

Washington state law provides two avenues to protect the public from impaired physicians. The Medical Quality Assurance Commission can mandate treatment when co-workers report questionable behavior. More recently, the legislature provided that physicians can refer themselves for treatment, or be referred by their colleagues or organizations, on a no-fault basis. In either case, if the physician is allowed to return to practice, he is monitored with on site inspections, meetings, and random testing. You can learn more at http://wphp.org/.

February 13, 2009 Heidi Shors, MD, orthopedic surgeon at the Virginia Mason Medical Center gave a very practical review of hand and elbow disorders.

February 6, 2009 David J. Vaughn, MD, Associate Professor of Medicine at the University of Pennsylvania spoke at Virginia-Mason Medical Center about testicular cancer. About 8000 men per year develop testicular cancer, but only about 400 die.

January 16, 2009 Raymond P. Robinson, MD, working in Orthopedics at the University of Washington and the Virginia Mason Medical Center reviewed the development of the various types of artificial knee now in use. Though the first artificial knee was designed in France in 1890, it was made of ivory and impractical for other reasons as well. Implantation of artificial knees began in the middle of the last century, using large implants often acting as a large hinge. Robinson, who has worked in this field for 30 years, noted that he and his colleagues study the failed knees intently, and the story of those failures was gripping and instructive. Hearing Dr Robinson describe the problems with the early and later implants, and the changes made to improve them, I learned a great deal about the more subtle movements and actions of the knee joint, and the interactions with the tissues around the joint. Modern knee implants are closer to a relining of the joint, and therefore reduce the problems of replacing a failed joint. With increasingly technical effort placed on design of the bearing surface, and vastly improved materials, knee implants placed twelve years ago have about a 95% operational survival. Robinson feels that a thirty year joint is presently attainable.

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2008

December 5, 2008 - Sheela Sathyanarayana, MD, MPH, Acting Assistant Professor in the Department of Pediatrics at the University of Washington and Seattle Children's Hospital reviewed the dangers of plastics to children's health.

Manufacturer's imprint most plastic products with a triangle surrounding a number to aid in recycling. The number identifies the class of plastic in the object. Briefly,

While the FDA published a report that stated that BPA is not a problem, Steve Hentges of the American Chemistry Council wrote most of that report.

November 21, 2008 - Brian Budenholzer, MD, the Chairman of the Health Technology Clinical Committee of the Washington State Health Care Authority, discussed measures being taken to reduce the cost of our health care system. So far, cost is largely ignored, and money is wasted.

November 14, 2008 - David A. Mankoff, MD, PhD gave a talk at Virginia-Mason on new imaging studies useful in the diagnosis and treatment of cancer. Today, rather than talk about x-ray studies, we use the term "imaging" to cover x-rays as well as newer methods such as CT scan, MRI, PET scan, SPECT scan, ultrasound, etc. Today the advances in imaging involve the use of molecular probes. Not only can such techniques localize cancer, they can tell us about the metabolic processes within the cancer. Knowledge of these processes allows more specific treatment, and tells us how much damage to the tumor the treatment is doing.

November 7, 2008 Gerald T. Nepom, MD, Daniel J. Campbell, PhD, and Srinath Sanda, MD of the Benaroya Research Institute at the Virginia Mason Medical Center described how their studies of mouse immune systems tells us more about human autoimmune conditions such as type 1 diabetes. With this knowledge, they treat patients with interleukins, cytokines, and other cell signals. This tunes the immune system in such a way that children are much less likely to develop diabetes and require insulin. You can read more at www.benaroyaresearch.org.

October 31, 2008 - Thomas M. Green, MD, an orthopedic surgeon and member of the Washington State Medical Quality Assurance Commission, described the operations of that commission to protect the public by the oversight and discipline of physicians.

October 24, 2008 - Veteran NASA Astronaut James P. Bagian, MD, is the Chief Patient Safety Officer at the Veteran's Health Administration. He discussed patient safety and how we can redesign hospital systems to improve safety.

October 17, 2008 - Alexi J. Phinney, MD and Mary C. Pinder-Schenck, MD, both from Virginia-Mason Clinic, spoke on "Breast Cancer in the Elderly Woman: Screening, Diagnosis and Treatment". In general, these issues are best dealt with on an individual basis, as the ability of older women to tolerate even the screening varies greatly. Vigorous older women, on the other hand, benefit more from treatment than many younger women.

October 10, 2008 - Ted Gibbons, MD, from the Virginia Mason Medical Center gave a talk titled "Diabetes, Pre-Diabetes and Cardiovascular Disease: When and How to Find and Treat." He points out that the risk of heart attack and stroke is up to 6 times higher in people with diabetes, compared to those who do not. Much of this damage occurs in the "pre-diabetic" phase; as soon as a person is found to have diabetes, we need to understand that their heart has already been affected and pay serious attention. That is because twenty percent of people with diabetes who appear to have no heart disease will have damaged blood vessels in the heart. When these people are identified and treated, some will have a return to normal blood flow into the heart.

Particularly helpful medications include aspirin, beta-blockers, ACE inhibitors to lower blood pressure and protect the kidneys, and statins to reduce the risk of heart attack and stroke. People with diabetes live much longer when they exercise. Families should learn CPR and learn not to be slow calling 911.

October 3, 2008 - Louis R. Caplan, MD, Professor of Neurology from Harvard Medical School spoke abut stroke. Mosts often strokes are caused by blood clots from the heart or blood vessels breaking loose, moving up into the circulation of the brain, and blocking circulation to part of the brain. No blood, no function, so something is lost- movement, sight, consciousness, or something else. However, other diseases can result in debris in the vascular system as well, such as atrial tumors, cardiac valvular diseases, and others. Caplan discussed newer diagnostic measures and principles, as well as treatment.

September 26, 2008 - This all day course from the Virginia-Mason Clinic began with a review of lupus erythematous by Michelle Petri, MD, from the John Hopkins Medical Center. Key points I took away are that subtle changes in blood tests can begin up to six years before symptoms begin, so that children of parents with lupus might be periodically screened and the disease perhaps aborted before symptoms begin. Lupus does not just attack the kidneys, joints, and other organs, but also affects the brain, so that 80% of people with the disease have cognitive losses.

Lupus, as with other auto-immune illnesses, occurs in people with a genetic predisposition. Too many genes are involved for genetic testing to be helpful. Not all those with a predisposition develop lupus or another auto-immune illness; certain triggers seem to set off these illnesses. Triggers include certain pharmaceuticals, smoking, mercury (in fish), ultraviolet light (from the sun), as-yet-unknown infectious agents, and others.

Many of the complications of lupus arise from the use of the steroids used to treat the illness. For the individual in severe pain and disability, prednisone is often the only option. However, such people are better off in the hands of skilled rheumatologists who are adept at using non-steroidal treatments such as mycophenolate, hydroxychloroquine, and others.

Jane Buckner, MD, studies auto-immune disease in general and reviewed general priniples of such illness. She pointed out that auto-immune illness, including childhood diabetes and multiple sclerosis, are much more common in the Pacific Northwest and other sun-deprived areas, and this is related to vitamin D deficiency. If you read much about the immune system, you know that one category of white cell is the lymphocyte, and that these come in two major types, the B cell (this makes antibodies) and T cell (this cell goes out into the circulation and finds and destroys bacteria, viruses, and abnormal cells). One category of T cell is the regulatory (also called suppressor) T cell, which governs the behavior of the T cell, and if the regulatory T cell does not operate effectively, the effector T cells can destory normal tissue, and this could lead to an auto-immune illness. We know, for instance, that children who develop diabetes have inadequate numbers of these regulatory T cells.

T cells and other white cells swim in an environment of nutrients, waste products, proteins, and cell signals within our bodies. Vitamin D, for example, stabilizes these cells. Smoking, to give another example, destabilizes these cells. People who smoke are more likely to develop rheumatoid arthritis, a common auto-immune illness, and will suffer more joint damage from it than will non-smokers who develop rheumatoid arthritis.

Improved understanding of how these diseases work on the cellular level is allowing for advances in treatment.

Jeffrey Carlin, MD, head of Rheumatology and Immunology at the Virginia Mason Clinic, reviewed advances in our understanding of rheumatoid arthritis (RA). One clear imperative is to diagnose and treat RA early. In RA, joint damage begins right away; today the rheumatologists have a number of agents that can modulate the hyperactive immune system and make the illness just stop. However, if one waits too long, the process becomes irreversible. This means that we need to be more alert to early diagnosis. One process occurring is the citrullination of arginine, common in people with RA, starting years the development of disease. A positive anti-CCP antibody test highly sensitive and specific for RA. Combination of anti-CCP and RF is 99% specific and 80% sensitive.

Parenthetically, Dr Carlin remarked that best research is now coming out of Europe, that the American research infrastructure receives little support. Such research shows that early intensive treatment not only can marked reduce or prevent disability, but prolongs longevity. Unfortunately, most of these treatments can have significant side effects. The take-home message is not to avoid these treatments, because untreated RA is a horrible illness, but to enlist the help of a skilled rheumatologist.

The immune system plays a major role in heart disease; inflammatory processes in the lining of the arteries lead to blood clotting. So, the same drugs that calm RA stabilize the blood vessel linings. And statins, that lower cholesterol but more importantly reduce inflammation, have a strong beneficial effect on the joints and on the inflammatory processes in general.

Pedro Trujillo, MD, a rheumatologist at the Virginal Mason Clinic brought us up to date on the diagnosis and treatment of gout. He pointed that while this is more a disease of men, post-menopausal women are susceptible as well because estrogen helps us excrete uric acid, and elevated levels of uric acid predispose to this illness. Gout is more common in people with metabolic syndrome, the common American condition of excessive abdominal fat, high blood pressure, high blood pressure, and so forth. While we all know that alcohol use increases the severity of gout, he pointed out that beer is more likely to cause a problem than are other forms of alcohol.

Andrew Holman, MD, of the University of Washington does research in arthritic conditions. He reviewed the latest concepts in fibromyalgia. He groups fibromyalgia with other conditions involving alterations in the regulation of the autonomic nervous system, function of the hippocampus. All these conditions, such as irritable bowel syndrome, esophageal reflux, and even panic disorder, result in great distress to the individual from sensations a normal person might not even notice. Such individuals do not just report distress, but show altered brain function on brain scanning. Changes in the architecture of the cervical spine can play a role as well. Treatments include gabapentin and duloxetine.

Antoine Jones, MD, reviewed the non-operative treatment of back pain. Since most back pain does not benefit from or require surgery, many such patients wind up in rehabilitation, Dr Jones' field.

Farideh Eskandari, MD, an endocrinologist at the Virginia Mason Clinic reviewed osteoporosis.

September 19, 2008 Mary Pinder-Schenck, MD, from the Floyd & Delores Jones Cancer Institute at the Virginia Mason Medical Center reviewed obesity as a cause of cancer. Common cancers, such as breast and colon cancer, are up to twice as common in the obese as in those of normal weight. Not only that, but overweight people are more likely to die from their cancer. Breast cancer survivors who gain weight are more likely to suffer a recurrence.

Weight and activity go together. More active people develop cancer significantly less frequently than less-active people, and they survive longer if they do develop cancer.

June 13, 2008 Chia Wang, MD of the Virginia Mason Medical Center reviewed the spread and treatment of hepatitis B and C. Congenital hepatitis B results in immune tolerance, so patients can carry very high viral loads with a normal ALT. The incidence of liver cancer rises with viral load, but since lowering viral load does not reduce risk, especially in people with low ALT, treatment is reserved for those with progressive disease. She has found that people with lower viral load had more liver fibrosis. Her theory is that as the immune system becomes more active with age, lowering viral load, the immune response results in liver damage.

For acute hepatitis C, women, especially those with symptoms, recover spontaneously much more frequently than men. Asymptomatic males do not clear the virus and require treatment.

June 6, 2008 Doctors Jason Eintracht, Paul Smith, Lee Burnside, Keith Dipboye, and Lee Ferguson, of Virginia Mason Medical Center reviewed changes Virginia Mason has made to improve patient care. These changes involve workplace design, computer assistance, and more intelligent use of nurses and medical assistants. They have collected information showing that patients more frequently achieve better health outcomes. I suspect this also resulted in lower costs.

May 16, 2008 - Bruce Nitsche, MD, of Virginia Mason Clinic reviewed rashes and skin symptoms that signal deeper disease. More familiar were syphilis, sarcoid, lupus, Raynaud's syndrome, erythema nodosum, seborrheic dermatitis, xanthomata, Cushing's disease, ichtheyosis, Kaposi's sarcoma, leukoplakia, fixed drug eruption, Lyme disease, meningococcemia, endocarditis, Reiter's syndrome, acanthosis nigricans, and Sister Mary Joseph nodule. Conditions not readily identifiable were erysipelas, Peutz-Jeghers syndrome, Osler-Weber-Rendu, dermatomyositis, amyloid glossitis, hypertrichosis lanuginosa, Hodgkin's lymphoma, and porphyria cutanea tarda.

April 25, 2008 Stanley A. Herring, MD, the Medical Director of Spine Care at the Harborview Medical Center is also the team physician for the Seattle Seahawks. He was trained in rehabilitation medicine, and so has much experience in treating traumatic brain injury.

He reviewed concussion in athletes, and pointed out that a mild traumatic brain injury can occur even without loss of consciousness. He outlined the protocols he uses on the field and on the sidelines to respond to injury. Because neuropsychological function helps determine how much injury has occurred and whether or not it has resolved, the Seattle Seahawk players are tested prior to play so Dr Herring knows what their baseline is. Amnesia and loss of normal neuropsychologic function seems more important to him than does a brief, less-than-a-second loss of consciousness.

Since he deals with this frequently and in a high-profile way he went into great depth. The major points of general importance are

1. Younger athletes, such as high school athletes, suffer a much higher risk of permanent impairment from head injury, than do older athletes. They need especially to be concerned about a repeat injury if they have already had an initial injury.
2. An athlete who is confused, dizzy, or has any impairment of memory or thought after a blow to the head is in danger.
3. Sports should not be resumed until subtle changes in mental functioning have cleared.

Helpful information for high school coaches can be found at www.cdc.gov/ncipc/tbi/Coaches_Tool_Kit.htm.

April 18, 2008 Alec C. Beekley, MD, a Major in the U.S. Army Medical Corps, reported on his experiences as a trauma surgeon in Iraq.

March 21, 2008 Donald E. Low, MD, a surgeon at Virginia Mason Medical Center reviewed treatment of hepatitis B.

March 7, 2008 Kimberly McLaren, MD of Virginia Mason Medical Center reviewed reviewed the boundaries physicians must put on relationships with patients.

February 29, 2008 Andrew Ross, MD, a gastroenterologist at Virginia Mason Medical Center diagnosis of people with bleeding into the GI tract. In about 90% of people, looking into the stomach and colon with a scope will discover the cause. Dr Ross discussed the problem of diagnosis in that last 10%. Often the bleeding comes from the small intestine in these cases. There are now new methods of examining the small intestine using a swallowed capsule. Also, new endoscopes can get down into the small intestine, and allow identification and treatment.

February 22, 2008 Shelly T. Karuna, MD, a research consultant at Virginia Mason, discussed Shared Decision Making: At the Confluence of Physician and Patient Expertise. Some of the patient decision aids they referenced are at www.decisionaid.ohri.ca

February 15, 2008 Roger W. Bush, MD, of the Virginia Mason Medical Center discussed Quality and Change Management, Educational Theory and Social Learning.

February 8, 2008 Michael J. Longo, MD, Deputy Section Head of Cardiology at Virginia Mason Medical Center discussed surgical complications. Such complications are much more common in people who already have serious medical problems, including history of stroke or heart attack, current heart disease, renal insufficiency, congestive heart failure, or diabetes. Additionally, if a patient cannot walk four blocks or climb two blocks of stairs, they are at much higher risk of cardiac complications during major surgery.

Such patients can be protected by giving them a cardiac stress test prior to surgery, so that the surgical team can know how their heart will respond during surgery.

Depending on the results of such studies, major reductions in surgical deaths occur with beta-blocking drugs. The same drugs may affect the heart adversely, so need to be used correctly and only in people who will benefit.

February 1, 2008 - Joel Sheinfeld, MD from Sloan-Kettering Cancer Center in New York reviewed controversies in the management of Low-Stage Nonseminomatous Germ Cell Tumors.

January 25, 2008 Drs Hugh W. Allen and Peter J. Manos of the Virginia Mason Medical Center discussed pain management and opiate treatment thereof.

January 18, 2007 - Carrie Horwitch, MD, in internal medicine at the Virginia Mason Medical Center discussed the role of laughter in good health.

January 11, 2008 Neil B. Hampson, MD, Medical Director of the Center for Hyperbaric Medicine at the Virginia Mason Medical Center reviewed the causes of carbon monoxide poisoning. Many people are not aware that carbon monoxide is a colorless, odorless, product of combustion. Dr Hampson has worked with governmental agencies to improve warning labels on charcoal briquets and portable generators, which resulted in dimishished death rates from those causes. Carbon monoxide poisoning results in headache, nausea, and eventually death. Dr Hampson estimates about half of people with carbon monoxide poisoning are identified by health care workers.