December
VOL. LI
2010
No. 12
Lucius M. Lampton, MD EDITOR D. Stanley Hartness, MD Richard D. deShazo, MD ASSOCIATE EDITORS Karen A. Evers MANAGING EDITOR PUBLICATIONS COMMITTEE Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD, Ex-Officio Myron W. Lockey, MD, Ex-Officio and the Editors THE ASSOCIATION Tim J. Alford, MD President Thomas E. Joiner, MD President-Elect J. Clay Hays, Jr., MD Secretary-Treasurer Lee Giffin, MD Speaker Geri Lee Weiland, MD Vice Speaker Charmain Kanosky Executive Director JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. CORRESPONDENCE: JOURNAL MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: (601) 853-6733, Fax: (601)853-6746, www.MSMAonline.com. SUBSCRIPTION RATE: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available. ADVERTISING RATES: furnished on request. Cristen Hemmins, Hemmins Hall, Inc. Advertising, P.O. Box 1112, Oxford, Mississippi 38655, Ph: (662) 236-1700, Fax: (662) 236-7011, email: cristenh@watervalley.net POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 391582548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association. Copyright© 2010, Mississippi State Medical Association.
DECEMBER 2010 SCIENTIFIC ARTICLES
VOLUME 51
NUMBER 12
Prolonged QTc Interval Due to Escitalopram Overdose
350
Reema Mohammed, MD; John Norton, MD; Stephen A. Geraci, MD;
D. Brian Newman, MD; Christian A. Koch, MD, PhD
Clinical Problem-Solving: Can’t Catch my Breath
355
Christopher J. Fort, MD
PRESIDENT’S PAGE Up in Smoke
357
Tim J. Alford, MD, MSMA President
SPECIAL ARTICLE
Mississippi College Commences State’s First Physician Assistant Program 362
Karen A. Evers, Managing Editor
EDITORIALS
Many Good Things Are Happening at our MSMA
358
Creating a Better Climate for the Nation’s Health Care Could Make Champions of all Physicians
360
Lucius M. Lampton, MD, Editor
William Lineaweaver, MD
RELATED ORGANIZATIONS
Mississippi State Department of Health MSMA MSMA Alliance
354 365 373
DEPARTMENTS
Physicians’ Bookshelf Images in Mississippi Medicine The Uncommon Thread Placement/Classified
367 372 374 375
INSTRUCTIONS FOR AUTHORS INDEX: VOLUME LI
376 378
ABOUT THE COVER:
Official Publication of the MSMA Since 1959
“ST. JOHN THE BAPTIST”— Robert B. Brahan, MD, an internist in Hattiesburg, took this photo of John the Baptist at St. Mary’s Basilica in Natchez. The historic Roman Catholic cathedral was undergoing exterior renovation which allowed Dr. Brahan to use the scaffolding to frame the iconic statue. Recognized as an architectural masterpiece among Catholic churches in the South, it is the spiritual home of a vibrant St. Mary Catholic community today. ❒
December
VOL. LI
2010
No. 12
DECEMBER 2010 JOURNAL MSMA
348
Medical Assurance Company of Mississippi With questions about a new practice, MACM gave her confidence.
“
As a physician just beginning my private practice, I did not have much experience with professional liability companies. MACM sets the bar so high that I can’t imagine being insured with anyone else.
MACM goes above and beyond to keep its insureds educated about risk management and keep them out of the courtroom. I have already attended educational seminars and completed on-line risk management training offered by MACM.
“
Being from Louisiana, I was hesitant to come to Mississippi to practice medicine. Now, I have no regrets. MACM has helped make Mississippi an easier place to practice medicine. Louise A. Gombako-Amos, MD OB/GYN McComb, Mississippi
For over 30 years, Mississippi physicians have looked to Medical Assurance Company of Mississippi for their professional liability needs. Today, MACM is an integral part of the health care community through its dedication to sound underwriting principles and risk management education for our insureds. ě ¢ ¢ guarantees that the interests of our policyholders remain the top priority. This, combined with the many years of loyalty and support from our insureds, is what allows us to be the carrier of choice in Mississippi. Please call on us to assist with your professional liability needs.
1.800.325.4172 www.macm.net
Reputation Above All Others
• SCIENTIFIC ARTICLES •
A
Prolonged QTc Interval Due to Escitalopram Overdose Reema Mohammed, MD; John Norton, MD; Stephen A. Geraci, MD; D. Brian Newman, MD; Christian A. Koch, MD, PhD
BSTRACT
Background: Drugs most commonly responsible for the acquired form of long QT syndrome are antibiotics and antidepressants. Escitalopram overdose leading to prolongation of the QTc interval has only twice been previously described in the literature. Methods: We report a 33-year-old Caucasian woman who attempted suicide by ingesting 15-20 pills of lithium (300 mg each), 15-20 pills of escitalopram (20 mg each), and alcohol. An electrocardiogram (ECG) on admission to the medicine telemetry unit showed a QTc prolongation of 491 ms and normal sinus rhythm. Repeat ECG 18 hours after admission showed a QTc of 502 ms and sinus bradycardia. Serial ECGs were continued with the following results of QTc/hours after admission: 499 ms/2, 485 ms/25 (> 1 day), 469 ms/41, 461 ms/71, 476 ms/97 (> 4 days). After the QTc interval had declined to 461 ms after more than 2 days (71 hours), the patient was transferred to the inpatient psychiatry ward service. Conclusions: Prescribers may wish to exercise caution when administering escitalopram to patients who have suicidal ideations and depression. In the event of an overdose, QT prolongation can occur and ECG monitoring should take place for at least 2 days after ingestion in order to prevent life-threatening arrhythmias such as torsades de pointes (tdp). Other factors and drugs that could contribute to prolongation of the QT interval should be taken into account when determining the time period needed for ECG monitoring in the individual patient.
KEY WORDS:
QT, ESCITALOPRAM, SUICIDAL IDEATION, DEPRESSION, ELECTROCARDIOGRAM,
PROLONGED
TORSADES DE POINTES
AUTHOR INFORMATION: Dr. Mohammed is presently a resident in the Dept. of Pediatrics at the University of Mississippi Medical Center. Dr. Norton is an associate professor in the Dept. of Psychiatry at UMC. Dr. Geraci is a professor of medicine in the Dept. of Medicine at UMC. Dr. Newman is presently a resident in the Dept. of Medicine at the Mayo Clinic, Rochester, Minnesota. Dr. Koch is director of the division of endocrinology at UMC.
CORRESPONDING AUTHOR: Prof. Dr. med. habil. Christian A. Koch, FACP, FACE Director, Division of Endocrinology, Dept. of Medicine, University of Mississippi Medical Center, 2500 N. State St., Jackson, MS 39216. Phone: (601) 984-5495 Fax: (601) 984-5769 E-mail: ckoch@umc.edu
INTRODUCTION
Long QT syndrome (LQTS) occurs due to an irregularity in cardiac repolarization because of defects in the ion channels.1 Torsades de pointes (tdp) or “twisting of points” may subsequently develop, leading to palpitations, syncope, seizures, and even sudden cardiac death. Tdp is a form of ventricular tachycardia in which the heart beats too fast and blood flow to the brain is compromised leading to sudden loss of consciousness and other complications. A QT interval above 440 ms is considered prolonged. Two forms of LQTS have been described: inherited and acquired. Two phenotypic variants of inherited LQTS are Jervell, Lange-Nielson and Romano-Ward syndrome. On the other hand, the acquired form of the disorder is due to the administration of medications.1,2,3,4 Genetic polymorphisms leading to differences in metabolism may increase or decrease susceptibility to drug-induced LQTS. Drugs most commonly responsible are antibiotics and antidepressants. Other causes of acquired LQTS are heart disease, neurological disorders, HIV infection, eating disorders and electrolyte disorders (hypokalemia, hypomagnesemia, and hypocalcemia). Corrected QT (QTc) is defined as QT interval divided by square root of RR interval. It is the QT interval adjusted for heart rate and is used commonly when measuring QT.1 Here we report a case of 33-year-old white female who attempted suicide by ingesting lithium, escitalopram, and alcohol. She had a history of bipolar disorder for at least 10 years. Escitalopram is the generic name for Lexapro. Escitalopram is the active enantiomer (s-enantiomer) of citalopram.4 Both of these drugs are selective serotonin reuptake inhibitors (SSRI) and are used in the treatment of depression and generalized anxiety disorder. Since it is a fairly new drug (FDA-approval in August 2002), there is limited data on escitalopram as opposed to citalopram. The similarities between the two drugs and resulting toxicities are of importance. The dose of escitalopram is 10 mg once daily initially and can be increased to 20 mg after one week. It is supplied in tablet form as 5 mg, 10 mg, 20 mg, or as oral solution (5 mg/5 ml). It is said that 10 mg of escitalopram may be equivalent to 40 mg of citalopram (http://www.fpnotebook.com). Compared to tricyclic antidepressants, SSRIs have
DECEMBER 2010 JOURNAL MSMA
350
• SCIENTIFIC •
few and different adverse effects. However, increasingly more cases of SSRI overdose causing severe side effects are being reported. For citalopram and escitalopram, these effects are due to the metabolites of citalopram and escitalopram. Both of these drugs are metabolized in the liver, and the metabolites produced are didesmethylcitalopram (DDCT) and desmethylcitalopram 5 (DCT). DDCT is considered the cardiotoxic metabolite and comprises less than 10% of citalopram’s metabolites. As the total amount of overdose increases, the potential for cardiotoxicity increases significantly. In the liver, biotransformation is accomplished by the isoenzymes (CYP = Cytochrome P450) CYP2C19, CYP3A4, and CYP2D6. Patients who are known to be poor metabolizers, especially due to polymorphisms of CYP2C19 or those who suffer from hepatic dysfunction, may experience varying degrees of toxicity. The hepatic and renal routes excrete escitalopram and its metabolites.6
CASE REPORT
A 33-year-old white female took 15-20 pills of lithium (300 mg each) one night with the intention of committing suicide. Upon waking the next morning, she took 15-20 pills of escitalopram (20 mg) amounting to an approximate maximum dose of 400 mg. She also drank alcohol (6 wine coolers made from wine and fruit juice, each bottle containing 355 ml of fluid) during the night. By the time she was brought to the emergency Fig 1a.
department, it was at least a few hours since her last drug ingestion. She was found to have altered mental status and was lethargic but arousable, sometimes even combative. Due to the time lapse, charcoal was not administered. There was no history of coronary artery disease or heart disease in herself or in any family members. An ECG on admission showed a QTc prolongation of 491 ms and normal sinus rhythm. The patient was monitored on telemetry at the general internal medicine service. Repeat ECG 18 hours after admission showed a QTc of 502 ms and sinus bradycardia (Fig.1a and Fig. 1b). Serial ECGs were continued with the following results of QTc/hours after admission: 499 ms/2, 485 ms/25 (> 1 day), 469 ms/41, 461 ms/71 (> 2 days), 476 ms/97 (> 4 days). After the QTc interval had decreased to 461 ms, the patient was transferred to the inpatient psychiatry ward service. A lithium blood level upon admission was 1.0 mmol/L (normal range: 0.5-1.5 mmol/l). Therefore, lithium toxicity was an unlikely cause of her ECG changes although lithium intoxication can occur with normal lithium serum concentrations.7 It was determined that the most likely cause of QTc prolongation was escitalopram overdose. Unfortunately, we could not measure serum levels of escitalopram or of its major metabolite, DDCT. The patient was provided general supportive care since no antidote is known. Further laboratory tests revealed her al-
Fig 1a: ECG on admission. Arrows indicate the QT interval. Ventricular rate was 63 bpm, QTc, 491 ms. Fig 1b.
351
Fig 1b: ECG 18 hours after admission. Ventricular rate was 53 bpm, QTc, 502 ms.
JOURNAL MSMA DECEMBER 2010
bumin and liver enzymes were within normal limits, indicating absence of liver damage and normal protein-binding ability. This is of importance because escitalopram is mainly metabolized in the liver and 56% of it is bound to human plasma pro6 teins. Other laboratory values pertinent for the QTc interval were potassium 4.0 meq/l (normal range: 3.5-5.1), calcium 9.2 mg/dl (normal range: 8.4-10.2), and magnesium 1.6 meq/l (normal range:1.3-2.0). Serum sodium was normal (142 mmol), although hyponatremia can be seen in patients taking citalopram or escitalopram.8,9 TSH was 2.2 uUI/ml (within normal range). The patient had a history of numerous suicide attempts in the past and continued to have suicidal ideation. Therefore, she was transferred to the psychiatry unit for further medical care 71 hours after admission when QTc was 461 ms. She was started on duloxetine (cymbalta) and quetiapine (seroquel).
DISCUSSION
Escitalopram is used therapeutically for major depression, generalized anxiety disorder, and social anxiety disorder. It is not recommended for children and adolescents under the age of 18 years due to absence of concrete data in this age group, although one recent report points out a prolonged QTc interval in a 14-year-old girl.10 Risk of commiting suicide increases with the use of escitalopram. However, untreated depression increases the risk of suicide as well. Frequent monitoring for suicidal ideation is recommended in patients being treated with this drug and suffering from depression. Other side effects reported with the use of escitalopram are hemorrhage, hyponatremia, insomnia and mania.6,8 However, clinically significant cardiac abnormalities and ECG changes have only been reported twice with escitalopram overdose.10,11 An association between citalopram and QT prolongation and torsades de pointes has been shown in studies with dogs and humans.2,12 The cardiotoxic metabolite DDCT was reported to be the cause. Electrocardiographic changes and seizures have been noted above doses of 600 mg of citalopram: generalized convulsions are seen in 33% and wide QRS complexes are seen in 33%.12 Because escitalopram toxicity has not been well-documented, caution should be exercised when prescribing escitalopram alone or in combination with other medications that may prolong the QTc interval, especially psychotropic drugs. If an overdose occurs, it is difficult to monitor levels of escitalopram in the serum/plasma.5,13 Hence, ECG monitoring for QTc interval prolongation may serve as a surrogate marker for escitalopram toxicity. Fluorimetry has recently been found to be suitable for assessing plasma levels of citalopram and escitalopram.13 With that method, fluorescence spectra of drugs, for instance citalopram and escitalopram, are measured utilizing a spectrofluorimeter as the fluorescence spectra of these drugs are unique. Cytochrome P450 (CYP) isoenzymes located in the liver are responsible for oxidative metabolism of many drugs. CYP2D6 and CYP2C19 are specific types of CYP isozymes which are mainly involved in metabolizing antidepressants and antipsychotics. Various genetic and environmental factors can
either inhibit or induce metabolism by influencing the CYP system. As a result, unexpected toxicities can develop. Genetic variations can result in individuals being either extensive metabolizers or poor metabolizers. Poor metabolizers are more likely to develop toxicity due to the drugs not being adequately biotransformed. In order to assess and predict the metabolic identity of an individual patient, further phenotypic profiling should be undertaken. Environmental factors include drug-drug interactions that 18 could lead to inhibition or induction of the cytochrome system. In this patient, co-ingestion of other drugs (lithium) and alcohol may have played an important role in the metabolism of escitalopram. Alcohol is known to influence hepatic enzymes involved in drug metabolism.14 This patient consumed 6 wine coolers (unknown quantities [grams] of alcohol) throughout the night before ingesting escitalopram. This may have affected the cytochrome system and escitalopram metabolism, contributing to the QTc-interval prolongation. The patient also consumed large quantities of lithium. Cases of lithium overdose leading to increased QTc-interval have been reported, but by the time this patient was seen at the hospital, her lithium levels were within normal range.15 However, since lithium enhances the serotonergic effects of escitalopram, it is important to monitor lithium levels closely, considering its half life of 22 hours. In addition, signs of lithium intoxication can be seen even in the setting of normal lithium serum concentrations.7 When analyzing the Swedish pharmacovigilance database, Astrom-Lilja et al16 recently found that tdp is an infrequently reported adverse drug reaction and that several (additional) risk factors are usually present including heart disease, age over 65 years, and female gender. Interestingly, according to these authors, in two thirds of the medications (with citalopram being the third most common suspected drug) implicated in the reports of this database, neither QT prolongation nor tdp were labelled in the summary of product information.16 Isbister et al17 developed a management protocol for QT abnormalities after citalopram overdose. The same principles should apply to escitalopram overdose since the cardiotoxic metabolite (DDCT) is the same. In a person with QT changes, it is beneficial to give single-dose activated charcoal (SDAC) within 4 hours of overdose and monitor QT until it is normal. For patients who have ingested a high dose (more than 1000 mg), SDAC should be given within 4 hours and cardiac monitoring continued for 13 hours after ingestion even if QT remains normal. For patients with an overdose between 600-1000 mg, SDAC should be given within 4 hours; if it is not, cardiac monitoring is recommended for 13 hours.17 Considering the amount of escitalpram ingested (approx. 400 mg with 10 mg escitalopram said to be equivalent to 40 mg of citalopram) and the time lapse, our patient most likely falls within this last category.
CONCLUSION
In summary, escitalopram overdose leading to QTc-interval prolongation and potentially life-threatening arrhythmia has
DECEMBER 2010 JOURNAL MSMA
352
only twice been previously described but increased awareness is needed, especially considering the now widespread use of such medications. Prescribers may wish to exercise caution when administering escitalopram to patients who have suicidal ideations and depression. In the event of an overdose, administration of charcoal and ECG monitoring for at least 2 days after ingestion are recommended in order to prevent life-threatening arrhythmias like torsades de pointes. Other factors and drugs that could contribute to prolongation of the QT interval should be taken into account when determining the time period needed for ECG monitoring in the individual patient.
REFERENCES 1.
2. 3. 4. 5. 6.
7.
8. 9.
Berul CI, Seslar SP, Zimetbaum PJ, et al. Acquired long QT syndrome. UpToDate 2008:16.1.
Blaschke D, Parwani AS, Huemer M, et al. Torsades de points during combined treatment with risperidone and citalopram. Pharmacopsychiatry 2007;40:294-295.
17. Isbister GK, Friberg LE, Duffull ST. Application of pharmacokinetic-pharmacodynamic modelling in management of QT abnormalities after citalopram overdose. Int Care Med. 2006;32:1060-1065.
18. Schrauzer GN, Shrestha KP. Lithium in drinking water. Br J Psychiatry. 2010;196(2):159-60.
For a bird’s eye view on medicine follow MSMA on
!
Pliquett RU, Eichfeld U, Stumvoll M, Koch CA. Long QT syndrome under mitotane therapy. J Endocrinol Invest. 2007;30:167-168.
Reilly JG, Ayis SA, Ferrier IN, et al. QTc-interval abnormalities and psychotropic drug therapy in pychiatric patients. Lancet 2000;355:1048-52.
Reis M, Cherma MD, Carlsson B, et al. Therapeutic drug monitoring of escitalpram in an outpatient setting. Ther Drug Monit. 2007;29(6):758-766. Escitalopram: Drug information. UpToDate 2008:16.1.
Habermeyer B, Hess M, Kozomara-Hocke P, et al. Lithium intoxications at normal serum levels. Psychiatr Prax. 2008;35(4):198-200.
Covyeou JA, Jackson CW. Hyponatremia associated with escitalopram. N Engl J Med. 2007;356(1):94-5.
Miehle K, Paschke R, Koch CA. Citalopram therapy as a risk factor for symptomatic hyponatremia caused by the syndrome of inappropriate secretion of antidiuretic hormone (SIADH): a case report. Pharmacopsychiatry 2005;38(4):181-2.
10. Scharko AM, Schumacher J. Prolonged QTc interval in a 14year old girl with escitalopram overdose. J Child Adolesc Psychopharmacol. 2008;18(3):297-298.
11. Baranchuk A, Simpson CS, Methot M, et al. Corrected QT interval prolongation after an overdose of escitalpram, morphine, oxycodone, zopiclone and benzodiazepine. Can J Cardiol. 2008;24(7):e38-40.
12. Catalano G, Catalano MC, Epstein MA, et al. QTc interval prolongation associated with citalopram overdose: a case report and literature review. Clin Neuropharmacol. 2001;24(3):158-62.
13. Serebruany V, Malinin A, Dragan V, et al. Fluorimetric quantitation of citalpram and escitalpram in plasma: developing an express method to monitor compliance in clinical trials. Clin Chem Lab Med. 2007;45(4):513-520.
14. Miners JO, Birkett DJ. Cytochrome P4502C9. an enzyme of major importance in human drug metabolism. Brit J Clin Pharmacol. 1998;45(6):525-538.
15. Mamiya K, Sadanaga T, Sekita A, et al. Lithium concentration correlates with QTc in patients with psychosis. J Electrocardiol. 2005;38(2):148-51.
16. Astrom-Lilja C, Odeberg JM, Ekman E, et al. Drug-induced tor-
353
sades de pointes: a review of the Swedish pharmacovigilance database. Pharmacoepidemiol Drug Saf. 2008;17(6):587-592.
JOURNAL MSMA DECEMBER 2010
There’s a lot going on in organized medicine so it’s easy to miss something if you’re on the go. To help you stay in touch no matter where you are, MSMA is now communicating via “Twitter.” In about three minutes, you can set up a free Twitter account for yourself. Simply visit www.twitter. com and submit your name, email address and mobile phone number (optional, standard text messaging rates apply). Once you’re signed up with Twitter, you can add MSMA by going to the following web page http://twitter.com/ MSMA1 and clicking “Follow” next to the MSMA icon.
MSMA1
• MSDH • Mississippi Reportable Disease Statistics
September 2010
* Totals include reports from Department of Corrections and those not reported from a specific district. ** Address unknown for 10 cases.
For the most current MMR figures, visit the Mississippi State Department of Health web site: www.HealthyMS.com DECEMBER 2010 JOURNAL MSMA
354
• CLINICAL PROBLEM-SOLVING •
Presented and edited by the Department of Family Medicine, University of Mississippi Medical Center, Diane K. Beebe, MD, Chair
Can’t Catch my Breath Christopher J. Fort, MD
A
55-year-old Caucasian female presented to the emergency department after being sent from clinic with complaints of fatigue, persistent cough, worsening shortness of breath on exertion and chest discomfort. The chest discomfort was described as several weeks of intermittent pressure and tightness which radiated into her left shoulder and neck. The pain was worse with activity and better with rest. In this patient, our differential diagnosis is broad. Multiple systems could be contributing to her symptoms, including pulmonary, cardiovascular, gastrointestinal, hematological, musculoskeletal or endocrine. Since the symptoms seem to be associated with the respiratory or cardiac system, I would initially consider pulmonary or cardiac pathology. I would obtain a complete blood count, electrolytes, cardiac enzymes, D-dimer and chest radiograph. Additional history is needed to narrow the differential diagnosis. The patient admitted to a history of smoking but had not smoked for over 30 years. She also denied any history of asthma. The patient reported a history of bronchitis, which had developed into pneumonia within the previous year. She was prescribed levofloxacin (Levaquin) and guaifenesin/dextromethorphan (Mucinex DM). Chest radiograph at that time did not show any focal infiltrates; however, due to her leukocytosis, she was treated with antibiotics. She felt some improvement with the treatment; however, her symptoms never fully resolved. The patient was seen in clinic 4 months later for limb and abdominal pain at which time she was taking ibuprofen. She was then prescribed meloxicam (Mobic) and ibuprofen was disconAUTHOR INFORMATION: Dr. Fort is a former resident in the Department of Family Medicine at the University of Mississippi Medical Center.
CORRESPONDING AUTHOR: Christopher J. Fort, MD; Mississippi Baptist Medical Center, 1151 N. State St., #504, Jackson, MS 392026. Ph: (601) 601-968-4155 E-mail: cfort21@yahoo.com.
355
JOURNAL MSMA DECEMBER 2010
tinued due to the abdominal pain. She was evaluated several months later for abdominal and chest pain. At the most recent visit, she had complained of abdominal pain and left chest pain that radiated to her back. These symptoms started the night prior to evaluation and had slightly improved with over-the-counter omeprazole (Prilosec). The abdominal pain was thought to be due to esophageal reflux or gastritis. After examination, the chest pain was determined to be musculoskeletal in nature, and she was continued on meloxicam. She reported having a normal echocardiogram and treadmill stress test 5 years earlier for mid-sternal chest pain. Our differential is still broad and further tests are required. The patient would benefit from further evaluation for possible myocardial infarct, congestive heart failure, pulmonary embolus and pneumonia. I will order an electrocardiogram, an echocardiogram and a chest radiograph. Though a myocardial infarct needs to be explored, her past history suggests that the cause of her symptoms is most likely pulmonary related. The patient’s cardiac enzymes were normal. Electrocardiogram showed sinus tachycardia, nonspecific ST and T wave abnormalities and left atrial enlargement. There was no ST elevation or depression. The patient reported waking at night with shortness of breath which was relieved by sleeping in an upright position. The electrocardiogram findings do not indicate an active myocardial infarction; however, further history and studies are still needed to investigate for myocardial infarction, congestive heart failure or another cardiac pathology. The patient will need repeat cardiac enzymes, and a possible cardiac stress test to further investigate for a myocardial infarction. This additional sleep history suggests that her presentation could still be related to the cardiac or pulmonary system. These symptoms suggest possible congestive heart failure, pulmonary hypertension or pneumonia, all of which can cause similar symptoms.
On physical examination the patient had an oxygen saturation of 97% while breathing room air. She was awake, alert and oriented to person, place and situation. She was well developed and in no distress. Pulmonary examination revealed clear breath sounds in the bilateral lung fields. Cardiac and abdominal examinations were normal. She did not have any signs of cyanosis or edema. However, it was noted that the she was extremely short of breath with ambulation to her room. Her white blood cell count (WBC) was 13.6 K/uL, and chest radiograph findings suggested a possible interstitial pneumonia. Her D-dimer was 0.81 ug/dL. Her comprehensive metabolic panel (CMP) was normal. The patient was given supplemental oxygen for comfort and levofloxacin (Levaquin) for the leukocytosis and suspected pneumonia. She was then admitted. The patient demonstrated some slight improvement over the following 2 days; however, her symptoms had not completely resolved. Her leukocytosis also resolved initially and then returned on day 3 with a white blood cell count (WBC) of 12.5 K/uL. At this point our differential is still broad, but her findings continue to suggest pneumonia. However, her elevated D-dimer suggests that she could also have a pulmonary embolus. A computed tomography (CT) will be ordered. The patient’s history and physical examination lead to some additional considerations. Her diagnosis did not seem to be simply a bacterial interstitial pneumonia as she experienced no improvement with repeated courses of antibiotic therapy. On day 3 the patient was questioned regarding other possible exposures that could have contributed to her symptoms. She reported spending much of her free time training horses. She worked in horse stalls that contained old, wet hay. With this additional history, other causes of pneumonia such as blastomycosis or histoplasmosis are considered, as this could explain why she did not respond appropriately to antibiotics. It was thought the patient would benefit from a future bronchoscopy and serology for blastomycosis and histoplasmosis. Also needed are anti-neutrophil cytoplasm antibodies for Wegener’s granulomatosis and angiotensin converting enzyme concentration for consideration of alpha antitrypsin deficiency. CT findings demonstrated mild patchy ground-glass interstitial densities in the lower lobes, most prominent in the right lower lobe. It also demonstrated a soft tissue attenuation lesion measuring 4.7 x 3.6 cm within the left atrium. A cardiologist was consulted for further evaluation of the right atrial mass. The patient underwent an echocardiogram that confirmed a left atrial mass encompassing the entire atrium. The cardiac ejection fraction was estimated to be greater than 60%. The patient underwent surgery without complications and tolerated the procedure very well. The patient had a follow-up transesophageal echocardiogram which demonstrated that the left atrial mass had been successfully removed.
A definitive diagnosis of a left atrial myxoma is made. It is now evident that this was most likely the cause of the patient’s symptoms. A cardiac myxoma can cause decreased cardiac output and increased pulmonary edema, both of which can cause shortness of breath, chest pain, coughing and fatigue. It is also believed that this was the cause of the interstitial lung changes and improvement will soon follow. Bronchoscopy will not be pursed, but follow up to evaluate for resolution of the interstitial lung changes is important. Cardiac tumors are very uncommon occurring with a lifetime incidence of 0.0017% to 0.02%; however, myxomas are 1,2,3 the most common type of cardiac tumors found in adults. Approximately 75% of primary tumors are benign and 50% of benign tumors are myxomas, resulting in 75 cases of myxoma per million autopsies.4 The incidence of primary tumors tends to decrease with age. Although cardiac tumors are more likely to 2 occur in females (61%) than males (39%), the frequency of primary tumors is found to be approximately 46% in men and 32% in women.5 The long term survival after myxoma resection is 2 not significantly different from that of the general population. The patient continued to show signs of improvement and was stable enough to be discharged home. The patient was scheduled to follow up with her primary care physician, pulmonologist, cardiologist and cardiovascular surgeon. She has been followed for 6 months and is currently undergoing cardiac rehabilitation with a low intensity exercise program. The patient’s symptoms have completely resolved, and she is doing very well with no current complications. KEY WORDS: CARDIAC NEOPLASMS, MYXOMAS, LEFT ATRIAL MASS, HEART FAILURE
REFERENCES: 1. 2. 3. 4. 5.
Silverman N. Primary cardiac tumors. Ann Surg.191:127– 138;1980.
ElBardissi AW, Dearani JA, Daly RC, et al. Survival after resection of primary cardiac tumors: a 48 year experience. Circulation. 2008;118:S7-S15. Gokhan I., Vedat E. Nilgun. et al. Surgical management of cardiac myxoma. J Card Surg. 2005;20:300-304.
McAllister HAJ, Fenoglio JJJ: Tumours of the cardiovascular system. Atlas of Tumour Pathology. 2nd Series. Washington, DC: 1977:122–124.
Bussani R, De-Giorgio F, Abbate A, Silvestri F: Cardiac metastases. J Clin Pathol. 2007;60(1):27-34.
PLEASE TELL OUR
ADVERTISERS
THAT YOU FOUND THEM IN THE
DECEMBER 2010 JOURNAL MSMA
356
• PRESIDENT’S PAGE •
W
Up in Smoke
hen one of your dissecting partners from medical school calls and asks you to be somewhere, you go— especially if she is the reigning State Health Officer. Dr. Mary Currier recently asked me to attend a meeting in Jackson. I am not going to divulge the topic yet because you will stop reading at this point. The subject at hand would be presented at the Blue Cross building in Jackson and the topic appeared to be a bit far-fetched. As I left the clinic to drive to Jackson, I mentioned the purpose of my trip to a clinic partner, and he was a bit skeptical about the pending discussion. I had just heard Mississippi Public Radio’s news release of a 13% reduction in heart attacks in Hattiesburg as a result of its comprehensive smoking ban in 2007 in TIM J. ALFORD, MD public places. My first thought was that this simply could not be correct and that the 2010-11 MSMA PRESIDENT Social Science Research Center’s (SSRC) data was off base. Even though we know many of the hazards of passive cigarette smoke exposure including lung cancer and increased childhood illnesses, the whole idea has seemed like one of those public health abstractions that you really can’t do much about. So now you know the rest of the story… But not really! The featured guest at Dr. Currier’s meeting was Dr. Terry Pechacek, associate director of science in the Office on Smoking and Health at the Center for Disease Control’s Smoking Prevention Division. Dr. Pechacek also writes the Surgeon General’s report and has concluded that there is an indisputable link between passive smoke and heart attacks , that the cause and effect is much greater than previously thought. Due to the fact that Mississippi is the proverbial black hole of cardiovascular death in these United States, Dr. Pechacek believes that Mississippi would have the most to gain by enforcing a statewide smoking ban in public places. Further that acute coronary syndrome often occurs only minutes to hours after exposure to second hand smoke. He reminds us that second hand smoke also increases the risk of SIDS and low birth weight babies which is significant since Mississippi continues to hold the dubious distinction of the highest infant mortality rate in the United States. The Surgeon General is soon to release this alarming information. For those who would say that our public health friends are getting ahead of their data, Dr. Pechacek reminds us that the Surgeon General has never had to “take back a report.” The SSRC has compiled statistics which show marked reduction in admissions for heart attacks in communities that have implemented a comprehensive smoking ban in public places. Liz Sharlot, spokesperson for the Mississippi State Department of Health, is running a bedazzling information and media campaign, taking into account that the deep claws of nicotine addiction have found safe haven in the culture of the southeastern United States. The secret weapon in this campaign is the “voice of children” who are often the best ambassadors for unseating immovable prejudices within our culture. The goal is to complete a two-year campaign that will inform Mississippians about the benefits of smoke-free air, educate residents about the harmful effects of breathing secondhand smoke, and support a comprehensive Mississippi smoke-free air law. Other Mississippi health advocate organizations are partnering with MSDH to help with the Smoke Free Air Mississippi campaign. The campaign will include extensive grassroots efforts, a statewide media campaign, and collaboration with key partners to support the passage of a comprehensive smoke-free air law. Check out the campaign at: http://www.smokefreeairms.com. So, as a member of this Association you are asked to endorse the enactment of a statewide comprehensive smoke-free air law for Mississippi that will restrict smoking in all public indoor environments and workplaces, thereby protecting the health of all Mississippians. This will represent a huge step in addressing the problem of too many preventable deaths across the age and gender spectra. We will work with our elected officials to this end and need your help to promote a Smokefree Air Mississippi in 2011!
References: 357
http://www2c.cdc.gov/podcasts/player.asp?f=10294 http://mstobacco.childhealthdata.org/DataQuery/SurveyAreas.aspx.
JOURNAL MSMA DECEMBER 2010
• EDITORIALS •
Many Good Things Are Happening at our MSMA
T
Lucius M. Lampton, MD, Editor
he MSMA Board of Trustees has been hard at work on many matters of great importance to our membership. At its most recent gathering on September 10 and 11 at MSMA headquarters in Ridgeland, the board welcomed a new chairman and discussed matters ranging from a record jump in membership to plans for an innovative website. At the end of the Natchez annual session on June 6, Dr. James A. “Jim” Rish of Tupelo was handed the chair’s gavel by Dr. Steve Demetropoulos of Pascagoula. Although many perceive the presidency as our association’s top position, the constitution and bylaws bestow the board chair more actual power and responsibility, and it is easily the most important position of all of the association leadership. Dr. Demetropoulos had served several terms as chair with distinction, leading our MSMA through many trying and difficult issues. Rish, a pulmonologist and critical care specialist, is known for his ubiquitous bow tie, his sharp intellect, and his calm and reassuring manner. Jim will fill Steve’s big shoes as chair with similar grace and integrity. The board usually meets in August but this year moved its quarterly meeting to September with several new board members, Dr. Dwight Keady of Meridian, Dr. Bill Grantham of Clinton, and Dr. Brent Smith of Jackson, in attendance with the rest of the board and its invited guests. Dr. Daniel Edney of Vicksburg, who has served our association in many important capacities, is the new vice chair of the board, and Dr. Claude Brunson of Jackson is the board’s new secretary (not to be confused with the MSMA officer position of secretary-treasurer, now held by Dr. Clay Hays of Jackson). The membership report is certainly deserving of mention. The association totals 4,618 members, up 909 from 3,709 in 2009. This is an historic number, the highest number of members ever for our MSMA as well as one of largest percentages of membership of total physicians for any state association currently. (According to 2009 numbers, Mississippi has 5,606 licensed physicians; thus more than 82% of the state’s physicians are members!) Large jumps were seen in all areas of membership: paid active members, up 351; student members, up 163; and resident/fellow members, up 401. In June, the board had voted unanimously to waive all dues requirements for medical students, residents, and fellows living in Mississippi. Thus, student and resident increases can be explained by this action. However, a significant increase was also seen in active and paid members, and there is no doubt that this increase is directly the result of our association’s deunification with the American Medical Association (AMA). Those against deunification, including this writer, had pointed to membership declines resulting from similar action in other states. Such had been the experience nationally. But Mississippi bucked that trend. That action not only attracted many members who wanted local membership without belonging to the AMA, but also lowered dues prices enough for the University Medical Center’s physicians to join as a group. UMC leadership had long expressed a desire to increase faculty membership in MSMA, and the AMA membership requirement made such cost prohibitive. MSMA member Claude Brunson, with the assistance of MSMA staff, crafted agreements which brought into our association most of the UMC faculty. Anna L. Morris, our new director of external relations, revealed at the board meeting many creative ideas to invigorate the association’s electronic capabilities and fund-raising efforts. “Anna has been on board only for two and a half months and already has moved us so far ahead,” said Charmain Kanosky, MSMA executive director. Morris gave an exciting presentation on our updated website which includes at our board’s request online venues giving Mississippi docs an electronic forum to discuss hot issues affecting the practice of medicine in a members-only format. A similar online forum was offered earlier this year as a way for our membership to post comments on the annual session House of Delegates resolutions. Dr. Rish summed up the feeling of the board that this would be “a great tool” for our physicians to communicate and discuss issues of importance. Many remember with appreciation the blog created by Dr. Ben Kitchens of Corinth during the tort reform crisis and hope that similar energy will
DECEMBER 2010 JOURNAL MSMA
358
be stimulated by the new forum. Also, a new “job bank,” patterned after a similar one on the Iowa Medical Society’s website, was introduced. This job bank will have the appearance of classified ads and allow people to submit jobs through the site and search for jobs by specialty. There was also discussion of a media campaign to influence the public to encourage Congress to fix the dysfunctional SGR formula which annually has physicians facing 20% cuts. An extensive campaign was felt too expensive by the board, but they did vote to prepare a $25,000 media campaign to communicate to the state’s citizens that the SGR formula is broken and Congress refuses to fix it. Significant board discussion was held on where to have our annual sessions in the future. Most felt this year’s session in Natchez was a grand success, not necessarily in numbers of attendance (which was almost 300) but in terms of satisfaction of those who attended the events, the CME, and the family friendly activities. “If you want young blood, you have to be sure that the session is family oriented,” said Dr. Grantham. Sadly, numbers reached their highest at annual session in Biloxi before Katrina (in 2005 more than 350 physicians attended annual session). A 2007 resolution was passed which requires the annual session to be held within the state’s borders, and a 2008 resolution was passed requiring the annual session site to be smoke-free, eliminating most of the hotels on the Coast. There is also sentiment on the board to rotate the annual session site around the state. Tupelo is next year’s gathering place. However, the board has changed the dates for the meeting due to scheduling conflicts with the 2011 graduation of the University of Mississippi School of Medicine. Tupelo’s BancorpSouth Conference Center and the adjacent hotel were able to accommodate a change for the meeting to be held May 19 to 23, 2011. Problems have emerged with the 2012 annual session in Hattiesburg. The only dates the Hattiesburg Convention Center had available were Memorial Day weekend which most of the board felt would negatively impact attendance. Dr. Clay Hays was asked to lead a board appointed geographically diverse committee to explore locations and dates of the 2012 meeting. Also, there was a suggestion to explore asking the House of Delegates to reconsider the in-state requirement for all annual sessions. Since this September meeting, the board has discussed on phone conferences the establishment of a relationship with Delta Health Alliance to help implement health information exchange under the Beacon grant. Says Dr. Alford, “This will help facilitate communication between physician offices and hospitals.” One final item discussed by the board was the creation of the first ever “Give-Back Gala” to be held December 3. This benefit for the MSMA Foundation will be held that Friday from 7 p.m. to 11 p.m. at the Trustmark Ballroom of the Jackson Convention Center Complex. The black tie event will feature cocktails, dinner, dancing, and live jazz entertainment. The $500 per couple cost is a tax deductible donation to the MSMA Foundation, and members can designate the gift to such deserving causes as the Rural Physicians Scholarship Program, the Journal MSMA, or the Mississippi Professionals Health Program.
NEW IN OUR JMSMA
Journal MSMA Associate Editor Dr. Rick deShazo has developed guidelines for two new features our JMSMA will introduce in the New Year:
1. “UpToDate” series - The purpose of this series of articles is to provide to practicing physicians of Mississippi brief reviews on topics of general interest in areas where recent developments in diagnosis or treatment have occurred. For instance, an article on recent advances in the diagnosis and treatment of lupus erythematosis would be an appropriate submission.
2. “Top Ten Facts You Need to Know” series - The purpose of this series of articles is to provide referenced information on clinical management of medical conditions in a concise fashion. The submissions should be directed toward practitioners who do not have specialty training on the specific topic as a matter of general information. The author of the best “top 10” submission for each year will receive a prize.
All articles should be forwarded to the Editor for peer review using the usual guidelines in the “Information for Authors,” found on page 376 of this issue or at MSMAonline.com. While you’re on the MSMA website, be sure and check out the flipthrough pages of your JMSMA online too. Your editors hope you like the clean pages and rapid loading of searchable online issues and find the website's reading pane easy to navigate. As this journal arrives at your offices, the board will be gathering again on December 4th for its winter meeting at the MSMA headquarters. The Committee on Publications, chaired by the gracious Dr. Dwalia South of Ripley, will also be gathering that weekend to select photographs for next year’s journal covers. Many good things are happening at your MSMA. Become more involved in your association: attend annual session and your local component society meetings, give to the worthy causes of the MSMA Foundation, write a letter to the editor or submit an article to your JMSMA, serve on one of MSMA’s councils or committees, or serve as a doctor of the day for the Legislature! Come be an active part of Mississippi’s medical family!❒
359
JOURNAL MSMA DECEMBER 2010
• GUEST EDITORIAL •
Creating a Be$er Climate for the Nation’s Health Care Could Make Champions of all Physicians
M
William “Bill” Lineaweaver, MD
y office fax machine recently delivered a series of messages. They required some assembly. When put together in apparent order, the story went as follows:
A prominent national figure, whose hairstyle and vigorous use of categoricals and non-sequitors have influenced countless aspiring politicians, serves as the “General Chairman” of an entity entitled “American Solutions for Winning the Future.” The General Chairman wrote a memo to a more operational executive of the committee announcing that I had “made the cut as one of our 2010 Champions of Medicine.” At the bottom of this memo, in a handwritten addendum addressed to me, the operational executive congratulated me, informing me that a table was reserved at the awards ceremony “so your guests will have a great view of you receiving the award.” I was dazzled. I could not imagine what selection process singled me out for such distinction. I envisioned my virtues as a doctor spontaneously emanating from my Mississippi office to win recognition at high national levels. Next in line was a photograph of a very professional desk holding a world globe and a handsomely framed certificate. The certificate stated that “American Solutions hereby recognizes Dr. William Lineweaver as 2010 Champion of Medicine in recognition for succeeding in the face of adversity and economic turmoil.” The minor misspelling of my name did not detract from my gratitude for being congratulated upon surviving the economic catastrophes of 2006-2008 with retention of my home and over 60% of my retirement investment funds. A message superimposed on the picture stated “this would look great in your office!” The next document was an “agenda and itinerary” for the Champions of Medicine Ceremony. The full day’s schedule included a Business Roundtable, a Meet and Greet event with the General Chairman (including photo opportunities), a dinner in the “historic and intimate Reagan Ballroom” (chestnut and artichoke risotto, beef tenderloin with potatoes, wild mushroom fricassee, truffle sauce, and more), several hours of speeches, participation in a nationwide election night broadcast (“You’ll be part of the broadcast….”) and, finally, “exclusive networking opportunities with….top business owners.” I felt more and more honored as these details unfolded. Finally, there was a personal memo to Dr. Lineweaver from the General Chairman himself. He kindly reiterated the distinctions conferred upon me by this award and its ceremony. One paragraph, however, startled me. I know how difficult this year has been with the uncertainty caused by the Obama Administration and the Democrat held Congress essentially dismantling the world’s greatest healthcare system and replacing it with the failed model of socialized medicine. As I have stated since the day after ObamaCare was passed, “THIS WILL NOT STAND.” As grateful as I was for the General Chairman’s recognition of my achievement, I was worried that he might be proceeding to make statements that would be embarrassingly mistaken. I understand that such a person as the General Chairman must rely on staff research for analysis of complex issues, and sometimes such secondary sources can go awry. I proceeded to forward some supplementary information to him to give him a chance to perhaps revise some statements. Given his generous recognition of me, I thought such a service was the least I could do. In calling the U.S. health care system “the world’s greatest,” it really is necessary to account for this system’s staggeringly high costs, part of which are results of insurance company overhead and profits. Relative to many other countries, the U.S. system has depressingly low outcomes in many areas including infant mortality and life expectancy. While the U.S. health care system has many remarkable features, there seems to be room for improvement in many areas.1 What the General Chairman called ObamaCare must be the Patient Protection and Affordable Care Act. Despite a blizzard of collateral national debate and perhaps some imprecise staff work underlying the General Chairman’s statements, this piece of legislation does not clearly dismantle or socialize anything. Generally, the act serves as a regulation of the insurance industry. Its provisions include:1 • Mandated individual insurance purchasing, with associated exemptions and subsidies;
DECEMBER 2010 JOURNAL MSMA
360
•
• •
Expansion of Medicaid eligibility and increased reimbursement rates for services;
Establishment of Health Insurance exchanges which will provide standardized formats for insurance policies, centralized enrollment, and options for group enrollments;
Prohibition of pre-existing condition exclusions for children, rescission (coverage cancellations during illness), and lifetime amount limits for specific illnesses. I bundled up a set of my previous editorials covering these topics and sent them to the General Chairman.2-4 I hope they gave him additional resources to contribute to balanced, un-embarrassing statements on health care. Sadly, I was not able to attend the ceremony. As an old-fashioned voter, I still need to go to my neighborhood fire station to cast my ballot on election day, the day of the ceremony. Also, I was scheduled to take call that day. During call, I have some great advantages relative to patient evaluation. I practice within a business model that identifies my specialty patients as a group. The group’s overall economic performance is the determinant of the financial viability of the practice. 5,6 Most recently, my definition of my practice (microsurgery and complex reconstruction) has extended to burns, and management of these cases now represents 50% of my practice. Remarkably, the state’s only trauma center refuses to treat these patients, and they have fit comfortably into the scope of my practice interests. Within these defined clinical areas, my hospital and parent practice group allow me to accept patients according to their medical need without economic screening. The overall practice generates satisfactory income for the principals, and I do not have to formulate a business plan for each referral. Working to create such a practice environment really does make me feel like a Champion of Medicine. Creating a similar climate for the nation’s health care could make champions of us all. REFERENCES 1.
Connors E, Gostin L. Commentary: Health care reform. JAMA 2010;303:2521-2522.
3.
Lineaweaver W. Health care reform: Some scenes from the cheap seats. Ann Plast Surg. 2010;63:363.
2.
4.
5. 6.
Lineaweaver W. Is health care a commodity? Ann Plast Surg. 2009;61:1-2. Lineaweaver W. Old deals, new deals. Ann Plast Surg. 2010;64:266-267.
Lineaweaver W, Hui K, Krave K, Mailhot C. Economics of microsurgical cases and routine cases in a medical center. Plast Reconstr Surg. 2000;105:46-54. Lineaweaver W, Rogers B, Oswald T. Hospital income from patients managed through a Center for Microsurgery and Complex Reconstruction. Ann Plast Surg. 2008;60:573-578.
Feel the Burn Exercise at a moderate intensity to get the most benefit from your workout. A light sweat, faster breathing and some strain in your muscles are all good indicators you’re exercising effectively. If you have a health condition or any other physical barrier, it’s a good idea to talk to your doctor before you begin. be healthy. exercise.
www.bcbsms.com Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company, is an independent licensee of the Blue Cross and Blue Shield Association. ® Registered Marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.
361
JOURNAL MSMA DECEMBER 2010
• SPECIAL ARTICLE •
B
Mississippi College Commences State's First Physician Assistant Program Karen A. Evers, Managing Editor
efore the thoughts of mid-level provider threat enter your mind, consider this: According to a study by the American Medical Association, solo practice physicians who employ physician assistants (PAs) are able to work one week less per year on average and provide greater access to care for their patients. “Physician assistants can lighten the workload considerably, giving physicians more time to do what they need to do,” says Dr. Robert Philpot, Chairman of the Department of Physician Assistant Studies at Mississippi College (MC) in Clinton. “The primary mission of the Mississippi College Physician Assistant Program (MCPAP) is to prepare physician assistants to provide primary health care services in medically underserved areas of Mississippi and surrounding states. As part of the health-care team, PAs allow physicians to extend their office hours. The capstone clinical experience places students in primary care settings. Many of those will be with potential employers in underserved areas,” Dr. Philpot said. “One of the greatest challenges for physicians in medically underserved areas is the lack of time to meet the needs of all of the patients. PAs can help the physician find more time, whether it’s for research and special cases or personal and family time. As part of the medical team, a PA can provide patients with quality medical care on a daily basis with limited supervision,” he said. According to the Medical Group Management Association (MGMA), PAs generate revenues well beyond the cost of their paychecks. A 2009 study by the MGMA revealed that for every dollar generated for PA care, the employer paid an average of 30 cents to employ a PA. Studies conducted by the Kaiser Permanente Center for Health Research found patient satisfaction levels with PAs high, ranging in the 90th percentile. “When hospitals and private practices have one or more PAs on staff, the medical team can serve significantly more patients in a day, expand office hours to serve working families, or extend practice by opening satellite offices. PAs can diagnose patients, write
DR. RODERICK "ROD" CUTRER, MCPAP MEDICAL DIRECTOR, AND DR. ROBERT "BOB" PHILPOT, PROGRAM DIRECTOR— Dr. Cutrer was born and reared in Magnolia. After graduating from Mississippi College in 1972, he attended the University of Mississippi Medical School and completed his Family Practice Residency at UMMC in 1979. He has also served as an Adjunct Professor at the University of Southern Mississippi. Dr. Cutrer is Board Certified in Family Practice and has practiced medicine for 31 years in Hattiesburg. Dr. Cutrer said, "For me, the PA education more closely resembles a condensed version of medical school than does any other health professions curriculum. Within the Physician-PA relationship, PAs exercise autonomy in medical decision-making and provide a broad range of diagnostic and therapeutic services. Flexibility and a broad-based education makes the PA profession very attractive to prospects, and even more so, to future employers." Dr. Philpot, who heads the new initiative, earned a bachelor’s degree from Belhaven University in 1983. A National Health Service Corps Scholar, he graduated from the PA Program at Emory University College of Medicine in 1994. He practiced primary care medicine in medically underserved areas of South Florida until he was recruited to the PA Program at the University of Florida College of Medicine in 1998. A retired military officer with 26 years of service, Dr. Philpot served in Operation Iraqi Freedom and directed medical operations for the Florida Army National Guard during relief operations following the 2004 Florida hurricanes and Hurricane Katrina. He earned a PhD in Education from the University of Florida and completed a Fellowship in Medical Education from the University of Florida College of Medicine in 2006. Dr. Philpot recently served as the Chairman of the Department of Physician Assistant Studies at South University, providing oversight and supervision of PA programs in Savannah, GA and Tampa, Florida. On September 1, 2009, he was appointed as the Chairman of the Department of Physician Assistant Studies at Mississippi College in Clinton.
DECEMBER 2010 JOURNAL MSMA
362
prescriptions, and counsel patients on preventive health strategies under physician direction. Even in growing practices PAs can lighten the workload considerably,” Dr. Philpot said. Dr. Rod Cutrer, MCPAP medical director says his association with the PA profession has been one of mutual respect and has led him to observe some very positive attributes of a good PA. “They have a broadbased knowledge of most medical and surgical disciplines; they show excellent judgment and have a good grasp of their limitations; they are the ultimate team-players and as a group are humble; and probably the most attractive trait is they genuinely care about people and communicate that caring to their patients. Personally, for me, I am extremely excited about teaching and mentoring these bright young minds, as is our entire faculty,” he said. “Hopefully a lot of gray hair has produced some small amount of wisdom, and combined with a good sense of humor, the combination will allow me to have a little fun as I do what I truly love to do: Teach,” Dr. Cutrer exclaimed. THE CURRICULUM The MCPA curriculum is a 30-month master of medicine curriculum. The first 15 months provide a broad grounding in medical principles with a focus on their clinical applicability. First-year instruction is in the classroom and the lab and consists of coursework in the basic sciences, including anatomy, physiology, biochemistry, pharmacology, physical diagnosis, pathophysiology, microbiology, clinical laboratory sciences, behavioral sciences and medical ethics. Courses are scaffolded in a manner that allows synchronization of relevant topic discussions across a number of concurrent courses such as Clinical Medicine, Diagnostic Medicine, Pharmacology, and Fundamentals of Medical Science. The final 15 months of the program place students in various 6-week supervised clinical rotations where they receive over 2,000 hours of patient care experience in disciplines such as internal medicine, family medicine, pediatrics, behavioral health, surgery, OB/GYN, emergency medicine, and critical care. Students may also choose an elective. After successful completion of clinical rotations, students participate in a semester-long clerkship. Throughout the program, there is a great deal of emphasis placed on teaching students to work with physicians as part of the health care team. On matriculation, the students are each assigned to a 6-member faculty-coached learning team. Learning teams work with their faculty coaches on a weekly basis to develop important critical thinking and
MISSISSIPPI COLLEGE PHYSICIAN ASSISTANTS PROGRAM (MCPA) Established:
May 25, 2011
Building target date: January 15, 2011 Inaugural class size: Anticipate 30 students. As resources grow, the size of the class will gradually increase to a maximum of 48 students. Initial Graduation:
December 2013
Core Faculty: The core faculty of the physician assistant program currently consists of 2 board certified physicians and 3 NCCPA certified physician assistants. Along with some teaching responsibilities, each core faculty member performs integral administrative tasks within the program. Clinical and classroom teaching is augmented by over 100 board certified physicians and physician assistants serving as guest lecturers and adjunct instructors from area hospitals, medical centers and private practices. Core Competencies: The competencies for this program and for the PA profession are: • Patient Care • Medical Knowledge • Practice Based Learning and Improvement • Systems Based Practice • Professionalism • Interpersonal Skills and Communication Specialty Distribution: According to the Twenty-Fifth Annual Report on Physician Assistant Educational Programs in the United States, 2008-2009, 2,609 PAs graduated in 2008, about half (49.8%) of those were employed in primary care specialties and half (50.2%) in non-primary care specialties.
Pre-clinical phase curriculum map: The physician assistant professional program typically takes about two and a half years to complete.
363
JOURNAL MSMA DECEMBER 2010
Demographics: Nationwide, 70% of matriculants into PA programs are female. The average age is 27 years and the males tend to be a couple of years older than the females.
problem-solving skills. This model also facilitates the use of a number of innovative approaches such as Team Based Learning, Objective Structured Clinical Examinations, and Problem Based Learning. Once students complete the 30-month program, they will be eligible to sit for the Physician Assistant National Certification Examination (PANCE). Following successful completion of the PANCE, they can apply for licensure in all 50 states. Physician assistant training differs from traditional medical school in that PAs enter supervised medical practice without years of residency training. PAs are then required to log 100 hours of continuing medical education every two years and pass a recertification exam every six years.
PRACTICAL EXPERIENCE
After 15 continuous months of laboratory and classroom training, the students are evaluated by the program to determine their readiness to participate in supervised clinical training. Prior to entering the clinical phase of the program, the students must demonstrate competency in history taking and physical examination, specific clinical procedures and familiarization with concepts of Advanced Cardiac Life Support (ACLS.) Strong emphasis is placed on training in inter-professional teams, and each student will be required to complete eight core rotations: internal medicine (inpatient), family medicine (outpatient), pediatrics, general surgery, critical care, behavioral health, OB/GYN and emergency medicine. Students will also complete an elective rotation of their choice and the semester long clerkship at the end of their training. The training will be performed at numerous hospitals, community health centers, and outpatient clinics across the state. “We have been fortunate to have strong support from institutions such as the University of Mississippi Medical Center (UMMC), Mississippi Baptist Medical Center, North Mississippi Medical Center, Central Mississippi Medical Center, River Region Health System, Central Mississippi Health Services, Mississippi Primary Health Care Association, Baptist Memorial Hospital – DeSoto in Southaven, and a number of other outpatient clinics and community health centers,” Dr. Philpot said.
FACILITY
Under construction is a 10,000 square foot learning center on the third floor of the Baptist Healthplex building on MC’s main campus. The center will feature numerous classrooms, mock exam rooms and offices. The entire facility has been designed to support the learning team approach to medical education. According to Dr. Philpot, “We’re also installing a state-of-the art video recording system (http://www.323link. com/), which will allow us to video stream or podcast lectures and demonstrations of clinical procedures, record simulated patient encounters, and videoconference with experts from the medical community. Construction is expected to be complete by mid January 2011,” he said. “Some of the preclinical training will occur on MC’s Clinton campus with the remainder conducted at UMMC.”
REGULATION
“Because the PA practice is relatively new to the state of
Mississippi we still face some challenges in drafting legislation and policies which will optimize the use of PAs in all practice settings,” Dr. Philpot said. “Ideally, state laws should require supervision, define it and include provisions that allow for customization of health care teams to best meet the needs of patients. Because of the diversity of settings and specialties in which PAs practice, a specific requirement for on-site presence of the physician will be unavoidably arbitrary. Certain requirements may be appropriate for some settings, but would be too restrictive or permissive in others. For example, state laws that require a physician to be on-site for a specified amount of time can be a barrier to care in some circumstances. A much more patient sensitive approach is to allow the physician(s)-PA(s) teams to match supervision to the specific needs of the practice,” he said. “Similarly, we are still working to help define the appropriate ratio of PAs to supervising physicians,” he added. Several organizations have evaluated appropriate ratios of PAs per supervising physician. In 1996, the American Academy of Family Physicians (AAFP) revised its policy on the ratio of PAs to supervising physicians. The AAFP deleted a sentence in its Guidelines on the Supervision of Certified Nurse Midwives, Nurse Practitioners and Physician Assistants policy that recommended a physician supervise no more than two “non-physician” providers. The American College of Emergency Physicians (ACEP) also supports the practice level determining its own ratios of PAs to supervising physicians. In 2007, the ACEP approved a policy stating that the medical director of an emergency department should define the number of PAs whose clinical work can be simultaneously supervised by one emergency physician. The AMA adopted the recommendation of its Council on Medical Service in 1998. Charged with studying the issue of ratios, the Council recommended: The appropriate ratio of physician-to-physician extenders should be determined by physicians at the practice level, consistent with good medical practice and state law where relevant. The American Academy of Physician Assistants believes the appropriate number of PAs is best determined at the practice level rather than in state law. Health professional regulation should allow for flexible and creative innovation and appropriate use of all members of the health care workforce. In many primary care settings, such as well-child or family planning clinics, a supervising physician could supervise multiple PAs.
IN CLOSING
When asked about this, Dr. Cutrer closed by saying, “If there is anything I can do to help explain the role of the PA as a part of the medical team, just let me know. We take very seriously the education of our PA students. We plan on working very hard to make the first PA school in Mississippi something we will all be proud of!” Dr. Philpot added, “We feel that a PA program in the state can be more responsive to the needs and concerns of Mississippians and the medical community. We look forward to working with the medical organizations and boards within the state to make PA practice a winning solution for all.” ❒
DECEMBER 2010 JOURNAL MSMA
364
• MSMA • Patients First During the 2011 Legislative Session
I
n 2011, the Mississippi State Medical Association will continue to advocate at the Mississippi Legislature for fiscal responsibility and meaningful regulatory measures that result in expanded access to quality health care, enhanced protection of patient safety, and the promotion of individual health awareness. Based on the amount of incipient activity that has already taken place in and around the Capitol this fall in preparation for the 2011 session, next year promises to be yet another busy year for legislators and those who follow their business. Amidst the backdrop of statewide elections in November of 2011, legislators will convene in January for the upcoming annual session to grapple with not only the normal array of thousands of proposed bills but also other serious measures that could potentially affect the delivery of quality health care to the citizens of the State of Mississippi in some form. They will have to shape an untoward budget that attempts to adequately balance the needs of the public in light of the current financial realities associated with a nationwide economy in recovery from a recession. Also on the Legislature’s agenda will be the decennial redistricting process and some state implementation of portions of the new federal health care reform law. While conventional wisdom suggests that these issues may result in dissonance and perhaps at various times even contentious debate among legislators, MSMA finds itself uniquely positioned in 2011 to submit to the legislature a set of refreshing initiatives for consideration that will transcend the political schism and place patient care first. A priority for the Association next year will involve seeking minor revisions to the state’s compulsory automobile insurance laws which will have a major impact on driver and/or owner compliance and financially strengthen the Mississippi Trauma Care Trust Fund. Since the law’s enactment in 2001, it has provided the public with some protection from the perils associated with uninsured motorists on the roadways. However, a distributing trend has also emerged in response to the law whereby drivers have circumvented the intent of the law. They do so by terminating their insurance after they obtain a physical insurance card that they can present to law enforcement if and when they are involved in a traffic stop. In a state where there were an estimated seven hundred traffic fatalities last year, this kind of irresponsible driver behavior presents a threat to public safety and places a strain on a trauma system which is already struggling to cover the costs of uncompensated trauma care. In response to this issue, MSMA will support legislation that creates a database containing a cross-listing of insurance policies with vehicle identification numbers to assist officials with real time enforcement of the law. MSMA also supports amending the present law to increase monetary fines for those found to be in violation of the law with a portion of the fines collected allocated to the State Trauma Care Fund. In an effort to foster healthier lifestyles through the consumption of healthier foods, the Association intends to encourage legislation which eliminates state sales tax on health foods. This would include bottled water, fresh fruits, fresh vegetables, and other foods. The goal is to encourage consumers to make healthier grocery choices by making these foods more affordable than unhealthy alternatives. Hopefully this will lead to the increased consumption of these essential foods, leading to better health and ultimately reducing long term care costs for individuals and the state alike. The increased demand for these fresh foods could also represent an economic boost to local farming communities as well. In recognition of the state’s critical rural physician shortage, MSMA will continue to push for increased financial support of the Rural Physicians’ Scholarship Program. Last year, the program received $900,000 to support thirty scholarships. This year, the Association will encourage the legislature to dedicate an additional $300,000 to the program in order to create ten more scholarships for a total of forty. This nascent program will soon prove to be an invaluable mechanism for keeping young and talented physicians in our state as opposed to other states to practice. This will not only address a health care workforce shortage, but it will also increase patient access and begin to address minority health disparities in areas such as the Delta where such care is desperately needed.
365
JOURNAL MSMA DECEMBER 2010
In addition to the foregoing efforts, MSMA will continue to remain attentive and responsive to efforts that pose a threat to the practice of medicine and patient safety. These threats include but are certainly not limited to recurring nurse practitioner and midwifery scope of practice issues, state changes prompted by the Patient Protection and Affordable Care Act (PPACA), state administration of the Medicaid program, and fair treatment of reimbursements by insurance companies and third party payers. As in prior years, active physician involvement in the legislative process will be critical to the MSMA’s success this year. While legislators appreciate the efforts of lobbyists to call important issues to their attention for consideration, hearing a concern directly from a local physician can make an indelible impression. There are numerous ways for you personally to get involved in the process. You can sign up to become one of our legislative team’s “key contacts.” As a “key contact” you will become one of a group of individuals responsible for coordinating communications with a particular local legislator(s) throughout the session. As an MSMA physician, you can volunteer to participate in the Doctor of the Day program at the State Capitol and or the Capitol Screening Initiative (CSI) hosted by the MSMA Alliance. Each of these experiences offers physicians a close-up view of legislative action and the opportunity to promote the practice of medicine to our elected officials with a distinctive and personal approach. Member physicians who are contributors to the Mississippi Medical PAC can also participate in the legislative process in a unique way at the upcoming MMPAC legislative reception event on January 19, 2011. MSMA’s membership has proved time and again that it is up to the task of improving quality, cost-effective care while protecting patient safety. This ability was demonstrated and proven strong during prior scope of practice disputes and the tort reform debate. We look forward to your participation in MSMA’s efforts in 2011 to strengthen the practice of medicine in the state of Mississippi. —Christopher W. Espy, Esq. Counsel and Government Liaison
THE PERFECT PRACTICE PARTNER We represent our healthcare clients before state and federal agencies and courts. Our healthcare team’s extensive knowledge of regulatory compliance and litigation matters offers our clients an invaluable perspective. CCTB provides our clients with an efficient resolution of problems that arise, and sound legal advice to prevent problems from occurring in the first place.
1076 HIGHLAND COLONY CONCOURSE 600 SUITE 100 RIDGELAND, MS 39157
(601) 856-7200 WWW.CCTB.COM DECEMBER 2010 JOURNAL MSMA
366
• PHYSICIANS' BOOKSHELF •
Mississippi Native Pens Epic on Tort King’s Fall Bradford J. Dye, MD [ The following essay was written by Dr. Ford Dye, an Oxford otolaryngologist who is also a member of the MSMA Board of Trustees. Ford’s Oxford neighbor, Curtis Wilkie, is one of the most respected Mississippi writers and journalists, and Ford has explored Wilkie’s life and literary contributions. Wilkie’s book, The Fall of the House of Zeus, is one of the most eagerly awaited books written by a Mississippian this year. It will be of great interest to Mississippi physicians who have a keen interest in learning of the tort king’s fall from power. The book details the sordid activity which at times pained the lives and practices of Mississippi’s physicians. Ford offers a fascinating reflection on this unique Mississippian, Curtis Wilkie, and the editors felt our readers would enjoy this article.]–ED.
By Curtis Wilkie
ISBN: 9780307460707
400 pages. Crown Publishing Group, New York.
Hardcover: $25.99
C
urtis Wilkie is one of Mississippi’s most well known and respected journalists. He is also a successful author whose latest book The Fall of the House of Zeus was recently released. His writing skills have carried him from his native Mississippi to the eastern United States and various locations around the world. His roots in writing and journalism began in Pike County, Mississippi. He was kind enough to sit down and share his interesting life story with me. Curtis was born in Greenville and lost his father at a young age. He lived in seven or eight different towns the first six years of his life. He and his mother settled in Summit when he was seven years old. She got an administrative and teaching job at Southwest Mississippi Junior College, and they lived in a girls’ dormitory there. Curtis was “the campus brat and had all sorts of pretty girls who were live-in babysitters” for him. His first foray into journalism began with a paper he started called the Southwest Times. It contained stories about the school as well as a gossip column containing “who might be seen kissing which girl goodnight on the steps of the girls’ dorm.” In one edition, it also contained an obituary for Babe Ruth which was copied verbatim from the Times Picayune.
367
JOURNAL MSMA DECEMBER 2010
Summit was a charming small town with a traditional main street, Southern values and a host of characters who called it home. Curtis and his mother moved from the junior college into town when she remarried. Like most Southern towns, Summit was racially divided but Curtis recalls” a peaceful town with no real racial conflict.” It was a logging town and rail town on the Illinois Central railroad line where everyone knew everyone else. Nobody locked their doors and it was not unusual for Curtis to walk a few blocks to the Fox movie theater at night. “I am not sure these kinds of towns exist anymore,” he adds. Summit provided a sense of stability, and he still considers it his home.
Photo by Bruce Newman
The kindness of many of the townspeople is one of his most endearing memories of Summit. His stepfather was a Presbyterian minister, and many wonderful families in his congregation “kind of adopted me.” The Atkinsons, Covingtons, Watkins, and Barnes are some of the families Curtis most fondly remembers. Lew Barnes was an early influence on Curtis. Lew was two years older Curtis Wilkie, Overby Fellow and Kelly G. Cook Chair of Journalism — Wilkie has served as and was a “well visiting professor of journalism at the University of Mississippi since 2002. He was appointed to known character become the first Overby Fellow with the Overby Center for Southern Journalism and Politics at and practical the University of Mississippi in 2007. joker.” One having a neighbor running for governor.” He remembers Saturday night he “invaded the Baptist church and put `Red passing out leaflets for her knowing nothing about her Hot Boogie’ on the chimes.” Curtis has never forgotten Lew’s positions and realized later in life that “her positions were sense of humor and misses his friend who was killed in a much more conservative than my own.” Mary Cain felt that wreck in his early thirties. Curtis recalls some other friends the Social Security program was communistic, and she got in and peewee football teammates such as Billy Ray Jones, Carl trouble for refusing to pay Social Security taxes. This led to a Ray, Fulton Beck, and David Blackwell. Curtis played all government agency padlocking the door to the Summit Sun sports but was not as athletic as most of his running mates. offices until Mary Cain got a hacksaw and cut the lock. This Curtis got his first job as a journalist when he became action inspired the nickname “Hacksaw Mary.” She was a sports writer for the Summit Sun in sixth grade. He followed gifted speaker and colorful character who ran respectable Paul Atkinson and Jack Wardlaw who both went on to work races for Governor. Although she didn’t win the election and for the Times Picayune. Curtis finds it “interesting that three her views were different, she instilled an interest in politics people who became career journalists got their start being that stayed with Curtis throughout his life. sports writers for the Summit Sun.” He wrote up articles and Curtis and his family moved to Corinth for his senior scores from the local high school sports teams for the weekly year when his stepfather got transferred to a church there. Had paper. He got to travel with the teams and keep score during he stayed in Summit, he would have gone to McComb High games. School. That was the same year Summit High School was The legendary Mary Cain was another influence on consolidated into McComb. Curtis grew up playing baseball in young Curtis. She was editor of the Summit Sun and also gave McComb due to its close proximity to Summit, and he had Curtis his first job in journalism. She ran for governor in 1951 many friends there. Warner Alford, Louis Guy, Billy Neville, and in 1955, and Curtis was “very intrigued by the idea of
DECEMBER 2010 JOURNAL MSMA
368
369
JOURNAL MSMA DECEMBER 2010
Photo by Bruce Newman
and Butch Cothren were some of his buddies from McComb. There was no TV so they listened to the radio or played games for entertainment. One of his fondest memories of McComb was meeting Elvis Presley there during Curtis’s sophomore year of high school. Elvis opened for Johnny Cash that night. Elvis was friendly and visited with Curtis and his friends, and Curtis got Elvis to autograph his arm in red ink. This did not impress Curtis’s mother when he arrived home after his curfew. She had never heard of Elvis and instructed her son to wash off his arm and go to bed. Curtis entered Ole Miss in 1958. “It was much smaller then but we had great football teams” losing only four games in his five seasons at the school. Most students lived on campus and very few had cars. Oxford was dry at the time and to get a beer legally required a drive to either Holly Springs or Marks. He majored in journalism, and there were “no more than five or six of us in my freshman class who were majoring in journalism.” There were only two journalism professors at the time. Dr. Sam Talbot was chairman, and Dr. Jerry Hoar was a young professor. Dr. Hoar is still living in Oxford and has become a good friend of Curtis despite the fact that he flunked Curtis in feature writing. “I was late turning in a paper and he gave me an F. He taught me a lesson about deadlines,” Curtis recalls. The irony is that Curtis teaches that course at Ole Miss today. Another irony of that class failure is that it was the reason Curtis was still in Oxford during the 1962 fall semester when James Meredith entered Ole Miss. “Thanks to Jerry Hoar I was still here because I had to come back and take feature writing again.” He should have graduated in the spring, but he was still around to witness one of the university’s most significant and difficult times. “By that time I was considered by Mississippi standards a liberal and that was a rarity among the student body,” says Curtis, who closely followed everything that was going on with much interest. He was on the scene to witness some of the events firsthand as “the budding journalist” in him heightened his curiosity. He witnessed Governor Ross Barnett reject Meredith the first day, and he was in the crowd outside the Lyceum the night of the riots. Curtis recalls that most of the students that night were not causing trouble, but a handful of them were shouting and throwing things at the U.S. Marshals. This led to tear gas being fired into the crowd of around 500 students. Curtis and his friend Franklin Holmes from Tunica scampered across the campus into the lobby of a girl’s dorm to evade the tear gas. On the lobby television set was President John F. Kennedy making a speech to the nation saying that James Meredith had been peacefully enrolled at Ole Miss. The president called on the students to carry on the great and fine traditions of the university, and he didn’t know that “all hell had broken loose outside.” The riots escalated much more as a result of outside agitators than from the students within. Curtis hovered on the
Acclaimed author Curtis Wilkie has written numerous articles for national magazines such as The Nation, The New Republic, Newsweek, Playboy, George, Washington Journalism Review as well as many articles published in the Boston Globe Magazine. He is the co-author, with the late Jim McDougal, of Arkansas Mischief: Birth of a National Scandal published by Henry Holt 1998; author of Dixie: A Personal Odyssey Through Events That Shaped the Modern South published by Scribner 2001; co-author, with six others, of City Adrift: New Orleans Before and After Katrina published by LSU Press 2007. fringes of the rioting until he “realized a fellow could get killed out here and was smart enough to go back to my room.” James Meredith was very much a loner at Ole Miss, and Curtis has some inner guilt concerning this. Curtis has gotten to know Meredith over the years through numerous interviews and newspaper articles. Curtis has told Meredith how much “I regret that I never offered to go have a cup of coffee with you at the student union or go have lunch with you.” He was mostly shunned by the student body and was nearly always accompanied by a military escort. In one instance, a few students who did have lunch with him went back to their dorm rooms to find them trashed. There was a certain amount of peer pressure concerning Meredith, and Curtis regrets “never mustering enough courage to try to make life easier for him.”
Unfortunately, the riots surrounding Meredith’s admission to Ole Miss were the enduring imprint of Mississippi in the minds of the national media for years. Curtis thinks the “Presidential debate was the finishing touch of the rehabilitation of Ole Miss” in the eyes and minds of most journalists. Most of the leading American journalists are either friends or acquaintances of Curtis, and they “loved it” at Ole Miss during the debate. The debate was not his first trip to Oxford, but Tom Brokaw visits enough that Curtis is “ready to enroll him as honorary citizen. He loves coming to Ole Miss and Oxford.” Mark Shields, Tom Oliphant, Al Hunt and Judy Woodruff are some others who have all been impressed by Oxford and Ole Miss. Curtis has enjoyed his return to Oxford and the faculty at Ole Miss. “If you had told me fifty years ago that I would be living in Oxford happily as an old man, I would say you were out of your mind.” He finds the university town very appealing. He has been on the faculty for ten years and particularly enjoyed working under Chancellor Robert Khayat. Dr. Khayat was his platoon sergeant in ROTC during their days at Ole Miss. “The idea of me teaching here is very gratifying to me.” The journalism department now has over 500 students majoring in journalism and over 30 faculty members. Curtis has taken a very winding and rewarding path back to Oxford since he left Ole Miss as a student. He graduated in January 1963 and went to work for the Clarksdale Press Register. He stayed there for nearly seven years which was a long time for a first job. He enjoyed the job due to the activity and excitement of the civil rights movement in the Mississippi Delta during his time there. In 1969, he got a Congressional fellowship and moved to Washington and worked with Walter Mondale from Minnesota and John Brademas from Indiana for two years. Mondale would later serve as Vice President and Brademas would become president of NYU. Curtis has remained friends and stays in touch with both men. In 1971, Curtis returned to journalism and worked for The News Journal in Wilmington, Delaware, for three years. His next job was with the Boston Globe. Curtis would work for that paper for the next 26 years. He did a little bit of everything at the Boston Globe. One of his first jobs was to cover the Boston mayor’s election. As the “only Southerner on the staff,” his next assignment was to cover “this peanut farmer from Georgia named Jimmy Carter.” Carter’s election as President led to a job as White House correspondent for Curtis and a move back to Washington, D.C., one year later. Curtis stayed in Washington through the Carter and Reagan administrations. He then began to have overseas assignments mostly in the Middle East. He moved to Jerusalem in 1984 and established a Middle East bureau for the Boston Globe and was there for four years. He enjoyed living abroad but had a difficult time becoming fluent in the local languages. He moved back to Boston and lived there for a few years
but “didn’t care for the cold weather.” He persuaded his superiors at the Boston Globe to allow him to work out of New Orleans. He already owned a place in the French Quarter, and this allowed him to care for his ailing mother in Summit. He created a Southern bureau for the Boston Globe and worked his last six or seven years for the paper out of New Orleans. His mother was in a coma for a few years and died in 1997. He was able to be close to her during this time which was very important to Curtis. Both his mother and stepfather are buried in Summit, and he visits their gravesites regularly. Curtis covered many exciting stories during his tenure with the Boston Globe. Some that stand out are Three Mile Island, the refugee story in Southeast Asia in 1979, the Romanian revolution, the Camp David Accords between Israel and Egypt, and many diplomatic missions of President Carter. He also covered many civil wars in the Middle East. One memorable story was the TWA hijacking in 1985 in Beirut that lasted for about three weeks. This story was very important in Boston. The plane that had been hijacked was bound for Boston, so many of the hostages were from the city. It was a very “dramatic story that had a happy ending” for the most part. Sadly, there was one fatality when the plane was initially hijacked, but the remaining hostages survived the ordeal. One of his most enjoyable assignments was a two week stint traveling with the Boston Red Sox in 1977. That team had future Hall of Fame players Jim Rice, Carlton Fisk and Carl Yastrzemski. Don Zimmer was the manager. There also was a kid from Ole Miss on the team named Steve Dillard who was a utility infielder. “I would have paid to have that assignment,” Curtis adds. Needless to say, Curtis had come a long way from his first job as sportswriter for the Summit Sun. Curtis thinks there are two reasons why Mississippi has produced an inordinate number of writers and literary figures. One is “the reason everybody gives and I agree that we have a storytelling tradition. At our parties we don’t debate policy or pontificate – we tell stories. We like to entertain each other with stories in Mississippi and the South. Secondly, conflict is inherent in any good story.” Mississippi has had conflict on many levels. Racial conflict, conflict between wealth and poverty, and social conflicts have all been woven into the fabric of Mississippi. Southerners grew up with conflict much more so than those who grew up outside the South. Curtis believes this conflict is a driving force behind Southern writers including Faulkner and even Welty. Curtis is pleased with his latest book. The book is about Dick Scruggs’s involvement in a judicial bribery scheme. “Dick is a friend of mine,” Curtis points out. The name of the book is The Fall of the House of Zeus. Zeus was Scruggs nickname in college. “It was not a pleasant undertaking but a story that appealed to me as I knew so many of the players on all sides of the story.” These relationships have provided Curtis with unparalleled access to those involved as well as a unique perspective on the story. Jim Greenlee, the U.S.
DECEMBER 2010 JOURNAL MSMA
370
attorney prosecuting the case, has described the case as a Greek tragedy. Curtis did not think he would ever write another book after Dixie: A Personal Odyssey Through Events that Changed the Modern South, which he wrote over eight years ago. However, it was “such a mystery as to what in God’s name is Dick Scruggs doing involved in something like this” that Curtis felt compelled to write the story. The book was released in October and is now available. Growing up as an only child has given Curtis great appreciation and satisfaction with his family. Curtis has three children and many grandchildren. His daughter Leighton lives next door to Curtis in Oxford with her husband Campbell McCool and their three sons. His son Carter lives in Boston with his wife Allison and their three daughters. Carter is a writer for Bank of America. His younger son Stuart lives in Wilmington, Delaware, and is a teacher there. Stuart is named for Curtis’s stepfather. Curtis has a lovely wife Nancy who also has three children and five grandchildren. He can often be seen walking his retriever and best friend Willie around Oxford. Yes, the dog is named for his good friend and fellow Mississippi author Willie Morris, but that’s for another story. ❒
Photo by Bruce Newman
Left: Overby Fellow and Kelly G. Cook Chair of Journalism Curtis Wilkie walks his dogs, Binx and Willie, in his quaint Oxford neighborhood. He says he has enjoyed his return to Oxford and the faculty at Ole Miss, “If you had told me fifty years ago that I would be living in Oxford happily as an old man, I would say you were out of your mind.”
Save the Date for MSMA’s 143rd Annual
annual session
Obtain CME credits!
Find out the latest info on health reform and what it means for physicians!
Coming to you live from Tupelo, Mississippi Birthplace of
elvis presley MAY 19 – 22, 2011
Network and socialize with your peers during special events and receptions!
REGISTER ONLINE TODAY AT www.MSMAonline.com!
Take part in the state’s largest yearly gathering of physicians! 371
JOURNAL MSMA DECEMBER 2010
For more information: Becky Wells 601-853-6733, Extension 340 BWells@MSMAonline.com
Shape the future of health policy in Mississippi!
• IMAGES IN MISSISSIPPI MEDICINE •
JACKSON INFIRMARY, 1916 - 1954 — This old postcard is of the important Jackson Infirmary which was a large private hospital established in Jackson by Dr. George Adkins and Dr. N. C. Womack in the second decade of the twentieth century. This institution served as Jackson’s principal hospital for many years. Located in the capital city on the corner of President and Amite Streets, this hospital structure was erected in 1916, which is close to the time of this postcard. The Infirmary was purchased by the Dominican Sisters (of Springfield, Illinois) in 1946, and they assumed the hospital’s operation, renaming it St. Dominic Hospital. This building was used until 1954 when St. Dominic opened its new hospital on Lakeland Drive. The old Infirmary building was then torn down, and the Baptist Book Store was built at the site. Governor Earl L. Brewer (term 1912-1916), the only occupant of the Governor’s Mansion to be elected without opposition, died in March 1942 at the Jackson Infirmary. One of the first chiefs of staff of the Infirmary was Dr. John Woodson Barksdale (1876-1953), a native of Vaiden, who helped found one of the first hospitals in North Mississippi, the Winona Infirmary. The term “Infirmary” is from the Latin “infirmus” which means “weak” or “frail” and by definition is a place where the sick or injured are cared for, especially a hospital, clinic, or dispensary, often within another institution. Infirmary was a common name for a public hospital in 18th century England. If you have an old or even somewhat recent photograph which would be of interest to Mississippi physicians or further information on the old Jackson Infirmary, please contact the Journal or me at lukelampton@cableone.net.
—Lucius Lampton, MD, Editor Magnolia
DECEMBER 2010 JOURNAL MSMA
372
• ALLIANCE SPOTLIGHT •
Past President’s Spotlight: Mrs. Stanley (Beth) Hartness MSMA Auxiliary President, 1983-1984 • Kosciusko
MSMAA Presidential Portrait - Beth Hartness
W
Right: Dr. and Mrs. Hartness when Beth was Hospitality Committee Chair.
Above center: Beth and Stanley Hartness at the Inaugural Dinner for MSMA President Dr. Whitman Johnson, Jr. 1984. Above right: MSMAA Chair Linda Martin and MSMAA President Beth Hartness accept membership awards from AMAA Membership Chair Donna Fields at the AMA Auxiliary Annual Convention, Drake Hotel, Chicago, June 1983.
here did you grow up? My parents were living in Decatur, my birth place was Meridian, and I grew up in Lexington. I graduated from Lexington High School and MSCW with a B.S. in mathematics and a minor in accounting. How did you meet your physician spouse? After graduation from the “W,” I landed a job with IBM as an assistant systems engineer in Jackson and moved into the Parkview Arms apartment on Lakeland Drive that Stanley’s sister had moved out of when she got married. Conveniently, Stanley and his roommate Arthur Jones had decided if they were ever to meet any “decent prospects,” they needed to upgrade their living situation so they also relocated to Parkview Arms. The mutual roommate introduced us. Stanley and Arthur quickly learned when we were usually finishing dinner and would appear for any leftovers. I soon discovered that the way to a starving med student’s heart was through his stomach! What are the names and ages of your children? My older daughter, Julie, is 41-years-old and is the executive director of the Mississippi Academy of Family Physicians Foundation. She and her attorney husband, Kevin Humphreys, live in Madison and are the parents of Kyle (13) and Will (11). My 37-year-old daughter Laura is married to Derek Dyess, a radiologist. They live a stone’s throw from us down Meadowbrook Road with their two daughters, Mary Beth (10) and Ginny (8). Laura is an assistant teacher with 4 year olds at Jackson Academy.
373
JOURNAL MSMA DECEMBER 2010
How do you spend your free time? As strange as it may sound, I really enjoy using my organizational skills for family, friends, and my church. Since moving to Jackson, Stanley and I are enjoying the art/theater/music/restaurant/ grandchildren scene. How did you come to join the Alliance? When my husband became active in the medical association, it seemed only natural to become involved in the organization that supported his profession. I was impressed with the auxiliary’s commitment and thought their various projects worthwhile. What is your favorite Alliance memory? My favorite auxiliary memories include visiting local auxiliaries across the state, serving on the national AMA-ERF committee, and assisting with Jean Hill’s inauguration as AMA Auxiliary president. What are the highlights of your presidential year? Highlighting my year as president were auxiliary donations of $13,000 to AMA-ERF and $10,000 to the Impaired Physicians’ Program, both sizable contributions in 1984. Our long range planning committee recommended to the MSMA Board of Trustees that a part-time auxiliary executive secretary be hired and thus began our long relationship with Barbara Shelton whose assistance proved invaluable. Do you have any advice for fellow physician spouses? Show your support for your spouse and his/her profession by joining the Alliance – and becoming an ACTIVE member! Be flexible! Roll with the punches! ❒
• THE UNCOMMON THREAD •
R. Scott Anderson, MD
I
Author’s note: For all of you that didn’t, Connect the Dots was a picture of three accidental deaths that presented to an ER in a 24 hour period. You explain it how you like: divine providence, random happenstance, whatever. I chose a little bird called death. It seems that for me accidental deaths are so much harder to make sense of than those that we expect because we have been tipped off by the onset of symptoms. Maybe we just understand that the chronicity of disease has an inevitability about it. I had a patient with an advanced head and neck cancer that was essentially incurable. If the tumor would have killed him, he would have been just as dead, but a piece of tin roofing flying off of a pick-up truck on the highway and cutting off his head just seemed like a different thing somehow, a more dramatic thing, a worse thing. I don’t know why. This column is another way to look at death. It is the opening of a novel I’m rewriting right now, The Hard Times. It is from a doctor’s perspective this time, but maybe a little different viewpoint than you might expect.
Hard
f he wasn’t dying, Charlie Lee was doing a damned good impression of it. It all started when somebody hit him in the center of the chest with a baseball bat right after he’d finished his walk. Now he was lying face down on the floor and there was a bus parked on top of him. The weight of it was crushing him. He fought to breathe. Trying with all of his strength to lift the bus and let his ribs expand. He had to find some way to suck air into his lungs, but as hard as he tried, the bus wouldn’t budge. He got carried away for a moment by the pain and when he came back, his wife had rolled him over and was shaking him, calling his name again and again. He tried to say something back, but he couldn’t. He could only really see her when she was directly over him now. Looking up as she bent down over him what struck him most was the look of panic in her eyes. He wanted to tell her it was going to be all right, he’d be fine in a minute, if he could just catch his breath. Then she moved to the side and when he looked for her his eyes wouldn’t cooperate. He gave up on that as another wave of pain began to crush down upon him. With all of the weight of the universe centered in his chest, the thing that he was most aware of was that his heart didn’t seem to be beating any more. It was something that had gone on his entire life and he’d never noticed it, but he certainly was taking notice now that it had stopped. Instead of a nice steady lub-dub, it felt like bags of snakes were crawling around inside him. That was a bad sign, it meant the electrical impulses that controlled his heart had gone haywire, and there wasn’t much chance that they were going to get fixed by themselves. He needed… The pain carried him away again, getting worse and worse until he didn’t think that he could stand it for another second. Somehow, he stood it. He didn’t have a choice. There wasn’t anything else he could do. All he could do was ride it like a wave. Death didn’t much care what he wanted. He was going wherever it took him. He’d watched people die for thirty-five years of his life. He knew what it looked like. Now he was finding out for the first time just exactly what it felt like from the inside. His wife started to blow air into his mouth, pinching his nose shut. She was calling someone on the phone at the same time. The pain got slowly better. Subsiding little by little as she blew into his mouth. She spoke to someone on the phone and checked his pulse. “No,” she said. “He doesn’t.” Then she started to pump on his chest. She was doing it all wrong. He tried to tell her, but that wasn’t any use either. The sequences were crazy. There wasn’t any rhythm at all. Five pumps-one breath then eight compressions and two breaths. On she went, crying as she did it, four-one, seven-two, six-one, eleven-three. It was maddening, but apparently, it was working. He was still here wasn’t he? Or was he? He had to be, he was hurting too much not to be. He should have lost more weight he thought momentarily. He could feel the fat on his stomach shaking as his wife continued pumping with her erratic rhythm and then the pain carried him away again.
DECEMBER 2010 JOURNAL MSMA
374
He came back sometime after the paramedics had arrived, he could hear a voice he recognized, Bobby Pearson, talking on the radio to someone. He could feel himself lying on a stretcher now. He knew what was coming when he heard Bobby yell “clear� but there was nothing he could do about it. Then they shocked him. Nothing that you thought you knew could prepare you for what that felt like. The horrible jerking energy threw him out into space he spun, rigid, and awful away from the world and drifted back just in time to hear Bobby call “clear� again. Then it happened all over. This time it was harder and it took him longer to get back. He never did because they hit him again before he made it, and he was gone now. Gone but not all the way gone, just a long long way away, like looking through a telescope backwards. He felt the bumping as they locked him into place in the back of the ambulance, felt his wife’s hand. He could hear her voice coming to him. He could tell that she was talking to someone else and then to him. His eyes wouldn’t focus any more so he couldn’t see her. He felt her squeeze his hand. Even though he couldn’t really make out what it was that she was saying, he began to feel better as he listened to the rhythm of her voice, and he knew that whatever it was that they were doing now, it was working. He wasn’t going to die after all. He felt so much better. Hope you liked it.
—Scott
R. Scott Anderson, MD, a radiation oncologist, is medical director of the Anderson Regional Cancer Center in Meridian and past vice chair of the MSMA Board of Trustees. Additionally, he is an accomplished oil-painter and dabbles in the motion-picture industry as a screen-writer, helping form P-32, an entertainment funding entity.
The Pen is Mightier than the Sword
Express your opinion in the JMSMA through a letter to the editor or guest editorial. The Journal MSMA welcomes letters to the editor. Letters for publication should be less than 300 words. 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 us try to clear up ambiguities, to protect our letter-writers. You can submit your letter via email to KEvers@MSMA online.com or mail to the Journal office at MSMA headquarters: P.O. Box 2548, Ridgeland, MS 39158-2548. 375
JOURNAL MSMA DECEMBER 2010
•
PLACEMENT/CLASSIFIED
•
We specialize in the business of healthcare t t t t t t t t
$PNQSFIFOTJWF .BOBHFNFOU $PNQSFIFOTJWF $POTVMUJOH #JMMJOH "DDPVOUT 3FDFJWBCMF .BOBHFNFOU $PEJOH %PDVNFOUBUJPO 1SBDUJDF "TTFTTNFOUT 3FWFOVF &OIBODFNFOU 1SPĂśUBCJMJUZ *NQSPWFNFOU 1SBDUJDF 4UBSU VQT 1FSTPOOFM .BOBHFNFOU
/PSUI 4UBUF 4USFFU 4VJUF +BDLTPO .4 5FMFQIPOF 8"54 XXX NQTCJMMJOH DPN PHYSICIANS NEEDED
Physicians (specialists such as cardiologists, ophthalmologists, pediatricians, orthopedists, neurologists, etc.) interested in performing consultative evaluations Toll Free 1-800-962-2230 Jackson 601-853-5487 Leola Meyer (Ext. 5487)
DISABILITY DETERMINATION SERVICES
1-800-962-2230
• INSTRUCTIONS FOR AUTHORS •
The Journal of the Mississippi State Medical Association (JMSMA) welcomes material for publication submitted in accordance with the following guidelines. Address all correspondence to the Editor, Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS, 39158-2548. Contact the managing editor with any questions concerning these guidelines.
STYLE: Articles should be consistent with JAMA/ JMSMA style. Please refer to explanations in the AMA Manual of Style: A Guide for Authors and Editors. 10th ed. New York, NY: Oxford University Press; 2007. JAMA and JMSMA style differs from APA style. See JAMA: http://jama.amaassn.org/misc/ifora.dtl Any manuscript that does not conform to the AMA Manual of Style will be returned for revision.
MANUSCRIPTS should be of an appropriate length due to the policy of the Journal to feature concise but complete articles. (Some subjects may necessitate exception to this policy and will be reviewed and published at the Editor’s discretion.) The language and vocabulary of the manuscript should be understandable and not beyond the comprehension of the general readership of the Journal. The Journal attempts to avoid the use of medical jargon and abbreviations. All abbreviations, especially of laboratory and diagnostic procedures, must be identified in the text. Manuscripts must be typed, double-spaced with adequate margins. (This applies to all manuscript elements including text, references, legends, footnotes, etc.) The original and one duplicate hard copy should be submitted. In addition, the Journal also requires manuscripts in the form stated above be supplied in IBM-compatible digital format. You may email digital files as attachments to KEvers@MSMAonline.com or supply a compact disk with the files burned to to the CD. All graphic images should be included as individual separate files in TIFF, PDF or EPS format. Please identify the word processing program used and the file name. Pages should be numbered. An accompanying cover letter should designate one author as correspondent and include his/her address and telephone number. Manuscripts are received with the explicit understanding that they have not been previously published and are not under consideration by any other publication. Manuscripts are subject to editorial revisions as deemed necessary by the editors and to such modifications as to bring them into conformity with Journal style. The authors clearly bear the full responsibility for all statements made and the veracity of the work reported therein.
REVIEWING PROCESS: Each manuscript is received by the managing editor, and reviewed by the Editor and/or Associate Editor and/or other members of the MSMA Committee on Publications. The acceptability of a manuscript is determined by such factors as the quality of the manuscript, perceived interest to Journal readers, and usefulness or importance to physicians. Authors are notified upon the acceptance or rejection of their manuscript. Accepted manuscripts become the property of the
Journal and may not be published elsewhere, in part or in whole, without permission from the Journal.
TITLE PAGE should carry [1] the title of the manuscript, which should be concise but informative; [2] full name of each author, with highest academic degree(s), listed in descending order of magnitude of contribution (only the names of those who have contributed materially to the preparation of the manuscript should be included); [3] a one- to two-sentence biographical description for each author which should include specialty, practice location, academic appointments, primary hospital affiliation, or other credits; [4] name and address of author to whom requests for reprints should be addressed, or a statement that reprints will not be available.
ABSTRACT, if included, should be on the second page and consist of no more than 150 words. It is designed to acquaint the potential reader with the essence of the text and should be factual and informative rather than descriptive. The abstract should be intelligible when divorced from the article, devoid of undefined abbreviations. The abstract should contain: [1] a brief statement of the manuscript’s purpose; [2] the approach used; [3] the material studied; [4] the results obtained. Emphasize new and important aspects of the study or observations. The abstract may be graphically boxed and printed as part of the published manuscript. KEY WORDS should follow the abstract and be identified as such. Provide three to five key words or short phrases that will assist indexers in cross indexing your article. Use terms from the Medical Subject Heading list from Index Medicus when possible. Available at: http://www.nlm.nih.gov/mesh/ meshhome.html.
SUBHEADS are strongly encouraged. They should provide guidance for the reader and serve to break the typographic monotony of the text. The format is flexible but subheads ordinarily include: Methods and Materials, Case Reports, Symptoms, Examination, Treatment and Technique, Results, Discussion, and Summary.
REFERENCES must be double spaced on a separate sheet of paper and limited to a reasonable number. They will be critically examined at the time of review and must be kept to a minimum. You may find it helpful to use the PubMed Single Citation Matcher available online at: http://www.ncbi.nlm.nih. gov/entrez/query/static/citmatch.html to find PubMed citations. All references must be cited in the text and the list should be arranged in order of citation, not alphabetically. Reference numbers should appear in superscript at the end of a sentence outside the period unless the text cited is in the middle of the sentence in which case the numeral should appear in superscript at the right end of the word or the phrase being cited. No parenthesis or brackets should surround the reference numbers. Personal communications and unpublished data should not be
DECEMBER 2010 JOURNAL MSMA
376
included in references, but should be incorporated in the text. The following form should be followed: Journals: [1] Author(s). Use the surname followed by initial without punctuation. The names of all authors should be given unless there are more than three, in which case the names of the first three authors are used, followed by “et al.” [2] Title of article. Capitalize only the first letter of the first word. [3] Name of Journal. Abbreviate and italicize, according to the listing in the current Index Medicus available online at http://www.nlm.nih.gov/bsd/aim.html. [4] Year of publication; [5] Volume number: Do not include issue number or month except in the case of a supplement or when pagination is not consecutive throughout the volume. [6] Inclusive page numbers. Do not omit digits. Do not include spaces between digits of the year, volume and page numbers.
Example: Bora LI, Dannem FJ, Stanford W, et al. A guideline for blood use during surgery. Am J Clin Pathol. 1979;71:680-692.
Books: [1] Author(s). Use the surname followed by initials without punctuation. The names of all authors should be given unless there are more than three, in which case the names of the first three authors are used followed by “et al.” [2] Title. Italicize title and capitalize the first and last word and each word that is not an article, preposition, or conjunction, of less than four letters. [3] Edition number, [4] Editor’s name. [5] Place of publication, [6] Publisher, [7] Year, [8] Inclusive page numbers. Do not omit digits. Example: DeGole EL, Spann E, Hurst RA Jr, et al. Bedside Examination, in Cardiovascular Medicine, ed 2, Smith JT (ed). New York, NY: McGraw Hill Co; 1986:23-27.
ILLUSTRATIONS require high resolution digital scans to be provided. Printed copies should also be submitted in duplicate in an envelope (paper clips should not be used on illustrations since the indentation they make may show on reproduction). Legends should be typed, double-spaced on a separate sheet of paper. Photographic material should be high-contrast glossy prints. Patients must be unrecognizable in photographs unless specific written consent has been obtained, in which case a copy of the authorization should accompany the manuscript. All illustrations should be referred to in the body of the text. Omit illustrations which do not increase understanding of text. Illustrations must be limited to a reasonable number. (Four illustrations should be adequate for a manuscript of 4 to 5 typed pages.) The following information should be typed on a label and affixed to the back of each illustration: figure number, title of manuscript, name of senior author, and arrow indicating top.
TABLES should be self-explanatory and should supplement, not duplicate, the text. Each should be typed on a separate sheet of paper, be numbered, and have a brief descriptive title. Tables should be on individual pages separate from manuscript body text with placement indicated within.
377
JOURNAL MSMA DECEMBER 2010
ACKNOWLEDGMENTS are the author’s prerogative; however, acknowledgment of technicians and other remunerated personnel for carrying out routine operations or of resident physicians who merely care for patients as part of their hospital duties is discouraged. More acceptable acknowledgements include those of intellectual or professional participation. The recognition of assistance should be stated as simply as possible, without effusiveness or superlatives.
SUBMISSIONS TO JMSMA SCIENTIFIC SERIES Top Ten Facts You Need to Know Series The purpose of this series of articles is to provide referenced information on clinical management of medical conditions in a concise fashion. The submissions should be directed toward practitioners who do not have specialty training on the specific topic as a matter of general information. The author of the best submission for each year will receive a prize. Guidelines: 1) Articles should consist of 10 numbered paragraphs. Each of the paragraphs will begin with a fact that physicians need to know and a brief explanation of why. Facts will be referenced for each of the 10 points. 2) Suggested organization of manuscript is Introduction, Point 1, Point 2, etc., Conclusion, and References. 3) Articles will be about 3 pages (about 700 words) in length written at a level that can be easily understood by a practicing physician of any specialty. 4) A reference supporting the fact offered should be provided for each of the 10 points. Citations should not be review articles. 5) If there are specialty society guidelines in the area being discussed, the essential features of the recommendations should be included in the official guidelines cited in the references.
UpToDate Series The purpose of this series of articles is to provide brief reviews on topics of general interest to the practicing physicians of Mississippi in areas where recent developments in diagnosis or treatment have occurred. For instance, an article on recent advances in the diagnosis and treatment of lupus erythematosis would be an appropriate submission. Guidelines: 1) Articles should be practical and useful to physicians in office or hospital practice. 2) Suggested organization of manuscripts is Introduction, Diagnosis, Recent developments, Conclusion, and References. 3) Articles will be about 6 pages (1500 words) or so in length written at a level that can be easily understood by a practicing physician of any specialty. 4) Only those references that will be used to those physicians who desire further information in the area. Five to eight references that will be useful to those who desire further information should be included. 5) Figures are great as are “call-outs,” i.e., boxes with key points to remember emphasizing the “take home” messages. 6) If there are specialty society guidelines on the topic, the essential features of the recommendations should be summarized in the text and the official guidelines should be cited in the references. GALLEY PROOFS will be emailed to the principal author for review. Corrections should be clearly marked and returned promptly. To order reprints, request a price quote and place your order when you return your galley proof. ❒
• INDEX •
VOLUME LI
January - December 2010 SUBJECT INDEX
The letters used to explain in which department the matter indexed appears are as follows:“BR,” Book Review; “CPS” for Clinical Problem Solving”; “E,” Editorial; “H” Hardy Abstract; “I,” Images in Mississippi Medicine; “L,” Letters to the Editor; “NC” Numbers Count;“PB” Physician’s Bookshelf; “PM,” Poetry in Medicine; “PP,” President’s Page; “S,” Special Article; “UV” Una Voce; the asterisk (*) indicates an original article in the Journal, and the author’s name follows the entry in brackets. Matters pertaining to related organizations are indexed under the medical organization. -AAbstracts from the 2010 James D. Hardy Surgical Forum, 282H Abnormal 1 hour Glucose Challenge Test Followed by a Normal 3 Hour Glucose Tolerance Test: Does it Identify Adverse Pregnancy Outcome? [S. Pugh, A Poole, J Hill, E Magann, S Chauhan, J Morrison], 3* Advanced Squamous Cell Carcinoma Presenting as Osteomyelitis of the Hand: Midpalmar Resection and Suspensionoplasty Closure of Complex Defect [R Myers, P Blevins], 287-H An Interview with Timothy J. Alford, MD, 2010-2011 MSMA President [K Evers], 158-S
-BBilateral Cavernous Sinus Thrombosis Following Community-Acquired Methicillin-Resistant Staphylococcus aureus Infection: A Case Report and Review of the Literature [R Chick, J Glisson, S. Pierce], 317* Blood Levels in Mississippi Children [R Cox, P Kyle, B Brackin,
T Snazelle, J Surkin], 206* Blunt Renal Trauma and the Predictors of Failure of Nonoperative Management [J Simmons, N Haraway, R Schmieg, Jr., J Duchesne], 131*
-CCan the Delta Stop Singing the Blues? [J Bailey, T Beacham, K Weeks, C Smith, M Horn, V Herrin], 242* Cardiovascular Disease in Rheumatoid Arthritis: Disease and Treatment Interactions and their Implications on Treatment Decisions [S Sanders, S Geraci], 75* Chemical Colitis from a Hydrogen Peroxide Enema [Y Desai, J Orledge], 314*
Clinical Problem-Solving [presented and edited by the Dept. of Family Medicine, UMMC] Can’t Catch my Breath [C Fort], 355-CPS Deceptive Irritations [N Darby], 323-CPS I See Dead People [J Nielsen], 135CPS Now You See It, Now You Don’t [N
Islam], 183-CPS Off by a Factor of Eight [E Eldred], 211-CPS Perplexing Pyretic Polyarthritis [R Hanspal], 114-CPS Pseudo Seizures vs. Pseudo Zebra [M Pogue, J Gearhart, G Moll, Jr.], 83-CPS The Gastroenteritis That Wasn’t [D Norris], 289-CPS Uncommon but Not Rare [L Orozco], 11-CPS Comparison of Conventional Laparoscopic Appendectomy and Single Incision Laparoscopic Appendectomy in Pediatric Patients: A Retrospective Review [B Hamilton, D Sawaya, C Blewett, W Replogle], 283-H
Cover “Country Comes to Town at the Farmers’ Central Market” [C Stroud], August “Crown Jewel of Attala County” [S Hartness], October “Digitalis Derived from the Foxglove Plant” [S Bloom], April “Dunleith Historic Inn” [M Pomphrey, Jr.], May “Hope Prevails” [W Pontius], September “Leaf on the Trace” [M Pomphrey,
DECEMBER 2010 JOURNAL MSMA
378
Jr.], January “St. John the Baptist” [R Brahan], December “Stairway to Heaven” [M Pomphrey, Jr.], November “Stars and Stripes” [M Pomphrey, Jr.], July Timothy J. Alford, MD; 2010-11 MSMA President, June “Tricyrtis Hirta (Toad Lily)” [B Tisdale], March “Uppsala Cathedral” [J Jackson], February
-DDay 100 of the BP Oil Spill Disaster and Public Health in Mississippi [K Evers], 224-S Deaths, 45 Domestic Violence Screening in a Military Setting: Provider Screening and Attitudes [M Lutgendorf, J Busch, E Magann, J Morrison], 155* -E-
Editorials A Trip to Boston: Reflections on Battling the Obesity Epidemic [J Storey], 219-E Awestruck [M O’Dell], 192-E But Will It Take? [S Hartness], 123-E Creating a Better Climate for the Nation’s Health Care Could Make Champions of all Physicians [W Lineaweaver], 360-E Dignity [M O’Dell], 52-E “Draumatized” [M O’Dell] 143-E Getting Over It [S Hartness], 295-E Humanism [R deShazo], 331-E If Only We Knew [S Hartness], 170E Let’s Not Go Down Without A Fight [T Joiner], 257-E Many Good Things Are Happening at our MSMA [L Lampton], 358-E Sacred Spaces and Higher Ground [R deShazo], 255-E Start to Finish [S Hartness], 22-E The Great Myth [D South], 92-E The Perfect Storm: A Clinical
379
Vignette [R Cannon], 220-E There is a Tide in the Affairs of Men [L Weems], 91-E Will Politicians Ever Change? [M Lockey], 53-E -IImages in Mississippi Medicine Fin de Siecle Gross Anatomy for Medical Students [L Lampton], 236-I Hospital, Alcorn A & M, 1890s [L Lampton], 148-I Jackson Infirmary [L Lampton], 372-I Jackson Sanitorium, 1902-1916 [L Lampton], 276-I Miles A. Jones, B.S., Alcorn College, M.D., Meharry Medical College, College Physician, Alcorn A & M College, 1925-6 [L Lampton], 171-I The Taborian Hospital, Mound Bayou [L Lampton], 200-I
Impact of 80-Hour Duty Restrictions Upon Self-Reported Total Operative Experience [E Picarella, J Simmons, K Borman, M Mitchell], 287-H Impact of the Night Float System on Resident Operative Experience [M Hunt, M Morris, Jr., J Simmons], 285-H Improvement of Pre-Arterialized Venous Flap Survival Rate with Surgical Delay in the Rat Model [D Jackson, F Zhang, M Angel], 285-H Instructions for Authors, 61, 376
IQH 1-800-784-8669 - QUITNOW [J McIlwain], 94 Dr. Frothingham Named Recipient of the A. A. Derrick Physician Quality Award, 201 Drs. Hartness and Herrin Join IQH Staff, 301
JOURNAL MSMA DECEMBER 2010
Information & Quality Healthcare, 301 Patient Safety and Core Prevention [J McIlwain], 144 Regional Centers for Certified EHRs [J McIlwain], 94 Tobacco Quitline Updates [J McIlwain], 144 -LLegalease Talking to Lawyers about Patients: When is it really Okay? [S Rippee], 273
Letters In Reply to Editorial, “But Will It Take?” 223-L Observations, Analysis, Consideration, and Concerns of a Delegate [C Caine], 222-L Why Fight When You Can Go Cash? [S Owen], 333-L Local Legends Recognized in “Changing the Face of Medicine” Exhibit, 271 -M-
MACM Maples’ Musings: Assessing Risks, 296 MAFP Celebrity Roast of Daniel W. Jones, MD, Chancellor of the University of Mississippi, 106
Management of the Substernal Goiter: A Team Approach [R Cannon, R Lee, R Didlake], 179* Mississippi College Commences State’s First Physician Assistant Program [K Evers], 362-S Mississippi Welcomes First Osteopathic Medical School [K Evers], 334-S Mississippi Women in Medicine Leading the Way [K Evers], 258-S
Mississippi Women Physicians Recognized as “Local Legends”, 270
MSDH Dr. Mary Currier Named State Health Officer, 58 Health Department Commends Smokefree Cities, 252 In Memoriam, State Health Officer Ed Thompson, Jr., MD, MPH, 1947-2009, 28 Mississippi Reportable Disease Statistics, August 2010, 327 Mississippi Reportable Disease Statistics, March 2009, 139 Mississippi Reportable Disease Statistics, May 2009, 164 Mississippi Reportable Disease Statistics, July 2010, 292 Mississippi Reportable Disease Statistics, June 2010, 250 Mississippi Reportable Disease Statistics, November 2009, 57 Mississippi Reportable Disease Statistics, October 2009, 27 Mississippi Reportable Disease Statistics, September 2010, 354 MPHA Seeks Contributions to Fund Portrait for Dr. F.E. “Ed” Thompson, Jr. State Public Health Laboratory, 233 MSMA Member Appointed to the Mississippi State Board of Health, 251 Physicians Can Make a Child’s Smile [E Felder, N Mosca], 232 State Epidemiologist and Deputy State Health Officer for Medicine and Science Dr. Mary Currier Appointed Interim State Health Officer, 29
MSMA Address of the MSMA President 2009-2010, S. Randy Easterling, MD, 197 June 3-6, 2010 in Natchez, 142nd Annual Session of the
MSMA House of Delegates, 39 MSMA Awards: Community Service, Leadership, and Wellness Promotion Project Honored, 195 MSMA Election Results Announced, 194 Patients First During the 2011 Legislative Session [C Espy], 365 Public Health in Mississippi, Report Card 2010 [R Easterling], 15 Richard D. DeShazo, MD Appointed JMSMA Associate Editor, 193 MSMA Alliance Alliance Past President’s Spotlight, Faye B. Lehmann, 19691970, Natchez, 231 Past President’s Spotlight: Mrs. Stanley (Beth) Hartness, MSMAA President, 20022003, Kosciusko, 373 Past President’s Spotlight: Danita Horne, 2004-05, Laurel, 275 Past President’s Spotlight: Mrs. John McRae (Eileene), MSMAA President, 2002-2003, Hattiesburg, 309 -NNew Members, 43, 117, 165, 230
Numbers Count Physicians Licensed by the Mississippi State Board of Medical Licensure, 56-NC
-OObituaries, 119 On Disaster Response Call with Dr. Dan Edney [K Evers], 298-S Operator Estimate of Surgical Margins in Colon and Rectal Surgery [M Keller, D Snyder, D Sawaya], 286-H
-PPancreas Cancer in Mississippi: Present Challenges and Future Directions [T.
Helling], 99* Personals, 46
Physicians’ Bookshelf “Bringing Down High Blood Pressure” [Chad Rhoden, MD, PhD with Sarah Wiley Schein, MS, RD, LDN, National Book Network] [reviewed by L Lampton], 146-PB Forthcoming: “The Fall of the House of Zeus” by Curtis Wilkie [P Merideth], 54-PB Kings of Tort: The True Story of Dickie Scruggs, Paul Minor, and Two Decades of Political and Legal Manipulation in Mississippi [Alan Lange and Tom Dawson, Pediment Publishing, Battle Ground, WA, 2009] [reviewed by P Merideth], 54-PB Mississippi Native Pens Epic on Tort King’s Fall [B Dye], 367-PB Stiff: The Curious Lives of Human Cadavers [Mary Roach, W. W. Norton & Company, Inc.] [reviewed by A Roy], 307PB The Color Atlas of Family Medicine [Richard P. Usatine, Mindy Ann Smith, E. J. Mayeauz Jr., Heidi Chumley and James Tysinger, McGraw Hill Publishing, New York, NY, 2008] [reviewed by S Petersen], 25-PB Poetry in Medicine Danny’s Song [R Khayat], 107-PM Echocardiogram: A Reading [W Lineaweaver], 237-PM Gratitude [R deShazo], 172-PM “Just a Little Xylocaine” [J McEachin], 277-PM Rhythms of Life [R deShazo], 145PM The Macon Post-season Glee Club [J McEachin], 202-PM
DECEMBER 2010 JOURNAL MSMA
380
President’s Page A Prayer for Baby Cobb [T Alford], 329-PP Be Careful What We Ask for, We Might Get It [R Easterling], 49-PP Be Part of the Solution [R Easterling], 140-PP Have a Good Night [R Easterling], 19-PP I Wish You Hearts that Race, Minds that Dream... [R Easterling], 168-PP Inaugural Address of the 143rd
MSMA President [T Alford], 188-PP Let’s Change the Whole Damn System and Start Over, but We Have to Wait Until Tuesday [R Easterling], 121PP Pigs Have Already Flown [R Easterling], 89-PP Playing Like a Team [T Alford], 293PP Promise and Hope for Healthy Schools [T Alford], 253-PP Rising Tides [T Alford], 217-PP Up in Smoke [T Alford], 357-PP Prevalence and Trends in Obesity among Mississippi Public School Students, 2005-2009 [E Molaison, J Kolbo, L Zhang, B Harbaugh, M Armstrong, K Rushing, L Blom, A Green], 67* Prolonged QTc Interval Due to Escitalopram Overdose [R Mohammed, J Norton, S Geraci, B Newman, C Koch], 350*
-RRadical Prostatectomy for High-Risk Prostate Cancer: A SingleCenter Experience [D Spencer, J Griffin, J Bridges, J Seidmon, C Pound], 288-H Recurrent, Transformed NonHodgkin’s Lymphoma Presenting as Chiasmal
381
Syndrome with Hyperprolactinemia and Hypopituitarism [A Sumrall, V Herrin], 35*
-SSacral Neuromodulation in Patients with Voiding Dysfunction and Concomitant Gastrointestinal Dysfunction [A Haraway, M Runnels, T Abell, W Duncan], 284-H Screening for Vitamin D Deficiency in the Elderly [J Kositsawat, S Geraci], 7* Short and Medium Term Results of Iliac Artery Angioplasty and Stenting Combined with Superficial Femoral Artery Atherectomy [B Ghosheh, H McDaniel, F Rushton, Z Baldwin, M Hunt, M Mitchell], 283-H Surgical Management of Eyelid and Periocular Cancers [M Cotten], 247*
-TThe Uncommon Thread Boils and Goiters [S Anderson], 278 Connect the Dots [S Anderson], 310 Creative Writing [S Anderson], 203 Evidence Based [S Anderson], 238 Hard [S Anderson], 374 The Ghost [S Anderson], 125 The Loss of Magic [S Anderson], 341 The Manchurian Candidate [S Anderson], 173 The Thomasine Confluence [S Anderson], 149
-UUMHC UMHC Congenital Heart Surgeon Makes Mississippi History, 305
UMMC Dr. James Keeton Becomes New Vice Chancellor, 95 Jackson Heart Study to Mark 10th
JOURNAL MSMA DECEMBER 2010
Anniversary with Conference, 272 Stringer, Robbins Named Finalists for UMMC Vice Chancellor, 59
UMMC School of Medicine Profile of an Entering Medical School Class [S Case], 59 The School of Medicine Class of 2014 [S Case], 306 University of Mississippi School of Medicine – Moving in the Right Direction [L Woodward], 234
Una Voce A Note of Thanks (In Memoriam, Robert “Rob” Walter Bitter, 1928-2009) [D South-Bitter], 96-UV Culture and Sensitivity: Part 1, “Adventures with Juan and Bud” [D South-Bitter], 175UV Canine Behavior [S Anderson], 31UV “Celebrate. Remember. Fight Back.” - Thoughts on the American Cancer Society Relay for Life [D South-Bitter], 127UV Eavesdropping [S Anderson], 63-UV Meditations from Room 324 [D South-Bitter], 343-UV Shocking, Isn’t It? [D South-Bitter], 151-UV -WWillard Boggan, MD: A Giant of Mississippi Medicine [P Levin], 214* Women in Leadership at the University of Mississippi Medical Center School of Medicine [R deShazo], 269
INDEX
VOLUME LI
January - December 2010
AUTHOR INDEX
The letters used to explain in which department the matter indexed appears are as follows:“BR,” Book Review; “CPS” for Clinical Problem Solving”; “E,” Editorial; “H” Hardy Abstract; “I,” Images in Mississippi Medicine; “L,” Letters to the Editor; “NC” Numbers Count;“PB” Physician’s Bookshelf; “PM,” Poetry in Medicine; “PP,” President’s Page; “S,” Special Article; “UV” Una Voce; the asterisk (*) indicates an original article in the Journal, and the author’s name follows the entry in brackets. Matters pertaining to related organizations are indexed under the medical organization.
A
D
B
E
Abell, Thomas L., 284-H Alford, Tim J., 188-PP, 217-PP, 253PP, 293-PP, 329-PP, 357-PP Anderson, R. Scott, 31-UV, 63-UV, 125, 149, 173, 203, 238, 278, 310, 341, 374 Angel, Michael F., 285-H Armstrong, Mary G., 67*
Darby, Nathan, 323-CPS Desai, Yagnesh, 314* deShazo, Richard D., 145-PM, 172PM, 255-E, 269, 331-E Didlake, Ralph, 179* Duchesne, Juan D., 131* Duncan, William L., 284-H Dye, Bradford J., 367-PB
Bailey, Jessica Harpole, 242* Baldwin, Zachary, 283-H Beacham, Tracilia “Drew”, 242* Blevins, Phillip K., 287-H Blewett, Christopher J., 283-H Blom, Lindsey C., 67* Bloom, Sherman, April cover Borman, Karen R., 287-H Brackin, Bruce, 206* Brahan, Robert B., December cover Bridges, Jason P., 288-H Busch, Jeanne, 155*
Felder, Elizabeth M., 232 Fort, Christopher J., 355-CPS
C
G
Caine, Sr., Curtis W., 222-L Cannon, C. Ron, 179*, 220-E Case, Steven T., 59, 306 Chauhan, Suneet P., 3* Chick, Rebecca S., 317* Cotten, Milam S., 247* Cox, Robert D., 206*
Easterling, Randy, 15, 19-PP, 49-PP, 89-PP, 121-PP, 140-PP, 168PP, 197 Eldred, Edward B., 211-CPS Espy, Christopher W., 365 Evers, Karen A., 158-S, 224-S, 258S, 298-S, 334-S, 362-S
F
Gearhart, Judith G., 83-CPS Geraci, Stephen A., 7*, 75* Ghosheh, Bashar, 283-H Glisson, James K., 317* Green, Ashley, 67* Griffin, Joshua G., 288-H
H
Hamilton, Brian S., 283-H Hanspal, Rajvinder Singh, 114-CPS Haraway, A. Neal, 131* Haraway, Allen M., 284-H Harbaugh, Bonnie, 67* Hartness, Stanley, 22-E, 123-E, 170E, October cover, 295-E Helling, Thomas S., 99* Herrin, Vince, 35*, 242* Hill, James B., 3* Horn, Michelle, 242* Hunt, Matthew J., 283-H, 285-H
I
Islam, Nahid, 183-CPS
J
Jackson, John J., February cover Jackson, W. Dotie, 285-H Joiner, Thomas E., 257-E K Keller, Michael A., 286-H Khayat, Robert, 107-PM Koch, Christian A., 350* Kolbo, Jerome R., 67* Kositsawat, Jatupol, 7* Kyle, Patrick B., 206* DECEMBER 2010 JOURNAL MSMA
382
L
Lampton, Lucius, 146-PB, 148-I, 171-I, 200-I, 236-I, 276-I, 358-E, 372-I Lee, Robert, 179* Levin, Philip, 214-S Lineaweaver, William C., 237-PM, 360-E Lockey, Myron W., 53-E Lutgendorf, Monica, 155*
M
Magann, Everett F., 3*, 155* McDaniel, Huey B., 283-H McEachin, John D., 202-PM, 277PM McIlwain, James S., 94, 144 Merideth, Philip, 54-PB Mitchell, Marc E., 283-H, 287-H Mohammed, Reema, 350* Molaison, Elaine Fontenot, 67* Moll, Jr., George, 83-CPS Morris, Jr., Michael W., 285-H Morrison, John C., 3*, 155* Mosca, Nicholas G., 232 Myers, Robert S., 287-H
N
Newman, D. Brian, 350* Nielsen, Janet M., 135-CPS Norris, David R., 289-CPS Norton, John, 350*
O
O’Dell, Michael, 52-E, 143-E, 192E Orledge, Jeffery, 314* Orozco, Lynne A., 11-CPS Owen, Stanford A., 333-L
P
Petersen, Snow Marika, 25-PB Picarella, Emile A., 287-H Pierce, Samuel, 317* Pogue, D. Mark, 83-CPS Pomphrey, Jr., Martin M., January cover, May cover, July cover, November cover Pontius, William F., September cover Poole, Aaron T., 3* Pound, Charles R., 288-H Pugh, Suzanne K., 3*
R
Replogle, William H., 283-H Rippee, Stephanie M., 273 Roy, Alex, 307-PB Runnels, Mark A., 284-H Rushing, Keith, 67* Rushton, Fred W., 283-H
S
Sawaya, David E., Snyder, Davis C., 283-H, 286-H Schmieg, Jr., Robert E., 131* Seidmon, E. James, 288-H Simmons, Jon D., 131*, 285-H, 287H Smith, C. Cory, 242* Snazelle, Teri, 206* Snyder, David C., 286-H South-Bitter, Dwalia S., 92-E, 96UV, 127-UV, 151-UV, 175-UV, 343-UV Spencer, Jr., David L., 288-H Storey, Joanna Miller, 219-E Stroud, Catherine H., August cover Sumrall, Ashley, 35* Surkin, Joe, 206*
T
Tisdale, Brett, March cover
W
Weeks, Katie, 242* Weems, W. Lamar, 91-E Woodward, Lou Ann, 234
Z
Zhang, Feng, 285-H Zhang, Lei, 67*
Sanders, Suzanne, 75*
Now No w available! available! e! F Free Fr ree posting posting ffor or MSMA MSMA members memberrs
MSMAonline-jobs.com MS MAonlline-jobs.com An o An online nline llisting isting of of currently-open currently tly-open phy physician sician pos positions sitions iin n cl clinics, inics, h hospitals, ospitals, and private private practices practices throughout throughout Mississippi Mississippi
WANT W ANT M MORE ORE IINFO? NFO? NEED NEED TO TO L LIST IST A POSITION? POSIT I ION? Contact C Co ntact A Anna nna Morris Morris today! today! 601-853-6733, 601-853-6733, E Extension xtension 324 324
383
JOURNAL MSMA DECEMBER 2010
Haǀe zŽu ŽŶƐidered a LiĨe SeƩlemeŶƚ &Žr zŽur Kld LiĨe /ŶƐuraŶcĞ WŽlicLJ? tŚĂƚ ŝƐ Ă >ŝĨĞ ^ĞƩůĞŵĞŶƚ͍ ůŝĨĞ ƐĞƩůĞŵĞŶƚ ŝƐ ƚŚĞ ƐĂůĞ ŽĨ ĂŶ ĞdžŝƐƟŶŐ ůŝĨĞ ŝŶƐƵƌĂŶĐĞ ƉŽůŝĐLJ ŽŶ ƚŚe ƐĞĐŽŶĚaƌLJ ŵĂƌŬĞƚ ƚŽ Ă ƚŚiƌĚ ƉĂƌƚLJ ŝŶǀĞƐƚŽƌ͘
tŚŽ Žƌ tŚĂƚ DĂLJ YƵĂůŝĨLJ͍ 9 /Ĩ ƚŚĞ ƉĞƌƐŽŶ ŝŶƐƵƌĞd ďLJ ƚŚĞ ƉŽůŝĐLJ ŝƐ ĂŐĞ ϳϬ Žƌ ŽůĚĞƌ 9 /Ĩ ƚŚĞ ƉĞƌƐŽŶ ŝŶƐƵƌĞd ŚĂƐ ĂŶLJ ŵĂũŽƌ ŵĞĚŝĐĂů ĐŽŶĚŝƟŽŶƐ 9 /Ĩ ƚŚĞ ƉŽůŝĐLJ ŚĂƐ Ă ĚeĂƚŚ ďeŶĞĮƚ ŽĨ ΨϮϱϬ͕Ϭ0Ϭ Žƌ ŵŽƌĞ 9 WŽůŝĐŝĞƐ ŝŶĐůƵĚŝŶŐ͕ ďƵƚ ŶŽƚ lŝŵŝƚĞĚ ƚŽ͕ ƵŶŝǀĞƌƐaů ůŝĨĞ͕ ƚĞƌŵ ŝŶƐƵƌĂŶĐĞ͕ ǀĂƌŝĂďůĞ ůŝĨe ŝŶƐƵƌĂŶĐĞ Žƌ ǁŚŽůĞ ůŝĨĞ ŝŶƐƵƌĂŶce 9 /Ĩ ĂŶLJ ĐĂƐŚ ǀĂůƵĞ ĞdžŝƐƚƐ ŝŶ ƚŚĞ ƉŽůŝĐLJ͕ ƚŚĞ ĂŵŽƵŶƚ ŝƐ ƌĞůĂƟǀĞlLJ ƐŵĂůů
&Žƌ DŽƌĞ /ŶĨŽƌŵĂƟŽŶ ŽŶ >ŝĨĞ ^ĞƩůĞŵĞŶƚƐ͕ ĐŽŶƚĂcƚ͗ ,͘ >ĂƌƌLJ &ŽƌƚĞŶďĞƌƌLJ͕ W ͕ >h͕ Ś& džĞĐƵƟǀĞ WůĂŶŶŝŶŐ 'ƌŽƵƉ͕ W 1640 Lelia Drive, Suite 220 PO Box 16566 Jackson, MS 39216 ;ϲϬϭͿ ϵϴϮͲϯϬϬϬ
tŚLJ hƐĞ Ă >ŝĨĞ ^ĞƩůĞŵĞŶƚ͍ 9 dĞƌŵ lŝĨĞ iŶƐƵƌĂŶĐĞ ƉŽůŝĐLJ ǁŝůů ĞdžƉŝƌĞ 9 KůĚ ƉŽůŝĐLJ ƚŚĂƚ iƐ ŶŽ ůŽŶŐĞr ŶĞĞĚĞĚ Žƌ ƉƌĞŵŝƵŵƐ ĐĂŶŶŽƚ ďĞ ƉĂŝĚ 9 ƉŽůŝĐLJ ƚŚĂƚ ǁĂƐ ƉƵƌĐŚĂƐeĚ ĨŽƌ Ă ďƵƐŝŶĞƐƐ ďƵLJ/ƐĞůů ĂŶĚ ŝƐ ŶŽ ůŽŶŐĞƌ ŶĞĞĚĞĚ 9 ƉŽůŝĐLJ ǁĂƐ ƉƵrĐŚĂƐĞĚ ĨŽƌ Ă bƵƐŝŶĞƐƐ ƚŚĂƚ ŚĂƐ ďĞĞŶ ƐŽůĚ Žƌ ŝƐ ŶŽƚ Ŷeeded 9 dŚĞƌĞ ŵĂLJ ďĞ Ă ďĞƩeƌ ƉŽůŝĐLJ ĂǀĂiůĂďůĞ Ăƚ Ă ůŽǁĞƌ ĐŽƐƚ
9 ƐƚĂƚĞ ǀĂůƵĞ ŚĂƐ ĐŚĂŶŐĞĚ ĂŶd ƚŚĞ ƉŽůŝĐLJ ŝƐ ŶŽ ůŽŶŐĞƌ ŶĞĞded
^ĞĐƵƌŝƟĞƐ KīĞƌĞĚ dŚƌŽƵŐŚ sĂůDĂƌŬ ^ĞĐƵƌiƟĞƐ͕ /ŶĐ͘ DĞŵďĞƌ &/ER ͕ ^/W /ŶǀĞƐƚŵĞŶƚ ĚǀiƐŽƌLJ ^ĞrǀŝĐĞƐ KīĞƌeĚ dŚƌŽƵŐŚ sĂůDĂƌŬ dǀŝƐĞƌƐ͕ /ŶĐ͘ Ă ^ ZĞŐŝƐƚĞrĞĚ /ŶǀĞƐƚŵĞŶƚ ĚǀŝƐŽƌ ϭϯϬ ^ƉƌŝŶŐƐŝĚĞ DƌŝǀĞ͕ ^ƵŝƚĞ ϯϬϬ ŬƌŽŶ͕ KŚŝŽ ϰϰϯϯϯ-ϮϰϯϭΎ ϭͲϴϬ0-765-5201 džĞĐƵƟǀĞ WůĂŶŶŝŶŐ 'ƌŽƵƉ ŝƐ Ă ƐĞƉaƌĂƚĞ ĞŶƟƚLJ ĨƌŽŵ sĂlDĂƌŬ ^ĞĐƵƌŝƟĞƐ͕ /ŶĐ͘ ĂŶĚ sĂůDĂƌŬ dǀŝƐĞƌƐ͕ /ŶĐ͘ In a lifĞ ƐĞƩůement agreement, the current life insurance policy owner transfers the ownership ĂŶĚ ďĞŶĞĮĐŝĂrLJ ĚĞƐŝŐŶĂƟons to a third party, who receives the death proceeds at the passing of the insured. As a result, this buyer has Ă ĮŶĂŶĐŝĂl interest in the seller’s death. When an individual decides to sell their policy, he or she must provide complete access to his or her medical history, and other personal inforŵĂƟŽŶ͕ ƚhat mĂLJ Ăīect his or her life expectĂŶĐLJ͘ dŚŝƐ ŝŶĨŽƌŵĂƟon is requested during the ŝŶŝƟĂl ĂƉƉůŝĐĂƟŽŶ for a life ƐĞƩůĞŵĞŶƚ͘ Ōer the coŵƉůĞƟŽŶ ŽĨ ƚhe sale, there may be an ongoinŐ ŽďůŝŐĂƟŽŶ to disclose siŵŝůĂƌ ĂŶĚ ĂĚĚŝƟonal inforŵĂƟŽŶ Ăƚ Ă ůater date. ůŝĨĞ ƐĞƩlement may aīect the seller’s eligibility for certain public assistance programs, such as Medicaid, and there may be tax consequences. Individuals should discuss ƚŚĞ ƚĂdžĂƟŽŶ of the proceeds received with their tax advisor. ValMark SecƵƌŝƟĞƐ considers Ă ůŝĨĞ ƐĞƩůĞŵĞŶƚ Ă ƐecuritLJ ƚƌĂŶƐĂĐƟŽn. ValMark and its registered represĞŶƚĂƟǀĞƐ ĂĐƚ ĂƐ brokers on the transacƟŽŶ ĂŶĚ ŵĂLJ receive a fee from the purchaser. A life seƩůĞŵĞŶƚ tƌĂŶƐĂĐƟon may require an extended period oĨ ƟŵĞ ƚo complete. Due to complexity of tŚĞ ƚƌĂŶƐĂĐƟon, fees and costs incurred witŚ ƚŚĞ ůŝĨĞ ƐĞƩlement tranƐĂĐƟŽŶ ŵĂLJ ďe ƐƵďƐƚĂŶƟally higher than otheƌ ƐĞĐƵƌŝƟes.