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 105, Issue 1 (January 2006)

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Edward A. Belongia, MD
Pneumonia, mortality, and vaccines: Piecing together the puzzle
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Influenza and other respiratory infections cause a large burden of illness in the United States each year, with the most severe outcomes in the very young and the very old. From 1979-1980 through 2000-2001, influenza-associated hospitalization rates increased significantly for individuals aged >65 years.1 Seasons where A(H3N2) viruses were widespread had substantially higher influenza-related hospitalizations compared to seasons where A(H1N1) or B viruses were predominant. The annual number of influenza-associated deaths also increased significantly from the mid-1970s to 1999, and influenza A(H3N2) seasons were again associated with the highest mortality rates.2 National trends in pneumonia hospitalizations are also worrisome: discharges for pneumonia increased 20% from 1988-1990 through 2000-2002 in patients 65-84 years old.3 The proportion of elderly pneumonia patients with chronic cardiac or pulmonary disease also increased during this time period.

Thomas C. Meyer, MD
Issue examines both familiar and exotic diseases
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I find this issue of the Journal to be generally consciousness-raising. The articles concerning infectious disease are particularly illuminating, focusing on a variety of topics both familiar and exotic.

Sanjay K. Shukla, PhD
Community-associated methicillin-resistant Staphylococcus aureus: It’s time to pay attention
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Infectious disease physicians and infection control practitioners are aware of the multitude of diseases and clinical management issues associated with the “hospital” variety of methicillin-resistant Staphylococcus aureus (MRSA). Infections due to the hospital- associated MRSA (HA-MRSA) cause increased length of hospitalization, morbidity, mortality, and consequently increased economic burden on hospitals and patients. However, it is not certain if the same level of awareness exists for community-acquired or community-associated MRSA (CA-MRSA). CA-MRSA is phenotypically and genotypically different than HA-MRSA. Unlike HA-MRSA, CA-MRSA is generally susceptible to multiple classes of antibiotics, except for beta-lactams and occasionally erythromycin. It also produces Panton Valentine leukocidin (PVL), a tissue necrosis factor, which is considered one of its main virulence factors.

Lawrence P. Hanrahan, PhD, MS; Seth Foldy, MD, MPH, FAAFP; Edward N. Barthell, MD, MS; Susan Wood, BS
Medical informatics in population health: Building Wisconsin’s strategic framework for health information technology
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Medicine is increasingly practiced through the application of information sciences. Medical informatics deals with optimal information use within bioinformatics, imaging, clinical, and population health domains. Population health informatics plays an important role in that it critically informs practice in each of the other domains. Proper functioning of health care systems requires an advanced health information network that supports clinical care, personal health management, population health, and research. But this infrastructure does not yet exist in the United States. A number of federal initiatives are underway to address this problem, including the development of a framework for a national health information network and funding for implementation. This network will be facilitated by federal leadership, but public and private partnerships, and state, regional, and local implementation and policy development will play a critical role. In this article, we describe several Wisconsin initiatives that are keys to developing a strategic framework and building the state’s electronic health information infrastructure.

George M. Lange, MD, FACP
Society committed to maintaining stable liability environment
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The Wisconsin Medical Society received news in early December about the potential merger of PIC Wisconsin with ProAssurance Corporation. As we assessed the situation, one thing remained clear: the Society’s commitment to maintaining a stable medical liability climate in Wisconsin.

Governor Jim Doyle
Improving patient safety through electronic medical records
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I’m committed to ensuring that all Wisconsin citizens receive quality health care. Since I took office, I have worked to lower the price of prescription drugs, help our farmers and small businesses through health care cooperatives, and preserve BadgerCare, Medical Assistance, and SeniorCare for our most vulnerable citizens despite tough budget times.

Original Research

William A. Agger, MD; Rajiv M. Naik, MD
How Should We Approach Adolescent and Adult Pertussis?
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Previously considered a disease of childhood, pertussis is now also recognized as a significant problem for adolescents and adults; however, diagnosing pertussis remains problematic due to its nonspecific clinical presentation and the time delay, sensitivity/specificity, and expense of testing. To be effective, therapy is best started very early in the illness, when the illness is seldom recognized. Other than chemoprophylaxis in families with a non-immune infant, antibiotic therapy is controversial due to the ubiquitous nature of pertussis, its similarity to other respiratory infections, increased prevalence, prolonged outbreaks, and difficulties in determining true exposures in the general community. If antimicrobial therapy is used extensively for whooping cough prevention, drug reactions and increased bacterial resistance are expected. Likewise, without laboratory confirmation of infection, isolation of individuals is difficult and expensive. Fortunately, 2 new Food and Drug Administration-approved vaccines, 1 for adolescents and 1 for adolescents/adults, are now available. Both have been shown to be safe and to produce protective antibody responses. As vaccination of adolescent and adult groups is expanded, the rising incidence of pertussis in all age groups can be curtailed.

Timothy D. Drews, MD; Jonathan L. Temte, MD, PhD; Barry C. Fox, MD
Community-Associated Methicillin-Resistant Staphylococcus aureus: Review of an Emerging Public Health Concern
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Methicillin-resistant Staphylococcus aureus (MRSA) traditionally has been recognized as a virulent pathogen affiliated with health care institutions. However, community-associated strains of MRSA (CA-MRSA) have emerged over the past several years in young, healthy patients without significant health care contact. These isolates carry a distinct molecular makeup and lack the multidrug resistance pattern harbored by health care strains. CA-MRSA predominantly induces skin and soft tissue infections, though the presence of unique virulence factors may cause potentially lethal necrotizing pneumonia and other invasive infections. In response to this growing public health concern, clinicians must learn to identify risk factors for CA-MRSA, treat infections with judicious use of antimicrobial agents, and facilitate prevention strategies to limit transmission.

Mari Gasiorowicz, MA; Marjorie Hurie RN, MS; Angela Russell, MS; Neil Hoxie, MS; James Vergeront, MD
Epidemiologic Trends in Infection, Mortality, and Transplants Related to Hepatitis C in Wisconsin
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Hepatitis C virus (HCV) infection is the most common chronic bloodborne infection in the United States. An estimated 3.9 million persons nationally and 85,000 persons in Wisconsin are currently infected. The disease is responsible for approximately 8000 to 10,000 deaths nationally each year. This article summarizes epidemiologic trends in infection, mortality and transplants related to HCV in Wisconsin. It presents surveillance data collected during 1997-2004; HCV-related deaths during 1995-2002, with HCV as an underlying or contributing cause of death; and data for liver transplants related to HCV between 1993 and 2004. During the time periods reviewed, there were 16,668 cases of HCV infection reported, 1186 HCV-related deaths, and 356 HCV-related liver transplants involving HCV in Wisconsin. Infection rates and related adverse health outcomes related to HCV are highest in males, persons ages 35-64, Milwaukee residents, and inmates in the state correctional system. African Americans have high rates of morbidity (24% of cases) and mortality (16% of decedents), but are under-represented among recipients of HCV-related transplants (6% of recipients). Between the first and second half of the periods reviewed, there was an increase in the number of reported infections (112%), a result of improved detection and reporting. Increases in the number of deaths (70%) and transplants (118%) are a consequence of aging and disease progression in a population infected in previous decades.

Marjorie Hurie MS, RN; William J. Reiser, MSN, RN; James Vergeront, MD
Hepatitis C Virus Infection: An Overview of Wisconsin’s Public Health Resources
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Hepatitis C virus (HCV) infection is the most common chronic bloodborne infection in the United States, with an estimated 3.9 million infected persons nationally and 85,000 persons infected in Wisconsin. HCV infection results in significant morbidity and mortality and contributes to high health care costs associated with specialized medical care, medications, and hospitalization. This report is an overview of HCV-related resources for consumers and clinicians caring for persons with HCV infection in Wisconsin.

Casey L. Schumann, BS; Neil J. Hoxie, MS; James M. Vergeront, MD
Wisconsin Trends in Pneumonia and Influenza Mortality, 1980-2003
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Introduction: Mortality due to pneumonia and influenza continues to be a serious public health threat, especially among those aged >65. Continued monitoring of these high-risk populations is necessary for evaluating the impact of public health prevention activities, determining vaccine distribution policies, and ensuring that existing guidelines reflect the populations at risk. Objectives: We characterized pneumonia and influenza mortality in Wisconsin from 1980 to 2003, including trend analysis, identification of high risk populations, and assessment of Wisconsin’s progress toward state and national goals for vaccination. Methods: We examined mortality trends for pneumonia and influenza as underlying causes of death among all Wisconsin residents who died in the state from 1980 to 2003. Results: The pneumonia and influenza (P&I) mortality rate increased from 27/100,000 to 38/100,000 during 1980 through 1988, and then decreased to 26/100,000 through 2003. The decline in the mortality rate after 1988 was temporally associated with improving pneumococcal and influenza vaccination among those >65. By 2003, all age groups except those aged >85 had lower P&I mortality than in 1980. Conclusions: In Wisconsin, the increase in pneumonia and influenza mortality demonstrated during the 1980s was reversed. However, there was relatively little change in mortality among those aged 65-84 and rates among those >85 years have increased. Novel improvements in public health interventions are needed to improve the focus on the elderly, including efforts to increase vaccination, prevent pneumococcal disease, and explore other evidence-based strategies to reduce pneumonia and influenza mortality.

Case Reports

Vijay P. Balasubramanian, MD; Richard A. Komorowski, MD; Linus H. Santo Tomas, MD, FCCP
Pneumocystis carinii Pneumonia with Pleural Effusion in a Non-HIV Host
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Pneumocystis carinii pneumonia (PCP) is a life-threatening opportunistic infection that occurs in immunocompromised hosts, especially patients with the acquired immunodeficiency syndrome (AIDS). However, this infection is increasing in frequency in other immunosuppressed patients, including organ transplant recipients and those with malignancy who are treated with chemotherapeutic regimens. It carries a relatively high mortality in the non-human immunodeficiency virus (HIV) population. Pleural involvement is rare with PCP; all reported cases in the literature are associated with HIV disease and characterized as small effusions. We report a case of a renal transplant recipient with PCP and moderate-sized pleural effusion with pneumocystis cysts.

Don Lee, MD; Sunu Eapen, MD; Jeremy Van Buren, PhD; Paula Jones, MD; Dennis J. Baumgardner, MD
A Young Man Who Could Not Walk
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Infections affecting the central nervous system caused by Blastomyces dermatitidis are rare but curable. We describe a case of a 24-year-old man who presented to the emergency department with progressive bilateral lower extremity weakness over 1 month. On the day of admission, he had minimal muscle strength and was hyperreflexic in the lower extremities. Sensation, however, was intact. Skin examination revealed annular, raised, crusted lesions on his face and legs. A magnetic resonance imaging (MRI) scan showed marrow replacement of the T7 and T8 vertebral bodies and an epidural mass with cord compression. A chest radiograph showed an infiltrate, and a subsequent needle biopsy revealed yeast resembling B dermatitidis. A skin biopsy was then obtained, and the culture grew out B dermatitidis. He received 4 weeks of amphotericin B lipid complex (total of 6 grams), followed by oral itraconazole. After 1 week on antifungals, he was able to walk with a walker and the skin lesions virtually resolved. At 5 months he was ambulatory and riding a bicycle daily. Blastomycosis should be included in the differential diagnosis of epidural masses.

Your Practice

William J. Ehlenbach, MD; David A. Feldstein, MD
Clinical Questions #7: Systemic corticosteroid dosing for acute asthma: Is higher better?
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A 20-year-old man with asthma and allergic rhinitis is brought to the emergency department by emergency medical services. He is found to be in respiratory failure and requires emergent endotracheal intubation. He had 3-4 days of viral upper respiratory infection symptoms prior to his presentation. He has a history of non-adherence with his medical regimen for moderate persistent asthma.

Jay A. Gold, MD, JD, MPH
MetaStar’s medicine and culture project
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MetaStar is recruiting physician practices around Wisconsin to foster cross-cultural education in how to work more effectively with patients whose beliefs, values, and histories are significantly different from one’s own. The method used is the “Culturally and Linguistically Appropriate Services” (CLAS) standards developed by the US Department of Health and Human Services Office of Minority Health (OMH) (Table 1).

Melody C. Rute
Considering the Roth 401(k) Plan: What you need to know
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It’s hard to open a newspaper or a business journal today without seeing an article about the new retirement plan feature that became available January 1, 2006, called the Roth 401(k) deferrals. It’s a feature that allows you to deposit after-tax compensation to your 401(k) plan, creating a tax-free retirement account for your future.

Your Profession

Michael J. Dunn, MD, Dean and Executive Vice President, Medical College of Wisconsin
HIV/AIDS interventions and research have significance at home and abroad
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It’s a small world, especially as it pertains to the impact of an infectious disease such as HIV. From the proliferation of human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) cases across the ocean to the persistence of the disease in the United States, we are all affected in some way. Unfortunately, the world can seem quite large when attempting to weaken the threat of a deadly disease. Researchers at the Medical College of Wisconsin, however, have developed significant interventional tools to cultivate knowledge about HIV prevention, and then transfer that knowledge to the people who need it most.

Your Society

Arthur J. Patek, AB, MD, Editor, Wisconsin Medical Journal
The Suppression of the Bubonic Plague
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The following report, reprinted from the U.S. Consular Reports, is such a signal triumph for preventive medicine, and of such great interest the world over, that we publish it in full

Wisconsin Medical Society
Nominees for Society Offices
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The Wisconsin Medical Society’s House of Delegates Nominating Committee met on October 8, 2005, and se-lected nominees for the following positions. The Board of Directors, as directed by the Society’s Constitution, selected the candidate for Treasurer at its meeting on December 15, 2005. The slate of candidates will be presented on April 7, 2006, at the Annual Meeting in Madison.


2005 Foundation Donors
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Foundation donors