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Many medical institutions are initiating quality improvement and disease prevention programs. In this paper, we report the results of a program designed to increase the rate of hormonal replacement therapy (HRT) in a postmenopausal population. After initially assessing the rate of HRT use, we instituted an educational program directed at both physicians and patients. Reassessment two years later indicated the rate of HRT had increased from 31% to 48.4%. Further educational efforts were followed by a reassessment three years later that showed a further improvement in prescription rate to 64%. We conclude that our educational program directed at physicians and patients dramatically increased the rate of HRT prescription of postmenopausal women.

Gambling behaviors cover a spectrum from an enjoyable benign form of social entertainment to a disabling and potentially lethal medical condition. A companion paper, Medical Approaches to Gambling Issues--I: The Medical Condition, provides a literature review of gambling in its pathological and nonpathological forms. Physicians encounter patients who gamble, patients who have a treatable disorder of pathological gambling and family members of problem and pathological gamblers. This paper is intended to aid practicing physicians in their care of their patients who gamble and experience problems related to gambling, as well as in the care of those among their patient caseload who are symptomatically affected by someone else's gambling.

Gambling is a common human behavior. People who gamble encounter physicians. At times, gambling can produce adverse consequences for the player. Persistence of gambling despite adverse consequences can be called problem gambling. Roughly 1% of adults and 3% of adolescents exhibit signs of a medical disorder defined as pathological gambling. In many areas, including Wisconsin, gambling is increasing in legality, availability, and prevalence, and with it, pathological gambling is increasing in prevalence. This paper provides a descriptive review of gambling behaviors and the condition of pathological gambling, in the hope of increasing the awareness of practicing physicians, medical educators and researchers, and public policy makers, about what is known about these behaviors and the features of gambling illness that may present in a clinical setting. A companion paper focuses on the opportunities for constructive clinical activity by physicians regarding gambling problems.

A Hartmann's pouch is a blind segment of the rectum created in conjunction with a colon resection in which primary bowel reanastomosis is judged unsafe. Often forgotten, this defunctionalized rectal pouch has a high potential of pathologic lesions, including disuse proctitis, ulcers, bleeding and occasionally neoplasm formation. What are the consequences of Hartmann's pouches left unattended? In this paper, we discuss three patients with neoplasms in a long-term Hartmann's pouch and the pathophysiology of the long-term defunctionalized rectum. We also question the possibility of increased incidences of neoplasms in long-term Hartmann's pouches. To monitor this we recommend close observation of the rectal pouch with proctoscopy and contrast studies.

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.

Domestic violence against women occurs within and across all socioeconomic, demographic, and geographic regions of the United States. Many of the dynamics related to domestic violence, and which trap women in violent relationships, also cross these boundaries. These dynamics include societal and community attitudes toward violence, isolation, fear of exposure, lack of resources to facilitate leaving a violent relationship, and lack of sufficient accessible services for victims of violence. This paper highlights that these and other issues of domestic violence are intensified in rural settings. As such, physicians working in rural areas may face unique challenges in helping battered women. Such challenges will require solutions based on knowledge of specific rural location. A number of rural-based solutions for physician interventions with rural battered women are discussed.

Coumadin is a coumarin anticoagulant that induces a state similar to vitamin K deficiency and is routinely used for chronic oral anticoagulation. Intramural hematoma of the bowel is a rare complication of anticoagulant therapy. In this paper, we describe such a case of an anticoagulated patient who had complaints of abdominal pain and who had inadvertently been taking higher dose of coumadin. Although the diagnosis can usually be made by history and plain abdominal x-ray, we report here some radiographic signs that can be seen on a CT-scan of the abdomen and are relatively specific for this diagnosis. We stress the importance of recognizing the disorder because the management is conservative and surgery is reserved for cases in which no improvement is seen.

This paper examines a study of a brief contact smoking cessation program among 57 pregnant women at two urban clinics. All subjects were administered either a specially created videotape or a booklet on the topic of smoking. Subjects were then randomly assigned to receive either a nurse counseling message or to receive their usual care at the clinic. There was no statistically significant difference in smoking status among those who received either type of media or nurse counseling intervention. However, smoking cessation at one month after entry in the study was reported by 12% (N = 7) of subjects, by 18% (N = 10) of subjects in the ninth month of pregnancy, and by 9% (N = 5) of subjects at one month post-partum. Over half of the patients attempted to quit smoking in the first month and 68% (39/57) made at least one quit attempt during the entire study period. Our results suggest that future smoking cessation programs and methods need to consider more intensive nursing interventions and supportive measures to produce lasting changes in smoking prevalence.

Cigarette smoking is one of the most preventable causes of low birth weight in the United States. This paper presents new data on the relationship between low birth weight and maternal cigarette smoking in Wisconsin based on an analysis of 1991 birth certificates. In Wisconsin in 1991, 22.5% of mothers reported smoking cigarettes during pregnancy. Mothers who smoked cigarettes were twice as likely to bear low birth weight infants as were non-smokers. Low birth weight accounted for 49% of newborn hospital charges totaling $60.7 million. A 50% reduction in maternal smoking could potentially save $5 million in newborn hospital costs. A women is more likely to quit smoking during pregnancy. Physicians are in a unique position to encourage positive behavior change that will reduce the risk for low birth weight and have long term benefits for her and her family.

There has been concern since antiquity that the ingestion of alcohol by the pregnant woman could damage the fetus, but it was not until 1973 that the fetal alcohol syndrome was first described. The broad effect of alcohol-related birth defects, including fetal alcohol effects (FAE), has become apparent even more recently. Physicians can play a central role in the prevention of alcohol-related birth defects through early detection, education of the mother, and appropriate referrals. This paper reviews the effects of maternal alcohol use on the fetus, discusses the importance of assessing alcohol use among all women of child bearing age, and examines intervention strategies that physicians can use to help pregnant women stop or reduce alcohol use. Funding for this paper was provided by the Maternal and Child Health Block Grant.

Extreme prematurity (birth weight less than 500 g) with intact survival is very uncommon. This paper describes a preterm infant with birth weight of 354 g who is now 4 years old and developmentally normal. Intervention and management decisions in such a low birth weight group produce an ethical enigma. Survival of newborns with a birth weight less than 400 g is unusual. Decisions regarding intervention and care for extremely low birth weight infants impact on financial, emotional, and medical responsibilities of family members and health care professionals. It has been increasingly difficult to set guidelines or policies regarding resuscitation of "micropremies" based on weight and gestational age.

Since the first patient with AIDS was reported in 1981, the incidence of this illness has continued to rise. It is estimated that the cost of AIDS-related illnesses will be $15.2 billion by 1995. In this paper, we analyzed the number of admissions for AIDS to St Mary's Medical Center and St Luke's Hospital, both in Racine, Wis. Similar to the national trend, a rising incidence for hospital admissions was noted during the last 2 years. The rate of increase per year in this country was 31%, which is well above the national rate of increase. Twenty-nine admissions for 19 patients occurred during the past 5 years. One third of these patients moved to Racine from other states. Apparently, 10% of the patients contracted their illness through heterosexual contacts.

High pressure injection trauma to the upper extremity is a rare but potentially limb-threatening injury. The index finger on the non-dominant hand of young male workers is most commonly involved. Injected materials include paint, grease and diesel oil. Prompt recognition and initiation of treatment is necessary if a disastrous outcome is to be avoided. Primary treatment consists of surgical decompression and debridement. Amputation may be necessary. With early aggressive treatment, satisfactory results can be obtained. The use of high-pressure devices in industry has resulted in an unusual but potentially limb-threatening injury to the upper extremity known as the "high-pressure injection injury." This injury is a surgical emergency that demands prompt diagnosis and treatment if a disastrous outcome is to be avoided. The purpose of this paper is to present our recent experience and review the clinical features, evaluation and treatment principles.

Neuroleptic malignant syndrome (NMS) is a catatonic-like syndrome of uncertain etiology occurring in patients taking dopamine blocking medications. The paper describes how NMS presents and is treated and reports the case of a patient with undetected neurosyphilis who developed NMS. The case highlights the need for a thorough organic evaluation of all patients with initial-onset psychotic features and suggests the possibility of a CNS cofactor--neurosyphilis--initiating the NMS as proposed by other researchers.

Two editorials in the June 1991 Wisconsin Medical Journal communicated a concern for the equitable provision of health care to all Wisconsin residents. They requested greater commitment to this goal by the state government, and cited quality obstetric care as a worthwhile investment of the public dollar for long-term public health. As part of the discussion of resources available to improve obstetrical care, this paper will present a summary of the current status and potential expansion of midwifery practice in Wisconsin after a synopsis of the relevant historical information.

Breast cancer presentation is changing, with more tumors detected at an early stage. This makes choosing the most appropriate tests for evaluation of a particular tumor more difficult. Mammography with biopsy of suspicious areas reveals an increasing incidence of microscopic cancers, with a corresponding reduction in larger palpable cancers. Coincidentally, a number of tests for evaluating these cancers, which may affect treatment, have been developed. These includes immunohistochemical evaluation of estrogen receptor and progesterone receptor status and a number of tests still listed as investigational. This paper reviews the diagnosis, evaluation, and prognosis of breast cancers, and suggests an optimal way for handling these tumors.

In 1987, the Wisconsin Academy of Family Physicians developed the Wisconsin Research Network (WReN) to support practice-based primary care research throughout Wisconsin. WReN has three objectives: to support the research efforts of individual physicians in community practices, to facilitate collaborative research among practicing physicians, and to provide academically based investigators with access to community practice sites. Due to a policy of actively encouraging membership, WReN has grown to 460 members during its 4-year history. Five WReN-supported papers have been published, and 22 state and national level presentations of WReN-supported research results have been made. Competitive grants totaling more than $2 million have been awarded to university-based investigators for studies using the resources of WReN. This paper describes the development, organization, and success of WReN as well as the challenges which must be addressed.

This paper will review an acute onset of mental confusion associated with hallucinations secondary to vigorous administration of topical Caladryl lotion and Benadryl spray in an 8-year-old boy with chickenpox. The article discusses the toxicity of both oral and topical diphenhydramine use, along with the differentiation of varicella encephalitis from diphenhydramine toxicity. Delirium can be described as an acute clouding of consciousness associated with visual and tactile hallucinations, disorientation, and misperceptions. In a child who is already suffering from an infectious illness, encephalitis must be high on the list of the physician's differential diagnosis. The physician, however, must never overlook ingestions, even from topical, over-the-counter medications. The case described illustrates this point. Although this appears to be the fourth case report on this subject, the diagnosis was partially obscured by the fact that the local pharmacist could not find any documented cases despite a computer search of diphenhydramine toxicity at the time of admission and the report of only one or two cases by the Parke-Davis pharmacist.

More than 24,000 refugees of Southeast Asian descent live in Wisconsin. These people, of a different cultural background with different methods of treating the sick, on occasion seek medical aid. It is incumbent on the treating physicians to understand the cultural differences and the avenues open to them to render treatment to these people. This paper reviews these concerns.

The evidentiary exam following sexual assault provides crucial evidence that can be used by the prosecuting attorney to obtain a conviction in sexual assault cases. Evidence is collected for three purposes: to corroborate the use of force; to corroborate that recent sexual contact occurred; and to identify the perpetrator. Relatively few assailants (4%) go to jail for rape. To a great extent this is because of a lack of corroborating evidence and misinterpretation of this lack of evidence by police, courts, and jurors. This paper presents the results of a study to determine the likelihood of obtaining corroborating evidence of recent coitus along with an explanation of what negative results mean. Based on the results, recommendations are presented for sexual assault evidence collection in emergency departments.

The growing use of cocaine among pregnant women and its effect on the fetus have become issues of great concern to physicians and society in general. In this paper, we review the available data about the incidence of cocaine use during pregnancy in the United States and in Wisconsin. The pharmacology of the drug is examined as well as its effect on pregnancy outcomes. Medical, neurobehavioral, and developmental effects on the fetus, newborn, and infant are discussed, as well as the relationship to the timing of drug use during pregnancy. Suggestions relevant to physicians for prevention and treatment are given.

This paper analyzes current and future needs for primary care physicians--particularly family practice physicians--in Wisconsin in light of predictions of a national physician glut by the year 1990. The current shortfall of family physicians is estimated to be at least 150, with the most severe deficits found in rural and underserved urban areas. Forty-nine to 79 family practice physicians will be needed each year to meet the growing demand and to replace losses due to retirement, speciality change, and other factors. At the current rate of training, 63 new family physicians will enter practice each year; it appears that the current deficit will be made up slowly, if at all. The number of primary care specialists appears unlikely to increase due to the declining interest in the speciality among medical students; only half the number of new family physicians entering practice each year will enter practice in 1994, resulting in an additional shortfall of about 30 to 50 family physicians each year. Programs should be undertaken at medical schools to bolster student interest in family practice and primary care.