FEBRUARY 2012 JMSMA by Journal MSMA

February

VOL. LIII

2012

No. 2

We proudly announce that Advocate, MD and The Doctors Company have united. Together, we set a higher standard. We aggressively defend your name. We protect good medicine. We reward doctors for their loyalty. We ensure members benefit from our combined strength. We are not just any insurer. We are the nationâ&#x20AC;&#x2122;s largest insurer of physician and surgeon medical liability. Richard E. Anderson, MD, FACP Chairman and CEO, The Doctors Company

The Doctors Company and Advocate, MD have officially joined forces. With the addition of Advocate, MD, we have grown in numbers, talent, and perspectiveâ&#x20AC;&#x201D;strengthening our ability to relentlessly defend, protect, and reward our 71,000 members nationwide. To learn more about how we can protect your livelihood and reputation with our medical professional liability program, call (800) 686-2734 or visit us at www.thedoctors.com.

We relentlessly defend, protect, and reward the practice of good medicine.

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 Thomas E. Joiner, MD president Steven L. Demetropoulos, MD president-elect J. Clay Hays, Jr., MD secretary-treasurer Lee Giffin, MD speaker Geri Lee Weiland, MD vice speaker Charmain Kanosky executive director Journal of the Mississippi state Medical association (issn 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. correspondence: Journal MSMA, Managing editor, Karen a. evers, p.o. Box 2548, ridgeland, Ms 39158-2548, ph.: (601) 853-6733, fax: (601)853-6746, www.MsMaonline.com. suBscription rate: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available. advertising rates: furnished on request. cristen hemmins, hemmins hall, inc. advertising, p.o. Box 1112, oxford, Mississippi 38655, ph: (662) 236-1700, fax: (662) 236-7011, email: cristenh@watervalley.net postMaster: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 391582548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association.

S SI

PPI S T

MED

E AT

I L A SSOC

official publication of the MsMa since 1959

FEBRUARY 2012

VOLUME 53

NUMBER 2

Scientific ArticleS Simultaneous Liver Metastasectomy at Operation for Primary Colorectal or Gynecologic Malignancy

J. Jarrett Corley, MD; Mary Kinney Corley, MD; Christopher J. Lahr, MD; David G. McIntosh, MD; Mildred Ridgway, MD and Naveed A. Ahmed, MD

Top 10 Facts You Need to Know About Kidney Transplantation

Fauzia K. Butt, MD and Ashley H. Seawright, DNP, ACNP-BC

PreSident’S PAge

Resolve Towards a Healthier Mississippi

Thomas E. Joiner, MD; MSMA President

Public HeAltH rePort cArd Poster Insert

MSMA In Celebration of Health Awareness Day

Karen A. Evers, Managing Editor

Notice of Proposed Changes to MSMA Constitution

Council on Constitution and Bylaws

editoriAl

Focusing on Professionalism

Ralph Didlake, MD, FACS and Patrick O. Smith, PhD

relAted orgAnizAtionS

Mississippi State Department of Health

dePArtMentS

Placement/Classified Una Voce

27 60

ASclePiAd

Harry G. Frye, Jr., MD

About tHe cover:

“Sea Treasures from the Viewbox” is the title W.F. Pontius, MD gave this black and white cover image. This photograph was on display and auctioned at the MSMA Annual Session in Tupelo. Dr. Pontius created these images using radiologic and photographic imaging. The three treasures are the starfish, the spindle, and the spotted tuns. Dr. Pontius resides in Ocean Springs with his wife Mollie. He retired from the practice of radiology in 2001 and continues his hobby of photography. r February

VOL. LIII

2012

No. 2

February 2012 JOURNAL MSMA 33

From the Editor

ack in January 2009, our Journal published the first annual Public Health Report Card, a collaboration of the Mississippi State Medical Association and the State Department of Health. Dr. Patrick Barrett, then President, called the report card “a huge office visit for our entire state population.” The annual report card explores each year the current health data for our “patient” (the state of Mississippi). The intent of the report card is to energize our efforts as physicians in transforming our “patient” by addressing its principal health problems and promoting healthy lifestyles and personal responsibility. On January 19th at the state capitol, our current president, Dr. Thomas Joiner, and State Health Officer Dr. Mary Currier released in a press conference the fourth annual Mississippi Public Health Report Card which is included in this issue. Unfortunately, our state remains the fattest in the country and first in teen birth rate, infant mortality, and traffic fatalities. We also have dismal rankings for diabetes, hypertension, cancer mortality, and adult tobacco use. However, let us pick our spears and swords and charge at these public health enemies. We as physicians can change patient behavior in all of these negative rankings. Yes, we are the poorest state, and yes, we have tragic deficits in education, but state docs can reverse Mississippi’s statistics. Each day let us make a difference in the lives of our patients. Also at the capitol on January 19th was the State Medical Association Alliance, hosting the seventh annual CSI (Capitol Screening Initiative). Nancy

Smith, wife of McComb ER physician Dr. Scott Smith, was the “chief” alliance officer who directed this outstanding public service event. This health fair for legislators featured booths, exhibits, blood pressure screenings, and eye screenings. This event is also a great public relations effort by our Alliance for state physicians, garnering the good will and thanks of legislators who vote on physician and public health issues. As docs, we benefit so much from the often unrecognized work of our Medical Alliance. They deserve our accolades every day, and certainly now for their wonderful CSI Lucius M. Lampton, MD project! Encourage your spouse to participate! Editor The Journal remains YOUR publication, created by and for physicians, with all the beauty and frailty such involves. The brilliant Dwalia South, who is out with a recent book, returns this month with a lovely poem, and the second “Asclepiad” photo features Dr. Harry Frye, long a member of the MSMA fifty year club! I invite our readers to submit letters to the editors, scientific articles, essays, book reviews, poetry, or photographs to grace this publication’s pages. It’s only as good as our physicians make it! — Lucius Lampton, MD, Editor

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

34 JOURNAL MSMA

February 2012

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 Chief of Staff 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, Jr., MD Surgeon Greenwood Leflore Hospital

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

Medical Assurance Company of Mississippi Partnership keeps physicians focused on medicine For the physicians of Biloxi Internal Medicine, Medical Assurance Company of Mississippi is not just their insurance company, but also a member of the team. MACM’s Risk Management Department is invited into the clinic for risk assessments and staff presentations on a regular basis. The physicians want to keep their focus on providing professional care and seek out MACM’s assistance to do just that. Having MACM available to them and to their office staff is just one of the benefits they realize as insureds. With MACM’s help and advice, they can improve on what they already love to do.

Left to Right: Regina C. Mills, MD Reza Motakhaveri, MD Yashashree Bethala, MD Ben W. Cheney, MD Marion J. Wainwright, MD

For over 30 years, Mississippi physicians have looked to Medical Assurance Company of Mississippi for their professional liability needs. Today, MACM is an integral part of the health care community through its dedication to risk management services for our insureds. A dedicated staff and physician involvement at every level guarantees that the interests of our policyholders remain the top priority. This, combined with the many years of loyalty and support from our insureds, is what allows us to be the carrier of choice in Mississippi. Please call on us to assist with your professional liability needs.

1.800.325.4172 • www.macm.net

February 2012 JOURNAL MSMA 35

â&#x20AC;˘ ScientiFic articleS â&#x20AC;˘

Simultaneous Liver Metastasectomy at Operation for Primary Colorectal or Gynecologic Malignancy J. Jarrett Corley, MD; Mary Kinney Corley, MD; Christopher J. Lahr, MD; David G. McIntosh, MD; Mildred Ridgway, MD and Naveed A. Ahmed, MD

bStrAct

Background: Treatment of synchronous resectable colorectal liver metastases has traditionally involved a staged surgical approach. Specialized centers have demonstrated good results with simultaneous resection. We aim to report our outcomes at the University of Mississippi Medical Center (UMMC) with simultaneous liver metastasectomy at the time of operation for primary colorectal or gynecologic malignancy Study deSign: From January 2010- September 2011, 6 patients underwent simultaneous resection of liver metastases and primary colorectal or gynecologic malignancy. Operative, postoperative, and pathologic data were retrospectively reviewed. reSultS: Four patients with colorectal primaries underwent simultaneous resection. One received abdominoperineal resection with resection of lesions in hepatic segments II and VII. A second received right hemicolectomy with en bloc resection of gallbladder and segments IV and V. The third and fourth patients both underwent left colectomy with resection of segments IV and V, respectively. All resections were nonanatomic, and frozen-sections were confirmed to be negative at the resection base. No patients suffered additional postoperative morbidity or mortality related to liver resection.

AutHor AffiliAtionS: Resident, Department of General Surgery (Dr JJ Corley), Resident, Department of Obstetrics and Gynecology (Dr MK Corley). Colorectal surgeon, Department of Surgery, (Dr Lahr). Department of Obstetrics and Gynecology, specialized training in gynecologic oncology (Drs McIntosh and Ridgway). Department of Surgery, specialized training in hepatobiliary surgery (Dr Ahmed).University of Mississippi Medical Center, Jackson, MS. correSPonding AutHor: Naveed Ahmed, MD, 2500 North State Street, Department of Surgery, University of Mississippi Medical Center, Jackson, MS 39216. (601)984-5120. (nahmed@umc.edu).

36 JOURNAL MSMA

February 2012

Two patients had ovarian cancer with metastatic disease to the liver. The first underwent en bloc resection of gallbladder and segments IV and V along with extensive debulking. The second had recurrent ovarian cancer with metastases with liver segments VI and VII. Both patients underwent simultaneous resection with no added postoperative morbidity or mortality attributed to hepatic resection. For gynecologic malignancy, the objective is to remove bulky disease, and although microscopic margins were positive, the goal of tumor load reduction was achieved. concluSionS: Liver resection at the time of operation for primary colorectal or gynecologic primary can safely be performed with the benefit of avoiding morbidity of a second laparotomy without compromising safety. key WordS:

Stage IV colorectal cancer; HepatIc metaStaSectomy; cytoreductIVe tHerapy for oVarIan cancer.

introduction Approximately 25% of patients with colorectal cancer present with synchronous hepatic metastases- a subset of patients that may encompass nearly 35,000 people annually.1 Survival in stage IV colorectal cancer has traditionally approached 10%, and the mainstay of treatment has been systemic chemotherapy. Surgical resection of liver metastases remains the only potentially curative therapy with five-year survival rates of nearly 25% reported in the literature.2-6 Treatment of synchronous resectable colorectal liver metastases has traditionally involved a staged approach with resection of the primary cancer followed by metastasectomy 2-6 months later.7-11 Some highly-specialized, high-volume centers have demonstrated good results with simultaneous resection, reporting a perioperative mortality <5%.4,12-16 Similarly, resection of liver metastases during cytoreductive surgery for ovarian cancer favorably affects survival.17-19

The aim of this article is to review our experience with simultaneous resection of synchronous colorectal or gynecologic malignancy with hepatic metastases at the University of Mississippi Medical Center (UMMC). Also, we will review current resectability criteria and benefits of a one-stage operative approach. MethodS We retrospectively review six patients who underwent simultaneous hepatic metastasectomy at the time of operation for colorectal or gynecologic malignancy from January 2010- September 2011. Our review examines the type of primary cancer resection, location of resected hepatic segments, number of liver lesions, surgical margins of the primary cancer, surgical margins of the metastasectomy, patient age, and complications such as postoperative bleeding or bile leakage. All patients who underwent simultaneous resection of synchronous colorectal or ovarian cancer with hepatic metastases were included. The Brisbane 2000 nomenclature was used to define the segmental anatomy of the liver (Figure 1).29 Figure 1. Segmental Anatomy of the Liver

before resections showed two lesions- both resectable based on their distance from major vasculature. Frozen sections from the base of the lesion representing the 3,6,9,and 12 oâ&#x20AC;&#x2122;clock positions were sent to confirm negative margins. The patient had no postoperative complications related to liver resection. The second patient underwent right hemicolectomy with en bloc resection of the gallbaldder and hepatic segments IV and V after intraoperative ultrasound demonstrated no other lesions. Intraoperative frozen sections were taken in a similar manner, and there were no complications related to liver resection. The third and fourth patients had left sided colon cancers with a single liver metastasis in segments IV and V, respectively. Again, intraoperative ultrasound confirmed preoperative CT findings, intraoperative frozen sections confirmed negative margins, and there were no complications related to liver resection. Gynecologic The first patient had ovarian cancer with hepatic metastasis. At operation, she underwent right salpingo-oophorectomy, omentectomy, bladder resection, right colectomy, and sigmoid colectomy by the GYN-Oncology team. There was gross invasion of tumor into the gallbladder and a lesion in segment V of the liver (Figures 2,3). Simultaneously, she underwent radical cholecystectomy with en bloc resection of liver segments IV and V. The bowel resection margins were negative for tumor. All gross disease was removed from the liver, keeping with our goal of cytoreduction. The hepatic resection margin was focally positive for metastatic disease. She had no postoperative bleeding or bile leakage from her liver resection but did suffer anastomotic leak of her rectosigmoid anastomosis and related intraabdominal abscess. Postoperative CT is shown (Figure 4). The second patient underwent omentectomy and low anterior resection with diverting ileostomy for recurrent ovarFigure 2. CT abdomen with a large ovarian mass with involvement of right colon and liver

Source: ACS Surgery - 2003 WebMD Inc.

reSultS Colorectal We have treated four patients, all men, with average age of 53. Planning was patient-centric with multidisciplinary cooperation. All patients had preoperative CTs for staging and underwent intraoperative liver ultrasound to confirm location of tumor, any change from preoperative imaging, and resectability. Intraoperative ultrasound was surgeon-performed, utilizing intraoperative radiology consultation for lesions that were difficult to visualize or characterized. All hepatic resections were non-anatomic. The first patient received abdominoperineal resection of the colorectal primary tumor with resection of two liver lesions in segments II and VII. Preoperative CT showed a lesion in segment VII only, but intraoperative ultrasound of the patients liver

February 2012 JOURNAL MSMA 37

Figure 3. CT specific for liver showing invasion of gall bladder and anterior liver in the patient

Figure 4. Post-operative CT

Figure 5. CT shows involvement of posterior liver, in a patient 5. omentectomy and low anterior resection with thatFigure underwent diverting ileostomy for recurrent ovarian cancer

38 JOURNAL MSMA

February 2012

ian cancer involving the sigmoid colon, residual omentum, and liver (Figure 5). She concurrently underwent two separate wedge resections of segments VI and VII. Pathology was positive for metastatic ovarian adenocarcinoma at the distal sigmoid resection margin. Postoperatively, she suffered no bleeding or bile leak. Postoperative CT is shown (Figure 6). Regardless of the primary tumor type or type of liver resection, no patient suffered postoperative complication related to the liver resection such as bleeding or bile leak. No patient suffered additional morbidity, mortality, or increased hospital stay due to simultaneous liver resection at the time of primary tumor resection (see Table 1). Cure is possible for a number of patients with stage IV colorectal cancer undergoing hepatic metastasectomy. Five year survival rates of patients undergoing resection of liver metastases has been reported as approximately 25% in selected patients. Patients with stage IV colorectal cancer should be discussed at a multidisciplinary tumor-board with an experienced hepatic surgeon to assess resectability status. Criteria for resectability includes likelihood of complete removal of all metastatic disease while maintaining adequate liver reserve. Currently, the best timing for resection of synchronous colorectal liver metastases and the primary tumor has not been well defined. The traditional approach has been staged resection. Safety of simultaneous resection has been shown at highly-specialized high-volume centers. Preoperative evaluation includes imaging modalities such as computed tomography (CT), preoperative and intraoperative ultrasonography, as well as positron emission tomography (PET). Use of triple-phase contrast enhancement during CT scanning helps define vascular anatomy and aids operative planning. Additionally, we use intraoperative ultrasound to ensure safe distance of tumors from vascular structures to confirm resectability and also to identify any other lesions. Hepatic colorectal metastases are currently deemed resectable when the diseased area can be completely resected, two Figureg6. Post-operative CT

Table 1. Results

Patient

Primary Tumor Location

Type of Liver Resection

Segments Resected

Liver-related Complication

Rectal

Non-anatomic

II, VII

none

Colon- ascending

Non-anatomic

IV, V

none

Colon- descending

Non-anatomic

none

Colon- descending

Non-anatomic

none

Ovarian

Non-anatomic

IV, V

none

Ovarian

Non-anatomic

VI, VII

none

adjacent liver segments can be spared, adequate vascular supply and biliary drainage can be preserved, and the future liver remnant is adequate-25% of the total liver volume. Modalities such as portal venous embolization can be used in cases of insufficient remnant liver volume to convert to resectable status by enhancing growth of the future liver remnant.20-22 This is true even in the setting of neoadjuvant chemotherapy which can lessen tumor burden and help convert to resectable status.23-24 The principles of cytoreductive surgery in stages II, III, and IV ovarian cancer involve aspiration of ascites or peritoneal lavage for cytologic examination, total hysterectomy, bilateral salpingectomy, bilateral oopherectomy, omentectomy, aortic lymph node dissection, and pelvic lymph node dissection. In an effort to achieve maximal cytoreduction, defined as less than 1 cm residual disease or resection of all visible disease, partial hepatectomy may be required.25-27 This is safe when performed with an experienced hepatic surgeon and significantly prolongs life-expectancy.28 Our data demonstrates safety of a simultaneous approach to synchronous colorectal and ovarian cancer liver metastases. This approach avoids second laparotomy and does not increase morbidity or mortality. Overall, there is a shorter overall treatment time than with staged resection. referenceS

1. American Cancer Society. Colon/Rectum Cancer Detailed

Guide. http://www.cancer.org/Cancer/ColonandRectumCancer/ DetailedGuide/colorectal-cancer-survival-rates. Accessed September 6, 2011.

Abdalla EK, Vauthey JN, Ellis LM, et al. Recurrence and outcomes following hepatic resection, radiofrequency ablation, and combined resection/ablation for colorectal liver metastases. Ann Surg. 2004;239:818-827.

Fernandez FG, Drebin JA, Linehan DC, et al. Five-year survival after resection of hepatic metastases from colorectal cancer in patients screened by positron emission tomography

with F-18 fluorodeoxyglucose (FDG-PET). Ann Surg. 2004 Sep;240(3):438-47. 4.

Fong Y, Cohen AM, Fortner JG, et al. Liver resection for colorectal metastases. J Clin Oncol 1997;15:938-946.

Tuttle TM, Curley SA, Roh MS. Repeat hepatic resection as effective treatment of recurrent colorectal liver metastases. Ann Surg Oncol. 1997;4:125-130.

Nadig DE, Wade TP, Fairchild RB, et al. Major hepatic resection. Indications and results in a national hospital system from 1988-1992. Arch Surg. 1997;132:1515-119.

Nordlinger B, Guiguet M, Vaillant JC, et al; Association Francaise de Chirurgie. Surgical resection of colorectal carcinoma metastases to the liver: a prognostic scoring system to improve case selection, based on 1568 patients. Cancer. 1996; 77:1254-1262.

Bolton JS, Fuhrman GM. Survival after resection of multiple bilobar hepatic metastases from colorectal carcinoma. Ann Surg. 2000;231:743-751.

Cady B, Stone MD. The role of surgical resection of liver metastases in colorectal carcinoma. Semin Oncol. 1991;18:399406.

10. Bismuth H, Castaing D, Traynor O. Surgery for synchronous hepatic metastases of colorectal cancer. Scand J Gastroenterol Suppl. 1988;149:144-149. 11. De Santibanes E, Lassalle FB, McCormack L, et al. Simultaneous colorectal and hepatic resections for colorectal cancer: postoperative and longterm outcomes. J Am Coll Surg. 2002;195:196-202. 12. Weber JC, Bachellier P, Oussoultzoglou E, Jaeck D. Simultaneous resection of colorectal primary tumour and synchronous liver metastases. Br J Surg. 2003;90:956-962. 13. Martin R, Paty P, Fong Y, et al. Simultaneous liver and colorectal resections are safe for synchronous colorectal liver metastasis. J Am Coll Surg. 2003;197:233-241. 14. Lyass S, Zamir G, Matot I, et al. Combined colon and hepatic resection for synchronous colorectal liver metastases. J Surg Oncol. 2001;78:17-21.

February 2012 JOURNAL MSMA 39

15. Jaeck D, Bachellier P, Weber JC, et al. Surgical treatment of synchronous hepatic metastases of colorectal cancers: simultaneous or delayed resection? Ann Chir. 1996;50:381-390.

24. Pawlik TM, Schulick RD, Choti MA. Expanding criteria for resectability of colorectal liver metastases. Oncologist 2008;13:51-64.

16. Doko M, Zovak M, Ledinsky M, et al. Safety of simultaneous resections of colorectal cancer and liver metastases. Coll Antropol. 2000:24:381-390.

25. Bristow RE, Puri I and Chi DS. Cytoreductive surgery for recurrent ovarian cancer: a meta-analysis. Gynecol Oncol 2009;112:265-274.

17. Huang PP, Weber TK, Mendoza C, Rodriuguiez-Bigas MA, et al. Long-term survival in patients with ovarian metastases from colorectal carcinoma. Ann Surg Oncol. 1998;5:695-698.

26. Aletti GD, Dowdy SC, Gostout BS, et al. Aggressive surgical effort and improved survival in advanced-stage ovarian cancer. Obstet Gynecol 2006;107:77-85.

18. Rayon D, Bouttell E, Whiston F, Stitt L. Outcome after ovarian/ adnexal metastasectomy in metastatic colorectal carcinoma. J Surg Oncol. 2000;75:186-192.

27. Eisenhauer EL, Abu-Rustum NR, Sonoda T, et al. The effect of maximal surgical cytoreduction of sensitivity of platinum-taxane chemotherapy and subsequent survival in patients with advanced ovarian cancer. Gynecol Oncol 2008;108:276-281.

19. Knowles B, Bellamy CO, Oniscu A, Wigmore SJ. Hepatic resection for metastatic endometrioid carcinoma. HPB (Oxford). 2010. Aug;12(6):412-417. 20. Vauthey JN, Pawlik TM, Abdalla EK, et al. Is extended hepatectomy for hepatobiliary malignancy justified? Ann Surg. 2004;239:722-32. 21. Abdalla EK, Hicks ME, Vauthey JN. Portal vein embolization: rationale, technique, and future prospects. Br J Surg 2001;88:165-75.

28. Winberger P, Lehmann N, Kimmig R, et al. Prognostic factors for complete debulking in advanced ovarian cancer and its impact on survival. An exploratory analysis of a prospectively randomized phase III study of the Arbeitsgemeinschaft Gynaekologische Onkologie Ovarian Cancer Study Group (AGO-OVAR). Gynecol Oncol 2007;106:69-74. 29. Strasberg SM, Belghiti J, Clavien P-A, et al. The Brisbane 2000 terminology of liver anatomy and resections. HPB 2000;2:3339.

22. Charnsangavej C, Clary B, Fong Y, et al. Selection of patients for resection of hepatic colorectal metastases: expert consensus statement. Ann Surg Oncol. 2006;13:1261-8. 23. Covey AM, Brown KT, Jarnagin WR, et al. Combined portal vein embolization and neoadjuvant chemotherapy as a treatment strategy for resectable hepatic colorectal metastases. Ann Surg. 2008;247(3):451-5.

Feel the Burn Exercise at a moderate intensity to get the most benefit from your workout. A light sweat, faster breathing and some strain in your muscles are all good indicators you’re exercising effectively. If you have a health condition or any other physical barrier, it’s a good idea to talk to your doctor before you begin. be healthy. exercise.

www.bcbsms.com Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company, is an independent licensee of the Blue Cross and Blue Shield Association. ® Registered Marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.

40 JOURNAL MSMA

February 2012

• top 10 FactS you need to Know •

About Kidney Transplantation Fauzia K. Butt, MD and Ashley H. Seawright, DNP, ACNP-BC

ntroduction

Renal transplantation is the preferred therapy for end-stage renal disease (ESRD). Compared to continued dialysis, successful transplantation is associated with enhanced survival and improved quality of life.1 Patients in early stage 4 chronic kidney disease (glomerular filtration rate [GFR] between 15 and 29 ml/min) should be referred for transplantation.2 When the GFR is ≤ 20 ml/min, patients can start accruing time on the wait list for deceased donor kidneys. The United Network for Organ Sharing (UNOS), a nonprofit organization under contract with the federal government, distributes all deceased donor organs. The allocation of kidneys is based on a formula that takes into consideration the blood type, length of time on the wait list, presence of antibodies in the blood, and the human leukocyte antigen (HLA) match between the donor and recipient, with prioritization for pediatric recipients.

1. Established guidelines assist with the evaluation of potential kidney transplant recipients. 3 Developed by the Clinical Practice Guidelines Committee of the American Society of Transplantation, these evidence-based recommendations facilitate the evaluation of renal transplant candidates. Potential recipients undergo extensive medical and psychosocial testing to determine their eligibility for transplantation. While specific selection criteria may vary AutHor AffiliAtionS: Dr. Butt is board certified in general surgery and ASTS-certified in abdominal transplant surgery. She is an Assistant Professor of Surgery at the University of Mississippi Medical Center (UMMC) and served as Interim Division Chief of Transplant Surgery from late 2010 until August 2011. Ms. Seawright is a board certified acute care nurse practitioner with transplant surgery at UMMC, who recently received her doctorate of nursing practice from Johns Hopkins. correSPonding AutHor: Dr. Fauzia K. Butt, Department of Surgery, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216.

slightly by transplant center, their main purpose is to ensure that potential candidates lack any unacceptable medical or psychosocial risks. Repeat testing after initial listing may be indicated for certain patients, such as those with cardiovascular disease, in order to determine continued suitability.4 2. A deceased person may donate tissues and solid organs after declaration of death by either neurologic or cardiopulmonary criteria.5 Neurologic criteria are used to identify the typical “brain dead” organ donor, and the guidelines followed in the United States are clearly defined.6 In an effort to prevent deaths on the wait list and honor the wishes to donate of patients who do not meet brain death criteria, donation after cardiac death (DCD) is an acceptable option in cases of severe neurological injury without any chance of meaningful recovery. Donation can proceed once withdrawal of the mechanical ventilator results in cardiac and respiratory cessation. Death is declared by a physician independent of the organ recovery team to avoid any potential conflicts of interest. In order to demonstrate irreversibility, termination of circulatory and respiratory function must exist for at least 5 minutes before the organ recovery process can begin.5 3. A living person may donate a kidney after extensive screening for any medical conditions or psychosocial issues that would preclude donation.7 Living donors can be genetically, or emotionally, related to the recipient, should be free of any significant medical problems, and must not be coerced into donation.7 Potential living donors undergo an extensive medical and psychosocial evaluation. Neither life expectancy nor the risk of developing kidney disease is altered by donating a kidney.8 Laparoscopic donor nephrectomy has less morbidity than the open technique and is now routinely offered at most transplant centers.9 An independent donor advocate ensures that the interests of the living donor are not compromised.7

February 2012 JOURNAL MSMA 41

4. Donor kidney quality affects post-transplant outcomes.10 Generally, kidneys from living donors are associated with superior graft function and survival. The current 1-year graft and patient survival rates for adult recipients of a deceased donor renal transplant in the United States are 91.8% and 95.7%.11 These numbers improve for adult recipients of a living donor renal transplant to 96.5% and 98.5%, respectively.11 There are several types of deceased donors.12 A standard criteria donor (SCD) is a young, healthy donor whose death is the result of a sudden, traumatic event, and this type of donor is associated with the best results in deceased donor transplantation. All donors â&#x2030;Ľ 60 years of age are considered to be expanded criteria donors (ECD). Donors between the ages of 50-59 are also included in the ECD category if they have two of the following three criteria: 1) death due to a cerebrovascular accident, 2) history of hypertension, or 3) terminal creatinine â&#x2030;Ľ 1.5. Deceased donor kidneys that are recovered in less than optimal circumstances may experience delayed graft function (DGF), necessitating the continuation of dialysis after transplantation until adequate recovery of graft function. ECD and DCD kidneys are associated with an initial risk of DGF; however, the benefits of discontinuing dialysis long-term may significantly outweigh this initial risk.10 ECD and DCD kidneys will be offered only to patients who have previously agreed to accept them. DCD kidneys from donors < 50 years of age have equivalent long-term graft survival as SCD kidneys.13 5. The number of listed patients awaiting kidney transplantation drastically exceeds the number of available donor organs.14 There are currently over 89,000 listed candidates who are awaiting kidney transplantation in the United States.14 In 2010, there were a total of 13,523 kidney donors, and 54% were deceased donors.15 The existing organ donor supply cannot even begin to meet the current demands, and the number of patients needing transplantation increases daily. During the first decade of this century, a 260% increase in the waiting list was accompanied by a mere 16% increase in the number of deceased donor transplants performed.13 The continual challenge to the transplant community to increase the availability of deceased donor organs has resulted in the utilization of ECD and DCD donors. Innovative approaches to living donation have also been developed, including paired donation exchanges and transplant chains.16 Occasionally, a transplant chain may be started by an altruistic, living donor without a designated recipient, thus enabling multiple recipients with incompatible donors to be transplanted.16,17 6. Post-transplant outcomes are improved with early transplantation.18,19 One important factor influencing post-transplant outcomes is the amount of time spent on dialysis. Increased pretransplant dialysis time is associated with inferior graft and

42 JOURNAL MSMA

February 2012

recipient outcomes.2,18,19 In fact, the superior outcomes associated with living donor transplantation may be partly due to decreased dialysis time in addition to better quality donor kidneys. This effect is so striking that a deceased donor renal transplant recipient on dialysis < 6 months has the same graft survival as the recipient of a living donor renal transplant on dialysis > 2 years.19 The best results are achieved with preemptive transplantation.2,18,19 With early referral, patients may be transplanted before the initiation of dialysis, especially when a living donor is available. In order to minimize the time spent on dialysis and maximize outcomes, it has been suggested that the standard of care should be to refer appropriate patients for transplantation at the same time as referral for vascular access.2 7. Potential recipients may choose to be listed at multiple centers.20 According to UNOS policy 3.2.2, patients have the option to be listed at multiple transplant centers which may reduce the time it takes to receive a transplant if the centers are located in different organ procurement organization (OPO) service areas. Locally listed candidates close to the donor hospital are usually considered ahead of those listed at more distant centers, so multiple listing may increase the patientâ&#x20AC;&#x2122;s chances of receiving a local organ offer. UNOS policy 3.2.1.9 also allows patients to transfer their waiting time from one transplant center to another, which may occur when patients relocate from one geographical area to another, permitting their position to be maintained on the wait list without the loss of any accumulated waiting time. 20 8. Optimal management of co-morbid conditions maximizes the full benefits of transplantation.21 Significant improvement in patient and graft survival rates in renal transplant recipients has resulted in an older patient population with multiple co-morbidities. Hypertension, diabetes, cardiovascular disease, and other co-morbidities must be optimally managed in order to maximize the benefits of renal transplantation. Transplantation reduces long-term mortality in diabetic patients by >50%;1 however, cardiovascular disease (CVD) is the leading cause of death in patients with a functioning graft.21 The highest risk of death occurs in the immediate posttransplant period (within the first 3 months), and then it decreases dramatically to much less than that for patients remaining on the wait list.22 Managing CVD, especially in diabetic recipients, may further improve patient survival post-transplantation.21 9. Native nephrectomy may be indicated before transplantation. 23 Typically, the diseased kidneys are left in place and the new kidney is placed extraperitoneally in the pelvis, where it is attached to the iliac vessels and the bladder.24 Although

not routinely performed, native nephrectomy may be indicated in cases of malignancy, chronic pyelonephritis, severe proteinuria, or uncontrollable hypertension. The presence of extremely large polycystic kidneys may also necessitate a native nephrectomy to create space for the transplant. 10. Established guidelines assist with the management of kidney transplant recipients.25 Increased survival after kidney transplantation requires community physicians and nephrologists to become increasingly familiar with the management of these particular patients.26,27 Comprehensive evidence-based practice guidelines developed by the National Kidney Foundation (Kidney Disease: Improving Global Outcomes [KDIGO] transplant work group) assist with the clinical management of kidney transplant recipients.25 The post-transplant regimen consists of a combination of several medications: immunosuppressive, antiviral and antibacterial agents. Although individual protocols vary by transplant center, immunosuppression generally consists of three agents: a calcineurin inhibitor (cyclosporine or tacrolimus), an antiproliferative agent (mycophenolate mofetil or azathioprine), and steroids.28,29 Immunosuppressive agents are powerful medications associated with multiple side effects, including drug interactions,28,29 and account for the majority of transplant-related morbidity. A delicate balance must be achieved between too little immunosuppression, which results in rejection, and too much immunosuppression, which leads to opportunistic infections and neoplasias. This balance is maintained through lifelong clinical and laboratory monitoring, including medication levels. Patients are typically required to attend clinic frequently during the first month after transplantation and then progressively less often. After several months, when kidney function and medical therapy are relatively stable, patients will return to their primary nephrologist for continued management. The transplant team will follow up regularly, but less frequently, and will always be available for any questions and concerns that may arise. For optimal management of these complicated patients, there must be consistent communication between their primary care providers and the transplant center. concluSion There are approximately 325,000 patients currently on dialysis in the United States.30 After receiving a successful kidney transplant, the majority of patients are able to return to work or school. Cognitive function steadily improves and reproductive capacity is restored. Some recipients may become competitive athletes and participate in the U.S. and World Transplant Games. Unfortunately, the number of patients awaiting transplantation has increased significantly over the years without a concomitant increase in available donor organs. In 2008, 4.6% of the nearly 100,000 patients on the kidney wait list died while awaiting transplantation.31 Maximal utilization of organs can be achieved by encouraging everyone to regis-

ter as an organ donor and inform one’s immediate family of this important, life-saving decision. Multiple resources regarding information on transplantation and donation are available for health care providers and their patients (see below). Available resources for additional information on transplantation: •

American Association of Kidney Patients: www.aakp.org

•

American Society of Transplant Surgeons: www.asts.org

•

American Society of Transplantation: www.a-s-.t.org

•

Association for Multicultural Affairs in Transplantation: www.asmhtp.org

•

Department of Health and Human Services: www. organdonor.gov

•

Donate Life America: www.donatelife.net

•

Mississippi Kidney Foundation: www.kidneyms.org

•

Mississippi Organ Recovery Agency: www.msora.org

•

Minority Organ Tissue Transplant Education Program: www.nationalmottep.org

•

National Kidney Foundation: www.kidney.org

•

National Transplant Assistance Fund: www.ntafund.org

•

National Foundation for Transplants: www.transplants.org

•

Organ Procurement & Transplantation Network: http:// optn.transplant.hrsa.gov

•

Scientific Registry of Transplant Recipients: www.srtr.org

•

Transplant information provided by Astellas: www. transplantexperience.com

•

United Network for Organ Sharing: www.unos.org

referenceS 1.

Wolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med. 1999;341:1725-1730.

Abecassis M, Bartlett ST, Collins AJ, et al. Kidney transplantation as primary therapy for end-stage renal disease: a National Kidney Foundation/ Kidney Disease Outcomes Quality Initiative (NKF/ KDOQI) conference. Clin J Am Soc Nephrol. 2008;3:471-480.

Kasiske BL, Cangro CB, Hariharan S, et al. The evaluation of renal transplant candidates: clinical practice guidelines. Am J Transplant. 2001;2(suppl 1):5–95.

Bunnapradist S, Danovitch GM. Evaluation of adult kidney transplant candidates. In: Danovitch GM, ed. Handbook of Kidney Transplantation. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:177-178.

February 2012 JOURNAL MSMA 43

Bernat JL, Dâ&#x20AC;&#x2122;Alessandro AM, Port FK, et al. Report of a national conference on donation after cardiac death. Am J Transplant. 2006;6:281-291.

Wijdicks EFM. Determining brain death in adults. Neurology. 1995;45:1003-1011.

The Authors for the Live Organ Donor Consensus Group. Consensus statement on the live organ donor. JAMA. 2000;284:2919-2926.

Ibrahim HN, Foley R, Tan L, et al. Long-term consequences of kidney donation. N Engl J Med. 2009;360:459-469.

Flowers JL, Jacobs S, Cho E, et al. Comparison of open and laparoscopic live donor nephrectomy. Ann Surg. 1997;226:483-490.

10. Merion RM, Ashby VB, Wolfe RA, et al. Deceased-donor characteristics and the survival benefit of transplantation. JAMA. 2005;294:2726-2733. 11. Scientific Registry of Transplant Recipients (SRTR) data. www. srtr.org. Accessed July 19, 2011. 12. Rao PS, Ojo A. The alphabet soup of kidney transplantation: SCD, DCD, ECD: fundamentals for the practicing nephrologist. Clin J Am Soc Nephrol. 2009;4:1827-1831. 13. Locke JE, Segev DL, Warren DS, et al. Outcomes of kidneys from donors after cardiac death: implications for allocation and preservation. Am J Transplant. 2007;7:1797-1807. 14. HRSA/ OPTN website. Current U.S. waiting list, overall by organ type. http://optn.transplant.hrsa.gov/latestData/rptData. asp. Accessed June 17, 2011. 15. HRSA/ OPTN website. Donors recovered in the U.S. by donor type. http://optn.transplant.hrsa.gov/latestData/rptData.asp. Accessed June 17, 2011.

25. Kidney Disease: Improving Global Outcomes (KDIGO) Transplant Work Group. KDIGO clinical practice guideline for the care of kidney transplant recipients. Am J Transplant. 2009;9(suppl 3):S1â&#x20AC;&#x201C;S157. 26. Howard AD. Long-term posttransplantation care: the expanding role of community nephrologists. Am J Kid Dis 2006;47(suppl 2):S111-S124. 27. Cohen D, Galbraith C. General health management and long-term care of the renal transplant recipient. Am J Kid Dis 2001;38(suppl 6):S10-S24. 28. Danovitch GM. Immunosuppressive medications and protocols for kidney transplantation. In: Danovitch GM, ed. Handbook of Kidney Transplantation. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:77-100. 29. Gaston RS. Current and evolving immunosuppressive regimens in kidney transplantation. Am J Kid Dis. 2006;47(suppl 2):S3-21. 30. American Association of Kidney Diseases website. Dialysis over the last 35 years. Available at http://www.aakp.org/newsletters/ Renalife-Magazine/Doctor-Articles/Dialysis-Last-35-Years/. Accessed May 27, 2011. 31. 2009 Annual Report of the U.S. Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients: Transplant Data 1999-2008. Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau, Division of Transplantation, Rockville, MD; United Network for Organ Sharing, Richmond, VA; University Renal Research and Education Association, Ann Arbor, MI.

16. Butt F, Gritsch HA, Schulam P, et al. Asynchronous, out-ofsequence, transcontinental chain kidney transplantation: a novel concept. Am J Transplant. 2009;9:2180-2185. 17. Rees MA, Kopke JE, Pelletier RP, et al. A nonsimultaneous, extended, altruistic-donor chain. N Engl J Med. 2009;360:10961101. 18. Cosio FG, Alamir A, Yim S, et al. Patient survival after renal transplantation, I: the impact of dialysis pre-transplant. Kidney Int. 1998;53:767-772. 19. Meier-Kriesche HU, Kaplan, B. Waiting time on dialysis as the strongest modifiable risk factor for renal transplant outcomes: a paired donor kidney analysis. Transplantation. 2002;74:13771381. 20. HRSA/ OPTN website. Policies, 3.2 Organ Distribution: UNOS Patient Waiting List. http://optn.transplant.hrsa.gov/ PoliciesandBylaws2/policies/pdfs/policy_4.pdf. Accessed June 17, 2011. 21. Ojo AO, Hanson JA, Wolfe RA, et al. Long-term survival in renal transplant recipients with graft function. Kidney Int. 2000;57:307313. 22. Meier-Kriesche, HU, Schold JD, Srinivas TR, et al. Kidney transplantation halts cardiovascular disease progression in patients with end-stage renal disease. Am J Transplant. 2004;4:1662-1668. 23. Bunnapradist S, Danovitch GM. Evaluation of adult kidney transplant candidates. In: Danovitch GM, ed. Handbook of Kidney Transplantation. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:169. 24. Veale JL, Singer JS, Gritsch HA. The transplant operation and its surgical complications. In: Danovitch GM, ed. Handbook of Kidney Transplantation. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:181-185.

44 JOURNAL MSMA

February 2012

BRANDON BYRAM CANTON CLINTON JACKSON LAUREL MADISON PEARL RICHLAND RIDGELAND SPILLWAY VICKSBURG

providing

PERFORMANCE

new hope

It is one of the most important things to consider when selecting an investment advisor.

to transplant patients across the Southeast.

Our past performance can be seen on our website...right now.

www.medleybrown.com

years 1989-2011

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

A D V I S O R S

601-982-4123

M&B Perf MSMA Feb'12.indd 1

1/31/12 12:06 PM

Dr. ChriSTOpher AnDerSOn Chief, Division of Transplant & Hepatobiliary Surgery Specializing in kidney & liver transplant and liver & bile duct surgeries Shouldnâ&#x20AC;&#x2122;t your doctor be a univerSity PhySician?

University of Mississippi Health Care

To talk doctor to doctor, call 866.UMC.DOCS or visit umhc.com. February 2012 JOURNAL MSMA 45 UP_anderson_JMMA.indd 1

1/5/12 8:00 AM

• preSident’S page •

Resolve Towards a Healthier Mississippi

t’s February and the new year is still full of optimism for a better 2012. Your MSMA has again issued the third annual public health report card which you’ll find in the centerfold of this JMSMA. I encourage you to hang the poster in a prominent place and use it to help your patients with their resolutions whether it is to lose weight, quit smoking, get fit, drink less alcohol, or eat healthier. These New Year’s resolutions are popular year after year. MSMA has taken the pulse of Mississippi, and our health is in critical condition. To make an impact on Mississippi’s health crisis we physicians should talk to our patients about undesirable health consequences and help them commit to make healthier choices. Hopefulness for a healthier Mississippi will require changing bad habits and substituting better behavior. People spend countless hours and dollars each year attempting to break bad habits, often without success. Why? Because there is no magic pill. Change is hard work and there is no short cut to achieving it. The public health report card has healthy resources to assist you in helping your patients thomaS e. Joiner, md achieve their goals. 2011-12 mSma preSident You’ll find resources like the 1-800-QUIT-NOW Mississippi Tobacco Quit Line listed on the back of the report card. This valuable resource offers telephone and online cessation counseling, referral to local cessation programs (when available), self-help materials, nicotine replacement therapy assistance (for eligible callers), a fax referral program for healthcare providers, and cessation program options for employers. Speaking of resources, physicians can help break the obesity cycle by simply outlining healthier choices. The December Journal included a portion and calorie program for Mississippi. Download it from MSMAonline.com and use it to effect a change in eating habits. You can teach your patients how to regain the ability to make healthier eating choices by showing them how to use the Southern Remedy Health Living dietary and lifestyle change tool. Even modest weight reductions are associated with decreased diabetes, hypertension, and stroke, all downstream effects of obesity. If it can work for the individual, it can work for the state. It is part of our job to advise and encourage. When you look at the report card found a few pages over, you will find the data for our patient (the public health report card for Mississippi). We have our work cut out for us. We are #1 in too many detrimental categories (adult obesity, infant mortality, teen birth rate, heart disease deaths, and traffic fatalities) and #2 in others (hypertension and sedentary adults). We are #3 in cancer mortality and diabetes cases, and #4 in adult tobacco usage. Take a moment and look at the rest of the data. The saddest part of all: hundreds of thousands of people die prematurely due to these entirely preventable behaviors. It doesn’t take a brain surgeon to know we need to focus more on the prevention of disease and the promotion of health than on the management of illnesses. As a long journey starts with a first step, we take this step together with the people of Mississippi with the hope and resolve of a new year. If it can work for the individual, it can work for the State. It is part of our job to advise and encourage. You know what they say about changing behavior: ultimately, it’s up to you.

P.S.: The Triple Crown season is off and running, and the horse to watch from Fair Grounds is Mr. Bowling, winner of the Lecomte Stakes. The Lecomte is annually a good gauge for what types of horses will be coming to the Kentucky Derby from Louisiana and surrounding areas. The long stretch of Fair Grounds, which is similar to the extensive stretch at Churchill Downs, also helps provide a better idea of whether a horse has the proper running style to be successful in the Kentucky Derby. As the season continues, more races will define more horses to watch. I’ll keep you informed on the races.

46 JOURNAL MSMA

February 2012

MISSISSIPPI STATE

MEDICAL ASSOCIAATION

SMAonline.com • 1-800-898-0251 • www.M -6733 • Fax 601-853-6746 -853 601 • 57 391 e Plac 548 • 408 West Parkway geland, Mississippi 39158-2

P.O. Box 2548 • Rid

Fellow Mississippians,

ippi State l Association and the Mississ the Mississippi State Medica to teen by ity red rtal nso mo spo nt d, infa Car and ort m obesity to diabetes ual Public Health Rep Fro ann es. i’s ipp issu siss lth Mis hea ing you to elm t We presen direction. herself with overwh st make a move in a better once again, our state finds care access, we simply mu lth Department of Health. And hea and s STD to s litie and traffic fata and economic issue. birth rate, from tobacco use blem is both a healthcare pro sity obe i’s ipp siss Mis . lthcare spending. state is obesity ning to public health in our will also decrease overall hea ate and thre es, st bet mo dia es ng issu udi the incl s, of One onic disease rates will reduce related chr ugh lifestyle Therefore, reducing obesity Obesity is preventable thro cial public health epidemic. cru this re. inst futu aga the rge and cha tion the era for this gen across the state to lead to put an end to obesity… This year, we urge physicians ts to eat better and get active ien pat r you age our enc , ion to fight changes! So physicians read how you can take act in the years to come. Below, and now lth hea ter bet to h huge difference on the pat Small steps today make a es! Mississippi’s health cris to exercise at least 30 How to Fight the Crisis: le grains; make it a priority who pi: and sip s, ble sis eta Mis in veg ts, sis Health Cri Eat a diet rich in frui Physical Activity per week. Adult Obesity and Lack of minutes three to five times mote smokefree air in your sissippi Tobacco Quitline. Pro mokeFreeAirMS.com. Mis the for OW IT-N QU 00Call 1-8 e at www.S the SmokeFree Air Initiativ Adult Tobacco Use community; get involved with re to second-hand smoke; smoking and reduce exposu p sto s; ing een scr lth hea Get regular annual . family history of the disease Cancer Mortality use sunscreen; know your es per 30 minutes three to five tim pressure; exercise at least od reducing ut blo r abo you tor trol doc r con g; you to okin Stop sm n and whole grains; talk nsio s, erte ble eta Hyp / veg es ts, bet frui Dia of / t e die Heart Diseas week; eat a healthy the risk of heart attack. ippi be pregnant; call the Mississ if you are or think you might ly ate edi imm an sici phy r See you 848-5683. Infant Mortality Pregnancy Hotline at 1-800prevented by seat belt deaths each year could be fic traf of t cen per paired 50 ut Abo in the US involve alcohol-im Wear your seatbelt! ries one-third of traffic fatalities ut abo e; driv and k drin ’t Traffic Fatalities / Trauma Inju use. Don drivers. avior. Teens, get educated s of irresponsible sexual beh risk the ut ings are abo n dre chil r e and private STD/HIV screen Parents, talk to you s/HIV before having sex. Fre STD and , ncy gna pre , Teen Birth Rate / STDs, HIV sex about department. available at your local health ize with drugs and alcohol. Util dren about risky behavior chil r you lth with Hea Talk s e. Kid um Parents, do not ass erica (drugfree.org) and Use tnership for a Drug-Free Am Teen Alcohol and Marijuana resources such as The Par lthy decisions. hea ke ma kids to help your (kidshealth.org) to learn how

PUBLIC HEALTH IN MISSISSIPPI

REPORT CARD

2012

pi healthier,

Yours in making Mississip

Thomas E. Joiner, MD Medical Association President, Mississippi State

lth Mary Currier, MD, MPH ippi State Department of Hea State Health Officer, Mississ

ippi. ho Care for Mississ The Physicians W

MISSISSIPPI STATE DEPARTMENT OF HEALTH

Report Card 2012 PROOF.indd 1

1/13/12 9:52 AM

Report Card 2012 PROOF.indd 2 1/13/12 9:52 AM

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.

The 2012 Mississippi Public Health Report Card is brought to you by the Mississippi State Medical Association and the Mississippi State Department of Health.

Mississippi ranks #1 in adult obesity and heart disease deaths  #2 in hypertension cases and in adults reporting no physical activity in the past month  and #3 in diabetes cases.  Mississippi is 4th in adult tobacco use  1st in teen birth rate  1st in infant mortality  1st in traffic fatalities  5th in trauma and unintentional injuries  3rd in cancer mortality  2nd best in breast cancer incidence but 7th worst in breast cancer mortality  and 15th in suicide rates.  39.2 percent of high school kids have consumed alcohol and nearly 18 percent have used marijuana.  28,943 new STD cases were reported in 2010 in Mississippi including 550 cases of HIV.  Mississippi ranks 50th in physicians per capita.

Runners rock!

• mSma • In Celebration of Health Awareness Day Karen A. Evers, Managing Editor

Health Awareness Day—Members of the MSMA Alliance and physicians join MSMA President Dr. Tom Joiner and State Health Officer Dr. Mary Currier at a press conference to release the Fourth Annual Public Health Report Card.

Patrick House, winner of the NBC-TV reality show “The Biggest Loser: Season 10,” poses with the size 58 pants he used to wear. House is working with the MSMA Alliance encouraging children to be active and make healthy choices. As he tours, he shows kids how they, too, can set goals and achieve them. “It’s about getting them active, raising awareness about how bad fast foods and fried foods are for them. Letting them know you can still eat healthy foods and it tastes good,” House said. Shown l. to r.: Carole Kelly, Communications Manager at Information & Quality Healthcare (IQH) exhibits for the Mississippi Chronic Illness Coalition (MCIC) with Ann Sansing, community health coordinator with the Mississippi State University Extension Service; House and Aundria Range, MCIC community-based prevention committee chair.

“H

ealth Awareness Day,” Thursday, January 19, was eventful at the State Capitol building as the MSMA Alliance hosted the seventh annual Capitol Screening Initiative (CSI VII) targeting members of our State Legislature and a media press conference was held to release the fourth annual public health report card. The report card, issued by MSMA in collaboration with the Mississippi State Department of Health, appears in the centerfold of this Journal MSMA. The activities were planned to get Legislators’ attention and let them know our MSMA wants to help them stay in the best physical and mental condition to make the critical decisions they face during the legislative session, particularly the health issues on MSMA’s legislative agenda. A variety of health screenings were offered at no charge to elected officials and staff. Members of our Alliance were on hand to meet and direct legislators through the screenings as well as to provide healthy snacks for consumption after the tests. Both events, the report card press conference and CSI VII, showed the Legislature the medical community cares about them. In the four years since the first Public Health Report Card release, most statistics have yet to improve. Some have worsened. To further enhance our MSMA’s advocacy efforts, we encourage members to display the report card by hanging it in a prominent place. Physicians can use the poster to inform patients, prompt dialogue, and encourage those who seek their advice. The 2012 Public Health Report Card is available on the MSMA website: MSMAonline.com. For extra copies, you may call MSMA headquarters and request a reprint of the poster. —continued p. 55....

Capitol Screening Inititive (CSI) — Rep. Joe C. Gardner was one of about 200 people who browsed exhibits and received a screening from over 20 exhibitors. Screenings included BMI, blood pressure, glucose, cholesterol, EKG, glaucoma, and diabetic retinopathy. Flu shots were also offered.

February 2012 JOURNAL MSMA 51

Be sure to join us for a beachside celebration on Friday, June 8 at the Annual Session President’s Reception…

LIFE’S A BEACH W I T H

T O R T

MDs

R E F O R M

Mudbugs

A Casual Crawfish Boil RESERVE YOUR ANNUAL SESSION HOTEL ROOM TODAY! 800-544-9933 / MarriottGrand.com Group Code: msmmsma 52 JOURNAL MSMA

February 2012

MSMA Annual Session Schedule Thursday, June 7 (Registration 1pm – 5pm) 8:30 10:30 CME Presented by MACM (2hrs CME) 11:00 until MACM Golf Tournament Grand Marriott Golf Club 3:00 5:00 Medical Affairs Forum (2hrs CME) 5:30 7:00 MSMA / UMC Welcome Reception 7:30 until Committee on Publications Meeting/Dinner Friday, June 8 (Registration 7am – 5pm) 7:00 8:00 MSMA Board of Trustees 7:30 9:30 Breakfast with Exhibitors 7:30 8:30 Reference Committee Orientation/Breakfast 9:00 11:30 House of Delegates 11:30 1:00 Lunch with Exhibitors 11:30 12:30 MPCN Executive Committee Meeting 12:30 1:30 MPCN Board of Directors Luncheon 1:00 1:30 MSMA Board of Trustees Meeting 1:30 3:30 Reference Committee Hearings 3:30 4:30 Journal Editorial Advisory Board Meeting 3:30 4:30 MMPAC Board of Directors Meeting 3:30 4:30 YPS Business Meeting 3:30 4:30 Women in Medicine Business Meeting 3:30 5:00 MSMA Surveyor Training Workshop/ Council on Medical Education 6:30 8:00 President’s Reception – Crawfish Boil 8:00 9:00 Southern Medical Ice Cream Social Saturday, June 9 (Registration 6:30am – 5pm) 6:30 8:00 Breakfast 7:00 12:30 Medical Affairs Forum (5hrs CME) 12:30 1:30 Candidate Speeches to Caucuses/ Boxed Lunch 1:30 2:30 Specialty Society Meetings 2:30 4:30 Guest Speakers with Book Signing Topic: World War II 3:30 5:30 MSMA Board of Trustees 6:30 7:30 MSMA Reception and Alliance Raffle 7:30 11:00 President’s Inaugural Dinner Dance Tickets: $120 per person Sunday, June 10 (Registration 7am – 11am) 7:15 7:45 Worship Service 7:30 9:00 Voting 7:30 9:00 Continental Breakfast 8:00 9:00 VIP Breakfasts: 50-Year Club and Past-Presidents’ 8:00 9:00 MSMA Board of Trustees 9:00 11:00 House of Delegates 11:00 11:15 MSMA Board of Trustees

MSMA ALLIANCE SCHEDULE Friday, June 8 10:00 am 12:00 pm

Pre-Convention Board Meeting Luncheon (Dutch Treat)

Saturday, June 9 8:30 am 12:00 pm

House of Delegates Installation Luncheon

Sunday, June 10 8:00 am

Past Presidents’ Breakfast

Name: Email: Specialty / Title: Address: City, State Zip: Phone: Fax: Cell: Spouse / Guest: Payment Information Credit Card Type: Visa MC AmEx

Exp. Date:

Credit Card #: Name on Card: Please check the boxes and indicate number of attendees for each event below. Physician Registration (Asterisks indicate family events.)

THURSDAY, JUNE 7

CME Presented by MACM ____ Medical Affairs Forum ____ Welcome Reception ____

FRIDAY, JUNE 8

Breakfast with Exhibitors ____ House of Delegates ____ Medical Affairs Forum ____ Lunch with Exhibitors ____ President’s Reception* ____ Ice Cream Social* ____

FRIDAY, JUNE 8

SATURDAY, JUNE 9

Medical Affairs Forum ____ Pres.-Elect Reception ____ Pres.’s Dinner/Dance ____ ($120 per person)

SUNDAY, JUNE 10

Breakfast ____ House of Delegates ____

Alliance Registration

Alliance Board Luncheon (Dutch) ____

SATURDAY, JUNE 9

Alliance House of Delegates ____ Alliance Installation Luncheon ____ ($45 tickets will be sold only on site.)

SUNDAY, JUNE 10

Past Presidents’ Breakfast ____

Mail completed form to

MSMA c/o Becky Wells PO Box 2548, Ridgeland, MS 39158-2548 Questions? BWells@MSMAonline.com or 601-853-6733 February 2012 JOURNAL MSMA 53

• editorial •

Focusing on Professionalism Ralph Didlake, MD, FACS and Patrick O. Smith, PhD

ver the past 15 years, medical professionalism has emerged as an increasingly prominent topic. This emergence is visible across the entire spectrum of clinical medicine from undergraduate education to private hospital practice but is most obvious in a series of mandates from the continuum of regulatory and oversight organizations. In 1999, the Accreditation Council for Graduate Medical Education (ACGME) established professionalism as one of its six core competencies for resident training. Likewise, the Liaison Committee on Medical Education (LCME) adopted its first explicit standard for professionalism in the medical student learning environment in June of 2008. The Joint Commission implemented LD.03.01.01, a new standard directed at controlling unprofessional Didlake Smith staff behavior in 2009. As of 2010, six states required content-specific continuing medical education on professionalism topics such as ethics, prescribing, reporting domestic violence, and cultural competence. Explication of this regulatory paradigm shift is complex and multi-factorial and may include factors such as changing societal expectations for physicians, specialty fragmentation, and evolving health care delivery models, such as transdisciplinary teams. Although each of these factors may have helped sustain an emphasis on professionalism, the central driving force currently is a growing body of literature that links unprofessional physician behavior with poor patient outcome. For example, in a study of emergency department physicians and nurses, unprofessional behavior was correlated with adverse outcomes, error, and compromise in patient safety and mortality.1 Other studies have shown that poor professional behavior contributes to high staff turnover, shortage of experienced nurses,2 poor communication, and degradation of team performance.3 In addition, disruptive and unprofessional physician behaviors increase organizational costs that accrue from recruitment and retention efforts, adverse events, malpractice, compliance issues, inefficiencies, and loss of market share.4 All of the factors associated with unprofessional behavior are known to contribute to sentinel events.5 It is critical that the medical profession respond vigorously to this new environment for several important reasons. The first and most obvious is that it is the right thing to do for our patients. In the language of evidence-based medicine, the literature cited above constitutes strong level II data supporting the fact that unprofessional behavior, arrogance and poor communication not only degrade care but also kill and injure patients. As a profession, we have a clear ethical obligation to govern ourselves more effectively in this regard. Indeed, effective self-governance is foundational to the definition of any profession. The University Mississippi Medical Center has responded to this obligation by establishing a “Professionalism Across the Curriculum” program. This five year project will embed professionalism content into the existing curriculum of all five UMMC schools to create a sustainable culture of professionalism. The size and scope of this program demonstrate that The University Mississippi Medical Center has made a firm commitment to graduate healthcare professionals who are not only technically skilled but who also exhibit the very best values and behaviors of the healing professions. To explore the specifics of this program, please visit our website at http://qep.umc.edu/. referenceS

1. Rosenstein AH, Naylor B. Incidence and Impact of Physician and Nurse Disruptive Behaviors in the Emergency Department. J of Emer. Med. 2011 Mar 19.

5. Joint Commission. Behaviors that undermine a culture of safety. Senti nel Event Alert. 2008 Jul 9;(40):1-3.

2. Johnson, SL, Rea RE. Workplace bullying: Concerns for nurse leaders. JONA. 2009 Feb;39(2):84-90.

author inforMation:

3. Saxton R. Negative Impact of Nurse-Physician Disruptive Behavior on Patient Safety: A Review of the Literature. J Patient Saf. Sept 2009; 5(3): 180-182. 4. Rosenstein, A.H. Measuring and managing the economic impact of disrup tive behaviors in the hospital. Journal of Healthcare Risk Management. 30(2):20-2, 2010.

54 JOURNAL MSMA

February 2012

Dr. Didlake, Director, Center for Bioethics and Medical Humanities. Patrick O. Smith, PhD, Associate Dean For Faculty Affairs and Professor of Family Medicine, School of Medicine. The University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216.

Health Awareness Day cont....

DiD your last meeting leave you feeling a taD

“ECTOPIC” If so, you should consider having your next meeting in Tupelo!

MSMA Alliance members did an excellent job of hosting and coordinating CSI-VII.

We’re right in the middle of the midsouth and tupelo is the headquarters of the north mississippi medical Center, the largest non-metropolitan hospital in the united states, and is a winner of the prestigious malcolm Baldrige national Quality award! And we promise you won’t feel out of place here! For information about setting up your next meeting, give Linda Elliff a call at 800-533-0611.

MSMA President Dr. Tom Joiner was interviewed by WLBT-3 news reporter Mike McDaniel.

Save The Date! Sign Up Now! 2012 MSMA Annual Session

Golf Tournament

Thursday, June 7, 2012 — 11 a.m. Lakewood Golf Club The Grand Hotel at Point Clear, Alabama CME Prior to Tournament — 8:30 a.m.

Sponsorship Opportunities Available! For more information, call Wendy Powell at Medical Assurance Company of Mississippi 1.800.325.4172

February 2012 JOURNAL MSMA 55

• mSdh • Mississippi Reportable Disease Statistics

December 2011 Figures for the current month are provisional

† Totals include reports from Department of Corrections and those not reported from a speciﬁc district. For the most current MMR ﬁgures, visit the Mississippi State Department of Health web site: www.HealthyMS.com. 56 JOURNAL MSMA

February 2012

• mSma • Notice of Proposed Changes to the MSMA Constitution Report of the Council on Constitution and Bylaws to the MSMA House of Delegates and Members

anuary 20, 2012 –According to the MSMA Bylaws Chapter XIII, Section (4) the Council on Constitution and Bylaws is described as follows: The Council on Constitution and Bylaws shall be responsible for the continuing study of the organization of the Association. It shall receive all referred suggested amendments and changes and shall recommend to the House of Delegates and the Board of Trustees any amendments or revisions which seem necessary or advisable. The Council shall meet at least once a year and shall make a report to the House of Delegates on the state of the Constitution and Bylaws every two years. The Council shall consist of three (3) members elected by the House of Delegates for terms of three (3) years each and shall meet at least on an annual basis and more often as necessary.* At its December 2, 2011 meeting, the MSMA Council on Constitution and Bylaws decided to propose a resolution for approval at the 144th MSMA Annual Session to be held June 7-10, 2012 to make changes to the Articles of Incorporation as explained below.

Reason for the Changes to the Articles of Incorporation

All corporations including non-profits and trade associations like MSMA are subject to state laws regarding corporations such as the Mississippi Model Nonprofit Corporation Act. During the 2011 Regular Legislative Session, Senate Bill 2444 was adopted which represented a revision to Mississippi’s Model Nonprofit Corporation Act. This legislative action coincides with the Council on Constitution and Bylaws two-year review of MSMA’s Constitution and Bylaws. Thus, the MSMA Council on Constitution and Bylaws recommends changes in the MSMA Constitution which will modernize the Association’s Constitution in a manner consistent with the new non-profit corporation laws. There are two proposed changes to the Articles of Incorporation: (1) a constitutional amendment clarifying the intent of the Association to limit the personal liability of its voluntary directors and officers to MSMA or its members as set forth in Miss. Code Ann. Section 79-11-267, and (2) though the adoption of an immunity constitutional amendment is significant to minimize exposure of trustees and officers, the Association should consider additional provisions in the constitution and bylaws which grant discretion to the Association to indemnify its trustees and officers. 2.

Content of the Change to the Articles of Incorporation

See attached Appendix A for the proposed changes to the Articles of Incorporation. 3.

Schedule

- Articles of Incorporation Changes for Approval at the 144th MSMA Annual Session:

June 7 -10, 2012, The Marriott Grand Hotel, Point Clear, Alabama

- Effective Date of the Changes to the Articles of Incorporation:

Effective Immediately upon Adoption

*This notice complies with MSMA Constitution Article XII regarding 90-days notice to members of proposed changes to MSMA Constitution and related state laws. Prior to Annual Session, MSMA will post these proposed changes to the Articles of Incorporation along with other proposed amendments to the bylaws on its website for review and comment. Questions may be submitted to: Dr. Eric Lindstrom, Chair, Council on Constitution and Bylaws, c/o Neely Carlton, General Counsel, MSMA, at NCarlton@MSMAOnline. com or 601-853-6733.

February 2012 JOURNAL MSMA 57

NOTICE OF PROPOSED CHANGES TO MSMA CONSTITUTION APPENDIX A PROPOSED CHANGE NO. 1 MSMA CONSTITUTION Article IX Board of Trustees: Section 1. Duties: The Board of Trustees shall be the executive and governing body of the Association during vacation of the House of Delegates and shall perform such duties as are prescribed by law governing directors of corporations and in the bylaws of the Association. Section 2. Composition: The Board shall consist of the district trustees, the president, president-elect, immediate past president, secretary-treasurer, Speaker of the House of Delegates, one medical student trustee and one resident/fellow trustee. Section 3. Finance: The Board of Trustees shall constitute the Finance Committee of the House of Delegates. Section 4. Liability of Board of Trustees: The members of the Board of Trustees shall not be liable to the Association or its members for money damages for any action taken or any failure to take any action as a director, except liability for: (a) The amount of a financial benefit received by the trustee to which the trustee is not entitled; (b) An intentional infliction of harm; (c) A violation of Miss. Code Ann. Section 79-11-270; or (d) An intentional violation of criminal law. PROPOSED CHANGE NO. 2 Though the adoption of the immunity constitutional amendment is significant to minimize exposure of trustees and officers, the Association should consider adopting an additional constitutional and complementary bylaw provision which grants discretion to the Association to indemnify its trustees and officers, to wit: MSMA CONSTITUTION Article XII Indemnification Each person who was or is made a party or is threatened to be made a party to or is involved in any action, suit or proceeding, whether civil, criminal, administrative or investigative by reason of the fact that he or she, or a person of whom he or she is the legal representative, is or was a trustee or officer of the corporation or while a trustee or officer of the Association is or was serving at the request of the Association as a trustee or officer of another corporation or of a partnership, joint venture, trust or other incorporated or unincorporated enterprise, including service with respect to employee benefit plans or trusts, whether the basis of such proceeding is alleged action or inaction in an official capacity as a trustee or officer or in any other capacity while serving as a trustee or officer may be indemnified and held harmless by the Association to the fullest extent authorized by the Mississippi Non-profit Corporation Act as the same exists or may hereafter be amended and pursuant to the Association’s bylaws as such bylaws may be amended. Bylaws Chapter - Indemnification of Trustees and Officers Section 1. Power to Indemnify in Actions, Suits or Proceedings. The Association may indemnify a person who was or is a party or is threatened, pending or completed action, suit or proceeding, whether civil, criminal, administrative or investigative, other than an action by or in the right of the Association, by reason of the fact that such person is or was a trustee or officer of the Association, against expenses, including reasonable attorneys’ fees, judgments, fines and amounts paid in settlement actually and reasonably incurred by such person in connection with such action, suit or proceeding to the extent provided by the provision s of the Mississippi Non-Profit Corporation Act, as such act shall be amended from time to time, and to the extent insurance coverage is available to fund the indemnification. Section 2. Insurance. The Corporation may purchase and maintain insurance on behalf of any person who is or was an employee, trustee or officer of the Corporation or who serves in the capacity of Medical Director for the Association, against any liability asserted against such person and incurred by such person in any such capacity, or arising out of such person’s status as such, whether or not the Association would have the power or the obligation to indemnify him or her against such liability under the provisions of this Article.

58 JOURNAL MSMA

February 2012

Inaction vs IN ACTION We understand the difference The Litigation Center of the American Medical Association and the State Medical Societies fights to protect doctors and uphold the highest standards of patient care. In courtrooms across America, we are achieving legal victories that preserve the rights of physicians, promote public health and protect the integrity of the profession. Whether we are challenging managed care organizationsâ&#x20AC;&#x2122; payment practices or preserving the autonomy of the hospital medical staff, one thing remains constant: The Litigation Center is an active force fighting for physiciansâ&#x20AC;&#x2122; rights. Learn more on how The Litigation Center can help you:

www.ama-assn.org/go/litigationcenter Membership in the American Medical Association and the Mississippi State Medical Association makes the work of The Litigation Center possible. Join or renew your memberships today.

www.ama-assn.org

www.msmaonline.com 12-0044:PDF:1/12

February 2012 JOURNAL MSMA 59

• una Voce •

hen scratch

he still and silent drawers of your desk Have patiently waited these two years

To be purged of defunct business cards,

And snapshots by the score of old acquaintances Nameless and unrecognizable now.

The dried-up highlighters from home health agencies And the once irresistible

Giveaway gizmos and gadgets

Did not cry out to me to be dealt with back then. They did not exert that smoldering daily pressure To be put away out of reach of my senses

Like your ancient tee-shirts and sweaty baseball caps did.

The same objects that would make your puppies tilt their heads quizzically And then dance with delight at the reassuring smell of their master Were objects that sent me reeling in a fog of tears.

Those were the first things that demanded putting away. Your desk had bided its time.

Within are those countless scattered notes

Containing your sweet scrawl, your undeniable hen scratch. Not only is it yours...it is quite simply you. You speaking to me once more... From where?

Who knows and who cares? You can still speak to me

In your essential hen scratch. A drug company’s sticky note pad

With directions to Pickwick and Shiloh, And new addresses for old Seabees... Where to find those

Ancient mariners, less the rhyme.

60 JOURNAL MSMA

February 2012

RWB... Incarnate in various scripts and scrolls

Scribbled to see if ink still appeared from that government issue pen. RWB...GRUBER...secret passwords...

Web sites for just one more software program you didn’t really need... Volkswagen parts numbers from J.C. Whitney Catalogs... For two years I have saved each little scrap of paper Found bearing your familiar hand,

Collected and hoarded them like precious silver coins.

Now after two years I was finally able to crush one between my palms And then, as if swallowing a millstone, Ceremonially toss it in the trash...

A 1928 Peace dollar leaving my hand... A milestone, no longer a millstone.

Dwalia S. South, MD

could not hang on to every precious memory.

I grew so weary of the stinging tears that came every empty Saturday morning When your absence proved a painful reminder of what and who no longer is.

No longer is my life exactly comfortable, But then who needs comfort?

I needed someone to leave new notes on the desk. Fresh instructions, fresh directions... To a renewed life.

And I am busy making room for him. Today, I found his unique missive... RNY...his hen scratch.

Song titles, play lists and chord progressions,

Crossword puzzles completed so boldly in blue ink, And “Hey, Babe, the printer’s on the blink.”

RNY...he is writing these things on my heart today. It is he who speaks to me now

Of music, joy, love, hope, and new precious memories... Precious hen scratch. It is him...RNY.

—Dwalia South, MD; Ripley November 2011

[“Una Voce” (With One Voice), is a column in the JMSMA featuring the prose of Dwalia South, MD. Her new book Una Voce, a collection of selected JMSMA columns, will soon be available. Having served as an associate editor of the JMSMA, she currently chairs the MSMA Committee on Publications. A past president of the MSMA and the Mississippi Academy of Family Physicians (MAFP), Dr. South is a family physician in Ripley affiliated with North Mississippi Primary Care Associates, Inc. She is a past recipient of the MSMA James C. Waites Leadership Award, the MAFP “Family Physician of the Year Award,” and was named one of America’s Top Family Doctors of the Year: 2004-2005. She has served on the Mississippi State Board of Medical Licensure and the Mississippi Foundation for Medical Care Board of Trustees. In addition to writing, Dr. South enjoys the art of oral storytelling and operating her family farm business, Green Hills Farm, producing Quarter horses, Longhorn cattle, and pine trees. This poem, “Hen Scratch,” is an epithalamium to her new husband, musician Roger Yancey, whom she married October 2, 2011.] —Ed.

February 2012 JOURNAL MSMA 61

• placement / claSSiFied • We specialize in the business of healthcare • • • • • • • •

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

CD or IRA

About to Roll Over and Play Dead? Learn the Safe and Secure Way to Earn Stock Market Linked Returns Without Market Risk to Your Principal.

Call now for a FREE copy of the book

Growth Without Risk L.D. O’Mire Financial

1600 North State Street Suite 400 Jackson, MS 39202 Telephone: 601.944.1717 WATS: 1.800.355.4231 www.mpsbilling.com 10th Annual Summer CME Seminar Sandestin, Florida July 19-22, 2012 Contact: Jenny White (601) 853-6733 or jwhite@msmaonline.com

This forum is intended primarily for young physicians beginning their practice though all members of the MSMA are invited to attend. Its purpose is to convey up-to-date information to promote knowledge and skills that will better enhance patient care and practice operations. The conference is designed to provide an avenue for learning through formal lectures, informal discussions with course faculty and exchange of ideas among peers related to issues of interest to young physicians.

62 JOURNAL MSMA

February 2012

Services 1.800.844.3254

PHYSICIANS NEEDED

Physicians (specialists such as cardiologists, ophthalmologists, pediatricians, orthopedists, neurologists, etc.) interested in performing consultative evaluations (according to Social Security guidelines) should contact the Medical Relations Office.

Toll Free 1-800-962-2230 Jackson 601-853-5487 Leola Meyer (Ext. 5487)

DISABILITY DETERMINATION SERVICES

Delta doctors: Don’t get left behind. Does your practice need electronic health records but you’re putting it off until tomorrow? MSMA and the Delta Health Alliance can help Delta physicians achieve better health outcomes for your patients and earn federal incentive payments through meaningful use of electronic health records…

AT LITTLE COST TO YOU!

Contact Toy Strickland for more information! TStrickland@MSMAonline.com 601‐853‐6733, Ext. 302

February 2012 JOURNAL MSMA 63 THIS OPPORTUNITY IS FUNDED THROUGH THE DHA WITH SUPPORT FROM DHHS ONC GRANT # 90BC0004‐01.

• aSclepiad •

he name of this JMSMA feature, Asclepiad, is an ancient term for physicians. This month’s portrait is Harry C. Frye, MD, of Magnolia. Dr. Frye was born in 1923 in Kansas City but grew up in Newton, Mississippi, later moving to Jackson and graduating from Central High School and Millsaps College. He was part of America’s “greatest generation,” serving in the Army at the Battle of the Bulge. After the war, he contracted polio which left him with an ambition to become a physician and with a love of swimming. He was mentored by his friend, the great public health champion Dr. Felix Underwood, who encouraged him to enter medicine and specifically public health. He graduated from Tulane School of Medicine in 1951 and performed his internship at Vicksburg’s Mercy Hospital. He joined the Mississippi State Medical Association in 1951 and has been a member ever since, loyally attending many annual sessions and participating in the South Central Medical Society. He has practiced family medicine in Magnolia at Beacham Memorial Hospital and Magnolia Clinic since 1952. Dr. Frye is shown in front of the Harry Frye Educational Building in Magnolia, which is named in honor of his 46 years of service on the South Pike School Board. In 1957, he was one of the community leaders who organized the school district, leading it as president for most of the next four decades. He remembers much turmoil as well as successes over the years, including consolidation of schools and integration of the district. Besides his love of golf, Dr. Frye was a talented musician, playing the alto sax and clarinet in his younger days. In high school, he won the award as “best clarinet player in the state,” and he played Miller and Dorsey “Big Band” tunes on swing bands. Over the years, Dr. Frye has become a medical icon in the state, respected and loved by his patients and his physician peers. He has been awarded many community and state service awards. After more than six decades as a physician, he is still practicing medicine, although he has slowed down and only works part time. “Yes, it is still fun and rewarding,” he notes. What has guided his treatment of patients? It’s simple: “Be available and take care of them.” Throughout his many years of medicine, Dr. Frye has seen a lot of changes, but he still emphasizes that the heart of medicine is the patient/doctor relationship. This photo is by Crawford Lampton. — Lucius Lampton, MD Editor

64 JOURNAL MSMA

February 2012

What’s Your Specialty? Our specialty is NETWORKING... TPAs Physicians

Hospitals

Physicians Care N E T WO R K

Employer Groups

Ancillary Providers Insurance Companies

MPCN - THE OBVIOUS CHOICE Change Networks. Not Doctors. 601-605-4756 • www.mpcn-ms.com Sponsored by the Mississippi State Medical Association

Have You Considered a Life Settlement For Your Old Life Insurance Policy? What is a Life Settlement? A life settlement is the sale of an existing life insurance policy on the secondary market to a third party investor.

Who or What May Qualify?  If the person insured by the policy is age 70 or older  If the person insured has any major medical conditions  If the policy has a death beneﬁt of $250,000 or more  Policies including, but not limited to, universal life, term insurance, variable life insurance or whole life insurance  If any cash value exists in the policy, the amount is relatively small

For More Information on Life Settlements, contact: H. Larry Fortenberry, CPA, CLU, ChFC Executive Planning Group, PA 1640 Lelia Drive, Suite 220 PO Box 16566 Jackson, MS 39216 (601) 982-3000

Why Use a Life Settlement?  Term life insurance policy will expire  Old policy that is no longer needed or premiums cannot be paid  A policy that was purchased for a business buy/sell and is no longer needed  A policy was purchased for a business that has been sold or is not needed  There may be a better policy available at a lower cost

 Estate value has changed and the policy is no longer needed

Securities Offered Through ValMark Securities, Inc. Member FINRA, SIPC Investment Advisory Services Offered Through ValMark Advisers, Inc. a SEC Registered Investment Advisor 130 Springside Drive, Suite 300 Akron, Ohio 44333-2431* 1-800-765-5201 Executive Planning Group is a separate entity from ValMark Securities, Inc. and ValMark Advisers, Inc. In a life settlement agreement, the current life insurance policy owner transfers the ownership and beneficiary designations to a third party, who receives the death proceeds at the passing of the insured. As a result, this buyer has a financial interest in the seller’s death. When an individual decides to sell their policy, he or she must provide complete access to his or her medical history, and other personal information, that may affect his or her life expectancy. This information is requested during the initial application for a life settlement. After the completion of the sale, there may be an ongoing obligation to disclose similar and additional information at a later date. A life settlement may affect the seller’s eligibility for certain public assistance programs, such as Medicaid, and there may be tax consequences. Individuals should discuss the taxation of the proceeds received with their tax advisor. ValMark Securities considers a life settlement a security transaction. ValMark and its registered representatives act as brokers on the transaction and may receive a fee from the purchaser. A life settlement transaction may require an extended period of time to complete. Due to complexity of the transaction, fees and costs incurred with the life settlement transaction may be substantially higher than other securities.