January 2013

S W E D I S H M E D I C A L C E N TUP E R Date Seattle, Washington | www.swedish.org A Dementia Diagnosis IN THIS ISSUE May Need a Second Look

Five to 10 percent of patients nationwide who have been diagnosed with some A1 Misdiagnosing Normal form of dementia actually have normal pressure hydrocephalus (NPH). Treat- Pressure Hydrocephalus ment for NPH has more than an 80 percent success rate and offers these patients A Medical Partnership to Address a chance for an improved quality of life. Sleep Disorders The Swedish Neuroscience Institute (SNI) at Issaquah has one of the few A2 Case Study: Normal programs in the United States dedicated to diagnosing and treating adults with Pressure Hydrocephalus NPH. Sarah Jost Fouke, M.D., a neurosurgeon at the SNI at Issaquah and program leader of the Swedish Adult Hydrocephalus Program, has developed a A3 Musculoskeletal Pain and Wellness structured evaluation to carefully assess these patients and correctly identify those A4 Case Study: Hip/Spine Syndrome individuals who may benefit from treatment. Case Study: Obstructive Hydrocephalus and dementias have common symptoms, which can contribute A6 Sleep Apnea to misdiagnosis. Primary symptoms of NPH in older adults (ages 60 years or older) include problems with gait, cognition and incontinence. Some patients A7 Continuing Medical Education also complain of headaches or dizziness. When a patient with a presumptive diagnosis of dementia presents with all three primary symptoms (gait, cognition and balance), it may be appropriate to conduct a specific evaluation to determine if there is a buildup of cerebrovascular fluid (CSF) in the ventricles that might be associated with NPH. The adult hydrocephalus team at the SNI uses a multi-phased approach to evaluate patients for NPH. During the initial consultation, a member of Fouke’s Transfer Center (continued on A2) 24 hours a day 7 days a week When it Comes to Sleep – Too Many 866-470-4233 Call us. We can Americans are Running on Empty streamline transfers and admissions for your patients. Insufficient, unrefreshing or nonrestorative sleep is associated with many of America’s greatest medical concerns. It can contribute to the onset of diabetes, Cardiovascular cardiovascular disease, hypertension, stroke, obesity and depression, as well as Neurology • Neurosurgery Ob/Gyn (including High-Risk Ob) compromise management of these disorders. And yet, in a self-reported online Oncology • Orthopedics poll on the National Sleep Foundation’s website, more than 67 percent of Intensive Care • Medical/Surgical responders said they don’t talk about sleep with their doctors during routine visits. The Centers for Disease Control and Prevention (CDC) reports that 25 The Transfer Center is your 24/7 access to percent of Americans occasionally do not get sufficient sleep and nearly 10 Swedish/Ballard percent have chronic insomnia. In the 2008 and 2009 Behavioral Risk Factor Swedish/Cherry Hill Surveillance Survey, Washington State men and women ages 25-34 years old Swedish/First Hill (continued on A5) Swedish/Issaquah

www.swedish.org January 2013 — A1 Normal Pressure Hydrocephalus (continued from A1) team takes a medical history and clinical history and symptoms suggestive to measure and record the results of conducts a thorough physical examina- of a diagnosis of NPH, Fouke’s team both sets of assessments,” says Fouke. tion. He or she may order additional performs a lumbar puncture to withdraw “Using videography before and after a MRI scans that include CSF flow studies approximately 30-40 milliliters of CSF. lumbar puncture and a standard evalua- to appraise cranial CSF flow, along with If the patient has NPH, removing this tion scale allows us to both qualitatively hippocampal, cortical and ventricular volume may result in some symptom and quantitatively assess patient volumes. improvement. improvements.” If this initial evaluation suggests a Returning to the clinic the next day, If there are improvements, Fouke possible NPH diagnosis, the team of the patient is again videotaped while considers the patient for surgical shunt evaluators performs a series of tests completing the same gait and balance implantation to regulate CSF volumes. to establish a baseline level of func- assessments. Cognitive testing is repeated. The shunt allows excess CSF to drain tion, including gait and balance, and The team compares the results of the into the abdomen, where it is absorbed. cognition. The patient is videotaped second set of tests to the baseline tests A valve attached to the shunt controls performing the gait and balance testing. from the previous day. spinal fluid flow. If the patient appears to have a “We use an objective scoring system (continued on next page)

Case Study: Normal Pressure Hydrocephalus Sarah Jost Fouke, M.D., program leader, Adult Hydrocephalus Program, Swedish Neuroscience Institute at Issaquah TS is a 74-year-old male who has experienced progressive gait difficulties for about three to four years. In addition to unsteadiness with ambulation, he recently fell several times. He has enjoyed traveling with his spouse since retiring, but finds that he can no longer keep up when walking in groups while on vacation. He has some memory impairment and feels “foggy” at times. He has urinary frequency, but no frank urinary incontinence. His symptoms have been progressing slowly. Mr. S approached his primary-care physician about his memory impairment and gait disturbance. Initially he was considered to have a diagnosis of Alzheimer’s or Parkinson’s disease. An MRI of the brain revealed increased ventricular volumes, out of proportion to the degree of cerebral atrophy seen. Because of a radiographic reading of “possible normal pressure hydrocephalus,” Mr. S’s physician referred him to our neurosurgical office for evaluation. Mr. S’s wife and daughter accompanied him to his initial appointment. He noted the symptoms described above. Gait testing revealed a magnetic type gait pattern with a slow, somewhat shuffling gait. He took 19 steps to cover a 20-foot distance in 17 seconds. He scored 25/30 on a Mini Mental Status Evaluation (MMSE). MR imaging with CSF flow studies revealed ventriculomegaly with increased aqueductal stroke volumes. Given the clinical and radiographic findings, as well as the signs on examination, we T2 weighted axial image from a brain MRI showing significant ventricular dilatation in a patient with normal pressure hydrocephalus. recommended high-volume lumbar puncture. Mr. S underwent high-volume lumbar puncture and returned to the Given this improvement, Mr. S and his family discussed placement office the following day for further evaluation. of a ventriculoperitoneal shunt. One month later, Mr. S underwent shunt His wife noted that they went out for dinner the previous evening placement without complications. At subsequent follow-up visits, he and her husband was more spirited than usual. They walked around after noted continuation of physical therapy with improvement in gait and dinner with much more ease than normal. In the office, Mr. S’s score on mobility. His wife and family noted an improvement in quality of life MMSE improved from 25 to 28. His gait testing revealed an improved with increased mobility on a family vacation approximately six months speed with increased foot pickup, covering the same 20-foot distance in following surgical intervention. During one follow-up visit, Mr. S’s wife 12 seconds, taking 14 steps. thanked the team for “giving me my husband back.” 

A2 — January 2013 Swedish Transfer Center 866-470-4233 (toll free)

If the test results show no improve- methodologies show greater than 80 ment, but the clinical evaluation and percent response to CSF shunting. When to Refer to Swedish MRI images suggest NPH, Fouke may Typically, treatment and follow-up Adult Hydrocephalus Program recommend that the patient be admitted physical therapy and rehabilitation 751 N.E. Blakely Dr. to the hospital for three to four days of provide the greatest improvement Issaquah, WA 98029 additional testing. In this case, the patient in restoring gait and balance. It is T: 425-313-7077 undergoes placement of a lumbar drain more difficult to predict how much F: 425-313-7180 to allow continuous draining of a larger improvement there will be with memory The Adult Hydrocephalus Program offers volume of CSF. These patients go impairment and urinary incontinence second opinions and accepts referrals of patients who are 60 years old or older who through daily gait/balance and cognitive symptoms. For a large number of exhibit all three primary symptoms of NPH: testing. If draining more fluid produces patients, clinical improvement results • Gait and balance problems symptomatic improvement, Fouke in greater independence and significant removes the drain and considers the improvement in quality of life, high- • Cognitive decline patient for an implanted shunt. lighting the importance of recognizing • Incontinence Studies have shown that patients this relatively under-diagnosed clinical Additionally, an initial CT scan or MRI may with NPH evaluated by these rigorous condition.  show enlarged ventricles. To consult on or refer a patient who may benefit from a structured evaluation for NPH, Musculoskeletal Pain and Wellness: please call 206-313-7077. A Pathway of Care with a Light Touch

Musculoskeletal pain can be Spine, Sports and Musculoskeletal diagnostic tests are needed or if the debilitating and an obstacle to normal Medicine. “As a referral resource, we are patient can begin a customized rehabili- daily life. Over time, patients who try to able to help diagnose and treat patients tation program. The components of mitigate the pain by altering the way they with a goal of minimizing their pain and such a program might include self-help sit, stand or move, may exacerbate the optimizing their function.” therapies (ice/heat, elevation, compres- condition and shift the pain to another Prehabilitation programs are avail- sion, rest, etc.), medications, physical area. Physical medicine and rehabilita- able to help athletes, employees and therapy, integrative therapies (manipula- tion specialists at Swedish Spine, Sports other individuals obtain their personal tion, acupuncture or massage), bracing, and Musculoskeletal Medicine (SSSMM) functional goals that will help them and diagnostic and therapeutic periph- have extensive training and expertise in perform specific activities. Rehabilitation eral joint and spinal injections (guided musculoskeletal wellness and nonsur- services focus on thorough evaluations by ultrasound or fluoroscopy). When gical approaches to spine, musculoskel- that lead to personalized care plans and further testing is needed to better define etal and nerve dysfunction and pain due the best possible outcomes. the problem, the physiatrists at SSSMM to degenerative conditions, and sports, The evaluation for pain or dysfunc- coordinate the most appropriate and work and daily-life injuries. They have a tion begins with an extensive conversa- efficient workup. They will order and light touch – and a holistic approach – to tion about the patient’s medical history interpret imaging, such as X-ray, MRI, relieve pain and restore function. and how the injury or condition affects CT, CT-myelogram, bone SPECT scans, “The pathway of care we use for his or her quality of life. A directed, and other imaging studies, and perform patients ages 12 years and older begins hands-on physical exam helps determine electrodiagnostic (electromyography and with the least invasive approach – trying how the injury might be affecting other nerve conduction studies) and musculo- to avoid surgery, whenever possible,” parts of the body through the kinetic skeletal ultrasound studies. says Andrew J. Cole, M.D., medical chain (the relationship or connection “We also coordinate exercise, stress director of Swedish Medical Group between the nerves, muscles, bones and reduction and nutritional counseling to – Department of Ambulatory Muscu- joints) or motion cascade. After deter- ensure the patient is not inadvertently loskeletal Services, Swedish Physical mining a presumptive diagnosis, the compromising his or her progress,” says Medicine & Rehabilitation, and Swedish discussion turns to whether additional Cole. “Most importantly, we believe (continued on A4)

www.swedish.org January 2013 — A3 Musculoskeletal Pain and Wellness

(continued from A3) in the power of patient literacy. Well- extensive network of specialists and network function as a collaborative team informed and educated patients become therapists, which helps ensure the to develop care pathways, and improve partners in making the most appropriate success of this type of highly personal- the quality and efficiency of that care. and effective health-care decisions. ized care plan. Their goal is more than just caring for In fact, we have found they are more In its academically-based system, patients; it is to discover ways of caring compliant and get better quicker.” these physical medicine and rehabilita- for patients in even better ways.  The practice has developed an tion specialists and their supporting

Case Study: Hip/Spine Syndrome Erik S. Brand, M.D., M.Sc., and Llewellyn N. Packia nostic studies, we concluded an office-based, fluoroscopically-guided, contrast-enhanced Raj, M.D., Swedish Spine, Sports and Musculoskeletal ultrasound-guided diagnostic and therapeutic transforaminal epidural injection. Betty’s pain Medicine, Division of Swedish Physical Medicine and injection of local anesthetic and steroid into her diary indicated that the injection relieved 90 Rehabilitation greater trochanteric bursa would help clarify our percent of her remaining back and anterior thigh Betty is a 48-year-old mother of two boys. diagnosis so we could advance her care. pain during the anesthetic and steroid phases. She was active in organized sports as a younger (see figures 1 and 2) Two weeks later, Betty remained pain free woman, and now enjoys hiking and climbing Betty returned to our clinic two weeks after except for some pain deep in the left hip/buttock with her family and being involved with her boys’ the injection, reporting that the anesthetic phase region, specifically when walking downhill. sports teams. She is moderately over weight, but of her injection relieved all of her lateral hip pain, Hip X-ray series demonstrated mild joint otherwise healthy. About six months ago she and the steroid phase reduced the pain enough space narrowing on the left. We referred her for developed pain in her lower back and left buttock that she was able to get a full night’s sleep, as well 6 to 12 appointments with a physical therapist and thigh, especially while walking the hills in her as stand and sit. She still had some pain, however, specializing in manual therapy, kinesiology and neighborhood. in her back and anterior thigh radiating to the aqua therapy to stabilize the hip joint and lumbar Betty’s primary-care physician ruled out pelvic lateral aspect of her left knee. Repeat examination region and optimize strength and flexibility. We and uterine issues, ordered a four-view spine now demonstrated a negative straight-leg-raise also provided personalized nutrition, weight-loss, X-ray series, prescribed anti-inflammatory medi- test, equivocal resisted straight-leg-raise test, pain-management and ergonomic counseling cation and referred her for a course of physical positive “femoral stretch” test and negative knee to help her understand the relationship between therapy. When the pain and physical limitations examination. Manual examination of her back lifestyle changes, exercise and her ability to miti- continued after four weeks of physical therapy, demonstrated abnormal “end feel” at L3 and L4. gate pain associated with hip/spine syndrome, Betty’s physician referred her to our clinic. An MRI was ordered and confirmed the name associated with this type of concurrent During her first appointment we took a foraminal stenosis with mild compression of disease of the hip and spine, which is not detailed medical history, including any family the left L3 nerve root. Betty agreed to a left L3 uncommon in middle-aged and older adults.  history of back, hip, rheumatologic or neurologic issues, allowing us to rule out genetic spine or hip conditions. The patient described her pain, explaining that she couldn’t sit, walk or stand in one place without left-sided, low-back and hip pain. She was clearly frustrated because the pain prevented restorative sleep and completion of her daily activities. Reviewing Betty’s previous spine X-rays and performing a thorough musculoskeletal and neurological exam, which included an evaluation of skeletal symmetry, balance, flexibility, strength, posture and manual examination to try to repro- duce the pain, led to a presumptive diagnosis of chronic trochanteric bursitis or gluteus medius tendinopathy and associated musculoskeletal restrictions. Figure 1. This ultrasound image shows the Figure 2. This ultrasound image shows distention After discussing various diagnostic options, approach for a greater trochanteric (subgluteus of the greater trochanteric (subgluteus maximus) maximus) bursa injection in the anatomic bursa after injection of local anesthetic and steroid. including additional X-rays, MRI, diagnostic transverse plane over the lateral facet of the greater injections under ultrasound and electrodiag- trochanter, approached from posterior to anterior.

A4 — January 2013 Swedish Transfer Center 866-470-4233 (toll free)

When to Refer to Swedish Swedish Spine, Sports and Musculoskeletal Medicine

Phone: 425-498-2272 We invite you to refer your patients who are two to four weeks post Fax: 425-498-2334 an acute episode that is nonresponsive to initial treatment. Swedish/Cherry Hill (two locations) Clinical care for: Clinical services: 550 17th Ave., Suite 500 • Neck and extremity pain • Comprehensive musculoskeletal evaluations (James Tower) Seattle, WA 98122 • Mid- and low-back pain, including low-back • Electrodiagnostic testing pain during pregnancy 1600 E. Jefferson, Suite 600 • Diagnostic ultrasound and (Jefferson Tower) • Acute and chronic/aging ultrasound-guided procedures Seattle, WA 98122 musculoskeletal disorders • Image-guided diagnostic Bellevue • Carpal tunnel/neuropathies and therapeutic injections 1750 112th Ave., N.E., Suite D-258 • Occupational injuries • Peripheral joint, bursa and Bellevue, WA 98004 • Workers’ Compensation claims tendon sheath injections Swedish/Redmond • Auto accident injuries • Trigger-point injections 18100 N.E. Union Hill Road Redmond, WA 98052 • Adult and adolescent athletic injuries Swedish/Issaquah 751 N.E. Blakely Dr., Suite 4020 Issaquah, WA 98029

Sleep Medicine

(continued from A1) reported insufficient sleep more initiated at the primary-care practice. internal medicine, obstetrics/gyne- frequently than any other age group. “Primary-care providers can order cology, pediatrics, pulmonology or Sleep disorders can affect health, home screening sleep studies to detect otolaryngology – allowing expert work, relationships and overall quality evidence of suspected sleep apnea,” advice for almost any sleep condition. of life, and they can be deadly. The says Sarah Stolz, M.D., medical The program also includes research National Department of Transporta- director of Swedish Sleep Medicine. protocols and clinical trials to improve tion reports drowsy driving causes 1550 “These initial screening sleep studies treatments and identify new approaches. fatalities annually, as well as 40,000 non- can help determine if more specialized These sleep medicine experts offer fatal accidents1. The CDC, the Institute treatment is needed. They also can be both pediatric and adult sleep services, of Medicine and the National Center on very useful when a patient is reluctant and also care for bariatric patients with Sleep Disorders Research support the to pursue a work up for sleep apnea sleep disorders. They are able to accept development and expansion of surveil- or when insufficient information is patients up to 1000 pounds. lance of sleep patterns and associated available to the primary-care provider For more information about outcomes because of the important role regarding symptoms, such as when a primary-care interventions or services sleep plays in the health and well-being patient does not have a bed partner.” available through Swedish Sleep of Americans. With seven locations in the Greater Medicine, or to refer a patient, please Swedish Sleep Medicine promotes Puget Sound area, the sleep medicine call 206-223-8515 (physician line) or a greater partnership in addressing this team at Swedish is the largest sleep 206-386-4744 (appointment line).  growing epidemic. While subspecialty specialty practice in Washington and 1 US Department of Transportation, National Highway Traffic Safety Administration, National Center on expertise exists with the Swedish’s sleep a regional referral resource. The team Sleep Disorders Research, National Heart Lung and medicine physicians, there are interven- includes sleep physicians who are also Blood Institute. Drowsy driving and automobile crashes [National Highway Traffic Safety Administration Web tions – beyond sleep aides – that can be specialists in neurology, psychiatry, Site]. Available at www.nhtsa.gov/people/injury/ drowsy_driving1/Drowsy.html#NCSDR/NHTSA Accessed February 10, 2011. (see case study on A6)

www.swedish.org January 2013 — A5

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Case Study: Obstructive Sleep Apnea (OSA) Anand A. Gersappe, M.D., Ph.D., Swedish Sleep Medicine A 49-year-old female with a history of ance only covered home autoPAP titration, which Six-week follow up post depression, mild obesity and hypertension precluded in-lab titration at this time. presented with symptoms of insomnia for CPAP adjustment The patient reported sleeping much better three to four years. She had difficulty sleeping Four-week follow up post and using the CPAP machine an average of six (frequent awakenings) and occasionally had CPAP initiation hours each night. Smart-card data indicated very difficulty getting back to sleep because of racing The patient reported having significant little leak and a normal AHI of 3.4. She also thoughts. She said she often woke up feeling difficulty tolerating CPAP. She was using indicated that she was much less tired during as tired as when she went to bed. She was tired it an average of three hours per night. Her the day. Her ESS score had improved to 4/24. during the day and had problems focusing smart-card data indicated significant leak and She said she was much more motivated during at work. She snored loudly, but there was no an elevated AHI of 9.2. Her 95th percentile the day and was planning a camping trip. history of apneas. pressure was at 11 cm. She wanted to give up She described her lifestyle as normally using CPAP and try something else. I explained Six-month follow up quite active. She hikes and camps frequently; that her pressure may not be adjusted correctly During her six-month follow-up appoint- however, in the past several months her daytime and encouraged her to continue CPAP a little ment, the patient reported that she continued to symptoms had limited those activities. She does longer. not smoke or drink, and consumes very little do very well with CPAP; however, she wanted caffeine. She is married with two children, one Subsequent CPAP titration study to consider an alternative treatment option living at home. On weekdays, she goes to bed that she could use when she was camping. She Given her poor response to autoPAP, I at 11 p.m., and gets out of bed at 5:30 a.m. On mentioned that she had not taken the CPAP obtained prior authorization from her insurance weekends, when she gets eight hours of sleep, with her during a recent camping trip and had for an in-lab titration. During the titration study, she wakes up feeling even more tired. I determined she required a CPAP pressure of (continued on next page) Her medications include: 6 cm. At this setting her AHI was 0.8 with a • Lexapro (an antidepressant), which she feels saturation nadir of 94 percent. At higher pres- controls her depression. Zung A and CES-D sures of 7-10 cm, I observed increased mouth When to Refer to Swedish scales (self-reported depression question- leak, sleep fragmentation and central apneas. Sleep Medicine naires) show very mild elevations. We reset her CPAP machine to 6 cm. Clinic line (Seattle): 206-386-4744 • HCTZ for hypertension, which she Clinic line (Eastside): 425-394-0024 takes at night Sleep and the Heart – Direct physician line: 206-223-8515 • Flonase (fluticasone) for allergic rhinitis Chicken and the Egg Each sleep medicine expert at Swedish Sleep Further assessment showed: Medicine is board-certified in sleep medicine • An Epworth Sleepiness Scale (ESS) score of The relationship between sleep disorders and and in a medical or surgical subspecialty. They 12/24 (a self-administered questionnaire to heart health is a bit like a discussion of which diagnose and treat the full range of adult and measure a person’s daily sleepiness) came first – the chicken or the egg. People pediatric sleep disorders, including services • BMI 31 with heart disease often have problems for patients weighing up to 1,000 pounds. • Neck circumference of 14 inches sleeping. They may wake up frequently with • Snoring/sleep apnea problems breathing because of fluid in their • STOP-BANG score of 3/8, indicating high lungs or palpitations. Research also shows, • Insomnia risk for obstructive sleep apnea (OSA) however, that people with healthy hearts • Narcolepsy During the appointment we discussed sleep who have sleep disorders also put their heart • Sleep terrors/Sleepwalking hygiene tips and stimulus control. Additionally, health at risk. I recommended taking HCTZ in the morning • Daytime sleepiness There is increasing evidence that there is and a home sleep test. • Restless legs syndrome a direct relationship between heart health and refreshing, restorative and sufficient • Parasomnias Treatment sleep. Poor quality of sleep or chronic sleep • Unexplained fatigue The home sleep test showed an apnea- deprivation has been linked to high blood • Shift work/Jet lag hypopnea index (AHI) of 6.2 with a saturation pressure, atherosclerosis, heart failure, heart nadir of 90 percent, indicating mild OSA attack, stroke, diabetes and obesity. • Children’s sleep disorders syndrome. During her follow-up appointment, we The American Heart Association and the • Women’s sleep disorders discussed several treatment options. The patient American College of Cardiology encourage chose a CPAP device because of its lower cost. To consult on a patient or request a referral, physicians to routinely assess patients’ sleep Initially she was treated with an autoPAP machine please call 206-223-8515 (physician line) or patterns as part of their overall care. set at a pressure of 5-18 cm. The patient’s insur- 206-386-4744 (appointment line).

A6 — January 2013

• Swedish Transfer Center 866-470-4233 (toll free)

taking Flonase. We discussed a mandibular advancement oral appliance as an alternative. Initially she Swedish Medical Center was hesitant to try this because of concerns For more than 102 years, Swedish Medical about changes in her bite/jaw alignment. I Center has brought the most advanced, assured her that this was much less likely to up-to-date medical care to the people of the occur with occasional use of the appliance. Seattle metropolitan area. Today, with five A dentist fitted the patient with a Thorton hospitals, multiple medical facility campuses ® Adjustable Positioner (TAP ) appliance. She and more than a hundred primary- and used the TAP appliance at home for two specialty-care clinics throughout the Greater weeks and was able to tolerate it fairly well. Puget Sound Area, Swedish is the area’s She felt that her sleep quality and fatigue largest, most comprehensive, nonprofit improved, although she self-reported an health-care system. As a regional referral improvement of about 70 percent compared center for cardiac care, maternal-fetal to 90-percent improvement with CPAP. I recommended a home sleep test with medicine, neurological care, oncology, not slept well. We discussed a battery charger the appliance to confirm efficacy. The test orthopedics, pediatrics and transplantation, for CPAP, but determined that was not a results showed a residual AHI of 5.2 with a the men and women of Swedish and the viable alternative because she often camped saturation nadir of 90 percent. As a result, I Swedish Medical Group care for patients in locations where she did not have access to recommended the dentist advance the oral from throughout the Northwest – and a power supply. We also discussed Provent® appliance a few millimeters. beyond. For more information, visit nasal strips or an oral appliance. (see above) After an additional six months, the patient www.swedish.org or call 1-800-SWEDISH Initially she settled on the nasal strips; returned to the Sleep Center. She uses the CPAP (1-800-793-3474). however, after seven to eight days, she machine at home and continues to do well. She reported having difficulty tolerating them. Ballard Lakeside also took the oral appliance on a recent camping This intolerance may have been partially 5300 Tallman Ave. N.W. 6506 226th Pl. S.E. trip and had done well with it.  Seattle, WA 98107-3985 Issaquah, WA 98027 related to allergic rhinitis, although she was 206-782-2700 425-427-8450 Cherry Hill Mill Creek 500 17th Ave. 13020 Meridian Ave. S. Seattle, WA 98122-5711 Everett, WA 98208 CME Course Listing January — March 2013 206-320-2000 425-357-3900 Edmonds Redmond Physicians from across the region and around the world come to 21601 76th Ave. W. 18100 N.E. Union Hill Road Swedish Medical Center’s Continuing Medical Education (CME) Edmonds, WA 98026 Redmond, WA 98052 425-640-4000 425-498-2200 courses to learn about new research and innovative treatment techniques. First Hill Swedish Medical Group 747 Broadway 600 University St., Ste. 1200 For times and locations, go to www.swedish.org/cme or call 206-386-2755. Seattle, WA 98122-4307 Seattle, WA 98101-1169 206-386-6000 206-320-2700 Ninth Annual Pediatric Specialty Update for the Multimodal Treatment of Spinal Tumors Issaquah 751 N.E. Blakely Dr. Primary-Care Physician Friday, March 29 Issaquah, WA 98029 Friday, Jan. 25 Join our email list: swedish.org/CMEProfile 425-313-4000 The Transradial Approach: A Case-Based and Hands-On Training Course Like us on Facebook: facebook.com/ SwedishCME and follow us on Twitter: Friday-Saturday, March 1-2 twitter.com/SwedishCME Physician Opportunities Clinical Research Investigator Training Friday, March 15 Are you a physician who would High-Risk Obstetrics: like to join a team-oriented, Tools for the Family Physician patient-focused practice? Friday, March 22 Swedish Medical Center is accredited by the Accreditation Council for Continuing Medical Contact Aaron Bryant Education to provide continuing medical education for physicians. Manager, Provider Services Swedish Medical Group at [email protected] or 206-320-5925.