May 2013 JMSMA by Journal MSMA

May

VOL. LIV

2013

No. 5

APR_MSC-MS_FullPg_Final(PressReady).pdf

4/1/13

4:48 PM

CAN YOU GUESS WHO'S THE ED DOCTOR AND WHO'S THE CEO?

At Hospital Physician Partners, It’s All About Family. Our co-founders are not only twins, but Dr. Schillinger (David) actively practices in our ED's in Mississippi as well as nationwide while serving as President and CMO. Jeffrey, our CEO, is on a first name basis with many of our providers. Why should this matter to you? HPP was recently awarded a number of EM contracts in Mississippi in addition to our existing partnerships. While we are a steadily growing national company, we are a family-led business with real people you can reach out to and connect with at all levels. As a matter of fact, on any given day, you might end up working alongside Dr. Schillinger. THIS IS THE HPP DIFFERENCE. C

We want you to know that despite being a larger company, we haven’t lost the human touch. Contact HPP for the opportunity to speak with Jeffrey or Dr. Schillinger personally and learn more about the HPP family.

CMY

MISSISSIPPI EMERGENCY MEDICINE JOB OPPORTUNITIES

What’s Important to YOU... Is What Matters to US!®

Booneville Oxford Clarksdale

• ED Volume Range: 15K – 50K

• Paid Malpractice With Tail

Amory Columbus Canton

• Diverse Patient Populations • Free and Discounted CME

Batesville

Jackson Natchez

Brandon

• Relocation & Sign-On Bonuses Bay St. Louis

CONTACT JEFFREY OR DR. SCHILLINGER: MSDIRECT@HPPARTNERS.COM | 9 5 4 . 6 2 8 . 4 5 1 5

W W W. H P PA R T N E R S . C O M

Biloxi

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

The Association Steven L. Demetropoulos, MD President James A. Rish, MD President-Elect J. Clay Hays, Jr., MD Secretary-Treasurer Lee Giffin, MD Speaker Geri Lee Weiland, MD Vice Speaker Charmain Kanosky Executive Director

Journal of the Mississippi State Medical Association (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. CORRESPONDENCE: Journal MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: (601) 853-6733, Fax: (601)853-6746, www.MSMAonline.com. Subscription rate: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available. Advertising rates: furnished on request. Cristen Hemmins, Hemmins Hall, Inc. Advertising, P.O. Box 1112, Oxford, Mississippi 38655, Ph: (662) 236-1700, Fax: (662) 236-7011, email: cristenh@watervalley.net POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 391582548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association.

S SI

PPI S T

MED

E AT

I L A SSOC

Official Publication of the MSMA Since 1959

MAY 2013

VOLUME 54

NUMBER 5

Scientific Articles

Clinical Problem-Solving: Mystery Disease or Wrong Diagnosis? Benjamin A. Fernando, MD

124

Significance of Elevated Cardiac Troponin I in Patients with Diabetic Ketoacidosis Ashraf S. Abdo, MD and Stephen A. Geraci, MD

127

Top 10 Facts You Need to Know- Prescription Drug Abuse: When the Treatment Becomes the Problem Ann Kemp, MD; Molly Clark, PhD; Justin Sherman, PharmD; Julie Dahl-Smith, DO

134

President’s Page

The Great Epidemic Steven L. Demetropoulos, MD, MSMA President

137

Editorial

To Wear the Long Coat C. Ann Myers, MD

Related Organizations

Mississippi State Department of Health American Medical Association University of Mississippi Medical Center

148

131 143 144

Departments

From the Editor: The Katrina Cocktail Legalease MSMA Annual Session

122 143 151

About The Cover: “China Grove Graveyard”- R. Scott Anderson, MD, took this photo of the cemetery at China Grove Methodist Church on Hwy. 585N, northeast of Tylertown in Walthall County. The church dates to 1836. Buried there is William Lampton, a common relative shared by Dr. Luke Lampton and Mark Twain (Samuel Clemens). China Grove was the site of the short story by Eudora Welty, “Why I Live at the P.O.” where Sister, the protagonist of that story, was the postmistress of “the second smallest post office in Mississippi.” Many of the older markers have split or fallen over; some can no longer be read. Sadly, vandalism is a problem. Prevalent in this cemetery are the Victorian motifs of the clasped hands (a unity symbol of the period), pearly gates, burial shrouds, enigmatic urns, or the lone hand pointing skyward. Some tombs are bricked over, usually a sign that the deceased died during a fever outbreak, the thought being that the bricks would keep the disease in the ground with the interred. There are numerous unmarked graves. In many cases, bare slabs mark the spot without a headstone. The earliest burial recorded was in the spring of 1849. China Grove is also the name of a new Mississippi-based literary journal edited by Drs. Scott Anderson and Luke Lampton, which will premiere in August 2013. r May

VOL. LIV

2013

No. 5

MAY 2013 JOURNAL MSMA 121

From the Editor: The Katrina Cocktail

his month’s Journal explores a common dilemma for the practicing physician: how to relieve suffering for our patients in a competent manner. Like equilibrists, we must delicately dance on a high wire to treat pain compassionately without creating addicts. The current statistics reveal that the number of people dying from prescription drug overdose in our country is second only to the number of deaths from automobile accidents. This is a staggering problem, approaching “epidemic” proportions. We all have stories of the epidemic in our practices. I remember when the winds of Hurricane Katrina blew in many Louisiana residents to South Mississippi. To my amazement, as I tried to care for many of these desperate and sick patients, many were taking routinely what some physicians came to call the “Katrina cocktail”: Lorcet Plus, Xanax, and Soma. Patient insight was poor, and most resented my refusal to continue the dangerous “cocktail.” However, for me, seeing the flood of patients addicted to such medicines, all prescribed by our fellow physicians in our sister state, revealed the problem which we must correct. Our state board of licensure is proactively encouraging us to “fix” the problem of prescription drug abuse rather than

waiting for others (i.e. the Legislature) to fix it in a way which doesn’t make medical sense. I’d like to focus your attention on three helpful articles in this issue: our “Top Ten Facts” on prescription drug abuse, Dr. Demetropoulos’s fine editorial, and the Department of Health’s article on “What Can Mississippi Providers Do?” Editor Dr. Luke Lampton What physicians must do is educate ourselves on appropriate pain treatment options for our patients and strategies to avoid patient addiction and death. “Wearing the Long Coat” of medicine is a joy as well as a burden, and we must assume with diligence the responsibility of treating our patients and protecting them from harm. This Journal remains one of the few in the United States still created by physicians and for physicians. It is only as good as you make it. Write and editorial, a letter, an essay, a scientific article, a case report, or take a photograph or contribute a physician portrait. Contact me at lukelampton@cableone.net. —Lucius M. Lampton, MD, JMSMA Editor

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

122 JOURNAL MSMA MAY 2013

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

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

Medical Assurance Company of Mississippi Serving Generations of Mississippi Physicians When Paul H. Moore, III, MD, began his practice of medicine in 2013, he had many decisions to make. But for the decision of medical liability insurance, he only had to look to his father and grandfather and follow in their footsteps. The Moore family of physicians is one of several multi-generational families that Medical Assurance Company of Mississippi has protected through the years by providing their professional liability insurance. For over 35 years, Mississippi physicians have looked to MACM for their professional liability needs. Today, MACM is an integral part of Mississippi’s healthcare community through its dedication to risk management and claims services for our insureds. A dedicated staff and physician involvement at every level guarantee that the interests of our policyholders remain the top priority. This, combined with the many years of loyalty and support from our insureds, is what allows MACM to be the carrier of choice in Mississippi for generations of Mississippi physicians.

Left to Right: Paul H. Moore, III, MD Urogynecology, Jackson P. H. (Hal) Moore, Jr., MD Radiology, Pascagoula Paul H. Moore, Sr., MD Radiology, Pascagoula

For more information on MACM’s professional liability coverage:

1.800.325.4172 • www.macm.net

MAY 2013 JOURNAL MSMA 123

• Clinical Problem-Solving • Presented and edited by the Department of Family Medicine, University of Mississippi Medical Center, Diane K. Beebe, MD, Chair

Mystery Disease or Wrong Diagnosis? Benjamin A. Fernando, MD

26-year-old African-American female presented to clinic after a recent visit to an Emergency Department (ED) complaining of nausea, vomiting and diarrhea for approximately 3 days. Further questioning revealed that she had had these symptoms intermittently for over 1 year. The initial ED investigation revealed hypereosinophilia (eosinophil count 13%). Stool cultures, fecal leukocytes, stool for ova and parasites, Clostridium difficile toxin were all negative or within normal limits. She was treated with promethazine (Phenergan) and diphenoxylate/atropine (Lomotil) and instructed to follow up in clinic for further evaluation of her hypereosinophilia and gastrointestinal symptoms. Since her initial stool studies were nondiagnostic, an infectious cause for her gastrointestinal symptoms becomes less likely. Her symptoms seem to be more chronic in nature, and her hypereosinophilia is of concern. Eosinophilia is not an uncommon finding in clinical practice and, when found in association with a constellation of signs and symptoms, can serve as a useful clue for differential diagnosis.1 Common causes of eosinophilia include helminthic parasite infections, allergic diseases, adverse drug reactions, and syndromes of eosinophilia, including eosinophilic leukemia, hypereosinophilic syndrome, allergic bronchopulmonary mycosis, eosinophilic pneumonia, Churg-Strauss vasculitis, and eosinophilic gastroenteritis.1 I need more history to get focused on my differential diagnosis. The patient reported a long history of asthma, seasonal allergies, sickle cell trait, and intermittent abdominal discomfort including nausea, vomiting, and diarrhea. The patient’s review of systems was remarkable for generalized chronic pain, fatigue, arthralgia, and muscle spasms. She denied hematemesis, hematochezia or melena. Her past surgical history included an appendectomy, bilateral Author Information: Dr. Fernando is a third year resident in the Department of Family Medicine at the University of Mississippi Medical Center in Jackson. Corresponding Author: University of Mississippi Medical Center, Department of Family Medicine, 2500 North State Street, Jackson, MS 39216. Phone: (601) 815-5700 (office) Fax: (601) 346-5708. (Bfernando@umc.edu).

124 JOURNAL MSMA MAY 2013

breast reductions, and cholecystectomy. Her family history was positive for diabetes mellitus, hypertension, and sickle cell disease. Her social history was unremarkable for any past or present use of alcohol, illegal drug abuse or tobacco use. She had no known drug allergies. Her current medications included fluticasone/salmeterol inhaled (Advair Diskus) 500-50 mcg/dose and albuterol inhaled (ProAir HFA) 90mcg/spray. The patient’s constellation and chronicity of symptoms still lead to a broad differential diagnosis. Inflammatory bowel disease is rarely associated with a peripheral eosinophilia. I am concerned about eosinophilic gastroenteritis, but other causes of this symptom complex include hyperthyroidism, fibromyalgia and irritable bowel syndrome. The patient’s long history of asthma and allergies may have contributed to her eosinophilia. In patients with asthma, eosinophils are in increased numbers in blood and sputum and are present in bronchoalveolar lavage fluid.2 In order to narrow my differential diagnosis, I need to perform a physical examination and order a thyroid-stimulating hormone for possible thyroid disease, a complete blood count to investigate for infection or anemia, human immunodeficiency virus test, inflammatory markers such as C-reactive protein, complete metabolic profile, and erythrocyte sedimentation rate. I will also check an anti-nuclear antibody test and a rheumatoid factor test to investigate for an autoimmune cause. Physical examination was significant only for mild diffuse abdominal tenderness to palpation. Except for a blood eosinophilia of 25%, all other laboratory studies were within normal limits. Since her physical examination and initial laboratory results did not indicate any relevant findings except for a high eosinophil count, I think hyperthyroidism, fibromyalgia, and infectious causes are unlikely. However, I am still concerned about eosinophilic gastroenteritis, which is a poorly understood condition associated with eosinophilic inflammation of the upper, lower or both components of the gastrointestinal tract. At this point she requires upper and lower gastrointestinal evaluation. Therefore, I will refer the patient to a gastroenterologist for further evaluation. An esophagogastroduodenoscopy with several biopsies showed mild focal chronic duodenitis. No evidence of

celiac disease was noted, and no Giardia or parasites were identified. A gastric biopsy indicated severe active chronic gastritis with a focally increased intramucosal eosinophilic infiltrate. Histologic findings were said to be “suggestive” of concomitant eosinophilic gastroenteritis, but no tissue cell count of eosinophilia was provided. Terminal ileum biopsy indicated small bowel mucosa showing markedly increased eosinophilic infiltrate within the lamina propria as well as fragments of acutely inflamed granulation tissue consistent with ulceration. No significant architectural distortion, cryptitis, crypt abscesses, vasculitis or infection were seen. A colonoscopy with several biopsies indicated large bowel mucosa showing no diagnostic abnormality and no evidence of inflammatory bowel disease. The colonoscopy and esophagogastroduodenoscopy findings seem to exclude inflammatory bowel disease as the cause of her current symptoms. The differential diagnosis based on the above findings includes eosinophilic gastroenteritis and drug-induced ileitis. Drug-induced ileitis is less likely as the patient is not taking chronic medications. Eosinophilic gastroenteritis is a syndrome that can present in an atopic patient with symptoms of esophagitis, gastritis or, in some cases, generalized gastroenteritis. Fifty percent of patients with eosinophilic gastroenteritis have asthma, and many patients have an elevated total serum IgE and a history of symptoms exacerbated by food. The diagnosis requires a biopsy showing greater than 25 eosinophils/mm3 in the intestinal mucosa in the absence of intestinal parasites.3 More pronounced eosinophilia in association with asthma should also prompt a consideration of Churg-Strauss syndrome (CSS) or allergic bronchopulmonary aspergillosis (mycosis).1 Allergic bronchopulmonary aspergillosis is associated with pulmonary infiltrates, bronchiectasis, and chronic asthma with both IgE and IgG antibody to aspergillus species. Gastrointestinal involvement does not occur. CSS (also known as eosinophilic granulomatosis with polyangiitis) is a rare necrotizing vasculitis of unknown cause characterized by chronic rhinosinusitis, asthma and pronounced peripheral blood eosinophilia.4-6 CSS is a multisystem disorder. Extrapulmonary manifestations of CSS include weight loss, myalgia, arthralgia, skin rashes, mononeuritis multiplex (nerve damage in two or more nerves in separate parts of the body), gastrointestinal tract infarction, and cardiomyopathy.3 Although the vasculitis may be subtle, the initial phase of CSS involves small to medium sized vessels with extravascular eosinophilic granulomas.3,4 The only specific finding for CSS is a biopsy of an organ showing eosinophilic vasculitis or evidence of vasculitis with tissue infarction on vascular imaging studies. Some patients with CSS can also have antineutrophil cytoplasmic antibodies (ANCA) with autoantibodies to myeloperoxidase. However, these same antibodies are present in some patients with inflammatory bowel disease. Two large cohort studies found the sensitivity of ANCA to be only 38%.5,6 The American College of Rheumatology (ACR) criteria requires 4 of the following 6 criteria for the diagnosis of CSS: asthma; eosinophilia >10%; paranasal sinusitis; mono-

neuropathy or polyneuropathy, demonstrated by physical exam, electromyography or biopsy; pulmonary infiltrates and biopsy containing eosinophilic vasculitis.3 Allergic fungal sinusitis, much like bronchopulmonary aspergillosis, is associated with asthma, and an elevated IgE and also must be considered. Criteria for that diagnosis include chronic sinusitis and the presence of degenerating mycelial elements in so-called allergic mucin obtained at rhinoscopy or at sinus surgery.7 Gastrointestinal symptoms are not a component of this syndrome. I will obtain a chest radiograph, serum ANCA for CSS, IgE antibody, and CT of the sinuses to investigate for paranasal sinusitis. The patient’s serum was ANCA negative. Serum IgE concentration was 2491 IU/ML. CT of the sinuses without IV contrast showed bilateral ethmoid and maxillary sinusitis. Chest radiograph did not show any acute pathology. Sinusitis, nasal polyps, asthma, eosinophilia and high concentrations of IgE may be seen in patients with eosinophilic, gastroenteritis or CSS. No vasculitis is present in eosinophilic gastroenteritis. Both respond to corticosteroid treatment, but Churg-Strauss vasculitis requires corticosteroid plus cyclophosphamide or rituximab treatment much like Wegener’s granulomatosis. Corticosteroid treatment alone may not prevent catastrophic vasculitic events including stroke, myocardial infarction or intestinal infarction. The best plan at this point is to consult an allergist-immunologist or rheumatologist and a gastroenterologist/pathologist so that the gastrointestinal pathology can be reviewed to determine eosinophil quantitation and the absence of vasculitis, both of which are necessary for the diagnosis of eosinophilic gastroenteritis. The patient was prescribed oral corticosteroids and transferred to specialty care. The patient is feeling better but awaiting further tests to confirm the diagnosis of either eosinophilic gastroenteritis or CSS. Key Words: Churg-Strauss Syndrome, Eosinophilia, Asthma, Vasculitis, Eosinophlic gastroenteritis. References

Roufosse F, Weller PF. Practical approach to the patient with hypereosinophilia. J Allergy Clin Immunol. 2010;126(1):39-44.

2. Bousquet J, Chanez P, Lacoste JY, et al. Eoinophilic inflammation in asthma. N Engl J Med. 1990; 323(15):1033-1039. 3.

Rothberg ME. Eosinophillic gastrointestinal disorders. (EGID). J Allergy Clin Immunol. 2004;113:111.

Guillevin L, Cohen P, Gayraud M, Lhote F, Jarrousse B, Casassus P. Churg-Strauss syndrome. Clinical study and long-term followup of 96 patients. Medicine (Baltimore). 1999;78(1):26-37.

Bacciu A, Buzio C, Giordano D, et al. Nasal polyposis in ChurgStrauss syndrome. Laryngoscope. 2008;118(2):325-329.

Sinico RA, Bottero P. Churg-Strauss angiitis. Best Pract Res Clin Rheumatol. 2009;23(3):355-366.

7. Ly T, deShazo RD, Oliver J, Stringer S, Daley W, Stodard C. Diagnostic criteria for atrophic rhinosinusitis. AJM. 2009;122(8):747753.

MAY 2013 JOURNAL MSMA 125

“As physicians, we have so many unknowns coming our way... One thing I am certain about is my malpractice protection.”

Medicine is feeling the eﬀects of regulatory and legislative changes, increasing risk, and profitability demands—all contributing to an atmosphere of uncertainty and lack of control. What we do control as physicians: our choice of a liability partner. I selected ProAssurance because they stand behind my good medicine and understand my business decisions. In spite of the maelstrom of change, I am protected, respected, and heard. I believe in fair treatment—and I get it.

Professional Liability Insurance & Risk Management Services ProAssurance Group is rated A (Excellent) by A.M. Best. ProAssurance.com • 800.492.7212

126 JOURNAL MSMA MAY 2013

• Scientific • Significance of Elevated Cardiac Troponin I in Patients with Diabetic Ketoacidosis Ashraf S. Abdo, MD and Stephen A. Geraci, MD [We were all taught to look for infection, myocardial infarction, and other known provocateurs of diabetic ketoacidosis when patients present with this condition. So we do. Often we find “troponin leaks,” troponin elevations insufficient to meet criteria for acute coronary syndromes in situations where other evidence for ACS is also lacking. In this systematic review, Drs. Abdo and Geraci provide a careful overview of the problem demonstrating that, for the present, the mechanism and prognostic significance of troponin leaks in DKA remain a mystery. My guess is these leaks, regardless of their physiology, are not good things.] —Richard D. deShazo, MD, Associate Editor

bstract

Background. Cardiac troponin I displays significant prognostic value in acute coronary syndromes and in other non-coronary conditions and systemic illnesses. Elevated levels of this biomarker in the setting of diabetic ketoacidosis may also provide useful prognostic information regarding outcome. Methods. A systematic review of the English language medical literature was performed using PubMed. Articles reporting original data on major clinical outcomes on cohorts of patients were included. Results. Three reports examining the relationship between cardiac troponin I and clinical outcomes in patients with diabetic ketoacidosis qualified for review. A spectrum of electrolyte and cardiac abnormalities were observed in the studied populations which were more frequent in those with troponin elevations. Short- and long-term outcomes appeared worse for patients with elevated troponin levels, but small study populations and other experimental issues including concurrent diseases which could have confounded the apparent relationship between troponin concentrations and outcome reduced the confidence of the findings.

Author Information: G.V. (Sonny) Montgomery Veterans Affairs Medical Center, Jackson, MS and Department of Medicine, University of Mississippi School of Medicine, Jackson, MS (Dr. Abdo); The Division of Cardiovascular Diseases and the Department of Medicine, University of Mississippi School of Medicine, Jackson, MS (Dr. Geraci). Corresponding Author: Ashraf S. Abdo, MD, Medical Service, Jackson VAMC, 1500 East Woodrow Wilson Dr., Jackson, MS 39216 Phone: (601) 362-4471. Fax: (601) 364-1278. (Ashraf.Abdo@va.gov)

Conclusions. The available literature suggests an association between elevated cardiac-specific troponin I serum concentrations and clinical outcomes among diabetic patients with ketoacidosis, but data are insufficient to draw conclusions at this time. Large prospective observational studies which exclude or control for other conditions which could contribute to troponin release will be needed before the predictive value of this biomarker in ketoacidosis can be reliably defined.

Key terms: troponin, diabetic ketoacidosis, outcome, prognosis

Introduction

Cardiac-specific troponin I (cTnI) has been validated as an important marker of myocardial injury in acute coronary syndromes (ACS). With improved sensitivity and specificity of assay techniques, elevated concentrations have been found in subsets of patients without signs or symptoms of ACS and often in patients proven to be free of coronary artery disease.1,2 In many such conditions, patients with troponin (Tn) elevations have more frequent negative clinical outcomes when compared to similar patients with normal Tn levels; such conditions include sepsis, chronic obstructive pulmonary disease, amyloidosis, and others.3,4,5 Although diabetes is a well-established risk factor for coronary atherosclerosis,6 whether Tn concentrations carry prognostic significance in patients with uncontrolled diabetes in the absence of ACS is uncertain. Therefore, we sought, through a systematic literature review, to describe the association of cardiac-specific troponin concentrations to clinical measures of disease severity and outcomes in patients with diabetic ketoacidosis (DKA).

MAY 2013 JOURNAL MSMA 127

Table. Summary of Included Studies. cTnI: cardiac troponin I

Table. Summary of Included Studies. cTnI: cardiac troponin I Study

Design

Exclusion criteria

Upper limit of normal for cardiac troponin I

Outcome

Study Limitations

Atabek

Prospective

- Clinical evidence of cardiovascular disease - Hepatic disease - Psychosis - History of smoking, alcohol or drug abuse

0.15 ng/dl

- cTnI levels on admission and at 24 h after admission

- Small series/preliminary study

Geddes

Prospective

- History of ischemic heart Disease - Dementia - Pregnancy

0.04 μg/L

- Evidence of obstructive coronary artery disease by echocardiography and thalium201 scintigraphy exercise stress testing

- small series/preliminary study - No coronary angiography to conclusively exclude atherosclerosis

AlMallah

Retrospective

- Age < 18 - Myocardial infarction

1 ng/dl

- In- hospital mortality - All cause mortality over 2 years - Major adverse coronary events* over 2 years

- Retrospective - cTnI measured at the discretion of the treating physician ( selection bias) - Increased prevalence of dialysis patients among population with positive cTnI

*Including death, myocardial infarction, and need for cardiac revascularization

Methods

reference range ≤76 µg/dl) were measured on admission and 24 hours later in both groups as were serum electrolytes, glucose, arterial pH, bicarbonate, base excess, blood urea nitrogen, and creatinine concentrations. At the time of admission, patients with DKA had significantly higher serum levels of cTnI (0.193±0.008 vs. 0.176±0.006 ng/dL; p<0.001), CK-MB (24.1±2.1 vs. 22.7±1.2 U/L; p=0.02), and myoglobin (85.5±7.4 vs. 52.5±8.3 mcg/dL; p<0.001) compared to their case-matched controls. Ketoacidosis patients also had higher 24-hour concentrations of CK-MB (24±2.1 vs. 22.7±1.2 U/L; p=0.02) and myoglobin (78.5±2.5 vs. 52.5±8.3 mcg/dL; p<0.001). No significant differences in cTnI were present between patients and controls at 24 hours (0.175±0.005 vs 0.176±0.006 ng/dL; p>0.05). A subgroup analysis comparing patients who had a serum pH ≥7.0 with those with pH<7.0 showed significantly higher levels of cTnI, CK-MB, and myoglobin in patients with more severe acidemia. The investigators identified a negative Results correlation between serum cTnI levels and blood pH (r= -0.57, Ten articles were identified in the raw search results. p=0.026) and between serum cTnI and plasma bicarbonate Seven case reports were excluded by pre-specified criteria. concentration (r=-0.65, p=0.008) in the diabetic patients, Three articles qualified for inclusion in this review with a total supporting the direct association of severity of illness with of 155 DKA patients reported (Table). troponin levels. Atabek7 conducted a prospective study comparing 19 In a prospective study by Geddes,8 40 patients with DKA DKA patients aged 9-18 with 19 non-diabetic age-, sex-, and were enrolled over a one-year period. Diabetic ketoacidosis body mass index–matched children as controls. Control patients was defined by the presence of an arterial hydrogen ion generally suffered from upper respiratory tract infections such concentration of >50 nmol/L, a plasma glucose concentration as sinusitis, pharyngitis or otitis. Diabetic ketoacidosis was >16 mmol/L, and ketonuria. Patients were excluded if they had diagnosed clinically, confirmed by identification of ketonuria, a history of ischemic heart disease, dementia, or were pregnant. plasma bicarbonate concentrations <18 mmol/L and arterial Blood urea nitrogen, serum creatinine, C-reactive protein, cTnI, pH <7.35. Patients with clinical evidence of cardiovascular CK-MB, beta-hydroxbutyrate, and cystatin C were measured disease, hepatic disease or psychosis, or with a history of on admission and repeated 24, 48, and 72 hours later. Daily smoking, alcohol abuse or drug abuse were excluded. Creatine resting electrocardiograms were performed on all patients. kinase MB fraction (CK-MB, upper reference range ≤25 U/l), cTnI (upper reference range ≤0.15 ng/dl) and myoglobin (upper 1 Elevated cTnI was defined as ≥0.04 mcg/L. Patients with A series of computer-based literature searches were performed using PubMed (accessed April 2012) and the following non-MeSH search terms: “troponin” and “diabetic ketoacidosis,” “myocardial injury” and “diabetic ketoacidosis,” “myocardial injury” alone, and “diabetic ketoacidosis” alone. Search limits included publication dates 1991-2012, English language articles, and cardiac biomarkers other than troponin. Abstracts and, when necessary, full manuscripts were reviewed to exclude papers which did not present original experimental data (i.e., reviews, editorials, and opinion papers), individual case reports, and reports where sample sizes were too small to allow for statistical comparisons of measures or outcomes associated with troponin concentrations. No exclusions were made based on study outcomes or groups compared.

128 JOURNAL MSMA MAY 2013

concentrations above this level underwent echocardiography and symptom-limited bicycle stress planar thallium-201 scintigraphy for evidence of coronary artery disease. Four of the 40 subjects had an elevated admission level for cTnI of 0.050.07 (median =0.06) mcg/L. One subject had several additional reasons for elevated cTnI (including chronic renal failure, severe bronchopneumonia, and a history of arteriopathy) and was excluded from further analysis. The other three subjects underwent echocardiography and nuclear stress testing which revealed no evidence of obstructive coronary artery disease in any patient. In all three patients, cTnI concentrations had returned to normal after 24 hours. The retrospective study by Al-Mallah9 examined the significance of cTnI elevations in the absence of apparent ACS in patients presenting with DKA. Cardiac troponin I level was considered negative when <1 ng/dL. Exclusion criteria for the study were age <18 years and definite myocardial infarction as defined by European Society of Cardiology/American College of Cardiology criteria.10 The diagnosis of DKA was made when the combination of hyperglycemia (serum glucose >250 mg/dL), hyperketonemia (elevated beta-hydroxybutyrate) or ketonuria, and acidosis (venous pH <7.3, serum bicarbonate <15 mmol/L, or anion gap >10) were present. Elevated cTnI was found in 26 of 96 (27%) of enrolled patients. There were no differences in age, gender, race or co-morbidities between the two troponin-defined groups. A significantly higher percentage of patients with initially elevated cTnI levels required dialysis at baseline compared to those with normal concentrations (23% vs. 7%, p=0.03). During the index hospitalization, 12 patients died: 6 of 26 (23.1%) with cTnI elevation, and 6 of 70 (8.6%) with normal cTnI levels. All-cause 2-year mortality among patients with elevated cTnI was significantly higher than among the cTnI-negative subjects (50.0 vs. 27.1%, HR 2.3, 95% CI 1.2â&#x20AC;&#x201C;4.8, p=0.02). Patients with elevated cTnI also had significantly more major adverse cardiac events as a composite endpoint of death, myocardial infarction and/or need for coronary revascularization (50% vs. 28.6%, HR 2.6, 95% CI 1.3-5.3, p=0.007). Cardiac troponin I elevation was independently associated with major adverse cardiac events (adjusted HR 2.3, 95% CI 1.1-4.6, p=0.02) after adjusting for race, gender, and prior history of hypertension, chronic renal insufficiency, dialysis, hypercholesterolemia, myocardial infarction, and congestive heart failure.

Discussion

The incidence of cTnI elevation in patients with diabetic ketoacidosis who have no evidence of ACS may be as high as 34% and appears to be associated with more frequent major adverse events.11,12 The severity of the episode of ketoacidosis may also be associated with the likelihood of cTnI elevation that possibly could be related to myocardial injury. However, data are insufficient at this time to formulate recommendations for prognostic use of this biomarker in DKA.

Al-Mallah9 first demonstrated the potential utility of cTnI as an important prognostic marker in the absence of ACS among DKA patients. Patients with elevated cTnI had higher in-hospital and 2-year all-cause mortality. However, a significantly larger percentage of patients with elevated Tn in this study needed dialysis at baseline, and elevated Tn concentrations predict a higher mortality in dialysis patients.13 Hence, the mortality increase reported in this paper may not be applicable to DKA patients without end-stage renal disease. The observations by Geddes8 demonstrated that during DKA, minor increases in cTnI concentrations can be detected in some adults without demonstrable underlying obstructive coronary disease. Atabek7 associated cTnI release with acute metabolic decompensation, reporting that cTnI negatively correlated with blood pH and serum bicarbonate levels and suggesting that greater degrees of cTnI elevation may be seen in patients with more severe DKA. Several potential mechanisms of Tn release, possibly linked to future adverse cardiac or overall clinical events, may be present in patients with DKA. Diabetic patients are known to be at significant risk of coronary artery disease, and myocardial ischemia is more likely to be â&#x20AC;&#x153;silentâ&#x20AC;? in these patients.14 Tachycardia, fluid shifts (resulting in systemic hypotension), fever (from precipitating infections), and increased sympathetic tone may all contribute to oxygen supply: demand mismatch and ischemic myocardial necrosis with subsequent cTnI release. In the reviewed studies, clinical evidence of ischemia was absent and/or flow-limiting epicardial coronary disease was specifically excluded (or highly unlikely in the pediatric population studied), limiting the possibility of contributory coronary disease. Another suggested mechanism is myocardial hypercontractility early in the course of ketoacidosis where neurohormonal abnormalities related to either acidosis or hyperglycemia may induce myocardial injury through excessive oxygen demand.15,16 Evidence that this mechanism could be contributory specifically during DKA remains unclear however. The profound abnormalities of electrolyte balance and serum osmolarity are recognized metabolic derangements of DKA.17 Few case reports that describe the evolution of myocardial infarction in the presence of severe hyperosmolarity secondary to DKA identify direct contribution by metabolic decompensation per se. Severe dehydration, hypernatremia and hyperglycemia which result in a hyperosmolar states and predispose to thrombotic complications may also be contributory.18,19,20 Electrocardiographic abnormalities (ST segment elevations, widened QRS complexes and pseudoinfarct patterns), with resolution of these abnormalities following correction of hyperkalemia and hyperosmolality and without progression to frank transmural infarction, support a coronary-independent mechanism of cardiac injury.21,22 As has been reported in other non-coronary and systemic disease states, however, the possibility that Tn could be a non-

MAY 2013 JOURNAL MSMA 129

organ specific but sensitive marker of vital organ compromise is enticing.13 Rather than a direct effect specifically resulting in cardiac complications, Tn elevations in DKA could define a higher severity of disease and be a marker of long-term systemic damage which could identify patients at overall higher risk of death or chronic morbidity. One reviewed paper7 identified a correlation of DKA severity with the likelihood of Tn elevation, adding potential support to this premise. If so, Tn could provide additional predictive value, independent of traditional disease severity markers, in patients with DKA. This review has several limitations. First, only three original investigations were identified over the timeframe of common availability of cardiac troponin assays. Second, these papers examined heterogeneous populations ranging from pediatric to geriatric patients where the incidence of underlying cardiac disease (as a confounder) varies widely. Third, study endpoints differed among the investigations reviewed. Finally, the small number of total patients reported, combined with the retrospective design of the largest reviewed study, fails to provide a robust population for determination of any predictive value of cTnI in this setting.

Conclusion

Elevated serum concentrations of cardiac-specific troponins have been found in some patients with DKA in the absence of suspected or proven coronary artery disease. Abnormal levels may correlate with DKA severity and predict worse short-term and long-term outcomes. However, the available data are insufficient to draw conclusions about the prognostic value of this biomarker in patients with DKA, and routine measurement of cTnI in these patients, in the absence of other evidence of acute/decompensated cardiac disease, cannot be recommended at this time.

References

Atabek ME, Pirgon O, Oran B, et al. Increased cardiac troponin I concentration in diabetic ketoacidosis. J Pediatr Endocrinol Metab. 2004;17:1077-1082.

Geddes J, Deans KA, Cormack A, et al. Cardiac troponin I concentrations in people presenting with diabetic ketoacidosis. Ann Clin Biochem. 2007;44:391-393.

Al-Mallah M, Zuberi O, Arida M, et al. Positive troponin in diabetic ketoacidosis without evident acute coronary syndrome predicts adverse cardiac events. Clin Cardiol. 2008;31:67-71.

10. Alpert JS, Thygesen K, Antman E, et al. Myocardial infarction redefined--a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. J Am Coll Cardiol. 2000;36:959-969. 11. Ammann P, Maggiorini M, Bertel O, et al. Troponin as a risk factor for mortality in critically ill patients without acute coronary syndromes. J Am Coll Cardiol. 2003;41:2004-2009. 12. Geraci SA. Canary in the Coal Mine: Cardiac Troponins in Noncoronary Diseases. Am J Med. 2012;125:527-528. 13. Gaiki MR, Devita MV, Michelis MF, et al. Troponin I as a prognostic marker of cardiac events in asymptomatic hemodialysis patients using a sensitive troponin I assay. Int Urol Nephrol. 2012;44:1841-1845. 14. Wackers FJ, Young LH, Inzucchi SE, et al Detection of silent myocardial ischemia in asymptomatic diabetic subjects: the DIAD study. Diabetes Care. 2004;27:1954-1961. 15. Malhotra A, Mordes JP, McDermott L, et al. Abnormal cardiac biochemistry in spontaneously diabetic Bio-Breeding/Worcester rat. Am J Physiol. 1985;249:1051-1055. 16. Rรถsen P, Pogatsa G, Tschรถpe D, et al. Diabetic cardiopathy. Pathophysiologic concepts and therapeutic approaches. Klin Wochenschr. 1992;69 Suppl 29:3-15. 17. Hamblin PS, Topliss DJ, Chosich N, et al. Deaths associated with diabetic ketoacidosis and hyperosmolar coma. 1973-1988. Med J Aust. 1989;151:439,441-2,444. 18. Grant PJ, Tate GM, Hughes JR, et al. Does hypernatraemia promote thrombosis? Thromb Res. 1985;40:393-399.

Jensen JK, Atar D, Mickley H. Mechanism of troponin elevations in patients with acute ischemic stroke. Am J Cardiol. 2007;99:867870.

19. Batra AS, Acherman RJ, Wong P, et al. Acute myocardial infarction in a 12-year-old as a complication of hyperosmolar diabetic ketoacidosis. Pediatr Crit Care Med. 2002;3:194-196.

Ricchiuti V, Apple FS. RNA expression of cardiac troponin T isoforms in diseased human skeletal muscle. Clin Chem. 1999;45:2129-2135.

20. Roberts KD, Levin DL. Diabetic ketoacidosis, respiratory distress and myocardial dysfunction. BMJ Case Rep. 2009:1530.

Mehta NJ, Khan IA, Gupta V, et al. Cardiac troponin I predicts myocardial dysfunction and adverse outcome in septic shock. Int J Cardiol. 2004;95:13-17.

Baillard C, Boussarsar M, Fosse JP, et al. Cardiac troponin I in patients with severe exacerbation of chronic obstructive pulmonary disease. Intensive Care Med. 2003;29:584-589.

Dispenzieri A, Kyle RA, Gertz MA, et al. Survival in patients with primary systemic amyloidosis and raised serum cardiac troponins. Lancet. 2003;361:1787-1789.

Yun CH, Schlett CL, Rogers IS, et al. Association between diabetes and different components of coronary atherosclerotic plaque burden as measured by coronary multidetector computed tomography. Atherosclerosis. 2009;2:481-485.

130 JOURNAL MSMA MAY 2013

21. Moulik PK, Nethaji C, Khaleeli AA. Misleading electrocardiographic results in patient with hyperkalaemia and diabetic ketoacidosis. BMJ. 2002;325:1346-1347. 22. Bellazzini MA, Meyer T. Pseudo-myocardial infarction in diabetic ketoacidosis with hyperkalemia. J Emerg Med. 2010;39:e139141.

• MSDH • Mississippi Reportable Disease Statistics

March 2013

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

MAY 2013 JOURNAL MSMA 131

• MSDH •

Increases in Prescription Drug Abuse: What Can Mississippi Providers Do? Joshua W. Fleming, Pharm D, University of Mississippi School of Pharmacy; Thomas Dobbs, MD, MPH and Paul Byers, MD, Mississippi State Department of Health, Office of Epidemiology

million in the same time frame. According to data from a National Institute on Drug Abuse (NIDA) report there were over Prescription drug abuse, defined as a maladaptive 210 million prescriptions for opioid pain relievers prescribed in pattern of substance use and characterized by repeated adverse consequences related to repeated abuse of the substance, Mississippi State Department of2010. HealthTo bring this number into perspective, there were enough opioids prescribed to medicate every American with 5 mg of has been growing at an alarming rate over the last several years. hydrocodone every 4 hours around the clock for one month. With the increases in prescription drug abuse, unintentional The drug overdose death rate has roughly tripled since the drug overdose deaths more than tripled from 1999 (11,155) to Volume 29, Number 1 March 2013 early 1990’s, fueled primarily by prescription drug overdoses. 2008 (36,450) in the US. Although many types of prescription According to a Centers for Disease Control and Prevention drugs are abused, opioid analgesics (commonly prescribed to (CDC) relieve pain) are now the most common source of drug overIncreases in Prescription Drug Abuse: What can Mississippi Providers Do? report issued November 2011, there were 36,450 (11.9 deaths per use 100,000 population)bydeaths due to drug overdoses dose deaths in the US, surpassing overdose deaths related to Introduction: Prescription drug abuse, defined as a maladaptive pattern of substance and characterized in the US in 2008; 20,044 of the heroin and cocaine combined in 2006. Additionally, repeated adverse consequences related to repeated abuse ofUS the sales substance, has been growing at an alarming rate deaths were directly related over the prescriptions last several years. thepain increases in prescription drug abuse, unintentional drugdrugs. overdose to prescription Ofdeaths the prescription drug overdoses in of and for With opioid relievers have quadrupled more from 1999 (11,155) to 2008 (36,450) in the US. Although manyopioid types of prescription 2008, pain relievers drugs were are implicated in 14,800 (73.8%) sincethan the tripled late 1990’s. abused, opioid analgesics (commonly prescribed to relieve pain) are now the most common source of drug of those deaths. The overall drug overdose death rates in 2008 overdose deaths in the US, surpassing overdose deaths related to heroin and cocaine combined in 2006. were highest in the thelate 45-54 year old age group (25.3) followed Scope of the roblem Additionally, USPsales of and prescriptions for opioid pain relievers have quadrupled since 1990’s. by the 35-44 year olds (20.9) and the 25-34 year olds (16.5). The prescribing patterns for two of the most commonScope of the Problem: The prescribing patterns for two of the most commonly abused drug classes (opioids and Additionally, according ly abused drug classes (opioids and stimulants) have shown stimulants) have shown marked increases over the last two decades in the US (Figure). The number of to the same CDC report, the nonof the opioid prescription pain relievers is estimated to marked increases over theincreased last twofrom decades in theinUS (Figure). prescriptions for stimulants 4 million 1991 to 45 millionmedical in 2010, use while number of prescriptions for opioids increased from 15 million to over 200 million in the same time frame. According to cost health insurers up to $72.5 billion dollars annually in direct The number of prescriptions for stimulants increased from 4 data from a National Institute on Drug Abuse (NIDA) report there were over 210 million prescriptions for opioid health care costs. According to the Drug Abuse Warning Netmillion in 1991 to 45 million in 2010, while the number of pain relievers prescribed in 2010. To bring this number into perspective, there were enough opioids prescribed to (DAWN), were approximately 1 million emergency prescriptions for opioids increased from 15 million to over 200 medicate every American with 5 mg of hydrocodone every 4 hours aroundwork the clock for onethere month. department (ED) visits in 2009 that were attributed to prescripFigure Figure tion drug abuse. The majority of these visits were related to TheCNS drug overdose deathaccounting rate has roughly depressants, for 363,000 visits, followed by tripled since the early 1990’s, fueled opioids which accounted for 343,000 visits. Other medications primarily by prescription drug overdoses. that were implicated in this Control report included CNS stimulants According to a Centers for Disease (22,000 visits) and non-benzodiazepine sleep aids (29,000 visand Prevention (CDC) report issued November 2011, there were 36,450 (11.9 its). More than half of these ED visits involved persons using deaths per 100,000 population) due of increased prescription multiple agents. Anotherdeaths dilemma to drug overdoses in the US in 2008; drug is neonatal abstinence 20,044 ofabuse the deaths were directly relatedsyndrome (NAS), a postnatal drug withdrawal syndrome primarily caused by maternal opito prescription drugs. Of the prescription drugate overdoses 2008, opioid use. Theinincidence of pain NAS significantly increased between relievers implicated in 14,800 2000were and 2009, according to a retrospective study conducted at (73.8%) of those deaths. The overall drug the University of Michigan published in 2012. Between 2000 overdose death rates in 2008 were highest and 2009year theold incidence among in the 45-54 age group (25.3)newborns increased from 1.2 to 3.39 per 1,000 hospital followed by the 35-44 year oldsbirths (20.9)per andyear. This trend mirrors the Source: National Institute on Drug Abuse, October 2011 ntroduction

Mississippi Morbidity Report

132 JOURNAL MSMA MAY 2013

the 25-34 year olds (16.5).

Additionally, according to the same CDC report, the non-medical use of opioid prescription pain relievers is estimated to cost health insurers up to $72.5 billion dollars annually in direct health care costs. According to the Drug Abuse Warning Network (DAWN), there were approximately 1 million emergency department (ED) visits

unintentional drug related deaths occurring in this age group from 2007-2011. The 35-44 year old age group accounted for 25% (301/1229) and the 25-34 year old age group accounted for 21% (263/1229) of the deaths in this same time frame. prescription behaviors and can help identify individuals obtaining prescriptions from multiple Top Five Controlled Substances Dispensed in Mississippi January, 2013* in Mississippi. locations Drug Total Prescriptions Total Units Prescribed In Mississippi, the PMP is a web-based Hydrocodone 179,740 10,404,330 tool designed to comply with the National All Alprazolam 49,600 3,109,115 Schedules Prescription Electronic Reporting Act Zolpidem 41,522 1,366,215 of 2005 and is under the control of the MissisTramadol 38,302 2,861,468 sippi Board of Pharmacy. The PMP was created Clonazepam 26,953 1,563,671 to assess prescribing trends and to alert the ap*Source: Mississippi Prescription Monitoring Program propriate authorities of any potential illegal use Addressing the Problem in Mississippi: Although there time are clear indications for the use of narcotic analgesics, increase in maternal opiate use during the same frame, of controlled substances. These data include all chronic, recurrent approached Guidelines to assist providers in from 1.19use permust 1000behospital birthswith percaution. year in 2000 to 5.63are available controlled substances addressing pain syndromesthere but referral to specialty pain centers may be advisable in manySchedule II-V, carisoprodol, tramadol, in chronic 2009. In Mississippi, were approximately 180,000 butalbital, and other substances at the discrecircumstances. As the most directfor pathway of obtaining controlled substances, physicians must non-scheduled maintain individual prescriptions hydrocodone products with over tion of the Board of Pharmacy. Any controlled substance prediligence to prevent improper use. 10 million unit doses prescribed in Mississippi for the month scribed to a Mississippi resident of sufficient quantity to reach of the January 2013, a quantity sufficient man, Identifying misuse of prescription drugs canforbeevery difficult butwoman, common characteristics of patients struggling a >48 hours supply is entered into the PMP. The PMP tracks with abuse or child diverting medications requests earlydoses refills, or destroyed” medications, indicators and in Mississippi to include: receive more thanforthree of “lostthe number of dosage units prescribed, how many different preof intoxication, pressuring behaviors, or “doctor shopping” (the practice of obtaining multiple hydrocodone in that month. and Themultisourcing most commonly prescribed scribers have written for controlled substances, and how many controlledcontrolled substancesubstances prescriptions from multiple providers). Additionally, people who take high daily doses, in Mississippi are presented in the Table pharmacies patient has to obtain low-income people living in rural areas, and people with a history of mental illness arethe also at risk forused abuse of controlled substances. above. Since 1990, the number of annual deaths due to unintenReports can be generated at any time prescription drugs. prior or (from concomitant abusedeath of illicit drugs is a common component of abuse behaviors, and are available to any tional drugAs overdoses Mississippi certificate data) or pharmacy/pharmacist that submits the required routine drug testing can be a mechanism for identifying at risk individuals. practitioner The Prescription Monitoring has increased 10-fold. In 1990 the total number of reported the Mississippi Program (PMP), described in detail below, is a valuable tool for physiciansregistration to monitortodrug prescriptionBoard of Pharmacy. Currently in duehelp to drug overdose was 23. This number remained Mississippi thereinare over 2,000 physicians registered to use behaviorsdeaths and can identify individuals obtaining prescriptions from multiple locations Mississippi. stable until the late 1990’s and early 2000’s, increasing to more the PMP. In Mississippi, theby PMP is aThe web-based tool designed to comply with the National All Schedules Prescription than 100 2001. yearly number has gradually increased In February 2013,The the PMP Mississippi Electronicover Reporting Act of 2005 and is under the control of the Mississippi Board of Pharmacy. was State Board of Medithe last 10 years to 232 in 2011. The highest number of cal Licensure incorporated changes to its Administrative Code created to assess prescribing trends and to alert the appropriate authorities of any potential illegal use of deaths has occurred consistently in the 45-54 year old age to improve awareness of the issue of prescription drug abuse controlled substances. These data include all controlled substances Schedule II-V, carisoprodol, tramadol, group with 31% (379/1229) of the unintentional drug related and to promote physician monitoring of patient medication utibutalbital and other non-scheduled substances at the discretion of the Board of Pharmacy. Any controlled occurring in this age group from 2007-2011. The 35substancedeaths prescribed to a Mississippi resident of sufficient quantity to reachlization a >48 hours supply is entered into patterns. Part 2640, Chapter 1 requires all physicians year old tracks age group accounted for 25%units (301/1229), and how the many the PMP.44The PMP the number of dosage prescribed, different prescribers who haveprescribe written or propose to prescribe licensed in Mississippi 25-34substances, year old ageand group for 21% (263/1229) for controlled howaccounted many pharmacies the patient of hasthe used tocontrolled obtain controlled substances. substances to enroll in the PMP program by Decemdeaths in this same frame. Reports can be generated at time any time and are available to any practitioner orberpharmacy/pharmacist submits 31, 2013. Part 2610, that Chapter 2 now requires all physicians the required registration to the Mississippi Board of Pharmacy. Currently intoMississippi there are over 2,000 receive five hours of CME credit hours every two years reAddressing roblem physicians registered tothe usePthe PMP. in Mississippi lating to the prescribing of medications, with an emphasis on Although there are clear indications for the offlap) nar(Continued on use back controlled substances. Of note, due to concerns about excessive cotic analgesics, chronic recurrent use must be approached prescribing of hydrocodone, the US Food and Drug Adminiswith caution. Guidelines are available to assist providers in adtration’s (FDA) Drug Safety and Risk Management Advisory dressing chronic pain syndromes, but referral to specialty pain Committee voted January 25, 2013 to recommend rescheduling centers may be advisable in many circumstances. As the most of hydrocodone from Schedule III to Schedule II. This change direct pathway of obtaining controlled substances, physicians would prohibit nurse practitioners and physician assistants must maintain diligence to prevent improper use. from prescribing hydrocodone and prevent refills. This recomIdentifying the misuse of prescription drugs can be difmendation is currently under FDA review. ficult, but common characteristics of patients struggling with Patients should be advised to dispose of controlled subabuse or diverting medications include: requests for early refills, stances as soon as they are no longer needed. This can prevent “lost or destroyed” medications, indicators of intoxication, prespossible theft and diversion. The Drug Enforcement Adminsuring behaviors, and multisourcing or “doctor shopping” (the istration (DEA) sponsors a National Prescription Drug Takepractice of obtaining multiple controlled substance prescripBack Day to provide opportunities for safe prescription drug tions from multiple providers). Additionally, people who take disposal. (http://www.deadiversion.usdoj.gov/drug_disposal/ high daily doses, low-income people living in rural areas, and takeback/index.html). The FDA also provides information people with a history of mental illness are also at risk for abuse about proper drug disposal for consumers and healthcare proof prescription drugs. As prior or concomitant abuse of illicit fessionals at: http://www.fda.gov/forconsumers/consumerupdrugs is a common component of abuse behaviors, routine drug dates/ucm101653.htm#GuidelinesforDrugDisposal. testing can be a mechanism for identifying at-risk individuals. Table

Table. Top Five Controlled Substances Dispensed in Mississippi January, 2013*

The Prescription Monitoring Program (PMP), described in detail below, is a valuable tool for physicians to monitor drug

References: Mississippi Morbidity Report 2013;(3)29:1 MAY 2013 JOURNAL MSMA 133

• Top Ten Facts You Need to Know • Prescription Drug Abuse: When the Treatment Becomes the Problem Ann Kemp, MD; Molly Clark, PhD; Justin Sherman, PharmD; and Julie Dahl-Smith, DO The time has come to address prescription drug abuse. Because we cannot accurately measure pain, we have been challenged as to what modality, drug or otherwise, is appropriate for a given patient or condition. Patients experience different types of pain associated with trauma, bone/joint disease and conditions like vascular headaches that are equally as disabling as cancer related pain. The simplistic solutions, like limiting the use of opioids for anything other than cancer related pain, is not in the best interest of our own patients. Facts 9 and 10 of this Top Ten appear key. We must learn to use nonaddictive pain therapy effectively while carefully considering and optimizing opioid therapy where necessary. It will take more time and effort to limit the number of pills and refills as we move toward use of opioids as rescue medicines rather than “controller” medicines for pain. abuse, and avoiding possible diversion. — Richard deShazo, MD, Associate Editor

ntroduction Prescription Drug Abuse has become a national concern for many reasons. In 2011, the Director of the Office of National Drug Control policy said, “Abuse of prescription drugs is our country’s fastest-growing drug problem.”1 According to the CDC, between 1997 and 2007, prescriptions of opioid analgesics increased 627%, enough “for every American to take 5 mg Vicodin every 4 hours for 3 weeks.”1 The Associated Press and other media outlets have featured articles on the topic repeatedly over the past few months. In 2012, at least 229 accidental drug overdose deaths were reported to the Mississippi Bureau of Narcotics; in 1990, the number was 23.2 This is a substantial increase, and 95% of those overdose deaths reportedly were from prescription drug abuse.2 Because of the growing prevalence of this problem, physicians should be aware of the facts. 1. Prescription drug abuse ranks #2 among drug abuse. Prescription drugs are abused at a rate second only to marijuana among illicit drug users. Approximately 68% of teenagers choose marijuana as their first illegal drug to try, followed by pain relievers at about 14%.4 Marijuana is considered the “gateway” drug for teenagers because it is usually the first illicit drug used. 2. Prescription drug abuse is growing. Prescription drug abuse is the fastest-growing segment of illegal drug use Author Information: Associate Professor and Family Medicine, Associate Residency Director, University of Mississippi Medical Center, Jackson, MS (Ann Kemp). Assistant Professor and Psychology Fellowship Director, University of Mississippi Medical Center, Jackson, MS (Dr. Clark). Affiliate Faculty, Family Medicine, University of Mississippi Medical Center, Jackson, MS (Dr. Sherman). Associate Professor and Osteopathic Residency Director, Medical College of Georgia, Augusta, Georgia (Dr. Dahl-Smith).

134 JOURNAL MSMA MAY 2013

in the United States. More people abuse prescription drugs than all other illicit substances combined, including cocaine, methamphetamine, and heroin.5 In most categories, male use slightly exceeds female usage, except for those 12 to 17 years old.4 However, more than half of the first time users for prescription drugs are female.4 3. Many teens are ok with prescription drug abuse. One in five or 20% of US high school students reports prescription drug abuse, and one in three teens believes “there is nothing wrong” with this practice “every once in a while.”6 Forty percent of teenagers say abuse of prescription drugs is much safer than abuse of illegal drugs. Almost 30% believe that pain relievers, even if not prescribed by a doctor, are not addictive.6 4. Teens get drugs from friends and relatives. The 2011 National Survey on Drug Use noted about 54% were given prescription drugs by a friend. Over 80% of the respondents stated that their friend or relative had obtained the prescription(s) from one doctor. 4 Less than 1% of the students surveyed stated that they had obtained the medications over the internet.4 5. Prescription drug overdose is common. Recent studies have revealed that overdoses from the abuse of prescription drugs occurs six times more than from all other illegal drugs combined.5 Reports of pain reliever overdose cases in 2009 increased five times since 2005, and stimulant abuse overdose has doubled.3 Zolpidem overdose more than doubled from 2005 to 2009.3 More than half of the emergency room overdose visits involved multiple drugs.3 The Mississippi Bureau of Narcotics monitors drug overdose incidents (death and nondeath-related). To report an overdose incident, call the Mississippi Bureau of Narcotics at 601-371-3600 or 1-800844-6272 or go online http://www.dps.state.ms.us/. continued on p. 139

When your medical office is short-staffed, you get frustrated. When you get frustrated, you dread going to work and you start playing hooky. When you start playing hooky, the bills pile up. When the bills pile up, Mama ain’t happy. When Mama ain’t happy, ain’t nobody happy.

24 YEARS Since 1989, the advisors at Medley & Brown have provided Mississippi families with sound, consistent management of their investment assets. We are proud of our record of care and performance, and invite you to learn more at

www.medleybrown.com or for an appointment, call 601.982.4123

KEEP MAMA HAPPY. When your office is short-staffed, use the MSMA Online Job Bank! MEDLEY & BROWN, LLC

Learn more: www.MSMAonlinejobs.com

F I N A N C I A L

M&B MSMA 24Yrs Feb12'13.indd 1

A D V I S O R S

2/12/13 10:34 AM

MAY 2013 JOURNAL MSMA 135

for iPhone, iPad, Android, and all web-enabled mobile devices MSMA has gone social! Quickly and easily join our nearly 1,000 Twitter followers and Facebook fans by downloading our app and selecting the Social Media link. #GetTheApp #Thanks

Loads of other features. Scan the code with your mobile device or download at

136 JOURNAL MSMA MAY 2013

• President’s Page •

The Great Epidemic

his is my twenty-sixth year to practice Emergency Medicine. When I first began my practice in 1987, we gave out pain medicine for acute injuries, kidney stones, and the occasional exacerbation of chronic problems like sciatica. All those prescriptions were for short periods of time, until the patient could get back in to see their Steven L. Demetropoulos, MD doctor, and none of those was long-acting narcotics. In the past several 2012-13 MSMA President years we have had an incredible increase in the number of requests from our patients for pain medicines. They are requesting pain medication for everything from a small cut on a finger to abdominal cramps associated with gastroenteritis to myalgia associated with a viral illness. In 2001 the Joint Commission imposed the pain scale on all ER admissions and began government validation of the idea that no one should have any type of discomfort when they arrive in the emergency department, and if they did, they should be treated promptly for it. Now we have created a society in which patients think they shouldn’t have any type of discomfort and if they do, that it should be treated completely. That means that patients now expect to have a narcotic for things that a narcotic would not normally be given. What have we become? One of the last patients that I saw with a viral illness wanted a shot of morphine for her muscle aches. I explained to her that most people take Tylenol or Motrin for this and that is usually all you can do until it gets better. The patients with sprained ankles and wrists that normally were treated with non-steroidals are now requesting narcotics to treat their level of pain. When is it going to stop? When are we as a society going to say, “Enough” with narcotic usage? Our society has been pushed more and more to grade their pain and to expect immediate relief. We as physicians certainly understand all the dangers that are associated with narcotic usage, and yet we are put in a position to seem uncaring or insensitive unless we address the pain completely. In 2008, there were 15,000 fatalities related to prescription opioid overdose. That amounts to 40 deaths every day. Opioids are the most frequently prescribed drug class, and 4,000,000 patients per year receive prescriptions for long-acting narcotics. Initially when the scale came out in 2001, it was promoted by a Dr. Portenoy. At that time he claimed that the addiction rate was less than 1% for use of narcotics. Now in 2013, we know that it is much higher, some say as high as 40%. Of course there are other significant problems associated with opiate use as well including tolerance, GI dysfunction and increased sensitivity to pain, immunosuppression, and decreased levels of cortisol, testosterone, and estrogen. These medications are not without serious side effects. Because of this we see cities now imposing government restrictions on the patient/physician relationship out of response to the epidemic that is occurring. In New York City, there are eleven public hospitals that have limitations on how narcotics are prescribed, for how many days, and the types of narcotics. We do not need more regulation. We need a cultural change within our country. Here are a few suggestions, some about principle while others are more practical. I think we need to send a resolution to the AMA asking the Joint Commission to reevaluate the pain scale as a fifth vital sign for every patient that comes through the emergency department. I think it unnecessarily escalates most people’s pain and then calls for some type of response. I am in complete favor of treating anyone that has serious pain, and we do that on a regular basis. But to heighten pain as a vital sign, I think serves only to promote the idea that no one should experience any type of discomfort without it being addressed. On a statewide level, I think we need to be very supportive of the State Board of Medical Licensure’s effort to try to eliminate “pill mills” that are active across the state. Physicians who are indiscriminately prescribing large amounts of opioids and benzodiazepines outside a pain management setting need to be dealt with and addressed by the licensure board.

MAY 2013 JOURNAL MSMA 137

On the practical side there are several things that you can do. In our hospital, we instituted a pain policy, and you could do this in your clinic as well as in emergency departments. What we did is limit the amount of narcotic that can be prescribed to patients to just several days. We avoided all long-acting narcotic prescriptions such as oxycontin, methadone or fentanyl patches and then we eliminated prescribing for prescriptions that were lost or stolen. In addition we developed resources for all drug treatment centers in our area so if someone has a dependency issue and they would like treatment, we can get them referred to one of those treatment centers. We also have a list of pain management doctors in the area that are willing to see patients that have legitimate chronic pain and refer them to a treatment center that can follow them and contract with them to legitimately and appropriately treat their pain. There are people that have chronic pain, and we do have pain management specialists that can see and treat these patients. They can contract with them and screen them randomly and on a regular basis to make sure that they are compliant with their contract. This is a real epidemic that we are seeing, and it seems as though physicians are caught in the middle of it. There has to be a cultural change in our society but we as doctors need to be the leaders in effecting change and in helping society understand that narcotic use does not come without a lot of unintended and negative side effects.

ust what the doctor ordered MINTED ORZO with CUCUMBER and FETA CHEESE

rzo is a rice pasta. It makes a great summer dish. I like to boil my orzo using the instructions on the package. Then I set it aside and let it cool. Next I chop up some cucumbers in quarters or halves. I then add fresh mint. You can add as much mint as you like to flavor the whole dish. I also add four green onions. Add the mint, cucumbers, and onions to the orzo. Then sprinkle it with olive oil until it is well coated. Add about two tablespoons of lemon juice and then a big handful of feta cheese. Then salt and pepper it to taste and mix thoroughly. Put it in the refrigerator, and let it cool. This is a dish you can use for several days. It is great with barbeque or as a side dish with any meat or fish dish. It is a great summer side dish because you can make it ahead of time and eat on it for several days. Bon AppĂŠtit!

OR PRINT or ONLINE The choice is yours...

ree online access to the Journal MSMA is available to current members of the Association. If you would prefer to receive only the online version and not the print version of the JMSMA let us know. If you would like to opt out of receiving the print version, please contact Managing Editor Karen Evers, KEvers@MSMAonline.com or 601.853.6733, ext. 323.

The price for membership will not change whether you wish to receive the print version or not.

138 JOURNAL MSMA MAY 2013

Top 10 Facts continued from p. 134

• Scientific •

Table. Top 5 Drugs Mississippi Prescription Monitoring Program 2012

2011 Mississippi Population Estimate: 2.9 million *rounded numbers Source: Mississippi Bureau of Narcotics

6. Hydrocodone is a top culprit for teens. Narcotics, stimulants, barbiturates, and antidepressants, as well as other prescriptions medications, may be potential drugs of abuse. Hydrocodone and a popular amphetamine derivative are the top prescription abuse culprits for teenagers, with over 7% of 12th graders admitting to usage within the past year.7 Some surprising medications that may be abused include quetiapine (sedating effect), bupropion (stimulant effect), and clonidine (“boosting” effect of opioids, benzodiazepines, and cocaine).9, 10, 11, 12, 13 Local law enforcement agencies are usually aware of the most prevalent drugs abused in their jurisdiction and can provide useful information to physicians. 7. Proper disposal of medications is important. Medicine cabinets often contain unused and expired medications. Disposing of old medications can reduce the potential for abuse. Although the traditional way to dispose of medications is to flush them, concern is growing that flushed medications are entering the water supply; traces of some prescription medications are not filtered by water treatment plants.15, 16,17 Some medications can be thrown in the trash by mixing them with “undesirable substances” such as coffee grounds and putting them in a sealed container or bag.18 The federal government has initiated national “Take-Back Day” programs for outdated and unused medications. For information on patient education about drug disposal, visit www.dea.gov.18 8. Mississippi prescription monitoring program registration is mandatory. Prescription monitoring programs (PMP) are now operational in 42 states. The purpose of the monitoring program is to enhance patient care by providing information to assure legitimate use of controlled substances. In Mississippi, healthcare practitioners, pharmacists, regulatory boards, and law enforcement agencies have access to monitor controlled substances within schedules II through V. Other drugs of concern, including carisoprodol, tramadol, and butalbital, are monitored as well. As of December 2013, every Mississippi physician who prescribes, administers or dispenses controlled substances must register with the Mississippi Prescription Monitoring Program. Pharmacies and other dispensers are required to report prescription data on these drugs on a weekly basis to ensure accurate and prompt dissemination of this information. By utilizing the PMP, healthcare practitioners can make more informed treatment decisions for their patients; the provider can generate a report that lists all of the scheduled medications a patient has had filled during a spe-

cific time period as well as the providers, the pharmacies, and amounts.19 In 2012, the top 5 controlled drugs most commonly prescribed in Mississippi were hydrocodone, alprazolam, tramadol, oxycodone, and zolpidem. For PMP registration, visit http:// pmp.relayhealth.com/MS/.19

9. Provider Education is Key. In 2009, over 15,000 deaths in the US occurred due to misuse of prescription drugs. Many of these involved opioid use. Because of the number of opioid prescriptions dispensed (23 million in 2011) and the fact that the extended release formulations are more likely to lead to abuse, the FDA asked pharmaceutical companies to develop Risk Evaluation and Mitigation Strategies (REMS) for long-acting narcotics. The key components of the REMS include the following: 1) voluntary training programs for providers, 2) updated medication guides for counseling by pharmacists, and 3) audits of manufacturers’ effectiveness of the programs. These free educational programs for providers started becoming available in March 2013.20 The State Board of Medical Licensure recently updated its new regulation requiring all licensees to earn 5 hours of prescription-focused CME per reporting period. The requirement, per the update, now only applies to those physicians holding a DEA license CME that focuses on prescribing; See www.msblml.gov for the complete regulation update. 10. Free educational tools for prescribers are available. The American Academy of Family Physicians (AAFP) has launched a five year campaign which “aims to prevent half a million teens from abusing medicine.” The campaign encourages parents to talk with children and teenagers about the dangers of abusing prescription and OTC medicines and to safeguard and properly dispose of unused medications. Resources on the AAFP website are listed under the “Medicine Abuse Project” (www.AAFP.org).14 In addition, many physicians may find patient educational brochures on pain, pain medications, and medication agreements/contracts helpful. There are a number of websites that offer suggestions and templates for medication agreements/contracts and patient education materials. The American Academy of Family Physician has a sample template for a medication agreement (http://www.aafp.org/ fpm/2001/1100/fpm20011100p47-rt1.pdf). Some other resources for both patients and physicians include the American Pain Society (www.ampainsoc.org) and the American Academy of Pain Medicine (www.painedu.org). Conclusion Prescription drug abuse is the fastest growing drug problem in the United States, second only to marijuana, and exceeds all other illicit drug use combined. Prescription drug abuse, in particular hydrocodone, is predominant among teenagers, the majority of whom obtain drugs from a friend or relative. To counter this growing problem, many tools such as the ones mentioned here are available for physicians. The partnership

MAY 2013 JOURNAL MSMA 139

of health care providers with regulatory and law enforcement agencies is essential in solving this problem.

References

12. Volpe KD. “Intervention Reduces Psychotropic Abuse in Correctional Facility; CNS News, JUNE 2005, VOLUME: 07:06”. Archived from the original on September 29, 2007. http://web.archive. org/web/20070929071643/http://www.cnsnewsonline.com/index. asp?section_id=113&show=dept&article_id=4907. Retrieved 2007-0527.

National Alliance for Model State Drug Laws (NAMSDL) http://www. namsdl.org/documents/ModelPMPAct111911withoutcommentary_001. pdf.

Source: Mississippi Bureau of Narcotics.

National Institute on Drug Abuse. http://www.drugabuse.gov/publications/research-reports/prescription-drugs.

National Survey on Drug Use and Health. http://oas.samhsa.gov/ NSDUH/2k10NSDUH/2k10Results.htm.

United States Department of Justice http://www.justice.gov/usao/gan/ programs/prescriptiondrugs.html.

Community Anti-Drug Coalitions of America: Prescription Tool Kit http://www.cadca.org/resources/detail/rx-abuse-prevention-toolkit.

Monitoring the Future Survey. http://www.monitoringthefuture.org/

18. DEA. http://www.deadiversion.usdoj.gov/exit_pages/fda_complaint. htm#fda_rx_dispose.

Khurshid KA, Decker DH. Bupropion insufflation in a teenager. J Child Adolesc Psychopharmacol. 2004, 14(1):157–8.

19. RelayHealth Prescription Monitoring Program. http://pmp.relayhealth. com/MS.

Lu JJ, Thompson TM, Narunatvanich D, Fischbein CB, Mycyk MB. Seizure after nasal insufflation of bupropion [abstract]. Clin Toxicol (Phila) 45: 632.

20. FDA information on Risk Evaluation and Mitigation Strategy (REMS) for Extended-Release and Long-Acting Opioids. http://www.fda.gov/ drugs/drugsafety/informationbydrugclass/ucm163647.htm.

13. Drugs of Abuse. Prescriber’s Letter March and November 2010. http:// prescribersletter.therapeuticresearch.com/home.aspx?cs=&s=PRL. 14. AAFP Medicine Project. http://www.aafp.org/online/en/home/publications/news/news-now/health-of-the-public/20120926medabuseproject. html. 15. FoxNews Release. http://www.foxnews.com/story/0,2933,336286,00. html. 16. Washington Post News Release. http://www.washingtonpost.com/wpdyn/content/story/2008/03/09/ST2008030901877.html. 17. US News and World Report News Release. http://www.usnews.com/science/articles/2009/04/19/tons-of-released-drugs-taint-us-water.

10. Welsh CJ, Doyon S. Seizure induced by insufflation of bupropion. N Engl J Med. 2007,347(12): 951. 11. McCormick J. Recreational bupropion abuse in a teenager. Br J Clin Pharmacol. 2002,53 (2): 214. JNLMSMed-BW2

FrAuD &Abuse: A TerminAl DiAgnosis.

Our healthcare specialists have solutions to most every situation you may encounter in your practice - and more importantly, can help you avoid many pitfalls that often occur in the complex world of today’s medicine. Every day we partner with hospitals, physicians and other healthcare providers with issues regarding reimbursement, Stark & Anti-kickback, Licensure, HIPAA, and Certificates of Need - as well as everyday needs such as practice structure, employment guidance and liability defense. We’re the perfect partner for your healthcare practice. Give us a call to review your challenges - we’ll make a prescription for a trouble-free path. 1076 HIGHLAND COLONY CONCOURSE 600, SUITE 100 RIDGELAND, MS 39157

(601) 856-7200 www.cctb.com

140 JOURNAL MSMA MAY 2013

to our 2013 Legislative Session

State Capitol

These physicians made a positive presence for medicine to legislators and elected officials by volunteering as MSMA’s State Capitol Doctor of the Day. From treating legislators and their staff for common ailments to visiting with officials on the House and Senate floor and in committee meetings, these doctors took the time to promote medicine to state policymakers – which resulted in yet another successful legislative session for medicine.

Dr. John W. Bethea Jr. Dr. Steven Brandon Dr. Cassie Burns Dr. C. Ron Cannon Dr. Susan Chiarito Dr. John Cross Dr. Damon A. Darsey Dr. Randy Easterling Dr. Lee Giffin Dr. Scott Hambleton Dr. Stanley Hartness Dr. Betty Herrington Dr. Briggs Hopson Dr. Thomas E. Joiner Dr. Harriet Jones

Dr. James Jordan Dr. Philip Levin Dr. William S. Mayo Dr. Stephen McDavid Dr. Fred McMillan Dr. Eric A. McVey III Dr. W. A. Middleton Dr. John Pruett Dr. Jorge Salazar Dr. Lawrence E. Stewart Dr. Chet Tharpe Dr. Kenneth Thomas Dr. Becky Waterer Dr. Chris Wiggins Dr. Julie Wyatt

Read about MSMA’s 2013 legislative victories at http://tinyurl.com/CESFNEL.

MAY 2013 JOURNAL MSMA 141

• Legal Ease • New Laws Expedite Physician Practices, Save Money J. Conner Reeves, JD

uring the 2013 Regular Session of the Mississippi Legislature, MSMA advocacy ensured the passage of several pieces of legislation that are “wins” for Mississippi’s physicians. Your MSMA legislative team successfully supported bills that reduce administrative burdens and facilitate physician compensation, ultimately saving doctors time and money – precious commodities for medical practices.

Assignment of Benefits (House Bill 374) House Bill (HB) 374, or Assignment of Benefits, was the first piece of legislation signed by Governor Bryant this legislative session. The new law authorizes a patient to directly assign their insurance benefits to out-of-network providers for services rendered and requires the insurance provider to honor such assignment. Though met with heavy resistance from insurance companies, MSMA prevailed due to extensive pre-session groundwork and partnerships with the Mississippi Ambulatory Surgical Association and the Medical Group Managers Association of Mississippi. Thanks to HB 374, out-of-network physicians will be able to avoid dedicating wasteful hours collecting payments from patients, eliminating yet another obstacle insurance companies place between physicians and their rightful payments.

Prior Authorization (HB 301) A recent survey found the average physician practice devotes one hour of physician time, 13.1 hours of nursing time, and 6.3 hours of clerical time, to the prior authorization (PA) process each week. To combat this unnecessary waste, MSMA sought introduction of HB 301 requiring all insurance companies in the state to utilize one standardized PA form per company for prescription drug PAs. This streamlines the existing process from over 340 prescription PA forms to less than 20. Additionally, insurance providers are required to respond to PA requests within two days. The decrease in paperwork will drastically save office and nursing staff time by avoiding lengthy “clarification” calls to insurance companies, thus freeing staff to perform other duties. The increase in

142 JOURNAL MSMA MAY 2013

statutory pressure on insurance companies to expedite PA responses will ensure patients receive appropriate medications quickly and efficiently. HB 301 is truly a win-win for doctors and their patients.

Telemedicine Services Reimbursement (Senate Bill 2209) Usage of telemedicine services has increased in recent years, resulting in the allocation of quality medical services in additional areas of Mississippi. Prior to the 2013 legislative session, physicians were not adequately compensated for treatment provided via telemedicine connections. Senate Bill (SB) 2209 addressed this issue by requiring insurance companies to reimburse physicians providing telemedicine coverage to the same extent as in-person visits. The bill defines telemedicine as “the delivery of health care services such as diagnosis, consultation, or other electronic media” and further states that “Telemedicine must be ‘real-time’ consultation, and it does not include the use of audio-only telephone, email, or facsimile.” Additionally, “treatment recommendations, including issuing prescriptions, will be held to the same standards of appropriate practice as those in traditional provider-patient settings.” As technology improves, the use of services such as telemedicine will increase, further evolving the practice of medicine and increasing access to care in currently underserved areas of Mississippi. With the passage of SB 2209, MSMA has ensured insurance reimbursement for physicians providing quality telemedicine care. View the above bills and all legislation considered by the Mississippi Legislature by visiting www.legislature. ms.gov.

J. Conner Reeves recently graduated from the Mississippi College School of Law. During his last semester, Reeves was a legal extern with MSMA, assisting in both legal and governmental affairs. Reeves plans to take the Mississippi Bar this summer and practice in Jackson after completion.

• AMA • The AMA Rolling up its Sleeves Jeremy A. Lazarus, MD, AMA President

hile physicians focus daily on the needs of their patients, the American Medical Association (AMA) works closely with state medical associations to advocate for the needs of physicians in their state capitals. This important work is done through the AMA Advocacy Resource Center (ARC) – the state legislative arm of the AMA. Made up of six state legislative attorneys and backed by a host of AMA content specialists, the ARC works across all 50 states to address state-level issues important to physicians and their practices including: state health system reform, Medicaid, medical liability reform, private payer reform, scope of practice, and public health improvement. The ARC works to identify problems proactively before they hit practicing physicians full force. The ARC’s advisory board is made up of 20 state medical association CEOs, lobbyists and general counsels. This Committee ensures that the ARC’s advocacy efforts are closely linked to local public policy realities and the needs of state and specialty societies. The ARC creates state-of-the-art model legislation, testimony, talking points, and white papers for use by medical societies across the country, and provides extensive research support and lobbying back-up – wherever and whenever needed. Real time and available 24-7, this collaboration and commitment helped the ARC secure more than 125 state legislative or regulatory victories in 2011 and 2012 nationwide. Here in Mississippi – over the years – AMA partnership with the Mississippi State Medical Association (MSMA) helped to illustrate how physicians drive the state and local economy. Specifically, the AMA’s Economic Impact Study specifically showed that Mississippi’s physicians support more than 24,000 jobs, generate $5 million in economic output, support $3 billion in wages and benefits, and contribute more than $190 million is state and local tax revenues. Other examples

of this AMA-MSMA collaboration include our continuing work to preserve the physician-led team based model of health care delivery in Mississippi, as well as our successful efforts to enact “truth in advertising” legislation. Together, we have successfully worked to enact a number of private payer reforms, as well - including, most recently, legislation addressing the prior authorization process. We are proud of these accomplishments on behalf of Mississippi physicians and stand ready to work with MSMA in the future. The AMA’s work on state-level issues, however, does not stop there. Physicians across the country benefit from our ability to develop strategic collaborations and influence national state policy-making organizations such as the National Association of Insurance Commissioners, National Governors Association, and others. More often than not, the AMA is the sole voice representing physicians when these organizations meet and develop their policy – policy that directly impacts physicians. It is through the AMA’s advocacy, for example, that we ensured that insurance companies must adhere to strict medical loss ratio standards – guaranteeing that insurers spend more money on the delivery of health care as opposed to their administrative expenses. Given the fact that the entire insurance industry opposed us at every step this was an impressive victory for both patients and their physicians. In all 50 states one thing is abundantly clear – physicians want to practice in an environment that delivers quality care and supports their needs and the needs of their patients. Working closely with state and specialty societies, and through the ARC, the AMA will continue to leverage the full force of organized medicine to accomplish goals shared by all physicians. It is only through the support of our members that this work from the AMA is possible. Help sustain our state advocacy efforts on issues of importance to you and your patients. Please activate your 2013 AMA membership by visiting amaassn.org or contacting member relations at 800/262-3211. r

MAY 2013 JOURNAL MSMA 143

• UMMC • Former Asylum Patients’ Resting Place Unearthed on Medical Center Campus, State Institutions to Document, Rebury Decades-Old Remains Gary Pettus, Office of Public Affairs

able Daniels’s great-grandmother was a patient in the State Insane Asylum about a century ago when she was laid to rest on the asylum grounds – before her family knew she had died. “Things were done different back then,” said Daniels of Forest, Mississippi. Apparently so; Daniels wonders if her ancestor’s remains could lie in one of the five dozen wooden coffins uncovered over the past few months beneath the former site of the vanished asylum – the campus of the University of Mississippi Medical Center. As has happened before at the University of Mississippi Medical Center (UMMC), a construction crew scraped away a decades-old layer of dirt and desertion near a stand of pine trees to reveal 66 unmarked graves, making it virtually impossible to name the people buried there. But if Epsie (Seals) Devine is among them, Daniels can be sure the remains of her great-grandmother are being treated with respect. In spite of an extensive campus road construction project delayed in part by the discovery, UMMC is working with several institutions to document, and then rebury, the people lost to their loved ones. “It’s the right thing to do,” said Jim Woodrick, director of the Historic Preservation Division of the Mississippi Department of Archives and History. “Things expand, but memory doesn’t expand with them. Archaeologists help us recover it,” he said. “This doesn’t stop progress, but we are also able to accommodate those who died. We learn things about our past. We honor the dead.” Already, investigators have made an educated guess about the general identity of the deceased, said Nicholas Herrmann, assistant professor of anthropology at Mississippi State University whose department is removing the remains for testing at MSU. “I believe the coffins are tied to the asylum,” he said. That was probably the suspicion from the moment in November when construction workers struck wood buried in

144 JOURNAL MSMA MAY 2013

the messy gunk of Yazoo clay. “That’s when the whole thing started,” said Nicole Reese, senior project manager in the Office of Planning and Design. It started because of a project designed to add a new north-south road and campus intersection with Lakeland Drive to improve traffic flow, providing a beltway that bypasses the

Stephen Michael Davis of Tennessee Valley Archaeological Research measures a coffin.

he pi

lel

t s.

elements – say, lead and carbon – reveal details about a person’s environment and approximate age. died on Feb. 14, 1916, Daniels said. “We’re having a hard time finding out much about them. I would like to know more about her if I could.” If Devine’s grave is among the 66, her marker and the other 65 have disappeared. Patient registries and other historical documents from the asylum are stored at the state archives, but many are sketchy. Fires that broke Mississippi State University archaeologists Derek Anderson and Forrest Follet remove Mississippi state University archaeologists derek Anderson and forrest out early in the the soil from the lid of one of more than 35 graves. asylum’s history may follet remove the soil from the lid of one of more than 35 graves. have destroyed some campus’s heart and eases future development. The roadway records. Complicating cuts through a wooded area and intersects an existing road matters: other cemeteries sat on or near the same site, Unexamined, the contents of the coffins haven’t disclosed much, Herrmann running parallel to Lakeland. including one with paupers’ graves. The remains were found just off the north side of that Naturally, construction workers have uncovered human said. existing road. From November and through early March, as remains at UMMC long before now. In the early 1990s, 44 crews dug out subsoil to see if it was fit to support a new road, unmarked emerged so during “We have found no grave goods. There have been no tracesgraves of clothing far.work on a steam line for a construction equipment exposed a total of 66 coffins. In size, new laundry. We find one button and shroud pins. theydid are fairly uniform – about six two feet long but alarmingly Another 29 or 30 graves found a few years earlier in narrow, as if each held a pair of stilts instead of a human another area did retain mostly intact markers and inscriptions, “All the remains are adults, male and female.” skeleton. Many were at least four or five feet deep in the including names and death dates ranging from the late 1800s As for the mystery of the coffins’ narrow size, Herrmann explained it easily: ground. to the early 20th century. Although they are linked to the “A lot of clay and junk was in the soil,” said Ron Horne, asylum which was for adults, they included the names of two “The weight of the soil compressed them,” he said. “The coffin lids collapsed, the director of construction projects, “and has to be replaced. We children. might pushed have builtin theand roadbed top of the graves ifup.” the subsoil Combined, those 70-plus marked and unmarked remains sides the on bottoms pushed had been solid.” now lie in the UMMC Cemetery in the northeast corner of the Still, some ofland’s the wood in pretty shape, hecampus said. Determining itsCenter makeup Because of the formeris occupant, the good discovery where the Medical has also placed a memorial wasn’t surprising; neither was it particularly expected. to medical donors. That cemetery also will be the eventual and approximate age is the work of a dendrochronologist at the University of Known as the Mississippi State Lunatic Asylum and then the resting place of the 66 latest remains unearthed so far. Southern MississippiMississippi. State Insane Hospital, the institution operated They could have been found even before the road crew from 1855 to about 1935, its main building rising four started digging. The MSU anthropology team is asking for two years to analyze all the stories alongside North State Street near the current Ronald An archaeological review is required before any work McDonald House site. of approximately $2,100 per grave. remains, at a cost UMMC is planning begins on public property, Woodrick said. The investigation Later, it was destroyed to make way for UMMC, was especially important in this case, since the land also towhich schedule opening ofmoved the new roadthe within the next couple of opened inthe 1955. The asylum and became embraces a Civil War battle site – in July 1863, Union artillery Mississippi State Hospital in Whitfield, but during its 80-year placed on a ridge bombarded the Confederate city of Jackson. months. history in Jackson, it treated thousands of patients, many of Preserved artillery earthworks on Asylum Ridge mark the spot MeaNwhIle, archaeologists will beoftransporting to the war may be buried nearby. whom died there. They were buried on a site hundreds to thisthe day,skeletons and relics from yards to the east, where 21st century workers discovered 66 Using metal detectors, radar, and Starkville, adhering to guidelines laid out by the Department of Archivesground-penetrating and graves. other methods, staff from the Center for Archaeological Over the years, relatives abandoned some patients, even Once Ole Miss’ Center for Archaeological Research. their work is done,ofthe Research at the University Mississippi surveyed the area after death. Or, as in Epsie Devine’s case, kinfolk couldn’t get between September 2011 and January 2012. The investigation remains will“Her be sent to Jackson forVaiden reburial,uncovered with Department of to them in time. family back had to come by train from “nothing of significance,” the center’s report states. to the asylum,” said Daniels, Epsie Devine’s descendant. “She But construction barriers for the School of Pharmacy Archives’ approval. was in the ground before they got there.” The family’s own building (under construction then) prevented researchers from But theresearch scope of thisthat investigation only grow larger. Beyond thealong roadtheprojgenealogical shows Epsie Devine, may or Divine, investigating a stretch north side of the existing

ect, more construction is in the offing, including plans for a nearby parking garage, MAY 2013 JOURNAL MSMA Horne said. “We could identify graves that may be in that spot.”

145

road, University Drive, where the first group of more than two dozen remains would surface. As for the existing road, under which about three dozen graves later emerged, “it was never surveyed because it was developed land,” Reese said. As with other surveys, this one was aimed only at undeveloped land. Crews who built the old road decades ago did no undercutting; that’s why they found no graves then, Reese said. Reporting the survey’s findings, the Department of Archives said the road site area was not eligible for historic preservation. Archives officials also reported, it’s unlikely we’ll find out if the burials located on the ridge to the east of the project area include inmates from the asylum or paupers or some other group of people.” But investigators will do their best. “Bone chemistry can help determine residential history,” Herrmann said. By examining tooth enamel, for instance, archaeologists can learn much about a deceased person’s diet – in this case, if it was typical for Mississippi. Traces of certain elements – say, lead and carbon – reveal details about a person’s environment and approximate age. Unexamined, the contents of the coffins haven’t disclosed much, Herrmann said. “We have found no grave goods. There have been no traces of clothing so far. We did find one button and two shroud pins.

“All the remains are adults, male and female.” As for the mystery of the coffins’ narrow size, Herrmann explained it easily: “The weight of the soil compressed them,” he said. “The coffin lids collapsed, the sides pushed in, and the bottoms pushed up.” Still, some of the wood is in pretty good shape, he said. Determining its makeup and approximate age is the work of a dendrochronologist at the University of Southern Mississippi. The MSU anthropology team is asking for two years to analyze all the remains at a cost of approximately $2,100 per grave. UMMC is planning to schedule the opening of the new road within the next couple of months. Meanwhile, archaeologists will be transporting the skeletons to Starkville, adhering to guidelines laid out by the Department of Archives and Ole Miss’s Center for Archaeological Research. Once their work is done, the remains will be sent back to Jackson for reburial with Department of Archives’s approval. But the scope of this investigation may only grow larger. Beyond the road project, more construction is in the offing, including plans for a nearby parking garage, Horne said. “We could identify graves that may be in that spot.” Rain has delayed the excavation of some of the coffins. Many at the bottom of a hill have been covered in wet silt and clay, Herrmann said. Throughout much of March, the MSU team had not been able to work in the lower part of the pit. “We might find more graves there,” Herrmann said. r

A PART-TIME CAREER

ThAT REMInds YOU whY YOU

bECAME A hEAlTh PROfEssIOnAl.

Serving part-time in the Air National Guard, you’ll have an unmatched opportunity to help others — from treating fellow Airmen to providing health care as part of a humanitarian mission. In return, you’ll receive comprehensive benefits and a flexible work schedule. Talk to an Air Guard recruiter today to learn more.

GoANG.com/MS

146 JOURNAL MSMA MAY 2013

1-800-TO-GO-ANG

We specialize in the business of healthcare • • • • • • • •

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

“Working with MEA full time since completing residency in June of 2012 has been more than I ever hoped for. I love going in to work every day. The opportunity to take care of my patients, work with our compassionate and efficient staff, treat a wide range of illnesses, perform various procedures, and tailor the practice to my interests makes working at MEA the perfect choice for me.”

Bradley J. Suggs, MD

What can we do for you?

Mississippi Physician Services is one of the largest physician owned and managed, groups in Mississippi. For over 30 years we have staffed the MEA Medical Clinics in the Jackson, Vicksburg and Laurel, MS areas...and we are growing! With nearly 40 physicians in our group, we are able to offer flexible scheduling, a generous base salary, a competitive incentive bonus and an unbeatable benefits package.

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

Whether you are in a current practice and tired of dealing with management problems, or a resident planning for your future, we encourage you to take a look at MPS.

Rachel Williamson 601-898-7527

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

OR Physicians to review Social Security disability claims at the

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

DISABILITY DETERMINATION SERVICES 1-800-962-2230

MAY 2013 JOURNAL MSMA 147

• Editorial •

To Wear the Long Coat

C. Ann Myers, MD

his month my youngest daughter graduated from medical school and will now “wear the long coat.” These past four years have flown by and I’ve watched her mature into a caring fledgling physician. Her classmates have been bright and hard working, striking me as awesome young individuals who will make us proud to call them physicians. They will face many changes in medicine by the time they finish their residencies, but I hope they will maintain their idealism and excitement about the field of medicine. When she was considering her career choices, I was hesitant to encourage the study of medicine too strongly. But I did remind her that, given her varied interests and talents, a career in medicine provides many advantages. The base of knowledge changes so rapidly that you can never really “learn it all,” and patients provide a continuing resource for fulfillment and humility. My advice in summary was “only go into medicine if you love it and think you will always find it

interesting” because the financial rewards will not be the same for your generation. We are bombarded every day with prospective changes in re-imbursement and coding, and the headaches of overhead, malpractice, and the naysayers and predictors of the approaching doomsday. And yet, most of us still manage to remember the human side of medicine in talking with our patients each day. My classmates and colleagues still care deeply about the health of their patients and deliver excellent care to them every day. As she and her classmates graduate, I trust that they will continue to receive excellent training and mentoring. Medicine still holds a better promise of employment than many other fields and should continue to be intellectually challenging and financially rewarding in spite of the changes that will come. Each day in caring for my patients I am reminded of some wise advice received years ago. “Care for the patient to the best of your ability” and “first do no harm.” My advice to them would be the same – that they do so with compassion for all and my hope is that they continue to love what they do each day they have the privilege to practice medicine. So to all the graduates I say, “Wear the long coat with pride, but also with compassion above all else.” Remember that it is still an honor and responsibility to be among the chosen few who get to do so. Best of luck! Elizabeth Schimmel, MD, (left) received her long coat from the University of Mississippi Medical Center (UMMC) during a ceremony held May 23, 2013 at the Jackson Convention Complex. She is the 2013 recipient of the Carl Gustav Evers, MD Award, given for demonstrating scholarship qualities, peer to peer support, and exceptional leadership in student activities of the AMA and the MSMA. Dr. Schimmel will do an otolaryngology residency at the Oregon Health & Science University in Portland, Oregon. Elizabeth attended William B. Murrah high school and participated in the Base Pair research mentorship program partnered with the UMMC. The primary focus for Base Pair is to utilize the physical resources and intellectual capital of UMMC to enable the pursuit of excellence in science education within a local public school environment. The program matches high school students with UMC faculty members for in-depth experiences in the sciences. Her mother (and the author), C. Ann Myers, MD is a rheumatologist practicing at St. Dominic Hospital in Jackson. She graduated from the UMC School of Medicine, where she did her residency and fellowship, teaching on staff until 1997. Married to George Schimmel (retired cardiologist), they have three children including Elizabeth. Andrew is a lawyer with the attorney general’s office. Julia earned her master’s in Spanish and is teaching in Querétaro, Mexico.

148 JOURNAL MSMA MAY 2013

Reducing costs in the clinical enterprise is about improving quality.

Those unable to compete in this

A L A B A M A

L O U I S I A N A

Sp Co-

Registration now open Register online at www.horne-llp.com or by phone at 601.326.1079.

d by MS ore M ns A

HDI’s Advanced Training Program is changing the way we deliver healthcare. Learn how to improve the quality of healthcare delivery in your practice or hospital using data — eliminating waste in the system, resulting in reduced costs. Registration now open for Fall 2013 and Winter 2014 terms. Approximately 80 CME hours available.

S SI

PreParing for the healthcare Delivery MoDels of the future requires Data-Driven Process iMProveMent

E AT

For more information about this program, contact Casey Jacobs, HORNE LLP, at casey. jacobs@horne-llp.com or 601.326.1079. For more information about CME, contact Kim Mathis, LPC, Mississippi State Medical Association, CME Director, at kmathis@msmaonline.com or 601.209.2306.

M I S S I S S I P P I

SIPPI S T

sphere will not survive.

T E N N E S S E E

T E X A S

MAY 2013 JOURNAL MSMA 149

MED

MSMA Helps Members Fulfill NEW Rx CME Requirements Prescribing Webinar Available NOW!

To register or learn more, click the “New CME Requirement” banner in MSMA’s Online CME catalog: http://MSMAonline.InReachCE.com

150 JOURNAL MSMA MAY 2013

11:30 a.m. Board of Trustees Lunch Meeting 11:30 a.m. MSMA Alliance Past President’s Luncheon 1:00 p.m. House of Delegates Addresses of MSMA President, AMA President, and Alliance President 1:00 p.m. MSMA Alliance Board Orientation 2:00 p.m. Reference Committee Hearings 7:00 p.m. Inauguration of 146th MSMA President James A. Rish, MD

8:30 a.m. MSMA Alliance House of Delegates

August 16 – 17, 2013 Jackson

8:30 a.m. Excellence in Medicine Awards 9:30 a.m. Candidate Speeches 10:30 a.m. Caucus Meetings

Hilton Hotel 1001 East County Line Road, Jackson Phone at 601.957.2800 Online at Jackson.Hilton.com Group Code: MSMA Reservations Deadline: July 16

11:30 a.m. Voting & Lunch Board of Trustees Meeting 12:00 p.m. MSMA Alliance Installation Luncheon 1:00 p.m. House of Delegates 3:30 p.m. Board of Trustees Meeting 6:30 p.m. UMMC Alumni Dinner

MAY 2013 JOURNAL MSMA 151

Online Registration Opens May 31 OR Register by Mail with this Form

FOR MEDICINE Name: Email:

Specialty / Title: Address: MSMA is now accepting resolutions to be presented to the House of Delegates (HOD) at the 2013 MSMA Annual Session business meeting August 16-17 in Jackson.

City, State Zip: Phone: Fax:

Any MSMA member in good standing may submit a resolution. Any local medical society may submit a resolution that has been approved by majority in accordance with local society bylaws.

Cell:

Resolutions emailed to MSMA will be formatted and fiscal notes and/or policy references may be added. For information on how to draft a resolution, contact our staff for a checklist to help streamline the process.

Payment Information

Resolutions received after August 2, 2013 are considered late and must be presented at the opening session of the HOD on Friday, August 16, 2013. The Committee on Rules and Order will determine whether it is of an emergency nature and will be accepted for consideration. Resolutions received on time will be posted at MSMAonline.com August 1-10 so members may review the resolutions online and submit comments to be considered by the appropriate reference committee. Any member of the association may submit online comments and/or testify in person at reference committee hearings. Only delegates present at the House of Delegates meeting may vote on resolutions. Online comments will be accepted through August 10; however, any member may testify in person August 16. Therefore, to make your views known after August 10, plan to testify in person on August 16. Please limit inperson testimony to topics or points you have not already raised via online comments. A resolution that proposes to change the MSMA Bylaws is required to be presented to the HOD a minimum of one day before the day on which it is voted. However, a resolution that proposes to amend the MSMA Constitution must be submitted to membership at least 90 days before the meeting; therefore, submit constitutional amendment resolutions by May 1 for distribution by May 10. We can help! For assistance in drafting a resolution contact MSMA Executive Director Charmain Kanosky at CKanosky@MSMAonline.com or 601-853-6733 Ext. 306.

152 JOURNAL MSMA MAY 2013

Spouse / Guest:

Credit Card Type: Visa MC AmEx

Exp. Date:

Credit Card #: Name on Card: Please check the boxes and indicate number of attendees for each event below. PHYSICIAN REGISTRATION FRIDAY, AUGUST 16

House of Delegates ____ Reference Committee Hearings ____ Presidentâ&#x20AC;&#x2122;s Gala ($100 per person) ____

SATURDAY, AUGUST 17

Excellence in Medicine Awards ____ Candidate Speeches ____ Lunch & Voting ____ House of Delegates ____

ALLIANCE REGISTRATION FRIDAY, AUGUST 16

Alliance Past-Presidents Luncheon ____ Alliance Board Orientation ____

SATURDAY, AUGUST 17

Alliance House of Delegates ____ Alliance Installation Luncheon ____

MAIL COMPLETED FORM TO: MSMA c/o Becky Wells PO Box 2548, Ridgeland, MS 39158-2548 Questions? BWells@MSMAonline.com or 601-853-6733

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

Hospitals

Physicians Care N E T W O R K

Employer Groups

Ancillary Providers Insurance Companies

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

Faster is better. Sometimes you need to get quality life insurance protection for your family - fast. Life Insurance. Quickly.

is the answer. Quick Life offers an excellent selection of personalized life insurance quotes all from highlyrated life insurance companies and offered by MSMA and The Executive Planning Group. Online. Fast. Itâ&#x20AC;&#x2122;s easy to get free life insurance quotes for competitively priced policies. Apply on online. We ask the right questions about your specific objectives and then guide you through the application process. We provide the important information you need to make the right decisions for yourself and your loved ones. Life Insurance. Quickly.

If you prefer personal service, Larry Fortenberry and The Executive Planning Group can give you straight answers you need to make informed decisions. Call1-888-285-9477 or visit MSMAquicklife.com

Shave three to four weeks off the old way of doing business using technology to get you the right protection, right away!