Improve the health of the people of Wisconsin by supporting and strengthening physicians' ability to practice high-quality patient care in a changing environment.

Volume 104, Issue 6 (August 2005)

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Thomas C. Meyer, MD, Medical Editor, Wisconsin Medical Journal
Few takers on theme allows chance to clear backlog
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We had hoped to have this issue of the Journal related to Rural Health, but very few papers on that topic were submitted so it was decided that this was a good opportunity to “clear the backlog” of accepted manuscripts again. What has evolved is an issue packed with items of interest and some peering into what is yet to come in medical practice.


Sue Ann Thompson
The Badger Heart Program: A successful model for improving health literacy and helping women make lifestyle changes
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For the past 7 years, the Wisconsin Women’s Health Foundation has been working to raise awareness about heart disease as a women’s health issue. While many more women are aware that heart disease is the number one killer of women, taking the lives of more women than all cancers combined, there is a significant need to focus on heart disease prevention.

Sonja Henry, MS; Richard M. Pauli, MD, PhD; Murray L. Katcher, MD, PhD
Genetic Services Plan for Wisconsin
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During 1999-2001, a multidisciplinary group met to develop a plan for the future of genetic services in Wisconsin. The result was The Genetic Services Plan for Wisconsin (available at http://www.slh.wisc.edu/genetics/stateplan_toc.html), a problem-oriented needs-identification guide to address current and future challenges likely to affect the provision of genetic services in Wisconsin. The Plan is directed to all individuals who have a stake in the future of medical genetic services in Wisconsin. These include, but are not limited to, primary and other health care professionals, genetics professionals, governmental representatives, policy makers, legislators, educators, third-party payers, and current and potential consumers. This article provides an overview of The Genetic Services Plan for Wisconsin (Plan) and highlights the recommendations made for the continuing integration of new genetic knowledge across the continuum of medical care delivery in Wisconsin.

John Frantz, MD
Is it time to regulate the pharmaceutical industry?
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Wisconsin is among the state governments that have set up Web sites instructing their citizens in how to import prescription drugs from Canada. Although the US Food and Drug Administration (FDA) says such importations are illegal, it has taken no action to stop this. The states respond that their citizens are the ones importing the drugs—not the states per se. So to protect them, the states have inspected some Canadian sources for quality and an absence of counterfeit drugs.

Original Research

Vatsal Chikani, MPH, BHMS; Douglas Reding, MD, MPH; Paul Gunderson, PhD; Catherine A. McCarty, PhD, MPH
Vacations Improve Mental Health Among Rural Women: The Wisconsin Rural Women’s Health Study
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Objective: To compare psychological stress, quality of marital life, and disruptive homelife due to work among rural women of central Wisconsin who take vacations frequently and those who do not.

Methods: Women were recruited from 1996 to 2001 for a prospective cohort study from the Marshfield Epidemiologic Study area, a geographic area in central Wisconsin. Stratified sampling was used to select a random sample of 1500 farm and non-farm resident women.

Results: The odds of depression and tension were higher among women who took vacations only once in 2 years (Depression: OR=1.92, 95%CI=1.2, 3.0; Tension: OR=1.7, 95%CI=1.2, 2.3) or once in 6 years (Depression: OR=1.97, 95%CI=1.2, 3.2; Tension: OR=1.9, 95%CI=1.3, 2.8) compared to women who took vacations twice or more per year. The odds of marital satisfaction decreased as the frequency of vacations decreased.

Conclusion: Women who take vacations frequently are less likely to become tense, depressed, or tired, and are more satisfied with their marriage. These personal psychological benefits that lead to increased quality of life may also lead to improved work performance.

Robert J Sanchez, RPh, MS; Lisette Khalil, MS
Badger Heart Program: Health Screenings Targeted to Increase Cardiovascular Awareness in Women at Four Northern Sites in Wisconsin
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Purpose: This study reports the results of initial statewide health screenings of the Badger Heart Program (BHP), which aims to increase the cardiovascular health awareness and health status of women living in Wisconsin.

Methods: In May 2004, the BHP provided cardiovascular disease risk screenings to women in 4 geographic areas throughout Wisconsin. Screening participants were informed of their results and counseled on issues concerning diet, exercise, smoking cessation, medications, and/or visiting their primary health care professional. Data collected included total cholesterol, high-density lipoproteins, low-density lipoproteins (LDL), triglycerides, blood pressure (BP), blood glucose measurements, height and weight, along with a brief survey of medical history, family history, smoking status, and current medication use. After the screening, participants were asked to volunteer for an opt-in 6-month educational program.

Results: A total of 318 women participated. The majority screened were Caucasian (95.9%) with an average age of 58 years (standard deviation [SD] = 13.2). Participants’ blood pressure and LDL goals were determined from the risk profile assessment. According to national guidelines, an optimal blood pressure goal of <140/90 was recommended for the majority of the participants (294 [92.5%]), while an optimal blood pressure goal of <120/80 was recommended for only 24 (7.5%) participants. An optimal LDL value <100 was recommended for 48 (15.4%) participants, an LDL goal of <130 was recommended for 106 (33.3%), and an LDL goal of less than <160 was recommended for 157 (50.5%) participants. Of screened participants, 35% were not at BP goal, 32.4% were not at LDL goal, and 53.5% were not at both goals. Conclusion: While the number of participants who were at BP and/or LDL goal is higher than what is generally reported in the literature, there is still opportunity for significant improvement. A follow-up analysis including re-screening of individuals aimed at measuring the improvements in CVD profile post educational interventions will occur in November. Matthew H. Guzzo, MD; Jeffrey Landercasper, MD; William C. Boyd, MD; Pamela J. Lambert, RN
Outcomes of Complex Gastrointestinal Procedures Performed in a Community Hospital
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Background: Complex gastrointestinal (GI) procedures have been defined as those that are associated with higher morbidity and mortality, require a high level of technical expertise, and occur in less than 6000 patients per year in the United States. Prior studies suggest a direct volume-outcome relationship.

Hypothesis: Complex GI procedures may be performed with good outcomes in a lower volume hospital with a commitment to surgical residency training.

Methods: Retrospective chart review of all patients undergoing non-emergent operations that are considered complex GI procedures (esophagectomy, total gastrectomy, major hepatic resection, pancreaticoduodenectomy, biliary tract anastomosis, and total abdominal proctocolectomy) from July 1989-June 1997 in a rural referral medical center.

Results: One hundred six consecutive patients underwent complex GI procedures during a 7-year period ending June 1997. Patients ranged from 19–90 years (mean 62). Forty-eight patients (45.3%) had 1 or more major comorbidities. Seventy-three patients (68.9%) had operations for malignancies. Average length of stay (LOS) was 13.2 days (range 5-38). Major complications occurred in 15 patients (14%). Two patients died (mortality 1.9%), 1 after esophagectomy and 1 after a Whipple procedure. LOS, morbidity, and mortality were less than or equivalent to published reports from high-volume medical centers.

Conclusion: Excellent outcomes for complex GI procedures can be achieved at lower volume medical centers. Regionalization strategies to improve patient care should be based on outcome studies rather than volume alone.

Noriaki Kawakami, MD; Heather Jessen; Brett Bordini, BS; Catherine Gallagher, MD; Jennifer Klootwyk, RN; P. Charles Garell, MD
Deep Brain Stimulation of the Subthalamic Nucleus in Parkinson’s Disease
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Objective: To evaluate the clinical effects of subthalamic nucleus deep brain stimulation in patients with Parkinson’s disease within the first 12 months after surgery.

Methods: We performed a prospective study in 8 patients with Parkinson’s disease, in whom electrodes were implanted in the subthalamic nucleus bilaterally. We compared levodopa-equivalents and the scores of the Unified Parkinson’s Disease Rating Scale pre- and post-operatively. The post-operative evaluation was done between 3 and 12 months after surgery.

Results: Antiparkinsonian medications were reduced post-operatively by a mean of 61.5% (P<0.01) from a levodopa-equivalent dosage of 1144.9±572.5 mg/day to 440.9±172.1 mg/day. Motor scores improved 44.4% (P<0.01) and activities of daily living scores 38.2% (P<0.01). Adverse events included a subcutaneous hematoma in 1 patient after internal pulse generator implantation necessitating evacuation. Conclusions: Bilateral stimulation of the subthalamic nucleus is associated with significant improvement in motor function and reduction of antiparkinsonian medications in patients with Parkinson’s disease in the first 12 months after surgery. On-state dyskinesias were greatly reduced, probably due to the reduction of total antiparkinsonian medications. The procedure is well tolerated. Sarina Schrager, MD; Michelle Girard; Marlon Mundt, MS
Dietary Calcium Intake Among Women Attending Primary Care Clinics in Wisconsin
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Background: Osteoporosis and related fractures are becoming more prevalent as the population ages. Primary care professionals counsel all women about adequate calcium intake as part of an overall osteoporosis preventive strategy. Population data shows that the average calcium intakes in women are substantially lower than standard recommendations. No data is available on dietary calcium intakes among a primary care population. This study looks at dietary calcium intakes and calcium supplementation among a sample of women attending 4 primary care clinics in Wisconsin.

Methods: A total of 210 women completed food frequency questionnaires while waiting to see a health care professional in the waiting room of 4 primary care clinics. The women estimated amount of high calcium foods eaten per day and frequency of ingestion per week. Women also indicated whether or not they were taking a calcium supplement.

Results: The overall mean calcium intake was 1309 mg per day. Women who were nonsmokers, postmenopausal, older, Caucasian, or who had been diagnosed with osteopenia or osteoporosis had higher calcium intakes. Over half of the study population took a calcium supplement regularly.

Conclusion: Women in a primary care population in Wisconsin had higher dietary calcium intakes than women from population studies. Primary care professionals need to continue counseling women about adequate calcium and vitamin D intakes as part of an overall osteoporosis prevention program.

Lucille Marchand, MD; Marlon Mundt, MS; Gail Klein, CT; Sonia Chadha Agarwal, MD
Optimal Collection Technique and Devices for a Quality Pap Smear
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Background: Collection technique is critical in the performance of the Papanicolaou (Pap) smear as an important screening tool for cervical cancer. While superior devices have been established, less effective devices continue to be used for both conventional and liquid-based Pap smears. Our aim is to determine the performance of collection devices currently used in obtaining conventional Pap smears and whether sequence of collection is important for higher quality results.

Methods: This prospective, blinded, cohort study used 2 cytology labs to analyze Pap smears done within a 1-year period. Study participants were 128 clinicians who practice in Dane County, Wis, who send their Pap smears to either of the 2 study cytology labs. Participants included advance practice nurses, family physicians, and obstetrician/ gynecologists. Logistic regression was utilized for analysis.

Results: In conventional Pap smears, sequence of collection did not affect any quality indicators. The Cervex-brushTM (broom) was associated with absent endocervical cells (Odds Ratio=3.12, P<.001), limited or unsatisfactory results (OR=1.68, P<.01), and obscuring inflammation (OR=2.01, P<.01). Of those clinicians who had high levels of absent endocervical cells on their Pap smears (defined as >3/30 Pap smears), 47% used the broom alone. The Cytobrush™ optimized quality indicators, and the combination of the Cytobrush™ for the endocervix and spatula for the ectocervix was superior. Presence of infectious agents also contributed to the absence of endocervical cells (OR=3.09, P<.001). Conclusions: The combination of the Cytobrush™ (endocervix) and spatula (ectocervix) is superior for a quality Pap smear. The sequence of collection was not important in conventional Pap smears. The broom alone performs poorly. Presence of infection decreases quality. A. Kenneth Musana, MD; Russell A. Wilke, MD, PhD
Gene-Based Drug Prescribing: Clinical Implications of the Cytochrome P450 Genes
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The Institute of Medicine recently mandated an increased effort to improve patient safety and reduce medical error. With the description of genetic polymorphisms in the drug metabolizing enzymes, the field of pharmacogenetics may improve medical care through a reduction in both therapeutic failure and adverse drug reaction. Investigators at the Marshfield Clinic in central Wisconsin are piloting the process of gene-based drug prescribing in a variety of contexts. This paper reviews the field of cytochrome P450 (CYP) genetics and explores factors that impact the utility of this information in clinical practice.

Case Reports

David A. Bryce, MD; Jeanine Nelson, NCMA; Ingrid Glurich, PhD; Richard L. Berg, MS
Intradiscal Electrothermal Annuloplasty Therapy: A Case Series Study Leading to New Considerations
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Objective: To evaluate outcomes of intradiscal electrothermal annuloplasty (IDEA) therapy in the treatment of chronic discogenic low back pain in consecutive IDEA patients treated at a rural pain management clinic.

Study Design: An observational case series study design was applied to consecutive IDEA patients qualifying under the inclusion and exclusion criteria. Patient assessment of pain and disability were performed at baseline and 6 weeks, 3, 6, 12, and 24 months post-IDEA.

Methods: Selected patients underwent IDEA for an average of 15 minutes at a temperature of 90°C. Analyses of outcomes included Visual Analog Scale (VAS) assessments of levels of pain, and Roland Morris Disability Questionnaire (RMDQ) assessments of functional capacity at pretreatment, and 6 weeks, 3, 6, 12, and 18 months post-treatment time points.

Results: At 6 months post-IDEA treatment, patients (n=51) demonstrated statistically significant improvement (P<0.001) as measured by a mean change of over 20 points from the pretreatment score on the RMDQ. At 1 year, post data remained significant in the 33 patients who had achieved this time point. VAS pain data were also statistically significant at 6 months (P=0.023). Analysis of patient profiles revealed that statistically significant improvement of pain and functional capacity was strongly associated with female gender and age (range of 18-45 years), and that statistically significant improvement was not sustained in males beyond the 3-6 month point. These data support the outcomes reported in the few existing observational studies to date. Of 86 patients receiving IDEA therapy, 73 provided RMDQ data at baseline and at 3 months or later and were included in the analyses. Some patients were lost to follow-up at later time points. Conclusions: These data show favorable outcomes after IDEA therapy, and suggest that women may experience more improvement than men, particularly with regard to perceived disability improvements. Data suggest that greater improvement in IDEA outcomes may be achieved by profiling the characteristics of patients who achieve the optimal long-term outcomes following treatment and should be considered during evaluation of patient eligibility for IDEA. A. Kenneth Musana, MD; Steven H. Yale, MD
Central Pontine Myelinolysis: Case Series and Review
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Objective: To review central pontine myelinolysis (CPM) and osmotic demyelination syndrome (ODS) and describe the clinical features, etiologic factors, and clinical outcomes of 6 patients diagnosed with CPM or ODS.

Study Design: A retrospective case series.

Methods: Medical records of patients diagnosed with CPM or ODS at Marshfield Clinic/St. Joseph’s Hospital from 1986 to 2003 were reviewed. Chart abstraction was completed with a standardized data abstraction form.

Results: Six patients were identified, ranging in age from 31-73 years (mean age = 51.5 years). Clinical presentations were nonspecific. Common symptoms included lethargy and dysarthria. Five of the 6 patients had chronic alcoholism. All had improvements in their clinical conditions upon hospital discharge.

Conclusions: CPM and ODS are rare demyelinating diseases of the pons and extrapontine sites. Prompt diagnosis and management of associated complications are essential for favorable clinical outcomes.

H. Erhan Dincer, MD, FCCP; Tasleem Raza, MD
Compartment Syndrome and Fatal Rhabdomyolysis in Sickle Cell Trait
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Sickle cell trait is a relatively common condition in the African-American population. Individuals with this condition may have any of several complications under rare circumstances. We report a patient who presented with extensive compartment syndrome leading to death. A 31-year-old African-American male with known history of sickle cell trait developed extensive compartment syndrome followed by rhabdomyolysis, severe acidosis, acute renal failure, and coagulopathy. Although the patient underwent multiple fasciotomies for extensive compartment syndrome and received aggressive resuscitation with massive transfusions of blood, blood products and intravenous fluids, he died. Multiple compartment syndromes in patients with sickle cell trait represent a very unusual complication and can cause significant morbidity and mortality. Avoidance of strenuous exercise, especially in hot climates, early diagnosis, and aggressive therapy are very important to prevent this catastrophic complication.

Your Practice

Tim Wassenaar, MD; David Feldstein, MD
Clinical Questions: Do Prophylactic Anticonvulsants in Patients with Brain Tumors Decrease the Incidence of Seizures?
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A 54-year-old male presents to an emergency department (ED) at an outside hospital with a 2-3 month history of worsening headaches, decreased visual acuity, and diplopia. A CT scan of the head shows two mass lesions. The ED physician requests transfer care to your facility. The patient has no previous history of seizures but the ED physician asks if you would like him to give the patient a loading dose of phenytoin prior to transfer for seizure prophylaxis.

Van Landowski, SVA Planners, Inc., Registered Investment Advisor
Your retirement nest egg: Are you creating a reliable stream of income?
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You’re following all the financial experts’ tips on saving for retirement and building a sizable nest egg along the way. But before you make the move to retire, don’t forget to consider life expectancy in your calculations.

Jay A. Gold, MD, JD, MPH
MetaStar’s rural health projects
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Starting in August 2005, MetaStar will be pursuing a number of projects directed at rural health. Rural hospitals always have been a special interest of the Medicare program. As directed by statute, MetaStar meets with at least 20% of the rural hospitals in Wisconsin per year. In 1997, Medicare created the Rural Hospital Flexibility Program, which pairs small rural hospitals with larger hospital facilities, and focuses on sharing resources and eliminating service duplications. At that time Medicare created the category of Critical Access Hospitals (CAHs): nonprofit or public hospitals in a rural area located more than a 35-mile drive (or a 15-mile drive if other criteria are met) from a hospital or another facility, or certified by the state as a necessary provider of health care services to residents in the area. (CAHs must make available 24-hour emergency care services that the state determines are necessary for ensuring access to emergency care services in the area, and must provide not more than 15 [or, in the case of a swing-bed facility, 25] acute care inpatient beds for providing inpatient care for a period not to exceed 96 hours.) CAH hospitals are paid by a different method than hospitals paid under Medicare’s Prospective Payment System (PPS).

Your Profession

Philip M. Farrell, MD, PhD
Plan to address physician shortage requires proper support
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Nearly five years ago, the University of Wisconsin (UW) Medical School made a concerted effort to expand and centralize its rural medicine initiatives when it recruited Dr Byron Crouse to become the first associate dean for rural and community health. In this role, he has worked diligently to enhance the school’s relationships with the Wisconsin Area Health Education Center system and the Wisconsin Office of Rural Health. Both these programs strive, ultimately, to improve the quality of health in rural and underserved Wisconsin communities.

Your Society

Arthur J. Patek, MD, Editor, Wisconsin Medical Journal
Noise and Health
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It is worthy of note that increasing amount of attention is given of late to the subject of unnecessary noises in all the more civilized communities of the world, and especially in cities where noise-producing agencies are so concentrated.