February 2015 JMSMA by Journal MSMA

February

VOL. LVI

2015

No. 2

Lucius M. Lampton, MD Editor D. Stanley Hartness, MD Richard D. deShazo, MD Associate Editors Karen A. Evers Managing Editor Publications Committee Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD, Ex-Officio and the Editors

The Association Claude D. Brunson, MD President Daniel P. Edney, MD President-Elect Michael Mansour, MD Secretary-Treasurer Geri Lee Weiland, MD Speaker Jeffrey A. Morris, MD Vice Speaker Charmain Kanosky Executive Director JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. CORRESPONDENCE: Journal MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: (601) 853-6733, Fax: (601)853-6746, www.MSMAonline.com. SUBSCRIPTION RATE: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available. ADVERTISING RATES: furnished on request. Cristen Hemmins, Hemmins Hall, Inc. Advertising, P.O. Box 1112, Oxford, Mississippi 38655, Ph: (662) 236-1700, Fax: (662) 236-7011, email: cristenh@ watervalley.net POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 39158-2548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association. Copyright© 2015 Mississippi State Medical Association.

Official Publication of the MSMA Since 1959

FEBRUARY 2015

VOLUME 56

NUMBER 2

Scientific Articles Quality Analysis of Congenital Heart Surgery at the Children’s Heart Center, University of Mississippi Medical Center

James R. Polson, DNP, NP-C; Mary B. Taylor, MD; Ali Dodge-Khatami, MD, PhD; Makram Ebeid, MD; Jorge D. Salazar, MD

Importance of Screening for Coarctation of the Aorta in Pediatric Patients

Marco Pinder, MD; Jarrod D. Knudson, MD, PhD; Andrew L. Rivard, MD, MS; Kristen H. Miller, MD; Daniel J. DiBardino, MD; Jorge D. Salazar, MD; Avichal Aggarwal, MD

Fecal Transplantation to Treat Initial Severe Clostridium difficile Infection with Sepsis

Luis A. Marcos, MD, MPH; Allen Gersh, MD; Kevin Blanchard, MD; Stephanie Foil; Brittany Mallini, PharmD; Steven E. Farrell, MD; Ralph Kahler, MD

President’s Page Advocacy 41 Claude D. Brunson, MD; MSMA President

Editorial Mississippi Medicaid from a Pediatric Perspective

Gretchen Mahan, MS Chapter AAP Executive Director

Related Organizations UMMC 47 MSDH 48

Special Article Lloyd Tevis Miller, MD: Professionalism in the Jim Crow South

Michael C. Trotter, MD

Departments From the Editor: Willie’s Memory of Dr. Miller and the “First” 30 Physician’s Bookshelf: The State of Health and Health Care in MS 42 Images in Mississippi Medicine: Mississippi Charity Hospital, 1920 44 Letters: Remembering Brown v. Stone 55 Poetry and Medicine 56

About The Cover: “With Heartfelt Thanks for the Love of Medicine and the Art of my Profession” As my helpmate occasionally observes, “In good medicine, there is often humor” to which I replied, “True, those ‘heart bones’ have always been a challenge for radiologists!” February is American Heart Month honoring health professionals, researchers, and heart health ambassadors whose dedication to fighting heart disease enables countless Americans to live full and active lives. —W.F. Pontius, MD; Ocean Springs

February

VOL. LVI

2015

No. 2

February 2015 JOURNAL MSMA 29

From the Editor: Willie’s Memory of Dr. Miller and the “First”

poignant story told by Yazoo City native Willie Morris appears in the opening pages of his classic memoir North Toward Home (1967). It describes the night that Dr. L. T. Miller saved his life having to come in through the back door. Morris writes: “When I was slightly less than a year old, in 1935, I almost died. I lay in a crazy fever in the back room, shook with convulsions, and gave every indication of a precocious death. My parents tried to telephone every white doctor in town. Finally, as I was told it later, they called Dr. Miller, the Negro doctor. He came right away and saved my life.” Later, Morris learned that Miller, despite being a physician coming to save a life, had utilized the back door, following the Jim Crow custom of the time. (North Toward Home, 8-9) In this issue, Greenville Thoracic Surgeon Michael Trotter offers an important article on Dr. Miller’s significant contributions to medicine in our state. Also, a related correction is here made to my article “Opening the Doors of the Great Republic” which centered on the integration of the MSMA. I wrote: “[Drs. Gilbert] Mason

and [Milas] Love appear to be the first African-Americans to receive full voting membership in the MSMA.” [J Miss State Med Assoc. 2013;54(7):212] Dr. Robert Smith asked me to explore if there were others joining Drs. Mason and Love as the first black members of the Association. Indeed, as I expected, Dr. Smith’s excellent memory is right. Although the JMSMA did not list these Lucius M. Lampton, MD new members in its pages, the 1967 MSMA Directory lists the following African-Americans who obtained full voting status by the time of the printing of the publication in early 1967: Drs. James Anderson, Milas Love, Gilbert Mason, Matthew Page, and Robert Smith.” Thus, there was flood of interest by black physicians to embrace full membership immediately after the opportunity was offered in 1966, and the above physicians should all be counted among the “first.” Contact me at lukelampton@cableone. —Lucius M. Lampton, MD, Editor

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

Maxie L. Gordon, MD Assistant Professor, Department of Psychiatry and Human Behavior, Director of the Adult Inpatient Psychiatry Unit and Medical Student Education, University of Mississippi Medical Center, Jackson

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

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

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

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

Jeffrey D. Carron, MD Professor, Department of Otolaryngology & Communicative Sciences, University of Mississippi Medical Center, Jackson Gordon (Mike) Castleberry, MD Urologist, Starkville Urology Clinic

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

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

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

Philip L. Levin, MD President, Gulf Coast Writers Association Emergency Medicine Physician, Gulfport Sharon Douglas, MD Professor of Medicine and Associate Dean for VA William Lineaweaver, MD Education, University of Mississippi School of Medicine, Editor, Annals of Plastic Surgery Associate Chief of Staff for Education and Ethics, Medical Director G.V. Montgomery VA Medical Center, Jackson JMS Burn and Reconstruction Center, Brandon Bradford J. Dye, III, MD Ear Nose & Throat Consultants, Oxford Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist, The Street Clinic, Vicksburg Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson

30 JOURNAL MSMA

February 2015

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

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

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

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

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

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February 2015 JOURNAL MSMA 31

• Scientific Articles • Quality Analysis of Congenital Heart Surgery at the Children’s Heart Center, University of Mississippi Medical Center James R. Polson, DNP, NP-C; Mary B. Taylor, MD; Ali Dodge-Khatami, MD, PhD; Makram Ebeid, MD; Jorge D. Salazar, MD

risk-adjustment for congenital heart surgery (RACHS-1) score Reporting surgical outcomes and defining quality of 1-6.1 Accordingly, simple cardiac defects classified as RACHS care are of utmost importance to any surgical unit, specifi1 are associated with a low risk and have an expected surgically to a highly specialized, expensive, and complex tertiary cal mortality approaching zero while the most complex lesions care program dealing with children’s heart disease. One of the in the RACHS 6 category have the highest expected mortality, more common measures used to report results, and hence qualsometimes up to 50% even in the most expert hands. More reity of care, is surgical mortality, although many other factors, cently, analyzing the results from 43,934 patients of the Society including major complications (or lack thereof) and length of of Thoracic Surgeons (STS) and 33,360 patients from the Eurointensive care or hospital stay, are just as important. As such, pean Association for Cardio-Thoracic Surgery (EACTS) Conoutcomes are not only about the results of an individual surgeon, Table genital Heart Surgery databases, the STAT Mortality Categories 1. Procedures by STAT category and RACHS score with associated mortality rates from the Heart Database. but of an entire health provider system dedicated to the well- STS Congenital 1-5 have been defined. The STAT outcomes (risk of mortality) being of children with heart disease. Communicating objective Table 1. Procedures by STAT category and RACHS score results for any given surgical cardiac procedure to potential pawith associated mortality rates from the STS Congenital tients, relatives, and referring physicians seeking information Heart Database. Complexity Mortality % (past 4 years) seems a straightforward expectation, as would benchmarks of Specific Procedure (non inclusive) STAT All Procedures excellence and efficiency provided to health legislators, hospiSTS UMMC STS UMMC VSD patch closure 0.7 0 tal administrators, and/or insurance entities. Defining quality of 1 0.7 0 Pulmonary valve replacement 0.3 0 care in an objective manner may allow for comparison of health TOF repair (transannular patch) 1.6 0 2 1 0.7 Fontan (non fenestrated external 1.6 0 systems, hospitals, pediatric cardiac programs, and finally indiconduit) Arterial Switch Operation 2.8 0 vidual surgeons, eventually providing a ranking on a national or 3 3.2 2.8 Pulmonary Atresia- VSD repair 1.6 0 international level, if desired. Therefore, finding a reliable and Pulmonary venous stenosis repair 8.9 8.3 4 7.4 7.6 Fontan revision/conversion 5.4 0 reproducible tool to define quality in a pediatric cardiac proHybrid approach "stage 1" (PDA 24.5 0 stent + RPA/LPA bands) gram is important: it defines not only the quality of a surgeon 5 16.8 8.1 TAPVC repair + systemic-pulmonary but also the robustness of a system, a determination of a team 33.3 0 shunt RACHS 1 STS UMMC STS UMMC vision to care. PAPVC repair 0.6 0 1 0.6 0 Surgery for congenital heart defects has come a long way: ASD patch closure 0.2 0 Bidirectional Glenn 1.3 0 rom its infancy in the mid-1940’s with high mortality rates for 2 1.1 0.5 RVOT obstruction repair 1.8 0 what are today considered simple defects to the outstanding reAortic valvuloplasty 1.3 0 3 3.6 1.9 PA banding 8.9 4.9 sults many expect in the current era, even with very complex Aortic arch repair 4.2 0 4 7.1 11.5 congenital lesions. One of the most common classifications for Truncus Arteriosus 8.3 12.5 There is only 1 category 5 procedure 5 expected outcomes uses the actual heart lesion needing cor(which we did not perform) Hybrid approach "stage 2" (Deband rection, being broken down into 6 categories as defined by the 15.2 0 ntroduction

+ Arch repair + DKS + Glenn) Norwood

7.1

16.4

8.8

Author Affiliations: Pediatric and Congenital Heart Surgery (Mr. VSD: ventricular septal defect, TOF: tetralogy of Fallot, Polson, Dr. Dodge-Khatami and Dr. Salazar); Division of Pediatric Cardiology (Dr. Taylor and Dr. Ebeid); Division of Pediatric Cardiac PDA: patent ductus arteriosus, RPA/LPA: right and left Critical Care, Children’s Heart Center, University of Mississippi Medical VSD:pulmonary Ventricular septal artery, defect, TOF: tetralogy of Fallot, patent ductus arteriosus, RPA/LPA: TAPVC: totalPDA: anomalous pulmonary right and left pulmonary artery, TAPVC: total anomalous pulmonary venous connection, PAPVC: Center, Jackson, Mississippi. Corresponding Author: Jorge D. Salazar, MD, Chief, Division of Cardiothoracic Surgery, University of Mississippi Medical Center, 2500 " N. State Street, Jackson, MS 39216, 601-984-5489.

32 JOURNAL MSMA

February 2015

venous connection, PAPVC: partial anomalous pulmonary venous connection, ASD: atrial septal defect, RVOT: right ventricular outflow tract obstruction, DKS: Damus-KayeStansel.

partial anomalous pulmonary venous connection, ASD: atrial septal defect, RVOT: right ventricular outflow tract obstruction, DKS: Damus-Kaye-Stansel.

Table 2. Length of hospital stay (LOS) and rates of 4 major potential post-operative complications

comparing the national average and UMMC results. Table 2. Length of hospital stay (LOS) and rates of 4 major potential post-operative complications comparing the national average and UMMC results. Complications Procedure

Median LOS (days)

Reoperation for bleeding (%)

Neurological deficit (%)

AV block req. permanent pacemaker (%)

Acute renal failure requiring temp dialysis (%)

STS

UMMC

STS

UMMC

STS

UMMC

STS

UMMC

STS

0.6

0.1

1.9

0.8

Coarctation of the aorta

STS

UMMC

STS

UMMC

STS

UMMC

STS

UMMC

STS

UMMC

0.6

0.3

0.2

Complete AV canal

STS

UMMC

STS

UMMC

STS

UMMC

STS

UMMC

STS

UMMC

VSD repair

TOF

Arterial switch

Norwood

UMMC

0.9

0.5

1.5

0.9

STS

UMMC

STS

UMMC

STS

UMMC

STS

UMMC

STS

UMMC

0.6

0.2

STS

UMMC

STS

UMMC

STS

UMMC

STS

UMMC

STS

UMMC

18.5

4.5

0.6

0.5

1.4

STS

UMMC

STS

UMMC

STS

UMMC

STS

UMMC

STS

UMMC

22.5

7.5

6.7

0.7

3.1

STS: Society of Thoracic Surgeons, UMMC: University of Mississippi Medical Center, VSD: Ventricular septal STS: Society of Thoracic Surgeons, UMMC: University of Mississippi Medical Center, VSD: defect, TOF: tetralogy Fallot, AV: atrio-ventricular. Ventricular septal defect, TOF: tetralogy of of Fallot, AV: atrio-ventricular. are based on the complexity of the operation performed rather )" " than on the lesion, with 5 being the most complex.2 This more inclusive score takes into account not only the cardiac lesion (potential for mortality and morbidity) but also the technical difficulty in performing the surgery and the post-operative care required to treat any given lesion. Using expected mortality per STAT category as a corollary for quality of care or measure of performance, pediatric surgical programs can be compared across the nation or internationally. The size of a program is based on annual surgical volume and, according to the STS Congenital Heart Database, is defined as small (<150 cases), medium (150-249) or large (>250 cases/year).3 Research utilizing the STS Congenital Heart Surgery database has shown an inverse relationship between case volume and operative mortality in pediatric heart programs. Put simply, practice makes perfect: the more surgery a heart program performs, the lower their mortality rates tend to be, particularly involving the most complex cases.3

Recent Developments In 2012, Dibardino and colleagues described the revitalization of the Children’s Heart Center, part of the state’s only Children’s Hospital at the University of Mississippi Medical Center.4 Since this publication, much additional program growth has occurred to provide high quality comprehensive care for babies, children, and young adults with congenital heart disease. This includes not only surgery but also pediatric cardiology, adult congenital cardiology, cardiac anesthesia, pediatric cardiac critical care, intensive care nursing, cardiac imaging, and extracorporeal membrane oxygenation (ECMO) support among others. Since program inception in 2010, surgical volume has also increased annually to a total of 1082 primary operations having been performed with a combined discharge mortality of 3%. According to the STS Congenital Heart Surgery Database, this surgical volume places the Children’s Heart Center in the medium-sized category. Table 1 shows the latest available mortality data provided by the STS Congenital Heart Database broken down into STAT and RACHS scores for both specific and all procedures. Mortality rates at the Children’s Heart Center of Mississippi are lower when compared to the national average in all complexity categories with the exception of RACHS and STAT 4. Further analysis of the same STS complexity and associated mortality data reports lower than expected mortality for the most complex operations (complexity score 6) at the Children’s Heart Center. The figure describes operative mortality of all medium-sized programs across the United States for the highest complexity category 5 operations, associated with the highest surgical risk and, therefore, mortality. Based on the most recent data from the STS for the most complex of cases, our Children’s Heart Center’s mortality (8.1%) was 3rd lowest of all similar sized programs in the country. As a second surrogate for quality of care, lower morbidity, more commonly designated by the lack of major complications, shorter length of intensive care stay or length of hospital stay (LOS), is quantified to give further insight into the efficiency of a program. Based on the STS national database presenting 6 standard surgical repairs for congenital heart defects of increas-

Figure. Medium volume programs Medium volume programs ‐STAT category 5 mortality rate (%)

60 50

50 40

33.3 33.3 33.3 34.1

30 20 10

11.1 8.6 8.7 10 10 6.7 7.1 8.1

14.8 13 13.3 13.6 14.3 14.3

16.7 16.7 17.2

20 20

22.2

24.1 25 25 25 25

35.7

37.5 37.5 38.1

26.9 27.8 27.8

February 2015 JOURNAL MSMA 33

ing complexity, the LOS are comparable to the national average. The rate of 4 major potential post-operative surgical complications is significantly lower and for some types of repair even eradicated (Table 2). This achievement in only 4 years results from the combined efforts and dedication of all aforementioned subspecialities involved in the care of children with congenital heart disease at the Children’s Heart Center which continues to strive for and improve on sustainable quality. Conclusions The presented data from the largest national database for congenital heart surgery (STS) emphasize the high level quality of care achieved by the Children’s Heart Center of Mississippi for patients undergoing the most complex heart surgery at UMMC Jackson. Despite meeting, and in some cases exceeding, national quality standards, the team remains committed to search for improved methodologies to achieve the best possible outcomes. We may not be the biggest (yet) but provide some of the highest quality of care for patients with congenital heart disease right here in Mississippi.

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References 1. Jenkins KJ, Gavreau K, Newberger JW, et al. Consensus-based method for risk adjustment for surgery for congenital heart disease. J Thorac Cardiovasc Surg. 2002;123:110-8. 2. O’Brien SM, Clarke DR, Jacobs JP, et al. An empirically based tool for analyzing mortality associated with congenital heart surgery. J Thorac Cardiovasc Surg. 2009;138:1139-53.

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3. Welke KF, O’Brien SM, Peterson ED, et al. The complex relationship between pediatric cardiac surgical case volumes and mortality rates in a national clinical database. J Thorac Cardiovasc Surg. 2009;137:1133-1140. 4. DiBardino DJ, Lancaster WJ, Merrill W, Mitchell ME, Taylor E, Gaymes C, Ebeid M, Shores J, Christ E, Taylor M, Sheth M, Jonas RA, Salazar JD. Revitalization of the University of Mississippi Children’s Heart Center: report card from the first 18 months. J Miss State Med Assoc. 2012;53:405-9.

The PEN is greater than the SWORD

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xpress your opinion in the Journal MSMA through a letter to the editor or guest editorial. Letters for publication should be less than 300 words. Guest editorials or comments may be longer, with an average of 600 words. All letters are subject to editing for length and clarity. If you are writing in response to a particular article, please mention the headline and issue date in your letter. Also include your contact information. While we do not publish street addresses, e-mail addresses or telephone numbers, we do verify authorship, as well as try to clear up ambiguities, to protect our letter-writers. You may submit your letter via email to KEvers@MSMA online.com or mail to: P.O. Box 2548, Ridgeland, MS 39158-2548.

34 JOURNAL MSMA

February 2015

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

• Scientific Articles •

Importance of Screening for Coarctation of the Aorta in Pediatric Patients Marco Pinder, MD; Jarrod D. Knudson, MD, PhD; Andrew L. Rivard, MD, MS; Kristen H. Miller, MD; Daniel J. DiBardino, MD; Jorge D. Salazar, MD; Avichal Aggarwal, MD

ntroduction

Coarctation of the aorta (CoA) is an obstructive lesion of the ascending, transverse or descending aorta that occurs in approximately 6-8% of children with congenital heart disease.1 Coarctation can have a wide variety of clinical manifestations ranging from being asymptomatic with a low grade systolic murmur and secondary hypertension to critical neonatal cardiac disease (cardiogenic shock requiring prostaglandin infusion and inotropic support). The most consistent initial finding is a difference in blood pressure of > 10 mmHg between upper and lower extremities. Evaluation of four extremity blood pressures is an easy and inexpensive screening tool that can be performed by the primary care physician. Such screening can lead to earlier recognition and definitive therapy (catheter-based or surgical), reducing morbidities such as hypertension, left ventricular hypertrophy, and intracerebral aneurysm formation.2

Case Description A four-year-old girl presented to cardiology clinic for evaluation of a heart murmur. She was born via c-section at 36 weeks gestation, and there were no reported complications with pregnancy or delivery. She had an uneventful postnatal course and was discharged home with her mother. Her past medical and surgical history was significant for recurrent otitis media, chronic sinusitis, tympanostomy tube placement, and tonsilloadenoidectomy. The patient’s mother had a history of mitral valve prolapse. The patient was referred to the cardiology clinic by her primary care physician for evaluation of a cardiac murmur present since birth. On evaluation, the patient’s mother described an active and playful child and only expressed concern about her daugh-

ter’s fatiguing more easily than other children her age. Review of systems was otherwise negative. Vital signs in cardiology clinic were: height 100 cm (29th percentile), weight 16.6 kg (43rd percentile), left arm blood pressure 169/93 mmHg, right arm blood pressure 170/96 mmHg, right leg blood pressure 105/63 mmHg, pulse rate 102 beats/min, respiratory rate 24/min, and pre- and postductal oxygen saturations of 100%. Cardiovascular examination revealed quiet precordium, a III/ VI holosystolic murmur best heard at the cardiac apex, and a continuous murmur heard on the back in the interscapular region. The lungs were clear to auscultation throughout with good air entry. There was no abdominal organomegaly, tenderness or distention. The peripheral pulses were palpable in the bilateral upper extremities but femoral and pedal pulses were weak and difficult to palpate. Electrocardiogram revealed normal sinus rhythm with left ventricular hypertrophy. Chest radiography revealed normal heart size and mediastinal contour. The lungs were clear with no increased vascular markings, pleural effusion or pneumothorax. Transthoracic echocardiogram revealed Figure 1. Three dimensional magnetic resonance angiogram profiling the aorta. There is a left aortic arch (posterior view) with long segment hypoplasia of the transverse arch and discrete CoA at the aortic isthmus. Additionally, as commonly seen in CoA, there is distal displacement of the left subclavian artery. CoA coarctation of the aorta.

Author Affiliations: Department of Pediatrics (Dr. Pinder and Dr. Knudson); Divisions of Critical Care and Cardiology (Dr. Rivard); Department of Radiology (Dr. Miller); Department of Surgery, Division of Pediatric and Congenital Heart Surgery (Dr. DiBardino and Dr. Salazar); Division of Pediatrics, Division of Cardiology (Dr. Aggarwal); Children’s Heart Center, The Blair E. Batson Children’s Hospital, University of Mississippi Medical Center, Jackson, Mississippi. Corresponding Author: Jarrod D. Knudson, MD, PhD, FAAP, Assistant Professor, Department of Pediatrics, Divisions of Critical Care and Cardiology, University of Mississippi Medical Center / Batson Children’s Hospital, 2500 North State St., Jackson, MS 39216. Phone: (601) 9845250 Fax: (601) 984-5283 (jknudson@umc.edu).

February 2015 JOURNAL MSMA 35

a small perimembranous type ventricular septal defect (VSD), normal left ventricular size and systolic function, and a Doppler pressure gradient of ~ 80 mmHg across the distal aortic arch. Cardiac magnetic resonance imaging revealed a severely hypoplastic transverse aortic arch and severe coarctation of the proximal descending aorta (Fig. 1). There were associated decreased flow and collateral vessels, increased systolic thickening of left ventricular myocardium due to hypertension, and a normally functioning bicuspid aortic valve. The child was referred to the congenital heart surgery service and underwent coarctation and VSD repair with excellent result. The VSD was closed primarily with pledgeted sutures. The aortic arch was incised longitudinally from the ascending to descending, and patch augmentation was performed using pulmonary homograft material resulting in no arch obstruction (Fig. 2). The postoperative course was uneventful, and the child is currently on propranolol for hypertension. Discussion The presentation of CoA can vary widely ranging from heart failure in infancy to children or adolescents with hypertension (with or without symptoms) or as a cardiac murmur. Earlier symptom presentation correlates to the severity of the CoA. There are limited data describing the environmental influence on developing CoA, but it is well known that there is a strong genetic association with Turnerâ&#x20AC;&#x2122;s syndrome (35% of affected patients).3 Once the suspicion of CoA has been confirmed with > 10 mmHg blood pressure differential between upper and lower extremities, timely referral to a pediatric cardiology is recommended. Echocardiography is an accurate and non-invasive modality for visualizing abnormalities of the heart and aorta. In the case of the patient discussed here, the degree of hypoplasia

was unclear based on the echocardiogram, thus prompting the cardiologist to obtain a Cardiac MRI with MRA. This study can clearly delineate the severity and area of coarcation for better surgical approach (Fig. 1). Other diagnostic tests useful in the diagnosis of coarcation are electrocardiogram (ECG), chest xray and cardiac catheterization. ECG in neonates reveals right ventricular hypertrophy (due to the right heart being dominant in the fetal circulation). Later in infancy, left ventricular forces will dominate the ECG. In older patients, signs of long-standing left ventricular outflow tract obstruction can be visualized by deep S waves in the right chest leads.4 Chest x-ray early in infancy will have limited benefit, but as patients get older, the contour of the aorta can be altered showing indentation of the aorta at the site of CoA known as the â&#x20AC;&#x153;3 sign.â&#x20AC;? Rib notching can occasionally be seen in patients greater than 5 years old due to collateral blood flow via the intercostal arteries to bypass the restricted flow across the CoA site. Catheterization can be diagnostic as well as therapeutic in the management of CoA. Percutaneous balloon angioplasty and stenting of the lesion are noninvasive, well-accepted interventions for CoA in select patients.5 The importance of timely diagnosis can be appreciated by the natural progression of the illness with progressive heart failure and persistent systemic hypertension, even despite repair if delayed.6,7 Frank et al. found the mean and median ages for referral were 8.4 and 5.8 years, respectively.8 Patients referred by the age of 9 years to a pediatric cardiologist had the best survival and a lower rate of residual hypertension.9 The appropriate timing of repair is dependent on early diagnosis. Nanton and Olley, in a study involving 147 children between 4 and 15 years of age before CoA repair, showed that the later operation, the less the reduction in the postoperative blood pressure index.10 Awareness of persistent elevated blood pressures (>95th percentile based on age, sex, and height on at least 3 oc-

Figure 2. Postoperative transthoracic echocardiogram. The transverse aortic arch and aortic isthmus are widely patent by 2D and color flow Doppler (panel A). There is no arch obstruction by continuous wave spectral Doppler interrogation (panel B).

A. B.

36 JOURNAL MSMA

February 2015

casions) is the most acceptable, consistent,n and reliable form of screening for coarcatation.

Conclusion / Recommendations

Currently the AAP recommends blood pressure screening to begin at the age of 3 years old. These measurements should be taken in the upper extremities as hypertension and/or CoA may be missed if only lower extremity pressures are assessed. Once a child has been classified as hypertensive, a 3-extremity evaluation should be performed to asses for signs of CoA. Femoral pulses should be evaluated on all neonates and infants.6 If they are difficult to palpate or weaker than the brachial pulse, 3 extremity blood pressure evaluation should be performed. Additionally, 3 extremity blood pressure evaluation should be performed in any neonate with a murmur persisting beyond the initial neonatal transitioning period (the first several hours of life) as these measurements are a useful and inexpensive part of an initial work-up for cardiac murmurs in children.

References

1. Seguela PE, Guerin P, Gournay V. Severe coarctation of the aorta in children revealed by high blood pressure: a case report. Arch Pediatr. 2011;18:405-407.

3. Loffredo CA, Chokkalingam A, Sill AM, et al. Prevalence of congenital cardiovascular malformations among relatives of infants with hypoplastic left heart, coarctation of the aorta, and d-transposition of the great arteries. Am J Med Genet A. 2004;124A:225-230. 4. Ziegler RF. The genesis and importance of the electrocardiogram in coarctation of the aorta. Circulation 1954;9:371-380. 5. Rao PS. Coarctation of the aorta. Curr Cardiol Rep. 2005;7:425434. 6. Ward KE, Pryor RW, Matson JR, et al. Delayed detection of coarctation in infancy: implications for timing of newborn followup. Pediatrics 1990;86:972-976. 7. Cohen M, Fuster V, Steele PM, et al. Coarctation of the aorta. Long-term follow-up and prediction of outcome after surgical correction. Circulation 1989;80:840-845. 8. Ing FF, Starc TJ, Griffiths SP, et al. Early diagnosis of coarctation of the aorta in children: a continuing dilemma. Pediatrics 1996;98:378-382. 9. Presbitero P, Demarie D, Villani M, et al. Long term results (1530 years) of surgical repair of aortic coarctation. Br Heart J. 1987;57:462-467. 10. Nanton MA, Olley PM. Residual hypertension after coarctectomy in children. Am J Cardiol. 1976;37:769-772.

2. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics 2004;114:555-576.

PHYSICIANS NEEDED Internists, Cardiologists, Ophthalmologists, Pediatricians, Orthopedists, Neurologists, Psychiatrists, etc. interested in performing consultative evaluations according to Social Security guidelines.

OR Physicians to review Social Security disability claims at the

Mississippi Department of Rehabilitation Services (MDRS) in Madison MS.

DISABILITY DETERMINATION SERVICES 1-800-962-2230 February 2015 JOURNAL MSMA 37

â&#x20AC;˘ Scientific Articles â&#x20AC;˘

Fecal Transplantation to Treat Initial Severe Clostridium difficile Infection with Sepsis Luis A. Marcos, MD; Allen Gersh, MD; Kevin Blanchard, MD; Stephanie Foil; Brittany Mallini, PharmD; Steven E. Farrell, MD; Ralph Kahler, MD

bstract

We report a case of initial severe colitis by Clostridium difficile infection (CDI) presenting with E. coli bacteremia likely secondary to colitis and profound hypotension (sepsis) in the intensive care unit. Despite aggressive medical management, the diarrhea persisted and the patient remained hypotensive for 72 hours. After 7 days of failure to control symptoms despite aggressive medical management, fecal microbiota transplantation (FMT) was added as an adjunctive therapy. Symptoms resolved in approximately 24 hours and the patient remained free of symptoms at 9 months. Although FMT has been extensively used in recurrent cases of CDI, its use may be considered in initial severe cases of CDI, especially in those with multiple comorbidities including chronic dialysis and malnourishment. Key Words: Clostridium difficile, colitis, fecal microbiata transplantation (FMT) Introduction Clostridium difficile is a gram positive, spore forming bacteria that can cause diarrhea by producing inflammation through a toxin-production mechanism in the colon of humans.1 CDI occurs when spores of C. difficile germinate and replace normal colonic flora altered by antibiotics. Primary CDI has shown an increase in the number of cases from 149,000 in 2001 to 300,000 in 2005 in acute healthcare facilities.2 CDI may cause significant morbidity and mortality with an estimated 5.5%-6.9% of attributable mortality by CDI reported.3 CDI may also cause mild disease including diarrhea which may respond to a 10-14 day course of metronidazole. Severe disease may include toxic megacolon, sepsis, ileus, or colonic perforation, usually leading to poor outcomes (i.e. total colectomy and death). For severe disease, metronidazole may have a deAuthor Affiliations: Antimicrobial Stewardship Program, Infectious Diseases (Dr. Marcos and Dr. Kahler); Nephrology (Dr. Gersh); Gastroenterology (Dr. Blanchard) Microbiology (Ms. Foil); Internal Medicine (Dr. Farrell); Forrest General Hospital, Hattiesburg, Mississippi. Corresponding Author: Luis A. Marcos, MD, FACP, MPH; #4 Medical Boulevard. Hattiesburg, MS, 39401. (marcoslrz@yahoo.com).

38 JOURNAL MSMA

February 2015

creased effectiveness. Other therapeutic options, such as high dose oral vancomycin along with intravenous metronidazole, are indicated.4 Recent studies have shown that fidaxomicin is more effective for preventing recurrent CDI than vancomycin but is just as effective as vancomycin for treatment of primary infections.5 Despite proper dosing and duration of antimicrobials against C. difficile, rates of failure and recurrent disease are still high, ranging about 9-26% for metronidazole-failure and 21-47% for recurrent disease after 60 days of metronidazole therapy.6 Studies have shown that the recurrence of C. difficile colitis within 28 days in patients treated with vancomycin was 35.5%, whereas with fidaxomicin was 19.7% (P = .045).7 New modalities of treatment for severe recurrent CDI such as FMT have been reported in several studies.8-15 The concept of FMT is not new. Since 1958 there have been 36 published reports of FMT for CDI representing about 583 patients.16-18 In this report, a case of severe CDI with multiple comorbidities treated successfully with FMT is presented. Case Presentation A 54-year-old man on intermittent hemodialysis because of end stage renal failure was admitted to the intensive care unit at Forrest General Hospital in Hattiesburg, MS, with diarrhea, abdominal pain, hypotension, and gram negative bacteremia. He had been recently exposed to broad spectrum antibiotics because of an infected diabetic foot ulcer. Subsequently he developed profuse diarrhea (6-8 episodes per day) which impacted his quality of life, including missed dialysis sessions. His past medical history included end stage renal failure on hemodialysis through an A-V fistula (monthly kt/v numbers between 1.6-1.8, indicating patient met or exceeded the standards for adequacy of dialysis), diabetes mellitus, peripheral vascular disease, hypertension, history of pancreatitis, and strokes. On physical exam, lower abdominal tenderness was remarkable. White blood cell count was 8,800/mm3 (83% neutrophils), albumin 1.5 g/dL (two months prior to admission his albumin was 3.3 g/dL) and creatinine 5.1 mg/dL (on hemodialysis). Both sets of blood cultures on admission were positive for Escherichia coli. Apache II score was 27 (predicted death rate 55%). Charlson Comorbidity Index (CCI) score was 6. Clostridium difficile

toxin test (Xpert C. difficile Assay) in stools also returned positive (Cepheid GeneXpert ÂŽDx Systems). He was considered to have severe CDI, complicated with hypotension and sepsis (E. coli bacteremia likely associated with colitis). He required immediate admission to the intensive care unit because of severe hypotension (systolic blood pressure 50 mm Hg), tachycardia (pulse 110/min), fever (Tm:102ÂşF), and given vasopressors. He was started on metronidazole 500mg intravenously every 8 hours, vancomycin 500 mg by mouth every six hours, and cefepime 500 mg intravenously daily (adjusted to renal function). His diarrhea was persistent, and he remained hypotensive on vasopressors during the first 72 hours. Though blood pressure normalized and vasopressors were discontinued, gastrointestinal symptoms persisted. Continuous hemodialysis was considered but as blood pressure improved, intermittent hemodialysis was resumed. The patient continued to have profuse liquid diarrhea (8 times a day), abdominal pain, and poor appetite despite high doses of vancomycin and metronidazole. No signs of ileus were identified. After two days, total peripheral WBCs increased to 10,300/mm3. Because of the severity of CDI and continuous diarrhea after seven days of high-dose vancomycin, early use of FMT was thought to be appropriate to prevent further clinical deterioration. After the patient signed informed consent (with a statement that FMT is an investigational procedure and not FDA approved), he received the FMT through post-pyloric nasogastroduodenal tube (NGT) placed by an interventional radiologist on day seven of hospitalization. The donor was his own adult young daughter who was healthy and screened negative for potential pathogens by history. The next day at 0730 (day eight of hospitalization) approximately 100 mg of fresh donor stool (collected two hours prior) were mixed with 250-300 mL of 0.9% normal saline. After filtering the stools in a cheesecloth embedded with surgical gauzes, five 50 mL syringes were collected. At 0800, each 50 mL syringe was infused through the NGT over three minutes. Prophylactic intravenous promethazine 25 mg was given to the patient. Once the infusions were completed, the NGT was clamped for three hours and removed the following morning. Renal diet was started 24 hours after the procedure. His symptoms resolved the next day. He was able to eat and drink without having diarrhea. Forty eight hours after FMT, a repeat C. difficile toxin test was negative. He was sent home on day 21 of hospitalization. Twenty one days later, the patient was re-admitted to the hospital with gangrene of the foot. He was given broad spectrum antibiotics and in three days underwent above the knee amputation. He was admitted to the rehabilitation unit. His C. difficile toxin test was repeated after 14 days of being hospitalized and returned positive. Patient denied any changes in his bowel movements, which were solid stools as baseline (not liquid). He was placed on vancomycin 125 mg by mouth every six hours for 14 days. Later the patient was discharged home, and at six month follow up, the patient had no further diarrhea episodes and remained free of gastro-

intestinal symptoms. His C. difficile toxin test was negative at 6-month follow-up and he remains asymptomatic from a gastrointestinal standpoint 9-months after FMT. Discussion and Review of Literature FMT is one of the most successful treatments for CDI. Restoration of intestinal flora and colonization resistance to correct the disruption caused by antibiotic treatment is likely the mechanism responsible for cure.17 The overall success rate for FMT, regardless of administration method, averages approximately 90%.19 Donor determination and screening must be utilized appropriately and continues to be debated. While most donors have been housemates or family members, some clinicians strongly advocate that donors should not share living quarters with the patient, as there is a possibility that one may share the same defective microbiota. However, the data has demonstrated that transmitting donated stool containing C. difficile is not necessarily correlated with treatment outcome. Alternatively, some clinicians elect to utilize donations from individuals living in the same household, hypothesizing that in close living arrangements and with intimate partners potential pathogens likely have already been shared by both parties. Further controlled studies need to be conducted before reliable recommendations can be made regarding the most effective donator/ recipient paradigm. 20 Our case was successfully treated by FMT without recurrent disease after six months of follow-up. Most cases of hospital-acquired CDI have been associated with exposure to antimicrobial agents with cephalosporins and clindamycin associated with the highest risk.21 Prolonged hospital stay (and re-admission) with new acquisition of nosocomial spores of C. difficile may have occurred in this patient despite no change in bowel habits during his second hospitalization. The quality of life of this patient after FMT was significantly improved. Given the rapid clinical deterioration and the severity on admission (sepsis) of this CDI case, it was thought that FMT was appropriate in this patient as early therapy to prevent further clinical deterioration. A severe case of CDI with poor response to standard therapy during the first 72 hours (still on high dose vasopressors) and sepsis (without other source of infection for his bacteremia by E. coli - colonic enteric flora) met criteria for FMT.22 Furthermore, length of stay was likely shortened on this case since diarrhea resolved promptly after FMT, but this suggestion may need to be confirmed on studies with larger sample size. Patients on dialysis are at increased risk for being colonized with C. difficile (OR=8.1; 95% CI: 1.8-36.6).23 and for developing C. difficile colitis.23 Among patients on dialysis, those with a low albumin and high comorbidity index are at higher risk for developing C. difficile infection,24 such as our case. Although FMT has been used extensively for recurrent C. difficile cases, data in initial severe episodes is limited.26 FMT may

February 2015 JOURNAL MSMA 39

have been neglected for decades for the treatment for CDI because it is aesthetically unappealing, logistically challenging, and has limited data from randomized controlled trials. Nonetheless, recent randomized clinical trials have shown a higher efficacy by using FMT (81% response) when compared to vancomycin alone (31%) in patients with relapsed CDI (P<0.001).27 In conclusion, FMT was a proper therapeutic option for our case of severe initial CDI which required admission to the intensive care unit due to hypotension requiring vasopressors. The patient responded well to FMT without recurrent disease at six months of follow-up. FMT should be considered an appropriate early therapy in severe initial CDI cases when other comorbidities (including low albumin) may predict poor outcomes.

Acknowledgements

Thank you to all nurses from Forrest General Hospital who collaborated and participated during the first FMT in this hospital. FMT was approved by IRB Committee at Forrest General Hospital.

17. van Nood E, Speelman P, Nieuwdorp M, Keller J. Fecal microbiota transplantation: facts and controversies. Curr Opin Gastroenterol. 2014;30:34-9. 18. Eiseman B., Silen W., Bascom G.S., Kauvar A.J. Fecal enema as an adjunct in the treatment of pseudomembranous enterocolitis. Surgery 1958; 44:854-9. 19. Bakken JS. Fecal bacteriotherapy for recurrent Clostridium difficile infection. Anaerobe 2009; 15:285-9. 20.

Rohlke, F, Stollman N. Fecal microbiota transplantation in relapsing Clostridium difficile infection. Therap Adv Gastroenterol. 2012 Nov; 5(6): 403–420. Available at: http://www. uptodate.com/contents/fecal-microbiota-transplantation-in-the-treatment-of-recurrent-clos tridium-difficile-infection

2 1.

Slimings C, Riley TV. Antibiotics and hospital-acquired Clostridium difficile infection: update of systematic review and meta-analysis. J Antimicrob Chemother. 2014;69:881-91.

2 2.

Moore T, Rodriguez A, Bakken JS. Fecal Microbiota Transplantation: A Practical Update for the Infectious Disease Specialist. Clin Infect Dis. 2014:58:541-5.

23. Leekha S, Aronhalt KC, Sloan LM, Patel R, Orenstein R. Asymptomatic Clostridium difficile colonization in a tertiary care hospital: admission prevalence and risk factors. Am J Infect Control. 2013;41:390-3. 24. Buchner AM, Sonnenberg A. Medical diagnoses and procedures associated with clostridium difficile colitis. Am J Gastroenterol. 2001;96:766-72. 25. Sheth H, Bernardini J, Burr R, Lee S, Miller RG, Shields M, Vergis EN, Piraino B. Clostridium difficile infections in outpatient dialysis cohort. Infect Control Hosp Epidemiol. 2010;31:8991. 26. Trubiano JA, Gardiner B, Kwong JC, Ward P, Testro AG, Charles PG. Faecal microbiota transplantation for severe Clostridium difficile infection in the intensive care unit. Eur J Gastroenterol Hepatol. 2013;25:255-7. 27. van Nood E, Vrieze A, Nieuwdorp M, et al. Duodenal infusion of donor feces for recurrent Clostridium difficile. N Engl J Med. 2013;368:407-15.

References 1. Khanna S, Pardi DS. Clostridium difficile infection: new insights into management. Mayo Clin Proc. 2012; 87: 1106–17. 2. Carrico RM, Archibald LK, Bryant K, et al. APIC Guide for elimination of Clostridum difficile in healthcare settings. In: Association for Professionals in Infection Control and Epidemiology. Elimination Guide Series. Washington DC: Association for Professionals in Infection Control and Epidemiology; 2008:1-66.

MAY 22-26

3. Dubberke ER, Butler AM, Reske KA, et al. Attributable outcomes of endemic Clostridium difficile-associated disease in nonsurgical patients. Emerg Infect Dis. 2008;14:1031-1038. 4. Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC, Pepin J, Wilcox MH; Society for Healthcare Epidemiology of America; Infectious Diseases Society of America. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA). Infect Control Hosp Epidemiol. 2010;31(5):431-55. doi: 10.1086/651706. 5. Louie TJ, Miller MA, Mullane KM, et al. Fidaxomicin versus vancomycin for Clostridium difficile infection. N Engl J Med. 2011;364:422-431. 6. Pepin J, Alary ME, Valiquette L, et al. Increasing risk of relapse after treatment of Clostridium difficile colitis in Quebec, Canada. Clin Infect Dis 2005;40:1591-7. 7. Conerly OA, Miller MA, Louie TJ, et al. Treatment of first recurrence of Clostridium difficile infection: fidaxomicin versus vancomycin. Clin Infect Dis 2012: 55 Suppl 2:S154-61. 8. Rohike F, Stollman N. Fecal microbiota transplantation in relapsing Clostridium difficile infection. Ther Adv Gastroenterol. 2012; 5: 403–19. 9. Brandt LJ, Reddy SS. Fecal microbiota transplantation for recurrent Clostridium difficile infection. J Clin Gastroenterol. 2011; 45(Suppl.): S159–67. 10. Guo B, Harstall C, Louie T, Veldhuyzen S, Dieleman LA. Systematic review: faecal transplantation for the treatment of Clostridium difficile-associated disease. Aliment Pharmacol Ther. 2012; 35: 865–75. 11. Borody TJ, Campbell J. Fecal microbiota transplantation. Gastroenterol Clin. 2012; 41: 781– 803. 12. Borody TJ, Khoruts A. Review: fecal microbiota transplantation and emerging applications. Nat Rev Gastroenterol Hepatol. 2012; 9: 88–96.

upto the mic r medicine.

13. Landy J, AL-Hassi HO, Mclaughlin SD et al. Review article: faecal transplantation therapy for gastrointestinal disease. Aliment Pharmacol Ther. 2011; 34: 409–15.

14. Brandt LJ. Intestinal microbiota and the role of fecal microbiota transplant (FMT) in treatment of C. difficile infection. Am J Gastroenterol. 2013; 108: 177–85. 15. Khoruts A, Dicksved J, Jansson JK, Sadowsky MJ. Changes in the composition of the human fecal microbiome after bacteriotherapy for recurrent Clostridium difficile-associated diarrhea. J Clin Gastroenterol. 2010; 44: 354–60. 16. Dodin M, Katz DE. Faecal microbiota transplantation for Clostridium difficile infection. Int J Clin Pract. 2014; 8:363-8.

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• Earn up to 17 hours of CME credit with prominent speakers on topics relevant to Mississippi medicine • Network with peers and enjoy a family beach vacation with lots of free time Memorial Day weekend!

• President’s Page •

Advocacy

olleagues,

I bet that every MSMA president in recent memory has written a President’s Page about advocacy. That’s because advocacy is just so darn important to our practices and to our patients. I was delighted to join a dozen pediatric residents, faculty mentors, and medical students at the State Capitol in February as they walked the halls and listened to legislative debates. For some, it was a real eye-opener. There are some truths about advocacy work. First, the Federalist system makes it difficult at best to pass even the most universally supported proposal. It’s a system that was well designed to provoke Claude D. Brunson, MD discussion, debate, and even dissent. It’s really quite remarkable that anything 2014-15 MSMA President ever makes it through that quagmire. Next, lawmakers don’t always vote based on logic or even science. Look at the 2015 legislative session: some lawmakers would allow parents to refuse to have their children immunized because the parents mistakenly believe that vaccines are dangerous. We know the science. We understand how easily measles and pertussis spread. And it’s part of our job to tell lawmakers what we inherently know about diseases that affect our patients. There were legislators this session ready to allow podiatrists to do surgery on anything below the knee and legislators who want to add social workers to the list of professionals who can commit patients against their will to a psychiatric facility. We know advocacy is necessary; yet, I talk every week with physicians who find the process offensive. It’s easy to become jaded, although I believe that it’s unrealistic to expect lawmakers to know anything at all about medicine and healthcare if we do not tell them. It’s just as unrealistic to expect a farmer from Mantachie to know how many vaccinations a child needs as it is to expect a homemaker from Meridian to know which antibiotic to prescribe for strep. Legislators don’t know much about health care. Governor Barbour once joked that a balanced diet is a cookie in each hand. There is no way your legislators will know what’s important to physicians and patients if we don’t tell them. That’s why we must take up the mantle just like the pediatricians at the Capitol in February. To keep you informed MSMA sends out an electronic newsletter each week during the session making it easy to follow progress and link to the actual text of bills. We owe it to our profession and to our patients to be a part of the solutions. MSMA President Dr. Claude Brunson joined the Mississippi Chapter of the American Academy of Pediatrics in hosting “Capitol Day,” held annually for pediatric residents, faculty mentors, and medical students at the State Capitol.

February 2015 JOURNAL MSMA 41

• Physician’s Bookshelf • The State of Health and Health Care in Mississippi Reviewed by Richard D. deShazo, Associate Editor

University of Mississippi Press, 2015 ISBN: 978-1-62846-0001 (Printed casebinding $75.00) 978-1-62846-001-8 (e-book) 480 pages (approx.), 8 1/2 x 11 inches, 66 figures and tables, introduction, bibliography, index

he State of Health and Health Care in Mississippi edited by Mario J. Azeudo, PhD, MPH, MA was published by University Press of Mississippi in early in 2015. The authors of the book’s 14 chapters are for the most part faculty members in public health and health related programs at Jackson State University and are affiliated with the Public Health Programs there. However, their backgrounds and experiences are diverse and far from parochial. Moreover, their knowledge of public health in Mississippi is broad, circumspect, and presented in historical context that places Mississippi’s worst case scenario of health within a national perspective. As a medical historian, I especially enjoyed the chapter on the history of health care in Mississippi. The editor skillfully directs the reader through the two sections of the book, the first devoted to health and health policy and the second to an analysis of where we are as a state in infectious disease, chronic disease, maternal and child health, and mental health, among others. The editor offers a helpful “health balance sheet” and commentary after each of the two sections. There have been few honest and well performed global assessments of the health of our state in the recent past. There have been fewer honest commentaries about our perennial failure to move forward in addressing the social determinants of health that make the health status of Mississippi so embarrassing that those who have the opportunity and power to address it are fearful of changing to the politics of poverty and race that caused it in the first place. The authors note, “Society as a whole and the state of Mississippi in particular have failed poor white and racial and ethnic populations and there is a dense web of causation. There is no attempt to place blame here but the evidence is appropriately placed in context.” They note several facts that speak to the priorities in place at present. For instance, the state ranks “44th among the states in the percentage of states General Funds allocated to Medicaid” and, of course, the same can be said about the support of the State Department of Health. They note that “only 2% of Medicaid dollars are part of preventative services for children, reflecting our emphasis on treatment rather than prevention.” They show data to support the conclusion that Mississippi’s health system is a fragmented fee-based health system that, according to national and state statistics, is ranked among the most inefficient and least effective in the nation. So why would or should any of us want to read this book? For the most part, we already know the conclusions without knowing the specifics of the data. The reason to buy, read, and re-read this book is the opportunities and innovations for change that are offered throughout the text. One that is most important is the under-utilization of geographic information systems (GIS) to integrate and utilize public health data at the state level to optimize the deployment and use of health personnel and resources. What a difference this could make in our present HIV recurrence in the Delta. There is also a very useful chapter on the statistics of primary care opportunities for improvement of systems of care. If you love Mississippi and Mississippians like I do, spend some time with this book. Maybe we can put our heads together to make health and health care better, right here, right now. r

42 JOURNAL MSMA

February 2015

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• Images in Misssissippi Medicine •

ISSISSIPPI CHARITY HOSPITAL, JACKSON, 1920--- This 1920 postcard described the institution as follows: “A State Hospital for the care of the sick and injured who are not able to pay their expenses at any hospital. Not open to anyone who is able to pay. A most worthy institution.” The State Charity Hospital at Jackson was established in 1912. It was located at 1219 North State Street, where the current Mississippi Baptist Hospital stands. This hospital was demolished in the 1950s after the opening of the University of Mississippi Medical Center, which assumed its role providing charity care to the state’s citizens. Among the physicians delivering babies there in 1920 was female physician, Dr. Irene Fatheree. The state’s charity hospital system dates to the early nineteenth century and included hospitals at Vicksburg, Laurel, Meridian, Natchez, and Biloxi. Although UMMC’s opening resulted in the closure of the Jackson Charity Hospital, others remained in operation until 1989, when Governor Ray Mabus proposed the closure of the last three remaining hospitals. Mabus asserted that the poor would be better served if the hospital money went into Medicaid and received the quite favorable federal funding match. If you have any old stories or factual data about the Jackson Charity Hospital, please contact me. Also, if you have an old or even somewhat recent photograph which would be of interest to Mississippi physicians, please send it to me at lukelampton@cableone.net or by snail mail to the Journal. --- Lucius M. “Luke” Lampton, MD; JMSMA Editor

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

Mississippi Medicaid from a Pediatric Perspective Gretchen Mahan, Chapter Executive Director, MS Chapter AAP

s of 2015, Mississippi Medicaid and the Mississippi Children’s Health Insurance Program (MSCHIP) insure about 64% of the state’s children. Of the total 745,000 lives covered by MS Medicaid, 57% of them are age 18 or younger. These numbers demonstrate the vital role that Medicaid and MSCHIP play for the children in our state. Since December of 2013, the leaders of the Mississippi Chapter of the American Academy of Pediatrics (MSAAP) have been meeting regularly with Dr. David Dzielak, the Executive Director of the Mississippi Division of Medicaid (MSDOM), as well as other members of his leadership team. The DOM’s “open door” policy with us has resulted in frank discussions on various aspects of Medicaid and Medicaid managed care in our state. Since we represent the great majority of pediatricians in the state, we have been focusing mainly on how Medicaid affects the care of children of Mississippi. It was clear early on that DOM was very committed to the Mississippi Coordinated Access Network (MSCAN) as a method to improve care for beneficiaries as well as save money for the taxpayers. While we knew that the status quo fee-forservice DOM model needed some major reforms and improvements, we would have preferred other provider-led coordinated care models such as those accomplished in Arkansas and North Carolina. However, DOM made it clear that they were committed to MSCAN for the foreseeable future. Respecting that decision, we made it clear that as MSCAN was developed further, we wanted to be at the table to represent both children covered by Medicaid as well as pediatricians who care for them. Since that time we have been meeting with the leadership of Magnolia Health and United Healthcare Community Plan (UHCCP) every 1-2 months to discuss issues relevant to children covered by MSCAN as well as by MSCHIP. We have worked with both companies to solve some system problems, and we will continue to help optimize care delivery as much as possible as more children are rolled into MSCAN later this year. Both companies have been developing care models that include some forms of pay-for-performance based on quality measures and /or incentives, and we have been told these models should be expanding more this year. While the initial startup of MSCAN under the previous DOM administration was poorly planned and led to massive confusion to patients and to the provider community, this DOM administration has made strides to improve the program and how it affects patients and providers: •

Increasing the filing time for claims from 90 to 180 days, as well as merging all drug formularies into one “universal formulary” for all Medicaid and MSCHIP patients are examples of how MSCAN has changed for the better in the last year.

•

DOM is currently working on updating and improving the EPSDT program by making it more reflective of the AAP’s Bright Futures guidelines for preventive care. Children should benefit from this move since their preventive care will be improved by being more evidence based.

February 2015 JOURNAL MSMA 45

•

MSAAP has been delighted to learn recently that DOM has named its first Medical Director to be UMMC Pediatrician Dr. Tami Brooks. Dr. Brooks has proven to be an outstanding leader and communicator at UMMC as well as within the AAP.

•

We were also very pleased with DOM in early 2014 when they supported extension of the ACA Medicaid Primary care payment increase beyond 2014 with state funding. During the 2014 MS Legislative session, DOM was instrumental in securing this important key to access to care for Medicaid patients through at least the 2016 fiscal year, and they expressed their commitment to extending this payment increase even beyond 2016. As of late 2014, we are one of only 14 states in which this Medicaid primary care payment increase will be extended into 2015. A recent study published in the New England Journal of Medicine showed that this pay increase significantly improved access to care for Medicaid beneficiaries in 10 states compared to those covered by private insurers, and states with the largest increase in payment showed the greatest improvement in appointment availability.

This current DOM administration has been in place only a little over 3 years, and they have had the tall task of implementing the many changes mandated by the ACA and CMS. It has been our experience that Dr. Dzielak and his team do truly want to improve quality of care and access to care for all Medicaid beneficiaries, and they have been very approachable in dealing with our team. Since the MSCAN model contracts for savings up front, it has saved Mississippi taxpayers money. The jury is still out on what kind of improvements in care quality and access to care that MSCAN can deliver. The program is only in its infancy, and it has been covering only small fragments of the Medicaid eligible population thus far. One major advantage the MSCAN companies have is the ability to track data and population health. DOM says it does not have the ability to gather and analyze this type of data on patients in its fee-for-service (FFS) population. Also, the MSCAN plans have staff to analyze this data as well as case managers who can help fill gaps in patient care by communication and education with the beneficiaries. These are theoretical advantages at this point, but they do offer potential for improvements in care delivery down the road. We know that Medicaid managed care is now active in most states, and there have been some shortcomings and failures with past managed care models. Moreover, we recognize that there are vast differences in how Medicaid managed care is set up and run in the different states. MSCAN has presented challenges along the way such as poor communication with providers, but both companies are saying they are increasing the presence of their provider reps this year. We have not seen very significant or meaningful usage of case managers, but we want to work with both companies to find ways their case managers can make a measurable difference at the population level. There have been some issues with MSCAN network adequacy, especially with adult subspecialists as well as some pediatric subspecialists in contiguous states, but we are investigating how these gaps can be improved. We will find out a lot more about the MSCAN program and its insurers later this year when most Medicaid eligible children are planned to move from FFS into Magnolia and UHCCP. We are concerned about the rate at which these remaining FFS children will be moved into MSCAN this year. We had initially been told the move would be a slower one, but now DOM is planning for a large movement of about 300,000 children over a 3 month period this summer. Despite these challenges, we do hope that MSCAN will be a success for Mississippi, and we will continue to work with all parties involved to help accomplish that end. We appreciate DOM, Magnolia Health, and UHCCP for their partnerships in working together over the past year, and we hope to continue working together with the common goal of improving the delivery of health care to Mississippi babies and children.

—Mississippi Chapter of the American Academy of Pediatrics

MS Chapter AAP 2015 Annual CME Meeting: Pediatrics that Make a Difference April 23-24, 2015 Embassy Suites Hotel -- Ridgeland, MS http://www.aapms.org/CME-and-Education/ 46 JOURNAL MSMA

February 2015

• University of Mississippi Medical Center • Woodward, in Driver’s Seat, Plans to Accelerate

r. LouAnn Woodward, the Medical Center’s newly selected vice chancellor, will take over from a man old enough to be her father but not too old to be her friend. After serving for more than five years as the institution’s leader, Dr. James Keeton, 75, will step down by summer in favor of his second-in-command and the first woman to ever sit in that chair. The exact date of the transition hasn’t been determined. Dr. LouAnn Woodward, “He has been a wonderful friend and an amazing mentor, and I’ve learned the Medical Center’s new a lot from him,” said Woodward, 51. “Working with him has been tremendously vice chancellor for health helpful for me.” affairs and dean of the For his part, Keeton said, “I could not have done my almost six years in School of Medicine this job without our partnership. Because it has been a partnership, and it’s been fun.” With the appointment of Woodward, announced Wednesday by Chancellor Dan Jones, the Carroll County native is poised to make history, if not major changes. “I don’t see any crashing of programs,” said Woodward, who will continue serving as associate vice chancellor for health affairs until Keeton officially retires as the Medical Center’s leader and medical school dean. “I believe we’re on the right track with all our missions. But I would like to see this institution put its foot on the gas and accelerate. Of course, we’ll always need to reassess, but the general direction we’re headed in is very good.” Woodward, an emergency medicine physician, has been a part of UMMC’s academic administration since 2003 and has served in the vice chancellor’s office with Keeton since 2009. Since then, she has been vice dean of the medical school as well. “I believe the leadership team in the School of Medicine, and in the whole organization, is as strong as it’s ever been,” she said. “The leaders here are strong and dedicated people.” With her rise to the Medical Center’s top post, “two of the most powerful advocates for the health of Mississippians are women,” said Keeton, referring also to Dr. Mary Currier, State Health Officer, who, like Keeton and Woodward, earned her medical degree at UMMC. The new vice chancellor, basically the CEO of the Medical Center, will be responsible for 10,000 employees, 3,000 students, four teaching hospitals, two community hospitals, five health professions schools, and an annual operating budget of $1.6 billion. Jones announced his choice of Woodward following a meeting of the board of the Mississippi Institutions of Higher Learning, which affirmed it. “Dr. Woodward’s years of experience with the University of Mississippi Medical Center make her the perfect choice to lead the institution,” said Aubrey Patterson, president of the IHL board. “She understands every aspect of the UMMC mission and will provide leadership to expand the medical center’s service to its patients, its students, and the state.” The selection was the culmination of a national search that began around July when Keeton announced his intention to retire. The other finalist was Dr. Stephen J. Spann, a family medicine physician and chief medical officer for the Johns Hopkins Medicine-affiliated hospital in the United Arab Emirates. “The search committee, headed by Dr. Patrick Smith, was frequently commended for its integrity,” Woodward said. “The only thing that could have improved it was it could have been a little faster,” she said with a laugh. —Gary Pettus, UMMC Public Affairs

February 2015 JOURNAL MSMA 47

• Mississippi State Department of Health • Ocean Springs Pediatrician Named District Health Officer for Coastal Counties

Jackson native, Dr. D’ette Lorio has been with the MSDH since September. She earned her Bachelor of Science degree from Millsaps College and her medical doctorate from the University of Mississippi Medical Center. D’Ette Lorio, MD, has been Upon completion of her residency in pediatrics at the Arkansas Children’s named the District Health Hospital, she began practicing pediatrics in Charleston, S.C., where her husband Officer for the Mississippi was in surgery residency. She moved her pediatrics private practice to Ocean State Department of Health Springs in 1997. (MSDH) Coastal Plains “As a Public Health District IX, long-time which comprises Pearl River, Stone, George, pediatrician, Hancock, Harrison, and I’ve always Jackson counties. had a deep interest in the community and its future, especially through immunizations and early intervention strategies,” said Dr. Lorio. “I look forward to stepping into a public health role that will keep me involved with the health of Mississippi parents and children.” Dr. Lorio has also been active in numerous “MEA physicians offer our patients professional and civic organizations. She has had a continuity of care. At every leadership roles in organizations such as the 4-H MEA Medical Clinic, you’ll see “Health Rocks!” Healthy Life Series and Girl Scouts familiar faces together with new Fitness and Healthy Foods Programs, as well as local members of our growing school wellness committees promoting safety, health, Primary Care team.” immunizations and influenza vaccination programs. “Dr. Lorio brings a wealth of experience and William E. Loper, MD, ABFP expertise to the public health arena. She will be a MEA Board Member and great addition to the Mississippi State Department of Medical Director of MEA in Ridgeland Health and the coastal area,” said MSDH State Health Partner since 1998 Officer Dr. Mary Currier. “We are thrilled to welcome her aboard.” Dr. Lorio replaces longtime District IX Health Officer Dr. Robert Travnicek, who retired in 2013. Contact us today for information on Deputy State Epidemiologist Dr. Paul Byers has been how you could become part of MEA’s winning team. serving as Acting District IX Health Officer since Stephanie Holt recruiter@meamedicalclinics.com Travnicek’s retirement. r 601-898-7567 meamedicalclinics.com

A Continuity of Care.

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• Special Article •

Lloyd Tevis Miller, MD Professionalism in the Jim Crow South Michael C. Trotter, MD, FACS

ntroduction

One of the most famous surgeons Mississippi has produced was not a member of the American College of Surgeons nor is he listed in the encyclopedic work of Claude H. Organ, MD, FACS, A Century of Black Surgeons.1 Yet his story is one of professionalism in an unlikely time and place. The Mississippi Delta is a storied and legendary place with many enduring influences on art, music, literature, cuisine, and culture, largely due to its socioeconomic history.2 To quote author Gene Dattel, “The Delta is truly the quintessential intersection between cotton and race. Cotton dominated the economy; blacks dominated the population.”3

Figure 1. Lloyd Tevis Miller, MD (Courtesy of Paul D. Jackson, MD)

Against this background Lloyd Tevis Miller, MD, overcame obstacles throughout his life and achieved personal and professional success (Figure 1).4 His contributions to patient care, physician education, and organized medicine in the settings of the Jim Crow South and the Mississippi Delta are a significant chapter in Mississippi’s medical history.

Lloyd Tevis Miller, MD Lloyd Tevis Miller was the youngest of seven children born to Washington Miller and his wife Emily in 1872 during Reconstruction. He was nicknamed “Daisy” (later shortened to “Dais”) because his mother wanted a girl. Washington was a slave owned by a man named Hagan, and Emily had been a house slave at Melrose Plantation in Natchez, Mississippi. Washington was taken to California by Hagen at the outset of the Civil War and allowed to work and save his earnings to purchase his and his family’s freedom. After emancipation Washington returned to Natchez and re-united with his family.5,6 James Hagan Miller was their first child born after emancipation. Because James had been named after Hagan, Washington Miller was given a cow, and the money made from selling milk was saved for the education of the children. Washington had been a hackman who drove a horse and carriage for hire and started a successful livery business after selling his home and land to the Illinois Central Railroad. Lloyd, or L.T., graduated from high school in St. Louis, returned to Natchez, and attended Natchez College. He subsequently graduated from Meharry Medical College in Nashville in 1893.5,6,7 James, or J.H., attended Tougaloo College in Jackson and then medical school in Illinois, perhaps influenced by his youngest brother who preceded him in medical education.7 Another possible influence was A. W. Dumas, MD, a distant relative and a pioneering AfricanAmerican physician in Natchez, who had graduated from the Illinois College of Medicine in 1899. Another brother, Washington, became a pharmacist in South Carolina. Following their respective graduations, L.T. went to Yazoo City after a short period in Natchez, and J. H. came

February 2015 JOURNAL MSMA 49

Figure 2. James Hagan Miller, MD (Courtesy of Paul D. Jackson, MD)

Fullilove, MD, (Figure 3) a 1907 Meharry graduate, joined Miller in practice around 1911. Like Miller, Fullilove’s parents had been slaves. Also, like Miller, his father was allowed to work and earn money with which to purchase his freedom.9 Fullilove initially practiced in Tupelo before joining Miller in an apprentice-type relationship. Their association would last until Miller’s death 40 years later.

Figure 3. Robert Elliott Fullilove, MD

(Reproduced with permission; Afro-American Sons & Daughters; Joseph C. Thomas, author)

to Greenville after a short period in Meridian (Figure 2). After J. H. decided to leave Meridian because of racial instability, L. T. encouraged him to come to Greenville as it was closer to Yazoo City and they could help each other.7 Essentially these were upwardly mobile moves based on better socioeconomic opportunity. With minimal access to healthcare for African-Americans, each was soon very busy. Shortly after L.T.’s arrival in Yazoo City, a smallpox epidemic enabled him to treat patients of both races and acknowledged him as the “Doctor of the Delta.”6,8 It was unheard of for African-American physicians to practice at white infirmaries, sanitariums, or hospitals, and white physicians had to “vouch” for them in order for the AfricanAmerican physicians to be able to practice. The brothers traveled between Greenville and Yazoo City, with each trip taking a full day, and assisted each other with operations. Without access to hospitals and support services, they had to improvise. This is exemplified by the fact that amputated limbs and tumors were buried in the backyard and covered with bricks, lime, carbolic acid, and stones. A portion of their homes served as offices, clinics, and operating rooms. Beds were rented in private homes for postoperative care.5,6,8 With an enlarging practice presence by 1907, Miller opened his first sanitarium in Yazoo City, the 18-bed Miller Infirmary.5,8 He averaged 30 operations per month at that time. Additionally he owned his own pharmacy, Peoples Drug Store, with his wife Emma.5,6 The 18 beds of his infirmary more than doubled the available hospital beds for African-Americans in Mississippi in 1907. Robert Elliott

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“Doctor of The Delta” and “Cousin Tom” Thomas Jefferson Huddleston was the son of a slave and became a teacher, farmer, businessman, and building contractor in Yazoo City. He was also the grandfather of Mike Espy, the first African-American Secretary of Agriculture under President Bill Clinton and Henry Espy, longtime mayor of Clarksdale. Huddleston brought Miller the idea of forming an organization named the Afro-American Sons and Daughters (AASD) for the purpose of becoming a statewide fraternal insurance organization offering death and hospitalization benefits to its members.5,6,7,9,10 They became cofounders and the organization was chartered in 1924 with 1000 members (Figure 4).5,6 Huddleston was an excellent speaker and salesman and was known as “Cousin Tom” because he said every member was his “cousin.”11,12 By 1927 there were 16,000 members and by the 1930s the organization had 35,000 members.11 In 1928 they built a $50,000 32-bed hospital in Yazoo City, the Afro-American Sons & Daughters Hospital (AASDH).8 Before the hospital

Figure 4. Afro-American Sons and Daughters Organization (Reproduced with permission; Afro-American Sons & Daughters; Joseph C. Thomas, author)

served as Medical Director until 1951. In the 1930s and 1940s the hospital operated a nursing school (RN degree) which helped ensure adequate nursing staff for the hospital. Miller and the hospital were profiled in Ebony magazine in 1950.5 In the article it was noted that the 75-year-old Miller had performed 34,000 career operations. He had performed 785 major operations in the first 10 months of the previous year and averaged 65 per month in the 104-bed AASDH (Figure 5). He was described as a “foremost surgeon.” The hospital had a single operating room with two OR tables where both Miller and Fullilove worked with caseloads up to 10-12 cases per day.5,6,15 The gamut of general surgical practice included trauma, orthopedics, abdominal, breast, ENT, and ob/gyn. One remarkable case was that of esophageal diversion in a child for caustic stricture with long term survival into adulthood via rudimentary tube feedings.9 The facility achieved excellent results with a mortality rate between 1931-1935 of just over 4% despite challenges such as anesthesia (ether, chloroform, spinal) and limited resources.11,15,16 A comparison with similar facilities in South Carolina at the time noted a mortality rate of 13%.11 On the other hand, “No white folks would be caught dead out there in bed with black folks.”7 AASDH served as the inspiration for the Taborian Hospital in Mound Bayou which was founded by the International Order of Twelve Knights and Daughters of Tabor in 1938.10 This was the only similar facility in the Delta, and they maintained a friendly competitive relationship without antagonism.10,11 The story of the Taborian Hospital is perhaps better known than that of the AASDH for several reasons. One of these is the long-standing relationship with Meharry Medical College’s Department of Surgery under Matthew Walker, MD, FACS, and the consistent rotation of surgical residents through the Mound Bayou hospital.8,17,18

was built, Mississippi had less than 50 beds for more than a million African-American citizens. The hospital was enlarged to 104 beds in 1935.13 The hospital was a “boon” for African-American patients and developed an excellent reputation in the African-American community as compared to the Colored King’s Daughters Hospital in Greenville, despite the good work being done there.7,14 Patients came from all over Mississippi as well as Arkansas and Louisiana to the AASDH.11,15 The Mississippi Delta counties of Sunflower and Washington were the two largest sources of patients within the state.11 In 1932 Huddleston capitalized on the traditions of white funeral homes not Figure 5. Afro-American Sons and Daughters Hospital circa 1950 caring for African-American bodies and the propensity of Delta African-American (Reproduced with permission; Afro-American Sons & Daughters; Joseph C. citizens to obtain a decent burial regardless Thomas, author) of their socioeconomic circumstances. By developing and owning burial insurance and funeral home businesses, Huddleston was reportedly the wealthiest AfricanAmerican in the Delta. In 1942 his Century Burial Association had about 100,000 members, a casket factory, 15 funeral homes, and 500 employees.11 Capitalizing on another opportunity, his hearses served a dual role as ambulances to carry critically ill African-American patients to the only two hospitals available to them in the Delta. Miller brought Robert Fullilove and three nurses to staff the hospital and

February 2015 JOURNAL MSMA 51

Miller’s practice was busy. He was regarded very highly in the white community. Plantation owners referred their workers and sharecroppers to him and often paid the bills. When a white physician could not be reached, white patients requested house calls from him. Willie Morris, renowned writer from Yazoo City, was treated by Miller during childhood.7,8 In addition to surgery, Miller and Fullilove treated malaria, typhoid fever, asthma, pneumonia, influenza, tuberculosis, diphtheria, acute (cardiac) indigestion, diabetes, soft tissue infection, diarrhea, pellagra, anemia, hypertension, hepatitis, and arthritis.9 Pharmaceutical company samples were a true asset to their practices.9 Both physicians maintained private practices with patients outside of the AASD. The hospital also treated patients outside the organization on a fee-for-service basis; however, the consistency of the revenue stream was undeniably linked to the order.9,15,16

for publishing in major medical journals was likely limited so the local newspaper served as a repository for case reports.21 Miller was among the co-founders of the Mississippi Medical and Surgical Association in 1901 which represented AfricanAmerican physicians in the state.4 The organization’s 1934 annual meeting was held in Yazoo City and the group provided free clinics at the AASDH – 15 free operations – over a twoday period.8

Epilogue

Miller has been described as a kind, gentle, and generous physician and a shrewd businessman.7 He did not travel much and his main past-time appears to be playing bridge.7 He had an excellent professional reputation throughout the state and regionally.22 Miller sustained a stroke and died in 1951 in the AASDH.15 The L. T. Miller Scholarship at Meharry Medical School was established by his family, and the community Medical Education and Philanthrophy center in Yazoo City was named in his memory.6 Fullilove Miller appears to have entered practice directly from became the second Medical Director of the AASDH until his medical school,5 or after an internship.6 Regardless, his death in 1965, also in the AASDH.15 The hospital began to practice was of a general nature as was typical of the time experience financial difficulties in the 1960s as healthcare costs and place. Soon, however, the practice became primarily escalated and the business of medicine was forever changed 5 surgical due to the great need. Miller can be considered a with the advent of Medicare and Medicaid.11,23 Additionally the “GP-Surgeon” whose practice evolved into a surgical one facility suffered from the organization’s insurance premiums through experience and self-study during a unique period and not being escalated in conjunction with rising costs and the in a unique setting. This was not unusual for the time, and the lack of what would come shortly – federal funding – as well Mayo brothers initially evolved similarly by entering practice as continued African-American migration to the North, state with their father.19 Surgical training was beginning to evolve, regulation, and desegregation.7,10,23 The facility was renovated and Mississippi had begun to experience the arrival of formally by the Yazoo County Board of Supervisors in 1967 and used trained surgeons.14 until 1972 when it was closed and sold at auction. It was Miller’s practice can be described as “limited to skin listed on the National Register of Historic Places in 2006 and and contents.” As a result, Miller had a deep appreciation for was listed on the Ten Most Endangered Historic Places in the combination of experience and being well-read but not Mississippi list in 2007.24,25 It remains in ruin today (Figure 6). so much for mere observation where surgical education was concerned.5 Opportunities for post-graduate training were Figure 6. Afro-American Sons and Daughters Hospital in Yazoo City today limited for many African(Courtesy of the author). American physicians. Miller addressed this issue by employing or allowing young African-American physicians to spend time with him in apprenticeships, functionally creating an internship or miniresidency.5,6,20 Additionally, there is evidence of “exchange doctors” from Tuskegee who would spend time with Miller.15 He also provided financial assistance to African-American medical students.8 Access

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Conclusions L. T. Miller achieved personal and professional success in an unusual place – the Mississippi Delta – during an unlikely time period for such accomplishment – the Jim Crow era. He elevated the standard of care for both AfricanAmerican patients and African-American physicians. He was instrumental in developing a unique business model of medicine that served successfully before becoming extinct in the evolutionary process of healthcare and demonstrated quality care at affordable costs despite limited resources. During a time when practice and educational opportunities were significantly limited or non-existent for AfricanAmericans, he innovated and succeeded, to the betterment of us all.

References

1. Organ, CH; Kosiba, MM, (eds.). A Century of Black Surgeons: The USA Experience, Vol. 1 & 2. Norman, OK: Transcript Press. 1987. 2. Trotter, MC. “Healthcare in the Mississippi Delta: A Journey of Historical Significance.” Presentation at The Delta – Everything Southern! Conference. University of Memphis. Memphis, TN. 2012. 3. Dattel, G. Cotton and Race in the Making of America. Chicago: Ivan R. Gee, Publisher. 2009.

14. Trotter, MC. Hugh Agnew Gamble, MD, FACS: A Legacy to the College. Bull Am Coll Surg. 2014;99(12):44-48. 15. Nelson, Eunice. Interview with Barbara Allen. Yazoo County Scholar-in-Residence Oral History Project. May 6, 1980. Special Collections, B. S. Ricks Memorial Library, Yazoo City, MS. 16. Galloway, Leola; White, Carrie. Interview with Barbara Allen. Yazoo County Scholar-in-Residence Oral History Project. April 3, 1980. Special Collections, B. S. Ricks Memorial Library, Yazoo City, MS. 17. Walker, M. Mound Bayou – Meharry’s Neighbor. J Natl Med Assoc. 1973; 65(4):309-312. 18. Smith, RJ. Managed Health Care: The Taborian Hospital Experience, 1942-1983. J Natl Med Assoc. 2003;95(1):84-89. 19. Clapesattle, H. The Doctors Mayo. Minneapolis: University of Minnesota. 1941. 20. “Yazoo’s Dr. Miller Featured in Ebony, Negro Magazine.” Yazoo City Herald. March 2, 1950. 21. “Unusual Case is Treated by Colored Doctor.” Yazoo City Herald. Oct. 13, 1933. 22. “Dr. L. T. Miller, Negro Physician, Dies Thursday.” Yazoo City Herald. March 15, 1951. sec. 2. p. 1. 23. deShazo, RD; Lampton, L. The Educational Struggles of African-American Physicians in Mississippi: Finding a Path Toward Reconciliation. J Miss Med Assoc. 2013;54(7):189198. 24. http://misspreservation.com. Accessed May 5, 2014.

4. Lampton, LM. Opening the Doors of the Great Republic: Sex, Race, and Organized Medicine in Mississippi. J Miss Med Assoc. 2013;54(7):205-213.

25. http://mississippiheritage.com. Accessed May 5, 2014.

5. “Delta Doctor Performs 34000 Operations.” Ebony magazine. March, 1950.27-30.

About the author:

6. Sewell, GA; Dwight, ML. “L. T. Miller: Delta Doctor – Humanitarian” in Mississippi Black History Makers. Jackson, MS: University Press of Mississippi. 1987. 361-364. 7. Green, Daisy; Miller, Mary Louise. Interview with Barbara Allen. Yazoo County Scholar-in-Residence Oral History Project. Feb. 19, 1980. Special Collections, B. S. Ricks Memorial Library, Yazoo City, MS. 8. Ward, TJ. Black Physicians in the Jim Crow South. Fayetteville, AR: The University of Arkansas Press. 2003. 47, 71, 147, 160, 162-163, 198. 9. Balsley, Daisy. Interview with Barbara Allen. Yazoo County Scholar-in-Residence Oral History Project. 1980. Special Collections, B. S. Ricks Memorial Library, Yazoo City, MS.

Michael C. Trotter, MD of Greenville, Mississippi, practiced at Delta Regional Medical Center until his retirement from thoracic and cardiovascular surgical practice last year. He maintains a strong interest in medical history, particularly surgical history of the South and Civil War medicine. Dr. Trotter has authored multiple articles on these subjects, several of which have been previously published in our Journal MSMA.

10. Beito, D. Black Fraternal Hospitals in the Mississippi Delta, 1942-1967. Journal of Southern History. 1999;65:1:109-140. 11. Beito, DT; Beito, LR. “Let Down Your Bucket Where You Are.” The Afro-American Hospital and Black Healthcare in Mississippi, 1924-1966. Social Science History. 2006;30:4: 551-569. 12. Thomas, JC. Afro-American Sons & Daughters. Yazoo City, Mississippi. 1849-1949. Yazoo City, MS: Thomas & Kirk Publishing. 1997. 90. 13. Narrative Description. National Register of Historic Places Construction Sheet. United States Department of the Interior. National Park Service. NRIS Reference No.05001558. Section 7. Page 1.

February 2015 JOURNAL MSMA 53

MSMA STAT SCHOLAR

Passionate about physician advocacy? Participate in the MSMA STAT Program to get involved with your MSMA! STAT 2.indd 1

1/30/15 11:23 AM

MSMA STAT Program (Student Advocacy Training) Complete 6 of 12 activities during medical school and receive recognition and certificate from MSMA.

-Visit the Mississippi Capitol during the Legislative session with MSMA staff -Attend a local medical society meeting -Attend a Mississippi Board of Medical Licensure meeting -Join in on an MSMA legislative update conference call -Participate in a grassroots effort by writing a letter to a legislator -Write an article for the Journal MSMA

-Attend the MSMA Annual Session -Volunteer in an MSMA Foundation event -Participate in an AMA recruitment event/

AMA meeting

-Attend an MSMA Council on Medical Service meeting -Volunteer in an MSMA PAC event -Participate in an activity with the Medical Assurance Company of Mississippi

To get started, contact Conner Reeves with MSMA at 601-853-6733 or CReeves@MSMAonline.com 54 JOURNAL MSMA STAT 2.indd 2

February 2015

1/30/15 11:23 AM

• Letters • Remembering Senate Bill 2650 and Brown v. Stone: The Creation and Preservation of Mississippi’s Outstanding Immunization Law Dear JMSMA Editor, Mississippi’s immunization requirements are a topic of debate in the recent legislative session and in the recent editions of the Clarion- Ledger. During my service as State Health Officer (1972-1993), our state legislature enacted several laws that have proven to be effective for protection of the public’s health in Mississippi. The most important of those was Senate Bill No. 2650. This act required that all children enrolling in either public or private school in our state must be immunized against vaccine preventable diseases. At the time it was passed, Senate Bill No. 2650 was endorsed and supported by the State Medical and State Nursing Associations together with numerous child advocacy groups. It contained two main provisions. The first provision stated that immunizations could be exempt in children for medical reasons. This exemption, “could be offered on behalf of a child by a duly licensed physician…(and) accepted by the local health officer.” The original bill also contained a provision for religious exemptions, which could be filed “by an officer of a church of a recognized denomination.” Senate Bill No. 2650 contains no other basis for exception from its provisions such as personal beliefs or preferences. In the fall of 1979 our State Supreme Court received an appeal addressing one revision of the act from the Chickasaw County Chancery Court. The appeal rested on the contention that the religious exemption in the act was not broad enough. A father who had “strong and sincere religious beliefs” refused to vaccinate his son. He had appealed to his minister to sign a certificate on his behalf, but the minister said that their particular denomination “does not teach against the use of medicines,” but that “our local chiropractor, who is a member of the (Church), does have strong convictions against the use of any kind of medications and we respect his views.” This was apparently not a sufficient religious exemption. Having failed to get an “officer of a church” to fully endorse his cause, this particular father argued that his first amendment rights had been infringed upon. His argument illustrates a key problem in these discussions. Any provision gets slippery really quickly. Whose beliefs should be valid reason for exemption? What kind of religious beliefs should count for exemptions? What sort of personal reasons, as the states with those exemptions must surely find themselves asking, are sufficient justification for the corresponding risk to public health? The decision of the court, rendered in “Brown v. Stone,” is a fun read. It argues, “In cases too numerous to mention, it has been held, in effect, that a person’s right to exhibit religious freedom ceases where it overlaps and transgresses the rights of others.” As Oliver Wendell Holmes said so well, “My right to swing my fist ends where the other man’s nose begins.” The Court also differentiates between the rights of the parents and the rights of the child. Does a parent’s right to religious beliefs trump an innocent child’s right to “protection against crippling and death that immunization provides?” The child’s rights are often forgotten in these discussions, but he too has “rights in his own person…Where its safety, morals, and health are involved, it becomes a legitimate interest of the state.” The court opinion concludes with its findings that to allow exemptions for parental beliefs would violate the 14th amendment because an allowance of these exemptions would deny to the other students in the community “equal protection of the laws.” Thus, the “interests of the school children must prevail.” We should be thankful for Senate Bill No. 2650 and for the opinion of our Supreme Court in 1979. The enforcement of the act since its passage forty years ago has protected hundreds of thousands of Mississippi children from preventable disease and disability and possibly death.

Sincerely, —Alton B. Cobb, MD, MPH; Jackson February 2015 JOURNAL MSMA 55

• Poetry and Medicine • [This month, we print a poem by William “Bill” C. Lineaweaver, MD, a Brandon plastic surgeon and burn specialist who’s also a member of the JMSMA Editorial Advisory Board. He’s medical director of the JMS Burn and Reconstruction Center in Brandon, the state’s only inpatient burn service. He is also the editor of the “Annals of Plastic Surgery.” He has appointments from the Department of Orthopedics of Fudan University in Shanghai, China, and the Division of Plastic Surgery of the University of Florida. The poem refers to the groundbreaking 1965 album of jazz great John Coltrane (1926-1967) entitled, “A Love Supreme,” which is also consistently mentioned as one of the greatest albums in jazz. As well, he mentions “L’Arianna,” the second opera written by the revolutionary Italian composer Claudio Giovanni Antonio Monteverdi (1567-1643), which is also one of the most famous specimens of the early Baroque opera. The Italian translation of the opera’s lyrics is, “Leave me to die. / And who do you think can comfort me/ In such a hard (harsh) state,/ In such great suffering?” Any physician is invited to submit poems for publication in our Journal MSMA, attention: Dr. Lampton or email me at lukelampton@cableone.net.]—Ed.

Music Lessons: Coltrane’s Love, Monteverdi’s Arianna

n medical school, I listened to A Love Supreme; And even with A little wine and reefer (Toke of this, it is My Breath) It sounded like A plastic bag full of cans Rolling down a stairway.

A seventy-eight year old Seventy two pound lady Blew up her home oxygen Having a smoke and Dreaming of her dead husband. She said to me, more or less: Imsorryforthetrouble Sostupiditsmytime.

Thirty years later I believe that If heaven exists Coltrane explained why.

Lasciatemi morire! E che volete voi che mi conforte In cosi dura sorte, In cosi gran martire?

Thirty years after I learned To resuscitate, intubate, Excise and graft, Save and prolong,

I found her a room Away from the ICU. She died among Softly arguing daughters.

—William “Bill” C. Lineaweaver, MD Brandon

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February 2015

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

PARTICIPATE IN MSMA’S DOCTOR OF THE DAY PROGRAM

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