April
VOL. LI
2010
No. 4
Join us: The Physicians Who Care for Mississippi
142
nd
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R
egister at
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Lucius M. Lampton, MD Editor D. Stanley Hartness, MD Michael O’Dell, 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 Randy Easterling, MD President Tim J. Alford, 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© 2010, Mississippi State Medical Association.
APril 2010
VOlUMe 51
nUMBer 4
Scientific ArticleS
Pancreas cancer in Mississippi: Present challenges and future Directions clinical Problem-Solving: Perplexing Pyretic Polyarthritis
114
errata: Vol. 51, no. 3 J Miss State Med Assoc. 2010;50(3):83.
116
Rajvinder Singh Hanspal, MD
PreSiDent’S PAge
let’s change the Whole Damn System and Start Over, but We Have to Wait Until tuesday
121
Randy Easterling, MD; MSMA President
eDitOriAl
But Will it take?
123
D. Stanley Hartness, MD; Associate Editor
relAteD OrgAnizAtiOnS
Mississippi Academy of family Physicians
106
DePArtMentS
Poetry in Medicine new Members Obituaries the Uncommon thread Placement/classified Una Voce
107 117 119 125 126 127
ABOUt tHe cOVer:
“DigitAliS DeriVeD frOM tHe fOxglOVe PlAnt” - This exotic flower photographed by Sherman Bloom, MD comes from a genus of about 20 species of plants commonly called foxgloves. Also known as digoxin and digitoxin, digitalis is a drug that strengthens the contraction of the heart muscle, slows the heart rate and helps eliminate fluid from body tissues. In 1785, William Withering published his classic account of foxglove and some of its medical uses, describing the syndrome of digoxin toxicity and remarking upon his experience with digitalis. Indians in South America had used cardiac glycosides in their dart poisons. Some have suggested that the toxic visual symptoms of digitalis may have played a role in Van Gogh's use of swirling greens and yellows. During the early 20th century, the drug was introduced as treatment of atrial fibrillation. Only subsequently was the value of digitalis for the treatment of congestive heart failure established. Dr. Bloom is a retired professor and former chair of the Department of Pathology at the University of Mississippi Medical Center who now resides in the greater Salt Lake City area of Utah. As a fine art photographer Dr. Bloom is primarily concerned with visual esthetics. The majority of his work emphasizes personal views of nature and beautiful things rather than commercial objectives. His photographs have been shown in galleries in Mississippi, Arkansas, Colorado, and New Mexico and have appeared with articles in a number of photography journals. Photographs by Dr. Bloom can be seen at www.phototov.com.r VOL. LI
April
No. 4
2010
April
VOL. LI
Official Publication of the MSMA Since 1959
99
Thomas S. Helling, MD, FACS
april
2010
No. 4
2010 JOUrNal MSMa
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• SCieNTiFiC arTiCleS •
Pancreas Cancer in Mississippi: Present Challenges and Future Directions Thomas S. Helling, MD, FACS
A
intrODUctiOn
BStrAct
Pancreatic cancer remains a deadly disease. Currently, the only hope for cure is surgical resection at an early stage of the disease. However, there is evidence that many individuals do not receive this treatment, perhaps because of health care disparities. Mississippi, because of its socioeconomic composition, has been the focus of concern for health care disparities. In order to determine whether such disparities exist in Mississippi for pancreatic cancer, a retrospective analysis was done from 2000 – 2006 of case diagnosis, treatment, and mortality from this disease. The Mississippi Cancer Registry, the American College of Surgeons (ACS) National Cancer Data Base (NCDB), and the National Cancer Institute (NCI) Surveillance Epidemiology and End Results (SEER) program were surveyed. Outcomes at all 12 ACS Commission on Cancer (CoC) accredited hospitals within the state were compared to the NCDB nationwide (n=1331 hospitals). In 2006 Mississippi had the highest death rate from pancreas cancer in the nation (12.7/100,000). Age-adjusted incidence by county ranged to a high of 26.91/100,000. Fifty-one percent of patients who died from pancreatic cancer in the state were treated at ACS CoC hospitals. The fate of the other 49% is not known. Of the patients tracked at CoC hospitals, there was essentially no significant difference with respect to age distribution, stage at diagnosis, or first treatment modalities when compared to NCDB nationwide CoC data. There were fewer patients surviving two years with locally advanced disease compared to national figures. Of concern was the large number of patients whose treatment for pancreatic cancer is unknown. It is incumbent on health care providers in the state to develop a system of care for pancreatic cancer that is accessible, inclusive, and comprehensive.
Key WOrDS:
PANCREATIC DuCTAl ADENOCARCINOMA (PDA), HEAlTHCARE DISPARITIES, PANCREATIC CANCER
AUtHOr infOrMAtiOn: Dr. Helling is in the Department of Surgery at the University of Mississippi Medical Center in Jackson, MS. cOrreSPOnDing AUtHOr: Thomas S. Helling, MD, Department of Surgery, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, ph: (601) 8151161, Fax: (601) 815-1165, thelling@surgery.umsmed.edu
With a uS Census Bureau population of 2,848,293 in 20001, Mississippi is largely a rural state with 48.8% of the population residing outside urban areas. As a grim reminder, Mississippi ranks last among the 50 states in families below the poverty level and in percent of the population with less than a high school education, next to last in median household income, and 48/50 in percent unemployed. Mississippi has the highest of any state in percent of resident African Americans (AA) (36.6%).2 As such, Mississippi has been used as an example of disparities in health care.3,4 Residents in certain regions of the state have been found to die more often from common ailments of cardiovascular disease, strokes, injury, and cancer than residents of the united States (uS). With respect to pancreatic cancer, the age-adjusted death rate in Mississippi 2002-2006 was 12.7/100,000, the highest in the nation.5 Ductal pancreatic adenocarcinoma is a leading cause of cancer deaths. In 2008 it was estimated that 37,680 new cases would be diagnosed and that almost an equal number, 34,290 individuals, would die of the disease.6 In fact, five-year survival rates for pancreatic cancer remain dismally low with only modest improvement over the past 28 years, from two percent to five percent.6 Rather surprisingly, information from the American College of Surgeons (ACS) National Cancer Data Bank (NCDB) 2000 – 2006 indicates that 40 percent of patients with pancreatic cancer received no first line cancer-directed treatment.7 Socioeconomic status has been linked to poorer clinical outcomes and refusal of treatment.8 Bilimoria and colleagues9, using information provided in the ACS NCDB, reported that the majority of patients (71.4%) with Stage I pancreatic cancer, those with potentially curative disease, did not, in fact, receive surgery. Patients who were black, less educated, poorer, or were operated on in smaller community hospitals were less likely to receive surgery, situations that may exist in many areas of Mississippi It is the intent of this study to define the status of pancreatic cancer in the state of Mississippi using available state and national databases to guide strategy in the future for the treatment of this lethal disease. april
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MAteriAlS AnD MetHODS
reSUltS
The primary aim of this study was to compare the distribution of pancreas cancer in a state population with national figures. Age, stage, first treatment modalities, and survival were examined. The hypothesis was that, due to racial differences and educational and economic disadvantages, there would be corresponding disparities in treatment and outcome of pancreatic cancer. The Mississippi Cancer Registry was established in 1993 through funds appropriated by the Mississippi legislature. The ensuing Central Cancer Registry was established to serve as the state's comprehensive resource for statewide cancer data. Currently, the Mississippi Cancer Registry is supported through funds from the Centers for Disease Control and Prevention, the Mississippi Department of Health and the university of Mississippi Medical Center. The Mississippi Cancer Registry, the ACS NCDB, and the National Cancer Institute (NCI) Surveillance Epidemiology and End Results (SEER) program were surveyed. The NCDB, a joint program of the ACS Commission on Cancer (CoC) and the American Cancer Society, is a nationwide oncology outcomes database for more than 1,400 CoC approved cancer programs in the uS and Puerto Rico. All CoC accredited hospitals, as part of monitoring for quality of care, must submit their cancer cases to the NCDB. The SEER database provides organ specific information through its state cancer profiles, a joint project between the NCI and the Centers for Disease Control. The Mississippi Cancer Registry provided information on the number of cases diagnosed within the state from 2003 – 2006 and all deaths within the state from 2000 – 2006. The ACS NCDB compared cases diagnosed in the state of Mississippi, among all 12 ACS CoC hospitals within the state, with national data. From the NCDB age and stage distribution and first course treatments were surveyed. The SEER database was surveyed for information concerning mortality rate, incidence, rate trends, and historical trends, comparing Mississippi with national statistics. Survival statistics were supplied by the NCDB. Descriptive statistics are provided as frequency counts and percentages. Pearson’s chi square test with Yate’s correction was used for differences in categorical variables. Cumulative survival was calculated according to the Kaplan-Meier technique for estimations of survival.10
In 2006 the SEER database indicates that Mississippi has the highest death rate from pancreatic cancer in the nation – 12.7/100,000 population. From 2000-2006, according to the Mississippi Cancer Registry, 2258 patients died from pancreatic cancer in the state of Mississippi, an average of 376 patients per year. using information supplied by the NCDB for all 12 ACS CoC hospitals within the state, 1149 patients were diagnosed and treated during the same time period, an average of 192 patients per year. This represents 51% of deaths recorded for pancreatic cancer for that time period. Figure 1 illustrates age-adjusted invasive pancreatic cancer incidence by county for 2003-2006, the earliest year incidence was recorded by the Mississippi Cancer Registry. Age-adjusted county incidence ranged from 0.00 (Issaquena) to 26.91 (Kemper). There is no apparent clustering of high or low county incidence across the state. Figures 2 – 4 compare age at diagnosis, stage at diagnosis, and first treatment for patients encountered at CoC hospitals within the state with national NCDB data for 2000 – 2006.
figUre 1: age-aDJUSTeD iNCiDeNCe OF paNCreaTiC CaNCer iN
MiSSiSSippi By COUNTy. “UNSTaBle” reFerS TO COUNTS < 15 (TOO Few TO CalCUlaTe a STaBle age-aDJUSTeD raTe). SOUrCe: MiSSiSSippi CaNCer regiSTry HTTp://MCr.UMS.eDU/
figUre 2: age aT DiagNOSiS OF paNCreaTiC CaNCer MS = NCDB COC HOSpiTalS MiSSiSSippi (N = 12) US = NCDB COC HOSpiTalS US (N = 1350) NONe OF THe age grOUp COMpariSONS were SigNiFiCaNTly DiFFereNT SOUrCe: aMeriCaN COllege OF SUrgeONS NaTiONal CaNCer DaTa BaNk Age (years)
0
stne ap fo tnecreP
5 10 % pts US
15
% pts MS
20 25 30 35
35
Percent of pa ents
30 25 20
% pts MS
15
% pts US
10 5 0
Age (years)
figUre 3: aJCC STage aT preSeNTaTiON MS = NCDB COC HOSpiTalS MiSSiSSippi (N = 12) US = NCDB COC HOSpiTalS US (N = 1350) THere were NO STaTiSTiCally SigNiFiCaNT DiFFereNCeS aMONg THe STage grOUpiNgS
SOUrCe: aMeriCaN COllege OF SUrgeONS NaTiONal CaNCer DaTa BaNk AJCC stage at presenta on 0
I
II
III
IV Unknown
0
stne ap fo tnecreP
10 20
% pts US % pts MS
30 40 50 60
60
Percent of pa ents
50 40 30 % pts MS 20
% pts US
10 0 0
I
II
III
IV
AJCC stage at presenta on
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Unknown
figUre 4:
= 0.005). Therefore, 190 patients in Mississippi from 2000 – 2006 in 12 CoC hospitals likely received potentially curative surgery for their pancreatic cancer (17%), or 2.6 procedures/hospital/year. The corresponding figure from uS NCDB data is 3.8 procedures/hospital/year. Figure 5 depicts the cumulative percent survival by stage for pancreatic cancers diagnosed at 12 CoC hospitals within Mississippi compared to uS statistics nationwide among 1331 CoC hospitals. There is no statistically significant difference in survival by stage compared to the NCDB for patients treated at the CoC hospitals in Mississippi, although there may be a clinical trend towards better survival for Stage II and III patients nationwide compared to Mississippi at two years (Stage II: uS 17.4% vs. MS 9.8%; Stage III: uS 21.7% vs. MS 12.0%).
FirST COUrSe TreaTMeNT FOr paNCreaS CaNCer SUrgery = CUraTive iNTeNT ; raD = raDiaTiON THerapy; CHeM = CHeMOTHerapy MS = NCDB COC HOSpiTalS MiSSiSSippi (N = 12) US = NCDB COC HOSpiTalS US (N = 1350) all grOUpiNgS exCepT “CHeM ONly” NOT SigNiFiCaNTly DiFFereNT SOUrCe: aMeriCaN COllege OF SUrgeONS NaTiONal CaNCer DaTa BaNk only Surgery
Chem Rad +
treatment only + Chem specified treatment Chem Surg + Rad Other No
0 5
stne aP fo tnecreP
10 15
% pts US
20
% pts MS
25 30
p<0.001
35 40 45 50
50 45
Percent of Pa ents
40 35
p<0.001
30 25
% pts MS
20
% pts US
15 10 5 0
Surgery only
Rad + Chem
Chem only
No Surg + Rad Other + Chem specified treatment treatment
all ageS, BOTH SexeS, all raCeS.
aNNUal perCeNT CHaNge Over THe 5-year periOD CalCUlaTeD By Seer STaT. DeaTH DaTa prOviDeD By THe NaTiONal viTal STaTiSTiCS SySTeM pUBliC USe DaTa File. DeaTH raTeS CalCUlaTeD By THe NaTiONal CaNCer iNSTiTUTe USiNg Seer STaT. DeaTH raTeS are age-aDJUSTeD TO THe 2000 US STaNDarD pOpUlaTiON. Average Annual Percent Change -5
-4
-3
-2
-1
0
1
2
3
All Cancer Sites Prostate Brain & ONS Non-Hodgkin Lymphoma Stomach Acute lymphocy c leuk Cervix Lung & Bronchus Breast (Female) Bladder Leukemia Oral Cavity & Pharynx Colon & Rectum Pancreas Thyroid Melanoma of the Skin Liver & Bile Duct Ovary Esophagus Lymphomas Uterus
There are no significant differences with respect to age, stage at diagnosis, or first treatment except those patients in Mississippi receiving only chemotherapy for first treatment (29% vs. 23%, p < 0.001). A large percentage of patients received no treatment for their pancreatic cancer (42% Mississippi, 45% uS). The AA race comprised 36% of the pancreatic cancer patients in the NCDB for Mississippi compared to 11% nationally (p < 0.0001). From the Mississippi NCDB 83% of patients received no surgery on the pancreas; nationally, the figure was 80% (p figUre 5: kaplaN-Meier OBServeD CUMUlaTive SUrvival OF paTieNTS wiTH paNCreaTiC CaNCer, CaSeS DiagNOSeD
figUre 6: 5-year raTe CHaNge FOr MOrTaliTy, MiSSiSSippi 2002-2006,
Uterus Lymphomas Esophagus Ovary Liver & Bile Duct Melanoma of the Skin Thyroid Pancreas Colon & Rectum Oral Cavity & Pharynx Leukemia Bladder Breast (Female) Lung & Bronchus Cervix Acute lymphocy c leuk Stomach Non-Hodgkin Lymphoma Brain & ONS Prostate All Cancer Sites
1998-2001. NO
-5
-4
-3
STaTiSTiCally SigNiFiCaNT DiFFereNCeS were realizeD BeTweeN
MiSSiSSippi (MS) aND UNiTeD STaTeS (US) paTieNT pOpUlaTiONS. THere appearS TO Be a CliNiCally relevaNT DiFFereNCe iN CUMUlaTive 2 year SUrvival FOr STage ii aND iii paTieNTS US verSUS MS (arrOwS). SOUrCe: aMeriCaN COllege OF SUrgeONS NaTiONal CaNCer DaTa BaNk MS n = 476 Stage at Diagnosis 0
I
II 1.0
III
US n = 54909
IV I II III Years From Diagnosis 2.0 3.0
IV 4.0
5.0
20
60 70
US Stage III 21.7% 2 year survival US Stage II 17.4% 2 year survival
MS Stage II 9.8% 2 year survival
80 90 100
100 90 80
MS Stage II 9.8% 2 year survival
70
Cumula ve Survival Percentage
egatnecreP lavivruS ev alumuC
MS Stage III 12.0% survival
40 50
60
US Stage II 17.4% 2 year survival
50
US Stage III 21.7% 2 year survival
MS Stage III 12.0% survival
20 10 0 Stage at Diagnosis
1.0 I
II
III
MS n = 476
2.0 3.0 Years From Diagnosis IV I II III
US n = 54909
4.0 IV
0
1
2
3
DiScUSSiOn
40 30
-1
Figure 6 shows the average annual percent change for cancers in the state of Mississippi. While pancreatic cancer has not increased or receded, further demographic portrayal of death trends is depicted in Figure 6. Figure 7 shows trends in deaths per 100,000 comparing Mississippi to the united States. While deaths in AAs have decreased across the uS, there has been a noticeable rise in deaths from pancreatic cancer in Mississippi to over 16/100,000. In contrast, deaths among whites, both in Mississippi and the uS, have remained fairly flat at 10-11/100,000.
10
30
-2
Average Annual Percent Change
5.0
There is an average of 376 individuals who die from pancreatic cancer each year in Mississippi. According to available data from local (Mississippi Cancer Registry) and national (NCDB) sources, only about one-half of these patients are treated in CoC hospitals with availability of state-of-the-art cancer care. Of those treated, as recorded in the NCDB, there does not seem to be a disparity with age of onset or stage at diagnosis. Mirroring the demographics of the state, over onethird of the patients were AA. While, generally, there was no difference april
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figUre 7: DeaTH DaTa prOviDeD By THe NaTiONal viTal STaTiSTiCS SySTeM pUBliC USe DaTa File. DeaTH raTeS CalCUlaTeD By THe NaTiONal CaNCer iNSTiTUTe USiNg Seer STaT. DeaTH raTeS are ageaDJUSTeD TO THe 2000 US STaNDarD pOpUlaTiON. regreSSiON liNeS CalCUlaTeD USiNg THe JOiNpOirT regreSSiON prOgraM. CreaTeD By STaTeCaNCerprOFileS.CaNCer.gOv ON 11/17/09.
in first course treatment for their cancers, the NCDB revealed that more patients in Mississippi received chemotherapy only, as opposed to combination treatment, and more patients did not receive any type of surgery on their pancreas compared to national figures. On average, fewer operations on the pancreas with intent to cure were performed per hospital per year compared to all uS hospitals. These data must be put in the context, however, of the total number of deaths from pancreatic cancer per year in Mississippi and the fact that, in almost one-half of these deaths, there is no retrievable information on age, stage, or treatment rendered. It is not clear if these patients left the state to obtain treatment elsewhere, received treatment at non-ACS CoC hospitals, or whether they simply did not receive any treatment. There did not appear to be appreciable differences in patient outcomes for early (stage I) or late (stage IV) disease. However, there is some discrepancy in outcome for patients with locally advanced (stage II and III) disease. Fewer patients in Mississippi survived to two years compared to the national sample for both stages. Prolongation of survival may be possible in these patients with a combination of surgery, chemotherapy, and radiation therapy. It could be that Mississippi patients were not afforded the scope of treatment found in other centers nationwide. Pancreatic cancer, specifically ductal adenocarcinoma, has been notoriously difficult to cure. While five-year survival rates have noticeably improved for breast and colon cancers over the past 30 years, similar survival rates for pancreas cancer have remained disappointingly stagnant, usually not exceeding five percent. Data from the NCDB indicate that only 22% of patients with invasive cancer present with localized disease (stage I or II) and only 16% are resected for cure. In fact, over 40% of patients receive no treatment at all for their pancreatic cancer. Even with patients who survive more than one month, Krzyzanowska and colleagues11 reported that only 49% received can-
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cer-directed treatment. More disturbingly, the report by Bilimoria and colleagues9 points to a potential problem in delivering the only current curative treatment for pancreatic cancer – pancreatectomy. Riall and lillemoe12 believe this could be an issue with referral for surgical evaluation by primary physicians (including gastroenterologists and oncologists) and lack of familiarity and training by surgeons who are consulted. Perhaps most disturbing is the association of inadequate (or no) treatment with race and socioeconomic class13,14,15, despite presenting at similar age and stage as our data indicate. In fact, some speculate that the shift of patients to high volume centers where outcome is expected to improve may leave the poor and socioeconomically disadvantaged to seek care at less qualified low volume hospitals.16 There are additional data to show that stage for stage, AA receive potentially curative surgery less often than their Caucasian counterparts.17 This may be due to the fact that the AA population less often have a primary care physician, less often are referred for surgical evaluation, and less often are advised and receive surgical treatment.18 This may be due to consultation with surgeons who are less qualified to evaluate and treat patients with pancreatic cancer, a reflection of treatment at low volume hospitals. Both hospital and surgeon volume has been linked to better outcomes as a surrogate marker for quality care, including disease specific and overall hospital resources.19,20 As volume increased significant increases were seen in hospitals meeting leapfrog criteria, HealthGrades five-star ratings, teaching programs such as surgery and gastroenterology, and availability of interventional radiology services. This applies not just to individual surgical procedures such as pancreatectomy but also to overall outcomes following cancer-directed treatment. Birkmeyer and co-authors21 reported an adjusted decrease in hazard ratio of mortality in high-volume hospitals for pancreatic cancer of 0.77 for patients surviving surgery. While reasons for improved late survival in cancer victims are not entirely clear, Murray Brennan commented in an editorial that “high-volume institutions create support environments essential to quality care”.22 High volume hospitals treating cancer victims are also often National Cancer Institute recognized cancer centers with availability of collaborative oncological care and access to early phase clinical trials. Despite the difficulties and disappointments in treating pancreatic cancer, there are still system issues that might enhance care and provide the infrastructure for progress in the future. On behalf of the American College of Surgeons, a panel of 20 pancreatic cancer experts ranked potential quality indicators for validity using accepted appropriateness methodology.23 Among validated indicators were surgical resection for clinical stage I or II disease, administration of adjuvant chemotherapy/radiation therapy for resected patients, initiation of cancer directed treatment within two months of diagnosis, performance of at least 12 pancreatectomies per year, retrieval of at least 10 lymph nodes with resected specimens, monitoring of resected margins for residual tumor, risk-adjusted perioperative mortality (< 5%), monitoring of 30-day readmission rate following surgery, and, importantly, participation in clinical trials. While only a minority of hospitals surveyed complied with these performance indicators, the gauntlet has been thrown and performance parameters have been set. It is incumbent on hospitals and health care systems to provide care that all citizens de-
serve as well as a foundation for progress into the future. The major limitation of this report is the lack of uniform data on all victims of pancreatic cancer in the state of Mississippi. Information concerning demographics and treatment is lacking in almost one-half of the deaths, and this could dramatically skew the otherwise not too dissimilar statistics from uS NCDB reports. It is not immediately clear what happened to these patients. Some, no doubt, left the state to receive care in out-of-state facilities. Some may have received care at non-ACS CoC hospitals within the state. Others, for a variety of reasons, may not have received any care at all and were sent home (or chose to return home) to die. With this in mind, it is important to recognize barriers to care for vulnerable groups that could lead to outcome disparities, as outlined by Bierman and coauthors24: access to the healthcare system, barriers within the healthcare system such as difficulty getting appointments and referrals to specialists, and the ability of providers to address the patients’ needs such as referral to the proper specialists for comprehensive care. Equally important, systems of care should be established that are patient-centered rather than providercentered. The maze through which patients who are already burdened by illness and its psychological impact must navigate can be formidable and discouraging. This process should be as simple as possible in order to deliver compassionate, timely, and appropriate care. This report has served to illustrate the state of care for victims of PDA in Mississippi. While those that receive care in CoC hospitals are on equal par with national outcomes, there are a sizeable number of patients, probably half, for whom there is no information on treatment or outcome. In recognition of the prevalence of PDA in Mississippi, it is incumbent on the state’s health care providers to ensure that all patients have easy and timely access to physician specialists and facilities which are qualified to deliver expert care. This can be done through dissemination of information and coordination of treatment programs throughout Mississippi as a network of cancer care.
12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24.
Riall TS, lillemoe KD. underutilization of surgical resection in patients with localized pancreatic cancer. Ann Surg 2007; 246:181-182. Zell JA, Rhee JM, Ziogas A, et al. Race, socioeconomic status, treatment, and survival time among pancreatic cancer cases in California. Cancer Epidemiol Biomarkers Prev 2007; 16:546-552. Krzyzanowska MK, Weeks JC, Earle CC. Treatment of locally advanced pancreatic cancer in the real world: population-based practices and effectiveness. J Clin Oncol 2003; 21:3409-3414. Chang KJ, Parasher G, Christie C, et al. Risk of pancreatic adenocarcinoma: disparity between African Americans and other race/ethnic groups. Cancer 2005; 103:349-357. Stitzenberg KB, Sigurdson ER, Egleston Bl, et al. Centralization of cancer surgery: implications for patient access to optimal care. J Clin Oncol 2009; 27:4671-4678. Murphy MM, Simons JP, Hill JS, et al. Pancreatic resection: a key component to reducing racial disparities in pancreatic adenocarcinoma. Cancer 2009; 115:3979-3990. Riall TS, Townsend CM, Kuo Y-F, Freeman Jl, Goodwin JS. Dissecting racial disparities in the treatment of patients with locoregional pancreatic cancer: a 2-step process. Cancer 2010. Bellal J, Morton JM, Hernandez-Boussard T, et al. Relationship between hospital volume, system clinical resources, and mortality in pancreatic resection. J Am Coll Surg 2009; 208:520-527. Eppsteiner RW, Csikesz NG, McPhee JT, et al. Surgeon volume impacts hospital mortality for pancreatic resection. Ann Surg 2009; 249:635-40. Birkmeyer JD, Sun Y, Wong Sl, Stukel TA. Hospital volume and late survival after cancer surgery. Ann Surg 2009; 245:777-783. Brennan MF. Quality pancreatic cancer care: it’s still mostly about volume. J Natl Cancer Inst 2009; 101:837-838. BIlimoria KY, Bentrem DJ, lillemoe KD, et al. Assessment of pancreatic cancer care in the united States based on formally developed quality indicators. J Natl Cancer Inst 2009; 101:848-859. Bierman AS, Magari ES, Jette AM, et al. Assessing access as a first step toward improving the quality of care for very old adults. J Ambul Care Manage 1998; 21:17-26.
referenceS 1.
united States Census Bureau population estimates: http://www.census. gov/popest/states/NST-ann-est.html accessed December 1, 2009. 2. united States Census Bureau: http://www.census.gov/main/www/cen2000. accessed December 1, 2009. 3. Jack l Jr, Hayes SC, Wilson V. Social inequities in Mississippi: a call to action. J Public Health Manag Pract 2009; 15:167-172. 4. Cosby AG, Bowser DM. The health of the Delta Region: a story of increasing disparities. J Health Hum Serv Adm 2008; 31:58-71. 5. National Cancer Institute state cancer profiles: http://statecancerprofiles. cancer.gov/ accessed December 1, 2009. 6. American Cancer Society: Cancer Facts and Figures 2008. American Cancer Society, Atlanta, GA. 7. National Cancer Data Base. American College of Surgeons Commission on Cancer Benchmark Report Vol 9. 8. Zell JA, Rhee JM, Ziogas A, et al. Race, socioeconomic status, treatment, and survival time among pancreatic cancer cases in California. Cancer Epidemiol Biomarkers Prev 2007; 16:546-552. 9. Bilimoria KY, Bentrem DJ, Ko CY, et al. National failure to operate on early stage pancreatic cancer. Ann Surg 2007; 246:173-180. 10. Kaplan El, Meier P. Nonparametric estimation from incomplete observations. J American Statistical Assoc 1958; 53:457-481. 11. Krzyzanowska MK, Weeks JC, Earle CC. Treatment of locally advanced pancreatic cancer in the real world: population-based practices and effectiveness. J Clin Oncol 2003; 21:3409-3414. april
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Medical Medical A Assurance ssurance Company Company o off M Mississippi ississippi After many years, MACM is still his ch hoice. When W n I first began my practice, I was insured by another noth company. After just a few years, a med-mal crisis hit Mississippi and the rest of the country. As Mississippi physicians, we knew the only way to manage the availability of professional liability coverage was to form our own company and MACM was founded in 1976 by some very foresighted physicians. I joined the company back then and am proud to say I’ve been with them ever since. Even in the most recent med-mal crisis, MACM led the charge in educating its insureds about the legal and judicial reforms that could affect them. From the beginning through today, I’m grateful that MACM is th heree whenever and however I need them. James M. Cooper, MD Anethesiologist Tupelo, Mississippi
For over 30 years, Mississippi physicians have looked to Medical Assurance Company of Mississippi for their professional liabilit y needs. Today, MACM is an integral part of the health care communit y providing a legacy of services to our insureds. Dedicated staě 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 us to be the carrier of choice in Mississippi. Call on us to assist with your professional liabilit y needs.
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• MaFp •
Celebrity Roast of Daniel W. Jones, MD Chancellor of the University of Mississippi JOneS celeBrity rOASt — Cartoonist Marshall ramsey created this caricature for the MaFp Foundation fundraiser.
u
niversity of Mississippi Chancellor Dr. Daniel W. Jones was the focus of the third annual celebrity roast benefiting the Mississippi Academy of Family Physicians (MAFP) Foundation. The event was held February 6 at the Inn at Ole Miss in Oxford to benefit the Mississippi Academy of Family Physicians Foundation which provides scholarships and programs for aspiring family doctors and community health programs. Roasters for the evening included: Dr. Randy Easterling, Dr. James E. Keeton, Dr. Robert C. Khayat, Mr. Ken Ray, Dr. Helen R. Turner and Dr. louAnn Woodward.
Dr. JAMeS e. KeetOn, vice chancellor for health affairs and dean of the school of medicine at the University of Mississippi Medical Center, roasts his predecessor Dr. Dan Jones.
During the celebrity roast of Dr. Daniel Jones, MaFp Foundation Board president Dr. Michael O’Dell presented a check in the amount of $2,000 to Janie guice, Mississippi rural physicians Scholarship program Director. cHAncellOr Dr. DAn JOneS poses by a drawing of his likeness on a Bankplus sponsor sign.
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• pOeTry iN MeDiCiNe • [This month, we print the remarks of Robert C. Khayat, Chancellor Emeritus at the University of Mississippi at Oxford. Although not a physician, Khayat has written a song about a physician, inspired by the old Irish ballad “Danny Boy.” In the tradition of pun and poetry, this humorous tongue-in-cheek verse was presented at the Mississippi Academy of Family Physicians Foundation Celebrity Roast of Daniel W. Jones, MD, Chancellor of the University of Mississippi. The black tie optional event was held at The Inn on the Ole Miss campus on Saturday night February 6, 2010. This third annual physician roast (previous roasts were Dr. Ed Hill and Dr. Randy Easterling) was a grand success, with over 114 tickets sold and over $10,000 raised for medical Former University of Mississippi Chancellor robert C. khayat education in the state. Kim Erickson, foundation executive director, and shares a jingle he wrote in jest of his successor, Dr. Daniel w. Beth Embry, MAFP chief executive, deserve much praise for pulling off Jones (l.). Master of Ceremonies Dr. lucius lampton (r.) said such a classy event. Among the roasters were MSMA President Randy the crowd was enamored with the lyrics. Easterling, UMC Vice Chancellor James E. Keeton, Past MSMA President Helen Turner, and UMC Associate Vice Chancellor Lou Ann Woodward. Many of the comments were memorable, and Dr. Khayat’s song captures the mood of the evening and the warm sentiment expressed for Dr. Jones. Strumming a guitar at the podium and standing next to defenseless Dr. Jones, Khayat warbled the following producing smiles and laughter at almost every line. Any physician with Mississippi ties is invited to submit poems for publication in the journal, attention: Dr. Lampton or email lukelampton@cableone.net.] —Ed.
Danny’s Song Oh Danny Boy, the chapel bells are ringing An ode to you and your sweet lydia. It’s 3 a.m. and the Kappa Sigs are singing Just a hint of what they plan for you.
And now you live on a famous street That we know as Fraternity Row Where more beer is consumed on Saturday night Than you ever want to know.
Ole Miss is a place of free expression Of thoughts your Baptist ears have never heard. We see you leading Hotty Toddys late at night And await your Calvinistic cleansing of HEll YES, DAMN RIGHT!
You’ll search for ways to rest your mind And hope to reduce the pain. So please take comfort in knowing this simple truth THE SOuTH SHAll RISE AGAIN.
Your devotion to academic quality And relentless quest for research grants Will be pushed aside by home-runs and TD’s And how to repair an aging sewerage plant. There was no alcohol in your childhood home And whiskey has never touched your lips. You earned your white coat and served mankind With no need to take a sip THEY SAY WHEN IN ROME…
But I jest, and it’s time for me to close. So together let’s raise a glass of cheer And offer a toast in lieu of a roast To a couple we hold so dear. We pray that God will bless you And bring you happiness. Remember that we love you And wish you the very best.
—Robert Khayat February 5, 2010
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Join us: The Physicians Who Care for Mississippi
142
nd
annual Session of the
House of Delegates & Medical affairs Forum 2010 June 3-6
natchez Convention Center
xperience Dunleith Mansion at a welcome reception on the grounds of this circa 1856 historic landmark. Shuttles will depart from the Natchez Grand Hotel. The University of Mississippi Medical Alumni Chapter is the official sponsor of this evening soiree and will present its first ever “Distinguished Medical Alumnus of the Year” award to a deserving medical alumnus from the University of Mississippi Medical Center. Afterwards, you’re invited to observe other local “spirits” with the famous “Angels on the Bluff ” guided cemetery tour at dusk. A complete schedule of meeting events is available at: MSMAonline.com. Highlights include:
E
• Opening session of the MSMa House of Delegates on Friday with the closing session and election of officers on Sunday. • Friday sessions for history buffs - A program on military medicine and surgery during the Civil War presented by Dr. William Hanigan and a presentation by Dr. Michael Trotter on Dr. Tichenor’s Mississippi medical practice and use of his famous elixir. • Seersucker & sundresses on the bluff President’s reception... Shouts & murmurs political stump speeches... Make a splash with the carnival dunk tank featuring MSMA Pres. Dr. Randy Easterling trying to stay high and dry. • official inauguration of MSMa’s 143rd President Dr. Timothy J. alford - Acclaimed novelist Greg Isles will kick off the gala reading from his bestsellers and signing books. Celebrity Chef Luis Bruno will host an eclectic dinner with wine pairing and share his inspirational healthy eating and wellness story. Dance to the swing of crooner Ned Fasullo and the fabulous big band orchestra. Van’s Photography will provide professional formal photos available for purchase. • Kids only - Build & fly a kite, float a boat, river rat races, a treasure hunt and more... Events are free, but you need to pre-register.
M ake reservations now natchez grand hotel 111 North Broadway St. 1-866-488-0890 $129.99 per night, cut off date: May 15
Eola 110 North Pearl Street 601-445-6000 $79.00-$150.00 per night, cuts off date: May 15
CME ursday, June 4, “lunch and learn” MaCM golf Tournament Diagnosis and Prevention of Diabetes Mellitus Drs. Ed Daly and Ken Stubbs
Saturday, June 5 Update on Healthcare Reform - Cynthia Brown (AMA) Can We Save the Profession? - Charles Bond, Esq. The Eye in Relation to Diabetes Mellitus - Ching J. Chen, MD The Feet in Relation to Diabetes Mellitus - Bradley Boland, MD Pharmacy/Treatment of Diabetes Mellitus - Wes Pitts, PharmD Mississippi State Medical Association is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. The Mississippi State Medical Association designates this educational activity for a maximum of 6 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.
MSMA Annual Session & Medical Affairs Forum ’10 Registration Form
Clip & fax form to: 601.853.6746 or register at: MSMaonline.com Please indicate the number of individuals attending
Wednesday June 2 6:00 PM 7:30 PM
MsMA Welcome reception Angels on the bluff cemetery tours
____________ ____________
Thursday, June 03 11:30 AM - 12:30 PM 1:00 - 5:00 PM
Medical Affairs Forum "lunch and learn" (1 hour cME) Kids only: go Fly a Kite
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Friday, June 4 7:00 AM 10:30 AM - 2:30 PM 11:00 AM - 3:00 PM 11:30 AM - 1:30 PM 6:00 - 10:00 PM 6:00 - 8:00 PM
breakfast With Exhibitors Kids only: Float-a-boat MsMAA Pre-convention board Meeting - $30 Pizza Party With Exhibitors Kids only: bubbles on the bluff President reception "seersucker & sundresses in the Park"
____________ ____________ ____________ ____________ ____________ ____________
Saturday, June 05 7:00 AM - 9:00 PM 7:00 - 12:00 PM 8:30 - 2:30 PM 12:00 PM - 2:30 PM 6:00 - 10:00 PM 8:00 - 11:00 PM
breakfast Medical Affairs Forum (5 hours cME) - non-member fee: $150 Kids only: river rat relay MsMAA installation luncheon - the carriage house - $35 Kids only: treasure hunt inaugural gala saturday - per person: $100
____________ ____________ ____________ ____________ ____________ ____________
Sunday, June 06 8:30 AM - 10:30 AM 7:00 - 9:00 AM 7:00 - 9:00 9:00 - 11:00
MsMA Alliance Past President breakfast - callon Petroleum bldg. continental breakfast honoring 2010-2011 President V.i.P. breakfasts: 50-Year club & Past Presidents house of delegates
____________ ____________ ____________ ____________
Please print the following information Name __________________________________________________________________________________________________ Title or Degree ___________________________________________________________________________________________ Mailing Address (Street/P.O. Box) ____________________________________________________________________________ City __________________________________ State ____________________ Zip Code ________________________________ Daytime Telephone Number _______________________________________FAX number _______________________________ E-mail address ________________________________________
Non-Member CME Registration Fee: $150
Make check for CME fee payable to MSMA and mail with registration form to: MSMA, P. O. Box 2548, Ridgeland, MS 39158-2548. MSMA members may FAX registrations to (601) 853-6746 and pay on site or you can pay online now at www.MSMAonline.com. Click on “Annual Session” in the top tab and complete fields in the registration form. Please direct inquiries to Susie Pettit: (601) 853-6733, or spettit@MSMAonline.com. MSMA offers equal opportunity in employment and education, M/F/D/V. Please call (601) 853-6733 prior to 5/3/10 if special accommodation is required.
CALL FOR ENTRIES
Seeking Nominations for the 2010 MSMA Award for Community Service The Annual Physician Award for Community Service, sponsored by Mississippi State Medical Association, is designed to provide recognition to members of the association who are actively engaged in the practice of medicine, for the many and varied services above and beyond the call of duty which they render to their respective communities. Each recipient of the award is nominated by his or her component society and selection is made by the members of the Council on Public Information. The intent of the program is to honor only living persons, and to honor no person more than once. Presentation is made at the annual meeting of the association’s House of Delegates. Every society has many members worthy of this distinguished award. It is your society’s responsibility to see that they are nominated. A nomination form is avaiable on the MSMA Web site. All nominations should be submitted to the Mississippi State Medical Association by May 7, 2010. The award is a handsome plaque which features a cast bronze medallion. The medallion’s design symbolizes the close relationship between medicine and the community. A $500 contribution is also made by the association to a civic organization designated by the award recipient. Nominations should be submitted in writing. Since the award is for outstanding community service it is important that all accomplishments of the nominee in this regard be presented in detail. The Council on Public Information encourages you to seek the assistance of your local MSMA Alliance in preparing the written nomination and supporting materials. Nomination supporting documents may include all or some of the following: a narrative about the person and his community involvement, newspaper clippings, letters of support from community leaders, newspaper or magazine articles written about the person, photographs and other materials that show the physician’s community involvement. Nominations should be sent to MSMA, P.O. Box 2548, Ridgeland, MS 39158-2548, as soon as possible, but no later than May 7, 2010. For further information contact: Karen Evers, Director of Communications, (601) 853-6733 or 1-800-898-0251, or KEvers@MSMAonline.com.
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Let Us SHOWCASE Your ARTWORK
by donating it to the Silent Auction to be held at Annual Session Silent Auction Annual Session June 3-6, 2010 Natchez, Mississippi Benefiting the University of MS Medical Center AMA Foundation Scholars Fund for M3’s and M4’s
MSMA & MSMA ALLIANCE ALL types of artwork welcome: photography, paintings, pottery, ceramics, woodwork, jewelry, sculpture, etc. Contact Amy Gammel, AMA Foundation Chair, at fivegammels@bellsouth.net or Sondra Pinson @twptupelo@comcast.net
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• CliNiCal prOBleM-SOlviNg • Presented and edited by the Department of Family Medicine, University of Mississippi Medical Center, Diane K. Beebe, MD, Chair
Perplexing Pyretic Polyarthritis Rajvinder Singh Hanspal, MD
A
67-year-old black male presented in the emergency department with vague complaints of moderate, persistent fever; decreased appetite; chest and back pain; generalized arthralgia and myalgia for 1 to 2 weeks. The diffuse pain was so severe that he could not stand or sit; he had been voiding in a bedpan for the previous 7 days. In a 67-year-old man with a history of chest pain, back pain, mild fever and generalized arthralgia and myalgia, the differential may include myocardial infarction, septic arthritis, viral arthritis, osteoarthritis, endocarditis and rheumatoid arthritis. Considering his age, we will keep in mind prostate cancer with possible bone metastasis or primary bone malignancy. We will also consider lyme disease, West Nile virus and syphilis. We’ll explore his past medical history in detail. He had a past history of coronary artery disease , diabetes mellitus type II, hypertension, gout, chronic renal insufficiency, peripheral vascular disease and congestive heart failure. His surgical history included a triple bypass, a femoral-popliteal bypass and hand surgery. There was no significant family history. He quit smoking and alcohol use years ago and denied ever using illicit drugs. A coronary event can explain the patient’s chest pain but not the generalized joint pain and myalgia. Gout usually involves one joint, but the patient reports generalized arthralgias. Patients with rheumatoid arthritis can present with generalized arthralgias. Severe peripheral vascular disease could cause pain in the limbs at rest but does not explain the chest pain and fever. Congestive heart failure can cause decreased appetite and shortness of breath, but the patient did not complain of shortness of breath or edema. Patients with renal insufficiency can present with anemia, general weakness and decreased appetite. The clinical picture is still not very clear. We will see what medications he is taking. The patient’s medications were gabapentin (Neurontin), spironolactone (Aldactone), esomeprazole (Nexium), colchicine, metoprolol (Lopressor), glipizide (Glucotrol), indomethacin (Indocin), aspirin, allopurinol (Aloprim), hydralazine and nitroglycerine (Nitrostat) for chest pain. AUtHOr infOrMAtiOn: rajvinder Hanspal, MD is a former resident in the Department of Family Medicine at the University of Mississippi Medical Center in Jackson and practices in Canada. cOrreSPOnDing AUtHOr: rajvinder Singh Hanspal, MD, 159 Fatima Drive, Sydney, Nova Scotia, Canada, B1S-1l9
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The patient has been taking colchicine, allopurinol and indomethacin without relief which indicates his symptoms may not be gout related. His other medications are appropriate for his clinical conditions. We are also considering the possibility of hydralazine induced lupus. I’ll complete the physical examination. His vital signs included a temperature of 100.5° F, pulse of 128 beats per minute, respiratory rate of 25 breaths per minute, blood pressure of 120/84 mmHg and an oxygen saturation of 98% while breathing room air. He was well developed, well nourished, but in acute distress due to pain. His physical examination revealed dry mucous membranes and poor oral-dental hygiene. Cardiovascular examination revealed tachycardia, regular rhythm and no murmur, rub or gallop. Chest wall tenderness was present all over, and his lungs were clear to auscultation bilaterally with good air movement and no rubs, wheezing or rhonchi. Strength could not be detected because of the patient’s condition; he was unable to move his limbs, hands and feet due to pain. No joint deformity was noted except for clubbing of inter-phalangeal joints of both hands. There was diffuse tenderness of his hands, elbows, shoulders, back, hips, knees and feet. Also there was tenderness on palpation of limbs and chest wall. He could feel pain when touched on any area of his body. He had intact cranial nerves II to XII but was unable to walk due to pain. His reflexes were 2+. His head, eye, ear and nose; psychiatric; gastrointestinal; genitourinary and skin examinations were within normal limits. The patient is mildly febrile, has tachycardia and tachypnea but his blood pressure is not elevated. Fever with leukocytosis and joint tenderness makes us think of infective arthritis, but involvement of multiple joints gives a confusing picture. We will order an echocardiogram to investigate for endocarditis and also order blood and urine cultures. We will also do cardiac studies. He has a history of gout so I will also order uric acid determination. I’ll also ask for a computed tomography (CT) of abdomen and pelvis to look for any malignant lesions. His abdomen and pelvis CT without contrast showed a scarred right kidney. His complete blood count showed white blood cells 15000/hpf, and his uric acid was 8.6 mg/dL (2.5-8.5 mg/dL). His echocardiogram, urine and blood cultures were pending. The scarred kidney indicates chronic kidney disease, and his slightly elevated uric acid may be related to gout but the cause of his elevated white blood cell count is not yet clear. At this stage I am going to admit this patient. I will order prostate specific antigen (PSA) and
bone scan to investigate for prostate malignancy, although he had a normal PSA about 5 years ago. To further investigate the fever, I will also order West Nile titers, lyme titers and rapid plasma reagin (RPR) for syphilis. We will discontinue hydralazine because his symptoms may be caused by hydralazine induced lupus. We will also discontinue colchicine, allopurinol and indomethacin because these medicines don’t appear to be working. We’ll continue his other medications and also order a 1800 calorie diet, furosemide (lasix), ciprofloxacin (Cipro), doxycycline (Adoxa), hydrocodone/acetaminophen (lortab), morphine (Avinza), enoxaparin (lovenox) and lorazepam (Ativan) for anxiety and rest. For diabetes we will start a flexible insulin dosage regimen with regular insulin (Novolin R). On day 2, his vital signs included a temperature of 101.1° F, pulse of 120 beats per minute, respiratory rate of 24 respirations per minute and blood pressure of 183/81 mmHg. Despite taking hydrocodone/acetaminophen and morphine, there was little improvement in pain, and he was unable to move in bed due to pain. The results of the echocardiogram, fecal occult blood, hepatitis panel, HIV, hemoglobin A1C, lipid panel, PSA, RPR, rheumatoid factor, antinuclear antibodies, West Nile, systemic lupus erythematosus (SLE) and ehrlichia antibodies were normal. Additional studies included an elevated erythrocyte sedimentation rate (ESR) of 65 mm/hr (<17 mm/hr), a C-reactive protein of 33.5 mg/L (<1 mg/L) and a hemoglobin A1C of 6.6%; his blood and urine cultures were still pending. The echocardiogram does not show evidence of infective endocarditis though his blood culture is still pending. Test results do not indicate rheumatoid arthritis, SlE, West Nile, syphilis, hepatitis or HIV. His diabetes appears to be well controlled. His digital rectal examination is normal, and his PSA is 0.98 ng/ml, so a malignancy of the prostate is not indicated. His raised C-reactive protein concentration only indicates an inflammatory process, and his elevated ESR only tells me it’s a chronic condition. Our patient is not having much relief from pain and is still febrile. A neurologist suggested magnetic resonant imaging (MRI) of lumbar spine to look for epidural or paraspinal abscesses and advised to continue with the same medications. I think an abscess can explain his raised white blood cell count and his generalized pain and fever. We will also ask for a whole body bone scan to make sure we are not missing any bony lesions. On day 3 the patient’s vital signs were normal except for a pulse rate of 150 beats per minute. The patient denied any improvement in pain and was still unable to move any part of his body. The MRI of lumbar spine with and without contrast to evaluate for a possible abscess showed significant spinal stenosis at the L3-L4 level secondary to a central bulging disc; similar changes were seen at the level of L4-L5. There was no evidence of an abscess. A whole body nuclear scan showed multiple areas of joint centered uptake consistent with arthritic changes. There was mild uptake in the lumbo-sacral region suggestive of degenerative changes. The whole body nuclear scan also showed multiple joints with degenerative changes, and the patient still had an elevated ESR. His blood and urine cultures were negative. At this stage, there is no evidence of paraspinal and epidural abscesses, but we find spinal stenosis at l3-l4 and l4-l5 levels. I think
it could be a coincidental finding because it can explain pain in the lower extremities, but what of the pain in his shoulders and upper extremities? The patient has nuclear scan findings consistent with osteoarthritis, and his elevated ESR probably indicates chronicity of the problem. We will consult a neurosurgeon and rheumatologist. On day 4 the patient had temperatures of 98.7° F and 101.3° F and mild tachycardia. He still complained of persistent pain and was still unable to move. He was sleepy due to the effects of lorazepam and morphine. The neurosurgeon advised that we deal with the spinal stenosis at a later stage. He was suspicious of paraspinal or epidural abscess around cervical or thoracic spine due to raised white blood cells count, fever and generalized back pain. An MRI of cervical and thoracic spine to look for abscesses was normal. A rheumatologist performed an arthrocentesis on the right knee. Synovial fluid analysis showed white blood cells 8964/hpf, polymorphs 94%, lymphocytes 3%, red blood cells 1674/hpf and many intracellular and extracellular uric acid crystals under polarizing light. The culture was pending. The normal MRI of cervical spine and thoracic spine does not indicate abscesses in the cervical or thoracic spine. The rheumatologist’s diagnosis is polyarticular gout (PAG), based on synovial fluid results from arthrocentesis. He recommends colchicine and 15-day tapering dose of steroids. PAG can be suspected in the case of chronic sero-negative polyarthritis, and diagnosis can be confirmed with plain radiographs and laboratory results showing uricemia.1 Risk factors for gout in the general population include hyperuricemia, obesity, weight gain, hypertension and diuretic use.2 Patients with hematological malignancy may present with joint pain and hyperuricemia.3 PAG may lead to secondary amyloidosis recognized by monoclonal antibodies. PAG may be misdiagnosed in the elderly as rheumatoid arthritis, which may appear to be “diuretic gout” with polyarticular onset.4 On day 5 his vital signs were temperature of 99.9° F, pulse of 89 beats per minute, respiratory rate of 20 respirations per minute, blood pressure of 146/72 mmHg and oxygen saturation of 97% while breathing room air. The patient felt better and was able to move his T-spine. He still had some pain in his lower back but was improving. The next day the patient continued to improve and started moving and lifting his hands. We continued prednisone and colchicine along with his other medications. On day 6 he was doing much better and was able to move arms and sit up on the side of his bed. In the next 4 days the patient was able to move around in a wheel chair but was weak. He needed help standing and walking, so he was transferred to swing bed for physical therapy to regain his strength. After 2 weeks he was discharged. He was doing well at one-month followup. PAG has also been seen in patients with hypouricemia receiving total parenteral nutrition (TPN) with a purine free diet.5 Postmenopausal females present at a younger age than males with PAG, and it is usually mistreated as rheumatoid arthritis which may lead to joint damage. Several conditions may precipitate PAG including acute myocardial infarction, heart transplantation and kidney transplantation. Medications or therapies including TPN, immunosuppressant drugs april
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such as cyclosporine, and uricosuric therapy can also precipitate PAG.5,6 Episodes of PAG are common in renal transplant patients and have resolved after switching from cyclosporine to tacrolimus-based immunosuppression.6 In a South African population, PAG was seen in 44.4% of gout patients.7 Similarly, in a German population, 40% of the male patients suffering from gouty arthritis treated during a 3-year period showed a chronic polyarticular course. About 40% of patients with gout have polyarticular involvement after years of prolonged illness.8 Elderly patients on long-term diuretic therapy are at higher risk of developing PAG and are usually misdiagnosed and inadequately treated for the condition.4,9 Acute PAG may mimic common rheumatological disorders such as septic arthritis, rheumatoid arthritis, degenerative joint disease and even hemiparesis.10 Physicians should be aware of the potential for PAG in patients with consistent risk factors. Corticosteroids have proven benefit in patients with gout.11 They are especially useful when colchicine and anti-inflammatory drugs are contraindicated. A uric acid concentration of 6.8 mg/dl is considered the saturation point for the crystallization of monosodium urate.12 urate lowering treatment is required for hyperuricemia, especially in patients with chronic gout that causes joint damage, tophi and nephrolithiasis.13 The concentration should be kept at or below 6 mg/dl. Allopurinol, a xanthine oxidase-dehydrogenase inhibitor, is commonly used to inhibit uric acid synthesis. It decreases the concentration of uric acid within 24 hours, but maximum benefit usually takes up to 2 weeks. Therapy should begin with 100 mg per day and increase by 100 mg per week to a maximum dose of 300 mg per day. uric acid should be monitored every 2 – 3 weeks until stabilized, then every 6 months.14
Key WOrDS:
POlYARTICulAR GOuT (PAG)
referenceS 1. 2. 3.
4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.
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Pouye A, Fall S, Diallo S, et al. Polyarticular gout in young adults: a curable rheumatic disease. Med Trop (Mars). 2006;66(3):273-276. Stamp l, Searle M, O’Donnell J, et al. Gout in solid organ transplantation: a challenging clinical problem. Drugs. 2005;65(18):2593-2611. Meijer FA, Peeters HR, Starmans-Kool MJ, Van der Tempel H, Houben HH. Two patients with joint pain as initial presentation of a haematological malignancy. Ned Tijdschr Geneeskd. 2005;149(39):1799-1801. Sewell Kl, Petrucci R, Keiser HD. Misdiagnosis of rheumatoid arthritis in an elderly woman with gout. J Am Geriatr Soc. 1991; 39(4):403-406. Moyer RA, John DS. Acute gout precipitated by total parenteral nutrition. J Rheumatol. 2003;30(4):849-850. Pilmore Hl, Faire B, Dittmer I. Tacrolimus for the treatment of gout in renal transplantation. Transplantation. 2001;72(10):1703-1705. Tikly M, Bellingan A, lincoln D, Russell A. Risk factors for gout. Rev Rhum Engl Ed. 1998;65(4):225-231. Becker-Capeller D, Helker K, Weber MH. Polyarticular gout--change in the clinical picture. Z Arztl Fortbild (Jena). 1996;90(3):227-231. Schousboe JT, Davey K, Gilchrist Nl, Sainsbury R. Chronic polyarticular gout in the elderly: a report of six cases. Age Ageing 1986;15(1):8-16. Raddatz DA, Mahowald Ml, Bilka PJ. Acute polyarticular gout. Ann Rheum Dis. 1983;42(2):117-122. Harris MD, Siegel lB, Alloway JA. Gout and hyperuricemia. Am Fam Physician. 1999;59:925-934. Rott KT, Agudelo CA. Gout. JAMA. 2003;289(21):2857-2860. Eggebeen AT. Gout: an update. Am Fam Physican. 2007;76(6):801-808. Terkeltaub R. Gout in 2006: the perfect storm. Bull NYU Hosp Jt Dis. 2006;64(1-2):82-86.
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Errata: Vol. 51, No. 3 J Miss State Med Assoc. 2010;50(3):83. In Clinical Problem-Solving: “Pseudo Seizures Vs Pseudo Zebra” — March 2010 on page [83] (authored by D. Mark Pogue, MD; Judith G. Gearhart, MD and George Moll, Jr., MD, PhD), part of the diagram identified as Figure 1: Hypocalcemia – Diagnostic Pathways was omitted when the PDF did not display properly. The corrected figure appears here: FIGURE Hypocalcemia – Diagnostic Pathways Low Serum Calcium – Confirmed with ionized Calcium and/or serum protein concentrations High Creatinine/BUN Renal Failure High Serum Low/Normal Serum Phosphorous Phosphorous Low Urine Phosphorous
High Urine Phosphorous
Functional PTH Deficiency Normal Alkaline Phosphatase (normal for bone/age) No Clinical Rickets Low PTH or Inappropriate “Normal” PTH Severe HypoMagnesemia (<1.0 mg/dL)
High PTH
Low Urine Calcium
Functional Vit D deficiency Elevated Alkaline Phosphatase (normal for bone/age) Clinical Rickets High PTH
Activating Calcium Receptor Mutations (High urine Calcium)
Hypo-PTH Transient, Familial, Autoimmune, 2nd to metabolic disease
High Urine Calcium
Excessive Phosphorous Load Tumor Lysis, Excessive Phosphorous Intake
High PTH
High PTH
High PTH
RTA Vit. D deficiency Vit. D resistance VDDR types 1,2
PTH Resistance PHP
Calcium Sequestration “Hungry Bone Syndrome”
Malabsorption Liver Disease Drugs
PHP – Diagnostic Pathways PTH TEST: determine PTH stimulated plasma or urinary cAMP, TmP/GFR PHP type 2 – cAMP equivocal or normal, TmP/GFR decreased PHP type 1 – cAMP decreased, then erythrocyte Gs decreased (PHP 1A) or normal (PHP 1B) Abbreviations: BUN=blood urea nitrogen, PTH=Intact Parathyroid Hormone, Vit. D=Vitamin D analogues as primarily 25OH-VitaminD (calcifediol), RTA=renal tubular acidosis, VDDR=Vit. D dependent rickets, PHP=pseudohypoparathyroidism, cAMP=cyclic Adenosine MonoPhosphate, TmP/GFR=quotient maximum rate of tubular phosphate reabsorption and glomerular filtration, Gs =guanine nucleotide stimulating regulatory intra-membrane multi-subunit protein
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• New MeMBerS • ADILI-KHAMA, BABEK K., union; Born 9/14/1971 Tehran, Iran; Graduated MD Debrecen Medical university, Hungry 2000; Specialty: Family Practice; laird Hospital, Inc. BOSARGE, JOSEPH R., Gulfport; Born 5/7/1973 Pascagoula, MS; Graduated MD university of Mississippi School of Medicine, Jackson 2004; Specialty: Internal Medicine; Pulmonary @ MHG. BRITTON, MARCUS L., Tupelo; Born 9/8/1977 Jackson, MS; Graduated MD university of Mississippi School of Medicine, Jackson 2004; Specialty: Nephrology; Nephrolosy & Hypertension Assn. CUMMINS, CHRISTOPHER J. M., Ripley; Born 9/26/1974 Clarksdale, MS; Graduated MD 2003; Specialty: Family Practice; Magnolia State Family Medicine. DUNCAN, WILLIAM L., McComb; Born 3/6/1972 Tupelo, MS; Graduated MD university of Mississippi School of Medicine, Jackson 1998; Specialty: urology; Southwest urology. FINCH, JON D., laurel; Born 6/12/1963 Michigan; Graduated DO Kirksville College of Osteopathic Medicine, Kirksville 1990; Specialty: Emergency Medicine; South Central Regional Medical Center. FOSTER-GALBRAITH, PAULETT , Gulfport; Born 1/15/1967; Graduated MD university of Texas Medical School, Houston 1992; Specialty: Family Practice; New Coast Cardiology, PllC. FOWLKES, THOMAS D., Oxford; Born 4/8/1963 Greenwood, MS; Graduated MD university of Ten-
nessee College of Medicine, Memphis 1989; Specialty: Emergency Medicine; Thomas Fowlkes, MD, PA.
Specialty: Emergency Medicine; South Mississippi Emergency Physicians, PA.
GEORGE, STEVEN, Meridian; Born 10/10/1956 Birmingham, Al; Graduated MD university of South Alabama College of Medicine, Mobile 1991; Specialty: Obstetrics & Gynecology; Woman's Group of Meridian PllC.
LUZARDO, GUSTAVO , Jackson; Born 11/21/1972 Zulia, Venezuela; Graduated MD Faculty Medicine Alexandria university, Egypt 1998; Specialty: Neurological Surgery; university Physicians, PA.
GOEL, NISHEETH K., Jackson; Born 6/29/1975 Hardwar, India; Graduated MD university of Mississippi School of Medicine, Jackson 2001; Specialty: Cardiovascular Disease; Baptist Health Systems. HASHMI, RAZA U., Hattiesburg; Born 9/22/1978 Pakistan; Graduated King Edward Medical College, Pakistan 2002; Specialty: Internal Medicine; Hattiesburg Clinic. HENSON, ZEB, Jackson; Born 11/17/1978 Jackson, MS; Graduated MD university of Mississippi School of Medicine, Jackson 2007; Specialty: Internal Medicine; university Internal Medicine Associates, llP. IRVING, JOSEPH L., Jackson; Born 11/17/1973; Graduated MD university of Mississippi School of Medicine, Jackson 2004; Specialty: Anesthesiology; Jackson Anesthesia Associates. LAM, SON G., Tupelo; Born 3/8/1976 Ho Chi Mingh VM; Graduated MD university of Mississippi School of Medicine, Jackson 2003; Specialty: Nephrology; Nephrology & Hypertension Associates. LOTT, MARTIN, Hattiesburg; Born 1/19/1957 Hattiesburg, MS; Graduated MD university of Mississippi School of Medicine, Jackson 1983;
MCAFEE, JAMES E., Columbus; Born 6/11/1935 Dyersburg, TN; Graduated MD university of Tennessee College of Medicine, Memphis 1963; Specialty: Occupational Medicine; Columbus Occupational Medicine PllC. MCCOWAN, TIMOTHY, Jackson; Born 4/7/1956 Hot Springs, AK; Graduated MD university of Arkansas School of Medicine, little Rock 1981; Specialty: Radiology; uMC Dept. of Radiology. MCMURPHY, ANDREA B., Pascagoula; Born 8/13/1974 Mobile, Al; Graduated MD university of Alabama School of Medicine, Birmingham 2000; Specialty: Otolaryngology; South MS Ear Nose & Throat. MOORE, CHARLES R., Hattiesburg; Born 4/10/1972 Baton Rouge, lA; Graduated MD louisiana State university School of Medicine, New Orleans 2003; Specialty: urology; Southern urology, PA. OTTO, KRISTEN J., Jackson; Born 5/18/1978 Newburg, NY; Graduated MD university of South Florida College of Medicine, Tampa 2002; Specialty: Otolaryngology; university Physicians, PA. PREWITT, THOMAS, Jackson; Born 2/24/1961 Jackson, MS; Graduated MD university of Mississippi april
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School of Medicine, Jackson 1988; Specialty: General Surgery; uMC, Dept. Surgery. ROBERTSON, DONALD C., Iuka; Born 8/7/1972 Poughkeepsie, NY; Graduated DO university of Health Sciences, College of Osteopathic Medicine, Kansas City 2004; Specialty: Internal Medicine; Iuka Medical Clinic. SCHAFFER, DAVID I., union; Born 5/13/1966 Pittsburg, PA; Graduated MD Spartan Health Science university, St. lucia West Indies 1997; Specialty: Family Practice; laird Hospital, Inc. SCHIEFER, AMANDA R., Jackson; Born 6/22/1977 Nacogoloches, TX; Graduated MD university of Mississippi School of Medicine, Jackson 2003; Specialty: Internal Medicine; Premier Medical Group of MS llC.
SCHNEGG, JOANN C., Mc Comb; Born 8/20/1965 Detriot, MI; Graduated MD College of Osteopathy of the Pacific, Pomona 1990; Specialty: Family Practice; Premier Medical Clinic.
TULI, PAMELA J., Gulfport; Born 3/7/1971 Altoona, PA; Graduated MD Temply university School of Medicine, Philadelphia 1998; Specialty: Internal Medicine; The Medical Oncology Group, PA.
SPREHE, SAMUEL E., Amory; Born 11/26/1955 Oklahoma City, OK; Graduated MD university of Oklahoma College of Medicine, Oklahoma City 1983; Specialty: Otolaryngology; Amory ENT & Allergy.
VIJAYAKUMAR, SRINIVASAN, Jackson; Born 8/29/1954 India; Graduated MD Sri Venkatesvara Medical College, Sri Venkatesvara university, Tirupati 1978; Specialty: Radiation Oncology; university Physicians Radiation
TAYLOR, KATHRYN G., Jackson; Born 3/15/1979 Flowood, MS; Graduated MD university of Mississippi School of Medicine, Jackson 2005; Specialty: Family Practice; university Physicians, PA.
WALDROP, CHRISTINE, Jackson; Born 12/15/1975; Graduated MD university of Mississippi School of Medicine, Jackson 2004; Specialty: Anesthesiology; Jackson Anesthesia Group, PA.
TIDWELL, WILLIAM, Tupelo; Born 4/15/1976 Biloxi, MS; Graduated MD university of Mississippi School of Medicine, Jackson 2003; Specialty: Neurological Surgery; Imaging Associates of N. MS.
BlueCross BlueShield of Mississippi Committed to a Healthier Mississippi.
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• OBiTUarieS • DR. GLENN BENNETT – LAFAYETTE, LOUISIANA Dr. Glenn Harris Bennett, 65, formerly of Baldwyn and Sidon, Arkansas, died Friday, Feb. 26, 2010, at his home. Services were held Sunday, Feb. 28, at Sidon Baptist Church in Sidon. Graveside services were held at Sidon Cemetery. Roller-Daniel Funeral Home of Searcy, Ark., was in charge of the arrangements. He was born Aug. 23, 1944, in Searcy, Ark., to the late Emmett and Tessie lemon Bennett. He obtained his medical degree from the university of Arkansas and practiced family medicine and emergency medicine in Northeast Mississippi for over 25 years. upon moving to lafayette, la., he continued to serve as an emergency room physician for several local hospitals. Survivors include one son, George Bradley Bennett of Tuscaloosa, Ala.; one daughter, lindsay Bennett Page and her husband, Brandon, of Petal; and one sister, Mary Bennett Ardemagni of Kingsport, Tenn. Memorials may be made to Baldwyn First united Methodist Church, Baldwyn, Miss. Expressions of sympathy may be left at www.rollerfuneralhomes.com.
DR. RAYMOND GRENFELL - JACKSON Dr. Raymond Frederic Grenfell, 92, died on April 5, 2010, at St. Dominic Hospital after a brief illness. Funeral services were held April 7, 2010, from the Chapel of First Baptist Church, Jackson, followed by interment in lakewood Memorial Park. He was preceded in death by his wife, Maude Byrnes Chisholm Grenfell. Dr. Grenfell was born an only child to Elisha Raymond and Pearle Nelly Grenfell in West Bridgewater, Pennsylvania. When Dr. Grenfell was 16 (during the Great Depression) his father passed away. He then began working in the mill for uS Steel Corporation. Dr. Grenfell received a full Carnegie Scholarship which enabled him to earn Bachelor of Science and Doctor of Medicine degrees from university of Pittsburgh. During WWII, he enlisted and served as a Captain in Puerto Rico. After the war, Dr. Grenfell was transferred to Fort Jackson in Columbia, S.C., where he met his future bride, Maude Byrnes Chisholm. They were married on August 19, 1944 in Columbia, S.C. After an Honorable Discharge as a Major in 1946, they moved to Jackson where Dr. Grenfell began the private practice of medicine followed by the study of the drug treatment of hypertension. In 1955, Dr. Grenfell opened the Hypertension Clinic of the university School of Medicine which he maintained as Clinical Assistant Professor of Medicine until 1979. From 1979 until his retirement in 1999, Dr. Grenfell limited his practice to the diagnosis and treatment of hypertension. During his work at the medical school, he was a pioneer in the double blind evaluation of many new antihypertensive drugs. Dr. Grenfell published many papers in the united States and Swiss journals. He was a member of many professional societies including American Medical Association, Southern Medical Association (Served as Counselor), American College of Chest Physicians, American Society of Hypertension and American College of Clinical Pharmacology. Dr. Grenfell was a life deacon and long term member of the sanctuary choir of the First Baptist Church of Jackson. He also served as president of the Jackson Symphony Orchestra 1961-62. He is survived by his four sons and their wives, Raymond Frederic Grenfell, Jr. (Pat), Milton Wilfred Grenfell (Gioia), James
Byrnes Grenfell (lynn), and Robert Chisholm Grenfell (Amy); eight grandchildren, Ric Grenfell (Tracy), Matt Grenfell (Caroline), Sarah Grenfell, Catherine Grenfell, Robert Grenfell, Jr., Eleanora Grenfell, Mallory Bass, and Ross Bass; and two great-grandchildren. In lieu of flowers, memorials may be made to the charity of your choice.
DR. FRANK LAROY LEGGETT - BASSFIELD Dr. Frank laRoy leggett, 83, died at Hospice Ministries in Ridgeland on February 22, 2010, after a lengthy battle with cancer. A family physician in Bassfield for 44 years, Dr. leggett lived in Oxford after his retirement before moving to Trace Pointe Assisted living Community in Clinton last year. Funeral services were held February 27 at College Hill Presbyterian Church in Oxford, Rev. Alan Cochet, pastor. united Funeral Service of New Albany was in charge. A memorial service was held March 6 at Bassfield High School. Those who say doctors don’t make good patients weren’t around Dr. leggett in the last year as he thanked and joked with every doctor and nurse for performing their duties. The fourth child born to Clarence Wesley and Bessie Chandler leggett of Brookhaven on November 6, 1926, Roy, as he was known by his family, grew up on the family farm. After moving to Bassfield, he closed his medical office and spent every Thursday afternoon with his parents. He left New Site High School to enter the u.S. Navy where he served as an operating room corpsman in Norfolk, Va. during World War II. After his discharge, he attended Copiah-lincoln Junior College, Baylor university and the university of Mississippi Medical School under the two-year program then in place. He completed his M.D. at Baylor university Medical School. under the terms of a state of Mississippi scholarship program, he was to serve five years in rural Mississippi. Frank, as others knew him, remained in Bassfield from 1956 to 2000, serving as an alderman from 1967-2001, including several terms as the Mayor Pro Tempore. He served three terms as the Jefferson Davis County Coroner. Dr. leggett was the chief of staff at the Jefferson Davis County Hospital for many years. He was a Sunday School teacher and chairman of deacons at Bassfield Baptist Church. upon his retirement, the local library was named in his honor. He retired to Oxford where he was active in College Hill Presbyterian Church serving as an elder and as chairman of the missions committee. A world traveler, Dr. leggett made numerous mission trips to Central and South America and Eastern Europe. He provided financial assistance for several young men to attend seminary. Doc, as many knew him, is survived by his brothers, Ray leggett of Columbia, Jay leggett of Orlando, Fla., David leggett of Haughton, la., Johnny leggett of Sevierville, Tenn. He was preceded in death by two brothers, Woodrow and Chandler, in childhood, his parents, his brother, Robert leggett, and his sister, Evelyn Davis. Donations may be made to the Frank l. leggett library in Bassfield.
DR. RON E. PERSING - BRANDON Dr. Ron E. Persing, 59, died March 13, 2010, at the Crossgates River Oaks Hospital in Brandon. Visitation was held March 18, 2010, at Ott & lee Funeral Home in Brandon. Funeral Services were held March 19, 2010, at the St. Jude Catholic Church in Pearl. april
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• OBiTUarieS • Dr. Persing was born in Sioux Falls, S.D. and has been a resident of Brandon for the past 10 years. He was a member of the St. Jude Catholic Church in Pearl and was also a member of the Model Railroaders Club. Dr. Persing retired after 25 years of service with the united States Air Force and was currently employed in the Dept. of Pediatrics at the university of Mississippi Medical Center in Jackson. He is preceded in death by his father, George Persing; and his brother, Tom Persing. Dr. Persing is survived by his wife, Joan Persing of Brandon; his mother, Morine Persing of Sioux Falls, SD; his daughter, Carol Olszewski and husband, Mark of Solon, OH; his son, Brian Persing and wife, Jammie of Ocean Springs; two sisters, Carol Born and husband, Terry of Sioux Falls, SD and Sue Mollison and husband, John of Sioux Falls, SD; one brother, Scott Persing of Eau Claire, WI; and five granddaughters, Gavriella Persing, Hannah Olszewski, Erica Olszewski, Genevieve Persing and Emree Olszewski. Memorials may be made to the Blair E. Batson Children's Hospital, 2500 N. State St. Jackson, MS 39216.
DR. FASER TRIPLETT - JACKSON Dr. Rodney Faser Triplett, 77, died at home on Thursday, January 28, 2010. Visitation and funeral services were held at Christ united Methodist Church with burial at Wright and Ferguson's Parkway Cemetery in Ridgeland, January 30, 2010. A native of louisville, Dr. Triplett was the son of the late Mr. and Mrs. Rod Triplett. He graduated valedictorian of his class from louisville High School in 1951 where he was named All-Choctaw Conference halfback after an undefeated season. Faser earned the rank of Eagle Scout in an 18 month period at the age of 13, evidence of the exceptionally bright, remarkably driven, boundlessly energetic man he soon became. He had a passion for politics from an early age, delivering political circulars every summer from age 10-14. At age 15, in 9th grade, he was the personal page to lieutenant Governor Sam lumpkin for the entire legislative session, returning to louisville each weekend to pick up his school work which he taught himself during the week. In the summer of 1951, he was assistant to the campaign manager for Hugh White and was the youngest person on the governor's staff for White's inauguration. In 1955, Faser worked in the campaign headquarters of J.P. Coleman, who was elected governor. Because he believed it was his duty to help elect strong leaders, he worked diligently for many other campaigns. His yearning to make a difference led him to run for the state Senate in 1988. Although he was defeated in the race for the Senate seat, he never missed a beat as he moved on to medical politics on a national level. He served on the board of the American Medical Association Political Action Committee (AMPAC) and later as Chairman. Faser attended the university of Mississippi as a freshman on a full scholarship as football manager. He was a member of Phi Delta Theta fraternity where he was Rush Chairman his sophomore year. His junior year, he was elected cheerleader, was President of the School of liberal Arts, was on the Debate Team and was a member of the academic fraternity, ODK. Faser was a double Taylor Medalist in Political Science and Speech, completing his B.A. in 2½ years. He attended the university of Mississippi School of law in January, 1954, but became disenchanted with law. Faser then entered the university of Mississippi School of Medicine in September 1955, graduating with his medical degree from Tulane university in 1959. Faser completed a year of internship in San Francisco and a
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year of pediatric residency in Memphis where he met and married Jackie, his wife of 48 years. They moved to Abilene, TX, where Faser was a flight surgeon in the u.S. Air Force for two years. He returned to Memphis for a second year of pediatrics followed by a pediatric allergy fellowship. He completed his training in Denver with a yearlong fellowship in immunology. Dr. Triplett became the first Board Certified Allergist in Mississippi and was one of the founders of the Mississippi Asthma and Allergy Clinic where he practiced for 34 years. Dr. Triplett has served as president of many organizations including the Central Medical Society, the Mississippi State Medical Association, the American College of Allergy and Immunology, the university of Mississippi Alumni Association, and the Country Club of Jackson. He has served on the Board of Directors of MCCA, SkyTel, Mtel, Jackson Federal Savings, Gulf Guaranty life Insurance Company, Cal-Maine Foods, Great Southern National Bank, and the Wilson Foundation of the Mississippi Methodist Rehabilitation Center. In addition to Faser's innate medical ability, his business acumen and entrepreneurial prowess were what set him apart. He was a passionate investor in many public and private business ventures. One of his first investments was with his fraternity brother, John Palmer, in 1969. He helped acquire the Doctor's Exchange which eventually grew to become the very successful Mtel. Faser's advice has always been “invest in people, not ideas.” Other business ventures include Outback Steakhouse, Avanti Travel, and Swensen's. Faser was also instrumental in starting the physician-owned medical malpractice insurance company, Medical Assurance Company of Mississippi (MACM), where he served as President and Chairman of the Board from inception until 2005. All of these accomplishments along with his undying love for the university of Mississippi led to his induction into the Ole Miss Alumni Hall of Fame in 1998. Faser was a loyal member of Christ united Methodist Church, serving in several roles including chairman of the Finance Committee. He inspired many with his determined will to walk down the aisle of his church after his stroke. When he could no longer walk, he rose humbly from his wheelchair with the help of two of his friends who sat nearby each time the Affirmation of Faith was recited. He regularly visited Methodist Rehab to encourage stroke survivors by example. He was preceded in death by his sister, Diane Pearson Guyton; and his twin infant grandsons, William Faser and Thomas Clayton. He is survived by his wife, Jacqueline (Jackie) Dempsey Triplett; son, Chip Triplett (Susan) of Ridgeland; daughters, Diane Holloway (J.l.) of Ridgeland, Suzy Fuller (Jim), liz Walker (Chip), and lou Ann Woidtke (Trent) all of Jackson; and grandchildren, Jay, lindsey, Kelsey, and Caroline Fuller, Elizabeth, Mary Faser, and Felton Walker, Parker, Gage, and Reece Woidtke, as well as Wes McCubbins, Wendy Martin, Tiffany Holloway, and Greg Holloway. He also leaves behind his beloved friend and caretaker levon Williams. The family would like to thank John Jones, K.B. Bolton, and Winnetka love-Mcleod for their outstanding care. In lieu of flowers, memorials may be made to the R. Faser Triplett, Sr., M.D. Chair of Allergy and Immunology at the university of Mississippi School of Medicine, attn. Travis Schmitz, Dept. of Medicine, 2500 North State St., Jackson, MS 39216.
• preSiDeNT’S page • Let’s Change the Whole Damn System and Start Over, but We Have to Wait Until Tuesday There is nothing like a friendly face! How many times have we heard that, said that, felt that? No truer words were ever spoken. Allow me a moment to elaborate. Yesterday morning, March 6, Janie was out of town visiting her mother, and I was winging it alone. I slept late (until 6:00 a.m.), got up, ate breakfast, and watched the news, the whole time preparing myself mentally for a full day of “things that needed to be done.” The few Saturdays that I am in town are spent catching up on errands and clearing items off the proverbial “to do” list. The first stop: the hospital. Make rounds for an hour and then head off to the hardware store for a few odds and ends. The rest of the day was to include the rAnDy eASterling, MD grocery store, bank, cleaners, and then home to spend several hours working in the 2009-10 MSMA PreSiDent front pasture on my tractor prior to Janie and me going to an announcement party that evening (she would be back home around 5:00 p.m. from louisville). The second stop: Haden’s Hardware. With a few purchases in tow, I climbed into the cab of my two-year-old Ford F150 pickup truck, and guess what, it would not crank! Nothing, nodda, not a whimper, graveyard dead (you get the picture). My day flashed before me. What was I to do? Right away, two friendly faces jumped to my aide. A pair of jumper cables and 10 minutes later, I was on the road again. However, calling on my well-honed diagnostic skills, I was haunted by the knowledge that my truck was not well. The battery was only one and a half years old; the truck, well maintained, should not have suffered such an abrupt multi organ failure. My solution: get to T.D.’s as soon as possible! Point of information: T.D. is the founder and owner of a local tire store and garage. He is many things to me – friend, patient, honest and reliable merchant, and of all things, he and I share the same last name (no kin though). As I charted a B-line for T.D.’s, my once reliable means of transportation began renewed signs and symptoms of a yet undiagnosed illness. A strange sound bellowed from the engine, fatigue was apparent, and there was obvious dyspnea on exertion. Having seen it many times before I knew I had a “CODE BluE” just around the corner. If I could just make it to T.D.’s, he would solve the problem. Well, low and behold, as I limped down Clay Street I could see his familiar sign just ahead. As I approached the garage, “CODE BluE,” total shutdown, time to intubate. I literally coasted into the garage and came to a dead stop just in time to see the entire Saturday morning crew punching out. I opened the door (the power windows would not work) and asked in a desperate tone “Is T. D. here?” About that time, I saw the friendly face of T.D. Easterling rounding the corner. “What’s up? Doc?” he bellowed. In the wink of an eye, like a well-trained OR crew, they descended on my lifeless vehicle like a swarm of bees. The diagnosis: a sudden infarct to the alternator had drained my otherwise healthy battery and resulted in a complete cardiac arrest. By this time it was 1:00 p.m. on a Saturday, and there was no alternator in sight. T. D. assured me he could have me up and running by noon Monday, but how was I to get the eight miles back to Bovina? (Remember my dear wife is still out of town.) Without hesitation T.D. said, “Well Doc, just take this old pickup I have here in the garage.” As much as I appreciated the offer, I could not further impose on him by bringing one of his company vehicles home. He insisted and would not have it any other way. With a warm handshake and a transfer of the keys, I was on my appointed rounds. long story short, Janie made it home, and she and I went to the party that evening (in her car of course). Now for the contrast: the opposite, the omega following the alpha. After the party, Janie and I decided to make a late night run to our local Kroger Grocery Store (the death of my truck had resulted in the grocery store getting eliminated from my earlier chores). As we grabbed a few essentials for Sunday dinner and some additional staples, the clock struck 10:30 p.m. in our local 24-hour Kroger. As we approached the checkout stand there were no human beings in sight. Not a single friendly face! april
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There I was, a 58-year-old baby boomer pushing a cart full of groceries and staring down the barrel of the â&#x20AC;&#x153;dreaded automatic computer machine self-checkout.â&#x20AC;? I was as frightened and frustrated as hours before when I left my beloved truck on life support at T.D.â&#x20AC;&#x2122;s Intensive Care unit. To make matters worse, one of the checkout machines (not persons) was having chest pain and the 19-year-old store clerk was frantically engaging in computer resuscitation. The harder he worked, the longer the lines grew and the angrier the store patrons became. It was obvious to me; I was in the midst of a corporate nightmare. At the first utterance of complaint, I was abruptly informed that all clerks were sent home at 10:00 p.m. and my only means of escape from this food conglomerate was through the jaws of a computer maze that was at best a challenge to me, but more importantly, not properly working at the time. Where was T.D. when I needed him? There was no friendly face, no assurance that things would be okay, no old pickup to loan. Frankly, I got the impression that Kroger could have cared less. Well, thank you for indulging my rant, but what does this have to do with medicine? This page is, after all, the appointed method by which the President of the Mississippi State Medical Association reports monthly on the â&#x20AC;&#x153;State of Medicine.â&#x20AC;? At the risk of waxing philosophically, I think my two contrasting experiences on this given Saturday highlight in a very real sense the essence of our seemingly never ending â&#x20AC;&#x153;health system reformâ&#x20AC;? debate. What our patients want, what America wants, is exactly what you and I try to deliver in our practices day in and day out, 24-7. We seek out, yes, we even hunger for relationships. I am convinced that our patients (remember all Americans are patients at one time or another) want a relationship with their doctor. America needs to know that when they are sick or a loved one is ill, there will be a friendly face to care for them: someone who has their individual best interest at heart, someone who works for themâ&#x20AC;Śnot the federal government, not a drug company, not an insurance company. I am of the opinion that in the united States today there exists a frightening degree of mistrust and isolation between â&#x20AC;&#x153;Joe lunchbucketâ&#x20AC;? citizen and those whom we have elected to look after our best interest in Washington. The health system debate is a symptom of a more malignant process. Healthcare is very personal to us all. It has become obvious that the majority of Americans are having serious reservations about turning over additional control of our healthcare to a bureaucracy that has grown impersonal and out of touch. We, both patients and physicians, are fed up with systems that have been put in place over the past decades that increasingly separate us from each other. The â&#x20AC;&#x153;systemâ&#x20AC;? tells us how much our services are worth, what medicines we can prescribe, how long we can keep our patients in the hospital, and what studies and lab work we can order. While some measure of regulation and oversight is necessary, the federal government has taken it to an unreasonable and even unhealthy level. I submit to you that the last 10 months have not been so much about President Obama, Harry Reed, Nancy Pelosi, or even Health System Reform, but more about an American electorate that feels disenfranchised and ignored. Hey, I got a great idea! Why donâ&#x20AC;&#x2122;t we reform the health care system in America? Why donâ&#x20AC;&#x2122;t we create a system where doctors answer to patients, where hospitals provide quality care because it is the right thing to do, and not because the joint commission requires it?
We specialize in the business of healthcare
â&#x20AC;˘ Why donâ&#x20AC;&#x2122;t we create a system where providers are paid fairly and commensurate with years of education, training, and experience? â&#x20AC;˘ Why donâ&#x20AC;&#x2122;t we create a system that responds to the needs of patients and not to a federal bureaucracy that seems to have lost sight of its charter? We need a health care system that allows physicians to practice good medicine, not wasteful and unnecessary defensive medicine. I think we might be on to something here! letâ&#x20AC;&#x2122;s change the whole damn system! I have even got a better idea. letâ&#x20AC;&#x2122;s put T.D. in charge! But, we have to wait until Tuesday; he has a truck to fix! Partnering with you to make Mississippi healthier,
Randy Easterling, Md President, Mississippi State Medical Association
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• eDiTOrial •
But Will It Take?
S
o what's all the fuss about? I know for a fact that Healthcare Reform was initiated months ago in (of all places) rural central Mississippi. Granted this abbreviated version pales in comparison to the overarching Obama/Reid/Pelosi plan and also calls to mind the familiar opening lines of “A Tale of Two Cities.”
In the fall of 2009, the now former administrator of Kosciusko's Montfort Jones Memorial Hospital (note the operative word “former”) convinced his board of trustees to agree to a $650,000/year contract with a Texas outfit (read “monies hemorrhaging from our community”) to supply hospitalist services for our 82-bed facility. Hospitalist services confined to unreferred (read “indigent”) patients admitted to our hospital from the emergency department (perhaps 2 or 3 during a really busy week) which services had historically been provided pro bono by our clinic physicians. I might add that this arbitrary decision was made without any dialogue with the hospital medical staff (read “our clinic physicians”). As strange as it may seem, this turned out to be a win-win situation: It was the proverbial straw that broke the beleaguered administrator’s back (hence “former”), and it started our doctors’ toying with the idea of developing a hospitalist service for our own patients. While this practice may already be de rigueur in communities across our state, I wasn’t totally convinced that the idea would fly in small town Mississippi where doctor/patient relationships are special, if not downright sacred. The basic plan goes something like this: Each week a different clinic physician manages all hospitalized patients (except for the ones under the care of those high-priced longhorn recruits). The remaining clinic physicians, no longer obligated to hospital rounds, begin morning appointments earlier and are free in the evenings to vacate the premises when the last patient is seen. Well, this old dog, only a heartbeat away from retirement at the time and fairly resistant to new tricks especially when they involve my patients, opted out of the hospitalist rotation, continued to make morning AND EVENING hospital rounds (which seemed to be appreciated by both patients and nursing staff), and conducted a clinic practice as usual. Just as questions continue to swirl about national healthcare reform, several uncertainties concerning the local variety waft through my head. Are patients content to absolve “their doctor” of their hospital care? How will this hospitalist movement truly impact continuity of care? Will patients view the hospitalist system as self-serving for money-grubbing doctors anxious to head out early to the golf course? How will patient/family rapport and trust established over the years and even more crucial in the hospital setting be sustained? Who sees the patient in hospital followup? I’m now removed from the scenario described above, but I plan to monitor the process. I would venture to guess that many of our readers have answers to the above questions. If not answers, then surely opinions ... unless already totally spent on Obama/Reid/Pelosi!
—d. Stanley Hartness, Md Associate Editor
The Pen is Mightier than the Sword! Express your opinion in the JMSMA through a letter to the editor or guest editorial. The Journal MSMA welcomes letters to the editor. letters for publication should be less than 300 words. Guest editorials or comments may be longer, with an average of 600 words. All letters are subject to editing for length and clarity. If you are writing in response to a particular article, please mention the headline and issue date in your letter. Also include your contact information. While we do not publish street addresses, e-mail addresses or telephone numbers, we do verify authorship, as well as try to clear up ambiguities, to protect our letter-writers.
You can submit your letter via email to KEvers@MSMAonline.com or mail to the Journal office at MSMA headquarters: P.O. Box 2548, Ridgeland, MS 39158-2548. april
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2010 MSMA Annual Session
Golf Tournament Thursday, June 3, 2010 Beau Pre Country Club in Natchez Shotgun start at 1 P.M. Box lunch will be served.
For more information and to sign up, call Wendy Powell at
Medical Assurance Company of Mississippi 1.800.325.4172
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• THe UNCOMMON THreaD •
The Ghost
I
don’t know much about ghost stories. I don’t like reading them ‘cause my life is scary enough as it is. You want to scare me you can hold the ghosts and tell me about a woman and her two daughters loose in Bergdorf’s with my credit card. Now that’s what scares the bejesus out of me. As far as trying to tell a ghost story, I was never any good at ‘em. I usually messed up the scary part, and everybody’d laugh when they were supposed to be hollering and screaming. Although that happens about a lot of stuff for me. The laughing part, not the hollering and screaming. I guess it’s just the way I say things. I remember once when I was just going into radiation oncology and was still doing a lot of work at the Children’s Hospital of the Kings Daughter. I was trying to tell a friend with whom I’d deployed on dive jobs around the world about how it was making me feel, about how I was running a lot better now because I wasn’t running through woods imagining getting away from Russians or Arabs or whatever, about how I was running down the streets of Virginia Beach trying to get away from the eyes of the dead children I’d taken care of. His response didn’t help me find a way to deal with the way I was feeling about stuff. He cracked up and said, “Man you should do stand-up. This stuff is hilarious.” I changed the subject. So if you’re hoping for a scary ghost story, save yourself the trouble and bail out now ‘cause that’s not what this is going to be. Anyway, Barry Hannah died last month (March 1st). He was the kind of author that took chances, sometimes too many, but he was a good writer for itand despite it, too. He died up in Oxford where he taught creative writing, but I never knew him there. He was born here in the town where I live (Meridian, Mississippi), but I never knew him here either. I went to the university of Alabama. When I was there we won the national championship in football twice, Bear Bryant was our coach, Sela Ward was one of our cheerleaders, and Barry Hannah was in a drunken whirlwind, shooting arrows through folks’ houses, stealing motorcycles, and teaching in the English Department. That’s when I was aware of his existence. I wasn’t the kind to get too impressed with a wild man English professor back then. I was in the honors English program and was studying Southern literature because I liked it, but I was a pre-med major. All I really cared about was Biochemistry and Physics and Advanced Analytic Spectroscopic Technique. My one stab at writing was a research paper on “The Clinical and laboratory Characteristics of Macroamylasemia”, a clinical syndrome where your amylase molecules are too big with large redundant sections so they don’t get excreted normally and you get high serum amylase levels. I’m pretty sure Barry wouldn’t have viewed it too favorably as it didn’t take a lot of chances with the English language. Anyway, Airships had just come out, and one of the big stories that drew a lot of local ire was Constant Pain in Tuscaloosa. The constant pain had ended up with him in Bryce Hospital, the local inpatient psychiatric unit, for alcoholism explaining some things later in the story. Now this morning was a rodeo Saturday at Casa Charlo (that’s the name we gave our new house; the last one was called The Monkey House because of all of the kids who lived in it with us). We were up at 5:45 am to get ready, get everything together (horses, trailers, trucks, etcetera) so the girls could drive across the state to ride horses around stuff in a dirt pen somewhere else instead of here. Since I wasn’t going, after I took them to breakfast and the barn and watched them drive away in a pick-up with a gooseneck horse trailer on the back, I got to go home and go back to bed for another hour or so. Barry Hannah That’s when Barry showed up. Which was kind of disconcerting because I’d known about his being 1942-2010 dead for about a week or so. Anyway, I was lying there asleep and there he was. His hair was even still
r. Scott Anderson, MD
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dark, no gray in it yet, althought he died with a bunch of gray hair. He was leaning over the bed and shouting down into my face, like he was famous for doing in class all those years ago. “Tom…Tom…listen to me now, Tom.” My name’s not Tom, but I figured it was the alcohol talking. “…just listen. You’re never going to be a real writer if you keep yourself all bottled up in your own life. You got to let go. You just got to let go and see what in the hell happens. let your characters run their own lives. Stop getting in the middle of it. You gonna be dead soon enough, just like me. Write something worth leaving before you go, Tom. Damn it, write something worth leaving.” It never occurred to me that he might have gotten the wrong address. Somehow I knew he was talking to me; he just had the wrong name, which wasn’t unusual back then either. “So what is it you’re trying to tell me to do, man?” I asked, still in college, I suppose. “When opportunity knocks, you open the door, Tom. Open the freakin’ door.” In the dream, I guess, I heard the doorbell ring, and I was confused. Barry was gone, and I didn’t know if the doorbell had really rung or not. The dogs weren’t barking. That was a sign that it was just in the dream, but I couldn’t just lay there. I got up, put on my robe, and went from door to door, but I didn’t see anybody out there. Opportunity had not knocked. I tried to figure it all out, but it didn’t make sense. I poured a cup of coffee and sat down at my desk and rewrote the ending of The Hard Times, the novel I was editing, and I wrote well, which is always a nice thing. It was raining outside, the coffee was still warm, and I knew that while opportunity knocks and is gone, inspiration’s the one that takes the time to ring the bell. — R. Scott Anderson, Md Meridian
R. Scott Anderson, MD, a radiation oncologist, is medical director of the Anderson Regional Cancer Center in Meridian and vice chair of the MSMA Board of Trustees. Additionally, he is an accomplished oil-painter and dabbles in the motion-picture industry as a screen-writer, helping form P-32, an entertainment funding entity.
•
plaCeMeNT/ClaSSiFieD
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PHYSICIANS NEEDED
Mark Your Calendar! the 142nd Annual session of the MsMA house of delegates and Medical Affairs Forum 2010 will be held
Physicians (specialists such as cardiologists, ophthalmologists, pediatricians, orthopedists, neurologists, etc.) interested in performing consultative evaluations (according to social security guidelines) should contact the Medical relations office. toll Free 1-800-962-2230 Jackson 601-853-5487 leola Meyer (Ext. 5487)
June 3-6, 2010 in natchez. DISABILITY DETERMINATION SERVICES
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• UNa vOCe •
“Celebrate. Remember. Fight Back.” Thoughts on the American Cancer Society Relay for Life Dwalia South-Bitter, MD
R
ecently I was asked to make a ten-minute talk to the student body of Blue Mountain College in preparation for the American Cancer Society Relay for Life on the subject of cancer. Wow! When your head stops spinning you realize that this is akin to asking a freshman Congressman to give a synopsis of the new 10,000 page healthcare reform bill in 100 words or less. I hope that sharing the following text of my speech will motivate Mississippi physicians to help educate and enlighten our youth on the dangers of cancer. Considering the request, I contemplated whether I should talk about my personal experience just over one year ago as a cancer patient. Do I talk about my journey through the valley of the shadow of death from lung cancer with my husband Robert last fall…a journey that I am still on each day as I navigate the process of grief? Do I provide the scary scientific statistics? Do we discuss the warning signs of cancer? Cancer prevention and/or, cancer screening? Then I began to think about my audience: the fine young people they call “Generation Y,” the “Millennium Generation” and sometimes referred to as the “Dot Com Generation.” Rather than try to pigeon-hole this group of young students, I decided to simply put myself in the position I was in when I was a student there, not so many moons ago it seems…for they were not so different than I was then. At age 20, we are all ten feet tall and bullet-proof. The undercurrent is that ‘Cancer means nothing to me right now…that is something only old people die of.’ I am here to tell you this is just not so. The hallmark of Generation Y is touted to be encapsulated by this phrase: “I need to know why this is important to me, why do I need to care about this?” In one simple sentence, you should care about this because sooner or later cancer will touch your life if it has not already. At any given time, and right now in this room, every one of us has cancer cells floating around in our bodies. Did you know that? We all have these stray mutant cells that have the potential to thrive and develop into a malignancy. With the fantastic capability of a stealth bomber, our immune system attacks and kills these rogue cells. But what happens one day when our immune system fails us? One day when tobacco abuse has finally overloaded it, or environmental toxins or ultraviolet radiation or the onslaught of a viral intruder or, for some, simply a sequelae of a ripe old age, our immune system becomes inadequate and cancer takes a foothold in our bodies. Thus, one out of three of you in this auditorium will have cancer in your lifetime. look around you. One third of the people in this room! I am already a statistic. And if you are one of the fortunate ones who doesn’t become a cancer patient yourself, then your parent, your spouse, or your child might not be so lucky. And this, I guarantee you, will touch your life. This, in a bullet point, is why you need to care and care deeply about the Relay for life effort.
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Simply put, cancer is the second leading cause of death in America. In this year alone, 1,500,000 Americans will learn, as did I, that they have cancer. And every year, more than a half million Americans will die from their cancer. And it is not just a disease of us old folks. In your age group, the most prevalent cancers are the leukemias, the lymphomas, cervical cancer for young women, and testicular cancer in young men. I will give you one statistic that startles me. When I was in med school, we learned that approximately one woman in 14 will develop breast cancer in her lifetime. Thirty years later that stat now says one in eight. MSMA1
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medicine follow MSMA on For a bird’s eye view on
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The good news is that at long last the death rate from cancer has finally begun to fall. Why? Part of this progress has come from early diagnosis and cancer awareness. The earlier you detect a cancer, the greater the likelihood that you will be cured: a survivor. Another big part of the reduction in the cancer death rate has stemmed from advances in cancer treatments that have been made possible by money that has been poured into cancer research. Much of this money has been raised by the American Cancer Society through fundraising efforts for cancer research such as this Relay for life effort. What you are going to do here is truly going to make a difference in folk’s lives. Knowledge is power. If you don’t believe it, ask your major professor. If you make yourself knowledgeable about cancer and are on the alert for early warning signs, you stand a much greater chance for a complete cure. If you have a cancer warning sign, see your doctor and discuss it with him or her. The only stupid question is the one you don’t ask. Why do you need to care about cancer and the Relay for life? As we have earlier demonstrated, cancer can and will affect your life sooner or later. Here then today is a very important opportunity to begin to fulfill the noble goal of a Blue Mountain College education, doing God’s work on earth in service to all his children. Today, at this Relay for life ‘pep rally,’ we need to celebrate with those who have won their battle with the enemy cancer. We must remember our loved ones who were not victorious in their personal war. And we must join in the FIGHT with those of us who are still struggling with cancer both personally and professionally each and every day. Celebrate. Remember. Fight Back. —dwalia South-Bitter, Md Ripley
There’s a lot going on in organized medicine so it’s easy to miss something if you’re on the go. To help you stay in touch no matter where you are, MSMA is now communicating via “Twitter.” In about three minutes, you can set up a free Twitter account for yourself. Simply visit www.twitter. com and submit your name, email address and mobile phone number (optional, standard text messaging rates apply). Once you’re signed up with Twitter, you can add MSMA by going to the following web page http://twitter.com/ MSMA1 and clicking “Follow” next to the MSMA icon.
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