VOL. 57 NO. 4 2016 JMSMA by Journal MSMA

VOL. LVII • NO. 4 • 2016

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Medical Assurance Company of Mississippi

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VOL. LVII • NO. 4 • APRIL 2016

EDITOR Lucius M. Lampton, MD

THE ASSOCIATION President Daniel P. Edney, MD

SCIENTIFIC ARTICLES Top 10 Facts You Need to Know about Keloids and their Treatment 108 Amanda Daggett, M4; Jay Songcharoen, MD; Ricky Clay, MD Abdominal Distension and Vascular Collapse Gina Cosentino, MD and Gabriel I. Uwaifo, MD

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President-Elect Lee Voulters, MD

Clinical Problem-Solving Case: Life-saving NSAIDs Anthony R. Washington, III, MD

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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 Leslie E. England, MD Ex-Officio and the Editors

Speaker Geri Lee Weiland, MD

Academic Health Center-Rural Community Collaborations: 118 ‘Healthy Linkages’ to Improve the Health of Rural Populations Bettina M. Beech, DrPH, MPH; Marino A. Bruce, PhD; Abigail Gamble, PhD; Claude Brunson, MD; Michael L. Jones, RN, MSN, MBA

ASSOCIATE EDITORS D. Stanley Hartness, MD Richard D. deShazo, 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. SUBSCRIPTION RATE: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available. ADVERTISING RATES: furnished on request. Cristen Hemmins, Hemmins Hall, Inc. Advertising, P.O. Box 1112, Oxford, Mississippi 38655, Ph: 662-236-1700, Fax: 662-236-7011, email: cristenh@watervalley.net POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 39158-2548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association. Copyright © 2016 Mississippi State Medical Association.

Official Publication

MSMA • Since 1959

DEPARTMENTS From the Editor – Confessions of a Bibliophile Lucius M. Lampton, MD; Editor

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President's Page – I’ll Be Glad When They Go Back Home Daniel P. Edney, MD; MSMA President

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Letters- EHR is a Main Contributor to Physician Burnout

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Editorial- Is it Just Me? Observations of a Seasoned Practitioner Stanley Hartness, MD, Associate Editor

125

Legalese- Informed Consent: Process Behind The Paperwork Stephanie Edgar, MACM Legal Counsel

126

MSMA Physicians Leadership Academy- Ervin Fox, MD

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MSMA- Nominating Committee Seeks Candidates for Vacancies

131

RELATED ORGANIZATIONS Mississippi State Department of Health - Making Strides in Decreasing Heart Disease - Reportable Disease Statistics

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University of Mississippi Medical Center- New School of Medicine 132 ABOUT THE COVER “Froggie”– This moderately large North American green tree frog is a wide-ranging species. The males are usually slightly smaller than the females. The toe pads on Hyla cinerea are large. The hind feet display extensive webbing and have two metatarsal tubercles between the toes. Some populations have individuals that lack lateral stripes, but normally H. cinerea exhibits a lateral white or yellow stripe from the jaw to the thigh on either side of the body. White or yellow spots are often scattered on the back. The external, subgular vocal sac is mostly white or yellow in males when not inflated. During breeding season, the sides of the sac may turn green. Green tree frogs use a variety of calls to communicate. Males attract females through a specific mating call. Alarm calls are used to broadcast that there is an immediate threat or predator around. There is also a noticeably different rain call, which is vocalized when frogs sense that there will soon be rain. Photo by Martin M. Pomphrey of Mayhew. VOL. LVII • NO. 4 • 2016

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F R O M

T H E

E D I T O R

Confessions of a Bibliophile The most treasured book in my library is not one bound in marbled calf or in richly tooled morocco. Rather, it’s a thin volume bound in brown cloth, likely not even to be noticed on my shelf. With most of its spine missing, it’s an 1899 copy of Shakespeare’s “Comedy of the Tempest” edited by William J. Rolfe. It is also a relic salvaged from a burning house at Walker’s Bridge, Mississippi, by a medical student more than a century ago. Its scorched binding barely holds the fragile book together. Inside, the endpages are mottled by fire and water, with a wave-like warp to the interior. The front page of the book is signed in pencil by my maternal great-grandfather: “B. Lampton Crawford, Magnolia, Mississippi.” In 1901 he would receive his MD from Jefferson Medical College and in later years would become president of our MSMA, serving from 1944-46. Handling this book not only connects me with a physician ancestor and his yearning and odyssey to become a physician, but also touches my own path as a physician, a journey intimately connected with books.

smiled and recalled her own mother running back into a burning home in West Virginia, throwing her collection of Dickens out an upstairs window. I am unsure whether my great-grandfather rushed into his father’s burning home in rural Pike County to save this Shakespeare play or simply picked it up in the charred ruins, deeming it worthy of keeping, despite its damaged condition. Either way, the relic underscores that he valued words and books and literature, just as Eudora’s mother did.

I once told this story to the Mississippi writer Eudora Welty, who

— Lucius M. Lampton, MD, Editor

For physicians, books have always proved indispensable in our professional ramble. Sir William Osler, the great physician and a “bibliomaniac,” to use his term, asserted that “books are the tools of the mind” and “doctors are craftsmen.” Books and physicians were intimately linked always. Ours is a journey of the mind and an art wedded to science. Our tools remain words, either digital or printed, the latter, by the way, my preference. Contact me at lukelampton@cableone.net.

JOURNAL EDITORIAL ADVISORY BOARD Timothy J. Alford, MD Family Physician, Kosciusko Medical Clinic Michael Artigues, MD Pediatrician, McComb Children’s Clinic 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, Grenada 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 State Epidemiologist, 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 Bradford J. Dye, III, MD Ear Nose & Throat Consultants, Oxford

106 VOL. 57 • NO. 4 • 2016

Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist, The Street Clinic, Vicksburg Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson Maxie L. Gordon, MD Assistant Professor, Department of Psychiatry and Human Behavior, Director of the Adult Inpatient Psychiatry Unit and Medical Student Education, University of Mississippi Medical Center, Jackson Nitin K. Gupta, MD Assistant Professor-Digestive Diseases, University of Mississippi Medical Center, Jackson

Brett C. Lampton, MD Internist/Hospitalist, Baptist Memorial Hospital, Oxford Philip L. Levin, MD President, Gulf Coast Writers Association Emergency Medicine Physician, Gulfport Lillian Lien, MD Professor and Director, Division of Endocrinology, University of Mississippi Medical Center, Jackson William Lineaweaver, MD Editor, Annals of Plastic Surgery, Medical Director, JMS Burn and Reconstruction Center, Brandon Michael D. Maples, MD Vice President and Chief of Medical Operations, Baptist Health Systems

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

Heddy-Dale Matthias, MD Anesthesiologist, Critical Care Internist, Madison

J. Edward Hill, MD Family Physician, North Mississippi Medical Center, Tupelo

Samuel Calvin Thigpen, MD Hematology-Oncology Fellow, Department of Medicine, University of Mississippi Medical Center, Jackson

Jason G. Murphy, MD Surgeon, Surgical Clinic Associates, Jackson

Thad F. Waites, MD Clinical Cardiologist, Hattiesburg Clinic

W. Mark Horne, MD Internist, Jefferson Medical Associates, Laurel

Alan R. Moore, MD Clinical Neurophysiologist, Muscle and Nerve, Jackson

W. Lamar Weems, MD Urologist, Jackson

Scott Hambleton, MD Medical Director, Mississippi Professionals Health Program, Ridgeland

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

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

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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Top 10 Facts You Need to Know about About Keloids and Their Treatment Amanda Daggett, M4; Jay Songcharoen, MD; Ricky Clay, MD Introduction Classical wound healing has been described with three interdependent phases: an initial inflammatory phase, a following proliferative phase, and a remodeling or regeneration phase. The inflammatory phase begins at the moment of injury with a series of steps to begin hemostasis. Cut vessels contract and damaged capillaries trigger the aggregation of platelets, resulting in clot formation. This thrombus then releases chemotactic factors which trigger the migration and formation of neutrophils and macrophages. The macrophages subsequently release a fibroblast attractant called transforming growth factor beta (TGF-Î˛). The second, proliferative phase begins with neo-angiogenesis and new capillary formation, important for bringing nutrients to the wound and for healing to begin, but the key process of this step, collagen formation, is begun by the newly arrived fibroblasts, laying down proteins to begin the actual closing of the wound. The third, regeneration phase usually begins two to three weeks after an initial injury and can continue for as long as one year. In this stage, there is scar maturation, re-epithelialization, and remodeling. Scar maturation is an ongoing process of collagen production by the fibroblasts and collagen breakdown by collagenolytic enzymes. Collagen properly crossing the wound borders, supporting the wound, is stretched by the wound stress, and lytic enzymes will not attach to its distorted protein skeleton. Collagen that is not under stretch has a normally shaped protein skeleton for attachment and is readily broken down. Thus, as more collagen is laid down, only the fibers selectively supporting the wound remain long term. As maturation progresses, collagen production slows eventually to baseline, leaving a mature wound of collagen fibers crossing the wound. It is the final control mechanism Fig 1. An example of the keloid extending of this production/breakdown balance that is largely unknown and is the source of scar beyond the wound area on an earlobe. anomalies such as keloids and hypertrophic scars.1 Hypertrophic scars and keloids present a difficult challenge for both patients and physicians. Not only can they be deforming or unsightly, but they can also produce symptoms such as pruritus, pain, and functional impairment.1,2 This discussion will focus on keloids, specifically their differentiation from hypertrophic scarring, their hereditary patterns, and their treatment. There is a difference between a keloid and a hypertrophic scar. Keloids and hypertrophic scars are both pathological scar formation due to an abnormal healing response. Both may be painful, cause functional disability, and become cosmetically undesirable. Their general distinguishing characteristics are provided in the Table 1.2,3

Since they have many similar characteristics, the history and physical exam of the lesion is of paramount importance. Pathologic examination cannot effectively distinguish between keloids and hypertrophic scars. The key point is listed first in the table. While Fig 2. Another example of keloids across the chest. the history of rapid vs. slow development is helpful, the differentiation is usually by one point only: Keloids extend outside the bounds of the original wound into uninvolved skin while hypertrophic scars do not. This is the pathognomonic sign of their differentiation. There are ethnic and genetic predispositions for keloids that have clinical importance. It is well known that keloids are more common in certain ethnic groups, i.e., African-Americans, Asians, and Hispanics. In general, darker pigmented populations have a higher incidence over lighter skinned groups. Consequently, it is the most common skin disease among ethnic Chinese in Asia and the fifth most common in adult blacks in the United Kingdom.3The high incidence among twins and strong familial predispositions make

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genetic factors a likely probability.4 However, the genetics of keloid formation are poorly understood at present. The type of inheritance is not known. Some have suggested either autosomal recessive, autosomal dominant with incomplete penetrance, and/or variable expression. The variability of phenotypic expression makes locating a specific gene location unlikely and multi-gene involvement more probable.3,4,5

Table 1. Hypertrophic Scars Versus Keloids 2,3

HYPERTROPHIC SCARS Remain limited to the wound area Regress over time May be raised, but usually <4 mm, flatten over time Appear identical on light microscopy

KELOIDS Grow beyond the wound area Continue to grow for years Remain raised, often > 4 mm

Not associated with skin pigmentation

More common in dark skin types, higher incidence in African-Americans, Asians, and Hispanics More common in younger than 30 y/o

Common in young patients, especially during periods of rapid growth Very common in shoulders and anterior chest in females Appear as early as 1 month and develop rapidly

Appear identical on light microscopy

Most common on earlobes

Attention to the possibility of abnormal scar formation is an Can take 3 months to years to develop and important consideration following continue to grow slowly any injury or operative procedure. There is a variety of actions that can be employed to lessen its occurrence, particularly reducing inflammation and ensuring swift wound closure. After wound closure, several factors may help reduce abnormal scarring: 1) avoidance of tension on the wound 2) pharmacologic manipulation of the wound process and 3) pressure which may be in the form of massage, taping, silicone gels, or pressure garments. Studies show that reducing mechanical forces (tension relief ) reduces excessive scarring.6 In addition, in the acute open wound, moisture-retaining dressings such as petrolatum gauzes and hydrogels appear to restore the water barrier, allowing more rapid epithelialization and thus reducing pain and scar size as well as improving overall scar appearance.7 The use of prophylactic pressure garments, especially in burn victims and patients with widespread scarring, has been beneficial as well.8 Pressure on a scar appears to be one of the most effective ways of altering scar maturation. Although its mechanism has yet to be completely defined, it appears to be related to decreased blood flow through the scar, reducing tissue pO2, and since O2 is a required co-factor in collagen synthesis, this appears to lessen collagen formation. Another area of intervention for scar prevention is the modulation of inflammatory cytokines, specifically transforming growth factor 3 (TGF-β3). Although it has not become a clinical mainstream option, studies have been favorable using a recombinant form of TGF-β3.9,10 The treatment of keloids is difficult and controversy remains over best-practice therapy since so many options seem to work in some keloids but not in others. Initial treatments must be planned taking keloid size and location into account. First-line options may include cryotherapy, silicone sheeting, pressure treatment, and corticosteroid injections. As a general rule, simple excision of keloids is not favored as a first line treatment as they will virtually always recur, usually larger. Excision should be combined with a secondary modality of treatment in order to attempt a decrease in the recurrence rates. Second-line options consist of surgical excision combined with some additional treatment to lower recurrence, usually corticosteroid injection but possibly including cryotherapy, radiation, pressure treatment, pulsed dye laser, or multimodal therapy. While no single, best treatment has been determined, combination approaches, have shown to have better response rates over single modality intervention. Cryotherapy is a first-line treatment. Cryotherapy has been shown to be a useful first-line treatment modality. It is an easy procedure to perform, consisting of inserting a metal rod into the keloid and utilizing extremely low temperatures to destroy the keloid. Cryotherapy has been shown to decrease the volume of the keloid and reduce its hardness, elevation, and redness. It has a response rate of between 50-75%, but it has certain limitations. It is useful only for smaller lesions (acne) and can cause pain and hypopigmentation, especially with dark skin.2,11

3 4

Intralesional corticosteroid is a first- line treatment.

Steroid injections, usually triamcinolone acetonide (Kenalog), are often utilized as a first-line therapy in the treatment of keloids. They work by suppressing inflammation and mitosis and reducing angiogenesis through vasoconstriction. In our practice, Kenalog in a concentration of 40 mg per mL is mixed half-and-half with 1% Lidocaine and is injected directly into the lesion in a protocol of three injections spaced a month apart to determine if the keloid is “steroid sensitive.” Care must be taken to keep the injected material completely inside the lesion to avoid side effects such as surrounding tissue atrophy and to lessen depigmentation in darker skin. As a monotherapy, it has a response rate of 50-80% with a recurrence rate of 9-50%. However, when combined with cryotherapy, response rates improve. If the keloid shrinks but does not completely resolve, we will then add secondary excision with subsequent reinjection to lessen recurrence rates.11

Silicone sheets and gels can be effective. Silicone-based products for scar management have been available for over 25 years. Although they are easy to use, they are expensive and side effects include pruritus and contact dermatitis. The sheets consist of a semi-occlusive, soft silicone sheet. It has a silicone JOURNAL MSMA

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membrane as backing, which provides durability, flexibility, and ease of handling. Formulations vary by manufacturer with some using combinations such as silicone and Teflon to improve user experience. There has been recent development of gels applied as a thin layer to the skin and allowed to dry and form a transparent layer impermeable to water. Gels may also improve patient compliance over sheets for large surface areas, joint areas, and exposed areas where public viewing may be a problem for patients. The use of these devices has been studied extensively, and these studies provide evidence-based support for their use. Silicone sheeting has a response rate of 50-100% when added to subsequent excision. Sheeting or gels when combined with pressure dressing have improved outcomes over single therapy approaches. The exact mechanism by which silicone sheeting improves scarring remains somewhat controversial.11

Pressure dressings can be effective.

Pressure dressing or compression therapy has been shown to be effective in scar management, especially for hypertrophic scarring as opposed to keloids. Pressure on a scar decreases local blood flow likely inhibiting scar formation by decreasing local interstitial oxygen tension since oxygen is a co-factor for the initial step in collagen formation This same mechanism, to a lesser extent, may be the mechanism by which silicone sheeting works as well. These garments can only be used once the wound has closed and the patient is able to tolerate the pressure from the compression device. Response rates for pressure dressings when worn for six to 12 months are between 90 and 100%. Drawbacks to this mode of treatment include difficult patient compliance due to discomfort, long duration of treatment, and expense associated with custom-made garments.10 SECOND-LINE TREATMENTS:

Surgical excision may be required.

Pulsed dye lasers show inconsistent results.

Other intralesional therapies are sometimes necessary.

Surgical excision is often indicated for the treatment of keloids. Alone, it has a recurrence rate approaching 50 to 100%. Most often it is used in combination with some form of intralesional injection such as corticosteroids or 5-Fluorouracil (FU) and another adjunct treatment like silicone sheets/gels and pressure dressings. When used in this fashion, it has a very good response rate with low recurrence rates. Reports at thirteen months show a recurrence rate of only 12.5% when used with intralesional steroids and silicone sheeting. Incision type, incision location, and type of closure are important considerations when utilizing surgical excision of keloids.2 Scar prevention, as previously discussed, also plays an important role in overall management of this complex and challenging condition. Lasers are said by some to promote tissue regeneration similar to that seen in fetal tissue resulting in wound healing with little to no scarring.12 However, the use of lasers for scar management has shown inconsistent results in studies with response rates ranging from 57 to 83%.2 They are most often employed in hypertrophic scars rather than keloids to improve scar texture, treat telangiectasia or hyperpigmentation.13 Since pulsed dye lasers induce coagulation in superficial capillaries, they may have a mechanism of action similar to pressure therapy by reducing local blood flow, and thus lowering available oxygen for collagen formation in fibroblasts. It is recommended that lasers not be used as single therapy but combined with compression therapy and intralesional steroids. Lasers are being used with increasing frequency in scar management, especially in burn scarring. They have been shown to reduce scar thickness, contractures, pruritus, pain, and pigmentation problems in this population.11

Agents other than corticosteroids are being used intralesionally to treat keloids. These include 5-Fluorouracil (FU), Verapamil, Bleomycin, and Interferon. 5-FU is a chemotherapeutic agent that works by inhibiting fibroblast proliferation and is usually injected two to three times per week. In early studies, it has response rates, when combined with steroids, of approximately 88% and relapse prevention of 100%. Limitations to its use are that it may cause pain, pruritus, burning at the injection site, and hyperpigmentation. Verapamil, a calciumchannel blocker, decreases collagen synthesis and increases collagen breakdown. Its response rate is approximately 54% at 18 months. Limitations to its use are that it requires repeated injections and can produce pain at the injection site. Best results have been seen when combined with surgical excision and silicone sheeting.14 Bleomycin is another chemotherapeutic agent which is used in two to six sessions. Response rates show a total regression of 84%. Systemic use of this agent can result in pulmonary fibrosis, hair loss, and various cutaneous reactions. However, the use of “bleomycin tattooing”, which entails multiple intralesional injections, results in less than 5% of the dose reaching the bloodstream and is therefore thought to be less likely to produce systemic effects. Consequently, the most common reported side effects include pain, erythema, hyperpigmentation, and ulceration.15 Interferon (IFN), specifically IFN-α2, has antifibrotic, antiviral, and antiproliferative properties and functions to reduce the production of collagen I and III. Its use in keloid scar management is its ability to inhibit cell proliferation. It is injected twice a day for four days and has a response rate of 30-50% with a recurrence rate of 8 to 19%. As a therapy it is expensive at approximately $100 per treatment, and side effects include flu-like symptoms, pruritus, pigmentation changes, and pain.15 Lastly, radiation therapy has been used alone or as a post-surgical modality. Its response rate has been on average 56% (alone) and 76% (post-surgical). It is usually added to excision as a secondary therapy if the lesion has recurred after excision and steroid injection. Since many keloids occur in the very young and in the head and neck, there is concern about the long-term effects of even lower doses of radiation. Less severe side effects are paresthesias, skin discoloration, and ulceration. 110 VOL. 57 • NO. 4 • 2016

“Triple keloid therapy” may be necessary.

Triple keloid therapy consists of surgery, corticosteroids, and silicone sheeting. Response rates for this combination are around 88% and recurrence rates are low at 12.5% after 13 months, making it an effective form of treatment. With this treatment option, surgical excision is performed where either the entire scar is removed if possible or a small portion is left along the wound margins. Corticosteroid injections are administered immediately by some, but the senior author prefers to allow initial healing to complete and inject at approximately 8 weeks postop when collagen formation is at its maximum. Silicone sheets are then added if possible and generally worn for a minimum of 12 hours each day. Drawbacks to triple keloid therapy are that it is labor and time intensive as well as expensive.2 Conclusion Keloid formation is a complicated and difficult condition to manage as is made obvious when one notes that many therapies work sometimes and nothing works every time. Awareness of a higher incidence of keloid development in certain population groups can help identify patients at higher risk for keloid formation. In these cases, greater vigilance toward scar prevention can allow early intervention when the pathologic scars are smaller. As of yet, definitive genetic loci responsible for this phenotypic expression have not been determined. Higher rates in identical twins lead one to suspect a genetic influence, but variable penetrance among these population groups suggest multiple sites of influence. More research in this area is needed and continues. The difficulty lies in the lack of an appropriate animal model.16 Combination therapy clearly is superior to monotherapy. The different combinations of therapeutic approaches utilized for keloid treatment have varying response rates and all have their unique, yet common, side effects. The final answer to pathologic scar formation is still pending and will require elucidating the control mechanism of collagen synthesis and breakdown during scar maturation. Until that day, patients must be given realistic expectations that there is no “cure” for keloids and that all of our current modalities of therapy have significant recurrence rates over time. References 1.

Darby IA, Laverdet B, Bonté F, Desmouliere A. Fibroblasts and myofibroblasts in wound healing. Clin Cosmet Investig Dermatol. 2014 Nov 6;7301-11.

Management of Keloids and Hypertrophic Scars - Am Fam Phys. http://www.aafp.org/afp/2009/0801/p253.html. Accessed December 1, 2014.

Halim AS, Emami A, Salahshourifar I, Kannan TP. Keloid Scarring: Understanding the genetic basis, advances, and prospects. Arch Plast Surg.. 2012;39(3):184-189. doi:10.5999/aps.2012.39.3.184.

Marneros AG, Norris JEC, Watanabe S, Reichenberger E, Olsen BR. Genome scans provide evidence for keloid susceptibility loci on chromosomes 2q23 and 7p11. J Investig Dermatol.. 2004;122(5):1126-1132.

Keloid Research Foundation. http://keloidresearchfoundation.org/. Accessed January 2, 2015.

Son D, Harijan A. Overview of Surgical Scar Prevention and Management. J Korean Med Science. 2014;29(6):751-757. doi:10.3346/jkms.2014.29.6.751.

Gurtner GC, Dauskardt RH, Wong VW, et al. Improving cutaneous scar formation by controlling the mechanical environment: large animal and phase I studies. Ann Surg .2011, 254: 217-25.

Gassner HG, Sherris DA, Otley CC. Treatment of facial wounds with botulinum toxin A improves cosmetic outcome in primates. Plast Reconstr Surg .2000; 105: 1948-53.

Mustoe TA. Evolution of silicone therapy and mechanism of action in scar management. Aesthetic Plast Surg. 2008; 32: 82-92.

10.

Engrav LH, Heimbach DM, Rivara FP, et al. 12-year within-wound study of the effectiveness of custom pressure garment therapy. Burns 2010; 36: 975-83.

11.

Meaume S, Le Pillouer-Prost A, Richert B, Roseeuw D, Vadoud J. Management of scars: updated practical guidelines and use of silicones. Eur J Dermatol. 2014; 24(4): 435-43.

12.

Leclere FM, Mordon SR. Twenty-five years of active laser prevention of scars; what have we learned? J Cosmet Laer Ther. 2010; 12:227-34.

13.

Alster TS. Improvement of erythematous and hypertophic scars by the 585-nm flashlamp-pumped pulsed dye laser Ann Plast Surg. 1994; 32(2): 186-190.

14.

D’Andrea F. Brongo S, Ferraro G, Baroni A. Prevention and treatment of keloids with intralesional varapamil. Dermatology. 2002; 204(1): 60-62

15.

Trisliana Perdanasari A, Lazzeri D, Su W, et al. Recent developments in the use of intralesional injections keloid treatment. Arch. Plast Surg. 2014;41(6):620-629.

16.

Kelly Paul A. Update on the management of keloids. Semin Cutan Med Surg. 2009 Jun;28(2):71-6.

Author Information: Division of Plastic Surgery at the University of Mississippi Medical Center, Jackson, MS (Ms. Daggett, Dr. Songcharoen, Dr. Clay).

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Abdominal Distension and Vascular Collapse GINA COSENTINO, MD AND GABRIEL I. UWAIFO, MD, FACE, FACP

Abstract We present the case of a 43-year-old gentleman who presented to the emergency room with acute abdominal distension, confusion and vascular collapse. The emergent radiologic imaging obtained showed massive bilateral adrenal enlargement, but despite the initial clinical suspicion of possible overwhelming sepsis and/or massive abdominal/intralesional hemorrhage, lab tests based obtained rapidly confirmed the diagnosis of acute Addisonian crisis which responded dramatically to adrenocorticoid hormone replacement therapy and aggressive fluid resuscitation. The patientâ&#x20AC;&#x2122;s established history of metastatic lung cancer confirmed this as a case of metastatic massive bilateral adrenal metastases with an initial presentation of acute adrenal insufficiency which is uncommon in the setting of metastatic carcinomatosis but more typically associated with lymphomas. Recognition of this clinical possibility is vital to enable rapid diagnosis and consequent life saving therapy. Key Words:

Bilateral adrenomegaly, Addisonian crisis, Acute Adrenal insufficiency, Adrenal metastases

Introduction Acute adrenal insufficiency (aka Adrenal crisis or Addisonian crisis) (AAI) is an uncommon but potentially life threatening emergency which can occur denovo or in the setting of an established history of chronic adrenal insufficiency.1,2. While the initial presentation is often non specific and often characterized by symptoms such as nausea, emesis, anorexia, nonspecific abdominal pain, malaise, fatigue, lethargy, fever and asthenia, detection of AAI at this point with appropriate management can prevent the subsequent deterioration to confusion, coma and shock that invariably brings such patients to emergency medical attention and can be life threatening if not rapidly recognized and treated in that setting.1,2 The distinction between chronic adrenal insufficiency and AAI is an important one though both entities may share common etiologies. The major hormonal precipitant of the rapid deterioration typical of AAI is mineralocorticoid deficiency rather than glucocorticoid deficiency, and thus AAI can develop in subjects receiving physiologic or even pharmacologic doses of exclusive glucocorticoid therapy.3,4

While autoimmune adrenalitis and adrenal tuberculosis are the most common etiologic causes of primary adrenal insufficiency and are responsible for over 90% of causes of AAI secondary to primary adrenal disease, awareness that other adrenal pathology such as infarction, hemorrhage, medications, infections (especially other granulomatous and fungal infections) and far less commonly metastatic adrenal disease can also lead to AAI.3,4 Beyond primary adrenal disease, however, AAI can be precipitated in the setting of pharmacologic glucocorticoid use with associated acute physiologic stressors such as systemic infection, hemorrhage, dehydration or abrupt withdrawal of the glucocorticoid rather than a gradual taper.3,4 While primary adrenal insufficiency especially when of autoimmune etiology has been shown to have 4 stages of progression (stage 1, increased plasma rennin activity and normal aldosterone; stage 2, impaired serum cortisol response on ACTH stimulation; stage 3, increased morning ACTH and normal fasting serum cortisol; and stage 4, low fasting morning cortisol with overt clinical symptoms) these distinctions are often lost in the acute decompensated setting of AAI5-7. Furthermore, combination of primary and secondary adrenal insufficiency can further â&#x20AC;&#x153;muddy the diagnostic watersâ&#x20AC;? making early recognition, diagnosis and treatment difficult unless the clinician is particularly astute and with a high index of suspicion in appropriate clinical scenarios.5-7 The vast majority of the causes of AAI due to primary adrenal disease are associated with destructive and atrophic appearing adrenals on abdominal imaging, thus making the presence of bilateral massive adrenomegaly in the setting of AAI a unique and unusual clinical scenario most often seen in the setting of either adrenal lymphoma or certain opportunistic or fungal infections involving the adrenals.8,9 We present the case of our patient as a cautionary tale regarding the possibility of AAI presentation in the setting of bilateral massive adrenomegaly also occurring secondary to metastatic adrenal disease, though not typical nor common.

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Clinical Case Presentation A 43-year-old construction worker from Micronesia was rushed to the emergency department (ED) after collapsing in his home and complaining of profound weakness. He had a past medical history of hypertension, heavy alcohol and tobacco abuse, and stage IV adenocarcinoma of the lung with known metastases to the brain and liver, diagnosed 2 months prior with a lung biopsy. At the time of diagnosis, he had normal serum electrolytes and was hemodynamically stable. Earlier in the month of this admission he had been started on high dose dexamethasone while undergoing radiation treatment for brain metastases and had completed 10 treatments. During that time he began to experience progressive weakness, progressively worsening abdominal fullness and dark urine and stools. In the ED he presented with diffuse non specific abdominal pain, abdominal distension, confusion and profound asthenia. His home medications were hydrochlorothiazide 25 mg daily and dexamethasone 4 mg, four times daily. He had smoked one and a half packs of cigarettes daily for almost 30 years and quit just before his cancer diagnosis. He had also previously been a 12-pack of beer per day drinker and quit about 3 years ago. Examination Findings Initial vitals showed hypotension (88/34 mmHg) and tachycardia (110) beats per minute with initial temperature 99.9 F and respiratory rate 27 breaths/minute. Physical examination revealed a thin, tattooed man with mental disorientation and mild pallor. He was anicteric and dehydrated with no peripheral edema or asterixis. He had white oropharyngeal exudates, decreased breath sounds in the left lower lung fields both anteriorly and posteriorly, tympanitic abdominal distension and tender hepatomegaly 5 cm below the costal margin with no evidence of splenomegaly or demonstrable ascites. His pupils were normally reactive to light, thyroid was not palpably enlarged, and he had no peripheral lymphadenopathy palpable. The rest of his clinical examination was unremarkable. In the ED the major differential diagnostic concerns were possible catastrophic intra-abdominal hemorrhage or systemic sepsis with impending shock. Investigation Findings Initial laboratory evaluation in the ED revealed marked hyponatremia (sodium 104), hyperkalemia, (potassium 5.3), hypochloremia; chloride 71, (90-110meq/l) and mild hyperglycemia, (glucose 143). He also had mild transaminitis (AST and ALT 55/76) with a normal complete blood count (HCT 38.7 and WBC 8.6 with normal differentials and normal RBC indices). Imaging from his prior oncology visits included a chest x-ray which revealed a left lower lung mass extending to the left hilum and associated pleural fluid with mediastinal lymphadenopathy. Prior abdominal imaging obtained at the time of the lung carcinoma diagnosis had been unremarkable. Emergent CT of the abdomen and

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pelvis in the ED demonstrated bilateral 12 cm adrenal glands (figures A and B below) which were heterogeneously enhancing and centrally necrotic with the right adrenal mass extending into the posterior right liver lobe and bilaterally inferiorly displaced kidneys. Multiple nodular lesions ranging from 0.4 – 1.9 cm were seen in the brain on MRI.

Fig. A

Fig. B

Endocrine review obtained additional lab tests which revealed a very low a.m. cortisol 0.7, undetectable ACTH (<10pg/ml), low aldosterone <1.0, and elevated plasma renin activity (53.5). Marked serum hypo osmolarity (217) and elevated Urinary sodium (51) were also detected. The overall findings were indicative of acute Addisonian crisis which appeared to have both primary and secondary components (the primary component due to adrenocortical destruction by metastatic neoplastic infiltration and the secondary component from hypothalamo-adrenal axis suppression from high dose dexamethasone therapy). Management and Clinical Course The patient’s hydrochlorothiazide was discontinued and he was initially given aggressive fluid replacement with normal saline followed by hypertonic saline and then back to normal saline with rapid correction of his hyponatremia in the following days. He was concurrently allowed an ad lib salt-rich diet and liberal oral intake of electrolyte rich fluids. His hemodynamic status improved rapidly with restoration of normotension and resolution of both the tachycardia and tachypnea within 48 hrs of admission without the need for parenteral pressors. He was started on fludrocortisone 100mcg daily in addition to continuation of high dose dexamethasone for treatment for his brain metastases. He remained clinically and hemodynamically stable and afebrile for his extended hospital stay but ultimately decided to decline any further active treatment for his metastatic cancer (including suggested chemotherapy, radiation and possible bilateral adrenalectomy). He was discharged subsequently at his request and returned to Micronesia to be with his family. Discussion While the adrenals are a fairly frequent site of metastases from malignant tumors,10,11 these are often single or multiple small lesions with no associated anatomical significance. The vast majority of such lesions are hormonally quiescent. While lung cancer is the most commonly identified primary associated with adrenal metastases,11 these lesions are typically solitary and asymptomatic (often found as incidentalomas in the course of the malignancy work up).12 Bilateral lesions are very uncommon and, even when large, are typically asymptomatic 12

with small cell lung carcinoma being the most common histologic variant.11,12 Massive bilateral adrenomegaly associated with adrenal insufficiency is far more commonly associated with primary adrenal lymphoma8 than with metastatic disease though a few cases of this uncommon presentation have been reported with13 small cell lung carcinoma. Adrenal insufficiency associated with massive adrenomegaly in the setting of non small cell adenocarcinoma as occurred in our patient is very uncommon but is a clinical possibility that needs to be considered and rapidly ruled out to enable immediate therapeutic intervention in patients with metastatic cancer presenting with vascular collapse and painful abdominal distension. The fact that our patient was already on high dose glucocorticoids underlines the centrality of mineralocorticoid deficiency in the acute deterioration typical of AAI. This also explains the low measured ACTH in the patient despite his clinical presentation which had features of both primary and secondary adrenal insufficiency.

3. Jacobs TP, Whitlock RT, Edsall J, Holub DA. Addisonian crisis while taking high-dose glucocorticoids. An unusual presentation of primary adrenal failure in two patients with underlying inflammatory diseases. JAMA 1988;260(14):2082-4. 4. Cronin CC, Callaghan N, Kearney PJ, Murnaghan DJ, Shanahan F. Addison disease in patients treated with glucocorticoid therapy. Arch Intern Med 1997;157(4):456-8. 5. Saenger P, Levine LS, Irvine WJ, et al. Progressive adrenal failure in polyglandular autoimmune disease. J Clin Endocrinol Metab 1982;54(4):863-7. 6. Betterle C, Dal Pra C, Mantero F, Zanchetta R. Autoimmune adrenal insufficiency and autoimmune polyendocrine syndromes: autoantibodies, autoantigens, and their applicability in diagnosis and disease prediction. Endocr Rev 2002;23(3):327-64. 7. De Bellis A, Bizzarro A, Rossi R, et al. Remission of subclinical adrenocortical failure in subjects with adrenal autoantibodies. J Clin Endocrinol Metab 1993;76(4):1002-7. 8. Holm J, Breum L, Stenfeldt K, Friberg Hitz M. Bilateral primary adrenal lymphoma presenting with adrenal insufficiency. Case Rep Endocrinol 2012;2012:638298. 9. Vyas S, Kalra N, Das PJ, et al. Adrenal histoplasmosis: An unusual cause of adrenomegaly. Indian J Nephrol 1998;21(4):283-5. 10. Wagnerova H, Lazurova I, Felsoci M. Adrenal metastases. Bratisl Lek Listy 2013;114(4):237-40. 11. Lam KY, Lo CY. Metastatic tumours of the adrenal glands: a 30-year experience in a teaching hospital. Clin Endocrinol (Oxf) 2002;56(1):95-101.

Conclusion AAI, though uncommon, is an acute medical emergency that all clinicians involved in the primary and emergent care of patients need to be aware of and familiar with. As the clinical presentation is often nonspecific and often dominated by vascular collapse, confusion and/or coma, early consideration of this possibility with appropriate lab testing and emergent potential life saving therapy with mineralocorticoid repletion therapy and aggressive intravenous hydration is critical. Finally, our case reminds clinicians that metastatic carcinomatous bilateral adrenal enlargement is another consideration to be included in the differential diagnoses of bilateral adrenomegaly associated with AAI. Â&#x201E; References 1. Burke CW. Adrenocortical insufficiency. Clin Endocrinol Metab 1985;14(4):947-76.

12. Singh N, Madan K, Aggarwal AN, Das A. Symptomatic large bilateral adrenal metastases at presentation in small-cell lung cancer: a case report and review of the literature. J Thorac Dis 2013;5(3):E83-6. 13. Faulhaber GA, Borges FK, Ascoli AM, Seligman R, Furlanetto TW. Adrenal Failure due to Adrenal Metastasis of Lung Cancer: A Case Report. Case Rep Oncol Med 2011;2011:326815.

Author Information: Staff Endocrinologist, West Jefferson Medical Center, 1111 Medical Center Blvd. Suite N-713, Marrero, LA 70072. endodrcosentino@att.net; ginacosentino@gmail.com (Dr. Cosentino). Senior Clinical Research Scientist and Endocrinologist, Ochsner Health Center, Northshore Section of Endocrinology, Diabetes, Metabolism and Weight management, 2750 Gause Boulevard, Slidell, LA 70461 email: gabriel.uwaifo@ochsner.org Phone; 985-639-3777 fax; 985-661-3555 (Dr. Uwaifo, corresponding author).

2. Piedrola G, Casado JL, Lopez E, Moreno A, Perez-Elias MJ, Garcia-Robles R. Clinical features of adrenal insufficiency in patients with acquired immunodeficiency syndrome. Clin Endocrinol (Oxf) 1996;45(1):97-101.

PHYSICIANS NEEDED Internists, Cardiologists, Ophthalmologists, Pediatricians, Orthopedists, Neurologists, Psychiatrists, etc. interested in performing consultative evaluations according to Social Security guidelines.

OR Physicians to review Social Security disability claims at the Mississippi Department of Rehabilitation Services (MDRS) in Madison MS.

DISABILITY DETERMINATION SERVICES 1-800-962-2230 JOURNAL MSMA

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Life-saving NSAIDs ANTHONY R. WASHINGTON, III, MD

A 54-year-old white male presented to the emergency department (ED) complaining of left forearm pain and a 5-day history of worsening nausea, vomiting and non-radiating abdominal pain located in the right upper quadrant and epigastrium. The patient had been evaluated for his left forearm pain 1-month ago at a local hospital by a nurse practitioner. He was diagnosed with a left forearm cyst, given tramadol (Ultram) for pain and instructed to follow up with his primary care physician. The patient reported taking an unknown amount of naproxen 3-4 times daily for his recent persistent left forearm pain and also reported subjective unintentional weight loss over the past few months. He reported that the “cyst” had been present for over 5 years but had been slowly enlarging and had recently become painful. He denied fevers, night sweats, diarrhea, hematemesis, hematochezia or melena. He reported a past medical history of depression and denied a past or present history of alcohol use, smoking or illicit drug abuse. While in the ED, his vitals signs were stable and his exam revealed mild diffuse tenderness to palpation of his abdomen and a 4 cm x 4 cm non-tender, non-draining, fluctuant mass along the radial aspect of his left forearm. A complete blood count, electrolyte analysis, hepatic function, amylase and lipase lab studies returned unremarkable. However, computed tomography (CT) scan of the abdomen and pelvis revealed inflammatory pancreatic changes from acute pancreatitis vs. duodenitis due to contained perforated duodenal ulcer. The CT scan incidentally revealed a small right lower lung lobe pulmonary nodule. CT chest scan revealed multiple bilateral spiculated, non-calcified pulmonary lung nodules suspicious for malignancy. The patient was then admitted for the abdominal pain, nausea, vomiting and suspicion for metastatic pancreatic cancer. I am concerned about the cause of the patient’s abdominal pain, nausea, vomiting and ulcer. However, I am even more concerned about the pulmonary lung nodules incidentally found on CT. Is it an infection, multi-focal primary lung cancer or metastatic disease? The patient has no history of smoking, is afebrile and has normal lab results. This helps narrow my differential diagnosis list by making a smoking related lung nodule and infectious causes less likely. Lung nodules are detected very commonly on CT scans of the chest.1 Multiple pulmonary nodules are most commonly encountered in patients with metastatic disease to the lungs.1,2 Other less commonly encountered diseases that present as multiple pulmonary nodules include infections, arteriovenous malformations, Wegener’s granulomatosis 116 VOL. 57 • NO. 4 • 2016

and lymphoma.2 For evaluation of centrally located pulmonary mass lesions, sputum cytology with bronchoscopy is a common diagnostic tool. Transthoracic needle biopsy is indicated when the mass lesion is located in the lung periphery.4 Obtaining a biopsy of the pulmonary nodules is the next crucial step toward a more definitive diagnosis. The patient was admitted, given nothing by mouth overnight, and given ondansetron (Zofran) as needed to control nausea and hydrocodone/acetaminophen (Lortab) as needed for pain. The next morning he reported that his nausea, abdominal pain, and left forearm pain had decreased. His diet was advanced accordingly. He also reported wanting to be discharged since his symptoms had significantly improved. We informed him of the importance of obtaining a biopsy of the lung nodules as quickly as possible for proper diagnosis. The patient refused to remain as an inpatient and was discharged with an outpatient interventional radiology appointment for lung nodule biopsy. The patient did not present for this scheduled biopsy but presented to the ED 3 weeks after his previous discharge complaining of similar abdominal pain and nausea. The patient’s exam results were unchanged from his most recent admission. More lab studies were ordered including hepatitis panel, H. pylori antibodies and lipase. He was admitted and given ondansetron as needed for nausea, morphine IV as needed for pain and given nothing by mouth. He was scheduled to undergo lung nodule biopsy with interventional radiology and abdominal ultrasound the next morning. The new lab study results were normal and the abdominal ultrasound results were unremarkable. While undergoing lung nodule biopsy, the patient sustained a small left pneumothorax that resolved after chest tube placement for 1 day. The lung nodule biopsy samples were sent to pathology and microbiology for analysis. At this point, an infectious cause appears less likely. I will follow up on his biopsy gram stain and culture results as well as his pending blood culture results to effectively rule out infectious causes of his symptoms. His vitals signs have remained within normal limits and his lab study results have returned unremarkable, in particular, his complete blood count, lipase and hepatic studies. So far, the only abdominal pathologies that have been identified are inflammatory changes to the pancreas and a duodenal ulcer seen on CT abdomen/ pelvis. A gastroenterologist will likely need to be consulted to perform an esophagogastroduodenoscopy for further evaluation of the ulcer as the patient still reports some abdominal pain and intermittent nausea.

The lung nodule biopsy results returned as malignant spindle cell sarcoma favoring myxoid leiomyosarcoma. An oncologist was consulted for patient evaluation and recommendations. Magnetic resonance imaging (MRI) studies of the brain returned normal. The source of the primary cancer must be identified. The mass on the patient’s left forearm that has recently become painful, progressively enlarging over years and dismissed for years as a mere cyst could possibly be the source of the primary cancer. Could the forearm mass be an epidermoid cyst that has recently ruptured and become painful? Not likely, as ruptured epidermoid cysts are inflammatory lesions and often appear infected.5 His forearm mass is non-erythematous and non-tender. A lipoma must also be considered as part of the differential; however, lipomas are not associated with pain or tenderness. However, angiolipomas, a variant form of lipoma, have a vascular component and may be tender in cold temperatures and with compression.5 An MRI scan of his left forearm mass is now necessary to help evaluate its anatomical structure and rule out malignancy. The MRI scan findings of the left ulna and radius were consistent with a primary connective tissue neoplasm. CT guided biopsy findings of the left forearm indicated Grade 2 leiomyosarcoma. Soft tissue sarcomas are rare malignancies of mesenchymal origin commonly involving the extremities, trunk and retroperitoneum.3 Sarcomas account for 1% of all adult malignancies and 15% of all pediatric malignancies.4 Limb-sparing surgical resection is the mainstay of treatment.3,4

Key Words: Soft tissue sarcoma, Leiomyosarcoma, Pulmonary nodule, Orthopedic Oncology References 1.

MacMahon H, Austin J, Gamsu G, et al. Guidelines for management of small pulmonary nodules detected on CT scans. November 2005 Radiology; 237:395-400.

Viggiano RW, Swenson SJ, Rosenow EC. Evaluation and management of solitary and multiple pulmonary nodules. Clinics in Chest Medicine 1992;13(1): 83-95.

Gilbert N, Cannon C, Lin P, et al. Soft- tissue sarcoma. J Am Acad Orthop Surg. 2009; 17: 40-47.

Gould M, Maclean C, Kuschner W, et al. Accuracy of positron emission tomography for diagnosis of pulmonary nodules and mass lesions. JAMA. 2001; 285(7): 914-924.

Wolf K, Johnson R. Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology. Sixth edition. McGraw-Hill. 2009.

Demetri G, Antonia S, Benjamin R, et al. Soft tissue sarcoma. J Natl Compr Canc Netw. 2010; 8: 630-647.

Corresponding Author Anthony R. Washington, III, MD; Hospitalist Florida Hospital Physician Group Pioneer Medical Group 3908 Flatiron Loop unit, 101 Wesley Chapel, FL 33544 ph 813 929-5470 twash3md@gmail.com

An orthopedic oncologist was consulted for patient evaluation and recommendations. Chemotherapy was initiated prior to the patient’s hospital discharge. The patient underwent 4 cycles of gemcitabine and paclitaxel (Gem/Tax) chemotherapy as an outpatient. The patient returned to the hospital 2 weeks after discharge for severe epigastric pain, nausea and hiccups likely related to his chemotherapy. Esophagogastroduodenoscopy with biopsy findings revealed a large ulcer in the duodenal bulb that bled on contact. The patient was prescribed 72 hours of pantoprazole infusion. His abdominal pain responded to treatment, and both the hiccups and nausea improved with baclofen and ondansetron therapy, respectively. The patient was discharged again to continue follow up with the oncologist as an outpatient. A cardiothoracic surgeon was then consulted for evaluation of lung metastasis and treatment options. The orthopedic oncologist performed wide resection of the soft tissue sarcoma with a radial artery sacrifice procedure and cleared the patient for continued chemotherapy and lung resection. In summary, most soft tissue sarcomas present as painless, slow growing masses that are easily mistaken for lipomas or cysts and are usually only excised for cosmetic purposes. This patient’s soft tissue sarcoma had become painful to the point where he began self-medicating with heavy doses of non-steroidal anti-inflammatory drugs to control the pain. This induced a duodenal ulcer that fortunately led to the diagnosis and expeditious treatment of a spreading cancer. JOURNAL MSMA

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Academic Health CenterRural Community Collaborations: ‘Healthy Linkages’ to Improve the Health of Rural Populations BETTINA M. BEECH, DRPH, MPH; MARINO A. BRUCE, PHD, MSRC, CRC; ABIGAIL GAMBLE, PHD; CLAUDE BRUNSON, MD; MICHAEL L. JONES, RN, MSN, MBA Abstract Purpose: The purpose of this paper is to describe an extant theoretical model framing Mississippi Healthy Linkages, a successful academic-community partnership undergirding an emergency department (ED) diversion program. Description: The partnership between the University of Mississippi Medical Center, Mississippi State Department of Health, and Federally Qualified Health Centers is grounded in the Structuration Model of Collaboration and utilizes collective action to support an organized system of care linking academic and community care settings to address health disparities, particularly for rural and vulnerable populations. Assessment: Partners identified three interconnected segments of an integrated patient referral system to improve patient-level care, including galvanization of primary care services for ED patients, connection of primary care patients to specialty care, and linking ED patients with aftercare services. Conclusions: This academic-community partnership has significant benefits for linking health care and public health systems to address remote and vulnerable population health issues and serves as a model to be replicated in other areas of the United States, particularly in the Southeast and in rural areas. Key words: clinical-community linkages, academic health centers, rural health, population health Introduction Numerous reports have asserted the need for new collaborative models of health care delivery systems that simultaneously reduce escalating costs and improve overall health of the nation.1-3 A recent Institute of Medicine (IOM) report, Primary Care and Public Health: Exploring Integration to Improve Population Health,3 examined emerging opportunities for health care collaborations and provided a set of core principles to forge stronger connections between primary care and public health. Authors of the report argue that strong relationships between primary care and public health are necessary to achieve significant and sustainable improvements in population health.3 The recommended core principles were grounded in standards for successful systems 118 VOL. 57 • NO. 4 • 2016

integration and included: 1) the common goal of improving population health; 2) involvement of communities in defining and addressing health needs; 3) strong leadership working to bridge disciplines, programs, and jurisdictions; 4) sustainability; and 5) the collaborative use of data and analyses.3 The desired outcome of implementing these principles in forging collaborative health care models is consistent with the overall mission of academic health centers – the commitment to improve the nation’s health.3 Building long-standing, effective, and efficient academic-community partnerships is central to achieving this goal. Despite the numerous benefits of collaboration, efforts to establish successful partnerships or coalitions have been impeded by a number of organizational, historical, interactional, and interpersonal factors.4 Additionally, competition from other health care providers and threats to funding and reimbursement serve as marketplace barriers to robust interagency and inter-organizational collaborations.5 Models of academic-community collaborative frameworks designed to overcome these barriers are critically needed, especially for those targeting vulnerable populations such as rural residents.6 Baquet and colleagues7 established a successful model of academic-community engagementwhich demonstrates significant benefits and relevance for addressing complex rural health issues in Eastern Maryland. This bidirectional academic-community collaboration embraces the concept of community engagement to address health and social issues in partnership with the University of Maryland School of Medicine and the Eastern Shore Area Health Education Center.7 The partnership was created to address rural health needs of residents along the eastern shore of Maryland (9-county region) through support for partnered research, clinical trial education and recruitment, bioethics education, and public trust in research.7 The success and sustainability of this partnership is in part due to the organized system of health care afforded by the University of Maryland and the creation of the Office of Policy and Planning to address emerging health issues in access to health care, community-based research, and health disparities. Health and health-related challenges in rural communities in the United States (U.S.) have been long-standing and well-documented.8,9 The

defining characteristics of a rural community can vary by geographic region; however, there are common, yet notable, disparities among the nation’s rural communities.10 For example, residents of southern rural states often lack access to organized systems of preventive care.8 Mississippi is one of the most rural states in the nation as 65 of its 82 counties (79%) are designated as rural and nearly every county is considered a Health Professional Shortage Area (HPSA). This health care professional shortage has been positively correlated with the utilization of emergency departments (EDs) for primary care services, particularly for individuals who do not have a regular source of health care.11,12 In addition to health care professional shortages, several factors contribute to the escalation in ED use for non-urgent issues in rural areas. These include a significant population of elderly and chronically ill adults, lack of primary care after regular business hours, long wait times for physician appointments, and patient preferences.13-15 Consequently, diverting patients with non-urgent conditions away from EDs to more suitable health care settings has garnered significant attention both nationally and internationally.16-18 Numerous diversion programs have been implemented to reduce utilization of the ED for primary care services including computer algorithms,19,20 patient education,21 requiring preauthorization for ED use from managed care,22,23 and referring to primary care providers in community-based settings for same day appointments.24-27 The majority of these programs, however, have been implemented in urban hospital settings. Policymakers, patients, and residents of rural communities have challenged health-related organizations to develop innovative collaborations to connect rural residents with primary and specialty care providers in Mississippi to reduce the use of EDs as a substitute for primary care services and to improve overall community health.28 The purpose of this paper is to describe 1) an extant model based on organizational sociology that frames a successful inter-organizational academic-community collaboration, Healthy Linkages and 2) early successes with the implementation of this collaborative model, particularly with regard to an ED diversion

program connecting patients with primary health care providers in their respective communities. We operationalize “collaboration” as a system in which contributors with diverse knowledge are mobilized to generate effective problem-solving across boundaries of function, occupation, and level.29 Structuration Model of Collaboration Social theory involves a set of interrelated definitions and relationships that organizes our understanding of observations in a systematic way.30 Structuration theory is founded upon the notion that individual and collective behaviors emerge from an interaction of structural and individual-level forces.31,32 From this basic idea, D’Amour developed a conceptual framework, the Structuration Model of Collaboration, in an effort to examine how “complex and heterogeneous multi-level healthcare systems” collaborate 29. According to D’Amour and colleagues29 collective action has four dimensions that can be operationalized with 10 indicators (Figure). Shared Goals and Vision along with Internalization are individual-level dimensions that describe relationships between individuals. This component of the model highlights the significance of striking a balance between the importance of shared goals among collaborators and the recognition of the inevitability of partner maintenance of numerous allegiances and divergent motives. Formalization and Governance are considered structural dimensions because they operate at the organizational level. These dimensions refer to the extent to which collaborators adhere to documented responsibilities and expectations and exhibit leadership behaviors that support collaboration, respectively. The intersection of these dimensions presents an opportunity for the emergence of a collaborative process through

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which individual and organizational interests are served.29 This model is offered as a heuristic for the approach utilized in the Healthy Linkages initiative.

among health care providers enabled through timely patient referrals and joint usage of electronic health records are vital to the continuum of health care.33

Description

The improved communication among the Healthy Linkages partner organizations facilitates continuity of care throughout the lifecycle and addresses the four areas in the Structuration Model of Collaboration; Governance (connectivity), Formalization (information exchange), Shared Goals and Vision (shared mission to improve health for underserved communities in Mississippi), and Internalization (trust) (Figure). As postulated in the Structuration Model of Collaboration, increased communication facilitates interactions among partner organizations and improves the effectiveness of the structural dimensions of collaborations.29

Mississippi Healthy Linkages The Healthy Linkages initiative is an academic-community collaboration among three partners: University of Mississippi Medical Center (UMMC), Mississippi State Department of Health (MSDH), and 21 Federally Qualified Health Centers (FQHCs) which are predominately located in rural areas. UMMC is Mississippi’s only academic health science center, is one of the largest employers and health systems in the state, and is located in Jackson, the state capital. UMMC encompasses six health science schools, including medicine, nursing, dentistry, health related professions, graduate studies, and pharmacy. As part of its mission, UMMC is dedicated to improving the health of Mississippians and eliminating health disparities. MSDH is the leading public health agency in the state and has an important mission to serve and protect the public health of the citizens of Mississippi. MSDH is a centralized system, organized into nine administrative districts with oversight from the central office located in Jackson. The county health departments provide health services to the underserved population. The Mississippi Primary Health Care Association provides oversight to the FQHCs; in all there are 154 sites that provide access to medical care for residents who are plagued by a paucity of medical services, financial restrictions, and other social or economic barriers. The FQHCs qualify for enhanced reimbursement from Medicare and Medicaid and must serve an underserved area of population, offer a sliding fee scale, provide comprehensive services, have an ongoing quality assurance program, and have a governing board of directors. Together, UMMC, MSDH, and the FQHCs make up the three largest entities in the state that provide health care for the most vulnerable citizens of Mississippi. The Healthy Linkages initiative was initially designed to address two main goals to: 1) improve communication deficiencies among the partners; and 2) ensure that patients receiving primary care from the FQHCs and MSDH health clinics have “seamless” access to UMMC consultants through a formal patient referral process. The devastation of Hurricane Katrina in 2005 demonstrated the critical and immediate need to address systemic barriers in access to health care services experienced by the most vulnerable citizens in Mississippi; many of whom reside in rural areas. Prior to hurricane Katrina, there was no formal mechanism for communication regarding patient referrals among the three partners. The primary goal of Healthy Linkages was to improve communication among UMMC, MSDH, and the FQHCs via electronic modalities. During the early stages of the collaboration, each FQHC and MSDH health clinic was equipped with satellite technology to electronically link and foster communication among the three entities. A significant outcome of this initial effort was the creation of the Center for Telehealth at UMMC which provides medical services using telemedicine technology to over 100 clinical sites that serve under-resourced communities and patients throughout Mississippi and includes over 30 adult and pediatric medical specialties. Effective communication 120 VOL. 57 • NO. 4 • 2016

Development of a formal patient referral process to improve the connection of patients with primary and specialty care was the second goal of Healthy Linkages. The partners identified three interconnected segments of an integrated patient referral system that would accomplish the goals of improving the continuum of care for patients and potentially have a positive impact on the health of Mississippi’s most vulnerable residents. The three segments include: 1) the diversion of non-emergent ED patients to a primary care provider within a local FQHC or MSDH health clinic; 2) the connection of primary care patients to specialty care services; and 3) linking ED patients with primary care and/or specialty care services following emergent care of chronic conditions. The development of this patient referral system began at UMMC in the Department of Emergency Medicine and was piloted with one urban FQHC site. Approximately one-third of all ED visits are considered non-emergent.34 Strategies to redirect inappropriate ED demand include enhancing relationships between multiple levels of care, improving patient referral processes, and providing patient education regarding the appropriate use of health services.35 Beginning in July 2008, patients who presented to the UMMC-ED for a non-emergent health problem and who did not have a primary care provider were assessed and referred to a triage process for referral to a local FQHC to receive medical care and to establish a medical home. Patients that resided outside of the participating FQHC service area were provided with educational materials regarding FQHCs and health department clinics, the importance of having a medical home, and the name and location of the nearest FQHC and/or MSDH health clinic based on the patients’ residential zip code. This pilot diversion program permitted staff in the UMMC-ED to access the electronic health record system at the participating FQHC and schedule either same day or next day primary care clinic appointments. The participating FQHC was an ideal facility to pilot the electronic referral system as approximately 80% of the patients with non-emergent concerns lived within the service delivery area of this particular FQHC.26 Patients who were referred to the FQHC were not billed for an ED visit, and UMMC was not required to absorb the cost for visits that were redirected to the non-emergent health care setting. Approximately 2,500 referrals were made to the FQHCs between the years 2008-2010. The most common presenting issues were: pain (back, chest, abdominal groin, general body aches); nasal congestion and cold related symptoms; and swelling.

The Structuration Model of Collaboration provides a framework through which one can observe and understand how three partner organizations collaborate and coalesce to redirect non-emergent patients via an electronic referral process to a local primary care provider, thereby addressing an important health systems challenge in Mississippi.29 The effort to transfer non-emergent cases to facilities better suited for primary or outpatient care underscores the importance of the four areas in the Structuration Model of Collaboration for effective interaction among the Healthy Linkages partners and the patient. Trust is a primary component in this process, as it has to be established at the organizational and individual levels. Trust among Healthy Linkages partners provides an environment that encourages patients to trust that the primary care or outpatient services they receive is of highest quality and addresses their immediate health needs. At the organizational level, the development, implementation, and assessment of the ED diversion process were dependent upon leadership within the UMMC Department of Emergency Medicine, support from the partnering FQHC, and connectivity and formalization tools to allow for necessary information exchange. The outcomes of this process during the pilot phase met the shared and independent goals of each partner, which facilitated successful collaboration. Discussion The success of the Healthy Linkages Mississippi pilot provides evidence justifying the expansion of this initiative to other FQHCs and MSDH health clinics. Leaders in partner organizations are beginning to strategize and plan for addressing the other two segments in the integrated patient referral system via electronic modalities (connecting primary care patients to specialty care services and linking ED patients with primary care and/or specialty care services following emergent care of chronic conditions). The partners have also recently identified an immediate need to establish connectivity with MSDH health clinics to improve maternal and child health as a particular area of importance. Given that much of Mississippi is rural and medically under-resourced, the MSDH health clinics located in each of the 82 Mississippi counties serve as a critical resource for local resident’s health care needs, specifically for the vulnerable population served by the Special Supplement Nutrition Program for Women, Infants and Children (WIC). MSDH health clinics are the primary point of contact for women and children to become certified, participate, and remain enrolled in the WIC program. Client participation requires routine (annually and more frequent for pregnant women) health screenings conducted by MSDH health clinic staff for each participant. The participants frequent contact with the MSDH health clinic provides a vital opportunity for: 1) participants without a medical home to be connected with primary care services; 2) participants with a critical or emerging chronic health ailments to receive a referral for specialty care services; and 3) continuity of care for maternal WIC participants from pregnancy to post-partum, and for pediatric participants from in utero to infancy and childhood. Currently, all referrals to UMMC specialty health care services are executed via a telephone system which fields all patient scheduling calls at a central location which are then diverted to the appropriate clinic or physician office based on each patient’s medical need. Many of the

FQHCs and MSDH health clinics are still in the process of formalizing electronic health records systems. As these systems are put into place and become fully functioning, the partners will link these facilities to the integrated referral process. Conclusion Following Hurricane Katrina in 2005, the need to improve communication among public health and health care organizations in Mississippi became abundantly clear. Through Healthy Linkages, Mississippi’s leading health agencies have forged a partnership by which to engage in ongoing collaboration to develop and implement patient referral strategies that foster continuity of patient care and aim to improve population health and eliminate health disparities. The Structuration Model of Collaboration is a framework illuminating elements of the Healthy Linkages initiative facilitating an effective, efficient, and sustainable academic-community partnership in Mississippi. Through this partnership, Mississippi’s three leading health agencies are addressing the core principles of an integrated health care delivery system to improve the continuity of care, namely for the state’s most vulnerable and rural residents. At the foundation of this partnership is the shared common goal to improve population health and collectively, the partners recognize the immediate need to bolster maternal and child health care continuity and agree that initiatives, which yield successful progress are priorities. The Healthy Linkages partners have established and continue to strengthen a converged leadership to work towards bridging disciplines, programs, and jurisdictions though improved communication across the agencies. At the forefront of the collaboration is an ongoing process and planning for fostered sustainability. Future connections will expand to involve communities and will include the collaborative use of data-driven outcomes to define and address evolving health needs. The collective philosophy of the Healthy Linkages partners is to foster, enhance, and maintain relationships to improve the health of Mississippians. This requires sustained levels of transparency and a consistency in messaging among the partners and other community stakeholders. To this end, a Healthy Linkages meeting is held bimonthly with representatives from each of the FQHCs, MSDH health clinics, and representatives from UMMC to keep the partners apprised of relevant activities and ongoing projects in each organization. This venue is also utilized to discuss challenges and barriers to patient referrals (low utilization of referral appointments if scheduled more than 24-hours after visit to the ED),26 access to specialty care (long wait times for appointments with specialists), and to plan new collaborative ventures (diversion program expansion). The Healthy Linkages collaboration served as the catalyst to create a strong relationship between health care and public health entities in Mississippi through the establishment of a well-connected and organized system of care. As the Healthy Linkages partners continue to collaborate and tackle emerging public health and health care needs, plans to sustain the partnership need to be clearly delineated taking care to address equitable processes and procedures, tangible benefits to all partners, and a balance between partnership process, activities,

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and outcomes.36 This model can be replicated in other areas of the U.S., particularly in the Southeast and in rural areas.

22.

Hurley RE, Freund DA, Taylor DE. Gatekeeping the emergency department: impact of a Medicaid primary care case management program. Health Care Manage Rev. 1989;14(2):63-71.

Acknowledgements

23.

Shaw KN, Selbst SM, Gill FM. Indigent children who are denied care in the emergency department. Ann Emerg Med. 1990;19(1):59-62.

The authors thank Dr. James Keeton, Healthy Linkages partners, participating FQHCs, and the Mississippi Department of Health for their support of this study.

24.

Derlet RW, Nishio D, Cole LM, Silva J, Jr. Triage of patients out of the emergency department: three-year experience. Am J Emerg Med. 1992;10(3):195-199.

25.

Derlet RW, Nishio DA. Refusing care to patients who present to an emergency department. Ann Emerg Med. 1990;19(3):262-267.

26.

Nguyen ND, Moore JB, McIntosh NP, Jones ML, Zimmerman J, Summers RL. Emergency department triage of low acuity patients to a Federally Qualified Health Center. J Miss State Med Assoc. 2013;54(10):280-283.

27.

Washington DL, Stevens CD, Shekelle PG, Baker DW, Fink A, Brook RH. Safely directing patients to appropriate levels of care: guideline-driven triage in the emergency service. Ann Emerg Med. 2000;36(1):15-22.

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Author Aﬃliations: Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS (Dr. Beech, Dr. Gamble). Myrlie Evers-Williams Institute for the Elimination of Health Disparities, Jackson MS (Dr. Beech, Dr. Bruce, Mr. Jones). Department of Sociology and Criminal Justice, Jackson State University, Jackson, MS (Dr. Bruce). Department of Anesthesiology, University of Mississippi Medical Center, Jackson, MS (Dr. Brunson). Corresponding Author: Bettina M. Beech, DrPH, MPH Associate Vice Chancellor for Population Health Executive Director, Myrlie Evers-Williams Institute for the Elimination of Health Disparities Professor of Pediatrics and Family Medicine University of Mississippi Medical Center 2500 North State Street Jackson, Mississippi 39216 bbeech@umc.edu

P R E S I D E N T ’ S

P A G E

I’ll Be Glad When They Go Back Home erving as president of the association carries several diverse duties and obligations most of which are enjoyable and are a pleasure to fulfill. However, one of the most frustrating duties has been to serve as your spokesperson at the State Capitol while the Mississippi Legislature is in session.

The frustration arises from the fact that the individuals who possess the most power to affect negatively our profession clearly know the least about it; they are our legislators. As I write this, it appears that we have had a very successful legislative year. We have moved the Interstate Compact bill through and soon physicians can be fully licensed in as short a time period as 4-6 weeks rather than 6-8 months (providing the conference report is approved by the Governor). We have worked hard this year to require Medicaid to recognize the specialty of OB/GYN in the list of primary care physicians so OB/GYNs can be reimbursed for primary care codes by Medicaid at 100% of Medicare rates like other primary care physicians. However, our three most difficult battles were all on the defensive side with nurse practitioners pushing for independent practice, a telemedicine vendor seeking easy access to our patients, and protecting our law that requires school age immunizations which is nationally recognized as the best vaccine law in the country. We were successful in all three battles but we had significant challenges throughout the legislative session. Thanks to the expertise of Government Affairs Director David Roberts and all of our staff, we were able to take losses we encountered in the House of Representatives and parlay them into victories on the Senate side. All three of these major legislative battles were won because years of hard work by our members have built strong relationships. The industriousness of our staff to present and explain our policy positions paid off. The wise counsel of our Council on Legislation chaired by Dr. Mike Mansour successfully guided these efforts; and, very importantly, our Mississippi Medical Political Action Committee (MMPAC) investments made a true difference. What I have learned this year is that whenever the legislature is in session, we must realize that our profession is at risk. The legislature has the final authority on the practice of medicine in Mississippi including who can do it, how they do it, and what the practice of Medicine even is. The practice of medicine is whatever they say it is. Whenever they are in Jackson, anything can happen to our patients, the profession, and us. This year the House of Representatives in all its wisdom decided that it was a good idea to remove the process of medical exemptions for vaccinations of school age children from the experts at the Health Department and place it with school administrators. They also thought it is okay to allow any physician anywhere in the country to approve these exemptions. They chose to make the excellent public health policy of children’s vaccinations a political issue rather than a medical one and with one vote almost destroyed decades of public health achievement. My frustration was great. We had to listen to the anti-vaccination crowd (using emotion and falsehoods) convince their colleagues that parents should have a right to determine whether their children should be vaccinated and allowed to attend public school without being vaccinated. Legislators were very ignorant of the medical fact that changing this public health policy suddenly placed all of Mississippi’s children at risk for childhood illnesses that have been under good control for many years. The House also chose to listen to out-of-state telemedicine companies wanting to do business in Mississippi by having their doctors from anywhere in the world do “phone only” medical visits to treat any condition without ever laying eyes on that patient or having any further follow-up. Also, there were those in the Senate who were championing the ability of nurse practitioners to practice without any physician oversight or accountability in our state. Nevertheless, the physicians who care for Mississippi were indeed heard. continued next page....

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Due to your powerful grassroots response to our several calls to action, we were able to convince the Senate that collaboration works and that NPs serve the patients of our state best when they are working in a healthy full collaborative relationship with a physician. We killed that bill at the committee level. We were able to explain to Senate leadership why the House passed a bad telemedicine bill that put patients at risk, endangered the pioneering telemedicine work at UMMC as well as our hard working primary care specialists throughout our state and negatively affects the ability to recruit physicians to the underserved areas of our state. We were very importantly able to protect the lives and health of our children by killing the immunization bill in the Senate committee on Public Health. We were able to mobilize several hundreds of phone calls both to those representatives that failed us by passing HB 938 as well as the senators looking to receive it with the sentiments of the silent majority on the issue of vaccinations. Thanks to you, our vulnerable children and seniors will be safer and healthier and many of those same representatives will think twice before voting against medicine on this issue in the future. We are in good shape this year as the session slows down but we know that these battles will be ever before us. We must be more tenacious than our opponents who want to practice medicine without going to medical school, change practice standards against our objections, or continue to push a misguided philosophy into the lives of every family with school age children. We did it this year but only because of you and your faithful support to the principles of organized medicine. So, now you see why I will be so very happy when our legislators go home. It’s because at their homes they can do far less damage to our profession. Understanding how determined our opponents are to negatively reshape our world, it shows how important your membership and activity in MSMA and MMPAC truly are. Together we are stronger and together our state is healthier.

Daniel P. Edney, MD MSMA President

L E T T E R S

EHR is a Main Contributor to Physician Burnout Dear JMSMA Editor, In your recent issue on physician wellness (JMSMA, vol. LVII, no. 1), I did not see any reference to what I consider is the main reason for the increase in physician burnout which is the electronic medical record and the requirement to have so many items checked each visit so, rather than talking to the patients about their problem, most of the visit is spent clicking off things you already know about the patient so you can get paid for the visit, leaving but minimal time to deal with the real issues. The physician’s main relationship during the visit is with the computer rather than the patient, and the interpersonal connection with the patient is largely destroyed. To me, most of the satisfaction in seeing patients comes from the personal interactions that allow you to understand the patient, his/her way of life, interests, etc. I know, after more than 55 years of practice in multiple different settings, that “epic” and the related requirements to check off what I already know about the patient has caused me more stress and feeling of being burned out than anything that has happened in my career. We have become technicians, not physicians. Sincerely, Robert M. Herndon, MD UMC Professor of Neurology Jackson

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E D I T O R I A L S

Is It Just Me? Observations of an Old a Seasoned Practitioner

thought I was doing right by the patient. The elderly lady and I had never before laid eyes on one another, but the moment I opened the exam room door I could tell I was dealing with a sick puppy. Chest x-ray and WBC confirmed my physical examination suspicions: bilateral lower lobe pneumonia superimposed on chronic interstitial disease. To my mind, considering her advanced age (88 years), her past medical history, and the severity of her acute illness, hospitalization seemed the logical option, so I contacted the hospitalist who grilled me like I was a third year medical student on morning rounds. His response: “She doesn’t qualify for direct admission.” Thank goodness for the understanding ER physician who agreed to “re-evaluate” my patient. The following morning I felt vindicated—and relieved—to find her name on the hospital census. I could only wonder if she had been assigned to that same score-carrying hospitalist who probably didn’t even remember our conversation.

I knew the Japanese take-out eatery—with the special pink sauce—was my grandchildren’s favorite, but I couldn’t for the life of me figure out why all of a sudden the spate of television commercials for OEC. Imagine my amazement on paying closer attention to discover they were talking about OIC—Opioid Induced Constipation! Strangely, all of the “victims” appear impeccably dressed professionals scurrying off to their offices. In light of the opioid tsunami currently engulfing us, the irony of a medication developed specifically to thwart this dreadful malady is not lost on me. All I can muster is, “Make mine a #2…with pink sauce.” The old saying “Be careful what you wish for” came to mind after our recent MSMA press conference at the State Capitol. Presidents Dan Edney (MSMA) and Sam Crosby (MAFP), flanked by an impressive assemblage of physicians and medical students, left no doubt in their presentations that audio-only telemedicine is bad medicine. A day or so later, however, I actually began to worry what if the legislators responded that, what with our obsession with computers in the exam rooms, our patients have complained that we were, in effect, already practicing audio-only medicine with our backs turned to them focused on that keyboard. Trust me. Patients crave that eye contact as they relate their physical complaints or pour out their emotional concerns. A smile…a raised eyebrow… some signal that, in addition to typing at the speed of an 11th grader, we’ve acknowledged on a personal level what they’re saying. Over the last few years since EHR has been foisted on me at this late stage in my career, I feel fortunate that I’ve been able to develop a balancing act that seems to satisfy my patients’ needs for personal interaction as well as that meaningful use mumbo-jumbo. I find myself agreeing with Lewis Carroll’s heroine as she cried, “Curiouser and curiouser!” D. Stanley Hartness, MD Associate Editor, JMSMA

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L E G A L E S E

Informed Consent: Process Behind The Paperwork

Stephanie Edgar, JD Legal Counsel Medical Assurance Company of Mississippi

nce upon a time, a physician was permitted to act unilaterally on clinical judgments, and all that was required to obtain a patient’s consent was the simple affirmation that the patient agreed to be treated. 101 years ago one judge changed the course of American medical ethics by expressly recognizing the patient’s dual rights of determination and autonomy. Today, the term “informed consent” is not foreign to any of us. It’s batted around incessantly in medical clinics, hospitals, and courtrooms, but I fear, based on examples we’ve seen, that history may be repeating itself. We’ve seen this play out unintentionally by physicians that either give so much information that a patient doesn’t understand or by physicians that don’t give enough information for fear the patient won’t understand. Both of these scenarios seem driven, in large part, by a desire to just complete the paperwork and check the proverbial box for informed consent off the list.

Don’t misunderstand me- the paperwork is vitally important but only as a memorialization of the process behind it. Informed consent is far more than just a date and signature on a form. Bearing this in mind, your consent process should include simple, easy to understand explanations regarding diagnosis; nature and purpose of the proposed treatment; risks and consequences of the proposed treatment; probability that the proposed treatment will be successful; feasible treatment alternatives; and prognosis if the proposed treatment is not given. A good rule of thumb is to put yourself in the shoes of your patients. You know medicine. They don’t. Otherwise, they wouldn’t be in your office. When I was defending physicians in medical malpractice cases and would update clients on their cases, I would on occasion catch myself wanting to use legal terms. The problem with this is that while I knew exactly what I was intending to communicate, I wasn’t really communicating at all because the client had no concept of what I meant. So, rather than saying, “we filed an answer on your behalf today,” I would say, “we filed an answer on your behalf today, which is just a formal, written response to the complaint that was filed against you.” The same is true in your practice and particularly with regard to informed consent. Take the time to explain in simple, everyday language what’s wrong, what you think should be done about it, what might happen as a result of your suggested treatment, what you think the chances of success with your recommended treatment are, other options that are available, and what will likely happen if they don’t accept the treatment you’ve offered. Don’t talk at your patients. Talk to them. After you’ve documented the actual substance of your conversation in the chart and not just the standard, “explained risks and benefits to patient and patient consents”, have your patient sign the consent form and make sure to include it in the chart. Will this process take extra time? Probably. Will it be worth it in the end? Absolutely. Even after doing all of this, can you still be sued for lack of informed consent? Sure, but if you’ve gone through these steps and you’ve got the documentation to substantiate that you’ve gone through these steps, it will be an uphill climb for a plaintiff to prove his case. Remember that informed consent is more than just a date and signature on a form. It should be an exchange of information that includes instruction as well as time to ask and answer questions so that you have some concept that the patient understands precisely what is being communicated. Rather than just an endpoint, the consent document should be the basis for a meaningful exchange between you, as the physician, and the patient. Information contained in this publication is obtained from sources considered to be reliable. However, accuracy and completeness cannot be guaranteed. Information herein should not be regarded as legal advice. Source: The Risk Manager, Medical Assurance Company of Mississippi

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M I S S I S S I P P I

S T A T E

D E P A R T M E N T

O F

H E A L T H

Mississippians Make Strides in Decreasing Heart Disease

Though heart disease is the leading cause of death in the state and the country, Mississippi has seen a 19.6 percent decrease in deaths attributed to heart disease from 2004–2013. The numbers are even better for women in the state, down 22.5 percent, while men saw a 17.8 percent decrease overall in those 10 years. Mississippi’s black women in particular have made the greatest strides in the state, with heart disease mortality down 25 percent over the last 10 years, while mortality among white women was down 21.5 percent. For white men in the state the mortality rate was down 20 percent, while black men came in last at a 12.9 percent decrease. High blood pressure, high LDL cholesterol and smoking are key risk factors for heart disease. According to the Centers for Disease Control and Prevention, 49 percent of Americans have at least one of these three risk factors. Several other medical conditions and lifestyle choices can also put people at a higher risk for heart disease, including diabetes, obesity, poor diet, physical inactivity and excessive alcohol use. The 2013 Behavior Risk Factor Surveillance System reported that 38.2 percent of adults had no leisure time physical activity for a 30-day period. “Mississippians characteristically have low rates of physical activity,” said State Epidemiologist Dr. Thomas Dobbs. “In 2015, Mississippi was ranked 49th for overall health by America’s Health Rankings. The state ranked 45th for smoking, 48th in obesity and last for physical inactivity,” he said. Incorporating physical activity into daily life can be done by making small changes, such as parking farther away from your destination or using stairs instead of elevators. “Along with the right diet, maintaining an exercise regimen has been shown to decrease the risk of heart-related diseases. MSDH recommends taking a brisk 30-minute walk five days a week,” Dobbs said. Follow MSDH by email and social media at HealthyMS.com/connect.

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M I S S I S S I P P I

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O F

H E A L T H

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JOURNAL MSMA

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M S M A

This is part of a spotlight series on the MSMA Physician Leadership Academy class of 2016.

Dr.

Ervin Fox didn’t always plan on being a physician, he says. “After doing the co-op program in biological engineering at Mississippi State University, I had the option of taking a job upon graduating, doing graduate school in biological engineering or pursuing a career in medicine. I chose the latter because it appeared to give me more options to specialize in a career that I developed skills and interest in after medical school. It also catered to my interest in human physiology, cardiovascular hemodynamics and research.”

Ervin Fox, MD

The cardiologist now has several degrees under his belt: a bachelor’s degree in biomedical engineering from Mississippi State University, a master’s degree from Harvard School for Public Health, and his M.D. from University of Mississippi Medical Center, where he currently practices and teaches. His interest in cardiovascular physiology and human physiology and cardiovascular research geared him toward his specialty, and he says his time teaching fellows in the Noninvasive Laboratory and mentoring residents and medical students in cardiovascular research is the most rewarding. Mentorship, both giving and receiving, has played a significant role throughout his career. “I had several mentors in Cardiology fellowship at Tulane University and in my Clinical/Research Echo fellowship at Massachusetts General Hospital. They helped me feel more confident in what I was doing, gave me guidance to pursue my greater interests and supported my decisions with further advice.” Dr. Fox’s strong interest in research led him, with the guidance of his mentors, to his decision to pursue a research/clinical fellowship and a career in academic medicine. “My mentors helped formulate a plan to pursue a clinician-researcher tenured track. These relationships helped mold my career and give me examples on how to approach young trainees and faculty members to help them in their pursuits of a career in medicine.” As a student in the Physician Leadership Academy, Dr. Fox hopes to glean skills that will help him become an effective advocate for good medicine in both academic and public settings. “In terms of academics, I hope to gain tools that make me a good candidate for a leadership or administrative position within the department. I hope to be more eligible to become a principal investigator for a large cohort study, such as Jackson Heart Study, or lead an academic section in population-science research, preventive medicine or in faculty development.” In the public setting, Dr. Fox hopes the Academy will lead him to take on a more active role within MSMA and in turn influence policy-making in the state. Dr. Fox has been an MSMA member for as long as he’s been in practice. Organized medicine is important to him because “it brings doctors from different disciplines ttogether in order to formulate and execute a strategic plan that optimizes patient care delivery.” To him, that means creating an environment that “provides strong, knowledgeable, and fair leadership, encourages research, enhances diversity as opportunity provides and raises the next generation of scientists,” he says. “I strongly feel that good medicine should be equally accessible to all who want and seek it.” n 130 VOL. 57 • NO. 4 • 2016

M S M A

Committee Seeks Candidates for Vacancies in MSMA Offices Delegates attending the 148th MSMA Annual Session August 12-13, 2016 in Jackson will cast ballots to fill new terms of office for a number of association posts. The Nominating Committee is seeking input from the membership as the committee prepares a slate of nominees. The list of nominees developed by the Nominating Committee will be published to the entire membership before June 12, 2016. Eligibility: All nominees must be active members of the association. No physician may be put forth on the ballot unless that physician has expressed a willingness to serve if elected. Nominations for Vacancies: A chart follows listing the vacancies that will be filled by election in 2016. The names of incumbents, the length of each term of office and the incumbentâ&#x20AC;&#x2122;s eligibility to be re-elected are indicated. Nominating Committee: The Nominating Committee is composed of the nine most recent Past Presidents of the association residing in Mississippi. The Immediate Past President is the chair. OFFICERS & TRUSTEES President-elect at large Secretary at large Trustee District 2 Trustee District. 4 Trustee District 5 Trustee Resident/Fellow Trustee Student

INCUMBENT Lee Voulters Michael Mansour Brett Lampton William Grantham Dwight Keady Nicole Lee Brock Banks

AMA DELEGATES & ALTERNATE DELEGATES Position 1 Delegate at large Position 2 Delegate at large Position 3 Delegate at large Position 4 Alternate at large Position 5 Alternate at large Position 6 Alternate at large Position 7 Work Team at large Position 8 Work Team at large Position 9 Work Team at large Position 10 Work Team at large Position 11 Work Team at large Position 12 Work Team at large JOURNAL MSMA Associate Editor

Sharon P. Douglas J. Clay Hays, Jr. Claude Brunson Randy Easterling Lucius Lampton James Rish R. Lee Giffin Lee Voulters Jennifer J. Bryan Thomas Joiner Geri Lee Weiland Hugh Gamble, II INCUMBENT Stanley Hartness

COUNCILS Accreditation at large Accreditation at large Budget & Finance at large Budget & Finance at large Constitution & Bylaws at large Constitution & Bylaws at large Constitution & Bylaws at large Constitution & Bylaws at large Ethical and Judicial Affairs Ethical and Judicial Affairs Ethical and Judicial Affairs Legislation District 1 Legislation District 2 Legislation District 3 Legislation Resident Legislation Student Medical Education District 2 Medical Education District 4 Medical Education District 5 Medical Service District 4 Medical Service District 5 Medical Service Resident Medical Service Student Public Information District 1 Public Information District 2 Public Information District 3

INCUMBENT Lori Marshall Crystal Tate Susan Chiarito Chip Holbrook John Cross J. Martin Tucker Crystal Tate Victor Pang S. Kenn Beeman Ryan McGaughey Kathleen Lyons Michael Mansour B. Pearson Windham J. Murray Estess James Wilkinson Neal Boone DeWayne Gammel Jonathan Jones John Voss J. Anthony Cloy Michael Shrock Jonathan Buchanan Daniel Hester Robert Suares Son G. Lam Charlotte Magnussen

Terms of Office: President-elect: 1 year 2016-2017; Officers, Trustees & Councils (physicians): 3 years 2016-2019; Delegates to the AMA: 3 years; Trustees & Councils (students & residents): 1 year 2016-2017. Journal Associate Editor: 2 years 2016-2018. Incumbents NOT eligible for re-election are noted as the color grey. Email Nominations to CKanosky@MSMAonline.com or contact any member of the Nominating Committee: Claude Brunson, MD: Jim Rish, MD; Steve Demetropoulos, MD; Tom Joiner, MD; Tim Alford, MD; Randy Easterling, MD; Pat Barrett, MD; Dwalia South, MD; Eric Lindstrom, MD.

JOURNAL MSMA

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Gov. Bryant, UMMC Mark Highpoint in School of Medicine Construction

ov. Phil Bryant helped celebrate a milestone in the construction of an emerging School of Medicine building during a â&#x20AC;&#x153;topping-outâ&#x20AC;? ceremony at the University of Mississippi Medical Center.

Touting the economic and health-care implications of a more spacious, state-of-the-art medical school, Bryant was among some 100 dignitaries and other attendees who watched as a construction crane hoisted a structural beam to the top of the building, signifying that it has reached its maximum height.Â Along with medical students, as well as representatives of UMMC and the construction contractor, Bryant signed the beam before it was lifted, hewing to a construction tradition also meant to express appreciation to the building contractor and crew. â&#x20AC;&#x153;This new medical school will have a $1.7 billion impact on our state by 2025 and will help create a support system of 19,000 â&#x20AC;&#x201C; thatâ&#x20AC;&#x2122;s 19,000 jobs created,â&#x20AC;? Bryant said. The 151,569 square-foot, five-story building will help advance Bryantâ&#x20AC;&#x2122;s goals of increasing the number of physicians working in Mississippi and boosting the stateâ&#x20AC;&#x2122;s health-care economy. â&#x20AC;&#x153;Bringing one physician into a community has a $2 million impact,â&#x20AC;? he said. â&#x20AC;&#x153;It is the most effective economic development opportunity we have in the state of Mississippi.â&#x20AC;?

Signing the construction beam during Mondayâ&#x20AC;&#x2122;s topping-out ceremony are, from left, M2 John Lippincott; M4 Sara Ali; Dr. LouAnn Woodward, vice chancellor for health affairs and dean of the School of Medicine; Gov. Phil Bryant; Chris Monsour, an RIÂżFLDO ZLWK 5R\ $QGHUVRQ &RUS &RQWUDFWRUV 'U -DPHV .HHWRQ distinguished professor and advisor to the vice chancellor; and M1 Michelle Wheeler.

Dr. LouAnn Woodward, UMMC vice chancellor for health affairs and dean of the School of Medicine, thanked Bryant for â&#x20AC;&#x153;being a great championâ&#x20AC;? of the effort to build a new school and ultimately providing greater access to health care for more of the stateâ&#x20AC;&#x2122;s residents, particularly those in rural areas. â&#x20AC;&#x153;We are on a mission to train Mississippians to take care of Mississippians in this state,â&#x20AC;? Dr. Woodward said. She also thanked her predecessor at UMMC, Dr. James Keeton, for his dedication to the construction project, as well as to the crew of Roy Anderson Corp. Contractors. Construction on the building is on track for completion within 12 to 14 months, that is, the spring of 2017, Woodward said. Medical students will start classes in the new facility the following fall. This new space will enable the School of Medicine to enlarge its incoming class size each year from 135 students to at least 165. â&#x20AC;&#x153;Down the road, this is a great day for the state of Mississippi,â&#x20AC;? Woodward said. Rising in the northeast area of the campus, facing Lakeland Drive, the new school will be similar in size to the University of Mississippi law school in Oxford. Road work linked to the site has been completed. UMMC has not had a new School of Medicine facility since the current one opened in 1955 as part of the Medical Center complex on State Street. Medical students have no dedicated medical school building, but use several: the Research Wing, University Rehabilitation Center, the VA Medical Center, Jackson Medical Mall and various other educational buildings and clinical sites on- and off-campus.

â&#x20AC;&#x153;We have classrooms and labs that are not just our space alone,â&#x20AC;? said Michelle Wheeler of Greenwood, a first-year medical student and one of the students who signed the construction beam. â&#x20AC;&#x153;Having a new medical school gives me a feeling of gratitude that someone cares enough to give us our own building. â&#x20AC;&#x153;Weâ&#x20AC;&#x2122;re going to love it and cherish it.â&#x20AC;? The current economic impact of the practicing Mississippi physicians who trained at the School of Medicine is $6.3 billion annually. They support an estimated 60,395 jobs and generate about $706 million in annual federal and state tax revenue. The new school will, among other things: â&#x20AC;˘ Consolidate most classes and labs into one building, decreasing cross- and off-campus travel by students. â&#x20AC;˘ Offer flexible, technology-rich classrooms with all-movable furnishings adaptable for lecture-style learning, teamwork sessions, and other non-traditional learning methods. â&#x20AC;˘ Provide a dedicated floor for simulation labs where medical and other health-professions students can learn techniques on software programs and computercontrolled interactive mannequins. â&#x20AC;˘ Give students space for individual study, group study, congregating and social interaction. â&#x20AC;˘ Provide large, tiered auditoriums with unobstructed views, room to swivel and work in groups, and wide desktops suitable for laptops, texts and notebooks. n

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