DECEMBER 12 JMSMA

December

VOL. LIII

2012

No. 12

BEACON Imagine the possibilities.

You’ve heard of the Beacon Grant.

It’s a $14.7 million grant to the Delta Health Alliance (DHA) from the Office of the National Coordinator for Health Information Technology with goals of building and strengthening Mississippi’s Health IT infrastructure, testing healthcare innovations and improving healthcare efficiency.

What can the Grant do for my practice and my patients?

DHA has established the BLUES (Better Living Utilizing Electronic Systems) Beacon Community to work with physicians and other healthcare providers across the Delta region. Your Delta BLUES Beacon is testing innovations with over 35 Delta providers, including Clinical Decision Support, Diabetic Retinopathy Screening, Medication Therapy Management, Care Transitions and Health Information Exchange.

Imagine the possibilities!

The Delta BLUES Beacon Program is available to physicians in ten counties across the Mississippi Delta area until March 2013. How can the BLUES Beacon guide you?

Learn more:

www.DeltaHealthAlliance.org

Lucius M. Lampton, MD Editor D. Stanley Hartness, MD Richard D. deShazo, MD Associate Editors Karen A. Evers Managing Editor Publications Committee Dwalia S. South, MD

Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD, Ex-Officio Myron W. Lockey, MD, Ex-Officio and the Editors

The Association Steven L. Demetropoulos, MD President James A. Rish, MD President-Elect J. Clay Hays, Jr., MD Secretary-Treasurer Lee Giffin, MD Speaker Geri Lee Weiland, MD Vice Speaker Charmain Kanosky Executive Director

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

Periodicals postage paid at Jackson, MS and at additional mailing offices.

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

SUBSCRIPTION RATE: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available.

ADVERTISING RATES: furnished on request. Cristen Hemmins, Hemmins Hall, Inc. Advertising, P.O. Box 1112, Oxford, Mississippi 38655, Ph: (662) 236-1700, Fax: (662) 236-7011, email: cristenh@watervalley.net POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 391582548.

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

Copyright© 2012 Mississippi State Medical Association.

Official Publication of the MSMA Since 1959

DECEMBER 2012

VOLUME 53

NUMBER 12

Scientific Articles Clinical Problem-Solving Case: Allergy Confusion?

396

Rebecca A. Rose-Hand, MD

Coordinated Cardiac Delivery: Reducing Mortality in High Risk Fetal Cardiac Lesions at the University of Mississippi Medical Center

400

Daniel J. DiBardino, MD; Jennifer C. Shores, MD; Michelle Sheth; Mary Taylor, MD; Kenneth Liechty, MD and Jorge D. Salazar, MD

Revitalization of the University of Mississippi Children’s Heart Center: Report Card from the First 18 Months Experience

405

Daniel J. DiBardino, MD; William J. Lancaster, BA; Walter Merrill, MD; Marc E. Mitchell, MD; Emilee Taylor, RN; Charles Gaymes, MD; Makram Ebeid, MD; Jennifer Shores, MD; Elizabeth Christ, MD; Mary Taylor, MD; Michelle Sheth, MD; Richard Jonas MD and Jorge D. Salazar, MD

President’s Page You Have to Have Some Skin in the Game

411

Steven L. Demetropoulos MD, MSMA President

Editorial The Magic Kingdom

413

Reed B. Hogan, II, MD

Related Organizations Mississippi State Department of Health Office of Mississippi Physician Workforce

MSMA Alliance

416 418 420

Departments From the Editor Poetry in Medicine Images in Mississippi Medicine Uncommon Thread

394 414 415 421

Subject Index: Volume LIII Author Index: Volume LIII

423 427

About The Cover: Spotting an Owl —Mickey Wallace, MD, an otolaryngologist in Jackson, photographed this Barred Owl (or perhaps Spootted Owl) while hunting in the Mississippi Delta. Spotted Owls Strix occidentalis resemble Barred Owls Strix varia in that both species lack ear tufts and have large, all-dark eyes. In areas where the two species’ ranges come into contact, Barred Owls tend to out-compete spotteds. They are widespread in North America, where they occur across most of the eastern half of the continent from Florida northward to southern Canada; they are also spreading westward in the north of their range. Their spread westward is causing concern as they may compete with the endangered Spotted Owl. r

DECEMBER 2012 JOURNAL MSMA 393

From the Editor

A

s Mississippi’s physicians recover from last month’s divisive elections and slouch towards the looming fiscal cliff, the balm of poetry can heal this winter weariness. The great physician Sir William Osler, a bibliophile of the first order, once commented to a group of physicians that “it is particularly poetry that has such a value in helping a man to cherish thoughts that lift him above the petty details of life, that strew his path with flowers, that make him hopeful and helpful among his fellows.” Ours is a consuming and demanding profession, both emotionally and physically, even when things are going right! We need to find comfort for our souls in this very stressful world.

For those dark and dreary winter days, the most comforting among my favorite poems is “Ulysses” by Alfred, Lord Tennyson. It is an often quoted poem, and parts of it appear here and there in books, newspapers, and movies (most recently the new James Bond movie Skyfall). The king and warrior Ulysses, years after his return from the Trojan War, faces advancing age and death. He notes that “all times I have enjoy’d greatly, have suffer’d greatly, both with those that loved me, and alone….I am a part of all that I have met.” Despite sensing his mortality, he seeks to continue his heroic adventures of past days. He adds, “Old age hath yet his honour and his toil; death closes all: but… some work of noble note, may yet be done, not unbecoming

men that strove with Gods.” Seeing the lights twinkle from distant rocks, he calls to his old soldiers: “Come, my friends, ‘tis not too late to seek a newer world…to sail beyond the sunset….Tho’ much is taken much abides; and tho’ we are not now the strength in which old days moved earth and heaven; that which we are, we are, one equal temper of heroic hearts, made weak by time and fate, but strong in will.” The poem concludes, “To strive, to seek, to find, and not to yield,” which are encouraging words for those in our profession! Find and read this poem!

After these holidays, we must re-engage politically for our profession. How can you as a physician do this? Sign up to serve as a Doctor of the Day at the Mississippi Capitol between January and April. As well, find ways to help our MSMA Alliance at the Capitol Screening Initiative on the morning of January 17th!

This Journal remains one of the few in the United States still created by physicians for physicians. It is only as good as you make it. Write an editorial, a letter, an essay, a scientific article, a case report, or take a photograph or contribute a physician portrait. Contact me at lukelampton@cableone.net.

—Lucius M. Lampton, MD, Editor

Journal Editorial Advisory Board R. Scott Anderson, MD, FACR Chair, Journal Editorial Advisory Board Radiation Oncologist and Medical Director, Anderson Regional Cancer Center, Meridian Diane K. Beebe, MD Professor and Chair, Department of Family Medicine, University of MS Medical Center, Jackson Claude D. Brunson, MD Senior Advisor to the Vice Chancellor for External Affairs, University of Mississippi Medical Center, Jackson Jeffrey D. Carron, MD, FAAP, FACS Associate Professor, Department of Otolaryngology & Communicative Sciences, University of Mississippi Medical Center, Jackson

Gordon (Mike) Castleberry, MD Urologist, Starkville Urology Clinic Mary Currier, MD, MPH State Health Officer Mississippi State Department of Health, Jackson Thomas E. Dobbs, MD, MPH Health Officer, District VII/VIII Mississippi State Department of Health, Hattiesburg Sharon Douglas, MD Chair, AMA Council on Ethical & Judicial Affairs Professor of Medicine and Associate Dean for V A Education, University of Mississippi School of Medicine, Associate Chief of Staff for Education and Ethics, G.V. Montgomery VA Medical Center, Jackson Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist, The Street Clinic, Vicksburg

Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson Maxie L. Gordon, MD Assistant Professor, Department of Psychiatry and Human Behavior, Director of the Adult Inpatient Psychiatry Unit and Medical Student Education, University of Mississippi Medical Center, Jackson Scott Hambleton, MD Medical Director Mississippi Professionals Health Program, Ridgeland John Edward Hill, MD, FAAFP Residency Program Director North Mississippi Medical Center, Tupelo John D. Isaacs, Jr., MD Infertility Specialist, Mississippi Fertility Institute at Women’s Specialty Center, Jackson Kent A Kirchner, MD Nephrologist 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

William Lineaweaver, MD, FACS Editor, Annals of Plastic Surgery Medical Director JMS Burn and Reconstruction Center, Brandon John F. Lucas,III, MD Surgeon Greenwood Leflore Hospital

394 JOURNAL MSMA DECEMBER 2012

Gailen D. Marshall, Jr., MD, PhD, FACP Professor of Medicine and Pediatrics, Vice Chair for Research, Director, Division of Clinical Immunology and Allergy, Chief, Laboratory of Behavioral Immunology Research The University of Mississippi Medical Center, Jackson Alan R. Moore, MD Clinical Neurophysiologist Muscle and Nerve, Jackson Paul “Hal” Moore Jr., MD, FACR Radiologist Singing River Radiology Group, Pascagoula Jason G. Murphy, MD Surgeon

Surgical Clinic Associates, Jackson Ann Myers, MD Rheumatologist Mississippi Arthritis Clinic, 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 Samuel Calvin Thigpen, MD Assistant Professor of Medicine and Associate Program Director of the Internal Medicine Residency University of Mississippi Medical Center, Jackson Thad F. Waites, MD, FACC Clinical Cardiologist, Hattiesburg Clinic Chris E. Wiggins, MD Orthopaedic Surgeon Bienville Orthopaedic Specialists, Pascagoula John E. Wilkaitis, MD, MBA, CPE, MS Chief Medical Officer Brentwood Behavioral Healthcare, Flowood

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Representing Physicians DECEMBER 2012 JOURNAL MSMA 395

• Clinical Problem-Solving • Presented and edited by the Department of Family Medicine, University of Mississippi Medical Center, Diane K. Beebe, MD, Chair

Allergy Confusion Rebecca A. Rose-Hand, MD

A

65-year-old white male presented to the emergency department with a problem with his peripherally inserted central catheter (PICC).

Four to 5 days earlier he had noticed right-sided facial swelling and arm swelling around the PICC line insertion point.

The PICC line had been placed for home intravenous (IV) antibiotics for a post-operative knee replacement infection. He also noted that since the most recent home health nurse visit, there were new blisters around the site where new tape had been used. His vital signs were slightly abnormal with a temperature of 99.4°F, heart rate of 103 beats per minute and a blood pressure of 143/90 mmHg. His respiratory rate and oxygen saturation were normal. Further exam revealed that his right arm, face and neck were swollen, erythematous, warm to the touch and tender to palpation. There were two large unbroken blisters around the insertion site of the PICC line.

The localized pain and swelling appear to be consistent with a deep vein thrombosis (DVT), and the blisters appear to be an allergic reaction to the new tape. But the patient has had a severe, known infection requiring IV antibiotics. Could the blisters, facial redness and swelling be due to an infection? Are they from the same cause or is there more than one thing occurring?

The blisters around the insertion site must also be considered. The differential for blisters could be a previously undiagnosed autoimmune disorder causing bullous pemphigoid.

They could indicate herpes zoster or something more sinister such as Stephen-Johnson’s syndrome as the patient has had a known infection but unknown organism. With the history of infection, staph scalded skin syndrome or toxic epidermal necrolysis must also be excluded. Thankfully for our patient, the blisters were localized and not diffuse. The lack of systemic symptoms of fever and chills, in addition to the contained nature of the blisters, made a benign reason much more likely.

A venous Doppler of the right upper extremity showed echogenic material in the right internal jugular vein, subclavian vein and axillary vein. There was also echogenic material in the proximal brachial vein and basilic vein. The vessels Author Information: Dr. Rose-Hand is a former resident in the Department of Family Medicine at the University of Mississippi Medical Center in Jackson.

Corresponding Author: University of Mississippi Medical Center Department of Family Medicine, 2500 North State Street Jackson, MS 39216. Phone: 601-984-6800.

396 JOURNAL MSMA DECEMBER 2012

were noncompressible. A complete metabolic panel was within normal limits. A complete blood count indicated white blood cells (WBC) 10.2 K/uL with 1% bands and 10% eosinophils.

Once these results were known, the PICC line was discontinued. The emergency department physician administered a single dose of fondaparinux (Arixtra) for anticoagulation.

The venous Doppler confirms the diagnosis of DVT. According to the American College of Radiologists Appropriateness Guidelines, ultrasound is the diagnostic standard for DVT in a peripheral vein and a magnetic resonance angiogram the standard for central veins. The likelihood of a serious infection affecting the arm and face in the absence of an elevated white count is very low. The question is why would a healthy man with no previous medical problems, such as cancer or a hematologic hypercoagulable state, spontaneously form a DVT? Is a PICC line enough to cause a DVT, or is there an underlying hypercoagulable state? The risk of a DVT with a PICC in the upper extremity is approximately 3%.5 The white count was noted to be normal, but the abnormal differential was noted. Eosinophilia is most commonly noted in severe allergic reactions.

The plan is to admit the patient and consult the orthopedic surgeon who had done the knee replacement and the infectious disease physician who was managing the infection. They were consulted to clarify antibiotic use and duration. The patient will be prescribed enoxaparin (Lovenox) 1mg/kg twice a day and warfarin. The enoxaparin will be discontinued once the patient’s INR is within the therapeutic range of 2.0-3.0.1 The fondaparinux was initially given by the ED physician, and the medication will be switched to enoxaparin on admission.

The patient was agreeable to this plan but had 2 requests. He wanted a primary care physician and a prostate specific antigen (PSA). He did not currently have a primary care physician, and he had heard everyone needed a PSA. The patient completed the full course of antibiotics for the post-operative infection, presumed to be osteomyelitis, and otherwise was recovering well from his knee surgery. Wound care was consulted to care for the blisters around the PICC insertion point. On examination the morning following admission, the patient was found to have a diffuse macular rash that blanched with pressure.

It was most notable on his head and thinned out progressively down the body. He had an elevated PSA of 11.19 ng/mL and a WBC of 9.1 K/uL with 12.5% eosinophils.

The elevated PSA increased the likelihood that the DVT was due to a hypercoagulable state from a malignancy with the central catheter causing vein injury, a nidus for the clot to form.

This fulfills 2 elements of Virchow’s triad: venous injury plus a hypercoagulable state.4 And it may be argued that the PICC line also provided the final elements of venous stasis and turbulent blood flow. However, the new rash is concerning. It is a different rash from the allergic blisters noted on admission.

His normal white count and high eosinophil count makes us think that there could be an allergic component. The distribution and pattern of the rash suggests an allergic response.

The patient was prescribed Benadryl and prednisone for the severely pruritic rash. A CT scan of chest, abdomen and pelvis was done to search for occult malignancy. A nuclear bone scan was also ordered to evaluate for bone metastasis from prostate cancer.

The CT scan showed prominence of the prostate gland but was otherwise unremarkable. The exam on hospital day 3 showed that the rash was spreading but with decreased pruritus. The bone scan was negative for metastasis.

CBC showed a WBC of 17.6 K/uL with 0.1% eosinophils.

Based on the appearance of the rash and eosinophilia, the most likely cause of the rash was the fondaparinux. The eosinophilia that resolved with steroids and Benadryl shows that there is a severe allergic reaction taking place; this is consistent with the allergic appearing rash. Rash has been reported

in 8% of patients taking fondaparinux.2 Of the patient’s new medications, including fondaparinux, enoxaparin and Coumadin, fondaparinux has the highest rate of rash at 8%.2,3,4 Review of previous urology records indicated that the patient had a previous prostate biopsy that was malignant. The length of time since this diagnosis was greater than 1 year. On the fourth day of admission, the rash was improving. The patient was discharged home and prescribed enoxaparin/Coumadin with close follow-up with a primary care physician and urologist.

In summary, it is believed that the patient had a DVT. Elements of Virchow’s triad include prostate cancer by previous biopsy, which puts him at risk of hypercoagulable state, and the PICC line provided local endothelial injury with increased turbulent flow.5 Finally, he had blisters due to an allergic reaction to the new tape, and the rash was an allergic reaction to the fondaparinux.

Keywords: Allergic reaction, Arixtra, DVT, Prostate Cancer References:

1. Prandoni P, Bernardi E. Upper extremity deep vein thrombosis. Current Opinion in Pulm Med. 1999;5(4):222-226.

2. Arixtra [package insert]. Research Triangle Park, NC: GlaxoSmithKline; 2010.

3. Lovenox [package insert]. Bridgewater, NJ: Sanofi Aventis; 2007.

4. Coumadin [package insert]. Princeton, NJ: Bristol-Myers Squibb Company; 2010.

5. Evans, RS, Sharp JH, Linford LH, Lloyd FJ, et al. Risk of symptomatic DVT associated with peripherally inserted central catheters. Chest. 2010; 138(4):803.

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DECEMBER 2012 JOURNAL MSMA 397

MISSISSIPPI RISING A PREVENTIVE HEALTH SYMPOSIUM

Presented in Cooperation with:

Mississippi Chapter

Mississippi Board of Health

HILTON JACKSON http://www.msacc.org/RegistrationPacket2013.pdf

398 JOURNAL MSMA DECEMBER 2012

MISSISSIPPI RISING: A PREVENTIVE HEALTH SYMPOSIUM COURSE OVERVIEW The Mississippi Chapter of the American College of Cardiology is hosting a Preventive Health Symposium to engage health care professionals in promoting a healthier Mississippi. This symposium will address measures that will make a tremendous impact on cardiovascular health in Mississippi. Join fellow colleagues as we work together to raise Mississippi’s standing in national health standards and not only make Mississippians healthier but also significantly lower the cost of delivering healthcare in our state.

SCHEDULE

State Health Officer

Mississippi State Department of Health

Sam Dagogo‐Jack, MD, FRCP Professor of Medicine & Director Division of Endocrinology, Diabetes & Metabolism A. C. Mullins Chair in Translational Research Director, General Clinical Research Center University of Tennessee Health Science Center

Friday, February 8, 2013 7:00 PM - *Welcome Dinner

(*Not included in registration fee. Additional registration required)

Saturday, February 9, 2013 7:30 AM Registration and Breakfast 8:00 AM Welcome 8:00 AM Morning Session 11:30 AM Lunch Afternoon Session 1:00 PM 5:00 PM Adjourn

Richard D. deShazo, MD Billy S. Guyton Distinguished Professor Professor of Medicine and Pediatrics The University of Mississippi Medical Center

Dipti Itchhaporia, MD, FACC Chair, Board of Governors, American College of Cardiology( ACC) Robert and Georgia Roth Chair for Excellence in Cardiac Care Director of Disease Management Hoag Memorial Hospital Presbyterian, Newport Beach

Carl J. Lavie, M.D., FACC, FACP, FCCP Professor of Medicine Medical Director, Cardiac Rehabilitation and Prevention Director, Stress Testing Laboratory John Ochsner Heart and Vascular Institute Ochsner Clinical School ‐ The University of Queensland School of Medicine

TARGET AUDIENCE This conference is intended for cardiovascular specialists, internists, family physicians, advanced practice nurses, nurses in cardiology and physicians assistants.

ACCREDITATION

The Health Preventive Symposium is being submitted for 7.5 hours of AMA PRA Category 1 Credit ™.

Michael Mansour, FACC, FACP President MS Chapter American College of Cardiology American College of Cardiology Board of Governors

REGISTRATION Registration for this conference is $50 and includes breakfast, breaks, lunch and CME certificate. Additional registration is required if attending the Welcome Dinner on Friday, February 8, 2013.

HOTEL INFORMATION This conference will be held at the Hilton Jackson. Rooms are available by contacting:

Hilton Jackson

1001 East County Line Road Jackson, MS 39211

601‐957‐2800

FACULTY Mary Currier, MD, MPH

Group Rate: $99 +tax and fees Group Code: MS Chapter, ACC Cutoff Date: January 9, 2013

EVENT REGISTRATION: Name: _____________________________________________________

Professional Initials (Please circle): MD DO NP PA Other _____________

Practice Name:______________________________________________

Preferred address: ___________________________________________

City: _______________________ State: _____ Zip: _________________

Daytime Telephone: _______________ Email:_____________________

Thomas J. Payne, PhD Professor, Department of Otolaryngology and Communicative Sciences Associate Director, ACT Center for Tobacco Treatment, Education and Research University of Mississippi Medical Center

David A. Sabgir MD FACC Founding CEO, Walk with a Doc

Frank W. Smart, MD, FACC, FACP Professor and Chief Section of Cardiology LSU School of Medicine in New Orleans Director of the Cardiovascular Center of Excellence LSU Health Sciences Center

J. Clinton Smith, MD, MPH Professor Emeritus of Pediatrics (Cardiology) University of Mississippi Medical Center Medical Consultant, Mississippi Public Health Institute

Welcome Dinner ‐ $250/Couple Friday, February 8, 2013 – Hilton Jackson Meeting Registration ‐ $50 Saturday, February 9, 2013 – Hilton Jackson

PAYMENT OPTION: Make checks payable to MS Chapter, American College of Cardiology Send completed form and payment to: MS Chapter, American College of Cardiology Attn: Jenny White, PO Box 2548, Ridgeland, MS 39158

Hector Ventura, MD, FACC

President LA Chapter American College of Cardiology American College of Cardiology Board of Governors Professor of Medicine Medical Director Cardiac Transplant and Heart Failure Ochsner Clinical School ‐ The University of Queensland School of Medicine

Thad Waites, MD, FACC

Immediate Past Chair, Board of Governors American College of Cardiology Director Cardiac Catheterization Laboratories Southern Heart Center (A Service of Hattiesburg Clinic, P.A.)

Janet Wright, MD, FACC Executive Director Million Hearts Department of Health and Human Services (HHS) Centers for Disease Control and Prevention (CDC) Centers for Medicare & Medicaid Services (CMS)

QUESTIONS: Contact Jenny White at JWhite@MSMAonline.com or 601‐

853‐6733 x 332.

DECEMBER 2012 JOURNAL MSMA 399

• Scientific Articles • Coordinated Cardiac Delivery: Reducing Mortality in High Risk Fetal Cardiac Lesions at the University of Mississippi Medical Center Daniel J. DiBardino, MD; Jennifer C. Shores, MD; Michelle Sheth; Mary Taylor, MD; Kenneth Liechty, MD; Jorge D. Salazar, MD

I

ntroduction The extensive use of prenatal ultrasound and fetal echocardiography has resulted in an increased number of congenital anomalies being detected before birth.

Identification of these anomalies in utero has a direct impact on the management of these potentially life-threatening anomalies.

The accurate prenatal diagnosis of these anomalies provides time for development of a pre- and perinatal management plan, including the route and timing of delivery, to ensure the best potential outcome for these patients. It also provides time for education and discussion with the family regarding the etiology and pathophysiology of the particular anomaly, the complex management and delivery plan, and potential outcomes.

The recent development of The University Center for Fetal Medicine and the Division of Congenital Heart Surgery at The Batson Children’s Hospital and The University of Mississippi Medical Center now allows patients from Mississippi and the region to receive this high level of comprehensive care close to home for the first time. In the past, these patients with complex congenital anomalies were required to travel to other distant institutions to receive care.

Complex congenital heart lesions represent one of the more striking examples of a congenital anomaly that can be impacted by accurate prenatal diagnosis and this comprehensive management approach. Fetuses diagnosed with hypoplastic left heart syndrome (HLHS) and a restrictive

Author Information: Division of Congenital Heart Surgery (Dr. DiBardino and Dr. Salazar). Division of Pediatric Cardiology (Dr. Shores). Division of Pediatric Anesthesia (Ms. Sheth). Division of Pediatrics and Critical Care (Dr. Taylor). University Center for Fetal Medicine, Division of Pediatric Surgery (Dr. Liechty). Children’s Heart Center, University of Mississippi School of Medicine and The Blair E. Batson Children’s Hospital, Jackson.

Corresponding Author: Daniel J. DiBardino, MD, Division of Pediatric Cardiac Surgery, Department of Surgery, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216. Phone: (601)-984-5450 [DDibardino@umc.edu].

400 JOURNAL MSMA DECEMBER 2012

or intact atrial septum or fetuses with any form of partial or totally obstructed totally anomalous pulmonary venous return (TAPVR) represent patients who are significantly at risk in the immediate delivery period. A standard delivery approach makes immediate treatment impractical, if not impossible, and results in a delay in treatment, leading to unacceptably high morbidity and mortality. Following standard delivery, either by cesarean section or vaginal routes, these patients immediately develop severe pulmonary hypertension and pulmonary vascular reactivity, resulting in systemic hypotension and pulmonary injury leading to a dramatic increase in morbidity and mortality. The institution of extracorporeal membrane oxygenation (ECMO) support, while able to restore cardiac output and lower lactate levels, does not decompress the pulmonary venous chamber in patients with either of these lesions, and high morbidity and mortality are the rule. In order to minimize the delay in treatment and resulting complications, we have instituted a program of Coordinated Cardiac Delivery (CCD) to improve the outcome of these patients.

The Coordinated Cardiac Delivery- Delivery Plan and Team Specifics The needs of each individual fetus need to be taken into consideration when planning a CCD. It is preferable to undergo scheduled caesarian section or vaginal delivery in the operating room adjacent to the pediatric cardiac operating room. In order to minimize confusion, only the necessary personnel are present in each room. The OBGYN team and appropriate anesthesiology personnel conduct delivery, and the newborn is immediately transitioned to the NICU team, wrapped and transported o the pediatric cardiac operating room table. Here the standard NICU resuscitation is performed, including umbilical line placement and airway management coordinated with the pediatric cardiac anesthesia team. The entire pediatric cardiac surgery team is scrubbed and completely prepared for immediate operation in the case of inability to resuscitate. The appropriate sized cardiopulmonary bypass and ECMO circuits

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are available and primed, and the perfusion team is on standby.

Airway management is performed by the anesthesia team and is followed by transthoracic or transesophageal echocardiogram (TEE) by a pediatric cardiologist. This allows for confirmation of the diagnosis and discussion between the cardiology team and surgical team as to the final operative plan. The NICU team can transfer the newborn to the cardiac ICU or tentative or standard definitive repairs can be considered in this controlled fashion. In the latter case, the baby is positioned and prepped by the usual cardiac team members and the operation can begin.

Figure 2. Following CCD, immediate post-birth transesophageal echocardiogram on-table in the pediatric cardiac operating room confirmed aneurysmal atrial septum with a small opening.

Example Case

A fetus with a known prenatal diagnosis of HLHS was followed by our center. Episodic fetal supraventricular tachycardia (SVT) led to close repeat echocardiographic examinations. A large aneurysmal atrial septum was seen occasionally bowing into the systemic tricuspid valve (figure 1).

Figure 1. Fetal echocardiogram at 32 weeks and 6 days gestation revealing a large aneurysmal atrial septum.

The fetus was suffering from episodes of supraventricular tachycardia, and at times the aneurysmal septum was seen to be bowing in and out of the tricuspid valve. Only a small opening in the septum was ever able to be imaged in multiple repeat studies, thus indicating likely restriction.

Coordinated Cardiac Delivery (CCD) was planned.

the patient was prepped. Median sternotomy and aorto-right atrial bypass was performed and an open atrial septectomy was completed using pump-sucker bypass as an adjunct during the few minutes the atrial septum was open. After atrial closure, a 3.5mm Gortex tube graft was cut into two small rings and used for bilateral pulmonary artery bands in order to prevent overcirculation and heart failure during the convalescent period.

Completion echocardiogram is shown in figure 3. The newborn Figure 3. Following CCD, post-birth confirmation and immediate open atrial septectomy with bilateral pulmonary artery banding, post-repair transesophageal echocardiogram reveals wide open atrial septum. The patient was transferred to the cardiac intensive care unit with stable single ventricle hemodynamics.

The latter was thought to be related to the SVT; however this resolved by 36 weeks and the fetus developed to 2.2kg and was non-hydropic. In addition to the appearance shown, only a very small opening could ever be demonstrated in the atrial septum which was thus presumed to be restrictive. A CCD intervention was planned with the appropriate personal as previously outlined. A scheduled caesarian section was performed as first case with the cardiac team on standby in the adjacent room. Delivery was uneventful; the newborn was cyanotic and saturating 60-70% once the airway was controlled and monitors and lines placed. PGE1 infusion was initiated.

TEE confirmed the diagnosis (figure 2). After discussion with cardiology, the mother was updated in the adjacent room and

was subsequently extubated and began feeding. During the next week, the hybrid approach to single ventricle palliation was completed with the placement of a ductal stent in the cardiac catheterization laboratory. The patient was discharged

DECEMBER 2012 JOURNAL MSMA 403

* Includes hypertension, coronary artery disease, hyperlipidemia, organic heart disease, atherosclerosis # Includes COPD, ROAD, and Pulmonary Embolus + Includes osteoporosis gout, polio, renal disease, hepatitis, home and returned at age 4 months for the second stage of the peptic ulcer single ventricle pathway. She was eventually discharged from this and remains close outpatient follow-up. every patientwith in this series had several comorbidities.(Tableiii) The most common of these included organic heart disease, diabetes Conclusion mellitus and obesity. There was also one patient who had polio in the The Society of Thoracic Congenital Database distant past. despite these varied andSurgeons potentially serious medical probhas emerged as the standard reference for expectations in lems, there were no deaths in the series, complications from these co1,2 pediatric cardiac surgery.

As of the most recent reports, morbidities, or prolonged hospital stay. it does pose the question of parents of HLHS newborns can expect an average of 17% proceeding with a total thyroidectomy with the advantage of avoiding discharge mortality and much higher for certain combinations further surgery in the future versus performing a lobectomy only and3 of lesions like intact septum and total anomalous venous repair. thus avoiding potential surgical complications and allowing for a The hybrid approach to HLHS management is a well known shorter anesthesia time. alternative to standard operative management for high risk Our tendency has been to perform a lobectomy; however, as furpatients and it is one which we have experience. The addition ther operative experience is gained there may be a trend to total thyof CCD to our armamentarium of ensuring stable delivery and roidectomy. Netterville et al have advocated total thyroidectomy with initial management help ensure the best possible candidates for good results.1 Others have recommended total thyroidectomy, total medical and surgical therapy and can possibly result in survival lobectomy or subtotal lobectomy, depending on the clinical situation.14 for even the most hopeless of lesions.

Regardless of the the procedure advocated, the literature suggests surgical excision as the treatment of choice. There have been few comReferences plications and a low morbidity rate in this series of patients. Not 1. Clarke DR, Breen LS, Jacobs ML et al. Verification of data in surprisingly the rate of complications is higher in patients congenital cardiac surgery. In: 2008 Supplement to undergoing Cardiology 15 substernal in thethyroidectomy.

Young: Databases and The Assessment of Complications associated with The Treatment of Patients with Congenital Cardiac Disease, Prepared by: The Multi-Societal Database Committee conclUSion for Pediatric and Congenital Heart Disease, Jeffrey P. Jacobs, MD Substernal goiters are often asymptomatic due to their slow

182

jOuRNAl MSMA

july

9.

10.

2.

11.

12.

3.

13.

14.

4.

15.

688, April 2009.

Terris dJ, bonnett A, gourin Cg, et al. minimally invasive Thyroidectomy using the Sofferman Technique. Laryngoscope. 2005; 115(6):1104-8. mackle T, meeney J, Tirem C. Tracheoesophageal Compression Associated With Substernal goiter.

Correlation Symptoms with Cross (editor).

Cardiol Young. 2008 Dec;18 Suppl of 2:177-87.

Sectional imaging Findings. J Laryngo Otol. 2007; 121(4):358-61.

O’Brien SM, Clarkem,DR, Jacobs JP et al.goiter:15 An empirically based ben Nun A, Soudack Retrosternal Thyroid years experience. tool for Assoc analyzing mortality associated with congenital heart J. 2006; 8(2):106-9.

ISR Med surgery.

J Thorac Surg. 2009;138:(5):1139-53.

Sancho JJ, KraimpsCardiovasc Jl, Sanchez-blanco Jm, et al. increased mortality and morbidity Associated with Thyroidectomy for intrathoracic goiters Jacobs JP, O’Brien SM, Pasquali SK et al. Richard E. Clark Paper: Reaching the Carina Tracheal. Arch Surg. 2006; 141(1):82-5.

Variation in outcomes for benchmark operations: an analysis of the de perrot m, Fadel e, mercier O. Surgical management of mediastinal Society Thoracic Surgeons Congenital Surgery Database. goiters: ofWhen is a Sternotomy Required? Heart Thoracic Cardiovasc Surg.

Richard Clark Award recipient for best use of the STS Congenital 2007; 55(1):39-43.

Heart Surgery Database.

Ann Thorac Surg. goiter: 2010;92(6):2184-92. possetto b, liquori g, Rombola F. Substernal A diagnostic and Therapeutic problem.

(Report of 39 surgically treated cases). EA. Ann Star Dibardino DJ, McElhinney DB, Marshall AC, Bacha A Chir. 1999; 70(1):29-35. review of ductal stenting in hypoplastic left heart syndrome; pieracci Fm, Fahey TJ. Substernal Thyroidectomy is associated with bridge to transplantation hybridasstage I palliation.

Pediatric increased morbidity and and mortality compared with Conventional Cardiology 2008:29(2):251-7.

Cervical Thyroidectomy.

Am J Surg. 205(1):1-7, July 2007.

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www.meamedicalclinics.com 404 JOURNAL MSMA DECEMBER 2012

• Scientific •

Revitalization of the University of Mississippi Children’s Heart Center: Report Card from the First 18 Months Daniel J. DiBardino, MD; William J. Lancaster, BA; Walter Merrill, MD; Marc E. Mitchell, MD; Emilee Taylor, RN; Charles Gaymes, MD; Makram Ebeid, MD; Jennifer Shores, MD; Elizabeth Christ, MD; Mary Taylor, MD; Michelle Sheth, MD; Richard A. Jonas, MD and Jorge D. Salazar, MD

I

ntroduction

There is an established and well known relationship between team experience (annual institutional volume as the most commonly utilized measurable surrogate) with clinical outcomes in the delivery of pediatric cardiac surgical care. In the era of scrutinized clinical outcomes and regional competition among viable operative care lines, it is more difficult than ever to initiate and maintain a successful program. Such an initiative requires meticulous attention not only to the details of each individual patient but monitoring and tracking outcomes in the effort to identify clinical deficiencies, system issues and individual performance issues. This relentless combination of daily tasks on top of providing consistent 24 hour care can be overwhelming for a new program which is often concomitantly challenged by inexperienced team members including nurses, critical care providers and various members of the surgical team.

During a period of clinical inactivity, all patients requiring operative care for congenital heart defects were sent outside the state of Mississippi to several large centers in several different regions of the United States. In an effort to provide consistent in-state care, a senior surgeon (RAJ) was sought and contracted Author Information: University of Mississippi School of Medicine, Children’s Heart Center, The Blaire E. Batson Hospital for Children, University of Mississippi Medical Center, Jackson. Division of Pediatric and Congenital Heart Surgery (Dr. DiBardino, Mr. Lancaster, Ms. Taylor and Dr. Salazar). Division of Cardiothoracic Surgery (Dr. Merrill). Chairman, Department of Surgery (Dr. Mitchell). Division of Pediatric Cardiology (Dr. Ebeid and Dr. Shores). Department of Pediatrics and Critical Care (Dr. Christ and Dr. Taylor). Department of Pediatric Anesthesia (Dr. Sheth).

Division of Pediatric Cardiac Surgery, Children’s National Medical Center, Washington D.C., (Dr. Jonas).

Corresponding Author: Daniel J. DiBardino, MD, Division of Pediatric Cardiac Surgery, Department of Surgery, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216 Phone: (601)984-5450 [DDibardino@umc.edu].

and began building a base team and performing basic operations on site at the University of Mississippi Medical Center.

More complex operations were sent to Children’s National Medical Center in Washington, DC. In April of 2010, administrative reorganization occurred in an effort to establish an independent, in-house pediatric cardiac surgery program. The first operation occurring under this revitalization was April 15, 2010, and all data from operations and procedures since then were submitted to the Society of Thoracic Surgeons Congenital Database (STSCD) in real time. The purpose of this study is to analyze the first 18 months of data from this revitalization effort with emphasis on results for the major most common pediatric heart operations. It is our hypothesis that our hospital discharge mortality for each of these procedures compares favorably with published STSCD benchmark data.

Methods

All data from the divisional operations and procedures were submitted to the STSCD. This database contains preoperative, operative, and postoperative outcomes data on all children undergoing heart surgery at participating centers, which now totals >85% of all congenital heart surgery in the United States.1-3 It is the largest existing clinical congenital heart surgery data registry in the world. Data quality and reliability are assured through intrinsic verification of data and a formal process of site visits and data audits. The most recent publication from this database once again established updated benchmark outcomes with which program performance can be measured, and these data were used for comparison to our own.3 Following approval by the Institutional Review Board at the University of Mississippi Medical Center, our institutional STSCD submissions were reviewed for the 18 months from 5/15/2010 to 11/31/2011. All procedures and operations were tabulated on a Microsoft Excel spreadsheet (Microsoft Corporation, One Microsoft Way, Redmond, WA) and all preoperative and demographic, operative and postoperative data were

DECEMBER 2012 JOURNAL MSMA 405

similarly tabulated. STS database information regarding the precise details of the anatomic diagnosis and operative repairs were verified via direct review of the institutional operative notes. Representative lesions for program performance were collected, tabulated and analyzed and included operations performed for patients coded with the following primary cardiac diagnoses: ventricular septal defect (VSD), tetralogy of fallot (TOF), transposition of the great arteries (D-TGA), atrioventricular canal defect (AVC), end-stage heart failure (ESHF) and single ventricle patients (SVPs). In order to make the most homogeneous SVP analysis, the results of first stage surgery for hypoplastic left heart syndrome variants (HLHS) as well as all bidirectional Glenn anastomoses (BDGs) and fontan completions were each individually analyzed. The primary outcome measures for all diagnoses were discharge mortality, median length of stay and readmission for an unplanned reoperation.

Our results were then compared to the most recent above mentioned STSCD published results.3

Results

There were 392 cases performed between 4/15/2010 to 11/31/2011 with consistent growth between 2010 and 2011 (figure 1). Monthly volume has steadily strengthened from 5 cases in April 2010 to consistently over 20 cases per month in the latter half of the series, resulting in more than doubling of growth from 135 cases in 2010 to 257 cases thus far in 2011 (figures 2 and 3). Current data and operative scheduling trends project 400-450 total operations and procedures in the calendar year 2012 alone. As of July 1, 2011 the program expanded from 1 to 2 dedicated pediatric cardiac surgeons with the senior surgeon (JDS) performing 311 cases and the junior surgeon (DJD) 81 cases by the 18 month mark. Figures 2 and 3 demonstrate graphically the gradual monthly increase in case volume as well as the percentage of cases performed on neonatal patients and the percentage of procedures performed through redo sternotomies, both a reflection of overall case complexity.

While there were no neonates and only 4 redo sternotomies during the first two months of the new program, acuity and difficulty gradually increased through November 2011, with 11 neonatal and 18 reoperations in 33 total procedures. This was our highest total monthly number and highest acuity monthly tally. In 2010, 21 of the 135 cases (16%) were neonates and 65 (48%) were redo sternotomies while 257 procedures in 2011 have been neonates in 70 procedures (27%) and 126 redo sternotomy (49%). For the entire experience, the overall unadjusted hospital mortality rate for all index cases (the major index operation for each patient’s admission) was 3%.

Results for the chosen diagnoses representative of program performance are listed in table 1. The only hospital discharge mortality among any of these benchmark diagnoses was in the SVP category, giving a 100% discharge survival rate among all the other categories and program performance that was above the published STSCD benchmarks in all categories (table 1).

406 JOURNAL MSMA DECEMBER 2012

Figure 1. Yearly growth since revitalization, totaling 393 cases from 4/15/2010 -11/30/2011.

Figure 2. Monthly operative volume for 2010, totaling 135 cases from 4/15/2010 to 12/31/2010. The fraction of each month’s cases which were neonates (30 days of age or less) and redo sternotomies are shown respectively.

Figure 3. Monthly operative volume for 2011, so far totaling 257 cases from 1/1/2011 -11/30/2011.

Page 18 of 18 Table 1. Representative index operations reflective of program performance from 4/15/2010 to

Table 1. Representative operations program performance 12/31/2010 and comparison toindex the most recent STS reflective Benchmark of data [3]. from 4/15/2010 to 12/31/2010 and comparison to the most recent STS Benchmark data. 3 Procedure

Number of cases

Outcomes by procedure Median postHospital operative discharge length of stay mortality rate 19 days 10%

STS National Hospital Discharge Mortality

Norwood

10

Arterial Switch Glenn

5

9 days

0%

2.9%

19

11 days

0%

N/A

Fontan

10

9 days

0%

1.3%

AVC repair

8

5.5 days

0%

2.2%

TOF repair

15

6 days

0%

VSD repair

27

5 days

0%

Heart Transplant

3

22 days

0%

VSD as Primary Diagnosis There were 40 operations and procedures performed for a primary cardiac diagnosis of VSD, 19 in 2010 and 21 so far in 2011. Eight patients judged to be in CHF from overcirculation with especially small size or other complicating factors underwent pulmonary artery band (PAB) placement. Of these, 4 currently await repair while 4 have undergone subsequent PAB removal, PA reconstruction and complete repair, and in two cases multiple intervening procedures were required for  pericardial drainage (n=1), airway malacia (n=1) and sternal wound complication (n=2). Twenty-three patients underwent primary VSD closure with no previous band. PAB placements, removals and VSD closures were often associated with other secondary procedures such as PDA ligation, sub-aortic stenosis resection, aortic valve repair and a supravalvar mitral ring resection. To date there was 100% survival to hospital discharge for all patients and procedures and median length of stay after VSD closure of 5 days.

Tetralogy of Fallot There were 22 operations and procedures performed for a primary cardiac diagnosis of TOF. Small pulmonary arteries and/or very small (premature) patient size led to the placement of 5 systemic to pulmonary artery shunts, and 3 of these (60%) have gone onto complete repair with 2 currently awaiting repair. One patient was found to have tricuspid valve (TV) tissue causing near total obstruction of the VSD and RV hypertension at the time of attempted repair and thus underwent resection of the obstructing TV tissue and partial relief of RVOT obstruction (“banded� physiology) and returned for subsequent successful complete repair. An additional patient underwent complete RVOT resection but extremely friable tissue precluded VSD repair; a band was placed and the child returned for band removal and successful compete re-

19.3%

pair. Ten patients underwent primary complete repair. Of these, one patient was a 35-year-old adult s/p Waterston shunt in childhood who underwent complete repair with fenestrated VSD closure, 27mm pulmonary valve replacement, PA reconstruction and Waterston shunt takedown. To date there was 100% survival to hospital discharge for all patients and procedures. Median length of stay after complete repair of TOF was 6 days.

Transposition of the Great Arteries There were 9 operations and 0.64% procedures performed for D-TGA and N/A associated lesions such as VSD, ASD and PDA. In one case the patient has severe left ventricular outflow tract obstruction/ subpulmonary stenosis (LVOTO/subPS) and thus underwent a systemic to pulmonary artery shunt procedure. This child is currently undergoing evaluation for possible arterial switch and concomitant resection versus Rastelli type repair. The remaining 5 patients underwent arterial switch operation (ASO) and single stage complete repair of all associated lesions in the neonatal period, including one patient at 1.8kg with an intramural coronary artery pattern. Three patients required initial management with an open sternum and delayed sternal closure 1 (n=1) or 2 (n=2) days following ASO. To date there was 100% survival to hospital discharge for all patients and procedures. Median length of stay after ASO was 9 days.

1.1%

Partial and Complete Atrioventricular Canal Defects There were 8 patients with atrioventricular canal defects referred for surgical repair, including one who had undergone previous pulmonary artery banding at an outside hospital. All underwent complete repair, including 3 partial defects and 5 complete or intermediate. To date there was 100% survival to hospital discharge for all patients and procedures with median length of stay following complete repair of AV canal defect was 5.5 days.

End-Stage Heart Failure Program In order to keep up with the seemingly growing needs of children and adolescents with advanced heart failure, a pediatric cardiac transplant and heart failure program was initiated and became active with the first transplant on 9/18/2011. In 3 months we have performed 3 orthotopic heart transplantations (OHTs) and a Bautista LV remodeling procedure for advanced heart failure. To date there was 100% survival to hospital discharge for all patients and procedures with no unplanned reoperation. This program currently also includes the care of

DECEMBER 2012 JOURNAL MSMA 407

young patients previously receiving OHTs and now living in the state of Mississippi, the ongoing follow-up of patients who may require listing and will most likely involve VAD therapy for bridge to transplant in the near future.

Single Ventricle Surgery Program Of the 392 total cases since programmatic reorganization, 110 operations and procedures (28%) were performed for the ongoing care of single ventricle patients (SVPs), thus constituting the largest percentage patients cared for in our center and the most complex patient population in the specialty. First stage treatment for hypoplastic left heart syndrome (HLHS) variations was required in 14 patients and required 33 operations to complete; 10 patients underwent a variation of Stage I Norwood operation and 4 underwent the “hybrid” transcatheter-surgical approach.

The 10 patients who underwent Stage I operative reconstruction were performed with a Sano shunt in 8 and a modified Blalock-Taussig shunt in 2, resulting in only one operative death for a 10% discharge mortality. All patients were managed with an open sternum and underwent at least 1 exploration for delayed sternal closure. The 1 Stage I operative death was a respiratory event on postoperative day 58 after a successful ECMO run and decannulation. This compares very favorably with the published STS benchmark discharge mortality of 19%.3 Median length of stay following Norwood operation was 19 days. Among the 4 patients who were selected to undergo a combined Hybrid surgical-catheterization approach, there was 1 death from a vascular access related issue for a 75% hospital discharge, also comparing favorably to published data.4 There were 16 patients undergoing bidirectional Glenn anastomosis as part of second stage single ventricle palliation pathway and in 2 of these the DKS connection had to be redone secondary to known or suspected stenosis. The sternum was left open in 3 patients, requiring delayed sternal closure.

There was 100% stage II survival to hospital discharge for all patients and procedures. There were 10 Patients undergoing Fontan Stage III operation, including 3 who were complex redo-Fontans. There was 1 patient left open after surgery thus necessitating 1 delayed sternal closure, 1 patient required pigtail placement for effusion and 1 patient required thoracic duct ligation. There was 100% stage II and stage III survival to hospital discharge for all patients and procedures. Median length of stay was 11 days following Glenn and 9 days following Fontan operation.

Discussion The program’s first operation was performed April 15, 2010, and the first 100 cases performed without a hospital discharge mortality. Mississippi Medicaid named the congenital heart program its preferred program less than 1 year after its creation, and in December 2011 we were approved for “center

408 JOURNAL MSMA DECEMBER 2012

status” as the Children’s Heart Center at the University of Mississippi Medical Center. The success of the Mississippi congenital heart program depended on the serendipitous existence of multiple conditions. Recognition of these conditions during planning was critical as was the continued acknowledgement of these conditions during implementation. Most importantly, there was clinical need. The entire state of Mississippi had been without a stable congenital heart program for over 10 years.

This meant that for a population of over 3 million people and 45,000 live births yearly, congenital heart surgical services instate were unavailable. The implications to the individual child and family, especially those less advantaged, are staggering in terms of decreased access to care and consistency of follow up.

When one considers that very few congenital heart patients require only one intervention and that the very best outcomes rely on careful follow-up and subsequent management, it is easy to understand the profound implications of all of Mississippi children needing to leave the state for care.

A second set of very important conditions leading to a receptive environment for a successful program in Mississippi was both political and financial in nature. The funding reality for Mississippi patients with congenital heart disease was such that the vast majority of patients were covered by Mississippi Medicaid. The exportation of congenital heart patients out of state for care resulted in a significant financial burden on the state and, therefore, a great sense of need. This condition, coupled with the political unease associated with the absence of a stable congenital heart program in Mississippi for over a decade, led to an environment that was very open to change.

A third factor leading to a receptive environment was the existence of only one Children’s Hospital and an academic medical center in the entire state of Mississippi. The well-known challenges of having multiple congenital heart programs in the same state or even the same city were not in existence in this case. In total, the overall environment was quite receptive to the creation of a successful congenital heart program.

This “perfect storm” of unique conditions led the possibility of creating a “win-win” for everyone in the state: for patients, families, the Children’s Hospital and Medical Center, Mississippi Medicaid and the wellbeing of Mississippi society.

Specific to the Children’s Hospital and Medical Center, recognition of the need to serve the congenital heart surgical population led to an alliance with Children’s National Medical Center, Washington, DC, in 2008 under the leadership of Dr. Richard Jonas. This important relationship helped provide for a more consistent access to care by transporting the more complex cases to Washington, DC for surgical management while performing the less complex cases in Mississippi on monthly visits. Dr. Jonas and his team partnered with the Mississippi leadership to begin setting up the structure necessary to house an independent program. Without this important groundwork and infrastructure-building, the success of the Mississippi program would not have been possible. Most importantly, the DC

National team impressed upon the leadership in Mississippi the absolute necessity of a comprehensive approach to the management of congenital heart disease. The essence of the message was that “if you are going to do it, you have to do it right.” Whatever the specific model for a successful congenital heart program used, all successful examples point to several essential variables and components necessary to create the possibility of success.

It is also important to recognize the serendipity of having many excellent clinicians already practicing at the Children’s National Medical Center. Although these clinicians had not been rallied in a coordinated fashion for the comprehensive management of congenital heart disease, it is important to recognize the excellent, albeit few in numbers, pediatric cardiologists, anesthesiologists, neonatologists, nurses, respiratory therapists, and many others already on the ground in Mississippi. In many ways these clinicians had already been proven by the trial by fire of not having a home-based surgical program to partner with in the management of these complex patients. The presence and investment of these clinicians were, and are, essential factors leading to the receptive environment enabling our success. The empowerment of already present competent team members and the recruitment and integration of new members have allowed the team to grow and thrive.

As we continue in growth, it will be important to remain true to the founding successful ingredients and remain a “team.”

Comment:

As of the printing of this article, the UMC Congenital Heart Program has now completed its 875th case (450 for 2012 so far) with a 2.2% overall operative mortality and 3.2% ECMO rate.

References

1.

Clarke DR, Breen LS, Jacobs ML et al. Verification of data in congenital cardiac surgery. In: 2008 Supplement to Cardiology in the Young: Databases and The Assessment of Complications associated with The Treatment of Patients with Congenital Cardiac Disease, Prepared by: The Multi-Societal Database Committee for Pediatric and Congenital Heart Disease, Jeffrey P. Jacobs, MD (editor). Cardiology in the Young, Volume 18, Issue S2 (Suppl.

2),177–187.

2.

O’Brien SM, Clarke DR, Jacobs JP et al. An empirically based tool for analyzing mortality associated with congenital heart surgery. J Thorac Cardiovasc Surg. 2009;138:(5):1139-53.

3.

Jacobs JP, O’Brien SM, Pasquali SK et al. Richard E. Clark Paper: Variation in outcomes for benchmark operations: an analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database.

Richard Clark Award recipient for best use of the STS Congenital Heart Surgery Database. Ann Thorac Surg. 201;92(6):2184-92.

4.

Dibardino DJ, McElhinney DB, Marshall AC, Bacha EA. A review of ductal stenting in hypoplastic left heart syndrome; bridge to transplantation and hybrid stage I Palliation. Pediatric Cardiology 2008:29(2):251-7.

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DECEMBER 2012 JOURNAL MSMA 409

NEW ICD-10 DEADLINE:

OCT 1, 2014

2014 COMPLIANCE DEADLINE FOR ICD-10 The ICD-10 transition is coming October 1, 2014. The ICD-10 transition will change every part of how you provide care, from software upgrades, to patient registration and referrals, to clinical documentation, and billing. Work with your software vendor, clearinghouse, and billing service now to ensure you are ready when the time comes. ICD-10 is closer than it seems.

CMS can help. Visit the CMS website at www.cms.gov/ICD10 for resources to get your practice ready.

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410 JOURNAL MSMA DECEMBER 2012 CMS_ICD-10_Journal_MSMA.indd 1

10/30/12 3:27 PM

• President’s Page • You Have To Have Some Skin in the Game

T

hree different patients present to the emergency department. One is a patient who has back pain. He is a 42-year-old male that had worked all day in his yard and the next day is having pain in his back. It did not radiate down his legs and there was no numbness or weakness associated with it. The pain was severe enough though to cause him to miss work so he came to the emergency department. He was seen and evaluated. It was felt that this was musculoskeletal. He was going to be prescribed appropriate medications with anti-inflammatories and muscle relaxers but he was insistent that he wanted an MRI of his back. I explained Steven L. Demetropoulos, MD to him that most back pain such as he has gets better in two weeks with the 2012-13 MSMA President medication we are prescribing and the MRI would not be indicated at this point but he was still insistent. I explained to him that we do not do nonemergent MRIs thru the emergency department but that I would order one as an outpatient if he insisted. When he started thinking about the co-pay that was associated with the outpatient testing, he decided to take the medication and wait two weeks to see if he improved.

The second patient is an 18-year-old female who came in with cold symptoms that had been going on for two days. She had sinus congestion and a cough, no fever, no chest pain or shortness of breath. She has Medicaid. She came in because it was convenient for her and she wanted to be checked out. She was diagnosed with a viral URI and prescribed over-the-counter medication in the form of Claritin and Robitussin for her cough.

The third patient is a 10-year-old boy who cut his hand while playing outside. His parents have a health savings account and so they went all over our little town looking for a doctor’s office that was available that could sew up his hand. They found one and his hand was sewn up at the doctor’s office since they did not want to pay all the additional expenses of coming to the emergency department because they have to pay for all that themselves, they found the least costly place to have the patient treated.

What was different about all these patient presentations? For one thing, do you notice that when someone has to pay for something, suddenly they seem to appreciate or value it more and they are more selective about how they want to spend their money? I would submit to you that what is missing from the whole healthcare industry today is that patients no longer have any skin in the game. Unless they have health savings accounts or high deductible insurance, they are separated from the cost of any services by the insurance companies themselves or by government-run programs like Medicaid or Medicare. When that happens, as you well know from your personal experience, if you don’t have to pay for something you do not value it nearly as much. You tend to over-utilize and you don’t have a sense of appreciation for either the service or the person providing it. If we all just had to pay some small portion for any of the services that we were provided, we would appreciate them much more and we would be much more careful in the way that we adhere to recommendations and would be much more compliant. So regardless of what type of insurance is out there, whether it is a government-supported insurance or commercial, having some personal responsibility is essential for your appreciation of the care that you receive.

So what can we do as physicians?

1. First of all we can at least bring this issue to the attention of our politicians and let them know that personal responsibility is absolutely essential to any successful healthcare program like Medicare and Medicaid and that some level of co-pays (however small) actually help patients value care and utilize it more appropriately.

2. Second we can let our AMA delegation from the State Medical Association know that this is a principle that we want promoted in the AMA that personal responsibility has to be a part of successful and financially stable healthcare reform.

The only way that we will get back to sustainable healthcare in our country is if patients take responsibility for their care and that means taking financial responsibility as well and having insurance pay for catastrophic coverage as it once was intended to do.

DECEMBER 2012 JOURNAL MSMA 411

J

ust what the doctor ordered APPETIZER

This month’s recipe is for an appetizer. This is an easy appetizer that is great to throw together before a party. I take feta cheese and blend olive oil in with it until it is very creamy. Then I add a generous amount of dried basil or dried oregano or dried rosemary. You serve this on toasted slices of French baguettes that are sliced thin and put in the oven with a little bit of olive oil until they are toasty. Then pull those out and serve the feta cheese on that. Another option if you don’t want to use bread is to use sliced cucumbers or celery sticks and serve it like the old-fashioned celery-stuffed pimento cheese sticks but using feta cheese mixture Feta Cheese Tasting Appetizer instead.

Let me give you a short course on feta cheese. Feta cheese was originally developed in Greece and it uses predominantly sheep’s milk but now they can blend in up to 30% goat’s milk in the Greek feta cheese. It is generally salty and tangy and crumbles easily. Feta means “to slice” so they make it in bigger pieces and slice it up. Other countries have their version of feta cheese. The Greeks would say that feta cheese only comes from Greece. In Bulgaria they make a white cheese that is called Bulgarian feta. It comes from mostly sheep’s milk and it is a creamy, less salty-tasting feta. The French have their own version of feta cheese as well and it is again mostly sheep’s milk and it is also less tart than Greek feta. American-based feta cheese like you would buy in most of the supermarkets is mainly made from cow’s milk and it is not quite as tart as the Greek or When your medical office is short-staffed, Bulgarian feta cheese. You can usually find these different you get frustrated. cheeses in Mediterranean specialty shops. The Bulgarian When you get frustrated, usually comes in a tin and the French is usually in a tin as you dread going to work well. The best way to keep any type of feta cheese is to and you start playing hooky. keep it in a brine. After you open it, you put it in a plastic When you start playing hooky, container and have another container in which you have the bills pile up. mixed salt with cold water until it no longer dissolves.

When the bills pile up, Pour the brine mixture over the feta cheese to completely Mama ain’t happy. submerge it and that keeps it from drying out. If you don’t do this, feta cheese dries out and becomes more dry When Mama ain’t happy, and crumbly. You can keep it this way for several months. ain’t nobody happy.

We typically buy a big chunk of the feta cheese at Sam’s and it is an American feta cheese. We put it in a big plastic container and eat off of it on a regular basis.

We recently had a dinner party and I did a feta cheese tasting. I had the French feta cheese, the Bulgarian feta cheese, and the Greek feta cheese. I mixed it up just like I described earlier and we had a taste test from eight couples. The winner was the Greek feta. Anyway, try some feta cheese for your next appetizer. You can throw in finely chopped sun-dried tomatoes. You can throw in some olives as well. I think the key though is making it When your office is short-staffed, creamy by adding the olive oil to make it very smooth. use the MSMA Online Job Bank!

You can have your own taste test at your next dinner party.

Until next month’s column, “good eating.”

Learn more:

KEEP MAMA HAPPY.

www.MSMAonlinejobs.com

412 JOURNAL MSMA DECEMBER 2012

• Editorial •

The Magic Kingdom

“O

Reed B Hogan, II, MD

h daddy,” she sighed, a shallow whispered voice, as her weak carotid pulse disappeared and her rhythm vanished to the flat line of electrical inactivity.

The eldest of my four children, Marley, 30-years-old, is full of life: active, artsy, and a great mother to three of my eight grandchildren. Since high school, her mid-teens, she experienced intermittent episodes of palpitations, feeling faint at unexpected times, chest discomfort without a cause, and a situational anxiety precipitated by the anticipation of recurrence. A colleague describes as “squirrelly girly” symptoms that young women have at the most random times. Being the typical “doctor dad,” I too was convinced that the “squirrelly girly syndrome” was rampant not only in my home but throughout society with increasing pressures both socially and situational on our young female citizens.

Shortly after the birth of her second child, after a brief stroll with her newborn, she once again proclaimed, “I’m having it again.” Questioned, she described palpitations and near-syncopal symptoms. After assuring her this was the result of childbirth, being out of shape and trying to exercise, I thankfully paused to check her pulse, which was about 180, thready and barely palpable.

After attempts to break what I assumed was a supraventricular tachycardia with carotid massage, ice water, and valsalva, a rapid trip to the ER ensued. Unfortunately, as the leads were attached to her chest, she proclaimed, “It’s gone,” and indeed, she was back in normal sinus rhythm.

A cardiac workup ensued, negative, and eventually she was diagnosed with Graves disease. After ablation of her thyroid and normalizing her endocrine status, the next year or so passed with only minor episodes of palpitations, rarely enough to make her stop or alter activities.

Three years after the first ER visit, we enter the Magic Kingdom. This 30-year-old child of mine loves the world created by Walt Disney and would gladly vacation in Orlando on a monthly basis if finances and the daily grind of life allowed. Christmas season in Disney is likewise magical to me, especially when accompanied by my growing brood of children and grandchildren.

We had just finished a very late meal in the classic Disney venue, The Liberty Tree Restaurant. I had just escorted my grandbabies outside when suddenly I heard the call for help back at our table. Lethargic and laid out on a bench, my daughter was weakly arousable, diaphoretic, and with an almost undetectable pulse. Recognizing the probable SVT, my oldest son, a 3rd year Baylor medical resident and I began the usual attempts to break the attack: carotid massage, hard valsalva, and even throwing ice water on her face as we became increasingly worried about her apparent severe hypotension and increasing chest pain. We feared an impending medical disaster.

Arrival of an efficient and well-trained group of paramedics immediately revealed a heart rate of 220, profound hypotension, and an EKG revealing supraventricular tachycardia. After gaining IV access and rapidly repeating attempts to break the tachycardia, the situation only worsened. Sensing a rapid deterioration in her status, adenosine was called for and pushed with prayers for rapid conversion. I warned her she might feel some discomfort or unusual symptoms as the ACLS instructors have warned me in the past, even though I had never seen it administered in my 25 years of practice.

“Oh daddy” she sighed as her weak carotid pulse disappeared and her EKG went to the flat line of electrical inactivity. The flatline was prolonged, but within several seconds the sinus rhythm returned as did the blood pressure, cognitive functions, and my own breathing. On questioning later about the “feeling,” she replied, “I thought I was dying.”

She was loaded on a gurney, rolled across Disney Boulevard, with the Christmas parade halted by a small army of mouseketeers, roping off a small corridor to pass through to a hidden entry down to underground Disney World. She looked up to the seven dwarfs on a Christmas float waving her on, a very strange medical send-off. From an extensive underground network of support services, an ambulance awaited to transport to the local emergency department.

The miracles of medicine: since graduating 30 years ago, they never cease. The myriad of resources with diagnostic tools and medications at our disposal have me in awe. Adenosine, briefly stopping the SVT allowing the normal rhythm to resume, is amazing! Even more impressive is the current crop of cardiologists like my daughter’s physicians, Drs. Chris Waterer and Judson Coley the electrophysiologist, who can identify and obliterate the accessory nerve pathway that leads to AV nodal reentry tachycardia. These talented physicians are working on minute pathways that were almost imaginary when taught to us 30 years ago.

Now they are mapable, treatable, and shown to me on a smart phone at the end of the procedure, frequently curing one of the most common arrhythmias in young women!

I’ll always be a “doctor daddy” or “granddad,” but now one much more attentive to the “squirrely girly” symptoms so commonly encountered in many of our practices. Vague, harmless sounding symptoms suggestive of anything but a life threatening rhythm disorder; I am refocused, attentive, and forever grateful for the many miracles of modern medicine. Modern Medicine-my magic kingdom. r

DECEMBER 2012 JOURNAL MSMA 413

• Poetry in Medicine • [[This month, we print a poem by John D. McEachin, MD, a Meridian pediatrician and JMSMA’s unofficial poet laureate.

This poem, written a couple of years ago, is a reflection on Cat scratch disease (CSD). McEachin reflects: “As in all phases of medicine, if you don’t think of it, you’re not going to make the diagnosis! This is a condition that is common. Statistics reveal that as much money is spent on ‘hospital’ studies for Cat scratch disease today as was spent 30 years ago when much less information was available. It is a fascinating illness that usually resolves on its own, even though multiple antimicrobial approaches are given anecdotal credit for cures. A caveat: In severely ill patients with systemic inflammatory symptoms, antimicrobials as well as corticosteroids may be advisable.” McEachin adds a personal note: “I have on two occasions been called in consultation by local Ophthalmologists to see febrile children presenting with visual loss due to neuroretinitis. (They both had CSD! In one of these children a sibling had incurred CSD at a younger age.) Each of these new cases, in addition to optic neuritis, had a classic subacute ‘Phoenix’ skin papule-at site of original scratch, regional lymphadenitis, and low-grade fever.” The physician-poet concludes: “My personal experience with CSD in Memphis and in Meridian taught me to respect it as the etiology of a multitude of complications that the medical literature has ‘yet to learn.’…By the way you don’t have to be scratched by the kitten. You can likely just be intimately touched, or perhaps licked! In fact, I jokingly referred to CDS as CTD (Cat touch disease) on occasion!” For more of Dr. McEachin’s poetry, see past JMSMAs and look for more in coming months.

Any physician is invited to submit poems for publication in the journal, attention: Dr. Lampton or email me at lukelampton@ cableone.net.] —Lucius Lampton, MD, Editor

CSD You Docs do indeed have egos; You despise writing “FUO” When that’s the case, you then must think, “What to ponder, what else to know??”

If the Physical gives no clue, And all routine lab is “no help,” A Bartonella henselae--IFA is a first class step!

When you’ve exhausted all the lab You ever hoped to consider, Bring to mind a common villain--Could make you a big league hitter!

Info for CSD curious: Yes! Protean presentations!

Get details in ID “Red Book” For all the manifestations.

Go back to visit that History!

Did you ask about a kitten, One that is less than two years old, Was the patient scratched, not bitten?

A final brief word to the wise, Since there is little left to say, “Febrile illness and a kitten, Think Bartonella henselae!”

Typically, Cat scratch disease Presents with “old” scratch, and a node.

But often we don’t get this help; We shift gears to a different mode!

(FUO for ten days or more In a child in a Southern state, CSD is high on the list; I assure you, without debate!)

414 JOURNAL MSMA DECEMBER 2012

—John D. McEachin, MD Meridian

• Images in Mississippi Medicine • Main Street And Hospital, Booneville: Home of the “Mississippi Doctor” and State’s First Hill-Burton Hospital—

B

ooneville, located in Prentiss County in northeast Mississippi, is a special community for your Journal because of its connection to our predecessor, the “Mississippi Doctor,” long (1926-1959) the official publication/ journal of the MSMA. Booneville physician, Dr. William Henry “Wick” Anderson, who served our association as president in 1940-41, founded and edited the “Mississippi Doctor,” printing and publishing it in his hometown. In addition, Dr. Anderson was on the medical staff of Booneville’s Northeast Mississippi Hospital from 1918-1969, long serving on its board of directors. This hospital would become the first Hill-Burton Hospital in the state of Mississippi, largely through the work of Anderson. These two photos show the bustling town’s main street as well as its hospital around 1920. Named for early settler Col. Reuben Boone (a relative to Daniel, yes), Booneville was birthed as a stop on the Mobile and Ohio Railroad, finished in 1858. The village was located on the highest point on the line, and legend contends that the Chickasaws had earlier utilized the site as a refuge from storms because of its protection from the Tippah Hills. The town was the site of much fighting during the Civil War during the campaigns for Corinth and Shiloh. Booneville’s current hospital, Baptist Memorial, is a general medical and surgical hospital with 99 beds. Survey data for the latest year available shows that 14,138 patients visited the hospital’s emergency room. The hospital had a total of 1,482 admissions. Baptist Memorial Hospital Booneville joined Baptist Memorial Health Care in 1982. It established, in conjunction with the Baptist Memorial Health Care Foundation, an endowment fund to help recruit and educate physicians. If you have a photograph or image related to Mississippi medicine which would be of interest to your fellow physicians, please send as a high resolution jpg file to Dr. Lampton at lukelampton@cableone.net or contact the Journal]. — Lucius Lampton, MD, Editor DECEMBER 2012 JOURNAL MSMA 415

• MSDH • Mississippi Reportable Disease Statistics

October 2012 Figures for the current month are provisional

Totals include reports from the Department of Corrections and those not reported from a specific District. For the most current MMR figures, visit the Mississippi State Department of Health website: www.HealthyMS.com.

DECEMBER 2012 JOURNAL MSMA 416

• MSDH •

This Month in the Mississippi Morbidity Report Volume 28, Number 5; November 2012 School Immunization Requirements, 2012-2013 School Year Introduction: The list of immunizations required for school entry and child care entry is specified by the State Health Officer and is promulgated at least annually as directed by state statute (§ 41-23-37, Mississippi Code of 1972). All vaccines are to be given at the appropriate age and intervals according to the Advisory Committee on Immunization Practices (ACIP) recommendations.

The following report discusses pertussis activity and the new Tdap requirement for the 7th grade entry, outlines the Mississippi State Department of Health (MSDH) Medical Exemption Policy for vaccine exemptions, and provides a weblink for the school entry and child care entry immunization requirements for the 2012-2013 school year.

Increased Pertussis Activity in the US and Tdap Requirement: The number of reported cases of pertussis, both in the US and Mississippi, has been increasing over the last several years. In 2011 there were over 18,000 cases with 13 deaths reported in the US; 11 of the deaths were in infants <1 year of age. 2012 has been a very active year for pertussis in the US so far, with more than 35,000 cases and at least 16 pertussis related deaths reported through the week ending November 10; 14 of the deaths are in children <1 year of age. Additionally, there have been a number of pertussis outbreaks in the US in 2012, primarily in Washington, Minnesota, Wisconsin and Colorado. In these outbreaks children in early adolescence (10-14 years of age) consistently account for the highest number of cases. In the Wisconsin outbreak, children 11-12 years of age who had not received Tdap were significantly more likely to have pertussis infection than those 11-12 year olds who had received Tdap. In Mississippi, there were 49 reported cases of pertussis with no deaths in 2011. As of November 20, 2012, there are 69 reported cases and one pertussis-related death in a child <1 year of age in Mississippi.

Pertussis immunity typically wanes 5-10 years after the childhood booster vaccination leaving adolescents vulnerable to infection. Adolescents can then serve as a source of infection in children <1 year of age who have not yet been completely vaccinated against pertussis. Infants are typically at the greatest risk for severe disease and death from pertussis infections. In 2005 the ACIP first recommended Tdap for all adolescents aged 11-18 years. The ACIP also recommends vaccination against meningococcal disease and human papillomavirus (HPV) for children in this age group. Since 2006, the Centers for Disease Control and Prevention has conducted the National Immunization Survey—Teen (NIS-Teen) in order to estimate vaccine coverage for Tdap, meningococcal and human papillomavirus (HPV) in adolescents aged 13-17 years. In the most recent NIS-Teen survey for 2011 the vaccine rate for Tdap among Mississippi adolescents was about 37%. While this rate has increased from the 2010 rate of 29%, it still lags behind the US rate of 78% and is the lowest in the US. Mississippi also has some of the lowest rates in the US for meningococcal and HPV vaccination. The full NIS-Teen survey is available on the National Immunization Survey CDC website at http://www.cdc.gov/vaccines/stats-surv/nis/nis-2011-released.htm#nisteen Tdap Requirement: For the 2012-2013 school year, Mississippi joined 41 other states in instituting a requirement for Tdap among adolescents. All students entering 7th grade are required to have documentation verifying Tdap vaccination at seven years of age or older. This includes new, current and transfer students in both private and public schools. The new requirement should reduce the disease burden among adolescents and protect those children <1 year of age, as well as provide an opportunity to emphasize the need for other adolescent vaccinations.

Medical Exemption Policy: In order to enroll in any public or private kindergarten, elementary or secondary school in Mississippi, a student must provide the school with a Certificate of Immunization Compliance (Form 121) or a Certificate of Medical Exemption (Form 122). The child’s pediatrician, family physician or an internist, who must be duly licensed in the state of Mississippi, may submit a letter requesting the medical exemption for their patient to the local public health District Health Officer.

The exemption will be granted unless there is a local or statewide occurrence of disease which would indicate that the exemption will cause “undue risk to the community.” The exemption expiration date will be based on the circumstances for the exemption and will be for a minimum of one school year. The full policy can be accessed at: http://msdh.ms.gov/msdhsite/_static/41,9332,71,303. html Child Care and School Entry Immunization Requirements: The child care immunization requirements and the school entry immunization requirements for Mississippi are available on the MSDH website at: http://msdh.ms.gov/msdhsite/_ static/41,0,71,303.html The full November 2012 Mississippi Morbidity Report is available online at: http://msdh.ms.gov/msdhsite/_static/resources/5124.pdf .

417 JOURNAL MSMA DECEMBER 2012

• Office of Mississippi Physician Workforce • Physician Workforce Office Helps Fund Residency Program to Address Doctor Shortage

A

budding venture to put more physicians to work in Mississippi has scored its first triumph with the potential of a new family medicine residency program, only the third of its kind in the state.

Dr. Diane Beebe, interim director of the newly-formed Office of Mississippi Physician Workforce, announced that Forrest General Hospital in Hattiesburg has submitted documents for accreditation of a family medicine residency to the Accreditation Council for Graduate Medical Education that oversees all residency training.

“This shows that the Office of Mississippi Physician Workforce is up and running and on the move,” said Beebe, professor and chair of family medicine at the University of Mississippi Medical Center (UMMC), where the workforce initiative is housed.

Beebe also announced that a search is on for a permanent director of the Office of Mississippi Physician Workforce, which was launched in April to reverse Mississippi’s standing as the state with lowest per-capita supply of primary care physicians, including family physicians, general internists, pediatricians and obstetrician-gynecologists.

“By legislation, the director must be a physician,” Beebe said. “We are starting a national search and a state-wide campaign to seek qualified applicants who might be interested in this permanent, paid position.”

The new director will head an initiative funded by state lawmakers and led by a 21-member advisory board chaired

by Dr. John Mitchell, a family physician from Tupelo; the board will help determine where in Mississippi physicians are needed most.

A major mission of the workforce is to support and help fund new family medicine residency programs similar to Forrest General’s.

“We want to be able to place family medicine training programs in at least one or two other places in the state over the next five years,” Beebe said. “Forrest General has been working on its program a couple of years, but the funding has been an issue.

“It takes several million dollars to start a program.

The workforce provided an initial outlay of money for the hospital to get it on its way. Obviously, we have to wait for accreditation, but I definitely believe it will happen.”

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418 JOURNAL MSMA DECEMBER 2012

• OPW • Forrest General’s goal is to begin training up to six family medicine residents a year by July 2014. For now, only UMMC and North Mississippi Medical Center in Tupelo have such a program.

In order to help create others, as well as to assess and monitor the physician workforce needs of the state, the Physician Workforce office will seek more, and expanded, funding each year from the legislature, Beebe said.

The Mississippi Academy of Family Physicians first championed the Physician Workforce initiative; the Mississippi State Medical Association and UMMC supported its creation in a bill sponsored by State Rep. Sam Mims, R-McComb.

On signing the legislation in April, Gov. Phil Bryant alluded to Mississippi’s need to add an extra 1,000 physicians to its workforce by 2025.

“Expanding our state’s medical residency programs will directly increase the number of physicians who remain in Mississippi to practice… . and more doctors means better health care for our citizens,” Bryant said.

Blake Wilson, a member of the workforce’s executive committee, said its efforts will be critical in addressing the physician shortage.

“You prove it works, with programs such as the one at Forrest General, and then you hope for more funding,” said Wilson, president and CEO of the Mississippi Economic Council. “We believe Forrest General will be a model.”

For more information, visit the workforce’s website, http:// www.umc.edu/opw.

PHYSICIANS NEEDED Generalist, Family Practitioner, Internist

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All administrative needs including scheduling, transcription, assisting and billing are provided. Physicians working for us have various background and training including, IM, FP, pain mgt, surgery, orthopedics, neurosurgery, cardiology and general practice. There is minimal risk and stress involved with this position. You will have time to enjoy your life and not be stressed out. Contact

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John Mitchell, MD

Shown here presenting a Mississippi Rural Physicians scholarship check to Stephanie Caldwell, Gov. Phil Bryant expressed the need for Mississippi to add 1,000 physicians to its workforce by the year 2025. As one of the most medically under served states in the country, Mississippi has the lowest per-capita primary care physician supply in the nation. Figures estimate the state has 8.3 doctors per 10,000 residents, compared to the national average of 12.8 physicians per 10,000 residents. Mississippi must add 1,330 primary care physicians to its workforce to raise its per-capita doctor count to the national average. Studies show new doctors generate about $2 million in economic impact in their communities, and more doctors means better health care. The Office of Mississippi Physician Workforce, with its 21-member advisory board, will oversee physician workforce development needs by: •Supporting the creation of accredited family medicine residency programs in the state, including the awarding the state financial support for creation of these programs; •Encouraging the development of an adequate and geographically distributed physician workforce in all specialties with an evolving strategic plan; •Assessing the current numbers, ages, types of practice, hospital affiliations and geographic distribution of physicians in each medical society in Mississippi; •Assessing the current and future physician workforce needs of Mississippi. r

DECEMBER 2012 JOURNAL MSMA 419

MSMA ALLIANCE

Happy Holidays!

A wish for health and happiness in the coming year is being sent to you by members of the Mississippi State Medical Association Alliance Contributions by the following have been made to the MSMAA Scholarship Fund designated to benefit medical students at the University of Mississippi School of Medicine.â&#x20AC;Šâ&#x20AC;Š Marsha Avara Amy Gammel Shoba Gaymes Jean Hill Danita Horne

Ann Blair Huffman Nancy Leader Nancy Lindstrom Karen Morris Sondra Pinson

420 JOURNAL MSMA DECEMBER 2012

Mollie Pontius Susan Rish Nancy Smith Donna Witty Heather Wood

• Una Voce •

A Long Ago Christmas Howard Kavanaugh MS

R. Scott Anderson, MD

Editorial note: This is a story I was sent by an old friend, a retired medical physicist from Louisiana named Howard Kavanaugh. I adjusted a thing or two, but this is a wonderful tale that, with only minor adjustments, is Howard’s story. I hope you like it. —sa

“It was the best of times—it was the worst of times.”

I

t was the autumn of 1939 and while the rest of the nation was finally beginning to recover, the rural South was still mired in the depths of the Great Depression. Up to then I’d been a city boy, but that year my family returned home to rural Louisiana, and it was here I started school.

The school was a large wooden building painted a dark shade of red, the only one in town. The upper and the lower grades were all in there together. This was not the city. I remember watching my new schoolmates get off of the dilapidated yellow school bus that hauled them in from the farms. Skinny kids wearing bib overalls, the knees torn out and ragged at the bottom from dragging the ground around bare feet. Feet that I remembered stayed bare all winter, even when there was ice on the ground. At recess the boys played with Coke bottles pushing them along grooves they’d scraped in the dry earth of the playground, pretending they were cars, the girls carried the same bottles in their arms talking to them, pretending they were dolls. When recess ended, the bottles were left scattered on the ground and what may have been a cattle truck today hauling a new bull would be a baby named Jamie Lynn tomorrow.

It was the high school girls that turned me into a celebrity of sorts. They’d gather around me and say, “Howard, let’s see how wide you can get your mouth open.” It seemed like a strange request, but I was new here and they were a lot older, so I did as they asked. It wasn’t until I heard one of them whisper, “Look, I told you he had metal in his teeth,” that I realized that even the older girls didn’t have any idea of what fillings were. Such is the state of dental care in a town without a dentist.

Within two weeks, every person in our little village of twelve hundred souls knew who I was. The fillings weren’t the only thing that set me apart. I was the newly returned grandson of the only doctor around and was soon addressed as Lil’ Doc by one and all. A country doctor was everything to the people of that little town. It set them apart, it made them special. Folks from all around the parish came to get taken care of, and when they did, they did whatever business they could while they were there.

The barter system was very much alive, and in times of no money was the only way to get paid. People brought vegetables, fresh fish, or bushel baskets of crabs to the house to settle their bills. Office visits were two dollars and a house call was three. My grandfather never sent a bill, trusting folks to know what they owed. Because cars were few and far between, house calls were made every afternoon. Since they were after school, I was allowed to ride along, which quickly became the highlight of my day.

At one point my grandfather agreed to set up a free clinic in a small fishing encampment if they would furnish him with a building for an office. This turned out to be a log cabin with a dirt floor, and no heat, water, or electricity.

This started a new adventure for me as I became an active part of the “doctoring business.” It was up to me to bring clean sheets, two glass jugs of fresh well water (there wasn’t any plastic back then), and enough oil for the lamps and stove. As soon as we arrived, I’d fire up the stove and put water on to boil, to sterilize the instruments. When I wasn’t busy “doctoring,” I’d wander down the streets of the fish camp whose residents were all LaCombe Indians. There was a little shed where they had woven baskets and leather goods they’d made by hand out on display for sale. I didn’t have any money to buy anything, so

DECEMBER 2012 JOURNAL MSMA 421

mostly I just stood there in the yard, looking, at one thing and then another. The occupants would sit there in the shed and look back. We never spoke. We would just watch each other. After a while I would wave goodbye to the Chief, who owned the place, and he would raise his hand and nod in return. I was sure that this was a secret Indian ritual that only he and I completely understood.

Back at home, life was ruled by the telephone. The line had to be kept open for calls to the house. The phone was a large wooden box that hung on the wall, with two large bells on the top. That old phone would make you jump right out of your skin when it rang, it was so loud. You didn’t have to worry about missing a call; you could hear it anywhere in the house, in the yard, or pretty much half way down the street.

To make a call you had to turn the crank and wait for the operator. Our phone number was 67, but nobody knew that.

They just told the operator that they needed to get up with the doctor. She knew where to ring them. If the phone rang at two or three in the morning, I knew it meant my grandfather was going somewhere. Rain or cold he got up got dressed and went. I always wondered why he never told them to wait until morning came, but he never did.

Saturday nights were always busy. I always wondered how folks with no money always came up with enough to get drunk and then get into fights, but bar fights were a regular part of every weekend. They’d come by the house bleeding or throwing up, sometimes both. After they’d leave it was up to my grandmother and me to clean the floor, as Tabby, my grandfather’s housekeeper, would be off by then.

I knew Tabby wasn’t just the housekeeper, my grandmother told me all the time. She was something special. Tabby had to be the best cook in the whole parish, probably even the best cook in the whole state of Louisiana. My dad and uncle liked to tease her. She was strong in her religion, and as they had for years, they knew that they could rile her by starting a discussion on the subject of religion. One night they made the argument that there was no such place as hell, so they might as well act however they wanted, as it wasn’t going to matter anyway.

Once she’d had enough of their foolishness, she’d appeal to my grandfather to settle the argument. “Doctor Van Zant, ain’t there a hell?”

My grandfather looked up from what he was reading and replied, “Yes Tabby, there is. I know because I see a little of it every day.” That was medicine then, it hasn’t changed.

The Christmas Eve I remember most from that period, as most of them I remember, involved a house call. We drove ten miles out of town on the paved road, then turned onto a bumpy dirt road that ended at the woods edge. An old man sat on a horse drawn wagon just inside the shelter of the trees, trying to get a little break from the wind that was blowing strong and cold from the north. He greeted us and we climbed aboard and made our way through the woods until we arrived at a rough timber cabin. We stayed for a while, we didn’t get out any instruments, and when • Comprehensive Management we left, all we left behind were some pills. On the drive back, my • Comprehensive Consulting grandfather looked at me and said, “Did you see how that old man • Billing & Accounts Receivable Management looked?”

• Coding & Documentation I nodded.

• Practice Assessments & Revenue Enhancement “He’s dying, he probably won’t make it through Christmas • Profitability Improvement Day,” he said.

• Practice Start-ups “Then why didn’t you do something to save him?” I asked • Personnel Management naively.

“Things just don’t work that way sometimes. The pills we left will ease his passage.”

There were no miracle drugs then.

I woke the next morning to the smell of pine wood burning in a cast iron stove and Tabby’s high-pitched voice calling us all down for hot biscuits before church. It was a good Christmas for the parish. The telephone didn’t ring one time all day.

1600 North State Street Suite 400 It was the 1930’s and times were hard, but for a 7-year-old Jackson, MS 39202 boy growing up in Louisiana, it was truly, “the best of times.”

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422 JOURNAL MSMA DECEMBER 2012

• Index • Volume LIII

January - December 2012

Subject Index

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

401(k) Changes Will Help

Physicians Better Understand

Their Practice Retirement

Plans [L Fortenberry], 305-S

-A-

Abstracts from Research Day

Sponsored by the American

College of Physicians for the

University of Mississippi

Medical Center Department

of Medicine (D Pepper, C

Thigpen et al) 356* A Mean Spleen: Splenic

Sequestration Crisis in a

53-Year-Old with Sickle Cell

Disease [K Wilkinson, C

Thigpen, F Criddle, J Lam],

366* A Mitral Mystery: Disparate

Response to R-CHOP of

Diffuse Large B-cell

Lymphoma Lesions in a

Patient with AIDS

[K Bridges, J Hamilton,

Thigpen, K Bennett,

C Bigelow], 357 Acute CVA in the Setting of Graves’

Thyrotoxicosis and

Moyamoya: A Rare

Combination [J Bennett, S

French, S Ahmad], 369 Adding Fuel to the Fire: A Case of

Severe Hypercalcemia in

the Setting of Extrapulmonary

Sarcoidoisis [A Green, R

Chick, E Reiners, V Majithia],

367*

Brainstorm: A Case Report of Anti N-Methyl-D-Aspartate

Receptor Antibody

Encephalitis [D Ballard, G

Abraham], 363* Confusion Abounds: Posterior

Reversible Encephalopathy

Syndrome in the Setting of

Inflammatory Breast Cancer

[K Waespe, C Thigpen, D

Hamilton, R Vance], 365* Cutting to the Chase: An Unusual

Complication of Cocaine Use

[A McCann, D Pepper, L

Atchley, J Bell], 362* Don’t Play With Mismatches:

Acute Hemolytic Reaction

During Allogeneic Stem

Cell Infusion for High Risk

Myelodysplastic Syndrome

[C Thigpen, K Bridges, S

Elkins], 364* Double Trouble: Paraneoplastic

Hypercalcemia Hyperleukocytosis Syndrome

in Cutaneous Squamous Cell

Carcinoma [C Carter, C

Thigpen, K Harkins], 358* Flail Chest: New Treatment for a

Paradoxical Problem [J

Bennett, B Dalal], 368* Getting to the GIST of the

Gastrointestinal Bleed [S

Boyd, S Tanner, N Ahmad, S

Daram, J Sheehan], 357* Hemolytic Havoc: HELLP,

DIC, and TTP in a Patient

with Intrauterine Fetal

Demise [J Graham, C Thigpen, Z Henson, C

Bigelow], 361*

Inflammation Gone Awry:

Pyoderma Gangrenosum in

Newly Diagnosed Crohn’s

Disease [E Reiners, Z

Henson], 363* Normal Alkaline Phosphatase in

Active Paget’s Disease of

Bone [S French, J Subauste],

361* Now You See It, Now You Don’t:

Evans Syndrome in a Patient

Suspected To Have

Lymphoma [B Tullos, S

Gaugler, C Thigpen, Z

Henson, V. E. Herrin], 365* Transarterial Chemoembolization

(TACE) Associated

Pancreatitis and Gastric

Ulceration [K Gharaibeh, S

Daram, K Ball, R Garretson],

367 * An Interview with Charles D.

“Buddy” Daughdrill,

Executive Director of

the Missisisppi Public Health

Association [R deShazo],

278-S* An Interview with Steven L.

Demetropoulos, MD, 2012 2013 MSMA President [K

Evers], 154-S* Asclepiad Benjamin Macklin Carmichael,

MD [L Lampton, K Evers],

280 Harry C. Frye [L Lampton], 64 Helen B. Barnes, MD [L Lampton],

352 Hugh Agnew Gamble, II [K Evers],

392

DECEMBER 2012 JOURNAL MSMA 423

John Murrell McRae, II [K Evers],

316 Kelly Scott Segars, Sr., MD [L

Lampton], 171 Leonard (Len) Brandon, MD, and

son, Steven Brandon, MD [M

Pomphrey], 100 Ralph Lucius Brock [L Lampton],

136 William A. “Bill” Middleton, MD

[L Lampton], 32 William F. Pontius, MD [L

Lampton], 244

-C-

Clinical Problem-Solving [presented and edited by the Dept. of Family Medicine, UMMC] A Common, but Unexpected,

Suspect [A Morgan], 260-

CPS Allergy Confusion [R Rose-

Hand], 396-CPS Chasing Zebras [A Pullen], 12-

CPS Just a Simple Cerebral Vascular

Accident? [T Phan], 111-CPS Too Old for this Joint! [C Latorre],

222-CPS Cover Autumn Landscape [M Pomphrey,

Jr.], October Daylily [B Tisdale], August “Dunn’s Falls, located in

Enterprise, Lauderdale Co.,

MS” [J Jackson], September Garden Girl [M Pomphrey, Jr.],

June Hummingbird in Nest [W Locke],

March Presidential Portrait of Steven L.

Demetropoulos, MD, May “Pretty in Pink” [C Stroud], April “Sea Treasures from the Viewbox”

[W Pontius], February Spotting an Owl [M Wallace],

December Summer Rainbow [R Cannon],

July Underpass Cathedral [S Hartness],

November Yockanookany Sepia [S Hartness],

January

Current Use of Intrapleural Tissue

Plasminogen Activator in

the Treatment of Complex

Pleural Processes: A Review

of the Literature and Report

of 9 Cases [C Dulaney, W

Merrill, S Tesseneer, L

Jenkins-Lonidier, C Tribble],

216*

-D-

Dietary Recommendations in

Ambulatory Care: Evaluation

of the Southern Remedy

Healthy Eating Plate [A

Smith, D Minor, L Tillman, R

deShazo, W Replogle], 330* Do the Supreme Court Elections

Really Matter? [R Jones],

302-S Does One Medical School’s

Admission Policy Help a

Rural State “Grow Their

Own” Physicians? [P Mason,

J Cossman], 284*

-E-

Editorials A Look into Preconceived Ideas [E

Browning], 123-E An Interview with Dr. Randy

Easterling, President,

Mississippi State Board of

Medical Licensure [R

deShazo], 378-E And a Good Time was Had by All

[S Hartness], 343-E Bold Changes to the Norm [P

Merideth], 118-E Editor Interview: A Visit with

Dr. Fred L. McMillan,

President of Mississippi

Physicians Care Network [R

deShazo], 80-E Electronic Medical Records and

the End of Value: Physicians,

Nurses, and Scribes [C

Feind], 84-E Epicuritorial - New Feature/Old

Favorite [S Hartness], 20-E Focusing on Professionalism [R

Didlake, P Smith], 54-E Mirror, Mirror [S Hartness], 115-E

424 JOURNAL MSMA DECEMBER 2012

My View from Second Year:

Reflections of a Mississippi

Medical Student [E Brandon],

272-E Raising the Bar, but Failing

to Meet the Goal: A Young

Physician Reflects on Match

Day and Mississippi’s

Primary Care Workforce [B

Smith], 270-E The Catastrophe of Unwed

Motherhood and Teenage

Pregnancy: A Physician’s

Call to Action [H Matthias],

81-E The Magic Kingdom [R Hogan,

II], 413-E EXIT Procedure: A Report of the

First Three Mississippi Cases

[J Brewer, K Liechty, J

Bofill], 104*

-F-

From the Editor [L Lampton], 2,

34, 66, 102, 138, 169, 214,

246, 282, 318, 354, 394

-G-

G. H. Tichenor, MD, and His

Antiseptic Solution: The

Mississippi Years - Part 1 of

2 [M Trotter], 88-S G. H. Tichenor, MD, and His

Antiseptic Solution: The

“Dr.” in Dr. Tichenor - Part 2

of 2 [M Trotter], 127-S

-I-

Images in Mississippi Medicine Booneville Hospital [L Lampton],

415-I Instructions for Authors, 28, 93,

211, 311

-J-

Just Off the Press - Info You Want to Know Aspirin for Primary Prevention [R

deShazo], 73

Bacterial Rhinosinusitis Guidelines

[J McKee, R Ogletree, Jr.],

161 Clopidogrel with Proton Pump

Inhibitors [H Gwin, R

Ogletree, Jr.], 274 Control in Patients with Type 2

Diabetes Mellitus [L

Cadwallader, R Ogletree, Jr.],

109 Don’t Forget the Stethoscopes [R

Ogletree, Jr.], 235 Probiotics– Are They Beneficial? [L

Cadwallader, R Ogletree, Jr.],

295 Prophylaxis Against Post-Stroke

Depression [E Lukienko, R

Ogletree, Jr.], 344

-L-

Letters EHR May Not Be the Oppressor:

Response to EMR End of

Value Editorial [C Cannon

Jr.], 152-L Light at the Tunnel’s End: Response

to EMR End of Value

Editorial [T Wiley], 126-L Physicians Should See Their Own

Consults on the First Visit [W

Jones], 87-L

-M-

Message from MSMA President

Steve Demetropoulos, MD Annual Session [S

Demetropoulos], 384-S Mississippi Medicine Up-to-date Mississippi Medicine Up-to-Date:

Lyme Disease-like Illnesses

in the South [J Goddard, A

Varela-Stokes, R Finley], 68* MRPSP Scholars– Embracing the

Vision for a Healthier

Mississippi [K Evers], 299-S MSDH Reportable Disease Statistics &

Morbidity Report [Paul

Byers], 415 Mississippi Reportable Disease

Statistics - October 2011, 11 Mississippi Reportable Disease

Statistics - December 2011, 56

Mississippi Reportable Disease

Statistics - January 2012, 74 Mississippi Reportable Disease

Statistics - February 2012, 110 Mississippi Reportable Disease

Statistics - April 2012, 164 Mississippi Reportable Disease

Statistics - May 2012, 237 Mississippi Reportable Disease

Statistics - June 2012, 265 Mississippi Reportable Disease

Statistics - July 2012, 296 Mississippi Reportable Disease

Statistics - August 2012, 337 Mississippi Reportable Disease

Statistics - September 2012,

370 Mississippi Reportable Disease

Statistics -October 2012,

414 Mississippi Second in the Nation

to Implement Life-Saving

Cardiovascular Emergency

Response Plan, 75 MS Morbidity Report - June 2012,

266 MSMA In Celebration of Health Awareness

Day [K Evers], 51 MSMA Cosponsors First-Ever

Mississippi Rx Drug Summit

[K Evers], 267-S Notice of Proposed Changes to the

MSMA Constitution, 57 Report and Highlights of the 144th

Annual Session of the MSMA

House of Deleates and

Medical Affairs Forum 2012

[K Evers], 227 Report of the Council on

Constitution & Bylaws, 119

-N-

New Members, 19

Obituaries, 26

-O-

Office of Mississippi Physician

Workforce, 418 Outpatient Treatment of Adults with

Cystic Fibrosis by Primary

Care Physicians [N

Chaudary], 255*

-P-

Patterns of ENT Injuries in Sports Related Accidents [B Suggs,

R Cannon], 4* Personals, 21 Physician’s Bookshelf Dr. Dwalia South and the Literary

Terrains of Medicine. Una

Voce: A Collection, [Dwalia

South, MD, China Grove

Press, Magnolia, MS, 2011]

[reviewed by L Lampton],

132-PB More About Una Voce (The Book)

[S Anderson], 134-PB The Immortal Life of Henrietta

Lacks: Evolving Medical

Ethics in a Constantly

Changing World [Rebecca

Skloot, Crown Publishers,

2010] [reviewed by W

Sherman], 309-PB Poetry and Medicine Boatlike [W Lineaweaver],

308-PM Cat Scratch Fever [J McEachin],

414-PM President’s Page A Good Death [S. Demetropoulos],

373-PP And Down the Stretch They Come!

[T Joiner], 113-PP Inaugural Address [S

Demetropoulos], 225-PP Just What the Doctor Ordered [S

Demetropoulos], 263-PP Last Random Thoughts [T Joiner],

151-PP My Adventure Enrolling in the PMP

[T Joiner], 16-PP Resolve Towards a Healthier

Mississippi [T Joiner],

46-PP Tort Reform [S Demetropoulos],

297-PP When a Colleague Refers a Patient,

“Do the Right Thing” [T

Joiner], 77-PP Why Smoke-Free? [S

Demetropoulos], 334-PP You Have to Have Some Skin in the

Game [S Demetropoulos],

411-PP

DECEMBER 2012 JOURNAL MSMA 425

Prevalence and Trends in

Overweight and Obesity

among Mississippi Public

School Students, 2005-2011

[J Kolbo, L Zhang, E

Molaison, B Harbaugh, G

Hudson, M Armstrong, N

Werle], 140* Public School Parents’Perspectives

of the Mississippi Healthy

Students Act of 2007:

Findings from 2009-2011

[L Southward, K Ragsdale, C

McKee, A Buffington, D

Baggett, T Blanchard, J

Edwards], 247*

-R-

Revitalization of the University

of Mississippi Children’s

Heart Center: Report

Card from the First 18 Months

Experience [D DiBardino, W

Lancaster, W Merrill, M

Mitchell, E Taylor, C Gaymes,

M Ebeid, J Shores, E Christ,

M Taylor, M Sheth, R Jonas, J

Salazar], 405

-S-

Series: Concepts in End of Life Care

- Introduction - Death: An

Important Part of Life [R

Faught, S Gaugler, S

Douglas], 375* Simultaneous Liver Metastasectomy

at Operation for Primary

Colorectal or Gynecologic

Malignancy [J Corley, M

Corley, C Lahr, D McIntosh,

M Ridgway, N Ahmed], 36* Southern Remedy Healthy Living

Fitness Program [R deShazo],

171-S Subject/Author Index Volume 53,

423 Substance Use and Sexual Risk

Behaviors Among Mississippi

Public High School Students

[J McGuire, B Wang, L

Zhang], 323*

-T-

Tax Revenue in Mississippi

Communities Following

Implementation of Smoke free Ordinances: An

Examination of Tourism

and Economic Development

Tax Revenues [R McMillen, S

Shackelford], 319* They Come Alone or in Pairs:

Ta-Tas to Go, Breast Cancer

Survivor Creates Custom-Fit

Prosthesis [K Evers, 340-S] Top 10 Facts You Should Know About Depression [S Chandraiah],

147* About Diabetes [R Call, M Wofford,

D Riche], 175* About Endocrine Aspects in

Patients Infected with the

Human Immunodeficiency

Virus [N Ungnapatanin, J

Subauste, H Henderson, C

Koch], 347* About Headaches [R deShazo, A

Bond], 293* About How to Improve CPAP

Compliance for the Treatment

of Obstructive Sleep Apnea [S

Tamanna, I Ullah], 220* About Kidney Transplantation [F

Butt, A Seawright], 41* About Pit Viper Snakes and

Envenomation [B Tollefson,

K McKenzie, R. Galli], 9* About Secondary Causes of

Diabetes Mellitus [H East, J

Subauste, A Gandhi, C Koch],

380*

-U-

UMC SOM Literati Medicus- the M3/M4

Humanism in Medicine Book

Club at the University of

Mississippi School of

Medicine [M Porter, J

Graham, J Clark, S Douglas],

385

426 JOURNAL MSMA DECEMBER 2012

UMMC The University of Mississippi

Medical Center Division of

Multicultural Affairs [J Taylor,

M Westerfield], 238 Una Voce Hen Scratch [D South], 60-UV How to Be a Better Patient [D

South], 98-UV The Tattoos of Life [D South],

165-UV

Uncommon Thread A Long Ago Christmas [S

Anderson], 421 Anderson Family Driving School

(Under New Management) [S

Anderson], 239 Birthdays [S Anderson], 387 Doctors and Magic [S Anderson],

350 Stars [S Anderson], 313 Supralumenal Neutrinos and “The

God Particle” – A CERN

Update [S Anderson], 97 Welcome to 2012 [S Anderson],

30

Volume LIII

January - December 2012

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; the asterisk (*) indicates an original article in the Journal.

A

Abraham, George, 363 Ahmad, Shema R., 369 Ahmed, Naveed A., 36*, 357 Anderson, R. Scott, 30, 97, 134-PB,

239, 313, 350, 387, 421 Armstrong, Mary G., 140* Atchley, Lance, 362

B

Baggett, Dorris, 247* Ball, Kenneth, 367 Ballard, Dane, 363 Bell, Jericho, 362 Bennett, Janelle, 368, 369 Bennett, Kenneth, 357 Bigelow, Carolyn, 357, 361 Blanchard, Troy, 247* Bofill, James A., 104* Bond, Allyn, 293* Boyd, Stewart, 357 Brandon, Emily , 272-E Brewer, Justin, 104* Bridges, J. Kevin, 357, 364 Browning, Elliott, 123-E Buffington, Anne, 247* Butt, Fauzia K., 41*

C

Cadwallader, Lucy, 109, 295 Call, Rosemary J., 275* Cannon, C. Ron, 4*, July cover Cannon, Charles D., Jr., 152-L Carter, Cory, 358 Chandraiah, Shambhavi, 147* Chaudary, Nauman, 255* Chick, Rebecca, 367

Christ, Elizabeth, 405* Clark, Jerry, 385 Corley, J. Jarrett, 36* Corley, Mary Kinney, 36* Cossman, Jeralynn S., 284* Criddle, Frank J., 366 Dalal, Bavin, 368 Daram, Sumanth, 357, 367 Demetropoulos, Steven J., 225-PP,

263-PP, 297-PP, 334-PP,

373-PP, 384-S, 411-PP deShazo, Richard D., 73, 80-E,

171-S 278-S, 293*, 330*

378-E DiBardino, Daniel J., 400*, 405* Didlake, Ralph, 54-E Douglas, Sharon P., 375*, 385 Dulaney, Caleb R., 216*

E

East, Honey E., 380 Ebeid, Makram, 405* Edwards, John, 247* Elkins, Stephanie, 364 Evers, Karen A., 51, 154-S, 227,

267-S, 280, 299-S, 316,

340-S, 392-A, 401, 419, 420

F

Faught, Rachael W., 375* Feind, Carl R. (Kel), 84-E Finley, Richard, 68* Fortenberry, H. Larry, 305-S French, Sarah E., 361, 369

G

Galli, Robert, 9* Gandhi, Ayush, 380 Garretson, Roland, 367 Gaymes, Charles, 405* Gaugler, Sarah M., 365, 375* Gharaibeh, Kamel, 367 Goddard, Jerome, 68* Graham, Jacob, 361, 385 Green, Andrea, 367 Gwin, Hannah, 274

H

Hamilton, Darryl, 365 Hamilton, James, 357 Harbaugh, Bonnie L., 140* Harkins, Kimberly, 358 Hartness, D. Stanley, January cover,

20-E, 115-E, 343-E,

November cover Henderson, Harold M., 347* Henson, Zeb K., 361, 363, 365 Herrin, V.E., 365 Hogan, II, Reed B., 413*-E Hudson, Geoffrey M., 140*

J

Jackson, John F., September cover Jenkins-Lonidier, Lora, 216* Joiner, Thomas E, 16-PP, 46-PP,

77-PP , 113-PP, 151-PP Jonas, Richard A., 405* Jones, Robert M., 302-S Jones, William B., 87-L

DECEMBER 2012 JOURNAL MSMA 427

K

Koch, Christian A., 347*, 380 Kolbo, Jerome R., 140*

L

Lahr, Christopher J., 36* Lam, John T., 366 Lampton, Lucius, 2, 32, 34, 64, 66,

102, 132-PB, 136, 138, 169,

171, 214, 244, 246, 280, 282,

318, 352, 354, 394, 415-I Lancaster, William J., 405* Latorre, Carlos A., 222-CPS Liechty, Kenneth W., 104*, 400* Lineaweaver, William “Bill”,

308-PM Locke, Will R., March cover Lukienko, Eugene, 344

M

Majithia, Vikas, 367 Mason, Philip B., 284* Matthias, Heddy-Dale, 81-E McCann, Andrea, 362 McEachin, John D., 414-PM McGuire, James, 323* McIntosh, David G., 36* McKee, Colleen, 247* McKee, Jasmine, 161 McKenzie, L. Kendall, 9* McMillen, Robert, 319* Merideth, Philip, 118-E Merrill, Walter H., 216*, 405* Minor, Deborah S., 330* Mitchell, Marc E., 405* Molaison, Elaine Fontenot, 140* Morgan, Andrea, 260-CPS

O

Ogletree, Richard “Buddy”, 73 Ogletree, Richard L., Jr., 109, 161,

235, 274, 295, 344

P

Pepper, Dominique J., 362 Phan, Thaibinh T., 111-CPS Pomphrey, Martin, 100 Pomphrey, Martin M., Jr., June

cover, October cover Pontius, W. F., February cover Porter, Maribeth, 385 Pullen, Ashley B., 12-CPS

R

Ragsdale, Kathleen, 247* Reiners, Eric, 363, 367 Replogle, William H., 330* Riche, Daniel M., 275* Ridgway, Mildred, 36* Rose-Hand, Rebecca A., 396-CPS

S

Salazar, Jorge D.,400*, 405* Seawright, Ashley H., 41* Shackelford, Signe, 319* Sheehan, John J., 357 Sheffield, Thomas E., November

cover Sherman, Whitney, 309-PB Sheth, Michelle,400*, 405* Shores, Jennifer C., 400*, 405* Smith, Amanda K., 330* Smith, P. Brent, 270-E Smith, Patrick O., 54-ESouth, Dwalia S., 60-UV, 98-UV,

165-UV Southward, Linda H., 247* Stroud, Catherine H. (Cathy), April

cover Subauste, Jose S., 347*, 361, 382 Suggs, Bradley J., 4*

T

Tamanna, Sadeka, 220* Tanner, Stephanie, 357 Taylor, Emilee, 405* Taylor, Jasmine, 238 Taylor, Mary, 400*, 405* Tesseneer, Stephanie, 216*

428 JOURNAL MSMA DECEMBER 2012

Thigpen, S. Calvin, 357, 358, 361,

364, 365, 366 Tillman, Lindsey E., 330* Tisdale, Brett, August cover Tollefson, Brian J., 9* Tribble, Curtis G., 216* Trotter, Michael C., 88-S, 127-S Tullos, Bobby W., 365

U

Ullah, M. Iftekhar, 220* Ungnapatanin, Nuttha, 347*

V

Vance, Ralph, 365 Varela-Stokes, Andrea, 68*

W

Waespe, Kelly, 365 Wallace, Mickey, December cover Wang, Bo, 323* Werle, Nichole, 140* Westerfield, Matt, 238 Wiley, Thomas L., 126-L Wilkinson, Kelly J., 366 Wofford, Marion R., 275*

Z

Zhang, Lei, 140*, 323*

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