Annual Meeting

Charter Law of the SMS

State Medical Society

Charter Law

Author Affiliations: Wisconsin Medical Society

Corresponding Author: Please address correspondence to the Wisconsin Medical Society at 608.442.3800

Focus On...

Cases Involving Discipline for Inappropriate Prescribing of Controlled Substances

Arthur K. Thexton JD

Of the approximately 350 disciplinary orders issued by the Medical Examining Board (MEB) between 1988 and mid-1996, 8% involved a principal allegation of inappropriate prescribing of controlled substances. During the same period, 3% of the 127 Dentistry Examining Board’s disciplinary orders related to similar allegations.

Author Affiliations: Arthur Thexton, JD, has been a Prosecuting Attorney for the Wisconsin Department of Regulation & Licensing, prosecuting professional misconduct cases involving physicians, pharmacists and other health care professionals. His great grandfather, Louis Thext

Corresponding Author: Please address correspondence to the Wisconsin Medical Society at 608.442.3800

Proceedings from the 2000 Annual Meeting of the American College of Physicians–American Society of Internal Medicine, Wisconsin Chapter

Edited by Frank Graziano, MD, PhD

The Wisconsin Chapter of the American College of Physicians-American Society of Internal Medicine annual meeting was held in Madison, WI September 7- 9, 2000. Once again, a highlight of the meeting was the presentation of posters and vignettes by residents from the five residency programs in the state (Gundersen Clinic, Marshfield Clinic, Medical College of Wisconsin, Mt. Sinai Hospital, and the University of Wisconsin Hospital and Clinics). So that all may appreciate the quality of our Internal Medicine residents and the quality of care given by these residents in our Wisconsin residency programs, the full text presentations for the poster and vignette sessions held at the Associates part of the meeting are presented below. Through the cooperation of the Wisconsin Medical Journal we will publish these presentations yearly, however, there is nothing like the lively medical discussion these posters and vignettes produce at the ACP-ASIM meeting.


Author Affiliations: American Society of Internal Medicine, Wisconsin Chapter

Corresponding Author: Please address correspondence to the Wisconsin Medical Societyat 608.442.3800

Editorials

A Primer for Treating Chronic Pain

Thomas C. Meyer, MD, WMJ Medical Editor

Relief of pain is surely one of the medical profession’s prime roles in the care of patients. This issue of WMJ is directed primarily at the current status of the management of patients with chronic non-cancer pain in the hope that we will re-think our approach to patients whose lives have been radically changed and whose quality of life has deteriorated because of severe, debilitating pain. In the majority of these patients an underlying cause remains obscure, and we sometimes find ourselves wondering whether some strange psychoneurosis lies behind the seemingly constant whining of these unfortunate patients.


Author Affiliations: WMJ, Medical Editor

Corresponding Author: Please address correspondence to the Wisconsin Medical Society at 608.442.3800

Volunteer Experience in Tanzania, Africa

Ernest Pellegrino, Jr, MD

As a premed student, I was inspired by a biography of Dr. Albert Schweitzer. Years later, after I retired from my career as an orthopedic surgeon, my wife Barbara and I dedicated 2 months of our lives to help people in a Third World. Through Health Volunteers Overseas (HVO), we traveled to Tanzania, Africa in October 1998 and again in July 2000. Tanzania has a population of approximately 30 million, with an annual median income of $250. Its economy is primarily agriculturally-based, but it has important natural resources such as diamonds and gold. Unfortunately, most of the mines are owned by foreign nationals. We chose Tanzania because it is a relatively safe area with a great need for my particular specialty.


Author Affiliations: Guest Editorial

Corresponding Author: Please address correspondence to the Wisconsin Medical Society at 608.442.3800

Advances in Pain Management Good for Patients and Physicians

June L. Dahl, PhD

There have been remarkable advances in the science and medicine of pain in the last 20 years. Research has provided insights into pain pathways and critical neurotransmitter systems and also called attention to the plasticity of the nervous system. We have learned that a painful stimulus can initiate changes in neural fields that make them hypersensitive to pain signals and less responsive to analgesics and other pain therapies. Clearly pain is much more than an unpleasant sensation; unrelieved pain has profound effects on physiological function and psychological well being. New drugs, new drug delivery systems, and non-drug therapies have expanded the treatment options for clinicians. We have learned the value of multi-modal therapy for post-operative pain and the critical role of an interdisciplinary approach for the treatment of chronic pain syndromes. The WMJ Editorial Board is to be commended for dedicating part of this issue to pain management so as to provide important information about the subject to Wisconsin physicians.



Author Affiliations: Doctor Dahl is Professor of Pharmacology, University of Wisconsin Medical School, Madison, WI.


Corresponding Author: Please address correspondence to the Wisconsin Medical Society at 608.442.3800

Long-Term Opioid Analgesia and Chronic Non-Cancer Pain

W. Jerry Hisgen, MD

There continues to be considerable controversy over the long-term use of opioid analgesics in patients with chronic non-cancer pain. It seems appropriate, therefore, to review briefly some of the issues related to this topic: 1. The personal and societal impact of chronic pain. 2. The pathophysiology of chronic pain. 3. The barriers to treatment of chronic pain. 4. Background for using opioids in the management of chronic pain. The hope is that the reader will feel more comfortable about using these medications when treating patients with this very serious problem. The articles listed in the bibliography provide helpful details.



Author Affiliations: Doctor Hisgen is Board Certified in Internal Medicine. He is medical staff president at Meriter Hospital in Madison, and chairs the hospital’s Ethics Advisory Group. An associate professor of medicine for the University of Wisconsin Medical School,

Corresponding Author: Please address correspondence to the Wisconsin Medical Society at 608.442.3800

State Medical Society of Wisconsin Statement on the Use of Opioids for the Treatment of Chronic Pain

Adapted from a consensus statement from the American Academy of Pain Medicine and the American Pain Society

The management of pain is becoming a higher priority in Wisconsin. In the last several years, health-policymakers, health professionals, regulators and the public have become increasingly interested in the provision of better pain therapies. This is evidenced, in part, by the US Department of Health and Human Services’ dissemination of Clinical Practice Guidelines for the management of acute pain and cancer pain. These publications state that opioids, sometimes called “narcotic analgesics,” are an essential part of a pain management plan. There is currently no nationally accepted consensus for the treatment of chronic pain not due to cancer, yet the economic and social costs of chronic pain are substantial, with estimates ranging in the tens of billions of dollars annually.

Author Affiliations: American Academy of Pain Medicine and the American Pain Society

Corresponding Author: Please address correspondence to the Wisconsin Medical Society at 608.442.3800

SMS: 160 years

Raymond C. Zastrow, MD, SMS President

One of the proudest moments of my life was being sworn in as President of the State Medical Society of Wisconsin.

Author Affiliations: SMS President

Corresponding Author: Please address correspondence to the Wisconsin Medical Society at 608.442.3800

New Ways to Define Conditions Related to Pain and Addiction

Michael Miller, MD

Guest Editorial

Author Affiliations: Doctor Miller is the director of Behavioral Services and medical director of Adult Addiction Services at Meriter Hospital in Madison. An assistant clinical professor at the University of Wisconsin Medical School, Dr. Miller is also an AMA Alternate Deleg

Corresponding Author: Please address correspondence to the Wisconsin Medical Society at 608.442.3800

Original Research

Attitudes and Approaches to Acute Ischemic Stroke in Wisconsin Hospitals

Douglas A. Dulli, MD, MS; Robert J. Dempsey, MD; Ross L. Levine, MD

The standard of care in acute ischemic stroke was radically altered in June, 1996 with the approval by the Food and Drug Administration of intravenous tissue plasminogen activator (t-PA). This followed the results of a multicenter trial by the National Institute of Nervous Disorders and Stroke (NINDS),1 which demonstrated significant benefit of t-PA in acute ischemic stroke if administered within 3 hours.

Author Affiliations: Authors are with the Department of Neurology, University of Wisconsin Medical School. Doctors Dulli and Levine are Associate Professors; Dr. Dempsey is Professor and Department Chair.

Corresponding Author: Address correspondence to Douglas A. Dulli, MD, MS, 608.263.9058; fax 608.263.0412; e-mail dulli@neurology.wisc.edu

Chronic Pain Rehabilitation: Principles and Practice

Nathan J. Rudin, MD

Chronic pain affects more than 50 million Americans and costs the economy billions of dollars each year. Because chronic pain may involve physical, emotional and social-role dysfunction, treatments that only address the physical problems are often ineffective. In chronic pain rehabilitation, a team of skilled professionals employs multiple therapies and a structured treatment plan to address all the dimensions of chronic pain. Patients undergoing pain rehabilitation demonstrate lasting reductions in pain, improved coping skills, and improved physical and social function. This article reviews the basic principles and current practice of chronic pain rehabilitation, with a guide to the evaluation techniques and therapies employed to aid these most challenging patients.



Author Affiliations: Doctor Rudin is affiliated with the Pain Treatment and Research Center and Department of Rehabilitation Medicine, University of Wisconsin Medical School, Madison, WI.

Corresponding Author: Please address correspondence and reprint requests to Nathan J. Rudin, MD, University of Wisconsin Hospital and Clinics, 600 Highland Ave E3/348, Box 3256, Madison, WI 53792.

Assessing the Quality of Life in Children with Cystic Fibrosis

Raymond J. Kotwicki, MD; Laura Condra, PharmD; Lee Vermeulen, MS; Timothy Wolf, PharmD; Jeffrey Douglas, PhD; Philip M. Farrell, MD, PhD

Although patients with cystic fibrosis (CF) are experiencing increased longevity, it is unclear that improved quality of life (QoL) accompanies the greater quantity of life. This is especially true of children with CF where the burdens of treatment are substantial. Assessing QoL in such children is difficult, and only one instrument—the Quality of Well-Being (QWB) scale—seems to have been used extensively to assess QoL in children with CF. After thoroughly reviewing the literature, we surveyed the 113 certified CF centers in the United States about QoL assessment. With 84% responding, it was found that only 7 centers are assessing QoL—4 have been using the QWB instrument. Concurrently, we pilot tested the QWB instrument in children being followed longitudinally in the Wisconsin CF Neonatal Screening Project. Our results indicated that QWB scores reflecting QoL decreased as the number of respiratory infections increased, as the number of concurrent medical conditions increased, and as the number of different medications increased. However, we recognized problems with the assessed domains and data interpretation. In fact, the QWB instrument has limited sensitivity and responds more to the extent of physician-determined treatment than to QoL. There is a need for more QoL assessment and better instruments, particularly in young children with CF.

Author Affiliations: Authors are affiliated with the University of Wisconsin Medical School, School of Pharmacy, and the University of Wisconsin Hospital and Clinics, Madison, WI. Supported in part by grant DK34108 from the National Institutes of Health.

Corresponding Author: Address Correspondence to Philip M. Farrell, MD, PhD, Dean, UW Medical School, 1300 University Ave, Madison, WI 53706.

Urban Wisconsin Pediatric Patients Using an After-Hours Telephone Triage Service: Outcomes and Compliance

Stephanie J. Frisbee, MSc; Marsha Malloy RN; John R. Meurer, MD; Kathryn A. Kuhagen, RN; Narendra M. Kini, MD

Obiective: Evaluate the ability of a telephone triage service (TTS) to assess illness acuity of and patient compliance with advice given. Design: Retrospective, observational study. Patients: Patients of an urban, academic, pediatric clinic whose parents or caregivers called the TTS between July 23, 1997 and August 23, 1997. Outcome Measures: Patient outcomes and visit information at related medical encounters subsequent to a TTS call. Results: Patients were primarily African-American, under age 5, enrolled in a Medicaid HMO, and most often called for fever, HMO authorization, or asthma. Homecare and PED referrals were the two most frequent dispositions; overall compliance rate was 60%. No patient referred for non-emergent care required care on an urgent or emergent basis. Conclusions: Initial results suggest that the TTS can effectively evaluate illness acuity in an urban population and compliance with advice is reasonable. A TTS may offer significant benefits to ensure care quality and contain costs in this population.



Author Affiliations: Ms. Frisbee and Dr. Kini are with Children’s Hospital of Wisconsin, Milwaukee, WI; Ms. Kuhagen is with the hospital’s Telephone Triage Program. Ms Malloy and Dr. Meurer are with the Center for the Advancement of Urban Children, Department of P

Corresponding Author: Correspondence to N.M. Kini, MD, c/o Administration,Children’s Hospital of Wisconsin, 9000 W Wisconsin Ave, PO Box 1997, MS #950, Milwaukee, WI 53201-1997; 414.266.3002.

Your Practice

‘Modern Medicine’ Includes Pain Management and Sensitive End-of-life Care

Michael J. Dunn, MD, Dean, Medical College of Wisconsin

The phrase “modern medicine” has connotations for most of us that include the latest diagnostic and therapeutic devices and procedures. For physicians, “modern medicine” must also include transformed approaches to pain management and to the process of dying. At the Medical College of Wisconsin, we are sending messages to our students that most pain is very treatable, and that dying is part of a normal life cycle. As such, it is an important part of the doctor-patient relationship.


Author Affiliations: Dean, Medical College of Wisconsin


Corresponding Author: Please address correspondence to the Wisconsin Medical Society at 608.442.3800

Increasing Lipid Testing in African-Americans with Diabetes

Jay A. Gold, MD, Joseph Blustein, MD, Kristin Michalowski, Debra Stone and Dennis Spurlin

Diabetes and its complications most heavily impact the elderly and certain racial and ethnic groups, including African-Americans, Hispanics, Native Americans, and Alaska Natives. It is important to reach members of these groups, as well as the practitioners who treat them, to stress the value of receiving regular medical care. As we know, in addition to glucose testing and HgbA1c monitoring, lipid panels are an essential part of diabetes management. When diabetes is left uncontrolled, elevated glucose and lipids stay in the bloodstream. Over time, these compounds increase diabetes’s damage to blood vessels, resulting in complications such as heart disease. In fact, persons with diabetes have twice the risk of coronary heart diseases—the leading cause of death in the United States—compared to persons without diabetes.



Author Affiliations: Authors are with MetaStar, Inc. Doctor Gold is Senior Vice President and Health Care Quality Improvement Program Director, Dr. Blustein is Associate Medical Director, Ms. Michalowski and Ms. Stone are Health Care Analysts, and Mr. Spurlin is in the Commun

Corresponding Author: Please address correspondence to the Wisconsin Medical Society at 608.442.3800