April 2011 JMSMA by Journal MSMA

April

VOL. LII

2011

No. 4

UMHC GAVE ME MORE THAN HOPE. THEY GAVE ME LIFE. Â´, ZDV GLDJQRVHG ZLWK D FRQJHQLWDO KHDUW GHIHFW DV D FKLOG %\ DJH , ZDV ZKHHOFKDLUÄ¦ERXQG DQG FDUWLQJ DURXQG DQ R[\JHQ WDQN 7ZR PRQWKV ODWHU , KDG D QHZ KHDUW LQ P\ FKHVW 0\ GRFWRUV DW 80+& FDUHG IRU PH OLNH IDPLO\ $QG RI FRXUVH P\ HQWLUH IDPLO\ ZDV WKHUH ZLWK PH Ä§ LQFOXGLQJ P\ QHZO\ZHG KXVEDQG ,WÂ·V D UHDO EOHVVLQJ WR KDYH WKLV NLQG RI FDUH VR QHDU WR KRPH 7KH LQVWDQW , ZRNH XS , WRRN WKH ILUVW GHHS EUHDWK RI P\ OLIH , OHW 80+& NHHS WKDW ZKHHOFKDLU , SUHIHU UXQQLQJ VKRHV WKHVH GD\V Âµ Liz Carpenter, heart transplant recipient, 2005

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Lucius M. Lampton, MD EDITOR D. Stanley Hartness, MD Richard D. deShazo, MD ASSOCIATE EDITORS Karen A. Evers MANAGING EDITOR PUBLICATIONS COMMITTEE Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD, Ex-Officio Myron W. Lockey, MD, Ex-Officio and the Editors THE ASSOCIATION Tim J. Alford, MD President Thomas E. Joiner, 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.

APRIL 2011

SCIENTIFIC ARTICLES

VOLUME 52

NUMBER 4

A Comparative Study of American Football Helmet Removal Techniques Using a Cadaveric Model of Cervical Spine Injury

103

Mississippi Medicine Up-to-Date: Sports-Related Concussion

106

Clinical Problem-solving: “Stick out your tongue and say ‘Ahhhh’!”

110

Andrew Anderson MD; Brian Tollefson MD; Rob Cohen MD; Jeremy Johnson RN, BSN and Richard L. Summers, MD Steve A. Watts, MD

Tanima Jana, MS and John Schweinfurth, MD

PRESIDENT’S PAGE

Children Cannot Vote, Shouldn’t We Advocate for Them?

115

Tim J. Alford, MD, MSMA President

EDITORIALS

After All Is Said and Done

118

Appropriate Prophylactic Aspirin Use for Mississippi Physicians

120

D. Stanley Hartness, MD, Associate Editor

Ryan A. Yates, M4, UMC School of Medicine

RELATED ORGANIZATIONS

University of Mississippi School of Medicine Delta Health Alliance

126 128

DEPARTMENTS

Letters Poetry and Medicine Personals Obituaries The Uncommon Thread Placement/Classified

123 125 130 134 139 140

ABOUT THE COVER:

Confederate Soldiers’ Memorial at Shiloh National Military Park (Dedicated May 17, 1917) — The figure here located on the right end of the monument depicts an artillery soldier. He represents the first day’s action and appears vigilant, looking out upon the battlefield. An inscription on the back of the monument reads: “The States of the South Sent to the Battle of Shiloh Seventy Nine Organizations of Infantry. Ten Organizations of Calvary and Twenty-Three Batteries of Artillery. How Bravely and How Well They Fought. Let the Tablets of History on This Field Tell As a Greeting to the Living Remnant of That Host of Gray and in Honor of Its Dead Whether Sleeping in Distant Places or Graveless Here in Traceless Dust. This Monument Has Been Lifted Up By The Hands of A Loving and Grateful People.” April 6-7, 2012, will mark the 150th anniversary of the Battle of Shiloh. Next year there will be a sesquicentennial re-enactment of the bitter struggle that was fought here in these beautiful hills, two truly horrific days in our nation’s history. Photo by MSMA Past President Dwalia S. South, MD, Ripley. ❒ April

VOL. LII

Official Publication of the MSMA Since 1959

2011

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JOURNAL MSMA APRIL 2011

• SCIENTIFIC ARTICLES •

A Comparative Study of American Football Helmet Removal Techniques Using a Cadaveric Model of Cervical Spine Injury

Andrew Anderson MD; Brian Tollefson MD; Rob Cohen MD; Jeremy Johnson RN, BSN and Richard L. Summers, MD

BSTRACT

Background: American football is the source of a significant number of cervical spine injuries. Removal of the helmets from these individuals is often problematic and presents a potential for exacerbation of the injury. There are two widely recognized helmet removal techniques that are currently in practice. In this study, the two methods are compared for cervical movement and potential for cord injury to determine their relative efficiency and clinical utility. Methods: A single cadaver with a simulated cervical injury was used to compare the National Athletic Trainers’ Association (NATA) and cast saw techniques of helmet removal. Directed lateral fluoroscopy was used to measure the relative changes in angulation, translation, distraction, and space available to the spinal cord during helmet removal using the two techniques as performed by medical personnel with limited training in the methods. Results: By radiologists’ reports, there were no detectable changes in disc height, translation or space available for the spinal cord during helmet removal with either of the studied techniques. Operators noted that the noise of the cast saw would probably be significantly uncomfortable for any live subject inside of a helmet. Conclusion: Both the NATA and cast saw methods appear effective for the safe removal of a football helmet and with little risk of further injury to the cervical spine. Considering the simplicity and efficiency of the NATA helmet removal technique, the authors conclude that the NATA technique should be the preferred helmet removal method.

AUTHOR INFORMATION: Dr. Anderson, Dr. Tollefson, Dr. Cohen, Ms. Johnson and Dr. Summers are affiliated with the Department of Emergency Medicine at the University of Mississippi Medical Center in Jackson. CORRESPONDING AUTHOR: Brian Tollefson, MD; Department of Emergency Medicine University of Mississippi Medical Center, 2500 North State Street. Jackson, Mississippi 39216 (btollefson @umc.edu).

KEYWORDS:

CERVICAL SPINE INJURY,

AMERICAN FOOTBALL,

HELMET REMOVAL, CADAVER

INTRODUCTION

Spinal cord injury accounts for approximately 8,000 to 10,000 new trauma cases annually.1 Approximately 55% of spinal cord injuries occur within the cervical region, and 10% of these injuries have a second, noncontiguous vertebral column fracture.2 A small percentage of spinal cord injuries are a result of axial loading or deceleration type injury patterns sustained during contact sports. Football, one of the country’s most popular team sports, is associated with the largest overall number of sports-related catastrophic cervical spine injuries in the United States.3 Recent data on football injuries suggest that approximately 0.2 per 100,000 high school football players and 2 per 100,000 college football players are diagnosed with cervical cord neuropraxia.3 More severe injuries leading to permanent neurologic damage have been noted in 0.5 per 100,000 high school football players and 1.5 per 100,000 college football players over the past 30 years.3 Acute injury to the cervical spine not uncommonly results in injury to the phrenic nerve leading to reduced and/or inadequate ventilation. Injuries sustained at or above C5 increase the possibility for hypoventilation and/or apnea.1 Approximately one third of patients who receive a cervical spine injury die at the scene due to apnea. A large number of those with potentially devastating vertebral column bony or ligament injuries survive without neurological deficits because of the wide cervical canal present from the foramen magnum to the lower part of the second cervical spinous process.2 Because of the possibility of spinal instability following cervical trauma while playing football, a preliminary assessment of the cervical spine is often necessary in the prehospital setting but can be limited by protective gear.4 Current literature agrees that the face mask should be immediately removed from the helmet of an injured athlete with a suspected cervical spine injury regardless of respiratory status.1,2,5 The injured athlete

APRIL 2011 JOURNAL MSMA

103

should then be immobilized to a backboard still wearing the helmet and shoulder pads and transported to a trauma center capable to evaluating such an injury.1,2,6 Upon arrival to the emergency department, consideration should be given to imaging the injured athlete using CT prior to removing the helmet and shoulder pads.6 However, some evidence suggests that protective gear might limit image quality and should be removed prior to radiologic imagining.7,8 If the protective equipment must be removed prior to C-spine clearance either due to inadequate images or clinical necessity, the helmet and shoulder pads should be removed simultaneously.9 The removal of the football helmet presents a particularly unique clinical challenge in this process.10 The injured athlete must be handled cautiously until the extent of the injury has been definitively established.11 Improper removal of protective sports equipment by the emergency department or sideline healthcare providers may result in iatrogenic neurological injuries or even death.1,9 The American College of Surgeons Committee on Trauma and the National Athletic Trainersâ&#x20AC;&#x2122;Association (NATA) often debate as to safest and most efficient technique for removing protective sports equipment such as helmets.12 In this study we compare spinal stability during the performance of the two most commonly employed techniques using a cadaveric model with a simulated cervical injury.

METHODS

Study design The study used a controlled laboratory design to compare the two commonly accepted techniques of helmet removal for objective measures that would potentially exacerbate a cervical injury. The first technique evaluated has been previously described and is referred to as the NATA method.1,13 The second technique evaluated was the cast saw method which involved using a standard cast saw to bivalve the helmet. The study was conducted on a single randomly assigned cadaver in the hospital morgue. The subject was placed on support structures that lifted him out of the morgue tray and allowed for more realistic manipulation of football helmets and fluoroscopic equipment. Space was made available so that video graphic evaluation of the procedures could be utilized. A deliberate cervical spinal column injury was established by surgically dissecting through posterior neck anatomy. The cadaver was given a typical football cervical spine injury by dissecting with a scalpel through the posterior cervical neck fascia at the level of C5 â&#x20AC;&#x201C;C6 in a manner similar to that described in a previous study.14 Dissection transected much of the deep fascia and extended through the ligamentum flavum between the involved vertebrae. Subsequently lateral cervical spine radiographs were taken of the cadaver while manually producing full flexion and extension to ensure an adequate injury had been rendered. Helmet removal teams were established by asking for volunteers from a cadre of emergency department healthcare personnel who professed limited experience using the helmet

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removal techniques being evaluated in this study. Radiology department personnel were selected based on experience with the radiological technology being utilized in the study. Cervical column displacements were objectively measured while removing the football helmet from the cadaver using both of the techniques. The first method tested was the NATA technique. Four medical personnel were assigned to the helmet removal team and were given specific training on how to correctly perform the technique prior to removing the helmet from the cadaver. Continuous video fluoroscopy was utilized to image the lateral aspect of the cervical spine during the helmet removal process. The radiographic images were collected using a portable video fluoroscopy machine (machine model) for later blinded review by the radiologists. The procedure was then repeated using the cast saw technique. As previously described, the cast saw method involved bivalving the helmet on a frontal plane and subsequently removing the helmet from the head in two pieces. The two different helmet removal techniques were repeated a total of four times each while closely monitoring the team members to provide consistency. It was determined by the Institutional Review Board of the University of Mississippi Medical Center that this study did not need review since it did not involve live human or animal tissue. Outcome measures Baseline portable video fluoroscopy radiographs were compared to those taken continuously during the physical manipulation stages of helmet removal using both techniques. The radiographic images obtained were evaluated by senior and staff level radiologists for cervical angulation, translation, distraction, and space available to the spinal cord. Significance is determined at a displacement of >2mm as has been done in prior studies.15 The radiologists reports concerning these properties were used to directly compare the two different methods of football helmet removal being studied. The differences in the degree of angulation, translation, distraction and space available for the spinal cord were to be compared for the two methods using a standard studentâ&#x20AC;&#x2122;s t test (p< 0.05).

RESULTS

After careful evaluation of the video imaging obtained from the study, the radiology team determined that there were no radiologically discernible or measurable movements of the cervical spine of any consequence during either of the helmet removal techniques studied. Thus, with regard to spinal column stabilization, both techniques were found to be equally effective in preventing undesirable movement. However, the researchers did find an advantage in using the NATA technique over the cast saw technique for helmet removal in efficiency. Subjectively, the helmet was removed much faster with the NATA technique and without the generation of the loud and harsh noise provided by the cast saw cutting the helmet. Operators noted that the noise of the cast saw would probably be very uncomfortable for any live subject inside of a helmet.

DISCUSSION

Although it is well known that collision sports such as American football can infrequently cause significant unstable cervical spine injuries, few emergency department personnel have adequate training in the removal of protective equipment including helmets and shoulder pads. Even the best trauma centers are unlikely to have well established protocols and coordinated teams capable to efficiently removing this equipment. This deficiency is partly due to the lack of consistency in the literature as to the most appropriate technique to use. In this study we measure the relative cervical spine stability during helmet removal from a cadaver with a known cervical spinal column injury using the two most commonly accepted techniques. The results suggest that these two recognized techniques are equally effective and provide little risk of additional cervical spine injury. However, it subjectively appears that the NATA technique would probably have a greater efficiency and a more comfortable subject experience as compared to the cast saw removal technique. These secondary issues could be an important consideration in deciding which football helmet removal technique should be used on an injured athlete with a potential cervical spine injury. There are a number of limitations to this study to be considered. First, only one cadaver was used during the study, and the results may have been different if multiple cadavers with a variety of injury patterns had been studied. A previous cadaveric model study did show some small displacements.14 The pliability and malleability of the cadaveric cervical spine anatomy probably varies between cadavers and does not completely simulate that of a living, breathing human trauma victim. Also, there may have been subtle cervical spine movements that were not detected by the radiographic analysis used in our study. However, these slight movements might not be clinically consequential. Additionally, the controlled, low-stress environment encountered in this study protocol would not likely be present in the real-world application of these helmet removal techniques. It is interesting to note that a previous study using flouroscopy during helmet removal in live subjects also showed no significant displacements.15 However, they did not compare the two methods. Based on the results of this study, it is reasonable to think that with adequate training and deliberate controlled movements, secondary injury to the cervical spine caused by helmet removal can be greatly diminished. The NATA technique appears to have some logistical advantages over the cast removal technique that would make it easier to train providers and implement a standardized protocol. Further study with live subjects is needed to differentiate the efficacy of the two techniques. Regardless of which technique is preferred, it should be one that has been well practiced by the health care team prior to its implementation and providers should be proficient at removing this gear from injured players both in the emergency department and in the prehospital setting.

REFERENCES

1. 2. 3. 4. 5. 6. 7. 8. 9.

Fazio J. Spinal cord and neck trauma. In: Criddle L, Newberry L, Sheehy S, eds. Manual of Emergency Care. 6th ed. St Louis, Mosby. 2005:637-47. American College of Surgeons Committee on Trauma. In: Advanced Trauma Life Support for Doctors Student Course Manual. 7th ed. Chicago. ATLS Program for Doctors. 2004; Chapter 15: 23-4,177-89. Rihn JA, Anderson DT, Lamb K, Deluca PF, Bata A, Marchetto PA, Neves N, Vaccaro AR. Cervical spine injuries in American football. Sports Med. 2009;39:697-708.

Domeier RM, Frederiksen SM, Welch K. Prospective performance assessment of an out-of-hospital protocol for selective spine immobilization using clinical spine clearance criteria. Ann Emerg Med. 2005;46:123-31. Guidelines of the Inter-Association Task force for Appropriate Care of the Spine-Injured Athlete. 1999. Waninger K. Computed Tomography is Diagnostic in the Cervical Imaging of Helmeted Football Players with Shoulder Pads. J Athl Train. 2004;39:217-222.

Davidson RM, Burton JH, Snowise M, Owens WB. Football protective gear and cervical spine imaging. Ann Emerg Med. 2001;38:26-30. Swenson TM, Lauerman WC, Blanc RO, Donaldson WF 3rd, Fu FH. Cervical spine alignment in the immobilized football player. Radiographic analysis before and after helmet removal. Am J Sports Med. 1997;25:226-30. Waninger K. Management of the Helmeted Athlete With Suspected Cervical Spine Injury. Am J Sports Med. 2004;32:13311350.

10. Waninger K. On-field management of potential cervical spine injury in helmeted football players: leave the helmet on! Clin J Sport Med. 1998;8:124-129. 11. Davis JW, Phreaner DL, Hoyt DB, Mackersie RC. The etiology of missed cervical spine injuries. J Trauma. 1993;34:342-346. 12. Prinsen RK, Syrotuik DG, Reid DC. Position of the cervical vertebrae during helmet removal and cervical collar application in football and hockey. Clinical J Sport Med. 1995;5:155-61.

13. Kleiner DM. Guidelines for the appropriate care of an athlete with a suspected spine injury: a report from the Inter-Association Task Force. National Athletic Trainers Association. Emerg Med Serv. 1998;27:35.

14. Donaldson WF 3rd, Lauerman WC, Heil B, Blanc R, Swenson T. Helmet and shoulder pad removal from a player with suspected cervical spine injury. A cadaveric model. Spine.1998;23:1729-32. 15. Peris MD, Donaldson WF WF 3rd, Towers J, Blanc R, Muzzonigro TS. Helmet and shoulder pad removal in suspected cervical spine injury: human control model. Spine. 2002;27:995-8.

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APRIL 2011 JOURNAL MSMA

105

• MISSISSIPPI MEDICINE UP-TO-DATE •

Sports-Related Concussion

Steve A. Watts, MD

NTRODUCTION

Injuries in competitive collision and contact sports such as football, rugby, and soccer are often related to the head and neck. The large majority of injuries to the head in football are classified as concussions. A concussion is considered a mild traumatic brain injury (mTBI) and is a complex pathophysiological process affecting the brain induced by biomechanical forces. Concussions account for 5-9% of sport-related injuries among high school and collegiate athletes in the United States. A conservative estimate of the number of concussions sustained by high school athletes is 62,800 per year. The large majority of concussions occur in football (63.2%). Other sports with significant incidence of concussions include soccer (11.9%), wrestling (10.5%), and basketball (9.4%). In high school sports involving both sexes, females sustained a higher concussion rate, and concussions represented a greater proportion of total injuries than in male counterparts. Furthermore, adult females are at greater risk of post-concussive symptoms three months after sport-related concussion compared to male patients. Although concussion has been accepted as a part of competitive sports for many years, the importance of concussion recognition and intervention has been a recent issue gaining broad media attention, particularly in American football. Recognizing a concussion in a competing athlete is important in order to prevent further injury and perhaps avoid long term effects of multiple mild insults to the brain. Significant impact to the head of an athlete who has not fully recovered from a previous concussion can lead to severe brain injury or death. This condition has been termed the “second impact syndrome.”

AUTHOR INFORMATION: Dr. Watts is an Associate Professor in the Department of Orthopedic Surgery and Rehabilitation / Department of Family Medicine at the University of Mississippi Medical Center in Jackson.

CORRESPONDING AUTHOR: Steve A. Watts, MD; Associate Professor, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216 (sawatts@umc.edu).

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JOURNAL MSMA APRIL 2011

The long-term effect of multiple mild concussions has been linked to traumatic encephalopathy and dementia in older athletes who experienced many concussive events during competition. In a study of 1,094 professional football retirees, 51% had a concussion with loss of consciousness during their career, 30% had three or more concussions, and 15% had greater than 5 concussions. Thirty-one percent had persistent memory difficulties, and 71% were not asked to sit out after a concussion.1 A sub-population of these athletes has developed dementia at a younger age than expected. One investigator has found tau-protein deposition in the spinal cord of deceased former athletes with symptoms of amyotrophic lateralizing sclerosis, raising questions regarding the long-term effects of repetitive concussions in sports.2

KEY WORDS: SPORTS, CONCUSSION INJURY, ATHLETES DIAGNOSIS

In collision and aggressive sports such as American football, rugby, and soccer, symptoms and signs of concussion may be subtle and difficult to differentiate from other causes. Players are often in a “hyped” psychological and physiological state and will not readily admit to anything that would keep them out of the game. The obvious sign of a loss of consciousness is not a required event for diagnosis of a concussion. Symptoms may include a headache, nausea, imbalance, blurred vision, irritability, emotional lability, or sensitivity to light. Signs may include a dazed appearance or vacant expression, confusion, forgetfulness, disorientation, or a change in typical behavior. (Table 1) It is useful to consider the manifestation of concussion in five clinical domains. These include somatic symptoms, physical signs, behavioral changes, cognitive impairment, and altered consciousness. (Table 2)

CLASSIFICATION OF CONCUSSIONS

Over 16 concussion scales have been published since 1973. Most scales describe three grades of severity but vary in the definitions and return to play recommendations. No current scale is accepted universally, and clinical judgment remains the critical element in establishing the severity of an injury. Furthermore, none of the proposed scales has been prospectively validated. The 3rd international consensus statement on concussion in athletes was released in November 2009. This statement marks a significant change in the evaluation and management recommendations for athletes with sports concussion.3 (Table 3) Previous attempts in grading concussions were based on subjective criteria and were subsequently unreliable and nonprognostic. In the new guidelines, grading scales for concussion have been eliminated, and athletes are advised not to return to play in a practice or game if symptoms or signs of a concussion are recognized. The neuropsychometric tool SCAT2 is recommended for objective measurement of neuropsychological aberrations in concussed athletes.4,5 However, clinical judgment remains the final determinant of return to play. Computerized neuropsychological testing, when available, has also been recommended. This testing requires a pre-injury neuropsychological test which is repeated after an injury to compare the scores after a concussion. However, to date, the widespread use of this testing is limited by availability and affordability. In colleges where ImPACT testing, a proprietary computerized neuropsychological testing software, was used,

athletic trainers relied more on symptoms than on neurocognitive test scores when making return to play decisions.6 Computerized neuropsychological testing such as ImPACT has been validated only in athletes whose first language is English and may fail to account for socio-cultural complexities of individual athletes. A useful tool to aid athletic trainers and coaches in assessing the athlete suspected of having a concussed brain is the Pocket SCAT2 card. This card and the full SCAT 2 concussion assessment are available for reproduction at the web site http://bjsm.bmj.com/content/43/Suppl_1/i89.full.pdf.

CLINICAL MANAGEMENT OF THE CONCUSSED ATHLETE

After the athlete has been discovered to have symptoms of a concussion, he or she should be removed from the practice or game. The athlete should not be allowed to continue or to return to play until evaluated by a health care provider trained in the management of sports concussions. Once emergency issues have been addressed, particularly clearance of cervical spine injury, an assessment of the concussive injury should be made. The Pocket SCAT2 referenced above should be used to assess the athlete. Serial monitoring for neurological deterioration is important over the initial few hours following injury. The player should not be left alone after the game but should be escorted home by family or friends. Every athlete who has a concussion should be evaluated by a physician who is familiar with the treatment of sport-related concussion.

Table 1. SIGNS AND SYMPTOMS OF A CONCUSSION

•

Signs • • • • • • • • •

Dazed appearance Vacant facial expression Confusion Forgetfulness Disorientation to circumstances Inappropriate emotions Incoordination Loss of consciousness Change in typical behavior

•

Symptoms • • • • • • • • • •

Headache Nausea Dizziness Blurred or double vision Sensitivity to light/noise Feeling slow/groggy Insomnia or sleepiness Memory impairment Irritability Sadness or emotional liability

Table 2. CLINICAL DOMAINS OF CONCUSSION EVALUATION 1. 2. 3. 4. 5.

Somatic symptoms (e.g. headache) Physical signs (e.g. imbalance) Behavioral changes (e.g. irritability) Cognitive impairment (e.g. slowed reaction times, amnesia, disorientation) Altered consciousness (e.g. drowsiness)

If any one or more of these components are present, a concussion should be suspected and the appropriate management strategy instituted. APRIL 2011 JOURNAL MSMA

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Table 3. ACUTE SIMPLE CONCUSSION3 • • • •

Concussion signs/symptoms resolve over 7-10 days in 80-90% of cases. Management focuses on the athlete resting until all signs/symptoms are gone. Follow a progressive activity program prior to returning to sport. Resolution may be longer in adolescents and children.

Data from McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport –the 3rd international conference on concussion in sport held in Zurich, November 2008 .J Sci Med Sport. 2009 May; 12(3):340-351.

Table 4. GRADUATED RETURN TO PLAY PROTOCOL3 1. 2. 3. 4. 5. 6.

Complete physical and cognitive rest. Light aerobic exercise, e.g.: walking, using stationary bike, no weight training. Sport-specific activity, e.g.: skating, running, cutting, and passing/throwing. (No heading) Non-contact training drills and progressive weight training. Full contact practice following physician clearance. Build confidence and allow for functional assessment. Game participation.

Athletes should follow the above steps in return to play after a concussion. The athlete should have no symptoms at each level before proceeding to the next step. No more than one step should be attempted in one day. Data from McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport –the 3rd international conference on concussion in sport held in Zurich, November 2008. J Sci Med Sport. 2009 May; 12(3):340-351.

The office evaluation of an athlete who has had a suspected concussion should include a basic neurological and neuropsychological examination (e.g., SCAT2). Adequate time with the athlete and family should be given to answer questions and provide support through the process of recovery. Players should be re-examined within 3-7 days using the SCAT2 to document improvement in cognitive performance. Referral for further imaging (MRI, SPECT, CAT), neurosurgical evaluation, or formal neuropsychological testing may be necessary depending on the clinical status of the patient.

RETURN TO PLAY AFTER CONCUSSION

Only when an athlete is asymptomatic at rest and with exertion and has a normal neurological assessment should he or she be allowed to return to play. For most athletes the minimum time to return to normal neuropsychological testing is 7-14 days. In high school athletes the time may be even longer.1 A graduated return to play protocol is recommended in which the athlete may progress in intensity of exercise and sport-specific drills. Return to a competitive game is the final step in the process. (Table 4)

RECENT DEVELOPMENTS

Advances in the diagnosis and evaluation of concussion include neuro-imaging, genetic testing, and autonomic dysfunction evaluations. Functional magnetic imaging demonstrates

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activation patterns that correlate with symptom severity and recovery. Positron emission tomography, diffusion tensor testing, and magnetic resonance spectroscopy are also being investigated for use in concussion management. Genetic testing includes Apolipoprotein (Apo) E4, ApoE promotor gene, Tau polymerase and other genetic markers of susceptibility to concussive injury are under investigation for clinical application to management of concussions. Autonomic dysfunction of the brain following a concussion can be demonstrated by a decrease in heart rate variability (HRV). Using new technology the pattern of HRV can be measured in athletes who have had a concussion and may become available to assist in the evaluation and management of concussion.7

CONCLUSION

The following points should be considered for every athlete who sustains a concussive injury to the brain in the field of play. • Each athlete must be carefully assessed by appropriate personnel. • Careful documentation of assessments and recommendations is imperative. • Clinical judgment remains the final determinant of return to play.

• • • •

• SCIENTIFIC •

Repeat examinations should be conducted. No athlete should be allowed to return to play unless asymptomatic at rest and with exertion and neuropsychological testing is normal. (Usually 7-10 days) Return to play protocols should be followed. Use of pre-injury computerized neuropsychological testing is encouraged but does not replace thorough assessment and communication with athlete, coaches, and family.

REFERENCES

1. 2.

Guskiewicz KM, Marshall SW, Bailes J, et al. Association between recurrent concussion and late-life cognitive impairment in retired professional football players. Neurosurgery. 2005; 57(4):719-724. McKee AC, Cantu RC, Nowinski CJ, et al. Chronic traumatic encephalopathy in athletes: progressive tauopathy following repetitive head injury. J Neuropathol Exp Neurol. 2009; 68(7):709-735.

3. 4.

5. 6.

McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport – The 3rd international conference on concussion in sport held in Zurich, November 2008. J Sci Med Sport. 2009;12(3):340-351.

Collins MW, Field M, Lovell MR, et al. Relationship between postconcussion headache and neuropsychological test performance in high school athletes. Am J Sports Med. 2003;31(2):168– 173.

Schatz P, Pardini JE, Lovell MR, et al. Sensitivity and specificity of the ImPACT Test Battery for concussion in athletes. Archives of Clinical Neuropsychology. 2006;21(1):91-99.

McCrea M, Guskiewicz KM, Marshall SW, et al. Acute effects and recovery time following concussion in collegiate football players The NCAA Concussion Study. JAMA. 2003; 290(19):2556-2563. Gall B, Parkhouse W, Goodman D. Heart rate variability of recently concussed athletes at rest and exercise. Med Sci Sports Exerc. 2004;36(8):1269-1274.

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• CLINICAL PROBLEM-SOLVING •

“Stick out your tongue and say 'Ahhhh'!” Presented and edited by the Department of Family Medicine, University of Mississippi Medical Center, Diane K. Beebe, MD, Chair

Tanima Jana, MS and John Schweinfurth, MD

76-year-old white female presented to her otolaryngologist with a two-year history of flat, circumferential spots on her tongue. The spots were intermittent and migratory in nature. In addition to the spots, the patient also described a mild and intermittent burning sensation on the anterior tip of the tongue. The symptoms were not exacerbated by consumption of food or beverages. Review of systems was negative except as stated above. Her past medical history was significant for a heart murmur, high cholesterol, hypertension and hypothyroidism. There was no history of diabetes, human immunodeficiency virus or other immunosuppression. Past surgical history was significant for an appendectomy, complete hysterectomy, total thyroidectomy and cholecystectomy. Family history was significant for heart disease in the patient’s father and hypertension in the patient’s mother. The patient did not report any tobacco or alcohol use and stated that she did not drink excessive amounts of caffeine. Review of medications showed that she was taking amiodarone (Cordarone), hydrochlorothiazide, escitalopram (Lexapro), nabumetone (Relafen), a multivitamin (Centrum Silver), a dietary supplement containing glucosamine and chondroitin (Osteo Bi-Flex), calcium, amlodipine (Norvasc), aspirin, levothyroxine (Levoxyl), gabapentin (Neurontin), digoxin (Digitek), cyclobenzaprine (Flexeril) and rosuvastatin (Crestor). Superficial transient discoloration of the tongue can be attributed to foods and beverages, such as coffee and tea, habits such as tobacco or crack cocaine use or medications.1 Drugs noted for causing skin pigmentation include nonsteroidal antiinflammatory drugs, heavy metals, antimalarials, amiodarone, cytotoxic drugs, psychotropic drugs and tetracyclines. Vitamin deficiencies, especially involving nicotinic acid and vitamin B12, can lead to pigmentation that is further aggravated by light AUTHOR INFORMATION: Ms. Jana is a 4th year medical student and Dr. Schweinfurth is Associate Professor in the Department of Otolaryngology at the University of Mississippi Medical Center in Jackson.

CORRESPONDING AUTHOR: John Schweinfurth, MD; Professor, Department of Otolaryngology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216.

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exposure.2 Tongue lesions can also be seen in systemic diseases such as candidiasis, herpes simplex, lichen planus, systemic lupus erythematosus and leukoplakia.3 These diseases would be unlikely in this case due to lack of systemic symptoms. Additionally, acute pseudomembranous candidiasis would be more likely in a patient with other serious underlying conditions, such as diabetes, leukemia or HIV.4 Discoloration due to amiodarone tends to occur much more commonly in sun-exposed areas, such as the nose or ears.2 Superficial changes in the epithelium of the tongue may occur in conditions such as benign migratory glossitis, also known as geographic tongue. There are many causes of pain in the mouth, and they are best divided into 4 groups: local, systemic, emotional/psychiatric and idiopathic. Local causes include oral infections caused by Candida, Enterobacter, Klebsiella or Staphylococcus aureus, along with allergic reactions.5-10 Infection with any of these organisms would be unlikely for this duration of time, and the patient would also have presented with systemic symptoms such as fever or a rash. Additionally, an allergic reaction would be unlikely due to the chronic nature of the symptoms. Systemic causes include vitamin deficiencies (vitamin B12, vitamin B6, folic acid, vitamin C), anemias, low serum zinc, Sjögren’s disease, diabetes mellitus, hypothyroidism and medication usage (antihistamines, neuroleptics, benzodiazepines, anticholinergics, antiretrovirals, antiarrhythmics, tricyclic antidepressants, serotonin uptake inhibitors, omeprazole, antibiotics and antihypertensives). A vitamin deficiency is unlikely due to regular usage of a multivitamin. Sjögren’s disease is unlikely in this case due to lack of xerostomia and xerophthalmia. Psychiatric causes include anxiety, depression, obsession, panic syndrome or personality disorders 5-9,11 but are unlikely due to lack of associated complaints by the patient. Dietary habits such as hot, spicy and acidic foods, along 3,7 with dried, salty nuts may exacerbate oral burning symptoms. Routine stress/fatigue, excessive speaking and usage of antiseptics, toothpaste, chewing gum, smoking or alcohol, including alcohol-containing dental rinses, may also aggravate symptoms.7 In this patient, lack of excessive caffeine consumption, smoking history and illicit drug use rule out social habits as possible causes for her symptoms. On physical exam, she was afebrile, in no acute distress and was breathing without stridor. Her voice was strong and

clear. No masses or lesions were identified in the neck. Nares were patent and mucosa was pink and moist, without polyps. Her tongue showed a single, 2 cm circumferential area of denuded papillae to the left of midline. The area was non-tender to palpation. There were no abnormalities of the anterior tip. Dentition was fair. No additional masses, vesicles, plaques or ulcerations were identified within the oral cavity or oropharynx. The palate was symmetric and mobile bilaterally. The remainder of the physical exam was unremarkable. While tongue lesions can be seen in herpes simplex infections, mucosal tenderness, along with small vesicles surrounded by an inflammatory periphery is usually present.12-13 Also, fever usually coincides with arrival of symptoms.13 Patients with acute pseudomembranous candidiasis are usually asymptomatic and present with soft, white superficial colonies. Chronic atrophic candidiasis would be more common in a denture-wearer, and patients typically present with an asymptomatic, erythematous mucositis limited to the denture-bearing mucosa.4 In oral lichen planus, either a reticular, white, lacy pattern, or an erosive pattern with shallow ulcerations is common. Oral leukoplakia appears as a raised, homogenous, white lesion or as an irregular white-red lesion with a nodular appearance.14 In lupus erythematosum, superficial ulcers with surrounding erythema, much like those seen in lichen planus or leukoplakia are seen, in addition to a malar rash, urticaria, photosensitivity or multi-organ involvement. At this point, the patient appears to have two separate conditions: atrophic patches on her tongue and a burning sensation. The atrophic patches are likely related to geographic tongue as evidenced by the migratory and intermittent nature of the spots described by the patient, and areas of denuded papillae as seen on physical exam. The absence of vesicles, growths and classical lesions seen in other conditions, along with the lack of systemic symptoms and negative social history, help to narrow the differential. The painful sensation at the anterior tip of the tongue is thought to be glossodynia. This diagnosis is based on the burning qualities of the pain, location of the pain and the lack of systemic symptoms. Antidepressants and neuroleptics are considered the drug of choice in the treatment of glossodynia but may aggravate symptoms due to dry mouth caused by anticholinergic effects. Gabapentin, which functions via inhibition of excitatory glutamate synthesis and potentiation of inhibitory gamma-aminobutyric acid (GABA) effects, is often used in 15 treatment. In this case, neither the antidepressant nor the gabapentin the patient was taking were alleviating symptoms. For the atrophic patches, the patient was initially given triamcinolone cream. Due to problems with a gagging sensation, this was later switched to dexamethasone (Decadron) elixir. For the glossodynia, the patient was instructed to take B vitamin supplements and to increase her current dose of gabapentin from 300 to 900 mg daily. On subsequent follow-up visits, the patient reported that the dexamethasone did not eliminate the spots. The gabapentin and B vitamin supplements provided only minimal relief.

The lack of response to B vitamins shows that vitamin deficiency is most likely not responsible for the patientâ&#x20AC;&#x2122;s oral manifestations. The lack of response to gabapentin shows that the burning sensation is not purely neuropathic. The minimal response to traditional therapies indicates that there is another cause present that has not been identified. At this point, we turn to drug-induced reactions as a possible cause. Of all of the drugs the patient is taking, the drug that appears most likely to be the culprit is amiodarone. Cutaneous side effects of amiodarone include slate-gray pigmentation of sun-exposed areas of skin, cutaneous hyperpigmentation, angioedema and chalazia. More systemic adverse effects include hair loss, pseudoporphyria, erythema nodosum, exfoliative dermatitis, toxic epidermal necrolysis, dose-dependent vasculitis and hyperand hypothyroidism.16,17 The majority of its adverse effects are dose-related and reversible.17 While amiodarone commonly causes hyperpigmentation in sun-exposed areas (57-75% of patients),16 it rarely causes discoloration in unexposed areas, as was the case in our patient. Thus, it was not considered high in the differential initially. The patient was asked to speak with her cardiologist about altering her amiodarone dosage. Her cardiologist preferred to decrease the frequency of amiodarone rather than substitute with a new medication. Amiodarone was discontinued for two weeks but then had to be restarted due to return of arrhythmias and palpitations. During this two-week period, the patient noted significant improvement in both the tongue patches and the burning sensation. While other treatments provided mild symptomatic improvement, the greatest change was noted with the change in amiodarone regimen, indicating that both conditions are most likely related to an amiodarone-induced autoimmune reaction. In these types of situations, oral pigmentation may remain for a prolonged period and, as was the case with this patient, ceasing or interrupting treatment is not always feasible. In the case of amiodarone, the risk of developing hyperpigmented areas decreases significantly at doses below 200 mg daily.2 In this case, improvement was seen when the dosage of amiodarone was kept at 200 mg but the frequency reduced. On the most recent visit, the patient experienced symptomatic improvement which was confirmed on physical exam in the affected area of the tongue. She had been taking the weekends off from amiodarone and thought that it was helping relieve the burning sensation. An additional day off from amiodarone, possibly in the middle of the week was requested. Her cardiologist approved of this plan and requested routine follow-up to monitor for arrhythmias. We anticipated continued improvement and encouraged follow-up visits.

COMMENTARY

Geographic tongue most commonly occurs on the tip, lateral borders and dorsum of the tongue. The erythematous, ulcerlike lesions are typically due to loss of filiform papillae.3, 18 When zones of papillary atrophy are predominant, lesions may appear

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• SCIENTIFIC •

as red patches.18 The migratory pattern is due to alternating patterns of remission and exacerbation of the lesions. During remission, the lesions resolve without scar formation, and when they recur, they appear in different locations. The lesions can either be asymptomatic or cause soreness.3,5,18 During exacerbations, the tongue lesions may be joined by burning sensations, paroxysmal pain in the ears and ipsilateral lymph nodes.3 Some studies indicate a congenital association while other studies imply a physiological relationship with a number of conditions including Reiter’s syndrome, Down syndrome, nutritional deficiencies, psoriasis, diabetes, hormonal changes, emotional stress and allergies.3, 18 It is not associated with human immunodeficiency virus or tobacco use. There may be an association with fissured tongue and pustular psoriasis.3 Extra sensitivity may be caused by spicy or hot foods.3, 18 Most patients with geographic tongue do not necessitate treatment. The condition is generally benign and localized and often requires no treatment other than reassurance. Topical steroid gels, such as triamcinolone, and antihistamine mouth rinses, such as diphenhydramine elixir, may help reduce tongue sensitivity. Symptomatic treatments, including antihistamines, anxiolytics, steroids, acetaminophen and mouth rinsing with a topical agent have shown mixed success. Systemic antipsoriatic therapy and vitamin A acid therapy have also been proposed.19, 20 A persistent burning sensation in the oral mucosa is often indicative of burning mouth syndrome. The most commonly affected areas are the lateral borders and tip of the tongue, warranting the name “glossodynia.” The lips and anterior palate may also be involved. There is often no visible pathology, clinical data or laboratory data.6-8,11,15 Oral dryness, stinging on the lips and mouth, excessive salivation and taste alterations may be present,6-7 and patients tend to be very preoccupied with their pain.15 This phenomenon tends to be seen most predominantly in middle-aged patients and postmenopausal women.6-7 Stress/fatigue, anxiety, consumption of spicy foods and speaking too much can exacerbate the pain, while cold food, distraction and leisure activities can alleviate the pain.7 Although the cause of glossodynia is unknown, studies show that it is likely neuropathic in origin.5 Thus, antidepressants, 15 neuroleptics and gabapentin are often given initially. Some studies postulate that topical clonazepam is a better option than gabapentin (lack of efficacy), oral capsaicin and clonazepam (adverse effects), trazodone (significant side effects) and alpha-lipoic acid (loss of efficacy over time).11 Group psychotherapy may also be beneficial.21 Above all, treatment should be tailored to the individual patient. Any modifiable habits and risk factors (diet, smoking, alcohol etc.) should be addressed. Vitamin deficiencies and medication causes should be examined.6 The current case is a unique case in that 2 distinct conditions were present: geographic tongue and glossodynia. When traditional treatments showed minimal improvement, the decision was made to adjust amiodarone dosage. This proved to be very beneficial, leading to the conclusion that the problems were due to an amiodarone-induced autoimmune reaction. Although amiodarone could not be completely discontinued due to return of the patient’s arrhythmias, a decreased dosing frequency showed significant symptomatic improvement.

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KEY WORDS: GEOGRAPHIC TONGUE, BURNING REFERENCES: 1. 2. 3. 4. 5. 6. 7. 8. 9.

MOUTH

SYNDROME, GLOSSODYNIA, AMIODARONE

Scully C, Bagan JV. Adverse drug reactions in the orofacial region. Crit Rev Oral Biol Med. 2004;15(4):221-239.

Dereure O. Drug-induced skin pigmentation: epidemiology, diagnosis, and treatment. Am J Clin Dermatol. 2001;2(4):253-262.

Littner MM, Dayan D, Gorsky M, Moskona D, Harel-Raviv M. Migratory stomatitis. Oral Surg. Oral Med. Oral Pathol. 1987;63:555559. Lynch DP. Oral Candidiasis: History, classification, and clinical presentation. Oral Surg Oral Med Oral Pathol. 1994;78:189-193.

Scully C, Shotts R. ABC of oral health: Mouth ulcers and other causes of orofacial soreness and pain. BMJ. 2000;321:162-165.

López-Jornet P, Camacho-Alonso F, Andujar-Mateos P, Sanchez-Siles M, Gomez-Garcia F. Burning mouth syndrome: update. Med Oral Patol Oral Cir Bucal. 2010;15(4):E562-568.

Cerchiari DP, Dutra de Moricz R, Rapoport PB, Moretti G, Guerra MM. Burning mouth syndrome: etiology. Rev Bras Otorrinolaringol. 2006;72(3):419-424. Llorca CS, Serra MPM, Silvestre FJ. Drug-induced burning mouth syndrome: a new etiological diagnosis. Med Oral Patol Oral Cir Bucal. 2008;13(3):E167-170.

Miziara ID, Filho BCA, Oliveira R, Rodriques dos Santos RM. Group psychotherapy: an additional approach to burning mouth syndrome. J Psychosomatic Res. 2009;67:443-448.

10. Terai H, Shimahara M. Tongue pain: burning mouth syndrome vs. Candida-associated lesion. Oral Diseases. 2007;13:440-442.

11. Serra MPM, Llorca CS, Donat FJS. Pharmacological treatment of burning mouth syndrome: a review and update. Med Oral Patol Cir Bucal. 2007;12:E299-304.

12. Sciubba, JJ. Oral mucosal lesions. In: Flint PW, Haughey BH, Lund VJ, eds. Cummings Otolaryngology- Head and Neck Surgery. 5th ed. Philadelphia, PA: Mosby; 2010:1222-1244. 13. Whitley RJ, Rotzman B. Herpes simplex virus infections. Lancet. 2001;357:1513-1518.

14. Van der Wall I, Schepman KP, van der Meij EH, Smeele LE. Leukoplakia: a clinicopathological review. Oral Oncology. 1997;33(5):291301.

15. Meiss F, Boerner D, Marsch WCH, Fischer M. Gabapentin- a promising treatment in glossodynia. Clin and Exp Derm. 2002;27:523-529. 16. Frishman WH, Brosnan BD, Grossman M, Dasgupta D, Sun DK. Adverse dermatologic effects of cardiovascular drug therapy: part II. Cardiology in Review. 2002;10(5):285-300.

17. Jafari-Fesharaki M, Scheinman MM. Adverse effects of amiodarone. PACE. 1998; 21(Part 1):108-120. 18. Jainkittivong A, Langlais RP. Geographic tongue: clinical characteristics of 188 cases. J Contemp Dent Pract. 2005;6(1):123-135.

19. Reamy BV, Derby R, Bunt CW. Common tongue conditions in primary care. American Family Physician. 2010; 81(5):627-634.

20. Assimakopoulos MD, Patrikakos MD, Fotika C, Elisaf M. Benign migratory glossitis or geographic tongue: an enigmatic oral lesion. Am J Med. 2002;113:751-755. 21. Zakrewska JM, Forsell H, Glenny AM. Interventions for the treatment of burning mouth syndrome (Review). Cochrane Database of Systemic Reviews. 2005;1.

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• PRESIDENT’S PAGE •

TIM J. ALFORD, MD 2010-11 MSMA PRESIDENT

Children Cannot Vote Shouldn't We Advocate for Them?

recently had the privilege of attending to a newborn ICU graduate at his initial well-baby visit. He had completed a long siege in the intensive care setting, and I was heartened by the wonderful job that his attentive young mother was doing in caring for him. I vividly recalled that his mother was the result of an unplanned teenage pregnancy, born prematurely as well. I remember the difficult conversations with this infant’s grandmother nearly two decades ago as we navigated through a sea of emotions and despair over the untimely pregnancy. The grandmother arrived at her own decision, and nothing more was ever said about it, although much was understood. Now this new grandmother proudly accompanied her grandchild to my office. This is an exceptionally happy ending to a far too common story of premature birth in Mississippi. Sadly, 10.5 out of 1,000 births end tragically.1

In the early 1900s the United States infant mortality rate was approximately 100 infant deaths per 1000. Historical social change includes the advent of an agricultural economy and improved water sanitation. More recently, regionalization of newborn care, WIC, and surfactant have contributed to lower the national infant mortality rate to 6.8 per 1000. Despite this single digit figure, according to the World Bank, the US has the highest infant mortality rate among thirty-three other advanced countries. Mississippi continues to occupy the bottom-dwelling position among other states as was reported on our Public Health Care Report Card in January, 2011.

No obstetrical, pre-natal assessment or intervention has been successful in predicting and preventing low birth weight delivery (LBW). The single best predictor of a LBW delivery is history of a previous pre-term or LBW delivery.2 We have known this for some time but have not acted on this leading cause of infant mortality. Dr. Alfred Brann, formerly of the University of Mississippi Medical Center (UMC), and his team at Grady Memorial Hospital in Atlanta were the first to gain the high ground and launch a surveillance program known as the Interpregnancy Care Program (IPC) to identify mothers of LBW 3 babies followed by education of that mother with the achievable goal of preventing further short integral pregnancy. This work is being replicated in other states including Mississippi and shows promise through the two year national decline in premature births. The beauty of this program is that a history costs nothing, the education costs are minimal, and the pay-off is huge. One wonders why we have been so slow to seize upon the obvious, but it often takes good ideas in medicine at least ten years to matriculate through our system. Over the course of this five-year (February 2009 -2014) interventional study, the cost of providing interpregnancy care to this population will be compared to the general costs incurred by the control group that did not receive interpregnancy care. Not all medical improvements require advanced technology; some just require simple new approaches to age-old problems. According to the Institute of Medicine, the costs related to premature birth run this country in excess of $26 billion per year.4 One would think this staggering amount would gain the attention of the budget committees in Congress. Sadly, this is not the case. The public health community has to make a very strong argument for its policies to be looked upon with favor by lawmakers for funding, especially during a recession such as we now face in the United States. At the time of this writing, the portion of Title X funding that would be used towards prevention of premature births has been de-funded. Short-term cuts are meant to project fiscal responsibility, but health care is not a temporary issue. Such cuts can have costly consequences. Instead, prevention is a proven investment that requires continuous re-education of both our patient population and our lawmakers.

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While in its early stages, the IPC, a combined initiative of UMC and the Mississippi State Department of Health, now has 120 enrollees including mothers with histories of recently born LBW babies. This program utilizes available community resources to educate mothers. The goal is preventing pregnancy within eighteen months. There is great emphasis on primary care and education with proven favorable outcomes. This approach works. The Mississippi Medicaid Accounting Office has followed the first ten enrollees of these 120 mothers of preemies managed by the Interpregnancy Care Program. According to Dr. Glenn Graves, neonatologist at UMC, Medicaid has determined that each of the first ten very premature, LBW enrollees cost the state nearly $1 million each! One may now begin to appreciate the return on investment of sound prevention strategies. The MSMA leadership recently attended a Leadership Conference in Washington that included visits to each of our Congressional offices. The issue of the day on February 18, 2011, was how the new freshman Congressional class would exert its influence upon the current federal debt. To their credit, all of Mississippi’s Congressional delegation engaged us on the issues with the exception of one. Senator Roger Wicker, with a glint in his eye, spoke of the “bloodbath” that was inevitable as the House budget assumed a leaner form. I could only hope that his crude reference to this image of the worst of the Holy Roman Empire had more to do with the political ramifications of a new budget than with the adverse effects to mother and child. I found it very unsettling as he showed little patience or tolerance for our physician perspectives, even when genuine arguments were made for adding efficiencies to vital programs affecting mothers and children. As it currently stands, there will be $210 million in cuts to the Maternal and Child Health block grants that support preventive care programs and services for children with special needs, such as LBW babies. This is money that comes from the federal government and can be used in a discretionary way by our State Health Department to provide vital services for children, including such basics as fluoride in water and also as bold as the Interpregnancy Care Program. A cut of $758 million from the special supplemental nutritional program for women (WIC) is proposed as well. WIC is known to hold the line on infant mortality, and yet it faces extreme cuts. Mitch Daniels, Republican Governor of Indiana, presents a reasonable approach to this budget discussion including recognizing the importance of maintaining essential child health services. In these difficult budgetary times, Governor Daniels was willing to compromise on behalf of children.

I recall standing at the isolette in the NICU two decades ago as a resident and hearing the attending neonatologist lament the enormous cost of intensive care and the seeming futility of the sick infant who lay before us. He summarized this discussion by saying, “Well, I guess this is a better investment than an MX missile.” Obviously the attending was making the point that we should advocate for children unapologetically and unashamedly. History records that improvements in infant mortality rate, the most telling of health indicators, have been made only through public support of such improvements as basic as safe food and water. Education, which is the essence of the Interpregnancy Care Program, is the new battleground. Children cannot vote. Shouldn’t we vote for them and be their advocate?

Programs at Risk: • Title X - $317 million (zeroed out) • WIC - $750 million (6% cut) • Community Health Centers - $1.3 Billion • Maternal and Child Health Block Grants - $210 million • Poison Control - $27 million • CDC’s program for prevention of prematurity - $755 million • National Institutes of Health funding research to prevent pre-term birth - $1 billion References: 1. 2. 3, 4.

116

Mississippi Infant Mortality Report 2008. The Contribution of Preterm Birth to Infant Mortality in the United States, Pediatrics. 118(4). Healthy Start Association website. What Works: Interconceptional and Preconception Care, Workshop presentation by Anne Lang Dunlop. Available at: http://www.healthystartassoc.org/Dunlop_Preconception.pdf. Accessed March 11, 2011. Preterm Birth: Causes, Consequences and Prevention in 2006, Institute of Medicine, July 13, 2006.

JOURNAL MSMA APRIL 2011

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• EDITORIALS •

After All Is Said and Done…

“L

D. Stanley Hartness, Associate Editor

isten up! I ain’t sayin’ this but once. Look under them covers real careful ‘fore you crawl in. They’s been a ‘infestation’—and I ain’t talkin’ bedbugs! Them legislators has been in secession, and they’s no tellin’ who’ll turn up between them sheets. I even heared them family doctors up and roasted ole Steve Holland. Don’t know if he was on a spit or just spit on…” By the time you read this, our Mississippi Senate and House will have haggled, harangued, hemmed, hawed, and finally headed for the hills. Hopefully each of you did due diligence with phone calls, emails, faxes, personal visits to the Capitol, and Doctor-of-the-Day duty in an effort to achieve pro-physician, patient-friendly legislation.

MY Doctor-of -the-Day stint provided an unexpected personal shot-in-the-arm. As is the custom, at the end of my shift, our capable, personable Capitol nurse, Evelyn Johnson, marched me over to the two chambers for introduction. After being welcomed graciously by Rep. Mary Ann Stevens and acknowledged ceremoniously by Speaker McCoy, I became aware of an attractive older woman with strawberry blonde hair in business attire making her way toward me down the aisle from the Speaker’s desk. “Hello. I’m Frances…” It turns out that she was McCoy’s assistant. I didn’t need to hear her last name. I instinctively knew that this was the same Frances who’d been my late older sister’s Millsaps roommate and maid-of-honor in her wedding even though we had not seen one another in almost 60 years! Thankfully the tear hung on the rim of my lower lid. I know I’m not alone when I tell you about two experiences that really pushed my button on the nurse practitioner and chiropractor issues. Now don’t get me wrong—some of my dearest friends are FNP’s and I’ve had the privilege of working with the best through the years. I opened the door of the exam room to find my patient, a registered pharmacist, shivering in the fetal position on the exam table as her concerned husband sat dutifully by. Three days earlier she had been seen by a nurse practitioner with typical flu symptoms. With negative flu swab results in hand, the FNP proceeded to administer an injection of Rocephin— PLUS prescriptions for ciprofloxin AND azithromycin. “Senator/Representative, your opposition to the bill which would allow independent practice for nurse practitioners would be greatly appreciated.” The 24-year-old male patient sat anxiously in the exam room clutching an x-ray jacket. His story was that he’d seen a chiropractor after a many month history of right lower thoracic back pain only to be told that x-rays showed at some point he’d obviously broken his back (news to him) and that his spine looked like that of a 40-year-old man (whatever that meant). A quick review of his technically poor films followed by a new set shot in my clinic allowed me to reassure him that the D.C. had misspoken and that he would not require the eternal adjustment plan. Hardly four weeks had passed when a 40-year-old male patient presented with a similar story. He had seen a chiropractor complaining of neck and shoulder discomfort. Would you believe his x-rays showed he had broken his neck in the past (say what?) and the bones had healed with terrible arthritis (no wonder he was hurting)? Repeat cervical spine films showed at best only mild straightening of the normally expected curve, snatching yet another unsuspecting victim from the jaws of months of manipulation. “Senator/Representative, your support of HB 263 which merely extends current practice for chiropractors is requested. Amendments to add the language ‘diagnosis’ of ‘whole body’ would be unwise and dangerous for our patients.”

If you didn’t bother to (or worse yet, feel the need to) communicate with legislators about issues which will impact the future of our profession and, more importantly, the quality of healthcare available to our patients, rest assured that every mid-level provider, their professional organizations, and their lobbyists did! With 2012 election campaigns looming on the horizon, you’ll have yet another opportunity to make your voice heard—but this time you’ll also be asked to put your money where your mouth is. ❒

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• EDITORIAL •

Appropriate Prophylactic Aspirin Use for Mississippi Physicians

Ryan A. Yates, M4, University of Mississippi School of Medicine

s a medical student at the University of Mississippi School of Medicine (UMC), I have spent much of the past few years either on the wards or in various clinics in and around Jackson. For part of this time, I also rotated at a primary care clinic in Magnolia, MS. Throughout my experience, I have seen multitudes of patients, a large number of which have been on aspirin. I rarely questioned this drug as I perused through hundreds of medication lists. After all, what harm could a small, OTC drug as simple as aspirin do? It turns out that it can do a fair amount of harm, however, as I found out after caring for someone on the ward with a major GI bleed. Thankfully, the patient didn’t die from the GI bleed, but it prompted me to look further into aspirin and its appropriate prophylactic use for cardiovascular disease (CVD), as the guidelines have recently changed. Aspirin has been around since the late 19th century when German chemist Felix Hoffmann first synthesized a stable form of the product which he used to help treat his father’s arthritis. As such, it was used for years to help treat pain and inflammation. As the 20th century progressed, it became evident that aspirin had important prophylactic uses as well, especially for CVD. Dr. Lawrence Craven, a California general practitioner, first noticed in 1948 that the men he prescribed aspirin to did not seem to have any heart attacks.1 Since that time, it has been well established that aspirin reduces CVD morbidity and mortality in patients who have suffered a previous myocardial infarction (MI) or stroke.2 This is important, of course, because CVD is the leading cause of death in the United States. In addition, several studies also suggested that aspirin may be beneficial as primary prevention of CVD events, meaning it is beneficial in people with no history of a CVD event. This led to guidelines in 2002 from the U.S. Preventive Services Task Force (USPSTF) recommending that doctors consider aspirin use in patients with increased cardiovascular risk factors.3 However, as new data has emerged, this claim has become more controversial, and it has led to numerous revisions in the guidelines surrounding aspirin’s prophylactic use for CVD both by the USPSTF and other governing bodies. According to new guidelines in 2009 from the USPSTF, physicians should consider low-dose (~75 mg/d) aspirin for men age 45 to 79 who are at risk for MI and women age 55-79 who are at risk for stroke whenever the potential CVD benefit outweighs the risk of GI hemorrhage.4 These guidelines reflect new evidence suggesting that aspirin may have differential benefits and harms in men and women. Men seem to derive more benefit in the reduction of MIs, and women derive more benefit in the reduction of ischemic stroke.5,6 The task force also recommends against the use of aspirin for stroke prevention in women under 55 and for MI in men under 45. For men and women 80 years of age and older, the USPSTF says that there is insufficient evidence to assess the benefits and harms of aspirin use, so they make no recommendation.4 Following these new guidelines requires us as physicians to assess accurately whether or not the potential CVD benefit from taking aspirin outweighs the risk of GI bleeding or hemorrhagic stroke. This differs slightly for men and women. For men, the net benefit of aspirin depends on the initial risk of coronary heart disease (CHD) events and the risk of GI bleeding, and this varies by age. A tool based on evidence from the Framingham Heart Study can be used to estimate the 10-year risk of a CHD event (http://www.mcw.edu/calculators/CoronaryHeartDiseaseRisk.htm).7 For women, the net benefit of aspirin depends on the initial risk of stroke and GI bleeding, which also varies by age. Another tool also based on the Framingham data can be used to calculate the 10-year risk of stroke (www.westernstroke.org/PersonalStrokeRisk1.xls).8 If the estimated 10-year risk of a CHD event for men or a stroke for women is greater than that specified in the table below (Table 1), then the benefit of taking aspirin outweighs the risk of a major GI bleed or hemorrhagic stroke, and aspirin should be recommended according to the USPSTF. While this seems fairly straightforward, it is very important to realize that the numbers in the table below only apply to adults with no risk factors for GI bleeding other than age and sex. Other risk factors for GI bleeding include NSAID use, GI ulcers, and upper GI pain. If any of these are present, then further counseling would be necessary, as the risk of GI bleeding in these patients is further increased with aspirin use.

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Table 1. 10-year CHD risk levels at which the number of cardiovascular disease events prevented is closely balanced to the number of serious bleeding events. CHD = coronary heart disease

Source: Ann Intern Med. 2009;150:396-404.

The guidelines put in place by the USPSTF do not make clear recommendations based on the presence or absence of diabetes, an ever-growing population especially in the state of Mississippi. Experts agree that the effect of aspirin for primary prevention of CVD events in adults with diabetes is presently not clear, and more research is needed to better understand the specific effects of aspirin in diabetes. Trials have yielded mixed results but suggest overall that there may be a modest reduction in 9 the risk of cardiovascular events in diabetics taking aspirin. Guidelines put in place in 2007 by the American Heart Association (AHA) and the American Diabetes Association (ADA) were revised in 2010 to reflect two recent randomized controlled trials of 10,11 aspirin performed specifically in patients with diabetes. As of now, the American College of Cardiology Foundation (ACCF), AHA, and the ADA jointly recommend low-dose (75-162 mg/d) aspirin for adults with diabetes and no history of vascular disease who are at increased CVD risk (10-year risk greater than 10%) and who are not at increased risk for bleeding. This includes most diabetic men over the age of 50 and diabetic women over the age of 60 who have one or more of the following additional major risk factors: smoking, hypertension, dyslipidemia, family history of premature CVD, or albuminuria. Aspirin use is no longer recommended for diabetics at low CVD risk (10-year risk less than 5%), which includes men under 50 and women under 60 with no major additional CVD risk factors. Clinical judgment is required for those people who fall into the intermediate risk (10-year risk between 5 and 10%), which includes younger patients with one or more risk factors and older patients with no risk factors, but 9 further research is needed to make a more definitive recommendation for these patients. The recommendations put forth by the ADA, AHA, and ACCF also require accurate assessment of cardiovascular risk. One of the tools they recommend for assessing the risk of CVD in diabetics is the UKPDS Risk Engine, which can be found at http://www.dtu.ox.ac.uk/riskengine/index.php. If you’re left at this point with more questions than answers, you probably aren’t alone. Ultimately, the decision about whether to take aspirin is a complex one in patients both with and without diabetes. The guidelines currently available are not very clear cut, and several people fall outside the specific realms of the guidelines. In addition, the optimum dose of aspirin needed for CVD prevention is unknown, although it appears as if 75 mg/d is as effective as higher doses and poses slightly less risk of GI bleeding. Also, consider that there are other effective methods for CVD reduction, including lipid control with statins, good blood pressure control, and smoking cessation. These all lower the absolute risk of CVD events and should be considered when deciding about aspirin use. What is clear is that further research is needed, which is somewhat ironic considering how long aspirin has been around. As with all things in medicine, there is usually no clear answer that applies to everyone, and guidelines are just that guidelines. Ultimately, the decision to use aspirin for cardiovascular prophylaxis should be an individual one after considering the risks and benefits with a physician. As an aside, new research from England seems to suggest that daily aspirin (at least 75 mg/d) for at least five years may lower cancer mortality from specific cancers, namely lung, colon, and esophageal cancers.12 A previous study had found that daily aspirin (75 mg/d) taken for several years can lower the long term incidence and mortality of colon cancer, benefits that seemed to increase depending on the duration of treatment.13 Importantly, the new study did not report on the side effects of aspirin. Both the USPSTF and the American Cancer Society currently do not endorse using aspirin for any type of cancer prophylaxis, but it will be interesting to see if this changes in the years to come as more research is done. REFERENCES 1.

The history of aspirin. http://www.wonderdrug.com/pain/asp_history.htm. Accessed January 26, 2011.

U.S. Preventive Services Task Force. Aspirin for the primary prevention of cardiovascular events: recommendation and rationale. Ann Intern Med. 2002;136:157-160.

4. 5.

Antithrombotic Trialists’ (ATT) Collaboration, Baigent C, Blackwell L, et al. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet. 2009;373:1849-1860.

U.S. Preventive Services Task Force. Aspirin for the prevention of cardiovascular disease: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2009;150:396-404. Berger JS, Roncaglioni MC, Avanzini F, et al. Aspirin for the primary prevention of cardiovascular events in women and men: a sex-specific meta-analysis of randomized controlled trials. JAMA. 2006;295:306-313.

continued on page 122

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• EDITORIAL •

continued from page 121 6. 7.

Ridker PM, Cook NR, Lee IM, et al. A randomized trial of low-dose aspirin in the primary prevention of cardiovascular disease in women. N Engl J Med. 2005;352:1293-1304.

Wilson PW, D’Agostino RB, Levy D, et al. Prediction of coronary heart disease using risk factor categories. Circulation. 1998;97:1837-1847.

Wolf PA, D’Agostino RB, Belanger AJ, et al. Probability of stroke: a risk profile from the Framingham Study. Stroke. 1991;22:312-318.

Pignone M, Alberts MJ, Colwell JA, et al. Aspirin for primary prevention of cardiovascular events in people with diabetes: a position statement of the American Diabetes Association, a scientific statement of the American Heart Association, and an expert consensus document of the American College of Cardiology Foundation. Circulation. 2010;121:2694-2701.

10. Ogawa H, Nakayama M, Morimoto T, et al. Low-dose aspirin for primary prevention of atherosclerotic events in patients with type 2 diabetes: a randomized controlled trial. JAMA. 2008;300:2134-2141. 11. Belch J, MacCuish A, Campbell I, et al. The prevention of progression of arterial disease and diabetes (POPADAD) trial: factorial randomised placebo controlled trial of aspirin and antioxidants in patients with diabetes and asymptomatic peripheral arterial disease. BMJ. 2008;337:a1840.

12. Rothwell PM, Fowkes FG, Belch JF, et al. Effect of daily aspirin on long-term risk of death due to cancer: analysis of individual patient data from randomised trials. Lancet. 2011;377:31-41.

13. Rothwell PM, Wilson M, Elwin CE, et al. Long-term effect of aspirin on colorectal cancer incidence and mortality: 20-year follow-up of five randomised trials. Lancet. 2010;376:1741-1750.

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• LETTERS •

Mississippi's Complex Obesity Epidemic

ear JMSMA Editor,

I read with interest Dr. Richard deShazo’s recent editorial piece [deShazo RD. Missisippi: How did we get to this place? J Miss State Med Assoc. 2011;52(2):54-57] on the tragic state of health in our state. No one disagrees with his delineation of the spectrum of issues, and he correctly suggests that the obesity problem is a major issue for concern by the medical community. Unfortunately, as he details the many problems, he looks to organized medicine, state medical societies and the state and federal government for management. Regrettably, personal responsibility is omitted, and for most of us, this is the core issue. It is parents’ responsibility to raise and feed their children, not state or federal government (i.e. “money”). It is a woman’s responsibility, not her “right,” to have a child. “Parenting” has been abdicated; the appalling rate of single mother births in the state is a disgrace. It should not be the state’s “responsibility” to subsidize irresponsible behavior. So yes, it should be the concern (and “responsibility”) of all physicians and citizens to “help.” But we can only apply “dressings” to the “problems.” Each and every problem described in the “mixture” that, as stated, could “unravel” us, are problems rooted in personal choices of each and every one of us (initiative, academic pursuit, exercise, food, etc.). The “problems” will only stop when individual people take personal responsibility. Richard C. Boronow, MD Clinical Professor Emeritus University of Mississippi Medical Center

P.S. The recent several-day symposium on obesity was viewed by most, other than the organizers and the speakers, as a sham. If a “symposium” was needed, it could well have been covered in one day. Half the time could have been spent on the American diet, fast foods, processed foods, hidden sugar and the abundant medical literature on the nutrition/health link. The other half could have focused on physical activity, exercise and, similarly, the abundant medical literature on the exercise/health link. A brief concluding panel could have enunciated a series of goals and “how to” achieve them.

n response:

I appreciate Dr. Boronow’s thoughtful response to my editorial, an editorial which asked for responses. I also understand and respect his point of view. I do believe in personal responsibility. However, if you are born poor, have parents who are undereducated, have poor health literacy and little access to healthy food, knowing what “responsible” is and how to be “responsible” is a real challenge. Someone, somewhere, has to teach you that. I think we physicians, the majority of whom have been educated in state institutions at the expense of the public and enjoy the privileges of our profession, have a responsibility of our own: to make every effort to provide the information and encouragement for our people to make healthy choices. We, and I include myself, have been so engaged in treating disease; we have not invested enough time to prevent it. I am trying to do better and I hope we all can work together to make the lives of those we serve better. I bet Dr. Boronow will agree with me on that. If we don’t support the Legislature’s attempt to help us do that with the Healthy School’s legislation, who will? Rick

Richard D. deShazo, MD Associate Editor, Journal MSMA Jackson

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â&#x20AC;˘ LETTERS â&#x20AC;˘

ear JMSMA Editor,

McEachin's Poem Pops

It was a delight to read Dr. McEachinâ&#x20AC;&#x2122;s insightful note of prelude and his poem [â&#x20AC;&#x153;Pediatric Pearl: Quick Fixâ&#x20AC;? J Miss State Med Assoc. 2011;52(3):98]. As a practicing pediatric orthopaedist for a bit shorter time than Dr. McEachinâ&#x20AC;&#x2122;s active pediatric practice, my experience has been similar. The commonly seen annular ligament displacement in young children often is not diagnosed or treated in an efficient manner. â&#x20AC;&#x153;Nursemaidâ&#x20AC;&#x2122;s Elbowâ&#x20AC;? is most frequently seen in children age two to three years. It most commonly occurs when the childâ&#x20AC;&#x2122;s arm is pulled and pronated but may also happen from a fall with a twisting injury. Rather than being an elbow dislocation, it is a partial soft tissue interposition of the annular ligament between the radial head and capitellum. Typically, the child holds the elbow partially flexed, has pain with rotation and may point to the wrist as the site of pain. Local tenderness over the radial head, absence of swelling and a history that â&#x20AC;&#x153;fits,â&#x20AC;? can make the diagnosis without the need for imaging. Gently, but firmly rotating the elbow into full supination usually elicits an audible â&#x20AC;&#x153;popâ&#x20AC;? as the ligament slips from over the radial head back to where it belongs around the radial neck. My preference is to manipulate with the elbow flexed just above 90 degrees. If full supination doesnâ&#x20AC;&#x2122;t do the trick, then full pronation might be the ticket. Complete relief of symptoms and full use of the elbow is expected â&#x20AC;&#x201C; after a couple of minutes of unhappiness. Thanks to Dr. McEachin for poetically emphasizing the diagnosis and treatment of this painful injury in children and a cause of anxiety for parents. High charges for imaging and treatment are indeed of concern. John M. Purvis, MD Associate Professor Pediatric Orthopaedics Department of Orthopaedics and Rehabilitation University of Mississippi Medical Center

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• POETRY AND MEDICINE •

[This month, we print a poem by John D. McEachin, MD, a Meridian pediatrician. This poem, written recently, offers up another reflection from his many years of pediatric practice. Dr. McEachin tells me that this poem is “a true story from 1973.” He continues, “How many times have we lost concentration during a physical or during the history and ‘fade out,’ hopefully for seconds only, as we ponder the wisdom of diagnostic or therapeutic decisions made in the room of the previous patient!!” My friend, Dr. Dick Field of Centreville, tells a similar story of the great Rudolph Matas (1860-1957) of Tulane who also fell asleep in the middle of roundswhile leaning over a patient auscultating heart sounds. And then too, all the residents were amazed at his concentration and then heard him let loose a loud snore. The prolific Dr. McEachin holds a special place at the Journal as our unofficial poet laureate. For more of Dr. McEachin’s poetry, see past JMSMAs and look for more in coming months. Any physician is invited to submit poems for publication, attention: Dr. Lampton c/o the JMSMA or email me at lukelampton@cableone.net.]—ED.

How to Check a Chest A mother stopped by my office, To offer a really kind word. “The new partner just checked my son; You have a jewel, be assured. He’s so nice, so considerate— Never seemed to be in a rush; And with all the questions I ask, He never once asked me to hush! And when he checked Bob’s little chest— The most thorough exam ever — He listened, listened, and listened, Then used his bare ear—oh, so clever!” I was pleased to hear such good news— New Doc with a heart for the art. So I paid Bill a visit: “Thanks, You are off to such a fine start!” Well, once sharing that mom’s story, Bill laughed ‘til his head hit his lap. “You know I was up all last night; That chest!! I was taking a nap!!” —John D. McEachin, MD Meridian

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• UMC SCHOOL OF MEDICINE •

Student Services Update

he responsibility and rigor of a modern medical education are well documented. It’s stressful and demanding to say the least. A huge burden for gathering and retaining information leaves minimal opportunity for relaxation and recreation, much less the routines of everyday life. The typical medical student is subjected to lots of stress factors: the pressure of academics with an obligation of success, an ever-increasing debt load, the uncertainty of the future, difficulties imagined with assimilating into a strange new system. These students face social, emotional, physical and family problems too, all of which may affect their learning ability and academic performance. Left unchecked, these stressors can cause impaired judgment, reduced concentration, loss of self-esteem, increased anxiety and depression.

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Student Affairs at the University of Mississippi School of Medicine is intent on fostering an environment that promotes academic success as well as student development. Our team of professionals delivers a wide variety of services and activities that influence all medical students. Operating essentially as a conduit between the student, faculty and administration, we work closely with the student to help him/her meet challenges head-on with resources or services that include advisement, enrollment management, orientation, advocacy, health care, academic counseling, tutoring, financial aid, safety, recreational activities, community service and leadership opportunities. Working in a coordinated effort, the student affairs team is engaged in nurturing a campus culture that’s student-centered and of the highest quality. A number of projects are underway at this writing that will improve our ability to support students. Implementation of an integrated and comprehensive student data system is ongoing. Whether it’s inputting grades, revising student data, or managing a financial aid package, this tool provides significant efficiencies for the student, faculty and administrator. Classrooms 3A through 7A look largely as they did in 1955. We’ve begun a renovation project to modernize many of these rooms with completion expected by January of 2012. The addition of modern teaching spaces will bolster our faculty’s ability to pursue team based learning opportunities

and new instructional technologies. We just completed the remodel of a small medical student lounge. This space gives medical students room to study, shower, relax or even heat up last night’s lasagna between classes or post call. The Rowland Medical Library is in the midst of a much-needed refurbishment. A recent overhaul of our Student Assistance Program gives our students 24 hour access to free, confidential professional counseling services and referrals. Our alumni and community partners have provided such wonderful support over the years, enabling us to sustain outstanding programs that contribute to a rich medical school experience for Mississippi’s future physicians. When we benchmark our student services against other

institutions across the southeast, many standout, including student health care, student recreational activities, campus safety, peer tutoring programs, and student fitness facilities. The Student Affairs team is very optimistic as we look to the future of medical training in Mississippi. University of Mississippi School of Medicine students are achieving at record levels in terms of board exams, licensure exams and residency placement. We are proud and thankful for the opportunity to participate in making Mississippi’s health care landscape brighter.

— Jerry Clark, PhD, MBA; Chief Student Affairs Officer, Associate Dean for Student Affairs, School of Medicine

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• SPECIAL • ARTICLE • DELTA • HEALTH ALLIANCE

MSMA Leads Physician Participation

in Delta Health Alliance Grant Program

Toy Strickland, MBA; MSMA Project Director

ll eyes are on Delta Health Alliance (DHA) as one of only 17 locations across the country to receive a $14.7 Million grant from the Office of the National Coordinator for Health Information Technology to improve chronic illness, especially diabetes care, for residents of the 18-county Mississippi Delta. This goal will be achieved by implementing (1) Electronic Health Records (EHR), (2) connectivity to a major new Health Information Exchange (HIE) to bring a patient’s total health information together to support better health care decisions and more coordinated care, (3) pharmacy intervention to assure that patients are taking their medications correctly, and (4) care management through more frequent contact with patients.

What Does the BLUES Beacon Community Project Mean for the Delta Physicians?

The Mississippi Delta struggles with a particularly high rate of diabetes — approximately 13% of residents, compared with a national average of 7%. This region has a low number of health care providers and health care facilities with resultant low access to health care, reflected by the very poor health statistics in the Mississippi Delta. To combat this, the DHA BLUES Beacon Community is dedicated to advancing delivery of care for residents of the Mississippi Delta who will ultimately benefit from a healthcare delivery system that is more cost efficient and easier to navigate. The BLUES (Better Living Utilizing Electronic Systems) Beacon Community will focus on improving the health of people living with diabetes, but the overall goal is to improve the health of all people living in the Delta, using proven practice and information technology. We aim to make it easier for residents of the Delta to access care.

Goal of the Program

The goal of the BLUES Beacon Community is to improve access to care for diabetic patients to create a community dedicated to improving health in the Delta. The community will do this by the meaningful use of electronic

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health records (EHRs) and health information exchange by primary care providers in the Mississippi Delta. The program also seeks to increase the efficiency of health care in the area by reducing excess health care costs for patients with diabetes through the use of EHR-related interventions that will: • Encourage the use of best practices for the management of diabetes and related conditions,

• Reduce preventable hospital stays due to diabetes, • Provide more accurate billing information.

The BLUES Beacon Community will provide support for the use of best practices in clinical care as well as in the implementation of EHRs in the Mississippi Delta. The program will also help to build the infrastructure for health information exchange that will connect these providers with each other and with local hospitals and will allow them to work more effectively and cooperatively to improve the disease management of their patients. The implementation of EHR’s and HIE provides an opportunity to redesign processes within practices and throughout the health care system in the area in order to:

• Promote best practices in chronic disease management and care coordination, • Improve monitoring systems for diabetes control, • Enhance patient education efforts so that patients have the information they need to manage their conditions, • Set up providers to achieve meaningful use of EHRs, • Ensure that health information can flow reliably and securely among authorized parties, and

• Improve effectiveness and efficiencies in the practice setting, including better patient outcomes.

The BLUES Beacon Community will also address significant barriers to the implementation of EHR and telemedicine initiatives in the area, including the lack of high speed telecommunication lines, physician and staff acceptance to change, and the lack of fully implemented Practice Management systems in the provider’s office.

Improvements for Patients and the Community

Widespread use of EHRs and HIE means that medical history will be available when a patient seeks care from another provider. By looking at that history, the provider will see what other professionals have prescribed and the history of that patient’s lab results. This will help facilitate faster, more accurate and more efficient diagnosis and care. Providers will improve their current care by having additional staff to help patients navigate the healthcare system. They will also have new electronic tools called “Care Guides” that provide evidence based clinical decisions support. It is in this way that providers can recommend the best, most up-todate treatment for a patient’s care. Health information technology can also allow patients to become more active in their own care. For example, when patients can see the tracked results of laboratory results via their own personal health record, they see the connection between their daily habits and medication adherence and their health outcomes. Through a program with the University of Mississippi School of Pharmacy, patients will receive monthly telephone calls to see if they have questions about their medications or how to take them. It is hoped that this program will help reduce the negative impact—including hospital admissions — of mis-used or un-used prescription medications. In addition, EHRs will help providers be more responsive to patients who call the practice with questions or concerns. Telephone messages will now become electronic documents that are linked to the chart, eliminating lost messages and facilitating more complete and accurate provider responses since the patient’s health information will be available at the time of call back.

A Team Approach

Through a grant from the Delta Health Alliance (DHA), MSMA can help physicians 1) take advantage of electronic health record technology, 2) connect those EHR systems to other hospitals and clinics in the Delta and 3) meet meaningful use criteria and qualify for financial incentives while improving patients’ outcomes. This is an opportunity for Delta physicians to get free or very low cost connection to the area HIE. The challenges to improving health care and implementing health information technology in the Mississippi Delta are similar to those faced by other areas of the country – only larger and more urgent. The success of the BLUES Beacon Community program will help identify best practices and effective strategies and, in turn, help other communities, especially rural communities with small healthcare provider facilities, improve outcomes through EHR’s and HIE. For more information about benefits to your Delta practice through MSMA’s partnership with the BLUES Beacon Community Grant Program, contact Toy Strickland, MBA, MSMA Project Director, at 601-853-6733, Ext. 302, email: TStrickland@MSMAonline.com. ❒

ONLINE JOB BANK Free position listings for MSMA members and for group clinics which employ at least 70% MSMA-member physicians. • List a position by visiting MSMAonlinejobs.com. • For more information, contact Anna Morris: AMorris@MSMAonline.com, 601-853-6733, Ext. 324 My solo practice listed a free position on the MSMA online job bank, and within only a couple of weeks we received several inquiries from qualified candidates and were able to fill the position quickly and easily. I highly recommend the job bank! —Tom Joiner, MD

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• PERSONALS •

Adams

McKissic Bush

Cannon

Thomas F. Adams, MD has joined the staff of Delta Regional Medical Center. Dr. Adams has spent the majority of his career in private practice. He practiced in Columbus from 19861995 and then in West Point and Aberdeen from 1999 to 2010 specializing in internal medicine and pediatrics. While in private practice, he also held positions at several healthcare facilities including Bolivar County Medical Center and North Mississippi Medical Center as an E.R. physician. Dr. Adams obtained his medical degree in 1982 from Howard University College of Medicine where he also did his internship and residency in internal medicine/pediatrics. He is board certified in pediatrics with certifications in advanced trauma life support, pediatric advanced trauma life support, advanced cardiac life support and neonatal resuscitation.

Freda McKissic Bush, MD, FACOG, is nearing completion of her term as chair of the Federation of State Medical Boards’ (FSMB) Board of Directors. The former president of the Mississippi State Board of Medical Examiners and a longtime leader in women’s health issues was elected during the organization’s 98th Annual Meeting in April 2010 in Chicago, Illinois. As the FSMB’s chief elected official, Dr. Bush presides over meetings of the board of directors, provides leadership in governing the organization and represents the FSMB to the leadership of other organizations. Dr. Bush has served on the FSMB Board of Directors since 2003 and as treasurer from 2008-2009 before being elected chair-elect of the organization. She has served as a member of the Step 3 Committee of the United States Medical Licensing Examination, the three-step examination for medical licensure in the United States that is co-sponsored by the FSMB and the National Board of Medical Examiners. Dr. Bush served on the Mississippi State Board of Medical Licensure from 1994-2006, including a term as president from 20002002. Dr. Bush has been deeply involved in women’s health issues for more than four decades. In 1968, she was a clinical instructor in Maternity Nursing at the University of Arkansas, Little Rock, graduating from Columbia University in New York as a certified nurse midwife in 1970 and working at Harlem Hospital. In 1974, Dr. Bush became the director of Nurse Midwifery Programs at the University of Mississippi, responsible for the education of nurse-midwives and for their placement for service in the southeastern United States. In 1983, Dr. Bush received her medical degree from the University of Mississippi Medical

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School, and in 1987 she completed a residency in obstetrics and gynecology at the University of Tennessee Medical Center, Memphis. A board-certified Ob-Gyn, Dr. Bush is a partner with East Lakeland Associates in Jackson. Dr. Bush spends much of her time speaking on sexuality education, sexually transmitted diseases and social behavior education. She has served on the Presidential Advisory Council on HIV/AIDS, the Centers for Disease Control and Prevention/HRSA Advisory Committee on HIV and STD Prevention, the Medical Institute of Sexual Health, and the Out of Wedlock Pregnancy Task Force for the Mississippi Legislature.

C. Ron Cannon, MD, performed the first radical robotic tonsillectomy in the state of Mississippi at River Oaks Hospital using the da Vinci Surgical System. Radical tonsillectomy using transoral robotic surgery (TORS) is a new technique that offers excellent access for resection of carcinomas of the tonsils. The procedure is performed using the da Vinci Surgical System providing a full-range of motion that resembles human hands with pinpoint accuracy. The surgeon sits at a console several feet away from the patient and uses hand controls as well as foot controls to operate the robotic arms. The robot has four arms, one of which controls a camera. Surgeons have their hands on two controls and their foot on a clutch, which allows it to readjust the robotic hands in the patient. The clutch also allows the surgeon to move from controlling one arm to the other. Another foot pedal focuses the camera. The da Vinci System enables surgeons to perform even the most complex and delicate procedures such as a radical tonsilectomy through very small incisions with unmatched precision. Potential patient benefits include avoidance of disfiguring mandibulotomy, avoidance of tracheostomy, quicker return to normal speech and swallowing (as compared to open surgical techniques), less pain, less blood loss, shorter hospital stay, shorter recovery time, and minimal scarring. Various robotic surgical procedures such as a robotic-assisted thyroidectomy have been performed in recent years, and most reports have proved that the application of robotic technology for surgery is technically feasible and safe. There are a growing number of robotic head and neck procedures upon the horizon including tongue base surgery, oropharyngeal neoplasm and supraglottic laryngeal surgery. Dr. Cannon is in practice at Head and Neck Surgical Group off River Oaks Drive in Flowood.

Maroun E. Hayek, MD, oncologist at the Delta Cancer Institute in Greenville, has been named Delta Regional Medical Center’s chief of staff. Dr. Hayek will serve as the chief medical officer and principal official of the staff. Dr. Hayek, who joined the medical staff of Delta Regional Medical Center in 2000, received his M.D. from St. Joseph’s University in Beirut, Lebanon, in 1990. He then attended Seton Hall University School of Graduate Medical Education where he completed his residency in internal medicine in 1993. He completed a Fellowship in hematology/oncology at Columbia University. He is board certified in internal medicine/hematology/oncology. Dr. Chad Huckabay, a urologic surgeon with specialty in minimally invasive and robotic urologic surgery, has joined the University of Mississippi Medical Center faculty as an assistant professor of surgery. He will see patients through University of Mississippi Health Care. A 1994 graduate of the University of Oklahoma, Norman, Huckabay received the M.D. from the University of Oklahoma College of Medicine, Oklahoma City, in 1998. He served an internship in general surgery, postgraduate training in pre-urology and a residency in urology at Texas A&M University, Temple, where he was chief resident, urology from 2003-04. He also did a fellowship in urology at New York University from 2004-05 and was a fellow in laparoscopy/robotics at the Arthur Smith Institute of Urology, North Shore/Long Island Health System, New Hyde Park, N.Y., from 2007-08. Dr. Huckabay joined the University of Minnesota Twin Cities faculty in 2005 as an assistant professor of urology before serving as a urologic surgeon at North Shore/Long Island Jewish Health System, New Hyde Park from 2007-10.

Daniel Dare, MD is performing 30-year knee replacement surgeries using VERILAST technology. With this procedure, recommended for those requiring knee surgeries who are younger and want a replacement to last for a long time, Central Mississippi Medical Center offers the very latest in knee replacement technology. The product itself has been extensively lab-tested to simulate and withstand 30 years of physical activity. This more than doubles the typical lifespan of a regular replacement knee. Increased mobility and decreased pain are just two of the major benefits of this type of surgery. Dr. Dare has over 30 years of experience as an orthopedic surgeon and is a graduate of Louisiana State University where he received both his bachelor and medical degrees. Dr. Dare completed his residency at Tulane Medical Center and has been a clinical instructor in orthopedic surgery at the University of Mississippi School of Medicine since 1979.

Neal Gregg, MD, a general orthopaedic surgeon, has joined Southern Bone and Joint Specialists, P.A. Dr. Gregg, a Hattiesburg native, received his bachelor’s degree from William Carey University. He received his doctor of osteopathy degree from Kansas City University of Medicine and Biosciences. He completed an orthopaedic residency from the Medical College of Georgia. He also worked at Southern Bone and Joint Specialists, P.A. and Southern Surgery Center as a medical assistant for one and a half years.

Lance Line, MD of Southern Bone and Joint Specialists, P.A. has received subspecialty certification in sports medicine from the American Board of Orthopaedic Surgery (ABOS). Candidates are required to document proficiency in surgical procedures and also non-surgical management of sports medicine problems. This was followed by an intensive four-hour examination. ABOS administers the exam every 10 years. Dr. Line maintains an active sports medicine practice with a subspecialty interest in shoulder conditions in Hattiesburg since 1995. He is currently a team physician for the University of Southern Mississippi, William Carey University, Pearl River Community College and many area high schools. He also sees patients in Southern Bone and Joint’s satellite clinics in Columbia, Poplarville and Collins once a week. Dr. Line attended the University of Mississippi Medical Center and subsequently completed his residency at University Medical Center in Jackson. Following residency, he completed a one-year fellowship in Sports Medicine and Arthroscopy in Richmond, Virginia, which included an internship with the Pittsburg Steelers professional football program. He is a fellow of the American Academy of Orthopaedic Surgeons. He is a member of the American Association of Orthopaedic Surgeons, Mississippi Orthopaedic Society and American Orthopaedic Society for Sports Medicine. Dr. Line and his wife Marcia have two children, Hayes and Haley. They are members of St. Thomas Catholic Church. Michael Mansour, MD, FACC was recently elected Mississippi Governor to the American College of Cardiology (ACC). He will be the Mississippi Governor-elect for a one-year period and then assume the 3 year governorship in March of 2011. In addition, Dr. Mansour will concurrently serve as the President-elect and President of the Mississippi Center of the American College of Cardiology. Dr. Mansour is a cardiologist at Delta Regional Medical Center in Greenville. He is board certified in Internal Medicine and Cardiology and has additional board certifications in Interventional Cardiology, Nuclear Cardiology, and Cardiovascular Computed Tomography. Dr. Mansour is a graduate of the University of Mississippi Medical School and received his post graduate training at the Ochsner Clinic, the University of Florida, and Harvard Medical School. He served as Assistant Professor of Medicine at the University of Florida, and Clinical Assistant Professor of Medicine at Emory University prior to establishing his practice in Greenville in 1998. He lives in Greenville with his wife, Kathleen Mansour, MD, FACC and their four children. Omolara Otaigbe, MD attended the James B. Herrick Symposium: Sickle Cell Disease and Research: Past, Present and Future medical conference in Bethesda, Maryland. The national symposium was held to mark the centennial of the publication of Herrick’s landmark case study on sickle cell anemia, which was the first of its kind in Western medicine. The conference provided healthcare professionals an opportunity to meet and learn about advancements in the treatment of the disease. Dr. Otaigbe, a family medicine physician with Wesley Medical Group, has a clinical interest in the disease and is well versed in the treatment of this condition. Sickle cell anemia and other he-

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moglobinopathies affect African Americans, Hispanics and Caucasians of Mediterranean descent. According to the Mississippi Department of Health data from the year 2000, approximately 3000 people living in the Pine Belt and surrounding areas suffer from some form of a hemoglobin disorder.

Raymond Orgler, MD, North Mississippi Medical Center in Tupelo and Manubhai Patel, MD, St. Dominic Hospital in Jackson recently received a three-year appointment as Cancer Liaison Physician for each of their respective cancer programs. Cancer Liaison Physicians are an integral part of cancer programs accredited by the American College of Surgeons Commission on Cancer (CoC). Dr. Orgler and Dr. Patel are among a national network of over 1,600 volunteer physicians who are responsible for providing leadership and direction to establish, maintain, and support their facilities’ cancer program. Both physicians have a significant interest in the diagnosis and treatment of patients with malignant diseases and are members of the multidisciplinary cancer committee at these institutions which are dedicated to facilitating the delivery of comprehensive quality cancer care. Cancer Liaison Physicians are responsible for spearheading CoC initiatives within their cancer program, collaborating with agencies such as the American Cancer Society (ACS), and facilitating quality improvement initiatives utilizing data submitted to the CoC’s National Cancer Database (NCDB). The CoC collects data from its accredited cancer programs and provides tools back to these facilities to facilitate the analysis of patterns of diagnosis, treatment, and quality of care. The NCDB currently contains patient demographics, tumor characteristics, treatment, and outcomes information for over 25 million malignant cancers diagnosed and treated at hospital-cancer programs in the United States between 1985 and 2007. The Cancer Liaison Physician works with the cancer program staff to facilitate the submission, presentation, use, and interpretation of NCDB data.

Sabitha R. Pabbathi, MD has joined the medical staff of Delta Regional Medical Center. Dr. Pabbathi comes to Greenville following the completion of her internal medicine residency at the University of Tennessee Health Science Center in Memphis. She did her externship in internal medicine at Baton Rouge General Hospital in Baton Rouge, Louisiana. Dr. Pabbathi obtained her medical degree in 2004 from Osmania Medical College in Hyderabad, Andhrapradesh, India, where she also did her clinical rotation internship. She has been a member of the American College of Physicians since 2007.

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Watts

Weisser

Willis

Alexandria Polles, MD, a psychiatrist, has joined Wesley Medical Center as a member of the medical staff. Dr. Polles received her medical degree from Tulane University School of Medicine. She completed an internal medicine internship at Alton Ochsner Foundation Hospital, an emergency medicine residency at Charity Hospital of Louisiana and a psychiatry residency at the University of Mississippi School of Medicine. She also completed a fellowship in addiction medicine at the Pine Grove Recovery Center in Hattiesburg. Dr. Polles is board eligible in emergency medicine, board certified in psychiatry and is certified by the American Society of Addiction Medicine. She is a diplomate of the American Board of Addiction Medicine. She has certificates of added qualifications in addiction and forensic psychiatry. Dr. Polles is also a fellow of the American Psychiatry Association and is a Certified Sexual Addiction Therapist. Dr. Polles is further certified in Eye Movement Desensitization and Reprocessing therapy. Harper Stone, MD was elected to serve on the board of directors for the Greater Southeast Affiliate of the American Heart Association which services Alabama, Florida, Georgia, Louisiana, Mississippi, Tennessee and Puerto Rico. He is a cardiologist with Jackson Heart Clinic and is board certified in internal medicine and cardiovascular disease.

Barbie D. Sullivan, MD, OB/Gyn with The Woman’s Clinic has been named executive medical director of women services at Baptist Medical Center in Jackson. Dr. Sullivan will continue her very active private medical practice with The Woman’s Clinic, and in addition, she will serve in this new executive leadership role for Baptist. She will be responsible for the oversight, development and execution of approved initiatives for Baptist for Women. Dr. Sullivan will work closely with Terri Meadows, Women’s Services product line director, and the Women’s Services Physicians Advisory Council. “Dr. Sullivan is an excellent choice for this new role. She has been an active member of the Baptist medical staff since 1996 and is board certified in Obstetrics & Gynecology,” added Baptist Medical Center President Mark Slyter. “She has chaired many medical staff committees including the OB Section and Surgery Section. She currently serves as medical director for the Baptist for Women Center for Surgery.” This unique role demonstrates Baptist’s commitment to elevating the level of care for the women of Mississippi through greater communication and collaboration with all members of the Baptist medical staff. For many years, the private physician practice and the hospital have operated as completely separate

entities. Slyter added, “In today’s health care environment, the need to collaborate is vital. By having one person looking at the patient’s, physician’s and hospital’s needs, we are confident that everyone, especially our patients, will benefit from efficient, quality care.”

Thad F. Waites, MD, a Hattiesburg Clinic Southern Heart Center cardiologist and Forrest General Hospital’s Cardiac Catheterization Lab medical director, was elected to serve as the Chairman of the Board of Governors for the American College of Cardiology (ACC). Dr. Waites currently serves as the Governor for the state of Mississippi on the ACC Board of Governors and is also the President of the Mississippi Chapter of the ACC. “One of the current focuses of the American College of Cardiology is reformation, of a healthcare system that places an emphasis on the patients paying for quality care rather than quantity care,” said Dr. Waites. “I view serving in this position as being at the pinnacle of my career.” His duties include the oversight of more than 50 Governors. These representatives of the U.S., Armed Services, Canada and Puerto Rico were elected based on their credentials, achievements and contributions to cardiovascular medicine in an organization that is made up of more than 37,000 members. “It is a great honor for Hattiesburg Clinic, the Southern Heart Center, and our community and state, to have a physician elected to this prestigious position during such a critical time in our nation’s health care system,” said Ken Smith, administrator of the Southern Heart Center. “Dr. Waites is most deserving of this honor which was bestowed upon him by his peers.” Dr. Waites attended the University of Mississippi School of Medicine in Jackson and completed an internship at Emory University, Grady Memorial Hospital in Atlanta, Georgia. He completed his residency at the University of Colorado in Denver. Dr. Waites served as chief resident and as a fellow in cardiology at Emory University Hospital in Atlanta, Ga. He was a staff member of the Ochsner Clinic in New Orleans, Louisiana, prior to joining the Southern Heart Center.

Steve Watts, MD, an associate professor of medicine and a primary care sports medicine physician, was inducted as a fellow of the American Academy of Orthopedic Surgeons (AAOS) during ceremonies at the academy’s 2011 annual meeting in San Diego, California. Dr. Watts was one of 667 new members inducted. The AAOS has more than 36,000 members worldwide. The academy is the largest medical association for musculoskeletal specialists. Lydia Weisser, DO of Whitfield recently assumed responsibility as Medical Director for the Mississippi Department of Mental Health (DMH). has been named medical director of the Mississippi Department of Mental Health. She also serves as the chief psychiatrist and administrator of psychiatric and medical care for Mississippi State Hospital where she has worked since 2007. Dr. Weisser holds a master’s degree in business administration from Troy University and a medical degree from West Virginia School of Osteopathic Medicine. Dr. Weisser is certified by the American Board of Psychiatry and Neurology for which she has also served as a board examiner.

She has additional certification in Psychiatric Administration and Management. She is a Fellow of the American Psychiatric Association, a member of the American Association of Psychiatric Administrators, and a delegate to the APA Committee on Psychiatric Administration and Management. Before her career with DMH, Dr. Weisser served as Clinical Director for East Central Regional Hospital in Augusta, Georgia, and Clinical Director for West Central Georgia Regional Hospital in Columbus, Georgia. She obtained her medical degree from West Virginia School of Osteopathic Medicine where she was an honor graduate, Board of Regent’s scholar, and member of Psi Sigma Alpha honor society. Dr. Weisser completed her residency in psychiatry at the University of Alabama at Birmingham (UAB) where she served as Chief Resident. During her tenure at UAB, Dr. Weisser was recipient of the Upjohn Achievement Award and Pfizer Award for Psychiatry Resident of the Year. She began her employment as Assistant Professor of Psychiatry at the Medical College of Georgia in 1997 where she was twice named Department of Psychiatry and Health Behavior Clinical Supervisor of the Year and also received the Educational Excellence Award. She completed the Georgia Department of Human Resources Leadership Development Institute in 2003 and also received her Master’s Degree in Business Administration from Troy State University in 2004. She is also a graduate of the Mississippi Certified Public Manager Program, Stennis Institute of Government and the DMH Focus Program. Jeffrey Todd Willis, MD has joined the growing team of family medicine providers at Neshoba County General Hospital. He will continue to practice in his current location at 1003 Holland Avenue in the Neshoba County Medical Arts Clinic, Suite 104, Philadelphia. Dr. Willis received his medical degree from the University of Mississippi Medical Center in Jackson in 1989. He completed an internship in 1990. He began practicing in Neshoba County in 1994. Dr. Willis previously served as the Neshoba County General Hospital ED Director from 1997-2000.

Raymond Arriola, MD and Kathryn Jane Pastrell, MD of Fulton; Roderick Cutrer, MD and Naim Salloum, MD of Hattiesburg; Michael Yuri Torchinsky, MD and Joseph Howard Robinson, MD of Jackson; Richard Gerald Burris, MD of Monticello; William Rowe Ehlert, MD of Pascagoula; Cheryl Gay Clark, MD and Jimmy Isbell, MD of Meridian; Charles McCarley Elliott, MD of Ripley; and James Walter Holmes, MD of Wiggins recently received the AMA Physician’s Recognition Award (PRA). The PRA award recognizes physicians who earn at least an average of 50 credits per year from educational activities that meet the AMA standards. ❒ MSMA Members: Share your personal news (promotion, award, CME, elected office, etc.) with the Journal MSMA. Please include a high resolution (at least 300 dpi) photograph. Contact Karen Evers, managing editor, (601)853-6733, ext 323. Submit MSMA press releases and obituary announcements for publication via e-mail to: KEvers@MSMAonline.com.

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• OBITUARIES •

James Murray Brock, Sr., MD (91) died Feb. 4, 2011, at his home in McComb. A father, physician, flugabonist and farmer, “Jim” Brock was born in Mt. Hermon, Louisiana, on May 13, 1919 to Dr. Lucius William Brock and Dannie Lee Tate Brock. Dr. Brock practiced medicine for 62 years and was a pioneer in the field of skin surgery. He was an avid musician and hobbyist farmer, serving as an inspiration to many with a life dedicated to service, science and the arts. “Dr. Jim,” as he was known throughout the community, was a civic leader renowned for his integrity and compassion. He couldn’t wait to go to work every morning and he stayed active and inquisitive with a drive to learn that never waned, even through his final days. He graduated from McComb High School and attended the University of Mississippi, receiving the Bachelor of Arts degree in 1941, and completing two years of medical training before transferring to Harvard Medical School. While there, he contracted rheumatic fever and was subsequently confined to bed at home for more than two years. This time was not spent idly, however, as young Jim took the opportunity to memorize all of Beethoven’s symphonies while he recuperated. Afterwards, doctors discouraged him from stressing his heart further by returning to the cold, northern climate of Cambridge, Mass. It was war time, however, and he was unsure of his prospects of completing his medical education. Even so, a visit to Tulane University Medical School with his father resulted in his acceptance, and he graduated with the Doctor of Medicine degree there in 1947. In 1946, Jim married Mary Ellen Prosser of McComb. He completed a rotating internship at Charity Hospital in New Orleans in 1948. Dr. Jim and Mary Ellen returned to McComb, where he was in general practice from 1948 to 1960. From 1955 to 1960, he completed a fellowship in dermatology at Louisiana State University Medical School, while maintaining his practice in McComb. In 1960, Dr. Brock opened the Brock Skin Clinic, where he practiced dermatology until June 2010. From 1960-1980, he also served as the director of Dermatologic Surgery Clinic at Louisiana State University Medical School in New Orleans. Dr. Brock trained with Dr. Frederic Mohs of the University of Wisconsin-Madison and was a founding member of the American Society of Mohs Micrographic Surgery, an innovative technique that allows patients with skin cancer to retain as much healthy tissue as possible. At that time, skin surgery was a new field for dermatologists, so medical residents from the Mayo Clinic, Louisiana State University and Tulane Medical Centers traveled to McComb to be trained by Dr. Brock, one of the earliest practitioners. Dr. Brock was a Diplomate of the American Board of Dermatology, a member of the American Academy of Dermatology, AMA, SMA, MSMA, Louisiana Dermatology Society and the American Society of Dermatologic Surgery. As devoted as he was to the patients in his medical practice, he was equally gifted as a musician. While in high school, he was a member of the McComb High School band and the McComb Stage Band. At Ole Miss, he played with The

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Mississippians dance band, and for many years after graduation, he gained fame with his brother, Jep, as the oldest members of the Alumni Marching Band. In later life, he played with the Billy Fane Orchestra and the Lue Fane Trio. In the early 1990s, he founded Dr. Jim’s One More Time Band, which traveled the South playing a unique repertoire of big band, classic jazz and show tunes with Dr. Jim often featured in a variety of themed hats to support the stories told through the music. As Dr. Jim aged, he was known to exclaim to the audience, “I can’t walk, but I can still dance,” leading a conga line around the room to the band’s final number – “When the Saints Go Marching In.” Dr. Jim was a brass man at heart — at home on the trombone, flugabone and helicon. But over the years, he also taught himself to play several string and percussion instruments, even mastering the keyboard in his 80s. In 2005, Dr. Jim received the Mississippi Health Care Association Volunteer of the Year Award for his regular performances in Pike County nursing homes, where he continued to play jazz on Thursdays and hymns on Sundays through December 2010. Dr. Jim also owned several local farms, where he raised livestock and cultivated a variety of crops. He enjoyed discussing cattle, and as his family and friends traveled, he never failed to inquire about the species of cow in the local area. He was also a deacon at First Baptist Church of McComb, was a retired member of the McComb Rotary Club and was a former director at Trustmark National Bank. Although successful in medicine, music and farming, Dr Jim’s greatest accomplishments came as patriarch of the Brock family. From 1979, he served as both mother and father to five children, inspiring them through example to seek careers in health care and the arts. Dr. Brock was preceded in death by his parents; his wife of 33 years, Mary Ellen Prosser Brock; and long-time family friend, Lue Fane Alford. Survivors include five children, James Murray “Spunk” Brock Jr., MD, and wife Linda Young Brock of McComb, Lucius William “Dub” Brock II of McComb, Dannie Ellen Brock Maples and her husband Michael Dudley Maples, MD, of Jackson, Mary Prosser Brock of McLean, Va., and Oliver Eugene Brock II and wife Tina Penick Brock of San Francisco; five grandchildren, Lea Ellen Brock Welborn and husband Jerry Ryan Welborn of Oxford, James Lucius Brock and wife Martha Boswell Brock of Oxford, Mary Ellen Maples Stancill and husband Jefferson Kendall Blake Stancill of Birmingham, Ala., Nathan Dudley Maples, MD, of Jackson, and Brock Michael Maples of Jackson; and a great-grandchild, Brock William Welborn of Oxford; a twin brother, Jep S. Brock, DDS., of McComb; his younger brother, Ralph L. Brock, MD, of McComb; and longtime faithful assistant, Janice Rawls of Magnolia. In lieu of flowers, donations can be made to Hospice Compassus, 140 N. 5th St., Suite B., McComb, MS 39648; or to First Baptist Church General Fund, 1700 Delaware Ave., McComb, MS 39648.

Donald E. Butkus, MD (76) died Feb. 2, 2011, at the University of Mississippi Medical Center (UMMC) after a long battle with Parkinson’s disease . He was a professor of medicine, specializing in nephrology at the UMMC until his retirement in 2003. Dr. Butkus served as a U.S. Army physician for 30 years and was a veteran of the Vietnam War. He retired from Walter Reed Army Medical Center at the rank of colonel. A Requiem Eucharist was celebrated Saturday, February 5, 2011, at St. Philip’s Episcopal Church in Jackson. Dr. Butkus was born October 9, 1934, in Binghamton, New York, the son of the late John G. Butkus, MD and Mary Koval Butkus. Dr. Butkus advanced the understanding of kidney disease and cared for many people with advanced kidney failure and kidney transplants. He is survived by his wife, Nancy; daughter, Allison Cunningham of Denver, Colorado; son, Brian Butkus of Portland, Maine; son, Grant Wilson of Palm Springs, California; daughter, Christine Koval, MD of Cleveland, Ohio; grandson, Kevin Cunningham of Denver, Colorado and sister, Cindy Gilbert of Atlanta, Georgia. Memorials may be made to St. Philip’s Episcopal Church, 5400 Old Canton Road, Jackson, Mississippi 39211 or Mississippi Organ Recovery Agency, 12 River Bend Place, Flowood, MS 39232.

Don Grillo, MD (77) died Dec. 16, 2010, at Baptist Medical Center in Jackson. A native of New York, Dr. Grillo was a graduate of Columbia University and Albany Medical College. He retired as a colonel from the United States Air Force. He helped establish the first Ob/Gyn residency at Keesler Air Force Base where he became chairman of the Department of Ob/Gyn. After retirement, Dr. Grillo worked for 20 years with the Mississippi Department of Health where he established the first statewide ultrasound and mammogram program for health department patients. While in Jackson, he taught midwives, nurses, family medicine students and Ob/Gyn residents at UMMC. He also served as District 5 health officer for many years. A funeral mass was conducted Dec. 20 at St. Richard Catholic Church in Jackson, and Dr. Grillo was interred at Natchez Trace Memorial Park Cemetery. In lieu of flowers, memorials may be sent to the American Kidney Foundation or the American Cancer Society.

Van Robinson Burnham, Jr. MD, (90) died peacefully at his home early Saturday morning, Dec. 4, 2010, from complications caused by kidney failure. Dr. Burnham was born Feb. 20, 1920, in a Sears & Roebuck prefabricated house in Marks that still stands today. He was raised in Ruleville and attended Ruleville High School. Upon graduation at age 17, he attended Sunflower Jr. College in Moorhead. While there, he captained and quarterbacked the junior varsity football squad. Dr. Burnham’s next stop on the education totem pole was at the Ole Miss medical school. It was a two-year curriculum, and it was in Oxford that he received his Bachelor of Science degree. In 1941 he transferred to medical school at Northwestern University in Chicago. With World War II in full battle, Dr. Burnham enlisted in the Navy. He was kept on reserve until his medical training was completed in 1943. He did his internship and pathology residency at Pennsylvania Hospital in Philadelphia, which was founded by Benjamin Franklin.

Having completed his medical training by the time he was 23, Dr. Burnham was a Lieutenant Commander in the Navy. He spent a year overseas in Manila, Philippines, and along the Yangtze River in China where he treated both Chinese and Japanese injured soldiers. He was discharged to Ruleville and when he could find no medical openings in the Mississippi Delta, he went to Vaiden and practiced for two years. There, he met his future wife, Barbara Braswell, and the two were married in 1948. Three days after saying their vows, they moved to Clarksdale where Dr. Burnham worked under Dr. Ike Carr on the second floor of the McWilliams Building. His medical career was interrupted in 1953 when he was recalled into the Navy during the Korean War. Stationed in Birmingham, Ala., the Burnhams remained there for two years, returning home to Clarksdale in 1955. It was then that the good doctor opened his own family medical practice on the fifth floor of the McWilliams Bldg., right across from Dr. Wilkins and Wilkins and Dr. T. G. Hughes. He remained in the same location until his retirement in December, 2003. Dr. Burnham delivered babies until 1962, made house calls all over Coahoma County for many more years, and was the team doctor for the Clarksdale Wildcats during that same decade, sitting on the field with the team at every Friday night home game. Besides being a devoted doctor as well as one of the top diagnosticians in the Mid-South, he was a member of MENSA and INTERTEL. He was also on the Board of Trustees of the Miss. Dept. of Archives and History from 1988-2003 and established the Barbara B. Burnham Memorial Fund Endowment for the Foundation for Miss. history following her death in 2006. This fund allows archaeologists from Mississippi to travel to meetings all over the world. Dr. Burnham was an active supporter of the University of Mississippi Foundation for the Civil War Museum, Dept. of Anthropology and the Ole Miss Rebel track team. He served as president of the North Delta Museum’s Board of Trustees and was a member of the Clarksdale Rotary Club from 1956 until earlier this year. He was selected by the Rotary Club as a Paul Harris Fellow. He was an avid supporter of the Carnegie Public Library in Clarksdale. Dr. Burnham was also a member of the First United Methodist Church. An avid football fan, he followed his Ole Miss Rebels religiously and was one of the first fans to actively study recruiting, dating back to the 1960s. Dr. Burnham is preceded in death by his wife Barbara who died in 2006, as well as his parents, Dr. Van R. Burnham, Sr. and Nettie Burnham, and a sister Eloise who died in 1935. He leaves a daughter, Babs Burnham Sweatt of Clarksdale; two sons, Van (Bubba) Burnham and wife Ginger of Sumner; and Conner Burnham and fiancé Sherri May of Clarksdale. He also leaves five grandchildren, Scott Hollis and wife Natasha of Olive Branch; Dr. Van Hollis of Mandeville, Louisiana; Denson Hollis of Oxford; Beth Burnham of Hattiesburg; and Bo Burnham of Portland, Oregon. Funeral services were held at First Methodist Church with burial at Oakridge Cemetery. Memorials may be made to the University of Mississippi Foundation, Box 249, University, MS., 38677, in his memory, to the First United Methodist Church in Clarksdale, or the charity of the donor’s choice.

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Paul C. Ellzey, MD (89) died Saturday, Jan. 15, 2011, at his home after an extended illness. Services were held at the Jefferson Street Chapel of W.E. Pegues. Born in Natchez to William Frank Ellzey and Lula Kittie Smith Ellzey, he graduated as valedictorian from New Zion High School in 1939. He attended Copiah Lincoln Junior College and Mississippi State University. He honorably served in the war as a pilot, bombardier and navigator. Upon completing his tour of duty in the military, he remained in the Air Force Reserves and attended Vanderbilt University in Nashville where he completed his education. He received his B.A. in chemistry in 1948 and his medical degree in 1951. He completed a 12-month internship at Fitzsimmons Army Hospital in 1952 where he received the highest ratings in a class of 22 interns. In 1953 he established his medical practice in Booneville and opened the Booneville Medical Clinic. As a family practitioner for 44 years, he deeply cared for his patients, their family members and his clinic staff. Dr. Ellzey held every office in the local medical society and was a member of the Northeast Mississippi Medical Society, MSMA and the AMA. He served as the medical director of Longwood Manor in Booneville for three years. He was devoted to the Booneville community through his involvement in his church, the educational systems and civic organizations. He was a charter member of the Booneville Jaycees and past president of the Prentiss County Power Association. He passionately supported the Booneville High School football and basketball teams, providing free physicals and serving as a team medical doctor. Dr. Ellzey retired from his medical practice in 1997 at the age of 76 and moved to Tupelo with his wife, Dena, where they were members of the First United Methodist Church. Through his church, he served as the team doctor on two mission trips to Mexico, and he volunteered at the Tupelo Free Clinic. He was an avid golfer and loyal Mississippi State alumnus. Survivors include three daughters, Paula E. Peterson of Olive Branch, Elta E. Brunet (Darwin) of Tupelo and Marla E. McCarthy (Eddie) of Tupelo; two sons, Michael Ellzey of Olive Branch and Rex Ellzey (Stephanie) of Edmond, Okla.; eight grandchildren, Heather White of Houston, Texas, Natalie Brunet Mohrman (Kennett) of Daytona Beach, Fla., Deanna Peterson Perkins (Roger) of Loveland, Colo., Joel Peterson of Olive Branch, Kayla Turner and Mary Turner of Tupelo, Robert Ellzey and Zach Ellzey of Edmond, Oklahoma; two greatgrandchildren, Gabriel Paul Dean and Jordyn Alexandra Perkins; one sister, Mabel Bass of Prentiss; his caregivers for four years, Glenda Hatcher, Charlene Dillard, Freddie Hickman, Tina Bell and Thomas Hendrick. He was preceded in death by his parents; his wife, Dena; and his two brothers, Kerman and Lyman Ellzey. Memorials may be made to St. Jude Children’s Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105. Thomas Homer Horton, MD (69) died at his home on Friday, March 4, 2011, after a brief illness. Dr. Horton was born in Grenada to Deloris White Horton and Earl Horton. Named for his paternal grandfather, Earnest Homer White, he was known around the square in Grenada as “Earl’s boy.” He excelled in his studies, first attending Mississippi State University to study engineering and later transferring to Ole

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Miss to major in pre-med. Specializing in anesthesiology, Dr. Horton graduated from the University of Mississippi School of Medicine in 1970, and was certified by the American Board of Anesthesiology. He was a practicing anesthesiologist with Tupelo Anesthesia Group, P.A. from 1970 to September 2002 and served as managing partner from 1990-2000. Dr. Horton served as medical officer for 134th Mobile Army Surgical Hospital, United States National Guard from1967 to 1973. From 1993-1998, Dr. Horton was coordinator and clinical instructor, University of Alabama, School of Nurse Anesthesia, Tupelo clinical site. He served as medical director of North Mississippi Surgery Center from 1986-2002. In 2002, he became medical director for HealthLink Preferred Provider Organization, medical director for Acclaim and NurseLink. A man of many interests, Dr. Horton learned to fly when he was in high school. He piloted his own plane for many years and was frequently heard to remark, “Now, this would be a good day for flying!” Boating was another passion of Dr. Horton’s. He navigated many rivers in the South, traveling from marina to marina. Collecting and reading books about Warren Buffet, Charlie Mounger and Benjamin Graham, Dr. Horton also studied investments and business management. He enjoyed examining the habits of other executives and following the success of the businesses associated with them. He was a lifetime learner. In recent years, he enjoyed taking courses in the Bible, welding, auto mechanics, piano and guitar. His library was extensive, and his love of books and learning never diminished. However, outside of medicine, his greatest interest was music. Dr. Horton loved all kinds of music and particularly enjoyed analyzing and researching lyrics. He was designated Medical Examiner, 1971-1990, President of Mississippi Society of Anesthesiologists, 19791980, Member of Finance Committee North Mississippi Medical Center 1990-1993,Chairman of Medical Staff NMMC 1991 and Member of Credentials Committee of Medical Staff, NMMC, 1992-1997, serving as chairman 1997-Present. He was a member of the NMHS Corporation, Calvary Baptist Church, Tupelo Rotary Club and Pi Kappa Alpha Fraternity, the American College of Physician Executives, the AMA, the American Society of Anesthesiologists, the MSMA and the Mississippi Society of Anesthesiologists. A service celebrating Dr. Horton’s life was held at the Tupelo Chapel of Holland Funeral Directors with Dr. David Eldridge, the Rev. Jimmy Criddle and the Rev. Jeff Flynn officiating. Entombment was held at the Chapel of Faith Mausoleum at Lee Memorial Park with the North Mississippi Medical Center Honor Guard providing a military salute. He is survived by his wife, Letitia Parham Horton; sons, Thomas Homer Horton Jr. (Kerri) of Verona and Steven Earl Horton (Shelonda) of Charlotte, North Carolina; stepsons, Douglas Wright (Stephanie) of Saltillo and Bennett Wright of Houston, Texas; grandchildren, Victoria Horton, Ayden Horton, Ashley Horton, Nick Sims, Jordan Wright, Leighton Wright and Britton Wright. He was preceded in death by parents; his previous wife, Elizabeth Harness Horton; and a sister, Ann Horton Jay. Memorials may be made to the Calvary Baptist Church Music Department, P.O. Box 1008, Tupelo, MS 38802.

Henry Frank Howell, II, MD (65) died Feb. 27, 2011, at his home in Brandon. Funeral services and visitation were held March 4, 2011, at the chapel of Wright and Ferguson Funeral Home on Highland Colony Parkway in Ridgeland with interment in the Parkway Memorial Cemetery. Dr. Howell went to Provine High School and then to college at Mississippi State University. He then attended medical school which led to a 30 year career as a family physician in south Jackson. He was a long time member at Annandale golf club. Dr. Howell is preceded in death by his parents, Henry and Nell Howell; wife, Mary Howell; and sister, Joan Scruggs. He is survived by his sons, Paul Howell, Hank Howell and wife Tassie; daughter, Kim Hooper; sisters, Ann Hairston and husband Brownie; grandchildren, Tristan Hooper, Haley Grace Hooper, Elly Howell, and Vance Howell.

John E. Lindley, MD ( 84) of Marion died Thursday, Jan. 27, 2011, at his residence. Dr. Lindley was born in Macon. He was a member of First Baptist Church of Meridian. He attended Mississippi State University and received a B.S. degree in chemistry from University of Mississippi and a certificate from University of Mississippi two year medical school. He later graduated from Harvard Medical School. He did his residency and was Chief Resident in Obstetrics and Gynecology at Jeff Davis Hospital in Houston, Texas. Dr. Lindley was an assistant instructor in obstetrics and gynecology at Baylor University and at University of Mississippi. He was Past Chief of the Department of Obstetrics and Gynecology and Past Chief of Staff at Jeff Anderson Regional Medical Center. Dr. Lindley practiced Obstetrics and Gynecology in Meridian for 33 years. He was in the United States Navy from 1944-1946, beginning as an Apprentice Seaman to Pharmacist Mate 2/C. He did his boot camp training at Camp Perry in Virginia. Dr. Lindley received many awards and accomplished many achievements. He was recipient of the Wisdom Award of Honor of the Wisdom Society, author of 13 articles to professional journals, founder and President of Board of Directors of Jefferson Davis Academy for 17 years, incorporator and first mayor of Marion, inventor of the Lindley I Newborn Resuscitator and Lindley II Neonatal Resuscitator, inventor of TOILEFRESH, a patented commode odor removal system, and the holder of 17 patents on various inventions in the United States and foreign countries. He was also a member of many professional and civic organizations such as The Diplomat, American Board of Obstetrics and Gynecology, Past President of the Mississippi Obstetrical and Gynecological Society, Fellow American College of Obstetrics and Gynecology and Surgeons, MSMA, Past President of the East Mississippi Medical Society and Past President of University of Mississippi Ob/Gyn Alumni Association. Past Chairman of the Section of Obstetrics and Gynecology, Past President of East Mississippi Medical Society, Past member of Central Association of Obstetricians and Gynecologists, American Fertility Society, American Association of Physicians and Surgeons, AMA, SMA, University of Mississippi Medical School Dean’s Advisory Committee and Advisory Committee of the Endowment for Excellence in Obstetrics and Gynecology, Guardian Society of the University

of Mississippi Foundation, of the Wisdom Hall of Fame and the Winfred L. Wiser Society of the University of Mississippi. Dr. Lindley was also a member of the Sons of the American Revolution, the Sons of Confederate Veterans, Order of Star and Bars, Veterans of Foreign Wars, the American Legion, and the Board of Trustees of Beauvoir. He was a Mason with membership in the Scottish Rite, York Rite, Hamasa Shrine and Past Director of the Royal Order of Jesters. He was a member of the Meridian Little Theatre, Navy League, founding member of the Navy Memorial, and also a member of the Mississippi and Louisiana Thoroughbred Associations and American Quarter Horse Association. Survivors include his wife, Marie of Marion; children: Lisa Lindley McCleskey and her husband Pete, John E. Lindley Jr. and Mark Lindley; his sister, Linda Jensen and her husband Gene of Baton Rouge, La.; and, numerous nieces and nephews.

William Chappell (Chappie) Pinkston, MD (62) of Ridgeland passed away in Seattle, Washington, following complications from a bone marrow transplant on March 5, 2011. Dr. Pinkston was born in Oxford to William O. and Valeria Pinkston. His spouse, Susan G. Pinkston of Ridgeland and his son, Christopher Ellis Pinkston of Austin, Texas, survive him. Dr. Pinkston graduated from Oxford High School and the University of Mississippi where he was a charter member of Phi Kappa Tau Fraternity. He completed medical school, an internship, residency and pulmonary fellowship at UMMC. Upon graduation, Dr. Pinkston served in the Air Force where he became the Chief of Pulmonary Services at Keesler Air Force Base in Biloxi, obtaining the rank of Major. Upon completing his military service, Dr. Pinkston returned to Jackson where he was on the pulmonary staff at UMMC. After leaving UMMC, Dr. Pinkston co-founded Jackson Pulmonary Associates practicing pulmonary, critical care and sleep medicine until 2002. Upon leaving Jackson Pulmonary Associates, Dr. Pinkston joined the staff of the G. V. (Sonny) Montgomery VA Medical Center as Chief of Pulmonary and Respiratory Services. In August 2009 he returned to UMC to establish Intensiview, a visual, remote intensive care monitoring unit bringing to MS cutting edge technology in the monitoring of critical care patients. He was board certified in Internal Medicine, Pulmonary and Critical Care. He was the President of the MS Thoracic Society, a Fellow of the American College of Chest Physicians serving as the MS Governor from 1987 to 1992, and a member of the MS Lung Association. Dr. Pinkston’s passions in life were his son, patient advocacy, teaching medicine, flying his Cessna 206, mastering computer technology, music, and playing his guitar. Many hours were spent entertaining his friends with his humor and guitar playing. A special acknowledgement goes out to Kathryn Roberson, a special friend. His life was celebrated with visitation and a church service at Christ United Methodist Church in Jackson with interment at Parkway Memorial Cemetery on Highland Colony Parkway in Ridgeland. In lieu of flowers, the family requests that donations be sent to the William C. Pinkston Lectureship in Critical Care Medicine, Pulmonary Division, UMMC, 2500 N. State Street, Jackson, MS 39216. ❒

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• THE UNCOMMON THREAD •

Do Not Spill Up Nose!!!

R. Scott Anderson, MD

ccidents are peculiar things. They come along when you least expect them (I guess if you expected them you wouldn’t have them) , and they can, even if they aren’t fun, be pretty funny. Now I’m not really a small guy, and I’m not the kind of body habitus that you expect to be doing acrobatics. But I did try to fly the other day. The outcome of that, as you might expect, was a victory for Sir Isaac and that gravity stuff he described.

It was a typical school night. I was hiding in my study trying to avoid helping with cleaning up the dishes after supper or being any help with the various homework assignments that had to be dealt with. My strategy is to keep hollering, “I’ll be there in a minute,” until whatever I am needed for has been completed by those too impatient to wait for the expanding minute to pass. Unfortunately my youngest, Maddie, has figured out my strategy and developed one of her own to combat it. She shows up with the entire retinue of irritating dogs and proceeds to do cheer routines, acrobatics, and dance practice in my study. The dogs love it; I don’t. My office is small and filled with irreplaceable treasures that can be easily displaced or broken by flying legs and running dogs. So as Little Mat was trying the ivory teeth from an elk I shot in Wisconsin or Wyoming or somewhere in our Yorkie Cocoa’s mouth, I relented. “Alright, alright, put those back in my treasure box, and I’ll help you with Mercator’s projections.” “Do you know who Mercator was?” she asked.

“Some guy with a projector I guess. We’ll look him up in your book,” I replied.

I picked up my glass of tea and the gun magazine I was looking at and followed her to the stairs. Mat, being eleven, doesn’t always descend stairs like other humans, and in this instance she was in the middle of the dogs and headed down face first on her hands and knees trying to go down them like a dog. I knew that this was a bad thing and dangerous for someone. I just didn’t guess it was me, so I let it go. Somewhere, about half-way down, everything went kind of haywire. Some of it had to do with little muscle pajama clad legs, some of it had to do with dogs, and a lot of it had to do with being old and forgetting to take my reading glasses off. But I suddenly lost track of where my outstretched foot was going and missed the next step. Because my hands were full and I wasn’t holding onto the hand rail, there was no chance of recovery. I knew that if I proceeded on my current downward trajectory somebody was going to get smashed. Now if it was just the dogs, it would have been every pooch for himself, but with Maddie the pretend pooch down there I couldn’t see letting that happen, so I used the foot that was still in marginal contact with the earth to try and launch myself over them. Mostly what I accomplished was to change my trajectory from that of a falling tree to that of a rocket.

You should have seen the look of surprise on Maddie’s and the dogs’ faces as I flew over them. The truth is I barely had time to notice them myself. It wasn’t a very long flight. I quickly found the right side of my head and then my right shoulder and arm meeting the wonderful softness of the oriental carpet that Charlene had placed at the bottom of the steps. It wasn’t as much of a cushion as you might think. I don’t know what kind of threads those Orientals were using, but they were abrasive enough that they sanded off a good chunk of hide on the side of my face. All of this was pretty much expected and didn’t really come as much of a surprise, but what happened next did. Somehow in our airborne transit the tea had gotten out of the glass I was carrying and was flying along independently. And about now it landed too. Being kind of upside down and I guess to prevent some kind of injury or other, I had opened my mouth. Do not listen to Maddie about her version of any of this. I was NOT cursing at the dogs.

Anyway, somehow the tea landed on me (on my face to be specific), filling up my mouth and nose and choking the stew out of me in the process. I coughed and sputtered, spitting tea as I continued the graceful progression of my landing and slid across the mud room into the kitchen flat on my back.

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• UNCOMMON THREAD •

“Mom, Mom, Dad fell down the steps and is shooting stuff out of his mouth and nose,” Maddie shouted into the living room. “He better not be getting it on my good carpet,” Charlene responded. “Are you okay?” Maddie asked, her face grim and serious.

“I think I’m drowning in tea,” I answered as I began to move stuff just to be sure everything still worked.

It was then that she dissolved into a puddle of laughing pajamas. “You can’t believe how funny you looked.”

She was sweet. She brought me a towel and cleaned up the spilled tea while I tried to assess whether or not I had avulsed my brachial plexus and why I was having numbness in the distribution of my right ulnar nerve. I turned out to be fine. Thank goodness there was a doctor in the house. The next morning I came into the kitchen. Sitting beside the coffee machine was a white Styrofoam cup hand lettered with Maddie’s irregular script. On one side it said “DO NOT FALL” and on the other it ordered “DO NOT SPILL UP NOSE!!!” Both of them sounded like a good idea to me. Scott

P.S. Lest you draw the conclusion that Charlene is not much help in the case of a fall, I have to tell you that she can be a real asset. Once while she and Holton, my adopted nephew, were working inside a shoot-house we were reconditioning and I was working on the roof with an electric drill, the section of the roof I was standing on crushed in and dumped me over the side. As I fell past the window, a pair of hands shot out and snatched the drill out of my hands. After meeting the earth and discovering that I was still breathing, I looked up to see Charlo holding the drill and looking down. “I didn’t want you to drill a hole in yourself when you landed,” she offered simply. ❒ R. Scott Anderson, MD, a radiation oncologist, is medical director of the Anderson Regional Cancer Center in Meridian and past 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 •

PHYSICIANS NEEDED

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)

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