VOL. LVIII • NO. 2 • 2017 by Journal MSMA

VOL. LVIII • NO. 2 • 2017

EVEN THE PROS NEED ADVICE AND SUPPORT In golf, a caddy is the person who carries a player's bag and clubs, gives insightful advice, and provides support. A good caddy is aware of the challenges and obstacles of the golf course being played, along with the best strategy in playing it. When selecting a professional liability partner, you want a carrier who has the experience and the fortitude necessary to help guide you. Let MACM walk beside you and carry your bag.

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VOL. LVIII • NO. 2 • FEBRUARY 2017

EDITOR Lucius M. Lampton, MD

THE ASSOCIATION President Lee Voulters, MD

SCIENTIFIC ARTICLES The Trouble with IVC Filters Arjun Jayaraj, MD; Erin Murphy, MD and Seshadri Raju, MD, FACS

ASSOCIATE EDITORS D. Stanley Hartness, MD Richard D. deShazo, MD

President-Elect William M. Grantham, MD

Interstitial Lung Disease in Patients Hospitalized for Acute Illness: Is Thoracoscopic Lung Biopsy Worth the Risk? Jacob R. Moremen, MD; Christopher E. Greenleaf, MD; Samantha M. Stokes; Alan Tom; Pavan K. Rao; Catherine R. Sears, MD; Thomas J. Birdas, MD; DuyKhanh P. Ceppa, MD

MANAGING EDITOR Karen A. Evers

Secretary-Treasurer Michael Mansour, MD

Top 10 Facts You Should Know about Lung Cancer in Women 46 Jeremy D. Courtney, MD; Derek T. Hansen, MD; Joe M. Pressler, Jr., MD

PUBLICATIONS COMMITTEE Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD and the Editors

Speaker Geri Lee Weiland, MD

Economic Impact of Medicare Physician Payment in Mississippi Charles M. Robertson, MD and Douglas Maposa, MD

Vice Speaker Jeffrey A. Morris, MD Executive Director Charmain Kanosky

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.

DEPARTMENTS From the Editor – Physician for the Island of Misfit Toys Lucius M. Lampton, MD, Editor President’s Page – Opioid Abuse: A Comprehensive Problem Demands a Comprehensive Solution Lee Voulters, MD

Special Article - The 2017 Nancy O’Neal Tatum Lecture: Does Mississippi’s Health Status Reflect Ethical Shortcomings? Richard D. deShazo, MD; Daniel W. Jones, MD; and a Distinguished Response Panel

Images in Mississippi Medicine – Kuhn Memorial State Hospital

Una Voca – “Patients Say the Darndest Things” Dwalia South, MD

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POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 39158-2548.

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Comments – MACRA: How to Prepare for the Unknown Edward T. A. Fry, MD, FACC

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MSMA Physicians Leadership Academy - Meredith Travelstead, MD 54

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

“OSPREY NEST” Belinda B. Alexander, MD, a Biloxi internist in the outpatient clinic at Memorial Hospital in Gulfport, has practiced on the Gulf Coast for more than 18 years with camera in tow to capture the beautiful and unique images of Mississippi near the water’s edge. Titled simply “Osprey Nest,” the cover image was taken while on an ecological tour in the Pascagoula area in April 2011. The osprey is also known as a fish eagle, sea hawk, river hawk or fish hawk. It is piscivorous and has several unique adaptions that improve its hunting skills such as reversible outer toes, closable nostrils to keep out water during dives, and backwards-facing scales on the talons which act as barbs to help hold its catch. Oily dense plumage prevents its feathers from getting waterlogged. The osprey is known to spot a swimming fish from more than 100 feet above the water surface. The osprey tolerates a wide variety of habitats, but is always nesting near a body of water with an adequate supply of fishes under 4 pounds. – Ed.

VOL. LVIII • NO. 2 • 2017

JOURNAL MSMA

F R O M

T H E

E D I T O R

Physician for the Island of Misﬁt Toys

y practice resembles most rural medical practices in Mississippi: extraordinary diversity of race, income, education, and insurance status, with a heavy lean towards the geriatric population. Many patients possess multiple comorbid conditions, sometimes more than a half dozen and sometimes even more than two dozen, with lists of allergies so lengthy the chart says simply “See list.” Imagine an anticoagulated diabetic with Lucius M. Lampton, MD atrial fibrillation, COPD, CHF, CAD, RA, Editor chronic kidney disease, and don’t forget schizophrenia, who smokes. Many are what one might call “train wrecks” and outliers. I often joke to my students and staff that I am the physician on the Island of Misfit Toys, providing a loving medical home to the sickest and neediest on the planet. I also joke that there is always a full moon shining over the Island. The Island of Misfit Toys dates to the 1964 Christmas special “Rudolph the Red-Nosed Reindeer.” In that long-running television program, Rudolph runs away with his friends to the “Island of Misfit Toys,” a refuge for unwanted

and unloved toys. Among the misfit toys are a bird that swims, a boat that doesn’t float, a cowboy who rides an ostrich, and a train with square wheels. Santa later finds loving homes for them all. My own misfits include a chronic GI bleeder who requires anticoagulation for a mechanical heart valve and frequent transfusions. Another had an opiate allergy and required antihistamines with opiates post-operatively to treat the pain and control the allergy. Treating such complex patients often requires a balancing act to accomplish best care. Many of my patients are damaged and unfixable, presenting unique challenges and no cookbook answers. All are in need of compassionate, individualized, and engaged medical care. As our medical system evolves in coming years, it should be judged by how well it cares for the inhabitants of the Island and how well it supports the physicians who stick their necks out caring for them. The Islanders, i.e. the outliers in our patient populations, must be provided not only a safety net for care which falls outside of usual care but also medical homes which will competently care for them as individuals. Q Contact me at lukelampton@cableone.net.

— Lucius M. Lampton, MD, Editor

JOURNAL EDITORIAL ADVISORY BOARD Timothy J. Alford, MD Family Physician, Kosy Direct Care

Bradford J. Dye, III, MD Ear Nose & Throat Consultants, Oxford

Michael Artigues, MD Pediatrician, McComb Children’s Clinic

Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist, Medical Associates of Vicksburg

Diane K. Beebe, MD Professor and Chair, Department of Family Medicine, University of Mississippi Medical Center, Jackson Rep. Sidney W. Bondurant, MD Retired Obstetrician-Gynecologist, Madison Jennifer J. Bryan, MD Assistant Professor, Department of Family Medicine University of Mississippi Medical Center, Jackson

Lillian Lien, MD Professor and Director, Division of Endocrinology, University of Mississippi Medical Center, Jackson

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

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

Nitin K. Gupta, MD Assistant Professor-Digestive Diseases, University of Mississippi Medical Center, Jackson

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

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

Matthew deShazo, MD, MPH Assistant Professor-Cardiology, University of Mississippi Medical Center, Jackson

J. Edward Hill, MD Family Physician, Oxford

Sharon Douglas, MD Professor of Medicine and Associate Dean for VA Education, University of Mississippi School of Medicine, Associate Chief of Staff for Education and Ethics, G.V. Montgomery VA Medical Center, Jackson

34 VOL. 58 • NO. 2 • 2017

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

Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson

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

Thomas E. Dobbs, MD, MPH Chief Medical Officer, VP Quality, South Central Regional Medical Center & Infectious Diseases Consultant, Mississippi State Department of Health, Hattiesburg

Brett C. Lampton, MD Internist/Hospitalist, Baptist Memorial Hospital, Oxford

W. Mark Horne, MD Internist, Jefferson Medical Associates, Laurel Daniel W. Jones, MD Sanderson Chair in Obesity, Metabolic Diseases and Nutrition Director, Clinical and Population Science, Mississippi Center for Obesity Research, Professor of Medicine and Physiology, Interim Chair, Department of Medicine Ben E. Kitchens, MD Family Physician, Iuka

Michael D. Maples, MD Vice President and Chief of Medical Operations, Baptist Health Systems

Jack D. Owens, MD, MPH Neonatologist, Newborn Associates, 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 Shou J. Tang, MD Professor and Director, Division of Digestive Diseases, University of Mississippi Medical Center, Jackson

Heddy-Dale Matthias, MD Anesthesiologist, Critical Care Internist, Madison

Samuel Calvin Thigpen, MD Hematology-Oncology Fellow, Department of Medicine, University of Mississippi Medical Center, Jackson

Jason G. Murphy, MD Surgeon, Surgical Clinic Associates, Jackson

Thad F. Waites, MD Clinical Cardiologist, Hattiesburg Clinic

Alan R. Moore, MD Clinical Neurophysiologist, Muscle and Nerve, Jackson

W. Lamar Weems, MD Urologist, Jackson

Paul “Hal” Moore Jr., MD Radiologist, Singing River Radiology Group, Pascagoula Ann Myers, MD Rheumatologist , Mississippi Arthritis Clinic, Jackson Darden H. North, MD Obstetrician/Gynecologist , Jackson Health Care-Women, Flowood

Chris E. Wiggins, MD Orthopaedic Surgeon, Bienville Orthopaedic Specialists, Pascagoula John E. Wilkaitis, MD Chief Medical Officer, Brentwood Behavioral Healthcare, Flowood Sloan C. Youngblood, MD Assistant Medical Director, Department of Anesthesiology, University of Mississippi Medical Center, Jackson

Committee Seeks Candidates for Vacancies in MSMA Offices Delegates attending the 149th MSMA Annual Session August 10 - 12, 2017 in Jackson will cast ballots to fill new terms of office for a number of association posts. The Nominating Committee is seeking input from the membership as the committee prepares a slate of candidates. The slate developed by the Nominating Committee will be published to the entire membership in June. All nominees must be active members of the association. No physician may be put forth on the ballot unless that physician has expressed a willingness to serve. The chart below lists the vacancies that will be filled by election in 2017. The names of incumbents and the incumbent’s eligibility to be re-elected are indicated. Terms of Office: President-elect: 1 year 2017-2018; Officers, Trustees & Councils (physicians): 3 years 2017-2020; Trustees & Councils (students & residents): 1 year 2017-2018. Journal Editor: 3 years 2017-2020; Journal Associate Editor: 2 years 2017-2019. Incumbents NOT eligible for re-election are noted in gray type. AT LARGE POSITIONS President-elect at large Speaker of the House Vice-Speaker of the House Journal Editor Journal Associate Editor Board of Trustees, YPS AT LARGE COUNCILS Accreditation at large Accreditation at large Budget & Finance at large Constitution & Bylaws Ethical & Judicial Affairs

INCUMBENT William Grantham Geri Lee Weiland Jeﬀrey A. Morris Luke Lampton Richard deShazo John Cross Mary G. Armstrong Shirley Schlessinger Roderick Givens Mary G. Armstrong Jeﬀrey A. Morris

DIST. 1 COUNCILS Medical Education Medical Service DIST. 2 COUNCIL Medical Service DIST. 3 COUNCILS Medical Education Medical Service DIST. 4 BOARD/COUNCIL Board of Trustees Public Information DIST. 5 COUNCIL Public Information DIST. 6 BOARD/COUNCILS Board of Trustees Legislation Public Information DIST. 7 BOARD/COUNCILS Trustee District 7 Legislation District 7 DIST. 8 BOARD/COUNCILS Trustee District 8 Legislation District 8 RESIDENT BOARD/COUNCILS Board of Trustees Legislation Medical Service STUDENT BOARD/COUNCILS Trustee/Student Legislation Student Medical Service Student

INCUMBENT Katherine Patterson Abhash Thakur INCUMBENT William Mayo INCUMBENT J. Murray Estess, Jr. Laura Gray INCUMBENT J. Clay Hays, Jr. Christopher Boston INCUMBENT Vacant INCUMBENT Mark Horne William Waller J. Stephen Beam INCUMBENT Joseph Austin Roderick Givens INCUMBENT W. David McClendon David Sawyer INCUMBENT Ryan McGaughey Day Smith Lennep Phillip Dixon INCUMBENT Neal Boone Mary Elizabeth Butts Vy Mai

Email Nominations to CKanosky@MSMAonline.com or any member of the Nominating Committee: Drs. Daniel Edney, Claude Brunson, James Rish, Steve Demetropoulos, Tom Joiner, Tim Alford, Randy Easterling, Pat Barrett, Dwalia South. JOURNAL MSMA

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The Trouble with IVC Filters ARJUN JAYARAJ, MD; ERIN MURPHY, MD AND SESHADRI RAJU, MD, FACS

Key Words: IVC filter, IVC filter thrombosis, IVC filter-induced deep vein thrombosis, IVC filter removal Introduction Permanent inferior vena cava (IVC) filters have been in use for over half a century. The indications for use in thromboembolism are well defined: contraindication to anticoagulation, complication of anticoagulation and inefficacy of anticoagulation. In rare cases of pulmonary embolism with threatened catastrophic right ventricular failure, filters may be used to prevent the proverbial last straw that broke the camel’s back. These indications were well understood and in place until the advent of “temporary” IVC filters. The idea behind these filters was that they could be used in instances of transient threat of thromboembolism with removal once the threat had passed. Since the introduction of these devices, two distinct problems have developed that increased the overall risk to the patient instead of reducing it. Though clearly designated as temporary, these filters are seldom removed in time (9-35%) due to a variety of reasons resulting in permanent residence.1-3 This itself would not be problematic except that the temporary devices are particularly prone to IVC wall fibrosis,

fracture and thrombosis of the ilio-caval segments.4 The propensity to thrombose appears to be related to the surface contact of the filter with the IVC wall.5 In any event, the complication is profoundly disabling often with bilateral edema and pain. Symptoms may be severe enough to confine the patient to bed. Because of the seriousness of this complication, The Food and Drug administration (FDA) has issued a warning circular to physicians and device makers highlighting the importance of timely removal of “temporary devices.”4 Once thrombosis has occurred, removal of the filter becomes more difficult, perhaps even impossible. Additionally, even if the filter enmeshed in the thrombus is successfully removed, the occluded veins need to be recanalized. Two to three weeks after the thrombotic event the clot has organized and successful lysis is no longer feasible. A recanalization procedure with balloon compaction of the thrombosed filter then becomes necessary. We describe two cases: one where successful lysis of thrombus and removal of the filter was possible and another where a recanalization procedure had to be carried out with compaction and stenting across the filter.

FIGURE 1. (A) Initial venogram demonstrated IVC and bilateral iliofemoral occlusion with occluded IVC ﬁlter at the very top of the image (B) Post thrombolysis revealing no remaining thrombus within the IVCF (C) Post-IVCF retrieval and IVC and bilateral iliofemoral venous stenting

36 VOL. 58 • NO. 2 • 2017

Case 1 A 72-year-old male presented with acute onset of massive bilateral lower extremity pain and swelling. He had a medical history significant for a left iliofemoral deep vein thrombosis (DVT) one-year prior which had been managed with placement of an inferior vena cava filter (IVCF), thrombolysis, and 6 months of anticoagulation. On exam, the patient had massive bilateral lower extremity pitting edema. Imaging revealed acute occlusion of the IVCF, the distal inferior vena cava and the right ilio-femoro-popliteal veins as well as a chronic occlusion of the left iliac vein. The patient was immediately started on therapeutic anticoagulation. Surgical management of his DVT was initially delayed by coincident diagnoses of renal failure (serum creatinine 4.4), cystitis, and prostatitis managed by urology. However, after being cleared by urology for the use of local thrombolytic therapy, the patient was taken to the operating room on hospital day eleven. In the operating room, access was obtained in the right popliteal vein and a venogram performed (Fig 1A). Percutaneous pharmacomechanical thrombectomy was performed of the IVCF, IVC and right ilio-femoro-popliteal veins with the AngioJet peripheral thrombectomy system (Boston Scientific, Marlborough, MA). Catheter-directed thrombolysis was then performed overnight in the ICU through the popliteal sheath. The next day the patient returned to the operating room. At this time, the IVCF was noted to be free of thrombus and was retrieved via right internal jugular vein access (Fig 1B). While acute clot was mostly resolved, residual stenosis was identified in the IVC, iliocaval confluence and right iliofemoral veins. In addition, the left iliac vein remained chronically occluded. The remaining disease was managed with recanalization of the chronic left iliac occlusion followed by angioplasty and stenting of the IVC and bilateral iliofemoral veins (Fig 1C). At close to 1-year follow-up the patient has patent bilateral femoroilio-caval stents and was asymptomatic without either pain or swelling. Considering his history of multiple episodes of extensive unprovoked DVT, he is being maintained on lifelong anticoagulation. Case 2 A 64-year-old male had presented to us with bilateral lower extremity

chronic venous insufficiency, left worse than right. His symptoms included pain and achiness of legs in addition to hyperpigmentation and swelling. Remainder of history was positive for recurrent episodes of venous thromboembolic events requiring placement of IVC filter elsewhere 10 years ago. Comorbidities included coronary artery disease requiring placement of coronary stents, asthma and obstructive sleep apnea. He was intolerant to use of compression therapy. Workup included a computerized tomographic (CT) venogram that demonstrated bilateral iliocaval occlusion including the IVCF with patency restored at the level of the renal veins. After counselling of the risks and benefits, the patient elected to proceed with intervention which included recanalization of bilateral iliocaval segments and crushing of the IVC filter. Under general anesthesia, access to the left mid-thigh femoral vein was obtained, a 11-French access sheath placed and venogram performed (Fig 2A) which confirmed the CT findings. Using a combination of 0.035 Glidewire and Glidecath, recanalization of the occluded left iliocaval segment was attained including through the IVC filter and finally into the patent cava above. Recanalization tract was then created using a 12 x 60 mm and subsequently an 18 x 60 mm angioplasty balloon. Once this was done, the IVCF was crushed to the side using a 24 x 40 mm angioplasty balloon and placement of a 24 mm Wallstent across the IVCF. It was post dilated using a 24 mm angioplasty balloon. Stenting of the left femoro-ilio-caval segment was then performed using 20 mm Wallstents. Replicating the technique used on the left side, the right side was recanalized, and angioplasty and stenting were performed. On each side a 25 mm Z-stent was used to bridge the iliac confluence with an additional Z stent in the distal IVC (Fig 2 B-C). IVUS interrogation and venogram demonstrated optimal results (Fig 2 D). He went on to experience complete resolution of symptoms in both lower extremities and continues to remain so at 11 months follow-up. Therapeutic long-term anticoagulation was instituted. Discussion The advent of “temporary” IVC filters has led to an alarming overuse of this device extending far beyond traditional indications on the expectation that they will be removed in time. That has not proven to

FIGURE 2. (A) Initial venogram demonstrated left iliofemoral occlusion (B) Bilateral stent stack post IVC ﬁlter crush demonstrating stent conﬁguration (C &D) Right and left ascending venograms, respectively, demonstrating patency of stented segments A

JOURNAL MSMA

FIGURE 3. Stenting across Greenﬁeld ﬁlter

be the case and the resultant complications are more severe than those experienced with permanent filters. For example, temporary filters are widely used in cases of trauma, weight loss surgery, neurosurgery and in elderly patients for mere fear of bleeding, not actual bleeding FIGURE 4. Permanent vena caval filter models. (A) The stainless steel Greenfield filter. (B) modified-hook titanium Greenfield filter. (C) The bird’s nest filter (D) The Simon nitinol filter. (E) The Vena Tech filter. [From Strieff MB. Vena caval filters: a comprehensive review. Blood. 2000 Jun 15;95(12):3669-77]

by history or pathology. The “temporary” designation has led to the expectation of easy use with no penalty. That has not proven to be the case. Ironically, the condition of IVCF thrombosis with occlusion of the bilateral iliocaval segments is among the most severe thrombotic events seen overshadowing any benefit that might have accrued from their use. It should be noted that certain permanent filters with large contact area with the IVC wall suffer a similar complication. They can be successfully dealt with as well in comparable fashion to Case 2 (Fig 3). Ideally, the filter, whether temporary or permanent, should be successfully removed as the first step if at all feasible. Certain permanent filters (Fig 4) can be successfully removed and some temporary filters cannot despite their designation. The removability of filters regardless of the type becomes more difficult with passage of time due to tissue incorporation of the devices with resultant encasement of the IVCF.2,6 In cases of IVC thrombosis, the fibrous structure can totally encompass the filter in a fibrous tomb. When compaction of the filter with recanalization is the only option, there is justifiable concern that the compacted filter can penetrate adjacent vital structures. A good percentage of even non-thrombosed patent filters penetrate the IVC usually without clinical malsequalae.7 A small fraction of functional IVC filters require removal because of erosion into the ureter, duodenum or neural structures. Data indicate that such an event is likely to be rare.2 It is important to have a full discussion with the patient about the risk of erosion by the compacted filter into vital structures and also the loss of embolic protection from compaction of the filter for informed consent. In our published cumulative experience, occlusive postthrombotic disease requiring recanalization was more frequent in patients with IVC filter than in patients without filters. However, a comparison performed between limbs stented only for recanalized occlusions with (n=23) and without IVC filters (n = 92) showed no difference in patency (cumulative primary and secondary patency rates of 30% & 35% and 71% and 73%, respectively). Multiple logistic regression analysis revealed a significant association between patency rate and occlusive disease but not with presence of an IVC filter (Table 1).8 Table 1. Multiple logistic regression analysis of potential factors associated with stent patency [From Neglen P, Oglesbee M, Olivier J, Raju S. Stenting of chronically obstructed inferior vena cava ﬁlters. Journal of vascular surgery : oﬃcial publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter. 2011;54(1):153-61] x2 Statistic

Factor

Presence of IVC ﬁlter

2.0840

.5552

Occlusive disease

29.3900

<.0001

Gender

0.8368

.3603

Sidedness

1.2493

.2637

Age

7.0355

.0297

Gender-sidedness

6.0683

.0138

Gender-age

5.3381

.0693

P value

DF, Degree of freedom; IVC, inferior vena cava.

Conclusion Prophylactic IVC filters should be avoided if at all possible. Permanent filters should be placed if traditional indications are met or if the

38 VOL. 58 • NO. 2 • 2017

socioeconomic situation/compliance of the patient suggests high likelihood of loss to follow-up. This is because permanent filters, particularly the Greenfield filter, has documented low incidence of morbidity and long-term patency up to 20 years.9 If temporary IVC filters are used, an actionable follow-up protocol is mandatory.10 Interestingly, long-term IVC filter data indicate no advantage in mortality but only a reduction in pulmonary embolus rates at the cost of increased lower limb DVT rates.11 For this reason, the risk-benefit ratio of use of IVC filters is favorable only when utilized for standard indications. Q References 1.

Tao MJ, Montbriand JM, Eisenberg N, Sniderman KW, Roche-Nagle G. Temporary inferior vena cava filter indications, retrieval rates, and followup management at a multicenter tertiary care institution. J Vasc Surg. 2016;64(2):430-437.

Angel LF TV, Galgon RE, Restrepo MI, Kaufman J. Systematic review of the use of retrievable inferior vena cava filters. J Vasc Interv Radiol. 2011; 22(11):1522-30.

Sarosiek S, Crowther M, Sloan JM. Indications, complications, and management of inferior vena cava filters: the experience in 952 patients at an academic hospital with a level I trauma center. JAMA Intern Med. 2013;173(7):513-7.

Administration USFaD. Removing retrievable inferior vena cava filters: FDA Safety Communication 2014. Available from: http://www.fda.gov/ medicaldevices/safety/alertsandnotices/ucm396377.htm.

Christie DB, Kang J, Ashley DW, Mix W, Lochner FK, Solis MM, et al. Accelerated migration and proliferation of smooth muscle cells cultured from neointima induced by a vena cava filter. Amer Surg. 2006;72(6):491-6.

Lyon SM, Riojas GE, Uberoi R, Patel J, Lipp ME, Plant GR, et al. Short- and long-term retrievability of the Celect vena cava filter: results from a multiinstitutional registry. J Vasc Interv Radiol. 2009;20(11):1441-8.

Jia Z, Wu A, Tam M, Spain J, McKinney JM, Wang W. Caval penetration by inferior vena cava filters: A systematic literature review of clinical significance and management. Circulation. 2015;132(10):944-52.

Neglen P, Oglesbee M, Olivier J, Raju S. Stenting of chronically obstructed inferior vena cava filters. J Vascular Surg. 2011;54(1):153-61.

Greenfield LJ, Proctor MC. Twenty-year clinical experience with the Greenfield filter. Cardiovasc Surg. 1995;3(2):199-205.

10. Morales JP, Li X, Irony TZ, Ibrahim NG, Moynahan M, Cavanaugh KJ, Jr. Decision analysis of retrievable inferior vena cava filters in patients without pulmonary embolism. J Vasc Surg Venous Lymphat. 2013;1(4):376-84. 11. Young T, Tang H, Hughes R. Vena caval filters for the prevention of pulmonary embolism. Cochrane Database Syst Rev. 2010(2):CD006212.

Author Information: Dr. Seshadri Raju is the Director of the RANE Center Vein, Lymph, and DVT Clinics. He is a founding member of the American Venous Forum, and a Distinguished Fellow of the Society for Vascular Surgery. Dr. Arjun Jayaraj is a venous vascular surgeon who practices at The RANE Center at St. Dominic, Jackson, MS. He trained at University of Washington, Seattle and the Mayo Clinic. He has numerous journal publications and book chapters. Dr. Erin Murphy specializes in venous vascular surgery at The RANE Center at St. Dominic, Jackson, MS. She trained at University of Texas and University of Pennsylvania. She is nationally recognized for her contributions in venous disease. She was recently appointed as the National Principle Investigator for a clinical trial sponsored by Medtronic Inc. Corresponding Author: Seshadri Raju, MD, The RANE Center Vein, Lymph, and DVT Clinics at St. Dominic Hospital, 971 Lakeland Drive, Suite 401, Jackson, MS 39216, Phone: (601) 939 â&#x20AC;&#x201C; 4230, Rajumd@earthlink.net.

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.

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Interstitial Lung Disease in Patients Hospitalized for Acute Illness: Is Thoracoscopic Lung Biopsy Worth the Risk? JACOB R. MOREMEN, MD; CHRISTOPHER E. GREENLEAF, MD; SAMANTHA M. STOKES; ALAN TOM; PAVAN K. RAO; CATHERINE R. SEARS, MD; THOMAS J. BIRDAS, MD; DUYKHANH P. CEPPA, MD Abstract Rationale The role of surgical lung biopsy in the diagnosis and management of interstitial lung disease is controversial. Some diagnoses, such as idiopathic interstitial pneumonia, can be distinguished only by surgical lung biopsy histology. The relative safety of thoracoscopic lung biopsy in interstitial lung disease has been demonstrated only in low risk groups. Additionally, debate still remains regarding the therapeutic benefit of pursuing specific interstitial lung disease diagnoses. Objectives Our goal was to review our institutional experience in this matter to assess the frequency of clinical significance compared to the surgical morbidity. We hypothesized that the overall risk of thoracoscopic lung biopsy would not justify its clinical benefit. Methods Following institutional review board approval, a retrospective review of thoracoscopic lung biopsy done for interstitial lung disease in the inpatient setting from 2009-14 was performed. We reviewed demographics, pre- and post-operative diagnoses, therapeutic plans, surgical pathology and post-operative outcomes. Measurements and Main Results

patient is a high-risk procedure, but therapy can be impacted at a high rate by obtaining histologic diagnosis. Introduction The interstitial lung diseases (ILD) are a diverse group of pulmonary disorders classified together because of similar clinical, radiographic, physiologic, or pathologic features (Table 1). A recent consensus statement from the American Thoracic Society and European Respiratory Society concluded that several types of ILD such as cryptogenic organizing Table 1. Types of interstitial lung disease pneumonia (COP) are more Known Cause responsive to treatment and Connective tissue diseases have a better prognosis than the Occupational exposure Drug side eﬀects most common ILD—usual interstitial pneumonia (UIP) Idiopathic interstitial pneumonias or idiopathic pulmonary Granulomatous fibrosis (IPF).1 Recently, novel Sarcoidosis pharmacological therapies Hypersensitivity pneumonias have received FDA approval Infections for pathologically confirmed Other cases of UIP.2 For this reason, Lymphangioleiomyomatosis surgical lung biopsy (SLB) Pulmonary Langerhan’s cell histiocytosis Eosinophilic pneumonia plays a key role in the diagnosis Pulmonary alveolar proteinosis of responsive types of ILD.

Thirty patients were included in the study. Biopsy resulted in a change in the therapeutic plan in 19 cases (65%). In 8 of those patients (42%) steroid therapy was initiated or escalated, and 9 patients (47%) underwent a change in antimicrobial regimen. Mean preoperative hospital stay was 12.0 ± 13.6 days (range 1-73). Respiratory failure requiring mechanical ventilation for more than 48 hours was the most common complication (n=13, 43%). In-hospital death occurred in seven patients (24%). Preoperative intensive care unit stay of any duration (n=10) was a significant risk factor for postoperative respiratory failure (80% vs. 20%, p < 0.05) but not death (40% vs. 15%, p=0.23). Preoperative hospital stay was not a significant predictor of death (OR 1.0, CI 0.9-1.1) or respiratory failure (OR 1.0, CI 0.8-1.1).

The exact role of SLB in the diagnosis and management of ILD remains controversial.3 It is generally accepted that elective videoassisted thoracoscopic surgery (VATS) in outpatients provides a low risk means of obtaining tissue for pathologic evaluation.4 Current literature, however, often excludes higher risk patients when assessing the safety of thoracoscopic lung biopsy (TLB).5,6 Acutely ill patients with clinically diagnosed acute respiratory distress syndrome (ARDS) who underwent open lung biopsy (OLB) were found to have low procedure related morbidity with only 52% of patients surviving to discharge.7 The safety of TLB for ILD has not been evaluated in the same way in acutely ill, hospitalized patients.

Conclusions

The diagnostic yield of SLB in outpatient ILD is high,3 and therapeutic interventions can have deleterious effects when applied without

Thoracoscopic lung biopsy in the acutely ill interstitial lung disease

40 VOL. 58 • NO. 2 • 2017

accurate diagnosis. While some of the less common idiopathic interstitial pneumonias (IIP) are responsive to corticosteroid therapy, there is no good evidence to support the routine use of corticosteroids in the management of IPF, the most common IIP. We hypothesize that thoracoscopic lung biopsy for diffuse parenchymal infiltrates in the acutely ill inpatient setting is associated with higher risk than that reported in the majority of the currently published SLB data, which typically occurred in an elective outpatient setting. Also given the poor prognosis of ILD in general, patients who are acutely ill or require mechanical ventilation represent an especially high-risk group of patients is unlikely to benefit from traditional therapies. Patients and Methods Following institutional review board approval, we performed a retrospective review of all patients undergoing SLB at our institution between January 2009 and December 2014. For the purposes of this study, we included all patients who underwent SLB in the acute, inpatient setting for a diagnosis concerning for interstitial lung disease. The patients that were referred for SLB were decided on by the primary service. Typically these were patients with diffuse parenchymal disease on a chest radiograph with an etiology that could not be gleaned from history, physical exam, radiological studies, or bronchoscopy. The procedure performed was thoracoscopic biopsy using standard techniques including 1 or 2—10 mm ports and an access incision of 2 to 3 cm. A minimum of two specimens from separate lobes are obtained and sent for pathologic assessment. All open biopsies were excluded. Patients with discrete nodules detected on preoperative imaging and those admitted on the day of surgery were excluded from the study. Collected variables included patient demographics (age, gender), preoperative clinical history (preoperative diagnosis, treatment plan, level of supplemental oxygen use, mechanical ventilation), and post-operative course (surgical pathology, failure to extubate post-op, air leak, myocardial infarction, respiratory failure requiring ventilator more than 48 hours, tracheostomy, mortality, level of care, oxygen requirements, ICU length of stay, hospital length of stay, discharge status). All collected data were managed in a REDCap database (Version 6.10.8 - © 2016 Vanderbilt University). Logistic regression was used to analyze relationships between preoperative conditions and postoperative outcomes. Results Thirty patients met inclusion criteria and were included in this study. There were no cases converted from VATS to thoracotomy. The mean age was 50.5 years with a standard deviation (SD) of 13.3 years (range 21-72 years). (Table 2) Fifty-three percent of the patients were female. The average preoperative hospital stay was 12.0 days with an SD of 13.6 days (range 1-73); ten patients were admitted to the intensive care unit preoperatively for an average of 3.6 days with an SD of 5.7 days (range 0-22 days). Six of the patients in the intensive care unit were mechanically ventilated preoperatively. Eleven patients (42%) had a known preexisting diagnosis of some form of ILD. Other common comorbid conditions included chronic obstructive pulmonary disease (7/30, 27%), diabetes (7/30, 27%), and previous history of either solid organ or blood-born malignancy (6/30, 23%).

Table 2. Patient demographics and pre-operative clinical history on 30 patients Age (Years) Gender

50.5 with an SD of 13.3 (21-72) Male Female

14 (47%) 16 (53%)

Comorbid Conditions Interstitial lung disease 11 (42%) COPD 7 (27%) Diabetes 7 (27%) Malignancy 6 (23%) Coronary artery disease 5 (19%) Renal insuﬃciency 4 (15%) Immunosuppressed 4 (15%) Cerebrovascular disease 1 (4%) Pulmonary hypertension 0 (0%) Pre-Operative ICU LOS (Days) 3.6 with an SD of 5.7 (range 0-22) Pre-Operative Hospital LOS (Days) 12.0 with an SD of 13.6 ( range 1-73) LOS = length of stay, COPD = chronic obstructive pulmonary disease

Table 3 summarizes the post-operative complications. Of the 30 patients, one did not have post-operative hospital data available and was excluded from risk analysis. There were no observed prolonged air leaks; one patient (3%) required bronchoscopy for atelectasis. Respiratory failure requiring mechanical ventilation for more than 48 hours was the most common post-operative complication (13/29, 45%). At the time of chest tube removal 12 of 29 patients (41%) continued to be on more oxygen (O2) supplementation by modality (room air < nasal cannula < high flow < PAP < ventilator) than preoperatively. Six more persisted unchanged on the ventilator, and 11 were unchanged and unventilated. The mean ICU and hospital length of stay was 5.2 days with an SD of 8.7 days (range 0-35 days) and 12.7 days with an SD of 12.2 days (range 2-47 days), respectively. Inhospital mortality occurred in seven patients (24%) and five of those deaths occurred in the ICU within 10 days of the procedure. Table 3. Post-operative variables Complications Respiratory failure (vent > 48 hrs post-op) 13 (45%) Death 7 (24 %) Tracheostomy 2 (7 %) Atelectasis requiring bronchoscopy 1 (3 %) Prolonged air leak > 48 hrs 0 (0.0%) Pulmonary embolism 0 (0.0%) Myocardial infarction 0 (0.0%) Arrhythmia 0 (0.0%) Pre-Operative ICU LOS (Days) 5.2 with an SD of 8.7 (Range 0-35) Pre-Operative Hospital LOS (Days) 12.7 with an SD of 12.2 (Range 2-47) LOS = length of stay

Tables 4 and 5 demonstrate post-operative escalation in level of care as denoted by location in the hospital (ICU vs floor) and level of oxygen supplementation, respectively. Seven patients (7/29, 24%) were moved to the ICU post-operatively from the floor. Of the 10 patients in the ICU preoperatively, three escalated oxygen requirements and six JOURNAL MSMA

and pathological findings of infiltration of the interstitium with inflammatory cells and varying degrees of fibrosis. The American Table 4. Escalation in level of inpatient care Thoracic Society/European Respiratory Society (ATS/ERS) Floor bed no change 7 consensus statement identified diagnostic criteria for the ILD.1 Within Floor bed w increased O2 supplementation 6 ILD the diagnostic challenge specifically concerns idiopathic interstitial Floor bed to ICU bed 7 pneumonias (IIP). Table 7 shows the relative diagnoses of the idiopathic ICU bed w increased O2 supplementation 3 interstitial pneumonias. While usual interstitial pneumonia (UIP) ICU on ventilator no change 6 is the least responsive to traditional therapy, two drugs (pirfenidone O2 = oxygen and nintedanib) were recently approved by the FDA specifically for use in Table 5. Escalation in oxygen supplementation patients with UIP.2 O2 at time of chest tube removal

Preoperative O2

Room air

Nasal Cannula

High-ﬂow NC

Nasal Cannula High-ﬂow NC

NIPPV Ventilator

NC = nasal cannula, NIPPV = noninvasive positive pressure ventilation

remained on the ventilator. Patients that remained on the floor after TLB increased their level of O2 supplementation in 6 of 13 cases, seven remained on their preoperative O2 modality. Overall 12 patients were unable to be extubated in the immediate post-operative period. Six of these patients were ventilated preoperatively but 50% (6/12) were not. By the time of chest tube removal (mean CT duration 5.6 days) 8 of 12 (67%) remained ventilated. Preoperative clinical diagnoses included interstitial lung disease not otherwise specified (19/30, 63%), atypical infection (10/30, 33%), allergic pneumonitis (4/30, 13%), sarcoidosis (3/30, 10%), and vasculitis (3/30, 10%). Table 5 lists the preoperative clinical and postoperative pathologic diagnosis, change in treatment administered to each patient, as well as mortality outcomes. Changes to the therapeutic plan were made based on biopsy results in 19 of the 29 cases (65 %). Of the treatment changes, 42% (8 of 19) were to add or increase steroids, 47% (9 of 19) were to change antibiotic or antifungal regimen, and 16% (3 of 19) were to discontinue steroid therapy. All three patients who had discontinuation of steroid therapy had a pathologic diagnosis of usual interstitial pneumonia (UIP). Patients on the ventilator preoperatively (n=6) were significantly more likely to experience respiratory failure post-operatively than patients who were not mechanically ventilated preoperatively (100% vs 29.2%, p<0.05). Preoperative ICU stay of any duration (n=10) was a significant risk factor for postoperative respiratory failure (80% vs 20%, p<0.01) but not significantly associated with death (40% vs 15%, p=0.23). Preoperative hospital LOS was not a significant predictor of death (OR 1.0, CI 1.0-1.1) or respiratory failure (OR 1.0, CI 0.9-1.2) after logistic regression analysis. Discussion Interstitial lung diseases comprise a heterogeneous group of lung diseases characterized by similar clinical and radiographic features 42 VOL. 58 • NO. 2 • 2017

The controversy surrounding SLB for 1 0 ILD is centered on the 0 1 risk of the procedure, the 0 1 likelihood of a meaningful therapeutic change as 0 0 a result of the biopsy, 6 and the risk of empiric therapy without histologic guidance. SLB has the highest sensitivity of any diagnostic tool for ILD. Despite this, many clinicians are pessimistic about its value and reluctant to pursue SLB.3 The ATS/ERS established major and minor criteria for the diagnosis of IPF without surgical biopsy. Using these criteria Hunninghake and colleagues conducted a multi-center study comparing pulmonologists and radiologists specializing in ILD with non-specialists in their ability to establish an accurate diagnosis of IPF without SLB. The experienced group achieved sensitivity, specificity, and accuracy of 72, 84, and 77% respectively amongst the clinicians and 77, 72, 75% amongst the radiologists. By comparison, non-specialists in referring hospitals reported a high rate of false positive IPF diagnoses (specificity of 43%). The disparity increased when groups were asked for “confident” diagnoses. However, a “confident” diagnosis was only offered in approximately half of the patients with the disease.5 In a recent metaanalysis of SLB in patients with ARDS, Libby and colleagues found that biopsy provided a specific diagnosis in 84% of patients and altered management in 73%. They concluded that SLB is a potentially productive procedure for ILD.8 PAP

Ventilator

Several authors have evaluated the surgical outcomes of open lung biopsy (OLB) for patients with ILD4,5 and ARDS.7-11 The few reports that focus on TLB for ILD deal primarily with procedures performed in an outpatient setting. When excluding their highest acuity patients, Hunninghake et al reported morbidity and mortality rates following VATS lung biopsy for ILD of 10% and 1%, respectively.5 Similarly Mouroux et al found TLB to be a safe alternative to OLB for ILD, but their review included only 13.6% of patients on oxygen supplementation preoperatively.6 In contrast, there are several studies evaluating OLB in acutely ill patients defined as those admitted to an ICU or ventilated patients with ARDS.7,9-13 These retrospective reports include between 17 and 80 patients with 25% to 100% of those patients on mechanical ventilation preoperatively. The acuity is highlighted by reported survival-to-discharge as low as 30%.12

Table 6. Pathologic diagnosis, change in treatment, and (30-day) mortality Patient No.

Surgical Pathology

Change in treatment

30-day mortality

UIP/IPF

Steroids

Survived

No speciﬁc diagnosis

No change

Survived

Malignancy

Chemotherapy

Survived

Acute inﬂammation/ﬁbrosis

Steroids; smoking cessation

Survived

Atypical infection

Antifungal

Survived

No speciﬁc diagnosis

No Change

Survived

UIP/IPF

Steroid wean; transplant work-up

Survived

Organizing pneumonia

No Change

Survived

DAD

No Change

Survived

Acute inﬂammation/ﬁbrosis

Increased steroids

Survived Survived

Organizing pneumonia & atypical infection

Steroids

UIP/IPF

No Change

Organizing pneumonia & UIP

Change antibiotic therapy

Survived

DAD

No Change

Survived

Malignancy

Chemotherapy

UIP/IPF

Limitation (cessation) of therapy (d/t poor prognosis)

Organizing pneumonia & chronic ﬁbrosis

Steroids

Survived

No speciﬁc diagnosis

Steroids, Change antibiotic therapy

Survived

UIP/IPF

Limitation (cessation) of therapy

Survived

Organizing pneumonia & atypical infection

No Change

Survived

DAD

Change antibiotic therapy

Survived

DAD

No Change

Survived

Organizing pneumonia & atypical infection

Change antibiotic therapy

Survived

No speciﬁc diagnosis

Change antibiotic therapy

Survived

Atypical infection

Change antibiotic therapy

BOOP

Steroids

Survived

NSIP

No Change

Survived

Atypical infection

No Change

DAD

No Change

RB-ILD

Increased steroids, Change antibiotic therapy

x x

with regards to patient morbidity in a variety of clinical settings. Halko et al reported that in a small series of patients with ILD patients undergoing thoracoscopy had a decreased need for analgesia, decreased blood loss and decreased length of hospital stay in comparison to patients undergoing thoracotomy.14 In patients with poor lung function from non-ILD causes Ceppa et al demonstrated that patients undergoing thoracoscopic lobectomy had markedly decreased pulmonary complications when compared to those undergoing thoracotomy and lobectomy (P = 0.023).15 Recently Fibla et al16 attempted to establish a risk assessment score for lung biopsy in ILD patients. In their cohort of 311 patients the four variables most significantly associated with mortality on multivariate analysis were age greater than 67 years, ICU admission, immunosuppression, and thoracotomy. In their scoring model, when 0 or 1 risk factors were present the post-operative mortality was 2 and 12% respectively. When 2 risk factors were present the mortality risk increased to 40%. This assessment was trialed by Rotolo et al,17 and they similarly found a substantial increase in mortality from 0-2% up to 33% when 2 or more of Fibla’s risk factors were present.

BOOP = bronchiolitis obliterans organizing pneumonia; DAD = diffuse alveolar damage; IPF = idiopathic pulmonary fibrosis; NSIP = nonspecific interstitial pneumonia; RB-ILD = respiratory bronchiolitis–associated interstitial lung disease; UIP = Usual interstitial pneumonitis, x = Mortality within 30 days

Table 7. Percentage of histopathological diagnoses in patients with idiopathic pulmonary

Bjoraker JA, et al.19 109 patients Flaherty KR, et al.20 168 patients

UIP

NSIP

DIP

BOOP/COP

RB-ILD

Other

62%

14%

63%

20%

0.5%

13%

4.5%

AIP = acute interstitial pneumonia; COP = cryptogenic organizing pneumonia; DIP = desquamative interstitial pneumonia; NSIP = nonspeciﬁc interstitial pneumonia; RB-ILD = respiratory bronchiolitis– associated interstitial lung disease; UIP = Usual interstitial pneumonitis

Baumann et al reviewed their experience with 27 patients with ARDS requiring mechanical ventilation, all of whom had open thoracotomies with 67% of biopsies performed at the bedside.7 They reported no mortality specifically related to the procedure, but reported morbidity was over 60% and only 52% of patients survived to discharge. They identified 5 patients with IPF and several with forms of interstitial or organizing pneumonias. Thoracoscopy has been demonstrated to be superior to thoracotomy

Unlike idiopathic pulmonary fibrosis, many of the interstitial pneumonias (nonspecific interstitial pneumonia, cryptogenic organizing pneumonia, acute interstitial pneumonia, respiratory bronchiolitis interstitial lung disease, lymphocytic interstitial pneumonia) are steroid responsive. Assessing the risk of empiric corticosteroid treatment in these patients is an important alternative in selected higher risk groups. In a large multicenter trial from The National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network the authors randomly assigned ventilated patients with a clinical diagnosis of ARDS to receive placebo or methylprednisolone.18 They found a significant increase in 30- and 180-day mortality in the steroid group. This has been referenced as evidence against empiric corticosteroid therapy in the setting of ARDS, which is always in the differential diagnosis of acute ILD.7 However, the mortality difference was only seen in those cases where therapy was initiated later than 14 days after diagnosis. Additionally the treatment group experienced earlier separation from ventilation, fewer ICU days and fewer days of shock. Further study in this area is warranted. This study represents one of the first reports of a cohort of acutely hospitalized inpatients with suspected ILD undergoing thoracoscopic lung biopsy. Our observed 65.5% change in the care plan based on JOURNAL MSMA

pathologic analysis of SLB is similar to prior reports of inpatients with ARDS/ILD.7,8 Like Bauman et al the most frequent change was to increase or add corticosteroid therapy. As reported in the outpatient ILD setting, this study identified few immediate operative complications (Table 3) related to TLB, and survival-to-discharge was high (22/29, 76 %). This is unsurprisingly better survival than strictly ARDS populations7,8 but significantly more morbid than typical ILD SLB performed on outpatients.5,6,14 This study has several limitations. Due to its retrospective nature, information on patients who were not referred for biopsy or selected for non-operative treatment was not available. The effect of empirical therapy changes could not be studied, or compared to changes instigated by SLB. Finally, the volume of patients was relatively small. This study adds to other series that address the issue of safety and efficacy of lung biopsy in acutely ill ILD/ARDS patients in whom the risks of surgical lung biopsy must be weighed against the benefits of accurate diagnosis to guide medical therapies. Further inquiry into this surgical topic is merited as the study and treatment of ILD has grown more robust in recent years. Q References 1.

American Thoracic Society ERS. American Thoracic Society/European Respiratory Society international multidisciplinary consensus classification of idiopathic interstitial pneumonias. Am J Respir Crit Care Med. 2002(165):277-304. King TE, Jr., Bradford WZ, Castro-Bernardini S, et al. A phase 3 trial of pirfenidone in patients with idiopathic pulmonary fibrosis. N Engl J Med. 2014;370(22):2083-2092. doi: 10.1056/NEJMoa1402582. King TE, Jr. Clinical advances in the diagnosis and therapy of the interstitial lung diseases. Am J Respir Crit Care Med. 2005;172(3):268-279. doi: 10.1164/rccm.200503-483OE. Riley DJ, Costanzo EJ. Surgical biopsy: its appropriateness in diagnosing interstitial lung disease. Curr Opin Pulm Med. 2006;12(5):331-336. doi: 10.1097/01.mcp.0000239549.70573.d9.

11. Patel SR, Karmpaliotis D, Ayas NT, et al. The role of open-lung biopsy in ARDS. Chest. 2004;125(1):197-202. http://www.ncbi.nlm.nih.gov/ pubmed/14718441. 12. Warner DO, Warner MA, Divertie MB. Open lung biopsy in patients with diffuse pulmonary infiltrates and acute respiratory failure. Am Rev Respir Dis. 1988;137(1):90-94. doi: 10.1164/ajrccm/137.1.90. 13. Chuang M, Lin I, Tsai Y, Vintch J, LC P. The utility of open lung biopsy in patients with diffuse pulmonary infiltrates as related to respiratory distress, its impact on decision making by urgent intervention, and the diagnostic accuracy based on the biopsy location. J Intensive Care Med. 2003;18:21-28. 14. Halkos ME, Gal AA, Kerendi F, Miller DL, Miller JI, Jr. Role of thoracic surgeons in the diagnosis of idiopathic interstitial lung disease. Ann Thorac Surg. 2005;79(6):2172-2179. doi: 10.1016/j.athoracsur.2004.06.103. 15. Ceppa D, Kosinski A, Berry M, et al. Thoracoscopic lobectomy has increasing benefit in patients with poor pulmonary function: a Society of Thoracic Surgeons Database analysis. Ann Surg. 2012;256(3):487-493. 16. Fibla JJ, Brunelli A, Cassivi SD, Deschamps C. Aggregate risk score for predicting mortality after surgical biopsy for interstitial lung disease. Interact Cardiovasc Thorac Surg. 2012;15(2):276-279. doi: 10.1093/icvts/ivs174. 17. Rotolo N, Imperatori A, Poli A, et al. Assessment of the aggregate risk score to predict mortality after surgical biopsy for interstitial lung diseasedagger. Eur J Cardiothorac Surg. 2015;47(6):1027-1030; discussion 1030. doi: 10.1093/ejcts/ezu389. 18. Steinberg KP, Hudson LD, Goodman RB, et al. Efficacy and safety of corticosteroids for persistent acute respiratory distress syndrome. N Engl J Med. 2006;354(16):1671-1684. doi: 10.1056/NEJMoa051693. 19. Bjoraker J, Ryu J, Edwin M, et al. Prognostic significance of histopathologic subsets in idiopathic pulmonary fibrosis. Am J Respir Crit Care Med. 1998(157):199-203. 20. Flaherty KR, Toews GB, Travis WD, et al. Clinical significance of histological classification of idiopathic interstitial pneumonia. Eur Respir J. 2002;19(2):275-283. http://www.ncbi.nlm.nih.gov/pubmed/11866008.

Author Information:

Hunninghake GW, Zimmerman MB, Schwartz DA, et al. Utility of a lung biopsy for the diagnosis of idiopathic pulmonary fibrosis. Am J Respir Crit Care Med. 2001;164(2):193-196. doi: 10.1164/ajrccm.164.2.2101090.

Dr. Moremen and Dr. Greenleaf - Division of Cardiothoracic Surgery, Department of Surgery, University of Mississippi Medical Center, 2500 North State St, Jackson, MS 39216

Mouroux J, Clary-Meinesz C, Padovani B, et al. Efficacy and safety of videothoracoscopic lung biopsy in the diagnosis of interstitial lung disease. Eur J Cardiothorac Surg. 1997;11(1):22-24, 25-26. http://www.ncbi.nlm. nih.gov/pubmed/9030785.

Ms Stokes, Dr. Birdas and Dr. Ceppa - Division of Cardiothoracic Surgery, Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, EH 215, Indianapolis, IN, 46202

Baumann HJ, Kluge S, Balke L, et al. Yield and safety of bedside open lung biopsy in mechanically ventilated patients with acute lung injury or acute respiratory distress syndrome. Surgery. 2008;143(3):426-433. doi: 10.1016/j.surg.2007.06.003.

Libby LJ, Gelbman BD, Altorki NK, Christos PJ, Libby DM. Surgical lung biopsy in adult respiratory distress syndrome: a meta-analysis. Ann Thorac Surg. 2014;98(4):1254-1260. doi: 10.1016/j.athoracsur.2014.05.029. Flabouris A, Myburgh J. The utility of open lung biopsy in patients requiring mechanical ventilation. Chest. 1999;115(3):811-817. http://www.ncbi. nlm.nih.gov/pubmed/10084496.

10. Papazian L, Thomas P, Bregeon F, et al. Open-lung biopsy in patients with acute respiratory distress syndrome. Anesthesiology. 1998;88(4):935-944. http://www.ncbi.nlm.nih.gov/pubmed/9579502. 44 VOL. 58 â&#x20AC;˘ NO. 2 â&#x20AC;˘ 2017

Mr. Tom and Mr. Rao - Indiana University School of Medicine, 340 W 10th St #6200, Indianapolis, IN 46202 Dr. Sears - Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Walther Hall, 980 W. Walnut, Room C547 Corresponding Author: Jacob Moremen, 2500 North State St., Jackson, MS 39216, Phone: 601.984.5176, Fax: 601.984.5198, Email: jmoremen@ umc.edu.

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Top 10 Facts You Should Know about Lung Cancer in Women JEREMY D. COURTNEY, MD; DEREK T. HANSEN, MD; JOE M. PRESSLER, JR., MD Introduction Lung cancer has been the leading cause of cancer mortality for over a quarter century. Contributing more deaths than breast, colon, and cervical cancer combined, this disease is a major women’s health issue. This is even more evident in several rural counties in Mississippi which are noted to have substantially higher incidence and mortality rates. Improvement in mortality statistics over time is felt to be based on multiple factors including the decline in smoking rates, novel treatment regimens, and early detection and awareness programs.1 This should serve to reinforce the importance of screening modalities, timely diagnosis, and new research to increase treatment options. What are the Lung Cancer Demographics for Mississippi’s Women? Women’s lung cancer is of particular concern in the state of Mississippi. Overall, our state is slightly above national mean in ageadjusted invasive lung cancer incidence rates at 56.5 per 100,000 compared to a national mean of 53.3. This is also reflected in morality rates with a state average of 41.8 and an observed national mean of 37 per 100,000.2 Statistics are even more skewed when broken down into individual counties in the state. Mississippi is noted to have roughly a dozen counties with rates substantially higher than state and national averages (Figure 1, Figure 2). These counties appear to be geographically clustered in the Delta as well as coastal areas. Some of these counties are noted to be in rural areas with limited medical resources. Race was another area where discrepancies were noted. White females in the state of Mississippi were reported to have a higher incidence as well as higher mortality rates in comparison to African Americans (Figure 1, Figure 2).3 This fact does not hold true nationally.

Figure 1. Highest Women’s Lung and Bronchus Cancer Age-adjusted Incidence Rates per County 2009-2013 All Races

Black

White

Yalobusha

97.14

59.27*

114.61

Lawrence

78.74

108.31*

73.58

Harrison

73.76

50.71

78.80

Grenada

73.61

93.78

65.09

Holmes

70.36

57.10

N/A

Statewide

56.56

48.12

60.4

Data obtained from Mississippi Cancer Registry. Age-Adjusted rates per 100,000. * Did not meet 15 case minimum. N/A Did not meet Population at Risk Minimum.

Figure 2. Highest Women’s Lung and Bronchus Cancer Age-Adjusted Morality Rates per County 2009-2013 All Races

Black

White

Yalobusha

79.17

52.72*

88.45

Madison

63.35

57.57

66.24

Lawrence

58.16

78.10*

56.30

George

58.06

N/A

57.39

Grenada

56.19

26.44*

51.86

Statewide

41.05

35.37

43.64

Data obtained from Mississippi Cancer Registry. Mortality rates per 100,000. * Did not meet 15 case minimums. N/A Did not meet Population at Risk Minimum.

Has Women’s Lung Cancer Incidence and Mortality Rate Shown a Decline? There is a strong correlation between the epidemic of smoking and the lung cancer incidence rate; as smoking rates have declined in the general population, there has been a concomitant decrease in lung cancer death rates (Figure 3). However, tobacco use peaked two decades later in the female population compared to males, thereby shifting the lung cancer incidence and decline for the female group.4 Statistical evaluation shows that age-adjusted incidence rates in men peaked in 1980 at 99.9 per 100,000 and has shown a steady decline to 64.8 from 2011-2014. Lung cancer incidence in women, however, did not peak until 2005 at 53.7 and has shown initial signs of decline to 48.6 from 2011-2014.1 This pattern of slower and delayed decline is also seen when comparing mortality rates (Figure 4). Men’s mortality rates peaked in 1990 at 90.5, dropping to 57.8 from 2011-2014. Mortality rates in women did not peak until 2000 at 41.1 and has shown a slow decline to 37.0.1 This trend should continue to be monitored. As will be discussed later, women have an increased incidence of lung cancer in our non-smoking population. Consequently, it’s unclear if women’s mortality and incidence rates will show the same slope of decline as men based on smoking rate declines alone.

46 VOL. 58 • NO. 2 • 2017

FIGURE 3. Trends in Tobacco Use and Lung Cancer Death Rates* in the US

1900 1905 1910 1915 1920 1925 1930 1935 1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2009

Per Capita Cigarette Comsumption

Lung Cancer Deaths per 100,000 persons

Do Women Never-Smokers Have an Male lung cancer Increased Rate of Lung Cancer? 100 5000 death rate 90 4500 Though smoking is the predominant 80 4000 cause of lung cancer worldwide, there is a sub70 3500 segment of the population that have no smoking Per capita cigarette comsumption 60 3000 history. Interestingly, this incidence is noted 50 2500 to be significantly higher in women than men. 40 2000 This number varies greatly based on smoking 30 1500 prevalence in each country. However, women 20 1000 still account for a disproportionate amount Female lung cancer 10 500 death rate of never-smokers in heavy smoking countries 0 0 such as the United States. In the U.S., ageadjusted lung cancer incidence rates in women nonsmokers from the ages of 40-79 ranges from * Age-adjusted to 2000 US standard population. Source: Death rates: US Mortality Data, 1960-2009, US Mortality Volumes, 1930-1959, National Center for Health Statistics, 14.4 to 20.8 per 100,000 person-years. In their Centers for Disease Control and Prevention. Cigarette consumption: US Department of Agriculture, 1900-2007. male counterparts, incidence rates vary from 4.8 5 FIGURE 4. Lung cancer incidence per 100,000 persons, by sex and U.S. Census region --- to 13.7. If categorized as a separate class, these statistics are comparable to the rates of cervical United States, 1999--2008* cancer in women and myeloma in men.

What are the Lung Cancer Risk Factors in Women Never-Smokers? Given the comparative incidence rates noted of nonsmoking-related lung cancer in women, it is imperative for providers to have an understanding of associated risk factors. Unfortunately, this has been up for debate. There is substantial evidence to support second-hand smoke as the most critical risk factor in female nonsmokers with lung cancer.6,7 Other risk factors were noted to include occupational exposures and indoor or outdoor pollution.6 However, in the largest study to date, 1.2 million United Kingdom women were placed in a prospective cohort study to analyze effects of 34 proposed lung cancer risk factors on incidence rates upon female neversmokers. These risk factors included, but were not limited to, personal cancer history, occupational exposure, hormonal therapy, Human Papilloma Virus (HPV) exposure, second-hand smoke exposure, and dietary habits. Interestingly, only three risk factors demonstrated significantly increased incidence rates: non-white ethnicities, asthma requiring treatment, and tall stature.8 These factors differed from the important risk factors noted in other countries with the same study. Therefore, there does appear to be a population effect as well.

Are Women More Susceptible to Smoking-Induced Lung Cancer? Numerous earlier studies have suggested that women smokers are at an increased risk for lung cancer in comparison to men.9,10 However, these studies have now been brought into question. Recent prospective cohort studies report very similar hazard ratios between men and women, failing to support this claim.11 More recent literature comparing gender-based lung cancer mortality during times of equal smoking prevalence has also shown similar susceptibility between genders.12,4

Do Women Exposed to HPV Have an Increased Risk of Developing Lung Cancer? HPV has been detected in squamous cell lung cancer as early 1979.13 One Taiwanese study detected HPV 16/18 in 54.6% of lung cancers, while sparing surrounding normal tissues.14 Recent studies have even shown this increased risk being noted in female nonsmokers as well as smokers.15 This has raised suspicion that the virus may play a role in the diseaseâ&#x20AC;&#x2122;s carcinogenesis. However, these studies have focused on prevalence and detection. In recent research, no mechanism has been discovered yet explaining the causality of this relationship, leaving the role of preventive measures in question.16

JOURNAL MSMA

Does Estrogen Plus Progestin Therapy Increase Lung Cancer Mortality? Hormonal replacement therapy is common practice in post-menopausal women. Clinical trials performed by the Women’s Health Initiative (WHI) in post-menopausal patients on dual therapy, estrogen plus progestin, have shown a significant increase in lung cancer mortality while incidence rates have remained unchanged.17 Out of the 109 instances of lung cancer in patients on dual therapy, 72 deaths were observed. In comparison, only 42 deaths were noted in the 85 patient placebo incidence group. These effects were primarily noted to be in non-small cell cancer with an observed 62 versus 31 deaths. In contrast, estrogen therapy alone had no effects on lung cancer incidence or mortality rates.18

What are some Uncommon Clinical Presentations of Lung Cancer? Providers recognize common clinical manifestations such as cough, chest pain, dyspnea, hoarseness, and hemoptysis. However, it is important to identify other less common presentations of lung cancer. An obstructing mediastinal mass can lead to superior vena cava syndrome. This may present as facial edema, neck vein distension, or prominent chest wall venous engorgement. Pancoast tumors have similar mechanism leading to shoulder pain and Horner’s Syndrome. Paraneoplastic syndromes such as hypercalcemia, Cushing’s syndrome, and SIADH secretion are also uncommon yet distinct presentations. Lastly, hypertrophic osteoarthropathy is periosteal proliferation that can manifest as digital clubbing and cause symptoms such as bilateral ankle, wrist, knee, and elbow pain.19

Do Women Have Better Outcomes in Non Small Cell Lung Cancers? Several studies have demonstrated better clinical outcomes in women with Non Small Cell Lung Cancers (NSCLC).20 The National Cancer Institute Surveillance Epidemiology and End Results Program (SEER) and Centers for Disease Control and Prevention database reviews reveal consistently higher 1- and 5-year survival rates, documented as far back as 1975.1 Clinical studies also have shown a better response to chemotherapy and concurrent superior survival rate. Recent literature demonstrates that women are noted to have higher survival rates, regardless of stage, in comparison to men.21

Who Should be Screened for Lung Cancer? Though not specific to women’s lung cancer, it is vital to place emphasis on the benefits associated with screening. Literature published in 2011 by the National Lung Screening Trial reported a 20% relative reduction in mortality with low-dose computed tomography (LDCT) screening in high-risk patients when compared with basic chest x-ray.22 The current guidelines published by United States Preventive Services Task Force recommend annual screening for lung cancer with LDCT scans in adults between the ages of 55 to 80 years, with a 30 pack-year smoking history. This includes both current smokers and those who have quit within the past 15 years. Continued screening should be an ongoing discussion with the patient. Guidelines recommend discontinuation of lung cancer screening once the patient has not smoked for 15 years or has a limited life expectancy.23 The Center for Medicare and Medicaid Services has similar beneficiary guidelines, covering asymptomatic patients between the ages of 55-77 years old with a 30 pack-year history who currently smoke or have quit within the past 15 years.24 Q

References 1.

Dubey AK, Gupta U, Jain, S. Epidemiology of lung cancer and approaches for its prediction: A systematic review and analysis. Chin J Cancer. 35(1). doi:10.1186/ s40880-016-0135-x.

Centers for Disease Control and Prevention. http://www.cdc.gov/about/default.htm. Accessed September 13; 2016.

Data Request. (n.d.). September 13, 2016. https://www.umc.edu/Administration/Outreach_Services/Mississippi_Cancer_Registry/Data_Request.aspx. Accessed.

lberg AJ, Brock MV, Ford JG, et al. Epidemiology of lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians EvidenceBased Clinical Practice Guidelines. Chest. 2013;143(5 Suppl), e1S–e29S. http://doi.org/10.1378/chest.12-2345.

Wakelee HA, Chang ET, Gomez SL, et al. Lung cancer incidence in never-smokers. J Clin Oncol. 2007;25(5), 472–478. http://doi.org/10.1200/JCO.2006.07.2983.

Samet JM, Avila-Tang E, Boffetta P, et al. Lung cancer in never smokers: Clinical epidemiology and environmental risk factors. Clin Cancer Res. 2009;15(18), 5626– 5645. http://doi.org/10.1158/1078-0432.CCR-09-0376.

Taylor R, Najafi F, Dobson A. Meta-analysis of studies of passive smoking and lung cancer: Effects of study type and continent. Int J Epidemiol. 2007;36(5), 1048-1059. doi:10.1093/ije/dym158.

Pirie K, Peto R, Green J, Reeves GK, Beral V, for the Million Women Study collaborators. Lung cancer in never smokers in the UK Million Women Study. Int J Cancer. 2016;139(2), 347–354. http://doi.org/10.1002/ijc.30084.

Risch H, Howe G, Jain M, et al. Are female smokers at higher risk for lung cancer than male smokers? A case-control analysis by histologic type. Lung Cancer. 1994;11(12), 123-124. doi:10.1016/0169-5002(94)90296-8.

10. Zang E, Wynder E. Differences in lung cancer risk between men and women: Examination of the evidence. Lung Cancer. 1996;15(3):383. doi:10.1016/s01695002(96)80010-9.

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11. Bain C, Feskanich D, Speizer FE, et al. Lung cancer rates in men and women with comparable histories of smoking. J Nat Cancer Inst. 2004 ;96(11), 826-834. doi:10.1093/jnci/djh143. 12. Jemal A, Travis WD, Tarone RE, Travis L, Devesa SS. Lung cancer rates convergence in young men and women in the United States: analysis by birth cohort and histologic type. Int J Cancer. 2003;105(1):101-107. 13. Syrjänen KJ. Condylomatous Changes in Neoplastic Bronchial Epithelium. Respiration. 1979;38(5), 299-304. doi:10.1159/000194095. 14. Cheng Y, Chiou H, Sheu G, et al. The association of human papillomavirus 16/18 infection with lung cancer among nonsmoking Taiwanese women. Cancer Res. 2001;61(7), 2799-2803. 15. Lin F C-F, Huang J-Y, Tsai, et al. The association between human papillomavirus infection and female lung cancer: A population-based cohort study. Medicine. 2016; 95(23), e3856. http://doi.org/10.1097/MD.0000000000003856. 16. Anantharaman D, Gheit T, Waterboer T, et al. No causal association identified for human papillomavirus infections in lung cancer. Cancer Research. 2014;74(13), 35253534. doi:10.1158/0008-5472.can-13-3548. 17. Chlebowski RT, Schwartz AG, Wakelee H, et al. Estrogen plus progestin and lung cancer in postmenopausal women. Lancet. 2009;374(9697), 1243–1251. http://doi. org/10.1016/S0140-6736(09)61526-9. 18. Chlebowski RT, Anderson GL, Manson JE, et al. Lung cancer among postmenopausal women treated with estrogen alone in the women’s health initiative randomized trial. J Nat Cancer Inst. 2010;102(18), 1413–1421. http://doi.org/10.1093/jnci/djq285. 19. Midthun DE, Lilenbaum RC, Vora SR. (2015, February 23). Overview of the risk factors, pathology, and clinical manifestations of lung cancer. http://www.uptodate. com/contents/overview-of-the-risk-factors-pathology-and-clinical-manifestations-of-lung-cancer?source=search_result. Accessed September 11, 2016. 20. Wisnivesky JP, Halm EA. Sex differences in lung cancer survival: Do tumors behave differently in elderly women? Journal of Clinical Oncology. 2007;25(13), 1705-1712. doi:10.1200/jco.2006.08.1455. 21. Tanoue L. Women with pathologic stage I, II, and III non-small cell lung cancer have better survival than men. Y Pul Dis. 2008;104-105. doi:10.1016/s87563452(08)70595-4. 22. The National Lung Screening Trial Research Team. Reduced lung-cancer mortality with low-dose computed tomographic screening. NE J Med. 2011;365(5), 395– 409. http://doi.org/10.1056/NEJMoa1102873. 23. Humphrey LL. Screening for Lung Cancer With Low-Dose Computed Tomography: A Systematic Review to Update the U.S. Preventive Services Task Force Recommendation. Ann Intern Med. 2013;159(6), 411. doi:10.7326/0003-4819-159-6-201309170-00690. 24. Decision memo for screening for lung cancer with low dose computed tomography (LDCT) (CAG-00439N). (n.d.). https://www.cms.gov/medicare-coveragedatabase/details/nca-decision-memo.aspx?NCAId=274. Accessed October 5, 2016.

Author Information: jdcourtney@umc.edu, dhansen@umc.edu, jpressler@umc.edu (601-454-4747)

2017 MSMA “CME in the Sand”

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Economic Impact of Medicare Physician Payment in Mississippi CHARLES M. ROBERTSON, MD AND DOUGLAS MAPOSA, MD

Abstract Federal government spending through the Medicare program represents a large source of physician payments. Detailed payment and claims data has historically not been available; however, the Centers for Medicare and Medicaid Services recently released physician level billing data for calendar year 2012. These data allow assessment of the overall volume of Medicare physician spending in Mississippi and analysis of how spending varies by location, procedure and specialty. Overall Medicare spending for physician fees in Mississippi exceeded $723 million. Key Words: Mississippi, Medicare, Charges Introduction The Medicare program was established by President Lyndon Johnson in 1965 to provide health insurance to individuals age 65 and older. Medicare rapidly expanded to become a significant source of professional fees. While some aggregate charge data has been publicly available, physician level charge data has not been released. In early 2014, the Center for Medicare and Medicaid Services (CMS) released for the first time a highly-granular nationwide dataset covering calendar year 2012. In this publication, we examine payments made to physicians and other providers in the state of Mississippi. Methods The Medicare Provider Utilization and Payment Data set provides a Physician and Other Supplier Public Use File. We obtained that file from the website of the Center for Medicare and Medicaid Services and manipulated using Microsoft Access and Excel. The dataset contains an entry for every physician (and other provider) for each CPT code that was billed to Medicare for 11 or more patients in 2012. Apart from the physician name and CPT code, the data set includes physician address, physician gender, physician specialty, number of procedures performed and billing data for both charges and payments. Alphanumeric CPT codes were excluded from analysis. Results Total Medicare payments to providers in the state of Mississippi for calendar year 2012 were $723,164,356. Geographic distribution of payments is shown in Table 1. Jackson claims 18% ($131 million) of total state spending and the top 5 cities 50 VOL. 58 • NO. 2 • 2017

(Jackson, Hattiesburg, Tupelo, Meridian and Gulfport) represent half of total state spending. Sixty cities have spending exceeding $1 million. One hundred fifty-seven localities with less than $1 million in payments represent $35 million or slightly less than 5% of total payments.

Table 1. Geographic Distribution of Payments City JACKSON HATTIESBURG TUPELO MERIDIAN GULFPORT COLUMBUS, OXFORD, SOUTHAVEN LAUREL, CORINTH, FLOWOOD, BILOXI GREENVILLE, PASCAGOULA, OCEAN SPRINGS, GREENWOOD, MCCOMB, VICKSBURG, NATCHEZ, CLARKSDALE CLEVELAND, BROOKHAVEN, STARKVILLE GRENADA, NEW ALBANY, BOONEVILLE, RIDGELAND MADISON, KOSCIUSKO, AMORY, PICAYUNE, BATESVILLE IUKA, BRANDON, MAGEE, WEST POINT, OLIVE BRANCH, PEARL, BAY ST LOUIS, PHILADELPHIA, EUPORA SENATOBIA, MOSS POINT, PONTOTOC, MONTICELLO, CANTON, FULTON, COLUMBIA, RIPLEY, PETAL, CLINTON, YAZOO CITY, CARTHAGE, HERNANDO, LUCEDALE, HOLLY SPRINGS, COLDWATER, HOUSTON, HAZELHURST, HOLLANDALE ALL OTHERS (n=157)

Payments $132 million $78 million $61 million $45 million $33 million $20-22 million $15-19 million $10-$14 million $6.0-9 million $4.0-$5 million $3 million

$2 million

$1 million

$35 million

Payment allocation by specialty is shown in Table 2 representing 6,571 providers. The provider specialty is taken from the dataset directly. The number of providers and per capita payment is also listed. Of note, non-physician providers represent 36% (n=2388) of the individuals and 12% ($82 million) of payments. Nurse practitioners are the largest practice group by number, n=1103; family practice is the largest physician group, n=689. Internal medicine physicians received the largest overall payment of $89 million.

Table 3. Distribution of Payments by CPT code

Table 2. Distribution of Payments by Specialty Provider Type Internal Medicine Family Practice Cardiology Ophthalmology Emergency Medicine Diagnostic Radiology Nurse Practitioner Orthopedic Surgery Nephrology Pulmonary Disease Gastroenterology Hematology/Oncology Urology Dermatology Neurology Physical Therapist Optometry General Surgery Anesthesiology Pathology Radiation Oncology Otolaryngology CRNA Psychiatry Podiatry Neurosurgery Rheumatology Cardiac/Thoracic Surgery Endocrinology Infectious Disease Vascular Surgery Physical Medicine and Rehabilitation General Practice Obstetrics/Gynecology Chiropractic Interventional Pain Management Clinical Psychologist Physician Assistant

Total Payments

Provider Count

Per Capita Payment

$89,227,096 $79,404,666 $63,858,284 $50,066,321 $37,631,336 $34,946,347 $34,459,276 $24,928,239 $23,459,423 $21,353,681 $19,946,376 $18,575,174 $17,287,321 $16,438,742 $15,680,953 $15,509,741 $14,346,654 $13,622,680 $11,953,020 $11,031,916 $9,995,945 $8,791,891 $8,673,008 $8,498,048 $8,156,975 $5,646,676 $5,145,273 $4,912,636 $4,501,847 $4,448,210 $3,880,482 $3,639,752 $3,565,455 $3,386,791 $2,919,941 $2,899,256 $2,616,133 $2,210,790

546 689 159 134 382 192 1103 155 58 73 93 63 71 51 90 203 244 184 212 82 26 88 444 132 60 51 28 31 31 28 24 28 39 234 167 12 60 57

$163,420 $115,246 $401,624 $373,629 $98,511 $182,012 $31,241 $160,827 $404,473 $292,516 $214,477 $294,844 $243,483 $322,328 $174,233 $76,403 $58,798 $74,036 $56,382 $134,536 $384,459 $99,908 $19,534 $64,379 $135,950 $110,719 $183,760 $158,472 $145,221 $158,865 $161,687 $129,991 $91,422 $14,473 $17,485 $241,605 $43,602 $38,786

Payment allocation by CPT code is shown in Table 3. One hundred six CPT codes had total billing in excess of $1 million statewide. Hospital or office evaluation and management services (codes 992XX) cost slightly in excess of $346 million or 48% of payment statewide. The most common procedural service, cataract surgery (66984) has slightly over $15 million in payments for the state. Discussion There are some limitations to the data; in particular, CMS excluded procedures which a physician provided on fewer than 11 individuals per year. For example, a surgeon who had performed 11 cataract operations would appear in the dataset, but one who had performed 9 operations (or 11 separate operations on 9 individuals) would not. Physicians, specialties and locations with significant Medicare populations are over-represented and even busy practices may be absent

Description Office/outpatient visit est Office/outpatient visit est Subsequent hospital care Initial hospital care Emergency dept visit Cataract surg w/iol 1 stage Subsequent hospital care Office/outpatient visit new Eye exam & treatment Esrd srv 4 visits p mo 20+ Initial hospital care Tte w/doppler complete Office/outpatient visit new Emergency dept visit Therapeutic exercises Office/outpatient visit est Subsequent hospital care Ht muscle image spect mult Office/outpatient visit est Critical care first hour Tissue exam by pathologist Nursing fac care subseq Eye exam established pat Hospital discharge day Office/outpatient visit new Ther/proph/diag inj sc/im Drain/inject joint/bursa Total knee arthroplasty Eye exam new patient Emergency dept visit Nursing fac care subseq Insert intracoronary stent Chemo iv infusion 1 hr Complete cbc w/auto diff wbc Chest x-ray Nursing fac care subseq Extracranial study Ct abd & pelv w/contrast Destruct premalg lesion Ct head/brain w/o dye Repair venous blockage Hospital discharge day Anesth low intestine scope Office/outpatient visit new After cataract laser surgery Anesth lens surgery Colonoscopy and biopsy Upper gi endoscopy biopsy L hrt artery/ventricle angio Esrd srv 2-3 vsts p mo 20+ Chest x-ray Initial hospital care Radiation tx delivery imrt Comprehen metabolic panel Lesion removal colonoscopy Radiation tx management x5 Ct abd & pelvis Sense nerve conduction test Manual therapy

CPT Code 99214 99213 99232 99223 99285 66984 99233 99204 92014 90960 99222 93306 99203 99284 97110 99212 99231 78452 99215 99291 88305 99308 92012 99238 99205 96372 20610 27447 92004 99283 99309 92980 96413 85025 71020 99307 93880 74177 17000 70450 35476 99239 00810 99202 66821 00142 45380 43239 93458 90961 71010 99221 77418 80053 45385 77427 74176 95904 97140

Payments $78,690,964 $72,904,329 $37,597,524 $20,547,092 $19,994,512 $15,908,630 $15,170,486 $12,566,613 $11,689,408 $10,937,563 $10,758,964 $10,129,673 $9,968,200 $9,306,734 $9,214,320 $8,397,551 $8,236,682 $8,198,149 $7,943,237 $7,270,614 $7,241,142 $6,266,098 $5,629,968 $5,361,016 $4,491,994 $4,135,011 $4,013,226 $3,927,907 $3,725,715 $3,657,971 $3,487,949 $3,181,510 $3,124,025 $3,048,665 $3,000,285 $2,850,028 $2,804,807 $2,770,188 $2,731,677 $2,704,361 $2,679,538 $2,649,530 $2,635,645 $2,558,069 $2,439,447 $2,423,001 $2,311,476 $2,297,286 $2,294,840 $2,294,711 $2,278,244 $2,207,234 $2,151,913 $2,150,894 $2,139,095 $2,122,392 $2,093,092 $2,038,989 $2,027,760

JOURNAL MSMA

if the services provided are distributed over a large number of CPT codes. The CMS-registered address and specialty of a physician also may cloud the data. A cardiothoracic surgeon may be registered as a cardiac surgeon, a thoracic surgeon or a general surgeon, and procedures performed at different hospitals may all be attributed to a single billing address. Even so, these data provide an insight into how care is provided in our state. Medicare payments are a significant support for health care and the Mississippi economy as a whole. As data is released in subsequent years, it will be possible to determine how medical care is changing and potentially to identify areas of need within the state. Q

Author Information: Dr. Robertson is board-certified in pediatric anesthesiology. He practices at the University of Mississippi Medical Center where he holds the rank of assistant professor. Dr. Maposa is board-certified in pediatric anesthesiology. He is chief of pediatric anesthesia at the University of Mississippi Medical Center where he holds the rank of associate professor.

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P R E S I D E N T ’ S

P A G E

Opioid Abuse: A Comprehensive Problem Demands a Comprehensive Solution

hysicians and others on the front lines of the opioid abuse crisis in the U.S. have a very different view from the average American. We see a burgeoning problem with no sign of slowing down. Consider a few sobering facts:

•

In 2013, 43,982 people in America died from drug overdoses, 25% more than the 32,719 who died in car crashes.

•

Prescription drug overdoses account for nearly 60% of drug overdose deaths in the U.S. and 73% of those deaths stemmed from opioid use.

•

Sales of prescription painkillers have quadrupled since 1999, and deaths from them have similarly increased.

•

The rate of painkiller prescriptions in Mississippi is the sixth highest per capita in the nation, with 120 prescriptions for every 100 people.

This is tragedy writ large. In fact, there’s a good chance that everyone reading this issue of the Journal has a patient struggling with opioid addiction. Most of us also have a friend or loved one grappling with opioid addiction. You don’t have to be an alarmist to see something is terribly wrong here. This crisis didn’t happen overnight and it is going to take a long-term, comprehensive plan to address it. Agreeing that physicians have a professional duty to help reverse the opioid tragedy, the American Medical Association created the Task Force to Reduce Opioid Abuse that set goals to increase physician education and use of effective Prescription Drug Monitoring Programs (PDMPs), promote comprehensive assessment and treatment of substance use disorders and expand access to naloxone in the community and through co-prescribing. Here in Mississippi, MSMA has hailed our legislature for increasing access to naloxone and promoting the PDMP. I am also steering an MSMA committee of physicians on the front lines reviewing the CDC prescribing guidelines and making recommendations to the Governor’s Opioid Task Force. This is bringing physicians together with law enforcement, pharmacists and counselors. We’ve been addressing substance abuse among our profession for years now. The Mississippi Physician Health Program (MPHP) offers an anonymous track for physicians to overcome substance abuse with detection, evaluation and treatment. The program focuses on monitoring recovery and returning physicians to a safe and productive medical practice. Recovery is a tough, long, complex journey. Addressing the opioid abuse issue statewide is even more problematic. To find meaningful solutions, we must work together. Q

Lee Voulters, MD; Gulfport MSMA President 2016-2017 JOURNAL MSMA

M S M A

This is part of a spotlight series on the MSMA Physician Leadership Academy class of 2017.

Meredith Travelstead, MD

r. Meredith Travelstead knew as a child that she wanted to be a physician. Her father, an oral surgeon, introduced her to his work, showing her slides and procedures, piquing her curiosity. She worked part time in his office here and there and over the summers. Eventually she shadowed other physicians and this fed her interest in medicine and service. Dr. Travelstead’s early interest in surgery was eventually replaced during her OB-GYN rotation in med school. “When I saw the joy of delivering a baby and sharing in that most precious time with a family, I felt it was a calling” she said. “I have always said this is the best specialty, because you have some primary care with annual visits, developing relationships with patients year after year; you are able to do surgery and many procedures; and you get the privilege of delivering babies.” Dr. Travelstead took inspiration from her parents. Her father taught her hard work and determination in her profession. Her mother modeled grace and compassion. Today, as a mom of three boys, she manages career, family and faith with her husband in hopes that her parents’ legacy stays alive. By participating in the Physician Leadership Academy, Dr. Travelstead hopes to take the natural leadership role that doctors occupy and transform it. She wants to sharpen her communications skills and become more knowledgeable in policy and advocacy. “Every physician is a leader whether they like it or not,” she said. “They are respected and held in high esteem by their clinics, their hospitals, their communities and their patients. Therefore, it is not whether we are to be leaders, but how effective we are as leaders.” Dr. Travelstead takes her leadership role seriously and will surely have a big future in MSMA. Q

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MACRA: How to Prepare for the Unknown EDWARD T. A. FRY, MD [Editor’s note: This article was first published in Cardiology, the American College of Cardiology’s official member publication, in January 2017. It is being published in JMSMA for the general interest of our readers. Comments as letters to the editor are welcome.] Repeal of the Sustainable Growth Rate (SGR) formula and passage of the Medicare Access and CHIP Reauthorization Act (MACRA) in 2015 are proof that what might seem both impossible and improbable can happen. However, let’s face it. Even those closest to the process and those in positions of leadership in the medical community know very little about what is to come with the actual launch of MACRA. We have never been here before. The rules are still being written. Implementation and interpretation vary from practice to practice, hospital to hospital, and system to system. Yogi Berra’s prediction about predictions will hold true: “It’s tough to make predictions, especially about the future.” What do we know? • MACRA, or at least the concept of tying reimbursement to outcomes (or measures), is here to stay. Though being rolled out initially through the Centers for Medicare and Medicaid Services, this concept will be agnostic to the type of payer (public, private, single, commercial, voucher system, etc.). There is no going back. • MACRA is, first and foremost, about controlling total cost. Like SGR, it is designed to slow, reverse, and then limit the growth of total expenditures through Medicare, Medicaid and the Children’s Health Insurance Program, which accounts for the majority of health care spending in the U.S (and about two-thirds of cardiovascular care). If one totals the amount of deferred spending cuts amassed from the beginning of SGR in 1997 and compares it to the minimal “adjustments” called for in MACRA, combined with anticipated inflation, it is a wash. Total public spending on health care will decline about 20 percent over the next 10 years relative to inflation and commensurate with the anticipated growth in number of recipients, based on current eligibility (which itself is likely to change). • MACRA, in reality, is not about “volume to value.” The winners in MACRA will be those providers, institutions and systems that provide care, no matter what arrangement, to the largest number of people. Bigger accountable care organizations will generate more revenue than smaller ones. Orthopedists doing more total joints in bundles will make more money than those doing fewer. • MACRA is really a system to define “sliding scale” reimbursement and redistribution of available funds to cover care based on achieving pre-specified metrics that may or may not reflect true clinical quality. These metrics are certainly intended to represent “value” and to be surrogates for efficiency and enhanced process of care. As we are learning, some of these metrics, such as chronic heart failure 30-day readmissions, may have a paradoxical, negative impact on actual quality of care. • MACRA will determine economic winners and losers along a continuum. There is not a “threshold” for receiving better reimbursement. The pie is baked; the slices will all add up to one full pie, not more. • MACRA will change the economic calculus of health care finances at the provider, hospital and system level. Somewhat counterintuitively, not all winners will be providing the best care and not all losers will be delivering sub-standard care. For example, a system that “overinvests” in staff, technology and other infrastructure to achieve 100 percent of all measures for all providers, without careful planning and detailed financial information, may actually lose money when compared with another system that invests more strategically and may actually reach fewer targets. This “paradox” might be illustrated by two similar systems: Both may deliver the same actual quality of care, but one may have documented it more thoroughly than the other, or one may have focused on what they believe to be more important components (e.g., mortality), rather than other metrics (e.g., 30-day readmissions), or one may have over-spent to build their MACRA process. Beware of unintended consequences. There are other examples of this concept of over-preparation and under-performance. When one looks at return on investment for Meaningful Use and for Value-Based Payment (VBP), there are many examples of practices and systems being financially upside-down. However, the goal of global electronic health record (EHR) adoption and VBP are still the right things to do and likely will have longer term benefits. Nonetheless, perfection may be the enemy of good. All parties will be looking for the Goldilocks “just right” balance between the costs associated with complying vs. the rewards of doing so.

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• MACRA is not a cardiology-specific initiative. No doubt, cardiovascular medicine is an important component, as reflected in the proposed metrics and in the portion of all patients receiving cardiovascular care, but it is by no means the main driver. MACRA is still predominantly a primary care-centric incentive plan. Health systems, practices and hospitals that put all their chips on cardiology services alone, at the expense of developing efficient, accessible, high-quality integrated primary care networks, will not be successful. However, the house of cardiology, and especially the ACC, is probably best prepared for this paradigm shift because of the long-standing commitment to quality metrics, science, evidence based medicine, registries and clinical practice guidelines. • MACRA will be the vehicle through which the majority of us will receive our care as we age over the next decade, given the average age of cardiologists is 56. • MACRA will evolve and be tweaked, but its core essence will be retained. We must be nimble enough to change with it and to be engaged enough to influence that change (on behalf of patients, not necessarily ourselves). How do we prepare for the unknowable, to be successful in MACRA? • Take great care of patients! Use clinical practice guidelines, appropriate use criteria and evidence-based tests and treatments. This is what we do best and where we as clinicians can have the greatest impact. For some, there is an immediate urge to throw up our hands and wilt at the intimidating complexities of MACRA; however, this is one thing we can immediately and instinctually do to succeed in the new MACRA world order. • Document, document, document! Encourage health information technology (IT) vendors to build and configure EHRs to do much of this for us faster, better and cheaper! • Participate in (all) registries. • Focus on true process improvement: measure, benchmark, get to the root cause, implement change, re-measure. Rinse and repeat. Focus on real descriptors of quality of care and end points that are meaningful to patients, not just “scorecard” checkboxes. “MACRA will evolve and be tweaked, but its core essence will be retained. We must be nimble enough to change with it and to be engaged enough to influence that change (on behalf of patients, not necessarily ourselves).” — Richard A. Chazal, MD, FACC • Innovate and be adaptable. Fellows in Training and early career professionals are already showing us how to do this. Follow their lead. Challenge IT to provide useful tools to be successful. • Go to meetings like ACC’s Cardiovascular Care Summit, Annual Scientific Session, Legislative Conference, etc. Read extensively outside the traditional clinical literature (read the clinical literature as well). Make what is going on in health care reform a part of the day-to-day conversation at your institution. Become a student of MACRA. • Embrace and develop multidisciplinary, integrated teams of care and service lines for all specialties. Learn from each other within cardiology and learn from other specialties. Orthopedists have much to teach us about delivering high-quality care within bundled payments. • Do not be afraid to make mistakes, but recognize failure quickly and learn from those mistakes. • Remove barriers to access. See more patients. Leverage the whole cardiovascular team to do this. • Make all operational and strategic decisions patient-centric. We will see what 2017 brings with respect to MACRA! The good news is that the Cubs won their first World Series in 108 years in 2016 – another seemingly impossible and improbable event. I like to think there is a little bit of each Cubs’ fan eternal optimism in all of us. In 2016, these fans showed us that optimism is not always misplaced. Edward T. A. Fry, MD, FACC is chair of the Cardiology Division at St. Vincent Health in Indianapolis, IN; chair of the Cardiovascular Service Lines for St. Vincent Health and Ascension Health; and the immediate-past ACC governor of Indiana. Q

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The 2017 Nancy O’Neal Tatum Lecture: Does Mississippi’s Health Status Reflect Ethical Shortcomings? RICHARD D. DESHAZO, MD; DANIEL W. JONES, MD; AND A DISTINGUISHED RESPONSE PANEL

Introduction to the 2017 Tatum Lecture (Dr. Didlake)

FIGURE 1. The Nancy O’Neal Tatum Lecture 2017

The annual Tatum Lecture was held on the 28 of February at the University of Mississippi Medical Center (UMMC) in memory of Dr. Nancy O’Neal Tatum, Associate Professor of Family Medicine, to honor her pioneering work to establish the first formal medical ethics program at the University of Mississippi Medical Center (Figure 1). These lectures, open to the public, address complex topics in bioethics and the human aspects of medical practice. A Mississippi native, Nancy attended the University of Southern Mississippi with music education as her initial career goal. However, a love of science and the influence of her father, Dr. A. T. “Deet” Tatum, a beloved general practitioner in Petal, MS, led Nancy to a medical education at UMMC. After graduating in 1980, she completed a Family Medicine residency, also at UMMC, and entered practice with her father. They were at that time the only father-daughter physician partners in the state. After her father’s death, Dr. Tatum trained in medical ethics at Vanderbilt University and joined the UMMC Department of Family Medicine faculty. In this role, she was an outstanding physician, teacher, and advocate, as well as an effective professional role model. Her exemplary commitment to her patients and her profession were tragically cut short by lymphoma in 1999. The Tatum Lecture series seeks to continue the work she started. This year’s topic, “Does Mississippi’s Health Status Reflect Ethical Shortcomings?” presented views on exactly the sort of professionalism topics that Nancy would want us to explore. This year’s lecturer was Richard D. deShazo, MD, Billy S. Guyton Distinguished Professor of Medicine and Professor of Medicine and Pediatrics at UMMC. Dr. deShazo has held many national roles in academic medicine, having served as an elected member of the American Board of Internal Medicine, American Board of Allergy and Immunology, the American Board of Medical Specialists and on the Administrative Board of the Council of Academic Faculty and Specialty Societies of the American Association of Medical Colleges. He served as Chair of Medicine at the University of South Alabama and University of Mississippi Medical Center and is the author of over 300 published scientific articles and a book on Mississippi Medicine during the civil rights era, Practice in Parallel, which is in press with University Press of Mississippi. The 2017 Tatum event was a collaboration of the UMMC Department of Medicine, Department of Surgery, Office of Public Affairs, and the Center for Bioethics and Medical Humanities. Ralph Didlake, MD, Director of the Center for Bioethics and Medical Humanities and Associate Vice Chancellor for Academic Affairs

Many Questions (Dr. deShazo) I have many questions and few answers. I do know all of us share anxiety over the ongoing culture wars in our society and in particular how these affect health and healthcare. Not a day goes by that I don’t go home wishing I could have done more to help the patients I have seen that day. We health providers find ourselves in a double bind of increasing needs and fewer resources. Maybe a look at where we are and how we got there will be helpful. Let’s start with ethics. There are well-established definitions of what ethics are in general and, in particular, what medical ethics are. Medical ethics are core values of the health professions. JOURNAL MSMA

FIGURE 2. Mississippi Health Status from America’s Health Ranking Mississippi has maintained the last position in both child and adult at http://www.americashealthrankings.org/explore/2015-annual- health in the US since data have been kept. The average life span of report/measure/Overall/state/MS. Mississippians is about 5 years less than other Americans. Disparities

in health among whites and people of color are frozen in time (Figure 2). With the resources and opportunities available to us, how can this continue to be the case? Does the present health status of Mississippians reflect ethical shortcomings among health professionals or can we blame that on others?

Ethical Principles and Health Policy At almost every level, decisions about who has access to health and healthcare are subject to the ethical principles that inform state and national health policy. Despite our oaths and egalitarian principles, organized medicine has been slow to address ethical issues. We have often favored our needs first and incorporated societal biases into our profession. It was not until 2008 that the American Medical Association acknowledged over a century of discrimination toward black physicians and patients by its predominately white members and explicit bias as a root cause of our disparities in health.1 In 2014, the Mississippi State Medical Association President Dr. Claude Brunson similarly apologized during his inauguration speech for “whatever role the Association had in the past of fostering racial inequity, whether it was by engaging in actions that promoted racial inequity or by inaction in not supporting racial equity.”2 His position was supported in the 2015 MSMA Resolution to “recruit all physicians and work closely with the Mississippi Medical and Surgical Association, welcoming increased dialogue with all physicians.” As physicians, we are complicit with the present health status of those we serve, one way or the other. At the time of his apology, our state medical association initiated an effort to increase the diversity of what had been a majority white organization. To a large degree, this reflected the leadership of MSMA presidents Dr. Edward Hill and Dr. Claude Brunson. It is working. State Medical is now more inclusive. Bias in healthcare is a national problem. Published data show evidence of unconscious (implicit) racial bias toward people of color by about 75% of primary care providers. That bias is quantifiable by decreased minority access to diagnostic procedures and other quality indicators.3 In 2003, the Academy of Medicine of the National Academies of Sciences documented racial prejudice in health as a national problem in their report.4 Those findings were quantified in Mississippi in 2015 by the report by Dr. Mario Azevedo.5 Those data provide a direct connection to our past and to our present.

Empathy Walls and Reconciliation Few will argue that the present turmoil in American culture has direct connections to the unresolved moral failure of slavery incorporated into the national code of ethics, our first US Constitution. It was a short trip from the US Constitution to the incorporation of support for racism into our religious life which should have been a moral compass. Research shows that slavery created “Empathy Walls” in our society that even today allow us to see and rationalize wrongs and do nothing to correct them.6 Again, we are frozen in time. Why bring all of this uncomfortable history up again? Why don’t we just forget it and move on? Although those who lived in slavery have passed on, the years of segregation that followed have left distrust that is as real as today’s news. Bishop Desmond Tutu ‘s amazing trip to racial reconciliation with the white and black people of South Africa discovered that nonjudgmental ownership of the past by all parties can heal wounds and generate positive change.7 There is proof of principle for that approach where the open dialog among the races he created prevented impending civil war in South Africa. In our state, there is similar proof of principle in the reconciliation story of Mississippi African American civil rights leader Dr. John Perkins and Mississippi White Knights Klansman and Jackson bomber Thomas Torrants. This is recorded in their book, He’s My Brother.8 Putting light on the past can be therapeutic. Most of us eventually stumble onto the “Greatest Commandment,” a troubling ethical directive found in the writings of most religions. That directive appears once in the Old Testament and 3 times in the New Testament. “You shall love the Lord Your God with all your heart, soul and mind; and your neighbor as yourself (Leviticus 19:18, Matthew 22:35-40, Mark 12:21-28, Luke 10:25-28). If the poor health of our state is a moral issue and our response to it should be based on ethical principles, who is our neighbor and who should lead in health?

Does Bias Have Multiple Colors? We often talk about the effects of bias on blacks. Many whites feel there is a bias toward them as well. My ethics are challenged every day as I try to avoid Lakeland Drive at the intersection of Old Fannin Road and Flowood Drive on the way to work

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FIGURE 3. The Seven AM workday scene on Old Fannin Road at (Figure 3). My choices are to sit in the right turn lane forever or use craft Flowood Drive, Flowood, MS, 2017 to shorten the wait. Some crafty people use the middle lane until they get

near the intersection and then break into the right lane to make a right turn. The craftiest use the left turn lane up to the intersection and break in line across both the middle and the left lane into the right lane. Most of these folks drive large pickups. All of this breaking in line generates road rage. Didn’t their mothers teach them that breaking in line is unethical?

FIGURE 4. Cover of Dr. AR Hochschild’s book, Strangers in Their Own Land

A new book suggests the idea of “breaking in line is a root cause of today’s culture wars.” A Professor of Sociology took a 5-year sabbatical and moved to Louisiana to seek an explanation for what she called The Great Paradox.6 How did salt-of-the-earth, bible-believing, white Southerners become determined to repeal health care and other federal programs that were targeted at their impoverished neighbors and relatives, programs like Medicaid, Medicare, ObamaCare, Food Stamps and CHIPS? Why do white Southerners despise the federal government that implemented these programs; programs that for decades have provided almost 50% of annual state budgets to southern states like Mississippi? In her recently released best seller, Dr. AR Hochschild concluded that historical events explain present morality, politics and the culture wars (Figure 4).6 Here are some of those observations. The South sent a whole generation of its best and bravest youth to die under for Southern honor and the Southern way of life. Whites still mourn that failure. With the Union victory came the release of 2 million hungry and sick African slaves into a decimated South filled with returning Confederate soldiers. They, like the Freedmen, were hungry and sick.9 Federal Reconstruction legislation guaranteed former slaves not only the right to vote, own property, have trial by jury, and travel without restriction, but also free health care and education. The government’s Freedman’s Commission built a network of almost 1000 hospitals, clinics, almshouses and feeding centers for Freedmen in the South. Poor whites got none of this. The Commission provided seed and farm animals to the Freedmen but not to the poor whites. Southern whites felt that the government had helped blacks break in line. So the bloody Mississippi Plan of Southern Redemption stopped Reconstruction cold and reestablished white supremacy.10 It was followed by the Supreme Court’s Plessy vs. Ferguson decision in 1898 making segregation legal again. Mississippi became a society that was closed over 70 years.

The Story of TRM Howard, MD and the Civil Rights Movement It was a black Mississippi physician who helped fuel the beginning of the national civil rights movement in 1955 and black physicians, dentists, pharmacists and undertakers who provided the energy and money for the civil rights movement in our state and took unbelievable risks in doing so (Figure 5).11 In November 1955, the NAACP sent black activist Dr. TRM Howard, Chief Surgeon of the Taborian Hospital in Mound Bayou in the Delta, to a fundraiser at the Dexter Ave. Baptist Church in Montgomery, Alabama.12 His host was 26-year-old pastor, Martin Luther King, Jr. As founder of the Mississippi Regional Council of Negro Leadership, Howard reported the recent body count of murdered Council members in the Mississippi Delta and his extensive personal investigation of the Emmitt Till murder case.13 Howard noted many black physicians had been run out of the state for their support of voting rights. Those left were daily targets of the White Citizens’ Councils, KKK, and local law enforcement.

FIGURE 5. Some Mississippi Black Physician Civil Rights Leaders. [deShazo RD, Smith R, Skipworth LB. Black physicians and the struggle for Civil Rights: Lessons learned from the Mississippi experience: Part 2: Their lives and experiences. Am J Med. 2014; 127(11):1033-40.]

Church member Rosa Parks quietly listened to Dr. Howard that night and later recounted the impact of Howard’s presentation. Four days later, she refused to give up her seat on a city bus to a white man and was sent to jail, an event that ignited the Montgomery Bus Boycott and the

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American civil rights movement. Other Mississippi black physicians including, Dr. Robert Smith, cared for white college students who came to Mississippi in 1964 to register black voters when local physicians would not see them.14 The murder of 3 Freedom Summer participants in Neshoba County by the Klan that summer fueled the passage of the Civil Rights Act of 1964, the Voting Rights Act of 1965 and President Lyndon Johnson’s War on Poverty with Medicare, Medicaid, and Head Start. White Southerners concluded, once again, the federal government had helped blacks break in line.

Others Break in Line and the Workplace Changes Other groups quickly followed African Americans to assert their civil rights. In 1965, a new federal Immigration and Naturalization Act allowed immigration by large numbers of Latinos from Cuba, Mexico and Central America, displacing European immigration. Southeast Asians and the Middle Easterners followed. In 1966, the National Organization for Women demanded reproductive rights, equal pay for equal work and protection from sexual harassment for women. In 1973, the American Psychiatric Association removed homosexuality from the list of mental disorders, and the LGBT Movement joined the Native American push for civil liberty. “Made in America” changed to “Made in China.” Jobs were lost to mechanization and cheap wages offshore. The unions were no longer in control of the wages of the American workforce. Family values went missing. White men in the US were losing their traditional sources of personal pride and worth. Income disparities among Americans became extreme as 76% of the country’s wealth was in the hands of the top 10% of the population. Only 1% of the total pie was left for the entire bottom half of the population. Everybody was breaking in line.

Voice for Those Who Felt Left Behind So what happened next? Hochschild says in her book, “The Tea Party Movement came to fruition and gave voice to those who felt left behind.” It became a movement to restore the honor of the white middle class and relieve the country of the burden of support of those who cut in line. The leadership of the rich would end a culture of dependency. There would be cutbacks on entitlement programs, smaller government, lower taxes, business growth and more Made in America. There would be respect for those who worked and America would be great again. Today, we find ourselves as Americans and as physicians more divided and polarized than ever. We desire to provide equitable healthcare for all Americans, regardless of their politics. Major changes are proposed in health care. Cutbacks are happening to safety net programs. A great silence has come over our professional organizations. What behaviors FIGURE 6. Response Panel for Tatum Lecture, Left to Right: Daniel W. should help professionals demonstrate that reflect our personal and Jones, MD, Edward Hill, MD, Michelle Wheeler, BS, M2, Janice Bacon, professional ethics? MD, and Robert Smith, MD. How should ethical principles guide our thinking and actions?

The Panel’s Response (Dr. Jones) These difficult questions proposed by Dr. deShazo were addressed by a response panel (Figure 6) that included Dr. Janice Bacon, a Mississippi native who had both her medical school and pediatrics training here and has worked as a physician leader in the Federally Qualified Heath Centers in Belzoni and Jackson; Dr. Edward Hill, a family medicine training program director in Tupelo and has served as President of the Mississippi State Medical Association and the American Medical Association and as a leader in the World Medical Association; Dr. Robert Smith, a family medicine physician and a nationally recognized civil rights pioneer, one of several Mississippi black physicians whose lives and experiences formed the basis for John Dittmer’s book, The Good Doctors; and Miss Michelle Wheeler, an M2 from Greenwood, Mississippi and a graduate of Millsaps College who has a major interest in health disparities. The host of the panel was Dr. Dan Jones, acting Chair of the Department of Medicine. He led the medical center as vice chancellor and the university as chancellor into a watershed of reconciliation. Dr. Jones also served as President of the American Heart Association. After individual presentations and interaction with the audience, there was consensus among the panel that ongoing, open, multi-cultural conversations among physicians and other health professionals are necessary to affirm common values, ethical principles, and goals. This may be a most expeditious way to identify a way forward, based on the South African experience. With Mississippi’s history of cultural separation, it will take many conversations to identify mutually acceptable methods to break down empathy walls. There was also a call for organizations of health professionals including nursing, allied health professionals, pharmacists, and clinical psychologists, among others, to sponsor open forums and presentations on Mississippi health disparities and black-white professional issues in their local and state meetings. These could identify advocates and develop advocacy efforts to improve health and healthcare delivery in the state.

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The panel also agreed that Mississippi physicians should be more vocal about the needs of Mississippi patients and more involved in advocacy efforts. In particular, the Mississippi State Medical Association established a “Commission on Health Equity” that to date has met 7 times with representatives of many groups to include MSMA, the UMMC Department of Preventive Medicine, the UMMC Myrlie Evers-Williams Institute, the Jackson-Hinds Comprehensive Health Center, representatives of Jackson State University, and others. Q References 1.

Davis RM. Achieving racial harmony for the benefit of patients and communities. JAMA 2008;300(3): 323.

J Miss Med Assoc. 2015 House of Delegates. Resolution 3.

Cooper LA, et al. The Association of clinicians’ implicit attitudes about race with medical visit communication and patient ratings of interpersonal care. Am J Pub Health. 2012;102(5): 979-87.

Smedley BD, Stith AY, Nelson AR. Unequal treatment: Confronting Racial And Ethnic Disparities in Health Care. Washington, D.C.: National Academy Press, 2002.

Azevedo MJ. The State of Health and Health Care in Mississippi 2015. University Press of Mississippi. Jackson, MS.

Hochschild AR. Strangers in Their Own Land: Anger and Mourning Are the American Right. A Journey to the Heart of Our Political Divide. New York, NY, 2016.

Tutu D. No Future without Forgiveness. New York: Doubleday, 2000.

Perkins J, Tarrants TA. He’s My Brother: Former Racial Foes Offer Strategy for Reconciliation. Chosen Books. Baker Book House, Grand Rapids, MI 1994.

Downs J. Sick from Freedom: African-American Illness and Suffering During the Civil War and Reconstruction. Oxford U Press, New York, NY, 2015.

10. Lemann N. Redemption: The Last Battle of the Civil War. Farrar, Straus and Giroux, New York, NY, 2007. 11. deShazo RD, Smith R, Skipworth LB. Black physicians and the struggle for Civil Rights, lessons learned from the Mississippi experience: Part 2: Their lives and experiences. Am J Med. 2014; 127(11):1033-40. 12. Beito DT, Beito LR. Black Maverick: T.R.M. Howard’s Fight for Civil Rights and Economic Power. U of Illinois Press, Urbana, 2009. 13. Anderson DS. Emmett Till: The Murder That Shocked the World and Propelled the Civil Rights Movement. University Press of Mississippi. 2015;217-218. 14. Dittmer, John. The Good Doctors: The Medical Committee for Human Rights and the Struggle for Social Justice in Health Care. Bloomsbury Press. New York, New York. (First paperback edition) 2010.

Author Information: Dr. deShazo is from the Departments of Medicine and Pediatrics at the University of Mississippi Medical Center, Jackson, MS. Dr. Jones is from the Department of Medicine at the University of Mississippi Medical Center, Jackson, MS.

Corresponding Author: Richard D. deShazo, MD. Billy S. Guyton Distinguished Professor. Professor of Medicine and Pediatrics. University of Mississippi Medical Center, 2500 N. State St., Jackson, MS 39216.

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UHN MEMORIAL STATE HOSPITAL IN VICKSBURG--- Situated on the old Jackson Road, now 1422

Martin Luther King, Jr. Blvd., between Vicksburg’s Military Park and the city’s downtown, the now abandoned Kuhn Memorial State Hospital stands on a 12-acre site speaking to Vicksburg’s long history of medicine and charity hospital care. The hospital dates to 1832 with the creation of Vicksburg’s City Hospital during a small pox epidemic. That hospital was moved to this location, then a suburban estate with a large central house, in 1847. Dr. George K. Birchett and his descendants for three generations ran the hospital during the Civil War and throughout the Yellow Fever epidemic of 1878. The state assumed management of the hospital in 1871, and it was renamed the State Charity Hospital at Vicksburg, a sister institution to other charity hospitals located at Laurel, Jackson, Natchez, Meridian, and Biloxi. An annex for Confederate veterans was erected in 1901(later burning in 1918), and the University of Mississippi opened its clinical training for its first four-year medical school here in 1909, although Abraham Flexner’s visit to the school resulted in discontinuation of the Vicksburg program by 1911. In 1954, Vicksburg native Lee Kuhn, a New York City resident, left his estate of $400,000 to the Vicksburg Charity Hospital. In his will, Kuhn directed a 7-person committee to oversee the distribution of the money. The committee recommended the construction of a new building, which opened in 1959. The institution would be named for Mr. Kuhn, and in 1962 the older original structures were torn down and replaced with the structure seen above, which is said to have been designed by architect Raymond Birchett, great grandson of the first Dr. Birchett. The hospital was known as a major obstetrical center. In 1944, it was reported that 360 babies were born that year at the facility, with 90% of those born “colored.” Kuhn Hospital would close in 1989 as a result of state politics and funding issues. (See the Vicksburg Evening Post, June 25, 1989.) During its last year of operation, 1989, the Legislature approved a $2.08 million budget for the facility, which Governor Mabus vetoed. (Mabus had planned to re-channel the charity hospital monies into Medicaid in order to receive federal matching funds.) Kuhn Hospital has stood vacant since, its solid structure holding firm despite exterior and interior vandalism. Many thanks to Dr. Randy Easterling of Vicksburg and Bovina, past MSMA President, for venturing to the Kuhn Hospital ruins recently to take this photograph: a final glimpse of this historic medical site. Surrounded by an eight-foot chain link fence, the structure has been condemned by the city and is scheduled to be demolished in the near future. 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. Q

— Lucius M. “Luke” Lampton, MD; JMSMA Editor 62 VOL. 58 • NO. 2 • 2017

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“Patients Say the Darndest Things” DWALIA S. SOUTH, MD We could all use a good laugh after the election cycle of 2016. Everyone needs to simply rear back and belly-laugh about something other than the orange squirrel on the Donald’s head or Hillary’s e-mail fiascos. What better way to put a smile on your face than listening to some of the outrageously funny things that our patients report to us every day? I keep a box of loose sticky notes in a file cabinet, and also a small, very discrete little notebook in my bag where I preserve these things clandestinely. Some are things that people say to me. Some are notes that are passed to the nurse or to me as the treating physician. Since I last shared an article on chief complaints with you, I have accumulated quite a few more to share with our readers… so here goes round three in no particular order: 1.

“I’ve got old and I’m losing ground so I bought me some Ensurance and I been a drinking it every day. It tastes like stump water and it is as high as a cat’s back to buy, but I think it has hope me some.”

“If you are giving me any biotics, you might as well give me some East infection medicine to go along with it. Any time I take them biotics, I need a wire brush to scratch with before it is over.”

“I don’t like your new weighing scales, they flatulate too much.”

“I read the package insertion on that Metformin, and I had every symptom of that Latick Acidophilus it can give you….plus enough gas to drive to Kalamazoo.”

“Doc, we can’t put Momma in a nursing home. Her and daddy are so close that if you give one of them a laxative, why, they both have a BM.”

“Dr. Stone told me I had ‘romantic fever’ when I was little; reckon I still have it?”

“The bone doctor told me the cartridge in my knees is completely shot.” (Time to reload.)

“I had a skroke and died for a little bit. They had to incubate me.”

“Doc, I am feeling so bad, I think I just need for you to seduce me into a coma.”

10. “Little old Dr. Mauney told us our Daddy was a High-Condrack. I know what that means. You think you are sick when you are not. I reckon she was right because he has told us at least once a day for the last 40 years he was dyin’, but he has outlived us all.” 11. “I am just old and wore out and disabilitated.” 12. “That nerve medicine you gave me is not working…I am still having panickintacks. I get mad, and then I squall till I pass out. ” 13. “Please check my son for AIDS when he comes in to see you. He is one more Hotty Toddy Poddy Boy.” (Ole Miss Party boy is all I can figure on this.) 14. “I know my husband must have that emezema because I can’t sleep for him wheezling all night.” 15. “What do you mean I have the gouch? I thought that was something you caught between your legs?” (gout) 16. “My Daddy may be old but he is in such good shape, they’ll have to knock him in the head on judgment day.” 17. “My momma died of compulsive heart failure.” (Are all OCD folks predisposed to this?) 18. “My boyfriend needs that camera run up him, you know, for man stuff.” 19. “That last doctor I saw gave me a bunch of Viagra, and I told him that was like putting a flag pole on a condemned building.” 20. “My husband has seen a specialist in Tupelo. I think he was a urin-o-cologist.” 21. “I’m about ready to get rid of my old man; he ain’t nothing but an obitual liar.” 22. “My ears feel really wearied lately.” (Weird? Or tired ears?) 23. “I have been looking on the computer and I am pretty sure I have that sleep acne.”

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24. “My technicals are about to kill me.” (testicles, as near as I can guess) 25. “In the passed I have been diagnosed as biopolar sexsophenic. I also have anexity attacks…insomia… blood pressure…fibroalligynia… osteoarthis really bad… knees bone to bone…takin shots of rooster combs…don’t help…need Loratabs and nobody won’t help me anymore.” (This was an actual note handed to me.) 26. “My Medicaid is supposed to be radioactive for three months.” 27. “My bladder has dropped and they said I was too old to put to sleep, so here I am wearing a patsy.” 28. “I am supposed to be in my golden years, but the only damn thing I got that’s gold is pee.” 29. “On my bill it said that I had an ‘exacerbation of COPD.’ What is that exactly?” I told the patient that it was a $2.00 word for worsening in your breathing troubles. She said, “Well, now you remember you are dealing with a 50 cent gal, so from now on just give me the 50 cent word.” 30. “My sister in Memphis told me I had too much wrong with me to be messing around with regular doctors. She said I needed to go see an eternal medicine specialist. Well, I just told her that I am going to stick with Dr. South until I die.”

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Call of 1:7 Full health benefits 4 day work week Malpractice paid Vacation, Holiday, sick and CME time sĂĐĂƟŽŶ͕ ,ŽůŝĚĂǇ͕ ^ŝĐŬ ĂŶĚ D ƟŵĞ Competitive base salary guarantee with potential income as a partner x Profit sharing after the first year For more information, please email Tommy Cobb: tjcquail@yahoo.com

I love it. That one will do to quit on until next time. Q

Dwalia South, MD

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64 VOL. 58 • NO. 2 • 2017

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