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 4 (July 2007)

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John J. Frey, III, MD, Medical Editor
Tis The Season
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Remembering the line from the Noel Coward song “Mad dogs and Englishmen go out in the noonday sun,” we are warned that summer is a time for being in the great outdoors with family and friends but also a time for unusual illnesses. Summer presents an “opportunity” for clinicians to sort through our atlases of rashes and to look up the management of heat related illnesses, but this issue of the Journal highlights 2 rarer but quite serious consequences of mosquitoes and ticks that should be on our minds when the bugs are out (Pfeiffer CD, Kazmierczak JJ, Davis JP. Epidemiologic features of human Babesiosis in Wisconsin, 1996-2005. WMJ. 2007;106(4):191; Sotir MJ, Glaser LC, Fox PM, et al. Endemic human mosquito-borne disease in Wisconsin residents, 2002-2006. WMJ. 2007;106(4):185).


Kathleen Powell-Mattioli, MD; Lata M. Gupta, MD; Alixandra Crepeau, MD; Suneet P. Chauhan, MD
Residents are right, and I am confused: A short story
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As the new clinician at Aurora Health Care, I was volunteered for a didactic sessions with the residents. They were eager and enthusiastic to start; I was comfortable and confident discussing the topic: aberrant amniotic fluid.

Original Research

Mark J. Sotir, PhD; Linda C. Glaser, DVM; Patricia E. Fox, DVM; Michael Doering, BS; David A. Geske, MS; David M. Warshauer, PhD; Jeffrey P. Davis, MD
Endemic Human Mosquito-borne Disease in Wisconsin Residents, 2002-2006
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Introduction: West Nile virus (WNV) and La Crosse virus (LAC) are the primary mosquito-borne arboviruses associated with human disease in Wisconsin. We examined WNV and LAC human illness surveillance data collected during 2002 through 2006.
Methods: ELISA-based tests developed by the Centers for Disease Control and Prevention (CDC) were used to detect acute WNV and LAC infection in patient sera or cerebral spinal fluid. Public health personnel conducted patient follow-up using standard arbovirus reporting forms. CDC/Council of State and Territorial Epidemiologists definitions were used to determine cases.
Results: From 2002 through 2006, 114 confirmed human cases of WNV illness were reported in Wisconsin residents; 82% of illness onsets occurred during August or September. Median age of WNV case patients was 51 years, 49% reported neuroinvasive disease, 56% were hospitalized, and 7 cases were fatal. Confirmed LAC illnesses declined from a high of 27 cases during 2003 to a low of 3 cases during 2005 and 2006. Most LAC illnesses occurred in residents of Western Wisconsin; median age of LAC cases was 9 years. Mean annual incidences of reported confirmed WNV illnesses calculated for high, medium, and low population density groupings were very similar (range: 0.40-0.46 cases/100,000 population).
Conclusions: Humans are at risk for mosquito-borne diseases in Wisconsin. Protection and prevention measures are important statewide, especially during July through September when the risk is greatest.

Christopher D. Pfeiffer, MD; James J. Kazmierczak, DVM, MS; Jeffrey P. Davis, MD
Epidemiologic Features of Human Babesiosis in Wisconsin, 1996-2005
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To characterize epidemiologic, clinical, and laboratory features of babesiosis occurring in Wisconsin residents. Conduct a review of all cases of babesiosis reported to the Wisconsin Division of Public Health with onsets during 1996-2005. For case patients with onsets during 2004, pertinent medical records were reviewed and patient interviews were performed. Increase awareness of the occurrence and recent trends and facilitate prompt, appropriate diagnosis and treatment of babesiosis. Increase awareness among clinicians of the Infectious Diseases Society of America guidelines for the management of babesiosis, Lyme disease, and human granulocytic anaplasmosis. The study represents an analysis of data received through passive surveillance of a disease that is officially reportable to the Wisconsin Division of Public Health. Other than the description of the occurrence of babesiosis among Wisconsin residents, there were no planned outcome measures. Of the 32 cases of babesiosis reported to the DPH during the study interval, 23 (72%) occurred during 2004 and 2005. The majority of cases occurred in northwestern and west-central Wisconsin. At least 6 patients were co-infected with other tick-borne pathogens. Anemia, thrombocytopenia, and elevation of liver transaminase levels were the most notable laboratory abnormalities among case patients. The apparent increased incidence in babesiosis among Wisconsin residents should impact clinicians’ workups for acute febrile illness with known tick exposure, especially in northwest and west central Wisconsin. Babesiosis should now also be considered in patients diagnosed with Lyme disease who have marked constitutional symptoms, especially those with anemia or thrombocytopenia.

Mary Foote, MS; Jackie Matloub, MB, BS; Rick Strickland, MA; Laura Stephenson, BA; Heather Vaughan-Batten, MPH
Improving Cancer Incidence Estimates for American Indians in Wisconsin
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Objectives: The purpose of this study was to improve the measurement of cancer incidence among American Indians in Wisconsin and compare incidence rates with state and national incidence rates.
Methods: The Wisconsin Cancer Reporting System (WCRS) entered into a data linkage project with CDC and the Indian Health Service (IHS) to improve classification of American Indian cancer cases in Wisconsin. WCRS data were linked to IHS patient registration files to identify American Indian cases that were misclassified as a non-Indian race for the years 1998-2002. American Indian age-adjusted rates and rate ratios for major cancer sites were compared before and after the linkage, and with statewide and national rates.
Results: The age-adjusted incidence rate for all cancer among American Indians increased from the pre-linkage rate of 386.3 per 100,000 to the post-linkage rate of 471.7 per 100,000, a statistically significant increase. The post-linkage rate was over twice the comparable Surveillance Epidemiology and End Results (SEER) national rate among American Indians at 233.6 per 100,000. Post-linkage American Indian incidence rates for male colorectal and female lung cancers were higher than those for the state average.
Conclusions: In contrast to earlier data, the linkage results show that American Indians had similar cancer incidence compared to the general population in Wisconsin, and over twice as high as national SEER American Indian rates. Post-linkage rates resulted in more accurate site-specific and geographically focused cancer incidence rates to help target the national and state priorities of addressing disparities among American Indians.

Jeffrey S. Sartin, MD; Terri F. Rydmark, RN; Jane F. Robinson, BS; Marilyn A. Michels, MSN
Implementing CAP Guidelines: Impediments and Opportunities
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Context: The implementation of guidelines for treatment of Community-Acquired Pneumonia (CAP) has been proposed as a quality improvement and cost-saving strategy, though the effectiveness of several recommendations has yet to be confirmed through clinical trials. We sought to analyze the development and implementation of guidelines at our hospital, and to identify particular successes and impediments.
Evidence Acquisition: Date sources included the Web sites of the Joint Commission on Accreditation of Healthcare Organizations, the Infectious Disease Society of America, and the American Thoracic Society. References from their guidelines were reviewed, and further citations were obtained using Ovid software to search for references within the last 15 years using “pneumonia guideline,” “pneumococcal vaccination,” and other relevant search terms. Our own hospital data was compiled, analyzed, and presented using Excel software.
Evidence Synthesis: Significant improvement was seen during the 2-year study period when CAP guidelines were implemented at our hospital. However, we also identified several impediments, which will require further attention to achieve our quality improvement goals.
Conclusions: Our implementation of CAP guidelines was challenging but overall instructive and contributory to patient care. We review further areas for improvement.

Svapna Sabnis, MBBS; Albert J. Pomeranz, MD; Jingnan Mao, MS
Physician Beliefs and Practices Regarding the Use of Hepatitis A Vaccine
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Background: In 1999, the Centers for Disease Control and Prevention recommended routine vaccination of children against hepatitis A in states, counties, and communities with rates twice the national average or greater. Milwaukee is such a community.
Objectives: To assess physician knowledge, beliefs, and practices regarding hepatitis A disease and hepatitis A vaccine recommendations in Milwaukee.
Methods: A cross-sectional study of 291 Milwaukee pediatricians and family physicians using a self-administered questionnaire.
Results: The response rate was 46%. Of physicians responding, 88% were aware that hepatitis A vaccine was recommended for all children in Milwaukee >2 years of age; 61% believed hepatitis A was a significant health problem, with a significant difference between pediatricians and family physicians (74% versus 43%); and 65% stated they offered the vaccine “almost always” or “most of the time” to children between the ages of 2 and 19 years.
Conclusions: More physician education is needed regarding the public health impact of hepatitis A and the value of the vaccine.

Mary Gleason Heffron, PhD; Deborah Simspon, PhD; Mahendr S. Kochar, MD, MACP
Competency-based Physician Education, Recertification, and Licensure
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Discussions about competency-based education are occurring at all levels of medical education: medical school, residency, and continuing education. Competencies are also an important aspect of certification and are likely to be a part of physician licensure. The 6 General Competencies from the Accreditation Council for Graduate Medical Education (ACGME)—patient care, medical knowledge, practice-based learning and improvement, professionalism, interpersonal and communication skills, and systems-based practice—are firmly established in residency education and are rapidly infusing and changing both medical student and continuing medical education. As physicians must continuously learn and maintain certification throughout their careers, it is essential to understand what competency-based education is and its implications. This article provides an overview of the meaning, history, and evolution of competency-based education and emerging approaches to assessing competence across the continuum of physician education. The discussion asserts that a new view of education is required in which individual competence in key areas is synergistically taught, learned, and assessed.

Review Articles

Shereif H. Rezkalla, MD; Mubashir Ahmed, MD
Management Strategies for ST-Elevation Myocardial Infarction in the Emergency Department
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Review of existing evidence supports that percutaneous coronary intervention (PCI) is superior to thrombolytic therapy in patients with acute myocardial infarction. If, however, a dedicated intervention team is not available onsite, transfer to another facility should be considered if reperfusion could be achieved within 90 minutes. If that goal cannot be achieved within 120 minutes, thrombolytic therapy should be administered with a planned transfer to a facility with PCI capability. In patients with cardiogenic shock or recurrence of anginal chest pain, PCI should be immediately considered. The value of administering full or modified dose thrombolytic therapy and then transferring for immediate PCI has not been demonstrated yet. Development of dedicated protocols for management of ST-elevation myocardial infarction developed by a community-based emergency medical service, emergency department, and cardiovascular service is highly recommended.

Case Reports

Mahazarin Kaikobad, MD; Yee Chung Cheng, MD; Hongyung Choi, MD; Denise Teves, MD
Primary Mediastinal Embryonal Carcinoma Masquerading as Chronic Pancreatitis
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Primary mediastinal embryonal cell carcinomas are aggressive tumors commonly presenting between the ages of 20-50 years with pulmonary symptoms (e.g., cough, chest pain, and hemoptysis), as well as extrapulmonary symptoms due to pressure on adjacent structures. Here we describe a 72-year-old man who remained undiagnosed for a prolonged period of time because of intractable epigastric pain. The patient was thought to have chronic pancreatitis for several months until a chest computed tomography scan demonstrated the mass. This case exemplifies that embryonal cell carcinoma may present in older age groups. It also illustrates the importance of including mediastinal tumors in the differential diagnosis of chronic epigastric pain and the need for further investigations to identify these tumors.

Your Practice

Nicole Fett, MD; Rebecca Smalley, MD; Kathryn Kiehn, MD; David A. Feldstein, MD
Clinical use of evidence-based medicine: Studies used to assess harm
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Does the Atkin’s diet increase risk of cardiac morbidity and mortality in women?

Brian L. Buchanan, JD
The DEA Proposes Schedule II Substance Rule
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The DEA published a Notice of Proposed Rulemaking on September 6, 2006 that, if made final, would allow physicians to provide individuals with multiple prescriptions for the same Schedule II substance at one time, to be filled sequentially, allowing the patient to receive up to a 90-day supply. This rule would overturn an earlier clarification issued by the DEA that stated that preparing multiple prescriptions on the same day with instructions to fill on different dates is equivalent to illegally authorizing refills of a Schedule II controlled substance.

Daniel Gibson, CFP®, Financial Consultant
Roth IRA opportunity expanded in 2010
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Recent changes in the tax laws are prompting individuals who historically have not qualified for Roth IRAs to take a second look at the Roth. Currently, an individual taxpayer or married couple filing jointly whose modified adjusted gross income is greater than $100,000 annually cannot convert a traditional IRA to a Roth IRA. Also, under current law, income taxes are due in the year of the conversion.

Jay Gold, JD, MD, MPH
Medicare Physician Quality Reporting Initiative
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Starting July 1, 2007, physicians have the opportunity to obtain a bonus payment from Medicare for reporting a designated set of quality measures. We here reprint CMS’s fact sheet about the initiative (www.cms.hhs.gov/PQRI/Downloads/2007_pqri_fact_sheet.pdf). If you would like additional information about such topics as registration, measure specifications, or submission of information, please contact Bill French, MBA, RHIA, CPHQ, CPHIT, MetaStar’s Vice President of eHealth Strategies, at bfrench@metastar.com or 608.274.1940.

Your Profession

Robert N. Golden, MD
Academic campuses extend the school’s reach to all corners of the state
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The University of Wisconsin School of Medicine and Public Health and the Marshfield Clinic recently announced the signing of an official affiliation agreement that formalizes a very productive, decades-long relationship primarily involving educational initiatives. The newly designated “Marshfield Academic Campus” becomes the school’s third statewide partner, joining Aurora Healthcare Corporation—our “Milwaukee Academic Campus”—and Gundersen Lutheran Medical Center in La Crosse—our “Western Academic Campus.”