Journal MSMA • VOL. LIX • NO. 11/12 • 2019

VOLUME LX • NO. 11/12 • 2019

A fabulous holiday gift for anyone in medicine!

Images in Mississippi Medicine: A Photographic History of Medicine in Mississippi

D and Karen A. Ever Lucius "Lu ke" M · Lampton, M

Pickup in Ridgeland for $49.95 or $57.95 includes shipping.

Order three or more to receive a discount at: http://tinyurl.com/yb7ab974 “ Images In Mississippi Medicine by Dr. Luke Lampton and Karen Evers is a handsome and impressive book,

filled with stories and scenes ranging from primitive operating rooms and rows of hospitalized tornado victims a century ago to the new teaching complex at the University of Mississippi Medical Center with its modern breakthroughs. The volume is a piece of our history that every Mississippian can appreciate.”

– Curtis Wilkie, journalist, author, and professor at Ole Miss

Images in Mississippi Medicine: A Photographic History of Medicine in Mississippi; MSMA; Jackson, MS: 2018.

OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION VOL. LX • NO. 11/12 • NOVEMBER/DECEMBER 2019

SCIENCE OF MEDICINE

EDITOR Lucius M. Lampton, MD ASSOCIATE EDITORS D. Stanley Hartness, MD Philip T. Merideth, MD, JD

THE ASSOCIATION President J. Clay Hays, Jr., MD President-Elect W. Mark Horne, MD

MANAGING EDITOR Karen A. Evers

Secretary-Treasurer Joe Austin, MD

PUBLICATIONS COMMITTEE Sheila Bouldin, MD, Chair Dwalia S. South, MD, Chair Emeritus Thomas C. Dobbs, MD Wesley Youngblood, M4 and the Editors

Speaker Geri Lee Weiland, MD

An Unusual Case of Ameboma Presenting as a Large Cecal Ulcerated Exophytic Necrotic Mass Successfully Treated with Nitazoxanide Niraj James Shah, MD; Patrick Basu, MD; Ked Fortuzi, MD; Mark M. Aloysuis, MD, PhD; Elona Shehi, MD; Brian B. Borg, MD; Nitin K Gupta, MD

Top 10 Facts You Need to Know about Management of Sepsis and Septic Shock in Children Padma Garg, MD; Jennifer Hong, MD

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DEPARTMENTS

Executive Director Claude D. Brunson, MD

Images in Medicine – Science Building At University of Mississippi, 1911 364 Lucius M. Lampton, MD

CORRESPONDENCE: Journal MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: 601-853-6733, Fax: 601-853-6746, www.MSMAonline.com.

SUBSCRIPTION RATE: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available.

ADVERTISING RATES: furnished on request. Karen A. Evers, Journal MSMA, Managing Editor. Ph. 601-853-6733, ext. 323, Email: KEvers@MSMAonline.com POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 39158-2548.

The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association.

Copyright © 2019 Mississippi State Medical Association.

MSMA • Since 1959

Fecal Microbiota Transplantation for Clostridium difficile Colitis:

A Review and Report of the Jackson, Mississippi Experience 359 James A. Underwood, III; James Q. Sones, MD

Vice Speaker Jeffrey A. Morris, MD

JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39157. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual).

Periodicals postage paid at Jackson, MS and at additional mailing offices.

Official Publication

From the Editor – Aspiring to JFK's More Mature Qualities Lucius M. Lampton, MD

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Poetry and Medicine – In Dissecting Room [Offered by the first medical school class at Ole Miss– University of Mississippi School of Medicine, Class of 1904]

365

Una Voce – Why I Still Believe in Christmas Cards Dwalia S. South, MD

368

ABOUT THE COVER

“Rodney Presbyterian Church in Port Gibson”– According to the U.S. National Register of Historic Places, the church was chartered in January 1828 as the Presbyterian Church of Petit Gulf. The church building was built from 1829 to 1832 in the Federal architectural style with red bricks, rounded archives, a stepped gable and an octagonal bell tower.

In September 1863, Union soldiers attending service inside were taken captive by Confederate soldiers. When other Union crew members aboard the gunboat “Rattler” found out about the Confederate violation of a Sunday truce, they began shelling the town. At least one cannonball fired hit the church, and it can still be seen there today, mortared in place. The shot can be seen embedded above the window on the cover image photographed by Robert B. Brahan, MD, a Hattiesburg physician board-certified in internal and geriatric medicine. In June 1955, the Synod of Mississippi resolved to restore the church, cooperating with the Presbytery of Mississippi on the project. The Presbytery met at Rodney in October 1955, to draw attention to the church’s need for restoration. But the congregation’s main problem was lack of membership. After Mac Hart resigned from the Fayette church in October 1956, the pulpit was listed as vacant in subsequent Presbytery minutes. In 1966, the last remaining members of the congregation voted to sell the building to the United Daughters of the Confederacy. The building is now owned by the Rodney History and Preservation Society. You can find more information and make a contribution to the preservation of the building at https://rodneyhistory.org. n

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F R O M

T H E

E D I T O R

Aspiring to JFK's More Mature Qualities

T

he spring before his death in 1963, unable to attend a 40th birthday celebration for Time magazine, President John F. Kennedy sent a telegram which saluted the magazine with a few well-phrased remarks. Towards the end of his comments, after praising Time for enlarging the intellectual and cultural horizons of our nation, he added wryly: “I hope I am not wrong in occasionally Lucius M. Lampton, MD detecting these days in Time those more Editor mature qualities appropriate to an institution entering its forties–a certain mellowing of tone, a greater tolerance of human frailty and, most astonishing of all, an occasional hint of fallibility.” [Time. Nov. 29, 1963 (82:22), 19.]

When Kennedy wrote these words, he was about to turn 46 years old.

Despite his relatively short span of years, he possessed a precocious magnanimity which had not come easy. As a child, he survived multiple life-threatening illnesses. It was said that he had come so close to death that he had been read the last rites three times. His most serious health

problem was Addison’s disease. When he was diagnosed around age 30, his doctor gave him less than a year to live. He was also plagued with back pain. X-rays from the 1950s reveal osteoporosis and multiple lumbar compression fractures, probably resulting from overuse of steroids for his multiple ailments. The severity of the daily pain he suffered is perhaps underscored by his visit to Mississippi in October 1957: his night in the Governor’s Mansion was spent with staff trying to get a door off its hinges to place under his mattress in order give his back the support it needed for him to sleep.

JFK’s “more mature qualities” are essential for the practice of our medical art. These qualities should be aspired to by old and young alike. As we treat our fellow humans, we must exercise these qualities. A tolerance of human frailty and acknowledgement of our own fallibility as well as a desire to project a mellow tone and equanimity are requisite perspectives for any practicing physician. When fully developed, these qualities bless not only the physician who possesses them but also provide comfort to all who come into contact with him or her.

Contact me at lukelampton@cableone.net. n — Lucius M. Lampton, MD, Editor

JOURNAL EDITORIAL ADVISORY BOARD ADDICTION MEDICINE Scott L. Hambleton, MD

EMERGENCY MEDICINE Philip Levin, MD

INTERNAL MEDICINE/EPIDEMIOLOGY Thomas E. Dobbs, MD

ALLERGY/IMMUNOLOGY Stephen B. LeBlanc, MD Patricia H. Stewart, MD

FAMILY MEDICINE Tim J. Alford, MD Diane K. Beebe, MD Jennifer J. Bryan, MD J. Edward Hill, MD Ben Earl Kitchens, MD

MEDICAL STUDENT John F. G. Bobo, M3

GASTROENTEROLOGY James Q. Sones, MD

OBSTETRICS & GYNECOLOGY Sidney W. Bondurant, MD Sheila Bouldin, MD Darden H. North, MD

ANESTHESIOLOGY Douglas R. Bacon, MD John W. Bethea, Jr., MD CARDIOVASCULAR DISEASE Thad F. Waites, MD CHILD & ADOLESCENT PSYCHIATRY John Elgin Wilkaitis, MD CLINICAL NEUROPHYSIOLOGY Alan R. Moore, MD DERMATOLOGY Robert T. Brodell, MD Adam C. Byrd, MD

GENERAL SURGERY Andrew C. Mallette, MD HEMATOLOGY Carter Milner, MD INFECTIOUS DISEASE Rathel "Skip" Nolen, III, MD INTERNAL MEDICINE Daniel P. Edney, MD Daniel W. Jones, MD Brett C. Lampton, MD

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NEPHROLOGY Harvey A. Gersh, MD Sohail Abdul Salim, MD

ORTHOPEDIC SURGERY Chris E. Wiggins, MD OTOLARYNGOLOGY Bradford J. Dye, III, MD PEDIATRIC OTOLARYNGOLOGY Jeffrey D. Carron, MD PEDIATRICS Michael Artigues, MD Owen B. Evans, MD

PLASTIC SURGERY William C. Lineaweaver, MD Chair, Journal Editorial Advisory Board PSYCHIATRY Beverly J. Bryant, MD June A. Powell, MD PUBLIC HEALTH Mary Margaret Currier, MD, MPH PULMONARY DISEASE Sharon P. Douglas, MD John R. Spurzem, MD RADIOLOGY P. H. (Hal) Moore, Jr., MD RESIDENT / FELLOW Cesar Cardenas, MD UROLOGY W. Lamar Weems, MD VASCULAR SURGERY Taimur Saleem, MD

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Management of Ameboma Presenting as a Large Ulcerated Cecal Mass NIRAJ JAMES SHAH, MD; PATRICK BASU, MD; KED FORTUZI, MD; MARK M. ALOYSIUS, MD, PHD; ELONA SHEHI, MD; BRIAN B. BORG, MD; NITIN K. GUPTA, MD Introduction Colonic amebiasis is characteristically an inflammatory and ulcerative infestation of the colon. We present a rare case of colonic amebiasis presenting as an ameboma or an inflammatory mass which mimicked a colonic tumor and which completely resolved after therapy with Nitazoxanide.

Figure 2. H and E stained histological section shows an inflammatory infiltrate.

...... ,

Case A 45-year-old woman presented with diarrhea, abdominal discomfort and significant weight loss over a 2 month period without nausea, vomiting, fever or chills. There was a remote history of travel to India 4 months preceding her symptoms but no exposure to sick contacts.

The workup included serum lipase, amylase, serum chemistries, stool ova and parasites and was all normal. The sonogram of the liver did not reveal any lesions. Colonoscopy showed a large cecal exophytic ulcerated mass measuring 4 cm (Figure 1). Biopsies confirmed the diagnosis of an inflammatory mass (Figure 2) within the colonic mucosa embedded with numerous trophozoites featuring eccentric nuclei and flagellae on higher magnification (Figure 3). Patient was

treated with Nitazoxanide 500mg orally once a day for 4 weeks for amebiasis and resulted in full resolution of symptoms. A repeat colonoscopy 4 weeks later showed (Figure 4) complete resolution of the previous cecal ameboma.

Figure 1. Colonoscopy showing a large (4 cms in size) exophytic ulcerated Discussion and Review of Literature cecal mass.

Ameboma is a rare presentation of colonic amebiasis mimicking a cecal carcinoma, first described by Read et al. in 1950.1 Its occurrence is tropical, and consequently almost all published literature (case reports and series) have predominantly been confined to this zone. 2-11 However, in the current era of global travel, this entity ought to be suspected in symptomatic individuals in the US with a travel history to high-risk geographical locations. Owing to its insidious and variable clinical presentation, only a few cases are diagnosed prior to surgical intervention, especially if biopsy proves to be inconclusive. Occasionally amebomas have been reported to cause bowel obstruction, bleeding, perforation or fistulation into another hollow viscus resulting in a surgical emergency. 12-15 It is critical to determine the location of the amebic infestation as successful therapy is dependent on the choice of treatment with a luminal, tissue or liver amebecide. Medical therapy with complete resolution has been described on previous occasions with metronidazole for colonic amebomas.16 Nitazoxanide has never been previously tried as a colonic amebecide for ameboma although

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Figure 3. Higher magnification of the histology showing numerous trophozoites with eccentric nuclei and flagellae.

Figure 4. A repeat colonoscopy performed 4 weeks after treatment shows complete resolution of the previous cecal ameboma.

it has shown efficacy in amebic dysentery.17 To our knowledge, this is the first reported successful therapy with Nitazoxanide, leading to a complete resolution of an ameboma.

Conclusion Colonic amebiasis is typically characterized by ulcers, but this is the first description of colonic amebiasis presenting as a large ulcerating mass mimicking a malignancy which completely resolved after a 4 weeks treatment with Nitazoxanide. n Table 1. Key Points.

carcinoma. Report of two cases with their roentgenologic manifestations. J Med Liban 1965;18:259-63.

4. Bertoye A, Naudin E, Garin JP, Humbert G, Phrasithideth P. Apropos of an indigenous case of cecal ameboma. Rev Lyon Med. 1966;15:713-21.

5. Parikh MK. Ameboma of colon and rectum. A report of 58 cases. J Assoc Physicians India. 1968;16:333-4.

6. Jofre Gutierrez JA. [Rectal ameboma]. Rev Esp Enferm Apar Dig 1976;47:249-54.

7. Wongpaitoon V, Kanjanapanjapol S, Nithiyanant P, Nirapathopongporn S. Gastric ameboma, a complication of amebic liver abscess: a case report. J Med Assoc Thai.

1985;68:378-83.

Table. Key Points about Intestinal Ameboma

8. Viswanathan R, Paul J, Jayaraman L, Venugopal K, Natarajan R. An ameboma--lest we forget. J Indian Med Assoc. 1986;84:18-20.

Ameboma, also known as an amebic granuloma, is a rare complication of Entamoeba infestation where the host response to the parasite results in the formation of colonic granulation tissue, resulting in a large local lesion of the bowel mimicking carcinoma, inflammatory bowel disease, tuberculosis or lymphoma.

A good travel history is crucial to suspect the diagnosis.

A biopsy is critical to establish the diagnosis.

A course of Nitazoxanide can be a potentially curative treatment and can be tried.

Complete resolution needs to be confirmed by colonoscopy after treatment.

9. Matsuura M, Nakase H, Fujimori T, Mizuma K, Tsuda Y, Chiba T. Cecal ameboma. Gastrointest Endosc. 2005;62:442-3; discussion 443.

10. Ray G, Iqbal N. Right colonic mass with hepatic lesion--remember ameboma? Indian J Gastroenterol. 2006;25:272.

11. Fernandes H, D’Souza CR, Swethadri GK, Naik CN. Ameboma of the colon with amebic liver abscess mimicking metastatic colon cancer. Indian J Pathol Microbiol. 2009;52:228-30.

12. Carayon A, Coyne F, Gaillard F, Herve A. Acute intestinal occlusion by ameboma; report of 5 personal cases. Med Trop .(Mars) 1956;16:663-76.

13. Lieberman RC, Goldberg HM. Perforated ameboma of the transverse colon: a case report. Mil Med. 1970;135:284-5.

Acknowledgment: The authors report no conflicts of interest.

References 1. Read WA, Nushan H. Amebic granuloma (ameboma) simulating carcinoma.

Gastroenterology 1950;15:771-9.

2. Parodi L. Ameboma, inflammatory colic tumor of characteristic anatomical features; concerning 4 cases. Med Trop. (Mars) 1958;18:755-82.

3. Balikian JP, Garabedian MM. Ameboma of the transverse colon simulating

14. Menda RK, Chulani HL. Cholecystocolonic fistula following ameboma of the ascending colon: report of a case. Dis Colon Rectum. 1971;14:386-8.

15. Legris T, Jaffar-Bandjee MC, Favre O, Lefrancois N, Genin R, Ragot C, Fernandez C, Reboux AH. Ameboma: an unusual cause of gastrointestinal bleeding during severe leptospirosis. BMC Infect Dis. 2014;14:299.

16.

Hardin RE, Ferzli GS, Zenilman ME, Gadangi PK, Bowne WB. Invasive amebiasis and ameboma formation presenting as a rectal mass: An uncommon case of malignant masquerade at a western medical center. World J Gastroenterol.

2007;13:5659-61.

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17. W hite AC, Jr. Nitazoxanide: an important advance in anti-parasitic therapy. Am J Trop Med Hyg. 2003;68:382-3.

Author Information Author Information: Department of Medicine, Division of Digestive Diseases, University of Mississippi Medical Center, Jackson (Shah, Borg, Gupta). Cornell School of Medicine, New York (Basu, Fortuzi). Icahn School of Medicine at Mount Sinai, JJP VA Medical Center, New York (Aloysius).

Calling All Mississippi Physician-Photographers Enter the 2020 Journal Cover Photo Contest

Corresponding Author: Niraj James Shah, MD; Assistant Professor of Medicine, Department of Medicine, Division of Digestive Diseases, University of Mississippi Medical Center, 2500 North State St., Jackson, MS 39216 Ph: (601)984-4540 ext. 7915 (jnshah@umc.edu).

Film or Digital Shoot anything you can capture as a high-resolution image. Subjects given the highest consideration are those indicative of Mississippi.

Photos of original artwork are also acceptable.

Pen > Sword

E

xpress your opinion in the JMSMA through a letter to the editor or guest editorial. The Journal MSMA welcomes letters to the editor. Letters for publication should be less than 300 words. Guest editorials or comments may be longer, with an average of 600 words. All letters are subject to editing for length and clarity. If you are writing in response to a particular article, please mention the headline and issue date in your letter. Also include your contact information. While we do not publish street addresses, e-mail addresses, or telephone numbers, we do verify authorship, as well as clarify ambiguities, to protect our letterwriters. You can submit your letter via email to: KEvers@MSMAonline.com or mail it to the Journal office at MSMA headquarters: P.O. Box 2548, Ridgeland, MS 39158-2548.

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The MSMA Committee on Publications will judge the entries on the merits of quality, composition, originality, and appropriateness to the JMSMA. Specifications: Vertical composition.

Color slides, digital files & photos (at least 300 DPI/PPI). A hard copy print is required for judging.

Please include a brief description of the photo and information about the physician/photographer.

Submit your narrative of the image to appear as “About the cover” in the magazine.

Size: Vertical format 5 x 7” or 8 x 10” Deadline: January 15, 2020

For more info contact:

Karen Evers, Managing Editor 601-853-6733, ext. 323 or KEvers@MSMAonline.com

Mail to:

P.O. Box 2548 Ridgeland, MS 39158-2548 or deliver to MSMA headquarters 408 W. Parkway Place, Ridgeland, MS 39157

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Top 10 Facts You Need to Know about Management of Sepsis and Septic Shock in Children PADMA GARG, MD; JENNIFER HONG, MD Keywords: Pediatric, Sepsis, Septic Shock, Shock, SIRS Abbreviations: Systemic inflammatory response syndrome (SIRS), quick sequential organ failure assessment score (qSOFA score) Introduction: Evolving Definitions of Sepsis Sepsis is a major contributor to pediatric morbidity and mortality.

Over the years, the definition of sepsis has been revised to allow early recognition and intervention to improve patient outcomes. The definitions of sepsis and sepsis-related syndromes were published in 1991 (“Sepsis-1”), revised in 2001 (“Sepsis-2”) and then in 2016 (“Sepsis-3”). The earlier two reports are recognized as “Sepsis-1” (1991) and “Sepsis-2” (2001), respectively. Sepsis-3 is the most recent report available with a modified definition of sepsis.

“Sepsis-1” In 1991, a consensus panel of experts provided with definitions for Systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis and septic shock.1 SIRS was defined as a systemic inflammatory response to a variety of severe clinical insults. The patient had to meet at least two of the following four criteria, one of which must include an abnormal temperature or leukocyte count: 1. Temperature >38°C or <36°C; 2. Heart rate >90 beats per minute; 3. Respiratory rate >20 breaths per minute or PaCO2 <32 mmHg; and 4. White blood cell count >12,000/cu mm, <4,000/cu mm, or >10% immature (band) forms.2 Sepsis was defined as a systemic response to infection (presumed or documented), manifested by two or more of the SIRS criteria.2 Severe sepsis was defined as sepsis associated with organ dysfunction. And Septic Shock was defined as sepsis-induced with hypotension despite adequate fluid resuscitation along with the presence of perfusion abnormalities “Sepsis-2” In 2001, the panel of experts revisited the definition and modified it to be later called “sepsis-2.” The consensus retained the original definitions of sepsis as SIRS due to infection (presumed or confirmed), and severe sepsis was defined as sepsis associated with organ dysfunction. The criteria for SIRS were, however, expanded to include more varied organ dysfunction variables for severe sepsis.3 The adult SIRS and sepsis criteria were modified for children in 2005. Age-dependent variables

were taken into account, and values above 2 standard deviations for age were considered abnormal.3 Adapting this definition to pediatrics remained difficult even after using age modified criteria for vital signs like heart rate, blood pressure in children. SIRS is a common manifestation in febrile children, especially in winter months. Despite being afebrile, many children can easily meet the criteria for SIRS, even without an infection.4 “Sepsis-3” Considering the previous limitations, new sepsis criteria were designated as “Sepsis-3” in 2016 which defined sepsis as “lifethreatening organ dysfunction caused by a dysregulated host response to infection.”

Septic shock is now to be defined as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities substantially increase mortality. The term “severe sepsis” has been removed.5 The task force has identified new clinical criteria to facilitate the diagnosis of sepsis that providers can use in their offices, emergency departments, and hospital wards to quickly evaluate and assess patients for sepsis. The new diagnostic tool is called quicksofa or qSOFA (quick Sequential Organ Failure Assessment) tool.5 The qSOFA tool directs providers to look for these 3 warning signs in patients: • An alteration in mental status • A decrease in systolic blood pressure of less than 100 mm Hg • A respiration rate greater than 22 breaths/min Data indicate that morbidity and mortality increase for patients with two or more of these conditions. If a patient has two or three components of qSOFA, the patient should also be examined for organ failure.

The task force identifies two new clinical criteria to diagnose patients with septic shock. These criteria are: • Persisting hypotension requiring vasopressors to maintain MAP ≥65mm Hg • Blood lactate >2 mmol/L despite adequate volume resuscitation The mortality rate of septic shock is 4 times greater than sepsis alone. 5 To adapt the Sepsis-3 criteria to pediatrics, the qSOFA criteria have been modified for pediatric use by Matics et al.6 However, there is still

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Table. Definitions/Crieteria 2006 (Sepsis-3)

Table. Definitions and Criteria 2006 (Sepsis‐3) Terminology

Definition

Clinical criteria

Screening for sepsis (Suspected sepsis)

An increase of 2 or more in the qSOFA score should create a suspicion of sepsis and organ dysfunction.

qSOFA score 1. Altered mental status (GCS score <15) 2. Systolic blood pressure <100 mmHg 3. Respiratory rate >22/min Two or more than 2 criteria should be present.

Sepsis

Sepsis is life‐threatening organ dysfunction caused by a dysregulated host response to infection.

Suspected or documented infection and an acute increase of ≥2 SOFA points (a proxy for organ dysfunction as shown above)

Septic shock

Septic shock is a subset of sepsis in which underlying circulatory and cellular/ metabolic abnormalities are profound enough to increase mortality substantially.

1. Sepsis 2. Vasopressor therapy needed to elevate MAP ≥65 mm Hg 3. lactate >2 mmol L−1 (18 mg dL−1) despite adequate fluid resuscitation All 3 criteria should be present.

a need for more widely used consensus criteria for pediatric SOFA and pediatric sepsis. A task force of leading sepsis experts is continuing to work in order to provide better tools to the providers to allow early diagnosis and management of sepsis.

Management of Sepsis and Septic Shock in Children With the changing definitions, more emphasis has been placed on timely recognition of sepsis and appropriate management.

Here are 10 facts that will help with the management of sepsis and septic shock in children.

Assessment, Diagnosis and Early Intervention.

Once a working diagnosis of suspected sepsis, sepsis or septic shock has been made, the circulatory and respiratory status of the child should be assessed, and support should be provided accordingly.

1

Appropriate respiratory support includes face mask oxygen, nasal cannula, high flow nasal cannula, non-invasive positive pressure ventilation or intubation. The choice of the type of respiratory support should be determined by the work of breathing and the patient’s response to the respiratory support provided. Even without respiratory distress, oxygen should be provided to increase the availability of oxygen to the tissues to meet the increased metabolic needs.7 In clinical trials, the early appearance of oxygen debt suggested that lack of tissue oxygenation may be the primary event leading to organ failure and death. Increasing oxygen delivery can decrease organ failure and mortality.7 Intravenous or intra-osseous access should be established. Intravenous fluids and inotropes can be provided through these until stable central access can be obtained.

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Arrangements should be made to transfer the patient to an ICU early in the management, especially if the patient does not improve with the initial resuscitative efforts or is critically ill secondary to septic shock.

Fluid Resuscitation.

The goals for resuscitation should be the reversal of shock. Signs of shock include hypoxia, heart rate above more than 2 standard deviations for age, blood pressure lower than 2 standard deviations for age, weak central and peripheral pulses, prolonged capillary refill (could be brisk in case of compensated shock), elevated serum lactate (more than 2 mmol/L), urine output less than 1ml/kg/hour, Mixed venous oxygen saturation<70%, altered mental status.5

2

In the case of shock, fluid resuscitation should begin with 20ml/kg of crystalloids or albumin, using either the manual “push-pull” method or a rapid infuser. After the initial bolus, the patient should be immediately assessed for signs of shock reversal or need for further boluses.8 If hepatomegaly or rales develop, inotropes should be initiated. 9 However, if the child is not hypotensive and has severe anemia, the use of packed red blood cells is superior to crystalloid or albumin boluses.9 Antibiotics.

Intravenous antibiotics should be initiated within 1 hour of diagnosis of sepsis. Combination therapy with at least two classes of antibiotics should be used when a patient is in shock along with sepsis (aka septic shock). Combination therapy should not routinely be used for patients without shock.10

3

Ideally, blood cultures should be obtained before administering antibiotics but should not delay administration of antibiotics. The selection of antimicrobial agents is based on a combination of patient factors, predicted infecting organism(s), and local microbial resistance patterns.11 Routinely, an anti-microbial combination effective against most typical gram-negative and gram-positive organisms is chosen. A common combination used is third generation cephalosporins with

vancomycin. If there is acute kidney injury on presentation, the dosage of antibiotics should be renally adjusted. If an abdominal infection is suspected or anaerobe coverage is necessary, metronidazole should be added. Piperacillin-tazobactam along with vancomycin combination has fallen out of favor because of increased nephrotoxicity with the combination of these antibiotics.12 Additional antimicrobials should be added if unusual organisms not covered by the chosen antibiotics are suspected. For example, oseltamivir should be added in suspected or confirmed influenza infection. In patients with neutropenia, recent ICU stay, repeated hospitalization with increased risk for pseudomonas and hospital-acquired infection a fourth-generation cephalosporin is preferred over a third generation. Neonates are treated with ampicillin and gentamycin as first-line antimicrobials. Acyclovir is added for suspected or pending HSV tests.9 Empiric use of antifungals may be needed in some patients who have already been on prolonged antibiotics and/or have central venous catheters and/or are at increased risk for fungal infection. Early and aggressive source control should be achieved. Depending on suspicion and age of child, obtaining urine and CSF cultures should be considered. In neonates, blood, urine and CSF cultures should be obtained. Obtaining a lumbar puncture should not delay the initiation of antimicrobials.

Fluid Refractory Shock.

If the clinical state of shock is not reversed with fluid resuscitation, it is then termed as “fluid refractory shock.” For fluid refractory shock, vasoactive agents are indicated. Norepinephrine is the first choice for patients who need vasopressors in septic shock, often a state of “warm shock” (warm extremities and brisk capillary refill).9 Vasopressin or epinephrine can be added if the goal blood pressure cannot be maintained on norepinephrine alone. For patients who remain unstable, dobutamine may be added.9 Infants and younger children may sometimes present with “cold shock”(hypotension with cold extremities and poor perfusion). Epinephrine is considered as the first choice vasoactive agent in these patients.13,14 Nor-epinephrine can be added as a second-line agent. Use of vasopressors and inotropes should prompt transferring the patient to a critical care unit.10

4

Obtaining an echocardiogram should be considered under these circumstances to assess the contractile function of the heart to repeatedly evaluate hemodynamics among septic children as sepsisassociated myocardial dysfunction is known widely.4,15,16 Blood Products.

Blood transfusion should be reserved for patients with a hemoglobin concentration of <7.0 g/dL, except in special circumstances such as acute hemorrhage or myocardial ischemia. Platelets should be given if the platelet count is <10,000/ mm3 or <20,000/mm3 with active bleeding.10 Steroids.

Intravenous hydrocortisone (200 mg/day) is suggested for the treatment of septic shock in adult patients who are hemodynamically unstable despite fluids and vasopressors.10

5

6

There is evidence to support the treatment of children with fluidresistant, catecholamine-refractory septic shock with hydrocortisone (50 to 100mg/m2/24hrs).17 Such patients may have relative adrenal insufficiency, more recently termed critical illness-related corticosteroid

insufficiency. Children at risk for absolute adrenal insufficiency should be given stress-doses of hydrocortisone (50 to 100mg/m2/24hrs) as soon as possible.4,18 Risk factors for absolute adrenal insufficiency include use of exogenous steroids for more than seven days in the past two weeks; hypothalamic, pituitary, or adrenal disease; and purpura fulminans.17,18 Ventilator Support.

Neonates and infants have a low functional residual capacity and a high work of breathing, which increases further if the metabolic needs of the body increase. Intubation and mechanical ventilation should be considered early if the child is in respiratory distress, requiring high inotropic support or requires sedation for placement of central venous access.8

7

Induction drugs for intubation should be carefully selected so as to avoid excessive cardiovascular depression. Large doses of thiopentone, propofol and midazolam should be avoided.8 Low doses may be cautiously used depending on the hemodynamic status of the patient. Ketamine (1-2mg/kg) is considered a good induction agent of choice. Rapid sequence induction with pre-oxygenation with 100% FiO2, if feasible, is preferred. Short-acting neuro-muscular blockade is used to facilitate intubation. There is a potential for rapid deterioration peri-intubation, and appropriate fluid boluses and inotropes should be available.

Blood Sugar Control.

Hypoglycemia is a common finding in neonates and younger infants with sepsis because of decreased glycogen stores. This should be identified early and corrected using boluses of dextrose.

Short-term treatment of hypoglycemia consists of an intravenous (IV) bolus of dextrose 10% 2-5 mL/kg. After the bolus is administered, an IV infusion that matches normal hepatic glucose production (approximately 5-8 mg/kg/min in an infant and about 3-5 mg/kg/min in an older child) should be continued.

8

Hyperglycemia is also a common finding in children with septic shock and has been identified as a risk factor for mortality in observational studies.19 Currently, guidelines recommend insulin therapy to avoid blood glucose value >180 mg/dL while also avoiding hypoglycemia 9 Glucose infusion should accompany insulin therapy in neonates and young children.

Extracorporeal Membrane Oxygenation (ECMO).

ECMO should be considered for fluid, and catecholamine refractory pediatric septic shock and respiratory failure.9 Data now suggest a 50% and 80% survival to discharge in pediatric and neonatal patients, respectively, with septic shock following ECMO. 18 ECMO is not curative; rather, it supports the organ systems while other supportive measures are continued, infection is controlled and the cardio-pulmonary insufficiency recovers. If ECMO is not available at your center, early transfer to a center capable of initiating and managing ECMO should be initiated.

Quality Improvement.

A sepsis identification pathway using quality improvement methodology has been found to provide timely evaluation and treatment for pediatric sepsis, which in turn improves outcomes.

The pathway provides a standardized process to identify and evaluate children with possible sepsis.17 This includes but is not limited to

9

10

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electronic medical record systems giving alerts to evaluate for sepsis when the vital signs for a particular child are in the abnormal range.

8. Keeley A, Hine P, Nsutebu E. The recognition and management of sepsis and septic shock: a guide for non-intensivists. Postgrad Med J. 2017;93(1104):626-634.

Commentary Presently, many of the emergency departments in the country have an electronic medical record system set up to alert the providers to evaluate patients for sepsis based on abnormal vital signs and/or abnormal laboratory values, for instance, leukocytosis or leukopenia. This is a highly effective approach to identify possible sepsis. The specificity, however, is low. Providers should recognize that a patient may have systemic inflammatory responses to diverse disorders including infection, pancreatitis, ischemia, multiple trauma, hemorrhagic shock, and immunologically mediated organ injury.2 Sepsis is a subset of SIRS. In cases of suspected sepsis, cultures should be obtained when feasible, and organ dysfunction should be evaluated. This gives a quick appraisal of the seriousness of illness and also prompts the provider to address the organ dysfunction early. However, diagnostic tests should not delay treatment. Tertiary care hospitals should be called for guidance from the time of initial management of a septic child and discussions be initiated regarding early transfer for continued care. n

9. Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med. 2013;39(2):165-228.

Acknowledgment

10. Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Crit Care Med. 2017;45(3):486-552.

11. Buckman SA, Turnbull IR, Mazuski JE. Empiric Antibiotics for Sepsis. Surg Infect (Larchmt). 2018;19(2):147-154.

12. Rutter WC, Burgess DR, Talbert JC, Burgess DS. Acute kidney injury in patients treated with vancomycin and piperacillin-tazobactam: A retrospective cohort analysis. J Hosp Med. 2017;12(2):77-82.

13. Ventura AM, Shieh HH, Bousso A, et al. Double-Blind Prospective Randomized Controlled Trial of Dopamine Versus Epinephrine as First-Line Vasoactive Drugs in Pediatric Septic Shock. Crit Care Med. 2015;43(11):2292-2302.

14. R amaswamy KN, Singhi S, Jayashree M, Bansal A, Nallasamy K. DoubleBlind Randomized Clinical Trial Comparing Dopamine and Epinephrine in Pediatric Fluid-Refractory Hypotensive Septic Shock. Pediatr Crit Care Med. 2016;17(11):e502-e512.

The authors report no conflict of interest.

15. Rudiger A, Singer M. Mechanisms of sepsis-induced cardiac dysfunction. Crit Care Med. 2007;35(6):1599-1608.

References

16. Zanotti-Cavazzoni SL, Hollenberg SM. Cardiac dysfunction in severe sepsis and septic shock. Curr Opin Crit Care. 2009;15(5):392-397.

1. Bone RC, Sibbald WJ, Sprung CL. The ACCP-SCCM consensus conference on sepsis and organ failure. Chest. 1992;101(6):1481-1483.

2. Bone RC, Balk RA, Cerra FB, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/ Society of Critical Care Medicine. Chest. 1992;101(6):1644-1655.

17. Martin K, Weiss SL. Initial resuscitation and management of pediatric septic shock. Minerva Pediatr. 2015;67(2):141-158.

18.

Brierley J, Carcillo JA, Choong K, et al. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med. 2009;37(2):666-688.

3. Goldstein B, Giroir B, Randolph A, International Consensus Conference on Pediatric S. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med. 2005;6(1):2-8.

19. Branco RG, Garcia PC, Piva JP, Casartelli CH, Seibel V, Tasker RC. Glucose level and risk of mortality in pediatric septic shock. Pediatr Crit Care Med. 2005;6(4):470-472.

4. Kawasaki T. Update on pediatric sepsis: a review. J Intensive Care. 2017;5:47.

Author Information Author Information: Pediatric critical care medicine, Blair E.Batson Children’s Hospital, University of Mississippi Medical Center, Jackson, MS (Garg, Hong).

5. Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810.

6. Matics TJ, Sanchez-Pinto LN. Adaptation and Validation of a Pediatric Sequential Organ Failure Assessment Score and Evaluation of the Sepsis-3 Definitions in Critically Ill Children. JAMA Pediatr. 2017;171(10):e172352.

7. Roberts JK, Disselkamp M, Yataco AC. Oxygen Delivery in Septic Shock. Ann Am Thorac Soc. 2015;12(6):952-955.

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Fecal Microbiota Transplantation for Clostridium difficile Colitis: A Review and Report of the Jackson, Mississippi Experience JAMES A. UNDERWOOD, III; JAMES Q. SONES, MD Abstract As the rudimentary understanding of the scope and significance of the human gut microbiome expands, there is understandable progression of efforts to manipulate it for therapeutic purposes. Arguably the most direct and impactful such attempt has involved the ongoing evolution of fecal microbiota transplantation for Clostridium difficile colitis, the most common etiology of healthcare-associated infections in the United States. From March 2018 through April 2019, fecal transplantations performed by Gastrointestinal Associates in Jackson, MS, using exclusively stool bank donor material, produced clinical cure in 85% cases of recurrent or relapsing Clostridium difficile for which follow-up data were available.

Keywords: Clostridium difficile, fecal microbiota transplantation, gastrointestinal microbiome, Mississippi THE HUMAN GUT MICROBIOME Often used interchangeably, the human “microbiota” refers to all the bacteria, archaea, and viruses—pathogenic or otherwise—that share the human body space, while the term “microbiome” refers to the collective DNA of these organisms.1 The human microbiome of any individual is estimated to contain anywhere from one to ten times the amount of genetic material as that of its human host, and the majority is located within the intestinal tract.2 This genetic material possesses the ability to trigger and interact with our heritable gene pool and has a major role in development of the immune system. Significant variation in the human gut microbiota composition has been noted based on sex, ethnicity, and age.1 Additionally, large-scale differences have been found between the fecal microbiota of rural, third-world subjects consuming primarily plant-based diets and those consuming the typical Western diet.3 Within both the scientific community and the general public, there has been growing interest in better understanding the role of the intestinal microbiome, with an eye toward keeping it healthy and manipulating it for therapeutic purposes. Multiple studies have supported that the diversity of bacterial species in the human gut may be associated with health and that particular groups (e.g., Bacteroides, Bifidobacterium, some Clostridium species, and Lactobacillus) may have specific health impacts.4 While the gut microbiome has generally been shown to be

resilient in its ability to recover from insults induced by such factors as antibiotic use, travel, and changes in activity, some such alterations have shown the capacity to negatively impact human health.1 CLOSTRIDIUM DIFFICILE INFECTION In 2011 it was reported that Clostridium difficile, a Gram-positive, anaerobic, spore-forming and toxin-producing bacillus, had surpassed methicillin-resistant Staphylococcus aureus as the most common cause of healthcare-associated infection in the southeastern United States.5 C. difficile infection (CDI) causes symptoms ranging from mild, watery diarrhea to potentially deadly pseudomembranous colitis.6 The standard therapy for both non-severe and severe initial episodes of CDI is a course of oral vancomycin or fidaxomicin. As of 2018, metronidazole is no longer recommended as first-line therapy.7 However, a sizable portion of patients with CDI develop recurrence which can lead to significant morbidity and mortality. Antibiotics have been implicated in the pathogenesis of CDI as their use can lead to microbial imbalance, or dysbiosis, which allows C. difficile to flourish.8 Metagenomic analyses have revealed reduced richness and diversity in the gut microbiome of CDI patients compared with healthy controls, leading to efforts to therapeutically restore gut microbial communities in a sustained manner.9 FECAL MICROBIOTA TRANSPLANTATION Despite a movement toward the more aesthetically pleasing term “intestinal microbiota transplantation,”10 fecal microbiota transplantation (FMT) remains the most commonly used descriptor for the delivery of fecal material from a donor into the intestinal tract of a recipient for the purpose of directly altering the recipient’s microbial composition and conferring a health benefit.8 The idea of FMT has parallels in veterinary medicine where “transfaunation” has been used for centuries to treat equine diarrhea and other gastrointestinal disorders.11 The first known description of fecal therapy in humans was in fourth-century China for the treatment of a variety of conditions including diarrhea.12 Its first appearance in mainstream medicine was in a 1958 report by Eiseman and colleagues in which four patients with pseudomembranous colitis, three of whom were “in a critical state,” were asymptomatic within hours of receiving fecal enemas.13 For years, FMT remained a largely forgotten therapy; the first documented case of confirmed CDI successfully treated with FMT was reported in 1983.14 NOVEMBER/DECEMBER • JOURNAL MSMA

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Since then, the epidemic of increasingly severe CDI,15 our greater understanding of the human intestinal microbiome, and favorable media coverage have led to significant increases in FMT utilization as well as speculation that it may eventually prove helpful in other conditions associated with intestinal dysbiosis, such as inflammatory bowel disease, irritable bowel syndrome, neurologic disorders, the metabolic syndrome, and many others.8 Despite reported 87-90% CDI cure rates16 and literature support as a safe and well-tolerated treatment,8 FMT is not yet universally available. Additionally, the U.S. Food and Drug Administration (FDA) still considers FMT investigational, and its June 2019 safety communication reporting transmission of multidrug resistant organisms (MDROs) in two immunocompromised recipients (one of whom died) provided the reminder that “while we support this area of scientific discovery, it’s important to note that FMT does not come without risk.”17 Such reports emphasize the need for further research and continued standardization of protocols.

CURRENT FMT GUIDELINES AND METHODS In 2010, representatives from various invested specialties created an FMT consensus statement.11 Outlined primary indications are: 1.Recurrent or relapsing CDI, defined as (a) three or more episodes of mild to moderate CDI and failure of a 6-8 week vancomycin taper, with or without an alternative antibiotic such as rifaximin, nitazoxanide, or fidaxomicin, or (b) at least two episodes of CDI resulting in hospitalization.

2. Moderate CDI not responding to standard therapy (vancomycin or fidaxomicin) for at least a week.

3. Severe (even fulminant) CDI with no response to standard therapy after 48 hours.

Donor selection and screening are obviously key and evolving elements of the FMT process. The donor may be an intimate partner, friend, or unrelated volunteer. Current guidelines recommend using a donor questionnaire similar to current protocols for screening blood donors and excluding individuals with history of, for example, recent antibiotic use, gastrointestinal (GI) illnesses (irritable bowel syndrome, chronic constipation, inflammatory bowel disease, etc.), autoimmune illnesses, chronic pain syndromes, obesity, or malignancy. Suggested laboratory testing is rigorous and includes serologic (viral hepatitis, HIV, RPR) and various stool pathogens. It should be noted that the stool donor source implicated in the recent FDA alert was reportedly not screened for MDROs as recommended. Evidence shows that the success of FMT does not depend on the donor-patient relationship, and, as a result, the use of unrelated donor stool is becoming widely accepted with the creation of stool banks.18 One such independent stool bank in Massachusetts, OpenBiome (www.openbiome.org), operates as a nonprofit while a number of for-profit microbiome-based therapeutic ventures have also been founded.

Donated fecal samples are prepared by mixing with water or normal saline, followed by a filtration step to remove any particulate matter.

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The mixture can then be administered nasoenterically, via upper or lower GI endoscopy, by retention enema, or orally with frozen FMT capsules.19,20j Current data have suggested that colonoscopy may be the most effective strategy, but capsule FMT offers advantages of convenience and aesthetics. Cost-effectiveness models support FMT over antibiotic therapy for treating recurrent CDI, though more data is needed regarding the cost-effectiveness of capsule FMT.18 FMT: THE JACKSON, MISSISSIPPI, EXPERIENCE In 2012, Gastrointestinal Associates and Endoscopy Center, PA, (GIA) located in Flowood, MS, performed its first FMT for CDI. As was the case worldwide, early FMT efforts involved rigorously screened patient relatives or healthy volunteers as donors. Over the ensuing years, numbers of FMT procedures gradually increased until in early 2018 when, citing lack of demonstrated inferiority as compared with related donors, ease of donor access and availability, and avoidance of difficult conversations with related donors, GIA elected to turn to exclusive use of unrelated donors via stool banks. Since March 2018, all FMTs performed by GIA have used donated specimens provided

by OpenBiome which now provides most of the fecal matter for FMTs in the United States.22 Given this and the fact that GIA is reported to have performed all or nearly all of the FMTs done in central Mississippi since that time, the decision was made to assess the data available for all FMTs performed over the one year time period from onset of exclusive utilization of stool bank donors.

Methods And Results

A retrospective chart review was performed on all FMT procedures performed by GIA physicians during the defined study period.

From March 1, 2018, when GIA transitioned to obtaining all FMT transplant specimens from OpenBiome, through April 26, 2019, 52 FMT procedures were performed for recurrent or refractory CDI. Protocols for both GIA and OpenBiome require an office visit 8 weeks after the FMT procedure, and 33 patients complied. Of those patients presenting for follow-up, 28 (84.8%) reported symptom resolution and were considered cured, while five patients (15.2%) were deemed non-responders based on a combination of persistent symptoms and positive repeat stool testing for C. difficile.

DISCUSSION These results, involving GIA patients with recurrent or refractory CDI receiving FMT from a stool bank source, are consistent with the historical efficacy reported in the literature. While follow-up data are unavailable for nineteen of the 52 patients undergoing FMT, it is known that all were successfully discharged following FMT and likely that the majority of these subjects were lost to follow-up due to perceived symptom resolution. Additionally, it is acknowledged that the means of diagnosing CDI and defining “cure” are inexact in that a patient with diarrhea from causes other than CDI can have low levels of toxin gene related to C. difficile colonization, resulting in a positive highly sensitive polymerase chain reaction stool assay.23 This would suggest that the FMT efficacy data reported here and elsewhere

might actually be higher with the use of stricter definitions or altered diagnostic protocols.

It is anticipated that the local Mississippi experience with FMT will continue to mirror that occurring nationally and worldwide with expansion of confidence and comfort in this treatment modality for C. difficile bolstered by the broadened availability provided by stool bank donor sources. Of course, this expansion must be balanced by the need for further standardization of protocols and longer-term data. While the FDA’s advisements for caution are understandable and prudent, the exploding interest—both scientific and otherwise—in pathology perceived attributable to intestinal dysbiosis makes retreat on the microbiome battlefront unlikely. n Acknowledgment The authors report no conflict of interest.

References 1. Hollister E, Gao C, Versalovic J. Compositional and functional features of the gastrointestinal microbiome and their effects on human health. Gastroenterology.

2014;146:1449-1458.

2. Qin J, Li R, Raes J, et al. A human gut microbial gene catalogue established by metagenomic sequencing. Nature. 2010;464:59-65.

3. De Filippo C, Cavalieri D, Di Paola, et al. Impact of diet in shaping gut microbiota revealed by a comparative study in children from Europe and rural Africa. Proc Natl Acad Sci USA. 2010;107:14691-14696.

4. Wang Y, Hoenig J, Malin K, et al. 16s rRNA gene-based analysis of fecal microbiota from preterm infants with and without necrotizing enterocolitis. ISME J. 2009;3:944-954.

5. Miller B, Chen L, Sexton D, et al. Comparison of the burdens of hospital-onset, healthcare facility-associated Clostridium difficile infection and of healthcareassociated infection due to methicillin-resistant Staphylococcus aureus in community hospitals. Infect Control Hosp Epidemiol. 2011;32:387-390.

13. Eiseman B, Silen W, Bascom G, et al. Fecal enema as an adjunct in the treatment of pseudomembranous enterocolitis. Surgery. 1958;44:854-859.

14. Schwan A, Sjolin S, Trottest U, et al. Relapsing Clostridium difficile enterocolitis cured by rectal infusion of homologous faeces. Lancet. 1983;2:845.

15. Dubberke E, Olsen M. Burden of Clostridium difficile on the healthcare system. Clin Infect Dis. 2012;55(Suppl. 2):S88-S92.

16. Kassam Z, Lee C, Yuan Y, et al. Fecal microbiota transplantation for Clostridium difficile infection: systematic review and meta-analysis. Am J Gastroenterol.

2013;108:500-508.

17. McSeveney M. FDA in brief: FDA warns about potential risk of serious infections caused by multi-drug resistant organisms related to the investigational use of fecal microbiota for transplantation. U.S. Food & Drug Administration. https://www. fda.gov/news-events/fda-brief/fda-brief-fda-warns-about-potential-risk-seriousinfections-caused-multi-drug-resistant-organisms. June 13, 2019. Accessed August 25, 2019.

18. R amai D, Zakhia K, Ofosu A, et al. Fecal microbiota transplantation: donor relation, fresh or frozen, delivery methods, cost-effectiveness. Ann Gastroenterol.

2019;32:30-38.

19. Hopkins R, Wilson R. Treatment of recurrent Clostridium difficile colitis: a narrative review. Gastroenterol Rep (Oxf). 2017;6(1):21-28.

20. McDonald L, Gerding D, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018;66(7):987-994.

21. GI Associates & Endoscopy Center. GI Associates & Endoscopy Center in Mississippi. https://gi.md/about-us#history. Accessed August 25, 2019.

22. Faecal quality control. Nat Microbiol. https://www.nature.com/articles/s41564019-0535-1. July 23, 2019. Accessed August 25, 2019.

23. Lamouse-Smith E, Weber S, Rossi R, et al. Polymerase chain reaction test for Clostridium difficile toxin B gene reveals similar prevalence rates in children with and without inflammatory bowel disease. J Pediatr Gastroenterol Nutr. 2013;57:293-297.

Author Information

7. Ng K. Updates in the management of Clostridium difficile for adults. US Pharmacist.

2019;44:HS9-HS12.

Author Information: Founder and Director of Halfhuman.org; Senior, Jackson Preparatory School, Flowood, MS (Underwood).

Professor of Medicine, Division of Digestive Diseases, University of Mississippi Medical Center, Jackson (Sones).

8. Kelly C, Kahn S, Kashyap P, et al. Update on fecal microbiota transplantation 2015: indications, methodologies, mechanisms, and outlook. Gastroenterology.

2015;149:223-227.

Corresponding Author: James A. Underwood, III; 732 Arlington St., Jackson, MS 39202 Ph: (601)278-8267 (jimmy@halfhuman.org).

6. Bauer M, Notermans D, Van Benthem B, et al. Clostridium difficile infection in Europe: a hospital-based survey. Lancet. 2011;377:63-73.

9. Shahinas D, Silverman M, Sittler T, et al. Toward an understanding of changes in diversity associated with fecal microbiome transplantation based on 16s RRNA gene deep sequencing. MBio. 2012;3:e00338-12.

10. Cleaning Up an Image: the Crusade to Rename Fecal Microbiota Transplant.

Healio Website. https://www.healio.com/gastroenterology/infection/ news/online/%7Bf631321d-929b-4e38-a286-62d143218686%7D/ get-the-lsquofrsquo-out-of-here-a-crusade-to-rename-fecal-microbiotatransplant?page=2. Published August 26, 2019. Accessed August 28, 2019.

11. Bakken J, Borody T, Brandt L, et al. Treating Clostridium difficile infection with fecal microbiota transplantation. Clin Gastroenterol Hepatol. 2011;9:1044-1049.

12. Zhang F, Luo W, Shi Y, et al. Should we standardize the 1,700-year-old fecal microbiota transplantation? Am J Gastroenterol. 2012;107:1755-1756.

[The JMSMA editors note that this article is unusual in that a high school student submitted it. Jimmy Underwood should give all of us who are practicing physicians in Mississippi great hope for the future.

Jimmy became interested in the gut microbiome, and his study led him to found an organization to spur interest in this important area of study, Half Human.org. He spent time last summer in San Diego, working in the lab of one of the foremost research scientists in the field of intestinal microbes. Jimmy is the son of MSMA member Dr. James A. Underwood. Congratulations to Jimmy Underwood, and we look forward to observing his career unfold in the future.] —Ed.

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I M A G E S

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THE SCIENCE HALL AT OLE MISS, THE FIRST MEDICAL SCHOOL BUILDING, 1906-1934 – After being formulated as far back as 1870, the University of Mississippi School of Medicine, then called the Department of Medicine, finally opened at Oxford in the fall of 1903 with sixteen students (the 1904 annual later lists only fifteen). Chancellor Robert F. Fulton, Dr. Waller S. Leathers, and Dr. Peter Rowland appear to have been the critical leaders accomplishing its creation. The Medical Department was an evolving work in progress from the day it opened until years afterwards. The first “home” of the department was two classrooms and an office located in a wing of the antebellum Lyceum building. A small frame structure was built nearby for dissection purposes. The major expense of the department’s first year of operation was not construction but rather the purchase of enough microscopes for the original sixteen students. More monies were needed to develop the school fully and that funding would only come from the Legislature. In the 1904 session, the Legislature passed $12,500 for “apparatus and equipment for scientific department” and $10,000 for “building… and furnishing for infirmary.” In the 1906 session, a more ambitious $40,000 was provided for the erection of “a science hall” and an additional $5,000 was allocated for “the equipment of science hall.” This larger appropriation was directly related to the medical school, as it would serve as its home. This photograph features on the left the Science Hall, the massive structure built from these monies in 1906-07. The School of Medicine was located here from that time until 1934, when it moved to Guyton Hall (which would serve as the home of the medical school until it moved to Jackson in 1955). On the back of this photo is written: “Univ. of Miss. Oxford, Miss.

Dec. 5, 1911- Science Building and Old Dormitory.” The structure had modern laboratories and a prominent basement which was crafted with large concrete troughs to store human cadavers. By 1918, the “Ole Miss” annual would even refer to the structure as the “Medical Building.” Historian David G. Sansing notes: “Of the several new buildings constructed in the early 1900s, the most imposing was the Science Hall, a four-story brick structure that housed most of the science departments and the university’s medical school. The Science Hall was located on the site now occupied by Hume Hall.” This building no longer stands, and photographs show it during its more than fifty-year life in the heart of the Ole Miss campus, across University Circle from the Confederate statue which was also erected in 1906, near present-day Hume and Shoemaker Halls, which were built in the 1960s after Science Hall was razed. If you have an old or even somewhat recent photograph which would be of interest to Mississippi physicians, please send it to me at lukelampton@ cableone.net or by snail mail to the Journal. n — Lucius M. “Luke” Lampton, MD JMSMA Editor

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Edited by Lucius Lampton, MD; JMSMA Editor

[This month, we print a poem offered by the first medical school class of 1904 at the University of Mississippi School of Medicine, inspired by one of the first gross anatomy classes ever offered in Mississippi. Yes, it is only a brief five lines, which includes its title, but in its brevity, it seems to capture the serious approach of most students to dissection (“with steady eye and careful aim”), as well as the prodigious breadth of anatomical nomenclature. It appears on page 135 of the Ole Miss annual of 1904, the first year of Ole Miss’s medical school. Reference to the expression “helatious” may capture one of the first slang uses of the word in history. The origin of the word “hellacious” appears to have first been college slang as fanciful formation from hell of a (see “hell”) + “-acious”(see bodacious or audacious). It means “exceptionally powerful or violent,” “remarkably good,” “extremely difficult,” or “extraordinarily large.” The third definition appears to be its slang use here. The first known use of the word (prior to the discovery of this poem) is recorded to be 1929 and the 1930s (according to Merriam-Webster and other dictionaries). However, its use here in 1904 in the Ole Miss annual marks the first recorded use of the term and suggests its American origin dates to an earlier period than previously thought by etymologists.

Did Ole Miss medical students introduce the term into our modern lexicon after suffering through Gross Anatomy? Such seems possible and understandable to those of us who also experienced Gross Anatomy at the University of Mississippi! The fact that it is misspelled “helatious” with one “l” and not two perhaps indicates a sensitivity not to spell the word in that time of Victorian values as the dreaded home of the devil “hell.” Also, could this be a play on Flexor and Extensor Hallucis Longus and Brevis muscles and tendons (the Latin term “hallucis” meaning “of the big toe”)? Any further etymologic insight by our readers is appreciated. See also this month’s “Images” for more on the first gross anatomy classes at Ole Miss. Any physician is invited to submit poems for publication in the Journal either by email at lukelampton@cableone.net or regular mail to the Journal, attention: Dr. Lampton.] — Ed.

In Dissecting Room With steady eye and careful aim He cut each slender muscle entwain, And though no matter from whence it came Each muscle had an helatious name.

— Offered by the first medical school class at Ole Miss, University of Mississippi School of Medicine, Class of 1904, Reprinted from the Ole Miss annual, page 135 NOVEMBER/DECEMBER • JOURNAL MSMA

365

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U N A

V O C E

Why I Still Believe in Christmas Cards 1

Why I Still Believe in Christmas Cards DWALIA Dwalia S. South, MDS. SOUTH, MD My Bigmama, Dora Lee Whitten McCown, bequeathed me the legacy of a deep appreciation for life’s simplest joys-- long, cooling drinks of water from the gourd dipper by the side of her well-house, little afternoon siestas on sweltering August days next to that softly droning ‘Sears and Roebuck’ floor fan of hers, chocolate stacked teacakes, mud ‘frog houses’ we made at the end of the long cotton rows, and her timeworn shoebox from Braddock’s Dry Goods store packed full of wonderful old Christmas cards tied with string. While all the others of the family had to drag cotton sacks My Bigmama, Dora Lee Whitten McCown, bequeathed me the legacy of a deep through Papaw’s fields, Bigmama and I were excused. I was too little to appreciation simplest joys--what long, coolingcalled drinks be of much use,for andlife’s Bigmama had suffered Dr. Mauney “a of water from the gourd dipper bylight thestroke” side back of her well-house, little afternoon siestas on in the early ’50s. She and I were spared the ardors ofsweltering August days next to that softlyindroning ‘Sears and Roebuck’ floor fanbigofcotton hers, chocolate stacked teacakes, fieldwork those stifling and back-breaking days over in the patch‘frog we called the “Old ” mud houses’ weFlat. made at the end of the long cotton rows, and her timeworn shoebox

from Braddock’s Dry Goods store packed full of wonderful old Christmas cards tied with string. While all the others of the family had to drag cotton sacks through Papaw’s fields, we were sitting in a snowbank. We would daydream about how it Bigmama and I were excused. I was too little to be of muchwould use, not andbeBigmama hadSt. Nick would be coming to see us. Over long before old suffered what Dr. Mauney called “a light stroke” back in the early ’50s.

She and I were shared King Leo peppermint sticks carefully wrapped in wax paper, spared the ardors of fieldwork in those stifling and back-breaking days over in the big she would tell me about the excitement of her childhood Christmases of long ago. We would examine those lovely yellowing old Christmas cotton patch we called the “Old Flat.” of hers overso andwas overshe. again until we literally almost wore them Instead, life for us was grand. I was around 5, and incards some ways, out and were both covered that silvery glitter that never failed to Papaw had to put the ‘side-planks’ on his pickup to hold the day’s cotton harvest. inMy fly. She would go over the front of the card for me, and then read the duty was to tromp around in the cotton to pack it down so that an even bigger load could sweet rhyming greeting inside, then finally the hand-scrawled message be hauled to the gin. When the truck bed would get almost at full, would the Bigmama bottom and the “Withpull Loveout From” part. At that point, I was to her box of Christmas greetings from years’ past to begin our afternoon entertainment.

In who had sent her the card. It shout the name of the friend or relative the mountain of soft whiteness, it was easy to pretend we were in agame snowbank.

We was asitting marvelous that neither of us ever tired of playing. In the my Papaw s truck, under would daydream about how it would not be long before oldback St. of Nick wouldWillie’ be coming to a sweet gum shade at the end of a 30-acreincotton bothshe of us could taste, see and feel the thrilling see us. Over shared King Leo peppermint sticks carefully wrapped waxfield, paper, promise of Christmas just around the corner. would tell me about the excitement of her childhood Christmases of long ago. We would examine those lovely yellowing old Christmas cards of hersWell, over and over again until we over fifty years later comes the advent of yet another Christmas. literally almost wore them out and were both covered in that that never Forsilvery the pastglitter few years, it has seemed more like a dreadful chore than failed to fly. She would go over the front of the card for me, and then read the sweet the magical time it once was. All I can think about when dragging rhyming greeting inside, then finally the hand-scrawled message at the bottom and the those huge boxes of seemingly endless collections of glass balls, beads and bangles the attic is how soon I will endure the time“With Love From” part. At that point, I was to shout the name of the down friendfrom or relative consuming of tired wagging who had sent her the card. It was a marvelous game that neither of uspain ever of them back upstairs. What a dreadfully overblown pile of artificial cheer Instead, life for us was grand.

I was around 5, and in some ways, so playing. In the back of my Papaw Willie’s truck, under a sweet gum shade at the endI have of aaccumulated over the decades. It was she. Papaw had to put the side-planks on his pickup to hold the looks as if Santa Claus has barfed all over my living room floor yet again.

30-acre cotton field, taste, see and feeltothe The thrilling promise of wag Christmas more stuff I drag and the darker my mood seems to become. day’s cotton harvest.

Myboth duty of wasus to could tromp around in the cotton just around the corner. pack it down so that an even bigger load could be hauled to the gin. But, in the most remote corner of the attic storage room dedicated to Well, fifty years laterfull, comes thewould advent yet another Christmas.

For the the housing of our accumulated Christmas paraphernalia I find THEM When the truckover bed would get almost Bigmama pullofout once again….under the growing her box Christmas greetings frommore years past our afternoon past fewofyears, it has seemed liketoabegin dreadful chore than the magical time it oncepile of defunct Christmas lights (that might someday find time to rescue) I once again found the remaining entertainment. the mountain of soft whiteness, it was easyhuge to pretend was.

All I canInthink about when dragging those boxesI of seemingly endless collections of glass balls, beads and bangles down from the attic is how soon I will 368 VOL. 60 • NO. 11/12 • 2019

fragments of my Christmas spirit. In a green tangle of wire that should have met its demise in a dumpster long ago lay my motley collection of Christmas cards. A 55-gallon drum would likely not hold them all.

It is a heart-yanking feeling to discover something once again unconsciously hidden away from your self for years. There were numerous pasteboard shoeboxes full of bound Christmas cards and letters dating back through the 40 years since I left home for medical school. They have all been there every year when I do the ritual wagging and dragging thing with the wreaths, garlands and plastic poinsettias, but somehow I have not always appreciated their presence.

A closer examination of some of the boxes brought a flood of emotions at the familiar sweet handwriting of my Mother on envelopes sent from Rural Route One, Ripley, to a homesick girl in a dormitory room at 2500 North State Street in Jackson, Mississippi…big pretty cards with Memphis, Tennessee, postmarks from my older sister Shirley and family at 806 North Mendenhall… and in later stacks, “Happy Holidays” greetings sent to a young pregnant intern’s apartment off Old Hickory Boulevard in Jackson, Tennessee, these from literally everyone my husband Chard and I knew. All of them were deemed necessary to keep in the Bigmama tradition I had been taught. They all found their way back home with me somehow.

.eJ Liberty I 'Q

In many of the years, the cards contained congratulatory messages for graduations, new jobs, marriages, or babies. Some cards brought words of consolation for the losses that particular year had bestowed.

Without fail they contained newsy messages and updates framed by closing phrases such as “come see us sometime,” or “please write soon,” and then, most importantly, the “with love from” part.

A deep and abiding appreciation for the meaning and importance of heartfelt and handwritten Christmas cards was bestowed upon me over a half-century ago by my Bigmama through the childish games we played in my Papaw’s cotton field. Now I AM the Bigmama of the family, and with the passing of every immediate family member older than me, it has become a bit of a scary feeling. After my Mother died in 2014, I discovered in one of her linen drawers some of Bigmama’s treasure trove of Christmas cards and family photos. These are as valuable as pieces of silver and gold to me now.

An old familiar Christmas carol tells us about "tidings of comfort and joy.” I didn’t know it then, but I do now, that Christmas cards are precisely that–heartfelt prayers and hopes lovingly sent to our friends and family asking God to grace us with health, happiness, and a better year ahead. Oh, Lord, do we ever need exactly that!

Because of my simple Bigmama’s loving example to me, I vow to never cut corners by not making that once a year effort to send out some Christmas cards – and not ever to begrudge the time spent addressing envelopes or the laborious writing for the one-hundredth time: “With Love From.” n

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• Index • Volume LX January - December 2019

Subject Index

The letters used to explain in which department the matter indexed appears are as follows: “E,” Editorial; “L,” Letters to the Editor; “PM,” Poetry and Medicine; “PP,” President’s Page; “S,” Special Article; “UV” Una Voce; the author’s name follows the entry in brackets. Matters pertaining to related organizations are indexed under the medical organization.

-A-

A Brief Review and Commentary: Marijuana’s Effects on Brain Structure and Function: What Do We Know andWhat Should We Do? [R DeShazo, S Parker, D Williams, J Ingram, M Elsohly, K Rodenmeyer, K McCullouch], 64-S A Comprehensive Evaluation of Mississippi Opioid Prescribing Practices by Strength and Days of Supply, 2012-2017: Summary of Updated Mississippi Board of Medical Licensure Opioid Prescribing Rules [M Staneva, M Pearson, T Dobbs, P Byers], 51-S A Novel Case of Minocycline-Induced Myofasciitis in a SixteenYear-Old Girl [ J Xie, E Ward, V Majithia, A Mathew, N Washington], 149 An Interview with University of Mississippi Medical Center Vice Chancellor Louann Woodward, MD [M Cosnahan, P Merideth], 120-S An Unusual Case of Ameboma Presenting as a Large Cecal Ulcerated Exophytic Necrotic Mass Successfully Treated with Nitazoxanide [N Shah], 352 Autoimmune Hepatitis (AIH): A Case Report and Review of Literature [T Momah, R Yi, W Payne, D Green, A Persanti, M Meece], 177 Autologous Bone Marrow

Transplantation for Multiple Myeloma: An Analysis of Risk Factors that Affected Patient Outcomes at the University of Mississippi Medical Center [D Hansen, T Williamson, J Hsu, T Buck, C Milner], 185 AMA Jackson Physician Dr. Sharon Douglas Elected to the AMA Council on Medical Education, 263

-B-

Backstories on the US Opioid Epidemic: Good Intentions Gone Bad, an Industry Gone Rogue, and Watchdogs Gone to Sleep [R DeShazo, M Johnson, I Eriator, K Rodenmeyer], 56-S

-C-

Central Line Associated Thrombus vs.

Superimposed Vegetation in the Setting of Staphylococcus aureus Bacteremia [R Ballard, J Brock, E Kerut, E Fox, D Wolfe, M Hall], 145 Cerebral Venous Thrombosis and Escitalopram: A Case Report and Review of Literature [ L Gibson, D Kohli, C Nobleza], 12 Consults in TelEmergency: A Descriptive Analysis [S Sterling, N Novotny, M Puskarich, L McKenzie, R Summers, A Jones], 111 Current Approaches in Perioperative Management of the Opioid-

Tolerant Patient [R Hulet, L Kurnutala], 74-S Commentary A Conversation with Thomas Payne, PhD on Limiting E-Cigarette Sales to Teens to Prevent Nicotine Addiction, 98 The Phenomenon of Practice Drift: Liars, Pimps and Snake Oil Salesmen: Should Physicians and Nurse Practitioners Practice Outside their Training and Expertise? [H Matthias], 80 Understanding Levels of Care in Substance Use Disorder Treatment [R Pannel], 84 Cover Addiction edition, February cover “American Chameleon” [P Loria, Jr.], October cover “Causeyville General Store” [M Pomphrey], April cover “Idle Time” [M Pomphrey], August cover J. Clay Hays, Jr., MD, September cover “Red Snapper Catch” [B Rifkin], May cover Rodney Presbyterian Church in Port Gibson [R Brahan], November/ December cover Summer’s Delight [R Cannon], June/ July cover “The Horse with No Leg” [S Hartness], January cover “Wasps on Goldenrod” [P Loria, Jr.], March cover

NOVEMBER/DECEMBER • JOURNAL MSMA

371

-D-

Dementia Facts: Distinguishing the Differential Diagnosis [N Patel, L Massihi, A Patel, A Majeste], 172 Demographic and Socioeconomic Factors and Trends Associated with Blood Lead Levels among Children Younger than 6 Years Old in Mississippi, 2009-2015 [N Han, C Veazey, B Polk, G Cannon-Smith, L Zhang], 206 Drug Testing in the Chronic Pain Management Population: Recommendations from the University of Mississippi Medical Center Opioid Task Force [P Kyle, W Gusa, A Kemp, J Parker, R Rockhold, P Rogers], 331

-E-

Early Impact of a Statewide Screening Program for Critical Congenital Heart Disease in Newborns [L Moore, D McVadon, A DodgeKhatami, C Blackshear, F Faruque, M Taylor, S Batlivala], 282

Editorials A New Person to Push the Boulder [P Merideth], 21-E Disability is in the Eyes of the Beholder [D Hartness], 218-E Touch Where It Hurts [D Hartness], 341-E

-F-

Fecal Microbiota Transplantation for Clostridium difficile Colitis: A Review and Report of the Jackson, MS Experience [ J Underwood, III, J Sones], 359 Foot Drop Associated with a Pulsatile Leg Mass [W Lineaweaver, R Ratliff, C Adams], 4 From the Editor [L Lampton] Aspiring to JFK’s More Mature Qualities [L Lampton], 350 Curing Deafness Before Church [L Lampton], 322 372 VOL. 60 • NO. 11/12 • 2019

Evolving Soul and Southern into Mediterranean [L Lampton], 138 Les Savants Ne Sont Pas Curieux [L Lampton], 242 “Mens Sana” In a World of Rising Suicide [L Lampton], 166 Modern Medicine: Three Kids, Three Jobs [L Lampton], 198 Relish the Joy of Healing [L Lampton], 2 Thank God I am a Physician! [L Lampton], 106 There is No Magic Money Tree [L Lampton], 274 Vaping in the Age of Addiction [L Lampton], 42

-H-

Head and Neck Trauma Trends with Changing Temperature and Spare Time [A Robichaux, J Jordan, C Moore, C Spankovich], 115

-I-

Images in Mississippi Medicine Archie Jackson Stacy, Sr., MD (1888-1956), Tupelo, Pioneer Mississippi Radiologist [L Lampton], 345 Dentistry in Lambert, 1906 [L Lampton], 239 Junkie: Pulp Fiction Confessions of an Unredeemed Drug Addict, 1953 [L Lampton], 101 Mississippi Baptist Hospital, From North State Street, 1922 [L Lampton], 132 Mississippi Baptist Hospital, Jackson, 1914 [L Lampton], 34 Mississippi Baptist Hospital, Two Views, 1950, 1960 [L Lampton], 163 Southern Surgical Association Meeting, December 1936, Held at Edgewater Park at the Edgewater Gulf Hotel [L Lampton], 318 The Science Hall Building at Ole Miss, The First Medical School Structure [L Lampton], 364

The Turner Hospital, Meridian, 1910 [L Lampton], 194 Tougaloo College Hospital, 1909 [L Lampton], 267 In Memoriam, 23, 159, 238 Invest Mississippi Invest in a Healthier Future, 28

-J-

Juul Awareness, Trial, and Continued Use among Undergraduate Students in Mississippi [E McClelland, N Valentine, J Gorzkowski, A Winter, R McMillen], 44-S

-L-

Letters Commemorative issue “a beautiful record”: A memory of the legendary Dr. Henry Holleman [ J McEachin], 127-L Dr. Currier shares her “path to public health” in an address to honor society [H Badon], 156-L Editor “nailed it” with recent editorial: However, have we become a profession of salmon swimming upstream, helpless to effect necessary change? [W Spencer], 127-L Editor spot on with “Secret Sauce” editorial: What is organized medicine doing about it? [ J Burns], 127-L Editorial hits at the reason that we are physicians! [R Cannon], 190-L Inez Kelleher, MD– Physician, Health Advocate and Legislative Candidate [P Levin], 226-L It is important to appreciate the privilege and joy of taking care of patients! [W Lineaweaver], 190-L

-M-

Major Depression, Chronic Medical Illness, and Access to Mental

Health Services among Mississippi Adults [T Smith, G Norquist, D Johnson, R McAnally, A Sullivan, I Paul], 290 Mumps Infection in a Previously Vaccinated Child with a Positive Rapid Strep Test: A Case Report [ J Sexe, N Miller], 328 MMPAC Join MMPAC’s Newest Exclusive Diamond Level, I.V. League, 227 MRPSP Governor Bryant Signs MRPSP Exemption to Include a Psychiatry Option, 190 MSDH Dr. Thomas E. Dobbs Named New State Health Officer, 30 Hepatitis A Outbreak, Mississippi 2019: What Physicians Need to Know [P Byers], 261 Mississippi Provisional Reportable Disease Statistics, December 2018, 100 Mississippi Provisional Reportable Disease Statistics, January 2019, 162 Mississippi Provisional Reportable Disease Statistics, February 2019, 189 Mississippi Provisional Reportable Disease Statistics, June 2019, 260 Mississippi Provisional Reportable Disease Statistics, August 2019, 317 Mississippi Provisional Reportable Disease Statistics, September 2019, 342 MSMA 2019 MSMA Annual Session Election Results, 308 2019-20 MSMA Board of Trustees, 304 Annual Session Recap, 305 Brunson Named New Executive Director [ J Bryan], 90 Committee Seeks Candidates for Vacancies in MSMA Offices, 87 Increasing Access to Health Care in Mississippi – Understanding

the Challenges and Possible Solutions (Address of the President, Michael Mansour, MD, 2018-19 MSMA President), 300 Meet the Class of 2018-19, 221 MSMA Awards, 306 Physician Leadership Academy, 220 UMMC Honors Day Awards, 310

-N-

New Members, 22, 103, 196, 226, 316, 348

-P-

Physicians Helping Physicians: A Template for Success [S Hambleton], 324 Provider Perceived Barriers to HPV Vaccination in Mississippi [M Ridgway, S Multani, K Wallace, B Sabins], 6 Poetry and Medicine Blood Transfusion [M Moore], 346-PM In Dissecting Room [Offered by the first medical school class at Ole Miss– University of Mississippi School of Medicine, Class of 1904.

Reprinted from the Ole Miss annual], 365-PM He Was a Different Fellow After a Few Drinks [M Moore], 102-PM Hematuria [M Moore], 240-PM Killed in Mississippi Hotel Fire; Greenville, March 4 (It Could Be Any Year) [M Moore], 195-PM Les Savants Ne Sont Pas Curieux [M Moore], 268-PM Liquor Cerebrospinalis (A Sonnet Review of the Literature on Cerebrospinal Fluid with Special Reference to Three Important Events) [M Moore], 133-PM Poems are Stimulants [M Moore] 320PM Two Things I Will Remember as Long as I Live [M Moore], 164-PM Yockanookany [S Hartness], 35-PM

President’s Page A Better Job [M Mansour], 265-PP Inaugural Address of the 152nd President, J. Clay Hays, Jr., MD [ J Hays, Jr.], 312-PP Incarceration of the Mentally Ill – A Public Health Crisis [M Mansour], 154-PP Increasing Access to Health Care in Mississippi – Understanding the Challenges and Possible Solutions [M Mansour], 234-PP Physician Wellness – A Focus on Mental Health [M Mansour], 123-PP Professionalism and Advocacy - The Physician Citizen [M Mansour], 15-PP The Opioid Crisis: Ongoing Epidemic and Evolving Solutions [M Mansour], 94-PP The Past is Prologue; Keeping the Patient First – Remembering James C. Waites, MD, MSMA President 1991-1992 [M Mansour], 192-PP Transplant Medicine [ J Hays, Jr.], 344PP

-SStrategies for the Physician Workforce Shortage in Mississippi [K Dang, V Nguyen, O Arain, W Pruett, R Didlake], 212 -T-

Ten Examples of How Evolutionary Medicine Can Furnish Ideas for Clinical Research and Improve Medical Practice [M Bailey, P Borse, N Bosworth, N Brewer, N Douglass, R Guastella, G Haddad, M Haire, K Hill, A Penman], 180 The Growth of Pediatric Complex Care in Mississippi [S Weisenberger, A Hayslett, S Jones, A Klar, R Qadan, R Hill, C Paine], 202 The PROMISE Initiative: Who Should Give Patients Information on Opioids? [M Robertson, D

NOVEMBER/DECEMBER • JOURNAL MSMA

373

Williams, H Seitz, L Downey, A Hardman, D Buys], 68-S Top 10 Facts You Should Know About Achalasia [B Harrison, J Moremen], 276 About Antibiotic Stewardship [D Pendergrass, P Pendergrass, P Byers, T Dobbs], 9 About Behavioral Disturbances in Dementia [S Shipley, A Pierre, S Sanders, D Majithia], 108 About Breast Implants and Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIAALCL) [P Brownlee, B McIntyre], 249 About Heat Illnesses [F Carlton, Jr.], 200 About Knee Radiographs [D Hofstede, D Gilmer, R Morris], 140 About Liver Disease [E Paine], 338 About Management of Sepsis and Septic Shock in Children [P Garg, J Hong], 355 About Musculoskeletal Ultrasound [L Villarinho, K Nutter], 168 About Pharmacogenomics [S Bondurant], 246 About Screening and Brief Intervention for Alcohol Use Disorders [S Gleason J Schumacher, L Houston, M Ladner, D Williams], 244

-UUMMC Heart-liver transplant one for UMMC history books, 31 University Medical Alumni Chapter Additions to Hall of Fame [G Pettus], 256 UMSOM Full Match Results Day 2019, 251 Una Voce [Dwalia S. South] Birthing Babies: From New York LyingIn Hospital to Mount Olive, Mississippi [ J Johnston], 269-UV Good Riddance Day [D South], 36-UV Why I Still Believe in Christmas Cards [D South], 368-UV 374 VOL. 60 • NO. 11/12 • 2019

Volume LX

January - December 2019

Author Index

The letters used to explain in which department the matter indexed appears are as follows: “E,” Editorial; “L,” Letters to the Editor; “PM,” Poetry and Medicine; “PP,” President’s Page; “S,” Special Article; “UV” Una Voce; the author’s name follows the entry in brackets. Matters pertaining to related organizations are indexed under the medical organization.

Jones, Sarah M., 202 Jordan, J. Randall, 115

A Adams, Craig, 4 Arain, Omair, 212

F Faruque, Fazlay S., 282 Fox, Ervin R., 145

B Badon, Hannah Roberts, 156-L Bailey, Mary C., 180 Ballard, Richard D., 145 Batlivala, Sarosh P., 282 Blackshear, Chad, 282 Bondurant, Sidney W., 246 Borse, Piyush S., 180 Bosworth, Nicholas A., 180 Brahan, Robert, November/December cover Brewer, Nicholas H.., 180 Brock, James B., 145 Brownlee, Pam, 249 Bryan, Jennifer J., 90 Buck, Tondre, 185 Burns, Jeff, 127-L Buys, David, 68-S Byers, Paul, 9, 51-S, 261

G Garg, Padma, 355 Gibson, Lakeshia C., 12 Gilmer, Daniel L., 140 Gleason, Sara H., 244 Gorzkowski, Julie, 44-S Green, David, 177 Guastella, Rosario K., 180 Gusa, William E., Jr., 331

C Cannon-Smith, Gerri, 206 Cannon, Ron, 190-L, June/July cover Carlton, Frederick B., Jr., 200 Cosnahan, Margaret, 120-S D Dang, Khang H., 212 DeShazo, Richard D., 56-S, 64-S Didlake, Ralph, 212 Dobbs, Thomas, 9, 51-S Dodge-Khatami, Ali, 282 Douglass, Nelson P., 180 Downey, Laura, 68-S E Elsohly, Mahmoud, 64-S Eriator, Ike, 56-S

H Haddad, Ghali G., 180 Haire, Mary M., 180 Hall, Michael E., 145 Hambleton, Scott, 324 Han, Ninglong, 206 Hansen, Doris K., 185 Hardman, Alisha, 68-S Harrison, Brannon, 276 Hartness, Stanley, January cover, 35PM, 218-E, 341-E, 365-PM Hays, J. Clay, Jr., 312-PP, 344-PP Hayslett, Andrew R., 202 Hill, Kelly G., 180 Hill, Rebecca, 202 Hofstede, Dustin, 140 Hong, Jennifer, 355 Houston, L. Joy, 244 Hsu, Johann, 185 Hulet, Rene, 74-S I Ingram, John B., 64-S J Johnson, Dick, 290 Johnson, McKenzie, 56-S Johnston, Joe, 269-UV Jones, Alan E., 111

K Kemp, Ann M., 331 Kerut, Edmund K., 145 Klar, Angelle L., 202 Kohli, Disha, 12 Kurnutala, Lakshmi N., 74-S Kyle, Patrick B., 331 L Ladner, Mark E., 244 Lampton, Lucius M., 2, 34, 42, 101, 102-PM, 106, 132, 133-PM, 138, 163, 164-PM, 166, 194, 195-PM, 198, 239, 240-PM, 242, 267, 268, 274, 318, 320, 322, 345, 346-PM, 350, 364, 365-PM Levin, Philip L., 226-L Lineweaver, William C., 4, 190-L Loria, Philip R., Jr., March cover, October cover M McAnally, Ron, 290 McClelland, Emily, 44-S McCullouch, Kyle, 64-S McEachin, John, 127-L McIntyre, Ben, 249 McKenzie, L. Kendall, 111 McMillen, Robert, 44-S McVadon, Deani H., 282 Majeste, Andrew, 172 Majithia, Deepika, 108 Majithia, Vikas, 149 Mansour, Michael, 15-PP, 94-PP, 123PP, 154-PP, 192-PP, 234-PP, 265-PP Massihi, Lilian E., 172 Mathew, Anna, 149 Matthias, Heddy-Dale, 80 Meece, Matthew, 177

NOVEMBER/DECEMBER • JOURNAL MSMA

375

Merideth, Philip, 21-E, 120-S Miller, Ned, 328 Milner, Carter P., 185 Momah, Tobe, 177 Moore, Cindy, 115 Moore, Lily M., 282 Moore, Merrill, 102-PM, 133-PM, 164PM, 195-PM, 240-PM, 268-PM, 320-PM, 346-PM Moremen, Jacob, 276 Morris, Robert W., 140 Multani, Sukhpreet S., 6 N Nguyen, Vy T., 212 Nobleza, Christa O’Hana S., 12 Norquist, Grayson S., 290 Novotny, Nicole R., 111 Nutter, Kathryn, 168 O Offered by the first medical school class at Ole Miss – University of Mississippi School of Medicine, Class of 1904, 365-PM P Paine, C. Christian, 202 Paine, Elizabeth R., 338 Pannel, R. Stephen, 84 Parker, Jefferson D., 331 Parker, Sara B., 64-S Patel, Ashishkumar, 172 Patel, Netrali, 172 Paul, Ian A., 290 Payne, Will, 177 Pearson, Meg, 51-S Pendergrass, Desiree B., 9 Pendergrass, Peter W., 9 Penman, Alan D., 180 Persanti, Alana, 177 Pettus, Gary, 256 Pierre, Ardarian Gilliam, 108 Polk, Beryl W., 206 Pomphrey, Martin, April cover, August cover Pruett, William A., 212 Puskarich, Michael A., 111 Q Qadan, Regina, 202

376 VOL. 60 • NO. 11/12 • 2019

R Ratliff, Rachel, 4 Ridgway, Mildred, 6 Rifkin, Brian, May cover Robertson, Mary Nelson, 68-S Robichaux, Andrew, 115 Rockhold, Rob, 331 Rodenmeyer, Kathryn, 56-S, 64-S Rogers, Penny, 331 S Sabins, Bethany, 6 Sanders, Sara, 108 Schumacher, Julie A., 244 Seitz, Holli, 68-S Sexe, Jordan, 328 Shah, Niraj James, 352 Shipley, Sonya, 108 Smith, Theresa A., 290 Sones, James Q., 359 South, Dwalia S., 36-UV, 269-UV, 368UV Spankovich, Christopher, 115 Spencer, William, 127-L Staneva, Manuela, 51-S Sterling, Sarah A., 111 Sullivan, Amy L., 290 Summers, Richard L., 111 T Taylor, Mary B., 282 U Underwood, James A., III, 359 V Valentine, Nell, 44-S Veazey, Crystal, 206 Villarinho, Luciano de Lima, 168

W Waites, Thad F., 192 Wallace, Kedra, 6 Ward, Emily H., 149 Washington, Nina, 149 Weisenberger, Sara J., 202 Williams, Daniel, 64-S, 68-S, 244 Williamson, Thomas, 185 Winter, Amy, 44-S Wolfe, Douglas, 145 X Xie, Jesse, 149

Y Yi, Rachel, 177 Z Zhang, Lei, 206

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