Editorials

International medicine and a whole lot more

Thomas C. Meyer, MD, Medical Editor, WMJ

When the Editorial Board met last fall and selected the themes for this year’s issues of WMJ, international medicine was among those chosen. And, perhaps ironically, as we began to develop this issue, news of SARS and monkeypox was everywhere. So we are fortunate to have had Marc Kennedy interview three Infectious Disease-ologists on these topics that have received much attention in the popular press recently. The stories of the unfolding of monkeypox at Marshfield, the role of the Wisconsin Division of Public Health—both now and in the event of future outbreaks of strange diseases—and the projections for the future of infectious diseases in this country make for a fascinating 20 minutes of reading. We salute Drs Reed, Davis and Mejicano, along with Mr Kennedy, for the succinct summary of the issue.


Author Affiliations: Wisconsin Medical Society, Medical Editor

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

Original Research

Medical Services Provided at the Olympic Village Polyclinic During the 2002 Salt Lake City Winter Games

Jonathan C. Reeser, MD, PhD; Stuart Willick, MD; Mark Elstad, MD

Since being established by Pierre de Coubertin in 1896, the modern Olympic Games have grown into the single largest sporting event in the world. Every 2 years people from around the world gather in the spirit of Olympism. Olympic disciplines are contested every 4 years, but are set up to overlap so that the Olympic Games occur every 2 years, alternating between the summer events and the winter events. Although many of the participants have no realistic chance of winning a medal, they still compete with passion for the sake of competition, and to bring honor to themselves and to their nations. The athletes taking part in the Olympic Games represent the best athletic talent of their respective countries, and it is therefore a tremendous honor and responsibility for the host organizing committee to attend to their safety and security while they are participating in the Games. As part of this responsibility, comprehensive medical services must be provided for the athletes and their respective national delegations, in case of injury or illness. Although many of the wealthier countries in the Olympic family of nations can afford to bring teams of well-trained and well-equipped medical personnel to attend to their athletes, most of the athletes participating do not have that luxury. Indeed, it is well known that athletes and delegates from other nations often seek elective care during the Games since expert medical assistance and advanced health care technology are readily available at no cost to the athletes or members of their delegation.



Author Affiliations: Doctor Reeser, a Physical Medicine and Rehabilitation Physician, is with Marshfield Clinic, Marshfield, Wis. Doctor Willick, also a Physical Medicine and Rehabilitation Physician, and Doctor Elstad, a Pulmonary Medicine Physician, are with the University

Corresponding Author: Address correspondence to Jonathan Reeser, MD, PhD, Department of Physical Medicine and Rehabilitation, Marshfield Clinic, 1000 N Oak Ave, Marshfield, Wis 54449; 715.387.5327; fax 715.387.5776; e-mail reeser.jonathan@marshfieldclinic.org

Stroke and Atrial Fibrillation Following Cardiac Surgery

David K. Murdock, MD; L. Rosemary Rengel, BA; Audrey Schlund, RN; Karen J. Olson, RN, BSN; Jeffrey W. Kaliebe, MT; John A. Johnkoski, MD; Fernando A. Riveron, MD

Objective: Stroke is an occasional devastating complication of cardiac surgery. Transient atrial fibrillation (AF) is a frequent complication of cardiac surgery. Emboli originating from the fibrillating left atrium are a known cause of stroke in the non-surgical setting. The purpose of this quality improvement initiative, conducted by the Wausau Heart Institute, was to characterize strokes after cardiac surgery and to investigate the relationship between AF and the occurrence of postoperative strokes.

Methods: We conducted a retrospective record review of all patients undergoing cardiac surgery utilizing cardiopulmonary bypass without associated carotid surgery at our institution between January 1, 1993 and June 30, 1999. The occurrence of strokes and AF was noted. The timing of the AF (duration and relationship to surgery) was recorded.

Results: Of the 2104 eligible patients, strokes occurred in 68 (3.2%). In 18 patients (27%), stroke was immediately apparent as the patient recovered from anesthesia (intra-operative stroke). Fifty of the 68 strokes (74%) were acquired following the immediate operative period after the patient awoke from anesthesia neurologically intact (postoperative stroke). Postoperative stroke occurred in 2.1% of patients undergoing coronary bypass surgery only, in 2.2% if valve surgery only was performed, and 4.6% if both valve and bypass surgery were performed. AF occurred in 700 patients (33%). The incidence of postoperative stroke was 5.4% in patients with AF and 0.89% in those without AF (p <0.001). Of those patients suffering a postoperative stroke, 76% had AF following cardiac surgery, compared to 32% if a postoperative stroke did not occur (p <0.001). Carotid bruits were present in 7 (14%) of the patients with postoperative stroke. Carotid ultrasound studies were performed in 32 patients (63%) and a lesion of >70% was found in 8 patients (25%). Cerebral lesions contralateral to the stenotic carotid artery occurred in 3 of these 8 patients.

Conclusion: Most strokes complicating cardiac surgery occur in patients without significant carotid disease, and are acquired after the patient awakens neurologically intact. The high incidence of postoperative AF in these patients suggests a possible embolic cause for some of the strokes. As such, some postoperative strokes may be preventable.



Author Affiliations: Authors are affiliated with the Cardiovascular Research and Education (CaRE) Foundation, Wausau, Wis, Cardiovascular Associates of Northern Wisconsin, Community Health Care/Wausau Hospital and Wausau Heart and Lung Surgeons.

Corresponding Author: Address correspondence to David Murdock, MD, 520 N 28th Ave, Wausau, Wis 54401; 715.847.2611. Research supported in part by The CaRE Foundation, Inc., Wausau, Wis and Community Health Care/Wausau Hospital, Wausau, Wis.

Is Knowing Enough? Increasing Physical Activity by Wearing a Pedometer

Brenda Rooney, PhD; Kathy Smalley, BS; Jennifer Larson, RD; Sarah Havens, BS

Objective: Physical inactivity is a health concern in the United States with nearly 70% of the population getting inadequate amounts of exercise. We set out to determine if wearing a pedometer could significantly increase awareness and amount of physical activity among female employees at a large health care setting.

Methods: Employees purchased a pedometer, completed a survey, and were encouraged to walk 10,000 steps daily. Eight weeks later, they completed a follow-up survey.

Results: Initially, 510 employees initially participated. Results from 400 women are reported. Setting daily step goals, keeping a log of steps walked, and wearing the pedometer all the time were the indicators most likely to predict significant improvements in level of awareness and amount of physical activity, self-efficacy, and other physical improvements (increased energy, ill less often, and weight loss). A majority (71%) indicated they would continue to wear the pedometer after the study ended.

Conclusions: Wearing a pedometer is a simple, non- invasive way for women to increase awareness of daily activity and does lead to increased physical activity. Maximum results in improved activity and improvement in health occurred in women who were most compliant with the intervention.


Author Affiliations: All authors are with Gundersen Lutheran Medical Center, La Crosse, Wis.

Corresponding Author: Address correspondence to Brenda Rooney, PhD, Gundersen Lutheran, 1836 South Ave, La Crosse, Wis 54601; 608.775.2152; fax 608.775.5887; blrooney@gundluth.org. This work was supported by the Gundersen Lutheran Medical Foundation.

Risk Factors Associated with Hospitalization for Unintentional Falls: Wisconsin Hospital Discharge Data for Patients Aged 65 and Over

Clare E. Guse, MS; Rebecca Porinsky, BS

Objective: To identify risk factors associated with hospitalizations for falls in Wisconsin in patients aged 65 and older.

Methods: This study was a cross-sectional study of year 2000 hospital inpatient discharge records for patients aged 65 and older who did not have a diagnosis-related group code indicating rehabilitation, obtained from the Wisconsin Bureau of Health Information. The database includes all discharges from all non-federal Wisconsin hospitals.

Results: Of 223,085 discharged older adults, 6.9% had an unintentional fall diagnosis. Independent predictors of an unintentional fall diagnosis were age, sex, time of year of discharge, region of residence, alcohol-related problems, dementia, Parkinson’s disease, mechanical and motor problems, altered consciousness, convulsions/epilepsy, anemia, and glaucoma.

Conclusions: Alcohol-related problems and mechanical and motor problems significantly increased the risk of a fall diagnosis in hospitalized patients aged 65 and over.



Author Affiliations: Ms Guse is with the Department of Family and Community Medicine and Injury Research Center, Medical College of Wisconsin. Ms Porinsky is with Wisconsin Lutheran College.

Corresponding Author: Address correspondence to Clare E. Guse, MS, Department of Family & Community Medicine, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, Wis 53226; 414.456.8699; cguse@mcw.edu. This work was partially supported by the Centers for Disease

Myeloneuropathy from Nitrous Oxide Abuse: Unusually High Methylmalonic Acid and Homocysteine Levels

Andrew J. Waclawik, MD; Christopher C. Luzzio, MD; Katalin Juhasz-Pocsine, MD; Valerie Hamilton, RN

A 23-year-old patient developed diffuse paresthesias and sensory loss. He had mildly reduced serum vitamin B12 (B12) concentration with unusually high levels of methylmalonic acid (MMA) and homocysteine and no evidence of B12 malabsorption. Following parenteral B12 administration, his neurological deficit promptly resolved and B12 and MMA levels normalized, but elevated levels of homocysteine persisted. One year later, he admitted to inhaling nitrous oxide (NO). After halting NO abuse his homocysteine level normalized. This case demonstrates the importance of serum homocysteine level measurements in cases of suspected NO toxicity.



Author Affiliations: Authors are with the Department of Neurology, University of Wisconsin Medical School, Madison, Wis.

Corresponding Author: Address correspondence to Andrew J. Waclawik, MD, Associate Professor of Neurology, Dept of Neurology, CSC H6/574, UW Medical School, 600 Highland Ave, Madison, Wis 53792; 608.263.7539; fax: 608.265.0172; e-mail: waclawik@neurology.wisc.edu.

The Wisconsin Research Network Firearm Safety Survey

Leon J. Radant, MD; Thomas M. Johnson, PhD

Abstract National surveys have reported information on firearm ownership and storage practices, but primary care physicians question whether such information can be generalized to their communities and the patient populations they serve. In this study, an anonymous survey was distributed to 100 consecutive patients in 11 primary care clinics throughout Wisconsin. Demographic information and information on the patient’s willingness to have firearm safety discussed as part of their routine care, firearm ownership in the household, firearm storage practices, and the patient’s purpose for owning firearms were collected. The study found that patients were willing to answer anonymous survey questions about firearm ownership and storage in their homes. The most effective screening question on gun safety was whether firearms were kept in the home for personal protection. Patients at rural clinics were more likely to own firearms than patients in urban clinics. Keeping firearms for recreational purposes was more common than keeping them for personal protection, which was associated with unsafe storage practices. A majority of patients reported not wanting to receive information on firearm safety from their physician. Overall, the study found that it was not possible to generalize national information on firearm ownership and storage to surveyed patients of primary care clinics in Wisconsin.



Author Affiliations: Doctor Radant is in private practice in central Wisconsin. He is an Assistant Clinical Professor at the University of Wisconsin, the Medical College of Wisconsin, and an Instructor Clinician at the Mayo School of Medicine. Dr Johnson is a Researcher at th

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

Your Practice

New initiative aims to improve home health care

Jay A. Gold, MD, JD, MPH, and Shanin Pepple

Approximately 35,000 elderly and disabled Wisconsinites receive care from the state’s 118 Medicare-certified home health agencies annually. The quality of home care is of great importance to physicians, as it helps determine whether or not your decisions about what your patients need will be carried out appropriately once they leave the hospital or office.



Author Affiliations: Authors are with MetaStar, Inc. Doctor Gold is senior vice president and principal clinical coordinator; Pepple is a communications specialist. This material was prepared by MetaStar, Inc., the Quality Improvement Organization for Wisconsin, under a contr

Corresponding Author: Please address correspondence to MetaStar, Inc.

Should you invest internationally?

Brian Reamer, CFP, CFS, CRS, Financial Consultant

With the current turbulence in the financial markets, many investors are now questioning the advisability of investing in foreign markets. However, investors may not have all the facts about the merits of investing overseas.



Author Affiliations: Brian Reamer is a fee-only financial consultant with SVA Planners, Inc., Registered Investment Advisor. He creates financial plans, provides investment consulting, and manages assets for clients by implementing and monitoring prudent investment strategies

Corresponding Author: For more information, call toll free 866.442.3810.

Your Profession

Public health is a global responsibility

Michael J. Dunn, MD, Dean

Deans Corner

Author Affiliations: Dean and Executive Vice President, Medical College of Wisconsin

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

Other

Handling Infectious Disease: How Wisconsin copes with monkeypox and more

Marc Kennedy

Wisconsin is no stranger to exotic infectious diseases. Legionnaire’s disease and La Crosse encephalitis in the 1970s; toxic shock syndrome (TSS) and Lyme disease in the late 1970s and 1980s; and West Nile virus since 2000 are just a few of the more prominent culprits. So, when a few unusual cases began appearing in north central Wisconsin and outside of Milwaukee that did not fit the pattern of any recognized illness, health care officials were more intrigued than surprised. The surprise came when they found out what it really was.


Author Affiliations: Special Focus On for the Wisconsin Medical Journal

Corresponding Author: For more information, contact Kurt Reed, MD at Marshfield Clinic: 715.387.5511, reed.kurt@marshfieldclinic.org, and Jeff Davis, MD, at the Wisconsin State Department of Health, 608.267.9006; davisjp@dhfs.state.wi.us.

Old Foes and New Adversaries:Infectious diseases may come and go, but they rarely stay gone

Marc Kennedy

In the 1960s, health care professionals were extremely optimistic about treating and preventing infectious diseases. Polio, smallpox, tuberculosis, malaria and diphtheria—all were virtually eradicated in the United States. The surgeon general declared in 1967 it was time to “close the book” on infectious diseases; the war was over and modern science had won. Hardly. Fast forward to 2003. New enemies are massing at the borders, literally. Global travel, climactic changes, antibiotic abuse, land use patterns, microbial adaptation and other factors have opened a Pandora’s Box of emerging diseases: Sudden Acute Respiratory Syndrome (SARS), monkepox, AIDS, hantavirus, Lyme disease, just to name a few. Plus old foes, ostensibly erased from the map, began to reappear: tuberculosis (TB), dengue fever, malaria, diphtheria and cholera, among many others.


Author Affiliations: Special Focus On for the Wisconsin Medical Journal

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