January 2013 JOURNAL MSMA by Journal MSMA

January

VOL. LIV

2013

No. 1

BEACON Imagine the possibilities. You’ve heard of the Beacon Grant.

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Lucius M. Lampton, MD Editor D. Stanley Hartness, MD Richard D. deShazo, MD AssociAtE Editors Karen A. Evers MAnAging Editor PublicAtions coMMittEE Dwalia S. South, MD chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD, Ex-Officio Myron W. Lockey, MD, Ex-Officio and the editors thE AssociAtion Steven L. Demetropoulos, MD president James A. Rish, MD president-elect J. Clay Hays, Jr., MD secretary-treasurer Lee Giffin, MD speaker Geri Lee Weiland, MD vice speaker Charmain Kanosky executive director Journal of the Mississippi state Medical association (issn 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. correspondence: Journal MSMA, Managing editor, Karen a. evers, p.o. Box 2548, ridgeland, Ms 39158-2548, ph.: (601) 853-6733, fax: (601)853-6746, www.MsMaonline.com. suBscription rate: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available. advertising rates: furnished on request. cristen hemmins, hemmins hall, inc. advertising, p.o. Box 1112, oxford, Mississippi 38655, ph: (662) 236-1700, fax: (662) 236-7011, email: cristenh@watervalley.net postMaster: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 39158-2548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association. copyright© 2013 Mississippi state Medical association.

JANUARY 2013

VOLUME 54

NUMBER 1

Scientific ArticleS Opioids for Chronic Noncancer Pain: Are They Safe and Effective?

Scott Hambleton, MD

Traumatic Vulvar Hematoma Masquerading as a Bartholin Duct Cyst in a Postmenopausal Woman

James D. Perkins, MD and Paula F. Morris, FNP

164 Years Later, A Case Report: U.S. Grant, Eye Pain and Swelling in Mexico 1848

Robert K. Collins, MD and John F. Marszalek, PhD

Just Off the Press - Info You Want to Know: About Group A Streptococcal Pharyngitis Guidelines

Richard L. Ogletree, Jr., PharmD

PreSident’S PAge When Do Your Rights End and My Rights Begin?

Steven L. Demetropoulos, MD, MSMA President

editoriAl Out With the Old…In With the Old

D. Stanley Hartness, MD, Associate Editor

The Second Rule

Brian Temple, MD, and Sulaimin Conteh

relAted orgAnizAtionS Mississippi Rural Physicians Scholarship Program Mississippi State Department of Health

22 29

dePArtmentS From the Editor Physician’s Bookshelf Images in Mississippi Medicine Uncommon Thread

2 21 31 32

About the cover:

official publication of the MsMa since 1959

Winterscape— Susan A. Chiarito, MD took this photograph at a pond in north Warren county near Eagle Lake. Dr. Chiarito is a family physician at Mission Primary Care in Vicksburg. She also is the current president of the Mississippi Academy of Family Physicians, r

January

VOL. LIV

2013

No. 1

JANUARY 2013 JOURNAL MSMA 1

From the Editor

new year is upon us. 2013 opens with many good things happening to our profession in the state. On January 7th, Governor Phil Bryant joined Dr. James Keeton, Dr. Dan Jones, Speaker of the House Philip Gunn, and other dignitaries to break ground on UMMC’s new School of Medicine, a proposed $63 million building to provide room for increasing the medical school class size upwards from its current 135 students (recently increased from 100, where it had been for more than two decades) to 165 students. The current medical school facility, built in 1955, is outdated and inadequate to train the larger student body. This new School of Medicine is one of the keys to solving Mississippi’s physician workforce crisis. Another key is the Mississippi Rural Physicians Scholarship Program, an innovative and award-winning program, based at UMMC and focused on mentoring rural medical students to return to rural Mississippi and practice primary care. (For more on that program, see Janie Guice’s article on pages 22-23) There has been no better friend to Mississippi medicine than Janie Guice, and the success of the program can be attributed largely to her brilliant leadership. Sadly, after serving as MRPSP Executive Director for the last six years, Janie is retiring at the end of January. Her successor, Wahnee Sherman, will start on February 1. While no one can fill Janie’s big shoes, Wahnee is a talented and capable individual who should lead the program with success. So, welcome Wahnee to her important role helping our

profession. And when you see the one and only Janie Guice, please thank her for all she has done to make our profession stronger in Mississippi! January also is the month our MSMA and the Department of Health release Mississippi’s Public Health Report Card. (See center poster insert) Not much has improved over the last year: the state’s health remains poor at best, with too much obesity, diabetes, smoking, cardiovascular Lucius M. Lampton, MD disease, and too many teen births. There is a Editor little good news that things may be improving slightly with obesity and teen births, but not much else good. Much work remains to be done by our profession. We can and must make a difference each day in our practices. As the wise Dr. William Osler said a century ago: “To prevent disease, to relieve suffering and to heal the sick--- this is our work.” Osler’s sage observation should guide a physician’s focus as we approach our patients and change their lives for the better. This Journal remains one of the few in the United States still created by physicians for physicians. It is only as good as you make it. Write an editorial, a letter, an essay, a scientific article, a case report, or take a photograph or contribute a physician portrait. Contact me at lukelampton@cableone.net. — Lucius M. Lampton, MD, Editor

Journal editorial advisory Board R. Scott Anderson, MD, FACR Chair, Journal Editorial Advisory Board Radiation Oncologist and Medical Director, Anderson Regional Cancer Center, Meridian Diane K. Beebe, MD Professor and Chair, Department of Family Medicine, University of MS Medical Center, Jackson Claude D. Brunson, MD Senior Advisor to the Vice Chancellor for External Affairs, University of Mississippi Medical Center, Jackson Jeffrey D. Carron, MD, FAAP, FACS Associate Professor, Department of Otolaryngology & Communicative Sciences, University of Mississippi Medical Center, Jackson Gordon (Mike) Castleberry, MD Urologist, Starkville Urology Clinic Mary Currier, MD, MPH State Health Officer Mississippi State Department of Health, Jackson Thomas E. Dobbs, MD, MPH Epidemiologist Mississippi State Department of Health, Hattiesburg Sharon Douglas, MD Chair, AMA Council on Ethical & Judicial Affairs Professor of Medicine and Associate Dean for V A Education, University of Mississippi School of Medicine, Associate Chief of Staff for Education and Ethics, G.V. Montgomery VA Medical Center, Jackson Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist, The Street Clinic, Vicksburg

Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson Maxie L. Gordon, MD Assistant Professor, Department of Psychiatry and Human Behavior, Director of the Adult Inpatient Psychiatry Unit and Medical Student Education, University of Mississippi Medical Center, Jackson Scott Hambleton, MD Medical Director Mississippi Professionals Health Program, Ridgeland John Edward Hill, MD, FAAFP Residency Program Director North Mississippi Medical Center, Tupelo John D. Isaacs, Jr., MD Infertility Specialist, Mississippi Fertility Institute at Women’s Specialty Center, Jackson Kent A Kirchner, MD Nephrologist G.V. Montgomery VA Medical Center, Jackson Brett C. Lampton, MD Internist/Hospitalist Baptist Memorial Hospital, Oxford Philip L. Levin, MD President, Gulf Coast Writers Association Emergency Medicine Physician, Gulfport

Gailen D. Marshall, Jr., MD, PhD, FACP Professor of Medicine and Pediatrics, Vice Chair for Research, Director, Division of Clinical Immunology and Allergy, Chief, Laboratory of Behavioral Immunology Research The University of Mississippi Medical Center, Jackson Alan R. Moore, MD Clinical Neurophysiologist Muscle and Nerve, Jackson Paul “Hal” Moore Jr., MD, FACR Radiologist Singing River Radiology Group, Pascagoula Jason G. Murphy, MD Surgeon Surgical Clinic Associates, Jackson Ann Myers, MD Rheumatologist Mississippi Arthritis Clinic, Jackson Jimmy L. Stewart, Jr., MD Program Director, Combined Internal Medicine/ Pediatrics Residency Program, Associate Professor of Medicine and Pediatrics University of Mississippi Medical Center, Jackson Samuel Calvin Thigpen, MD Hematology-Oncology Fellow, Department of Medicine University of Mississippi Medical Center, Jackson Thad F. Waites, MD, FACC Clinical Cardiologist, Hattiesburg Clinic

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

Chris E. Wiggins, MD Orthopaedic Surgeon Bienville Orthopaedic Specialists, Pascagoula

John F. Lucas,III, MD Surgeon Greenwood Leflore Hospital

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

2 JOURNAL MSMA JANUARY 2013

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Defense of Claims JANUARY 2013 JOURNAL MSMA 3

• ScieNtific ARticleS • Opioids for Chronic Noncancer Pain: Are They Safe and Effective? Scott Hambleton, MD

kyrocketing

deAthS

The prescription drug crisis is driven primarily by the use of opioids which account for approximately 75% of prescription drug-related overdose deaths, according to the Centers for Disease Control and Prevention (CDC).1 Prescription drug abuse has become a focal point for the media, and for good reason. The rate of accidental drug overdose deaths has skyrocketed in the last decade.1 In 2009, over 37,480 Americans died because of drug overdoses, actually surpassing the number who died from motor vehicle accidents for the first time in our nation’s history.2 The population in the United States increased from 206 million in 1970 to over 306 million in 2009, an increase of approximately 50%.3 By contrast, the number of accidental overdose deaths increased over tenfold during the same period.2,4 In 2010, the CDC reported that approximately 12 million Americans used opioids for nonmedical purposes for the first time.4 According to Substance Abuse & Mental Health Services Administration (SAMHSA), almost 35 million Americans have used opioids for nonmedical purposes.5 The consequences of prescription drug abuse affect millions of American families, and there is a growing sense of outrage. Thankfully, the 2011 National Survey on Drug Use and Health, a survey of approximately 67,500 Americans, reports that illicit prescription drug use is decreasing among children and young adults.5 However, official death rates for 2011 are pending, and, in my opinion, overdose deaths will likely remain a leading cause of accidental death in each age group.5

Author informAtion: Dr. Hambleton is Medical Director of the Mississippi Professionals Health Program, which is the Physician Health Program for the state, located in Ridgeland, Mississippi, at the office of the Mississippi State Medical Association. correSPonding Author: Scott Hambleton, MD, Medical Director, Mississippi Professionals Health Program, 408 West Parkway Place. Ridgeland, MS 39157-6010 Phone: 601-420-0240 ext.104 Fax: 601-707-3795.

4 JOURNAL MSMA JANUARY 2013

cAll for chAnge There are a growing number of physician leaders who are calling for change. On July 25, 2012, a group of physicians organized by the Physicians for Responsible Opioid Prescribing sent a petition to the FDA6 requesting changes for opioid analgesic labels. The petition was signed by 37 physicians who are national leaders in the treatment of chronic pain as well as the treatment of addictive disorders. The changes include striking the term “moderate” from the indication for noncancer pain; adding a maximum daily dose equivalent to 100 milligrams of morphine for noncancer pain; and adding a maximum duration of 90 days for continuous (daily) use for noncancer pain. The Federal Food, Drug, and Cosmetic Act established that a drug intended to treat a condition must be proven safe and effective for use as labeled.7 The petition asserts that the current label on opioid analgesics does not comply with this law. Not surprisingly, the opioid manufacturers are adamantly opposed to this petition which, if enacted, would undoubtedly result in decreased opioid sales. National leaders in the field of pain management as well as nationally recognized pain societies have voiced their objections to this petition. The forces opposing this petition are very strong and may prevail, despite the lack of legitimate evidence to support the industry’s assertion of safety and efficacy.

the 2nd u.S. SenAte inveStigAtion On June 8, 2012, the US Senate Finance Committee began an investigation into the financial relationships between pharmaceutical manufacturers, medical societies, regulatory agencies, and several physicians who are nationally recognized as leaders in the field of pain management. The named parties have been ordered to provide a detailed account of all payments from 1997 to the present between opioid manufacturers (Purdue, Johnson & Johnson, and Endo) and non-profit health care organizations (American Pain Foundation, American Academy of Pain Medicine, The American Geriatric Society,

and others), regulatory agencies (the Joint Commission and others) and several individually named physician leaders who promote the use of opioids.8 The investigation will attempt to clarify the relationship between these entities and determine the involvement of supposedly independent medical organizations which are said to be financed by the pharmaceutical industry. The investigation specifically mentions the book “Responsible Opioid Prescribing” which is promoted by regulatory agencies.9 The book is alleged to proclaim opioid use for chronic, noncancer pain as both safe and effective, “despite the lack of science supporting the use of opioids for chronic, noncancer pain.”8

the eye of the Storm More than 85% of opioids, as measured by total morphine equivalents, are dispensed to patients with chronic pain,10 and, in my estimation, the promotion of opioids for chronic, noncancer pain represents the eye of the storm which has caused the epidemic. Twenty years ago, most physicians would not consider prescribing schedule II opioids for chronic noncancer pain of moderate severity because of fears of causing addiction or overdose. The change in medical practice was most notable in 1996 when Oxycontin was initially marketed in the USA. One training video which promoted Oxycontin was sent to thousands of doctors in 1998. 11 It convincingly reported

addiction rates “much less than one percent” and added, “They (opioids) do not have serious medical side effects.”11 In 2003, a GAO report pointed to Purdue’s partnership with the Joint Commission to promote the 5th Vital Sign Campaign as a possible means for Purdue to have “facilitated its access to hospitals to promote Oxycontin.” The report revealed that Purdue “funded over 20,000 pain-related educational programs through direct sponsorship or financial grants.” 13

mArketing SucceSS The opioid manufacturers’ combined marketing efforts to make physicians more comfortable prescribing opioids has been a tremendous success. Yearly sales of Oxycontin approached $3.1 billion in 20101 and over 110 tons of hydrocodone and oxycodone were dispensed in the USA the same year.15 By the end of 2010, the United States had consumed 55% of the global supply of morphine, 56% of the global supply of hydromorphone, 80% of the global supply of oxycodone, and 99% of the global supply of hydrocodone, although Americans represented only 5.2 % of the earth’s population.15 Enough opioids are now prescribed in the USA to medicate every man, woman, and child every 4 hours around the clock for an entire month.1 Although we may have an epidemic of untreated pain, it is not because we do not prescribe enough opioids.

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the 1St u.S. SenAte inveStigAtion

concluSion

After a US Senate Finance Committee investigation in 2007, Purdue Pharma paid $634.5 million in fines for misbranding related to minimizing the addictive potential of Oxycontin. Physicians’ initial fears about addiction appear to have been well founded because addiction is extremely common in individuals treated with opioids for chronic, noncancer pain.16, 17 Highly respected pain clinics like the Cleveland Clinic Chronic Pain Rehabilitation Program and others report addiction rates of 30-35% in patients treated with opioids for chronic, noncancer pain.16, 17 In fact, patients with mental health and substance abuse co-morbidities are more likely to receive opioids than patients who lack these risk factors, a phenomenon referred to as adverse selection.18

The medical community is starting to take notice and effect change. Mississippi has taken the lead in many respects, and this is extraordinary news for our state. In July 2012 the Mississippi State Medical Association co-sponsored the first Mississippi Prescription Drug Summit which brought together prescribers, law enforcement, regulatory boards, and hospital systems in a collaborative effort to address the problem of prescription drug abuse. The Mississippi State Board of Medical Licensure has taken a stand against the improper use of opioids and has issued rules and regulations for opioid therapy in patients with chronic non-terminal pain. Registration for pain clinics is required, and it is becoming almost impossible for “pill mills” to operate in Mississippi. Various proposals, including mandating CME activities on addiction and prescribing controlled substances, are being considered. Utilization of the Mississippi Prescription Monitoring Program is one of the best tools for a prescriber to identify diversion, provide intervention, and refer to treatment. Unfortunately, according to the Board of Pharmacy, less than 25% of Mississippi physicians are registered to use this program. In conclusion, opioids are effective drugs that should be used to alleviate pain. However, physicians need to know the risks of opioid therapy and act accordingly, especially when treating high risk patients or using high dose therapy. As an addictionologist, I find the ravages of accidental death and addiction from opioid abuse to be particularly loathsome. My hope is that this article will stimulate discussion and help to effect meaningful change.

the chAllenge of effecting chAnge Despite the increase in overdose deaths and the unmistakable correlation between death rate and amount of opioids prescribed,19 especially at doses exceeding 100 morphine equivalents/day,20, 21, 22 the forces calling for more and more opioid prescribing are powerful and ubiquitous. It seems that every week, a new “report” or “position statement” is issued which calls for increased prescribing of opioids. The industry seems to prey on physicians’ natural desire to alleviate suffering and frequently cites the untreated pain epidemic as a rationale to prescribe more opioids. One recent position statement proclaimed, “There is simply no reason to let millions of frail, elderly Americans live with horrible pain.” The inference is that millions of frail, elderly Americans need more opioids. Unfortunately, the author failed to mention the side effects of using opioids in the elderly which include hypogonadism, insomnia, confusion, injury and increased risk of fractures,23 accidental overdose, and opioid-induced hyperalgesia24 (a paradoxical increase in pain caused by opioids25 and reversible with discontinuation of opioid therapy)26, 27 Courses on “Safe Opioid Prescribing” are taught by faculty and organizations that are financed by the opioid manufacturers to promote the practice, and the end result is that many physicians currently believe that opioids are safe and effective for treating chronic, noncancer pain.

evidence bASed medicine What about the evidence? Despite the hundreds of millions of dollars the pharmaceutical corporations have invested in studies and educational programs, to date no prospective study has demonstrated long-term safety or long-term efficacy of using opioid therapy to treat chronic, noncancer pain.28 No prospective study has demonstrated long-term analgesia or improved functionality, and long-term benefits for chronic pain have not been established.28,29,30 Existing prospective studies have flawed empirical efficacy, cannot document improvement in functioning, lack clinically significant reduction in pain, are based on short-term outcomes (usually less than 12 weeks) and often have obvious publication bias.28

6 JOURNAL MSMA JANUARY 2013

referenceS 1.

Centers for Disease Control and Prevention. Policy impact: prescription painkiller overdoses. Atlanta, GA: US Department of Health and Human Services, CDC; 2011. http://www.cdc.gov/homeandrecreationalsafety/ rxbrief/index.html. Accessed June 15, 2012.

Kochanek K, Xu J, Murphy S, et al. Deaths: preliminary data for 2009. National Vital Statistics Reports. 2011.59(4):20. http://www.cdc.gov/ nchs/data/nvsr/nvsr61/nvsr61_07.pdf. Accessed June 15, 2012.

United States Census Bureau Web site. http://www.census.gov/population/ estimates/nation/popclockest.txt. Accessed June 15, 2012.

Centers for Disease Control and Prevention. CDC grand rounds: Prescription drug overdoses- A U.S. epidemic. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. 2012; 61(01); 10-13.

Substance Abuse and Mental Health Services Administration. Results from the 2011 national survey on drug use and health: Volume I Summary of National Findings. Rockville, MD: Office of Applied Studies, SAMHSA. 2011. http://www.oas.samhsa.gov/NSDUH/2k10NSDUH/2k10Results. pdf. Accessed June 15, 2012.

Physicians for Responsible Opioid Prescribing Web site. http://www. citizen.org/documents/2048.pdf. Accessed July 26, 2012.

Hamburg MA. Innovation, regulation, and the FDA. N Engl J Med. 2010;363:2228-2232.

United States Senate Committee on Finance. Finance Leaders Investigate Whether Pharmaceutical Companies Encouraged Non-Profit Beneficiaries to Promote Misleading Information about Narcotic Painkillers. 2012. http:// www.finance.senate.gov/newsroom/chairman/release/?id=021c94cdb93e-4e4e-bcf4-7f4b9fae0047. Accessed May 9, 2012.

Federation of State Medical Boards Web site. http://www.fsmb.org/painoverview.html. Accessed October 15, 2012.

10.

Von Korff M, Kolodny A, Deyo RA, Chou R. Long-term opioid therapy reconsidered. Ann Intern Med 2011; 155:325-328.

20.

Dunn K, Saunders K, Rutter C, et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med 2010;152:85-92.

11.

Van Zee A. The promotion and marketing of OxyContin: Commercial triumph, public health tragedy. Am J Public Health. 2009;99:221–7.

21.

12.

Physicians for Responsible Opioid Prescribing. Long term opioid therapy reconsidered. Addiction is not rare in pain patients [video]. http://www. youtube.com/watch?v=DgyuBWN9D4w. Accessed October 15, 2012.

Bohnert A, Valenstein M, Bair M, et al. (2011). Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA. 305:1315-21.

22.

13.

U.S. General Accounting Office. Prescription drugs: Oxycontin abuse and diversion and efforts to address the problem. Washington, DC, U.S. General Accounting Office; 2004. http://www.gao.gov/new.items/d04110. pdf. Accessed October 15, 2012.

Gomes T, Mamdani MM, Dhalla IA, et al. Opioid dose and drug-related mortality in patients with nonmalignant pain. Arch Intern Med. 2011;171: 686–91.

23.

Saunders K, Dunn K, Merrill J, et al. Relationship of opioid use and dosage levels to fractures in older chronic pain patients. J Gen Intern Med. 2010;25:310-5.

14.

US Department of Justice Drug Enforcement Administration. Automation of reports and consolidated orders system. Available at http://www. deadiversion.usdoj.gov/arcos/faq.htm. Accessed October 15, 2012.

24.

Chu L, Clark D, Angst M. Opioid tolerance and hyperalgesia in chronic pain patients after one month of oral morphine therapy: A preliminary prospective study. J Pain. 2006;7(1):43-48.

15.

International Narcotics Control Board Web site. Report 2011. Estimated world requirements for 2012- Statistics for 2010. Part 4 statistical information on narcotic drugs. 73-93. http://www.incb.org/incb/en/ narcotic-drugs/Technical_Reports/2011/narcotic-drugs-technicalreport_2011.html. Accessed October 15, 2012.

25.

Angst M, Clark J. Opioid-induced hyperalgesia: a qualitative systematic review. Anesthesiology. 2006; 104(3):570-587.

26.

Bannister K, Dickenson A. Opioid hyperalgesia. Curr Opinion in Supportive and Palliative Care. 2010;4(1):1-5.

27.

Baron M, McDonald P. Significant pain reduction in chronic pain patients after detoxification from high-dose opioids. J Opioid Management. 2006;2(5):277-282.

28.

Chou R, Fanciullo G, Fine P, et al. American Pain Society – American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10:113-130.

29.

Sullivan MD, Von Korff M, Banta-Green C, et al. Problems and concerns of patients receiving chronic opioid therapy for chronic noncancer pain. Pain. 2010;149(2):345-53.

30.

Eriksen J, Sjogren P, Bruera E, et al. Critical issues on opioids in chronic noncancer pain. An epidemiological study. Pain. 2006;125:172-9.

16.

Boscarino J, Rutstalis M, Hoffman S, et al. Risk factors for drug dependence among out-patients on opioid therapy in a large US healthcare system. Addiction. 2010;105:1776-1782.

17.

Boscarino J, Rukstalis M, Hoffman S, et al. Prevalence of prescription opioid-use disorder among chronic pain patients: comparison of the DSM-5 vs. DSM-4 diagnostic criteria. J Addict Dis. 2011;30:185-194.

18.

Edlund MJ, Fan MY, DeVries A, Braden JB, Martin BC, Sullivan MD. Trends in use of opioids for chronic noncancer pain among individuals with mental health and substance use disorders: the TROUP Study. Clin J Pain 2010;26:1-8. http://www.citizen.org/documents/2048.pdf.

19.

Paulozzi L. Epidemiology of the overdose epidemic. Common Threads in Pain and Addiction. Pain and Addiction Common Threads XIII. 43rd Annual Meeting of the American Society of Addiction Medicine, Atlanta, GA, April, 19, 2012.

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JANUARY 2013 JOURNAL MSMA 7

â&#x20AC;˘ ScieNtific â&#x20AC;˘

Traumatic Vulvar Hematoma Masquerading as a Bartholin Duct Cyst in a Postmenopausal Woman James D. Perkins, MD and Paula F. Morris, FNP

bStrAct

Vulvar hematomas, while typically occurring following vaginal delivery, are occasionally seen in the nonpregnant patient following perineal trauma. When these, as well as any vulvar mass, are discovered in a postmenopausal woman, concern regarding a neoplasm exists. Case: A 66-year-old woman was found to have a large vulvar mass which was initially believed to be a Bartholin duct cyst. At surgery a vulvar hematoma was found and evacuated. Subsequent biopsy was negative for malignancy. Conclusion: Any vulvar mass discovered in a postmenopausal woman warrants meticulous evaluation to exclude malignancy. Although usually occurring in younger women, a vulvar hematoma may be noted in older women who have sustained trauma to the perineum. Key Words: VulVar mass, hematoma, postmenopausal, Bartholin duct cyst

introduction Lesions of the female perineum are common and are frequently seen by womenâ&#x20AC;&#x2122;s health physicians and generalists alike. The vast majority of these are non-neoplastic in nature and include mild infections, abscesses, cysts and other benign Author informAtion: Department of Obstetrics and Gynecology, Family Health Center, Laurel, Mississippi; Adjunct Clinical Assistant Professor, Obstetrics and Gynecology, Morehouse School of Medicine; Adjunct Clinical Instructor in Obstetrics and Gynecology, Tulane University School of Medicine; Affiliate Faculty, Department of Obstetrics and Gynecology, University of Mississippi Medical Center (Dr. Perkins). Family Nurse Practitioner, Department of Obstetrics and Gynecology, Family Health Center, Laurel, Mississippi (Morris). correSPonding Author: James D. Perkins, MD, FACOG, FACS, Family Health Center OB/GYN Clinic, 103 S. 12th Avenue, Laurel, MS. Phone: 601-425-4033. [perksurg@hotmail.com]

8 JOURNAL MSMA JANUARY 2013

conditions. However, particularly with a well-delineated mass in the vulvar region, a more detailed evaluation is warranted. While in the younger patient these masses are almost always benign, in older, particularly postmenopausal women the clinician must harbor an index of suspicion regarding the possibility of malignancy. Thus a detailed history and examination are of paramount importance. Vulvar hematomas develop as a result of extravasation of blood into the underlying tissue planes of the labial region due to trauma to and rupture of vasculature of this region. The overwhelming majority of these hematomas occur during or shortly following vaginal delivery. While relatively uncommon, nonobstetric vulvar hematomas do occur and typically are found in younger premenopausal women. When these, as well as any vulvar mass, are discovered, one must consider other causes, including cysts and malignancy. We present a case of an elderly woman who was noted to have a large vulvar mass requiring subsequent surgical exploration and management.

cASe rePort A 66-year-old African American female presented to our clinic with a history of a large, painful mass in the vulvar region which developed spontaneously and gradually increased in size and tenderness over a period of several days. She had previously been seen at an outside urgent care center where she was given an antibiotic and told that the mass needed to be drained. On presentation she reported pain associated with sitting but denied any urinary difficulty. Her medical history was remarkable for hypertension, Type I diabetes mellitus, and asthma. She also had undergone coronary artery stent placement approximately 8 months earlier. She reported taking medicines for the conditions noted above as well as a statin for elevated cholesterol level. Examination showed a pleasant, mildly obese, normotensive, and afebrile woman who was slightly apprehensive.

Pelvic examination revealed a large egg-shaped mass involving the posterior half of the left labium majus and extending slightly into the distal vagina. The mass was somewhat cystic and tender. The initial impression was one of a large Bartholin duct cyst. In preparation for surgical exploration and possible biopsy, she was appropriately counseled concerning the risk and imponderables of the proposed procedure and acknowledged understanding. Her preoperative hemoglobin and hematocrit levels were 12.5g/dL and 35.8% respectfully. At surgery the mass was incised and opened. Immediately on entry, very old, dark clotted blood was noted. Following evacuation of the clot and copious irrigation, the cavity was explored and its base biopsied. Following irrigation the cavity was packed with Iodoform gauze. Because of mild but persistent bleeding from the incisional margins, the edges were sutured with 3-0 Vicryl in an interrupted fashion. Subsequent discussion with the patientâ&#x20AC;&#x2122;s daughter following the procedure revealed that the patient had sustained a fall prior to initial presentation at which time she hit her perineum against a piece of furniture. The patient herself later confirmed this and added that she had also been on clopidogrel for antiplatelet therapy. Her postoperative course was uneventful. Biopsy was negative for malignancy. After a period of local wound care including daily sitz baths, the wound closed completely by the fourth postoperative week.

diScuSSion Vulvar hematomas, while generally seen in the obstetric population due to trauma related to delivery, are relatively uncommon in the nonpregnant patient. This is largely due to the concealed location of the female external genitalia. Nonobstetric vulvar hematomas are almost always found in adolescents and younger women. Because of rich vascularization surrounded by abundant subcutaneous tissue in this region, even minor trauma may result in hemorrhage and subsequent hematoma formation. They are usually the result of straddle injuries, overzealous intercourse, sexual assault, and penetrating injury. However, atypical etiologies such as riding recreational mechanical devices,1 cattle horn injuries, and leech bites have been reported.2 Occasionally the injury may result in a very large hematoma such as that which followed a bicycle straddle accident reported by Virgili and associates.3 The cornerstone of initial management of the patient presenting with a vulvar hematoma is a careful history and meticulous examination. Occasionally complete assessment requires examination under anesthesia in those with severe pain or who are otherwise unable to cooperate such as children. Examination is focused on size and degree of hematoma expansion, as well as assessment for pelvic fracture and urinary tract injury. Goldman et al noted that approximately a third of women with injury to the external genitalia had concomitant urologic injury.4 In general, the patient requires admission for observation

while bedrest and application of local ice packs are instituted. Determination of continued hemorrhage is based on serial hemoglobin/hematocrit measurements, increasing hematoma size and/or the presence of hemodynamic abnormality. Radiographic imaging, such as computed tomography and x-rays of the pelvis, is performed as indicated. Patients who are unable to void should be catheterized and analgesics administered for pain relief. There exists debate over the method of definitive treatment. While some surgeons have reported success with observation and local therapy alone.5,6,7 others have advocated a surgical approach earlier in the observation period.8,9 Benrubi et al found that initial operative intervention decreased complication rates, readmission and need for transfusion.8 Generally, however, patients presenting with large hematomas as well as those demonstrating hematoma expansion, progressive anemia or hemodynamic abnormality require surgical exploration, evacuation of the hematoma and control of any bleeding points. This patient presented with a vulvar mass which was initially thought to be a Bartholin duct cyst. Because of her age and thus the concern about possible malignancy, she underwent surgical exploration and biopsy. Had it been known prior to surgery that she had sustained blunt perineal trauma and had been on antiplatelet therapy, then hematoma formation would have been considered. It is known that antiplatelet therapy increases the risk of bleeding complications.10 However, regardless of suspected etiology, any postmenopausal patient presenting with a vulvar mass requires surgical exploration and biopsy to exclude malignancy. Bartholin duct cysts typically occur in the younger age group and are treated by drainage or marsupialization to prevent recurrence. In women 40 years of age and older, the concern about malignancy rises. In postmenopausal females, particularly those with Bartholin gland enlargement, excision has been advocated, although some have questioned the justification for this procedure given its associated morbidity and the rarity of Bartholin gland carcinoma.11

SummAry Nonobstetric vulvar hematomas, while uncommon, do occur, primarily in younger women following perineal trauma. Meticulous evaluation for urinary tract injury and pelvic fracture is necessary. Initial management includes admission for observation, bedrest, local ice application, and urinary catheterization as needed. Surgical exploration and evacuation are warranted for larger and/or expanding hematomas. In postmenopausal women with a history of blunt perineal trauma, especially in the setting of antiplatelet therapy, a vulvar hematoma must be considered. Finally, any older woman presenting with a vulvar mass requires surgery with biopsy to exclude malignancy.

JANUARY 2013 JOURNAL MSMA 9

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referenceS 1.

Naumann RO, Droegemueller W. Unusual etiology of vulvar hematomas. Am J Obstet Gynecol. 1982;142:357-358.

Jana N, Santra D, Das D, et al. Nonobstetric lower genital tract injuries in rural India. Int J Gynaecol Obstet. 2008;103:26-29.

Virgili A, Bianchi A, Mollica G, et al. Serious hematoma of the vulva from a bicycle accident. J Reprod Med. 2000;45:662-664.

Goldman HB, Idom CB, Dmochowski RR. Traumatic injuries of the female external genitalia and their association with urological injuries. J Urol. 1998;159:956-959.

Vermesh M, Deppe G, Zbella E. Non-puerperal traumatic vulvar hematoma. Int J Gynaecol Obstet. 1984;22:217-219.

Propst AM, Thorp JM. Traumatic vulvar hematomas: Conservative versus surgical management. South Med J. 1998;91:144-146.

Gianini GD, Method MW, Christman JE. Traumatic vulvar hematomas. Postgrad Med. 1991;89:115-118.

Benrubi G, Neuman C, Nuss RC, et al. Vulvar and vaginal hematomas: A retrospective study of conservative versus operative management. South Med J. 1987;80:991-994.

Hudock JJ, Dupayne N, McGeary JA. Traumatic vulvar hematomas. Am J Obstet Gynecol. 1955;70:1064-1073.

10.

Serebruany VL, Malinin AI, Eisert RM, et al. Risk of bleeding complications with antiplatelet agents: Meta-analysis of 338,191 patients enrolled in 50 randomized controlled trials. Am J Hematol. 2004;75:4047.

11.

Visco AG, Del Priore G. Postmenopausal Bartholin gland enlargement: A hospital-based cancer risk assessment. Obstet Gynecol. 1996;87:286290.

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164 Years Later, A Case Report: U. S. Grant, Eye Pain and Swelling in Mexico 1848 Robert K. Collins, MD and John F. Marszalek, PhD [Your JMSMA offers the following case report both timely and appropriate for its historic appeal. Recently, the U.S. Grant Association announced that Mississippi State University Libraries is the official repository for the Presidential Library for Ulysses S. Grant (1822-1885), making MSU one of only five universities to share the distinction of hosting a Presidential Library. The Grant Presidential Library contains copies of every known letter U.S. Grant wrote and copies of every letter written to him. This is the most complete collection of Grant correspondence in the world, consisting of copies of originals at the Library of Congress, National Archives, other public repositories, and private collections around the world. The Libraries also have three manuscript boxes of original Grant correspondence, particularly Grant family material before and after Grant’s death in 1885. The great irony is that while Grant was not from Mississippi, the state was the crucible of his military career, especially his successful campaign for Vicksburg and control of the Mississippi. Dr John F. Marszalek, a noted Civil War scholar and an MSU Giles Distinguished Professor Emeritus of History, is the Executive Director and Managing Editor of the association and played a critical role in the collection’s placement in Mississippi. MSMA member Dr. Bob Collins, Executive Director for MSU’s University Health Services and their team physician, writes: “Dr. Marszalek has been a patient of mine for 30+ years. He occasionally presents me with vignettes from history and asks what happened from a medical perspective. This case report is an elaboration on an event that occurred just after the end of the Mexican War.” For more information on the collection, check their website: http://www.usgrantlibrary.org.] —Ed.

n the spring of 2012, Dr. John F. Marszalek, Executive Director of the Ulysses S. Grant Association at Mississippi State University, asked me to read and comment on a passage from The “Personal Memoirs of Ulysses S. Grant.”1 In Chapter XIII Grant describes an expedition he and a party of officers undertook to climb “Popocatepetl, the highest volcano in America (17,802’).” This trip occurred in the spring of 1848, after the end of the Mexican-American War. Grant describes a windy, snow-blown ascent. Recognizing that they would not be able to summit in one day, they turned back, descended below the snow-line, and stopped for the night in the village of Ozumba. Grant writes: “The fatigues of the day and the loss of sleep the night before drove us to bed early. Our beds consisted of a place on the dirt floor with a blanket under us. Soon all were asleep; but long before morning first one and then another of our party began to cry out with excruciating pain in the eyes. Not one escaped it. By morning the eyes correSPonding Author: Robert K. Collins, MD, Executive Director University Health Services, Team Physician Mississippi State University, PO Box 6338, Mail stop 9732, Mississippi State University, Mississippi State, MS 39762. Phone: 662-325-2431, Fax 662-325-8888 [rcollins@lshc.msstate.edu]

of half the party were so swollen that they were entirely closed. The others suffered pain equally. The feeling was about what might be expected from the prick of a sharp needle at a white heat. We remained in quarters until the afternoon bathing our eyes in cold water. This relieved us very much, and before night the pain had entirely left. The swelling, however, continued, and about half the party still had their eyes entirely closed; but we concluded to make a start back, those who could see a little leading the horses of those who could not see at all. We moved back to the village of Ameca Ameca, some six miles and stopped again for the night. The next morning all were entirely well and free from pain.”

Dr. Marszalek was curious as to what the ailment was that struck so many simultaneously and would clear within two days. In summary, we have a group at high altitude, low latitude, on a snow-covered surface in a windy situation for at least 12 hours. As a group they developed severe eye pain, swelling, and in some blindness, that lasted for up to 48 hours and resolved with rest and cold compresses. Upon reflection, and a brief review in “Wilderness Medicine,”2 this passage described a group suffering from ultraviolet keratitis, commonly known as “snow blindness.”

JANUARY 2013 JOURNAL MSMA 11

First Lieutenant Ulysses S. Grant served with the 4th Infantry Regiment during the Mexican War. While Grant disagreed with the reasons for going to war with Mexico, he praised the U.S. Army’s performance during the conflict. Grant was one of several junior officers serving in Mexico who would rise to prominence during the Civil War. (The Granger Collection, New York) Ultraviolet radiation is the most common cause of radiation injury to the eye.3 There is a lag time of 6-12 hours between exposure and symptoms.3 The cornea usually heals within 48 hours.2,3 Historically treatment has consisted of eye rest, cool compresses, and time.2,3 Ultraviolet radiation intensity is substantially affected by latitude, altitude, season, time of day, and surface reflection.4 For each degree of latitude you move away from the equator, ultraviolet radiation decreases by 3%.2 For each 1000 feet of altitude gain above sea level ultraviolet radiation increases by 4-10%.5 Wind likewise increases the effects of ultraviolet radiation.6 Surface reflection also amplifies ultraviolet radiation exposure. Clean snow reflects up to 85% of the ultraviolet radiation that strikes it.7 The question I had regarding this event was why weren’t they better prepared? The effects of sunlight on the eye have been known since the time of King Tut. Kohl, a combination of Galena (lead sulfate)* and soot, was used to protect the eye from the impact of sun and wind.8 The Tibetans manufactured sunglasses from bronze in the 8th century.9 Snow blindness is a well-known phenomenon in the Polar Regions.10,11 The Inuit have manufactured slit snow goggles from ivory since at least the 3rd century.12 More specifically in the 1840s, snow goggles were in use by English speaking people. A pair was recovered from the remains of the Franklin expedition, which occurred from 1843-1848.13 New England coachmen were also using them in Massachusetts in the 1840s.14 There are two possibilities: Grant and his cohorts were not aware of the problem, or they were aware but did not have access to the proper equipment. I think the issue was the former for several reasons. Grant was an average student at West Point, attending 1839-1843 and graduating 21st of 39 graduates. He notes in his brilliant memoirs that he:

12 JOURNAL MSMA JANUARY 2013

“did not take hold of my studies with avidity, in fact I rarely ever read over a lesson the second time during my entire cadetship.”1

At that time West Point was an engineering school.15 Medical problems of the soldier would not have been a part of the curriculum. Grant was a quartermaster while in Mexico,16 and as such he would have had access to snow goggles if they were available and if he realized the need for them. The improvisation of snow goggles is readily accomplished with lamp black, leather, and a piece of wood. Had he known of the problem of snow blindness and the readily available prevention, he could have easily devised a home-made pair. Finally Grant never mentions the problem as snow blindness, leading to Dr. Marszalek’s request of me for a post hoc diagnosis. * Galena, Illinois was U.S. Grant’s home before the Civil War.

referenceS 1.

Grant US. Personal Memoirs of U. S. Grant. New York : Charles L. Webster and Company, 1885-1886.

Auerbach PS MD, MS. Wilderness Medicine. 4th ed. St. Louis, MO : Mosby; 2001.

Brozen R, MD. Ultraviolet Keratitis. Medscape Drug, Disease, Procedures reference. [Online] [Accessed: January 26, 2013.] http:// emedicine.medscape.com/article/799025-overview. April 15, 2011.

Olsen CM. Increased Outdoor Recreation, Diminished ozone layer pose ultraviolet radiation threat to eye. JAMA. 1989;261(2):1102-1103.

Rigel DS, Rigel EG, Rigel AC. Effects of altitude and latitude on ambient UVB radiation. J Am Acad Dermatol. 1999;40(1):114-116.

Owens DW. Influence of wind on ultraviolet injury. Arch Dermatol. 1978;50(12):161-167.

Lynde CB, Bergstresser PR. Ultraviolet protection from sun avoidance. Dermatol Ther. 1997;4:72.180.

Alchin LK. Egyptian Make. KingTut. [Online] http://www.king-tut. org.uk/ancient-egyptians/egyptian-make-up.htm. January 18, 2009. [Accessed: January 26, 2013.]

Penn Museum. Secrets of the Silk Road. [Online] http://www. penn. museum/recent-exhibits/749-secrets-of-the-silk-road.html. 2011. [Accessed: January 26, 2013.]

10.

Atkinson EL. Snow blindness, its causes, effects, changes prevention, and treatment. Br J Ophthalmol. 1921;5(2):49-54.

11.

Guly HR. Snow blindness and other problems during the heroic age of Antartic exploration. Wilderness Environ Med. 2012;23(3):77-82.

12.

Royal Ontario Museum. The Role of Ivory; How the Inuit used Ivory. [Online] http://www.rom.on.ca/exhibits/ivory/role_imagegallery_3. php. 2004. [Accessed: January 26, 2013.]

13.

Arthropolis; Facts cold, icy and artic. Snow Blindness and Snow Goggles. [Online] http://www.athropolis.com/arctic-facts/fact-goggles. htm. 2012. [Accessed: January 26, 2013.]

14.

Fleishman DA, MD. Slideshow of Antique, Non-optical Sunshades #1. Antique Spectacles and other Visual Aids. [Online] http://www.antiquespectacles.com/slide_shows/eskimo/1/eskimo_1. htm#. October 10, 2011. [Accessed: January 26, 2013.]

15.

United States Military Academy. Wikipedia. [Online] http:// en.wikipedia.org/wiki/United_States_Military_Academy#Notes. May 14, 2012. [Accessed: January 26, 2013.]

16.

Ulysses S Grant. Wikipedia. [Online] http://en.wikipedia.org/wiki/ Ulysses_S._Grant. May 14, 2012. [Accessed: January 26, 2013.]

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Protecting the practice of medicine The American Medical Association is proud to have helped the Mississippi State Medical Association (MSMA) address concerns that federal interference is diminishing the role of state legislatures and medical boards in licensure and scope-of-practice issues. We believe physicians, not federal government bureaucrats, are best suited to regulate the practice of medicine and make clinical judgments that affect patient health and safety. The AMA and the MSMA support you in the state house, the courthouse and in your practice. Working together with the MSMA, the AMA will continue to make a difference.

Be a part of it. ama-assn.org/go/memberadvocate Please activate your 2013 AMA membership through the Mississippi State Medical Association at (601) 853-6733.

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PUBLIC HEALTH IN MISSISSIPPI ATION IA C O S S A L A IC D E M MISSISSIPPI STATE Fellow Mississippians,

Health Report Card, ssippi’s Annual Public ssi Mi u CRISIS: Obesity yo to and the t sen pre We al Association (MSMA) dic Me te Sta i pp ssi ssi sponsored by the Mi SOLUTIONS: ent of Health (MSDH). gies, and whole grains; Mississippi State Departm Eat a diet rich in fruits, veg least 30 minutes h alt he rcis se ed with adver portion size; and exe e at lm it he lim erw ov ll sti is te sta It’s 2013, and our ese and diabetic 3-5 times a week. and more overweight, ob rs, too many issues. Doctors see more the mo n tee to rn bo ies ny bab and not patients. There are too ma m cardiovascular disease… fro ths dea ny ma too rs, tobacco use e vide care. enough physicians to pro CRISIS: Adult Tobacco Us ve ha ty such as obesi publication, various topics SOLUTIONS: focused on Over recent years in this are ns cia ysi e at 800-QUIT-NOW; ph i pp ssi ssi Mi , Call the MS Tobacco Quitlin d an dh on been highlighted. In 2013 sec to re your community osu in air c health issue: exp and support smoke-free exposure of the m another important publi fro die s m). ian .co pp MS ssi than 500 Missi (www.SmokeFreeAir ng the smoke. Each year, more of evidence demonstrati es lum vo the te spi De e. secondhand smok to be an alarming oke exposure, it continues danger of secondhand sm ase public health hazard. ISIS: Cardiovascular Dise CR the is y lic po air ree e-f ehensive statewide smok SOLUTIONS: Implementing a compr s from exposure to ian pp ssi ssi Mi all of h alt he blood pressure; the ct ote the pr es to Stop smoking; control your only way one which includ -y lic po air ree e-f three to five times a ok s exercise at least 30 minute secondhand smoke. A sm r places, including oo ind st mo in e bles, and whole ok eta sm veg rted week; eat more fruits, elimination of secondhand rants and bars -- is suppo tau res s, about reducing the ice tor off doc s, r ing you ild to one grains; and talk ery Ev workplaces, public bu s. ter vo ely lik i pp ers of Mississi risk of heart attack. by more than three-quart . air ree e-f ok sm e deserves to breath the charge! Get ns: it is up to you to lead To Mississippi physicia officials to support by urging local and state CRISIS: Infant Mortality ment preventative involved in policymaking ple im to ts ien pat ur yo th rk wi ts fight disease clean, smoke-free air. Wo SOLUTIONS: in this report. Help patien ses cri lth hea c bli if you are or think pu the habits for your physician immediately e Se es. ng cha le sty life you are considering and illness with healthy you might be pregnant; or if ke Ta ns. future generatio becoming pregnant. : let’s set an example for air ree e-f ok To Mississippi patients sm ide tew sta e g a comprehensiv action now by supportin crises and solutions es on the various health elv urs yo te uca Ed y. lic po uld – build a healthier card. We can – and we sho highlighted in this report CRISIS: Teen Birth Rate, Mississippi! STDs and HIV to take action today! w ho rn lea to ht rig the See the box to SOLUTIONS: the risks of r, hie Talk to your children about ssippi Healt or. Teens need to be avi Yours in Making Missi beh irresponsible sexual ncy, and STDs/HIV educated about sex, pregna private STD/HIV before having sex. Free and county health all at screenings are available metropoulos, MD De ve Ste t den esi Pr MSMA departments.

ry Currier, MD, State Health Officer Ma

REPORT CARD

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MPH

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The 2013 Mississippi Public Health Report Card is brought to you by the Mississippi State Medical Association and the Mississippi State Department of Health. Sources: United States Department of Health and Human Services – Centers for Disease Control and Prevention (CDC), National Center for Health Statistics, National Vital Statistics Report, Mississippi Vital Records Mississippi State Department of Health (MSDH), Behavioral Risk Factor Surveillance System – CDC, MSDH STD/HIV Office, Henry J. Kaiser Family Foundation – State Health Facts.

PUBLIC HEALTH IN MISSISSIPPI ATION IA C O S S A L A IC D E M MISSISSIPPI STATE Fellow Mississippians,

ry Currier, MD, State Health Officer Ma

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• pReSiDeNt’S pAge • When Do Your Rights End and My Rights Begin?

here is an interesting discussion taking place surrounding the smoke-free air legislation. I have visited many different lawmakers presenting the argument for smoke-free air legislation. Some of them have expressed opposition to the legislation, not on medical SteveN l. DemetRopoUloS, mD grounds but because they feel that each person should have the right to make 2012-13 mSmA pReSiDeNt his own choices and smoking should be one of those. They feel that the government should not tell someone whether they should be able to smoke or not. I understand that argument and also sympathize with it on a number of different levels. However, as I have pointed out to these legislators, if smoking just involved the person who was smoking, it would be one thing, but secondhand smoke is just what it says--it is secondhand. Even though an individual has accepted responsibility for the negative consequences of his smoking, when his smoking affects me, a nonsmoker, with those negative consequences it directly impacts me. Philosophically your rights end when they infringe on someone else. We can take this a step further with smoking. If I have to pay for your right to make bad choices, should your rights end? And much more importantly, should I have to pay for the consequences of your bad choices as they relate to other people, specifically exposure to secondhand smoke? This discussion is very analogous to the discussion that we had over seatbelts about fifteen years ago. At that time everyone thought it was an individual’s right to determine whether to wear seatbelts or not. However, once data began to be collected revealing what the life plans were for those non-seatbelt wearers who had traumatic brain injuries and were left in vegetative states or had catastrophic spinal injuries and were left quadriplegic or paraplegic after the accident, we saw the true cost to the state. Almost all of those patients were shifted from any commercial insurance to the state Medicaid program because they soon exhausted the maximum amount of coverage that they had with any commercial insurance. As a state we all began to pay for people’s bad choices, and it made it much easier to decide that it was more important to wear a seatbelt than for everyone who wore seatbelts to pay for those who did not wear them. This is the same argument that we are having over secondhand smoke. Your rights to smoke wherever you want should end when I have to start paying for the medical consequences resulting from your bad choices. This is particularly pertinent to the secondhand smoke argument as it relates to patients who have Medicaid that we pay for as a state through our taxes and those that have no insurance funding and are taken care of by hospitals across the state as uncompensated care. As you talk to your legislators and promote the legislation to ban smoking “in indoor places, restaurants, and bars,” please let them know that this is a very powerful argument and directly related to Medicaid funding. We do not have specific numbers on the cost of secondhand smoke for Medicaid recipients, but we do know that they are disproportionately affected by smoking-related disease because their smoking prevalence is approximately fifty percent greater than that of the overall U.S. adult population. The CDC estimates that smoking accounts for approximately eleven percent of Medicaid program expenditures. In Mississippi smoking prevalence in the Medicaid population is about thirty-seven percent. The smoking-attributable fraction of Medicaid expenditures is approximately $264 million dollars per year or about $554 dollars per household. So why should we care? Why should we spend our political capital on an issue that is opposed on philosophical grounds by some of our legislators? Well, let me answer that on a personal level, not as a physician but as a Mississippian who is sick and tired of being number 50 in almost all healthcare measures--obesity, cardiovascular disease, stroke, cancer, and diabetes.

JANUARY 2013 JOURNAL MSMA 19

We don’t even know where to begin to address some of these issues. With the smoking ban on secondhand smoke, we can immediately start reducing heart attacks, stroke, and lung disease without costing us any money. As you can see, this discussion is not just about the health consequences of smoking, which most of the legislators understand and agree with, but about the costs associated with secondhand smoke and the philosophical argument against smoking. We need help with this bill so please talk to your legislators and make sure they understand the cost side of secondhand smoke and the decision regarding their philosophical position. If we as doctors don’t advocate for this, who will? Who should take the lead in protecting the health of our fellow Mississippians?

ust what the doctor ordered

ROSEMARY SWEET POTATOES

I haven’t given you many side dishes, but this is one that you can use in a lot of different ways with different substitutions and it is good every time. It is Rosemary Sweet Potatoes and provides more of a Northern Italian way to fix vegetables. I like to take four to five sweet potatoes and peel them. Then I slice them and cube them in bite-sized cubes. I put them in a Pyrex baking dish and sprinkle them with olive oil and add about three teaspoons of mixed garlic. After that I toss them with salt and pepper and add dried rosemary so that it is incorporated throughout the whole dish. Bake at 450 degrees until they are forktender. Turn on the broiler, and slide the baking dish in the upper rack for a minute or two until the tops get caramelized. If they are a little dry when you pull them out, you can sprinkle again with olive oil. This makes a great accompaniment to a pork loin, steak or any other kind of heavy meat that you might When your medical office is short-staffed, want to have. You can substitute the sweet potatoes with you get frustrated. butternut squash. This recipe gives you a different way When you get frustrated, to eat sweet potatoes and butternut squash other than you dread going to work with butter and brown sugar. You can also substitute and you start playing hooky. cauliflower and prepare it the same way except just before you put it on broil, sprinkle it down with grated Parmesan When you start playing hooky, cheese to give it a little bit more flavor. It makes a great the bills pile up. dish too. When the bills pile up, We love seasonal vegetables so try one of these Mama ain’t happy. during this winter season with the butternut squash or sweet potatoes or even both. You can mix them sometimes When Mama ain’t happy, and it makes a pretty color with the yellow and orange ain’t nobody happy. together. Also try the cauliflower this winter as well. Enjoy this side dish.

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20 JOURNAL MSMA JANUARY 2013

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• phYSiciAN’S BookShelf •

hat would the world be like without pain? Many respond, “Heavenly.” Dr. Paul Brand would consider it, at best, “incomplete” and, at worst, “hellacious.” Through decades of caring for and studying leprosy patients in India and Louisiana, he came to regard pain as one of God’s great gifts to us, one that is underappreciated unless the effects of its absence are recognized. His observations have far-reaching implications for our American culture where pain is avoided at all costs and we live at the greatest comfort level possible. Are we ill-equipped to handle suffering? Paul Brand was born to Christian missionaries in India in 1914. The first part of the book begins with his childhood amongst the “mountains of death,” so-called because of malaria-carrying mosquitoes. His parents chose to live in these hills despite the risk because of the people’s lack of access to medical care. He describes their work as characterized by ingenuity and a dogged determination to meet the needs of those they served, character traits passed on to their son. What they didn’t pass on initially was a love of medicine. Young Paul witnessed great suffering in his parents’ work and saw pain as something to avoid always. He notes that, after witnessing the power of medicine in a life-giving blood transfusion, he was sold and enrolled in medical school in London in 1937. He chose surgery because it seemed the most effective way to offer help at a time when medical doctors were more able to predict the course of disease than to alter it. Following completion of surgical residency, he was recruited to, of all places, Vellore, India, and its new medical school. He specialized in orthopedics, opening a foot clinic in which he learned the art of correcting clubfoot and other deformities. He relates an example of his early interest in pain when presented with an infant with clubfoot. He could continue twisting the foot until the infant became more interested in the foot than in the food, at which point he would wrap it in plaster and twist more at a later date. The second part of the book details the strides Dr. Brand would make in the treatment of leprosy patients during the following decades through painstaking research. Perhaps his greatest scholarly contribution was debunking the notion that the deformities characteristic of leprosy were caused by “bad flesh.” Having already succeeded in correcting foot deformities, he next turned his attention to the “clawhand” deformity characteristic of leprosy and pioneered the field of tendon transfer. From the hand, he moved to the face, transplanting hair into the places previously occupied by eyebrows and inserting artificial supports to correct “saddleback nose.” After nearly twenty years in India, the Brands moved to Carville, Louisiana, so that Dr. Brand could work in the leprosy

The Gift of Pain: Why We Hurt & What We Can Do About It By Dr. Paul Brand and Philip Yancey Grand Rapids, MI: Zondervan; 1993.

hospital. Much of his research there involved the thermograph which he used to look for temperature variations that could signal peripheral neuropathy in leprosy patients. He came to recognize three distinct dangers for the pain-insensitive person: direct injury (e.g., burning fingers on a cigarette), constant stress (e.g., wearing poorly fitting shoes), and repetitive stress (e.g., not adjusting stride when walking long distances). The goal was to find ways for patients to “tune in” to these different stresses, an idea difficult to convey to those who couldn’t experience the commanding power of pain. The third part of the book is perhaps the most important for physicians as it constitutes a philosophical treatise on pain and its usefulness. Dr. Brand goes into great detail regarding contextual factors of the pain experience and describes pain as “the loneliest, most private sensation.” He concludes that the way one thinks about pain plays a role in determining the level of suffering involved: those who view it as the enemy respond to it with bitterness (i.e., “Why me?”), whereas those who consider it useful can take a more clear-minded approach to its alleviation. He talks about other “pain intensifiers,” including the highly prevalent idea that pain represents punishment from God. Dr. Brand’s book is worthwhile reading for physicians and other health care providers. His discussion of pain intensifiers is a reminder that emotional and spiritual factors play as much of a role in chronic pain as does actual physical stress. In a country in which so much illness is self-inflicted and associated with guilt and resentment of self, loved ones, the health care system, and society, it appears worthwhile to attempt to alter patient attitudes about disease and symptoms rather than silently to hope one more medication will fix everything. Theory and practice are merged beautifully in this hybrid of philosophy and autobiography, a testament to the author’s insightful mind and servant heart. —Jacob Graham, MD, PGY-2, Internal Medicine University of Mississippi Medical Center

JANUARY 2013 JOURNAL MSMA 21

• miSSiSSippi RURAl phYSiciANS ScholARShip pRogRAm • Mississippi’s Rural Physicians Scholarship Program: Growing our Own Physicians

Janie Guice, MRPSP Executive Director

t the beginning of this new year, take a moment to reflect on the development and growth of your Mississippi Rural Physicians Scholarship Program (MRPSP) since its establishment five years ago: • MSMA and the University of Mississippi Medical Center advocate legislators to establish the Mississippi Rural Physicians Scholarship Program in the legislative session of 2008. • With the cooperation of the University of Mississippi School of Medicine, the policy and procedures are developed for the administration of a $1.62 million scholarship program that includes direct admission for top rural MRPSP college sophomores. • “Medical Encounters,” a unique two-day experiential educational program, is created for the innovative two-year pre-matriculation phase of MRPSP. (This pre-matriculation module is later recognized in 2010 by the American Academy of Family Physicians Foundation as the “Best Program in America.”)

A Message from Senate Appropriations Chair, Senator Eugene S. “Buck” Clarke: In my hometown of Hollandale access to care is an issue with far-reaching implications. We had always known that more physicians would be beneficial, but little was being done about the shortage -- until the Rural Physicians Scholarship Program was established. I have served in the Senate since 2004 and have watched this great program grow from an idea to a reality to a household name at the State Capitol. Soon after I was appointed to serve as Senate Appropriations Chair, MSMA came to me to advocate for the program’s funding. From the beginning, it was never a question that we would do everything in our power to keep the MRPSP going. For an elected official from the Mississippi Delta, I realize the critical need for this program. For the entire state of Mississippi, the MRPSP is a win-win.

22 JOURNAL MSMA JANUARY 2013

Gov. Phil Bryant and Janie Guice - After six years as director of the Mississippi Rural Physicians Scholarship Program, and 30 years with the state, Janie Guice is retiring January 17, 2013.

A Message from House of Representatives Appropriations Chair, Representative Herb Frierson: Over the past five years, the MSMA has advocated for the establishment and continued annual funding increases for the Mississippi Rural Physicians Scholarship Program. As Appropriations Chairman for the House of Representatives, I have worked closely and directly with your association, with the University of Mississippi Medical Center, and with fellow legislators to ensure this award-winning program receives necessary funding. I am proud of what we have been able to accomplish together, and I look forward to the dividends that will be paid back to the state and our citizens through the services of the fine young people chosen as rural scholars who will practice in underserved areas of our state.

• MRPSP is featured on National Public Broadcasting, the American Academy of Family Physicians “News Now,” local radio programs, and numerous statewide and community newspapers in Mississippi. • Governor Haley Barbour declares May 13, 2009 as “Rural Physician Scholars Day.” • Yearly scholarship awards grow from $300,000 in 2008 to $1.62 million for the 2012-2013 academic year. • Total scholarships awarded since 2008 total $4.71 million and should exceed $6.6 million by 2013-2014. • By 2012, fostered private scholarship funding from the Medical Assurance Company of Mississippi, the Selby and Richard McRae Foundation, and the Madison Charitable Foundation is donated to support four additional scholars.

• In 2013, MRPSP has one physician in private practice, one in fellowship training, twelve in residency, 54 in medical school and 35 pre-matriculates preparing for medical school. I began my career as a classroom teacher in Oxford and then was an academic recruiter for the University of Mississippi on the Gulf Coast for a quarter of a century. At the end of 2007, I had the rare opportunity to come to UMMC to make House Bill 1465 (MRPSP’s “birth certificate”) become the vibrant, growing, recognized rural physician pipeline program that it is today. On January 17, 2013, I will end my 36-year career of helping talented young Mississippians “connect the dots” with academic opportunities. I am confident the MRPSP will continue to thrive in the new year under the guidance of my successor and with your continued, steadfast support. From our home in Ocean Springs, my MRPSP and MSMA friends will not be far from my thoughts. r

Janie Guice, standing center, with Rural Scholars from various years

Dr. James Keeton, left, shown with honoree Janie Guice, Dr. Helen Turner, Dr. LouAnn Woodward, and Dr. Diane Beebe. At a reception, January 8, at Nick’s in Jackson, state and Medical Center leaders congratulated and presented her a citation upon her retirement.

Rep. Sam C. Mims, V, (R)-McComb, chair of the House’s Public Health and Human Services Committee and author of the bill appropriating increased MRPSP-funding, stands with Executive Director Janie Guice in front of an exhibit promoting the program. Using state and philanthropic funds, the MRPSP pays full tuition for dozens of medical students each year. In return, those students must work in a primary-care specialty in rural Mississippi after completing residency training.

JANUARY 2013 JOURNAL MSMA 23

• eDitoRiAl •

Out With the Old…In With the Old D. Stanley Hartness, MD; Associate Editor, Jackson

t seems nothing is sacred nowadays. On the Sunday before Christmas, Beth and I were headed north on I-55 to attend services at our home church in Kosciusko. All of a sudden there it was—no, not a massive buck in the middle of the road but a giant billboard alongside the highway proclaiming, “Santa Claus…For the People.” Oh, the costume looked authentic enough, but the face stretched the imagination for that “BELIEVE” mantra. Recalling that ubiquitous Morgan & Morgan, PA slogan brings to mind the television commercial featuring “Santa’s” two sons one of whose earliest memories is of their parents’ final words as they tucked them in at bedtime… “For the People.” Check it out. Now I don’t know about you, but at our house you were more likely to hear, “Now I lay me down to sleep…God bless Mommy…God bless Daddy.” By this time, you’re probably asking yourself, “Where, pray tell, is he going with this, and what could it remotely have to do with our medical association?” Simply put, I’m reminded, that despite our successes in the last election cycle as far as Supreme Court Justices and legislators are concerned, challenges to our profession are only a case or a vote away. The specter of non-economic damages is certain to rear its ugly and repressive head. A vigilant presence on our part is essential if we are to ensure the viability of tort reform gains which have helped erase the stigma of Mississippi as a “jackpot justice” state. And the list goes on and on as we face new and difficult situations such as Medicaid expansion, healthcare reform, electronic medical records (in general), meaningful use (in particular), and Medicare physician payments. Let one of your New Year’s resolutions be to stay informed, become involved, and remain indefatigable on behalf of our beloved and honorable profession. And the voice of our Mississippi State Medical Association can speak with more unity, clarity, and power than any one of its members individually. I don’t know about you, but I can hardly wait to see the Easter Bunny billboard. r

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• gUeSt eDitoRiAl •

“The Second Rule” Brian Temple, MD and Sulaimin Conteh

Problem

The first rule of medicine is “do no harm.” However, after the experience which follows, we think a second rule or codicil to the first is required. On a recent trip to Sierra Leone on the West Coast of Africa, we were faced with a common but deadly problem. What do you do for your patient when there are better treatment options available than the ones at hand? This question must be answered many times by physicians practicing in resource-limited settings and especially in Africa. We were faced with this problem at the HIV clinic at Connaught Hospital in Freetown, Sierra Leone. As with many young patients in any part of the world, nonadherence is a reality. The difference in Sierra Leone is that the consequences are often death. This particular Saturday morning, one of us (S.C.) received a call from a young woman diagnosed with HIV previously. She was started on the usual regimen of two nucleoside reverse transcriptase inhibitors (NRTI) and one non-nucleoside reverse transcriptase inhibitor (NNRTI).1,2 Due to suspected resistance, her regimen was changed to a boosted protease inhibitor (PI).1 She called to say, “I was boarding my flight and fell.” She had been having problems with diarrhea, nausea, and episodes of vomiting since starting the boosted regimen but had no fevers, chills or other symptoms. After being rushed to the hospital, she was resuscitated with intravenous fluids and had lab examinations. After 24 hours she was feeling much better and wanted to go home. We were now faced with the decision of “what treatment can we give now.” In Sierra Leone there are two first-line treatment choices and one second-line treatment for HIV cases. If someone cannot tolerate one of the first-line (two nucleoside reverse transcriptase inhibitors and one non-nucleoside reverse transcriptase inhibitor), they are switched to another regimen that includes another non-nucleoside reverse transcriptase inhibitor unless there is resistance.2 If there is suspected resistance, the boosted protease inhibitor is the last and final choice. Moreover, there is currently no resistance testing available in the country. This is where we were with our patient: she had suspected resistance to the non-nucleoside reverse transcriptase inhibitor class (K103),3 no genotyping was available, and now she was having difficulty tolerating the boosted protease inhibitor because of the most common side effects: nausea, vomiting, and diarrhea.4

the Solution During the first few days in the hospital, all anti-retroviral therapy (ART) medications were withheld, and she improved. On the third day she was challenged with her previous regimen of two NRTIs and a boosted PI. Nausea and diarrhea returned. There are no other medications available. We decided to re-challenge her with the same regimen but added symptomatic management for the nausea and diarrhea. Our patient was fortunate as she tolerated the re-challenge with anti-nausea and anti-diarrheal medications. The sad reality is that she is now on the last line of therapy available to us, which will eventually fail, resulting in death. This story is one that is replayed many times in Sierra Leone. Eventually these patients succumb to the disease and die. The death is not because of lack of knowledge or even access to care but lack of access to the resources for treatment we are accustomed to in the United States. Global funding for HIV care is withering. Access to care and delivery of care is a major concern. The Centers for Disease Control and Prevention and the World Health Organization recommend treatment at higher CD4 levels,2 and some experts now recommend treating all HIV positive individuals, regardless of CD4.5

leSSonS leArned In America we are fortunate to have numerous HIV treatment options, leaving physicians and patients sure that there is almost always another option. We are fortunate to have access to new HIV drugs that improve compliance, such as the recently released Striblid™ (elvitegravir, cobicistat, emtricitabine, and tenofovir disoproxil) and Complera® (rilpivirine, tenofovir, and emtricitabine). In Sierra Leone and many resource limited settings, physicians are faced with the immediate reality of death of their patients, despite knowing that life-saving therapy is available elsewhere. The lack of available choices leaves the physician with

JANUARY 2013 JOURNAL MSMA 25

the unnerving reality of “location induced death.” As we train the next generation of physicians providing care for those infected with HIV, we must stress the importance of medication adherence and compliance. As physicians we must become diligent warriors, ensuring that our patients understand the ramifications of their actions. We suggest that the second rule of medicine or the codicil to the first rule should be, “Do the best you can with what you have.”

Acknowledgement

Dr. Temple’s travel was supported by a grant from The Brown Initiative in HIV and AIDS Clinical Research for Minority Communities (Project # 5R25MH083620-03c) from the National Institute of Mental Health, awarded to Dr. Timothy Flanigan. We would like to thank Dr. Richard deShazo for his assistance with editing this article.

referenceS

Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. October 14, 2011; 1–167. http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Accessed January, 2012.

World Health Organization (WHO). Antiretroviral Therapy for HIV infection in Adults and Adolescents: Recommendations for a public health approach 2010 revision. http://whqlibdoc.who.int/publications/2010/9789241599764_eng.pdf. Accessed November, 2012.

Stanford University. HIV Drug Resistance Database. http://hivdb.stanford.edu/pages/3DStructures/rt.html#RT_NNRTIMuts. Accessed November, 2012.

Flexner, Charles. HIV Protease Inhibitors. NEJM 1998; 338 (18):1281-1292.

National Institute of Health. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. http://aidsinfo.nih.gov/guidelines. Accessed November 2012.

editor’S comment:

Brian Temple, MD, MS, a native of Sierra Leone, is an Assistant Professor of Medicine in the Division of Infectious Diseases at Texas Tech University Health Sciences Center, Lubbock, Texas. He completed his Infectious Disease training at the University of Mississippi Medical Center and served as tuberculosis and HIV physician at the Health Department and Crossroads Clinics and UMC HIV clinic. He recently completed a T-32 Advanced Research Fellowship at The Warren Alpert Medical School, Brown University, Rhode Island. Sulaiman Conteh, MBChB, MSc serves as a lecturer the Department of Microbiology at the Sierra Leone College of Medicine and as the HIV Medical Manager for the National HIV Control Program, Ministry of Health and Sanitation at Connaught JNLMSMed-BW1 Hospital in Freetown, Sierra Leone.

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• JUSt off the pReSS - iNfo YoU WANt to kNoW • About Group A Streptococcal Pharyngitis Guidelines Richard L. Ogletree, Jr., PharmD

Article: Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, Martin JM, Beneden CV. Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2012 Nov;55(10):e86–e102. Introduction: Group A streptococcal (GAS) pharyngitis is a common type of community-associated infection. It has been estimated to be responsible for 5 – 15% of sore throat visits in adults and as much as 30% of sore throat visits in children. Inadequate treatment could lead to peritonsilar abcess, cervical lymphadenitis, or, even acute rheumatic fever. However, the guidelines have not been updated since 2002. Purpose: This guideline is intended to provide recommendations on the management of GAS pharyngitis. It is targeted to healthcare providers who care for adult and pediatric patients with this common disorder. The guidelines are set up as clinical questions, followed by recommendations for answers to the questions. How should the diagnosis of GAS pharyngitis be established? • Throat swab using rapid antigen testing detection (RADT) is best. Clinical evaluation can sometimes lean toward viral infection, but it does not adequately rule out viral infection. The guidelines do not recommend the use of clinical evaluation as the sole criterion for beginning antibacterial therapy. • In children, a back-up throat culture for negative tests is recommended. A back-up method is not necessary for RADT positive patients. A back-up method is generally not needed in adults. • Anti-streptococcal antibody titers are not usually helpful, as they are more reflective of past rather than current infections. Who should undergo testing for GAS pharyngitis? • Testing is not recommended when clinical features are strongly indicative of viral pharyngitis (e.g., cough, rhinorrhea, hoarseness, and oral ulcers). Table 1. Epidemiologic and Clinical Features Suggestive of Group A Streptococcal versus Viral Pharyngitis GROUP A STREPTOCOCCAL Sudden onset of sore throat Age 5–15 years Fever Headache Nausea, vomiting, abdominal pain Tonsillopharyngeal inflammation Patchy tonsillopharyngeal exudates Palatal petechiae Anterior cervical adenitis (tender nodes) Winter and early spring presentation History of exposure to strep pharyngitis Scarlatiniform rash

VIRAL Conjunctivitis Coryza Cough Diarrhea Hoarseness Discrete ulcerative stomatitis Viral exanthema

Adapted from: Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, Martin JM, Beneden CV. Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2012 Nov;55(10):e86–e102.

• Testing is not recommended for children <3 years old since rheumatic fever is so rare in this age group. Testing could be considered with other risk factors such as an older sibling with GAS infection. • Follow-up post-treatment throat cultures or RADT are generally not recommended. They can be utilized in those at high risk of acute rheumatic fever or in those with classic symptoms pointing toward a recurrent GAS infection. • Diagnostic testing (or empiric treatment) of asymptomatic household contacts is not generally recommended.

JANUARY 2013 JOURNAL MSMA 27

What are the drug treatment recommendations for patients with a diagnosis of GAS pharyngitis? Table 2. Antibiotic Regimens Recommended for Group A Streptococcal Pharyngitis Drug, Route

Dose or Dosage

Duration or Quantity

Recommendation Strength, Quality

For individuals without penicillin allergy Penicillin V, oral

Children: 250 mg twice daily or 3 times daily; adolescents and adults: 250 mg 4 times daily or 500 mg twice daily

10 days

Strong, high

Amoxicillin, oral

50 mg/kg once daily (max = 1000 mg); alternate: 25 mg/kg (max = 500 mg) twice daily

10 days

Strong, high

Benzathine penicillin G, intramuscular

<27 kg: 600 000 U; ≥27 kg: 1 200 000 U

1 dose

Strong, high

20 mg/kg/dose twice daily (max = 500 mg/dose)

10 days

Strong, high

30 mg/kg once daily (max = 1 g)

10 days

Strong, high

For individuals with penicillin allergy Cephalexin,a oral a

Cefadroxil, oral Clindamycin, oral

7 mg/kg/dose 3 times daily (max = 300 mg/dose)

10 days

Strong, moderate

Azithromycin,b oral

12 mg/kg once daily (max = 500 mg)

5 days

Strong, moderate

Clarithromycin,b oral

7.5 mg/kg/dose twice daily (max = 250 mg/dose)

10 days

Strong, moderate

Abbreviation: Max, maximum. a Avoid in individuals with immediate type hypersensitivity to penicillin. b Resistance of GAS to these agents is well‐known and varies geographically and temporally.

Not recommended: Not recommended: Tetracyclines ‐ high prevalence of resistant strains •  Tetracyclines - high prevalence of resistant strains  Sulfonamides and trimethoprim‐sulfamethoxazole ‐ they do not reliably eradicate GAS from oropharynx •  Sulfonamides and trimethoprim-sulfamethoxazole - they do not reliably eradicate GAS from oropharynx Older fluoroquinolones such as ciprofloxacin‐ limited activity against GAS pharyngitis Newer fluoroquinolones such as levofloxacin and moxifloxacin ‐ are active in vitro against GAS, but are •  Older fluoroquinolones such as ciprofloxacin- limited activity against GAS pharyngitis expensive and spectrum is more broad than needed • Newer fluoroquinolones such as levofloxacin and moxifloxacin - are active in vitro against GAS but are

expensive and spectrum is broader than needed ***Adapted from: Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, Martin JM, Beneden CV. Clinical Adapted from: Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, Martin JM, Beneden CV. Clinical Practice Guideline for the Diagnosis Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2012 Nov;55(10):e86–e102. Infectious Diseases Society of America. Clin Infect Dis. 2012 Nov;55(10):e86–e102.

Should adjunctive therapy with NSAIDs, acetaminophen, aspirin, or corticosteroids be given to patients with a diagnosis of GAS pharyngitis? Should adjunctive therapy with NSAIDs, acetaminophen, aspirin, or corticosteroids be given to patients with a diagnosis of GAS pharyngitis? • Adjunctive therapy with an analgesic or antipyretic such as acetaminophen or a NSAID could help with pain or high fever.

•  Avoid aspirin use in children. Adjunctive therapy with an analgesic or antipyretic such as acetaminophen or a NSAID could help with pain or

high fever. • Use of a corticosteroid for adjunctive treatment is not generally recommended.  Avoid aspirin use in children.  Use of a corticosteroid for adjunctive treatment is not generally recommended. Is the patient with frequent recurrent episodes of apparent GAS pharyngitis likely to be a chronic pharyngeal carrier of GAS? Is the patient with frequent recurrent episodes of apparent GAS pharyngitis likely to be a chronic pharyngeal carrier of GAS? • Realize that frequent infections could be actually reinfection, but it could also be that the patient is a chronic carrier of GAS who is experiencing viral infections.  Realize that frequent infections could be actually reinfection, but it could also be that the patient is a chronic • GAS carriers do not ordinarily justify efforts to identify them nor do they generally require antimicrobial therapy carrier of GAS who is experiencing viral infections. because GAS carriers are unlikely to spread GAS pharyngitis to their close contacts and are at little or no risk for  GAS carriers do not ordinarily justify efforts to identify them nor do they generally require antimicrobial therapy developing suppurative or nonsuppurative complications. because GAS carriers are unlikely to spread GAS pharyngitis to their close contacts and are at little or no risk for developing suppurative or nonsuppurative complications . • Tonsillectomy solely to reduce the frequency of GAS pharyngitis is not recommended.  Tonsillectomy solely to reduce the frequency of GAS pharyngitis is not recommended. • If provider feels that antimicrobial therapy is appropriate for a particular patient, recommended regimens are in Table 3.  If provider feels that antimicrobial therapy is appropriate for a particular patient, recommended regimens are in Table 3. ... continued on page 30 28 JOURNAL MSMA JANUARY 2013

• mSDh • Mississippi Reportable Disease Statistics

November 2012 Figures for the current month are provisional

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

JANUARY 2013 JOURNAL MSMA 29

• mSDh •

Health Department Announces New District Health Officer for Public Health District VII

r. Leslie England of Natchez has been appointed District Health Officer for Public Health District VII. Public Health District VII includes Adams, Amite, Franklin, Jefferson, Lawrence, Lincoln, Pike, Walthall, and Wilkinson counties. Dr. England replaces Dr. Thomas Dobbs who is now the Mississippi State Department of Health’s (MSDH) State Epidemiologist. “MSDH is privileged to have Dr. England as a member of our team,” said State Health Officer Dr. Mary Currier. “England’s knowledge of infectious diseases, his expertise in internal medicine, and his community involvement will be a great asset to the agency.” Dr. England received his Bachelor of Science degree in Leslie England, MD Microbiology in 1971 from Louisiana State University in Baton Rouge, Natchez LA and became a Doctor of Medicine in 1975 from the Louisiana State University School of Medicine in New Orleans, LA. He has held many positions in the medical field, including Chief of the Medical Staff, Chairman of the Board of Trustees, Editor of the Journal of the Mississippi State Medical Association and President of the Homochitto Valley Medical Society. Dr. England currently practices general medicine in Natchez. “While I will continue my private practice,” England said, “this opportunity will allow me to practice medicine on a broader scale as public health affects entire populations. I look forward to the challenges and opportunities ahead.” r ... continued from page 28 (Just Off the Press - Info You Want to Know About Group A Streptococcal Pharyngitis Guidelines)

Table 3. Treatment Regimens for Chronic Carriers of Group A Streptococci Duration or Quantity

Recommendation Strength, Quality

Route, Drug

Dose or Dosage

Oral Clindamycin

20–30 mg/kg/day in 3 doses (max = 300 mg/dose) 10 days

Strong, high

Penicillin and rifampin

Penicillin V: 50 mg/kg/day in 4 doses × 10 d (max = 2000 mg/d); rifampin: 20 mg/kg/day in 1 dose × last 4 days of treatment (max = 600 mg/days)

10 days

Strong, high

Amoxicillin–clavulanic acid

40 mg amoxicillin/kg/day in 3 doses (max = 2000 mg amoxicillin/day)

10 days

Strong, moderate

Intramuscular and oral Benzathine penicillin G (intramuscular) plus rifampin (oral)

Benzathine penicillin G: 600,000 U for <27 kg and Benzathine 1,200,000 U for ≥27 kg; rifampin: 20 mg/kg/day in penicillin G: 1 dose; Strong, high 2 doses (max = 600 mg/day) rifampin: 4 days

Abbreviation: Max, maximum.

30 JOURNAL MSMA JANUARY 2013

• imAgeS iN miSSiSSippi meDiciNe •

dr. William lattimorE’s Hand-WovEn Frock coat

—The most important physician of the Mississippi Territory (and on into early statehood) was William Lattimore, MD (1774-1843). He arrived from Virginia to Natchez in 1801, working with his physician brother David to contain the smallpox epidemic of that year. William, who moved to Amite County, served as Mississippi’s first Territorial Congressman from 1803-1817. In that capacity, he selected the line of division of the Mississippi Territory and led the admission of the territory into the Union as a state. He also was one of the three men who in 1822 selected the site for the state capital, which became Jackson. Lattimore was one of the leading members of the state’s first constitutional convention. In 1823, he unsuccessfully ran for the governorship of the state, losing to Walter Leake. While Lattimore’s political accomplishments are significant, his medical accomplishments, especially in advancing the state on the path of medical licensure, are also critical. He helped create and was appointed in 1819 with his brother to serve on the state’s first board of medical licensure, the Board of Medical Censors, which regulated the admission of physicians and surgeons to practice in Mississippi. This image is of Dr. Lattimore’s dress coat worn to Washington, D. C. when he was a delegate to Congress from the Mississippi Territory, ca. 1810-1817. The coat is a hand-stitched, hand-woven, indigo dyed wool and white cotton frock coat. It is double breasted with two rows of 5 buttons down the front and 4 buttons on the tails. It is one of many unique artifacts that will be on permanent exhibit in the future Museum of Mississippi History, scheduled to open in 2017. This state history museum, along with the Mississippi Civil Rights Museum, is part of the Mississippi Museums project currently underway at the Mississippi Department of Archives and History. The opening of these two museums will be the centerpiece of the state’s year-long, bicentennial celebration. If you would like to make a tax-deductible contribution toward the design, fabrication, and installation of exhibits in these two state-of-the-art museums, please contact the Foundation for Mississippi History at www.mshistory.net or 601-576-6855. If you have a photograph or image related to Mississippi medicine which would be of interest to your fellow physicians, please send as a high resolution jpg file to me at lukelampton@cableone.net or contact the Journal MSMA. —Lucius Lampton, MD, Editor JANUARY 2013 JOURNAL MSMA 31

• UNcommoN thReAD •

s many of you do also, I struggle to understand the self-destructive impulses of humanity and how, knowing the damage that they are doing to themselves, our patients persist in doing themselves harm. This poem is an attempt to understand. —sa

American Bacchus

evere Weather is where I was born. I’m not sure when or why. I wasn’t smart and I wasn’t good. I didn’t need to be. I arose from a void within your hearts. Not something to consider, but as a thing Hammered whole and fully formed by need. Not someone the respectable admit to know. And so you don’t, and I don’t care. You can deny my claim, But in a secret place, I am everything that makes you want. Yes, I’m careless and unsentimental and hard. The stupidity of youth is the music of my soul. Scheming, sneaking…a beer commercial that can’t be shown. All things natural and grown are mine, Not just the grape, or fermentation, or the vine. Mania, cocaine or weeds, can serve as well. Drunk, high, or mad – all meet my needs. To lose control and set you free. The skinny girl in the magazine, she feels me, Tingling and pulling beneath her clothes, Entreating her to let things go, and revel in the attention. Until clothing is gone and I have moved, To the throbbing beneath the denim of the sweating boys, That strain and crane to see the little nothings that she shows. And kill themselves singing, “Hey looka here.” The sacrifice that I demand. Forget rehab, forget addiction, and forget your excuses. You do it because you want to. You do it because of me. And you love me for it. I am your god, little g, not big. Tell them you’ll dance the twelve steps to escape me. Do what you want. It won’t change a thing. Your doctors can not save you from that which drives you on. The Bacchanal continues, and as long as it does, so then will man. And I will serve to guide you on. I have since Dionysus. Russell Scott Anderson — 2012 (or 12 BC Who knows?)

32 JOURNAL MSMA JANUARY 2013

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