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 7 (September 2005)

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Thomas C. Meyer, MD, Medical Editor, Wisconsin Medical Journal
Starting the school year with a look at adolescent health
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August often brings with it a flurry of student physicals and back-to-school check ups. And now that kids across Wisconsin are back in school, we thought it an appropriate time to look at some of the issues affecting our young patients’ health.


Stephen W. Hargarten, MD, MPH
Public health implications of carrying concealed weapons: Have we thought this policy through?
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Last year, the Wisconsin Legislature was one vote away from overriding Governor Doyle’s veto of legislation that would have allowed individuals to carry concealed weapons (“conceal and carry”). Because the override failed, at the time of this writing Wisconsin remains one of four states that prohibit the concealed carrying of dangerous weapons by civilians.1 Legislators who supported last year’s efforts have already indicated their intent to reintroduce such “personal protection” legislation2 and supportive organizations have promised a vigorous advocacy campaign to garner passage and enough votes to override another veto.3 During previous debate, the potential impact of conceal and carry laws on the public’s health and on injury experience was not fully investigated nor discussed. It is imperative that policymakers and the public should vigorously discuss the implications of conceal and carry legislation from an evidence-based perspective of public health risk and benefit.

Murray L. Katcher, MD, PhD; Billee Bayou, BA; Henry A. Anderson, MD; Jeffrey P. Davis, MD
Wisconsin Emergency Assistance Volunteer Registry (WEAVR): How physicians can help and why they are needed
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The Wisconsin Division of Public Health (DPH) and its partners have developed the necessary public health infrastructure and core expertise to prepare for, and respond to, public health threats and emergencies. The infrastructure includes 12 public health preparedness consortia that have been established across the state. An important part of the response plan is to assure that the responder workforce is adequate to meet the need at the local, regional, and statewide levels. The responder workforce includes health professional volunteers who, if called on, will take on a variety of assigned roles relevant to a defined incident. In order to facilitate an organized system for volunteers to indicate their skills and availability, DPH has developed a secure and confidential database—the Wisconsin Emergency Assistance Volunteer Registry (WEAVR)—to collect and organize contact information on health professional volunteers and to make contact with volunteers when needed. Physicians, as well as other health professional volunteers, are critical to protect the health and safety of the community, especially if the need to dispense prophylactic medications or to vaccinate the entire population of Wisconsin arises. At the time of an event, volunteers will receive “just-in-time” training after reporting to their assigned location. In other states, physicians have found this emergency training to be of value to their overall practice of medicine. Information about how to sign on to WEAVR is provided.

Paul D. Silva, MD
Menarche and Lifestyle
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Menarche is the result of endometrial proliferation brought on by increasing ovarian hormonal output. The ovary is stimulated by rising pituitary gonadotropin production, which is signaled by increasing cyclic GnRH release from the hypothalamus. Various neuronal and endocrine inputs are thought to contribute to the increased GnRH release. However, their exact interactions and relative contributions are yet to be determined. The prevailing hypothesis suggests that there is a release of the GnRH neurons from the inhibitory effects of higher central nervous system (CNS) centers at the onset of puberty. Much attention has been made towards studying environmental triggers for menarche that presumably modulate these higher CNS centers.

Original Research

Laura A. Coleman, PhD, RD; Bickol N. Mukesh, PhD; Po-Huang Chyou, PhD; Charles S. McCauley, MD, FACC; James Thompson, MD, FAAP; Daniel J. McCarty, PhD
The Marshfield Youth Health Study: Design, Objectives and Cohort Characteristics
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Problem: The Marshfield Youth (MY) Health Study was designed to identify parental and infant factors associated with childhood and adolescent overweight.

Methods: The study examined 867 children (age 5–17 years) from the Marshfield Public Schools. Heights and weights were measured by standard methods. Age- and gender-specific body mass index (BMI) percentiles and z-scores were determined. Definitions of overweight from the Centers for Disease Control and Prevention were applied. Family characteristics were self-reported by questionnaire and included parents’ BMI, employment, education, smoking, physical activity; and child’s daycare attendance, and television/computer use. Maternal and child medical records were reviewed.

Results: The MY Health cohort included 361 families. The mean ± SD age of the children was 12.1 ± 3.0 yrs; 511 (59%) were born in Marshfield, Wis. Of the children studied, 70% had a healthy body weight (BMI >5th and <85th percentile); 14.4% were at risk of overweight (BMI >85th and <95th percentile) and 13% were overweight (BMI >95th percentile). There were no differences in gender or weight status between the study cohort and all Marshfield school children (n=2782).

Conclusions: Children in the MY Health Study are representative of all school-age children in Marshfield. This cohort will be studied to identify factors associated with overweight among children.

Susan Anderson Fohr, JD, MS; Peter M. Layde, MD, MSc; Clare E. Guse, MS
Graduated Driver Licensing in Wisconsin: Does It Create Safer Drivers?
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Objectives: The purpose of this study was to measure the effectiveness of Wisconsin’s graduated driver licensing law and determine whether a reduction in crash rates was due to reduced exposure, safer driving, or both.

Methods: General population crash rates for 16 and 17 year olds were computed for years before and after graduated drivers licensing. The induced exposure method was used to measure exposure and compute the odds ratio of at-fault crash involvement.

Results: For 16 year olds, general crash rates declined 13.8% while injury crash rates declined 15.6%. For 17 year olds, crash rates declined 6.2% for all crashes and 5.8% for injury crashes. There was no statistically significant change in the odds ratio of at-fault crash involvement for 16- or 17-year-old drivers, relative to the reference group. After graduated drivers licensing, 16-year-old drivers were more likely to have at least 1 adult present and less likely to carry 2 or more teen passengers. There was no statistically significant effect on driving habits by time for 16 year olds.

Conclusions: Graduated driver licensing in Wisconsin has resulted in a drop in the general population crash rates for 16 and 17 year olds. This decrease is the result of reduced exposure to the risk of collision rather than safer driving by teens.

Sarah L. Ashby, MD; Patrick L. Remington, MD, MPH; Murray L. Katcher, MD, PhD
Births to Teens in Wisconsin: Targeting High-Risk Populations
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Background: Adolescents giving birth represents an important public health issue with social, economic, and health-related consequences.

Objective: Compare birth rates and trends in birth rates among adolescents age 15-19 years in Wisconsin and the United States by race/ethnicity.

Methods: Teen birth rates from 1998-2002, and trends in birth rates from 1995-2002 for Wisconsin and the United States were compared by race/ethnicity using data from the Wisconsin Interactive Statistics on Health and data from the Centers for Disease Control and Prevention.

Results: The general statewide birth rates and birth rates for Wisconsin white teens were lower than national rates, while birth rates for black, Hispanic, and American Indian teens were well above national rates from 1998-2002. Disparities between births to minority adolescents and white adolescents were higher in Wisconsin than in the United States. Although teen birth rates in general have declined nationally and in Wisconsin, rates among Hispanics in Wisconsin have increased during the 1995-2002 period.

Discussion: Racial disparities in teen birth rates in Wisconsin far exceed national disparities. These disparities result from far-ranging, long-term social and environmental differences in underlying determinants of health that relate to ethnic and cultural beliefs, variation in access to health care that provides family planning and reproductive health services, decreased availability of school-based clinics, lack of role models, education, and variations in income and social status. Wisconsin should focus its teen pregnancy prevention activities on the groups at highest risk.

Tammy Harris Sims, MD, MS; Mario Sims, PhD
Tobacco Use Among Adolescents Enrolled in Wisconsin Medicaid Program
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Problem: There has been very little study done on tobacco use and cessation among the adolescent Medicaid population. Study objectives included determining the prevalence of tobacco use among adolescents enrolled in Medicaid, and identifying subgroups within this population.

Methods: To determine tobacco use among adolescents enrolled in the Wisconsin Medicaid program, we analyzed data from a medical chart-audit of health care visits by 11-21 year olds from January 1997 to January 1999.

Results: Tobacco use status was noted in 55% of adolescent charts. Of these, 24% were current smokers, while 38% of adolescents in the general Wisconsin population were current smokers. Females had higher rates of tobacco use than males (28% versus 11%), and those from rural areas had higher rates than those from urban areas (41% versus 17%). Of pregnant adolescents with tobacco use status documented, 31.6% were current tobacco users.

Conclusions: Based on the data reported, adolescents in the Wisconsin Medicaid program who were pregnant, female, or rural residents may benefit from targeted smoking prevention and cessation interventions by health care professionals, community coalitions, and state programs.

Livia Navon, MS, RD; Beth Fiore, MS; Henry Anderson, MD
Asthma and Tobacco: Double Trouble for Wisconsin Adolescents
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Background: Environmental tobacco smoke (ETS) exposure has been identified as a cause of asthma and a trigger of asthma attacks in children. We examined the relation of demographic and tobacco-related risk factors to both lifetime asthma diagnosis and the asthma attack rate among Wisconsin adolescents. The impact of asthma on adolescent school absenteeism was also examined.

Methods: Data used were from the 2004 Wisconsin Youth Tobacco Survey (n=3125), which was administered in a sample of Wisconsin public middle and high schools. Multivariable logistic regression was used to examine risk factors simultaneously. Results: Self-reported lifetime asthma prevalence was 19% among Wisconsin adolescents. Thirty-five percent of adolescents with asthma reported having an asthma attack in the past 12 months. Living with a smoker was a significant predictor of lifetime asthma diagnosis and, among adolescents with asthma, daily ETS exposure was associated with a 2-fold increased risk of having an asthma attack. Being diagnosed with asthma did not deter adolescents from smoking and was a significant predictor of school absenteeism.

Conclusions: Asthma is an important health problem for Wisconsin adolescents. Tobacco-related risk factors contribute to the burden of the disease. Interventions to reduce smoking and ETS exposure targeted to adolescents and their guardians are needed. Better asthma control among adolescents could reduce school absenteeism.

Todd L. Eisenberg, MD; Randall L. Glysch, MS; Patrick L. Remington, MD, MPH; Murray L. Katcher, MD, PhD
Youth Suicide in Wisconsin: Mortality, Hospitalizations, and Risk Factors
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Objective: To review Wisconsin data on youth suicide mortality, hospitalizations from nonfatal self-inflicted injuries, and self-reported risk behaviors.

Methods: Suicide mortality data for youth (defined here as persons 10-24 years of age) were obtained from the Centers for Disease Control and Prevention (CDC) for 1995-2001 and from the Wisconsin Division of Public Health for 2002. Hospitalization data for Wisconsin from 1995-2002 were obtained from the Wisconsin Division of Public Health. Survey data on self-reported risk behaviors were obtained from the CDC for 2001.

Results: While the rate of youth suicide declined by 24% in the United States during the 9-year period studied, Wisconsin’s rate declined only slightly (8%). Firearms accounted for 60% of completed youth suicides in Wisconsin. Medication overdoses and cutting accounted for 88% of self-inflicted injury hospitalizations for Wisconsin youth from 1995 to 2002. Wisconsin high school students reported similar rates of risk factor behaviors as youth in New Jersey (the state with the lowest suicide rates in the nation), but were more likely to use firearms (60% versus 32%).

Conclusion: Rates of suicide mortality, attempts, and self-reported risk behaviors among youth in Wisconsin continue to be unacceptably high. Physicians can play an important role in reducing youth suicide rates by acting within their clinical practices, as leaders in community suicide-prevention activities, and as advocates for policy change.

Anne M. Marbella, MS; Hongyan Yang, MS; Clare E. Guse, MS; John R. Meurer, MD, MBA; Peter M. Layde, MD, MSc
Adolescent Hospital Discharges Associated with Self-Poisonings in Wisconsin, 2000-2002
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Objective: This study investigates the Wisconsin adolescent self-poisoning problem, using state discharge data on medication-related self-inflicted injuries, focusing on medications used and risk factors.

Methods: Wisconsin inpatient discharge files for 3 years (January 1, 2000-December 31, 2002) were evaluated. Medication-related injuries were analyzed for intentionality, medications used, discharge status, and risk factors such as mental illness, eating disorders, and alcohol abuse or dependence.

Results: There were nearly 3000 medication-related injury hospitalizations—1150 of them self-poisoning hospitalizations—among Wisconsin 12-17 year olds during 2000-2002. Females 12-17 years had twice as many medication-related injuries as males. Sixty percent of medication-related injuries occurred in patients with a mental disorder diagnosis. Non-narcotic analgesics were most commonly used and had one of the highest rates of intentionality (65%). A large proportion of intentional/suicidal medication-related injuries were discharged to another facility (35%), compared to 14% among all medical injuries. Males with medication-related injuries were twice (95% CI: 1.60, 2.75) as likely and females 1.4 (95% CI: 1.2, 1.6) times as likely to have intentional/suicidal injuries if they also abused or depended on alcohol.

Conclusions: Given that a nonfatal suicide attempt is the strongest predictor of eventual suicide, the hundreds of self-poisoning discharges per year in Wisconsin 12-17 year olds is a serious public health concern. Both the medical community and public health community should heed the warnings of these nonfatal suicide attempts and implement educational programs addressing this issue.

Amy Trentham-Dietz, PhD; Hazel B. Nichols, MS; Patrick L. Remington, MD, MPH; Lucinda Yanke, RN; John M. Hampton, MS; Polly A. Newcomb, PhD; Richard R. Love, MD
Correlates of Age at Menarche Among Sixth Grade Students in Wisconsin
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We conducted a cross-sectional, school-based survey of sixth-grade girls living in the Reedsburg, Wis area school district to explore factors associated with age at menarche. Data collection included parent and student questionnaires for demographic, menstrual, physical activity, and nutritional information. School nurses conducted physical examinations to provide anthropometric measurements. Salivary samples were obtained for laboratory analysis of estradiol, estrone, estriol, and progesterone levels. Students (n=59) were an average of 11.9 years of age (range: 10-13). Nineteen students (32%) reported menarche, with an average of 11.4 years of age (range: 8-12). Cycle length of the menstruating students averaged 32.0 days (range: 25-46 days). Students’ age at menarche was positively correlated with their mothers’ age at menarche (r=0.53, P=0.02). Total caloric intake, macronutrients, hormone levels, birthweight, and family size were not associated with menstrual status. We observed an inverse association between increasing weight and earlier age at menarche (P=0.03). Students past menarche watched more television (P=0.03) and participated in fewer hours of sporting activity (P=0.08) than students who had not yet reached menarche. These preliminary data suggest that further investigation of the determinants of menarche is both feasible and warranted.

Case Reports

Steven N. Soneral, DO; Neil P. Connor, MD
Jimson Weed Intoxication in Five Adolescents
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Datura stramonium (jimson weed) is a poisonous shrub that grows wildly throughout the United States with a high potential for abuse. The plant possesses potent anticholinergic properties, and ingestion can cause serious illness or death. Intentional ingestions may result in unintended poisonings for people who attempt to experience the anticholinergic-induced delirium that typically manifests after ingesting the leaves, stem, seeds, or tea brewed from the leaves. We report 5 cases of D. stramonium intoxication seen within a 3-day span as well as recent data regarding anticholinergic plant exposures.

Your Practice

Annie Fuh, MD; David A. Feldstein, MD
Clinical Questions #5: Maintenance of normal sinus rhythm after cardioversion: Is amiodarone better than placebo?
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A 79-year-old male with ischemic cardiomyopathy (ejection fraction of 40%) and hypertension presents with a left cerebellar and left thalamic infarct secondary to new onset atrial fibrillation with rapid ventricular response. He is cardioverted to normal sinus rhythm because of rapid ventricular response and hypotension.

Daniel Gibson, Financial Consultant
New bankruptcy rules leave IRAs mostly safe and sound
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This spring, the Bankruptcy Abuse Prevention and Con-sumer Protection Act of 2005 (BAPA) was signed into law. Intended to improve bankruptcy law and practice, this legislation is the largest overhaul of the Bankruptcy Code since its enactment in 1978. While the law generally makes it more difficult to protect your assets, some exceptions can provide investors with additional flexibility in the management of their retirement assets. Individual Retirement Accounts (IRAs) will actually receive more protection than ever before.

Your Profession

Michael J. Dunn, MD, Dean and Executive Vice President, Medical College of Wisconsin
Adolescent medicine requires comprehensive array of services
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In the labyrinth of adolescence, bodies are changing and maturities developing, often at incongruent rates. Teens can feel like they don’t belong, hovering between the children they were and the adults they will become. Pediatricians with subspecialty training in adolescent medicine are the best guardians for ensuring that quality health care for teens is not lost in the middle.

Your Society

Arthur J. Patek, AB, MD, Editor, Wisconsin Medical Journal
Notification of Infectious Diseases
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In a circular letter issued by the Health Department of Milwaukee, attention is called to the fact that after August 1st, 1905, Chapter 192 of the laws of Wisconsin, 1905, entitled “An Act Prescribing the Duties of Physicians and Others Relative to Infectious Diseases,” will be strictly enforced.