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Reducing costs in the clinical enterprise is about improving quality.

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Lucius M. Lampton, MD Editor D. Stanley Hartness, MD Richard D. deShazo, MD Associate Editors Karen A. Evers Managing Editor Publications Committee Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD, Ex-Officio Myron W. Lockey, MD, Ex-Officio and the Editors

The Association Steven L. Demetropoulos, MD President James A. Rish, MD President-Elect J. Clay Hays, Jr., MD Secretary-Treasurer Lee Giffin, MD Speaker Geri Lee Weiland, MD Vice Speaker Charmain Kanosky Executive Director

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 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. 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. Cristen Hemmins, Hemmins Hall, Inc. Advertising, P.O. Box 1112, Oxford, Mississippi 38655, Ph: (662) 236-1700, Fax: (662) 236-7011, email: cristenh@watervalley.net POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 391582548. 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© 2013 Mississippi State Medical Association.

APRIL 2013

VOLUME 54

NUMBER 4

Scientific Articles Caution in Interpretation of the Tumor Marker CA 19.9 in Patients with Obstructive Jaundice: Illustrative Case Reports Thomas S. Helling, MD

Coagulase Positive Staphylococcal Infection: A Major Cause of Eczema Exacerbations

President’s Page The Medicaid Conundrum

105

Steven L. Demetropoulos, MD, MSMA President

Special Article A Medical Giant Remembered: Dr. Verner Holmes’s Example Continues to Inspire New IHL Physician Member

108

Bradford J. Dye, III, MD

Related Organizations Mississippi State Department of Health

104

The University of Mississippi Medical Center

111

The School of Medicine at the UMMC

113

Departments From the Editor: Functional HIV Cure Achieved in Mississippi

About The Cover: “Cypress Spring” – While the Cypress tree (Taxodium distichum) is a common sight in Southern swamps, as improbable as it seems this idyllic setting is found just off Meadowbrook Road in Jackson not far from I-55. The Cypress tree has a fascinating history that dates back to the ancient Egyptians who used the durable wood to build mummy cases. The Greeks also used its wood to create urns to store the ashes of those who died in battle. The gracefully curved trunks appear to be leading gaggles of misshapen gnomes (roots or “knees”). Bright yellow Dutch irises soften the setting. This image was captured by JMSMA Associate Editor Dr. Stanley Hartness, family physician. r VOL. LIV

of the MSMA Since 1959

101

John C. Chapman, MD; S.E. Bauman, BS and C. Ralph Daniel, III, MD

April

Official Publication

2013

No. 4

APRIL 2013 JOURNAL MSMA 93

From the Editor: Functional HIV Cure Achieved in Mississippi

n early March, front page headlines in newspapers across the world lauded a landmark medical accomplishment in of all places Mississippi. The New York Times led its March 3rd issue with: “In medical first, a baby with HIV is deemed cured,” and Gannett’s USA Today headed its March 4th issue: “Doctors cure first child with HIV.” Dr. Hannah B. Gay, a brilliant UMMC associate professor of pediatrics who specializes in HIV, achieved the first welldocumented case of HIV remission/cure in a perinatallyHIV infected child. This child, born in rural Mississippi to a noncompliant mother, was treated aggressively with antiretroviral drugs starting 30 hours after birth. This outcome not only helps researchers develop new cure strategies in infected neonates but also gives us hope in looking towards an HIV cure. It is always wonderful to have Mississippians mentioned positively in national news, especially when that person is a fellow Mississippi physician. The gracious Gay was recently named one of Time magazine’s 100 most influential people in the world, and much more pioneering medical work is anticipated from her.

What wasn’t mentioned by most of the writers in this global media fury was the critical role the Mississippi State Department of Health played and continues to play in its supportive role of much of the important work done at the medical center, especially in infectious Luke Lampton, MD disease management, specifically in this case the treatment and follow-up of HIV infected mothers and their babies. It was the Department’s employees who were doing much of the detective work of tracking down noncompliant mothers and ensuring that their medicines preventing transmission were taken. Every single day, the heroic staff of Dr. Mary Currier’s agency impacts the lives of every Mississippian by preventing disease and saving lives from infectious disease surveillance to emergency preparedness to wastewater inspection. These “behind the scenes” heroes deserve our kudos as well for their key supporting role in this tremendous HIV achievement. Contact me at lukelampton@cableone.net. —Lucius M. Lampton, MD, JMSMA Editor

Journal Editorial Advisory Board R. Scott Anderson, MD, FACR Chair, Journal Editorial Advisory Board Radiation Oncologist and Medical Director, Anderson Regional Cancer Center, Meridian Diane K. Beebe, MD Professor and Chair, Department of Family Medicine, University of MS Medical Center, Jackson Claude D. Brunson, MD Senior Advisor to the Vice Chancellor for External Affairs, University of Mississippi Medical Center, Jackson Jeffrey D. Carron, MD, FAAP, FACS Associate Professor, Department of Otolaryngology & Communicative Sciences, University of Mississippi Medical Center, Jackson Gordon (Mike) Castleberry, MD Urologist, Starkville Urology Clinic Mary Currier, MD, MPH State Health Officer Mississippi State Department of Health, Jackson Thomas E. Dobbs, MD, MPH Epidemiologist Mississippi State Department of Health, Hattiesburg Sharon Douglas, MD Chair, AMA Council on Ethical & Judicial Affairs Professor of Medicine and Associate Dean for V A Education, University of Mississippi School of Medicine, Associate Chief of Staff for Education and Ethics, G.V. Montgomery VA Medical Center, Jackson Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist, The Street Clinic, Vicksburg

94 JOURNAL MSMA APRIL 2013

Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson Maxie L. Gordon, MD Assistant Professor, Department of Psychiatry and Human Behavior, Director of the Adult Inpatient Psychiatry Unit and Medical Student Education, University of Mississippi Medical Center, Jackson Scott Hambleton, MD Medical Director Mississippi Professionals Health Program, Ridgeland John Edward Hill, MD, FAAFP Residency Program Director North Mississippi Medical Center, Tupelo John D. Isaacs, Jr., MD Infertility Specialist, Mississippi Fertility Institute at Women’s Specialty Center, Jackson Kent A. Kirchner, MD Nephrologist G.V. Montgomery VA Medical Center, Jackson Brett C. Lampton, MD Internist/Hospitalist Baptist Memorial Hospital, Oxford Philip L. Levin, MD President, Gulf Coast Writers Association Emergency Medicine Physician, Gulfport William Lineaweaver, MD, FACS Editor, Annals of Plastic Surgery Medical Director JMS Burn and Reconstruction Center, Brandon John F. Lucas,III, MD Surgeon Greenwood Leflore Hospital

Gailen D. Marshall, Jr., MD, PhD, FACP Professor of Medicine and Pediatrics, Vice Chair for Research, Director, Division of Clinical Immunology and Allergy, Chief, Laboratory of Behavioral Immunology Research The University of Mississippi Medical Center, Jackson Alan R. Moore, MD Clinical Neurophysiologist Muscle and Nerve, Jackson Paul “Hal” Moore Jr., MD, FACR Radiologist Singing River Radiology Group, Pascagoula Jason G. Murphy, MD Surgeon Surgical Clinic Associates, Jackson Ann Myers, MD Rheumatologist Mississippi Arthritis Clinic, Jackson Jimmy L. Stewart, Jr., MD Program Director, Combined Internal Medicine/ Pediatrics Residency Program, Associate Professor of Medicine and Pediatrics University of Mississippi Medical Center, Jackson Samuel Calvin Thigpen, MD Hematology-Oncology Fellow, Department of Medicine University of Mississippi Medical Center, Jackson Thad F. Waites, MD, FACC Clinical Cardiologist, Hattiesburg Clinic Chris E. Wiggins, MD Orthopaedic Surgeon Bienville Orthopaedic Specialists, Pascagoula John E. Wilkaitis, MD, MBA, CPE, MS Chief Medical Officer Brentwood Behavioral Healthcare, Flowood

Medical Assurance Company of Mississippi Serving Generations of Mississippi Physicians When Paul H. Moore, III, MD, began his practice of medicine in 2013, he had many decisions to make. But for the decision of medical liability insurance, he only had to look to his father and grandfather and follow in their footsteps. The Moore family of physicians is one of several multi-generational families that Medical Assurance Company of Mississippi has protected through the years by providing their professional liability insurance. For over 35 years, Mississippi physicians have looked to MACM for their professional liability needs. Today, MACM is an integral part of Mississippi’s healthcare community through its dedication to risk management and claims services for our insureds. A dedicated staff and physician involvement at every level guarantee that the interests of our policyholders remain the top priority. This, combined with the many years of loyalty and support from our insureds, is what allows MACM to be the carrier of choice in Mississippi for generations of Mississippi physicians.

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APRIL 2013 JOURNAL MSMA 95

• Scientific Articles • Caution in Interpretation of the Tumor Marker CA 19.9 in Patients with Obstructive Jaundice: Illustrative Case Reports Thomas S. Helling, MD

Fig 1. Hiliary Koprowski’s article published in 1979 in Somatic Cell Genetics describing the detection of an antigen associated with colorectal carcinoma by hybridoma antibodies initially designated “1116 NS 19-9” and later termed CA 19.9.

bstract

Background: Carbohydrate antigen (CA) 19.9 is a Lewis blood group oligosaccharide antigen which exists in fixed and soluble forms. The CA 19.9 antigen is synthesized by epithelial cells of the gastrointestinal tract, pancreatic duct, and biliary tree. The CA 19.9 antigen is commonly used as a tumor marker for malignancies of the pancreas and biliary tract. High levels (> 300 U/ml) of antigen have strongly suggested malignant processes. Methods: Four patients are described with markedly elevated levels of CA 19.9 due to benign calculous disease Results: Three of four patients underwent endoscopic stone removal followed by cholecystectomy; the fourth patient spontaneously passed stones and had a subsequent cholecystectomy with benign inflammatory pathology. Removal or passage of the obstructing stones produced normalization of the CA 19.9 in each case even with longterm follow-up up to one year. All pathology specimens were interpreted as benign. Conclusions: Marked elevations of CA 19.9 may be found in benign obstructive disease and should be interpreted with caution until biliary obstruction is relieved.

hile Hilary Koprowski attained fame from developing the world’s first successful oral polio vaccine using live attenuated viruses, he also contributed to the young field of tumor markers by identifying a new antigen borne by colorectal adenocarcinomas. In 1979 he and his co-workers 1 published a paper describing development of a monoclonal antibody by immunizing mouse hybridoma models with human colorectal cancer cell lines (Figure 1). The new antibody was originally designated “1116 NS 19-9” and was found to react with a sialylated lacto-N-fucopentaose, existing as a monosialoganglioside.2 Corresponding Author: Thomas S. Helling MD, Department of Surgery, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, Ph: (601) 815-1161, Fax: (601) 815-5241 [thelling@umc.edu].

96 JOURNAL MSMA APRIL 2013

Figure 1

The was found to beCellaGenetics carbohydrate oligosaccharide Hiliary epitope Koprowski’s article published in 1979 in Somatic describing the detection of an antigen associated with colorectalwith carcinomacell by hybridoma antibodies initially designated moiety associated membranes of mucosal cells of “1116 NS 19-9” and later termed CA 19.9 the gastrointestinal tract including stomach, pancreas, liver, gallbladder, and colon and sharing structural features with Lewis blood group antigens.3 Because of its carbohydrate nature, the fixed antigen was later termed Carbohydrate 8 Antigen (CA) 19.9. Koprowski’s group then demonstrated a soluble circulating antigen detected in sera of patients with gastric, colorectal, and pancreatic carcinoma using their same monoclonal antibody, CA 19.9, that was effective against the fixed antigen.4 The circulating antigen was subsequently identified as a mucin and not a ganglioside as found in tissue, secreted by normal gastrointestinal epithelial cells at low levels but in a heightened fashion by gastrointestinal epithelial cancers, including pancreatic cancers, and only in patients with Lewis subgroups a or b.5 In other words, subjects who are Lewis a-, b(about 5 – 7% of the population) will not elaborate this mucin/ antigen because they lack the fucosyltransferase necessary to synthesize the required sugar sequence belonging to the antigen. It is thought that overexpression of mucin producing

genes, particularly the MUC 1 gene, by neoplastic epithelia is responsible for increased levels of CA 19.9 antigen in sera of patients with pancreatic ductal carcinoma.6 The CA 19.9 has not supplanted the carcinoembryonic antigen test for screening in colorectal carcinoma.7 Its chief contribution has been in the diagnosis and treatment of periampullary 8, 9 and biliary tract malignancies10 and has been used to determine resectability and response to treatment.11, 12, 13 Nevertheless, there are reports documenting heightened levels of CA 19.9 in benign disease 14, 15, 16, which may add confusion to the interpretation of serum CA 19.9 and reduce its specificity. Herein, we present four cases of benign biliary tract disease associated with marked elevations of the CA 19.9 in an attempt to illustrate situations in which the CA 19.9 determination may be misleading.

Clinical Material

Case 1 A 51-year-old man troubled with abdominal pain was found to have cholelithiasis and choledocholithiasis by computerized tomography (CT). Blood work done on admission showed a total serum bilirubin of 6.5 mg/dl. A serum CA 19.9 drawn at the same time was 2869 U/ml. The day following hospital admission an endoscopic retrograde cholangiopancreatogram (ERCP) demonstrated calculi within the choledochus (Figure 2), as suggested by CT. A sphincterotomy was performed and balloon clearance of the choledochus was accomplished. Follow-up magnetic resonance (MR) imaging and MR cholangiography did not demonstrate any pancreatic or pancreatic duct abnormalities. The CA 19.9 fell to within normal ranges (29 U/ml) within one month. About six weeks after presentation a cholecystectomy was performed, and eight Fig 2. Case 1 demonstrating stones within the choledochus (arrow), cleared by ERCP. The markedly elevated serum CA 19.9 level of 2869 U/ml quickly fell to within a normal range within one month.

months later liver function tests remained within normal limits. At 14 months of follow-up the CA 19.9 was 8 U/ml. Case 2 A 58-year-old man was discovered to be jaundiced and suffered from abdominal pain. His initial total serum bilirubin was 16 mg/dl. Cholelithiasis was diagnosed by abdominal ultrasound. An MR cholangiogram suggested a distal common bile duct stricture concerning for neoplasm. The CA 19.9 was found to be 6134 U/ml. An ERCP was performed (Figure 3) which showed narrowing of the distal common bile duct without stones. A stent was placed. A cholecystectomy and common bile duct exploration was then performed. A large gallstone was found impinging on the distal common bile duct and was removed along with the gallbladder. This was interpreted as Mirizziâ&#x20AC;&#x2122;s syndrome. The patient recovered uneventfully, and the pathology report showed only acute and chronic cholecystitis. In a little over one month the CA 19.9 fell to 12 U/ml. Liver function tests have remained normal. At 9 months of follow-up the CA 19.9 was 10 U/ml. Case 3 A 70-year-old man was admitted with an acute illness characterized by nausea, vomiting, and abdominal pain. He was found to be deeply jaundiced. His admitting total serum bilirubin was 22.1 mg/dl. A CA 19.9 was found to be 3058 U/ml. An MR cholangiogram showed cholelithiasis and choledocholithiasis. An ERCP was then performed, and multiple stones were removed through a sphincterotomy. The jaundice did not clear. Fig 3. The ERCP in Case 2 demonstrated severe narrowing of the distal common bile duct without apparent stones (as indicated by arrow). The duct could be cannulated only with great difficulty. There is diffuse dilatation of the proximal biliary tree. The serum CA 19.9 was reported to be 6139 U/ml. At operation a stone was found impinging on the distal common bile duct causing a Mirizziâ&#x20AC;&#x2122;s syndrome.

Figure 3 APRIL 2013 JOURNAL MSMA 97 The ERCP in Case 2 demonstrated severe narrowing of the distal common

1 demonstrating stones within the choledochus (arrow), cleared by ERCP. The markedly apparent stones (as indicated by arrow). The duct could be cannulated on

A liver biopsy was then done which showed steatohepatitis. A repeat ERCP was then done about six weeks after the first, and a clear biliary tree was demonstrated. No further stones were encountered. Over the next several weeks the serum total bilirubin gradually returned to normal levels. Three months later the serum bilirubin was normal and remained normal. The last liver function tests done approximately 15 months after the second ERCP showed a total serum bilirubin of 0.4 mg/ dl and an alkaline phosphatase of 191 IU/L. The serum CA 19.9 level at that time was 8 U/ml. The patient has not had his cholecystectomy yet due to significant co-morbidity. Case 4 A 65-year-old male was admitted with confusion and dehydration. Positive blood cultures were reported containing E. coli. The serum total bilirubin at that time was 1.3 mg/dl. An ultrasound did not show gallstones. The patient was treated with antibiotics and released. He was readmitted about two weeks later with right upper quadrant pain and was found to have scleral icterus. The total serum bilirubin at that time was 3.1 mg/dl. The alkaline phosphatase had risen to 299 IU/L. A CA 19.9 drawn at the same time was reported at 864 U/ ml. An MRI/MRCP was performed which showed evidence of chronic cholecystitis with “sludge,” a polypoid lesion, no stones, and no evidence of biliary dilatation or stones. The pancreas was reported as normal appearing. During the hospitalization the patient reported disappearance of his right upper quadrant pain. Within one month his liver function tests had completely normalized and his CA 19.9 was 32 mg/dl. A laparoscopic cholecystectomy was performed. An intraoperative cholangiogram was done and interpreted as normal. The gallbladder showed evidence of acute and chronic cholecystitis. No malignancy was identified. A follow-up CA 19.9 level has not been drawn.

Discussion

Cell surface mucins, such as Mucin 1, are thought to play a role in host defense. For example, the presence of mucins, in both the transmembrane and soluble forms, inhibits gene transfer of the adeno-associated virus to human airway epithelia.17 Similarly, Mucin 1, expressed on the cell surface of gastric epithelial cells provides a protective barrier limiting colonization of H. pylori and limiting the inflammation caused by H. pylori infection.18 More pertinent, exposure of lipopolysacchride from E. coli, K. pneumoniae, and P. aeruginosa all stimulated mucin production in cultured biliary epithelial cells.19 This heightened production may be via enhanced mucin gene expression through action of cytokines such as Interleukin-4 (IL-4), IL-6, and Tumor Necrosis Factor-α (TNF-α).20 It has also been demonstrated in vivo that cell surface mucins act at both the extracellular domain, through a “decoy” function for bacterial adhesins and at the intracellular domain through messenger activity stimulating activation,

98 JOURNAL MSMA APRIL 2013

growth, and apoptosis of epithelial cells encountering bacterial pathogens.21 Clearly, then, expression and shedding of CA19.9 containing mucins could occur in infectious states affecting biliary epithelial cells. Furthermore, extrahepatic biliary obstruction is known to initiate proliferation of bile ducts within the liver, probably through activation of existing biliary epithelium.22 Other investigators23 have correlated raised serum CA 19.9 levels with evidence of proliferating bile ductules staining for CA 19.9 and proliferating cell nuclear antigen, hypothesizing that there is heightened CA 19.9 expression in proliferating biliary epithelium. There has been experimental work which corrected the proliferative response to a heightened expression of the protooncogenes c-myc and H-ras.24 Whether a mechanism akin to over-expression of the MUC 1 gene in neoplastic tissue accounts for production of increased levels of CA 19.9 in cholestatic situations is not known, but it is conceivable that such a process may be operative. The four cases described here point to the marked reactivity of serum CA 19.9 that is possible with cholestasis and presumed cholangitis from choledocholithiasis. Similar findings were described in three individual case reports with CA 19.9 levels of 5673.8 U/ml 14, 4,374 U/ml 15, and 5,128 U/ml 16, all due to calculus disease. While pain was present in all four patients in this review, the absence of pain – a typical presentation for malignant obstruction – and an elevated CA 19.9 cannot be assumed to be from a malignant etiology. Mann and colleagues25 reported on the range of serum CA 19.9 levels in a group of 164 jaundiced patients with both benign and malignant disease. Those patients with benign disease had a statistically lower interquartile range of CA 19.9 (50 – 264 U/ml) compared to those with malignant disease (263 – 6170 U/ml). However, there was significant overlap in benign and malignant cases, with four patients with benign diseases having CA 19.9 levels over 1000 U/ml. The authors also noted a linear relationship with increasing serum bilirubin and CA 19.9 levels, whereas with malignant disease this was not the case. In all instances of benign disease, following relief of obstructive jaundice, there was a fall of the CA 19.9 levels. As in our patients, relief of obstruction and treatment of cholangitis may favorably impact the CA 19.9 level. Persistent elevation after relief of obstruction would be an ominous sign and might point to a malignant etiology. Kim and colleagues26 determined receiver operator curves for serum CA 19.9 determinations. They found that the specificity of the CA 19.9 level in differentiating benign and malignant disease with evidence of cholangitis or cholestasis improved from 41.5% to 87% if the “cut-off” value (upper limit of normal) was increased from 37 U/ml to 300 U/ml. They observed that values of CA 19.9 > 1000 U/ml were distinctly uncommon, occurring in only 8 of 163 patients presenting with cholangitis or cholestasis. Similarly, Steinberg27 indicated that as serum CA 19.9 levels exceeded 1000 U/ml, the specificity

for pancreatic malignancy approached 100%. Yet, we have presented four patients with markedly elevated CA 19.9 levels, three of which were over 2000 U/ml. The etiology in each case was benign disease. While there were no clinical indicators of cholangitis or bacteriology of bile, the subclinical presence of infection cannot be discounted. The rapidity with which the CA 19.9 levels fell following biliary decompression would attest to immediate down-regulation of cytokines and/or mucin-type gene expression following resolution of the inciting inflammatory or infectious stimulus. We would suggest, based on these anecdotal experiences, that elevated serum levels of CA 19.9 be interpreted with caution. Even extremely high levels may be caused by cholestasis and cholangitis from benign disease, often calculous biliary tract disease. A fall to normal levels following relief of biliary obstruction is reassuring, but follow-up levels are desirable to ensure that there are no further elevations that may point to occult malignancy. In summary, the serum CA 19.9 is a sensitive indicator of stimuli for gene over-expression. This may be on the basis of cytokine or cholestatic intermediaries or might represent protooncogene activation by neoplastic changes. It is, perhaps, an erroneous assumption that markedly elevated levels of CA 19.9 represent malignant pancreato-biliary disease, as has been suggested by some. These four cases demonstrate the fallacy in attributing high levels of serum CA 19.9 to malignant disease. In these anecdotal situations, the specificity of the serum CA 19.9 does not approximate its sensitivity, and therefore, even extremely high levels in the face of cholestasis should be interpreted with caution.

References 1.

Koprowski H, Steplewski Z, Mitchell K, Herlyn M, Herlyn D, Fuhrer P. Colorectal carcinoma antigens detected by hybridoma antibodies. Somatic Cell Genetics. 1979;5:957-972.

Magnani JL, Brockhaus M, Smith DF, Ginsburg V, Blaszczyk M, Mitchell KF, et al. A monosialoganglioside is a monoclonal antibody-defined antigen of colon carcinoma. Science. 1981;212:55-56.

Magnani J, Nilsson B, Brockhaus M, Zopf D, Steplewski Z, Koprowski, et al. The antigen of a tumor-specific monoclonal antibody is a ganglioside containing sialylated lacto-N-fucopentaose II. Fed Proc. 1982;41:898.

Herlyn M, Sears HF, Steplewski Z, Koprowski H. Monoclonal antibody detection of a circulating tumor-associated antigen. I. Presence of antigen in sera of patients with colorectal, gastric, and pancreatic carcinoma. J Clin Immunol. 1982;2:135-140.

Magnani JL, Steplewski Z, Koprowski H, Ginsburg V. Identification of the gastrointestinal and pancreatic cancer-associated antigen detected by monoclonal antibody 19-9 in the sera of patients as a mucin. Cancer Res. 1983;43:5489-5492.

Ho JJ, Kim YS. Serologic pancreatic tumor markers and the MUC1 apomucin. Pancreas. 1994;9:674-691.

Filella X, Molina R, Grau JJ, Pique JM, Garcia-Valdecasas JC, Astudillo E, et al. Prognostic value of CA 19.9 levels in colorectal cancer. Ann Surg. 1992;216:55-59.

Tian F, Appert HE, Myles J, Howard JM. Prognostic value of serum CA 19-9 levels in pancreatic adenocarcinoma. Ann Surg. 1992;215:350-355.

Berger AC, Meszoely IM, Ross EA, Watson JC, Hoffman JP. Undetectable

preoperative levels of serum CA 19-9 correlate with improved survival for patients with resectable pancreatic adenocarcinoma. Ann Surg Oncol. 2004;11:644-649 10. Ohtsuka M, Ito H, Kimura F, Shimizu H, Togawa A, Yoshidome H, et al. Results of surgical treatment for intrahepatic cholangiocarcinoma and clinicopathological factors influencing survival. Br J Surg. 2002;89:15251531. 11. Hallorani CM, Ghaneh P, Connor S, Sutton R, Neoptolemos JP, Raraty MGT. Carbohydrate antigen 19-9 accurately selects patients for laparoscopic assessment to determine resectability of pancreatic malignancy. Br J Surg. 2008;95:453-459. 12. Ferrone CR, Finkelstein DM, Thayer SP, Muzikansky A, Fernandez-del Castillo C, Warshaw AL. Perioperative CA 19-9 levels can predict stage and survival in patients with resectable pancreatic adenocarcinoma. J Clin Oncol. 2006;24:2897-2902. 13. Maisey NR, Norman AR, Hill A, Massey A, Oates J, Cunningham D. CA 19-9 as a prognostic factor in inoperable pancreatic cancer: the implication for clinical trials. Br J Cancer. 2005;93:740-743. 14. Sheen-Chen SM, Sun CK, Liu YW, Eng HL, Ko SF, Kuo CH. Extremely elevated CA 19-9 in acute cholangitis. Dig Dis Sci. 2007;52:3140-3142. 15. Lowe D, Lee J, Schade R, Chaudhary A. Patient with markedly elevated CA 19-9 not associated with malignancy. South Med J. 2006;99:306-308 16. Sanchez M, Gomes H, Marcus EN. Elevated CA 19-9 levels in a patient with Mirizzi syndrome: case report. South Med J. 2006;99:160-163. 17. Walters RW, Pilweski JM, Chiorini MA, Zabner J. Secreted and transmembrane mucins inhibit gene transfer with AAV4 more efficiently than AAV5. J Biol Chem. 2002;277:23709-23713. 18. McGuckin MA, Every AL, Skene CD, Linden SK, Chionh YT, Swierczak A, et al. Muc1 mucin limits both Heliobacter pylori colonization of the murine gastric mucosa and associated gastritis. Gastroenterology. 2007;133:1210-1218. 19. Choi J, Klinkspoor JH, Yoshida T, Lee SP. Lipopolysaccharide from Escherichia coli stimulates mucin secretion by cultured dog gallbladder epithelial cells. Hepatology. 1999; 29:1352-1357. 20. Shekels LL, Ho SB. Characterization of the mouse Muc3 membrane bound intestinal mucin 5â&#x20AC;&#x2122; coding and promoter regions: regulation by inflammatory cytokines. Biochim Biophys Acta. 2003;162:90-100. 21. McAuley JL, Linden SK, Png CW, King RM, Pennington HL, Gendler SJ, et al. MUC1 cell surface mucin is a critical element of the mucosal barrier to infection. J Clin Invest. 2007; 117:2313-2324. 22. Slott PA, Liu MH, Tavoloni N. Origin, pattern, and mechanism of bile duct proliferation following biliary obstruction in the rat. Gastroenterology. 1990; 99:466-477. 23. Sohda T, Iwata Y, Shijo H, Egashira Y, Egashira K, Okumura M. Increased expression of proliferating cell nuclear antigen in autoimmune hepatitis in a patient with raised serum concentration of CA 19-9. J Clin Pathol. 1998;51:167-169. 24. Tracy TF Jr, Goerke ME, Bailey PV, Sotelo-Avila C, Weber TR. Growth-related gene expression in early cholestatic liver injury. Surgery. 1993;114:532-537. 25. Mann DV, Edwards R, Ho S, Lau WY, Glazer G. Elevated tumour marker CA19-9: clinical interpretation and influence of obstructive jaundice. Eur J Surg Oncol. 2000;26:474-479. 26. Kim HJ, Kim MH, Myung SJ, Lim BC, Park ET, Yoo KS, et al. A new strategy for the application of CA 19-9 in the differentiation of pancreatobiliary cancer: analysis using a receiver operating characteristic curve. Am J Gastroenterol. 1999;94:1941-1946. 27. Steinberg W. The clinical utility of the CA 19-9 tumor-associated antigen. Am J Gastroenterol. 1990;85:350-355.

APRIL 2013 JOURNAL MSMA 99

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• Scientific •

Coagulase Positive Staphylococcal Infection: A Major Cause of Eczema Exacerbations

John C. Chapman, MD; S.E. Bauman, BS and C. Ralph Daniel, III, MD ntroduction

Eczema is a common condition with many factors associated with flaring which can be recalcitrant to therapy. Infection, especially owing to methicillin-sensitive (MSSA) and methicillin-resistant Staphylococcus aureus (MRSA), is a frequent reason. Jevon first reported two cases of MRSA skin and soft tissue infections in 1961 thought to have been nosocomial or hospital acquired methicillin-resistant Staphylococcus aureus (HA-MRSA).1 Soon after, the number of reported cases of HA-MRSA infections sharply increased with other European countries and later Japan, Australia, and the United States reporting positive cultures.2,3 In 1993, incidences of MRSA soft tissue infections in patients without a history of recent hospitalization were identified in particular communities with the first being noted in certain tribes of Australian Aborigines.4 Physicians termed these infections community acquired methicillin-resistant Staphylococcus aureus (CA-MRSA). The predominate strain of CA-MRSA in the United States (USA 300) has evolved certain features: Panton-Valentine leukocidin, α-hemolysin, and arginine catabolic mobile element.5 Each of these elements contributes to enhanced virulence resulting in more serious infections including bacteremia, pneumonia, and life threatening skin and soft tissue infections. Risk factors for MRSA include recent admission to the hospital, over-crowded living conditions, immunosuppression, diabetes, and inflammatory skin conditions. Prevalence of MRSA is increasing, with CA-MRSA accelerating more rapidly than HA-MRSA.6 There being few reports on the prevalence of Staphylococcus aureus (S. aureus) skin infections, especially MRSA, in outpatient settings (e.g. Price), the authors considered it important to determine the prevalence of S. aureus infections in a typical outpatient Mississippi dermatology clinic.7 This paper is also unique in that it reports the culture results of 50 consecutive patients with a prior diagnosis of eczema who presented with an exacerbation suggestive of infection. Author Information: Dr. Chapman is from Tulane Medical Center, New Orleans, LA. Ms. Bauman is from the University of South Alabama. Dr. Daniel is a clinical associate professor of dermatology from the University of Alabama, Birmingham, Alabama and clinical professor of dermatology at the University of Mississippi. Corresponding Author: John Chapman 1430 Tulane Ave #8036 New Orleans, LA 70112. Ph: 601-918-1038. Fax 504-988-7382. [Jchapma4@Tulane.edu].

Materials and Methods This prospective study was performed over five months at an outpatient dermatology clinic which treated patients of all ages. The overall patient population during this period was approximately 60% white and approximately 40% black. The clinic averages over 5,000 patient-visits per year. Patients had to meet all three inclusion criteria: a) prior history of atopic dermatitis or eczema; b) weeping, pruritic, eczematoid dermatitis; c) recalcitrance to maintenance emollients and mid-strength topical steroids. There were no exclusion criteria. We did not consult the internal review board, as this was consistent with the clinic’s standard of care and the patients’ identities are not revealed. Skin cultures were obtained in 50 consecutive patients who met the study’s inclusion criteria. Specimens were collected using BBL™ culture swabs and incubated at 36o C for 48hrs on BBL™ Columbia colistin and nalidixic acid agars for gram positive cocci and BBL™ MacConkey agars for gram negative bacteria. Vitek® and Microscan® systems were used to determine the minimum inhibitory concentration. Results Patients ranged in age from seven months to 93 years with a median age of 56 and the mean age of 52. Eighteen patients were male and 32 were female. Results of cultures and susceptibility tests revealed coagulase positive MSSA was cultured as the single organism in 17 (34%) of the 50 participants (6 men and 11 women). MRSA was a single isolate in 7 (14%) of the 50 participants (5 men and 2 women). Overall, 48% of all participants grew S. aureus. Of the remaining patients, 16 cultures were positive for coagulase negative staphylococcus; 1 culture was positive for enterococcus; 1 culture was positive for bacillus species; and 1 culture was positive for micrococcus species. The remaining 7 cultures were negative. All S. aureus isolated were uniformly susceptible to Trimethoprim/Sulfamethoxazole (TMP/SX) and the majority of the other non-β-lactam anti-staphylococcal antibiotics. TMP/SX or a tetracycline showed the greatest antimicrobial activity, and the authors most frequently prescribed these two drugs in the treatment of our patients. Discussion We reported positive cultures of 48% for S. aureus and 14% for MRSA. Price reported similar prevalences, 14-45% and 11.6% respectively, of S. aureus and MRSA infections from a myriad of skin infections in an outpatient dermatology

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clinic.7 This strengthens the finding that a persistently high ratio of MRSA is present in outpatient settings. When managing patients with eczematous skin diseases it is important for the practitioner to make a distinction between infection and colonization, as the former requires systemic antibiotics while the latter can be mitigated with bleach baths and intranasal decolonization. As in the study patients, the clinician should look for signs such as weeping, oozing, fissuring, and adenopathy. The spectrum, colonization-to-infection, is not completely elucidated; however, hypotheses include an increased intralesional S. aureus bacterial count at the time of flare-up causing a higher level of superantigen.8, 9 In contrast to prior findings which reported higher femaleto-male MRSA positive patients, the current results revealed the opposite. However, because the number of MRSA positive patients was rather small in the present study, the gender difference is not likely to approach statistical significance.10, 11 Since CA-MRSA is typically susceptible to other nonβ-lactam anti-staphylococcal antibiotics while HA-MRSA is not, we suspect that the isolates cultured were most likely CAMRSA, although we did not perform genetic typing.12 Also, the susceptibility results in these patients are consistent with previous antibiograms of CA-MRSA in our community. Although staphylococcal skin infections, especially MRSA infections, may be life-threatening and may warrant hospitalizations, none of the patients in the present study required hospitalization. All culture-positive patients treated with antibiotics improved with the same previous failed topical medications. Non-compliance, change in climate, or an irritant dermatitis could explain the flaring of the culture-negative patients. We prescribed higher potency topical steroids to the culture negative patients. These patients responded with resolution of their flaring. This study can serve as a baseline for MRSA skin infections in patients with eczema for a broad range of outpatient Mississippi practitioners. The authors emphasize that the prevalence of MRSA infections varies geographically and can be specific to certain groups of patients. Monitoring the prevalence of MRSA has an important treatment implication, too. This would be particularly important if cases of MRSA suddenly increased, possibly indicating the need for household prophylactic measures. The ease of transmission of MRSA has been well documented between patients and family members. Transmission to other family members has ranged from 47%-87% with colonization increasing with the length of time the patient has the disease.13, 14 Therefore, early diagnosis and treatment is important.

References: 1.

Jevon MP. Celbenin-resistant Staphylococci. BMJ. 1961;1:124-125.

Chambers HF. The changing epidemiology of Staphylococcus aureus? Emerg Infect Dis. 2001;7:178-182.

Enright MC, Robinson DA, Randle G, Feil EJ, Grundmann H, Spratt BG. The evolutionary history of methicillin-resistant Staphylococcus aureus (MRSA). Proc Natl Acad Sci U S A. 2002;99:7687-7692.

Udo EE, Pearman JW, Grubb WB. Genetic analysis of community isolates

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of methicillin-resistant Staphylococcus aureus in Western Australia. J Hosp Infect. 1993;25:97-108. 5.

Deurenberg RH, Stobberingh EE. The evolution of Staphylococcus aureus. Infect Genet Evol. 2008;8:747-763.

Robinson DA, Enright MC. Evolution of Staphylococcus aureus by large chromosomal replacements. J Bacteriol. 2004;186:1060-1064.

Price MF, McBride ME, Wolf JE,Jr. Prevalence of methicillin-resistant Staphylococcus aureus in a dermatology outpatient population. South Med J. 1998;91:369-371.

Higaki S, Morohashi M, Yamagishi T, Hasegawa Y. Comparative study of staphylococci from the skin of atopic dermatitis patients and from healthy subjects. Int J Dermatol. 1999;38:265-269.

Kligman AM, Leyden JJ, McGinley KJ. Bacteriology. J Invest Dermatol. 1976;67:160-168.

10. Graham PL, Lin SX, Larson EL. A US population-based survey of Staphylococcus aureus colonization US population-based survey of Staph. Annals of Internal Medicine. 2006;144:318-325. 11. Jayasekera A, Jennings L, Holden CR, Bates C, Gawkrodger DJ. Methicillin-resistant Staphylococcus aureus in skin disease affects mainly elderly patients with eczema and leg ulcers who have associated chronic disease. Acta Derm Venereol. 2008;88:156-158. 12. Fey PD, Said-Salim B, Rupp ME, et al. Comparative molecular analysis of community- or hospital-acquired methicillin-resistant Staphylococcus aureus. Antimicrob Agents Chemother. 2003;47:196-203. 13. Bonness S, Szekat C, Novak N, Bierbaum G. Pulsed-field gel electrophoresis of Staphylococcus aureus isolates from atopic patients revealing presence of similar strains in isolates from children and their parents. J Clin Microbiol. 2008;46:456-461. 14. Mollema FP, Richardus JH, Behrendt M, et al. Transmission of methicillinresistant Staphylococcus aureus to household contacts. J Clin Microbiol. 2010;48:202-207.

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11:30 a.m. Board of Trustees Lunch Meeting 11:30 a.m. MSMA Alliance Past President’s Luncheon 1:00 p.m. House of Delegates Addresses of MSMA President, AMA President, and Alliance President

MSMA 145th Annual Session Business Meeting August 16 – 17, 2013 Jackson More information at MSMAonline.com!

1:00 p.m. MSMA Alliance Board Orientation 2:00 p.m. Reference Committee Hearings 7:00 p.m. Inauguration of 146th MSMA President James A. Rish, MD

8:30 a.m. MSMA Alliance House of Delegates 8:30 a.m. Excellence in Medicine Awards 9:30 a.m. Candidate Speeches 10:30 a.m. Caucus Meetings 11:30 a.m. Voting & Lunch Board of Trustees Meeting 12:00 p.m. MSMA Alliance Installation Luncheon 1:00 p.m. House of Delegates 3:30 p.m. Board of Trustees Meeting 6:30 p.m. UMMC Alumni Dinner

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• MSDH • Mississippi Reportable Disease Statistics

February 2013

Figures for the current month are provisional

Totals include reports from the Department of Corrections and those not reported from a specific District. For the most current MMR ﬁgures, visit the Mississippi State Department of Health website: www.HealthyMS.com.

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• President’s Page • The Medicaid Conundrum

he subject of Medicaid expansion has been a hotly contested topic this year. There are very strong views on many different sides of this public issue, and there are many complexities in the issues which surround Medicaid expansion. What I hope to do is try to explain the issues, being careful to present both sides fairly. The President’s plan to cover the uninsured in America through the Affordable Care Act is to expand Medicaid services. Currently in Mississippi there are about 750,000 Medicaid recipients, or about 25% of our population. It is predicted to expand this number to add another 300,000 people. This would increase Medicaid coverage in our state to about 35%. At 100% of the poverty level in Mississippi, the annual income for a family of four is about $23,000.00, Steven L. Demetropoulos, MD and at 138% of the poverty level for a family of four, it is about $32,000.00. The 2012-13 MSMA President Affordable Care Act would attempt to increase the level of Medicaid enrollment up to the 138% level. This is typically the working poor. These are individuals who work in health services, as wait staff or cooks in restaurants, in construction jobs, in maintenance work, and in agriculture. The majority of these individuals are currently receiving their health care through the emergency departments across our state or through free clinics or federally subsidized clinics that are available in their area. These Medicaid expansion numbers will actually be decreased some because the federally mandated Medicaid levels will actually be increased. This number will drop to about 240,000 people from the 300,000 previously projected. There will have to be additional funding to Medicaid regardless of whether or not the state chooses to expand Medicaid to cover the uninsured. The economic impact of Medicaid expansion on the state would be phased in over seven years. For the first three years the federal government would support the Medicaid expansion 100%. The next year that drops to 95%, with the state funding 5%. The next year the state would have to fund 6% and 7% the next. By 2020 the state would have to fund 10%. In 2025 the amount of money the state would have to come up with is estimated to be $159 million in addition to its current Medicaid budget. But that $159 million is estimated to release $1.2 billion in federal funds. Some people would say this is an impossible number for the state to reach inasmuch as we are already having difficulty funding our current Medicaid budget, which was $30 million over budget this year alone. Others would say, “If I come up with one dollar and you would give me nine, then I would take that match any time.” It is estimated that this $1.2 billion circulating in the state would create about 8,000 new jobs. These jobs would be in the form of nursing staff, technicians, doctors, administrators, and hospital support personnel. Some people have gone so far as to say that if the state were trying to recruit a business into the area and it would have to come up with $159 million each year but that business would generate $1.2 billion, they would be clamoring to take on that extra matching money. The opponents of Medicaid expansion point to the poorly functioning Medicaid system. They emphasize that it does not create any personal responsibility for the recipients and that if they do not have to pay anything for these services then they don’t really value them. Others would argue that we do not have enough primary care providers to care for all these people that would be coming to an organized form of healthcare. Still others argue that there should be some other way to cover the uninsured through some type of health insurance exchange, high deductible policies or tax credits. The final issue with Medicaid expansion is the DSH payments. This is the disproportionate share payments that hospitals across the state receive for caring for uncompensated patients. It is a little over $200 million a year and is split among 82 hospitals across the state. It is essential for those hospitals to maintain their bottom lines. Right now this DSH payment is projected to go away because that money will be used to fund the Medicaid expansion. There is still a lot of debate over how quickly it will go away and how much will go away. The Governor’s office is still waiting to hear from Health and Human Services Secretary Kathleen Sebelius as to how much and how fast this fund will be reduced. To give you an idea how DSH affects the hospital system, in my hospital system our margin was about $5 million this year. We gave away about $50 million in uncompensated care and we received about $25 million in DSH payments. Without the DSH payments in place, our hospital would have to lay off everyone from middle management to environmental services. For our patients, that would mean reduction of access to care, testing, and any other services the hospital provides.

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Now let me discuss my personal feelings and what I have observed about the whole debate and the different issues surrounding it. First I have become much more sensitive to the need for uninsured patients to have some form of insurance. In the past I have not been as sensitive to this as I should have, but I see these patients on a regular basis and they are actually the working poor. They are carpenters or sheetrock hangers or waitresses, and they come in episodically when they need care. Typically they come in with some kind of infection or with some type trauma. For their age group (less than 45 years of age) those are going to be the most common issues they have. For example, when a carpenter falls off a roof and has an open femur fracture, his cost for repairing that fracture is more than what he makes in several years. So one important aspect to me is that these patients have some type of backstop, and by that I mean some type of high deductible, catastrophic coverage so that if they have a bad auto accident or they have a serious injury, everything above a certain level (you can pick that level, whether $2,500.00 or $5,000.00) is covered so they are not bankrupted or have a bill they can never pay off. Secondly, these patients are not high medical utilizers. They are generally healthy. They are working and they are motivated to work and stay on the job so they also need some type of preventive or maintenance insurance along with the catastrophic coverage. By this I mean they need to have at least one or two visits a year where they could have their blood pressure checked, their sugar checked, their lipids evaluated, and women could have mammograms and Pap smears, depending on their age group. This group of patients—the working poor— need two components: (1) catastrophic coverage and (2) general maintenance wellbeing visits. The second point that I’ve noticed is that just continuing the DSH payments as the only reason to be opposed to Medicaid expansion is not a good reason. The DSH payments are an unorganized way of compensating hospitals for taking care of the unfunded patient but they do nothing to help insure the patients that are currently uninsured, and that should be our real focus. So, as much as discontinuation of the DSH payments would hurt the hospital infrastructure across the state and decrease access for our patients, that should not be the only reason that we are supportive of the Medicaid expansion. Third, the Medicaid system does have a lot of problems but I think it is a system that we could improve and make better. Currently it is the only plan that we have on the table to really evaluate. It is so frustrating to me that there have been no alternative plans by any of the free market think tanks like the Cato Institute or the Heritage Foundation. Nothing has come out of any other conservative group that offers an alternative for providing insurance coverage for the uninsured. All these groups knew that after the election, the Affordable Care Act was coming and yet no one has prepared an alternative. I believe in personal responsibility, and I believe that people value something when they have to pay for it, but no viable alternative has been made available for us to evaluate. Fourth, we see more and more of the states choosing to take the Medicaid expansion option as well as utilize 100% of the Medicaid funding for the first three years to develop their programs. I don’t want Mississippi to be the last state or among the last five states to do this, and I don’t want to see my tax dollars go to another state when those dollars are so desperately needed in Mississippi. As you can see, there are a lot of complexities surrounding this issue. Everyone has strong feelings about it. Many of these are philosophical. When you deal with philosophical issues, reasoning or pragmatic approaches are not effective so there is not much room for discussion. I have met with doctors from across the state as I have gone to the different component society meetings. Of course my experience is only anecdotal. There are very strong feelings both in opposition and in support of this issue. There have been some very vigorous debates around the board table at your State Association trying to develop some type of strategy that is reflective of our membership. We are still trying to sort thru what our position should be and to make sure that position is reflective of our physician membership and supportive of our patients’ needs. The debate is really just starting. It began during this legislative session. It will continue over the next year and should declare itself when we receive more information from the Health and Human Services Secretary as to the viability of the continued DSH payments.

ust what the doctor ordered

PEACH SALSA

his is a great side dish to use either in a salad or to put on fish or pork. You can use the same principle to make any kind of salsa. I usually like to use peaches in the summer, especially when the Chilton County peaches come in from Alabama and the Rustin peaches come in from Louisiana. I take the local peaches and chop them up in bite-sized chunks. Dice a purple

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onion. You can use about half a purple onion to about eight peaches, less if you dislike onion. Add several tablespoons of olive oil and about a tablespoon of lemon juice. Chop a large bunch of cilantro and add that to it. Add a couple dashes of salt and then a couple dashes of red pepper flakes to make it spicy. Then I taste it. If it is too tart, I add some sugar to sweeten it to the degree of sweetness I like. I let stand for a couple of hours so it marinates. It is good served over a bed of lettuce, salad, or as I mentioned earlier, over grilled fish or grilled pork. This is one of those recipes for which you can learn the principle and use a lot of different fruits. This is great using mango as well, with fresh cilantro, lemon juice, onion, olive oil, and red pepper flakes. You can also use tomatoes or avocado, the same way that you would make guacamole. You can do pineapple, mangoes, avocado, peaches and other fruits this way. I have even used strawberries this way. They make a nice salad as well. After you place it on a bed of lettuce, you can get creative and crumble some feta cheese over the top of it. That makes a nice accompaniment also. I hope this helps you have a great appetizer to serve with chips or salad or as an accompaniment with meat for this spring and summer. Bon AppĂŠtit!

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• Special Article • A Medical Giant Remembered: Dr. Verner Holmes’s Example Continues to Inspire New IHL Physician Member Bradford J. Dye, III, MD [MSMA Board of Trustees member Dr. Ford Dye of Oxford offers up this extraordinary reflection on Pike County physician Dr. Verner Holmes, who not only served the people of Pike County for years as a talented physician but also served the state at large in his leadership role on the State College Board, on which he served for more than two decades. Dr. Dye is following in Dr. Holmes’s big footsteps in many ways, not only in his choice of medical specialty (ENT) but also in his leadership on the State College Board, now the Mississippi Board of Trustees of State Institutions of Higher Learning (IHL). Dr. Dye also serves as the Magnolia Gazette’s Oxford Beat Writer. For more on Holmes, see: L. Lampton.“Mississippi Bridge Builder: Dr. Verner S. Holmes (1909-2000) Remembered.” JMSMA. July 2000;41:7; 671-7.) —Ed.

he was a pediatric patient of Dr. first met Dr. Verner Smith Holmes and recalls him fondly: “Dr. Holmes about 25 years ago Holmes was my ear doctor when I when he started dating a was a boy. I certainly value him for close family friend, Mary Williams. that but also for being such a good, Dr. Holmes had lost his first wife fine citizen of Pike County.” For me, to illness. Mary was my surrogate Dr. Holmes was always a source of grandmother. She had been my inspiration as I proceeded through babysitter, fellow church member pre-med courses and ultimately at Galloway Methodist Church, and medical school. He also was a dear friend. We ate Sunday lunch at significant influence on my own Galloway together for years and also choice of ENT as a specialty. spent numerous holidays enjoying During my 5 years of each other’s company. When Mary residency training, Dr. Holmes and Dr. Holmes married in 1989, constantly encouraged me in my I had the pleasure of serving as a professional choice. He possessed groomsman in their wedding. a great fund of medical knowledge Dr. Holmes was a wonderful and was always interested in my addition to our extended family. Verner S. Holmes, MD – A portrait of Dr. Holmes hangs outside the University of Mississippi progression through training. We He had a gentle disposition, a quick Rowland Medical Library located in the Learning often discussed unique medical wit, and an ever present smile. Resource Center which bears his name. The problems or surgical cases. We enjoyed many evenings of painting by Marshall Bouldin was unveiled at the Obviously he had conversation around the dinner table building dedication. vast experience and and shared many holidays together. extraordinary skill On occasion, his good friend and author Willie Morris in diagnosing and would join the group. This would always lead to merriment treating problems as well as the happy group discussed various interesting of the ear, nose, topics. Dr. Holmes loved to dance. As I got to know him better, I called him “Doc” or “Pop.” and throat. I tapped into that knowledge Dr. Holmes and I frequently discussed medicine as a and experience as career choice. I was well aware that he had enjoyed a long much as possible. After he entered his nineties, he suffered a career as an Ear Nose and Throat specialist in McComb. It was fall with resultant facial lacerations and fractures. I had the evident that he loved practicing medicine and felt a calling privilege and honor of treating him as a patient during this to help others. Long before acclaimed Mississippi author episode. and journalist Curtis Wilkie was known for his writing skills,

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Dr. Holmes’s greatest legacy may have been his 24 years of service on the College Board, now the IHL Board. He served from 1956 until 1980. He was initially appointed by Governor J. P. Coleman as they had been roommates and close friends in college at Ole Miss. The library complex at the University of Mississippi Medical Center (UMMC) in Jackson is known as “The Verner S. Holmes Learning Resource Center.” While I was studying in this building with a medical school classmate, he remarked “I don’t know who Verner S. Holmes is, but he sure built a fine learning resource center.” I told my classmate that I knew Dr. Holmes, and he was a family friend and retired physician. I didn’t know why the UMMC library was named for him until I later became aware of his contributions to higher education and to UMMC through his service on the College Board. Ford Dye wipes the brow of his friend Dr. Verner S. Holmes before his second marriage in the late 1980s—Board of Trustees member Dr. Ford Dye offers up a touching rememberance of the late Pike County physician and MSMA member Dr. Verner Holmes, who preceded him as a physician member of the State College Board, now IHL Board. Dr. David Sansing is one of Mississippi’s most wellknown and beloved historians. He was also a close friend of Dr. Holmes for many years. Dr. Sansing was kind enough to sit down and discuss their relationship with me recently. Former Ole Miss Chancellor Porter Fortune asked Dr. Sansing to write a biography about Dr. Holmes and his impact on the College Board. This collaborative effort resulted in a lifelong friendship. Dr. Holmes was a modest man who never sought attention for himself. He convinced Dr. Sansing to write a book on the history of higher education in Mississippi and the College Board. (This project was undertaken by Sansing rather than a biography focused only on the achievements of Dr. Holmes.) The result was the acclaimed book entitled “Making Haste Slowly: The Troubled History of Higher Education in Mississippi.” (University Press of Mississippi, 1990) Dr. Holmes was the key contributor to this book which took ten years to complete. Dr. Sansing stated that this book “was a tribute to him” and dedicated the book to Dr. Holmes and his first wife, Emma. Dr. Sansing, in that dedication, wrote: “To Verner Smith Holmes who honored his public trust with a faithful fidelity and to Emma Bauer Holmes who made the world a better, sweeter place.” In his comments to me recently, Dr. Sansing remembered the attributes that made Dr. Holmes such a valued College Board member: “He always thought in the larger terms. Devoted as he was to Ole Miss, when he thought a certain decision was better for all eight institutions, or for the students of Mississippi, or for the state, he would vote on that larger interest.” Dr. Holmes had the perfect demeanor for a College Board member. He was willing to cooperate

and had a sense of history and vision. He was an advocate for change but was “so low key about it. He never would embarrass anybody. He never would accuse anybody of being unfair or violating any rule of justice. He would always just make his point.” He was always persuasive yet diplomatic and non-combative. Dr. Holmes had a profound impact on the development of UMMC in Jackson. The beginning of his College Board tenure coincided with the move of the 2 year medical school in Oxford to the 4 year school in Jackson. Dr. Sansing comments that the medical school “under the great deans and also under the guidance and support of Verner Holmes became one of the great medical schools in this country.” Dr. Sansing knew all of the medical school deans, and they conveyed to him how fundamental Dr. Holmes was to the development of UMMC. They would often seek Dr. Holmes for advice, and “he would steer them in the direction of possibilities.” Dr. Holmes had a keen understanding of these possibilities and their political ramifications. The care that Dr. Holmes provided his patients over the years was exemplary. His legacy to our state and his contributions to higher education were significant. He was a role model for physicians in their care for their patients and also to fellow College Board members in their service to

Ford Dye and Verner Holmes—More than two decades ago, Verner Holmes married Mary Williams (Mary Ann Mobley’s mom). Ford, who served as a groomsman, is shown on the left with Holmes at the wedding.

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higher education. Dr. Robert Khayat, longtime Chancellor at Ole Miss, describes Dr. Holmes fondly: “He really would be a role model for anyone who hopes to be a gentleman.” He adds: “He was smart. He was kind. He was funny. He was dedicated to make Mississippi a better place.” Dr. Holmes died in the spring of 2000, and I was honored to be a pallbearer at his funeral. When Governor Phil Bryant asked me to serve on the College Board (now known as the Board of Trustees of the State Institutions of Higher Learning), I paused to consider this commitment. Balancing the time requirements of a family and a medical practice can be difficult. As I reflected on my journey to become a physician, I thought of all the people who took time to teach, mentor, and encourage me. My professors and counselors in college and medical school, as well as physicians at UMMC and in private practice during my residency, were all sources of encouragement and knowledge. My family and friends provided support through years of hard work. And my dear friend Dr. Holmes was there for me through it all. Serving on the IHL Board is a way to help repay, in a small way, the debt I owe to all of these people. My hope is that my care for my patients and my service on the IHL Board would make “Doc” proud. r

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• The University of Mississippi Medical Center • Researchers Describe First ‘Functional HIV Cure’ in an Infant

team of HIV experts from Johns Hopkins Children’s Center, the University of Mississippi Medical Center, and the University of Massachusetts Medical School describe the first case of a socalled “functional cure” in an HIV-infected infant. The finding, the investigators say, may help pave the way to eliminating HIV infection in children. A report on the case is scheduled was presentated at a press conference on Sunday, March 3 at the 20th Conference on Retroviruses and Opportunistic Infections (CROI) in Atlanta. Johns Hopkins Children’s Center virologist Deborah Persaud, M.D., lead author on the report, and University of Massachusetts Medical School immunologist Katherine Luzuriaga, M.D., headed a team of laboratory investigators. Pediatric HIV specialist Hannah Gay, M.D., associate professor of pediatrics at the University of Mississippi Medical Center, provided treatment to the baby. TIME named Dr. Gay to the 2013 TIME 100, the magazine’s annual list of the 100 most influential people in the world. The list, now in its 10th year, recognizes the activism, innovation, and achievement of the world’s most influential individuals. The infant described in the report underwent remission of HIV infection after receiving antiretroviral therapy (ART) within 30 hours of birth. The HIV experts say the prompt administration of antiviral treatment likely led to this infant’s cure by halting the formation of hard-to-treat viral reservoirs — dormant cells responsible for reigniting the infection in most HIV patients within weeks of stopping therapy. “Prompt antiviral therapy in newborns that begins within days of exposure may help infants clear the virus and achieve long-term remission without lifelong treatment by preventing such viral hideouts from forming in the first place,” Persaud says. The experts say they believe this is precisely what happened in the child described in the report. That infant is now deemed “functionally cured,” a condition that occurs when a patient achieves and maintains long-term viral remission without lifelong treatment and standard clinical tests fail to detect HIV replication in the blood.

In contrast to a sterilizing cure — a complete eradication of all viral traces from the body — a functional cure occurs when viral presence is so minimal, it remains undetectable by standard clinical tests, yet discernible by ultrasensitive methods. The child described in the current report was born to an HIV-infected mother and received combination antiretroviral treatment beginning 30 hours after birth. A series of tests showed progressively diminishing viral presence in the infant’s blood until it reached undetectable levels 29 days after birth. The infant remained on antivirals until 18 months of age at which point the child was lost to follow-up for a while and, the researchers say, stopped treatment. Ten months after discontinuation of treatment, the child underwent repeated standard blood tests, none of which detected HIV presence in the blood. Test for HIV-specific antibodies — the standard clinical indicator of HIV infection — also remained negative throughout. Currently, high-risk newborns — those born to mothers with poorly controlled infections or whose mothers’ HIV status is discovered around the time of delivery — receive a combination of antivirals at prophylactic doses to prevent infection for six weeks and start therapeutic doses if and once infection is diagnosed. But this particular case, the experts say, may change the current practice because it highlights the curative potential of very early ART. Specialists say natural viral suppression without treatment is an exceedingly rare phenomenon observed in less than half a percent of HIV-infected adults, known as “elite controllers,” whose immune systems are able to rein in viral replication and keep the virus at clinically undetectable levels. HIV experts have long sought a way to help all HIV patients achieve elitecontroller status. The new case, the researchers say, may be that long-sought game-changer because it suggests prompt ART in newborns can do just that. The experts caution they don’t have enough data to recommend change right now to the current practice of treating high-risk infants with prophylactic, rather than therapeutic, doses, but the infant’s case provides the rationale to start proofof-principle studies in all high-risk newborns.

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“Our next step is to find out if this is a highly unusual 33 million people worldwide infected with HIV. response to very early antiretroviral therapy or something we “Complete viral eradication on a large scale is our longcan actually replicate in other highterm goal but, for now, remains out of risk newborns,” says Persaud, who reach, and our best chance may come is also the scientific chair of the HIV from aggressive, timely, and precisely Cure Committee of the International targeted use of antiviral therapies in Maternal, Pediatric Adolescent high-risk newborns as a way to achieve AIDS Clinical (IMPAACT) network, functional cure,” Luzuriaga says. a consortium of researchers and Despite the promise this institutions that was critical in approach holds for infected newborns, spearheading the earliest clinical trials the experts involved say preventing of mother-to-child transmission and mother-to-child transmission remains early treatment of infants 15 years ago. the primary goal. A single case of sterilizing “Prevention really is the best cure has been reported so far, the cure, and we already have proven investigators note. It occurred in an strategies that can prevent 98 percent HIV-positive man treated with a bone of newborn infections by identifying marrow transplant for leukemia. The and treating HIV-positive pregnant bone marrow cells came from a donor women,” says Gay, the HIV expert with a rare genetic mutation of the who treated the infant. white blood cells that renders some Research portions of the case people resistant to HIV, a benefit were funded by the National Institutes that transferred to the recipient. Pediatric HIV specialist Hannah Gay, of Health and by the American Such a complex treatment approach, M.D., associate professor of pediatrics Foundation for AIDS Research however, HIV experts agree, is at the University of Mississippi Medical (amfAR). r neither feasible nor practical for the Center, provided treatment to the baby.

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112 JOURNAL MSMA APRIL 2013

• The School of Medicine at the UMMC •

Match Day 2013

A crowd of School of Medicine students, faculty and family members gathered at the Jackson Marriott on March 15 to find out where members of the class of 2013 would match.

During the Match Day 2013 ceremony March 15, Paul Redmond reads his match with his 2-1/2-year-old daughter, Anastasia. Redmond matched in pediatrics at UMMC.

Matched couple William and Layson Denney read aloud their pairings with at Virginia Commonwealth University in internal medicine and obstetrics and gynecology respectively during the University of Mississippi School of Medicine Match Day Ceremony.

Renaldo Williams announces his residency match to Vanderbilt University in general surgery while an eager crowd of parents, students, spouses, and families look on.

uring Match Day 2013, more than 100 fourthyear medical students at the University of Mississippi School of Medicine, plus thousands more across the country, discovered where they will receive specialty training for the next few years. A simultaneous nationwide event, Match Day was held March 15. A crowd of families, friends, faculty, and supporters gathered at the Jackson Marriott ballroom downtown to hear School of Medicine students announce where they will receive residency training, which ranges from three to seven years depending on the specialty.

Of the 106 students who announced their matches during the ceremony in Jackson, 45 will stay at UMMC. Others matched as far away as New Hampshire, Massachusetts, and Washington state. The newly-minted residents will train in 20 different specialties; 65 chose primary care areas, including family medicine, pediatrics, internal medicine, OB-GYN, and medicine-pediatrics. Results follow on the next page. —Gary Pettus UMMC Office of Public Affairs

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Mimi Abadie Georgetown University Hospital, Washington, District of Columbia Medicine-Pediatrics Caleb Adams Jackson, Mississippi

University of Mississippi Medical Center, Orthopedic Surgery

Wesley Aldred University of Mississippi Medical Center, Jackson, Mississippi Internal Medicine Najat Al-Sherri St. Louis, Missouri

Barnes-Jewish Hospital, Obstetrics-Gynecology

Stephen Anderson University of Mississippi Medical Center, Jackson, Mississippi Internal Medicine Christian Barnes University of California Irvine Medical Center, Orange, California Otolaryngology Mary Margaret Basham University of Alabama - Birmingham, Birmingham, Alabama Internal Medicine Peggy Boles University of Mississippi Medical Center, Jackson, Mississippi Anesthesiology Sedrick Bradley University of Mississippi Medical Center, Jackson, Mississippi Internal Medicine Kimberly Bridges Center, Jackson, Mississippi

University of Mississippi Medical Internal Medicine

Cherita Brown Dallas, Texas

Methodist Health System Dallas, Obstetrics-Gynecology

John Browning University of Mississippi Medical Center, Jackson, Mississippi Family Medicine Tyler Burns Little Rock, Arkansas

University of Arkansas, Anesthesiology

Taylor Burns Albert Einstein/Beth Israel Medical Center, New York, New York Psychiatry Nikki Cager University of Mississippi Medical Center, Jackson, Mississippi Medicine-Primary

Rob Cochran, III Vanderbilt University Medical Center, Nashville, Tennessee Medicine Preliminary Vanderbilt University Medical Center, Nashville, Tennessee Radiology-Diagnostic Cassie Confait University of Mississippi Medical Center, Jackson, Mississippi Ophthalmology Chad Cooley University of Mississippi Medical Center, Jackson, Mississippi Obstetrics-Gynecology Taylor Coppage University of Tenn. Medical Center at Knoxville, Knoxville, Tennessee Anesthesiology Kate Cunningham University of North Carolina Hospital, Chapel Hill, North Carolina Internal Medicine Jim Cunningham University of Mississippi Medical Center, Jackson, Mississippi Emergency Medicine Mark Davis Cedars-Sinai Medical Center, Los Angeles, California Anesthesiology Layson Denney Virginia Commonwealth University Health System, Richmond, Virginia Obstetrics-Gynecology William Denney Virginia Commonwealth University Health System, Richmond, Virginia Internal Medicine Austin Dillard Memphis, Tennessee

Baptist Memorial Hospital, Radiology-Diagnostic

Heather Douglas Wake Forest Baptist Medical Center, Winston-Salem, North Carolina Internal Medicine Caleb Dulaney University of Alabama - Birmingham, Birmingham, Alabama Medicine Preliminary University of Alabama - Birmingham, Birmingham, Alabama Radiation Oncology Mari Beth Eiland University of Mississippi Medical Center, Jackson, Mississippi Pediatrics

Gunter Cain Little Rock, Arkansas

University of Arkansas, Anesthesiology

Ashley Emerson University of Mississippi Medical Center, Jackson, Mississippi Medicine Preliminary Louisiana State University - New Orleans, New Orleans, Louisiana Dermatology

Philip Carter Rome, Georgia

Floyd Medical Center, Family Medicine

Kaitlin Gilham University of Nebraska Affiliated Hospitals, Omaha, Nebraska Internal Medicine

Sireesha Chinthaparthi University of Mississippi Medical Center, Jackson, Mississippi Pediatrics

Porter Glover Texas A&M College of Medicine-Scott and White, Temple, Texas Internal Medicine

Chris Clark University of Texas Southwestern, Dallas, Texas Otolaryngology

Jim Griffith, Jr. Baton Rouge, Louisiana

Haley Clark University of Texas Southwestern, Dallas, Texas Medicine Preliminary University of Texas Southwestern, Dallas, Texas Radiology-Diagnostic

Wilson Hannah University of Massachusetts Medical Center, Worcester, Massachusetts Internal Medicine

Charles Clark, Jr. Ochsner Clinic Foundation-LA, New Orleans, Louisiana General Surgery

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Earl K. Long Medical Center, Medicine Preliminary

Lori Harris LSU Health Sciences Center, Shreveport, Louisiana Internal Medicine Megan Harvey University of Mississippi Medical Center, Jackson, Mississippi Pediatrics

Kelley Hill University of Miss. Medical Center, Jackson, Mississippi Medicine-Pediatrics

Ryves Moore University of Tennessee, Memphis, Tennessee Orthopedic Surgery

Brittany Hines Mayo Graduate School of Med. Scottsdale, Arizona Internal Medicine

Colin Muncie Univ. of Miss.Medical Center, Jackson, Mississippi General Surgery

Peyton Hines Mayo Graduate School of Med. Scottsdale, Arizona Otolaryngology

Kurt Nelson University of Arkansas, Little Rock, Arkansas Otolaryngology

Shantele Hinton Univ. of Miss.Medical Center, Jackson, Mississippi Obstetrics-Gynecology

Michael Oâ&#x20AC;&#x2122;Neal Loma Linda University, Loma Linda, California Emergency Medicine

Nick Hoda University of Miss. Medical Center, Jackson, Mississippi Emergency Medicine

Sue Park McGaw Med. Center of Northwestern Univ., Chicago, Illinois Internal Medicine

Ben Horton University of Miss. Medical Center, Jackson, Mississippi Internal Medicine Sireesha Chinthaparthi reads her match to

Sharae Parker Univ. of Miss. Medical Center, Jackson, Mississippi Obstetrics-Gynecology

Austin Howard, III University of North Medicine Match Day Ceremony. Carolina Hospital, Chapel Hill, North Carolina Internal Medicine

Jonathan Peeples Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire Psychiatry

pediatrics at UMMC during the School of

Kyle Howard Texas Tech University Health Sciences Center, Lubbock, Texas Pediatrics

Jessica Perkins University of Mississippi Medical Center, Jackson, Mississippi Pediatrics

Sola Isikalu Wright State University Boonshoft School of Medicine, Dayton, Ohio Internal Medicine

Will Phillips Texas A&M College of Medicine-Scott and White, Temple, Texas Anesthesiology

Darrin Jackson University of Mississippi Medical Center, Jackson, Mississippi Family Medicine

Elaine Pigman University of Utah Affiliated Hospital, Salt Lake City, Utah Medicine Preliminary University of Utah Affiliated Hospital, Salt Lake City, Utah Radiology-Diagnostic

Allison Jones University of Tennessee, Memphis, Tennessee Dermatology Jake Lancaster University of Alabama - Birmingham, Birmingham, Alabama Internal Medicine Bronwyn LeBlanc Center, Jackson, Mississippi

University of Mississippi Medical Internal Medicine

Brandon Lennep University of Mississippi Medical Center, Jackson, Mississippi Internal Medicine Steven Lewis David Grant Medical Center, Travis Air Force Base, California Radiology-Diagnostic Lauren Lindsey Wake Forest Baptist Medical Center, Winston-Salem, North Carolina Internal Medicine Meghan Luter University of Mississippi Medical Center, Jackson, Mississippi Medicine-Pediatrics Andrea McCann University of Mississippi Medical Center, Jackson, Mississippi Anesthesiology Elizabeth McKey University of Mississippi Medical Center, Jackson, Mississippi Pediatrics Andrew Meador University of Tennessee, Memphis, Tennessee Ophthalmology John Miller, II University of Mississippi Medical Center, Jackson, Mississippi Family Medicine

Luke Rawson University of Tennessee Medical Center at Knoxville, Tennessee Transitional University of Tennessee Medical Center at Knoxville, Tennessee Radiology-Diagnostic David Ray University of Mississippi Medical Center, Jackson, Mississippi Radiology-Diagnostic Paul Redmond Jackson, Mississippi

University of Mississippi Medical Center, Pediatrics

Debbie Rigney University of Mississippi Medical Center, Jackson, Mississippi Surgery- Preliminary LanĂŠe Riley Jackson, Mississippi

University of Mississippi Medical Center, Internal Medicine

Richard Robertson, Jr. Orleans, Louisiana

Ochsner Clinic Foundation-LA, New Anesthesiology

William Rosenblatt Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire Medicine-Primary Katie Royals University of Mississippi Medical Center, Jackson, Mississippi Family Medicine Thomas Royals Louisiana State University - New Orleans, New Orleans, Louisiana Orthopedic Surgery Khalid Saleh University of Mississippi Medical Center, Jackson, Mississippi Radiology-Diagnostic

APRIL 2013 JOURNAL MSMA 115

Patrick Sánchez University of Mississippi Medical Center, Jackson, Mississippi Medicine-Primary

Julia Thompson University of Mississippi Medical Center, Jackson, Mississippi Medicine-Pediatrics

Elizabeth Schimmel Oregon Health & Science University, Portland, Oregon Otolaryngology

Katie Tumminello University of Alabama - Birmingham, Birmingham, Alabama Pathology

Armand Scurfield Little Rock, Arkansas

Vandana Vedanarayanan Buffalo, New York

University of Arkansas, Pediatrics

University at Buffalo, Anesthesiology

Joel Shores University of Mississippi Medical Center, Jackson, Mississippi Internal Medicine

Sruthi Veerisetty University of Massachusetts Medical Center, Worcester, Massachusetts Internal Medicine

Stephen Sills Seattle, Washington

Brandon Weatherly Center, Jackson, Mississippi

Virginia Mason Hospital, Anesthesiology

University of Mississippi Medical Radiology-Diagnostic

Brooke Sims University of Mississippi Medical Center, Jackson, Mississippi Pathology

Richard Webb University of Mississippi Medical Center, Jackson, Mississippi Anesthesiology

Laura Lee Skelton Smith Birmingham, Alabama

Patrick Williams San Francisco, California Los Angeles, California

Baptist Health System, Radiology-Diagnostic

Brent Smith University of Alabama - Birmingham, Birmingham, Alabama Obstetrics-Gynecology Day Smith University of Mississippi Medical Center, Jackson, Mississippi Internal Medicine Will Smithhart Virginia Commonwealth University Health System, Richmond, Virginia Pediatrics Clayton Stevens University of Mississippi Medical Center, Jackson, Mississippi Medicine Preliminary Tulane University, New Orleans, Louisiana Ophthalmology RachelAnn Sullivan Walter Reed National Military Med. Center, Bethesda, Maryland Pediatrics

St. Mary’s Hospital, Medicine Preliminary University of Southern California, Radiation Oncology

Renaldo Williams Vanderbilt University Medical Center, Nashville, Tennessee General Surgery Scott Williams Little Rock, Arkansas

University of Arkansas, Emergency Medicine

Jordan Windham University of Mississippi Medical Center, Jackson, Mississippi Urology Nilda Maria Witty University of Mississippi Medical Center, Jackson, Mississippi Radiology-Diagnostic Kully Woodruff Durham, North Carolina

Duke University Medical Center, Medicine-Pediatrics

Admissions Committee Chair Summarizes UMMC Medical School Class of 2016: Diversity and Excellence Predominate

ne of the privileges I have as Associate Dean for Admissions at the UMMC School of Medicine is to chair the medical school admissions committee, one of the most committed groups on our campus. They are dedicated to alignment of our admissions process with the mission, goals, and diversity interests of the School of Medicine. Each member agrees to serve a four year term. During most of the year they meet an average of two hours per week; however, from September through January, they allocate about seven hours per week for interviewing applicants and meeting to evaluate their applications and render decisions. For applicants who have who have sufficient academic metrics (grades and Medical College Admissions Test scores) to be invited for interviews, the committee conducts a holistic review of life experiences (including health care, volunteerism, leadership, research, employment, athletics, and artistic endeavors), and personal attributes (including written and verbal communication skills, demonstrated initiative, a record

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of interacting with people, motivation for medicine, heavy work load and desire to learn) when rendering decisions. The goal is to shape a medical school class where diversity will be the driver of educational excellence and graduate the competent and compassionate physicians who are needed to provide quality and equitable health care to all Mississippians and aid in the elimination of health care disparities that exist in our state. The 2012 entering class was selected from 368 applicants, the largest pool of Mississippi resident applicants in medical school’s history. From this pool, 225 applicants were interviewed and 135 members of School of Medicine’s class of 2016 enrolled on August 7th. Aside from the fact that 100% of the class are Mississippi residents, the diversity of this class can be described using an iceberg as a metaphor. What is readily apparent and visible above the surface is that the class contains 55 females (41%), 26 minorities underrepresented in medicine (19%), and 15 African Americans (11%). What is less apparent about the class below the surface is: the average age is

All 135 members of School of Medicine’s class of 2016 are Mississippi residents.

25 (range 20-34 years); it contains graduates from 35 colleges and universities (11 in-state, 24 out-of-state); the students have 25 different college degrees, 39% in biology; the class overall undergraduate Grade Point Average (GPA) is 3.72, their science and math GPA is 3.67; and their average MCAT is 28.4. If one digs deeper below the surface, what will be revealed is that the class has a remarkable collection of life experiences in health care, volunteerism, leadership, research employment, and other time consuming activities. Each member of the class has been assessed for personal attributes such as written and verbal communication skills, initiative, interactions with people, motivation for medicine, and a desire to learn. About 71% of the class comes from medically underserved counties, 36% from rural counties, 33% from socioeconomically disadvantaged backgrounds, 19% are the 1 first in their family to graduate from college, and 13% attended 2 educationally disadvantaged Mississippi public high schools. 3 If this class follows in the footsteps of those who recently preceded them, commit to their studies, embrace the 4 curriculum that the faculty will provide, and, when needed, 5 take advantage of academic achievement programs that are 6 available to them, this class too will perform at or above 7 the national medical student average on national board and 8 licensing examinations, and 97% of them will graduate. 9 The School of Medicine gratefully acknowledges the 10 time and dedicated service of members of the 2011-2012 11 admissions committee: Claude Brunson, MD, Senior Advisor 12 to the Vice Chancellor for External Affairs, Professor, 13 Anesthesiology; Margaret Peggy Davis, MD, Associate 14 Professor of Medicine, Assistant Dean for Medical School 15 Admissions; Demondes Haynes, MD, FCCP, Medical Director 16 of Respiratory Therapy, Assistant Professor of Medicine, 17 Associate Fellowship Program Director, Pulmonary, Critical 18 Care, & Sleep Medicine; Michael Hebert, PhD, Associate 19 Professor, Biochemistry; Robert Hester, PhD, Professor, 20 Physiology; Loretta Jackson-Williams, MD, Associate 21 Professor, Emergency Medicine, Associate Dean, Academic22 Affairs; Fred McMillan, MD, Ophthalmologist; John. Naftel, 23 PhD, Professor, Anatomy; Penni Smith, PhD, Assistant

Professor, Anesthesiology; Jasmine Taylor, MD, Assistant Professor, Psychiatry and Human Behavior, Associate Vice Chancellor, Multicultural Affairs; Thais Tonore, MD, Assistant Professor, Family Medicine, Director of Student Programs, Family Medicine; Rebecca Waterer, MD, Associate Professor, Medicine, Director, Student and Employee Health. —Steven T. Case, PhD, Professor of Biochemistry Journal of the Mississippi State UMMC Associate Dean for Medical Schools Admissions

Staff Physician Student Health Center Mississippi State University The MSU Student Health Center is looking for a BC/BE primary care physician to join the clinical staff. This is a robust clinical setting with focus on the healthcare of a university community. This is modern facility with adequate support staff and a fully integrated EHR environment. Compensation includes a base plus production incentive and full university benefits. Compensation is very competitive with primary care market. No hospital obligation. Malpractice insurance is paid by university. To apply go to www.jobs.msstate.edu search for “Staff Physician.” Inquires may be sent to rwc77@msstate.edu

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• The School of Medicine at the UMMC •

UMMC Breaks Ground on New Teaching Building $63M building to provide space for larger medical class sizes

Rendering of new University of Mississippi School of Medicine building, north face

overnor Phil Bryant, University of Mississippi Chancellor Dan Jones, and other state and local dignitaries unveiled plans and broke ground January 7, 2013 on a $63 million building that will permit larger class sizes at the University of Mississippi School of Medicine. The event marked significant progress toward Bryant’s goals of bringing more physicians to Mississippi and growing the state’s health-care economy. In October, Bryant directed $10 million in Community Development Block Grant funding to the University of Mississippi Medical Center to launch the effort. The new 151,000 square-foot building will provide stateof-the-art, flexible, and technology-rich classrooms and laboratories. The new space will allow the School of Medicine to increase its incoming class sizes from 135 students per year to more than 165. The five-story building is scheduled for completion in 2016. “I am thrilled to break ground on this expansion of the School of Medicine,” Gov. Bryant said. “Mississippi is in need of more bright, skilled physicians to provide quality medical care to our residents and to those patients from other states who seek outstanding care in Mississippi, and this state-of-theart expansion will allow us to provide better training to even more students.

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“Not only will this help us reach our goal of training more physicians to provide better health-care access, these new doctors will create a significant economic impact in the communities where they practice. I have said before that health care is an industry of necessity, and Mississippi is taking an important step today to proactively grow its health care economy.” UMMC projects that the larger class sizes accommodated by the new facility will generate about $1.7 billion in economic impact in Mississippi by 2025 and that the additional physicians trained will support more than 19,000 new jobs by the same year. The current economic impact of practicing UMMC-trained physicians is more than $6.3 billion annually, and those physicians are estimated to support more than 60,000 jobs in the state. Current School of Medicine facilities are cramped, outdated, and spread among numerous facilities on and off campus. The oldest are in UMMC’s original 1955-era building. Dr. Dan Jones, University of Mississippi chancellor, said the new facility will improve the Medical Center, the entire university and the state’s health outlook. “The university is interested not only in being a fine institution but also in making a difference in people’s lives. Because of this new medical school, lives will be changed in Mississippi,” Jones said.

Philip Gunn, speaker of the Mississippi House of Representatives, said he understands the importance of producing more physicians for the state and training them in cutting-edge facilities. “On behalf of the legislature, we pledge to do everything we can to support this new medical school,” Gunn said. Dr. James Keeton, UMMC vice chancellor for health affairs and School of Medicine dean, said the new building will help address Mississippi’s medical needs. “Today’s ceremony marks a defining step in building the space we need to train Mississippi’s next generations of physicians. This new School of Medicine facility Dr. James Keeton, UMMC vice chancellor for health affairs and School of Medicine directly addresses our mission to dean, told a crowd of ground-breaking ceremony attendees on January 7 the additional educate health-care providers for physicians trained at the new School of Medicine building will improve health-care in Mississippi’s vast medical needs,” Mississippi and boost the state’s economy. Keeton said. “We’re grateful to Gov. Bryant, the state Legislature and Mississippi Development Authority for recognizing how training more physicians for Mississippi will impact the When your medical office is short-staffed, state’s economy, and we’re glad to continue working with you get frustrated. the state’s leadership to improve the future of health care in Mississippi.” When you get frustrated, you dread going to work Gov. Bryant worked closely with the Mississippi and you start playing hooky. Economic Council to develop a comprehensive strategy for growing Mississippi’s health care economy, and increasing When you start playing hooky, the bills pile up. the state’s capacity to train physicians is key component of the plan. When the bills pile up, “Blueprint Mississippi’s Health Care as an Economic Mama ain’t happy. Driver study focuses on the importance of building our When Mama ain’t happy, capacity of physicians, and the new medical school is a ain’t nobody happy. ground breaking effort toward both attracting and training the best and the brightest,” said Blake A. Wilson, president and CEO of the Mississippi Economic Council, the state Chamber of Commerce. “It is another world class visionary move toward putting our state in the place of greatest opportunity.” During the 2012 legislative session, Gov. Bryant signed into law House Bill 317 to establish more medical residency programs throughout the state, a move that will allow more Mississippi-trained physicians to remain in the state. This When your office is short-staffed, session, Bryant will continue to pursue efforts to increase the number of physicians practicing in Mississippi’s most use the MSMA Online Job Bank! medically underserved communities. The school of medicine expansion is expected to create Learn more: about 930 jobs during construction. r

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Have You Considered a Life Settlement For Your Old Life Insurance Policy? What is a Life Settlement? A life settlement is the sale of an existing life insurance policy on the secondary market to a third party investor.

Who or What May Qualify?  If the person insured by the policy is age 70 or older  If the person insured has any major medical conditions  If the policy has a death beneﬁt of $250,000 or more  Policies including, but not limited to, universal life, term insurance, variable life insurance or whole life insurance  If any cash value exists in the policy, the amount is relatively small

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Why Use a Life Settlement?  Term life insurance policy will expire  Old policy that is no longer needed or premiums cannot be paid  A policy that was purchased for a business buy/sell and is no longer needed  A policy was purchased for a business that has been sold or is not needed  There may be a better policy available at a lower cost

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Securities Offered Through ValMark Securities, Inc. Member FINRA, SIPC Investment Advisory Services Offered Through ValMark Advisers, Inc. a SEC Registered Investment Advisor 130 Springside Drive, Suite 300 Akron, Ohio 44333-2431* 1-800-765-5201 Executive Planning Group is a separate entity from ValMark Securities, Inc. and ValMark Advisers, Inc. In a life settlement agreement, the current life insurance policy owner transfers the ownership and beneficiary designations to a third party, who receives the death proceeds at the passing of the insured. As a result, this buyer has a financial interest in the seller’s death. When an individual decides to sell their policy, he or she must provide complete access to his or her medical history, and other personal information, that may affect his or her life expectancy. This information is requested during the initial application for a life settlement. After the completion of the sale, there may be an ongoing obligation to disclose similar and additional information at a later date. A life settlement may affect the seller’s eligibility for certain public assistance programs, such as Medicaid, and there may be tax consequences. Individuals should discuss the taxation of the proceeds received with their tax advisor. ValMark Securities considers a life settlement a security transaction. ValMark and its registered representatives act as brokers on the transaction and may receive a fee from the purchaser. A life settlement transaction may require an extended period of time to complete. Due to complexity of the transaction, fees and costs incurred with the life settlement transaction may be substantially higher than other securities.