VOL. LVIII • NO. 4 • 2017

VOL. LVIII • NO. 4 • 2017

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VOL. LVIII • NO. 4 • APRIL 2017

EDITOR Lucius M. Lampton, MD ASSOCIATE EDITORS D. Stanley Hartness, MD Richard D. deShazo, MD

THE ASSOCIATION President Lee Voulters, MD President-Elect William M. Grantham, MD

MANAGING EDITOR Karen A. Evers

Secretary-Treasurer Michael Mansour, MD

PUBLICATIONS COMMITTEE Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD and the Editors

Speaker Geri Lee Weiland, MD Vice Speaker Jeffrey A. Morris, MD Executive Director Charmain Kanosky

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.

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

Copyright © 2017 Mississippi State Medical Association.

Official Publication

MSMA • Since 1959

SCIENTIFIC ARTICLES Advances in Dementia Care Using Telemedicine 112 Netrali Patel, MD; Anuj Marya, MD; Denise Lafferty, RN; Andrew Majeste, RN Pelvic Synovial Sarcoma of Unknown Primary Origin 114 Christie Theriot, MD Quality Management in Surgical Pathology 119 Varsha Manucha, MD; Veena Shenoy, MD; Mirna Vargas; Israh Akhtar, MD; Divya Shenoy, (M3); Jack Lewin, MD Educational Debt in Mississippi’s Emerging Health Care Workforce 122 Seth T. Lirette, MS and Ralph H. Didlake, MD Top 10 Myths and Facts about Anesthesia for Neonates, 126 Infants, and Children Thomas Hamilton, MD; Madhankumar Sathyamoorthy, MBA Top 10 Fertility Myths You and Your Patients Should Know 128 J. Preston Parry, MD, MPH DEPARTMENTS From the Editor – Lifting the Veil Lucius M. Lampton, MD, Editor President’s Page – The Value of Membership Lee Voulters, MD MSMA Physicians Leadership Academy - Dr. Peggy Boles Special Article – A Pediatrician, Antifreeze, and the FDA Owen B. Evans, MD Physician’s Bookshelf – The Mississippi Encyclopedia Finally Published, Lampton Served as Associate Editor of Medicine Karen A. Evers Letters Legalese – Mississippi Medical Professionals Feel Drug Enforcement Heat Scott Gilbert, JD Poetry and Medicine – Dr. Siegfried Iseman Edgar Lee Masters Images in Mississippi Medicine – East Mississippi State Insane Asylum, Meridian RELATED ORGANIZATIONS MSDH – Reportable Disease Statistics

110 132 133 134 136 138 142 146 147 131

ABOUT THE COVER

“STATE FLOWER” The flower or bloom of the magnolia or evergreen magnolia (Magnolia grandiflora L.) is hereby designated as the state flower of Mississippi. § 3-3-13. 1952.

The most familiar nickname for Mississippi is “The Magnolia State.” The name honors the stately beauty of the magnolia trees of Mississippi. This perfect magnolia specimen caught the attention of Dr. Michael Davis of Vicksburg on one of several magnolias in the landscape of his family residence.

In 1900, the schoolchildren of Mississippi elected the magnolia as the official State Flower. In 1952, the Legislature selected the magnolia as the official State Tree.

Dr. Davis is a recently retired nephrologist and a former MSMA member.

He captured the image with an iPhone camera and brought it to the consideration of Dr. Randy Easterling who forwarded it to the Journal.

—Ed. n VOL. LVIII • NO. 4 • 2017

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F R O M

T H E

E D I T O R

Lifting the Veil

A

patient awaits. He’s a 65-year-old male with multiple back surgeries, a thick file in his hands, a complicated medical history, and a long history of chronic pain and opiate dependence. He seems trustworthy and his clinical exam is consistent with his stated history. Years ago, physicians had few tools to verify their trust of a patient other than a gut feeling. Skilled addicts no doubt manipulated many well-meaning physicians Lucius M. Lampton, MD trying to do the right thing. Today, Editor physicians in Mississippi have two indispensable tools which help us lift the veil of deception, revealing truth in our attempts prescribe appropriately controlled substances: the Prescription Monitoring Program (PMP) and urine drug screens.

Physicians use many variables in their clinical decisions to write any controlled substances responsibly, but these two easy-to-use tools must be utilized routinely for any patients requiring controlled substances. The PMP allows any physician (or a designated clinical staff person) to obtain an extensive history of every controlled substance a patient has received. The

PMP alone can end so-called “doctor shopping” and allows physicians to confirm compliance with contracts. Amazing are the numbers of controlled substances patients are getting from dentists, various ERs, and even other docs they’ve never told you about. Urine drug screens are also extraordinarily helpful in substantiating patient compliance and honesty. They have their limitations, and physicians need to understand their nuances, but that said, 99% of the time, drug screens expose patient mendacity, allowing the physician to determine appropriate action.

Back to my patient: his PMP revealed he had seen two other doctors in the past 3 weeks receiving 2 months of his opiates in a single month. His drug screen was not only positive for cocaine and marijuana but negative for his opiates and another routine controlled agent. Interpretation: he has a cocaine and marijuana habit that he’s financing by selling his opiates and benzos. He certainly wasn’t getting any meds from me that day. As he wheelchaired out of my office, I wondered if 10 years ago my inability to lift the veil of deception would have resulted in the wrong medical decision. n Contact me at lukelampton@cableone.net.

— Lucius M. Lampton, MD, Editor

JOURNAL EDITORIAL ADVISORY BOARD Timothy J. Alford, MD Family Physician, Kosy Direct Care

Bradford J. Dye, III, MD Ear Nose & Throat Consultants, Oxford

Michael Artigues, MD Pediatrician, McComb Children’s Clinic

Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist, Medical Associates of Vicksburg

Diane K. Beebe, MD Professor and Chair, Department of Family Medicine, University of Mississippi Medical Center, Jackson Rep. Sidney W. Bondurant, MD Retired Obstetrician-Gynecologist, Madison Jennifer J. Bryan, MD Assistant Professor, Department of Family Medicine University of Mississippi Medical Center, Jackson Jeffrey D. Carron, MD Professor, Department of Otolaryngology & Communicative Sciences, University of Mississippi Medical Center, Jackson Gordon (Mike) Castleberry, MD Urologist, Starkville Urology Clinic Matthew deShazo, MD, MPH Assistant Professor-Cardiology, University of Mississippi Medical Center, Jackson Thomas E. Dobbs, MD, MPH Chief Medical Officer, VP Quality, South Central Regional Medical Center & Infectious Diseases Consultant, Mississippi State Department of Health, Hattiesburg Sharon Douglas, MD Professor of Medicine and Associate Dean for VA Education, University of Mississippi School of Medicine, Associate Chief of Staff for Education and Ethics, G.V. Montgomery VA Medical Center, Jackson

110 VOL. 58 • NO. 4 • 2017

Brett C. Lampton, MD Internist/Hospitalist, Baptist Memorial Hospital, Oxford Philip L. Levin, MD President, Gulf Coast Writers Association Emergency Medicine Physician, Gulfport

Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson

Lillian Lien, MD Professor and Director, Division of Endocrinology, University of Mississippi Medical Center, Jackson

Maxie L. Gordon, MD Assistant Professor, Department of Psychiatry and Human Behavior, Director of the Adult Inpatient Psychiatry Unit and Medical Student Education, University of Mississippi Medical Center, Jackson

William Lineaweaver, MD Editor, Annals of Plastic Surgery, Medical Director, JMS Burn and Reconstruction Center, Brandon

Nitin K. Gupta, MD Assistant Professor-Digestive Diseases, University of Mississippi Medical Center, Jackson Scott Hambleton, MD Medical Director, Mississippi Professionals Health Program, Ridgeland J. Edward Hill, MD Family Physician, Oxford W. Mark Horne, MD Internist, Jefferson Medical Associates, Laurel Daniel W. Jones, MD Sanderson Chair in Obesity, Metabolic Diseases and Nutrition Director, Clinical and Population Science, Mississippi Center for Obesity Research, Professor of Medicine and Physiology, Interim Chair, Department of Medicine Ben E. Kitchens, MD Family Physician, Iuka

Michael D. Maples, MD Vice President and Chief of Medical Operations, Baptist Health Systems Heddy-Dale Matthias, MD Anesthesiologist, Critical Care Internist, Madison Jason G. Murphy, MD Surgeon, Surgical Clinic Associates, Jackson Alan R. Moore, MD Clinical Neurophysiologist, Muscle and Nerve, Jackson Paul “Hal” Moore Jr., MD Radiologist, Singing River Radiology Group, Pascagoula Ann Myers, MD Rheumatologist , Mississippi Arthritis Clinic, Jackson Darden H. North, MD Obstetrician/Gynecologist , Jackson Health Care-Women, Flowood

Jack D. Owens, MD, MPH Neonatologist, Newborn Associates, Flowood Michelle Y. Owens, MD Associate Professor, Vice-Chair of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson Jimmy L. Stewart, Jr., MD Program Director, Combined Internal Medicine/ Pediatrics Residency Program, Associate Professor of Medicine and Pediatrics University of Mississippi Medical Center, Jackson Shou J. Tang, MD Professor and Director, Division of Digestive Diseases, University of Mississippi Medical Center, Jackson Samuel Calvin Thigpen, MD Hematology-Oncology Fellow, Department of Medicine, University of Mississippi Medical Center, Jackson Thad F. Waites, MD Clinical Cardiologist, Hattiesburg Clinic W. Lamar Weems, MD Urologist, Jackson Chris E. Wiggins, MD Orthopaedic Surgeon, Bienville Orthopaedic Specialists, Pascagoula John E. Wilkaitis, MD Chief Medical Officer, Brentwood Behavioral Healthcare, Flowood Sloan C. Youngblood, MD Assistant Medical Director, Department of Anesthesiology, University of Mississippi Medical Center, Jackson

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JOURNAL MSMA

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S C I E N T I F I C

Advances in Dementia Care Using Telemedicine NETRALI PATEL, MD; ANUJ MARYA, MD; DENISE LAFFERTY, RN; ANDREW MAJESTE, RN Over 5 million Americans are currently impacted by Alzheimer’s disease, and this number is expected to increase to nearly sixteen million by the year 2050.1 More than 52,000 Mississippians have Alzheimer’s or another type of dementia.2 Complicating delivery of care, 54% of Mississippians live in rural areas and 76 of Mississippi’s 82 counties are designated as health professional shortage areas.3,4 On average, Mississippi residents must drive over forty minutes to receive specialized health care.5 In 2014, the Memory Impairment and Neurodegenerative Dementia (MIND) Center and the Center for Telehealth at the University of Mississippi Medical Center (UMMC) launched “TeleMIND,” a partnership program which provides clinical services to patients experiencing cognitive decline and memory loss associated with Alzheimer’s disease or other dementias in remote areas of Mississippi.

Local providers are sent an after-visit summary following each appointment, and direct phone and email contact is made when indicated. The TeleMIND program also offers counseling, education, and support for caregivers to better manage disease symptoms as well as caregiver burden (Figure 2). In addition, TeleMIND providers offer guidance on difficult issues such as assisted living, skilled nursing or home health placement, as well as legal considerations. Once a treatment plan is established, the patient is seen in the TeleMIND program every three to six months for dementia management and instructed to follow-up with their local physician for all other medical needs. TeleMIND visits are reimbursed in the same manner as outpatient visits at the MIND Center Clinic in Jackson by Medicare and other payers, and the patient is responsible for paying a standard co-pay.

TeleMIND patients are evaluated using secure, real-time, audiovisual technology and have access to many of the same services provided to patients at the MIND Center Clinic in Jackson. A TeleMIND visit includes a comprehensive ninety-minute evaluation consisting of a cognitive evaluation, a complete history, physical and neurological exam, neurocognitive testing, and depression screening. Patients are encouraged to bring a family caregiver who can report on memory and cognitive changes they may have observed. Diagnostic labs and imaging studies, as well as pharmacological and behavioral therapies, are ordered when indicated. Ongoing care includes continued monitoring of disease progression, medication management, and communication with primary care providers to determine the best treatment options for each patient (Figure 1).

FIGURE 2. Dr. Gwen Windham, geriatrician (on screen), and Sue Ann Meng, social worker, coordinate care utilizing telehealth technology to provide memory and dementia care to patients in Lexington, MS.

FIGURE 1. Dr. Netrali Patel, director of the MIND Center Clinic, demonstrates a basic TeleMIND visit from her desk in Jackson. Her patient is over 100 miles away at the UMMC Grenada clinic. TeleMIND allows aging patients and their caregivers to remotely access health care services with clinicians specializing in the treatment of dementia-related issues.

112 VOL. 58 • NO. 4 • 2017

Using specialized equipment, MIND Center physicians in Jackson evaluate and diagnose patients at the remote or “originating site” utilizing a GlobalMed ClinicalAccess® Station. This technology allows a live, face-to-face interaction, facilitated by an on-site staff nurse. The MIND Center physician collects objective data through an examination camera and stethoscope that transmits heart and lung sounds via enhanced Bluetooth technology.6 The remote site nurses are trained by MIND Center staff to support TeleMIND patient appointments and are competent in administering MIND Center Clinic evaluation tools including: the Mini Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), Geriatric Depression Scale (GDS), heart and lung auscultation, and a neurological exam. For more information on eligibility guidelines, conditions treated and services provided through TeleMIND, please reference the Table.

References Table. Services Provided by the TeleMIND Program Eligibility Guidelines

Conditions Treated

Memory loss

Alzheimer’s disease

Cognitive impairment

Lewy body disease

Differential diagnosis of dementia syndromes

Frontotemporal dementia

Dementia medication management

Parkinson’s disease dementia

Vascular dementia

Polypharmacy management Multiple system atrophy Behavior management Progressive supranuclear palsy Family and caregiver support and guidance

Services Provided Clinical assessment and neurological exam Comprehensive memory and cognitive evaluation Geriatric depression screening Evaluation of diagnostic labs and imaging studies including CT scan and MRI

Mild cognitive impairment

Pharmacological and behavioral therapies and management

Reversible causes of dementia

Support and education for families and caregivers

Pseudo dementia

Each of the MIND Center physicians who conduct TeleMIND appointments spends a great deal of time educating the patient and caregiver about the progression of dementia, lifestyle and diet changes to promote brain health, and available community resources.

Community education and support for family members caring for dementia patients is an important mission of the MIND Center and TeleMIND program. Educational programs focus on informative topics for families and caregivers such as promoting brain health, recognizing the signs and symptoms of Alzheimer’s and other dementias, diagnosis and treatment, behavior management, and legal, financial, and end-of-life considerations.

The TeleMIND program is supported financially by state and community or private funding and is being implemented through a three-phased approach. Phase 1 involved launching TeleMIND at four outpatient/ambulatory sites in the Mississippi Delta to bring dementia-care services to this area where there is a shortage of geriatric and neurology specialists. The TeleMIND program is currently available in Holmes, Grenada, Bolivar, and Leflore Counties. Phase 2 will expand TeleMIND to outpatient sites in Lee, Franklin, Lafayette, and Harrison Counties to create a statewide footprint of specialized care for patients with memory loss and cognitive impairment. In Phase 3, TeleMIND will be expanded to serve nursing homes and home health patients across the state.

Since its inception, TeleMIND has provided more than 100 patient consultations at its four sites in the Delta region. TeleMIND is providing a service to residents of Mississippi who often have immense difficulty going to even their local clinics. Patients with cognitive impairments and their family caregivers frequently find travel a huge challenge, and TeleMIND makes navigating the medical system a little easier. Through its clinical and educational efforts, TeleMIND expands access to state-of-the-art treatment to reduce the suffering and burden of cognitive decline and dementia in Mississippi.

1. Latest Alzheimer’s Facts and Figures. Alzheimer’s Association website. http://www.alz.org/facts/overview.asp. Accessed February 7, 2017.

2. Mississippi Alzheimer’s State Fact Sheet. Alzheimer’s Association website. http://www.alz.org/documents_custom/facts_2016/statesheet_ mississippi.pdf ?type=interior_map&facts=undefined&facts=facts.

Accessed February 7, 2017.

3.

Alzheimer’s National Statistics. US Department of Agriculture Economic Research Service. https://data.ers.usda.gov/reports.aspx?StateFIPS=28& StateName=Mississippi&ID=10633. Accessed February 7, 2017.

4.

Mississippi county health rankings report 2014. Mississippi State Department of Health. http://msdh.ms.gov/msdhsite/_static/31,0,211. html. Accessed February 7, 2017.

5. University Center for Telehealth. The Center for Telehealth at University of Mississippi Medical Center. https://www.umc.edu/Administration/ Centers_and_Institutes/Center_for_Telehealth/About_University_ Center_for_Telehealth.aspx. Accessed February 7, 2017.

6. Dr. Netrali Patel Demonstrates TeleMIND. The MIND Center. https:// www.youtube.com/watch?v=SZSGChbdeGY&index=6&list+PLS03 qogTQiCpFwPcBx5sHataCqEqIg JmN. Accessed February 20, 2017.

Author Information: Assistant Professor in the Department of Medicine and Family Medicine, University of Mississippi Medical Center. Clinical Director of the MIND Center. Earned her MD from Ross University School of Medicine in 2008.

Completed her residency in Family Medicine at St. Vincent’s Medical Center in 2011 (Dr. Patel). Fellow in Geriatrics at UMMC who graduated in June, 2017. Completed undergraduate studies at Michigan State University and graduated St. Matthew’s University School of Medicine in December, 2011.

Completed his Family Medicine Residency at University of Mississippi Medical Center prior to the Geriatric fellowship. Certified by the American Board of Family Medicine physicians (Dr. Marya). Bachelor of Science degree in Nursing from Widener University in Philadelphia, Pennsylvania, practiced clinically at the Medical College of Pennsylvania Hospital in Medical-Surgical, ICU and Dialysis nursing for six (6) years, and in total has over thirty (30) years’ experience in the health care field. Ms. Lafferty has full operational and business oversight of the Center and was instrumental in launching The MIND Center’s telemedicine program (“TeleMIND”) in 2014 (Ms. Lafferty). Clinical research nurse for the MIND Center and Department of Neurology at the University of Mississippi Medical Center.

Experience in neuroscience intensive care nursing, stroke nursing, and telemetry/medical-surgical nursing. Doctoral student at the University of Mississippi Medical Center and expected to receive the Doctorate of Nursing Practice (DNP) degree in spring 2019 (Mr. Majeste).

Author Correspondance: TeleMIND program, Ph: 601-815-4237 or mindcenter@umc.edu.

For more information, contact the TeleMIND program at 601-8154237 or mindcenter@umc.edu. n

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Pelvic Synovial Sarcoma of Unknown Primary Origin CHRISTIE THERIOT, MD

Abstract A case report of a 26-year-old woman presenting with pelvic pain for one month duration. The physical exam was unremarkable, but a right pelvic mass was found on ultrasound.

Computed tomography (CT) of the abdomen/ pelvis confirmed a heterogeneous 6 x 4.4 cm mass within the right pelvis adjacent to the superior-lateral aspect of the uterus. Laproscopy was performed and the mass was found to be friable and necrotic. The origin of the mass was not able to be determined due to the collapse of the mass upon instrumentation. Histology revealed spindle cells. Further studies, including immunochemical staining, revealed a synovial sarcoma. Patient underwent laparotomy for staging and in hopes of obtaining clear tumor margins. Surgery revealed subsequent tumors involving the mesentery of the small intestine and the peritoneal wall. Biopsies taken at surgery did not reveal the primary origin of the original pelvic tumor. Despite complications, the patient remains alive and free of disease six years after diagnosis.

Objective Update to a previous article on presentation of a rare case of synovial sarcoma, to make the reader aware of a rare site synovial sarcoma, illustrate the necessity for a wide differential diagnosis, discuss accurate diagnosis including advanced immunohistochemical staining, and overview treatment options and prognosis.

Table 1. Summary of previously reported cases of synovial sarcoma of the small intestine/mesentery/omentum Reference Location Age/Sex Type Size (cm) Helliwell 199533 Ileal Mesentery 46/M Biphasic 9x7x7 Chan 200429 Jejunum 28/M Monophasic 15 Hemmings 20045 Omentum 37/F NK 15 Wang 200617 Omentum 66/M Biphasic 20x20x10 Schreiber-Facklam 200734 Duodenum 39/F Monophasic 5x4 Company-Campins 200930 Duodenum 69/F Monophasic 8x7x3 Garcia-Ruiz 201032 Duodenum 70/M Biphasic 9 Eriksen 201031 Mid Ileum 39/F Monophasic 4x5 Alsharief 201028 Ileum 29/F Monophasic 8x7x3 Martinez 201041 Mesentary 63/M Poorly 40x26x8 Differentiated Ryu 201243 Jejunum 59/M Monophasic 12x10x5 Mesentary Wong 201442 Jejunum 17/M Monophasic 14 Mesentary Romeo 201536 Ileum 49/M Monophasic 8 Romeo 201536 Ileum/Colon 17/M Monophasic 7.5

Outcome ANED 9m DOD 1m DOD 3y DOD 2 m ARD 8m DOD 1m NK ANED 24m ANED 24m ANED 11m ARD 2y ANED 9 m DOD 60m ANED 108 m

ANED-alive, no evidence of disease, DOD-died of disease, ARD-alive with recurrent disease, DOC-died of other causes, LTF-lost to follow up, NK-not known, m-months after diagnosis, y-years after diagnosis

Table 2. Summary of previously reported cases of synovial sarcoma of the pelvis Reference Location Age/Sex Adam 198420 Pelvis-side wall 25/M Fisher 200411 Pelvis-midline 72/F presacral Fisher 200411 Pelvis-side wall 38/M Fisher 200411 Pelvis-side wall 45/F Rekhi 200819 Pelvis-infero-lateral 19/M

to the urinary

bladder extending

into the thigh Hasan 201340 Abdomino-Pelvis- 17/M

extending into the thigh

Type Biphasic Monophasic

Size (cm) NK 11

Outcome ANED 24m DOD 24m

Biphasic Monophasic Poorly Differentiated

NK 9 1.5 x 1 x 0.4

DOD 24m ARD 43m NK-LTF

Poorly Differentiated

NK

ANED 12m

Key Words: S ynovial sarcoma, pelvic ANED- alive, no evidence of disease, DOD- died of disease, ARD- alive with recurrent disease, DOC- died of other synovial sarcoma, abdominal causes, LTF- lost to follow-up, NK- not known, m- months after diagnosis synovial sarcoma, rare site synovial sarcoma, synovial Introduction sarcoma of unknown origin, small intestine synovial Synovial sarcoma is a rare malignancy that arises from soft tissues. It sarcoma, mesentery synovial sarcoma, duodenal represents approximately 5-10% of soft tissue sarcomas1,2,3,4 and most synovial sarcoma, TLE-1 often arises from the extremities of young adults, usually between 114 VOL. 58 • NO. 4 • 2017

the ages of 15 and 35 years.5,6 On rare occasions, it may arise from such sites as the head and neck,7 thorax,6 breast,8 abdominal wall,9 abdomen,10,11,12,13,14,15,16,17,18 pelvis,11,19 retroperitoneum,11,20,21 vulva/ vagina,22,23 and inguinal region.24,25 Other rare sites of origin are from visceral organs such as the heart,26 pleura/ lung,27 mesentery/ omentum/small intestine (Table 1),5,28,29,30,31,32,33,34,35,36 kidneys,37 and prostate.38,39 These rare sites make up approximately 5-15% of synovial sarcoma locations14,17 with intra-abdominal synovial sarcomas being extremely rare. Studies have documented only approximately 33 known cases,11 with very few known cases of pelvic origin (Table 2).11,19,40 Based upon literature search, this is the second case to be documented involving the small intestine mesentery; however, since this patient’s presentation at least five other mesentary synovial sarcomas have been documented in the literature.41,42,43 Synovial sarcoma histologically resembles synovium, exhibiting a distinctive biphasic or monophasic variation of spindle and epithelial cells with a poorly differentiated variety occasionally occurring. Synovial sarcoma is a mesenchymal tumor and not a malignancy of synovium, rarely involving the joints.2,3,10,21 Differentiating synovial sarcoma from other tumors with similar histology can be challenging.

FIGURE 1. Computed tomography (CT) confirmed a heterogeneous, vascular, soft tissue mass measuring 6 x 4.4 cm, located adjacent to the superior-lateral aspect of the uterus on the right.

that leads to a SYT-SSX fusion gene, which is believed to lead to transcription dysregulation.1,3,4,44,45 This is an integral part of diagnosis given the overlap in staining for different solitary tumors of the abdomen. There is great variation in strong or weak staining for CD34, CD99, cytokeratin S100, Muscle specific actin, desmin, CD117, and DOG1 within different synovial sarcoma tumors and amongst other solitary fibrous tumors of the mesentary and abdomen.35,36,42,43 In this paper, a case of intra-abdominal synovial sarcoma is described with tumor of unknown primary and subsequent tumors involving the mesentery of the small intestine and peritoneal wall, with histological confirmation of synovial sarcoma.

Case Report A 26-year-old nulliparous white female presented with complaints of pelvic pain. She described intermittent painful episodes over the previous month. The pain was described as 8-9 out of 10 in intensity, located in the right flank and pelvis, with radiation to the groin. The sharp, throbbing pain began at maximum intensity and remained present for approximately 2-6 hours before subsiding. She reported five of these painful episodes without any association to time of day, eating, urination, bowel function, or menstrual cycle. She denied any other symptoms, including nausea, vomiting, menstrual irregularities or changes in bowel or bladder function. Her only medication was oral contraceptives, and review of systems was negative except as stated.

Past medical history was significant for asthma, migraine headaches, and an aspirin-induced GI bleed. Past surgical history was significant for strabismus surgery. Family history was unremarkable.

Synovial sarcoma can occur in a variety of anatomic locations, leading to great difficulty with narrowing a differential diagnosis. This becomes even more complicated given the overlapping clinicopathological features. Differential diagnosis ranges greatly based upon tumor location. Intra-abdominal tumors and especially tumors of the mesentary can have a wide range of morpholgical features from fibrous lesions to highly cellular lesions. There is significant variation in vasculature and hyalization. Differentials include gastrointestinal stromal tumor, soft tissue tumor of the mesentary, synovial sarcoma, mesenteric fibromatosis, sclerosing mesenteritis, inflammatory pseudotumor, desmoplastic small round cell tumor, and solitary fibrous tumor.35,36,42,43 This is why immunohistochemical staining becomes of utmost importance to accurately diagnose and determine treatment course.

Immunohistochemical staining with cytokeratin, vimentin,14 and EMA4,10,15,23,44 are important parts of diagnosis. Diagnosis is confirmed by presence of a reciprocal translocation t(x;18) (p11.2;q11.2)

The patient’s vital signs were within normal limits, and physical exam revealed mild diffuse abdominal tenderness to palpation, slightly worse in the right lower quadrant but with no guarding or rebound and no appreciated masses. Initial workup consisted of blood work, including complete blood count, complete metabolic panel, urinalysis and a plain film abdominal xray. All laboratory tests and the abdominal film were within normal limits. Patient was then referred to a local gynecologist for further evaluation as an ovarian cyst was suspected as the most likely cause. Transvaginal ultrasound revealed a large pelvic mass in the right adnexal region. Computed tomography (CT) confirmed a heterogeneous, vascular, soft tissue mass measuring 6 x 4.4 cm, located adjacent to the superior-lateral aspect of the uterus on the right (Figure 1). Based on these findings, a pedunculated fibroid was suspected and the patient was scheduled for diagnostic laparoscopy and resection of the mass.

During laproscopic surgery, a large, very friable tumor was discovered in the right posterior aspect along the base of the broad ligament.

Upon instrumentation, the mass collapsed and was removed with an endobag. No specific origin, attachment, or specific vascular supply was able to be identified, although the peritoneum where the mass was situated appeared very inflamed. All organs otherwise appeared normal upon inspection. Examination of a frozen section was performed intra-operatively and revealed highly cellular spindle cell architecture.

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FIGURE 2. (A)- High power photomicrograph of the pelvic tumor illustrating a high grade spindle cell tumor. (B)-Immunohistochemical staining showing spindle cells positive for Keratin. (C)- Spindle cell tumor positive for TLE-1 confirm the diagnosis of synovial sarcoma.

A

B peritoneum. Appendectomy, along with lymph node sampling and biopsy were also performed.

Pathology

C The mass was sent out for further histologic identification. (Figure 2A) Gross examination revealed a tan tumor with areas of hemorrhage.

Advanced immunohistochemical staining was performed for definitive tissue diagnosis, and positive stains for pankeratin (Figure 2B) and TLE-1 (a marker for the unique SYT-SSX fusion transcript) (Figure 2C) ruled out other etiologies and confirmed synovial sarcoma grade 3.

Staging work up was then begun. The chest CT did not identify an origin for the mass, nor did it identify any lesions suspicious for lung metastasis. PET scan revealed another 2cm nodule and abnormal uptake in the pelvic peritoneum.

Due to lack of confirmation of clear margins from the initial laproscopic procedure, the patient was scheduled for open laparotomy and cancer staging. Upon visual examination of the small bowel, a necrotic mass was noted on the mesentery approximately two feet from the terminal ileum. This finding resulted in a small bowel resection, along with the involved mesentery and adherent omentum. Nodularity seen in the right peritoneum with thickening over the cul-de-sac and posterior uterus resulted in a radical hysterectomy and resection of cul-de-sac 116 VOL. 58 • NO. 4 • 2017

All resected tissue was sent for pathology along with peritoneal washings. There were no malignant cells identifiable within the washings. The small bowel section along with accompanying mesentery showed monophasic synovial sarcoma measuring 2.4 x 2 x 1.5 cm. Tissue staining was positive for vimentin, pankeratin and EMA, with a mitotic rate of 18-20 per 10 HPF. These findings were consistent with the initial diagnosis of grade 3 synovial sarcoma. There was mesothelial hyperplasia and chronic inflammation of the omentum but no malignancy. There was also a focal monophasic synovial sarcoma satellite nodule on the right pericolic gutter peritoneum.

Sigmoid peritoneal biopsy revealed focal caseating granulomas which were negative for acid-fast bacteria (AFB) and Gomori’s methenamine silver(GMS) stains with no malignancy. Uterus, fallopian tubes, ovaries and serosa also showed caseating granulomas negative for AFB, GMS stains, as well as no malignancy. All lymph nodes examined were negative for tumor.

Subsequent Treatment The patient recovered from surgery well and began inpatient chemotherapy four weeks following surgery. Chosen chemotherapy treatment was six inpatient cycles consisting of Mesna, Adriamycin, Ifosfamide, and Dacarbazine (MAID). Each cycle consisted of three 24-hour infusions of MAID and one additional 24 hour infusion of Mesna. All six cycles were completed. The patient’s follow up CT and PET scans at 6 months revealed no recurrence or metastatic disease.

The patient then began treatment with 45 Gray (Gy) of external beam radiotherapy to the abdomen and pelvis.

After super vena cava thrombosis at the patient’s port site and a small bowel obstruction requiring surgical intervention with repeat small bowel resection, 6 years post diagnosis the patient continues to do well and she has returned to her full normal activity, and all follow-up testing has shown no evidence of disease recurrence.

Discussion Synovial sarcoma is a slow growing, high-grade soft tissue sarcoma.

It comprises approximately 5-10% of soft tissue sarcomas.1,2,3,4 It is generally a disease of adults, usually between the ages of 15 and 35 years.5,6 Synovial sarcoma is not, as its name implies, a malignancy of synovium but rather a mesenchymal tumor.2,3,16,21,22 Histologically, synovial sarcoma consists of spindle or epithelial cells with 30% being the biphasic subtype and 70% being the monophasic subtype.44 Poorly differentiated synovial sarcoma also exists with characteristic areas of high cellularity, little pleomorphism, numerous mitoses and necrosis.11,22,23 Although synovial sarcoma is graded by mitosis, necrosis, and tumor differentiation, it should be regarded as a high grade sarcoma.9 All subtypes of synovial sarcoma exhibit a reciprocal translocation t(X;18) (p11.2; q11.2). The SYT (also known as SS18) gene on chromosome 18q11 becomes fused with SSX1, SSX2, or SSX4 on Xp11.2.22 The exact mechanism of oncogenicity is unclear. It is believed that the fusion gene SYT-SSX leads to transcription dysregulation1,3,4 by upregulation of NCOA3, a protein that has been linked to the formation of many cancers.45 Synovial sarcoma most often involves the extremities, near joints, especially the knee. There, however, have been other primary sites noted, some exceptionally rare. These include the head and neck,7 thorax,6 breast,8 abdominal wall,9 abdomen (Table 1),10,11,12,13,14,15,16,7,18 pelvis (Table 2),11,19 retroperitoneum,11,20,21 inguinal region,24,25 vulva/ vagina,22,23 and multiple organs including the heart,26 lungs/pleura,27 small intestine/mesentery/omentum,5,28,29,30,31,32,33,34,35,36 kidneys,37 and prostate.38,39 Synovial sarcoma of nerves has also been documented.46 Synovial sarcoma has even presented as a distant pelvic metastasis from a rare primary site.8 This case represents one of very few pelvic cases of known synovial sarcoma. It is not uncommon for the primary site of retroperitoneal synovial sarcoma to be listed as unknown in the literature, especially when tumor size is large. In this case, there is no definitive location of primary of the original pelvic tumor. It is not believed that this tumor was an extension of the mesentery tumor or peritoneal tumors found during laparotomy due to distinct locations that were not within one plane. The tumor within the small intestine mesentery is, to the author’s knowledge, the second documented in this area in the current literature, although documentation in the literature is becoming more frequent. Finally, there are no other distant synovial sarcoma tumors detected; therefore, this pelvic synovial sarcoma may represent a primary tumor and is not felt to represent distant metastasis.

Synovial sarcoma is an aggressive disease and prognosis is generally poor. The presence of large tumor size, metastases at diagnosis, high histological grade, disease of the trunk, and inability to get clear margins at surgery are all associated with a worse prognosis.2,22 Metastasis is often seen in 50-70% of cases.2 Five year survival rates are approximately 25-75%.2,15 Local recurrence is not uncommon and distant, sometimes late, metastasis2,14,21 particularly to the lung,2,11,16,21 is often seen with pelvic synovial sarcoma.10,11,15 The frequency of late metastasis leads to a ten year survival rate of 20-63%, requiring close

and long term follow-up for a minimum of ten years. Surgery with wide local excision, amputation of an affected extremity, hemipelvectomy, and hindquarter amputation are the mainstays of treatment.28,47,48,49 This is of particular challenge for pelvic lesions given their proximity to vial structures and the complexity of the pelvic anatomy. The role of chemotherapy and radiotherapy are controversial but are often used as adjuvant therapy prior to surgery and to aid in preventing or suppressing metastasis.2,14,31,50 The use of wide excision was utilized in this case and affirms the need for clear margins to give the patient the best opportunity for survival.

It also tests the use of systemic chemotherapy and pelvic radiotherapy as a means of preventing metastasis in an aggressive strategy against an aggressive malignancy.

Conclusion Better identification techniques have helped to identify synovial sarcomas arising from unusual sites throughout the body. Therefore, synovial sarcoma should remain as a rare entity on the differential diagnosis of masses within the abdomen/pelvis. This case illustrates a rare case of synovial sarcoma of the pelvis with an unknown primary origin with an additional rare secondary site on the small bowl mesentery. It also illustrates the variations and overlap in differential diagnosis and the importance of staining techniques to accurately diagnose tumors in atypical locations. This case serves as an example of the use of wide resection, chemotherapy/radiation treatment, and the importance of long term follow-up to monitor for recurrent disease and distant metastasis.

In summary, this is a case of a 26-year-old female with pelvic synovial sarcoma of unknown primary origin and subsequent tumors of the small intestine mesentery and peritoneal wall which were felt to represent distinct primary tumors but could have represented extension of the primary tumor. The patient is alive with no evidence of disease at 72 months after diagnosis. n References 1. Jagdis A, Rubin BP, Tubbs RR, Pacheco M, Nielsen TO. Prospective evaluation of TLE1 as a diagnostic immunohistochemical marker in synovial sarcoma. Am J of Surg Pathol. 2009;33(12):1743-1751.

2. Krieg AH, Hefti F, Speth BM, et al. Synovial sarcomas usually metastasize after >5 years: a multicenter retrospective analysis with minimum follow up of 10 years for survivors. Ann Oncol. 2011;22(2):458-467.

3. Naka N, Takenaka S, Araki N, et al. Synovial sarcoma is a stem cell malignancy.

Stem Cells. 2010;28:1119-1131.

4. Tsuji S, Hisaoka M, Morimitsu Y, et al. Detection of SYT-SSX fusion transcripts in synovial sarcoma by reverse transcription-polymerase chain reaction using archival paraffin-embedded tissues. Am J Pathol. 1998;153(6):1807-1812.

5. Hemmings C, Fisher C. Primary omental synovial sarcoma: a case with cytogenetic confirmation. Pathology. 2004;36(2):208-211.

6. Kawano D, Yoshino I, Shoji F, et. al. Synovial sarcoma of the chest wall. Gen Thorac Cardiovasc Surg. 2010;58(2):95-97.

7. Simunjak B, Petric V, Bedekovic V, Cupic H, Hat J. Dimensions and outcome of synovial sarcoma of the head and neck: case presentation and review of the literature. J Otolaryngol. 2005;34(6):420-426.

8. Yoshitani K, Kido A, Honoki, K, et al. Pelvic metastasis of breast synovial sarcoma. J Orthop Sci. 2009; 14:219-223.

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9. Haas R, Bonenkamp J, Flucke Uta, et al. Snovial sarcoma of the abdominal wall: Imaging findings and review of the literature. J Radiol Case Rep. 2015;9(2):2430.

10. Buiga-Potcoava R, Crisan D, and Olinici CD. Primary intraabdominal synovial sarcoma: a case report. Rom J Gastroenterol. 2005;14(1):67-69.

11. Fisher C, Folpe AL, Hashimoto H, Weiss SW. Intra-abdominal synovial sarcoma: a clinicopathological study. Histopathology. 2004;45(3):245-253.

12. Kashima T, Matsushita H, Kuroda M, et al. Biphasic synovial sarcoma of the peritoneal cavity with t(X;18) demonstrated by reverse transcriptase polymerase chain reaction. Pathol Int. 1997;47(9):637-641.

monophasic synovial sarcoma of the duodenum with SYT/SSX2 type of translocation. Hum Pathol. 2007;38(6):946-949.

35. Val-Bernal JF, Mayorga M, Fernandex F, et al. Solitary fibrous tumor arising from the mesentery of adult patients. Report of two cases and review of the literature.

Rom J Morphol Embryol. 2014;55(1): 203-7.

36. Romeo S, Rossi S, Acosta M, et al. Primary Synovial Sarcoma (SS) of the digestive system: a molecular and clinicopathological study of fifteen cases. Clin Sarcoma Res. 2015;12(5):7.

37. Divetia M, Karpate A, Basak R, Desai SB. Synovial sarcoma of the kidney. Ann Diagn Pathol. 2008;12(5):333-339.

13. Kishino T, Morii T, Mochizuki K, et al. Unusual sonographic appearance of synovial sarcoma of the anterior abdominal wall. J Clin Ultrasound.

2009;37(4):233-235.

38. Jun L, Ke S, Zhaoming W, Linjie X, Xinru Y. Primary synovial sarcoma of the prostate: report of 2 cases and literature review. Int J Surg Pathol. 2008;16(3):329334.

14. Ko SF, Chou FF, Huang CH, et al. Primary synovial sarcoma of the gastrocolic ligament. Br J Radiol. 1998;71(844):438-440.

39. Olivetti L, Benecchi L, Corti S, et al. Monophasic Synovial Sarcoma of Prostatic Fascia: Case report and literature Review. Cas Rep Urol. 2015.

15. Narula MK, Madan R, Prakash Pathania O, et al. Primary intra-abdominal synovial sarcoma. Appl Radiol. 2007;36(7):48A-48D.

40. Hassan R, Kumar S, Rao L. Dumb-bell shaped poorly differentiated pelvic synovial sarcoma with molecular confirmation: a rare presentation of an uncommon disease entity. Indian J Pathol Microbiol. 2013;56(4): 396-8.

16. Vera J, Garcia MD, Marigil M, et al. Biphasic synovial sarcoma of the abdominal wall. Virchows Arch. 2006;449(3):367-372.

17. Wang YJ, Wen SC, Chien ST, et al. Primary intra-abdominal synovial sarcoma. J Chin Med Assoc. 2006;69(10):492-495.

18. Travaglini G, Biagette S, Alfonsi S, et al. Ann Ital Chir. 2013; 84(6).

19. Rekhi B, Jambhekar NA, Desai SB, et al. A t(X; 18) SYT-SSX2 positive synovial sarcoma in the pelvis of a young adult male: a rare case report with review of literature. Indian J Cancer. 2008;45(2):67-71.

20. Adam Y, Oland J, Halevy A, Reif R. Primary retroperitoneal soft-tissue sarcomas.

J Surg Oncol. 1984;25(1):8-11.

21.

Chatzipantelis P, Kafiri G. Retroperitoneal synovial sarcoma: A clinicopathological study of 6 cases. J BUON. 2008;13(2):211-216.

22. Asher V, Van Schalkwyk G, Bali A. Synovial sarcoma of the vulva: a case report. J Med Case Rep. 2011;5:95.

23. Sumathi VP, Fisher C, Williams A, et al. Synovial sarcoma of the vulva and vagina: A clinicopathologic and molecular genetic study of 4 cases. Int J Gynecol Pathol. 2011;30(1):84-91.

24. Fernandez BB, Hernandez FJ. Poorly differentiated synovial sarcoma. A light and electron microscopic study. Arch Pathol Lab Med. 1976;100(4):221-223.

25. Xu J, Wang J, Cui L, Wu X. Malignant inguinal monophasic synovial sarcoma: report of a case and review of the literature. World J Surg Oncol. 2010;8:102.

26. Zhang L, Qian J, Li Z, Jing H. Primary synovial sarcoma of the heart. Cardiol J. 2011;18(2):128-133.

27. Zonta S, Lovisetto F, Morbini P, Cobianchi L, Nazari S. Thoracic-abdominal approach in primary pulmonary synovial sarcoma. Asian Cardiovasc Thorac Ann. 2005;13(1):85-87.

28. Alsharief A, Fageeh M, Alabdulkarim Y. Monophasic synocial sarcoma presenting as a primary ileal mass: a case report and review of the literature. J Med Case Rep. 2012;6(1):83.

29. Chan GS, Yuen ST, Chan KW. Synovial sarcoma presenting as a polypoid jejunal mass. Histopathology. 2004;44(2):191-193.

30. Company Campins MM, Morales R, Dolz C, et al. Primary monophasic synovial sarcoma of the duodenum confirmed by cytogenetic analysis with demonstration of t(X;18): a case report. J Gastroint Liver Dis. 2008;18(1):8993.

31. Eriksen C, Burns L, Bohlke A, Haque S, Slakey DP. Management of monophasic synovial sarcoma of the small intestine. JSLS. 2010;14(3):421-425.

32. Garcia-Ruiz S, Jimenez-Rodriguez RM, Alcaide-Leon P. et al. Synovial two-phase sarcoma in third portion duodenal: clinical case and review of the literature. Re Esp Enferm Dig. 2010;102(1):62-63.

33. Helliwell T, King AP, Raraty M, et al. Biphasic synovial sarcoma in the small intestinal mesentery. Cancer. 1995;75(12):2862-2866.

34. Schreiber-Facklam H, Bode-Lesniewska B, Frigerio S, Flury R. Primary

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41. Hernan MJ, Bueno OS, Rosa J, et al. Middle aged male with recurrent episodes of confusion, aggressive behavior and loss of consciousness. Biol Asoc Med P R. 2011; 103(1): 41-4.

42. Wong NA, CAmpbell F, Shepherd NA. Abdominal monophasic synovial sarcoma is a morphological and immunohistochemical mimic of gastrointestinal stromal tumor. Histopathology. 2015; 66(7): 974-81.

43. Ryi HS, Heo I, Koh JS, et al. Primary Monophasic Synovial Sarcoma Arising in the Mesentery: Case Report of an Extremely Rare Mesenteric Sarcoma Confirmed by Molecular Detection of a SYT-SSX2 Fusion Transcript. Korean J Pathol. 2012;46(2):187-91.

44. Knosel T, Heretsch S, Altendorf-Hofmann A, et al. TLE1 is a robust diagnostic biomarker for synovial sarcomas and correlates with t(X;18): analysis of 319 cases. Eur J Cancer. 2010;46(6):1170-1176.

45.

Sun Y, Perera J, Rubin BP, Huang J. SYT-SSX1 (Synovial Sarcoma Translocated) regulates PIASy to cause overexpression of NCOA3. J Biol Chem.

2011;286(21):18623-18632.

46. Scheithauer BW, Amrami KK, Folpe AL, et al. Synovial sarcoma of nerve. Hum Pathol. 2011;42(4):568-577.

47. Puri A, Pruthi M, Gulia A. Outcomes after limb sparing resection in primary malignant pelvic tumors. Eur J Surg Oncol. 2014;40(1):27-33.

48. Truab F, Andreou D, Niethard M, et al. Biological reconstruction following the resection of malignant bone tumors of the pelvis. Sarcoma. 2013.

49. Nakamura T, Abudu A, Murata H, et al. Oncological outcome of patients with deeply located soft tissue sarcoma of the pelvis: a follow up study at minimum 5 years after diagnosis. Eur J Surg Oncol. 2013;39(9):1030-5.

50. Sugawara S, Ehara S, Hitachi S, Okada K. Patterns of soft-tissue tumor extension in and out. AJR Am J Roentgenol. 2010;194(3):746-753.

Author Information: Christie Theriot MD, DAAFP, Family Medicine, clinical faculty, North Mississippi Medical Center Family Medicine Residency, Tupelo Mississippi.

Corresponding Author: Christie Theriot, MD; 1665 South Green Street. Tupelo, MS 38801.

S C I E N T I F I C

Quality Management in Surgical Pathology VARSHA MANUCHA, MD; VEENA SHENOY, MD; MIRNA VARGAS, BSCT (ASCP); ISRAH AKHTAR, MD; DIVYA SHENOY, (M3); JACK LEWIN, MD Abstract Quality is a perceptual and subjective attribute that may be understood differently by different people. The College of American Pathologists (CAP) and other accreditation agencies mandate certain measures of quality in a pathology laboratory. However, it is up to the individual laboratory to use these guidelines to define their own quality management plan. In this article, we discuss quality in the surgical pathology laboratory as well as the different phases of quality and provide an example of quality management plan followed in our laboratory.

Introduction Elements of accuracy, timeliness and completeness of report define quality in surgical pathology.1 The quality assurance and improvement plans are categorized into three main phases (pre-analytic, analytic and post-analytic) in order to simplify the complex processes and account for all defects in the test cycle that can result in erroneous diagnoses (Table).

Three Main Phases Pre-analytic Phase This is the initial and most important phase where one error can result in a series of errors. Elements in this phase include specimen identification, adequate clinical history, appropriate fixation, appropriate specimen container or specimen bag, specimen delivery, and accessioning of specimens. Mislabeled specimens can result in grave consequences and is, therefore, the most critical specimen rejection criterion. CAP mandates that all primary specimen containers are labeled with at least two patient identifiers, and this should be maintained throughout all phases of testing. Lack of clinical history has been identified as the most common deficiency at the time of specimen receipt by the 1996 CAP- Q probe study.2 However, incorrect clinical information can be more damaging than missing information. Continued improvement in the pre-analytic phase must be an institutional goal as it involves clinicians and multiple individuals outside the laboratory.

Analytic Phase The analytic phase includes gross examination of the specimen, histological preparation, histochemical and/or immunohistochemical stains, and microscopic interpretation by the pathologist. Blind review, double-reading, case conference review, consultations, and diagnostic slide review of selected cases (new malignancies, breast biopsies, prostate biopsies, pigmented skin lesions, and others) are all considered to be different error reducing strategies. The CAP 1998 Q-probe study found that slide review of cases prior to completion lowered the rate of amended reports related to revision of diagnosis and change in information, affecting patient management or prognosis.3

At our institution, all new malignancies require a secondary review by another pathologist. All cases that are complex, unusual, or associated with unexpected findings also undergo a secondary review. Each month, approximately 10% of cases undergo intradepartmental consultation. Accurate microscopic interpretation by the pathologist not only depends on training and experience, but is also dependent on the quality of tissue sections and staining. A compromised tissue sample can lead to misdiagnosis.4 Another problem that contributes to mistakes in the analytic phase is a deficit in the number of trained histotechnologists. Automation in histology laboratories has resulted in the closure of histotechnology programs making it difficult to hire adequately trained personnel. Many laboratories have made up for this deficiency by offering in-house training in embedding and sectioning to qualified candidates. In our experience, proficiency in the principles and techniques of histology may become compromised in this type of training, increasing the likelihood of inadvertent error. Furthermore, rapid increases in technological advances such as molecular and genetic testing, automation, digital pathology, and computerization have placed more demands on histology laboratories. These changes are part of the 21st-century pathology practice.5 Post-analytic Phase The post-analytic phase begins with dictation of the gross specimen, microscopic examination, and the final diagnosis; it includes transcription, report correction, verification, and delivery.6 Pathologists must ensure completeness of the surgical report by including all necessary data which requires extensive text editing and transcriptionist’s support. Ultimately, the pathologist bears sole responsibility for the accuracy of the report.

Turnaround time (TAT) is a critical element of quality and usually covers all aspects of the laboratory test cycle. The Association of Directors of Anatomic and Surgical Pathology (ADASP) has stated that acceptable TAT should be determined on the basis of current literature and is variable depending on several factors such as: case complexity and the presence of a residency training program. It is recommended that interdepartmental working groups in each institution establish acceptable TAT that meets the laboratory capabilities and the need for timely patient care.7 Furthermore, TAT is subject to change with the advent of new technologies and other factors.

The ultimate goal of the pathologist is to serve as a consultant to other physicians by providing timely and accurate diagnoses of various diseases. The clinician’s opinion and perception is important in developing efficient laboratory services.8 Poor communication in spite of accurate and timely reports can result in physician dissatisfaction.

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findings, and delayed status of reports helps close the communication loop and allows pathologists to meet the clinician’s expectations.

Conclusion Quality assurance in surgical pathology is, to a large extent, dependent on the support it receives from the hospital, nurses and physicians. CAP recommends that every laboratory have its own quality management plan. Table 1 is an example of a quality plan in our surgical pathology laboratory. This plan not only helps the laboratory to improve but also serves as a tool that allows hospital administration and physicians to better understand the complexities of surgical pathology. n

References 1. Nakhleh RE. What is quality in surgical pathology? J Clin Pathol. 2006;59:669672.

2. Nakhleh R E, Zarbo R J. Surgical pathology specimen identification and accessioning: a College of American Pathologists Q‐Probes study of 1,004,115 cases from 417 institutions. Arch Pathol Lab Med. 1996;120:227–233.

3. Nakhleh Re, Zarbo RJ. Amended reports in surgical pathology and implications for diagnostic error detection and avoidance: a College of American Pathologists’ Q‐probes study of 1,667,547 accessioned cases in 359 laboratories. Arch Pathol Lab Med. 1998;122(4):303-309.

4. LeClaire J. Histology shortage opens doors. http://allhealthcare.monster.com/ training/articles/201-histology-shortage-opens-doors. Accessed on January 27, 2017.

Table. Example of Surgical Pathology Quality Management Plan Pre-analytic Indicator Goal Frequency of monitoring

Method

Specimen integrity ≤ 5% Daily/monthly

issues (labeling

errors, submission

errors, incorrect

clinical information)

Insufficient tissue ≤ 5% Monthly

for diagnosis Analytic Indicator Goal Frequency of monitoring

Manual and Electronically

Histology work load Daily/Monthly

(number of blocks,

slides & recuts)

Fixation/ Processing/ ≤ 2% Daily/Monthly

Microtomy problems

Quality of H&E ≤ 2% Daily/monthly staining

Quality of special ≤ 2% Each stain when stains ordered/Monthly Post-analytic Indicator Goal Frequency of monitoring

Manual/Electronically

Revised diagnosis

Extra departmental

consultancy cases – discrepancy

Frozen section- permanent discrepancy

TAT*

Method

Manual Manual Manual Method

≤ 1% ≤ 2%

Monthly Monthly

Electronically Electronically

≤ 5%

Monthly

Electronically

80%(within Monthly 48 hours)

*TAT is calculated from the time of specimen receipt to electronic release of final report

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Electronically

Electronically

5. Tufel G. Histotechnology faces new challenges and ongoing challenges.

Published on August 15, 2014. http://www.clpmag.com/2014/08/ histotechnology-faces-new-ongoing-challenges/?ref=cl-title. Accessed on January 27, 2017.

6. Fitzgibbons PL. Postanalytic variables: report adequacy and integrity. In: Nakhleh RE, Fitzgibbons PL (ed). Quality management in anatomic pathology: promoting patient safety through systems improvement and error reduction. Northfield: The College of American Pathologists. 2005:61–65.

7. Volmar KR, Idowu MO, Souers RJ, Karcher DS, Nakhleh RE. TAT for large or complex specimens in surgical pathology. A CAP Q-probes study of 56 institutions. Arch Pathol Lab Med. 2015;139:171-177.

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8. Richard J. Zarbo, Raouf E. Nakhleh, and Molly Walsh. Customer Satisfaction in Anatomic Pathology. Arch Pathol Lab Med. 2003;127(1):23-29.

MEA Medical Clinics are staffed with over 40 physicians committed to convenient, quality healthcare.

Author Information: All authors are affiliated with the University of Mississippi Medical Center, Jackson, MS. Associate Professor, Director of Surgical Pathology (Dr. Manucha). Associate Professor, Department of Pathology (Dr. V. Shenoy). Laboratory Manager (Mrs. Vargas).

Associate Professor (Dr. Akhtar). Medical Student (Miss. D. Shenoy). Professor, Director of Anatomic Pathology (Dr. Lewin).

Founded over 35 years ago, MEA continues to be an innovative and pro-active member of Mississippi’s healthcare community.

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Corresponding Author: Varsha Manucha, Associate Professor, Department of Pathology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216. Tel: 601-984-1570. Fax: 601-984-1531. E-mail: vmanucha@umc.edu.

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S C I E N T I F I C

Educational Debt in Mississippi’s Emerging Health Care Workforce SETH T. LIRETTE, MS AND RALPH H. DIDLAKE, MD Key Words: H ealth care workforce, Student debt, Health care policy Introduction Student debt associated with higher education has drawn increasing attention from educators, policy analysts, law makers, and economists.

Many factors commanding this attention are outlined in a 2015 U.S. Department of Education report which shows that more students are borrowing money for college and graduating with increasing loan burdens.1 Other data sources confirm the findings of this report including the disturbing statistic that from 2000 through 2012 the mean loan amount for first-time students in full-time undergraduate programs, adjusted for inflation, increased 36%. The total loan debt for American students is now $1.2 trillion, trailing only home mortgage as a component of consumer debt.2 This national trend is, in part, driven by the rising cost of higher education, commonly shifted to the student through tuition and fees especially in the present environment of decreasing state and federal investment at the university level.

Increasing concern about both the individual and societal impacts of this debt burden are reflected in a recent White House report addressing this issue as well as in congressional hearings, white papers from policy groups and mounting scrutiny from educational accrediting agencies.3,4,5 In Mississippi, concern about student debt has prompted the legislature to commission a task force charged with analyzing the cost of higher education in Mississippi and making recommendations about its stabilization.6 For students pursuing health care careers, employment prospects and job security are more favorable than for many new college graduates seeking employment in other sectors of the economy. However, debt burden remains considerable for graduates in health care professions.

According to the American Association of Medical Colleges (AAMC), 81% of 2015 U.S. medical students graduated with debt with 45% having debt greater than $200,000 per student.7 Analysis of data derived from nursing graduate surveys conducted from 2011 through 2014 indicates that 74% of these graduates have also incurred loan debt in order to obtain their degrees.8 Similar trends have been documented for graduates from physical therapy, pharmacy, and dental programs.9,10,11 Increasing student debt has significant implications for Mississippi’s future health care workforce. Large debt burdens can lead graduates to seek or establish practices out of state where more favorable economic conditions allow loans to be more easily repaid. For graduates who

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remain in the state, urban settings are likely to be more financially attractive than rural practice locations, perpetuating Mississippi’s long-established provider maldistribution. Efforts by the state and private foundations have been made to address both the debt load and practitioner distribution issues particularly through scholarships directed to medical and dental students. Although these scholarship programs show early promise for these two disciplines, rapidly changing health care delivery models and practice structures suggest that workforce development policy should consider all disciplines within the healthcare workforce in ways that reflect evolving teambased models of care. Toward these ends, this study analyzes educational debt burden across Mississippi students enrolled in six professional health care disciplines that contribute directly to front line ambulatory and hospital-based care in order to provide a more complete understanding of the level and potential impact of student debt on Mississippi’s emerging health care workforce.

Methods Student loan data for the graduating classes of 2012 through 2016 for six University of Mississippi Medical Center (UMMC) professional degree programs were obtained from the UMMC Office of Student Financial Aid. Data collection and analysis were performed in a manner that preserved the privacy of individual students and was conducted under a claim of exemption granted by the Institutional Review Board in compliance with U.S. Department of Health and Human Services Regulation for the Protection of Human Subjects (45 CFR 46.101(b) (4)). The educational programs studied were dentistry, dental hygiene, medicine, the bachelor of science degree in nursing, the master of science degree in occupational therapy, and the doctorate in physical therapy. Income data for physicians in residency training were taken from the AAMC 2014-2015 Survey of Resident/Fellow Stipends and Benefits Report.12 Income data for graduates from other disciplines were obtained from the Bureau of Labor Statistics database using 2015 tables.13 Means with standard deviations and counts with percentages were calculated for continuous and categorical variables, respectively.

Logistic regression models were constructed to quantify the odds of accumulating debt, stratified by program. Similarly, OLS regression was used to estimate the amount of debt associated with a one thousand dollar increase in tuition, also stratified by program, and only constructed for those students with loan debt. In order to quantify the repayment robustness of each profession, both a debt-to-income ratio and the average time to full repayment of the loan were calculated.

Eighty percent of the average salary for each profession was used to represent starting salary. Dividing debt by this value gave the debt-toincome ratio. The one exception was for medical graduates. The salary for these individuals is much lower during residency and fellowship than after entering practice. This debt-to-income ratio was divided in two parts based on an assumption that residency plus fellowship may last as long as six years. Finally, to calculate a time to full repayment, the standard formula for loan periodic payments was used assuming a 6% interest rate and a consistent 10% of monthly salary commitment to loan repayment. All analyses were completed using Stata v14.1 (StataCorp, College Station, TX).

Results Seventy percent (n=1650) of the 2354 UMMC health care students who received degrees during the six year period of this study graduated with some amount of loan debt. This debt stratified by program is shown in Table 1. The upper section gives five year averages for the classes of 2011-2015 which indicate that the level of individual debt varied widely both across and within programs. Mean loan debt for 2016 graduates (n=596), by program, is shown in the lower section of Table 1. As a proportion of the graduating class, dental students more often graduated with debt (94.1%) than any other professional discipline. For dental graduates debt ranged between $100,000 and $200,000 as they entered practice or sought specialty training. School

of Nursing graduates had the lowest proportion of students graduating with debt (53.3%) which ranged between $12,000 and $20,000. Both the proportion of nursing students with debt and the median debt level are lower than national norms.

Among all six programs studied, an increase in tuition did not significantly increase the probability of graduating with debt (all p>0.111). However, among those who did obtain loans, an increase in tuition was associated with an increase in the amount borrowed. The significance of this finding was program dependent. An increase in tuition for nursing students was not associated with an overall increase in loan debt. In contrast, each one thousand dollar increase in dental school tuition was associated with an extra $5317 dollars of debt over the five year study period (95% CI: $2208-$8425, p=0.001). Table 2 shows those programs for which tuition increases were related to increasing loan debt.

To further elucidate the ability of the average student in each program to repay debt, a debt-to-income ratio and the average time to full repayment were calculated and are presented in Table 3. Nursing graduates, on average, had both the lowest debt-to-income ratio and the quickest time to full repayment, 0.24 and 2.5 years, respectively.

Medical graduates during the years of residency and/or fellowship had, by far, the largest debt-to-income ratio, but this quickly dropped after entering into practice. Dental graduates had the longest average time to full repayment at 12.5 years.

Table 1. Loan Debt for Six Professional Degree Programs Program

N1

Percent with debt

5-Year Average (2011-2015) Dentistry 176 89 Nursing 459 59 Dental Hygiene 86 66 Occupational Therapy 174 79 Physical Therapy 290 70 Medicine 600 87 For 2016 Graduates Dentistry 34 94 Nursing 90 51 Dental Hygiene 20 65 Occupational Therapy 37 76 Physical Therapy 52 71 Medicine 128 84 1 Class size totals for the period 2 Calculation excludes students with no debt

Mean Loan Debt +SD2 $140,565 + 50,651 $ 18,573 + 11,306 $ 23,175 + 14,529 $ 52,064 + 25,595 $ 61,846 + 30,194 $147,771 + 47,885 $159,288 + 53,469 $ 18,962 + 11,530 $ 29,607 + 19,736 $ 48,584 + 25,552 $ 53,952 + 25,462 $159,074 + 48,710

Table 2. Amount of additional debt associated with each $1000 increase in tuition Program Dentistry Nursing Dental Hygiene Occupational Therapy Physical Therapy Medicine

Estimated Increase/$1000

95% CI

p-value

$5317 $368 $9008 $792 $1137 $3584

(2208, 8425) (-2193, 2928) (2615, 15400) (-4564, 6148) (-1021, 3294) (2039, 5130)

0.001 0.778 0.007 0.770 0.300 <0.001

Table 3. Average debt-to-income ratio and time to full repayment Program Avg. Debt-Income Ratio Medicine (Res./Fell.)

2.69 Medicine (In Practice) 0.52 Dentistry 0.88 Nursing 0.24 Physical Therapy 0.60 Occupational Therapy 0.62 Dental Hygiene 0.35 1 Assumes 10% of the annual salary devoted to repayment Res./Fell. = Resident/Fellow

Avg. Time to Repayment1 10 years 10 years 12.5 years 2.5 years 8.3 years 8 years 4 years

Discussion In general, personal investment in higher education carries sufficient financial reward to warrant some amount of loan debt. This is especially true in a loan environment wherein students can defer payments and secure loans using future earnings as collateral through federally subsidized programs. However, there is some “tipping point” for any level of potential income at which high principle amounts, extended pay-off terms, or excessive interest rates will limit a graduate’s freedom to make career and other life choices. For newly graduated health care professionals, this type of limitation has significant health policy implications when decisions regarding specialty selection, practice location, and practice structure are influenced. Over time, these factors can influence patient’s access to care, geographic disparities in patient outcome, and specialty misdistribution.

This study shows that although total debt correlated with the cost of tuition in only two programs, the large standard deviations within JOURNAL MSMA

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most programs indicate wide variations in individual debt. This is true even for programs such as nursing and occupational therapy which have seen more stable tuition rates (26% increase over 6 years) in comparison to medicine and dentistry wherein tuition has risen at a greater rate (39% and 35% increase over 6 years respectively). A small cohort of students is identifiable in each of the groups studied that will have longer repayment horizons than the calculated averages. For this group, financial obligations will almost certainly be a major factor in practice choices. The present study did not probe the determinants of large debt loads for these individual students, but factors such as financial literacy, socio-economic status, and predatory lending should be explored.

The finding that 70% of all students studied graduate with some level of debt provides communities, institutions, and lawmakers continued opportunity to incentivize graduates to remain in Mississippi or establish practice in underserved locations through debt assistance programs. Further, the finding that physical therapy and occupational therapy graduates have repayment times approaching those of medical and dental suggests that educational institutions should be strategic about allocating available scholarship dollars in ways that produce a balanced health care workforce.

Historically, building health care facilities such as community hospitals and developing programs designed to place additional physicians in underserved communities were the principle strategies used to address deficits in health care access. While components of these strategies may continue to have application in the current environment, new delivery models incorporating advanced practice providers, the potential of telehealth platforms, and advent of team-based care must be considered in workforce development discussions going forward and should include consideration of all professional disciplines. Such an approach will require careful analysis of longitudinal workforce data including student debt. n References 1. U.S. Department of Education. Strengthening the student loan system to better protect all borrowers. https://www2.ed.gov/documents/press-releases/ strengthening-student-loan‐system.pdf. Published October 1, 2015. Accessed December 21, 2016.

2. National Center for Education Statistics. Table 331.20. Full-time, first-time degree/certificate-seeking undergraduate students enrolled in degree-granting postsecondary institutions, by participation and average amount awarded in financial aid programs, and control and level of institution: 2000-01 through 2011-12. Digest of Education Statistics. https://nces.ed.gov/programs/digest/ d13/tables/dt13_331.20.asp. Accessed December 21, 2016.

7.

Association of American Medical Colleges. Medical student education: debt, costs, and loan repayment fact card. http://members.aamc.org/eweb/ upload/2015%20Debt%20Fact%20Card.pdf.

Published October 2015.

Accessed December 21, 2016.

8. Feeg VD, Mancino DJ. Nursing student loan debt: a secondary analysis of the national student nurses’ association annual survey of new graduates. Nurs Econ.

2014;32(5):231-239.

9. Thompson K, Coon J, Handford, L. Financing physical therapy doctoral education: methods used by entry-level students and the financial impact after graduation. J Allied Health. 2011;40(4):169-173.

10. Cain J, Campbell T, Congdon HB, et al. Pharmacy student debt and return on investment of a pharmacy education. Am J Pharm Educ. 2014;78(1):5. doi:10.5688/ajpe7815.

11. Stafford GL, Nourzad F, Lobb WK, Beall JR. The economic costs and benefits of dental education: an empirical analysis. J Dent Educ. 2014;78(11):1497-1507.

12.

Association of American Medical Colleges. Survey of resident/fellow stipends and benefits report 2014-2015. www.aamc.org/download/412558/ data/2014stipendsurveyreportfinal.pdf. Published November 2014. Accessed December 21, 2016.

13. United States Department of Labor: Bureau of Labor Statistics: Occupational Employment Statistics. www.bls.gov/oes/tables.htm. Published March, 2016.

Accessed August 15, 2016.

Author Information: Department of Data Science, School of Population Health (Ms. Lirette).

Center for Bioethics and Medical Humanities, University of Mississippi Medical Center (Dr. Didlake).

Corresponding Author: Ralph H. Didlake, MD, FACS; Associate Vice Chancellor for Academic Affairs, The University of Mississippi Medical Center, 2500 N. State Street, Jackson, MS 39216. Ph: 601-984-1198. Fax: 601-984-2970. Email: rdidlake@umc.edu.

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3. Executive Office of the President of the United States. Investing in higher education: benefits, challenges, and the state of student debt. https://www. whitehouse.gov/sites/default/files/page/files/20160718_cea_student_debt. pdf. Published July 2016. Accessed December 21, 2016.

4. Dynarski S. An economist’s perspective on student loans in the United States. https://www.brookings.edu/wp-content/uploads/2016/06/economist_ perspective_student_loans_dynarski.pdf. ES Working Paper Series. Published September 2014. Accessed December 21, 2016.

5. Council for Higher Education Accreditation. CHEA federal update. http:// www.chea.org/Government/FedUpdate/CHEA_FU48.html. Published July 9, 2015. Accessed December 21, 2016.

6. Mississippi Institutions of Higher Learning. The Cost of Higher Education in Mississippi: A Report of the IHL Tuition Study Task Force. December 2016.

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Top 10 Myths and Facts about Anesthesia for Neonates, Infants, and Children THOMAS HAMILTON, MD; MADHANKUMAR SATHYAMOORTHY, MBBS, MS, MBA Introduction Several million children receive anesthesia every year for various surgical procedures or diagnostic tests. Concerns about the anesthesia are most frequently discussed among parents and primary care providers. This article aims to discuss some of the myths and facts surrounding anesthesia in neonates, infants and children.

1

General anesthetics affect normal brain development in young infants and children. MYTH Most animal data and epidemiological studies suggest that a single short-duration exposure to anesthesia may not be harmful.1,2 The “SmartTots” consensus statement3 is that “since there is not enough information about the effects of anesthetic drugs on the brains of young children, it is not yet possible to know whether the use of these medicines poses a risk and if so, whether the risk is large enough to outweigh the benefit of the planned surgery, procedure or test.”

2

Recent upper respiratory tract (URI) infection increases the risks of anesthesia in children. FACT Elective surgery is usually rescheduled before induction of anesthesia if a child presents with fever (a temperature of more than 38°C), lethargy, mucopurulent nasal drainage, or lower respiratory tract signs, such as wheezing that does not clear with a deep cough. This is due to the increased risk of perioperative Adverse Respiratory Events (ARE), such as oxygen desaturation, breath-holding, laryngospasm, bronchospasm, etc., particularly if the URI symptoms started less than 2 weeks ago.4,5

3 4

Children need preoperative lab work before elective surgery. MYTH Healthy children without any medical conditions do not need routine lab tests and chest x-rays. A thorough history and physical exam, which includes an airway exam and chest auscultation by the anesthesiologist on the day of surgery, are acceptable.6

Children should have an empty stomach on the day of surgery. FACT Fasting (NPO) guidelines are in place to minimize the risk of aspiration. The most recent recommendations by the American Society of Anesthesiologists (ASA) for fasting guidelines for infants and children were made in 2011. Briefly, one must wait two hours for clear fluids (any transparent fluid through which one can see, such as water, pedialyte, or apple juice), four hours for breast milk, six hours for infant formula/non-human milk, and eight hours for solids.7

5

Anxiety before surgery is a significant problem in children. FACT Commonly used techniques to reduce preoperative anxiety are the use of premedication drugs, parental presence at induction, and behavioral/distraction techniques. Oral midazolam (0.5mg/kg up to a maximum dose of 20mg) is the most commonly used premedication. Utilization of a preoperative preparation workshop, avoidance of excessive reassurance to the child, distraction with videogames/tablet, and involving the child during mask induction can be equally as effective as premedication.8,9

6 7

Multimodal treatment is needed to treat moderate to severe acute pain in children after surgery. FACT Opioids such as morphine and fentanyl are most commonly used to treat acute pain after surgery. NSAIDs and regional anesthesia (caudal, epidural and peripheral nerve blocks) in appropriate cases are being used increasingly as part of multimodal pain management. They provide superior analgesia while reducing the risks of respiratory depression and other opioid-related side effects.10,11 Epidural block is not safe to perform in children under anesthesia. MYTH Epidural blocks and peripheral nerve blocks are commonly performed in children after induction of general anesthesia. The risk of nerve injury is reduced when a regional block is performed in an immobile child under general anesthesia versus an awake child who can move unexpectedly. Data published from the UK Epidural Audit, the French Language Study of Regional anesthetics (ADARPEF), and from the Pediatric Regional Anesthetic Network (PRAN) all support the safety of this practice.12,13

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8

Management of a pediatric airway is different from managing an adult airway. FACT Infants and children have a prominent occiput, a more cephalad placed larynx, and a long, floppy epiglottis. A shoulder roll to optimize the line of vision with laryngeal axis and a straight laryngoscope blade (Miller blade) to directly lift the epiglottis are commonly used for successful intubation. Laryngospasm and upper airway obstruction are more common in children. They also tend to desaturate quickly, which is only aggravated by crying and agitation.14

9

Children do not need to go to sleep completely for imaging studies. MYTH Children cannot lie still due to various developmental and cognitive issues. A perfectly still child is necessary to get proper images, especially in computed tomography (CT) or magnetic resonance imaging (MRI) where any little movement produces artifacts and makes the image difficult to read for the radiologist. General anesthesia with sevoflurane is commonly used. In some centers, total intravenous anesthesia (TIVA) with propofol or dexmedetomidine is used.15

10

Obese children are at higher risk for anesthesia. FACT Obese children have higher incidence of obstructive sleep apnea and higher sensitivity to opioids. They are at higher risk for difficult mask ventilation, difficult intubation, and adverse perioperative respiratory events. They have prolonged recovery room stays and more often need overnight admission in the hospital for monitoring and supplemental oxygen therapy.16 Conclusion Anesthesia in children is safe in the hands of the pediatric anesthesiologists and nurse anesthetists who are routinely involved in the care of these patients and risks of serious adverse events are very low. n References 1. Davidson AJ, Disma N, de Graaff JC, et al. Neurodevelopmental outcome at 2 years of age after general anaethesia and awake-regional anaethesia in infancy (GAS): an international multicentre, randomized controlled trial. Lancet. 2015 Oct 23; [Epub ahead of print].

2. Wilder RT, Flick RP, Sprung J, Katusic SK, Barbaresi WJ, Mickelson C, Gleich SJ, Schroeder DR, Weaver AL, Warner DO. Early exposure to anesthesia and learning disabilities in a population-based birth cohort. Anesthesiology. 2009 Apr;110:796-804.

3. http://www.pedsanesthesia.org/wp-content/uploads/2015/12/ConsensusStatement.pdf.

4. von Ungern-Sternberg BS, Boda K, Chambers NA, et al. Risk assessment for respiratory complications in paediatric anesthesia: A prospective cohort study. Lancet.

2010;376:773-783.

5. Tait AR, Malviya S. Anesthesia for the child with an upper respiratory tract infection: Still a dilemma? Anesth Analg. 2005;100:59-65.

6. Lerman, J. Pediatric Anesthesia. In: Barash PG, ed. Clinical Anesthesia. 7th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2013:12161256.

7. Apfelbaum JL, Caplan RA, Connis RT, et al. Updated by the American Society of Anesthesiologists (ASA) Committee on standards and practice parameters. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures. Anesthesiology. 2011;114:495-511.

8. Hilly J, Hรถrlin AL, Kinderf J, Ghez C, Menrath S, Delivet H, Brasher C, Nivoche Y, Dahmani S. Preoperative preparation workshop reduces postoperative maladaptive behavior in children. Paediatr Anaesth. 2015;25:990-8.

9. Kain ZN, Caldwell-Andrews AA, Mayes LC, Weinberg ME, Wang SM, MacLaren JE, Blount RL. Family-centered preparation for surgery improves perioperative outcomes in children: a randomized controlled trial. Anesthesiology. 2007;106:65-74.

10. Ecoffey C. Pediatric regional anesthesia-update. Curr Opin Anaesthesiol. 2007;20:232-235.

11. Willschke H, Marhofer P, Machata AM, Lรถnnqvist PA. Current trends in paediatric regional anaesthesia. Anaesthesia. 2010;65:97-104.

12. Taenzer AH, Walker BJ, Bosenberg AT, Martin L, Suresh S, Polaner DM, Wolf C, Krane EJ. Asleep versus awake: does it matter? Pediatric regional block complications by patient state: a report from the Pediatric Regional Anesthesia Network. Reg Anesth Pain Med. 2014;39:279-83.

13. Polaner DM, Drescher J. Pediatric regional anesthesia: what is the current safety record? Paediatr Anaesth. 2011;21:737-42.

14. Karsli C. Managing the challenging pediatric airway: Continuing Professional Development. Can J Anaesth. 2015;62:1000-16.

15. Tobias JD. Sedation of infants and children outside of the operating room. Curr Opin Anaesthesiol. 2015;28:478-85.

16. Mortensen A, Lenz K, Abildstrom H, et al. Anesthetizing the obsess child. Paediatr Anaesth. 2011;21:623-629.

Author Information: Resident in Anesthesiology training (PGY4), University of Mississippi Medical Center (thamilton@umc.edu) (Dr. Hamilton). Associate Professor of Anesthesiology, University of Mississippi Medical Center (msathyamoorthy@umc.edu) (Dr. Sathyamoorthy). The authors have no conflicts of interest to report.

Corresponding Author: Madhankumar Sathyamoorthy, MBBS, MS, MBA; University of Mississippi Medical Center, Department of Anesthesiology, 2500 N State Street, Jackson, MS 39216. Phone: 601-984-5900 FAX: 601-984-6283. (msathyamoorthy@umc.edu).

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Top 10 Fertility Myths You and Your Patients Should Know J. PRESTON PARRY, MD, MPH

1

“The position matters.”

From “aiming to succeed” to “hips supported by pillows after coitus,” this is one of the most persistent fertility myths. Sperm actually can reach the uterus within two minutes and the Fallopian tubes within five minutes.1 The truth is, if humans had to have perfect positioning each time to conceive and then lie still for hours, the species would have perished long ago. However, for patients wanting to back up common sense with evidence, multiple trials with fertility therapy demonstrate only brief reclining for optimal pregnancy rates.2,3

2

“I have to perfectly time intercourse.”

We see this concern frequently. Fertility becomes a fire drill, with a husband madly dashing home as soon as an LH predictor kit becomes positive. Sperm actually survive for three days with no difference in the pregnancy rates as one seminal article in the New England Journal of Medicine demonstrated.4 It showed that with a single act of coitus on the day of ovulation, one day prior or two days prior, there was no difference in pregnancy rates.

Additionally, this same article showed that there was no difference in pregnancy rates for one, two, three, four, or five acts of coitus in the days leading up to ovulation. For this reason, we advise our patients who want to conceive “spontaneously” to have relations once on approximately the 11th, 14th, and 17th days of the cycle (with day one being the first full day of heavy flow). This covers most women with regular cycles and avoids the need for LH predictor kits. Coitus can occur more frequently for those desiring it, but for those where it has become stressful or inconvenient, using a 72-hour window for optimal sperm survival may alleviate some tension.

3 4

“Bag the briefs and buy boxers.”

Scrotal temperature and sperm counts don’t seem to change meaningfully with underwear choice,5 though extremes of heat (such as can occur with prolonged hot tub use) may matter more. Similarly, cold showers won’t preserve sperm, unless showering in liquid nitrogen which would still be detrimental to reproductive health.

“Basal body temperature charting will meaningfully help me get pregnant.”

Though basal body temperature charting can provide gynecologic insight for many women, it is retrospective and, therefore, won’t help conception in a given cycle. It is even less valuable for women with irregular cycles, as they typically don’t need basal body temperature charting to know they are irregular. The “Two Day Algorithm” (where coitus can be on the day of cervical mucus change or one day prior if coincidentally occurring then) may help some, as it allows adjustment for changes in a particular menstrual cycle.6 However, using the 11/14/17 guide noted earlier, a woman with regular cycles can be completely unaware of what her body is doing and still maximize her chances for pregnancy. Further, poor timing for intercourse is a rare cause of infertility, and by the time most women would think to chart, their odds are high for a different underlying etiology, which charting would be unlikely to fix. Finally, having the first action (temperature charting) of every day serve as a reminder that one is not pregnant can exacerbate stress.

5 6

“Take a vacation and you’ll get pregnant. Just give it some time.”

In developed countries, up to 95% of infertility has an underlying etiology.7 Taking a vacation won’t fix azoospermia or repair damaged tubes. If anything, time can make matters worse, as many conditions such as diminishing ovarian reserve, endometriosis, and weight gain associated anovulation tend to progress.

“Clomiphene will greatly increase my chances.”

Given that most women with infertility are ovulatory and that a year of infertility at age 30 is associated with 2-3% monthly pregnancy rates, one has to ask how much those odds will change in going from one egg to two eggs per month. In fact, the majority of women receiving oral medication for fertility still release a single egg per month,8 so the medication isn’t helping them. For this reason, providing it can be done cost-effectively, the standard of care is increasingly shifting to combining insemination with oral 128 VOL. 58 • NO. 4 • 2017

medication (with ultrasound monitoring to optimize medication dosing for follicular recruitment), where monthly chances of pregnancy with multiple eggs released should be closer to 10-15%.9 The one exception where clomiphene can greatly increase chances is anovulatory infertility: going from zero eggs per month to one makes a huge difference. However, this is also where clinicians can get in trouble. Clomiphene can be overly successful by recruiting too many follicles, increasing the risk for multiple births. Additionally, the emerging standard of care for anovulation is letrozole instead of clomiphene, which seems to have a higher pregnancy rate, but fewer hot flashes and a trend towards a lower rate of multiples.10 However, letrozole is not FDA approved for this purpose.

7

“45 is the new 35.”

Though this may be true in other ways, it isn’t for reproduction. Media portrayal of celebrities pregnant in their late 40’s often ignores that donor egg was used. Not only does egg quantity decline with time, but quality does as well. If embryos are biopsied to assess for normal chromosomes, approximately 20-30% are abnormal in one’s late 20’s or early 30’s, but 90% are abnormal by the mid-40’s (and these may be underestimates of rates of DNA abnormalities).11 One study demonstrated the chance of live birth with IVF at 44 to be 2% and 1% at 45.12

8

“I have to wait three months after stopping the pill to get pregnant.”

In the first month after stopping oral contraceptive pills, there is a slightly higher chance of multiple pregnancies, but delays to conception are rare. In fact, oral contraceptives are used to synchronize cycles to improve pregnancy rates with in vitro fertilization.

The greatest delay to conception is not after oral contraceptives but after Depo-Provera where it can take over a year to fully regain fertility.13

9

“Stress is keeping me from getting pregnant.”

Though infertility frequently causes stress, stress is far less likely to cause infertility. Data during wars and pronounced economic transition show subtle effects on fertility.14,15 There are two primary ways stress affects fertility. First, if a woman is so stressed she stops ovulating, it is hard to get pregnant without the release of an egg. Fortunately, this is uncommon. More frequently, couples are stressed to a point where they not only fight with each other, but they also stop having sex. This scenario also meaningfully decreases the probability of conception.

10

“I have to lose weight and eat perfectly to get pregnant.”

Weight has less impact on conception than we used to think with IVF data suggesting modest effects for even morbid obesity.16 If one is anovulatory through anorexia or obesity induced PCOS, weight optimization may make more of a difference. However, it is common to walk into fast food restaurants or all you can eat buffets and see people surrounded by children, suggesting neither food quality nor quantity is critical to conception.

However, where weight can have larger impact is the pregnancy itself. Obesity does affect risks for preeclampsia, gestational diabetes (and shoulder dystocia), cesarean, and more. Additionally, the Barker hypothesis states that the intrauterine environment has long term effects on child well-being, where caloric choices in pregnancy will influence a child’s risk for diabetes and more, and studies seem to demonstrate this.17 The goal is not just conception but a healthy pregnancy and a healthy baby. n References 1. Settlage DSF, Motoshima M, Tredway DR. Sperm transport from the external cervical os to the fallopian tubes in women: a time and quantitation study. Fertil Steril.

1973;24:655-661.

2.

Purcell KJ, Schembri M, Telles TL, Fujimoto VY, Cedars MI. Bed rest after embryo transfer: a randomized controlled trial. Fertil Steril. 2007;87:322–6.

3. Custers IM, Flierman PA, Maas P, Cox T, Van Dessel T, Gerards MH, Mochtar MH, Janssen CA, van der Veen, Mol BW. Immobilisation versus immediate mobilisation after intrauterine insemination: randomised controlled trial. BMJ. 2009;339:1065-7.

4.

Wilcox AJ, Weinberg CR, Baird DD. Timing of sexual Intercourse in relation to ovulation. N Engl J Med. 1995;333(23):1517-21.

5.

Munkelwitz R, Gilbert BR. Are boxer shorts really better? A critical analysis of the role of underwear type in male subfertility. J Urol. 1998;160:1329-33.

6. Dunson DB, Sinai I, Colombo B. The relationship between cervical secretions and the daily probabilities of pregnancy: effectiveness of the TwoDay Algortihm. Hum Reprod. 2001;16: 2278-82.

7.

WHO Technical Report Series. Recent Advances in Medically Assisted Conception. 1992;820:1-111.

8. Steures P, van der Steeg JW, Hompes P, Habbema JD, Eijkemans M, Broekmans FJ, Verhoeve HR, Bossuyt P, van der Veen F, Mol B. Intrauterine insemination with controlled ovarian hyperstimulation versus expectant management for couples with unexplained subfertility and an intermediate prognosis: a randomized clinical trial.

Lancet. 2006;368:216-221.

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9. van Rumste M, Custers IM, van der Veen F, van Wely M, Evers J, Mol B. The influence of the number of follicles on pregnancy rates in intrauterine insemination with ovarian stimulation: a meta-analysis. Hum Reprod. 2008;14:563-70.

10. Legro RS, Brzyski RG, Diamond MP, Coutifaris C, Schlaff WD, Casson P, Christman GM, Huang H, Yan Q, Alvero R, Haisenleder DJ, Barnhart KT, Bates GW, Usadi R, Lucidi S, Baker V, Trussell JC, Krawetz SA, Snyder P, Ohl D, Santoro N, Eisenberg E, Zhang H. Letrozole versus clomiphene for infertility in the polycystic ovarian syndrome. N Engl J Med. 2014;371:119-129.

11. Franasiak JM, Forman EJ, Hong KH, Wemer MD, Upham KM, Treff NR, Scott RT. The nature of aneuploidy with increasing age of the female partner a review of 15,169 consecutive trophectoderm biopsies evaluated with comprehensive chromosomal screening. Fertil Steril. 2014;101:656-663.

12. Klipstein S, Regan M, Ryley DA, Goldman MB, Alper MM, Reindollar RH. One last chance for pregnancy: a review of 2,705 in vitro fertilization cycles initiated in women age 40 years and above. Fertil Steril. 2005;84:435-45.

13. McDaniel EB, Pardthaisong MA. Depot-medroxyprogesterone acetate as a contraceptive agent: Return of fertility after discontinuation of use. Contraception.

1973;407-414.

14. Agadjanian V, Prata N. War and Reproduction: Angola’s Fertility in Comparative Perspective. J S Afr Stud. 2001;27:329-47.

15. Agadjanian V, Dommaraju P, Glick JE. Reproduction in upheaval: Ethnic-specific fertility responses to societal turbulence in Kazakhstan. Pop Stud—J Demog.

2008;62:211-33.

16. Luke B, Brown MB, Stern JE, Missmer SA, Fujimoto VY, Leach R. Female obesity adversely affects assisted reproductive technology (ART) pregnancy and live birth rates. Hum Reprod. 2011;26:245-252.

17. Hales CN, Barker DJP. The thrifty phenotype hypothesis. Brit Med Bull. 2001;60:5-20.

Author Information: Corresponding Author: Dr. J. Preston Parry, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216. (jparry2@umc.edu). Reprints will not be available.

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Itawamba

Pontotoc Coahoma

Quitman

Bolivar

Yalobusha

Calhoun Monroe

Chickasaw Tallahatchie

Grenada Carroll

Montgomery

Washington

Clay Webster

Sunflower Leflore Attala

Humphreys

Issaquena

Oktibbeha Lowndes

Choctaw Winston

Noxubee

Holmes Yazoo

Madison

Leake

Neshoba

Kemper

Newton

Lauderdale

Sharkey

Warren

Scott Hinds

Adams

Clarke

Simpson

Copiah

Lincoln

Covington

Lawrence

Franklin

Marion

Pike

Forrest

Provisional Reportable Disease Statistics April 2017

Wayne

Jones

Jefferson Davis Lamar

Amite

Wilkinson

Jasper

Smith

Rankin Claiborne

Jefferson

Mississippi

Perry

Greene

Walthall George

Pearl River Stone

Northern Region Harrison

Central Region

Jackson

Hancock

Southern Region

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P R E S I D E N T ’ S

P A G E

The Value of Membership

W

hat can you do with $1.50 a day?

You might think, “Not much.” But if you’re an MSMA member, you already do a great deal with your buck fifty every day. After all, when it comes to return on investment, you can’t get much better than a membership at MSMA. A quick glance at some of the benefits that come with your $565 membership is enlightening.

•A voice with lawmakers. MSMA represents your interests before the legislature and other governing bodies, including the State Board of Medical Licensure.

This means your voice is heard on the issues that matter, from scope of practice concerns to improving public health.

•L eadership training. The Physician Leadership Academy is a unique opportunity for professional development that we offer to our members. We started the Academy in 2014 to prepare MSMA members for future leadership positions. The in-depth, nine-month program provides training in core aptitudes preparing physicians to excel as future leaders, in their own practices, and in organized medicine and the public policy arena.

•C ME. Whether in person at events like CME in the Sand or online, CME is available year round for our members. We find the CME that you need and schedule the speakers for you. And Annual Session even comes with five free hours of CME. •L egal resources. MSMA’s General Counsel provides general commentary and insight on laws and regulations that directly impact your practice. We’re often dialed in before new laws and rules are written, which gives us the opportunity to help shape the final product.

The list above is only scratching the surface of the value that comes with an MSMA membership. The membership fee of $565 a year (or $1.50 a day) is less a cost and more of an investment. If you are already a member, you know the value well. If you’re reading this and haven’t joined, now is the time. There’s no telling what the investment will do for you. n

Lee Voulters, MD; Gulfport MSMA President 2016-2017

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M S M A

This is part of a spotlight series on the MSMA Physician Leadership Academy class of 2017.

D

r. Peggy Boles remembers when she first thought about becoming a physician. She was ten years old and her little brother, Hilton, was diagnosed with leukemia. The diagnosis helped her young mind find a focus and a way to provide comfort and relief to others.

Today, Dr. Boles is an anesthesiologist, a career that matches her personality and temperament.

Peggy Boles, MD

“I chose anesthesiology because I loved the fast pace of the operating room,” she said. “I’m fascinated by the ability to manipulate physiology with our vast array of medications in real time. I also enjoy working with my hands and conducting procedures in the operating room.”

Today, as a physician at the beginning of her career, Dr. Boles has been mentored by several other professionals.

Drs. Bethea, Brunson, and Keller have all been influential in her residency and her interest in service and leadership. In addition to helping others through the practice of medicine, she looks forward to helping influence policy for physicians and their patients.

Dr. Boles said she hopes the Physician Leadership Academy will help hone her communications skills and her engagement with others, and to advocate.

“I hope this program will introduce me to new avenues in order to network with other physician leaders and advocate for our profession,” she said. “My top expectation is that the Academy will make me a more tenacious, well-rounded physician.”

Dr. Boles believes physicians should pursue great leadership roles in their communities, their states, and their country. She thinks the practice of medicine will remain stronger and more viable if the doctors who provide the treatment remain active and engaged.

“The biggest travesty would be that medical care is no longer controlled by the people who provide it,” she said. n

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A R T I C L E

A Pediatrician, Antifreeze, and the FDA OWEN B. EVANS, MD On September 24, 1937, Claiborne L. Anderson went to see his doctor for a sore throat and a headache. He had a two-year, intermittent history of back pain and right flank pain. He was prescribed six ounces of Massengill’s Sulfanilamide Elixir. Several days later, he developed severe nausea and vomiting, visual problems and “severe suppression of urine”.

Anderson was hospitalized and continued to deteriorate with hiccoughing, hearing problems and a dry throat. Urinalysis showed albuminuria. He died before the end of September and was one of the first to die after taking Massengill’s Sulfanilamide Elixir. In the month of October 1937 there were about 23 deaths in Mississippi and 107 deaths nationwide. Seventy-one people were prescribed the drug in Mississippi. Dr. Joe E. Green prescribed the Elixir for Claiborne Anderson.

Two other patients of his would also die of renal failure that month. Green prescribed the drug to seven others who survived or did not take the medication.1

Figure 1. Massengill began manufacturing and marketing the Elixir and 240 gallons was distributed nationwide in September, 1937.3

Other than being a physician who was interested in treating children, there is little information about Dr. Joe E. Green (1881-1940). He graduated from Tulane University School of Medicine in 1909. He practiced in Laurel and lived in nearby Richton. He was a founding member of the Mississippi State Pediatric Society in 1935 so he obviously had a special interest in children within his general practice. He was never a member of the American Academy of Pediatrics.2 Massengill’s Sulfanilamide Elixir was a liquid preparation of sulfanilamide, an antibiotic (Figure 1). There was a need for a liquid preparation, particularly for children. S. E. Massengill was a pharmaceutical company based in Bristol, Tennessee. The chief chemist for Massengill found that diethylene glycol (DEG) was a good solvent for sulfanilamide. The formula was 72% DEG, 10% sulfanilamide and 16% water plus other ingredients for taste and color. No studies of efficacy or safety were performed nor required.

DEG was a well-known product as an antifreeze agent, particularly for aircraft engines because Figure 2. Bottle label with prescribing of its high boiling temperature and low freezing temperature. The chemical is colorless and instructions for Sulfanilamide.6 practically odorless and has a naturally sweet taste. Massengill’s Elixir was flavored to taste like sweet raspberries. Its toxicity was known but not widely so. The chemical and its metabolites, ethylene glycol and glycolic acid, cause a metabolic acidosis resulting in renal failure, liver injury, and neurologic impairments.4 Apparently the chief chemist was not aware of its lethality. After the reporting of the mounting deaths related to the Elixir, he committed suicide.

In Mississippi, Massengill sent the drugs to 34 drug stores, 6 physician offices and 1 hospital. In Mississippi, 72 prescriptions were prescribed for 71 patients.1 Based on the amount of the drug left in the bottles of the Mississippi cases, 2-4 ounces (12-24 tsp) of the drug caused renal failure and death within 4-7 days.7 Most patients received a 6 ounce bottle which had instructions to take 2-3 tsp in water every four hours for the first day and then 1-2 tsp every 4 hours until recovery.

Based upon the estimated exposure to DEG the LD 50 is thought to be to be about 1 ml/kg.

Considering the composition of Massengill’s Elixir, about 15 teaspoons of the drug would be lethal for half those taking the medication.7 DEG is now spiked with a distasteful chemical to avoid children unknowingly taking poison.

In Mississippi and across the nation, deaths related to the drug became a national concern. The Food and Drug Administration became aware of the deaths in October 1937 and sent a recall for the drug nation wide. Only 30% was retrieved from Mississippi. Inspector Roland Sherman of the FDA office in New Orleans researched all the deaths in Mississippi. There was a clear connection between the dispensing of the drug and 134 VOL. 58 • NO. 4 • 2017

death. Mississippi had 23 deaths, one probable death, and one unlikely. This was twice the number of any other state. Sherman found that the amount of the drug sent to Mississippi was similar to that sent to surrounding states but more prescriptions were written for the drug than in surrounding states.1,3 During the FDA investigations, families were asked if any of the medication remained. Most families had destroyed or discarded what was left but some kept what was left for possible legal action. What was left in the bottles ranged from 2¾ to 4¾ ounces.

Lacking legal authority to penalize Massengill, the FDA was able to confiscate the drug by a technicality. The title “elixir” was reserved for medications that contained ethanol and Massengill’s Sulfanilamide Elixir was misbranded because it did not have ethanol in its formulation.7 In summary, from the FDA.gov website, the FDA evolved from a single chemist in the Department of Agriculture in 1862. There were concerns that food and drugs were being adulterated or misbranded and transported across state lines. At that time each state enforced its own standards but these varied greatly from state to state. In 1906, the federal Pure Food and Drugs Act was passed that prohibited interstate commerce of impure drugs and foods. In 1927 the Food, Drug, and Insecticide Administration was created and in 1930 the name was changed to the Food and Drug Administration (FDA). The FDA lacked appropriate enforcement to ensure the safety of foods and drugs, however.

According to the FDA, following the numerous deaths, many of whom were children, from Massengill’s Elixir there was a public outcry and demand for better standards to ensure drug safety. In 1938 the Food, Drug and Cosmetic Act was signed into law by President Roosevelt which required for the first time that pharmaceuticals had to show the safety of their products before marketing the drug. It wasn’t until 1962 with the passage of the Kefauver-Harris amendment to the 1938 act that required pharmaceuticals to show efficacy as well as safety before marketing a drug.

The death of Claiborne Anderson was one of the first in the nation. Dr. Green’s involvement was neither intentional nor avoidable. The deaths from the drug were tragic and preventable. However, countless lives have been saved because of the establishment and enforcement of federal FDA regulations requiring evidence of safety and efficacy of a drug prior to marketing and distribution. n References 1. Martin BL. Elixir of Sulfanilamide: Deaths in Mississippi. Pathophilia website. http://bmartinmd.com/eos-deaths-mississippi/. Accessed June 9, 2017.

2. Evans OB. A History of Mississippi Pediatrics. UMMC Department of Alumni Affairs website. https://www.umc.edu/uploadedFiles/UMC.edu/ Content/Administration/InstitutionalAdvancement/Alumni/History%20 of%20Mississippi%20Pediatrics%201.3.2.pdf. Accessed June 12, 2017.

3. Ballentine C. “Taste of Raspberries, Taste of Death- the 1937 Elixir Sulfanilamide Incident” FDA Consumer Magazine. June, 1981. Website https://www.fda.gov/aboutfda/whatwedo/history/productregulation/ sulfanilamidedisaster/. Accessed June 12, 2017.

4. Schep LJ, Slaughter RT, Temple WA, Beasley DM. Diethylene Glycol Poisoning.

Clin Toxicol. (Phila) 2009;47:840. doi: 10.1080/15563650903086444.

5.

Akst J. The elixir tragedy, 1937. Scientist. June 1, 2013.

6. Simon Cotton, Bristol University, Department of Chemistry, Molecule of the Month, Sulfanilamide (and its Relatives) Including the Drug That saved the Life of Winston Churchill. Website modified June 6, 2017. http://www.chm. bris.ac.uk/motm/motm.htm. Accessed June 12, 2017.

7. Diethylene Glycol Poisoning. Elixir Sulfanilamide-Massengill: Report of the United States Secretary of Agriculture. Cal West Med. 1938;48(1):68–70.

PMCID: PMC1705805. NCBI website. https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC1705805/pdf/calwestmed00370-0077.pdf. Accessed June 12, 2017.

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P H Y S I C I A N ’ S

B O O K S H E L F

The Mississippi Encyclopedia Finally Published, Lampton Served as Associate Editor of Medicine REVIEWED BY KAREN A. EVERS, MANAGING EDITOR

The Mississippi Encyclopedia [Book] University Press of Mississippi, 2017 1600 pages · 8.8 x 3.1 x 11.3 inches Hardback ISBN: 1628466928 eBook ISBN: 9781628466928 DLC: 2016043630 List price: $70.00 · Available online $56.00

T

he Center for the Study of Southern Culture at Ole Miss and the University Press of Mississippi recently announced the publication of The Mississippi Encyclopedia. Work on the Center for Southern Culture project that began in 2003 has climaxed with the Encyclopedia in publication. A searchable online version is in the works.

The literature describes The Mississippi Encyclopedia: A mammoth collaboration that includes over 1,600 entries, 1,451 pages, and features more than 700 scholars who wrote entries on every county, every governor, and numerous musicians, writers, artists, and activists. In browsing the attractive tabletop, conversation, and reference book, it’s everything anyone could ever want to know about Mississippi in a comprehensive, accessible and eminently readable volume. It’s an A-to-Z compendium of people, places, and events in Mississippi from prehistoric times to today.

A partnership between the Center and the Press, this multiyear project edited by Ted Ownby, Charles Reagan Wilson, Ann Abadie, Odie Lindsey, and Jimmy Thomas includes the work of 700 scholars and tells the expansive and complicated story of Mississippi and Mississippians. JMSMA Editor Dr. Lucius “Luke” Lampton of Magnolia served as Associate Editor of Medicine for the volume, writing an extended essay on the subject of Medicine in the state.

Dr. Lampton also authored ten additional entries for the volume.

These essays included: Whitfield (Mississippi State Hospital), Dr. John Wesley Monette, Dr. Samuel Cartwright, Dr. David L. Phares, Dr. Felix Underwood, Dr. Joseph Goldberger, journalist Paul Pittman, African American educator Eva Gordon, the historic John 136 VOL. 58 • NO. 4 • 2017

MAIN STREET BOOKS HOSTED A SIGNING EVENT FOR THE MISSISSIPPI ENCYCLOPEDIA -- Among the many events celebrating the publication of the Mississippi Encyclopedia was this recent author discussion and signing at Main Street Books in historic downtown Hattiesburg. From left, Encyclopedia Editor-in-Chief Ted Ownby of Oxford, Encyclopedia Medical Editor Dr. Luke Lampton of Magnolia, contributor Myron Noonkester of William Carey University, contributor Vanessa Murphree from the University of Southern Mississippi, and Main Street owners Diane and Jerry Shepherd.

Ford House, and Camp Van Dorn. A revised version of Lampton’s essay on Whitfield and the history of mental illness in the state was included in The New Encyclopedia of Southern Culture which was published by UNC Press in 2012. In addition to Lampton’s essays, The Encyclopedia includes many other entries by scholars on medical history in the state, including the topics of other physicians, hospitals, nursing, yellow fever, influenza, and the University Medical Center.

Said Dr. Lampton, “The medical entries in the Encyclopedia lay the foundation for further writing and research on the history of medicine in our state.

My own contributions in the volume took years to write and involved the utilization of primary resources scattered in various state and national archives. Not only scholars but also students of history of any age will find this tome indispensable.”

To celebrate the book’s publication, the Center has planned a number of events around the state, region. A recent dedication was held at the Library of Congress in Washington, D.C. Dr. Lampton appeared recently at a Main Street Books event in Hattiesburg that featured a discussion by the editors and others, including Dr. Lampton, on the writing of the medical aspects of the Encyclopedia.

Work on this mammoth project began in 2003 and included over 1,600 entries and 1,451 pages. There are entries on every county, every governor, and numerous musicians, writers, artists, and activists. This is the first encyclopedic treatment of the state since 1907. Each entry in The Mississippi Encyclopedia provides an authoritative but accessible introduction to the topic discussed. It also features long essays on agriculture, archaeology, the civil rights movement, the Civil War, contemporary issues, drama, education, the environment, ethnicity, fiction, folklife, foodways, geography, industry and industrial workers, law, medicine, music, myths and representations, Native Americans, nonfiction, poetry, politics and government, the press, religion, social and economic history, sports, and visual art.

The Mississippi Encyclopedia includes solid, clear information contained in a single volume, offering with clarity and scholarship a breadth of topics unavailable anywhere else. “We hope everyone who picks up the book will find surprises,” said coeditor Ted Ownby. “Any good encyclopedia, and we think this one is exceptionally good, has detailed, thorough, smart information on topics people want to find. So, from a journalist or traveler to a scholar or teacher to a kid doing a school project, everyone should find ways to use the book. But holding it in their hands, they should find all sorts of things they hadn’t thought to look up. We think it’s revealing that the work starts with ‘Abdul-Rauf, Mahmoud (Chris Jackson)’ and ends with ‘Ziglar, Zig,’ and both of those entries seem likely to surprise a lot of readers.” n

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L E T T E R S

Is Medicaid Expansion and Universal Healthcare Based on a Ponzi Scheme Our Grandchildren Will Have to Pay For? Dear JMSMA Editor: In recent letters to the editor, several doctors tell us that Medicaid expansion saves hospitals and improves Mississippi’s economy, and that the MSMA needs to get on the “right” side by supporting universal healthcare. These are noble sentiments. Anyone who differs must certainly be both insensitive and immoral.

So, I am going to be both insensitive and immoral: government simply cannot provide all things to all people. Multiple studies show that 50% of all illness is driven by bad lifestyle---obesity, alcohol, drugs, sloth, promiscuity, etc. It consumes 60% of all medical resources. We spend billions treating people who will not change their negative life behaviors. They and others insist that they have a right to total healthcare but they deny responsibility for their poor health. Why shouldn’t they? Someone else is paying. Such dysfunction diverts precious money away from those who are responsible and try to stay healthy but can’t because of age, genetics or kinetics (trauma).

A driver’s license or fire insurance coverage is earned by responsible behavior. Insurers cannot reward vehicular homicide or arsonists. If they did they would go broke.

So would sovereign governments. In the 60 seconds it takes to read this letter, the national debt has increased by 2 million dollars.

The national debt is now 104% of gross national product. When we spend more than we take in the result is always the same whether at our house or in the nation: bankruptcy.

I would gladly support pleas for more Medicaid and even for universal healthcare if the pleaders would answer two simple questions: 1) How to stop 50% of abusers from consuming 60% of resources.

2) How to spend money, print more money, keep spending, and avoid sovereign bankruptcy and financial devastation for our grandchildren. These answers eluded Weimar Germany, the USSR, Argentina (twice), and soon Greece, Italy, Spain, China, whose national debt nears twice GNP. The United States is not immune to the laws of economics.

There is a name for a strategy in which a plan pays returns to the original investors using proceeds from current investors. The original investors do very well until the supply of current investors is exhausted and then the whole pyramid implodes. It is called a Ponzi scheme. It never works and never will, except for the original investors who make out well! That’s us ---the current generation.

Our grandchildren and their unborn children are already burdened by at least 3 such schemes--- Social Security, Medicare, and federal and state pension plans all woefully unfunded and set to implode in the future. Do we need to add another Medicaid Ponzi scheme to crush our unborn grandchildren?

We all have passions. We all want vibrant hospitals in Mississippi and healthcare for all. But all rights have responsibilities. The abusers have the responsibility to modify behavior. The rest of us have the responsibility not to crush future generations because of our zeal and financial folly. Someone, kindly explain to me that Ponzi schemes, and their accessory the Trojan Horse, are facts, not fiction. n —Calvin Ennis, MD Pascagoula

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Physicians Remain on the Sidelines Again as the Future of Medicine is Decided Dear JMSMA Editor: Here is a resolution which I had intended to submit for debate at the House of Delegate’s annual meeting this year: “Whereas, Medicaid is imposing burdensome costs on the budgets of state and federal governments; and whereas, the free market is the most effective regulator of consumption; therefore be it resolved, that persons who become sick or injured should be consigned by society to suffer the consequences without access to health care services, if they can’t pay for it.”

I decided against this gambit out of concern that someone might take it literally, oblivious of the intended sarcasm.

The point is that a humane society can’t, in good conscience, deny health care to anyone who is sick. The other fact-of-life in the debate over repeal of the ACA is that health care costs, including Medicaid, are rising at an unsustainable rate. Costs must, somehow, be contained. There is no point in trying to devise a renovated health care system until these two indelible and conflicting requirements are reconciled at the outset. To date, the recent debate has been dominated by people of power who are deficient in professional knowledge and in the ethical traditions of the profession.

I was seated in the AMA House of Delegates in 1993 when Hillary Clinton presented her plan. It was not approved, of course, but it should have signaled to the profession of medicine that political pressure was building to revise the delivery system eventually.

By now, the AMA or some representative group should have a plan on the shelf that addresses the public needs and preserves, at the same time, the traditional role of physicians in the system. As it has turned out, unfortunately, physicians are effectively on the sidelines. n —W. Lamar Weems, MD, MSMA Past President Jackson

Hammering Physicians Not the Answer to State’s Opioid Crisis Dear JMSMA Editor: I recently read Dr Voulters’ article on the opioid crisis and not blaming doctors [Voulters L. President’s Page, Hammering physicians not the answer to state’s opioid crisis. J Miss Med Assoc. 2017;58(3):89]. I agree with the statements, however as being an Orthopaedic Spine Surgeon with more than 40 years experience in the treatment of spinal deformities as well as metastatic pain, I feel strongly that “pain” is not a diagnosis but a symptom which we as physicians must pursue and find the cause so that it can be treated and then the pain should go away. I used to teach my residents that diagnosing was like a large jigsaw puzzle which has many pieces and the more pieces you can put together the better you see the whole picture. I also taught them that the whole process starts with a detailed History and Physical. The use of Diagnostic tests should confirm what they already have determined with their H+P. There was a study from Roswell Park Cancer Research Center many years ago that reported on spinal pain in cancer patients that basically found that when pain started in the spine, that was the time to stabilize it with possible instrumentation and fusion because if the patient developed any neurological signs after the pain, the chances of stopping paralysis was not good.

My problem in the article was the use of the term “non-cancer” pain; this to me assumes automatically that cancer causes pain.

Again I feel strongly that patients with a cancer diagnosis need to have the cause of the pain diagnosed so it can be treated. Pain is a symptom not a diagnosis.

My request is that a complete workup needs to accompany the patient before a Pain Management program is started. I also believe that narcotics not have automatic refills without proof of a physician evaluation personally. n

—Robert J. Weierman, MD

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Charity Hospital, Vicksburg Dear JMSMA Editor: It was with pleasure that I read your article about Kuhn Memorial Hospital in the latest journal [Lampton LM. Images in Mississippi Medicine. Kuhn Memorial Hospital. J Miss Med Assoc. 2017;58(2):63]. It brought back many fond memories of my early relationship with the hospital and its staff. It had a significant influence on my career choice.

I wasn’t one who always wanted to become a physician and if I had not failed the first semester of typing in my junior year, I probably would be doing something in the field of business. Fortunately our high school had a two credit class that I could switch to and still graduate with my class. I can’t remember how it came about - I think it was a recommendation of my dear English teacher, Miss Janie Watkins, who was a friend of Dr. Willard Parsons, the chief of surgery at the Vicksburg Hospital, who suggested I work parttime in the hospital lab. The chief technician was Mr. Leslie Forsythe who was very helpful and encouraging.

Being a small private hospital, Vicksburg Hospital had a resident staff of only three physicians: Dr. Guy Sharp, who was a rather small, feisty doctor who settled in Greenwood, Dr. Elton Thomas, who spent his career in Columbus, and Dr. Jones Lamb. I don’t know where Dr. Lamb went after his residency.

As part of their training they spent a rotation at Charity Hospital as it was known then. I spent a great deal of my free time manning the laboratory in the evenings and helping in the emergency room, eventually being allowed to suture lacerations and assisting in surgery when another pair of hands was needed.

One time I’ll always remember was scrubbing with Dr. Sharp on a newborn with an open spina bifida. It was with considerable difficulty that he was able to identify and mobilize enough fascia and subcutaneous tissue to successfully close the defect.

During the 40’s-50’s, Charity Hospital was an impressive yellow stucco building sitting in a spacious lot­and a beautiful well-kept lawn with a fountain/gold fish pond in front.

I’m sure I am not the only Vicksburg resident who has fond, positive memories of Charity Hospital. n —Melvin R. Holman, MD Amory

Remarkable Journal Dear JMSMA Editor: Thank you for your very kind note.

With my submissions, I feel that I am only attempting to live up to the remarkable space you have created in the state medical journal. Not only have you done a great job in overhauling the journal, itself, but you clearly have been able to recruit a wide variety of articles and a wide variety of opinions all of which add up to make the journal a very rich publication.

Please accept my congratulations on your ongoing success and the great contribution that the journal is making to medicine in Mississippi. n —William C. Lineaweaver, MD Jackson

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Racial Bias of White Physicians Not to Blame for Health Disparities Dear JMSMA Editor: Dr. deShazo’s assertion [deShazo RD. Special Article. The 2017 Nancy O’Neal Tatum Lecture: Does Mississippi’s health status reflect ethical shortcomings? J Miss Med Assoc. 2017;58(2):57-61] in his lecture presentation that health disparities among the races in Mississippi are due to white Mississippi physicians being racially biased and lacking in ethics is an insult to Mississippi physicians and just plain wrong. I’ve had the pleasure of working with physicians of many specialties and have found them to give equal care, often very intensive, and time consuming, and whether compensated or not, to all races.

He then goes on to pick at scabs of long ago wounds that do nothing but cause racial division and race based politics. Mississippi has made great strides in her race relations.

Dr. deShazo quotes from a book by sociologist Hochschild who (and I assume Dr. deShazo agrees) tries to explain with psychobabble why “salt of the earth white Southerners” don’t embrace Obamacare and other big government programs meant to “help them.” I’d say it’s because they’re proud and believe in the work ethic, that all who are able to work should do so. They’re smart enough to know that Obamacare was based on lies: “If you like your doctor you can keep him”; “If you like your current plan, you can keep it.” Obamacare is a failure. Many live in areas where insurance providers no longer provide coverage and premiums that are available have skyrocketed.

Regarding reasons for Mississippi’s poor health ranking, many of the reasons–violence, drug and alcohol abuse, obesity, early pregnancy, dangerous sex practices resulting in high rates of HIV and STD’s–are due to bad individual choices, often not easily influenced for the better by physicians.

Racial bias and inadequate ethics by Mississippi’s white physicians are not to blame for health disparities, contrary to Dr deShazo’s false indictment. n —William Ford, MD Columbus

Dr. deShazo’s Response to Dr. Ford’s Letter At this time late in my career, it is pleasing to learn that anyone pays attention to what I say or write, even if they don’t agree. That includes Dr. Ford, so I thank him for his letter.

First, I ask him to read this year’s ethics lecture given to UMMC faculty, students, and staff again. Sometimes a cursory reading of something about which one has strong opinions leads to misunderstandings.

For instance, I did not assert that, as Dr. Ford says, “White Mississippi physicians being racially biased and lacking in ethics” are the sole or major contributors to “health disparities” in the state. I did say that white physicians in the past have demonstrated racial bias toward our black physician colleagues and that has contributed to fewer black health professionals practicing in our state. This deficiency of black providers created problems with access to care for black and white patients and the health disparities arising from that. White physicians have contributed to health disparities from the “access to care” component of the social determinants of health but not to all of them. Past bias against black physicians by white physicians has been well documented in numerous studies others and I have published in the peer-reviewed medical literature. A quick search on Google Scholar or a conversation with any black physician in our state will further support that contention.

Second, Dr. Ford asks the perennial question, why “pick scabs of long ago wounds?” The answer to that is in Bishop Tutu’s book I cited and likewise documented by other scholars in the humanities. As physicians, we know that the antibiotics alone are not effective in healing deep infections, scabs or not. That’s why we open wounds to facilitate complete healing, rather than covering up the problem and continue the pain and suffering.

Again, I thank Dr. Ford for his letter. n —Richard D. deShazo, MD

JMSMA Associate Editor JOURNAL MSMA

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Mississippi Medical Professionals Feel Drug Enforcement Heat SCOTT GILBERT, JD Scott Gilbert, JD

Medical professionals in Mississippi are feeling the effects of a new law enforcement priority related to drug overdoses. This article presents an overview of drug overdose statistics, the enforcement climate in Mississippi, and prudent practices for medical professionals.

A Look at Some Mississippi Statistics According to the Center for Disease Control and Prevention (“CDC”), drug overdose deaths are on the rise in the United States with 52,404 people dying from drug overdoses in 2015.1 Mississippi, however, may be bucking the trend. Based on information from the Mississippi State Department of Health, the number of overdose deaths in Mississippi peaked in 2014 at 300 persons2 and declined in both 2015 and 2016. In Mississippi, the auto accident death rate is more than double that of the overdose death rate in the state over the last few years.

• •

From 2011 to 2015, 3,519 people have died in auto accidents in Mississippi.

From 2011 to 2015, 1,336 people died from accidental overdoses in Mississippi.3

The Federal and State Enforcement Climate in Mississippi On the law enforcement side, the United States Drug Enforcement Agency (“DEA”) has mounted a major national campaign to combat prescription drug diversion. On March 21, 2017, the DEA published a proposed rule in the Federal Register that, if implemented, would allow the DEA to hire attorneys to be “detailed to the Department of Justice (“DOJ”) as Special Assistant United States Attorneys” to “assist in the investigation and prosecution of ” drug crimes. Recently, DEA Assistant Special Agent in Charge in Mississippi Danny Comeaux has characterized certain prescribers as drug dealers cloaked in lab coats.

On the state level, Mississippi Bureau of Narcotics (MBN) Director John M. Dowdy, Jr., has repeatedly emphasized the Bureau’s focus on prescription drug overdoses, including the prosecution of medical professionals. Dowdy joined the MBN as director in November 2016, bringing with him 28 years’ experience as a federal prosecutor. At a May 2017 press conference covered by the Clarion-Ledger, Dowdy made clear that investigations into overdose deaths would include a look into whether actions taken by the prescribing physician played a role in the death. Dowdy has more recently engaged with members of the physician community, in particular with Mississippi State Medical Association leadership, to discuss ways that MBN and physicians can work together to address overdose deaths.

The Mississippi State Board of Medical Licensure (“MSBML”) Investigative Division investigates violations of the Medical Practice Act and the Mississippi Uniform Controlled Substances Act by select medical professionals, including physicians, podiatrists, radiologist assistants, and physician assistants. Mississippi state law authorizes the MSBML investigators to act as law enforcement officers, bequeathing them the authority to execute search and arrest warrants.

Criminal Prosecution for Prescribing Methods Lawyers, including this author, should not tell medical professionals how to practice medicine, and this article does not purport to do so. There are, however, legal requirements that the government must meet if it intends to successfully prosecute a medical provider for an overdose death.

Medical professionals should be aware of these requirements.

The federal law dealing with prescribing controlled substances requires the government to prove that the prescriber issued the prescription “outside the scope of legitimate medical practice.”4 In other words, the prosecution is required to prove that a prescription was written in a setting that did not involve a legitimate doctor-patient relationship, that no legitimate medical examination was performed, or that the patient did not have a condition that would warrant the prescribing of the medication. While the prosecution will generally rely on expert testimony to establish what a normal, legitimate doctor-patient encounter and the accompanying documentation should entail, these cases do not generally

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turn on a “battle of experts” like many medical malpractice cases. Instead, federal prosecutors rely heavily on factual evidence, such as proof that the prescriber did not see the patient at the time the prescription was issued, or that the patient encounter was a sham, for example, lasting only a couple of minutes. Federal law does not criminalize prescribing actions, even if they result in an overdose death, if such physician action is based on the legitimate exercise of medical judgment in a properly conducted, documented doctor-patient encounter.

A prosecution in Mississippi’s state courts could take on a much different appearance. Instead of focusing on the legitimacy of the encounter and the doctor’s judgment, these criminal cases could focus on a criminal negligence theory such as, for example, manslaughter, a felony in Mississippi.5 Manslaughter is generally defined as a killing that occurs without malice, premeditation or deliberation, and includes “culpable negligence,” defined by Mississippi’s courts as “such gross negligence … as to evince a wanton or reckless disregard for the safety of human life, or such an indifference to the consequences of an act under the surrounding circumstances as to render such conduct tantamount to willfulness.” This theory of prosecution could be employed in a case involving a patient drug overdose where the prescribing history included mixing medications that have a high risk of fatal interaction, prescribing large amounts of certain types of drugs over a short time frame, failing to conduct indicated diagnostic tests before prescribing certain medications, prescribing an inappropriately large dosage amount, and prescribing in ways that have been identified as running a high risk of death by regulatory or trade groups, such as the FDA or the American Medical Association.

Precautions for the Medical Professional Mississippi law requires healthcare providers to report to the MBN any death caused by a drug overdose. An autopsy with a toxicology report will be conducted in any suspected overdose death. A medical professional who learns that the death of a patient resulted from a potential drug overdose should immediately consider contacting a criminal defense lawyer that handles healthcare matters. Experienced counsel can help ensure that the appropriate notifications are made to the government and can help determine whether there are any reasons to suspect a criminal investigation of the physician could be forthcoming as a result of the death.

In the event a physician or prescriber is contacted directly by law enforcement about a potential overdose death, he/she should take the agent’s name and phone number and politely decline to discuss the matter without legal counsel present.

Given the enforcement climate in Mississippi, medical professionals contacted by regulatory or law enforcement agents would be wise to assume the contact is related to a criminal investigation.

A Better Approach While enforcement agencies may be justified in their efforts to address addiction, drug diversion, and drug overdoses in this state, hyperbolic sound bites may serve only to chill well-intended medical professionals from exercising their learned medical judgment in the treatment of their patients. Rather than target medical professionals, this author believes a better approach to addressing these issues would be for the various government agencies to work collaboratively with the healthcare community to provide education and guidance. n References 1.

Overdose Deaths – United States, 2010-2015, Centers for Disease Control, https://www.cdc.gov/mmwr/volumes/65/wr/mm655051e1.htm.

2.

Mississippi State Department of Health, MSTAHRS as of June 17, 2017.

3.

ibid.

4.

See 21 U.S.C. § 841(a)(1).

5.

See Miss. Code Ann. § 97-3-47.

6.

Brown v. State, 981 So.2d 1007, 1016 (Miss. 2007).

Author Information: Scott Gilbert, JD is a criminal defense attorney at Watkins & Eager, PLLC (www.watkinseager.com). He served as an Assistant United States Attorney in the Criminal Division of the Southern District of Mississippi for ten years. Scott can be contacted at sgilbert@watkinseager.com.

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P O E T R Y

A N D

M E D I C I N E

Dr. Siegfried Iseman [I keep a pile of books on my bedside table, all dependable comforts to me. Besides my Bible, among the others are Chekhov’s short stories, a collection of Christopher Hitchens’s essays, and Boswell’s “Life of Johnson.” I have only two books of poetry, Rilke’s “Sonnets to Orpheus” and Edgar Lee Masters’s “Spoon River Anthology.” This month’s poem is one of my favorites from that last-mentioned book, a poem about a hard-working village physician. Masters (1868-1950), a Chicago attorney by trade, wrote other books, but his 1915 “Spoon River Anthology” remains his masterpiece. It is a collection of free-verse poems offered as confessional epitaphs of the dead residents of the fictional American village Spoon River. The poems were the dead speaking truth from the grave. Focusing on small-town, rural life, the poems cross-referenced and interlinked the stories of over two hundred characters, creating a rich tapestry of their struggles, secrets, and longings. The poem below, “Dr. Siegfried Iseman,” relates the story of a high-minded young physician whose noble aims of healing are beaten out of him as he faces the terrible challenges of a rural medical practice. His idealistic dream of medicine shattered, he concludes with a pessimistic view, “And you find too late that being a doctor/ Is just a way of making a living.” There are other physician poems in the volume which I will include in coming months. Any physician is invited to submit poems for publication in the journal, attention Dr. Lampton or email me at lukelampton@cableone.net.]—Ed.

I said when they handed me my diploma, I said to myself I will be good And wise and brave and helpful to others; I said I will carry the Christian creed Into the practice of medicine!

Somehow the world and other doctors Know what’s in your heart as soon as you make This high-souled resolution.

And the way of it is they starve you out.

And no one comes to you but the poor.

And you find too late that being a doctor Is just a way of making a living.

And when you are poor and have to carry The Christian creed and wife and children All on your back, it is too much!

That’s why I made the Elixir of Youth, Which landed me in the jail at Peoria Branded a swindler and a crook By the upright Federal Judge!

—Edgar Lee Masters, 1915

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I M A G E S

I N

M I S S I S S I P P I

M E D I C I N E

E

AST MISSISSIPPI STATE INSANE ASYLUM, MERIDIAN--- These images, which date to 1900-1908, are of

East Mississippi State Insane Asylum in Meridian. Each image features a different angle on the famous landmark which was so critical to mental health in Mississippi’s history as the state’s second psychiatric hospital. Established in a March 8, 1882 legislative act, the asylum was created in response to overcrowding at the historic Jackson Lunatic Asylum, with the city of Meridian obtaining the institution by the donation of 556 acres for its location two miles west of the city’s limits. The asylum opened its doors for service in January of 1885, with a 19-year-old man from Meridian as the first patient. In the years 1893 and 1894, three magnolia trees and three Japanese magnolia trees were planted in front of the Administration Building, and are still standing today. The name of the institution was changed from East Mississippi State Insane Asylum to East Mississippi Insane Hospital in 1898, and finally to East Mississippi State Hospital in the early 1930s, reflecting changing perspectives towards the mentally ill, similarly followed by the Mississippi State Hospital in Jackson and Whitfield. The institution was nearly self-sustaining with farming operations, a hog and cattle farm, dairy and poultry barns, and orchards of peach, apple, pear and pecan trees. A canning plant was constructed as well for the produce. The asylum’s main building consisted of the Superintendent’s Office and other administrative offices with three wards each for male and female patients, as well as up-to-date hydrotherapy departments for male and female, segregated by race until the 1960s. Also, large screened galleries were present on the end of each ward for the benefit of the patients. EMSH, the second largest of four state psychiatric hospitals and the third largest employer in the Meridian area, currently serves thirty-one counties that include five of fifteen mental health regions in Mississippi. This area covers a population of approximately 900,000. The facility is licensed for 372 psychiatric beds, 35 chemical dependency beds, 226 nursing home beds and serves more than 100 clients in the Division of Community Services. For a full history of mental health in Mississippi, see my essay in the recently published “Mississippi Encyclopedia” on “Whitfield.” If you have any old stories or factual data about the East Mississippi Insane Asylum, please contact me.

Also, if you have an old or even somewhat recent photograph which would be of interest to Mississippi physicians, please send it to me at lukelampton@cableone.net or by snail mail to the Journal. n

— Lucius M. “Luke” Lampton, MD; JMSMA Editor JOURNAL MSMA

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