The Lewis & John Dare Center at Virginia Mason

NE WS LE T T E R
Dedicated to providing proactive medical information to all DARE members

Volume 8, Issue 1, Spring 2010

Genetic Testing
Bruce Nitsche, MD
The Human Genome Project, working from 1990 to 2003, spent $2.7 billion to produce a single human genome. About a year ago it would have cost you $50,000 to sequence your own personal genome, and at this point you could nd a bargain for 1/3 to 1/2 that price. It is predicted that within a few years, the technology and competition will allow personal genome testing for around $1,000. So we have gone from Mendel in the mid 1800s, to the Human Genome Project. How can we relate this to our own personal health? Many possibilities exist. Genetic testing can help with a diagnosis if a patient has certain suggestive symptoms. It can detect whether a person is a carrier for a genetic disease (meaning they can pass on the gene to their children, but do not have the disease). It can be used both pre-natally or in the newborn to screen for known devastating pediatric conditions. Genetic testing can diagnose whether a person has an inherited disposition to a certain disease before symptoms start. We can even use genetic testing to determine the type or dose of medication pharmacogenetics that would best treat a given disorder in the individual.

diabetes, cirrhosis of the liver and arthritis. The gene associated with this condition was identied in 1996, and since that time much work has been done to decide who should be screened and who should be treated. What we have found is a complex picture where some people with the genes get the disease, but most people do not. The penetrance is incomplete and we still have much to learn.

So should you start saving? To answer that question probably requires a primer on the principles of genetic diseases.

Humans have 23 pairs of chromosomes and an estimated 50,000 to 100,000 genes are positioned in a precise manner on the chromosomes. Three billion base pairs of DNA comprise the human genome, and more than 99 percent of the DNA sequence is identical between individuals. Population genetic variations are from the remaining 1 percent. We inherit our own genetic footprint from our parents in a pattern that was rst described in the 1800s by the Augustinian monk, Gregor Mendel. Through the observation of plants, he dened laws of inheritance that included terms such as autosomal dominant, autosomal recessive, compound heterozygosity, sex-linked traits, penetrance, etc.

Its all very exciting, and quite frankly, it is becoming more exciting every year. The Human Genome Project results reporting just began in 2003; this eld is in its infancy and rapidly expanding. Because of this, we must proceed with caution. With all we have learned has come expanded knowledge of all that we have yet to learn, and we must rst gure out how best to use this information to help, and not hurt, our patients. For example, one of the most common genetic linked disorders in Northern European descendants is hemochromatosis. This is a disorder of iron absorption that can lead to

Unfortunately, there will be those who prey upon the uninformed (or even worse, the partially informed). Already if you do a Google search for genetic testing, you will turn up more than 4 million hits. I can guarantee you that a large percentage of those are from unscrupulous sites looking to capitalize on the frenzy over the human genome. I refer you to one of my favorite web sites, www.quackwatch.com. Do a search for dubious genetic testing and you will nd an excellent discussion on the topic.

So, keep genetic testing in mind. Keep talking about it with your physician, but for now, keep an eye on your wallet.

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Got Sleep?
Leland Teng, MD

Do you struggle with falling asleep? How about staying asleep? Insomnia is a huge problem in America. Millions of dollars are spent on medications to help make people sleepy. Insomnia has many causes, ranging from serious medical illnesses to mental health issues. On the other hand, some people have just learned bad habits. This article is about healthy sleep habits a concept called sleep hygiene. These basic principles that can help assist sleeping.

yourself to sleep. Instead, before you go to bed, spend some time doing something that you nd relaxing and enjoyable. Dont focus on worries or major decisions. Some people nd it helpful to envision dropping their mental work briefcase outside the bedroom door. Your bedroom is your sanctuary away from lifes issues.

8. Provide a comfortable bedroom environment. Make sure your bed, bedding and room temperature are comfortable. Keep the room dark. Figure out how to keep your room quiet. Deal with anything that is a stimulus to awakening. This includes the pets and kids!

1. Have a regular bed time and waking time. People are creatures of habit. Having a regular bed time is helpful to get in a good sleep pattern. This is based on your bodys natural circadian rhythms. Fluctuations in your social schedule and work schedule can wreak havoc on this. In essence, this is like inducing your own private form of jet lag without the fun of traveling!

2. Stay in bed and sleep for only as many hours as you need. Your bed should be only for sex and sleep. Watching TV, reading or laying awake in bed trains your brain to stay awake in that physical environment. If you are lying awake for more than 20 minutes, get out of bed. Go read a book or do something that is not visually stimulating. When you become sleepy, go back to bed. Staying in bed for 10 hours when you only sleep for eight hours trains you to have less good quality sleep.

There are many dierent reasons for insomnia, ranging from serious medical illnesses to mental health issues. On the other hand,some people have just learned bad habits.
4. Avoid daytime naps. There is a certain amount of sleep that your body needs per day. So, if you take daytime naps, this may decrease your inclination to fall asleep.

9. Establish a pre-sleep ritual. Read a book, get a snack or take a warm bath. How about a massage? These habit patterns can be very eective sleep aids.

10. The Stanford Sleep Disorders Clinic has shown that these sleep hygiene guidelines in conjunction with light phototherapy (for example with a LED daylight simulator) after morning waking was benecial for patients with chronic psychophysiologic insomnia.

So try these tips . and talk with your physician. Virginia Mason has an excellent sleep disorders clinic and even has classes for all you true insomniacs. Please let us know if we can help out. In the meantime . sweet dreams!

3. Let go of the stress! Stress is a potent insomnia stimulator. If you are stressed about something at work or in your personal life, then you may tend to ruminate about it. For many people, this stress delays sleep onset and decreases its quality. Commonly, people are worried about whether or not they will sleep. Sound familiar? That worry itself is the stimulus that keeps the brain awake. Do not try and force

5. Avoid alcohol and caeine for at least four to six hours prior to going to bed. Alcohol may make you initially drowsy however it can cause you to be more awake hours later. Similarly, avoid vigorous exercise within two hours of going to bed.

6. Avoid smoking in the evening.

7. Evening snacks may be benecial. Avoid excessive uids for obvious reasons.

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The Lewis & John Dare Center News

The Breaking Point

Lesley Althouse, MD
I recently received several phone calls from dierent patients regarding information they had been given by their dentists about the use of osteoporosis drugs known as biphosphonates (brand names: Fosamax, Actonel, Boniva and Reclast) who suggested these patients talk with me about potentially stopping these drugs before dental surgery. In the same week, there was a urry of media attention about biphosphonates potentially causing an unusual type of below-the-hip fracture aecting the thigh bone (femur). Some articles quoted experts as recommending patients take a drug holiday from these medications after several years of treatment. My phone started ringing o the hook! Its time to set the record straight and see what the evidence actually tells us. In context, osteoporosis, a bone disorder resulting in decreased bone strength predisposing to fracture, aects 10 to 12 million people in the US and is predicted to aect as many as half of all Americans over the age of 50 by the year 2020. In 2000, there were 9 million fractures worldwide, of which 1.6 million were hip fractures. In numerous clinical trials, biphosphonates have been shown to reduce the incidence of osteoporotic vertebral fractures and all but ibandronate have been proven to reduce hip fractures. These drugs bind avidly to bone constituents. They remain in the skeleton for years, and their eect on reducing fractures persists for some time after the drugs are stopped. So what is bothering the dentists? In 2003, reports began to surface in dental literature about a rare but severe problem of non-healing bone in the jaw, usually occurring after dental surgery or tooth extraction. This condition, Osteonecrosis of the Jaw (ONJ), was associated with the use of biphosphonates, primarily high dose, intravenous forms given to cancer patients for high blood calcium levels. It was not initially known whether there is a similar risk of developing ONJ for otherwise healthy patients taking oral biphosphonates to prevent or treat osteoporosis. Faced with this uncertainty, many dentists have erred on the side of caution and have asked patients facing major dental surgery to consider stopping their biphosphonates. Fortunately, in late 2008, in the light of more clinical studies, the American Dental Association Council on Scientic Aairs published updated recommendations for managing the care of patients receiving oral biphosphonates. This advisory statement concludes that the risk of developing ONJ in patients taking these drugs orally is between zero and 0.04 percent, extremely low. Unfortunately, there is no diagnostic technique available to determine which patients may be at risk of developing ONJ. However, in those patients with other risk factors for ONJ, which include preexisting dental disease, poor oral hygiene, smoking and the use of other drugs which may aect bone health such as corticosteroids (like Prednisone), the report recommends a comprehensive dental examination before starting biphosphonates. No data currently suggests stopping biphosphonates for a few months prior to dental surgery will lower the risk for ONJ, especially since the drugs remain in the bones for years, not months. Therefore, the Dental Council recommends patients should not alter their use of these medications without rst consulting their physicians. For the vast majority of patients, the benets of continued biphosphonate therapy will far outweigh the risks of ONJ during dental treatment. But, keep up good oral hygiene! And what is bothering the orthopedic physicians? Recently, physicians have described rare hip fractures occurring through the femur after little or no trauma. Some case reports have suggested that these atypical fractures may be more common in patients treated with biphopshonates. As it is frightening to think that drugs taken to prevent fracture might actually increase fracture risk, investigators have studied more than 14,000 patients in three large clinical trials of biphosphonates

looking at the frequency of dierent types of hip fractures. Of the 284 hip fractures identied, only 12 were found to be atypical thigh fractures. Statistically, this analysis does NOT suggest a causative link. The authors of the analysis took pains to emphasize that treating 1000 women who had osteoporosis for three years would prevent about 100 fractures (including about 11 hip fractures) a benet that far exceeds the risk of atypical hip fractures. Another important point is that those patients who subsequently suered an atypical thigh fracture frequently noted persistent thigh pain beforehand. I would encourage any patient who does experience new onset of upper leg pain and who is taking a biphosphonate to check in with your Dare physician. One question not yet resolved is the duration of time a patient should take biphosphonates; some case reports of atypical hip fractures suggested prolonged treatment with biphosphonates may increase the risk. There are no clinical guidelines as yet to recommend when patients may safely discontinue biphosphonate therapy, although some authorities consider it reasonable for patients to take a drug holiday after ve years of treatment, particularly once there appears to be a residual benet on bone density for up to ve years after stopping treatment. If a patient does stop treatment though, careful monitoring of bone density is important. So, although there remain some unresolved questions about biphosphonates, the evidence suggests there is no justication for suddenly stopping these very useful medications, at least not without checking with your doctor!

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A Decade in Dare
John Kirkpatrick, MD, FACP

The Lewis and John Dare Center opened its doors in January 2000. The beginning was somewhat controversial, following nearly a year of debate as to whether a medical center should oer what was then termed by the press concierge or boutique medicine. In truth, The Dare Center was our response to patient demand that Virginia Mason oer a service that was already available elsewhere in Seattle, or face losing many of our loyal patients to a rival medical center. Supported by the tireless eorts of some of you, endorsed by our respected, nationally recognized health care authority Austin Ross, and bolstered by the combined lobbying of our president and CEO, The Dare Center became a reality. The Dare family graciously allowed us to use their name, and we will always be indebted to granddaughter Nancy Dare Parker and her mother Gordy Dare (now deceased) for their part in our beginning.

later. Other wonderful patients and their families signed up as the years passed, and weve sadly had to say goodbye to some. All have expressed gratitude for the uncommon level of attention and service that is at the heart of The Dare Center.

We were an enthusiastic, close-knit group then, determined to blaze a trail as the rst practice of its type in a major U.S. medical center.

Lilly, Becky Gan and Pat Schwartz-Garrison are also superb, and always willing to go the extra mile for patients. Bellevues current location on the lower level of the VM Bellevue Clinic is spacious and private, a tribute to their success. We also thank previous Dare physicians Hope Druckman, MD, and Patricia Auerbach, MD, for their contributions to the success of The Bellevue Dare Center, and wish them well as they pursue other endeavors.

We opened in two locations, Buck Pavilion Level 2, where we shared a waiting room with the Department of Psychiatry, and a second site in the Virginia Mason Winslow basement, where Bruce Nitsche, MD, and his medical assistant extraordinaire Cathy Greenawalt were stationed below street level. Bruces oce doubled as the treadmill room and their second exam room was the overow chickenpox isolation room. In our downtown site were our two beloved founding nurses, Nancy Lencioni and Katie Clack, and one doctor, me. Humble beginnings indeed.

As we grew, we added doctors, nurses and administrative sta, each bringing their own unique talents and skills. Lesley Althouse, MD, joined us downtown in 2001, and brought with her 100 of her faithful patients. Her panel has grown considerably and she continues to provide stellar care to all. We are now supported downtown by our trio of terric nurses Karla Litzenberger, Maureen Grant and Michelle Rae who have ably stepped into the big shoes left by the retirement of Katie in 2007 and Nancy in 2008. Katie has now returned on a ll in basis, and of course hasnt forgotten many of you veterans.

The Dare Center on Bainbridge Island changed its look in 2003 when Bruce and his assistant moved into the freshly remodeled former quarters of the local PAWS organization, next door to VM Winslow. Its cozy atmosphere is perfect for this hometown practice; many of you drop in after a trip to the grocery store across the street. When Cathy Greenawalt left us to return to her own hometown roots in Maine, Sandy Stevens, RN, took over the nursing duties at the Bainbridge site, aided by Janice Page, LPN, who has worked in multiple positions at VM for more than 25 years. Sandy previously worked in our downtown oce, but the nearly two-hour commute from Kingston each day was dicult, so it was simpler for Sandy to work in Winslow. Bainbridge patients will also remember other previous medical assistants there, Heidi Mainwaring and Pam Cruz. Some of you were also patients of Greg Keyes, MD, on Bainbridge; we appreciated his eorts while he was with us.

We were an enthusiastic, close-knit group then, determined to blaze a trail as the rst practice of its type in a major U.S. medical center. Many of you joined our practice in the beginning, and are still with us 10 years

Leland Teng, MD, joined us in 2001, two weeks after Sept. 11, and opened our Bellevue practice. Leland has been a wonderful addition with the kind attention and seemingly unlimited time he gives his patients. The Bellevue sta of Sandy Weir, Loretta

Continued on page ve

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The Lewis & John Dare Center News

The History of Dare

Continued from page 4
As the downtown Dare Center became increasingly successful, it was obvious we were outgrowing our initial space, and in 2001 we moved from Buck Pavilion Level 2 to Lindeman Pavilion Level 2. We had just settled into the upgraded space in Lindeman when the Nisqually Earthquake struck. Not to worry. As 91-year-old patient Sylvia Crosetto said at the time, No problem, this building is newer. Then, in 2006, through the determined eorts of manager Jennifer Graves, our downtown sta gratefully moved upstairs to the large, gracious space we now enjoy. Highlights from the past 10 years: 2000 Jan. 2: opening of Dare Center on Buck Pavilion Level 2 October: move to the Lindeman Pavilion Level 2 Media coverage in USA Today, ABC Evening News and other publications 2001 Dr. Lesley Althouse joins Dare Dr. Leland Teng opens Bellevue Dare Center site Sept. 25 2002 Washington State Insurance Commissioner conducts hearings on concierge-style practices; WSMA rallies all innovative practices together for a successful outcome 2003 Consulting work for other other medical centers Park Nicollet, Scripps, Henry Ford, University of Alabama-Birmingham Presentations at national meetings of Society of Innovative Medical Practice Design 2006 Move to current location on Lindeman Pavilion Level 11, thanks to a generous donation from patients Marion and Mylo Charlston 2007 Consulting work for Cleveland ClinicWeston and University of Nebraska. 2008 Consulting work for Mayo Clinic Scottsdale 2009 Named Top Section in Virginia Mason Patient Satisfaction EVERY MONTH as measured by Press-Ganey; all our physician providers are in the 99th percentile nationally in patient satisfaction Celebrate with us! The highlight of 2010 promises to be our 10-Year Anniversary Celebration, which will be held June 3 from 5 to 7 pm on Lindeman Pavilion Level 11 and youre all invited! Well honor the charter members who have been in our practice for the entire decade, and many former sta will join us. A specially produced video will be shown for the rst time, and Dr. Gary Kaplan will make some remarks. Well have spirits and food and we hope youll be here to celebrate with us!

I would be remiss if I didnt mention numerous administrative directors and managers who have ably assisted us over the years. Special thanks to Mike Rona, Darlene Corkrum, Patti Crome and Danielle Smith for getting us rolling. Amin Neghabat, Bob Marks-Nichols, Jim Bevier, Terri Hazelton, Marnee Iseman, Jennifer Graves and former chief of medicine Bob Mecklenburg, MD, also played important roles in our development, leading up to todays excellent management team of Therese Shipley, Gregg Hatch, KayCee Olson and Theresa Craw, along with Chief of Medicine Joyce Lammert, MD, and Vice President Mike Ondracek. Gary Kaplan, MD, Chairman and CEO, remains one of our biggest cheerleaders!

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Happy 90th Anniversary Virginia Mason

While the Dare Center prepares to celebrate its 10th anniversary, Virginia Mason is celebrating its 90th anniversary! vision of providing patients with comprehensive medical care all from one trusted placehas ourished.

In This Issue
Genetic Testing pg. 1
Bruce Nitsche, MD Seattle (206) 341-1557 Bainbridge Island (206) 842-3809

Virginia Mason was founded in 1920 when a group of physicians decided to pioneer a new approach in a medical practice. Their goal: to work as one team. They pledged to provide the nest patient care possible by working together, asking only the best and brightest to join their team and committing themselves to lifelong learning and research.

Where did the name Virginia Mason come from? Actually, our name has its genesis in two young girls both named Virginia Mason. One of the founders, Dr. Tate Mason, had a daughter named Virginia. His partner, Dr. John Blackford, also had a daughter named Virginia Mason Blackford. And if that werent enough, both physicians graduated from the University of Virginia.

Got Sleep? pg. 2

Leland Teng, MD Bellevue (206) 344-7930

The Breaking Point pg. 3

Lesley Althouse, MD Seattle (206) 341-1557

A Decade in Dare pg. 4

John Kirkpatrick, MD, FACP Seattle (206) 341-1557

The founding physicians pooled their energies and resources and built an 80-bed hospital at the corner of Spring and Terry avenues in Seattle. Through the years, their