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Volume 107, Issue 4 (July 2008)

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Abstract

The articles in this issue of the Wisconsin Medical Journal demonstrate how environmental health touches many areas of Wisconsin and those living in Wisconsin. From a report ranking environmental health to a review of the use of honey for diabetic foot ulcers, these articles illustrate the range of Wisconsin’s health landscape.

Editorials

Where we live affects our health

John J. Frey, III, MD

None of us would argue with the idea that the context in which we live—family, neighborhood, schools, work, government, social services—affects our health. The social determinants of health have long been the focus of research in health policy, public health, and, increasingly, in applied population health. Those of us who provide health care know that our patients leave our hospitals and offices and return to daily life where they are challenged or supported to stay healthy or get better.

Author Affiliations: Wisconsin Medical Journal

Corresponding Author: Address correspondence to the Wisconsin Medical Society, 330 E. Lakeside St. Madison, WI 53715; e-mail wmj@wismed.org.

Original Research

Measuring the Environmental Health of Wisconsin’s Counties

Jessica Athens, MS; Marni Bekkedal, PhD; Kristen Malecki, PhD; Henry Anderson, MD; Patrick L. Remington, MD, MPH

Introduction: Environmental factors—such as air and water pollution, lead exposure in homes, or aspects of urban design—influence the health of a community. Monitoring these environmental health influences is a core function of public health, making it necessary to identify critical priorities and effectively target outreach and intervention efforts. This paper reviews the methods used to develop a summary measure of the environmental health of Wisconsin’s 72 counties and the city of Milwaukee.

Methods: We collected publicly available data on 9 indicators of environmental health, divided into 3 constructs—air quality, water quality, and the built environment. We looked at how the counties ranked in each construct and then combined the estimates into a summary measure of environmental health. We ranked the summary measure from lowest to highest risk, with higher representing a worse physical environment.

Results: In 2007, Wisconsin regions with major metropolitan areas had the worst environmental health risk. In contrast, the 10 counties with the best environmental health were all located in rural areas of the state.

Conclusion: Publicly available data can be used to compare and contrast environmental health in Wisconsin’s communities. Although the measures used to collect these data could be improved, the results can still be used in community health planning and improvement efforts.

Author Affiliations: Department of Population Health Sciences, University of Wisconsin-Madison, Madison, Wis (Athens, Anderson, Remington); Wisconsin Division of Public Health, Madison, Wis (Bekkedal, Malecki, Anderson); Center for Sustainability and the Global Environment (S

Corresponding Author: Jessica Athens, UW Population Health Institute, 610 Walnut St, Rm 753, Madison, WI 53726; phone 608.265.8973; e-mail jkathens@wisc.edu.

Administration of Tissue Plasminogen Activator for Acute Ischemic Stroke in a Rural Wisconsin Hospital

Ron Charipar MD, FACP; Elizabeth Charipar, MD

Background: Tissue plasminogen activator (tPA) has provided a means to improve functional outcome of patients in the treatment of acute ischemic stroke.

Methods: A retrospective chart analysis of ischemic stroke patients presenting from January 1995 to April 2007 to a particular hospital emergency department located in Ladysmith, Wis was conducted. The following factors were analyzed: door-to-tPA time, National Institutes of Health Stroke Scores (NIHSS) at admission and discharge, complication rates, disposition status, contraindications for receiving tPA, and specialties of physicians involved with stroke care.

Results: During this time period, data was available for 108 patients diagnosed with ischemic stroke treated by physicians in 3 specialties (family practice, internal medicine, and emergency medicine). Of these patients, 18 were treated with tPA for an overall tPA administration rate of 16.2%. Onset of symptoms >3 hours prior to presentation was the most common contraindication to tPA administration. Door-to-tPA time was <60 minutes in 38.9% of cases. Patients treated with tPA were more likely to be discharged home and were less likely to expire within the following month; however, these differences did not reach statistical significance.

Conclusions: This study provides evidence that tPA can be safely administered in rural hospitals. Physicians working in rural emergency departments are able to diagnose and manage acute ischemic stroke within the guidelines established by the National Institute of Neurologic Disorders and Stroke (NINDS) without increased complication rates. Making tPA available in rural communities increases access to treatment and improves outcomes of patients with acute ischemic stroke.

Author Affiliations: Marshfield Clinic–Ladysmith Center, Ladysmith, Wis (Charipar R); University of Michigan Health System, Ann Arbor, Mich (Charipar E).

Corresponding Author: Ron Charipar, MD, Department of Internal Medicine, Marshfield Clinic–Ladysmith Center, 906 College Ave, Ladysmith, WI 54848; phone 715.532.2300; fax 715.532.2379; e-mail charipar.ron@marshfieldclinic.org.

The Influence of Double-Credit Evidence-Based Continuing Medical Education on Presenters and Learners

Steven L. Lawrence, MD; Jeffrey A. Morzinski, PhD; Mary Ellen Radjenovich

Background: Medical specialties are adopting methods to improve continuing medical education (CME). A “double credit” option, sponsored by the American Academy of Family Physicians, is now available for presentations submitted and approved as evidence based (EB).

Purpose: To compare usual and double-credit CME presentations to determine differences in preparation resources and time, and to compare conference attendees’ satisfaction. Those not submitting double-credit applications were asked about perceived barriers.

Methods: Three pretested, written surveys were administered at a 2.5 day CME conference held annually in Southeastern Wisconsin. Subjects were 38 presenters and 172 attendees, mostly primary care physicians.

Results: Twelve presentations were approved for double-credit; these presenters used a greater percentage of on-line EB resources to prepare their talks (64% versus 23%), and preparation required an additional 4.75 hours on average. Over 90% of attendees perceived greater conference quality due to the EB emphasis. Top barriers to double-credit EB applications were time limits and perceptions that topics were inappropriate.

Conclusions: Double-credit presenters use a greater percentage of EB resources, while their counterparts used more professional experience to prepare CME presentations. Attendees reported improved quality and value with increased EB CME. Time is a perceived and real factor in preparing double-credit applications.

Author Affiliations: Department of Family and Community Medicine, Medical College of Wisconsin, Milwaukee, Wis.

Corresponding Author: Jeffrey Morzinski, PhD, Associate Professor, 8701 Watertown Plank Rd, Milwaukee, WI 53226; phone 414.4546.4985; fax 414.456.6523; e-mail jmorzins@mcw.edu.

Review Articles

Practical Considerations of Using Topical Honey for Neuropathic Diabetic Foot Ulcers: A Review

Jennifer J. Eddy, MD; Mark D. Gideonsen, MD; Gregory P. Mack, DPM

Context: It is increasingly important to identify and use low-cost effective dressings for treating diabetic foot ulcers as medical costs and rates of diabetes continue to rise. Honey is an inexpensive moist dressing with antibacterial and tissue-healing properties that has shown promise in the medical literature. Many clinicians are unfamiliar with its use, but patients with diabetic foot ulcers may wish to try honey therapy or discuss it with their physicians. The purpose of this review is to familiarize physicians with practical aspects of using honey to treat diabetic foot ulcers.

Evidence Acquisition: The authors have experience using topical honey and are currently conducting a randomized controlled trial of its effectiveness in treating diabetic foot ulcers. In this review, the authors summarize evidence of honey’s effectiveness, its hypothesized mechanism of action, potential risks and benefits, the types of honey available, and the nature of its application. Critical aspects of ulcer care are also reviewed.

Conclusion: Honey is a low-cost topical therapy with important potential for healing. Its use may be considered in diabetic foot ulcers after a discussion of risks and benefits and in conjunction with standard wound care principles.

Author Affiliations: Family Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis.

Corresponding Author: Jennifer J. Eddy, MD, Assistant Professor of Family Medicine, University of Wisconsin School of Medicine and Public Health, 617 W Clairemont Ave, Eau Claire, WI 54703; phone 715.855.2037; fax 715.839.5176; e-mail jennifer.eddy@ fammed.wisc.edu.

Case Reports

Successful Treatment of Aggressive HIV-associated Multicentric Castleman’s Disease: A Case Report

Magdalena Flejsierowicz, MD; Mohamed S. Ahmed, MD, PhD; Petio Kotov, MD; Yee Chung Cheng, MD

Background: Multicentric Castleman’s disease (MCD) in human immunodeficiency virus (HIV)-infected patients is an aggressive form of lymphoproliferative disorder that usually has a rapidly fatal outcome. Overall mortality is 70%-85%, and median survival is only 8-14 months. No standard or optimal therapy for MCD has been established.

Case: A 49-year-old man with HIV infection presented with 1-week duration of low-grade fever, night sweats, left sided abdominal pain, and generalized weakness. Physical examination revealed a supraclavicular, anterior cervical and axillary lymphadenopathy, and splenomegaly. Excisional biopsy of the left axillary lymph node confirmed the diagnosis of an angiofollicular hyperplasia, or MCD, hyaline vascular type with CD20 positivity. Treatment included a combination of the chemotherapy regimen of cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP) with the monoclonal anti-CD20 antibody rituximab. The chemotherapy was administered in parallel with highly active antiretroviral therapy (HAART). At a 3-year follow-up, the patient remains in complete remission and his HIV parameters have normalized with continued HAART.

Conclusion: This is the second publication describing the use of an aggressive combination of chemotherapy with rituximab in HIV-associated MCD. For an HIV patient with MCD, an aggressive treatment with full CHOP regimen combined with monoclonal anti-CD20 antibody rituximab should be considered, and the use of HAART does not need to be discontinued.

Author Affiliations: Division of Neoplastic Diseases and Related Disorders, Department of Medicine (Flejsierowicz, Ahmed, Cheng),

Department of Pathology (Kotov), Medical College of Wisconsin, Milwaukee, Wis.

Corresponding Author: Yee Chung Cheng, MD, Division of Neoplastic Diseases and Related Disorders, Department of Medicine, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226; phone 414.805.4600; fax 414.805.4606; e-mail ycheng@mcw.edu.

Your Practice

Economic credentialing issues

Brian L. Buchanan, JD

Rather than basing credentialing decisions on qualitative data and a physician’s clinical competence, some hospitals are placing emphasis on economic considerations when deciding when to grant hospital privileges. This practice is known as “economic credentialing.” The American Medical Association (AMA) is among the groups that have taken exception to this practice, and has asserted that it may be in violation of state and federal laws.

Author Affiliations: Wisconsin Medical Society

Corresponding Author: Address correspondence to the Wisconsin Medical Society, 330 E. Lakeside St. Madison, WI 53715; e-mail wmj@wismed.org.

Ask questions to better understand investment fees

Sean Cote, AIF

My sister-in-law recently asked me to review her investment portfolio. I asked her if she knew what types of fees and expenses she was paying. “I have no idea,” she replied.

This response is common among investors. Fees and expenses vary between investments and, in most situations, they are netted from the rate of return of the investments, leaving them out of sight and out of mind.

Author Affiliations: Sean Cote, AIF, is a Financial Consultant with SVA Wealth Management, Inc., Registered Investment Adviser, an affiliated company of Suby, Von Haden & Associates, SC.

Corresponding Author: For more information contact Wisconsin Medical Society Insurance and Financial Services, Inc. toll free at 866.442.3810.

Your Profession

Proceedings from the 2006 Annual Meeting of the American College of Physicians, Wisconsin Chapter

Wisconsin Medical Journal

The Wisconsin Chapter of the American College of Physicians held its annual meeting in Waukesha, Wis, September 6-8, 2006. 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. Text versions of the research can be found below. The next Annual Meeting for the Chapter will be held September 12-14, 2008, at the Wilderness Resort in Wisconsin Dells, Wis.

Author Affiliations: Wisconsin Medical Journal

Corresponding Author: Address correspondence to the Wisconsin Medical Society, 330 E. Lakeside St. Madison, WI 53715; e-mail wmj@wismed.org.

Medical College’s progress a positive for Wisconsin

Jonathan I. Ravdin, MD

The ability to address the dedicated members of the Wisconsin Medical Society through the Wisconsin Medical Journal is one I truly appreciate as I begin my tenure as Dean and Executive Vice President of the Medical College of Wisconsin. First, it gives me the opportunity to thank my predecessor, Michael J. Dunn, MD, whose ideas have appeared on these pages since the inception of the Dean’s Corner.

Author Affiliations: Dean and Executive Vice President, Medical College of Wisconsin

Corresponding Author: Address correspondence to the Wisconsin Medical Society, 330 E. Lakeside St. Madison, WI 53715; e-mail wmj@wismed.org.

Reduction of use of potentially inappropriate medications in the elderly

Jay A. Gold, MD, JD, MPH; Bill French, MBA, RHIA, CPHQ, CHPIT; Lee C. Vermeulen, MS, RPh

MetaStar recently completed a project designed to reduce the use of potentially inappropriate medications for elderly Medicare beneficiaries.

The Medicare Modernization act of 2003 directs Medicare Quality Improvement Organizations (QIOs) like MetaStar to offer quality improvement assistance pertaining to prescription drug therapy to providers, practitioners, Medicare Advantage organizations, and prescription drug sponsors offering prescription drug plans under the part D drug benefit.

Author Affiliations: Dr Gold is Senior Vice President and Chief Medical Officer of MetaStar, Inc.; Mr French is Vice President of Quality, Review, and Health Information Technology at MetaStar; and Mr Vermeulen is Director of the Center for Drug Policy, School of Pharmacy, Un

Corresponding Author: Address correspondence to the Wisconsin Medical Society, 330 E. Lakeside St. Madison, WI 53715; e-mail wmj@wismed.org.

Your Society

2008 honorees for Wisconsin Medical Society Physician Citizens of the Year

Steve Busalacchi

For most hard-working people, retirement is a time to exhale from a busy work life and relax a bit. But James Allen, MD, a retired ophthalmologist from Madison, chose another route. Doctor Allen not only contributes professionally to Wisconsin Medical Society activities, but he chose to embark on a long, challenging and ultimately successful quest to convince the US Congress to do the right thing on behalf of blind veterans.

And while Scott Walker, MD, of Fennimore, is not retired, he is cut from the same cloth as Dr Allen. In addition to his fulltime medical practice, Dr Walker serves as medical director of a free clinic. He inspires his patients and his colleagues alike in his selfless dedication to serving those in need.

Author Affiliations: Wisconsin Medical Journal

Corresponding Author: Address correspondence to the Wisconsin Medical Society, 330 E. Lakeside St. Madison, WI 53715; e-mail wmj@wismed.org.

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