By Tracy Severson, R.D., L.D.

With the growing popularity of all things gluten-free, are you wondering if this diet might be right for you? I’m frequently asked by patients if a gluten-free diet will help with weight loss, digestive issues, or other ailments. Unless you have a gluten allergy or intolerance, the simple answer is no.

Gluten is a protein found in certain grains — wheat, barley, and rye. People following a gluten-free diet avoid all products that contain these grains; other foods such as fruits, vegetables, meats, dairy, eggs, legumes, nuts, and gluten-free grains such as rice and quinoa are allowed. People who require a gluten-free diet are those with celiac disease and those with a gluten-sensitivity or intolerance. When people with celiac disease eat even a small amount of a food with gluten in it, they can develop abdominal pain, diarrhea, damage to their intestinal lining, weight loss, and eventually vitamin and mineral deficiencies. The only treatment for celiac disease is following a strict gluten-free diet. People who are gluten intolerant but do not have celiac disease also find relief from various digestive issues by following a gluten-free diet.

For the majority of people, however, gluten is not unhealthy or harmful. If you aren’t allergic or sensitive to gluten, removing it from your diet will not help you lose weight or make you feel better. Choosing a variety of whole grain foods such as whole wheat bread and pasta, barley, oats, brown rice, and quinoa is still recommended as part of a healthy diet. Many people may initially feel better after starting a gluten-free diet, but this is more often due to the person eliminating processed foods and paying closer attention to their overall diet while making this change. They may even lose weight initially since they have eliminated many foods from their diets, but this is typically short-lived.

Gluten-free diets are currently very trendy, with a number of products being promoted as “healthy” simply because they don’t contain gluten. However, common-sense advice still holds true — choose minimally-processed whole foods whenever possible, such as whole grains, fruits, vegetables, and lean proteins. Gluten-free cupcakes are still just cupcakes, not health food. Stick to a well-balanced diet, watch your portions, and get regular physical activity. Not the trendiest advice, but it is the most trusted.

If you are having digestive issues or are concerned you may have celiac disease, see your primary care provider to be tested. Keep in mind that you need to be eating gluten regularly for four weeks prior to being tested for celiac in order to get an accurate result.  You can also ask to see a registered dietitian to evaluate your diet and symptoms. For more gluten-free resources, contact the OHSU Nutrition Clinic or visit celiac.org.

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Tracy Severson is an outpatient clinical dietitian at OHSU. She earned Bachelor’s degrees in Nutritional Sciences and Sociology from the University of Arizona and completed her training to become a Registered Dietitian (R.D.) at the University Medical Center in Tucson, Arizona. Since becoming an R.D., she has also completed a Certificate of Training in Adult Weight Management.

Tracy moved to Portland from Tucson in 2010, and has worked at OHSU since 2011. She works with the OHSU Surgical Weight Reduction clinic and Cardiac Rehab program, and also provides medical nutrition therapy for General Adult Outpatient Clinics at OHSU.

By Hormozd Borzorgchami, M.D.

Just a few days after a stroke left Emil Evans paralyzed from the tip of his right toe to the tip of his right finger, he was back raking leaves in the yard of his McMinnville home. The OHSU Telemedicine Network played a vital role in his remarkable rebound by bringing the best stroke treatment expertise to his bedside minutes after he arrived at Willamette Valley Medical Center.

Evans was struck by a dizzy spell while standing in the kitchen of his McMinnville home Nov. 4. Paramedics took Evans to WVMC, and Siobhan Gray, M.D., the emergency room physician who examined Evans, immediately suspected he had suffered a stroke.

Gray sent Evans for a CT scan and called OHSU, requesting a telemedicine consultation. By the time Evans returned from his CT scan, I had connected to Willamette Valley Medical Center’s telemedicine cart. This secure two-way audio-video equipment allowed me to examine Evans, ask his family questions about his medical history and work with Dr. Gray to begin treatment. He was then transported to OHSU and taken directly to angiography, where a clot was removed using one of the latest stroke treatment devices. Two days later, he was headed home.

Dr. Gray , left, watches Dr. Borzogchami beam into the emergency room on a telemedicine robot.

As the Evans case demonstrates, the best treatment for ischemic stroke is early treatment. Many of our acute stroke therapies, including the clot-busting t-PA that Evans initially received, are time-dependent, and the sooner a patient can receive treatment to help remove the blood clot, the better the chance that they will recover.

These therapies are also complex and require efficient coordination of care from stroke centers that can provide comprehensive treatment so that care is administered effectively and appropriately.  Since adding telestroke services to the OHSU Telemedicine Network, we have been able to provide comprehensive stroke expertise throughout Oregon almost instantaneously 24 hours a day, seven days a week.

Check out this video to hear Evans tell his story – an example of how the OHSU Telemedicine Network is providing rapid assessment of stroke victims by subspecialists and how this translates to a swift and effective treatment. Or click here to download the OHSU Extra app from iTunes, and watch the story about telemedicine and stroke on your iPad.

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Hormozd Bozorgchami, M.D., is an OHSU stroke neurologist. Dr.

by Jone Sampson, M.D.

I admire Angelina Jolie for sharing her very personal medical information with the public. Her story, shared in the New York Times yesterday, highlights the importance of being aware of a hereditary cancer predisposition, the value of genetic testing, the information gained from testing, and the options for managing the increased cancer risks associated with having a BRCA1 mutation.

As Director of Clinical Cancer Genetics at the Knight Cancer Institute, I work closely with a certified genetic counselor, Kelly Hamman. We offer genetic counseling and testing for hereditary cancer predisposition syndromes including BRCA1 and BRCA2.  Individuals are referred to us because they have been diagnosed with breast cancer before they turn 50 years old, have triple negative breast cancer diagnosed before they’ve turned 60, have ovarian cancer or male breast cancer. Women who are of Ashkenazi Jewish descent and have breast or ovarian cancer at any age are also referred to us. If a woman has a very strong family history of breast and ovarian cancer, she may be considered for testing or seek recommendations for earlier or more frequent screening based on her family history.

Our consultation: What can you expect?

We obtain a complete family history, assess a woman’s risk of having a mutation based on personal and family history, and discuss the issues around genetic testing. Those issues include dealing with the knowledge that they are at increased risks for breast and ovarian cancer if a mutation is identified, and the recommended options for increased screenings, possible surgery, and/or preventative chemotherapy.  We also emphasize that if a mutation is found, there are issues for her family to cope with as well. First degree relatives (siblings, children) of a woman with the BRAC1 mutation have a 50 percent risk of having inherited the same mutation.

You are genetically predisposed to develop breast cancer. Now what?

We meet with women again to review the results, and provide them with information to discuss the implications with their families. At OHSU we have state of the art imaging in the Breast Center for mammography. Our center also offers a breast MRI, and experts to discuss surgical options. We also serve as a resource and frequently recommend women consider seeking support. Two groups we often mention to women with BRCA mutations FORCE (Facing our Risk of Cancer Empowered) and Be Bright Pink.

We are thankful that Angelina started a broad conversation that will help others. We look forward to keeping the dialogue going and improving options for women at high risk for cancer. There is no reason why anyone needs to face these issues alone.

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Jone Sampson, M.D., is an associate clinical professor and director of clinical cancer genetics for the Knight Cancer Institute.

April Thompson, R.N.

This week, the OHSU family celebrates some of our most skilled, dedicated and compassionate community members: nurses. And we recognize one nurse, in particular, whose commitment to the success and education of others is unparalleled.

We can all remember a teacher in our lives that really made a difference. He took time after class to answer your questions. She introduced you to a subject that changed your career path and encouraged you to go beyond your limits. April Thompson, R.N., is just such a teacher.

On OHSU’s 14K Bone Marrow Transplant unit, April is known for her teaching and coaching of new nurses. She has been honored this week with a Nurse of the Year award as one “who contributes significantly to the education, professional development or long-term learning of other nursing professionals.”

Like any great leader, April’s abilities can be hard to define, but her students are not shy with their praise. Read what one former student had to say:

“April was my preceptor during my final term of nursing school, and every day I learned more than I ever thought possible, and every day I had fun. Cancer is serious, difficult stuff, but April finds a way of connecting with her patients and co-workers in a way that relieves some of that tension. She sets an example of lightness without levity, and compassion based in knowledge. She taught me that a nurse has just as much, if not more, say in a patient’s care than any doctor or pharmacist.”

“Being a new nurse, I made many mistakes. April let me err, but she never let me fall on my face. We’d go back over what had happened and discuss all the possibilities. April understands that people don’t learn, that people can’t learn, when they feel attacked or under duress.”

“April gives her students the same compassion and fostering care that she does her patients, and that is what makes her such an effective and exciting teacher. Even though I am no longer her student, I continue to aim for her bar.” - Clea Plumb, R.N., 14K

If you would like to recognize an exceptional OHSU nurse, visit our Facebook page or click here to make a gift.

You may have read about a recent Spanish study (published this month in the New England Journal of Medicine) touting the benefits of a Mediterranean diet in the prevention of cardiovascular disease. There is certainly nothing new about the Mediterranean diet, but I am pleased to see that it’s currently garnering headlines. While not a “diet” in the weight-loss sense, the Mediterranean diet is more of a way of life, a plant-based eating pattern that incorporates lots of fruits, vegetables, legumes, nuts, fish, and olive oil, limiting meats and sweets to occasional foods. This new study—which showed a whopping 30% decrease in risk of cardiovascular disease among at-risk individuals following the diet—solidifies the notion that following a Mediterranean-style diet protects our hearts and preserves health.

Ready to get started? It’s easy to begin incorporating Mediterranean concepts into your daily diet—no foods are entirely off limits, there is an emphasis on delicious produce and fish that are abundant here in the Pacific Northwest, and it even includes a daily serving of wine! Check out this Mediterranean diet pyramid for a quick reference, and use the following tips for inspiration:

• At every meal, include plant foods such a vegetables, fruits, beans, lentils, and whole grains. Begin the meal with a salad or hearty vegetable soup, swap out meat for beans to create vegetarian entrées, experiment with whole grains such as quinoa and farro instead of the usual brown rice and whole wheat pasta (although those are both great choices also!).
• Add healthy fats, protein, and fiber to your diet with nuts and seeds (choose plain, not salted or honey-roasted)—sprinkle sunflower or pumpkin seeds onto salads, spread almond or peanut butter on whole grain bread, stir walnuts into your morning oatmeal, or just have a handful of nuts as a filling snack.
• Use extra virgin olive oil instead of butter, margarine, or other oils—add a splash to your sauté pan, mix it with vinegar or lemon juice for a quick salad dressing, and season it with lemon zest and cracked black pepper to use as a dip for whole grain bread.
• Eat fish and seafood at least twice a week, while reducing poultry, eggs, and dairy (low-fat and non-fat) to small portions daily (or less). Limit red meats to a few times per month, and remember that a serving of meat, poultry, or fish is 3 ounces (about the size of a deck of cards). Think of protein foods as a complement to your produce-rich meals, instead of as the main event!
• Now about that wine…the Mediterranean diet does allow wine “in moderation,” which is up to one 5-ounce glass per day for women or two per day for men (this is of course optional—don’t consume alcohol if it’s unsafe or otherwise unwise for you).
• Daily physical activity is a part of the Mediterranean lifestyle, along with enjoying meals with others. I find this last part particularly important—sitting down for a meal with loved ones rather than eating in the car or in front of the TV goes a long way towards reducing stress and fostering healthy relationships (and healthy hearts!).

Most Portland-area farmers’ markets gear up in May and are a great place to load up on fruits, vegetables, seafood, and other delicious local foods. I’m especially looking forward to the OHSU Farmers Market, which takes place on Tuesdays from 11 a.m. to 3 p.m. from June 4 through October 15. This weekly market is a convenient way for me to incorporate the healthy Mediterranean lifestyle into my busy Portland life.

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Tracy Severson is an outpatient clinical dietitian at OHSU. She earned Bachelor’s degrees in Nutritional Sciences and Sociology from the University of Arizona and completed her training to become a Registered Dietitian (R.D.) at the University Medical Center in Tucson, Arizona. Since becoming an R.D., she has also completed a Certificate of Training in Adult Weight Management.

Tracy moved to Portland from Tucson in 2010, and has worked at OHSU since 2011. She works with the OHSU Surgical Weight Reduction clinic and Cardiac Rehab program, and also provides medical nutrition therapy for General Adult Outpatient Clinics at OHSU.

Earlier this month, the OHSU Telemedicine Network treated two stroke cases that demonstrate how tele-stroke technology can assist in the development of new therapies and expand clinical research.

Case No. 1

A 51-year-old previously healthy businessman was brought to the Salem Hospital emergency room with stroke symptoms. Salem Hospital’s Peter Killefer, M.D., called OHSU and requested a tele-stroke consultation.

Hormozd Borzogchami, M.D.

Minutes later, OHSU stroke neurologist. Hormozd Borzorgchami, M.D., was examining the patient using a two-way audio-video robot that had been wheeled to the patient’s bedside. The exam showed the patient had suffered a very large stroke. He was unable to speak or move his right side. Dr. Borzorgchami talked to the family and learned they had last seen the patient two nights earlier. Unfortunately, he had been at home paralyzed and unable to seek help for more than 24 hours. He was far beyond the three-hour window for the standard clot buster treatment – t-PA.

The decision was made to transfer the patient to OHSU’s neurologic critical care unit for close observation and evaluation. Therefore, Dr. Borzorgchami discussed a new stroke treatment available at OHSU as part of a national multi-hospital research study.

This clinical trial involves the use of donor bone marrow cells to try and reduce stroke injury and improve patient recovery. The idea is based on the finding that when we are very young, the brain often recovers very well from injuries including stroke. As we get older, our ability to recover from a stroke and other injuries diminishes. The theory is the donor stem cells will travel to the brain and make the environment around the brain cells more like that of a young brain.

The study is testing whether the treatment will improve patient recovery and reduce the area of brain permanently damaged by a stroke.  Using telemedicine technology, we were able to obtain an accurate patient history and examination, explain the study in detail to the family and obtain informed consent for the patient to participate in the study. This allowed us to enroll him in the trial and start the potential therapy rapidly upon his arrival at OHSU. The Salem patient has started to talk and can now hold up his right arm.

Case No. 2

A second case last week showed how tele-stroke and clinical trial research work together to offer the best care for the patient.  A 82-year-old male with stroke symptoms was brought to Willamette Valley Medical Center. Timothy Brock, M.D., activated the telemedicine call with OHSU’s Andrew Rontal, M.D. Dr. Rontal’s tele-stroke evaluation found the patient was unable to speak and could barely move his right side.

In collaboration with Dr. Brock, a decision was to administer the t-PA clot buster therapy. This was started an hour and 20 minutes after the onset of the patient’s stroke symptoms. Administering t-PA so soon after a stroke occurs greatly improves the chances that the medication will work.

Since the patient was suffering major stroke symptoms, the medical team decided to transfer him to OHSU. Sometimes tPA alone doesn’t do the trick and OHSU has other tools for removing the clot – a process called a thrombectomy. As part of a research study, we also have a new imaging technique called CT perfusion that can help determine the size of the clot causing the stroke and assess whether there is still a portion of the brain that can be safely saved by removing the clot. Dr. Rontal discussed these issues with the family and they gave consent for the patient to be evaluated as part of this study.

Once again, tele-stroke was key to successfully using this intervention. Families usually cannot accompany a patient during the ambulance ride, so telemedicine allows us to immediately discuss the study with family and obtain their consent rather than waiting for them to arrive at OHSU. Fortunately for this patient, CT perfusion showed t-PA had done its job. The clot was gone and the patient’s brain was getting great blood flow. There was no need to use an additional clot removing technique. By the next morning, the patient was walking and talking almost normally.

Future potential applications 

In addition to early examinations and speeding up the process of obtaining consents, telemedicine has other potential applications in clinical stroke research. One is to use telemedicine to perform follow up visits in the homes of patients who live too far away to easily return to our clinic. Another idea is to allow local small hospitals to participate in some of these state-of-the-art therapies by using telemedicine to supervise the administration of the study drug at these hospitals. Finally portable telemedicine units are available for ambulances. Novel stroke therapies could be given in the field under the direction of the telestroke specialist. This would really shorten the time after stroke onset to when therapy starts. This could be very important, because in the world of stroke treatment, time is brain.

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Wayne Clark, M.D., is the director of the Oregon Stroke Center at the OHSU Brain Institute. Dr. Clark received his medical degree from Oregon Health & Science University and completed his neurology residency and stroke fellowship at the University of California at San Diego. Dr. Clark`s clinical interest is in the acute treatment of stroke, including the investigation of new potential stroke therapies.

By Jean McCormick, R.N., M.S.N.

Open dialogue is vital to building and maintaining successful health care collaborations. Having a “brown bag” session is a dynamic approach to educate, communicate and maintain that collaboration. It is also an important way to establish and maintain relationships between OHSU and transitional care facilities in addition to working toward a larger goal – reducing patient readmissions.

Since December 2012, the OHSU Telemedicine Network has offered a series of educational sessions with Skilled Nursing Facilities (SNFs) using videoconferencing software that can link up to 40 sites at one time. These sessions open up many avenues for discussion regarding nursing skills, research, and best practices.

Currently, the OHSU Telemedicine Network is connected to three of Prestige Care’s skilled nursing facilities. Our first four educational sessions focused on complex subjects that include care and use of PICC (Peripherally Inserted Central Catheter) lines, infectious disease, antibiotics and lab tests.

Although none of us knew what to expect when we launched the series, these lunch-time learning sessions were well received. Seeing everyone connected on a screen in a “Brady Bunch” format was great. Thanks to technology, these sessions also were completely interactive. For example, all of the participants were able to see a demonstration of the best approach to changing a dressing for the PICC lines that were performed on patient manikins. By discussing, simulating, educating, and collaborating, the discussions facilitate better care for the patient along with standardizing practice, which means improved outcomes and hopefully fewer readmissions.

Clearly, the same technology that allows OHSU specialists to treat patients across the state by way of the OHSU Telemedicine Network also makes it possible to improve collaboration with health care staff at area skilled nursing facilities – and no one has to leave their work place to participate in this learning experience.

OHSU has now presented four “brown bags” and while it’s still a work in progress, new ideas and topics are on the horizon. It has become another mode of communication that links OHSU with transitional care facilities, improving patient care and reducing complications and health care costs.

By Bob Applegate

Marquam Hill in the early 1920s

Did you know:

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Bob Applegate is the associate director of community engagement at Oregon Health & Science University.

By Wayne Clark, M.D.

Most everyone knows how important it is to seek immediate medical attention if you are experiencing stroke symptoms. Clot buster medications (TPA) are most effective when given within three hours of a stroke and newer clot removing devices (stent retrievers) are approved for use up to eight hours after known stroke onset.

However, patients and families cannot always get to the emergency room in time. Examples include if the stroke occurs while they are asleep or if they are found with stroke symptoms and are unable to communicate when the stroke started. In these situations, we have always used the time when the patient was last known to be normal to guide the treatment plan. This means that these patients usually arrive at the emergency room long after we are normally able to treat them.

New advances in brain imaging may be changing these strict time limits. Using a special brain CT or MRI perfusion (CTP or MRP) scan allows us to see how much of the brain is already too badly injured to save (core area) and how much is not getting enough blood but might still be saved if treated (low blood flow area). If the area of low blood flow is larger than the core damaged area, treatment might still help the patient regardless of how many hours have passed since the stroke occurred.

Last month, the OHSU Telemedicine Network treated a stroke case that demonstrates how advanced imaging may expand the stroke treatment window. A 84-year-old previously healthy woman was brought to the Salem Hospital emergency room with stroke symptoms. Salem Hospital’s Timothy Edelbute, M.D., called OHSU and requested a tele-stroke consultation. Minutes later I was able to examine the patient and talk with the family using a two-way audio-video robot that had been wheeled to the patient’s bedside.

The exam showed the patient was suffered a stroke on the right side of her brain. She was unable to move her left side and had slurred speech and vision problems. The patient was unable to say when the stroke happened. Her family found her on the floor at 7 a.m. But they had last seen her acting normally at 11 p.m. the previous evening. It was, therefore, more than ten hours since she was known to be normal. She was far beyond the three-hour window for the standard clot buster treatment – t-PA.

The decision was made to transfer the patient to OHSU’s neurologic critical care unit for close observation and evaluation. I discussed using our new CTP imaging with the family 0to determine if we might still be able to treat her stroke and they gave permission for us to proceed. Her CTP is show below:

The pictures on the left show in bright pink the “core” area of brain than is likely irreversibly damaged. In this case there is no area that showed up as pink!

The pictures on the right show in green the area of the brain that is not getting enough blood flow. This large area is at risk for dying if blood flow is not restored. Since the area at risk was large and the damaged area small, we treated her with our new clot removal stent retriever technique.

We successfully removed a large blood clot from the main artery to the right side of her brain (internal carotid artery) at 1 p.m., which was 14 hours after she was last known to be normal. By the next day, she was fully recovered. The brain CT scan 24 hours later showed no evidence that she had had a stroke!

I just saw her for a one month follow-up exam and she is back living her very active life. Interestingly, she doesn’t remember much about the stroke treatment procedure but does remember talking to me on the “TV screen in Salem”.

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Wayne Clark, M.D., is the director of the Oregon Stroke Center at the OHSU Brain Institute. Dr. Clark received his medical degree from Oregon Health & Science University and completed his neurology residency and stroke fellowship at the University of California at San Diego. Dr. Clark`s clinical interest is in the acute treatment of stroke, including the investigation of new potential stroke therapies.

By Tracy Severson, R.D., L.D.

Some people celebrate the holidays in December, but dietitians tend to get excited about March—it’s National Nutrition Month!

This year’s theme is “Eat Right, Your Way, Every Day,” which, according to the Academy of Nutrition and Dietetics website, “encourages personalized healthy eating styles and recognizes that food preferences, lifestyle, cultural and ethnic traditions and health concerns all impact individual food choices.”

So what does that mean for you? To me it means that every day, we should think about what we’re putting in our bodies. Figure out what you like, and why you like it. Did you grow up on traditional Mexican foods, Italian pasta dishes, or, like me, Southern fried chicken? Take those foods that resonate with you and learn how to adapt them for a healthy diet. Put some thought into your meals so they nourish your body and your soul—a healthy diet should be nutritious and enjoyable, otherwise it’s unrealistic to expect to stick with it permanently.

You can use each part of the 2013 National Nutrition Month theme to help make healthy food and nutrition a part of your daily life.

Eat right

Fill up half your plate with fruits and vegetables, use less salt, choose whole grains instead of refined grains, eat fish twice a week…I know you’ve heard the recommendations before; this month think about ways to incorporate healthy changes into each meal.

Your way

Develop a meal plan and grocery list filled with wholesome foods you enjoy. Look for healthy versions of your favorite recipes, or try modifying the ingredients or cooking techniques in your not-so-healthy standards. Get creative!

• Choose smaller portions of higher-fat foods.
• Experiment with herbs and spices in order to reduce the salt.
• Opt for baking or broiling instead of frying.
• Substitute whole grains whenever possible (e.g., whole wheat pasta instead of white pasta).
• Always (always!) think about ways to increase the vegetables in recipes and on your plate.

Every day

Incorporate small changes in your diet every single day to improve your overall health and well-being, and take time each day to think about the food you eat and how it impacts your life.

• Plan your meals in advance to help ensure a balanced diet.
• Cook with your kids to pass on family traditions and teach them about nutrition.
• Sit down for family dinners to catch up on everyone’s day.
• Host a potluck with friends or neighbors to share good times over healthy food.

I hope you spend National Nutrition Month enjoying nutritious meals with loved ones and thinking about how your food choices shape who you are. As for me, this month I plan on perfecting my not-so-Southern oven-“fried” chicken served on a bed of roasted vegetables. Not exactly like my grandmother would make, but still delicious, and certainly prepared my way.

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Tracy Severson is an outpatient clinical dietitian at OHSU. She earned Bachelor’s degrees in Nutritional Sciences and Sociology from the University of Arizona and completed her training to become a Registered Dietitian (R.D.) at the University Medical Center in Tucson, Arizona. Since becoming an R.D., she has also completed a Certificate of Training in Adult Weight Management.

Tracy moved to Portland from Tucson in 2010, and has worked at OHSU since 2011. She works with the OHSU Surgical Weight Reduction clinic and Cardiac Rehab program, and also provides medical nutrition therapy for General Adult Outpatient Clinics at OHSU.