Showing papers in "Wisconsin medical journal in 1995"

Conjoint screening questionnaires for alcohol and other drug abuse: criterion validity in a primary care practice.

Abstract: The US Preventive Services Task Force recommended that physicians use the CAGE questions to screen patients for alcohol abuse. A similarly brief screening instrument for abuse of other drugs is needed. Two conjoint screening questionnaires for alcohol and other drug abuse were adapted from the CAGE questions and the Short Michigan Alcoholism Screening Test (SMAST). For 124 patients of an academic, community family practice, the conjoint questionnaires and their forerunners were compared with DSM-III-R diagnoses of substance use disorders as measured by the Diagnostic Interview Schedule-Revised (DIS-R). The SMAST and its conjoint analog exhibited low sensitivity. The CAGE Adapted to Include Drugs (CAGE-AID) was more sensitive but less specific for substance abuse than the CAGE, especially when a reduced criterion score was employed. The CAGE-AID was more sensitive than the CAGE for subjects of varying sex, income, and level of education, as well as most patterns of substance use disorders. The diminished specificity of the CAGE-AID may have been, at least in part, artifactual. The CAGE-AID holds promise for identifying primary care patients with alcohol and drug disorders.

Skin cancer prevention: a peer education model.

Abstract: Results from a quasi-experimental project indicate that skin cancer prevention and sun protection education can successfully be promoted by using peer educators. Senior high students (40) facilitated and taught a sun protection curriculum to third-grade students (508) enrolled at the experimental sites. The curriculum's effects were assessed with pre-program, post-program, and 6-month follow-up survey-instruments. The experimental sites using high school (peer) facilitators were effective in conveying knowledge to younger students based on knowledge gained on the post-program surveys. Overall, the intervention group demonstrated a mean improvement of 3.4 questions on the post-program survey, while the control group improved 0.1 questions (p < 0.01). Additional benefits included a knowledge gain by the peer facilitators, a self-reported possible increase in desired behavior change, and an improved attitude about sun protection. Implications for pediatric clinical practice are noted.

Hypernatremic dehydration in breast-fed infants.

Abstract: Three cases highlight the association between elevated breast milk sodium and hypernatremic dehydration in the infant. All three mothers, breast-feeding exclusively, had sodium levels in breast milk elevated significantly above normal. Severe hypernatremic dehydration in otherwise normal infants who are exclusively breast fed can be due to elevated sodium levels in breast milk.

Ketorolac-induced postoperative acute renal failure: a case report.

Abstract: The nephrotoxic effects of nonsteroidal anti-inflammatory drugs (NSAIDs) are well recognized. Known potentiating risk factors include pre-existing renal disease, intravascular volume depletion, and concomitant administration of other nephrotoxic drugs. We present a case report of renal failure following short term usage of intramuscular ketorolac (Toradol) in a patient with no known risk factors who underwent an uncomplicated laparotomy. The literature concerning ketorolac-induced renal failure is reviewed and physicians are reminded to be aware of this potential complication.

Are clinicians intervening with their patients who smoke? A "real-world" assessment of 45 clinics in the upper Midwest.

Abstract: OBJECTIVE To determine the level of intervention provided by primary care physicians to individuals who smoke. SETTING 45 primary care clinics throughout the upper Midwest. PATIENTS 6,086 men and women (M:F = 1:2), ages 50 to 68, who sought medical care at any one of the 45 primary care clinics and completed two questionnaires regarding preventive medical services received during the previous 3 years (1990-1993). RESULTS Of patients who smoke, 92% reported that their clinician had asked about their smoking status. Additionally, 86% reported being informed at their clinic of the dangers of tobacco use. A smaller percentage of individuals (60.1%) reported being explicitly advised on how to quit, and fewer still (27.2%) reported being referred to a stop smoking program. CONCLUSIONS While most clinicians inquire about their patients' smoking status and recommend they quit, there currently exists a deficiency in the translation of these recommendations into concise, explicit instructions on how to quit. By increasing the frequency of clinicians giving specific advice about how to quit, the overall success rate of the public health campaign against tobacco use will be greatly enhanced.

Use of advance directives: a survey in three clinics.

Abstract: Advance directives (ADs) are instructions from patients to their physician and family regarding their wishes for medical care in the event they become incapable of communicating those wishes. This study sought to describe the characteristics of adults who have completed advance directives and those who have expressed interest in them, and to determine what distinguishes these groups from the group with no interest in ADs. A further objective was to survey the study population on the barriers to completion of ADs. A random sample of 160 outpatients visiting one of three clinics (General Internal Medicine Clinic (GIM), HIV Clinic, and Oncology Clinic) were selected for the study. A 10-item questionnaire was administered which included questions on familiarity with, sources of information on, and interest in ADs. Demographic information was collected as well as information on subject experiences with illness and death. Twenty-six of the 160 participants (16%) had completed ADs. The prevalence of completion differed among the three clinics: HIV Clinic 25%, Oncology Clinic 18%, and GIM Clinic 8%. Nearly all patients (95%) expressed interest in ADs. Those not interested in ADs were more likely than those who were interested or those who had already completed ADs to have been in an intensive care unit themselves. Multiple barriers to completing ADs were identified. Advance directives are still used by relatively few people despite a general openness and interest in them. Few characteristics, demographic and otherwise, were identified to distinguish those who completed ADs from those who did not.

Screening for risk of malnutrition in Wisconsin's elderly.

Abstract: In older adults, nutritional status is related to chronic disease risk, ability to maintain independent lifestyles, and rate and duration of hospitalizations. Significant numbers of American elders are either malnourished or at risk of malnutrition. Data from a recent survey of 21,000 Wisconsin participants in home-delivered or congregate meals 60 years of age and older indicated that in this group, over one fourth were at high risk for malnutrition. The Nutrition Screening Initiative, a collaborative effort of the American Academy of Family Physicians, the American Dietetic Association, and the National Council on the Aging, has identified risk factors for malnutrition in the elderly and is promoting systematic nutrition risk screening and intervention within the health care system. Risk factors for malnutrition in older adults, screening techniques available to medical practices, and resources for intervention are described in this paper.

Breast cancer screening complacency and compliance.

Abstract: An HMO initiative designed to increase the compliance rate for the preventive service (mammography) is described. By looking at Security Health Plan charge data and sending a letter of notification when women are not up-to-date on their screening mammography, we were able to increase the mammography compliance rate from 47% to 72%. This system is designed to supplement the preferred method of recommendations by the primary care physician aided perhaps by a chart reminder system. Some problems with the methodology are described.

Palliative medicine education at the Medical College of Wisconsin.

Abstract: Palliative medicine is an emerging worldwide discipline. This article describes efforts at the Medical College of Wisconsin to develop programs to enhance palliative care education and clinical care. New courses, seminars, and clinical programs have been developed with assistance from various medical school departments and affiliated hospitals. Education and clinical care activities since 1990 have included a new 6-week course for 2nd-year medical students; a hospice volunteer experience for preclinical students; clinical electives for 3rd- and 4th-year medical students; a clinical palliative care consultation service; a palliative care seminar series designed for housestaff; a nurse preceptorship program; and an allied health observership program. Palliative care activities include both the academic medical center and community health agencies. The MCW has integrated palliative care into its academic environment so that trainees at all education levels now have opportunities for didactic and clinical palliative care education.

Auscultation of the fetal heart presents advantages over electronic monitoring.

Abstract: Currently available data support the conclusion that within specified intervals, intermittent auscultation of fetal heart sounds is equivalent to continuous electronic fetal monitoring (EFM) for detecting intrapartum fetal compromise. One of the disadvantages of EFM is its associated increase in cesarean delivery rates. Patients should receive information on both intermittent auscultation and EFM to enable them to make an informed choice of method for intrapartum fetal assessment. Presently, EFM is routinely used with the majority of laboring patients in the United States. This is likely due to confusion regarding the proper technique used for intermittent auscultation as well as insufficient information about appropriate interventions in the event fetal bradycardia occurs. We have developed a protocol for the performance of intermittent auscultation, including recommended responses to different levels of bradycardia. Intermittent auscultation is simple, provides objective information, and appeals to many well-informed patients. In addition, when the collection of information not relevant to management decisions is eliminated, intermittent auscultation nursing requirements are not greater than with EFM. Laboring patients should receive information on both intermittent auscultation and EFM to enable them to make an informed choice of method for intrapartum fetal assessment.

Patient satisfaction with current impotence therapy.

Abstract: One hundred ninety-eight impotent men were evaluated between July 1993 and June 1994. A "patient goal-directed" approach was used in all cases. Treatment options presented to patients included: oral yohimbine, vacuum constriction devices, penile self-injection therapy, penile prostheses, and testosterone supplementation when clinically indicated. Thirty-two percent of patients declined treatment, and 67% chose nonsurgical therapy. Only two patients (1%) chose penile prostheses. In August 1994, a survey addressing satisfaction with therapy was mailed to all patients, and 99 men (50%) responded. Of the treated respondents, 80% stated that their therapy was "easy to use," and 70% reported that they were "able to have intercourse." Patients prefer nonsurgical impotence therapy, which restores satisfactory sexual function in most men.

Interdisciplinary treatment of the injured worker with chronic pain: long-term efficacy.

Abstract: The purpose of this study was two-fold: (1) to determine long-term efficacy of an outpatient interdisciplinary pain treatment and management program for injured workers with chronic pain, and (2) to determine if those referred earlier after injury are more likely to benefit. Ninety-one questionnaires were completed a median of 36 months following program completion. Ninety-three percent of patients reported improvement in pain symptoms at the time of program discharge and 76% reported maintenance or improvement of pain level between discharge and the time of survey. Of those not working at the time of initial evaluation, 74% reported return to work or current involvement in a retraining program. Patients referred < or = 12 months after injury reported greater mean pain improvement and were significantly more likely to return to work. We conclude that the interdisciplinary pain treatment and management approach is effective in treating injured workers with chronic pain and that early referral enhances outcome.

Caring for the diabetic patient.

Abstract: If you really want to be smarter, reading can be one of the lots ways to evoke and realize. Many people who like reading will have more knowledge and experiences. Reading can be a way to gain information from economics, politics, science, fiction, literature, religion, and many others. As one of the part of book categories, caring for the diabetic patient always becomes the most wanted book. Many people are absolutely searching for this book. It means that many love to read this kind of book.

Retroperitoneal paragangliomas: natural history and review of the literature.

Abstract: Retroperitoneal paragangliomas are uncommon neoplasms that arise from neural crest cells. Typical retroperitoneal sites of origin include adrenal medulla, organs of Zuckerkandl, and along sympathetic and parasympathetic nerves. We present a case of a woman diagnosed with retroperitoneal paraganglioma treated with debulking, intraoperative radiotherapy and external beam radiation therapy. She experienced a 7-year disease-free interval prior to symptomatic metastatic recurrence. Such remissions are consistent with the natural history for paragangliomas. The purpose of this report and literature review is to summarize the pertinent biologic and therapeutic options for these uncommon tumors.

A simplified method for treating Graves' disease with radioactive 131I.

Abstract: We reviewed the medical records of 53 patients treated in 1986 for Graves' disease with moderate doses of 131I. The cumulative incidence of hypothyroidism at 3 and 12 months after therapy was 38 and 80%, respectively. The hyperthyroidism, however, was rapidly cured and only 4(7.5%) patients required a second dose of 131I. In a separate study of 21 patients with Graves' disease, we determined that the 4-hour 123I uptake measurement was as reliable as the standard 24-hour test for supporting the diagnosis of hyperthyroidism. We also demonstrated that the 4-hour uptake accurately predicted the 24-hour uptake. Based on these findings and a review of the literature, we believe that either a 4 or 24-hour 123I uptake study followed by the administration of a fixed dose of 131I (10 or 15 mCi) provides a convenient and cost-effective method for treating Graves' disease.

Desire and efforts to quit smoking among cigarette smokers in Wisconsin.

Abstract: This research studied the desire and attempts of cigarette smokers in Wisconsin to quit smoking. Data were based on the 1993 Wisconsin Division of Health's Behavioral Risk Factor Surveillance System (BRFSS). Among the 23% of respondents who were current smokers, 79% said they wanted to quit smoking and 60% said they had quit smoking for a day or more in the preceding year. High rates of wanting to quit and having tried to quit were found in all demographic subgroups of smokers studied. Compared to lighter smokers, heavy cigarette smokers (20 or more cigarettes per day) were less likely to have tried quitting in the past year, but were almost as likely to want to quit. These results demonstrate the great demand for smoking cessation services among smokers in Wisconsin and support for efforts to increase the use and effectiveness of these interventions.

High dose methotrexate infusion with leucovorin rescue for treatment of ectopic pregnancy.

Abstract: The purpose of this article is to evaluate the effectiveness, side effects, and complications of high dose methotrexate infusion with leucovorin rescue in select patients with ectopic pregnancy. Between January 1991 and November 1994, 28 patients with ectopic pregnancies were prospectively treated with methotrexate (100 mg/m2 intravenous bolus followed by a 200 mg/m2 infusion over six hours) with leucovorin rescue. Twenty-seven of 28 patients (96%) were successfully treated. Only one patient (4%) required a second course of methotrexate to reach a normal hCG titer. One patient failed methotrexate infusion 45 days after treatment at a hCG titer of 12 mIU/mL. No Gynecologic Oncology Group grade 3 or 4 clinical, biochemical or hematologic toxicities occurred. Uterine bleeding and abdominal pain, not requiring transfusion or hospitalization, occurred in 71% and 56% of patients. The authors conclude that high dose methotrexate infusion with leucovorin rescue is a highly effective, well tolerated, nonsurgical treatment for select patients with ectopic pregnancy.

Cervical cancer radiation injury to the urinary bladder and ureters: management by cecal augmentation to a previous ileal augmentation cystoplasty.

Abstract: A case report of the management of severe post cervical carcinoma pelvic radiation injuries is presented. Management was accomplished by detubularized ileal augmentation cystoplasty followed by cecal augmentation to the detubularized ileal augmentation 4 years later when bilateral ureteral obstruction developed. The development of a vesicouterine fistula required the creation of a large bowel cecal conduit for cutaneous urinary diversion utilizing the cecal augmentation antireflux segment.

Malignant gastroesophageal polyp: a case report.

Abstract: This case illustrates the entity of esophagealadenocarcinoma presenting in an esophageal polyp. Esophageal polyps are rare. The clinical presentation, diagnostic evaluation, pathophysiology, and treatment are discussed.

Wisconsin's future requirements for generalist physicians: is the state's training capacity sufficient?

Abstract: The need for expansion of generalist residency training programs in Wisconsin is considered, using population-based considerations and projection models that estimate the future statewide supply of and requirements for generalist physicians. In 1990, Wisconsin's generalist physician-to-population ratio was relatively low, at 59 per 100,000 population. The supply of generalists per 100,000 population was also highly variable across broad geographic areas of the state, with 16 of Wisconsin's 25 Health Service Areas having ratios which fell below 59 per 100,000 population. These patterns may not automatically translate into the need for expansion of Wisconsin's generalist residency training capacity, however. The projection model indicates that, even with no expansion of graduate medical education capacity for generalist physicians, the statewide supply could grow to more than 70 generalists per 100,000 population by the year 2015. Expansion of the state's generalist training capacity would also not guarantee that any additional generalist physicians trained in the state would actually locate in areas where they would be most needed. Policy efforts to provide incentives for generalist physicians to locate in under-served areas should continue to be supported.

Selected topics in exercise stress testing.

Abstract: More than ever before, exercise stress testing (EST) has become a focus for primary care physicians. But there are definite indications and contraindications for EST administration. Criteria may include when cardiology referrals should be made and what role the family physician should play in follow-up with coronary artery disease patients. There also are considerations for using EST for individuals with atypical chest pain or with patients after bypass surgery, angioplasty, or the coronary artery disease diagnosis. There even are distinct criteria for administering EST to women. This article will attempt to examine the numerous factors surrounding EST's growing use by primary care physicians.

An assessment of prehospital provider needs in Wisconsin.

Abstract: The Emergency Medical Systems Advisory Board assessed via questionnaire the needs of Wisconsin prehospital providers. Overall, 323 out of 453 (71.3%) of the services responded to the query. Intermediate and paramedic services were more likely to respond than those prehospital providers offering basic services. Of the respondents, however, 235 (72.8%) identified their service as basic. In addition to providing information about service characteristics, each responding provider also rated its perceived needs. All prehospital providers, regardless of service level, ranked "lack of medical director" as the issue of greatest concern. Continuing on, intermediate and basic providers rated difficulty in recruiting new staff as the second greatest need. Paramedic providers, however, identified dispatching as their second greatest need. Rural providers rated difficulty in recruiting new staff and difficulty in collecting ambulance fees as their second and third greatest needs, respectively. Urban providers, meanwhile, indicated difficulty in collecting ambulance fees and access to local training as the second and third top needs, respectively. With the proposed new curriculum for basic EMT services, the needs for local medical direction will be even greater.

Compliance with Wisconsin Statute 134.66 regulating cigarette vending machines, Wood County, Wisc, 1993-95.

Abstract: Vending machines are a significant source of cigarettes for youth. The purpose of this study was to determine if retailers with cigarette vending machines on their premises are complying with Wisconsin law designed to prevent youth from purchasing. Three cigarette vending machine site inspection surveys were conducted in Wood County during the period of 1993 to 1995. Results of the three site inspections showed that 4%, 29% and 15% of machines were in complete compliance with Wisconsin law. The most common reason for non-compliance was the lack of an appropriate warning sign. It is recommended that vending machine compliance data be included in future undercover buying operations, and suggested that the only vending machine regulation that can prevent youth access to cigarettes is one that bans cigarette vending machines.