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GOVERNOR'S NEWSLETTER - FALL 1998

Regional ACP-WSIM Meeting - Racine, Wisconsin, September 10-12, 1998

Dominating our Regional meeting was the passage of a resolution to merge the ACP Wisconsin Chapter and the WSIM. Following the lead of the National ACP and ASIM, the two organizations in Wisconsin unanimously voted to merge. What followed this vote was a celebration of a new found sense of unity and excitement for the future of our organization. Dr. Greg Shove (President of the WSIM) put the feelings of all in the organization into eloquent comments that follow:

We are participating in an exciting and historical event; the merger of two great organizations. The end result will be better representation for Internal Medicine. The merger of ACP & ASIM will result in a synergy providing new energy to the profession of Internal Medicine. We will be better able to define and articulate what distinguishes an Internist from the expanding pool of primary care providers. We will be better able to develop our knowledge base, better able to advance the science of medicine, better able to conduct clinical research and clinical outcome studies. We will be better able to protect and advance medical education which is so dependent on strong Internal Medicine programs.

By speaking with one voice from under one roof we will have greater impact in the political and socioeconomic environment in which we now practice. Writing recently in JAMA, Richard D. Lamm, Governor of Colorado 1975-1987 and currently Executive Director for the Center for Public Policy and Contemporary Issues, University of Denver, quotes the Oregon Health Decisions process, " We cannot live under the idea that we can give everybody all the health care they need. Rationing of health care is inevitable because society cannot or will not pay for all of the services that modern medicine can provide. People in this state must search their hearts and pocketbooks and decide what level of health care can be guaranteed to the poor, the unemployed, the elderly, and others who depend on publicly funded health services."

John Kitzhaber first as the president the Oregon Senate and now as Governor, has been trying to get our attention: "When money is spent on one set of services, it is, by definition, not available to spend on other services. Health care services must compete with all other legitimate services state government must provide. An explicit decision to allocate money for one set of services means that an implicit decision has also been made not to spend money on other services. That, in essence, constitutes the rationing of health care."

I think that Internists are now poised to become the collective conscience that will be required to guide society through some of these very difficult issues. In closing, I hope to see all of you at future ACP-ASIM meetings where you can draw : "Enthusiasm for learning from the young Residents Tools for learning from the speakers and Inspiration for learning from our Laureates, awardees and ACP representative."

We all owe a great debt of gratitude to Dr. Shove for his support during this time of merger. His words truly capture what we all want for our new organization.

Associates' Presentations

Every year our associates continue to impress all of us with their level of thought, perceptiveness, knowledge base and presentation skills seen in the Associates program. Listed below are the titles of the posters and vignettes, and names (and program affiliation) of the Associates who presented them at the Regional Meeting:

Poster Title; Name; Program Affiliation

Stroke in Atrial Flutter: Frequency and Outcomes in the General Population
Granada, J
Marshfield Clinic/St. Joseph's Hospital

A Masquerading Mediastinal Mass
Hotten, K
University of Wisconsin Hospital and Clinics

Castleman's Disease
Juntunen, K
Medical College of Wisconsin

A Case of Takayasu's Arteritis
Keshena, K
Marshfield Clinic/St. Joseph's Hospital

Dermatomyositis and Its Association with Malignancy: A Classic Presentation
Meyer, T Gundersen Lutheran Medical Foundation

Late Relapse of Malaria
Prasad, GA
Sinai Samaritan Medical Center

Primary Rhabdoid Tumor of the Lung
Strong, D
Medial College of Wisconsin

First-Time Referrals for Myocardial Perfusion Scans to Detect Ischemia are Used More Cost-Effectively by Cardiologists Than by Family Practitioners
Zaidi, S
Milwaukee Heart Institute/Sinai Samaritan Medical Center

A Case of Staphylococcus Aureus Endocarditis with Typical Skin Lesions, and a Complete Remission of Acute Renal Failure
Zhang, X
Marshfield Clinic/St. Joseph's Hospital

Primary Cutaneous T Cell Lymphoma
Erickson, M
University of Wisconsin Hospital and Clinics

Hypercalcemia Associated with Sarcoidosis
Flejsierowicz, M
Sinai Samaritan Medical Center

Mortality and Clinical Predictors of Death in Newly Diagnosed Atrial Flutter: A Study in the General Population from the Marshfield Epidemiologic Study Area (MESA)
Granada, J
Marshfield Clinic/St. Joseph's Hospital

Tick Talk: It's Lyme To Get Going
Heun, R
Gundersen Lutheran Medical Foundation

Milk Alkali Syndrome: A New Resurgence
Hower, D
Medical College of Wisconsin

Cardiac Embolization
Ignace, L
Medical College of Wisconsin

Progressive Dyspnea - A Case Report of Idiopathic Pulmonary Fibrosis
Kamper, K
Marshfield Clinic/St. Joseph's Hospital

"I Can't Get My Wedding Ring Off" - A Case Report of Acromegaly
Kamper, S
Marshfield Clinic
St. Joseph's Hospital

Emphysematous Cystitis: A Case Presentation
Kleczko, J
Medical College of Wisconsin

TB or Not TB: That is the Question
Rao, R
University of Wisconsin Hospital and Clinics

Thyrotoxic Heart Disease
Rihawi, M
Sinai Samaritan Medical Center

An Elderly Man with Diabetes, Neurogenic Bladder and Abdominal Pain
Safdar, N
University of Wisconsin Hospital and Clinics

Travel Fever
Walsh, K
University of Wisconsin Hospital Clinics

We are pleased to inform you that the abstracts from the Associates meeting from 1997 were published in the Wisconsin Medical Journal (WMJ), October - 1998 issue. The abstracts from the Associates meeting from 1998 will also be published in the WMJ at a later date. The poster and vignette abstracts from the 1998 Associates meeting are available on our web site.

Scientific Program

Our scientific program focused on the practice of alternative medicine. The highlight of this scientific program was the talk by Dr. Raymond Murray (Michigan State University) who gave the Russell Quirk Memorial Lecture on the "Growing Use of Alternative Medicine". What follows below are some brief comments from Dr. Murray's presentation on this important topic. Alternative Medicine has long played an important part in the care of people with health problems in this country. Although there has been no comprehensive assessment of its use, there are good reasons to believe that alternative medicine has many adherents among all social classes. Most physicians are unaware of it popularity, much less that many of their own patients are also being cared for by practitioners of alternative medicine.

Although there is no recognized system of classification for alternative medicine, its practitioners can be conveniently divided into four categories, based on the type of treatment they use. The spiritual and psychological category includes faith healers from established religions, psychics and mystics who engage in paranormal healings and various divinations and those using psychological techniques such as mental imaging, hypnosis, and laughter therapy. The nutritional category includes those who recommend herbal vitamin, and mineral dietary supplements and prescribe specific diets, such as the macrobiotic diet. The drug and biologic category comprises specialist in the use of assorted chemicals, drugs, serums, and vaccines - e.g., treatments to enhance the immune system, homeopathy, and the injection of live cells from fetuses, and animals. The fourth category, involving treatment with physical forces and devices, includes chiropractors, massage and touch therapists, acupuncturists, and practitioners of various electrotherapies. Other methods are difficult or impossible to categorize, such as aroma therapy and iridology, the diagnosing of internal diseases by examining the iris of the eye.

More about alternative medicine can be found in the following references:

1. Murray R, Rubel A. Physicians and Healers - Unwitting Partners in Health Care Sounding Board. NEJM 326:61-64, 1992.
2. Eisenberg DM, Kessler RC, et al. Unconventional Medicine in the United States. NEJM 128:246-252, 1993.
3. Eisenberg DM. Advising Patients Who Seek Alternative Medicine Therapies. Ann Intern Med 127:61-69, 1997.

NCCAM and the Office of Alternative Medicine (OAM) have become the NIH offices that facilitates research and evaluation of unconventional medical practices and disseminate this information to the public. Their work has put truth into this area.

ACP-ASIM Awards

Laureate Award

The Laureate Award this year was presented to Dr. Joseph Mazza, M.D., FACP, Marshfield Clinic. The Wisconsin Chapter was pleased to honor Dr. Mazza with the 1998 Laureate Award. Dr. Mazza has been a long-standing and loyal supporter of the College, has rendered distinguished service to the Chapter, and has upheld the high ideas and professional standards for which the American College of Physicians - American Society of Internal Medicine is known.

Distinguished Internist Award

Dr. John Przybylinski (Marshfield Clinic, WI) was awarded the Distinguished Internist award for his outstanding contributions and life-long efforts on behalf of Internists in Wisconsin.

Young Internist Award

Dr. Lisa Benson (Marshfield Clinic, WI) was awarded the Young Internist award for her outstanding contribution as a young internist to patient care and medical education in the State of Wisconsin.

Addis Costello Internist of the Year Award

Dr. Lisa Ramsay (Racine, WI) was awarded the Addis Costello Internist of the Year award in recognition of her outstanding contributions to the socio-economic aspects of General Internal Medicine in Wisconsin.

College Representative (CR)

Dr. John Noble, Director, Center for Primary Care, Boston University School of Medicine was our CR. His energy, enthusiasm and interactions were infectious for all of us. We appreciate greatly his involvement in our program.

ACP-ASIM - Wisconsin Chapter Meeting 1999

The Annual meeting next year will be held at the Pfister Hotel, Milwaukee, WI on September 16-19, 1999. Dr. Charles (Chuck) Holmburg will again be the program chair. Other program planners will include Drs. Dick Dart, Kesavan Kutty, Larry Fleming, Mark Gennis, George Mejicano, Greg Buck, and Lisa Ramsay. We look forward to your participation in our exciting new organization.

National ACP-ASIM News

In the winter addition of the Governor's Newsletter, we will discuss in-depth the Lethal Drug Prevention ACT (HB 4006). This Bill, if passed will have a chilling effect on the appropriate and necessary use of pain medications in terminal illnesses. It will put Federal Investigators into the middle of the Patient-Doctor and Family Relationships at the end of life. It will infringe upon patient confidentiality. This is a bill that so far has not been approved but advocates vow to bring it up again. We will also discuss the Hospitalist issue and E and M documentation Guidelines.

ACP-ASIM Wisconsin Chapter New Members and Associates and Newly Elected Fellows

Congratulations and welcome to the ACP-ASIM to all new Members, Associates and new Fellows.

Members

Steven Baker, M.D.
Stephen M. Bullard, M.D.
Laura M. Cantwell, M.D.
Oliver A. Cantwell, M.D.
Susan Darmstadter, M.D.
Aret Y. Kahyaoglu, M.D.
Fawad K. Khan, M.B.B.S
Jennifer E. MacGaffey- Thurston, M.D.
Guglielmo C. Sala, M.D.
Joseph F. Szot, M.D.
Gregory V. Warren, M.D.

Associates

Tan Attila, M.D.
Meir Gare, M.D.
Juan F. Granada, M.D.
Aysha Shaikh, M.D.
Salim Torania, M.B.B.S

Fellows

Masood Akhtar, M.B.B.S.
Bruce B. Berry, M.D.
Jerome C. Brooks, M.D.
Edsel G. Doreza, M.D.
Kulwinder S. Dua, M.D.
Mark A. Gennis, M.D.
Virginia M. Gennis, M.D.
Charlotte A. Heidenreich, M.D.
Geoffrey C. Lamb, M.D.
Elias A. Lianos, M.D.
Ann Nattinger, M.D.
Lisa C. Ramsay, M.D.
Thomas J. Saphner, M.D.
Mohommad Tinawi, M.D.
Jerome V. Van Ruiswyk, M.D.

Medical Intelligence

From time to time the Governor's Newsletter will include discussion of some important and/or controversial clinical issues to update the General Internist.

We should all be aware of the fact that antiretroviral drugs have made a hopeful impact on HIV disease. Recently, discussion has centered on the use of antiretroviral therapy for "Non-Occupational" exposure. Excerpts from the CDC Update on this controversial topic follow below.

In recent years, the Public Health Service (PHS) has recommended the use of antiretroviral drugs to reduce the risk of occupational HIV transmission following workplace exposures (e.g., health care workers exposed through accidental needle-sticks). Scientific studies have shown these drugs to be both safe and effective for this use. While this type of therapy is not 100% effective, it has been found to significantly reduce the risk of HIV infection among health care workers following percutaneous (through the skin) exposures.

Questions have arisen about whether similar therapy should be offered to people with unanticipated sexual or drug injection-related exposures to HIV. However, researchers do not know if findings among health care workers are applicable in other settings where therapy may not be initiated as quickly, where the HIV status of the source may not be known, where the regimen cannot be closely monitored, and where repeated exposures may occur. To consider these questions, the PHS convened scientific experts from across the nation to review all available data. The September 25, 1998, issue of the Morbidity and Mortality Weekly Report summarizes the data considered and the outcomes of this consultation.

Primary conclusions of the report include:

Physicians and individuals at risk for HIV infection should remember that the most effective methods for preventing HIV remain those that prevent exposure to HIV in the first place. Attempting to prevent HIV infection by taking post-exposure antiretroviral therapy should never take the place of adopting and maintaining behaviors that prevent HIV exposure. These include sexual abstinence, having sex only with an uninfected partner, consistent condom use, abstinence from injection drug use, and consistent use of clean equipment for those who are unable to cease injection drug use.

There are no human data on the effectiveness of post-exposure therapy in reducing HIV infection following sexual or drug-related exposures. While some animal studies suggest potential benefits of its use, it is not known how applicable these data are for humans.

We do know that the therapy is not 100% effective. Even under ideal circumstances following an occupational exposure in a health care setting, where treatment is typically started within hours and can be closely monitored, infection has occurred despite therapy.

There is no such thing as a "morning after pill" to prevent HIV infection. Post-exposure antiretroviral therapy involves multiple drugs, taken several times a day, for at least 30 day. This is an extremely difficult and expensive regimen which can have severe side effects and cost $600 to $1,000.

Adherence to the regimen is critical, both to provide the best chance of effectiveness and to prevent the emergence of drug-resistant HIV. Several studies indicate that adherence to this lengthy regimen is difficult. Among rape victims in New York City, for example, only 16% of patients are known to have completed the regimen as prescribed. Among health care workers in the United States, just over 60% complete the regimen. Many report stopping the regimen because of side effects. If individuals at risk rely on this less effective strategy instead of maintaining consistently safe behaviors, they may be placing themselves in significant danger. Post-exposure therapy should never be considered a from of primary HIV prevention.

From this report, the PHS has concluded that there are no conclusive data on the effectiveness of antiretroviral therapy in preventing HIV transmission after non-occupational exposures. It is therefore not possible to make definitive recommendations regarding its use. Because the therapy remains unproven and can pose risks, physicians should consider its use only in individual circumstances when the probability of HIV infection is high, the therapy can be initiated promptly, and adherence to the regimen is likely. It should not be used routinely and should never be considered a form of primary prevention.

Governor's Notes

The merger of the ACP and WSIM to form the ACP-ASIM Wisconsin Chapter, Inc. has been celebrated at our Regional meeting. It is now time to use our new found unity and strength to move forward and educate our members and public; keep professionalism our goal; and fight for what is right in the care of our patients. Those of us in the leadership of the ACP-ASIM Wisconsin Chapter keep these tenants as our guide for the future.

The Wisconsin Chapter of the ACP-ASIM in 1998 once again received a Chapter Management Award. This award recognizes chapters that meet the standards for an effectively run regional office. I would like to thank Dr. Mahendr Kochar and Ruth Breitbach for their efforts in our chapter's receipt of this award. I would also like to especially thank Joan Enge for her loyalty to me and her hard work in making this chapter run smoothly and effectively.

Lastly, if anyone has comments about the newsletter, the Regional meeting or other national or local issues, please feel free to contact me at the Chapter office (608-263-3457) or at the e-mail address below.

Sincerely,

Frank M. Graziano, M.D., Ph.D., FACP
Governor, ACP-ASIM
Wisconsin Chapter

University of Wisconsin Hospital and Clinic
600 Higland Avenue, H6/368
Madison, WI 53792-3244
E-Mail: fmg@medicine.wisc.edu
Fax: 608-265-9604