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 3 (May 2006)

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Thomas C. Meyer, MD, Medical Editor, Wisconsin Medical Journal
More dendrimers, synthetic peptides, biomimetic cells, and biomems
(full text PDF)

In the last issue of the Journal, we were introduced to the wondrous world of Nanotechnology by Drs Powell and Kanarek. In this issue they are kind enough to review and remind us of the terminology before listing some of the common “nanomaterial” products on the market—paints, sunscreens, textiles, and “nanobiologicals” being produced for medical applications (p 18). All very interesting, but then they bring us back to earth with their outlines of how little is known about the toxicology, and workplace and public exposures to these materials, as well as the ecotoxicological effects of these substances that seem to possess similar dimensions and experimental effects as asbestos. Perhaps the most sobering observation is that researchers are not very sure they even have the right tools to study theses effects appropriately despite the fact that there are an estimated 1600+ nanotechnology companies operating in the country.


M. Ellin Doyle, PhD
Developments and applications of food antimicrobials, cleaning and sanitation
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FRI’s second Focus on Food Safety Series meeting was held on September 28?29, 2005 with a series of in?depth presentations on specific topics of interest to food producers and processors. Speakers from FRI, other universities, industry, and government discussed pathogens of concern, cleaning and decontamination of produce, animal carcasses, and surfaces in food processing plants, and commercial antimicrobials used in food production. Over 60 persons, representing 28 companies, attended the meeting.

Julie Whitehorse and Rebecca Cohen
May is mental health awareness month
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An estimated 26.2% of Americans ages 18 and older—about 1 in 4 adults—suffer from a diagnosable mental disorder in a given year. Four of the 10 leading causes of disability in the United States are mental disorders. Major depressive disorder causes the greatest disability with women impacted at twice the rate of men. Many people experience more than one mental disorder at a given time. Like adults, children and adolescents have mental health disorders affecting 1 in 5 at any given time.

Kirke Rogers
Improving elders’ communication with their doctors
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As the recipient of the Wisconsin Medical Society Foundation’s Summer Fellowship in Government and Community Service, I spent the summer between my first and second years of medical school working with the Area Agency on Aging (AAA) of Dane County to refine a training workshop and develop curricular materials that can be used to teach self-advocacy and health competency principles to the elderly in the Dane County area. This fulfills a recent recommendation by the Task Force on the Aging of Dane County to develop a program “to teach groups of older adults, and not-so-old adults how to take ownership of their health, how to talk to their health professional and to advocate for themselves.”

Original Research

Kathleen A. Hanson-Morris, MS, RN; Andrew N. Pelech, MD
The Wisconsin Pediatric Cardiac Registry: A Mechanism for Exploring Etiologies of Congenital Heart Defects
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On January 1, 2000, the Wisconsin Pediatric Cardiac Registry began registering families of infants born with a congenital heart defect (CHD) in Wisconsin. Pediatric cardiologists across the state developed the Registry as a database and as a research study exploring potential etiologies of CHDs. Participating pediatric cardiologists identify the infants and refer families to the Registry. Families are asked to participate by completing a comprehensive questionnaire that inquires into exposures and illnesses experienced during the 6 months prior to the pregnancy and during the pregnancy itself. A subset of families, based on the infant’s diagnosis (hypoplastic left heart syndrome, conotruncal abnormalities, and Ebstein’s anomaly) participates in DNA testing. This article describes the development of the Registry, family referral and participation to date, genetic advances in the etiology of CHDs, and research initiatives utilizing the data provided by families for the WPCR.

Norman Jensen, MD, MS; Anthony Suchman, MD, MA; Richard Dart, MD
Partnering with Citizens to Reform Wisconsin Health Care: A Report of Citizen Congress II
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Introduction: Commissioned by the Wisconsin Medical Society in 2003, the Wisconsin Citizen Congress project aims to get at least 5000 physicians and 100,000 citizens in a partnership for health and health care improvement in Wisconsin. The power of activated citizens and a citizen-physician partnership is one of few hopeful answers to current policy failures in health care. Citizen Congress II aimed to validate and extend the results of Citizen Congress I.

Methods: Citizens and physicians were recruited locally, aiming for an optimally-sized group that reasonably represented the diverse people and regions of Wisconsin. A weekend of dialogue with expert facilitators used state-of-the-art methods and sought common goals and a plan of action for health care policy improvement in Wisconsin.

Results: Fifteen hours of dialogue validated the results of Citizen Congress I by producing trusting and high-energy dialogue and very similar characteristics of ideal health and health care. As progress from Congress I, advocacy opportunities for local and state health policy improvement were explored and written plans produced. There was strong support for continuing Congress work, aiming toward a strong and focused advocacy group.

Conclusion: Citizen-physician dialogue and partnership is a hopeful innovation in the area of health policy and community health improvement. Its power comes from a partnership of organized voters and organized medicine. It has the potential to promote change longed for by many. It is strongly consistent with the quality and access initiatives of the new Wisconsin Medical Society strategic plan.

Susan N. Partington, PhD; Ron A. Cisler, PhD; Kathleen A. Blair, MS
Prevalence of Children with Special Health Care Needs in Milwaukee, Wisconsin: Data from the Milwaukee Metropolitan Statistical Area
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Background: The Milwaukee Health Department and the Wisconsin Southeast Regional Center for Children with Special Health Care Needs (CSHCN) were interested in understanding the level of need and prevalence of CSHCN in the city of Milwaukee. It was determined that a survey of the Milwaukee area was needed to obtain a prevalence estimate. Methods: A survey to identify children with special health care needs in the Milwaukee metropolitan statistical area (MSA) was conducted using the CSHCN Screener©. The survey was administered as part of the Greater Milwaukee Survey in October and November of 2004. Results from this survey were compared to state and national data from the National Survey of Children with Special Health Care Needs, 2001.

Results: The prevalence of CSHCN in Milwaukee (23.5%) was found to be almost double that of the surrounding Milwaukee MSA counties (12.1%), the state (13.4%), and the nation (12.8%). The number and type of positive screener questions were not significantly different among the geographic areas.

Conclusions: The prevalence of CSHCN has been consistently associated with poverty in numerous other studies. The survey conducted in Milwaukee MSA indicated increased prevalence in Milwaukee among poor and African American children. Improvement and augmentation of services available to urban poor is necessary to alleviate this excessive burden.

Maria C. Powell, PhD; Marty S. Kanarek, PhD, MPH
Nanomaterial Health Effects—Part 2: Uncertainties and Recommendations for the Future
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In this paper, we summarize some of the key data gaps, uncertainties, and unknowns that need to be addressed to develop adequate risk assessments for nanomaterials. We make recommendations to take timely and appropriate public health precautions. We also briefly discuss nanotechnology applications for food and food packaging, and describe the University of Wisconsin-Madison’s Nanotechnology in Society Project.

Jim Sanders, MD, MPH
The New Face of Refugee Resettlement in Wisconsin: What It Means for Physicians and Policy Makers
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Background: Historically, Wisconsin has received refugees from 3 large geographic areas: Southeast Asia, the Former Soviet Union, and the former Republic of Yugoslavia. However, recent trends demonstrate a dramatic increase in the number of countries from which current refugees originate. Further, state migration patterns show that most counties in Wisconsin have sizable per capita refugee populations and can expect more.

Objective: This paper describes past and current refugee resettlement trends and their ramifications on health care delivery, health policy, and social development in Wisconsin.

Methods: Statistical data on national, regional, and state refugee resettlement trends was obtained from the US Department of Health and Human Services’ Office of Refugee Resettlement and the Wisconsin Department of Workforce Development. Additional data was obtained from Milwaukee-based refugee service agencies. Further, discussions were held with health officials in Barron County and around the Midwest.

Findings: Beginning in the 1980s, with the influx of Laotian Hmong refugees, and continuing through the late 1990s with the end of the Balkan Wars, Wisconsin has provided safe refuge for thousands of refugees. Over the last 5 years the diversity of refugees being resettled in Wisconsin has accelerated to include an array of countries. This phenomenon has led to an increase in the range of health behaviors and health needs characteristic of these populations. The new face of refugee immigration has profound implications on Wisconsin’s health landscape, not only in terms of clinical disease, but also in health policy, planning, and social development.

Review Articles

Paramjith S. Chawla, MD; Mahendr S. Kochar, MD, MS
What’s New in Clinical Pharmacology and Therapeutics
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The US Food and Drug Administration (FDA) has approved several new drugs in the last few years. We have summarized a few of these that should be of interest to a primary care physician. These belong to either a new class of drugs or have a better drug profile in terms of ease of administration, prolonged duration of action, or fewer side effects. Daptomycin is a cyclic lipopeptide, active against methycillin resistant Staphylococcus aureus (MRSA). Telithromycin is a ketolide that can be used in place of macrolide antibiotics. Rifaximin is a semi-synthetic derivative of rifampin approved by the FDA for treatment of traveller’s diarrhea. Pramlintide is an injectable synthetic amylin useful in treating type 1 and 2 diabetes. Tiotropium is an anti-cholinergic bronchodilator that can be taken once a day for treatment of chronic obstructive pulmonary disease. Lanthanum Carbonate is useful in treatment of hyperphosphatemia in patients with end stage renal disease. Flumist is an intranasal influenza vaccine. Eszopiclone is a new hypnotic that has fewer side effects. Memantine is in a new class of drugs useful in the treatment of Alzheimer’s disease. Ibandronate is a new bisphosphonate approved for once a month use for osteoporosis in postmenopausal women. Acamprosate is approved for treatment of alcohol dependence.

Brian Guttormsen, MD; Lisa Nee, MD; J.C. Makielski, MD; Jon G. Keevil, MD
Transient Left Ventricular Apical Ballooning: A Review of the Literature
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Transient left ventricular apical ballooning is a newly defined syndrome characterized by sudden onset of chest symptoms, electrocardiographic changes characteristic of myocardial ischemia, transient left ventricular dysfunction—particularly in the apical region, low-grade troponin elevation, and no significant coronary stenosis by angiogram. This syndrome is also referred to as Takotsubo cardiomyopathy, “Ampulla” cardiomyopathy, Human Stress cardiomyopathy, and Broken Heart Syndrome. Emergency physicians, family physicians, general internists, and cardiologists may all encounter this syndrome at the point of contact. The similarity to acute coronary syndrome requires all clinicians who may potentially care for these patients to familiarize themselves with this newly recognized disease. We provide a recent case and review the current literature surrounding this syndrome.

Case Reports

M. Asif Iqbal, MD; Eric J. Lawatsch, MD; Douglas J. Coyle, MD; J. Jordi Rowe, MD; Rongshan Li, MD; Kulwinder S. Dua, MD; Mahendar S. Kochar, MD, MS
Signet-Ring Cell Carcinoma of the Urinary Bladder Mimicking Retroperitoneal Fibrosis
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We present the case of a 77-year-old white woman with a past medical history of transitional cell carcinoma of the urinary bladder that presented with symptoms of acute renal failure and duodenal obstruction and posed a diagnostic dilemma. Initially, she presented with bilateral ureteral strictures and eventually required bilateral nephrostomy tubes. Later, the patient developed intractable nausea and vomiting secondary to a duodenal stricture. The finding of a “stranding appearance” on computed tomography imaging of the retroperitoneal space raised the suspicion of retroperitoneal fibrosis. Subsequent endoscopic placement of metal stents to relieve the duodenal obstruction failed to relieve her symptoms. The patient’s poor general condition precluded an exploratory laparotomy. The patient expired shortly thereafter and an autopsy was performed. The autopsy results revealed full wall thickness signet-ring cell carcinoma of the urinary bladder with extensive metastasis to the retroperitoneum.

Your Practice

Michelle Leiker, JD, Assistant General Counsel
Aurora Health Care, Inc. and Wisconsin Physician Service Insurance Corporation engaged in lawsuit
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Many members of the Wisconsin Medical So-ciety (Society) have a relationship with Aurora Health Care, Inc. (Aurora) and Wisconsin Physician Service Insurance Cor-poration (WPS) and may be personally impacted by the outcome of the case between the parties. In addition, the outcome of the case may have an effect on current and future contracts between other payers and physicians. Due to the potential impact this case may have on our members, the Society is providing a brief summary of the ongoing dispute between Aurora and WPS.

Jay A. Gold, MD, JD, MPH; Kristine Hoffman, RN, BA, CPHQ
Fistula First: The National Vascular Access Improvement Initiative
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MetaStar is partnering with the regional Medicare End Stage Renal Disease (ESRD) Network (Network 11) on the National Vascular Access Improvement Initiative (NVAII) (also known as Fistula First), a 3-year project to promote the use of arteriovenous fistulas (AVFs) for vascular access in patients undergoing hemodialysis. Donald L. Berwick, MD, of the Institute for Healthcare Improvement, has called this initiative “one of the nation’s most innovative and effective quality improvement activities.”

Kurt G. Krumholz, CFP
Asset allocation reduces investment risk
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Many investors spend considerable time trying to pick the right mutual fund or investment security. But emphasis on securities selection should not be at the expense of your asset allocation strategy, which is the most significant factor in determining a portfolio’s return.

Your Profession

Michael J. Dunn, MD
Research in defense of terrorism will benefit medicine as a whole
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With human health already subject to myriad natural threats, the prospect of biological agents being used for malicious harm is particularly disconcerting. We work hard as physicians to prevent suffering and cure disease, and as new threats arise, I believe those with the expertise to protect our communities have a responsibility to do so

Edited by Kesavan Kutty, MD, FACP, Chapter Governor
Proceedings from the 2004 Annual Meeting of the American College of Physicians, Wisconsin Chapter, Part 1
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The Wisconsin Chapter of the American College of Physicians held its annual meeting in Waukesha, Wis, September 9-11, 2004. Internal Medicine residents from each of Wisconsin’s 5 residency programs (Gundersen Lutheran Health System, Marshfield Clinic, The Medical College of Wisconsin, University of Wisconsin Hospital and Clinics, and University of Wisconsin Milwaukee Clinical Campus [Aurora Sinai Medical Center]) presented their research and/or unusual clinical experiences via posters and vignettes. On behalf of the Chapter, it is my pleasure to provide the text versions of their presentations, in an attempt to not only showcase the scholarly work of these physicians-in-training, but also to provide Wisconsin Medical Journal readers an overview of the quality of care given by them in the fine residency programs in our state. Finally, although these minimally edited Proceedings are by themselves very educational, being there to listen to them live is, indeed, priceless. On behalf of our Chapter, I invite you to witness this unique experience at our next Chapter meeting, September 7-8, 2006, at the Milwaukee Marriott West, Waukesha, Wis. (Editor’s note: This is the first half of 2004’s Proceedings. The second half will be published in our next issue.)

Your Society

House of Delegates
2006 House of Delegates Action on Resolutions and Board Reports
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Arthur J. Patek, AB, MD, Editor
The Position of the Heart in Pericardial Effusion
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Since the day of Skoda, the teaching has prevailed, especially among the Germans, that in pericardial effusion the heart, owing to its greater specific gravity, sinks in the fluid and falls backward when the patient is recumbent.