VOL. LVII • NO. 12 • 2016

VOL. LVII • NO. 12 • 2016

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VOL. LVII • NO. 12 • DECEMBER 2016

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

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

MANAGING EDITOR Karen A. Evers

Secretary-Treasurer Michael Mansour, MD

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

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

JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices.

CORRESPONDENCE: Journal MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: 601-853-6733, Fax: 601-853-6746, www.MSMAonline.com.

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

Copyright © 2016 Mississippi State Medical Association.

Official Publication

MSMA • Since 1959

SCIENTIFIC ARTICLES Top 10 Facts You Should Know About Screening 378 for Critical Congenital Heart Disease Hasti Sanandajifar, DO; Mary B. Taylor, MD, MSCI; Sarosh P. Batlivala, MD

Mississippi Perspective: Dermatologic Manifestations 382 of Arsenic Poisoning Caroline Daggett, BA; Amanda Daggett, MD; Robert T Brodell, MD; C. Ralph Daniel III, MD

DEPARTMENTS From the Editor – A Man of Grace Remembered Lucius M. Lampton, MD, Editor

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President’s Page – Working for Cures in the 21st Century Lee Voulters, MD

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329

Commentary – Bariatric Surgery – A Viable Option and the Best Hope for Many Mississippians?

Emma L. Willoughby, MSc; Ellen S. Jones, PhD; Deborah S. Minor, PharmD

Poetry and Medicine – In Memoriam

387

In Memoriam – William Francis Roberts (1945-2016), Past MSMA Executive Director

394

Una Voce – Jaybird Pie: A Christmas Story Dwalia S. South, MD

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Vol. LVIII Subject Index

400

Vol. LVIII Author Index

405

POSTER INSERT Give Me A Shot

389

RELATED ORGANIZATIONS William Carey University – WCU College of Osteopathic Medicine Launches New Ambulance Drones

393

ABOUT THE COVER “Winter scene on Mayhew Pond”– Martin Pomphrey, MD took this picturesque image when global warming yielded to Mississippi cooling on Mayhew Pond in the backyard he shares with his wife, Sue. Over the years he has planted many Bald Cypress trees in and around the pond. The trees, in turn, have been seeding themselves in their yard and at the neighbor’s yard on the other side of the pond. Dr. Pomphrey says the Cypress is one of his favorite trees because they are beautiful green in the summer, orange in the fall, and can even dress up in the winter. – Ed. n VOL. LVIII • NO. 12 • 2016

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F R O M

T H E

E D I T O R

A Man of Grace Remembered

G

race: it’s the magic glue which holds our fragile civilization together. We see too little of grace in our everyday lives, too little of acts of selflessness and empathy to others and our world. William F. “Bill” Roberts, who served as MSMA’s executive director from 1998-2007 and who died in late November, was a man of grace. There are many definitions of grace, and Bill embodied many of them. The one I am Lucius M. Lampton, MD focused on is a noun meaning a disposition Editor to show kindness or compassion, usually tied with an effortless elegance and civilized manner in accomplishing this (and this does combine two definitions of the same word together!). The term comes from the Latin gratia meaning favor, charm, thanks, and also from gratus meaning pleasing, grateful. Grace stresses benevolence, goodwill, and tolerance of others.

My late physician-father liked the term “big-souled” to describe such humans of rare grace as Bill, and such a description fits. My many memories of Bill always contain his thoughtful words, his noble manner, a

sharp intellect, a warm and forgiving sense of humor, and his loyal friendship. Don’t get me wrong. A man or woman of grace is no pushover.

Bill’s courage and resilience as an MSMA warrior (which is what he was!) over decades of service beginning in 1973 should always be remembered by our profession. His leadership proved vital in accomplishing passage of significant tort reform legislation, the creation of MACM, the preservation of MSMA’s right to make nominations for the Board of Health (later medical licensure), and the design and construction of our association’s Ridgeland headquarters. We his friends who cherish his memory should remember even another definition of grace, as a verb: His life graced our profession, and we are extraordinarily grateful.

This issue contains a more extensive obituary as well as a revealing poem Bill wrote long ago. Also, for more on his extensive contributions to our MSMA, see “Reflections on a career of service to the MSMA: An interview with William F. ‘Bill’ Roberts, MSMA Executive Director 19982007.” JMSMA, May 2007, 146-157. n Contact me at lukelampton@cableone.net.

— Lucius M. Lampton, MD, Editor

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

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

Michael Artigues, MD Pediatrician, McComb Children’s Clinic

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

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

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

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

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

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

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

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

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

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

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Top 10 Facts You Should Know About Screening for Critical Congenital Heart Disease HASTI SANANDAJIFAR, DO; MARY B. TAYLOR, MD, MSCI; SAROSH P. BATLIVALA, MD Introduction Critical Congenital Heart Disease (CCHD) is defined as congenital heart disease (CHD) that requires surgical or catheter-based intervention for survival in infancy. These defects can cause significant morbidity or mortality once babies transition from fetal to postnatal circulation. The majority of CCHD lesions are dependent on a patent ductus arteriosus (PDA) to maintain either systemic or pulmonary blood flow. This makes early detection, monitoring, and treatment essential. So, the United States Department of Health and Human Services (USDHHS), based on recommendations from the American Academy of Pediatrics (AAP), American College of Cardiology, and the American Heart Association (AHA), added CCHD screening via pulse oximetry to the Recommended Universal Newborn Screening Panel in 2011.1,2 Since then, most states, including Mississippi, have incorporated CCHD screening into their statespecific newborn screen panel.3

1

The USDHHS and AAP recommend that all newborns not already diagnosed with CCHD undergo screening with pre- and post-ductal measurements of oxygen saturation by pulse oximetry (SpO2) on room air between 24-48 hours of life.

SpO2 is measured in the right arm (pre-ductal) and one of the lower extremities (post-ductal). A passing test requires SpO2 ≥ 95% and ≤3% difference between the pre- and post-ductal SpO2. SpO2 <90% at any point constitutes a failed test. Test failure also occurs if SpO2 is <95% or there is >3% difference in the pre- and post-ductal SpO2 during any of three attempts that are at least one hour apart.

Flow charts and algorithms are available from the MS Department of Health (DOH) and AAP (Figure 1).1,4 The baby’s age in hours, SpO2 values with respective locations, assessment of pass/fail, and subsequent management should also be recorded. Of note, screening should occur as close to discharge as possible for newborns discharged early.1

2

Clinicians should ensure the newborn is clinically stable and assess for causes of hypoxemia for all failed CCHD screens.

This includes physician examination and may involve pediatric cardiology consultation, echocardiography, and/ or screening for non-cardiac etiologies of hypoxemia.

Depending on the clinical situation, an evaluation for sepsis, persistent pulmonary hypertension of the newborn, pneumonia/lung disease, airway obstruction, central causes of cyanosis, or rarely hemoglobinopathies may be indicated.

Babies who have a ductal-dependent CCHD lesion should be started on a prostaglandin infusion in consultation with a pediatric cardiologist to keep the PDA open until surgical or catheter-based treatment is advisable.1

3

Pulse oximetry screening for CCHD evaluates for decreased blood oxygenation as neonates transition from fetal to post-natal circulation.

In utero, the pulmonary and systemic circulations are connected via the ductus arteriosus to allow blood to bypass the lungs, which are not involved in gas exchange. Once exposed to oxygen after birth, the PDA normally constricts and closes. Newborns with CCHD may have mixing of deoxygenated and oxygenated blood (e.g. truncus arteriosus) with associated hypoxemia from right-to-left shunting. Some

378 VOL. 57 • NO. 12 • 2016

FIGURE 1. CCHD screening algorithm endorsed by the USDHHS and the MS DOH (adapted from Kemper et al).1

may be ductal-dependent for systemic or pulmonary blood flow (e.g. hypoplastic left heart syndrome [HLHS] and pulmonary atresia, respectively). CCHD screening may thus demonstrate decreased SpO2 or a pre- and post-ductal SpO2 differential depending on the physiology of the defect, though it may also be initially normal, giving false negative results. With changes in transitional circulation (such as PDA closure and/or decrease in pulmonary vascular resistance), these infants may experience profound hypoxemia, acidosis, shock, and even death. Thus, screening aims to identify CCHD while the PDA remains open and transitional circulation persists.5

4

Seven primary cardiac lesions are targeted by universal pulse oximetry screening.

These lesions are tricuspid atresia, critical pulmonary stenosis/pulmonary atresia, Tetralogy of Fallot (TOF), truncus arteriosus, dextro-transposition of the great arteries (D-TGA), total anomalous pulmonary venous return (TAPVR), and HLHS.5 Secondary targets include other left-sided obstructive lesions such as critical aortic stenosis, aortic coarctation, and interrupted aortic arch as well as double outlet right ventricle (DORV), Ebstein anomaly, and other single ventricle lesions. Additionally, non-cardiac causes of hypoxemia may be detected with screening.

5

CHD is fairly common and the prevalence of CCHD is approximately 2-2.5/1000. Newborn exam is not a reliable screening tool for detection of CCHD. CCHD lesions often do not present with specific murmurs or exam findings. Many present with cyanosis, but detection can be subjective and is dependent on factors such as skin color, lighting, oxygen saturation, perfusion, and hemoglobin level (i.e. overestimated with polycythemia and underappreciated with anemia). Various studies have demonstrated that approximately 50% of CCHD is missed by physical exam.2,6 A large study noted the median age of death from missed CCHD was approximately 2 weeks, emphasizing the importance of screening and timely diagnosis.7

6

Routine antenatal US diagnoses only about 1/3 of CCHD cases and demonstrates high variability in detection rates.

The ability of obstetric US to detect CCHD depends on the lesion, type of care center, and the protocols utilized for assessment.

Prenatal US that are limited to the 4-chamber view can best visualize single-ventricle lesions (such as HLHS) but often miss lesions such as TOF, DORV, D-TGA, and truncus arteriosus which require evaluation of the ventricular outflow tracts. A recent multicenter study of patients who underwent surgery for CHD by 6 months of age found prenatal CHD diagnosis rates of 34%, with significant variability among U.S. regions and states.8

7

Pulse oximetry screening is a relatively sensitive and very specific screening tool for CCHD. A 2008 meta-analysis performed by an AHA and AAP-appointed committee found that pulse oximetry screening after 24 hours of life had a sensitivity of approximately 70% and low false-positive rates for detecting CCHD.5 Many of those screen-positive patients were not diagnosed via antenatal obstetric US. It is important to understand that performing the screen prior to 24 hours can increase the sensitivity, but reduces the specificity of the test as many babies without CCHD can be hypoxemic during the first day of life.9 Lastly, pulse oximetry screening can help identify hypoxemia due to non-cardiac causes that may also warrant further evaluation.

8

Though helpful in the detection of otherwise undiagnosed CCHD, pulse oximetry screening has important limitations.

False positive results may be encountered in high altitude settings where the partial pressure of oxygen is low.1 On the other hand, false negative results may occur with left ventricular obstructive lesions such as aortic stenosis and aortic coarctation. Those lesions can still lead to PDA-dependent systemic blood flow and could result in hypotension, shock, and even death when the PDA closes.6 Therefore it is important to continue educating families and health care providers about signs of CHD as part of the anticipatory guidance provided in the newborn nursery.

9

Pulse oximetry screening is a safe, easy, and cost-effective tool for detection of CCHD. According to the AAP, pulse oximetry screening for CCHD has comparable cost-effectiveness to other recommended preventative services. Moreover, screening is relatively fast and poses low risk of harm.10 The time required has been estimated between 1 and 9 minutes per newborn screened.11 Various studies have estimated per-capita costs between $5 - $14 depending on the protocol and institution.12 Use of reusable pulse oximetry probes has been postulated to lower cost to $0.50 per child.12

10

The MS DOH Newborn Screen Program is one of 48 states that has legislative or governmental regulations regarding CCHD screening.3 The MS DOH website, AAP, and CDC are some of the many entities that provide resources for further information regarding CCHD screening.10,13 A CCHD screening toolkit designed by Childrenâ&#x20AC;&#x2122;s National Medical Center is available on the MS DOH website. www.pulseoxtool.com is a screening tool from Childrenâ&#x20AC;&#x2122;s Healthcare of Atlanta to aid providers with CCHD screening. A list of questions and answers, along with additional resources for practitioners, can be found on the AAP website.10 Educational resources about state-specific newborn screening and CCHD screening in particular are also available for parents on sites such as www.babysfirsttest.org.

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Conclusion Screening via pulse oximetry is a simple and cost-effective tool for identifying newborns with CCHD who may be missed by antenatal obstetric US and postnatal physical exam alone. Though pulse oximetry screening should not replace these other modes of evaluation, several studies have demonstrated an association with screening and improved detection of CCHD, preventing morbidity and mortality associated with delayed diagnosis.5 This testing is now considered an integral component of newborn screening panels with nearly universal adoption in the U.S. since its endorsement by the USDHHS and AAP. As its use expands throughout the U.S., further longitudinal studies can be performed to determine the long-term role and efficacy of pulse oximetry screening for the detection of newborns with CCHD. n References 1. Kemper AR, Mahle WT, Martin GR, Cooley WC, Kumar P, Morrow WR, et al. Strategies for implementing screening for critical congenital heart disease. Pediatrics.

2011 Nov;128(5):e1259-1267.

2. Mahle WT, Martin GR, Beekman RH, Morrow WR, Section on Cardiology and Cardiac Surgery Executive Committee. Endorsement of Health and Human Services recommendation for pulse oximetry screening for critical congenital heart disease. Pediatrics. 2012 Jan;129(1):190–2.

3. MS Department of Health. Mississippi Newborn Screening and Birth Defects Registry [Internet]. Sect. Title 15, Part 4, Subpart 1. Available from: http://www. sos.ms.gov/ACProposed/00020841b.pdf.

4. Hom LA, Martin GR. Newborn Critical Congenital Heart Disease Screening Using Pulse Oximetry: Nursing Aspects. Am J Perinatol. 2016 Sep;33(11):1072–5.

5. Mahle WT, Newburger JW, Matherne GP, Smith FC, Hoke TR, Koppel R, et al. Role of pulse oximetry in examining newborns for congenital heart disease: a scientific statement from the AHA and AAP. Pediatrics. 2009 Aug;124(2):823–36.

6. Hoffman JIE, Kaplan S. The incidence of congenital heart disease. J Am Coll Cardiol. 2002 Jun 19;39(12):1890–900.

7. Chang R-KR, Gurvitz M, Rodriguez S. Missed diagnosis of critical congenital heart disease. Arch Pediatr Adolesc Med. 2008 Oct;162(10):969–74.

8. Quartermain MD, Pasquali SK, Hill KD, Goldberg DJ, Huhta JC, Jacobs JP, et al. Variation in Prenatal Diagnosis of Congenital Heart Disease in Infants. Pediatrics.

2015 Aug;136(2):e378-385.

9. Ewer AK, Middleton LJ, Furmston AT, Bhoyar A, Daniels JP, Thangaratinam S, et al. Pulse oximetry screening for congenital heart defects in newborn infants (PulseOx): a test accuracy study. Lancet Lond Engl. 2011 Aug 27;378(9793):785–94.

10. American Academy of Pediatrics. Newborn Screening for CCHD [Internet]. Available from: https://www.aap.org/en-us/advocacy-and-policy/aap-healthinitiatives/PEHDIC/Pages/Newborn-Screening-for-CCHD.aspx.

11. Peterson C, Grosse SD, Glidewell J, Garg LF, Van Naarden Braun K, Knapp MM, et al. A public health economic assessment of hospitals’ cost to screen newborns for critical congenital heart disease. Public Health Rep Wash DC 1974. 2014 Feb;129(1):86–93.

12. Peterson C, Grosse SD, Oster ME, Olney RS, Cassell CH. Cost-effectiveness of routine screening for critical congenital heart disease in US newborns. Pediatrics.

2013 Sep;132(3):e595-603.

13. MS DOH. MS DOH Information on Critical Congenital Heart Disease [Internet]. Available from: http://msdh.ms.gov/msdhsite/_static/41,0,285,687.html.

Author Information: Dr. Hasti Sanandajifar is a pediatric cardiology fellow at UMMC. Dr. Mary Taylor is the Professor of Pediatrics and Chief of Pediatric Cardiology at UMMC; she is also Program Director of the UMMC Fellowship in Pediatric Cardiology. Dr. Sarosh Batlivala is Associate Professor of Pediatrics, Director of Fellowship Training Programs for the UMMC Department of Pediatrics, and Associate Program Director of the UMMC Fellowship in Pediatric Cardiology.

Corresponding Author: Sarosh P. Batlivala, MD, University of Mississippi Medical Center, Division of Pediatric Cardiology, 2500 N. State Street, Jackson, MS 39216, Office: 601-984-5250 / Fax: 601-984-5283, sbatlivala@umc.edu.

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Mississippi Perspective: Dermatologic Manifestations of Arsenic Poisoning CAROLINE DAGGETT, BA; AMANDA DAGGETT, MD; ROBERT T BRODELL, MD; C. RALPH DANIEL III, MD Abstract A Mississippi perspective on arsenic poisoning is largely related to thousands of asthma patients cared for by one physician, Elmer D. Gay, MD, in the 1950s. The general medical uses of arsenic and its specific use in intractable asthma are reviewed along with the dermatologic manifestations of arsenic poisoning.

Key Words: Arsenic, Arsenicosis, Arsenic poisoning, Toxicity, Asthma, Dr. Elmer Gay Arsenic has been used as a therapeutic agent since 2000 BC. Hippocrates, Aristotle, and Paracelsus used arsenic to treat their patients. In 1786, Fowler’s solution was created using 1% of potassium arsenite. Several centuries later, in 1910, arsphenamine or Salvarsan was used as a chemotherapeutic agent. It was also used to treat syphilis and trypanosomiasis. More recently in 2000, arsenic trioxide was approved by the Food and Drug Administration (FDA) to treat leukemia.1 Arsenic in Mississippi In the 1950s, Mississippi physician Elmer D. Gay, MD developed a mixture containing “Fowler’s solution” supplemented with tincture of digitalis, sodium phenobarbital, and potassium iodide. Thousands of patients with refractory asthma were treated using this “Gay treatment” or “red medicine” in Biloxi, Mississippi.2,3 It was common for patients who had exhausted all other options to travel long distances to receive the Gay Treatment. Some of these patients settled permanently in Biloxi and were treated for long periods of time. Testimonials suggest that the treatment worked well returning some individuals to a normal life.2,3 Despite these anecdotes, the medical community criticized him for his unconventional approach. No prospective comparative trials were ever performed in Mississippi.

In 1967, Harvard researchers investigated Dr. Gay’s solution in severe asthmatics using a two-phase study. In phase I (uncontrolled), arsenic led to a 32% improvement, whereas, a control treatment consisting of Gay’s solution without arsenic led to only a 9% improvement. In phase II (controlled) using Gay’s solution, 72% of the patients had improvement. They concluded that Gay’s solution was an effective “treatment of severe asthma and that its effectiveness was dependent on the presence of arsenic in the mixture.”4 The Nature of Arsenic and Its Indications Through History Arsenic is a tasteless, odorless metalloid, which is found in abundance 382 VOL. 57 • NO. 12 • 2016

in the earth’s crust. It is usually bound to pyrite but can be dissociated in the soil related to pH and temperature changes. This can result in contamination of groundwater resulting in human toxicity. Worldwide, it is estimated that 200 million people are at risk of arsenic poisoning most specifically in Bangladesh, China, India, and South America. The United States Agency for Toxic Substances and Disease Registry (ATSDR) ranked arsenicosis number one for public health threat in 2011.5 As a therapeutic agent, arsenic in a paste has been used to treat skin and breast cancer and in oral forms to treat syphilis, hypertension, heartburn, chronic rheumatism, and ulcers.6 In the 16th century, Thomas Fowler began using arsenic in an orally administered solution he developed that contained arsenic trioxide in potassium bicarbonate (1% w/v) to treat a variety of illnesses such as asthma, anemia, eczema, psoriasis, and pemphigus. “Fowler’s solution” became the first therapeutic agent for treating leukemia after it was found to decrease white cell counts and remained the mainstay until the 1950s when newer chemotherapeutic drugs were introduced. Despite the reported benefits, the chronic use of arsenical compounds resulted in toxicity, and these compounds were eventually determined to be carcinogenic.7 Dr. Gay died in 1980 at the age of 73, and in 1998, Fowler’ solution, an important component of the Gay treatment, was removed from use by the FDA for safety issues. Interestingly, arsenic is back! The FDA approved arsenic trioxide in 2001 for intravenous use for the treatment of acute promyelocytic leukemia.

Hazards Associated with Arsenic A report about arsenic poisoning appeared in the Journal of the American Medical Association (JAMA) in 1952. The 41 year-old woman had been treated by Dr. Gay for asthma at the age of 36. Within three days of beginning treatment, she was “completely relieved of asthma for the first time.”8 She continued using “Gay’s solution” after returning home for a total of two years. A year after treatment began, she began to notice freckling of her skin and her nipples. Treatment with arsenic was stopped when she developed hepatomegaly followed by hyperkeratosis of the soles of her feet and her palms a few months later.8 This patient’s clinical presentation is typical of the manifestations of arsenicosis. Signs of arsenic exposure/poisoning can be found in the skin, nails, and hair, and arsenic deposits also occur in the liver, lungs, gastrointestinal wall, spleen, bones, nervous system, blood, respiratory mucosa, and vasculature.

Table 1. Typical Clinical Features of Arsenic Poisoning Affected organ

Features

Skin

• Excessive darkening of skin (hyperpigmentation) in areas that are not exposed to sunlight • Excessive formation of scaly skin on the palms and soles (arsenical keratosis) • Exfoliative dermatitis • Arsenic-induced skin cancers (especially Bowen disease)

Nails

• Transverse white bands of arsenic deposits across the bed of the fingernails (Mee’s lines)

Hair

• Arsenic deposits in hair

Nervous system

• Sensory changes, numbness and tingling in a “stocking-glove” distribution (sensory peripheral neuropathy) • Headache, drowsiness, confusion • Distal weakness of small muscles e.g. hands and feet

Blood and urine

• Hemolytic anemia (moderate) • leukopenia (low white cell count) • Proteinuria (protein in urine)

Other

• Inflammation of respiratory mucosa • Peripheral vascular insufficiency • Increased risk of cancer of lung, liver, bladder, kidney and colon

Other cutaneous signs include hyperkeratosis (either nodular or uniform) of the soles and palms, exfoliative dermatitis, and skin cancers such as Bowen disease.10 FIGURE 2. Arsenical keratosis on the sole of the foot. This 20 x 8 mm, non-tender, well- circumscribed, hard scaling patch occurred in a patient with arsenicosis. Image courtesy of Milan J. Anadkat, MD, Director Residency Program, Associate Professor, 660 South Euclid Ave, Campus Box 8123, Division of Dermatology, Washington University School of Medicine, St. Louis, MO 63110

Source: Dermnet New Zealand. Dermnet.org. http://creativecommons.org/licenses/by-ncnd/3.0/nz/

Arsenic is a carcinogen, and it is not surprising that cancer can occur in any of the organs where it is deposited. Visible signs of arsenic toxicity in the skin, hair, and nails take time to develop, usually at least several weeks. Diffuse brown macules may appear. Additionally, areas of hypopigmentation occur within hyperpigmented patches creating the appearance of “rain drops on a dusty road.”9

FIGURE Figure 2. 3. Bowen disease on the thumb. Squamous Cell Carcinoma in

situ (Bowen disease): A 1.9 x 1.5 cm, erythematous, scaling patch has persisted on the right thumb for 3 years, only very slowly enlarging.

Image courtesy of Stephen E. Helms, MD, Professor of Dermatology, University of Mississippi Medical Center.

FIGURE 1. Arrow 1. Arsenical keratosis of the palms of the hand. These lesions are usually punctate, non-tender, circumscribed, hard areas that appear over areas of friction or trauma on the palms and soles.

Arrow 2. Hypopigmented areas within areas of hyperpigmentation (rain drops on a dusty road appearance) are also present. Image Source: DermNet New Zealand. Dermnetnz.org. No changes have been made to the image. License: http://creativecommons.org/licenses/bync-nd/3.0/nz/

Figure 3.

2

1

The pathogenesis of arsenical keratosis results from arsenic’s high affinity for sulfhydryl groups found in abundance in keratin-rich cells such as the epidermal keratinocytes. Also, it disrupts normal keratinocyte processing, alters cell cycles, and promotes growth factor overproduction as well as keratinocyte proliferation. As a carcinogen, it increases the mutagenicity of other carcinogens and alters normal nucleotide repair.11 In the nails, Mees’ lines and Beau’s lines often appear. Mees’ lines are dyskeratinization and are not necessarily arsenic deposits.

Figure 1.

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FIGURE 4. Mees’ lines are transverse, white lines strongly associated with arsenic, thallium, and to a lesser extent, other heavy metals toxicity. They usually appear one per nail, appear on multiple nails, and do not disappear when pressure is placed on the nail, distinguishing them from Muehrcke’s lines. Image Source: Daniel CR, Piraccini BM, Tosti A.13

Beau’s lines Figure 4. occur when there is a pause in nail production at the nail matrix.

FIGURE 5. Beau’s lines are deep, horizontal grooves that may look like indentations or ridges running edge to edge across the nail.

Beau’s lines are commonly a result of injury or infection to the nail, and contrary to Muehrcke’s lines, migrate distally as the nail grows.

Image Source: DermNet New Zealand. Dermnetnz.org. No changes have been made to the image. License: http://creativecommons.org/licenses/ by-nc-nd/3.0/nz/

FIGURE 6. Muehrcke’s lines are superficial, white lines extending across the entirety of the nail, parallel to the lunula (the white crescent-shaped area of the nail bed). They are not grooved as in Beau’s lines and lie in the vascular part of the nail bed beneath the nail plate, and therefore, do not move as the nail grows. Muehrcke’s lines disappear when pressure is placed on the nail, a distinguishing feature from Mee’s lines. Image source: Wikimedia Commons.

Figure 6.

InMees’ lines, the timing of arsenic exposure can be estimated. terruption of normal nail growth (Beau’s lines) can be related to a wide range of causes, including trauma. Beau’s lines are deep, grooved lines that run from side to side on the fingernail or the toenail. Disruption of nail bed mitosis is their etiology and reflects severe illness. Many people have another discoloration of their nails known as leukonychia or nail color changes that appear as white lines or spots on multiple nails.

They are not uniform, appearing at various points on the nail and do cover the entire span of the nail. A result of minor trauma to the proximal nail bed, they are not significant and should not be confused with Mees’ or Muehrcke’s lines, which run parallel to the lunula, the white, crescent-shaped area at the base of the fingernail.12,13,15 12,13,14

There are no specific treatments for either the systemic or dermatologic manifestations of arsenic poisoning.16 Available remedies include removal of the arsenic source, chelation to bind residual arsenic for excretion, and time. Many patients see improvement of their dermatologic manifestations, but still remain at risk for skin and internal cancers. Other patients have persistent, life-long sequelae from their arsenic toxicity.5,17 Field treatment of arsenical keratosis with 5-fluorouricil or imiquimod 5% can be attempted, but it is difficult for topical treatments to penetrate the palm and sole skin. The nail changes grow out within months once the arsenic is discontinued.

Figure 5.

Of course, Mees’ lines and Beau’s lines are reaction patterns and are not pathognomonic of arsenicosis. With Mees’ lines, multiple nails are usually affected, and the nail bed is normal. The width of the line may vary, but over time, the transverse lines migrate distally, a distinguishing feature from Muehrcke’s lines, which do not migrate.

Also, Muehrcke’s lines are a result of abnormal vasculature in the nail bed and disappear when the nail is compressed, whereas Mees’ lines do not. Using normal nail growth averages and the migration distance of 384 VOL. 57 • NO. 12 • 2016

The Mississippi Experience with Arsenicosis Many patients passed through Dr. Gay’s clinic in the 1950s. His use of arsenic in intractable asthma drew national attention and often condemnation. Despite the praise and adulation of selected patients who were delivered from a life of misery and suffering, case reports and patient accounts reveal many experienced arsenicosis. Due to its tasteless and odorless properties, arsenic has also been used for nefarious purposes. The advent of better detection methods has reduced its use in that regard, but contamination with this naturally occurring element is a global problem. A known carcinogen, arsenic is associated with can-

cer of the bladder, liver, kidney, prostate, uterus, and skin. Its usefulness as a therapeutic agent is limited to certain, specific forms of leukemia.

Interestingly, the 1967 study out of Harvard looking at Gay’s solution in the treatment of asthma lists study patient ages from 10 to 70 years of age.4 Being born in 1906, Dr. Gay would have been approximately 61 years of age in 1967. If we extrapolate from those figures, the youngest patients from that study would be around 60 years of age today and the oldest in their nineties or beyond. Consequently, it is feasible that some of Dr. Gay’s patients could present as patients still, and therefore, a working knowledge of arsenic toxicity should be useful and should remain in one’s differential diagnosis. While dermatologists, especially in the south, have seen sequelae from arsenicosis, as time goes by, we can expect to see fewer and fewer cases. n References 1. Hughes MF, Beck BD, Chen Y, Lewis AS, Thomas DJ. Arsenic exposure and toxicology: a historical perspective. Toxicol Sci. 2011;123(2):305-332. doi:10.1093/toxsci/kfr184.

2. Cure. asthma-cure.net website. http://asthma-cure.net. Accessed November 1, 2016 3. Dorfman HA. Persuasion of my days, an anecdotal memoir: the early years.

Falls Village, CT. Hamilton Books; 2005 4. Harter JG, Novitch MA. An evaluation of Gay’s solution in the treatment of asthma. J Allergy. December 1967; 40(6): 327-33. http://dx.doi. org/10.1016/0021-8707(67)90022-6 5. Hunt KM, Srivastava RK, Elmets, CA, Athar, M. The mechanistic basis of arsenicosis: Pathogenesis of skin cancer. Cancer Lett. 2014;354(2):211– 219. doi:10.1016/j.canlet.2014.08.016.

6. Antman KH. Introduction: the history of arsenic trioxide in cancer therapy.

The Oncologist. 2001; 6 Suppl 2:1-2 7. Jolliffe DM. A history of the use of arsenicals in man. J R Soc Med. 1993;86(5):287-289.

8. Silver AS, Wainman PL. Chronic arsenic poisoning following use of an asthmatic remedy. JAMA. 1952;150 (6):584–585. doi:10.1001/ jama.1952.63680060003015a.

9. Naujokas MF, Anderson B, Ahsan H, et al. The broad scope of health effects from chronic arsenic exposure: Update on a worldwide public health problem. Environ Health Perspect. 2013;121(3). doi:10.1289/ehp.1205875.

10.

Ratnaike RN. Acute and chronic arsenic toxicity. Postgrad Med J. 2003;79(933):391–396. doi:10.1136/pmj.79.933.391.

11. Chen C-SJ, Siegel DM. Arsenical keratosis. Medscape Education website. http://emedicine.medscape.com/article/1099882-overview Updated March 30, 2016.Accessed November 9, 2016.

12. Fawcett RS, Linford S, Stulberg DL. Nail abnormalities: clues to systemic disease. Am Fam Physician. 2004;69(6):1417–1424.

13. Tully AS, Trayes KP, Studdiford, JS. Evaluation of nail abnormalities. Am Fam Physician. 2012;85(8):779–787.

14. Daniel CR, Piraccini BM, Tosti A: The nail and hair in forensic science. J Am Acad Dermatol 2004;50(2): 258-261. doi:10.1016/j.jaad.2003.06.008 15. Uede K, Furukawa F. Skin manifestations in acute arsenic poisoning from the Wakayama curry-poisoning incident. Br J Dermatol. 2003;149(4):757– 762. doi:10.1046/j.1365-2133.2003.05511.x.

16. Ngan V. Chronic arsenic poisoning. DermNet New Zealand-All About the Skin website. www.dermnetnz.org. Accessed November 10, 2016.

17. Mayer JE, Goldman, RH. “Arsenic and skin cancer in the USA: the current evidence regarding arsenic-contaminated drinking water.” Int J Dermatol 2016;55(11). doi:10.1111/ijd.13318

Author Information Caroline Daggett, BA, First Year Medical Student, University of Mississippi School of Medicine, 2500 N. State Street, Jackson, MS 39216. Amanda Daggett, MD, Preliminary resident, CedarsSinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048, Dermatology Resident, Tulane School of Medicine, 1430 Tulane Avenue, #8036, New Orleans, LA 70112. Robert T Brodell, MD, Professor and Chief, Department of Dermatology, Professor of Pathology, University of Mississippi Medical Center, Jackson, Mississippi, Instructor in Dermatology, University of Rochester School of Medicine and Dentistry, Rochester New York. C. Ralph Daniel III, MD, Clinical Professor of Dermatology, University of Mississippi Medical Center, Jackson, Mississippi, Clinical Professor of Dermatology, University of Alabama, Birmingham, Alabama.

Caroline Daggett performed library research on this subject and wrote the first draft of the manuscript. Ralph Daniel is responsible for the concept of the manuscript and served as a primary editor.

Amanda Daggett and Robert Brodell reviewed and approved the content of the final draft. This article has not been previously published in the literature.

Conflict of Interest: Robert Brodell, MD discloses the following potential conflicts of interest: honoraria have been received from presentations for Abbvie. Clinical trials have been performed for Genentech and Janssen Biotech, Inc. and Galderma. There was no financial support for the preparation of this manuscript.

Corresponding Author Caroline Daggett, MS1, 2433 Massena Drive, Jackson, Mississippi 39211, Cell: 601-953-4780, Fax: 601-510-9728, Email: cmdaggett1@gmail.com

T he Pen is Mightier

than the Sword.

Express your opinion in the JMSMA

through a letter to the editor or guest editorial. The Journal MSMA welcomes letters to the editor.

Letters for publication should be less than 300 words.

All letters are subject to editing for length and clarity. If you are writing in response to a particular article, please mention its headline and issue date in your letter. Guest editorials or comments may be longer, with an average of 600 words, including no more than 10 references.

Also, include your contact information. While we do not publish street addresses, e-mail addresses, or telephone numbers, we do verify authorship, as well us try to clear up ambiguities, to protect our letter-writers. You should submit your letter via email to KEvers@MSMAonline.com or mail to the JMSMA office at MSMA headquarters: P.O. Box 2548, Ridgeland, MS 39158-2548.

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Saturday, May 27, 2017 Raven Golf Club at Sandestin Golf and Beach Resort Shotgun start at 2 p.m.

For more information and to sign up, contact Wendy Powell at Medical Assurance Company of Mississippi 1.800.325.4172 / wendyp@macm.net

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[This month, we print a poem by the late William F. “Bill” Roberts, who died November 30, 2016. Bill served as Executive Director of MSMA from 1998 to 2007, with service to our MSMA and the AMA in a variety of capacities beginning in 1973. Please see my “Editor’s Note” and an obituary in this issue for more. Bill possessed Renaissance qualities and was a gifted leader and writer. The following poem, written when Bill was a junior at Ole Miss way back in 1966, was printed in his memorial service program and reveals the depth of his intellect even as a college student.

He describes precociously at the beginning of his path on the “merry-go-round that surrounds our very being” the joyous and serendipitous life journey we all take. Our prayers go out to his family and friends. Any physician is invited to submit poems for publication in the journal, attention: Dr. Lampton or email me at lukelampton@cableone.net.]—Ed.

In Memoriam No need to be sorry. We come here knowing nothing, wanting nothing, expecting nothing, snatched out of the womb and thrust into a great expanse of time and circumstance in which nothing is real and reality itself a longing we die with.

We meet obstacles, we pass landmarks, we slip into series after series of situations good and bad, like perennial actors endlessly reacting to the flow of life in countless different plays, day-long comedies and all night dramas. Nothing completely remains the same, from moment to moment our lives skidder along endlessly bleak paths, twisting, bending, winding around an inconceivable course of fate, a virtual circus of free-lance experiences, meeting life with life, one minute here, gone the next, we ride the merry-go-round that surrounds our very being.

—William F. “Bill” Roberts Junior year at Ole Miss, 1966

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P R E S I D E N T ’ S

P A G E

Working for Cures in the 21st Century

A

rare show of bipartisanship in Washington, D.C., has set the course of medicine to take America and Mississippi to the next level. The 21st Century Cures Act invests in next level medical technology moving to the forefront medical advances from regenerative medicine to curbing opioid addiction.

Here at MSMA we are thrilled by the prospects of the law. It aims to bring groundbreaking biomedical research into the examination room and beyond. If successful, research breakthroughs could help Americans develop an artificial pancreas, build replacement organs from a patient’s own cells, develop non-addictive painkillers, create an HIV/AIDS vaccine or even prevent Zika infection. The Precision Medicine Initiative and Moonshot to Cure Cancer also fall under this initiative.

Opioid abuse is a crisis-level concern in Mississippi and across the country. In fact, the number of overdose deaths in America topped the number of homicides in 2013. That’s why the new 21st Century Cures Act is meant to fund the research, treatments and prevention measures that will curb this national tragedy. Here at MSMA we have worked for years on this subject and fully endorse efforts to change the paradigm on opioid abuse in Mississippi.

I am also encouraged by the law’s mental health provisions. Much of the ongoing public health crisis in our state centers on mental health.

Shrinking budgets have hit the State Department of Mental Health hard and our state simply lacks the resources adequate to address the problems. With the 21st Century Cures Act, investments in mental health can be available at the state level to balance out the insufficient resources.

The intersection of technology and medicine also holds great promise. The new law promotes research into precision medicine and regenerative medicine, two fields that could take healthcare into what was previously science fiction territory.

Under the Precision Medicine Initiative researchers will map the genome of one million volunteers and make the data available to other researchers. The goal is to pinpoint treatments and cures specific to a patient’s genome -- what an efficient alternative to our current one-size-fitsall approach! Our colleagues at Vanderbilt University may be the first to receive genome research funding from this new source.

Regenerative medicine is another fascinating area where technology works at the genetic and cellular level to repair and rebuild organs or to cure disease. One patient in Tennessee had his sight mostly restored after cells from his hip bone were centrifuged and the appropriate isolated cells were injected into his retina. Clinical trials like this demonstrate clearly the advances that can be made in this field of medicine.

In all, the 21st Century Cures Act will give $500 million to the FDA and will make $1 billion in grants available to the states for research and services. The law is a breath of fresh air and it will be fascinating to watch the research advance. MSMA encourages our state leaders in medicine and policy to take advantage of this rare opportunity. We have the need. We have the expertise. Let’s move Mississippi forward in the 21st century. n

Lee Voulters, MD; Gulfport MSMA President 2016-17

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The Mississippi State Medical Association encourages YOU to give kids a shot at a healthy, happy future by joining the Mississippi Immunization Task Force as we spread the word about the benefits of vaccines.

Pull out this poster for your office or clinic and encourage parents to give all kids a shotâ&#x20AC;&#x201D;and keep our community immunity strong!

Find us on Facebook, Twitter, and Instagram, and visit GiveMeAShot.org to learn more.

Mississippi Immunization Task Force

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Protection from preventable diseases is something to smile about! Give kids a shot at healthy, happy futures by keeping up with life-saving vaccines. Talk to your doctor and visit GiveMeAShot.org to stay informed and stay on schedule.

The Mississippi Immunization Task Force wants you to give kids a shot and keep our community immunity strong. Find GiveMeAShot on Facebook, Twitter, and Instagram, and share your shot pics with #ShowYourShot!

#SHOWYOURSHOT

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PO Box 2548, Ridgeland, MS 39158 | 408 West Parkway Place 39157 | (601) 853-6733 | MSMAonline.com PRESIDENT Lee Voulters, MD Pass Christian PRESIDENT-ELECT William M. Grantham, MD Clinton PAST PRESIDENT Daniel Edney, MD Vicksburg SECRETARY-TREASURER Michael Mansour, MD Greenville SPEAKER Geri Lee Weiland, MD Vicksburg

Fellow Physicians, MSMA is once again taking a stand for our state’s greatest resource—our children.

We’ve founded an alliance of like-minded entities to form the Mississippi Immunization Task Force to tell everyone who will listen about the importance of childhood vaccinations and the seriousness of the diseases they prevent. This new generation of parents has never seen polio, indeed, many of us physicians have never seen polio. So, education is a critical role that physicians must play in keeping our children safe from preventable diseases.

Mississippi has the nation’s strongest immunization law and we have the highest percentage of immunized school children in the country. In fact, the Mississippi law has been used as the model by several states including California which copied Mississippi after its massive measles outbreak in 2014.

BOARD OF TRUSTEES J. Clay Hays, Jr., MD Chair, Jackson W. Mark Horne, MD Vice Chair, Laurel Timothy Beacham, MD Secretary, Greenville Brett C. Lampton, MD Oxford

Your MSMA and the Mississippi Immunization Task Force wants to ensure that all children receive the recommended five vaccines to attend public school unless they have a medical exemption approved by the State Department of Health.

You can help us spread the word by hanging this poster in your office or examination room and encouraging your patients to visit GiveMeAShot.org to learn more.

Together, we can give every kid in Mississippi a shot at a happy, healthy future.

John R. Mitchell, MD Pontotoc Jennifer J. Bryan, MD Jackson J. Lee Valentine, DO Meridian

Lee Voulters, MD MSMA President 2017

Joseph D. Austin, MD Vicksburg W. David McClendon, MD Ocean Springs John Cross, MD YPS, Jackson Ryan McGaughey, MD Resident/Fellow, Jackson Neal Boone Medical Student, Jackson EXECUTIVE DIRECTOR Charmain Kanosky

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C A R E Y

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WCU College of Osteopathic Medicine Launches New Ambulance Drones William Carey University College of Osteopathic Medicine students demonstrated how telemedical kits delivered by disaster drones could be used to assist victims and rescue personnel during a simulated mass casualty event on Dec. 6 at John Bell Williams Airport in Bolton. The development of the disaster drones is a joint project with the unmanned aerial systems program at Hinds Community College. The technology debuted before an audience including representatives from Homeland Security, federal law enforcement agencies, and the United Nations.

The Telemedical Drone project, known as HiRO (Health Integrated Rescue Operations), was developed by Italo Subbarao, DO, senior associate dean at WCUCOM, and Guy Paul Cooper Jr., a fourth-year medical student at WCUCOM.

The concept arose when the two studied the medical response to the devastating EF-4 tornado that struck Hattiesburg in February 2013. In the past two years, they’ve developed multiple prototypes to support rural and wilderness medical emergencies, including the two newest iterations: ambulance drones designed to support victims and rescue personnel during mass shootings, bombings, or other terrorist attacks.

Two new telemedical packages were deployed during the demonstration, one for a severely injured victim and the other for a mass casualty setup capable of treating up to 100 people with significant to minor injuries. Both kits incorporate Homeland Security recommendations provided through the “Stop the Bleed” initiative.

“The two highly advanced mobile telemedical kits provide immediate and secure access to a provider on the other end of the screen. The package was designed for use in the chaos and confusion where guidance must be simple, direct, and user friendly,” said student doctor Cooper. “We feel that the features in these kits empower the provider and bystander to save lives.”

When the critical care kit opens, a physician appears on video and can direct treatment. The kit includes Google Glass, which allow the wearer to be hands free and to move away from the drone while maintaining audio and visual contact with the physician.

Experts from Hinds Community College, in collaboration with Subbarao and Cooper, designed and built both disaster drones, which are capable of carrying telemedical packages in adverse conditions.

“These drones have impressive lift and distance capability, and can be outfitted with a variety of sensors, such as infrared, to help locate victims,” said Dennis Lott, director of the unmanned aerial systems program at Hinds Community College. “Working together, we’re able to develop, test, and bring this technology to the field. It is just a matter of time before the drones are universally adopted for emergency and disaster response toolkits.” n Source: http://mississippitoday.org/2016/12/06/telemedical-drone-project-takes-off/

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In Memoriam: William Francis Roberts (1945-2016), Past MSMA Executive Director William Francis Roberts, beloved husband and father passed away November 30, 2016, after a long and courageous battle with cancer. He was born March 26, 1945, to William Cooper Roberts and Dorothy Crawford Roberts of Pascagoula, Mississippi.

He is survived by his loving wife of 35 years, Marilyn Mock Roberts, and their daughter, Dr. Allison Roberts Cruse, and her husband Blake, of Jackson, Mississippi.

Also survived by daughters Rachael Roberts of Jackson, MS and Robyn Roberts Rea, husband Zack of Brooklyn, NY, and their mother Esther Baugh (Jim), also of Jackson. He is also survived by his brother Gaylen Cooper Roberts (Jo Ann) of Canton, GA, sister-inlaw Melinda Mock Familia (Bill) of Port Orange, FL, brothers-in-law George Mock (Kathy) of Nashville, TN, Randy Mock (Susan) of Metairie, LA, and Brian Mock (Tia) of Heathrow, FL, and numerous cousins, nieces and nephews throughout the South. He was predeceased by his parents and sisters-in-law Melissa Mock Fort and Carla Mitchell Roberts.

William (Bill) played basketball for the Pascagoula High School Panthers, graduating in 1963. In the same year, he enrolled in the University of Mississippi, where he pledged Sigma Nu Fraternity and joined several well-known singing groups and bands. He graduated in 1967 and, following in the footsteps of his uncle Galen Crawford, was commissioned as a Second Lieutenant in the US Army.

Following a short tour in California, Bill was assigned as an Armored Platoon Commander in the jungle area of Vietnam just south of the DMZ. During his yearlong service in close combat, he was awarded the Army Commendation Medal and the Bronze Star Medal. He later received the Purple Heart for injuries sustained while in Vietnam.

Following his military service, Bill returned to Jackson and worked his way through the Jackson School of Law and earned his Juris Doctorate degree. In 1973, he 394 VOL. 57 • NO. 12 • 2016

began his long career with the Mississippi State Medical Association (MSMA) and the American Medical Association (AMA). He served as legislative liaison with the state agency responsible for administering the Mississippi Medicaid program. He was Legal Counsel and Director of Governmental Affairs for statewide membership association for Mississippi physicians of the MSMA. He served as legislative liaison for the health sciences campus of the University of Mississippi.

He was appointed Legislative Counsel for the AMA in Washington, D.C. where he directed an eight-member field staff responsible for Congressional grassroots programs.

Following some time with the AMA in Chicago, he returned to Jackson in 1989 to assume the position of Assistant Executive Director and Legal Counsel of the MSMA. In 1998, Bill was named Chief Executive Officer of the MSMA, serving in that capacity until his retirement in 2007. There he developed the largest political action committee in Mississippi, which resulted in significant changes in the composition of the appeals courts in 2002. Bill secured legislative funding for the Office of State Medical Examiner, which had been unfunded for seven years following the passage of enabling legislation. He drafted and successfully pushed for passage of legislation authorizing establishment of a physician-owned medical liability insurance company,

now the largest in Mississippi. He also developed the strategic plan for the enactment of Mississippi’s landmark tort reforms in 2002 and 2004, and led the effort to secure their passage.

Bill was a kind and gentle soul who adored the women in his life, especially his three daughters. He was such a great father and role model for them. He was a tremendous source of strength for his girls, his wife, family and friends. He was a man who could be relied upon to assist with just about anything, from paint trim to public service, home construction to the perfect tenderloin. He enjoyed traveling with Marilyn throughout the states and Europe. He was a lifetime Ole Miss fan, and they loved spending time in Oxford, their second home. Bill was a magnificent chef who even wrote a cookbook for his daughters so they would know how to prepare their favorite dishes they grew up on. Word got around about the cookbook and, many printings later, all of his family and friends also have copies. He was a Renaissance man, worldly, cultured, and creatively curious, a writer and collector of books, art, decor, and meaningful photos and memories. He was a uniquely talented artist. On his travels throughout

Europe, he would take lots of photographs, return home and paint beautiful watercolors. These paintings have become, to his daughters, the most treasured gifts. He knew how to gracefully navigate a dance floor and graciously work a diversely crowded room. And, the laughs - no one was immune to the infectious laughter over his perfectly-timed humor. His joy and warmth still resonate with us all.

A Memorial Service celebrating Bill’s life was conducted by Rev. Calvin Cosnahan on Saturday, December 3, 2016 at 1:00 pm at Christ United Methodist Church in Jackson, MS. Immediately following the services, a reception was held at the church.

The family would like to thank Dr. Charles Pound and Dr. Louis Puneky at UMMC and Dr. Jennifer Frost at the VA for their wonderful care and support. In lieu of flowers, the family requests memorials to the Urology fund or the Hematology/Oncology fund at UMMC Office of Development, 2500 North State Street, Jackson 39216, or to Christ United Methodist Church, 6000 Old Canton Road, Jackson, Mississippi 39211. n

Register at www.MSMAonline.com/CMEDisney.

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Bring the entire family to Walt Disney World® this November! You’ll earn 9 CME credits and have plenty of time to enjoy the parks.

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Jaybird Pie: A Christmas Story DWALIA S. SOUTH, MD Memories, remembrances, recalled life events, family legends, personal histories, handed-down stories…whatever you choose to call them…we all have them, don’t we?

If you think about it, one generation is responsible for the preservation of these stories for the next to follow. And if they fail to, as is the usual case, the legends both grand and small pass into the grave of human forgetfulness, lost forever.

The majority of our human predecessors who were ever born, somehow survived to maturity, and who were able to reproduce, spent their entire lives simply focused on the business of survival. They then died in whatever fashion to which they fell victim … whether succumbing to age and infirmity or possibly just by getting eaten by something bigger and meaner than themselves. Most of our ancestors were not funeralized in the extravagant manner we practice today and perhaps not even buried at all. There exists for the oldest portion of our kind not so much as a recognizable stone bearing a name.

They are, as the poet Lord Byron once said, “Without a grave, unknelled, uncoffined, and unknown.”

Dwalia S. South, MD; Ripley

Though every human had a story to tell, precious few have survived. Some events might seem to need forgetting, but even the bad memories deserve a sacred space in our lives. How much richer is a family that can share these stories on into the minds of our future progeny who will never know or care about us otherwise. ~~~~~~~~~~~~~~~~ Since my Mother, Velma South, died in April 2014, words about her seemed trapped inside me. But, recently some shadowy and long suppressed childhood memories have resurfaced chameleon-like to my mind’s eye. This particular remembrance encompasses six generations of my family. While it is an event from my far distant childhood, it was recently brought back to me by small daily incidents with my own granddaughters…having to do with songbirds, getting an accidental poke in the eye, and the tale of eating jaybird pie.

The making of the jaybird pie must have happened about a week before Christmas, probably in 1959. I would have been four years old, so that year sounds about right. Four is a nebulous age when few specific memories can be recalled unless they were fairly dramatic occurrences.

Most are vague, shadowy things conjured back up in the nostalgic mind decades later when triggered by some related event. Because my Mother never brought up this terrible accident she and I had or cast blame on me for causing it, that little chunk of this story has been long suppressed.

Recently I was sitting at the kitchen table holding my 16 month old granddaughter Molly in my lap while going through the day’s mail stack. She was “helping me” sort through the pile, picking up envelopes one at a time and handing them to me. I looked away for a moment to converse with her parents and then later looked back quickly in her direction. She was holding up a manila envelope to show me and the corner of it jabbed squarely into my open left eye. Even a slight corneal scratch causes intense pain and profuse tearing. I handed Molly back to her mom, Kimmie, and began rubbing my suddenly burning and watering eye, grunting with the effort and searching the fridge for some anesthetic eye drops that I always keep on hand. Her daddy, my younger son Jack, started immediately apologizing for the mishap. There was no need of course as there was no fault in little Molly’s action.

When I had collected myself a bit, I told my son and daughter-in-law about the similar but far more serious accident involving an ‘eye-poking’ that happened when I was small. Jack remarked at the time that I had never told him this story before. I have no memory of the actual trauma I inflicted in this incident, just a recollection of a sense of shame based on a few times when I chanced to overhear the story brought up in adult conversations in later years.

In my childhood, as borne out by family photographs, we always had fresh cut cedar Christmas trees that usually were harvested from our back pasture fence row. Because she was not easily pleased, Mother

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would pick ‘the best one’ she could find, hand saw it down herself, put it in a red and green metal tree stand, and try bringing it inside the house. The process would nearly always have to be repeated because our ancient home had once been a sharecropper’s shack that had apparently been designed and built for hobbits. All our ceilings were 7 feet high or less. Back out she would go, having to whack off another foot or so and starting over. Then bringing the tree inside on the stand, she would try to figure out which was the ‘best side’ and then once she got it in the middle of the front room windows where our tree would always be placed, she would get her sharpest butcher knife to trim the tree of what she called the ‘spraggledy’ bottom limbs. The trimmings would be saved to make other good smelling wreaths and decorations.

Apparently that is when ‘IT’ happened. She was sitting in the floor under the tree that morning and I was standing nearby holding onto the butcher knife for her while she made other adjustments.

She turned toward me abruptly and the big kitchen knife I was grasping tightly punctured her squarely in the eye. I don’t know now which eye it was. I don’t know the specifics of the rest of the day’s chain of events regarding that awful incident. I am sure she must have screamed and run down the road to a neighbor’s for help. My Daddy was at work and we had neither a phone nor a car in those days. Everything about the time immediately following the incident is missing from my memory bank. Who wants to recall the day when they accidentally stabbed their Mother in the eye with a butcher knife?

Dwalia’s Bigmama: Dora Lee McCown

My first real memory of this pre-Christmas calamity was that my much loved Bigmama, Dora Lee McCown, came and was assigned to stay at the house and see after me for the rest of the day. My Bigmama would have been about 56 at this time but had already suffered a hypertensive stroke that had transformed her from a previously high strung firebrand into a calm, simple minded and childlike grandmother. Her deficiencies were simply accepted as the Lord’s will, she was gifted with a new and always pleasant personality. I can see her now with her wild white hair, cat-eye glasses sitting slightly askew on her nose, wearing an out of season flower-print cotton dress with a faded tan corduroy housecoat, and jelly-rolled thick brown stockings under her knees. In winter she would never fail to announce, “I’m not cold, fer I’ve got on 3 princess slips.” I remember she always spent a great deal of time backed up in front of whatever heat source was available with her coat tail hiked high up on her thighs to warm her backside.

Gosh, she was fun to be with. Time spent with her was a marathon of ancient family stories and songs and ditties remembered from her own childhood days just after the turn of the century. Like every other adult woman I knew in our family Bigmama dipped a little Garrett Sweet Snuff ‘for her nerves’ and she produced some from the black plastic purse she always carried. I asked for a dip, too.

“Oh, Child!” she said, “This kind is fer us old folks, but I’ll make you some.” She scrambled through the cabinets and found the Hershey’s Cocoa, spooned some in a cup and added lots of sugar to it. She stirred the dry brown mix around, and then showed me how to put the tasty concoction in my lower lip just like she did. I believe I did find that it settled my nerves because it made me feel all grown up.

Sometime later in the day we learned that Mother had been taken to Oxford to the eye specialist Dr. Charles M. “Bo” Murry and would be kept in the hospital overnight after surgery. This meant that Bigmama would need to spend the night with me, so she began talking about what she was going to fix us for supper. When Bigmama would get hungry she would always say, “I’m getting’ a little weak in the breech, ain’t you?”

She began ‘foddling’ around the kitchen taking an inventory of what was there to cook. Mother always kept plenty of food in our refrigerator and all varieties of dry and canned goods. Cooking was mainly just a matter of a fellow wrapping his mind around what to actually prepare for a meal.

While she pondered this task, my Uncle Alvie came by to check on us. Alva Condor Clemmer was the bachelor half-brother to my Papaw Willie McCown and he and my ancient Great-Grandma Clemmer lived together in a little red house in our back pasture. Uncle Alvie was physically quite sound but had always been a wee bit slow mentally. He called me “Slick” and Bigmama was “Dode.”

Bigmama’s husband, Papaw Willie was likely in the log woods cutting timber or at his sawmill. At any rate, Uncle Alvie had his squirrel gun and his little feist dog Flip with him, and he said he was ‘fixing to go a squirrel hunting.’ Bigmama saw an opportunity, explained our situation and asked Uncle Alvie to go shoot us some birds so she could cook them for our supper. He said that Flip weren’t no quail bird dog, that he treed game, not pointed, but that they would try.

“Just what kind of birds do you want, Dode?” he said.

She thought a minute and said, “Well, they has been a bunch of pretty fat robins all over this yard today, going every which a way. Pretty red birds and, jaybirds, and mockin’ birds, too.

Just don’t bring me no blackbirds or crows fer they eat keyarn. And don’t you dare shoot any of them white-throated sparrowbirds that sing and call out my name to me. One has been a saying JOURNAL MSMA

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‘Doralee, Doralee, Doralee….Doralee, Doralee, Doralee’ all week long. I wouldn’t want you shootin’ my Doralee birds for nothing.”

Uncle Alvie said, “Would you not just want me to go wring a rooster’s neck for you? That ‘ud be the easiest thing to do.”

“No,” she said, “Fer I don’t know which’uns Velmer would spare and she might get fightin’ mad at us when she gets back.”

So off Uncle Alvie and Flip dog went. It was certainly true that there was no shortage of wild fowl around our farm. Daddy was a bird fancier and he always had coops of all types of pigeons, pheasants, turkeys, and guinea hens. Grains of corn carelessly scattered on the ground near the barn area attracted masses of beautiful songbirds as well as pesky blackbirds to our place in winter. Not even Mother’s yard cats discouraged the constant wild bird visitation.

It wasn’t long before we began to hear the intermittent pops of Uncle Alvie’s 20 gauge. Bigmama peeled potatoes and onions, and searched out the milk, flour, butter and other ingredients she would need to carry out her afternoon cooking plan. In an hour or so, Uncle Alvie reappeared with his hunting sack on his shoulder and proudly emptied it into a metal foot tub on the porch. There were probably 15-20 or so limp birds forming a sad kaleidoscope of colors in that bucket. Blue jays mostly, but there were redbirds, and fat orange-chested robins, too. There were even a couple of mocking birds in the bucket so apparently they held no superstition that killing one was a sin. Uncle Alvie had also brought me back a small, still warm skillet shaped piece of Grandma Clemmer’s “dog bread.” When she heard about our plight she had been cooking up bread to feed Uncle Alvie’s dogs and so sent me a portion of what she knew I craved and would beg her for at every visit to their house. Grandma Clemmer’s ‘dog bread’ was a delicacy to me.

The two of them quickly cut off all their pretty heads and feet and gutted them. Bigmama went inside and retrieved a boiling dishpan of water from the stove, brought it out and dumped it on the carcasses. As they began to pluck the poor things, Bigmama began singing…

“Well, I picked pore Robin clean, I picked pore Robin clean, I picked his head, and I picked his feet, I woulda’ picked his body but it wasn’t fit to eat…

Now didn’t old Jaybird laugh when I picked pore Robin clean?

And I’ll be satisfied havin’ your family!!”

It didn’t make sense but it seemed to make the work lighter and was fascinating stuff. It seemed that this was something so ordinary and so rational for them to be doing. I didn’t question their simple-minded judgment in this effort (work). Uncle Alvie was no singer and not much of a conversationalist so he just grinned as he worked, and spat tobacco juice on the ground every so often.

Then Bigmama lit into another chorus…

“A jaybird a sittin’ on a hickory limb All across over to Jordan.

I upped with a rock and I hit him on the shin…

Oh, Jerusalem!

Shine on, shine on, All across over to Jordan.

Shine on, shine on, Oh, Jerusalem!!”

“Well, you did good Alvie, I didn’t find any of my Doralee birds in the bucket,” Bigmama bragged. “Now we’ve got to swinge ‘em, and wash ‘em and par boil ‘em before I put them in the pan to stew. I’m gonna make us a jaybird pie like my Mammy did back in hard times… with some good taters and onions in it. Would you stay and take supper with us?”

Uncle Alvie might have been a little slow, but he quickly passed on the offer, spat out his wad of chewing tobacco and allowed as how his Mother was expecting him home to eat some squirrel and dumplings she had been boiling for them.

I can somehow remember the familiar cooking aromas wafting from the kitchen that afternoon as she labored…not in the least unpleasant.

I didn’t watch the process as I was much too interested in inspecting the towering Christmas cedar which stood naked but exuding its intoxicating spicy fragrance, and dreamily looking at Mother’s boxes of glass balls, silvery garlands, and strings of bubble lights waiting to grace

398 VOL. 57 • NO. 12 • 2016

our tree. I’m sure that I looked at the Sears and Roebuck Christmas Wish Book for a good while too. Required reading for a four year old, mind you.

And though her voice would always get a bit weak and teary on the refrain of sacred songs, I could hear Bigmama singing as she worked…

“I sing because I’m happy, I sing because I’m free!

His eye is on the spar-row, Lord…

And I know He watches me!”

Bigmama had diligently boiled the songbirds, pulled the scant flesh from their bones and incorporated it all into a wonderfully crusted meat pie with soft dumplings, tender potatoes and onions surrounded with a creamy butter sauce. For dessert, we had what was left of Grandma Clemmer’s dog bread crumbled into good cold buttermilk of course. We ate it all “raveeniously” she said, so it must have been good.

“Your Mammy and your Daddy will probably make fun of us for eating jaybird pie, but when hard times come, anything that fills the belly fills the bill, don’t it?”

That night, in the bed, Bigmama tried to sing me to sleep but the song she chose made me tune up to cry: “Go to sleep, you little baby…

Go to sleepy, little baby.

Your Mammy’s gone away and your Daddy’s gonna stay Didn’t leave nobody but the baby!”

The next morning when I woke up my big sister Shirley and husband Curtis Dale Carter came to relieve Bigmama. Later that day my tired and frazzled Mother and Daddy came home from the Oxford hospital. Mother was wearing a big eye patch and they said she was supposed to lie around and take it easy for a few days. Things sort of fell in line and came back to normal over the next few days. When she somehow learned about me and Bigmama eating the Jaybird pie, all Mother ever said was “Oh, dear God in Heaven!”

I suppose that Christmas came and went uneventfully as no other features of the next few days stand out in mind. That might have been the year I got a great rocking horse, a Sheriff ’s outfit with a Texas hat, cowboy boots and a black scabbard with two shiny six-shooter cap pistols.

That was one of the best Christmas hauls I can ever remember!

The weather is changing and finally turning cold now. The winter’s chill and Christmas is coming upon us soon. Just the other Saturday my eight year old grand daughter, Jacie and her dad Jesse came by the house after I had scattered some corn to feed my ducks and chickens out by the barn. Jacie and I sat in the back yard and built a small fire in the fire pit to roast marshmallows, one of our favorite weekend afternoon activities. We watched from a distance as several different types of songbirds came to our oak trees searching below for something to eat.

Jacie asked me very seriously, “Big, tell me how I can catch one of those mocking jays so I can keep it in a cage as a pet?”

I told her there are mocking birds, and there are jaybirds but that there was no such thing as a mocking jay, that it was something in a story someone had just made up. She argued that there was and that they could imitate anything a person could sing to them. I was moved to tell her the story of the Doralee birds and the events of the December day when my own Bigmama cooked me a jaybird pie. I doubt she will ever forget the story. I doubt that Jacie or Molly will ever get to eat a jaybird pie…at least I hope that such hard times come again no more.

Moved by the lyrical memory of my own Bigmama, I burst into song that afternoon…

“All the little birdies on Jaybird Street Loved to hear the robin go tweet, tweet, tweet!

Rockin Robin...Tweet-Tweedly-dee…Rockin Robin…Tweet-Tweedly- dee!!

Go Rockin Robin cause we’re really gonna rock tonight!”

This bird song business must be something in our family genes. I am listening and looking for some of those Doralee birds to show up.

Somehow I know they will come again this season. n JOURNAL MSMA

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I N D E X

Volume LVII January - December 2016

Subject Index The letters used to explain in which department the matter indexed appears are as follows: “CPS” for Clinical Problem Solving”; “E,” Editorial; “H,” Hardy Abstract; “L,” Letters to the Editor; “PB,” Physician’s Bookshelf; “PM,” Poetry and Medicine; “PP,” President’s Page; “S,” Special Article; “UV” Una Voce; the author’s name follows the entry in brackets. Matters pertaining to related organizations are indexed under the medical organization.

-AA Case of Freeman-Sheldon Syndrome: Anesthetic Challenges [T Hamilton, M Sathyamoorthy], 6 Abdominal Distension and Vascular Collapse [G Cosentino, G Uwaifo], 113 Academic Health Center - Rural Community Collaborations: ‘Healthy Linkages’ to Improve the Health of Rural Populations [B Beech, M Bruce, A Gamble, C Brunson, M Jones], 118 AMA AMA Adopts New Guidance for Ethical Practice in Telemedicine, 257 AMA Launches STEPS Forward to Address Physician Burnout, 24 New Policy Builds upon the AMA’s Efforts to Create the Medical School of the Future, 257 Asclepiad John C. Neill, MD, of Jackson [L Lampton], 28 Assessment of Secondary Causes of Osteoporosis and Racial Differences in Men with Normal vs. Abnormal Bone 400 VOL. 57 • NO. 12 • 2016

Mineral Density in a Cohort of Men Undergoing Bone Mass Measurement [K Aujla, V Majithia], 285

Problem [V Sankoorikal, J Ricks], 213-CPS Colonoscopy Atlas of Colon Polyps and Neoplasms [S Tang, J Sones], 68

-BBedside Renal Ultrasound for the Primary Care Physician [B Tollefson, N Hoda, W Miller, J Harris, J Nichols], 206

-CCase Report: Unusual Manifestations of NSAID Overdoses [N Hoda, R Galli], 261 Chikungunya in Mississippi: The Health Department Response to Imported Cases [J Goddard, W Varnado, S Hand, F Meyer], 138 Clinical Problem-Solving

[presented and edited by the Dept. of Family Medicine, UMMC] I’m coughing up blood [S Barowka, T Perrine, K Hughes], 354 I’ve Forgotten How to Pray [J Bayles, J Vanderloo], 43-CPS Life-saving NSAIDs [A Washington, III], 116-CPS When the Treatment Becomes the

Commentary Bariatric Surgery - A Viable Option and the Best Hope for Many Mississippians?

[E Willoughby, E Jones, D Minor], 329 Child Abuse & Neglect in Mississippi: Beginning the Conversation [S Beam, K Tye] 363 Cover “Baldfaced Hornet Nest (Dolichovespula Maculata)” [B Tisdale], July “Capitol Improvements” [S Hartness], March “Froggie” [M Pomphrey], April “Howlin’ Wolf ’s ‘Little Red Rooster’ on the Side of West Point’s Main Street Depot” [M Pomphrey], August “Lee Voulters, MD - 2016-17 MSMA President”, September “Mushroom Flowers” [M Pomphrey], February “Quiet Reflection” [B Long], June “Stop and Pray” [M Pomphrey], November

“The Old Coal Chute in McComb” [B Tisdale], October “Three Certainties of Life: Death, Taxes ... and Obamacare?” [S Hartness], January “Winter scene on Mayhew Pond” [M Pomphrey], December “Wood Duckling Jump Day” [J Bumgardner], May

-EEditorials Call It What You Will [S Hartness], 304 JMSMA Colon Cancer Special Edition Guest Editorial —Help Make Colon Cancer Screening a Priority [J Sones], 59-E Is It Just Me? Observations of an Old a Seasoned Practitioner [S Hartness], 125-E Kudos for the Center of Telemedicine [H Matthias], 192-E Mississippi Health Disparities, Bias, and Social Justice in Health: Mississippi Physician Leadership Is the Best Rx [R deShazo, S Parker], 301 Oh, No, Another Patient with Back Pain [J Rish, J Maurer], 48-E The Unanticipated Consequences of “Meaningful Use” and Maintenance of Certification Requirements [R Brodell], 47-E Electronic Cigarettes in Mississippi: Issues Facing Healthcare Providers and Policy Makers [N Valentine, E McClelland, J Bryant, R McMillen], 181

-FFrom the Editor [L Lampton]

A Man of Grace Remembered, 376 A Solution Looking for a Problem, 308 Confessions of a Bibliophile, 106 Journal Wins National Award for Excellence, 204 Measles in Memphis, 136 No More Excuses for CRC Screening, 58 ObamaCare’s War on Small and Rural, 276 Physician Heal Thyself, 2 The Coming Storm of Zika, 172 The End of “Meaningless Use”, 30 The Perils of Telemedicine, 248 Will Trump Bring Relief to Docs and Patients?, 340

-HHow to Achieve Colon Cancer Screening in Average Risk Population: A Review of Different Screening Options [J Whatley, J Sones], 82

-IImages in Mississippi Medicine In Memoriam, 49, 200, 332, 394

-LLegalese Charity Care [C Reeves], 296 Emotion Incites Rights Fight: When Your Personal Liberty Infects Mine [S Mann], 216 Government Guidelines, Practice Parameters and Specialty Standards: Swords or Shields? [S Edgar], 337 Informed Consent: Process Behind the Paperwork [S Edgar], 126 Patient Health Information Breaches:

What Now? [R Comley, A Orlansky], 267 Letters EHR is a Main Contributor to Physician Burnout [R Herndon], 124-L EHRs Attributed to Physician Burnout [J Hey III], 242-L Homage to a Small Town Doc [B Long], 46-L More on Immunizations [E Dvorak], 242-L State Opposition to Obamacare Not Based on Race [W Ford], 18-L Tribute to a Role Model [B Long], 46-L

-MMississippi Perspective: Dermatologic Manifestations of Arsenic Poisoning [C Daggett, A Daggett, R Brodell, C Daniel III], 382 MAFP MAFP Foundation announces Dewitt G. Crawford, MD Memorial Scholarship Fund, 367 MAFP Library dedicated in honor of Dr. and Mrs. Dewitt G. Crawford, 367 MSDH 2016 Public Health Report Card, 13 Currier Honored as Dr. Nathan Davis Award Recipient, 55 Mississippians Make Strides in Decreasing Heart Disease, 127 Mississippi Infant Mortality Rates Reach All-Time Low in 2014, 20 Mississippi Provisional Reportable Disease Statistics December 2015, 19 Mississippi Provisional Reportable Disease Statistics January 2016, 54

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Mississippi Provisional Reportable Disease Statistics February 2016, 128 Mississippi Provisional Reportable Disease Statistics October 2016, 352 State-of-the-Art Thompson Public Health Laboratory Now Open for Business, 194

-OOverweight and Obesity Prevalence and Trends Among Mississippi Public School Students: A Decade of Data Between 2005 and 2015 [J Kolbo, L Zhang, N Werle, E Molaison, B Harbaugh, M Kirkup, E Walker], 310

-PMSMA 2016 Annual Report, 221 2016 Public Health Report Card, 13 2016 Component Society Meetings, 166, 199 Big discounts for MSMA Physicians, Put telemedicine to work in your practice, 295 Committee Seeks Candidates for Vacancies in MSMA Offices, 88, 131, 145 Nominating Committee Announces Slate of Election Offices, 244 Physician Leadership Academy - Angela Shannon, MD, 246 Physician Leadership Academy - Angela Wingfield, MD, 170 Physician Leadership Academy - Chasity Torrence, MD, 202 Physician Leadership Academy - Daniel Venarske, MD, 273 Physician Leadership Academy - Ervin Fox, MD, 130 Physician Leadership Academy - Gerald McKinney, MD, 245 Physician Leadership Academy Hossein Behniaye, MD, 283 Recap of the 2016 Session of the MSMA House of Delegates, 292

-NNew Members, 53, 334

402 VOL. 57 • NO. 12 • 2016

Parasitic Infection of the Gallbladder: Cystoisospora belli Infection as a Cause of Chronic Abdominal Pain and Acalculous Cholecystitis [M Martelli, J Lee], 174 Personals, 196, 368 Physician’s Health Corner Physician Wellness: The Burnout Antidote Change is Necessary [S Hambleton], 9 Poetry and Medicine Autonomy [J Glisson], 374-PM In Memoriam [W Roberts], 387-PM Seven Tomatoes [T Browne], 266-PM President’s Page Address of the 148th President Daniel P. Edney, MD [D Edney], 264-PP Colon Cancer [D Edney], 103-PP Free Drug Discount Card Can Help Your Patients Get Meds [L Voulters], 362-PP Getting into the Groove [D Edney], 45-PP I’ll be Glad When They Go Back Home [D Edney] 123-PP Neighbor State Sees Swell in Preventable Mumps Cases: Legislature Holds the Key [L Voulters], 328-PP

The Fight Continues [D Edney], 243-PP The Inaugural Address of the 149th President [L Voulters], 297-PP The Myth of the Invincible Doctor [D Edney], 17-PP Who is Right? [D Edney], 190-PP Working for Cures in the 21st Century [L Voulters], 388-PP You are the Guardians at the Gate [D Edney], 167-PP

-RRecurrent Diabetic Muscle Infarction Affecting Bilateral Thighs: Uncommon Presentation with Grave Prognosis [W Horton, A Tripathi, T Ragland, T Yousuf], 39 Reducing Barriers to 17-Hydroxprogesterone Caproate (17P) Injections to Prevent Recurrent Preterm Birth in Mississippi [J Bofill, C Collier, M Pearson, J Shwayder, J Morrison], 350 Review of Bowel Preparation Agents for Colonoscopy [S Patnana], 94

-SSpecial Article Back to Genesis or How We Got Here [W McKell], 90-S Colon Cancer: Yes, It’s a Terrorist [S Pace], 74-S GI Associates Serving the Community, 72-S Mississippi Telemedicine: Interviews with the Innovators [M Collins, C Brunson, E Jones], 251-S Subject/Author Index Volume 57, 400

-TTeen Pregnancy in Mississippi: A History and Analysis of Recent Legislative and Governmental Attempts to Address Different Aspects of this Issue in Mississippi [N Campbell-Lewis, S Bondurant, F Bush], 318 Telemedicine in Mississippi: Can It Improve Our Last Place in Health? [S Parker, R deShazo, M Adcock, K Rodenmeyer], 342 Ten Things You Want to Know about Vaccines for Adults [S Butt, A Tirmizi], 358 The Impact of Colorectal Cancer (CRC) in Mississippi, and the Need for Mississippi to Eliminate its CRC Burden [R Duhé], 62 The Impact of Preventive Screening Resource Distribution on Geographic and PopulationBased Disparities in Colorectal Cancer in Mississippi, 80 The Spice of Life...and Death: A Case Presentation and Review of Synthetic Marijuana Use in Mississippi [J Wilkinson, J Tullos, B Rifkin], 289 Top 10 Facts You Should Know About “Alpha-gal,” the Newly Described Delayed Red Meat Allergy [K Ramey, P Stewart], 279 About Absence Epilepsy [S Dawoud, J Ingram], 210 About Diagnostic Evaluation of Neonatal Cholestasis [L Burch, D Sawaya, M Steiner, C Subramony, M Nowicki], 324 About Hearing Loss and Cognitive Decline [G Sturdivant], 142

About Immunizations and Vaccine Exemptions in Mississippi [T Dobbs, P Byers], 322 About Keloids and Their Treatment [A Daggett, J Songcharoen, R Clay], 108 About Melanoma [A Davis, V Nahar, R Brodell, S Jacks], 258 About Mosquito Control and Zika Virus [J Goddard], 178 About Pneumococcal Vaccination in Adults [T Rehman, Z Khan], 32 About Screening for Critical Congenital Heart Disease [H Sanandajifar, M Taylor, S Batlivala], 378 About Zika Virus [S Albrecht, R Nolan], 4 Top Abstracts from the 2015 American College of Physicians Mississippi Chapter Abstract Day at the University of Mississippi Medical Center [S Thigpen], 146 2003-2012 Mortality-to-Incidence Ratios for Breast, Colorectal, and Cervical Cancer in Core Delta Counties Compared to NonDelta Mississippi Counties [J Henegan, Jr.], 148 A Case of Pulmonary Mucormycosis in a Patient with Granulomatosis with Polyangiitis [R Williams, J Ellis, S Gonnalagadda, S Thigpen], 164 A Fever from Africa: An Unusual Presentation of Hemophagocytic Lymphohistiocytosis [N Harrison, J Hsu, N Cager, W Aldred, Z Henson], 157 A Rare Case of Microvascular Pulmonary Arteriovenous Malformations in a Young Female

Presenting with Hypoxemic Respiratory Failure [M Poole, K Ball], 160 Analysis of the Current Rapid Response System Using the National Early Warning Score (NEWS) [J Grondin, A Wilhelm], 149 Babesia in the Southeast United States [S Duckworth, M Edwards, J Henegan, J Brock], 155 Chronic Eosinophilic Pneumonia Mimicking COPD Exacerbation [T Lewis, W Horton, C GomezSanchez], 158 Death by Diarrhea [E Turse, I Srinivasan, K Pallav, C Subramony, L Rezeanu, J Sheehan, S Tang, S Thigpen], 162 Don’t Forget About Latent Autoimmune Diabetes of the Adult [H Boler, L Aldred, S Kerut, J Sheppard], 154 Evaluating Perceptions of and Barriers to Successful Inpatient Glycemic Control Among Resident Physicians [W Horton, S Thigpen], 150 Hyperemesis Gravidarum Precipitating Thyroid Storm Resulting in Wernicke’s Encephalopathy [J Grondin, C Glover, S Ahmad], 156 Hyperpigmentation: A Rarely Recognized Manifestation of Vitamin B12 Deficiency [L Majors, J Wolfe, D Wolfe], 159 Lessons Learned in the Treatment of Stronglyoides Stercoralis Hyperinfection in a Patient with Acquired Immunodeficiency Syndrome [R Aru, L Behlen, C Lowe, F Asher, R deShazo], 152 Management of Metformin-Associated JOURNAL MSMA

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Lactic Acidosis with SLED [G Bader, J Tate, S Degen, W Latack], 153 Near Instant Bone Density Analysis of the Spine for the Abdominal Radiologist Using Color Enhanced CT Images [B Liu, A Smith, D Hankins, M Roda, D Joyner, M Khan, C Reed, N Swaminathan, J Bryan, A Vasanji, M Griswold, X Zhang, T Mosley], 149 Paroxysmal Nocturnal Hemoglobinuria: A Rare Disease with Expensive but Effective Treatment [J White, W Horton, J Lavender, F Criddle], 163 Refractory Hypoglycemia: A Rare Initial Manifestation of Advanced Hepatocellular Carcinoma [C Bowes, R Pace, J Subauste], 154 Severe Hypocalcemia Following Administration of Zoledronic Acid in an Osteoporotic Patient with a History of Roux-en-y Gastric Bypass [J Tate, B Elkins], 161 Simvastatin Inhibits Epithelial-toMesenchymal Transition Through Induction of HO-1 in Cultured Renal Proximal Tubule Cells [J Clark, A Carter, M Dixit, I Arany], 147 Stilbene Derivatives Inhibit Prostate Cancer Cell Proliferation and Expression of MetastasisAssociated Protein 1 [B Bates, D Whalen, A Kumar, J Weng, A Rimando, A Levenson], 147 Systemic Loxoscelism: A Rare Cause of Coombs Positive Hemolytic Anemia [K Murdock, J Grondin, 404 VOL. 57 • NO. 12 • 2016

S Letellier, J Bell], 160 The Kiss of Sudden Cardiac Death [L Aldred, E Turse, R Ballard, J Biglane, B Barksdale], 151 The Knock: Opening the Door to Improved Hand Hygiene in Dermatology Outpatient Clinics [J Rush, R Flowers, K Casamiquela, S Jacks, J Ibrahim, R Brodell], 151 They Say His Heart Grew Three Sizes that Day: An Unusual Cause of Esophageal Dysphagia [J Henry, J Hogg, S Thigpen], 157

-UUMMC #AskTheHIVDoc Campaign Taps Mena’s STD Expertise [L Mena], 372 Big Problem, Bigger Award: NIH Funds UMMC Obesity Research [K Bascom], 305 Correa Named Leader of Renowned Jackson Heart Study, 21 Gov. Bryant, UMMC Mark Highpoint in School of Medicine Construction, 132 Healthcare Management by Design [J Bailey, E Jones, A Burrell, B Rutledge], 357 “Queen of GME” Reduces Hours but not Commitment [G Pettus], 269 UMMC Announces New School of Population Health, 168 UMC SOM UMC SOM Match Day and Commencement Summon Moments of Inspiration, 231 University of Mississippi School of Medicine 2016 Match Results, 233

Una Voce [Dwalia S. South] A Doctor’s Prescriptions for a Happy Family Holiday Gathering, 338UV Jaybird Pie: A Christmas Story, 369-UV Medicine and Melancholy, 25-UV Whatever Happened to National Doctor’s Day?, 274-UV

-VValidation of the Sonographic Ottawa Foot and Ankle Rules (SOFAR) Study in a Large Urban Trauma Center [B Tollefson, J Nichols, S Fromang, R Summers], 35

-WWHO Mississippi Physicians Support Goal to Reduce Premature Mortality: The WHO 20 x 25 Target, 12 William Carey University College of Osteopathic Medicine William Carey University College of Osteopathic Medicine 2016 Match Results, 239 William Carey University College of Osteopathic Medicine Launches New Ambulance Drones, 393 n

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Volume LVII January - December 2016

Author Index The letters used to explain in which department the author’s matter indexed appears are as follows:“CPS” Clinical Problem Solving”; “E,” Editorial; “H” Hardy Abstract; “I,” Images in Mississippi Medicine; “L,” Letters to the Editor; “PB,” Physician’s Bookshelf; “PM,” Poetry and Medicine; “PP,” President’s Page; “S,” Special Article; “UV” Una Voce.

A

Adcock, Michael, 342 Ahmad, Shema, 156 Albrecht, Svenja J., 4 Aldred, L. Wesley, 151, 154, 157 Arany, Istvan, 147 Aru, Roberto G., 152 Asher, Frederick H., 152 Aujla, Khush, 285

B

Bader, G. A., 153 Bailey, Jessica H., 357 Ball, Kenneth, 160 Ballard, R. Dane, 151 Barksdale, Bryan, 151 Barowka, Sarah E., 354 Bascom, Karen, 305 Bates, Benjamin A., 147 Batlivala, Sarosh P., 378 Bayles, Joanna, 43-CPS Beam, Stephen, 363 Beech, Bettina M., 118 Behlen, L. Campbell, 152 Behniaye, Hossein, 283 Bell, Jericho L., 160 Biglane, J. Barr, 151 Bofill, James A., 350 Boler, H. Baker, 154 Bondurant, Sidney W., 318 Bowes, Christa, 154 Brock, James Benjamin, 155 Brodell, Robert T., 47-E, 151, 258, 382 Browne, Thomas, 266-PM Bruce, Marino A., 118 Brunson, Claude, 118, 251-S Bryan, Jason, 149 Bryant, Jessica, 181 Bumgardner, Joe R., May cover Burch, Leah, 324

Burrell, Angela, 357 Bush, Freda M., 318 Butt, Saira, 358 Byers, Paul, 322

F

C

G

Cager, Nikki, 157 Campbell-Lewis, Nycole, 318 Carter, Anthony, 147 Casamiquela, Kathleen M., 151 Clark, Jeb S., 147 Clay, Ricky, 108 Collier, Charlene H., 350 Collins, Mary Jane, 251-S Comley, Rusty, 267 Cosentino, Gina, 113 Criddle, Frank, 163

D

Daggett, Amanda, 108, 382 Daggett, Caroline, 382 Daniel III, C. Ralph, 382 Davis, Ashton B., 258 Dawoud, Salma, 210 Degen, S., 153 deShazo, Richard D., 152, 301, 342 Dixit, Mehul, 147 Dobbs, Thomas, 322 Duckworth, Savannah, 155 Duhé, Roy J., 62 Dvorak, Ed, 242-L

E

Edgar, Stephanie, 126, 337 Edney, Daniel P., 17-PP, 45-PP, 103-PP, 123PP, 167-PP, 190-PP, 243-PP, 264-PP, Edwards, Megan, 155 Elkins, Blake E., 161 Ellis, Jennie K., 164

Flowers, Richard H., 151 Ford, William, 18-L Fromang, Stephen, 35 Galli, Robert L., 261 Gamble, Abigail, 118 Glisson, James K., 374-PM Glover, Christina, 156 Goddard, Jerome, 138, 178 Gomez-Sanchez, Celso, 158 Gonnalagadda, Swathi, 164 Griswold, Michael, 149 Grondin, Jeffrey J., 149, 156, 160

H

Hambleton, Scott, 9 Hamilton, Thomas, 6 Hand, Sheryl, 138 Hankins, Danny, 149 Harbaugh, Bonnie L, 310 Hartness, Stanley, 125-E, January cover, March cover, 304 Harris, Jim, 206 Harrison, Nancy, 157 Henegan, John Clark, 155 Henegan, John Clark, Jr., 148 Henry, Jason S., 157 Henson, Zeb, 157 Herndon, Robert M., 124-L Hey, John, III, 242-L Hoda, Nicholas E., 206, 261 Hogg, James J., 157 Horton, William B., 39, 150, 158, 163 Hsu, Johann, 157 Hughes, Karen, 354

I

Ibrahim, Jamil, 151 JOURNAL MSMA

405

Ingram, John Bradford, 210

Nowicki, Michael, 324

J

O

Jacks, Stephanie K., 151, 258 Jones, Ellen, 251-S, 329, 357 Jones, Michael L., 118 Joyner, David, 149

K

Kerut, Sarah, 154 Khan, Majid, 149 Khan, Zarrish S., 32 Kirkup, Melissa, 310 Kolbo, Jerome R, 310 Kumar, Avinash, 147

L

Lampton, Lucius M. “Luke”, 2, 28, 30, 58, 106, 136, 172, 204, 248, 276, 308, 340, 376 Latack, W., 153 Lavender, Jessica S., 163 Lee, Johnathan Y., 174 Letellier, Scott M., 160 Levenson, Anait S., 147 Lewis, Tara C., 158 Liu, Boshen, 149 Long, Billy W., 46-L, 46-L, June cover Lowe, Catherine E., 152

M Majithia, Vikas, 285

Majors, Lance T., 159 Mann, Sarah, 216 Martelli, Matthew G., 174 Matthias, Heddy-Dale, 192-E Maurer, Janet, 48-E McClelland, Emily, 181 McKell, William M., 90-S McMillen, Robert, 181 Mena, Leandro, 372 Meyer, Florencia, 138 Miller, W. Ryan, 206 Minor, Deborah S., 329 Molaison, Elaine Fontenot, 310 Morrison, John C., 350 Mosley, Thomas, 149 Murdock, Keith W., 160

N

Nahar, Vinayak K., 258 Nichols, James, 35, 206 Nolan, Rathel L., 4

406 VOL. 57 • NO. 12 • 2016

Orlansky, Abram, 267

P

Pace, Rebecca, 154 Pace, Samuel C., 74-S Pallav, Kumar, 162 Parker, Sara, 301, 342 Patnana, Srikrishna, 94 Pearson, Meg, 350 Perrine, T. Ray, 354 Pettus, Gary, 269 Pomphrey, Martin M., February cover, April cover, August cover, November cover, December cover Poole, Meghan, 160

R

Ragland, Timothy J., 39 Ramey, Kristen, 279 Reed, Chris, 149 Reeves, Conner, 296 Rehman, Tayyab, 32 Rezeanu, Luminita, 162 Ricks, Janet, 213-CPS Rifkin, Brian, 289 Rimando, Agnes M., 147 Rish, James A., 48-E Roberts, William F. “Bill”, 387-PM Roda, Manohar, 149 Rodenmeyer, Kathryn, 342 Rush, Jess L., 151 Rutledge, Brian, 357

S

Sanandajifar, Hasti, 378 Sankoorikal, Vivek-Thomas J., 213-CPS Sathyamoorthy, Madhankumar, 6 Sawaya, David, 324 Sheehan, John, 162 Sheppard, Jerry, 154 Shwayder, James M., 350 Smith, Andrew D., 149 Sones, James Q., 68, 82 Sones, Jim, 59-E Songcharoen, Jay, 108 South, Dwalia S., 25-UV, 274-UV, 338-UV, 396-UV Srinivasan, Indu, 162 Steiner, Michael, 324 Stewart, Patricia H., 279

Sturdivant, Grace Gore, 142 Subauste, Jose, 154 Subramony, Charu, 162, 324 Summers, Richard L., 35 Swaminathan, Nisha, 149

T

Tang, Shou-Jiang, 68, 162 Tate, J.M., 153 Tate, Joshua M., 161 Taylor, Mary B., 378 Thigpen, S. Calvin, 146, 150, 157, 162, 164 Tirmizi, Amir, 358 Tisdale, Brett, July Cover, October Cover Tollefson, Brian, 35, 206 Tripathi, Avnish, 39 Tullos, Jessica McAllister, 289 Turse, Erica, 151, 162 Tye, Karla Steckler, 363

U

Uwaifo, Gabriel I., 113

V

Valentine, Nell, 181 Vanderloo, John P. F. H., 43-CPS Varnado, Wendy C., 138 Vasanji, Amit, 149 Voulters, Lee, 297-PP, 328-PP, 362-PP, 388PP

W

Walker, Evelyn, 310 Washington, Anthony R., III, 116- CPS Weng, Jian-Quan, 147 Werle, Nichole, 310 Whalen, Diva, 147 Whatley, James, 82 White, Jared A., 163 Wilhelm, Andrew M., 149 Wilkinson, James, 289 Williams, Ryan A., 164 Willoughby, Emma L, 329 Wolfe, Douglas A., 159 Wolfe, Jimmy, 159

Y

Yousuf, Tauqueer, 39

Z

Zhang, Lei, 310 Zhang, Xu, 149 n

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