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 106, Issue 1 (February 2008)

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John J. Frey, III, MD, Medical Editor, Wisconsin Medical Journal
A white male what?
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The United States is the most diverse and ethnically mixed country in the world. We need to know more about the family background and genetic history of our patients than whether they are “white males” or “black females.” When the department chair during my residency would hear someone at morning report describe someone as a “white male” he would say at the top of his voice from the back of the conference room “A white male WHAT? Cocker spaniel?? Cockatoo?? He is either a white MAN or an Italian-American MAN, or a Portuguese-American MAN, or whatever.” Today, it is even more important that we go beyond lumping people together by skin color and look into details that might raise issues of screening or risk that we had not imagined previously.


Bruce Barrett, MD, PhD; Melissa Stiles, MD
What a fair and rational health system would look like
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The costs and consequences of America’s fragmented and profit-driven health system have reached unsustainable levels. Far too much is spent on redundant bureaucracy, and on medical interventions that are either unproven or have been shown to be ineffective, while millions of people lack coverage for basic cost-effective health care. The current level of corporate influence on research, education, and dissemination of scholarly work is unacceptable. It is high time that we design and deliver government-mandated health insurance that makes evidence-based cost-effective health care universally accessible. All comparable nations achieve better outcomes with fewer resources using this model. We can too.

Original Research

Sandra C. van Calcar, MS, RD; Linda A. Gleason, MS, RD; Heidi Lindh, MS, CGC; Gary Hoffman, MS; William Rhead, MD; Gerard Vockley, MD; Jon A Wolff, MD; Maureen S. Durkin, PhD, DrPH
2-Methylbutyryl-CoA Dehydrogenase Deficiency in Hmong Infants Identified by Expanded Newborn Screen
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In April 2000, the Wisconsin Newborn Screening Program implemented tandem mass spectrometry (MS/MS) technology to expand the newborn screening panel from 13 to 48 disorders, the majority of which are inborn errors of metabolism. Among other tests, this technology measures the acylcarnitine profile from blood spots collected from infants at 24 to 48 hours of age. During the first 5.75 years of expanded screening, 27 infants were identified with elevated C5-acylcarnitine concentrations, an unexpectedly high number for any inborn error of metabolism. For these infants, elevated C5-acylcarnitines suggested a diagnosis of isovaleric acidemia (IVA), a metabolic defect of leucine metabolism. Subsequent testing showed that the infants did not have isovaleric acidemia, but did have 2-methylbutyryl-CoA dehydrogenase deficiency or 2-MBAD deficiency, a newly described defect of isoleucine metabolism. (An official abbreviation has not been established for this disorder. Other abbreviations include SBCADD, 2-MBG, and 2-MBCD deficiency.) All but 1 of the 27 infants identified with 2-MBAD deficiency are offspring of Hmong parents. To date, those diagnosed with the disorder in the Hmong community have been largely asymptomatic, though further research is needed to determine whether newborns with 2-MBAD deficiency are at risk for neurodevelopmental disorders.

Review Articles

Marty S. Kanarek, PhD, MPH
Nanomaterial Health Effects, Part 3: Conclusion—Hazardous Issues and the Precautionary Principle
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This is the third and final paper in a series about nanomaterials and their potential health effects. There has been an incident of apparent respiratory health effects in Germany in consumers using a “nano” cleaning product. Other recently proposed consumer products seem to carry potential health and/or ecological hazards. In light of rapidly evolving nanotechnology the “precautionary principle” in environmental health science is reviewed. Hopefully a balance can be reached that allows the realization of societal benefits from the development and implementation of nanotechnology while preventing its unquestioned use in ways that damage ecology and human health.

Gunther Pohlmann, MD
Continuing Medical Education in Wisconsin: Current Status and Future Directions
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Continuing medical education (CME) of physicians, a life-long commitment, is one of the foundations of medical professionalism. This article outlines CME objectives and the regulatory framework through which it is delivered, addressing the safeguards against commercial intrusion and the preservation of scientific objectivity. The article also includes a brief review of the principles of adult learning in general, and of physicians in particular. The overall effectiveness of CME in terms of proximal learning and distal improvement of patient care outcomes is critically analyzed, and the future of CME is outlined briefly.

Heather J. Wichman, MD
Discography: Over 50 Years of Controversy
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Low back pain is estimated to affect 80% of the general population at least once in their lifetime. It is the fifth leading cause of medical clinic visits and the leading work-related disability. Lumbar discography has been used to diagnose the source of low back pain when non-invasive imaging, such as magnetic resonance (MR), does not reveal morphologic abnormality consistent with symptoms. Controversy regarding the usefulness of discography has been ongoing for over 50 years. Modern advancements with imaging and technique still have not been sufficient to justify the practicality of this procedure for standard use. Based on review of current literature, pain provoked by discography of normal appearing discs on MR were likely due to internal disc disruption, increased pain sensitivity, and false positive result with chronic pain, psychological state, central hyperalgia, and technical difficulty of the procedure. These causes of positive pain provocation are not amendable to invasive treatment. In these cases, an invasive diagnostic procedure to identify problems best treated with conservative management is not practical. The conclusion of this review found no clear evidence-based purpose for discography in the diagnosis and treatment of low back pain.

Case Reports

Sreelatha Chalasani, MD, MPH; Satya SV. Bhupathi MD, MPH; Roxann Rokey, MD, FACC, FASE
The Secret Behind Profuse Bleeding Following a Routine Skin Biopsy
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A 73-year-old man underwent a facial skin biopsy, after which he experienced persistent, severe bleeding over a 4-day period that could not be staunched by suturing or cauterization. Patient history suggested a bleeding diathesis. A condition of chronic disseminated intravascular coagulation (DIC) that decompensated into an acute state of DIC subsequent to the biopsy was diagnosed based on laboratory findings. Physical examination followed by imaging revealed a large abdominal aortic aneurysm as the likely underlying etiology. The patient achieved stability with blood component replacement therapy and an initial round of heparin that was substituted with enoxaparin. Following cardiac catheterization, where triple vessel coronary artery disease was diagnosed, surgical correction of the abdominal aortic aneurysm and coronary artery bypass grafting were deemed to be too high risk. The patient was treated medically for his abdominal aortic aneurysm, coronary artery disease, and acute and chronic DIC. Within a year, the patient succumbed to a brain-stem stroke. In patients with acute or chronic DIC, a thorough examination is recommended to exclude rare causes and to improve overall general management.

Tan Attila, MD; Milton W. Datta, MD; Gary Sudakoff, MD; Majed Abu-Hajir, MD; Benson T. Massey, MD
Intrahepatic Portal Hypertension Secondary to Metastatic Carcinoma of the Prostate
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While the liver is a common site of metastasis, tumor metastases are not a common cause of portal hypertension. We report a case of a patient with symptomatic portal hypertension due to diffuse metastatic prostate carcinoma infiltration of liver parenchyma that was not appreciated with routine imaging.

Your Practice

Jennifer Hsu, MD; Quinn Pack, MD; David A. Feldstein, MD
Clinical Use of Evidence-Based Medicine – Clinical Questions
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Is Low-Dose Aspirin a Better Choice in Patients with Coronary Artery Disease and Bleeding Risks?

Molly J. McCarragher, JD
Pension Protection Act benefits individual employees
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The Pension Protection Act (PPA) of 2006 has been billed as the most comprehensive pension reform package in 30 years. The act is designed to provide or strengthen safeguards for employee pensions and provide relief to airlines. However, the act includes many provisions unrelated to pension plans that could benefit individual employees.

Jay A. Gold, MD, JD, MPH
The physician’s role in improving home health care
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MetaStar, under its contract with the Centers for Medicare & Medicaid Services, is working to improve the care of patients who receive home health services. Our efforts are focused on decreasing avoidable acute care hospitalization, as well as improvement on the measures in CMS’s Outcome and Assessment Information Set (OASIS), particularly improvement in dyspnea.

Your Profession

Michael J. Dunn, MD
Translational research has new home on Medical College campus
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In a modern example of form facilitating function, the Medical College of Wisconsin and the Children’s Research Institute dedicated a new, $140 million biomedical research building on January 16 to meet our growing needs for space and resources.

Your Society

Nominating Committee solicits nominees
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The House of Delegates Nominating Committee is requesting nominations for the following Society offices: Speaker for 2007-2009 – Kevin T. Flaherty, MD (incumbent); and Vice Speaker 2007-2008 Alan Schwartzstein, MD (resigned).

Wisconsin Medical Society Foundation
Foundation Donors
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