December 2014 JMSMA

December

VOL. LV

2014

No. 12

from the MSMA Alliance

Back row (left to right) Jean Hill, Angela Ladner, Shannon Warnock, Lauren Darsey, Lauren Reed, Heather Rifkin, Bo Zimmerman, Kathy Brandon, Heather Wood; Middle row (left to right) Nancy Lindstrom, Kathy Carmichael, Jo Terry (Immediate Past President, AMAA), Karen Morris, Ann Blair Huffman; Front Row (left to right) Donna Witty, Danita Horne, Eileene McRae

A wish for health and happiness in the coming year 2015 is being sent to you by members of the Mississippi State Medical Association Alliance

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 and the Editors

The Association Claude D. Brunson, MD President Daniel P. Edney, MD President-Elect Michael Mansour, MD Secretary-Treasurer Geri Lee Weiland, MD Speaker Jeffrey A. Morris, 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.

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

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

Copyright© 2014 Mississippi State Medical Association.

DECEMBER 2014

VOLUME 55

NUMBER 12

Scientific Articles IgG4-Associated Cholangitis

384

Vikas Nath, MD; Jack Lewin, MBBCh, MMed(Path), FFPath; Charu Subramony, MD; Veena Shenoy, MD

Clinical Problem-Solving Case: Sent for a Loop

389

Pratik A. Mehta, MD

Related Organizations MSDH 391

Editorial Follow the Physician Leader

395

D. Stanley Hartness, MD; Associate Editor

President’s Page A Warm and Hearty Holiday Wish

396

Claude D. Brunson, MD; MSMA President

Special Article Remembering JMSMA Editor Emeritus Myron Willis Lockey

399

Karen A. Evers, Managing Editor; et al.

Departments From the Editor: The Shame of Mississippi Medicaid The Roving Reporter: Skinny Insurance Plans Can Weigh You Down Richard D. deShazo, MD; Associate Editor

Physician’s Bookshelf: An Absent Mind 398 William Vail, M3

In Memoriam

406

Index: Volume 55 Subject Index Author Index

411 415

About The Cover: Sunset over Biloxi Bay in Ocean Springs- The late Myron W. Lockey, MD took this photo while visiting his coastal home in Ocean Springs where his oldest son also lives. The Biloxi Bay Bridge carries U.S. Route 90 over Biloxi Bay between Biloxi and Ocean Springs. Though the bridge’s ballast and accompanying railroad track was heavily damaged by Hurricane Katrina in August 2005, the superstructure remained and underwent major repairs, reopening to traffic on November 1, 2007.

See page 399 for a special tribute in memory of Dr. Lockey, who served the Journal MSMA as Associate Editor (1973) before being elected Editor 1984-1998, then was named Editor Emeritus until he died September 11, 2014. r December

VOL. LV

Official Publication of the MSMA Since 1959

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2014

No. 12

December 2014 JOURNAL MSMA 381

O

From the Editor: The Shame of Mississippi Medicaid

ur profession’s sense of powerlessness and uncertainty seems overwhelming at present. We are witnessing the corporate takeover of medicine at a state and national level: ACOs, bundling, risk shifts, and payment reform are all euphemisms for screwing the patient and the doctor. What can we do? Mississippi physicians must assert ourselves in reinventing and influencing our local medical marketplace. In the end, all healthcare is local, and what we must do is battle to shape the medical environment in Mississippi.

The first place to start is Medicaid. It is long overdue for the Division of Medicaid to operate focused on maximizing public health and medical care delivery in the state. For years, despite the pleas of our MSMA, there has been no medical director at the Division of Medicaid, “no doctor in the building” as is frequently said. To make matters worse, federal and state laws have been violated for years which mandate that the Division meet quarterly with a Medical Care Advisory Committee. The result: the Division is not operated on a sound public health or medical footing. Money is the bottom line, not healthcare. The Division’s foolish and shortsighted treatment

of the state’s fragile Perinatal High Risk Management (PHRM) Infant Services System, as well as its deaf ear to the failures of MississippiCAN, reveal clearly the lack of medical leadership.

Medicaid must be about maximizing the bang of state and federal match dollars to benefit and support the health system of our state.

As we go to press comes Lucius M. Lampton, MD news that Tami H. Brooks, MD, a respected Jackson pediatrician, has been appointed “parttime” Medical Director for the Division of Medicaid.

Frankly, I am stunned that the Division has selected such an outstanding and outspoken advocate of our profession and our patients. Although she will only be working one day a week, Mississippi’s doctors finally, finally have a physician’s presence at the Division of Medicaid. Not only will we need Tami’s help, but she will need ours to improve Medicaid’s focus on quality patient care.

Contact me at lukelampton@cableone.net.

—Lucius M. Lampton, MD, Editor

Journal Editorial Advisory Board Timothy J. Alford, MD Family Physician, Kosciusko Medical Clinic Michael Artigues, MD Pediatrician, McComb Children’s Clinic

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

Diane K. Beebe, MD Professor and Chair, Department of Family Medicine, University of MS Medical Center, Jackson

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

Jennifer J. Bryan, MD Assistant Professor, Department of Family Medicine University of Mississippi Medical Center, Jackson

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

Jeffrey D. Carron, MD Professor, Department of Otolaryngology & Communicative Sciences, University of Mississippi Medical Center, Jackson

Gordon (Mike) Castleberry, MD Urologist, Starkville Urology Clinic

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

Thomas E. Dobbs, MD, MPH State Epidemiologist Mississippi State Department of Health, Hattiesburg

Ben E. Kitchens, MD Family Physician, Iuka Brett C. Lampton, MD Internist/Hospitalist, Baptist Memorial Hospital, Oxford

Philip L. Levin, MD President, Gulf Coast Writers Association Emergency Medicine Physician, Gulfport Sharon Douglas, MD

Professor of Medicine and Associate Dean for VA William Lineaweaver, MD Education, University of Mississippi School of Medicine, Editor, Annals of Plastic Surgery Associate Chief of Staff for Education and Ethics, Medical Director G.V. Montgomery VA Medical Center, Jackson JMS Burn and Reconstruction Center, Brandon Bradford J. Dye, III, MD Ear Nose & Throat Consultants, Oxford 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

382 JOURNAL MSMA

Jason G. Murphy, MD Surgeon, Surgical Clinic Associates, Jackson Ann Myers, MD Rheumatologist Mississippi Arthritis Clinic, Jackson Darden H. North, MD Obstetrician/Gynecologist Jackson Health Care-Women, Flowood Michelle Y. Owens, MD Associate Professor, Vice-Chair of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson Jimmy L. Stewart, Jr., MD Program Director, Combined Internal Medicine/ Pediatrics Residency Program, Associate Professor of Medicine and Pediatrics University of Mississippi Medical Center, Jackson Samuel Calvin Thigpen, MD Hematology-Oncology Fellow, Department of Medicine University of Mississippi Medical Center, Jackson Thad F. Waites, MD Clinical Cardiologist, Hattiesburg Clinic W. Lamar Weems, MD Urologist, Jackson

Michael D. Maples, MD Chris E. Wiggins, MD Medical Director Orthopaedic Surgeon Medical Assurance Company of Mississippi, Ridgeland Bienville Orthopaedic Specialists, Pascagoula Alan R. Moore, MD Clinical Neurophysiologist Muscle and Nerve, Jackson

John E. Wilkaitis, MD Chief Medical Officer Brentwood Behavioral Healthcare, Flowood

Paul “Hal” Moore Jr., MD Radiologist Singing River Radiology Group, Pascagoula

Sloan C. Youngblood, MD Assistant Medical Director, Department of Anesthesiology, University of Mississippi Medical Center, Jackson

December 2014

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December 2014 JOURNAL MSMA 383

• Scientific Articles • IgG4-Associated Cholangitis Vikas Nath, MD; Jack Lewin, MBBCh, MMed(Path), FFPath; Charu Subramony, MD; Veena Shenoy, MD

A

bstract

We report a young female patient with IgG4-associated cholangitis (IAC) who presented with common bile duct (CBD) stricture and review the features that distinguish IAC from both primary sclerosing cholangitis (PSC) and other types of secondary sclerosing cholangitis (SSC). IAC is a biliary manifestation of IgG4-related sclerosing disease, an autoimmune condition characterized by elevated serum IgG4 and infiltrates containing lymphocytes and IgG4-positive plasma cells, accompanied by sclerosis. On endoscopic retrograde cholangiopancreatography, IAC consists of segmental biliary strictures with a predilection for the distal CBD, whereas in PSC the strictures are more band-like; other types of SSC often demonstrate unifocal ductal obstructions, sometimes associated with choleliths. On histologic examination, the bile duct wall in IAC contains a denser lymphocytic infiltrate and sparser sclerosis than in PSC; other types of SSC can be distinguished histologically by the types of inflammatory cells present. Unlike those of PSC, IAC-related strictures are reversible with corticosteroids.

Key Words: IgG4-associated cholangitis, IgG4-related sclerosing disease, primary sclerosing cholangitis, secondary sclerosing cholangitis Clinical Presentation A 25-year-old African-American woman presented to an outside hospital with jaundice and abdominal pain. Liver function tests showed elevated total and direct bilirubin, transaminases, and alkaline phosphatase. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a dominant stricture of the distal common bile duct 2 cm in length, as well as segmental Author Affiliations: Cytopathology fellow, Pathology (Dr. Nath); Director, Anatomic Pathology (Dr. Lewin); Director, Autopsy Pathology (Dr. Subramony); Director, Surgical Pathology (Dr. Shenoy); Department of Pathology, University of Mississippi Medical Center, Jackson, Mississippi.

Corresponding Author: Veena Shenoy, MD, Department of Pathology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216 Telephone: (601) 984-1571, Fax: (601) 984-1531 (vshenoy@umc.edu).

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strictures of the proximal branches of the right and left hepatic ducts (Figure 1); the common bile duct stricture was treated with a stent. Magnetic resonance imaging (MRI) at our institution confirmed these findings and additionally revealed the following: dilation of extrahepatic and intrahepatic bile ducts; dilation of the cystic duct; and thickening and enhancement of the gallbladder wall. Pertinent negative findings included a normal-sized pancreatic duct and absence of mass lesions in the liver and pancreas. Serologic testing for immunoglobulin showed elevated IgG4; accordingly, the patient was started on corticosteroid therapy, following which her liver enzymes significantly improved.

Figure 1: ERCP showing a distal CBD stricture with dilation of the proximal CBD. Segmental strictures are present in the right and left hepatic ducts.

She later underwent roux-en-Y choledocojejunostomy with common bile duct resection and cholecystectomy for relief of her CBD stricture, as well as intraoperative liver biopsy.

Histologic examination of the CBD showed dilation, reactive epithelial changes, focal obliterative phlebitis, and expansion of the bile duct wall by storiform fibrosis, with an increased number of plasma cells and eosinophils (Figure 2a). IgG4 immunostaining revealed numerous IgG4-positive plasma cells within the infiltrate (Figure 2b). Similar findings were present within the gallbladder wall, and the diagnosis of IgG4-associated cholangitis (IAC) was made on the basis of these features.

The liver biopsies showed portal inflammation with edema and focal periductal concentric fibrosis, determined to be secondary to IAC, in a background of mildly active steatohepatitis.

Postoperatively, the patient made a full recovery and was able to tolerate a regular diet. She was weaned from steroids prior to discharge.

Figure 2: a. The common bile duct wall contains an infiltrate of lymphocytes, plasma cells, and eosinophils (H&E; overall magnification ×60). b. An increased number of IgG4-positive plasma cells are present within the infiltrate (immunohistochemical staining for IgG4; overall magnification ×60).

Discussion IAC is a hepatobiliary manifestation of IgG4-related sclerosing disease (ISD), a condition, likely autoimmune in nature, characterized by elevated serum IgG4 levels and infiltration of multiple organs by lymphocytes and IgG4-positive plasma cells with subsequent sclerosis.1,2 In 2003, Kamisawa et al. observed that biopsy specimens from the gastrointestinal and hepatobiliary tracts of patients with autoimmune pancreatitis (AIP) contained IgG4-positive plasmacytic infiltrates and fibrosis identical to that seen in the pancreas. Accordingly, they concluded that AIP was part of a multiorgan syndrome, which they designated ISD.3 Today it is known that many autoimmune conditions, once believed to be specific to the organ in which they were first described, in reality exist within the ISD spectrum: examples include Mikulicz syndrome, which affects the lacrimal and salivary glands; Küttner tumor, which affects the submandibular glands; and Reidel thyroiditis.4,5 Among the extrapancreatic manifestations of ISD, IAC is the most common,1,4 having been described in over 70% of patients with AIP.2,4,6 IAC typically occurs in the 6th-7th decades, with 80-85% male predominance, and presents with obstructive jaundice, weight loss, and abdominal discomfort.7,8,9 Clinically, IAC may be categorized as a type of secondary sclerosing cholangitis (SSC), a term that encompasses a number of different disease processes that manifest as inflammation of the biliary tree, followed by obliterative fibrosis and ultimately biliary stricture.10 The etiologies are varied and may include infectious or inflammatory agents; mechanical obstruction due to choledocholithiasis or neoplasia; and ischemia secondary to allograft rejection, vasculitis, or hypoxia.10,11 What distinguishes SSC from a more prevalent entity in the differential diagnosis of hepatobiliary diseases, primary sclerosing cholangitis (PSC), which has overlapping clinical and radiologic features, is that the underlying condition triggering bile duct inflammation and fibrosis is known in the case of SSC, whereas the etiology of PSC is as yet uncertain.11,12,13 PSC, unlike IAC, is a chronic, idiopathic inflammatory process that results in progressive and irreversible biliary tree destruction, culminating in cirrhosis and liver failure.6,9 It presents in patients 30-40 years of age1,14 and also has a predilection for males, albeit lower than for IAC; approximately 65-66% of patients are male.8,12 PSC is strongly associated with inflammatory bowel disease (IBD), in particular ulcerative colitis (UC); 70-80% of PSC patients have underlying UC,12 whereas no such association has been clearly established with IAC.8,14 The most common presenting symptoms of PSC include fatigue, pruritus, jaundice, and abdominal pain; however, over 15% of patients are asymptomatic at the time of diagnosis and only develop these symptoms later as their disease progresses.12,13 Variant presentations of PSC include “small-duct” PSC in which cholestasis is present with histologic features of PSC on liver biopsy but with no evidence of biliary stricture on cholangiography and the “overlap syndrome”, which manifests as chronic liver disease with features of both PSC and autoimmune hepatitis.12

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Recently, Ghazale et al. outlined a diagnostic algorithm for IAC7 based on the HISORt criteria developed at Mayo Clinic for diagnosis of AIP.6,7,15 The HISORt rubric for IAC (Table 1) consists of 5 components: Histology, Imaging, Serology, Other organ involvement, and Response to therapy. Table 2 summarizes the comparison between IAC and PSC along each of these parameters.

14 Table 1. HISORt criteria for diagnosis of IAC. Table 1: HISORt criteria for diagnosis of IAC Feature Histology of bile duct

Imaging of bile duct

Serology Other organ involvement

Response to steroid therapy

Characteristics Lymphoplasmacytic sclerosing cholangitis on resection specimens (lymphoplasmacytic infiltrate with >10 IgG4-positive cells/high power field within and around bile ducts with associated obliterative phlebitis and storiform fibrosis) One or more strictures involving intrahepatic, proximal extrahepatic, or intrapancreatic bile ducts Fleeting/migrating biliary strictures Increased levels of serum IgG4 Pancreas: classic features of AIP on imaging or histology; suggestive pancreatic imaging findings: focal pancreatic mass/enlargement without pancreatic duct dilatation, multiple pancreatic masses, focal pancreatic duct stricture without upstream dilatation, pancreatic atrophy Retroperitoneal fibrosis Renal lesions: single or multiple parenchymal low-attenuation lesions (ro und, wedge-shaped, or diffuse patchy) Salivary/lacrimal gland enlargement Normalization of liver enzyme levels or resolution of stricture 15

Table 2: Comparison of IAC and PSC according to Table 2. Comparison of IAC and PSC according to HISORt criteria.

HISORt criteria Feature Histology of bile duct

Imaging of bile duct

Serology Other organ involvement

Response to steroid therapy

IAC Lymphoplasmacytic infiltrate in bile duct wall with IgG4positive plasma cells Storiform fibrosis Obliterative phlebitis Intact biliary epithelium Segmental intrahepatic and extrahepatic duct strictures CBD stricture with distal bile duct dilation Spontaneously resolving strictures Elevated serum IgG4 Nonspecific: ANA Pancreas: AIP Kidney: Tubulointerstitial nephritis Salivary glands: Sialadenitis Retroperitoneal fibrosis Lymphadenopathy Resolution of strictures and normalization of liver enzymes with steroid therapy Immunomodulatory drugs useful in relapse

PSC Concentric periductal “onionskin” fibrosis Bile duct destruction resulting in ductopenia Damaged biliary epithelium Diffuse biliary tree strictures with beaded or “pruned-tree” appearance Dominant stricture in CBD or common hepatic duct Nonspecific: P-ANCA, ANA, anti-smooth muscle antibody Gastrointestinal tract: IBD, especially UC Liver: Autoimmune hepatitis when component of overlap syndrome Poor response to steroid therapy and immunomodulatory drugs Ursodeoxycholic acid can improve liver chemistries Liver transplant is sole definitive treatment

Histology Histologic findings in IAC include lymphoplasmacytic infiltrate in the bile duct wall, storiform fibrosis, and obliterative phlebitis.2,14,16 In 88% of bile duct biopsy specimens from IAC patients, >10 IgG4-positive plasma cells per high-power field were identified by immunohistochemistry.7,8 Periportal inflammation and intrahepatic bile duct sclerosis may be seen within intrahepatic bile ducts,2,8 and some patients may have gallbladder thickening and infiltration of the gallbladder wall with IgG4-positive plasma cells.8 In contrast to PSC, in IAC the biliary epithelium is generally spared,14,18 the inflammatory infiltrate is denser, and the fibrosis is less extensive.2 Histologic sections of PSC demonstrate concentric periductal fibrosis in a characteristic “onion-skin” pattern—a pattern generally absent in IAC2-with subsequent bile duct destruction resulting in

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ductopenia.12,13 Differentiation between IAC and other forms of SSC on histologic grounds depends largely on the nature of the inflammatory infiltrate. Lymphoplasmacytic infiltrate, obliterative phlebitis, and sclerosis are also features of autoimmune hepatitis; however, IgG4-positive plasma cells are not present.

SSC due to hypereosinophilic syndrome and systemic mastocytosis is characterized by infiltrates of eosinophils and mast cells, respectively. A mixed inflammatory infiltrate consisting of plasma cells, eosinophils, macrophages, and fibroblasts is seen in the rare condition known as hepatic inflammatory pseudotumor.10 Imaging Imaging findings in IAC often consist of segmental strictures of intrahepatic and extrahepatic bile ducts classically involving the distal CBD with proximal bile duct dilation,6 though intrapancreatic bile ducts may be involved also. These strictures are known to be fleeting or resolve spontaneously on occasion.7 By contrast, the strictures in PSC are often described as having a band-like or beaded (“pruned-tree”), rather than segmental, appearance.1,6,8 In 45–58% of patients, a “dominant” stricture- a stenotic focus ≤1.5 mm in diameter in the common bile duct or ≤1 mm in the hepatic duct- may be present.13,17 Although the diffuse pattern of strictures throughout the biliary system is common to both diseases, lower biliary tract stenosis with only focal areas of bile duct dilation distally is more characteristic of IAC than PSC.2 Additionally, in many patients the presence of concomitant AIP is an important diagnostic clue.

AIP classically manifests as diffuse pancreatic enlargement resulting in a “sausage-shaped” pancreas surrounded by a hypodense capsule-like rim on computerized tomography (CT).

ERCP shows irregular narrowing of the main pancreatic duct.2,6 However, AIP may also present as focal pancreatic thickening that creates a discrete mass, especially at the head of the pancreas, which may prompt suspicion of pancreatic carcinoma.1,2 The cholangiographic manifestations of SSC are varied, but as a general rule, isolated peripheral ductal abnormalities are more characteristic of SSC than PSC. In the early stages of sclerosing cholangitis in critically ill patients (SC-CIP), a disease with a poor prognosis that affects patients in intensive care units, filling defects may be present; later on, the cholangiographic pattern may resemble that of PSC. AIDS cholangiopathy, which is caused by infection by Cryptosporidium or related parasites, is characterized by intrahepatic biliary lesions secondary to papillary stenosis. In recurrent pyogenic cholangitis, ultrasonography or CT may demonstrate obstructing choleliths; ERCP is not recommended due to the risk of sepsis.10 Serology Elevated serum IgG4 level is 74% sensitive for IAC,2,4,7 comparable to the sensitivity of this marker for AIP if one uses a threshold of 135–140 mg/dL;2,6 its specificity for IAC, however, is questionable.8,18 For this reason, Ghazale et al. do not recommend diagnosis of IAC solely on the basis of serum IgG4 level,

as elevated IgG4 may occasionally be present in other diseases such as PSC7,18 or pancreatic carcinoma.8 Antinuclear antibody (ANA) and rheumatoid factor are characteristic of the ISD syndrome generally, but these too are relatively nonspecific.1,8 Likewise, several markers exist that are sensitive for PSC, but lack sufficient specificity to be of diagnostic utility. The most sensitive is perinuclear antineutrophil cytoplasmic antibody (PANCA), which is present in 80% of PSC patients. ANA and anti-smooth muscle antibody are also common and are seen in 20–50% of patients.12 Other Organ Involvement The pancreas is the organ most commonly involved in IAC,7 which is unsurprising given the strong association between IAC and AIP; indeed, the presence of an unexplained pancreatic lesion in a patient with biliary stricture should prompt investigation for IAC.7,18 That said, the presence of AIP is not required for this diagnosis, as there have been many reported instances of IAC existing in the absence of a pancreatic lesion;6,7,18 these may be difficult to distinguish from PSC radiographically. Lesions in organs other than the pancreas may include tubulointerstitial nephritis of the kidney, sialadenitis of the salivary glands, retroperitoneal fibrosis, and lymphadenopathy. Histologic examination often reveals lymphoplasmacytic infiltrate with an increased number of IgG4-positive cells, consistent with multiorgan ISD.4,7 Additionally, some authors from Mayo Clinic have suggested a link between ISD and IBD, citing a prevalence of IBD in 6% of patients diagnosed with IAC or AIP in their studies; however, given the small sample sizes used, it is difficult to establish a clear association between the two.4,7 PSC, on the other hand, is a disease mostly limited to the intrahepatic and extrahepatic bile ducts, except when accompanied by UC and/or autoimmune hepatitis.12 Response to Treatment IAC frequently shows a dramatic response to corticosteroid therapy,6,9 resulting in complete resolution of strictures and/or normalization of liver enzymes;7 less commonly, persistent CBD stricture requiring surgical intervention may occur.6,19 However, despite the effectiveness of steroid treatment in alleviating the initial symptoms, relapse is common; for these patients, long-term therapy with immunomodulatory drugs such as azathioprine, mycophenolate mofetil, and cyclophosphamide has been shown to be of benefit.7 In sharp contrast, PSC responds poorly to medical management. Ursodeoxycholic acid has some benefit in improving liver biochemistries, but neither it nor the aforementioned immunomodulatory agents have proved effective at altering the course of the disease, which leads inexorably to end-stage liver disease requiring transplantation.12,13 As regards SSC as a whole, its management is a highly individualized process that depends on the nature of the underlying disease—antibiotic therapy and/or surgical drainage in the case of pyogenic cholangitis; balloon dilation and/or portosystemic shunt in the case of choledocholithiasis with obstruction.10 Pa-

tients with severe disease may ultimately require a liver transplant; although the prognosis of SSC is variable, many authors have found it to be generally worse than for PSC in patients who have not undergone liver transplantation.10,20 Summary Distinguishing between PSC and IAC in CBD specimens is critical due to the vastly different prognoses of these two diseases. Our patient was unusual in that she was a young female, a demographic rarely represented in IAC, which is primarily a disease of older males. Thus, although the dominant CBD stricture and segmental hepatic duct strictures identified on MRI were deemed most consistent with IAC, a diagnosis of PSC could not be excluded based on these findings alone.

The patient’s elevated serum IgG4 strongly favored a diagnosis of IAC, and it was on this rationale that her physician initiated steroid treatment. On histologic examination of the resected specimen, the pattern of lymphoplasmacytic infiltration of the CBD and gallbladder wall with IgG4-positive plasma cells, in conjunction with the storiform fibrosis present in the CBD and intrahepatic ducts, was sufficient for us to render a pathologic diagnosis of IAC. This patient’s example illustrates the need to correlate microscopic findings with clinical and radiologic findings in cases of unusual presentation of diseases of the biliary tract.

References 1. Vlachou PA, Khalili K, Jang HJ, et al. IgG4-related sclerosing disease: autoimmune pancreatitis and extrapancreatic manifestations. Radiographics. 2011;31:1379-1402.

2.

Takuma K, Kamisawa T, Igarashi I. Autoimmune pancreatitis and IgG4-related sclerosing cholangitis. Curr Opin Rheumatol.

2011;23:80-87.

3. Kamisawa T, Funata N, Hayashi Y, et al. A new clinicopathological entity of IgG4-related autoimmune disease. J Gastroenterol.

2003;38:982-984.

4. Khosroshahi A, Stone JH. A clinical overview of IgG4-related systemic disease. Curr Opin Rheumatol. 2011;23:57-66.

5. Stone JH, Zen Y, Deshpande V. IgG4-related disease. N Engl J Med. 2012;366:539-551.

6.

Nishimori I, Otsuki M. Autoimmune pancreatitis and IgG4associated sclerosing cholangitis. Best Pract Res Clin Gastroenterol. 2009;23:11-23.

7.

Ghazale A, Chari ST, Zhang L, et al. Immunoglobulin G4associated cholangitis: clinical profile and response to therapy.

Gastroenterology. 2008;134:706-715.

8.

Alderlieste YA, van den Elzen BDJ, Rauws EAJ, et al.

Immunoglobulin G4-associated cholangitis: one variant of immunoglobulin G4-related systemic disease. Digestion.

2009;79:220-228.

9.

Montano-Loza AJ, Lalor E, Mason AL. Recognizing immunoglobulin G4-related overlap syndromes in patients with pancreatic and hepatobiliary diseases. Can J Gastroenterol.

2008;22:840-846.

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10.

Imam MH, Talwalkar JA, Lindor KD. Secondary sclerosing cholangitis: pathogenesis, diagnosis, and management. Clin Liver Dis. 2013;17:269-277.

11. Abdalian R, Heathcote EJ. Sclerosing cholangitis: a focus on secondary causes. Hepatology. 2006;44:1063-1074.

12. Charatcharoenwitthaya P, Lindor KD. Primary sclerosing cholangitis: diagnosis and management. Curr Gastroenterol Rep. 2006;8:75-82.

13. Silveira MG, Lindor KD. Primary sclerosing cholangitis. Gastroenterol.

2008;22:689-698.

14. NovotnĂ˝ I, DĂ­te P, Trna J, et al. Immunoglobulin G4-related cholangitis: a variant of IgG4-related systemic disease. Dig Dis. 2012;30:216-219.

15.

Chari ST, Smyrk TC, Levy MJ, et al. Diagnosis of autoimmune hepatitis: the Mayo Clinic experience. Clin Gastroenterol Hepatol.

2006;4:1010-1016.

16.

Okazaki K, Uchida K, Miyoshi H, et al. Recent concepts of autoimmune pancreatitis and IgG4-related disease. Clin Rev Allerg Immunol. 2011;41:126-138.

17. Chapman R, Fevery J, Kalloo A, et al. Diagnosis and management of primary sclerosing cholangitis. Hepatology. 2010;51:660-678.

18.

Zhang L, Smyrk TC. Autoimmune pancreatitis and IgG4-related systemic diseases. Int J Clin Exp Pathol. 2010;3:491-504.

19.

Nishino T, Toki F, Oyama H, et al. Biliary tract involvement in autoimmune pancreatitis. Pancreas. 2005;30:76-82.

20. Gossard AA, Angulo P, Lindor KD. Secondary sclerosing cholangitis: a comparison to primary sclerosing cholangitis. Am J Gastroenterol.

2005;100:1330-1333.

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• Clinical Problem-Solving •

Sent for a Loop

Pratik A. Mehta, MD

A

25-year-old African American female presented to the emergency department with worsening abdominal pain and swelling. The pain was diffuse, nonspecific, had no exacerbating or relieving factors and was not preceded by trauma. Her abdomen had gradually grown over the past 2 weeks, causing her significant abdominal distention. She had gained approximately 10 pounds during the previous month and had increased fatigue.

In a 25-year-old with a rapid onset of abdominal distention I would try to determine the origin of the swelling. Even though the swelling is localized to the abdomen, the differential diagnoses are numerous including pregnancy and ascites from one or more abdominal organs. The first approach would be to obtain a complete history from the patient. Obesity can often have a similar presentation, but because of the patient’s rapid onset of symptoms, relative intolerance to the abdominal distention and peritoneal involvement as the likely source of her pain, obesity is less likely to be the cause. Alcohol use can lead to alcoholic hepatitis or cirrhosis, which in turn can cause ascites. On average the patient would need to consume 80 grams of alcohol daily (8 beers or ½ pint of liquor) for 10 to 20 years to achieve this, however.1 The patient is 25 years old, so even with moderate to heavy drinking it is unlikely that she would have liver disease progressing to ascites. Viral hepatitis can also be considered, but ascites would be a symptom of cirrhosis, which is a complication of end stage disease. Initially I would obtain a urine pregnancy test, complete blood count, complete metabolic profile, urinalysis, lipase and abdominal imaging, an abdominal ultrasound, flat and upright plain film initially and subsequently a radiograph or computed tomography (CT) if those results were inconclusive provided her pregnancy test was negative.

The patient’s medical history included juvenile rheumatoid arthritis and autoimmune hepatitis that was diAuthor Affiliations: Dr. Mehta was a resident in the Department of Family Medicine at the University of Mississippi Medical Center in Jackson.

Corresponding Author: Piedmont Family Practice at Baxter Village, 502 Sixth Baxter Crossing, Ste A, Fort Mill, SC 29708-6428.

Telephone: (803) 835-2088 (office) Fax: (803) 835-2099 (pratik. mehta@tenethealth.com).

agnosed when she was 10 years old. She did not receive treatment for either of these conditions for unknown reasons. The patient did not display stigmata of cirrhotic liver disease and had a flank and shifting dullness, as well as a fluid wave on physical exam performed in the emergency department. Her complete blood count and metabolic profile, including liver function studies, were within normal range and her urine pregnancy test result was negative.

Her glomerular filtration rate was >60 mL/M. Her lipase result was also normal at 15 L/U. CT scan of the abdomen revealed a normal appearing pancreas, spleen, liver and kidneys but was positive for large ascites, peritonitis versus serositis. A paracentesis performed in the emergency department showed that the peritoneal fluid was composed of 4.7 g/dL protein, 2.3 g/dL albumin, 90 mg/dL glucose, 120 U/L LDH and 25 U/L amylase. Bacterial cultures of the fluid were subsequently negative. Her serum albumin was 3 g/dL. Her serum creatinine was elevated at 1.3 mg/dL and urinalysis expressed both protein and creatinine. The patient had no baseline laboratory values for comparison.

The patient also had an elevated blood pressure that was approximately 150/90 mmHg. The patient was admitted to the family medicine inpatient service for further workup.

When analyzing ascites, it is often important to check the serum albumin to acetic fluid albumin gradient calculated using the formula, SAAG=serum albumin - ascities fluid albumin. Her SAAG value was 0.7 g/dL. A SAAG of less than 1.1 g/dL is consistent with the diagnosis of pancreatitis, serositis, nephrotic syndrome, peritoneal tuberculosis or carcinomatosis.

A SAAG of greater than or equal to 1.1 g/dL would usually indicate a hepatic cause, such as cirrhosis, hepatitis or hepatic metastases.2 Furthermore, this patient has a history of juvenile arthritis and, therefore, is at risk for other autoimmune diseases. I will order a C-reactive protein (CRP) and sedimentation rate (ESR).

CRP and ESR are considered acute phase reactants in autoimmune processes. ESR reflects fibrinogen concentration while CRP can vary with multiple stages of inflammation by binding with phosphocholine. Phosphocholine is usually seen in foreign pathogens and damaged cells. Both CRP and ESR are non-specific tests but in the context of this patient’s symptoms they will assist in obtaining a specific diagnosis. The urine protein to urine creatinine ratio helps identify the presence of se-

December 2014 JOURNAL MSMA 389

vere or “nephrotic range “ (> 3grams/24 hours) proteinuria is present. This degree of chronic proteinuria is often associated with signs of the nephrotic syndrome like peripheral edema, anasarca, and ascities. The normal value is <0.2 mg/mg. This patient’s urine protein (69mg/dl) to urine creatinine (58 mg/ dl) ratio is 1.19 and shows proteinuria lower that that seen in the nephrotic syndrome. Given the normal lipase and unremarkable CT scan appearance, liver and pancreatic sources are unlikely.

The patient was given gentle intravenous fluid hydration, and 5.2 liters of fluid were drained from the patient’s abdomen during a therapeutic paracentesis. This greatly improved her abdominal pain. The patients CRP was 2.5 mg/dL and ESR was 29 mg/dL, both of which are considered elevated.

The patient has a past medical history of an autoimmune disease, and given her current symptoms coupled with her elevated CRP and ESR, I will order autoantibody testing. I will also check serum complement concentrations, as hypocomplementemia is a potential sign of autoimmune disease.

Antibodies to antinuclear, antiphospholipid, double stranded DNA, anti-RO/SSA, and Anti-Smith should be checked. I will also consider ordering an echocardiogram to investigate for pericardial involvement or valvular abnormalities.

Her antinuclear antibody concentration of >3.5 EU and anti-Ro/SSA of 134.30 EU were elevated. Her C3 was 44 mg/dL, C4 was 7 mg/dL and total complement concentration was <10 mg/dL, all of which were below reference range. Her echocardiogram showed a small pericardial effusion and no valvular abnormalities. After 2 days, the patient’s ascites began to recur. She required another therapeutic paracentesis which removed 1.5 liters of fluid, and she was given intravenous furosemide.

Anti-Ro/SSA, in addition to anti-nuclear antibodies, can be found in patients with systemic lupus erythematosus (SLE) or Sjögren’s syndrome. Sjögren’s syndrome is unlikely, however, because the patient does not display diminished lacrimal and salivary gland function that would be typical of the disease. This patient displayed signs of serositis and pericardial effusion, which may have been secondary to SLE. Elevated anti-DNA titers and low complement (C3 and C4) concentrations often indicate active lupus, particularly lupus nephritis.

Pericardial involvement, usually a pericardial effusion, is the most common type of abnormality found in SLE.3 It is found in >50% of patients and is usually discovered on echocardiography.4 I will start medical treatment with steroids and order a renal biopsy.

A renal biopsy was performed, and oral prednisone was given pending biopsy results. The patient’s fatigue drastically improved following prednisone administration. The pathologist confirmed that the renal biopsy was consistent with focal proliferative lupus nephritis (World Health Organization class III).

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Rheumatology was consulted and the patient was continued on prednisone, which was rapidly tapered, and hydroxychloroquine (Plaquenil) and azathioprine (Imuran), both of which are potent immunosuppressive agents, were added. The patient continued to show improvement and no longer had abdominal distention, pain or fatigue. Her ascites did not reoccur once this therapy was initiated. The patient was discharged and slowly weaned to cyclophosphamide (Procytox) which is a potent immunosuppressant and antirheumatic medication that is particularly useful in controlling symptoms of lupus nephritis.6 In summary, the patient’s previous history of autoimmune diseases (juvenile rheumatoid arthritis and autoimmune hepatitis) predisposed her to other autoimmune conditions, such as SLE. The patient presented with ascites that was from serositis, in addition to a pleural effusion that was found on echocardiogram. Official diagnosis of class III proliferative lupus nephritis requires less than 50 percent of glomeruli affected by light microscopy.5 Most patients have hematuria and proteinuria as well as hypertension. Subsequently, the patient was given steroids, the cornerstone initial treatment in lupus nephritis.6 She showed improvement and was later prescribed immunosuppressive therapy. She had shown no reoccurrence of abdominal ascites after 15 months. SLE is a chronic autoimmune disease of unknown origin. The disease is most common in woman of childbearing age. SLE can affect many body parts including the heart, lungs, skin, joints and kidneys.8 Most patients will have skin or joint involvement. Gastrointestinal involvement, as this patient had occurs less often in SLE and may be characterized by peritonitis, either with or without ascites due to serositis involving the peritoneum.9 Key Words: Lupus Nephritis, Systemic Lupus

Erythematosus, Serositis References 1. Naveau S, Giraud V, Borotto E, et al. Excess weight risk factor for alcoholic liver disease. Hepatology 1997; 25:108-111.

2. Runyon BA, Montano AA, Akriviadis EA, et al. The serumascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites. Ann Intern Med 1992; 117:215-220.

3. Lloyd W, Schur PH. Immune complexes, complement, and antiDNA in exacerbations of systemic lupus erythematosus (SLE).

Medicine (Baltimore) 1981; 60:208-217.

4. Doria A, Iaccarino L, Sarzi-Puttini P, et al. Cardiac involvement in systemic lupus erythematosus. Lupus 2005; 14:683-686.

5. Sisó A, Ramos-Casals M, Bové A, et al. Outcomes in biopsyproven lupus nephritis: evaluation of 190 white patients from a single center. Medicine (Baltimore) 2010; 89:300-307.

6. Austin HA 3rd, Illei GG, Braun MJ, Balow JE. Randomized, controlled trial of prednisone, cyclophosphamide, and cyclosporine in lupus membranous nephropathy. J Am Soc Nephrol 2009; 20:901-911.

7. Bomback AS, Appel GB. Updates on the treatment of lupus nephritis. J Am Soc Nephrol 2010; 21:2028-2035.

8. Von Feldt JM. Systemic lupus erythematosus. Recognizing its various presentations. Postgrad Med 1995; 97:79, 83, 86 9. Luman W, Chua K.B, Cheong W.K. Gastrointestinal Manifestation of Systemic Lupus Erythematosus. Singapore Med J. 2001; 42(8): 380-384.

• Mississippi State Department of Health •

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• MSDH • MSDH Announces Launch of New App: Your PSH Helps Individuals Take Charge of Personal Sexual Health The Mississippi State Department of Health (MSDH) has launched Your Personal Sexual Health (PSH), the first app in the nation that not only promotes safer sexual health but also provides the tools for effective HIV/STD testing and prevention.

Your PSH is free on both Apple and Android devices and includes the following features: • Determine your HIV risk level • Find HIV/STD testing and treatment • Get free condoms • Send anonymous “get tested” messages • AIDS hotline direct call • Myths and facts about HIV/STDs • Prevention tips, and more “This app really gives Mississippi an edge on sexual health knowledge and action,” said MSDH State Epidemiologist Dr. Thomas Dobbs. “It’s a convenient way to get the answers to the questions you’ve always had but maybe didn’t feel comfortable asking.”

To find the app, search the App Store for Your PSH, visit www.HealthyMS.com/apps, or follow the links below: iPhone: https://itunes.apple.com/us/app/your-psh/id924599275?mt=8 Android: https://play.google.com/store/apps/details?id=com.mwb.hiv As of December 31, 2013, there were an estimated 10,473 Mississippians living with HIV. According to the 2012 National HIV Surveillance Report, Mississippi has the 10th highest rate of HIV infection in the United States. In 2013, there were 556 new reports of HIV infection in Mississippi.

HIV is treatable, but early diagnosis is key. Effective HIV treatments are available that reduce transmission and allow for a long, healthy life. Free, confidential testing for HIV and other STDs is also available at any county health department.

Mississippi is Fourth State to be Recognized by American Diabetes Association for Self-Management Education Program

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he American Diabetes Association recently recognized the Mississippi State Department of Health’s (MSDH) Diabetes Self-Management Education Program for achievement in diabetes education. The American Diabetes Association (ADA) cited the program for high-quality education that is an essential component of effective diabetes treatment. The MSDH’s Diabetes Self-Management Program is only the fourth state program to be recognized by the ADA. The Association’s Educational Recognition Certificate ensures that educational programs meet the national standards for diabetes self-management education programs. Programs achieve recognition for having a staff of knowledgeable health professionals who can provide participants with comprehensive information about diabetes management. “The ADA recognition sets a national standard of quality for diabetes programs,” said Victor Sutton, MSDH Director of Preventive Health. “And it gives assurance to our residents that they will receive high-quality service.”

In 2012, Mississippi ranked second in the nation for diabetes, with 279,000 adults having diabetes ―12.5% of Mississippi’s adult population. Nationwide, the adult diabetes rate is 9.3%. An estimated 8.1 million Americans are not aware that they have this disease. Many will first learn that they have diabetes when they are treated for one of its life-threatening complications – heart disease or stroke, kidney disease, blindness, nerve disease or amputation.

Your patients can learn more about steps they can take to help prevent or self-manage the disease: HealthyMS.com/diabetes.

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• The JMSMA Roving Reporter • Skinny Insurance Plans Can Weigh You Down

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he Reporter has learned that certain provisions of the Affordable Care Act of 2012 have spawned several species of so-called “skinny health insurance plans” that may adversely affect patient care and physician reimbursement. The Reporter paid a visit to Fred McMillan, MD, ophthalmologist and former executive director of MPCN, to get the skinny on skinny plans.

The Reporter (JMSMA Associate Editor Richard D. deShazo): Dr. McMillan, what are “skinny insurance plans?”

Dr. McMillan: It is a little complicated, so I need to give you some background; however because the ACA is so comprehensive and complicated, my comments will be a generalization of the facts. There are 10 provisions of the ACA that designate required minimum essential benefits (MEB) of insurance plans offered by insurance companies to all Americans going forward (www. cigna.com/health-care-reform/lor-article-16). Full implementation is to occur on or about January 1, 2015. However, the train is already on the track. These provisions pertain to outpatient care, emergency services, hospitalization, maternity/newborn care, mental health/addiction treatment, prescription drugs, rehabilitation services, laboratory services, wellness and chronic disease treatment, and pediatric services (Table).

Table. The Affordable Care Act’s Ten Essential Health Benefits 1. Ambulatory patient services - Clinic or same-day (“outpatient”) surgery care and home health services and hospice care are included. Some plans may limit coverage to no more than 45 days.

2. Emergency Services (Trips to the emergency room) - Trips to the emergency room include transport by ambulance and patients cannot be penalized for going out-of-network or for not having prior authorization.

3. Hospitalization - Hospitalization coverage also includes surgeries, transplants and care received in a skilled nursing facility, such as a nursing home. Some plans may limit skilled nursing facility coverage to no more than 45 days. (A loophole may exist for larger employers to offer policies that deny inpatient. See O’Donnell J. Insurance plans can deny hospital stays, USA Today, Clarion Ledger 3B, November 4, 2014) 4. Maternity and newborn care.

5. Mental health services and addiction treatment - Inpatient and outpatient care provided to evaluate, diagnose and treat a mental health condition or substance abuse disorder. This includes behavioral health treatment, counseling, and psychotherapy. Some plans may limit coverage to 20 days each year. Limits must comply with state or federal parity laws.

6. Prescription drugs - At least one prescription drug must be covered in each category of the classification of federally approved drugs, however limitations apply. Some prescription drugs can be excluded. “Over the counter” drugs are usually not covered with a prescription. Insurers may limit drugs they will cover, covering only generic versions of drugs where generics are available. Some medicines are excluded where a cheaper equally effective medicine is available, or the insurer may impose “Step” requirements where expensive drugs can only be prescribed if a cheaper alternative has failed. Some drugs will need special approval.

7. Rehabilitative services and devices – Rehabilitative services and habilitative services, like speech therapy for children and devices must be provided. Plans have to provide 30 visits each year for either physical or occupational therapy, or visits to the chiropractor. Plans must also cover 30 visits for speech therapy as well as 30 visits for cardiac or pulmonary rehabilitation. We are not yet sure what habilitative services will entail.

8. Laboratory services – Routine laboratory and some preventive screenings, such as breast cancer screenings and prostrate exams, are provided free of charge.

9. Preventive services, wellness services, and chronic disease treatment - This includes counseling, preventive care, immunizations and screenings, designed to prevent or detect certain medical conditions. Also, care for chronic conditions, such as asthma and diabetes, are required.

10. Pediatric services - Dental and vision care must be offered to children younger than 19. This includes two routine dental exams, an eye exam and corrective lenses each year.

Sources: www.cigna.com/health-care-reform/lor-article-16. Accessed November 1, 2014.

Rosenthal, E. “As Insurers Try to Limit Costs, Providers Hit Patients with More Separate Fees” New York Times National Edition, October 26, 2014:18.

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The ACA provides that an employer’s present insurance plan may be “grandfathered.” If so, an employer is exempted from having to offer certain requirements in the ACA to include providing 100% of ACA required wellness benefits, adherence to the $6,350 maximum annual “out of pocket” cost to each employee and adherence to the child benefit requirement for coverage of dependents until age 26. This allows the employer to place employees into a new plan with the same features of the old plan that may fail to meet the ACA plan requirements. This creates a policy under the ACA which appears to meet MEB requirements but does not, i.e., a “skinny plan.” Thus, employers can provide fewer benefits than those required for new insurance plans offered after January 2015.

The Reporter: How does this affect physicians?

Dr. McMillan: Some existing employer plans have less favorable physician reimbursement than the usual 80/20 (80% insurance, 20% patient responsibility) arrangement as with most insurance policies. This means patients may come to physicians as insured patients with a policy that provides lower than usual professional reimbursements per encounter and the physicians may be required to collect the patient responsibility component which could be more than 20%.

Since a given insurance company may offer a variety of different policies under the new arrangement, it will be challenging for physicians to know what co-pays and reimbursements will be in place for any given patient. In other words, different patients with XYZ insurance company may have different allowables and different co-pays and deductibles. Thus, physicians must contact the insurer to get details on each patient. (Rosenthal, E. “As Insurers Try to Limit Costs, Providers Hit Patients with More Separate Fees” New York Times National Edition, October 26, 2014: 18.)

The Reporter: So, as I understand it, that means that physicians could be in the position to see a patient who has a very high co-pay, a high yearly deductible and an unacceptably low physician reimbursement and/or the requirement for the physician to collect the professional component directly from the patient, rather than the insurance company collecting it. What a mess.

Dr. McMillan: You are correct. The ACA does require that new plans have at least a 60/40 payment arrangement as minimum.

That provision also allows employers to develop a second version of “skinny” insurance with a physician reimbursement of only 60% of allowable charges. A physician can see a patient with either of these variations of skinny insurance offered through an insurance carrier that handles standard more favorable policies as well.

We specialize in the business of healthcare

The Reporter: So, what should physicians do?

Dr. McMillan: Going forward, physicians must be prepared to verify the payment details on each patient regardless of insurer. Physicians can no longer assume that any insurance reimburses with the historic 80/20 arrangements and that all patients have the same allowables.

The Reporter: This too shall pass. r

The PEN is greater than the SWORD

• • • • • • • •

Comprehensive Management Comprehensive Consulting Billing & Accounts Receivable Management Coding & Documentation Practice Assessments & Revenue Enhancement Profitability Improvement Practice Start-ups Personnel Management

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xpress your opinion in the Journal MSMA through a letter to the editor or guest editorial. Letters for publication should be less than 300 words. Guest editorials or comments may be longer, with an average of 600 words. All letters are subject to editing for length and clarity. If you are writing in response to a particular article, please mention the headline and issue date in your letter. Also include your contact information.

While we do not publish street addresses, e-mail addresses or telephone numbers, we do verify authorship, as well as try to clear up ambiguities, to protect our letter-writers. You may submit your letter via email to KEvers@MSMA online.com or mail to: P.O. Box 2548, Ridgeland, MS 39158-2548.

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1600 North State Street Suite 400 Jackson, MS 39202 Telephone: 601.944.1717 WATS: 1.800.355.4231 www.mpsbilling.com

• Editorial • [Any physician is invited to submit editorials or letters to the editor for publication in the Journal, attention: Dr. Lampton or email me at lukelampton@cableone.net.] —Ed.

Follow the Physician Leader

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D Stanley Hartness, MD; Associate Editor

n the MSMA Strategic Plan developed by the Board of Trustees in 2012, Goal 4 emphasizes the importance of the physician as leader of the healthcare team. Recommended as a strategy to realize this goal is the promotion of stringent licensure requirements of nurse practitioners and physician’s assistants with continued education of both physicians and the general public as to the need for ongoing collaborative oversight of these allied health professionals.

Ideally, the nurse practitioner and/or physician assistant practice “in-house” with the collaborative physician with approved protocols. However, since many allied health professionals are located in free standing clinics defined as a clinic or other facility more than fifteen miles from the primary office of the collaborative/consultative physician, the MS State Board of Medical Licensure has established rules regarding these circumstances.

A physician anticipating collaboration with a nurse practitioner/physician assistant in a free standing clinic must first satisfy three requirements:

1. Appear either in person or by telephone before the MS State Board of Medical Licensure and/or the Joint Committee of the Board of Medical Licensure and the Board of Nursing.

2. Present and discuss the proposed protocol 3. Obtain the Board’s approval to serve as a collaborating/consulting physician.

Each collaborative/consultative relationship must include and implement a formal quality improvement program to be maintained on site and available for inspection by a licensure board representative. Requirements of quality assurance/ improvement programs include:

1. Review by the collaborative physician of a random sample of charts representing 10% or 20 charts (whichever is less) of patients seen by NP/PA each month.

2. Maintenance by NP/PA of a log of charts reviewed.

3. Face-to-face meeting with documentation quarterly between NP/PA and collaborating physician.

When the primary collaborative physician is unavailable, backup physician coverage must be ensured, and the backup physician must be on Advanced Practice Registered Nurse protocol. In the event of relocation, disability (physical/mental), or death of the collaborating physician, the NP/PA must immediately notify the MS Board of Nursing which then immediately advises the MS Board of Medical Licensure of the situation.

In order that patients may continue uninterrupted care, the NP/PA may be allowed a 90-day grace period while a collaborative physician replacement is secured. If after the 90-day grace period a collaborative physician has not been found, an additional 90 day extension may be granted by mutual agreement of the Executive Committee of the MS State Board of Medical Licensure and the Executive Committee of the MS Board of Nursing. During this additional 90 day period, the previously described collaborative agreement remains in effect.

Dr. Vann Craig, MS Board of Medical Licensure executive director, says, “The mission of the board is to protect the public, and that’s what these new regulations are for.” r

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• President’s Page • A Warm and Hearty Holiday Wish

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olleagues,

As we enter this season of change and the holidays approach, we give pause to thank all of you, our Mississippi physicians, for all of the wonderful things that you have done for your patients, their families and your colleagues throughout 2014.

Claude D. Brunson, MD 2014-15 MSMA President

As we all give thanks for our many blessings, we also remember those who are less fortunate during this holiday season. I am aware and thankful of many for your commitment to your community and your participation in toy drives and food drives for local food pantries and the like. Our physicians give back to society not just in the field of medicine, but in so many different ways that are evident to the public. Thanks so much to all of you and your families who participate.

We should give special recognition to our spouses or significant others and loved ones who make big sacrifices because of the profession we have chosen. Each year as the holidays approach, our families are held captive to the holiday call schedule. Will the physician be home this year or will the spouse and kids be traveling across the country alone to visit family or celebrating at home mostly with you absent? This season of celebration can be stressful. It can also be a blessing in disguise as the spouse of a physician recalls in a poignant story she tells about a physician’s career and commitment to his patients.

This spouse recalls a retirement luncheon for a physician colleague which she attended with her husband at a beautiful mansion where the details were awe inspiring. They sat at the table with this surgeon’s children, family, friends, close colleagues, and a few past patients. She recalls that the talk of the table was about the fine detail in the carvings of each piece of furniture, the paintings on the ceilings, and the bittersweet ending of this physician’s career.

As the luncheon came to a close there were a few people who wanted to say a word or two and give their farewells and wishes for a happy retirement. As people took their turn giving their recount of this physician and their interactions with him, one former patient stood up and gave a testimony that was beautiful and profound. She recalls that the patient who stood up to speak could barely get a few words out through all the tears. This patient had been burned on 80 percent of his entire body and stood before everyone close to this surgeon and thanked him for many things, but one thing really stood out: he thanked this doctor for “missing that Christmas with his family” so that he could spend many more Christmases with his children.

We have been blessed to be a part of this noble profession. And through it we bring blessings to others. Our loved ones are a big part of those blessings. So this holiday season, take time to thank your loved ones for the sacrifices they make on your behalf. And spend time with your loved ones so that you will receive a blessing in return of their love and commitment to you and what you do.

I extend a warm and hearty holiday wish to each of you and those that you love during this holiday season. Have a safe and joyful holiday and a 2015 filled with love, health, and good fortune!

My wish for the Mississippi State Medical Association and our physicians remains clear, as we strive to be the best organization we can be to live out our mission: a physician organization serving as an advocate for its members, their patients, and the public health.

Happy and safe Holidays,

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Points of Distinction Focused: A singular long-term, value-driven investment philosophy

District Health Officer/Physician, Senior Public Health District V The Mississippi State Department of Health is soliciting applications from qualified candidates for the position of District Health Officer for Public Health District V. The position, located in Jackson, MS, serves as the county public health officer for the ten counties within the district. Those counties are:

Rigorous: Comprehensive research and analysis

Issaquena Hinds

Rational: Thoughtful investment selection

Sharkey Rankin

Yazoo Claiborne

Warren Copiah

Madison Simpson

District Public Health Officers are charged by the State Health Officer and the Board of Health with facilitating the health interests of the residents of the counties served and enforcing the State laws and Board of Health Regulations.

Responsive: Exceptional client service

The positions report to the State Health Officer and are responsible for the following:

Seasoned: Experienced team with a breadth of disciplines

   

Committed: Our money invested alongside yours

   

Proven: Solid history of investment performance

Maintaining the public health through the enforcement of laws and regulations empowered in the District Health Officer.

Coordination of disease outbreak responses.

Promotion of improved community health including the prevention of infectious and chronic diseases.

Leadership in district efforts in emergency response to: bioterrorism events, natural disasters, and other events of public health significance.

Clinical oversight of county health department clinical activities.

Rendering consultative services in health matters to public officials, voluntary health agencies, committees, organizations, professional groups and the like.

Performing administrative and supervisory duties as required.

Effectively executing the strategies, tactics, programs, responsibilities or duties as may be assigned by the State Health Officer.

The minimum qualifications for these positions are:  

Graduation from an accredited school of medicine Licensed to practice medicine in the State of Mississippi

Preference will be given to Board Certified physicians and candidates with public health related experiences, training, certifications and degrees, including but not limited to Masters in Public Health.

Interested candidates should submit their resume and/or completed State of Mississippi Employment Application; copies of their degrees, certifications and licenses; and provide salary requirements to:

MEDLEY & BROWN, LLC F I N A N C I A L

Call us at 601-982-4123

A D V I S O R S

www.medleybrown.com

Mississippi State Department of Health Director of Human Resources The Mississippi State Department of Health P. O. Box 1700 Jackson, MS 39215-1700 is an Equal Opportunity Employer Phone: (601) 576-7642 http://www.msdh.state.ms.us/ The Mississippi State Department of Health is an Equal Opportunity Employer

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December 2014 JOURNAL MSMA 397

• Physician’s Bookshelf • An Absent Mind A Novel by Eric Rill (262 pp.)

Avante Press; New York, NY 2014

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fable concerning a rich woman named Kisa Gotami is one of the most prolifically told tales within the Buddhist canon.

In the story, Kisa Gotami awakes one morning to find that her only and much loved infant son has died in his sleep. Running out of her house and carrying her dead son in her arms, she desperately cries out for help. Despite the pleas from the people in her village to bury the dead boy, she continues to search the streets for someone who can bring him back to life. An old man, seeing the woman’s plight, tells her to see the Buddha. Upon seeing the woman in her anguish and desperation, the Buddha tells her that he can help her son only if she can return to him with some white mustard seeds from a house that has never experienced death. Believing the Buddha to be preparing a magic potion, Kisa Gotami joyously rushes back to the village to find the mustard seeds, but at every door she enters, she finds that the people inside have also suffered the loss of a loved one.

As the sun goes down, the exhausted woman still has not found a house free from death. Realizing that death is an inevitable part of the human condition, the story states that Kisa Gotami suddenly becomes enlightened, understanding that her quest to bring her son back is futile. Acceptance of death and illness is necessary to life.

There is similarly not a single household within the United States that likely has not in some way been touched by Alzheimer’s dementia, although the caregivers and sufferers of this disease may think themselves very alone, just as Kisa Gotami did.

Eric Rill’s “Independent Publisher Book Award” winning An Absent Mind shows the reader the life of a family as their patriarch Saul Reimer is diagnosed and declines due to Alzheimer’s disease. The story is told through a series of confessional style diary entries written by each member of the Reimer clan, moving chronologically from Saul’s early disease, through his diagnosis, and eventual death. The reader is given a window into the mind of each family member as they watch their father slowly slip away from them. Monique, Saul’s wife, speaks heartbreakingly of her bittersweet marriage with Saul and of the fatigue and sadness of taking care of him as he descends further into dementia. Saul’s children grapple with trying to forge a relationship they never had with their father by taking care of him while he becomes mentally less and less able to express his own desires for such a relationship. Saul himself speaks of the horrifying disjunction of wanting to communicate with his family while his body and mind collapse from beneath him.

The book is emotionally charged (Eric Rill dedicated it to his own father who suffered from the disease), and few will not be affected by its pathos in some way. What works is that Mr. Rill builds upon the nuanced reactions of his various characters to give an impression of experiencing a broad spectrum of human expression and suffering. Hearing the stories of each family member and their differing perspectives brings awareness of the extensive family tragedy wrought by the disease. What does not work is that stylistically, Mr. Rill’s writing tends to be rather flat, and the voices of the different characters often seem similar to each other and seem to step on each other’s toes.

I believe An Absent Mind would be a wonderful addition to any physician’s bookshelf and would especially recommend it to adolescents as well as patients and their families (members from middle school and above could read it easily) as they deal with living with Alzheimer’s. Mr. Rill gives a tragic dignity to the disease. He seems to be saying that it is by living and understanding others’ experiences that we, like Kisa Gotami, become enlightened, and it is by seeing how others have persevered over suffering that we too can overcome our own.

—William L. Vail, M3, Tulane University School of Medicine

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• Special Article • Remembering JMSMA Editor Emeritus

Myron W. Lockey, MD

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Karen A. Evers, JMSMA Managing Editor

r. Lockey was the Journal editor when I first started here in 1995.

Rarely did circumstances warrant a personal visit to MSMA headquarters but if there were email chatter or an editorial concern, he never hesitated to drop by unannounced. On those occasions, it was common for him to close the door behind him, look me in the eyes, and ask, “Karen, what the hell is going on?”

He always aimed to be fair, wanting to understand all sides before drawing a conclusion. He taught me the importance of doing whatever you set out to do well, and when you’ve given it your best then move on to the next thing. He said, “Be positive, patient, and persistent because the strongest people aren’t the people who always win, but the people who don’t give up when they lose.”

I can still see his smiling grin with inquisitive eyes as he listened to his colleagues at our annual committee on publications meetings. Once someone suggested an article for the Journal on the “Top 10 Things Physicians Should do before they Die” and Dr. England (who succeeded him as editor) suggested “like having a little oriental chick walk on his back” or “seeing the Rebels in a national championship game again.” Dr. Lockey’s eyes would beam as he gazed as if to say, “Did he really just say that?”

At weddings and funerals when Dr. Lockey was around, he was quick to show me he cared. Under the old oaks of St. James Episcopal Church at Dr. Dan Van Cleve’s funeral, he placed his compassionate arm around my shoulder as if he knew the void I felt left by my own dad’s premature death.

That single gesture was ever comforting. Some time after Dr. Lockey’s own funeral, in his memory and acknowledging the grieving of his family, I walked the labyrinth in the St. James Prayer Garden (which Dr. Lockey was instrumental in establishing) and several stories came to mind.

One story I heard him tell was about making up an exam. It was during his Physical Diagnosis class in the spring of his sophomore year. It came time for the class to go out to the old West VA Hospital in west Jackson and do their first individual history and physical examination. Dr. John Busey had assigned each student a patient for this. Dr. Lockey said he had to miss Aside from enjoying his grandchildren, his that day because he was a witness at a trial. Gene Davidson also missed family tree farm operation, and being an because of sickness. Dr. Blake told them to go see Dr. Busey and make up amateur radio operator, in 1996 at the age of the exam the following week. They entered Dr. Busey’s office and stated 65 Dr. Lockey returned to the pool to train for they were there to make up the missed examination. He said, “At that point his enjoyment of competitive swimming. The Dr. Busey became very irate and very quickly got into our ancestory. He very next year he placed in two events at the then said to follow him, and he went to the medical ward where he asked U.S. Senior Olympics and went on to win 10 Dr. John Davis, ‘Do you still have that damn Choctaw Indian that has been national championships in 10 years. In 2006, here sixteen times and can’t say anything but ugh?’ If so give him to these he ranked in the top 10 in the world in five two, and I want to grade their history and physical examination tonight.” events in his age group.

See Lockey....Continued on page 410

December 2014 JOURNAL MSMA 399

• What they Say about Him •

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Oh no, it so saddens me to hear that Myron is not with us, I almost can’t believe it. Myron was an inspiration to me in my masters swimming days. We met at FINA World Champs in 2006.

I was going to be moving to Jackson after the meet and I contacted Catfish Masters here to find out their practice schedule. They told me Catfish Myron Lockey had also qualified for Worlds and that he was a breaststroker (same as me)-and that he was 75. All I could think at the time was “wow” and that I must find him at the meet and introduce myself. Myron and I met at Worlds at the clerk of course. He was so welcoming and chatty for someone about to swim. He was also sharp as a surgeon and really precise which I always appreciated later.

He swam great at Worlds though he seemed to shrug off the 2nd place in the world as “that was okay, I’ll take it, but no biggie.” He had perfected a side breathing technique for breast that he said was easier on his back since a previous injury and surgery. I marveled that he could push himself to be so fast at his age by finding ways to keep his speed. Myron became an early morning swim buddy of mine after I moved here and I always admired his dedication to being there every morning and getting after it each day. He was always positive and always happy to be there. I would run into Myron the past few years at the Flowood YMCA on occasion when he would stop by to swim some laps. He would always ask me how my team was doing. I would ask him how he was swimming and he would say that he was swimming old but he was still swimming. That always brought a smile to my face and I always considered myself lucky when our paths would cross. He was awesome. I will miss him.

—David Orr, Jackson Head Coach, Sunkist Swim Team

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t is often said that we stand on the shoulders of giants who stood here before us. Myron will always be remembered for his efforts to advance the field of Otolaryngology - Head and Neck Surgery at the University of Mississippi Medical Center and in our state. Those of us who followed him at UMC were beneficiaries of his struggles at that institution. He acquiesced this fact and interacted with the otolaryngology program that followed him with equanimity and even public admiration. His endeavors for progress were recognized nationally and are applauded to this day. Myron was a walking encyclopedia of endless and incredible medical stories that he shared with his many colleagues and friends. Importantly, he recognized the medical enterprise for its imperfections, admired it for rapidly evolving knowledge, and especially enjoyed the great debates and controversies.

He exemplified the Hippocratic oath in a modern sense. Through him, many lives were healed, knowledge and skills disseminated, and a bar was raised in the world of medicine. —Vinod K. Anand, MD; Jackson

I

was privileged to work with Dr. Lockey during the years I wrote for the Journal, participated in the Publication Committee’s activities, and most recently in our attempts to protect the Journal’s editorial integrity. It was in this that I had my clearest insight as to the vision he held about his time as Editor of the Journal. Myron understood the power of his position. He, in all probability, had more influence on the understanding of issues of the day and the opinions of the physicians of this state than any other officer ever elected by our Association. Yet he was bound by the responsibility of that influence and made sure equal voice was given to all. He encouraged participation and guided gently to achieve a superb and balanced product. He did what the very best editors do: he worked relentlessly at remaining invisible while letting the writing between the covers of the Journal speak for itself. Rest in peace my friend.

— Scott Anderson, MD; Editor, China Grove

JMSMA Managing Editor Karen Evers with Editor Emeritus Dr. Myron Lockey— Though physically weak, Dr. Lockey called his son Payton to assist him so he could attend the MSMA 50-year-club breakfast during annual session last August.

SWIMMING FOR THE PURE JOY OF IT— Dr. Lockey grew up on the North Carolina coast where it was popular to swim. He didn’t swim competitively and had no coaching. That came when his family moved to Jackson and as a young teen he began going to the old Livingston Lake pool. He was quite the natural, and soon after he began competitive swimming, winning state championships and eventually Southern AAU championships. No Mississippi colleges had competitive swimming teams, so Lockey went away to the nearest place that did: Northwestern (La.) State. In four years there, he was undefeated against collegiate competition. SMU tried to recruit Lockey away from Northwestern, but he finished there before coming back to Jackson for med school. In Mississippi, he met his wife, Martha, who had been a synchronized swimmer herself.

I

had the privilege of working alongside Dr. Lockey for 25 years while I served as Executive Secretary, Central Medical Society. He served in every capacity for Central, including President, and was always available to help in any way. Dr. Lockey was the ultimate professional, intelligent, and witty. Our medical community lost a champion, and I lost a friend!

—Patsy Douglas, Jackson

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t was sometime between 1977 and 1979 at UMC. I was a lowly med student rotating through surgery. There had been a problem with a shortage of scrub suits for all of us. This was aggravating many people and slowing cases on the surgical schedule. One morning I heard a clamor of loud voices, and I looked out to see what was happening. Dr. Lockey was dressed out in a woman’s scrub dress, fully suited with scrub cap, mask, and shoe covers, scrubbing to go into a case. The head nurse was saying, “Dr. Lockey, there was no need for that!” He was so mad that it looked like smoke was pouring from his ears. He had very hairy masculine legs sticking out from under that dress, but believe you me he did not look feminine. No one dared to laugh! He went in and performed his case to the level of his usual surgical excellence, and I do believe that his defiance solved the problem. I am so very lucky to have known him. Years later, I ran into him at a medical meeting and reminded him of this episode. He seemed to enjoy the story, and we both laughed. He taught me plenty, not the least of this was the courage to act if needed regardless of the fear of what others may think.

—Carolyn Gerald, MD; Hattiesburg

I

really liked and admired him. He was not afraid to make a tough decision and stick by it. I always felt I had his total support regarding the Journal. He could be blunt though.

—Nola Gibson, JMSMA Managing Editor 1969-1979, Jackson

December 2014 JOURNAL MSMA 401

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have not forgotten Dr. Lockey’s comments on one of my editorials when I was associate editor. He reminded me of my father when I had done something naughty….He would only say, “Son, I don’t think I would do that again.” This one I had written after being in Los Angeles for an American Board of Family Medicine Board meeting when there were 300,000 LBGTs in town. I simply wrote that I guess, “AIDS would take care of the problem!” Well he was right, I just should not have written that one. —Joseph E. “Joe” Johnston, MD; former JMSMA Associate Editor, Mt. Olive

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yron Lockey, MD was both a courageous friend and a generous mentor to those of us here at our JMSMA. Having served in an editorial capacity from 1973 to 1998, first as Associate Editor and then as Editor, Myron was at the forefront of Journal production for a generation of Mississippi physicians. He was a bridge to the great Journal of old, and his wisdom was treasured by the Journal editors who came after him. He continued to serve this journal in his later years as Editor Emeritus and as second chair of the Journal Editorial Advisory Board. Few over the last 100 years have left such a mark on this Journal: over four decades of leadership in a variety of important roles.

We will not only miss Myron’s loyal friendship and his athletic passion about medical journalism, but also we will miss the fascinating folklore he passed on of those that produced the Journal over the last half century. The Publications Committee paid little attention to the eccentric tradition of Bloody Marys and Shrimp Cocktails at its annual meetings: it was Myron who reminded us it had been a cherished tradition started in the 1940s by then Editor Dr. Lawrence Long, who asserted journalists and writers would be literarily inspired by such a menu, and as well, they deserved the special treat due to their extensive free labor for the association. It was Myron who recalled various tales of offended readers and painful typographical errors: the persisting nature of this awkward beast known as medical journalism. His leadership spanned a great period of medicine in our state, and he played his role on that stage with grace, professionalism, and excellence. Could any of us ask for more?

In his last year, he participated in the creation of the new Journal strategic plan, and thus his influence will continue for years to come. We editors, in the end, are just another link on a long chain, this chain of JMSMA. This link on the chain (me) highly valued my predecessor Myron Lockey, certainly one of the strongest links of all. May others of his quality bless this Journal in the future. —Lucius M. Lampton, MD, Editor; Magnolia

D

r. Lockey was a great leader in medicine who spoke his mind and backed up his opinions with facts. He was a tireless worker for the Journal MSMA for many years. His editorial skills, good humor, and keen advocacy for medical journalism, will be missed by those who were fortunate to have worked with him on the Journal. He was also very involved in his church and his friends there recognized his leadership ability by electing him to important posts such as Senior Warden. No greater tribute can be made to Dr. Lockey than the words written by his sons that were printed in the program at his funeral and reprinted on the following page. He fought the good fight of faith. —Philip Merideth, MD, JD; Jackson

A

lthough I first met Dr. Myron Lockey during my initial stint with MSMA in 1973-78 when he became an Associate Editor of the Journal, I really didn’t get to know him until we were both working at the University of Mississippi Medical Center in 1978-80. At that time, he was a member of the faculty and Director of the Division of Otolaryngology while I was the assistant to Dr. Norman Nelson, who was Dean of the School of Medicine and Vice Chancellor for Health Affairs.

Dr. Nelson and I shared a suite of offices directly across from each other and Myron would often drop by either to get a cup of coffee or to meet with Dr. Nelson. Whenever he did that he would always come into my office to visit and chat, and that is when I began to develop an enormous appreciation for the kind of physician and man that Myron was. To say that he was principled and had strong convictions would be an understatement, and during that time he would frequently express to me his unhappiness with Otolaryngology’s status as a Division in the Department of Surgery, rather than a full-fledged academic and clinical Department.

Not long after that, I moved to Chicago and then Washington, D.C. to work for the American Medical Association and Myron left UMMC for private practice. When I returned to Mississippi and MSMA in 1989, Dr. Lockey had become Editor of the Journal MSMA, and we quickly renewed our friendship. We often sat next to each other at the long conference table where the MSMA Board of Trustees held its meetings, and we frequently shared a dinner table at meetings of Central Medical Society, which he attended regularly. Even though I seldom had the opportunity to work with Myron in his capacity as Editor of the Journal, I distinctly remember that his leadership led to many significant changes in both the content and tone of the Journal.

The things I remember most about Myron are: (1) he was an outstanding clinician and practitioner of ear, nose, and throat surgery, so much so that when my youngest daughter had problems with her tonsils and adenoids, we took her to Dr. Lockey, and his surgical and patient skills made our life enormously easier; (2) Myron Lockey always did things the right and honorable way, which is what one would expect from a man of his convictions and sense of what is right and just. He always did this

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in some very difficult, contentious, and personally threatening situations because those who chose him for such duties knew that he would do what was right, not expedient; and (3) although Myron was a no-nonsense, serious man without a phony bone in his body, he was not without a warmness and sense of humor that made it easy for people like me and others to instantly like and respect him. This is the Myron Lockey I will always remember and cherish.

—William F. “Bill” Roberts, JD; Past MSMA Executive Director, Ridgeland

I

t has been so achingly difficult to find words about the loss of our dear friend Myron Lockey. The death of such a man is indeed a keenly painful loss to countless family, friends, and colleagues. And the void he has left at MSMA runs deep and wide. The indefatigable Myron was plain and simply my hero.

As Chair of the UMC- ENT Department, Dr. Lockey was one of my attending physicians when I was a med student.

Years later, I was thrilled and fortunate to serve under him as an Associate Editor of the Journal MSMA during his lengthy and productive tenure in that position. His aim was always selfless service to the association and to the profession. He never sought kudos or self-acclaim, rather he sought accomplishments for the Journal MSMA. Dr. Lockey served for 14 years as duly elected Editor of the Journal. Then, one year he was finally asked to run for President of MSMA. Myron ran and all of us who worked with him loyally rallied in support for him. The plainspoken Dr. Lockey was never the smooth political schmoozer. Always one to convey his mind and positions which weren’t always popular or even politically correct, he suffered what for him was a painful defeat in his bid for the highest office at MSMA. I would have to say of that defeat in retrospect that although it hurt him at the time, it was really no big deal. An MSMA President serves a one year term and then is the summarily put out to pasture. Tiring of the struggles, most Past MSMA Presidents simply retire on their laurels and fade into the sunset. However, the mark Dr. Lockey made on our association was a far broader stroke than that made by any individual MSMA President. Myron Lockey was a real life long-distance athlete and did not walk away from our association after that defeat. His diligent work and influence continued at the Journal even up to a few short weeks before his death this past summer.

I recall that Myron was going through his first serious bout with cancer about the same time I was diagnosed with a parotid malignancy in 2008. We e-mailed back and forth, and because he was my old ENT professor, I was not above asking him questions about my condition. We became online cheerleaders for each other. Lord, how I loved that Dr. Lockey.

—Dwalia South, MD; Chair, MSMA Committee on Publications, Ripley

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yron Lockey and I shared careers in two very different worlds: first in academics at UMMC and, later, in the real world of private practice. He was always a friend and a professional “soul brother” in either venue. In contrast to myself, however, who has been woefully lacking in athletic prowess, Myron Lockey deserves to be in the Mississippi Sports Hall of Fame.

He apparently was a superior swimmer in college. Later in life, he activated his swimsuit and prepared for competitive swimming meets by getting up at 5 a.m. and swimming three miles almost every day. The result was national championships in his age group in more than one event. Very few Mississippians have earned individual national championships, in any sport, at any age. He was a unique physician, a unique athlete, and a solid citizen of organized medicine. —W. Lamar Weems, MD; Jackson

R

emembrances from his wife and sons

W

hile on a Celtic Pilgrimage trip to Ireland with CCN we were visiting a Church and noticed a saying on a headstone.

This had special meaning and stuck with us ever since. “Death leaves a heartache that no one can heal, love leaves a memory that no one can steal.” —Martha Lockey, Madison

I

remember a story from my Dad’s time at the University Medical Center about his diagnosis of a case of Hansen’s disease (Leprosy). He worked with Leprosy patients during his time as a physical therapist at the U.S. Public Health Service Hospital in Louisiana. When a patient at the University could not be properly diagnosed, Dad was called in because of symptoms on his nose. Dad immediately diagnosed him with Leprosy. His colleagues doubted his certainty but he was right. I always liked this story because when it came to medicine he was always on top of his game.

He strived always to be smarter than what he was working with, be it in surgery or learning the new air condition system in the Parish Hall. I am grateful that he taught me to be this way. —Myron Willis Lockey, Jr.; corporate pilot, Ocean Springs

December 2014 JOURNAL MSMA 403

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n the early 1980s, the University Hospital ENT department was sued for malpractice. During the trial, he was on the stand testifying when the Plaintiff s attorney asked him if he used Dr. X’s book in his teachings. Dad replied that he used many books in his teachings. The attorney then asked Dad if he thought Dr X was an expert in the field. Dad replied that just because someone writes a book it does not make him or her an expert. When asked about the specific surgery that was the subject of the litigation, Dad said that his students followed the standard procedures for that type of surgery, steps a, b, c, and d.

The attorney then pulled out Dr X’s book and told Dad that they had missed a step described in the book. Dad asked to see the book. When the attorney handed him the book, Dad opened to the front, looked at it, and then closed the book. Dad pointed out to the attorney that the book was published in the early 1980s and that the surgery had taken place in the late 1970’s; therefore, the book, and the procedures outlined therein, especially the extra steps, were irrelevant to the case. Needless to say, the case was over. —Russell Garrett Lockey, JD; Harrisonburg, VA

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ost peopleforcould write endless stories how their mobile father devices actively taught them important lessons in life, like how iPhone, iPad, Android, andabout all web-enabled to behave, or how to tie your shoes, or how to bait a hook, or throw a ball, or how to correctly hammer a nail, or how to be a true sportsman, howJournal to be a gentleman. am oneofofyour those hand. lucky people. My dad actively taught me lots of things.

Putorthe MSMA inWell, the Ipalm But I am actually way luckier than most. See, my dad had a gift, a very special gift. He could teach you things and you didn’t Full color. Flip-page. Every month. even know it. My dad actually taught me way more things in life in a passive manner. So passive, that I was in my mid-twenties before I realized his true gift. I learned from my dad all the ways not to behave or the ways not to treat people, or property, or things. I learned these things because of what my dad was not. He was not boastful or insensitive. He was not cruel or unkind.

Nor was he inconsiderate or unsympathetic. He was not callus or ruthless, or abrasive or coarse. He wasn’t boisterous or rowdy.

He wasn’t big-headed or a know-it-all. He was never negative or disapproving. What he was, was the perfect teacher, person, and father.

I am what I have become because of what he taught me, both actively and passively. Mostly by his example. Mostly by his image. What I am is one of the three luckiest boys in the world. I am his son...

I only know of one other more full of Grace...

He will never stop teaching me. —Payton Longmire Lockey, environmental geologist, Madison

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December 2014 JOURNAL MSMA 405

• In Memoriam • The JMSMA encourages families, friends, and our readers to submit obituaries and photos of Mississippi physicians for inclusion in the pages of our Journal. Email to kevers@msmaonline.com or slow mail to JMSMA. —Ed. James Edward Aldridge, MD Brandon Dr. John Edward “Jack” Aldridge died peacefully in his home Tuesday, October 14, 2014, after a lengthy illness.

Jack was born on December 11, 1938, to John Edward and Anne Jean (Butt) Aldridge. A native of Winona, he received his Bachelor of Science degree from the University of Mississippi where he was a member of Pi Kappa Alpha fraternity. He received his medical degree from UMMC in 1964 and subsequently completed a residency in urology and a fellowship in pathology. Dr. Aldridge also had a preceptorship at Ranchos Los Amigos Rehabilitation Hospital under Dr. Estin Comaar. Jack assisted in administering anesthesia for the world’s first human heart transplant in 1964.

It was performed by one of his favorite professors, Dr. James Hardy, using a donor heart from a chimpanzee. While serving as Assistant Professor of Surgery at UMC and Visiting Teaching Physician at University Hospital, Dr. Aldridge partnered with his valued mentor Dr. Lamar Weems in private practice. Jack then became a partner in Dr. Temple Ainsworth’s Group which became the Mississippi Urology Clinic.

A board certified Urologist, Dr. Aldridge joined the medical staff of Mississippi Methodist Rehabilitation Center when the facility opened in 1975 and established the urology program for the hospital. He specialized in the treatment of neurogenic bladder, and worked to improve the lifespan of patients with spinal cord injuries. A member of the American Fertility Society, he worked with paralyzed males and their spouses to help them conceive using a procedure developed by Dr. S.W.J. Seager of the National Rehab Hospital in Washington, D.C. Dr. Aldridge was Chief of Surgery at St. Dominic Hospital from 1984-1986 and Chief of Urology 1994-1995. He also served on the staff of Baptist, River Oaks, and VA hospitals. After his retirement in 2001, Dr. Aldridge volunteered at MMRC and received the 2005 Goodwill Volunteer of the Year Award. In August of 2014 he was thankful to be able to celebrate 50 years of medicine with his medical class of 1964 at a reunion ceremony in the Senate chamber of the Old Capital Museum in Jackson.

A Major in the Mississippi Army National Guard Medical Corps, Dr. Aldridge was a member of the 134th Surgical Hospital.

He enjoyed performing physicals on Eskimos above the Arctic Circle in Alaska as well as teaching medical procedures to fellow guardsmen in Jackson. Jack was a member of The United States Power Squadron and a Seaman in the United States Coast Guard.

Dr. Aldridge was a member of Grace Bible Church and served as a deacon. He was a Gideon and a member of the board of PATH Bible Study. He received a certificate from the Institute of Holy Land Studies in Jerusalem, Israel, from his participation in the academic study entitled Geographical and Historical Settings of

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the Land of the Bible. He also was recognized for Distinguished Missionary Service in Honduras by the foreign mission board of the Southern Baptist Convention. Dr. Aldridge enjoyed boating, fishing, art, painting and the study of languages, especially German and was a member of the German Study Group. He traveled with his family throughout the United States, Europe, the Middle East, the former USSR, Mexico, Canada, and Central America.

Jack will be remembered for his kind and generous heart.

He was contemplative and although not easily engaged in conversation, he loved people, no matter what race, class or social status. He enjoyed reading; whether his Bible, history, philosophy or books on solar energy and electricity, he was never without a book nearby. He truly practiced medicine, always staying current on the latest advancements but never afraid to try the good old fashioned remedies. He made house calls and took phone calls from patients at home. He was glad to accept fruit and vegetables as payment methods in the days before managed care when physicians were able to be doctors and not scribes.

A man of faith whose actions spoke volumes, Dr. Aldridge was always willing to share the hope of Jesus with others. His life was one of service and giving to others, never concerned with society’s latest trends or fashions. He was a gentle, caring father, loving and faithful husband, trustworthy friend and servant of Christ.

Dr. Aldridge is survived by his wife of 49 years, Nancy Thomas Aldridge; son, John Thomas (Christy) Aldridge of Meridian; daughter, Nancilynn (Scotty) Dickey of Brandon; and grandchildren John Thomas Aldridge, Jr., Anna Elizabeth Aldridge, Jesse Thomas Dickey, and Jonathan Morris Dickey. He is also survived by two brothers, Franklin Baroner Aldridge and Ronald Hugh (Beth) Aldridge of Jackson. The Family extends special thanks to Chester Davis, Lillie Griffin, Brenda Hughes, Lawrence Cosby, Tricia Morace, and Sta-Home Hospice for the excellent care they provided. Memorials may be sent to Grace Bible Church on the Parkway or Gideons International.

George Wells Armstrong, III, MD Coffeeville Dr. George Wells “Fella” Armstrong, III, 79, of Coffeeville, passed away Monday, October 20, 2014, at his residence. Dr. Armstrong was born October 10, 1935, to the late George Wells and Georgia Criss Armstrong. He was a graduate of Coffeeville High School and received his undergraduate degree from Millsaps College. He earned a degree in Pharmacy from the University of Mississippi then earned the Doctor of Medicine degree from the University of Tennessee. He practiced medicine in Denver, CO for over 25 years before moving back to Coffeeville in 1993 to open Dr. Fella’s Medical Clinic. Dr. Armstrong was a member of the Coffeeville United Methodist Church, a Mason, and US Air Force Reserves Veteran.

Survivors include his wife, Pat Maloney Armstrong; a daughter, Shawn Louise Armstrong; and a son, George Wells Armstrong, IV, all of Coffeeville; and two brothers, Joe Bates Armstrong of La Mesa, NM and Ralph Armstrong of Grenada.

He was preceded in death by his parents and a sister, Ann Armstrong Sides. Memorials may be directed to the Coffeeville United Methodist Church or St. Jude Children’s Research Hospital.

Darrell Burnham, MD Hattiesburg Darrell Burnham, MD, of Hattiesburg, died Sunday, October 19, 2014, at Forrest General Hospital. Burial was at Highland Cemetery. Dr. Burnham was a Deacon at Temple Baptist Church. He went on medical mission trips to Nigeria and Honduras with Baptist Medical Dental Mission International. He was the Director of LAW Outpatient Center, past Chairman of the Department of Anesthesia, served on the Hattiesburg Clinic Board, and was a member of the American Society of Anesthesiology. He also coached American Legion Baseball in Oak Grove. He was preceded in death by his father, James William Burnham. He is survived by his wife, Tracy McMahon Burnham of Hattiesburg; one daughter, Sarah Elizabeth Burnham of Hattiesburg; two sons, Luke William Burnham and Andrew David Burnham, both of Hattiesburg; his mother, Lucile Burnham of Laurel; two brothers, Dr. James Donald Burnham of Ridgeland and Dr. Brian Franklin Burnham (Beckie) of Perry, GA; nieces and nephews, Dr. Joshua Burnham, Eric Burnham, Bethany Burnham Bryant, Daniel Burnham, Allison Burnham, Thomas Burnham, Ashlin McMahon Grant, James Howard McMahon, III, and John Haskin McMahon. The family requests memorials be made to Temple Baptist Church.

Richard Jennings “Dick” Field Jr., MD Centreville Dr. Richard Jennings Field, Jr., died peacefully at his home in Centreville on July 22, 2014, from complications of Parkinson’s disease. Affectionately known by thousands of his patients as “Dr. Dick,” he shared his surgical knowledge and his faith around the world but always with an unwavering love and devotion to his hometown “folks,” his church, his school, his family, and tirelessly, his patients. The son of Dr. and Mrs. Jennings Field, Dr. Dick was born in Centreville on September 6, 1926. A 1943 graduate of Centreville High School, he played football for his beloved Tigers. He received his undergraduate degree in two years and completed his medical degree in 1949 from Tulane University. He received the Outstanding Senior Award from Nu Sigma Nu medical fraternity and served as its president. After completing a residency in General Surgery at Tulane/Charity Hospital under Dr. Alton Ochsner, he received advanced surgical training at the Lahey Clinic in Boston, MA. He served as an officer in the United States Navy before

returning to Centreville in 1956 to continue in the footsteps of his father, Dr. Jennings Field, and his uncle, Dr. Sam Field.

Always excited to share his knowledge and love of surgery, Dr. Dick maintained clinical teaching appointments at Tulane University, The University of Mississippi, and Louisiana State University. By establishing clinical teaching rotations, he introduced hundreds of medical students to rural medicine. A passionate advocate for bringing leading-edge surgery to save more lives in rural communities, Dr. Dick became a prominent and influential voice in American surgery. From his early days of driving injured patients to the emergency room in the family station wagon to serving in the highest ranks of the American College of Surgeons, he was always intensely focused on making life safer and better for his friends and neighbors in South Mississippi. Naturally merging his faith with his work, Dr. Dick led multiple medical mission trips to Honduras, prayed regularly with his patients and colleagues, and served as an Elder at the Thompson Memorial Presbyterian Church for more than 45 years.

Among many honors and distinctions that he received during his long career, the one that Dr. Dick cherished most was being team doctor for the Centreville Tigers for more than 50 years. Others included The Richard Field, Jr. Lectureship in Surgery, established in his honor at the University of Mississippi Medical School. A dedicated leader for the American College of Surgeons, he served as Governor of Mississippi and Chairman of the National Trauma Committee, where he received its Meritorious Award. He became the only Mississippi surgeon elected to its Board of Regents and was later selected second vice president. He was a Fellow of the Royal College of Surgeons and a member of the Southern Surgical Society, The Southeastern Surgical Congress, and The American Association for the Surgery of Trauma. He was chairman of the Mississippi Emergency Medical Services Council and a founding member of the Alton Ochsner Surgical Society. Dr. Dick received the Teacher of the Year award multiple times from Tulane Medical School, was president of the Tulane Medical Alumni Society and was honored for his contributions in medicine and rural surgery by the State of Mississippi and Governor Kirk Fordyce with “Dick Field Day.” Always an advocate for his community, Dr. Dick was an active member of the Centreville Public School and Centreville Academy boards of directors, President of the Centreville Chamber of Commerce, Founder of the Centreville Carousel of Arts Day, Founder of the Field Memorial Distinguished Lectureship, and charter member of the World War II Museum.

An avid nature lover, Dr. Dick was a member of the North American Bluebird Society. He established a blue bird trail at Pine Hills Country Club and always enjoyed sitting on his front porch watching bluebirds. Dr. Dick is survived by his soul mate of 64 years, “Miss Betty,” and his three children, Dr. Richard J. Field, III and his wife, Melissa of Centreville, Mrs. Betsy Field MacKay and her husband, Angus, of Dallas, TX, and Dr. Edward D. Field and his wife Julie of Oxford. He cherished his role as a father and grandfather, especially when each was old enough “to play sports.” His grandchildren are Richard Jennings Field, IV, Burton Foret Field, William Dunbar Stewart MacKay, Elizabeth Anne Field, and Catherine Newell Field. He is also

December 2014 JOURNAL MSMA 407

survived by his sister, Babe Field Carr of Oxford, his brother, Dr. Davis Field of Tupelo and many beloved nieces, nephews, and cousins. Memorial gifts may be made to Field Memorial Community Hospital, Centreville Academy, Thompson Memorial Presbyterian Church or the World War II Museum.

For more on Dr. Field, see Bob Pittman’s 2001 biography of him entitled “Dr. Dick: The Hands and Heart of a Rural Surgeon.”

Elmer Jacobs “Moe” Harris, MD Jackson Dr. Elmer Jacobs “Moe” Harris, 97, originally of Jackson later of Huntsville, AL, passed away Monday, June 23. He was preceded in death by his parents, Mitchell Luther Harris and Annie Docia Jacobs Harris and by two wives, Ellen Virginia Moncrief Harris and Leatrice VanLandingham Harris. Survivors include sister, Ruth Harris Peet; brother, Mitchell Harris; children, Lucile “Lucy” Harris Schardt, Rod Harris, and Mary Ellen Harris; grandchildren, Susan Schardt and husband Denny Guy , Matthew Schardt and wife Kate, Kristen Harris Folkman and husband Chris, Daniel Harris and wife Linda, Brian Foscue, Virginia Foscue, and four great-grandchildren.

Dr. Harris, the son of a Baptist minister, was born September 27, 1916 in Ozark, AL and spent his boyhood years in Prattville and Guntersville, AL. He attended Wake Forest College from 1934 -1937 and Tulane University School of Medicine from l9371941. He completed an internship at Charity Hospital in New Orleans in 1942. In World War II, Dr. Harris served in the 24th Medical Division of the US Army. He received a Purple Heart for service in Hollandia, New Guinea in 1944 after a severe injury to his left leg. After several experimental surgeries and 3 years of recuperation at Army Hospitals, he regained use of his left leg. Throughout his life, he was thankful to be alive and to be able to walk.

Dr. Harris completed a Residency in Radiology at Columbia Presbyterian Medical Center in New York City in 1950. He was a founding member to the Radiological Group at Mississippi Baptist Hospital in Jackson. In 1952 he was instrumental in establishing the first Radiological Technician Training School in Jackson. Changes in Radiology from development of single films in a darkroom to digital films and advances in radiation oncology occurred during Dr. Harris’s practice with the Radiological Group from 1950-1990. Dr. Harris felt fortunate to have worked in an intellectually challenging and exciting field with constant improvements in diagnosis and treatment.

He was a founding member of Covenant Presbyterian Church in Jackson, and an affiliate member of Covenant Presbyterian Church in Huntsville, AL. His donations helped secure the acquisition of a permanent home for Operation Shoestring in Jackson. Shoestring’s Ellen Harris Center is a living memorial to his first wife. During his last years, Dr Harris resided at Brookdale Place at Jones Valley Farm in Huntsville, and in his final 9 months at Floyd E “Tut” Fann State Veterans Home in Huntsville. At both Brookdale and “Tut” Fann, he cared deeply for the other residents and staff.

Dr. Harris was known for his bowtie and his snorkel. He

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wore a bowtie each week to church and swam 15 Olympic laps several times a week in his mid-nineties. In his last years he became a student of history, listening to at least three audio books per week provided by the Huntsville Public Library. He had a will of iron, foresight, keen insight, an ability to focus on matters of importance, and an ability to produce optimal outcomes. He always looked for the best in others. On one grim night in New Guinea in WWII, Dr. Harris promised God that if he could just live through the night, he would be the best person he could be and do the best he could for the rest of his life. He lived through the night, and he kept his promise.

Donations may be sent to: Covenant Presbyterian Church, 4000 Ridgewood Road, Jackson, MS 39211, Covenant Presbyterian Church, 301 Drake Avenue, SE, Huntsville, Alabama 35802, Operation Shoestring, 1711 Bailey Avenue Jackson, MS 39203, or charity of your choice .

Myron Willis Lockey, MD Madison Myron Willis Lockey, MD, 82, of Madison passed away on September 11, 2014, at Hospice Ministries in Ridgeland.

Dr. Lockey was born on October 9, 1931, in Morehead City, NC. He was the second oldest of four children of Garland and Louise Lockey. He was preceded in death by his parents and his oldest brother Howard Linly Lockey, Sr. The family moved from NC to Pearl after WWII. He graduated from Pearl High School in 1949 where he served as the Class President of the first graduating class. He was the one that suggested calling the mascot the Pirates. Dr. Lockey was a very accomplished swimmer growing up. He won state championships and eventually the Southern AAU Championships. No Mississippi colleges had competitive swim teams so he attended Northwestern Louisiana State University in Natchitoches, LA. In his four years there he was undefeated in all collegiate competitions. He graduated with a B.S. in 1953. Following graduation he attended The School of Physical Therapy at Charity Hospital in New Orleans, LA and received Certification from the American Physical Therapy Association. As a physical therapist, he worked in Carville, LA at the Carville National Leprosarium and in Mississippi at the Mississippi Crippled Children’s Hospital. He was one of the first Physical Therapists in Mississippi. He had a strong desire to help others so he completed his Pre-Med requirements in 1956 at Millsaps College. Myron attended the University Of Mississippi School Of Medicine from 1957-1961. Following graduation he completed his internship at UMMC. From July 1962 through June 1966 he completed his residency training in General Surgery and Otolaryngology at the VA Medical Center, Southwestern Medical School in Dallas, TX. Following his residency he returned to Jackson and became a Clinical Instructor at the University of Mississippi School of Medicine. Over the next fourteen years he held numerous teaching positions. As Chairman of the Otolaryngology Department he trained an entire generation of Mississippi head and neck surgeons. His skills in the operating room were

some of his most important contributions. He stepped down as Chairman of Otolaryngology in June of 1980. He was in private practice from 1966 through 2002 and held staff memberships at Doctors Hospital, Hinds General Hospital, Rankin General Hospital, University Hospital, VA Medical Center, St. Dominic Hospital, and Mississippi Baptist Hospital where he was Chief of Staff in 1991. As an accomplished Physician and Medical Professor, Myron was published in numerous publications relating to diseases of the ear, nose, and throat. He served as Governor of the American Academy of Otolaryngology from 1987-1991, on the Board of the American Cancer Society Mississippi Division from 1974-1984, on the Board of the Central Medical Society from 1972-1984, and on the board of Mississippi-Louisiana Ophthalmology-Otolaryngology Society from 1974-1978 and 1990-1994. He was President of the Mississippi-Louisiana O&O Society in 1980 and the Central Medical Society in 1984. Myron served as Associate Editor of the Journal of the Mississippi State Medical Association from 1973-1983 and became Editor in 1983 and served until 1998.

He was Editor-Emeritus at the time of his death. Myron married Martha Jo Garrett of Ocean Springs on July 4, 1958 at Trinity Episcopal Church in Pass Christian. He was a devoted husband and father of three boys, Myron Willis Lockey Jr. (Candace McBride) of Ocean Springs; Russell Garrett Lockey (Laura Minnich) of Harrisonburg, VA; and Payton Longmire Lockey (Amanda Williams) of Madison. He is survived by his wife of 56 years, his three sons and daughters-in-law, six grandchildren, Colin (22), Alec (16), Joseph (14), Phillip (10), Lacy (10), and Payton (7), his brother James Lockey (Audrey) and sister Carol L. Thompson (Bobby), and sister-in-law Marjorie Reed Lockey.

Lockey enjoyed spending time in the outdoors, especially on his farm in Jasper County. He served as Scoutmaster from 1974-1978 at Troop 9, St James’s Episcopal Church in Jackson.

His hobbies included spending time on the tractor at his farm, hunting, swimming, and communicating with people all around the world on his HAMM Radio. Following his retirement he returned to competitive swimming. After a 43 year hiatus he won ten National Championships and ranked in the top 10 in the world in three different events. He competed in 5 FINA Masters World Championships in 2006, finishing 2nd in one, 3rd in one, 5th in two, and 6th in one, and was ranked 2nd in the world

by FINA in the 50 meters breaststroke. Dr. Lockey attended St. James’s Episcopal Church in Jackson where he served on the Vestry three terms and as Junior and Senior Wardens during construction of the new Parish Hall and Youth Wing. Over the years he served on various committees, the most recent being the Labyrinth Committee. Memorials may be made to the Labyrinth Fund at St. James’s Episcopal Church or The Hope Lodge Campaign, 1380 Livingston Lane, Jackson, MS 39213.

James Elmer Nix, MD Jackson Dr. James Elmer Nix died Saturday, August 9, 2014 at Hospice Ministries with his wife and family by his side. He lived a wonderful life filled with love and full of family and friends. His kind heart and healing hands influenced the lives of the

many who were blessed to know and love him. Dr. Nix was born in Ellisville, October 24, 1931, to Robert Leroy and Gladys Jane (Strahan) Nix. He grew up with his 4 brothers and his sister in the Hattiesburg area. After graduating from high school, he attended Jones Junior College, where he played football and ran track. He loved to say that he held the state record for the 100 yard “for a brief time.” Dr. Nix attended Ole Miss, where he was a member of the Kappa Sigma Fraternity. He graduated from Jefferson Medical College, Philadelphia, PA in 1956. While at Jefferson, he met the love of his life, his wife of nearly 58 years, Rosemary Cochrane Nix. They married November 19, 1956.

Dr. Nix completed his orthopedic training at Hermann Hospital in Houston, TX. While at Hermann Hospital, he was honored as Intern of the Year and received the Hermann Hospital Violet Keller Award for Outstanding House Staff Member. Dr. Nix was a Co-Founder and Past President of North American Spine Society. He received the Dr. David Selby Award for his contributions to the art and science of spinal disorder management through service to NASS. In addition, Dr. Nix served as President of Clinical Orthopedic Society, Mississippi State Medical Association, and the University of Mississippi Medical Alumni Association. He also served as a delegate to the American Medical Association and as Secretary of the Board of Counselors of the National Academy of Orthopedics. Dr. Nix was active in the Mississippi Republican Party and in 1968 served as a delegate to the Republican National Convention. In addition to being an avid golfer, Dr. Nix looked forward to his breakfast meetings with the Walter Scott Coffee Club. He never lost his love for learning, enjoying all kinds of music, new words, reading, poetry, and especially the Ole Miss Rebels. Dr. Nix most loved his family and relished every moment he could spend with his wife, each of his children, grandchildren, and greatgrandchildren. He will be sorely missed by them all. Dr. Nix was preceded in death by his parents, his daughter Rosemary, his brothers Wayne, Hall, and Paul, and his sister Lou. In addition to his beloved wife Rosemary, he is survived by daughter Georgia (Gary) Miller of Green Bay, Wisconsin, daughter Susie (Buddy) Hill of Newport, Rhode Island, son James E. “Jimmy,” Jr. (Susan), of Jackson, and son Bobby (Trina) of Oxford. Thirteen grandchildren, Rosemary (Brannon) Stegall, Brad (Sarah) Nix, William Miller; Beau Hill, Ali Hill, Tori Hill, James E. III “Jimmy” (Anna) Nix, Eric Nix, John Nix, Peter Nix, Connor Nix, and Aidan Nix. Seven great-grandchildren James Nix, Natalie Nix, Luke Nix; Abigail Stegall, John Brannon Stegall, James Elmer Nix, IV and John Jennings “Jack” Nix. Also surviving Dr. Nix is his brother Jack Nix (Catherine) and many nieces, nephews, great nieces, and great nephews. Memorials may be made to Clinical Orthopedic Society for the Dr. and Mrs. J. Elmer Nix Ethics Award, 2209 Dickens Road, Richmond, VA 23230-2005, Covenant Presbyterian Church, 4000 Ridgewood Road, Jackson, MS 39211 or Hospice Ministries, 450 Towne Center Boulevard, Ridgeland, MS 39157.

Walter Thomas Rueff, MD Jackson Dr. Walter Thomas “Tommy” Rueff, 71, of Jackson, passed away on November 19, 2014, surrounded by his family, and supported

December 2014 JOURNAL MSMA 409

by numerous friends and colleagues at Baptist Hospital --- a place where he himself worked for many years. Born in McComb, Mississippi in 1943, Tommy was the son of Charles Rueff, a conductor for Illinois Central Railroad, and Allie Rueff, a nurse. He graduated from Millsaps College where he was a member of the Kappa Alpha Order. He attended medical school at the University of Mississippi Medical Center where he trained under James D. Hardy, specializing in general, thoracic, and cardiovascular surgery. After medical school, Tommy founded Central Surgical Associates with Dr. Karl Stauss, where he practiced surgery for more than 25 years. During his medical internship, Tommy met his wife, Ann, who was working as a nurse at UMMC. They married in 1982 and had two sons, T. and Andrew.

Tommy loved collecting antiques, fountain pens, books, and pocket knives. He traveled extensively but was most at home driving his tractor at his farm in Terry. Tommy was predeceased by his brother, Charles Rueff, Jr. Tommy is survived by his wife, Ann, as well as his two sons, Walter Thomas “T.” Rueff, Jr. and Michael Andrew Rueff, and his two daughters-in-law, Frannie Wesberry Rueff and Elise SmythGilbert. He also leaves behind his beloved black lab “Buddy,” and countless friends, colleagues, patients, and others whom he loved and who loved him dearly. Memorials may be made to the University Medical Center or to St. Andrew’s Cathedral.

Aaron Shirley, MD Jackson Dr. Aaron Shirley, 81, died November 26, 2014, in Jackson. He was Chairman of the Board for the Jackson Medical Mall Foundation and an associate professor in pediatrics at the University of Mississippi Medical Center. Shirley was born in Gluckstadt on January 3, 1933. He graduated from Tougaloo College and Meharry Medical College, completing an internship in Tennessee before entering private practice in Vicksburg. He set his sights on a pediatric residency out of state, but was invited to apply for a training position at UMMC by then chair of pediatrics, Dr. Blair E. Batson. After much consideration, he accepted, becoming the first African-American resident — and the first black learner in any program — at UMMC in 1965. He went on to serve as a clinical instructor in the Department of Pediatrics for more than 40 years.

In 1970, Shirley helped establish the Jackson Hinds Comprehensive Health Center, which became the largest community health center in the state and a model for federally funded community health centers nationwide. In 1993, Shirley was awarded a MacArthur Fellowship (also known as the “Genius Grant”) for his pioneering approach to rural and urban healthcare. In 1995, he and a group of partners transformed the dilapidated Jackson Mall into the Jackson Medical Mall, a health care facility for the underserved. In 2010, Shirley founded the HealthConnect program, which was modeled after a similar program in Iran which sends doctors and nurses to poor rural homes to prevent unnecessary ER visits. In 2013,

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Shirley was awarded the Herbert W. Nickens Award from the Association of American Medical Colleges, which honored his lifetime of service in support of diversity in medical education and the elimination of health disparities. In 2014, Shirley was awarded the MSMA’s Community Service Award in recognition of his civic work for the betterment of the community and state.

Survivors include his wife, Dr. Ollye Shirley, and four children.

Shirley’s family asks that memorials be made to the Dr. Aaron Shirley Foundation through the Jackson Medical Mall.

Samuel Joseph Simmons, III, MD Pascagoula Dr. Samuel Joseph Simmons, III, 84, passed away Tuesday, November 4, 2014, in Fairhope, AL. He became a resident of Daphne following Hurricane Katrina and is formerly of Pascagoula. He was born October 30, 1930. As a young man, he attended Gulf Coast Military Academy in Gulfport. He served his country proudly in the US Navy at Ft. Rucker, AL and at Pensacola Naval Air Station from 1948-1952, where he was trained as a pilot. He attended the University of Florida for his undergraduate studies. Following in the footsteps of his parents he entered the medical field and graduated from the Tulane University School of Medicine in 1959. He went on to serve his three year residency in medicine at Charity Hospital and at Touro Infirmary in New Orleans.

He was a beloved physician for fifty years in Jackson County and went on in the early 1960s to establish the very first Intensive Care Unit at Singing River Hospital. It was at Ocean Springs Hospital that he met the love of his life, a pretty young nurse, Gwen. Dr. Simmons remained in the private practice of internal medicine prior to Hurricane Katrina. He was devoted to the service of his community. Bicycling was a passion for him, belonging to the Gulf Coast Bicycle Club of Biloxi.

Preceding him in death are his parents, Dr. Samuel Simmons, Jr. and his mother, Jessie Simmons and his sister, Yvonne Best.

He is survived by his loving wife of forty years, Gwen; his son, Matthew Forbish; two daughters, Sharon Simmons and Renee Simmons; his nieces and nephew, Barbara Best, Linda Best, and Joseph Best. Memorials may be made to St. John’s Episcopal Church Triangle Project or to Grace Anglican Church, 817 Estella St, Fairhope, AL 36532.

Lockey....Continued from page 399 When I heard of Dr. Lockey’s sudden demise, I went to see him. Visiting hospice is never easy. However, I was reassured he was resting comfortably when he leaned over to drink water from a Camelback waterbag his cyclist son Russell had cleverly engineered to the side of his bed so he could lean and drink with ease. He was alert. I reassured him all is well and thanked him for his service. The second time I visited, I took some papers to Martha. When I used Dr. Hardy’s name in front of Dr. Lockey he groaned and went back to sleep.

Finding solace in the celebration of his life and emulation of his virtues, may light perpetual shine upon him! -ke

• Index • Volume LV

January - December 2014

Subject Index

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

-A-

A Technique for Implantation of the CentriMag LVAD to Allow Ambulation and Rehabilitation in Patients with Heart Failure [T Urencio, C Tribble], 344-H An Interview with Claude D. Brunson, MD, MSMA President 2014-2015 [K Evers], 262-S Axillary Lymph Node Treatment in Breast Cancer: An Update [P Williams, J Suggs, S Mangana], 145 AMA AMA Adopts New Policy to Encourage Access and Equity in Telemedicine Payments, 377 AMA Backs Interstate Compact to Streamline Medical Licensure, 377 MSMA Delegation Supports New AMA Principles for MOC, 377

-B-

Basic Skin Care: A Pragmatic Approach to Better Skin Using Over-the-Counter Cosmeceuticals [J Griffith, N McCowan], 316 Blunt Hepatic Trauma: Do We Ever Operate? [A Mallette, L Martin], 343-H

-C-

Change of Heart: Transplantation in Mississippi [J Gunalda, M McMullan, M Mitchell, C Tribble, W Merrill], 140 Clinical Problem-Solving

[presented and edited by the Dept. of Family Medicine, UMMC] All Dressed Up with No Place to Go [A Hubert, J Bryan], 322-CPS Call the Surgeon Please [L Treadwell], 191-CPS Denial of Scans [S Mehta], 287-CPS “I Keep Falling all the Time...” [J Jones], 259-CPS My Aching Muscles [P McDonnell, S Pittman-Moore], 124-CPS Sent for a Loop [P Mehta] -CPS Three Strikes and You’re Out [C Garrett], 22-CPS Complex HPB Experience: Does A Transplant Program Impact Resident Experience? [A Gaugler, T Earl, C Anderson], 339-H Concordance and Complications of Ultrasound Guided Breast Biopsies Performed by Surgeons at The University of Mississippi Medical Center [J Dinning, L Vick], 342-H Cultural Evolution and the Spread of Health Information on Twitter [D Murphy, P Hopkins], 344H

Cover 147th MSMA President, August Autumn Colors on the Natchez Trace [M Pomphrey], November Bottle Tree in an Herb Garden [W Locke], January “Goin’Green” [S Hartness], June Heron at the Mississippi Gulf Coast [M Lockey], October Hummingbird in Flight [R Cannon], May Monuments of the King and Queen of the Romani (Gypsies) [J Bumgardner], February River Morning [W Sorey], April Rock Paper Scissors [W Pontius], July Sunset over Biloxi Bay in Ocean Springs [M Lockey], December Wintering White Pelicans at the Ross Barnett Reservoir [R deShazo], September Yard Art [M Lockey], March

-D-

Dr. Kirby Bland Presents 13th Annual Hardy Surgical Forum Lecture, 334

-E-

Editorials A Glimmer of Hope in the Electronic Medical Records Plague [J Hey, III], 241-E A Return to the Asclepeia: A Physician’s Enduring Obligation to his or her December 2014 JOURNAL MSMA 411

Patients [D Smith], 161-E Follow the Physician Leader, [S Hartness], 395-E Health Disparities, Population Health, and Preventive Medicine [M Mansour], 128E No Room for Error [D Hartness], 195-E Remaining a Great Physician in Tough Times: Learning from Business Principles [R Brodell, S Helms], 239-E Round and Round She Goes... [S Hartness], 333-E Save the Date – Marston Symposium [R deShazo], 100-E The Veterans Administration Hospital Scandal: Views of a Mississippi Physician [J Hey, III], 196-E

-F-

From the Editor [L Lampton] An Apology Long Overdue, 350 Access to Care Problematic in State, 70 Auditor’s Outdated Study Disservice to State, 106 Awaiting Ebola at our Posts, 314 Buttermilk is Good for What Ails Farmer Jones, 30 Eliminating the Perverse Incentive, 282 Has Jackson Taken Over our MSMA?, 138 Katrina’s Lessons Learned in Louisville, 206 Reaching the Finish Line with Dignity, 250 The Coming Disaster of ICD-10, 2 The Dishonest Math of PPACA, 174 The Shame of Mississippi Medicaid, 382

-G-

Gulf Coast Tick Rash Illness in Mississippi Caused by Rickettsia parkeri [O Ekenna, C Paddock, J Goddard], 216 412 JOURNAL MSMA

-H-

How Early Elective Deliveries Impact Infant Health in Mississippi [A Radican-Wald, C Collier, D Johnson], 252

-I-

Images in Mississippi Medicine Death of Dr. Benjamin Rush (17461813) [L Lampton], 204-I Dr. W. H. H. Lewis of Fayette (1866-1936) [L Lampton], 158-I MSMA Annual Session Meets in 1928 at Elks Club, Meridian [L Lampton], 248-I Sure Cure for Small Pox and Scarlet Fever (formula) [D Hartness], 310-I University of Mississippi School of Medicine, 1904 [L Lampton], 348-I In Memoriam, 24, 304, 406 Initial Emergency Department Presentations of Colorectal Cancer at The University of Mississippi Medical Center [K Gambrell, T Helling, S Seals], 342-H IQH Becky Roberson Named IQH CEO, 201 Dr. Ed Bryant Receives Derrick Award, 201 Dr. McIlwain to Retire from IQH July 31, 202 Is FAST a Passing Fad? [N Maples, L Martin, M Martin], 340-H

-J-

JMSMA Roving Reporter -Skinny Insurance Plans Can Weigh You Down [R deShazo], 393RR Just Off the Press - Info You Want

to Know Oseltamivir for Influenza in Adults

December 2014

and Children [K Langley, R Ogletree], 356

-K-

King David, Son of Jesse: The World’s First Parkinson’s Patient...Observations from November 2013 [C R Voyles], 14-S

-L-

Legal Ease Harper Grace’s Law: Providing Hope to Suffering Children and Opportunity to the State [A Woods], 273 Legislative Session 2014 Wrap-up, 153 Letters A Deafening Silence: Has Expressive Aphasia Afflicted Mississippi Physicians? [T Alford], 94-L Adding Value to Membership [R Easterling], 305-L American Doctors Eagerly Practice Evidence-Based Medicine but Refuse to Learn from Failed Social Engineering [C Ennis], 133-L Buttermilk is Good for What Ails Farmer Jones [W Austin], 132-L Buttermilk is Good for What Ails Farmer Jones [J Smith], 132-L Case Report on Enteric Myiasis in Mississippi [J Goddard, K Hoppens, K Lynn], 133-L Concerned Health Advocacy Associations, 306-L Editor’s Response to Positions on Medicaid Expansion [L Lampton], 58-L In Response: Statement of the Board of Trustees [L Voulters], 243L JFC Seeks Good Samaritan Doctors [S Carter], 272-L Letter from Donna Hopkins, 245-L Letter from Rob Jones, 244-L

Positions on Medicaid Expansion and Response [T Joiner], 58-L Response to Letters on Medicaid Expansion [V Short], 134-L You Have a Voice in Mississippi Medicine; Attend the Annual Session in Jackson [S Anderson], 243-L -M-

MACM Medical Assurance Company of Mississippi Announces New Leadership, 346 Securing the Future of Healthcare: Students in your Practice [M Wee], 198 Management of Arterial Injuries Associated with Posterior Knee Dislocations [A Barker, R Roy, Z Baldwin], 337-H Management of Preeclampsia When Diagnosed Between 34-37 Weeks Gestation: Deliver Now or Deliberate Until 37 Weeks? [M Owens, B Thigpen, M Parrish, S Keiser, S Sawardecker, K Wallace, J Martin, Jr.], 208 Medical Student Education in the Department of Surgery at the University of Mississippi Medical Center in the 21st Century [C Tribble, M Mitchell], 352 MedWeb News Five Inadvertent HIPAA Violations

by Physicians [T Haas], 32 MSDH 2012 Annual Summary of Selected Reportable Diseases [T Dobbs, P Byers], 149 Health Department Recognizes Mississippi Accomplishments, 57 Mississippi Reportable Disease Statistics April 2014, 246 Mississippi Provisional Reportable Disease Statistics August 2014, 290

Mississippi Provisional Reportable Disease Statistics June 2014, 278 Mississippi Provisional Reportable Disease Statistics March 2014, 148 Mississippi Provisional Reportable Disease Statistics November 2013, 56 Mississippi Provisional Reportable Disease Statistics October 2013, 21 Mississippi Provisional Reportable Disease Statistics October 2014, 391

Free Clinic [JS Clark, A Bollaert, S Sills, JH Clark, D Norris], 113 Pediatric Bowel and Bladder Dysfunction: a Diagnosis and Treatment Protocol [R Head, D Andrews, E Harmon], 336H Percutaneous Endoscopic Cecostomy: A Safe Alternative for the Management of Neurogenic Bowel [A Baker, E Harmon, M Nowicki], 336-H

MSMA Committee Seeks Candidates for Vacancies in MSMA Offices, 90, 130 MSMA 146th Annual Session Recap, 294 MSMA Annual Report 2013, 221 MSMA Board of Trustees, 66 MSMA Nominating Committee Announces Slate of Officers, 199 MSMA Presents 2014 Excellence in Medicine Awards, 330

Physician’s Bookshelf An Absent Mind (by Eric Rill, Avante Press; New York, NY 2014) [W Vail]. 396-PB Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital (by Sheri Fink, Crown Publishers; New York, NY 2013) [J Graham, S Douglas], 135-PB John Marshall Stone, A Historical Narrative by Ben Earl Kitchens, MD (Thornwood Book Publishers, Iuka, MS) [D South], 378-PB Mortality (by Christopher Hitchens, Atlantic Books: New York, 2012) [M Gillette], 45-PB

MSMA Alliance Commit, Communicate, and Continue [E McRae], 347 When Life Presents a Lemon, Make Lemonade [M Pontius], 62 Multidisciplinary Survey to Identify Safety Issues in an Academic Surgical Intensive Care Unit [T Robertson, K. Horn, R Risher, N Ahmed, L Martin, L Frei, G Timberlake, J Porter], 341-H -NNew Members, 167

-P-

Palliative Care for the Terminal Heart Failure Patient [W Beard, R Long, S Geraci], 4 Patient Perception of Care Received

by Students at the Jackson

Personals, 60

Physicians’ Health Corner Dr. Scott Hambleton Answers Your Questions [S Hambleton], 200, 276 Poetry and Medicine A Little Gut Magic [J McEachin], 247-PM Cough [B Morris], 136-PM Diagnosis [T Browne], 203-PM Doctor’s Telephone [T Browne], 280-PM Donor [B Morris], 93-PM I Love Nurses [W Davis], 170-PM Long Night [J Brown], 309-PM Night Call [T Browne], 380-PM Sedation [B Morris], 64-PM December 2014 JOURNAL MSMA 413

President’s Page A Warm and Hearty Christmas Wish [C Brunson], 396-PP Farewell Address [J Rish], 269-PP Inaugural Address of the 147th President, Claude D. Brunson, MD, [C Brunson], 298-PP Mississippi Mental Health System – in Crisis [C Brunson], 367-PP More Thoughts on Medicaid Expansion [J Rish], 193-PP On Becoming a Doctor [J Rish], 237-PP SGR–The Gift that Keeps on Giving [J Rish], 19-PP The MSMA Physician Leadership Academy [C Brunson], 327PP The Prescription Drug Abuse Epidemic [J Rish], 126-PP The Season of Change [J Rish], 54-PP Thoughts on Medicaid Expansion [J Rish], 159-PP Towards a Smoke-Free Mississippi [J Rish], 88-PP Prevalence and Trends in Overweight and Obesity among Mississippi Public School Students, 2005-2013 [L Zhang, J Kolbo, M Kirkup, E Molaison, B Harbaugh, N Werle, E Walker], 80 Prognostic Value of CardiacSpecific Troponins in Chronic Obstructive Pulmonary Disease Exacerbations: A Systematic Review [N Chaudary, S Geraci], 40 Progress in the Early Identification of Hearing Impaired Infants in Mississippi [O Malphurs, Jr., W Mustain], 256 Public Health in Mississippi Report Card 2014, 47

-R-

Race and Health Care in Mississippi during the Civil Rights Years [J Dittmer], 358-S 414 JOURNAL MSMA

Relevance of Linguistic and Cultural Training among Non-Clinical Personnel at the University of Mississippi Medical Center: A Qualitative Study [C Pinell-Jansen, C Arthur, S Hart-Hester], 34 Remembering JMSMA Editor Emeritus Myron W. Lockey, MD [K Evers], 399-S Results of Vacuum-Assisted Delayed Primary Closure of Midline Wounds in Patients with Colorectal Cancer [J Corley, C McCoy, R Patel, B Gilliland, C Heritage, C Lahr], 338-H Reviving the Lost Art of VideoAssisted Mediastinoscopy: Novel Therapeutic Uses [T Kim, N Ahmed, P de Delva], 340-H

-S-

Series: Concepts in End-of-Life Care Advance Directives [D Hansen, S Douglas, R Bhagat], 108 Severe Ocular Trauma in the Emergency Room [A Lin, C Confait, M Ahmad, R Cox, C-J Chen], 176 Surgical mortality: a comprehensive assessment [W Cauthen, L Martin, T Helling, M Mitchell], 337-H Skinny Insurance Plans Can Weigh You Down [R deShazo] 393RR Subject/Author Index Volume 55, 407

-T-

The eFAST Examination for Trauma Triage [B Tollefson], 72 The James D. Hardy Lectureship in Surgery —Surgical Forum Abstracts [M Mitchell], 334 The Meeting [R deShazo, R Smith, L Skipworth], 370-S The Mississippi State Tuberculosis

December 2014

Sanatorium and the Evolution of Thoracic Surgery in Mississippi [J Groves, M Trotter], 180-S Top 10 Facts You Should Know About Liver Transplantation [F Butt, T Earl, C Anderson], 212 About Long Term Oxygen Therapy [G Abraham, III, T Dwyer, R Bhagat], 291 About Obese Adults Admitted to Hospital [D Pepper, M Brewer, C Koch], 11 About Smoking Cessation [L Lampton, W Vail], 325

-U-

Ultrasound-Guided Fine Needle Aspiration in the Diagnosis of Thyroid Nodules [H Hand, R Cannon], 284 UMC SOM UMMC Med Students Learn their Future on Residency Match Day [G Pettus], 162 Up-to-Date Medicine in Mississippi Avoiding Narcotic Analgesics in Young Children [J Carron], 235 Una Voce [Dwalia S. South] Professional Rasslin’, 311-UV The Albatross and the Dodo, 103UV Uncommon Thread [R. Scott Anderson] Vegetarian Hunting in Garlandsville, Mississippi, 67

-W-

What are we waiting f{OR}? analysis of UMMC operating room efficiency [R Hayes, L Martin, T Helling, N Gilbert], 339-H

Volume LV

January - December 2014

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; “RR,” Roving Reporter; “S,” Special Article; “UV” Una Voce.

A

Abraham, George E., III, 291 Ahmad, Madiha, 176 Ahmed, N., 340-H, 341-H Alford, Timothy J., 94-L Anderson, C.D., 339-H Anderson, Christopher D., 212 Anderson, R. Scott, 67, 243-L Andrews, D., 336-H Arthur, Chris Anne Rodgers, 34 Austin, William Darrell, 132-L

B

Baker, A., 336-H Baldwin, Z., 337-H Barker, A.K., 337-H Beard, Walter W., 4, 10808 Bhagat, Rajesh, 108, 291 Bollaert, Adam, 113 Brewer, Michael, 11 Brodell, Robert T., 239-E Brown, Jim, 309-PM Browne, Thomas, 203-PM, 280-PM, 380-PM Brunson, Claude D., 298-PP, 327PP, 367-PP, 396-P Bryan, Jennifer J., 322-CPS Bumgardner, Joe R., February cover Butt, Fauzia K., 212 Byers, Paul, 149

C

Cannon, C. Ron, May cover, 284 Carron, Jeffrey D., 235 Carter, Steven, 272-L Cauthen, W., 337-H Chaudary, Nauman, 40 Chen, Ching-Jygh, 176 Clark, Jeb S., 113 Clark, Joy H., 113 Collier, Charlene, 252 Confait, Cassie, 176

Corley, J.J., 338-H Cox, Robert, 176

D

Davis, Woody, 170-PM de Delva, P., 340-H deShazo, Richard D., September cover, 100-E, 370-S, 393-RR Dinning, J., 342-H Dittmer, John, 358-S Dobbs, Thomas, 149 Douglas, Sharon, 108, 135-P Dwyer, Terry M., 291

E

Earl, T.M., 339-H Earl, Truman M., 212 Easterling, Randy 305-L Ekenna, Okechukwu, 216 Ennis, Calvin S., 133-L Evers, Karen A., 262-S; 399-S

F

Frei, L., 341-H

G

Gambrell, K., 342-H Garrett, Cynthia Colson, 22-CPS Gaugler, A.C., 339-H Gillette, Michael, 45-PB Geraci, Stephen A., 4, 40 Gilbert, N., 339-H Gilliland, B.R., 338-H Goddard, Jerome, 132-L, 216 Graham, Jacob, 135-PB Griffith, James L., 316 Groves, John B., 180-S Gunalda, Jonah, 140

H

Haas, Tracey, 32

Hambleton, Scott, 200, 276 Hand, Hoyet A., 284 Hansen, Derek T., 108 Harbaugh, Bonnie L., 80 Harmon, E., 336-H Hart-Hester, Susan, 34 Hartness, D. Stanley, June cover, 195-E, 310, 333-E, 395-E Hayes, R., 339-H Head, R.B., 336-H Helling, T., 337-H, 339-H, 342-H Helms, Stephen E., 239-E Heritage, C., 338-H Hey, John P. III, 196-E, 241-E Hopkins, Donna, 245-L Hopkins, P., 344-H Hoppens, Kyle, 132-L Horn, K.C., 341-H Hubert, Ana-Maria, 322-CPS

J

Johnson, Dick, 252 Joiner, Thomas E., 58-L Jones, Jessica, 259-CPS Jones, Rob, 244-L

K

Keiser, Sharon D., 208 Kim, T., 340-H Kirkup, Melissa, 80 Koch, Christian A., 11 Kolbo, Jerome R., 80 L Lahr, C.J., 338-H Lampton, Lucius M., 2, 30, 58-L, 70, 106, 138, 158-I, 174, 204I, 206, 248-I, 250, 282, 314, 325, 348-I, 350 Langley, Katie, 356 Lewin, Jack, 384-S Lin, Albert, 176 December 2014 JOURNAL MSMA 415

Locke, William R., January cover Lockey, Myron W., March cover, October cover, December cover Long, R. Craig, 4 Lynn, Keicia, 132-L

M

McCowan, Nancye K., 316 McCoy, C., 338-H McDonnell, Preston, 124-CPS McEachin, John D, 247-PM McMullan, Martin H., 140 McRae, Eileene, 347 Mallette, A.C., 343-H Malphurs, Ojus, Jr., 256 Mangana, Sophy H., 145 Mansour, Michael, 128-E Maples, N., 340-H Marston, Robert Q., 100-E Martin, James N., Jr., 208 Martin, L., 337-H, 339-H, 340-H, 341-H, 343-H Martin, M., 340-H Mehta, Saumya, 287-CPS Merrill, Walter H., 140 Mitchell, M., 337-H Mitchell, Marc E., 140, 334, 352 Molaison, Elaine Fontenot, 80 Morris, Benjamin A., 64-PM, 93PM, 136-PM Murphy, D.L., 344-H Mustain, William D., 256

November cover Pontius, Mollie J., 62 Pontius, William (Bill), July cover Porter, J., 341-H

R

Radican-Wald, Amy, 252 Rish, James A., 19-PP, 54-PP, 88-PP, 126-PP, 159-PP, 193-PP, 237PP, 269-PP Risher, R.E., 341-H Robertson, T.E., 341-H Roy, R., 337-H

S

Sawardecker, Sandip, 208 Seals, S., 342-H Shenoy, Veena, 345-S Short, Valerie, 134-L Sills, Stephen O., 113 Skipworth, Leigh Baldwin, 370-S Smith, David P., 161-E Smith, J. George 132-L Smith, Robert, 370-S Sorey, Will, April cover South, Dwalia S., 103-UV, 311-UV, 378-PB Subramony, Charu, 345-S Suggs, Jeanann, 145

N

T

Thigpen, Brad, 208 Timberlake, G., 341-H Tollefson, Brian, 72 Treadwell, Lauren, 191-CPS Tribble, C., 344-H Tribble, Curtis G., 140, 352 Trotter, Michael C., 180-S

U

Urencio, M., 344-H

V

Vail, William Lee, 325, 398-PB Vick, L., 342-H Voulters, Lee, 243-L Voyles, C. Randle, 14-S

W

Walker, Evelyn, 80 Wallace, Kedra, 208 Wee, Maryann, 198 Werle, Nichole, 80 Williams, Patrick A., 145 Woods, Adam, 273

Z

Zhang, Lei, 80

Extensively screened.

Carefully matched.

Compassionate, Professional Home Care

Nath, Vikas, 384-S Norris, David, 113 Nowicki, M., 336-H

O

Ogletree, Richard L., 356 Owens, Michelle Y., 208

Mississippi’s first staffing agency to earn The Joint Commission certification.

P

Paddock, Christopher D., 216 Parrish, Marc R., 208 Patel, R., 338-H Pepper, Dominique J., 11 Pettus, Gary 162 Pinell-Jansen, Christianne M., 34 Pittman-Moore, Shannon, 124-CPS Pomphrey, Martin M., Jr., 416 JOURNAL MSMA

December 2014

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PARTICIPATE IN MSMA’S DOCTOR OF THE DAY PROGRAM

Every year, MSMA staffs the Capitol Medical Unit during the legislative session with a full time nurse and a volunteer physician each day. The Doctor of the Day program runs from January through March and allows MSMA members to participate in the legislative process by being front and center at the state capitol. Doctors of the Day are only asked to provide minimal health care services to legislators and capitol staff. Doctors of the Day volunteer for half days on Monday and Friday while Tuesday, Wednesday, and Thursday are full day commitments. As Doctor of the Day, you will be introduced in the House and Senate chambers by your local legislators and thanked for your service. This is a perfect opportunity to not only “give back,” but have valuable personal time with your legislator and voice support for pro-medicine policies.

To participate in MSMA’s Doctor of the Day program, please use the interactive calendar found on MSMAonline.com. please contact Blake Bell at BBell@MSMAonline.com.