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 2 (March 2006)

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Thomas C. Meyer, MD, Medical Editor, Wisconsin Medical Journal
Fullerenes, carbon nanotubes, quantum dots, and more…
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We received a lengthy manuscript about 6 weeks ago with a very polite note asking whether the Wisconsin Medical Journal would be interested in publishing it. We were fascinated. A whole new world was opening up: the world of fullerenes, nanotubes, “buckyballs,” and the like. Our heads were spinning with this new lexicon and we asked the authors whether they would consider splitting the article so that we could digest the overall concepts in 1 issue and review them briefly before getting into the further details in the next issue. Drs Powell and Kanarek were kind enough to do this and have provided a primer in nanotechnologies and some of the theoretical as well as laboratory-based observations on the biological effects of the ultrafine particles that may enter into clinical medicine in the not-too-distant future (p 16).

Monica Vohmann, MD; Alfred C. Meyer, AB
Wisconsin Environmental Health Network–A new resource for Wisconsin physicians
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As physicians, we are called on to recognize and foster the special beauty of Wisconsin’s environment and to promote its citizens’ health and well-being. The Wisconsin Environmental Health Network (WEHN) was created to educate and enable health professionals to be knowledgeable clinicians and effective voices on environmental health issues.

Original Research

Henry A. Anderson, MD; KM Monirul Islam, MD, PhD
Trends in Occupational and Adult Lead Exposure in Wisconsin 1988 – 2005
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Seventeen years of adult blood lead surveillance data (37,694 individuals and 71,622 total tests) reveal a Wisconsin success story. While lead continues to be widely used, most Wisconsin industries have made substantial strides toward reducing occupational lead exposure. The improvement is reflected in the reduced number of blood lead levels >40 µg/dL. In 2005 only a single adult blood lead test was >50 µg/dL, and since 2003 none have been reported above 60 µg/dL. However, as long as lead is used industrially, lead-based products remain in use, and new consumer products containing lead are marketed to the public, lead poisoning will remain a threat, not only to workers handling lead, but also to children exposed to lead-containing products already in existence. Wisconsin industry and workers, as well as the medical and public health community, must remain vigilant about new and reemerging lead exposures. Wisconsin’s Adult Blood Lead Epidemiology and Surveillance program will continue to investigate unusual lead exposure circumstances identified through statutorily mandated physician and laboratory reporting of adult blood lead levels. However, Wisconsin will need further advances if it is to achieve the US Healthy People 2010 objective of no adult blood lead level

Marni Bekkedal, PhD; Kristen Sipsma; Ernest S. Stremski, MD; Kristen Chossek Malecki, PhD, MPH; Henry A. Anderson, MD
Evaluation of Five Data Sources for Inclusion in a Statewide Tracking System for Accidental Carbon Monoxide Poisonings
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All accidental carbon monoxide poisoning should be preventable. Yet despite intervention efforts including promotion of inexpensive home carbon monoxide detectors, annual inspection of home gas and oil appliances, and general awareness campaigns, in 2002 there were 18 fatalities, 36 inpatient admissions, 351 emergency department visits and 117 poison center calls attributed to acute carbon monoxide exposure. The first step to help better focus public health interventions is adequate information on occurrences. The Wisconsin Environmental Public Health Tracking program identified and evaluated potential data sources for inclusion in a surveillance system for monitoring unintentional carbon monoxide poisonings. Criteria to evaluate the utility of the existing data systems were developed and included the number of new cases identified from that source, the circumstantial detail provided, timeliness of data availability, confidence that an actual exposure occurred, and the resources required to retrieve and summarize the data. Five candidate datasets were evaluated: emergency department visits, hospital inpatient stays, death certificates, Wisconsin Poison Center records, and newspaper reports. It was found that although there was some overlap between cases reported in the different datasets, each source provided unique cases. The sources also differed in the resources required for utilizing the data and the amount of circumstantial information provided. Based on the evaluation of the different sources, it was concluded that newspaper reports should not be included, but the other 4 data sources would each contribute substantially to establishing a comprehensive surveillance system for accidental carbon monoxide poisoning.

Gemma Gliori, MS; Pam Imm, MS; Henry A. Anderson, MD; Lynda Knobeloch, PhD
Fish Consumption and Advisory Awareness Among Expectant Women
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During the spring of 2003, the Wisconsin Department of Health and Family Services (DHFS) piloted a fish consumption advisory program targeted at pregnant women. Fish consumption recommendations and information about the prenatal effects of methylmercury were illustrated in multilingual posters, brochures, fact cards, and other promotional items. These materials were mailed to Women, Infants and Children (WIC) program providers, local health departments, and medical clinics, along with a cover letter that encouraged them to display the materials in waiting areas and distribute them to new mothers and expectant women who visited their facilities. In August 2003, a survey was mailed to 1000 women who had given birth during the first week of June 2003. The survey was intended to provide an estimate of the number and types of fish meals the women had consumed during pregnancy and evaluate their familiarity with the outreach materials. On average, survey respondents consumed 3 fish meals a month. The most frequently consumed fish were canned tuna and frozen fish. Approximately one third of women knew that older fish and predatory fish have the highest levels of mercury. While almost half of the women were aware of Wisconsin’s sport fish advisory, only 13% of them remembered seeing any of the outreach materials.

KM Monirul Islam, MD, PhD; Henry A. Anderson, MD
Status of Work-Related Diseases in Wisconsin: Five Occupational Health Indicators
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Direct and indirect costs of work-related injuries and illnesses in the United States are estimated to cost over $170 billion annually. Wisconsin’s costs alone may be as high as $1 billion annually. Considering the magnitude of these costs, it is disconcerting that there is no national surveillance program to track the occupational injuries, illnesses, and hazards responsible. Surveillance is an essential public health function and the foundation for recognizing and then designing and evaluating interventions to reduce the consequences of identified hazards. Wisconsin has a rudimentary occupational injury and illness surveillance program. It has recently been strengthened by receipt of a 3-year fundamental surveillance grant from the National Institute for Occupational Safety and Health (NIOSH). As part of that grant, Wisconsin will begin tracking 19 NIOSH occupational health indicators. In this paper we measured 5 occupational health indicators for Wisconsin: Pneumoconiosis hospitalizations, Pneumoconiosis mortality, Acute work-related pesticide poisonings, Incidence of malignant mesothelioma, and Elevated blood lead levels among adults. Year 2000 baseline results of these 5 occupational disease indicators show that Wisconsin has lower disease rates than the nation for some of the indicators and higher rates for others. Such surveillance data informs the understanding of environmental and other important risk factors for occupational diseases and injuries.

Kristen Chossek Malecki, PhD, MPH; Marni Bekkedal, PhD; Larry Hanrahan, PhD; Laura Stephenson; Mark Werner, PhD; Henry A. Anderson, MD
Linking Childhood Cancer with Potential Environmental Exposure Determinants
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Childhood chronic diseases, especially cancer, are of growing concern. Research has focused on 2 developmental periods, prenatal and postnatal. While it is hypothesized that chemical contaminants in the physical environment may play a role in the development and exacerbation of many chronic diseases, the role of environmental exposures in the etiology of these conditions remains uncertain. This can be somewhat attributed to the fact that it is very difficult to efficiently link chronic health effects with environmental exposures that are likely to have occurred temporally and spatially distant from diagnosis. This study explored the utility of linking childhood cancer cases with their birth certificate data as a method for increasing the number of geo-referenced data points available for linking health effect data with environmental monitoring data. This would begin to quantify the transiency of 1 subset of the population, and provide a basis for characterizing and estimating potentials for exposure to numerous environmental contaminants during prenatal and postnatal periods. A total of 441 unduplicated cancer diagnosis records of children who were both born and diagnosed with cancer in Wisconsin between 1995 and 2002 were linked with birth records to explore the variability between address at birth and diagnosis. The majority of records were matched to a birth record file (81.0%). Of these matched records, 86% moved <1 mile from birth to time of diagnosis. The results suggest that administrative and public health surveillance data can be used to quantify transiency. Data from the sample tested indicate that during the given time period children do not move far from their birth homes, suggesting minimal changes in exposure potential related to residence location from birth to diagnosis. This background is useful for future epidemiological investigations linking environmental factors with chronic health effects. Jane A. McElroy, PhD; Henry A. Anderson, MD; Maureen S. Durkin MS, PhD; Christine E. Cronk, ScD
National Children’s Study: Environmental Exposures in Waukesha County
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The National Children’s Study (NCS), launched in September of 2005, will investigate the effects of environmental exposures and children’s health and development. Waukesha County, Wis was selected as 1 of 7 sites to spearhead this ambitious undertaking. Residents of Waukesha County may experience different kinds of environmental exposures from water, land, and air based on where they live, work, and play. A selected number of Waukesha County’s environmental exposures described briefly in this report will serve the NCS well with their heterogeneity of potential exposures: from private well water and community water supplies that obtain water from both surface and groundwater; from the variable exposures to ambient air pollution from mobile sources, local industrial sources, and distant sources (ozone); and the different levels of exposures from soil and dust depending on the prevalence of pesticide use and lead-based paints. By combining data gathered from Waukesha County’s participants with other study sites, a holistic picture of environmental exposures in the United States can be evaluated as it influences the health of our nation’s children.

Maria C. Powell, PhD; Marty S. Kanarek, PhD, MPH
Nanomaterial Health Effects—Part 1: Background and Current Knowledge
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Nanotechnologies are among the fastest growing areas of scientific research, and have important applications in a wide variety of fields. At the same time, scientists and regulators are concerned about the potential health and environmental risks related to the widespread production and use of the nanomaterials created by these technologies. Several recent animal and cell culture studies have suggested that some engineered nanomaterials may have biological effects similar to ultrafine particulates. This paper describes what nanomaterials are and why they might be toxic, and then reviews existing toxicological studies on engineered nanomaterials.

Leonardo Trasande, MD, MPP; Melissa L. Schapiro, BAS; Raphael Falk, BS; Karla A. Haynes, RN, MPH; Ann Behrmann, MD; Monica Vohmann, MD; Ernest S. Stremski, MD; Carl Eisenberg, MD; Carolyn Evenstad; Henry A. Anderson, MD; Philip J. Landrigan, MD, MSc
Pediatrician Attitudes, Clinical Activities, and Knowledge of Environmental Health in Wisconsin
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Pediatricians can reduce exposures to environmental hazards but most have little training in environmental health. To assess whether Wisconsin pediatricians perceive a relative lack of self-efficacy for common environmental exposures and diseases of environmental origin, we assessed their attitudes and beliefs about the role of the environment in children’s health. A 4-page survey was sent to the membership of the Wisconsin Chapter of the American Academy of Pediatrics. We obtained a 35.4% response rate after 1 follow-up mailing. Respondents agreed that the role of the environment in children’s health is significant (mean 4.28 ± .78 on 1-5 Likert scale). They expressed high confidence in dealing with lead exposure (means 4.22-4.27 ± 1.01-1.09), but confidence in their skills for pesticide, mercury, and mold was much lower (means 2.49-3.09 ± 1.06-1.26; P<.001). Of those surveyed, 88.6% would refer patients to a clinic “where pediatricians could refer patients for clinical evaluation and treatment of their environmental health concerns.” These findings indicate that Wisconsin pediatricians agree that children are suffering preventable illnesses of environmental origin, but feel ill equipped to educate families about many common exposures. Significant demand exists for centers that can evaluate environmental health concerns, as well as for educational opportunities. Leonardo Trasande, MD, MPP; Christine E. Cronk, ScD; Steven R. Leuthner, MD, MA; Jeanne B. Hewitt, PhD; Maureen S. Durkin, PhD, DrPH; Jane A. McElroy, PhD; Henry A. Anderson, MD; Philip J. Landrigan, MD, MSc
The National Children’s Study and the Children of Wisconsin
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Prospective, multi-year epidemiologic studies such as the Framingham Heart Study and the Nurses’ Health Study have proven highly effective in identifying risk factors for chronic illness and in guiding disease prevention. Now, in order to identify environmental risk factors for chronic disease in children, the US Congress authorized a National Children’s Study as part of the Children’s Health Act of 2000. Enrollment of a nationally representative cohort of 100,000 children will begin in 2008, with follow-up to continue through age 21. Environmental assessment and examination of biomarkers collected at specified intervals during pregnancy and childhood will be a major component of the Study. Recruitment at 105 sites across the United States is planned, and will begin at 7 Vanguard Centers in 2008, including Waukesha County, Wis. The National Children’s Study will provide information on preventable risk factors for such chronic diseases as asthma, certain birth defects, neurobehavioral syndromes, and obesity. In addition, the National Children’s Study will provide training in pediatric environmental health for the next generation of researchers and practitioners.

Jeanne B. Hewitt, PhD, Steven R. Leuthner, MD, MA, Marianne Weiss, DNSc, David Whelan, MSW, Leslie Athey, MS, Jane A. McElroy, PhD, Maureen S. Durkin, PhD, DrPH, Christine E. Cronk, ScD
The National Children’s Study Waukesha County, Wisconsin Vanguard Center
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The National Children’s Study (NCS) is a large, longterm study designed to detect environmental influences on the health and development of children. Waukesha County, Wisconsin, was selected as 1 of 7 “Vanguard Centers” currently funded to finalize and lead the implementation of the study protocol. The authors provide an overview of key design and planning processes that will be used at all NCS Vanguard locations, the specific approaches to be used in the NCS Waukesha County Vanguard Center, and information about how Wisconsin physicians and other health care professionals can become involved in working with the NCS.

Case Reports

Michael F. Mazzone, MD; Jonathan Woolever, MD
Uterine Rupture in a Patient with an Unscarred Uterus: A Case Study
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Uterine rupture is a true obstetrical emergency. We present a case of a multigravid woman who had a spontaneous uterine rupture after induction with misoprostol and oxytocin, followed by a general discussion of uterine ruptures with a special emphasis on an unscarred uterus. Risk factors for uterine rupture in an unscarred uterus include grand multiparity, induction with misoprostol or oxytocin, malpresentation, or previous surgical abortion. Most cases present with maternal tachycardia, signs of fetal distress, and bleeding. The treatment for intrapartum uterine rupture includes fluid resuscitation and emergency laporotomy. Postpartum counseling regarding the risk of rerupture with subsequent pregnancies is an important piece of the management of these patients.

Your Practice

Frank A. Busalacchi
Be aware of fiduciary responsibilities with retirement plans
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If you sponsor or manage investments for your practice’s retirement plan, you may be a fiduciary. How you perform your fiduciary responsibilities and the decisions you make can determine the standard of living you and your employees will have at retirement.

Your Profession

Walter C. Rattan, MD
Management of postpartum uterine atony
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The purpose of this article is to describe a method of management of postpartum uterine atony that I refer to by the rather inelegant term “fist tamponade.”

Michael J. Dunn, MD Dean and Executive Vice President, Medical College of Wisconsin
Simulations enhance clinical aptitude in high-tech training facility
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Clinical rotations will likely remain the principal manner through which medical students learn how to interact with patients and make proper assessments and diagnoses. Ever-improving technology, however, is allowing medical educators to step beyond the traditional learning environment to offer marvelously realistic simulated experiences that are serving to improve physician competence and proficiency. At the Medical College of Wisconsin, these experiences take place within our state-of-the-art STAR (Standardized Teaching and Assessment Resource) Center.

Your Society

Arthur J. Patek, AB, MD, Editor, Wisconsin Medical Journal
The Malthusian Theory
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“A marriage with a castrated woman is the ideal Malthusian Marriage.” “When Lawson Tait made splaying popular, that seemed an ideal condition to disciples of Malthus, but a German, name Halberstaedter, concludes that the Röntgen ray is the thing. It destroys the ova in situ.” These two quotations have appeared in recent medical literature. We have never seen a reference to Malthus in any of the current literature of the day, either lay or medical, which did not clearly show that the writer believed that the “Malthusian idea” is to destroy the fruitfulness of the marital relation, and which did not convict him of having never read one word of the writings of Malthus.