JANUARY 2012 JMSMA

January

VOL. LIII

2012

No. 1

Ellen, Cancer Patient

Ellen, Cancer Survivor

My L i f e i s P r o o f.

A diagnosis of cancer changes everything for your patient.

But today, there are more cancer survivors than ever before. At University Cancer Care, our first priority is comprehensive and compassionate care.

Your patient will benefit from the collaboration of our multidisciplinary teams through specialized treatment plans. University Cancer Care has access to advanced research, technology and clinical trials that impact patient outcomes. And during the care of your patient, we communicate with you so when your patient returns to your practice, the continuum of care is seamless. To learn more about University Cancer Care, visit umhc.com/cancer or to talk doctor-to-doctor, call 866.UMC.DOCS. Dramatized to protect patient privacy

Lucius M. Lampton, MD Editor D. Stanley Hartness, MD Richard D. deShazo, MD AssociAtE Editors Karen A. Evers MAnAging Editor PublicAtions coMMittEE Dwalia S. South, MD chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD, Ex-Officio Myron W. Lockey, MD, Ex-Officio and the editors thE AssociAtion Thomas E. Joiner, MD president Steven L. Demetropoulos, MD president-elect J. Clay Hays, Jr., MD secretary-treasurer Lee Giffin, MD speaker Geri Lee Weiland, MD vice speaker Charmain Kanosky executive director Journal of the Mississippi state Medical association (issn 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual).

Periodicals postage paid at Jackson, MS and at additional mailing offices. correspondence: Journal MSMA, Managing editor, Karen a. evers, p.o. Box 2548, ridgeland, Ms 39158-2548, ph.: (601) 853-6733, fax: (601)853-6746, www.MsMaonline.com. suBscription rate: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available. advertising rates: furnished on request. cristen hemmins, hemmins hall, inc. advertising, p.o. Box 1112, oxford, Mississippi 38655, ph: (662) 236-1700, fax: (662) 236-7011, email: cristenh@watervalley.net postMaster: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 391582548.

The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association. copyright© 2012 Mississippi state Medical association.

JANUARY 2012

VOLUME 53

NUMBER 1

Scientific ArticleS

Patterns of ENT Injuries in Sports-Related Accidents

4

Bradley J. Suggs, MD and C. Ron Cannon, MD

Top 10 Facts You Should Know About Pit Viper Snakes and Envenomation 9 Brian J. Tollefson, MD; L. Kendall McKenzie, MD and Robert Galli, MD

Clinical Problem-Solving: Chasing Zebras

12

Ashley B. Pullen, MD

PreSident’S PAge

My Adventure Enrolling in the PMP

16

Thomas E. Joiner, MD; MSMA President

editoriAl

Epicuritorial

20

D. Stanley Hartness, MD; Associate Editor

relAted orgAnizAtionS

Mississippi State Department of Health

11

dePArtmentS

New Members Personals Obituaries Placement/Classified The Uncommon Thread

19 21 26 27 30

inStructionS for AuthorS

28

ASclePiAd

William A. “Bill” Middleton, MD

32

About the cover:

YockAnookAnY SePiA – The Yockanookany River is about 65 miles long in central Mississippi and meanders through Attala County en route to the Pearl. The exact definition of the Indian word “Yockanookany” is unknown. Dr. Stanley Hartness, family physician of Jackson, risked life and limb as he braved the Yockanookany Bridge with 18-wheelers to capture this image of ice-laden branches just as the setting sun gave a rosy glow to the usually muddy water. r

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official publication of the MsMa since 1959

VOL. LIII

2012

No. 1

January 2012 JOURNAL MSMA 1

From the Editor

2012

is here, bringing with it changes at the Journal. Our readers will find several new features as our editors and the publications committee work to provide a better journal.

First, you will notice below on this page the recently appointed members of our Editorial Advisory Board. The JMSMA Editorial Advisory Board (JEAB) is a group of MSMA member physicians who volunteer to advise the elected Editor and Associate Editors of the official publication of the MSMA. This group of talented fellow physicians will assist in the editorial product of this publication, from approving submissions to contributing articles of their own. I have asked Dr. Scott Anderson to serve as chair of this board of editors and look forward to working with them. If you would be interested in serving as a member of this board or you know a member who would contribute, please let Karen Evers or me know.

Also, our readers will notice a new JMSMA feature, Asclepiad, which will present a portrait of members of our association. Asclepiad is an ancient term for physicians. It is derived from the Greco-Roman god of medicine Aesculapius,

whose staff with a serpent coiled around it is the classic symbol of medicine.

Hippocrates is often called the “Asclepiad of Cos,” and the Greek term is loosely applied to members Editor Lampton with Dr. Bill Middleton in of the ancient medical Winona guild, followers of the god of medicine, and specifically to a family that had produced well-known Greek physicians for generations. Our goal is to show the diversity of personality of our own association, a professional family which has provided Mississippi its physicians for more than 150 years. It is fitting that this first portrait is of the admirable William A. “Bill” Middleton, MD, of Winona.

The editors and publications committee join me in wishing all of our readers a happy new year!

— Lucius Lampton, MD, Editor

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

2 JOURNAL MSMA

January 2012

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

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

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

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

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

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

Medical Assurance Company of Mississippi Partnership keeps physicians focused on medicine For the physicians of Biloxi Internal Medicine, Medical Assurance Company of Mississippi is not just their insurance company, but also a member of the team. MACM’s Risk Management Department is invited into the clinic for risk assessments and staff presentations on a regular basis. The physicians want to keep their focus on providing professional care and seek out MACM’s assistance to do just that.

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January 2012 JOURNAL MSMA 3

• Scientific articleS •

Patterns of ENT Injuries in Sports-related Accidents

A

Bradley J. Suggs, MD and C. Ron Cannon, MD

To evaluate sports-related ENT injuries regarding demographical trends of patients, location and mechanism of injuries, treatments required, and ability to return to sports activities, an observational study of patients was conducted. Each of the 120 participants in the study was evaluated in a private practice clinic. Males were injured more frequently, and the most common ages affected were 12 to 15-year-olds. Most injuries were the result of collision with other players or from impact of game balls, and most injuries occurred during sporting competitions.

The most commonly injured structure was the nose. Most patients were managed medically and able to return to sporting activities quickly. While the most frequent mechanisms for sports injuries are not always preventable, health care providers should be aware of these trends described regarding types of sports commonly producing injuries and the predominant sites of injury to provide optimal care for athletic participants.

data from the Center for Disease Control, Americans visited the emergency department over 1.5 million times for injuries suffered while participating in sports in 1999. Of those, nearly half occurred in school settings.

Facial injuries account for roughly 10% of all sports related injuries with the mandible, nasal bone, and zygomatic bones being the most frequently injured.2 However, in certain sports, the head and face are the most frequently injured parts of the body.3 These injuries span all age ranges with 21% of facial fractures seen in patients 17-years-old and younger, based on a survey of facial plastic surgeons.4 Because of the cosmetic importance of the facial features, it is extremely important that these injuries are diagnosed accurately and managed efficiently, especially in school-aged athletes.5 The purpose of this paper is to review the incidence of facial injuries sustained during sports activities in a private ENT practice population.

keY WordS:

maxillofacial inJury, naSal inJury, athlete,

methodS

SportS-related inJury

This study is a prospective observational review of patients who were seen in a private practice otolaryngology clinic for injuries incurred in athletic activities. The clinic where the patients were evaluated and treated is located in central Mississippi with a population area of 350,000 people.

Information was collected at the time of the patient visit, including age and gender of the athlete, sport in which the injury occurred, mechanism of injury, treatment modality, whether medical or surgical, and length of time to return to participation in athletic activities.

A complete head and neck examination was performed on each patient. Specific attention was paid to any fractures of facial bones as well as associated soft tissues injured. In the case of any significant facial or nasal edema, examination was postponed for five to seven days. Each patient’s nose was examined after being sprayed with decongestant solution. Particular attention was paid to any misshaping of the nose, palpable deformities of the nasal bones, intranasal lacerations, septal hematomas, or cerebrospinal fluid rhinnorhea. Radiographs were obtained to confirm diagnoses of fractured facial

bStrAct

introduction In 2008, 78.7% of Americans aged seven and older participated in sports and recreational activities, according to the National Sporting Goods Association.1 This totals about 230,000,000 people participating in sports. This number has steadily increased over the past decade, despite drops in participation in traditional team sports. Conversely, there has been an increase in the number of sports-related injuries over the same period. Data from the National Center for Sports Safety show that 3.5 million children ages 14 and under seek medical care related to injuries suffered during sporting activities. Based on Author informAtion: Bradley Suggs is a PGY-2 resident in the Department of Family Medicine at the University of Mississippi Medical Center in Jackson, Mississippi. Dr. Cannon is an otolaryngologist in Flowood, Mississippi, practicing at the Head and Neck Surgical Group. correSPonding Author: C. Ron Cannon, MD, 1038 River Oaks Drive, Flowood, MS 39232

4 JOURNAL MSMA

January 2012

bones. CT scans were generally not obtained unless injury to other structures was evidenced in the physical exam. If surgical intervention was indicated, it was carried out within two weeks of the occurrence of the injury with follow up exams scheduled 7-10 days post-operatively. If patients were found to be healing well, they were released to further athletic activity at their own discretion.

reSultS One hundred and twenty patients were seen and evaluated for facial injuries as a result of athletic activity. Of these, 72% were male (86 patients). Ages ranged from 7-years-old to 60-years-old with an average age of 18 years. The nose was the most common facial structure injured, with 93 injuries (Figure Figure 1: Skeletal schematic of injury locations with percentage of total injuries indicated.

Tablein 1. which Sports Ininjuries Which Injuries Occurred.

Table 1. Sports occured.

SPORT

NUMBER OF PATIENTS (% OF TOTAL)

Basketball

29 (24%)

Baseball

23 (19%)

Softball

19 (16%)

Soccer

15 (13%)

Football

13 (11%)

Unknown

6 (5%)

Martial Arts

3 (3%)

Trampoline

2 (2%)

Cheerleading

2 (2%)

Hunting

1 (1%)

Jungle Gym

1 (1%)

Kayaking

1 (1%)

Jet Skiing

1 (1%)

Badminton

1 (1%)

Swimming

1 (1%)

Tennis

1 (1%)

Hockey

1 (1%)

Table 2. Ages ofathletes Injured Athletes years) Table 2. Ages of injured (in(inyears).

NUMBER OF PATIENTS (% OF

AGE RANGE

TOTAL)

7-12

20 (17%)

12-15

31 (26%)

16-18

24 (20%)

19-22

16 (13%)

23-60

18 (15%)

Unknown

11 (9%)

Mechanism of Injury Table 3. MechanismTable of 3.injury.

1). Over 15 different types of sports and athletic activities were associated with facial injuries in these patients with basketball (24%) being the most frequently reported (Table 1). Baseball was also highly reported (19%). Table 2 reports the number of injuries stratified by age group affected. Patients aged 12 to 15 years were the most frequently seen in this study followed closely by 16 to 18-year-olds. Injuries occurred more frequently in game situations (44%) versus practice settings (38%). There was almost equal distribution of injuries associated with recreational and organized sporting activities (52% and 48%, respectively).

Among the reported mechanisms of injuries (Table 3), collision with another athlete was most common (48%), followed by being hit by game balls (33%). There were other injuries that were specialized depending on the athletic activity in which they occurred, such as injuries to the bridge of the nose by an ill-fitting football helmet and falling while jumping on a trampoline or climbing a jungle gym. The majority of patients were managed medically with only 36 of the 120 requiring surgical intervention. The vast majority of patients in this study were able to return to athletic activity quickly with 40% returning immediately, 20% returning in 1-2 weeks, 25% in 3-6 weeks, and only 15% requiring longer than 6 weeks or choosing not to return to sports at all (Table 4).

MECHANISM OF INJURY

NUMBER OF PATIENTS (% OF TOTAL)

Hit by Player

58 (48%)

Hit by Ball

39 (33%)

Fall

6 (4%)

Football Helmet Slid Down

3 (3%)

Unknown

3 (3%)

Hit by Baseball Bat

3 (3%)

Hit during Judo Sparring

2 (2%)

Hit by Hockey Puck

1 (1%)

Hit by firearm (hammer)

1 (1%)

Hit Nose on Bottom of Pool

1 (1%)

Hit Nose on Jet Ski

1 (1%)

Table 4. Time lapse between injury and return to sporting activities.

Table 4. Time lapse between injury and return to sporting activities TIME TO RETURN TO ATHLETIC ACTIVITY

NUMBER OF PATIENTS (% OF TOTAL)

Immediately

48 (40%)

1-2 Weeks

24 (20%)

3-6 Weeks

30 (25%)

Longer than 6 Weeks

18 (15%)

January 2012 JOURNAL MSMA 5

diScuSSion Echoing the findings of other studies, the nose was by far the most commonly injured facial structure, accounting for 74% of observed facial injuries.9 The ear and orbit were second and third in frequency, respectively. As noted previously, the majority of injuries occurred during game situations (44%) versus practice (38%) and non-competitive athletic endeavors (18%). This is likely due to the increased intensity and competitive nature of sports in this day and age, with athletes focusing on one particular sport to the exclusion of others at an earlier age than in the past. The data obtained in this study on ages of injured athletes correlates with this theory as well, with 59% of all of the injuries seen in this study occurring in junior high, high school, and college-aged athletes. The relatively high occurrence of injuries in younger athletes (17%) aged 7-12 may be due to enrollment in competitive athletics at earlier ages and increased intensity and pressure being placed on younger athletes to perform at high levels.

Almost 30% of facial injuries occur in female athletes.

This number is higher than one might expect and is likely due at least in part to anti-discrimination legislation such as Title IX and the Amateur Sports Act of 1972.6,7 In fact, a 2001 study comparing injuries in male and female college athletes showed very little difference in the patterns of injuries in comparable sports.8 Basketball and baseball were the most frequently identified sports in which athletes were injured in this study, at 24% and 19% of injuries evaluated, respectively. This is likely due

to the nature of these sports. Basketball consists of frequent player-player contact, often resulting in elbows colliding with opponents’ faces, while baseball players not infrequently misjudge a fly ball or ground ball, resulting in the ball hitting the player in the face. Surprisingly, the traditional “contact sports” of soccer and football combined contributed only 24% of the injuries seen in this study. Football helmets undoubtedly aid in the protection of players’ heads and noses in their sport. Helmets were the major contributor to the football maxillofacial injuries seen in this study, however.

Mechanism of injury varied widely and was largely sportdependent. However, collision with another player was the most frequent cause of facial injury across the board. As stated above, this was true even in the traditionally “non-contact sports.” Athletes also frequently suffered blows to the head by sporting goods, in particular balls used in their various sports.

Several players also reported being hit with baseball bats, and there was one incident of a player who was hit in the face with a hockey puck. Falls were associated with 4% of the facial injuries seen in this study. Other mechanisms were seen in accordance with particular sports, such as three instances of poorly-fitted football helmets sliding down and injuring the players’ noses, two athletes who were hit in the face during Judo sparring, and a hunter who was hit in the nose after firing his rifle.

Properly fitting helmets for football players and wearing face shields could eliminate a small number of injuries in that population. However, the vast majority of injuries seen in athletics are unintentional and cannot be prevented.10

Let’s Clear Things Up If your patients smoke or use tobacco, be honest with them about the serious health problems tobacco use can cause.

The decision to quit tobacco is one of the most important decisions a person can make, and you can support your patients with a plan to help them quit. The “be smoke-free” section of our website at www.bcbsms.com offers information and tips on making that important decision.

be healthy. be tobacco-free.

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

6 JOURNAL MSMA

January 2012

The majority of the patients seen in this study were able to be managed medically (62%). However, if surgery was indicated, it was performed within 2 weeks of the patient’s presentation. These two factors undoubtedly had a positive effect on the number of players who were able to return to their athletic endeavors quickly. Of the patients seen, 40% were able to return to sports immediately. Only 15% were out longer than 6 weeks, with 2 of those electing not to return to their respective sports at all. Patients with nasal contusions were allowed to return to their sports immediately while patients who had fractures of facial bones were advised to use caution in returning for at least 6 weeks. Facial splints and shields often can offer protection to the athlete’s nose and face and allow for faster return to competition and decrease the risk of re-injury, particularly in those athletes whose injury was significant enough to require surgical intervention. These are readily available commercially to athletes from a variety of sources.11,12

Beals KA, Meyer NL. Female athlete triad. Clin Sports Med. 2007;26(1) 69-89.

8. Sallis RE, Jones K, Sunshine S et al. Comparing sports injuries in men and women. Int J Sports Med. 2001;22(6):420-3.

9. Frenguelli A, Ruscito P, Bicciolo G, et al. Head and neck trauma in sporting activities. review of 208 cases. J Craniomaxillofac Surg. 1991;19(4):178-81.

10. Collins CL, Fields SK, Comstock RD. When the rules are broken: What proportion of high school sports-related injuries are related to illegal activity? Inj Prev 2008 14(1):34-8.

11. Heise M, Enfinger H, Rarredi T. Individualized facial protection after fracture management of the nasal bone and zygomatic arch in professional soccer players. Mund Kiefer Geschtschis 2000;5(5):320-2.

12. Morita R, Shumada K, Kawakami S. Facial protection masks after fracture treatment of the nasal bone to prevent re-injury in contact sports. J Craniofac Surg 2007;18(1):143-5.

7.

concluSionS In this study, the nose was the most frequently injured facial structure. This finding correlates strongly with other literature on the subject. Injuries are more likely to occur in game situations than in practice sessions and are more frequent in middle-school to college-aged athletes. Facial injuries are being seen more frequently in female athletes, who accounted for almost 30% of the injuries in this study. Facial injuries are seen in a wide variety of sports and athletic activities, and the mechanisms of injury are largely dependent on the sport in which they occur. However, collisions with other players and being struck with balls are the predominant causes of facial injuries across the board. Properly fitting equipment such as football helmets, facial splints, and shields may help prevent a small number of facial injuries and re-injuries, but the majority cannot be prevented. Fortunately, most athletes require only medical management of their facial injury. However, if surgery is required, making the diagnosis and performing surgery promptly positively contribute to the athletes being able to return to his or her sport more quickly.

referenceS 1.

2.

3.

4.

5.

6.

“How Active Are Americans?” National Sporting Goods Association, July 2009. www.nsga.org.

Maladiore E, Bado F, Meningand JP, et al. Etiology and incidence of facial fractures Sustained During Sports: A prospective study of 140 patients. Int J Oral Maxillofacial Surg. 2000;30(4):291-5.

Goldenberg MS, Hossler PH. Head and facial injuries in interscholastic women’s lacrosse. J Athl Train. 1995;30(1):3741.

Perkins SW, Deryou SH, Sklarew EC et al. The incidence of sports related trauma in children. Ear Nose Throat J. 2000;79(8):632-4.

Coxa J. Nasal fractures – the details. Facial Plastic Surg.

2000;16:87-94.

Lopiano, DA. Modern history of women in sports. Twenty-five years of Title IX. Clin Sports Med. 2000;(2):163-73.

DiD your last meeting leave you feeling a taD

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

We’re right in the middle of the midsouth and tupelo is the headquarters of the north mississippi medical Center, the largest non-metropolitan hospital in the united states, and is a winner of the prestigious malcolm Baldrige national Quality award!

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For information about setting up your next meeting, give Linda Elliff a call at 800-533-0611.

January 2012 JOURNAL MSMA 7

MSMA PHYSICIANS: NOMINATE NOW for the 2012 Mississippi State Medical Association

Excellence in Medicine Awards to be presented on June 8, 2012 at MSMA Annual Session in Point Clear, AL! DEADLINE FOR NOMINATIONS: MARCH 16, 2012

SUBMIT NAMES NOW FOR THE FOLLOWING ANNUAL AWARDS!

Recipients selected by the MSMA Council on Public Information.

MSMA Community Service Award Given to recognize a physician’s participation in civic activities for the betterment of his/her community; consists of plaque and $500 contribution to civic organization designated by the recipient.

MSMA Excellence in Wellness Promotion Award Given to recognize organizations, companies, individuals, or media members who improve public health through wellness promotion; consists of plaque and $500 award.

HOW TO NOMINATE:

Visit www.MSMAonline.com.

On the home page “Upcoming Events” menu, select the March 16, 2012 date.

Select the “brochure” button on the right side of the page to download awards information and nomination form.

Return completed form by March 16 to AMorris@MSMAonline.com (email) or 601-853-6746 (fax).

8 JOURNAL MSMA

January 2012

• top 10 factS you Should Know •

About Pit Viper Snakes and Envenomation Brian J Tollefson, MD; L. Kendall McKenzie, MD; Robert Galli, MD

introduction

Snakes are poikilothermic creatures and, as such, require environmental heat to function. As a result, snakes are much more active in warmer weather and more prevalent in warmer climates. It, therefore, stands to reason that most snakebites in the United States occur in the summer months. Poisonous snakes which are native to the US include pit vipers (copperhead, cottonmouth, and rattlesnake) and elapids (coral snakes and sea snakes). This paper will focus specifically on bites from the pit viper family given that pit vipers (crotolid) are responsible for the overwhelming majority of venomous snake bites in the United States.

1.

2.

3.

GEoGraphy: At least one species of venomous pit viper is found in every state with the exception of Alaska and Hawaii.1 As a result of favorable climate conditions, snakes are concentrated in the Southeastern and Southwestern states.

EpidEmioloGy: It is estimated that up to 9000 individuals are bitten by pit vipers each year in the United States resulting in approximately 5 deaths.2,3 The typical snake bite victim is a young male who is bitten on the hand or foot often while in the act of attempting to capture a snake. A recent study concluded that in 2007, 44% of pit viper envenomations reported to poison control centers were treated with antivenom.4 pit VipEr indEntiFication: Extreme caution should be used when handling recently killed or decapitated snakes as their primitive bite reflex may render even dead snakes capable of inflicting a venomous bite. Pit vipers have several features that distinguish them from nonpoisonous snakes. Pit vipers have a triangle-shaped head, elliptical pupils, heatsensing pits in front of their eyes and a single row of subcaudal plates.5

4.

5.

6.

7.

VEnom composition: Snake venom is a complex mixture of enzymatic proteins, cytotoxins, hemotoxins, neurotoxins, and anticoagulants.6 Proteolytic enzymes and cytotoxins destroy tissue adjacent to the bite site. Hemotoxins act directly on the heart and cardiovascular system, and neurotoxins act directly on the peripheral and central nervous systems. The specific composition of venom can vary to such a degree from snake to snake that predicting effects from individual snakebites given only the type of snake is not possible. siGns oF EnVEnomation: Approximately 20% of pit viper bites do not result in envenomation.7 The majority of bites do, however, result in envenomation, and local tissue effects quickly ensue: pain, erythema, edema, tenderness and myonecrosis.6 Hematologic effects typically follow with degradation of fibrinogen and platelet depletion resulting in oozing of blood and ecchymosis at the bite site.8 Systemic manifestations can include hypotension, angioedema and neurotoxicity. A metallic taste and localized muscle fasciculations are also frequently seen following envenomation.6 FiEld First-aid: Pre-hospital care should consist of minimizing victim movement and keeping the affected body part level with the heart. Application of tourniquets, incision followed by suction of the wound, and various other field techniques have never been proven to be effective and may actually cause more damage to the victim.

EmErGEncy room trEatmEnt: Perform a focused history and physical exam. Treat ABCs as required. Mark the leading edge of swelling and tenderness every 15-30 minutes.5 Immobilize affected extremity in relative extension.6 Determine requirement for antivenom administration early and avoid delays

January 2012 JOURNAL MSMA 9

8.

9.

10.

in giving antivenom when indicated. Opiates are the preferred pain medication. NSAIDs should be avoided due to theoretical increased risk of coagulopathy.

Provide tetanus immunization booster per standard CDC recommendations.9 Although somewhat controversial, it is typically recommended that patients with puncture wounds receive prophylactic antibiotics. One reasonable antibiotic regimen consists of an initial dose of ampicillin-sulbactam IV followed by amoxicillin-clavulanate given orally for 5 days. indications and dosinG oF antiVEnom: Progressive local soft tissue effects and systemic signs of toxicity should be treated with antivenom. The only currently available antivenom for use in the US against crotalid envenomation is CroFab. An initial dose of 4-6 vials should be administered intravascularly with repeated doses given if deleterious effects of the venom are not halted. Antivenom can cause an immediate anaphylactic reaction or a delayed serum sickness. Treatment of significant envenomations should be done in conjunction with a poison control center and/or a toxicologist experienced in treating snake bites.10 compartmEnt syndromE: Treatment of venom-induced increased compartment pressure is arguably one of the most controversial subjects involving the treatment of pit viper envenomations. In the past, some practitioners advocated early fasciotomy in nearly all rattlesnake envenomations.9 Animal studies and available human data fail to show a clear advantage of surgical fasciotomy over medical management even in those individuals with documented elevated compartment pressure.11 culprit snakEs in mississippi: According to data compiled by the Mississippi Regional Poison Control Center (MRPCC), there are approximately 100-125 venomous snake bites reported in Mississippi each year. Fortunately, the frequency of specific snake bites reported to the MRPCC is inversely related to the relative potency of the venom produced by the snake: copperhead 60%, cottonmouth 30%, rattlesnakes 10%.12

referenceS

Russell FE. When a snake strikes. Emerg Med. 1990;22:33-43.

ONeil ME, Mack KA, Gilchrist J, Wozniak EJ. Snakebite injuries treated in United States emergency departments, 2001-2004.

Wilderness Environ Med. 2007;18:281-287.

3. Langley R. Animal-related fatalities in the United States—an update. Wilderness Environ Med. 2005;16:67-74.

4. Spiller HA, Bosse GM, Ryan ML. Use of antivenom for snakebites reported to United States poison centers. Am J Emerg Med. 2010;28:780-785 5. Gold BS, Dart RC, Barish RA. Bites of venomous snakes. N Engl J Med. 2002, 347:273-279.

6. Lavonas EJ, Ruha A, Banner W, et al. Unified treatment algorithm for the management of crotaline snakebite in the United States: results of an evidence-informed consensus workshop. BMC Emergency Medicine. 2011;11:1-15.

7. Curry S, Horning D, Brady P, Requa R, Kunkel D, Vance M. The legitimacy of rattlesnake bites in central Arizona. Ann Emerg Med. 1989;18:658-663.

8. Kitchens CS. Hemostatic aspects of envenomation by North American snakes. Hematol Clin North Am. 1992;6:1189-1195.

9. Glass TG. Early debridement in pit viper bites. JAMA. 1976;235:2513-15.

10. Lavonas EJ, Schaeffer TH, Kokoo J, et al. Crotaline Fab antivenom appears to be effective in cases of severe North American pit viper envenomation: An integrative review. BMC Emergency Medicine. 2009;9:1-14.

11. Stewart RM, Page CP, Schwesinger WH, et al. Antivenin and fasciotomy/debridement in the treatment of the severe rattlesnake bite. Am J Surg. 1989;158:543-547.

12. Mississippi Regional Poison Control Center, Jackson, MS 39216 (1-800-222-1222).

1.

2.

We specialize in the business of healthcare

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concluSionS

Although an infrequent cause of death in the United States, pit viper snake bites can cause considerable morbidity and financial hardship. It is imperative that physicians caring for snake bites have a basic knowledge of the pathophysiology and potential complications related to envenomation. Moreover, physicians need to recognize the indications for antivenom (CroFab) administration. It is recommended that the local poison control center or toxicologist be consulted to provide treatment recommendation.

10 JOURNAL MSMA

January 2012

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

• mSdh • Mississippi Reportable Disease Statistics

October 2011 Figures for the current month are provisional

Totals include reports from Department of Corrections and those not reported from a specific district.

For the most current MMR figures, visit the Mississippi State Department of Health web site: www.HealthyMS.com.

January 2012 JOURNAL MSMA 11

• clinical problem-Solving •

Presented and edited by the Department of Family Medicine, University of Mississippi Medical Center; Diane K. Beebe, MD Chair

Chasing Zebras Ashley B. Pullen, MD

a

43-year-old african-american female presented to the Emergency department (Ed) with a complaint of sudden-onset, sharp, right-sided chest pain that had started approximately 1 hour earlier. she stated that she had been unable to work for the past month due to recurring episodes of chest pain. the chest pain was not associated with shortness of breath, diaphoresis, nausea, vomiting or left-arm or jaw pain. the patient denied exacerbating or alleviating factors. she reported a history of uncontrolled hypertension and hypercholesterolemia for which her medications were currently being adjusted by her primary care physician. she also had a history of asthma. the patient had a 20-pack-year history of tobacco use. she denied alcohol or illicit drug use. she denied a current regimen of physical activity aside from her daily routine as a truck driver. she denied a history of trauma. she had no history of esophageal reflux disease (GErd) or pancreatitis. she had a hysterectomy 10 years ago for benign reasons. she had been prescribed albuterol/ipratropium (combivent), diltiazem (cardizem), hydrochlorothiazide, and aspirin as an outpatient.

Chest pain can be the presenting symptom for many different medical conditions. The most dangerous conditions include acute myocardial infarction (MI), acute aortic dissection, pulmonary embolus or pneumothorax. With a chief complaint of chest pain, my initial concern is acute MI, especially given her history of tobacco use, uncontrolled hypertension, and hypercholesterolemia. However, she does not have other typical signs and symptoms of an acute MI including shortness of breath, diaphoresis, nausea, vomiting or arm, jaw, neck or stomach pain. I am also concerned about a pulmonary or musculoskeletal condition as the underlying cause of her chest pain. In addition, a pneumothorax is also concerning given her history of asthma. I will try to eliminate acute MI and pneumothorax as causes of her symptoms by ordering a complete blood correSPonding Author: Ashley B. Pullen, MD, 401 Baptist Drive, Suite 104, Madison, MS 39110, 601-605-3858 (office), 601-605-3898 (fax), Email: ashleypullen@bellsouth.net

12 JOURNAL MSMA

January 2012

count, complete metabolic panel, d-dimer, electrocardiogram and chest radiograph. Other diagnoses I am currently considering include pulmonary embolus and aortic dissection. Aortic dissection is possible given her history of elevated blood pressure and signs of chest pain.

Patients often describe the symptoms of an acute coronary syndrome (ACS) as chest discomfort rather than pain. The discomfort may be described as pressure, heaviness, tightness, fullness or squeezing. Ischemia is less likely if the discomfort is knifelike, sharp, pleuritic or positional. The classic location is substernal or in the left chest with possible radiation to the arm, neck, jaw, back, abdomen or shoulders. Pain that radiates to the shoulders or occurs with exertion significantly increases the relative risk for ACS. An aortic dissection most often presents with the sudden onset of sharp, severe pain.1 the patient was given morphine for pain and supplemental oxygen upon arrival to her room in the Ed. her initial vital signs included a temperature of 98.2ÂşF; heart rate of 85/min; respirations of 17/min; blood pressure of 165/103 mmhg and an oxygen saturation of 91% while breathing room air. the patient was well developed, well nourished and in moderate distress from pain. the patient had expiratory wheezes with prolonged respiratory phase. percussion of the chest wall did not reveal tympanic sounds. there was no tenderness on palpation of her chest wall. her heart rate and rhythm were regular with no murmur, rub or gallop. her abdomen was soft, nontender, nondistended with normal active bowel sounds. cranial nerves 2-12 were grossly intact. her extremities were without clubbing, cyanosis or edema. she was alert and oriented to person, place, and time.

Her pulmonary examination is consistent with her history of asthma and possible exacerbation of the underlying disease. The elevated blood pressure is likely indicative of a history of uncontrolled hypertension, increasing her risk for conditions such as acute MI or acute aortic dissection. The decreased oxygen saturation could be related to pulmonary conditions such as asthma, pneumonia, pulmonary hypertension or pulmonary embolus. The absence of labored breathing, dimin-

ished breath sounds and tympany on percussion of the chest wall further reduces my suspicions of pneumothorax. With no history of GERD or abdominal pain, I am less inclined to keep either of these in my list of differentials. I am still considering the potential for a musculoskeletal component given her history of strenuous long distance driving of a large truck and the loading and unloading of heavy objects. However, she states there has been no recent trauma or increased physical activity.

A musculoskeletal cause is also less likely to be the main cause of her chest pain without tenderness on palpation of her chest wall or increase in pain with movement. her initial white blood cell count was within normal limits at 7.6 k/ul; however, her hemoglobin and hematocrit were both above reference range at 17.1 g/dl and 51.9%, respectively. her platelets were normal. her complete metabolic profile and initial cardiac enzymes were within normal limits. her electrocardiogram showed normal sinus rhythm with no st segment changes. she had a d-dimer of 1.98 μg/l, which is greater than the upper limits value of 0.48 μg/l. a chest radiograph showed rib notching, normal cardiac silhouette, no evidence of widened mediastinum and no pulmonary infiltrate.

The initial laboratory values suggest her chest pain is not related to an acute MI although it is necessary to repeat serial enzymes as part of her continued care. Polycythemia is commonly suspected in patients with elevated hemoglobin and hematocrit. However, polycythemia does not match the patient’s symptoms, and these results are more likely due to her chronic tobacco use. The chest radiograph does not indicate a pulmonary infiltrate and reduces the possibility an infectious pneumonia as the cause of her chest pain. I am no longer concerned about a pneumothorax due to the absence of chest radiographic findings. Aortic dissection is now ranked lower on my differential with a normal mediastinum on chest radiograph. Her elevated D-dimer is suggestive of possible pulmonary embolus; thus, a contrasted computed tomography (CT) of the chest with contrast is ordered. I decide to admit the patient to the hospital for further studies and observation. the ct chest was negative for pulmonary embolus but did show new development of intercostal artery aneurysms bilaterally. other intercostal arteries were prominent in size. these aneurysms were not present on chest ct approximately 6 years ago. the cause of the aneurysms was uncertain. in addition to the intercostal artery aneurysms, rib notching was also noted. to investigate for other aneurysms, the patient underwent ct angiogram (cta) of the cervical spine, which was negative for aneurysms. she also had a cta of the chest and abdomen that yielded a 3.5 × 3.2 cm distal abdominal aortic aneurysm. she had a magnetic resonance imaging of her spine that showed multiple bilateral enhancing paraspinous nodules that were likely arterial aneurysms. an echocardiogram showed mild left ventricular hypertrophy (lVh) with an ejection fraction of

60%, mild biatrial enlargement, trace mitral regurgitation, trace tricuspid regurgitation and no pericardial effusion.

The aneurysms could be a vasculitis versus polyarteritis nodosa or other mesenchymal connective tissue disorder including neurofibromatosis. I am now concerned about a vasculitis or other autoimmune disorder as the cause of her newly diagnosed intercostal artery aneurysms. The patient was given a short course of steroids for treatment of possible vasculitis.

To further evaluate, I order a sedimentation rate, antinuclear antibody (ANA), myeloperoxidase, and proteinase 3 antibody.

I am less concerned about a cardiac cause of her chest discomfort with a normal echocardiogram and serial cardiac enzymes.

I am also less concerned about an ascending aortic aneurysm without findings on the chest CT. I am no longer concerned about a pulmonary embolism without evidence of embolism on the chest CT. Her echocardiogram finding of LVH is consistent with uncontrolled hypertension. I’m comfortable letting the patient go home to follow up in clinic since the likelihood of life threatening causes of chest pain including acute MI, aortic aneurysm, and pulmonary embolism has been reduced and her chest pain has resolved. in clinic 2 weeks later, the patient presented for a scheduled appointment with continued complaints of chest pain and unchanged tenderness to palpation over the right lower costal margin. her physical exam in clinic was otherwise unremarkable. the patient stated she was unable to work due to her discomfort. on review of records from her hospital admission 2 weeks ago, it was noted that her sedimentation rate, ana panel, myeloperoxidase, and proteinase 3 antibody were all within normal limits. additionally, it was thought that the patient would benefit from a biopsy of an intercostal artery for definitive tissue diagnosis. the patient was again admitted, and the subsequent intercostal artery biopsy revealed fibromuscular dysplasia. the patient was prescribed medications for pain control and discharged home in stable condition to follow up in clinic.

Fibromuscular dysplasia (FMD) is a rare, nonatherosclerotic, noninflammatory vascular disease that results in arterial narrowing and aneurysms of small and medium-sized vessels.

FMD has been reported in every arterial bed, but the most common locations remain the renal arteries and the carotid and vertebral arteries. Patients with FMD typically present with hypertension, transient ischemic attack or stroke, dependent upon which arterial bed is involved. Hypertension diagnosed at a young age (<35 years) may be related to fibromuscular dysplasia of the renal arteries.2 There have been cases of renal infarction identified. FMD is rare, and treatment recommendations are based only on case reports and expert opinion. There is a Fibromuscular Dysplasia Society of America that has made efforts to increase awareness of the disease and provide education and support to patients and their families.3-7 Atherosclerosis and vasculitis are generally listed in the

January 2012 JOURNAL MSMA 13

differential with FMD. FMD occurs in the middle to distal parts of vessels in contrast to atherosclerosis that is typically noted in the proximal portions of vessels. Also, FMD is typically found in a younger population than patients with atherosclerosis. Patients with FMD generally have fewer cardiovascular risk factors than patients with atherosclerosis. FMD is noninflammatory; therefore, the typical acute phase reactants that would be elevated in an acute inflammatory reaction are typically normal including C-reactive protein and sedimentation rate. This is in contrast to a typical vasculitis that is an inflammatory process and should have elevations in the acute phase reactants.3,4,8 There are 3 types of FMD: medial dysplasia, intimal fibroplasias and adventitial fibroplasias. Eighty to 90% of FMD are the medial type.3,8,9 There has been very little research on the pathogenesis of FMD, and its pathogenesis is not completely understood. Possible risk factors include female gender, tobacco use, hypertension, Caucasian race, and family history of FMD. It might be inherited in an autosomal dominant inheritance pattern with variable penetrance. There are other diseases that have been linked with FMD including Alport’s syndrome, Ehlers-Danlos syndrome, pheochromocytoma, Takayasu’s arteritis, and Marfan’s syndrome.3 FMD may involve only one arterial bed.2 Diagnosis of FMD of the renal or carotid arteries can usually be made by Doppler ultrasound, CTA or MRA of the arteries involved. The arteries will have a “string of beads” appearance due to the multiple stenoses related to medial fibromuscular dysplasia. The gold standard confirmatory test is intraarterial angiogram. The test is invasive and should be reserved for those in need of revascularization that can be performed in the same procedure.2,8-10 Treatment of renal FMD has consisted of pharmacologic management of hypertension. If unsuccessful, revascularization can be performed. There have been very high success rates reported for curing hypertension if the fibromuscular dysplasia of the renal arteries is diagnosed early and revascularization is performed. Angioplasty is the primary treatment for FMD of the extremities. Because FMD has been shown to be noninflammatory, steroids have not been shown to be beneficial.3,8,9 Complications of FMD are directly related to the vascular bed involved. With renal FMD, hypertension and renal infarction are possible.6 With cerebral FMD, stroke, headache, Horner’s syndrome and hemorrhage (subarachnoid and intracerebral) are possible complications. Mesenteric ischemia is possible with small vessels to the bowel involved. In our patient, intercostal muscle infarction was occurring from the involvement of her intercostal arteries.

The patient was given a short course of steroids for treatment of the underlying vasculitis and prescribed a chronic pain regimen which adequately controlled her pain. She continued to follow-up for pain management as well as treatment of her hypertension and hypercholesterolemia. She no longer complained of chest pain

14 JOURNAL MSMA

January 2012

keY WordS: fibromuScular dySplaSia, cheSt pain referenceS

Cayley W. Diagnosing the cause of chest pain. Am Fam Physician 2005;72:2012-2021.

2. Olin J. Recognizing and managing fibromuscular dysplasia.

Cleve Clin J Med. 2007; 74(4):273-282.

3. Olin JW. Contemporary management of fibromuscular dysplasia.

Curr Opin Cardiol. 2008; 23:527-536.

4. Ozdil M, Bariş S, Ozyilmaz I, Doğru O, Celkan T, Albayram S. A rare cause of ischemic stroke. Neurol Sci. 2009; 30(1): 77-79.

5. Sinnamon K, McNally D, Harty J. Fibromuscular dysplasia presenting as renal infarction. Kidney Int. 2007; 72(10): 12951296.

6. Slovut D. Fibromuscular dysplasia. NEJM 2004; 350(18):18621871.

7. A Distinctive Case of Fibro muscular Dysplasia. Neurol Res. 2007; 29(6):551-552.

8. Dittrich R, Nassenstein I, Ringelstein EB, Kuhlenbaumer G, Nabavi DG. A Distinctive Case of Fibro muscular Dysplasia.

Neurol Res. 2007; 29(6):551-552.

9. Plouin PF, Perdu J, La Batide-Alanore A, Boutouyrie P, Gimenez-Roqueplo AP, Jeunemaitre X. Fibromuscular dysplasia. Orphanet J Rare Dis. 2007; 2:28.

10. Yoshimuta T, Akutsu K, Okajima T, et al. “String of beads” appearance of bilateral brachial artery in fibromuscular dysplasia. Circulation. 2008; 117:2542-2543.

1.

Save the Date!

MSMA Annual Session June 7 – 10, 2012

Grand Hotel Marriott Resort Golf Club and Spa Point Clear, Alabama Reserve your hotel room today!

Call 800-544-9933 and mention code: msmmsma OR Visit www.marriottgrand.com and enter code: msmmsma

More info?

Contact Becky Wells at 601-853-6733, Ext. 340 or BWells@MSMAonline.com

January 2012 JOURNAL MSMA 15

• preSident’S page •

My Adventure Enrolling in the PMP

W

e all have the same stories, and we tell them to each other often. A first time patient comes in with the story that he needs pain meds, can’t really spell the name of the one that works, but comes close, and is allergic to the other ones. Red flags go up all over. This is where I pre-empt any further conversation and state bluntly that I will not give that medication for any circumstance. This has become very effective and usually results in a patient that is not happy, announces to the receptionist that he has left his checkbook in the car, and walks out the door never to be seen again. We all get better at this as the years go on, and the result is that we do not have this clutter in our practice that we had in the first few years. However, we all experience a learning curve, mostly without any assistance.

Fortunately, there is some help out there in the form of the Prescription Monitoring Program (PMP) which is administered through thomaS e. Joiner, md the Mississippi Board of Pharmacy (BOP). This has been in place for 2011-12 mSma preSident several years, but physicians have not taken advantage of it. There are approximately 6,000 active physicians in this state, but only approximately 15% are registered to use the PMP. Why is this percentage so low? Well, there are several reasons - all of which I understood years ago and understand even better now.

Recently, I decided to test my theories as to why physicians were not taking advantage of this service. I decided that I would be the test case and start from scratch by registering to use the PMP in order to determine how difficult it would be to put the PMP to use. Well, an adventure started.

I went to the BOP site to register and found a page from RelayHealth. (Apparently RelayHealth is the program administrator for Mississippi’s PMP and many other states.) The instruction page included written instructions and a link to a video tutorial to explain the process. My first thought was, “Why do we need a tutorial to retrieve a piece of paper that we are going to fill out, notarize and send in with a copy of our driver’s license?” My guess is that 75% of us stopped at that page.

What is also not apparent from the instructions is that there are TWO programs administered by the PMP – one to monitor patients and another for folks who dispense medications. Most of us need to register only for the monitoring service. But here is the catch - if you start from the top of the instruction page you will register for the wrong program!

That probably lost another 10% of us.

Now I am in the remaining 15%. My next instruction was to provide an “account number” and my “facility ID.” Huh? What I did not know was that the facility ID was my DEA number. I tried putting my name, then address; neither worked. I then called the 1-800 help number and was given the instructions on how to sign up for the Missouri Hot Line.

This probably eliminated another 10%, so now I am in the 5% of potential registrants determined to figure this out.

What next? I decided to go to the source and drove to the BOP where I was enrolled with ease. I now have a name and password and, with the help of BOP, I was able to use the PMP program with ease.

On behalf of the 95% of other physicians who gave up, I then discussed ways to make the process easier and more user friendly with the BOP Executive Director Frank Gammil and his staff. Updated instructions were provided which reflect my concerns and experience. Did my efforts make a difference? We will know only when more of you try to sign up! PMP instructions follow this article on the adjacent page in this issue of the Journal. What I would like you to do is give it the old college try and then let me know how it went, good or bad. Good luck!

Now for the important stuff: the 3-year-olds are massing at the fairgrounds in New Orleans and Oaklawn in Hot 16 JOURNAL MSMA

January 2012

Springs for the run up to the Kentucky Derby. It is too early to have a clear favorite, but one will come out of the Lecompt Stakes in New Orleans and the Smarty Jones Stakes in Hot Springs. Each month will have a new favorite. This is the fun time of the year.

you and the mississippi prescription monitoring program Presented by the Mississippi Board of Pharmacy Prescription Monitoring Program (MSPMP)

What goes through your mind when patients requests a controlled substance before they ever see a practitioner?

How about the new patient who comes in complaining of pain or anxiety and states they are not taking any medications? Do you ever wonder about telephone messages where a patient specifically asks for a particular controlled substance because they are “allergic” to other medications? Are you concerned about the patient who is taking multiple controlled substances on a daily basis?

There are numerous signs that may trigger suspicion of controlled substance abuse in an individual. The bottom line is it is nearly impossible to look at individuals and determine if they are “doctor shopping” or abusing controlled substances.

The reporting of dispensed controlled substances, and specified non-controlled substances, in, or into, the State of Mississippi became effective July 1, 2008, with the passage of Mississippi Senate Bill 2713, in compliance with federal regulations promulgated under the authority of the National All Schedules Prescription Electronic Reporting Act of 2005 and in compliance with federal HIPAA law.

The Mississippi Prescription Monitoring Program (PMP) collects information once every seven days on all controlled substances dispensed in, or into, the state of Mississippi by pharmacies, physicians, and veterinarians.

Currently the PMP has only a fraction of eligible users accessing the system for information. If you are not using the PMP, we encourage you to consider the benefits it can offer you and your patients. The sign-up process to obtain information on a new or active patient is simple. Go to www.mbp.state.ms.us, follow the bottom left link to “Prescription Monitoring” and download and follow the directions for the “Report Retrieval Registration Kit”.

The following definitions are key terms used in the registration process: administering: Giving medication to an individual in a clinic or pharmacy dispenser:

Any practitioner, pharmacy, facility or clinic that sells a patient medication to take home

dispensing:

Any individual, pharmacy, practitioner, or practitioner clinic or facility that sells medication to a patient to take home

monitoring:

Checking patient activity or prescribing activity checked in the MS PMP

prescriber:

Any individual licensed to prescribe medications

prescribing:

Any individual who prescribes medications

submit:

Any practitioner or pharmacy that needs to report dispensing activity

For the purpose of these definitions we are talking about controlled substance medication Schedules II, III, IV, and V. By law the State of Mississippi has made any product containing Ephedrine or Pseudoephedrine as well as any product containing Butalbital a Schedule III controlled substance and any drug containing Carisoprodol or Tramadol a Schedule IV controlled substance.

Any controlled substance medication dispensed for a period of 48 hours or less does not require reporting. Any medication samples dispensed do not require reporting.

The philosophy, attitude, and actions of the PMP are proactive in safeguarding public health and safety while supporting the legitimate use of controlled substance prescription medications. Questions should be directed to Deborah Brown at dbrown@mbp.state.ms.us.

January 2012 JOURNAL MSMA 17

You support MMPAC.

Your patients thank you.

We do, too.

MMPAC supports medicine-friendly elected officials.

Thanks to your support of the Mississippi Medical Political Action Committee (MMPAC), 80 percent of the healthy choice candidates endorsed by MMPAC were elected in 2011.

Now those officials can get to work promoting policies that

support doctors, protect patients,

and provide for

quality healthcare

in Mississippi.

Your practice and your patients benefit from these policies.

So to our nearly 1,000 member physicians and spouses,

THANK YOU

for a great year!

www.MMPAConline.com 18 JOURNAL MSMA

January 2012

601.853.6733

• new memberS • abdEl-aziz, ahmEd saas, Greenwood; Specialty: Anesthesiology. ataro, pEtEr raJoro, McComb; Specialty: Internal Medicine. badEro, olurotimi J., Jackson; Specialty: Internal Medicine. boothE, JamEs conlEy, Jackson; Specialty: Diagnostic Radiology. boWE, rEGina nicolE, McComb; Specialty: Internal Medicine. boWlEs, William E., Brandon; Specialty: General Surgery.

kinG, John J., Columbus; Specialty: Cardiovascular Disease. knEip, christophEr J., Flowood; Specialty: Orthopedic Surgery. kumar, sunil, Philadelphia; Specialty: Family Medicine. maurEr, trEVor paul, Brandon; Specialty: Pediatrics. mcadory, JanE, Southaven; Specialty: Obstetrics & Gynecology. mEndEl, richard charlEs, Columbus; Specialty: Neurosurgery.

Ellis, madElinE, Jackson; Specialty: Pediatrics.

mErEdith, courtnEy ElizabEth, Biloxi; Specialty: Obstetrics & Gynecology.

Furr. JoE c., Ocean Springs; Specialty: Internal Medicine.

nElson, John J., Biloxi; Specialty: Clinical Pathology.

GErmain, GErard Frantz, Hattiesburg; Specialty: Family Medicine.

nyE, andrEW b., Vicksburg; Specialty: Family Medicine.

pruEtt, taylor schWalEnbErG, Jackson; Specialty: Internal Medicine. pupa, laWrEncE EdWard, Meridian; Specialty: Cardiovascular Disease. raGan, FrEdErick paul, Natchez; Specialty: Family Medicine. schnEidEr, Gary michaEl, Jackson; Specialty: Internal Medicine. shEriGar, JaGannath mala, Clarksdale; Specialty: Internal Medicine. skElton, brandon W., Tupelo; Specialty: Diagnostic Radiology. talukdar, nazmul kabir, Hattiesburg; Specialty: Psychiatry. thomas, kEnnEth r., Starkville; Specialty: Urology. thomasson, JamEs d., Jackson; Specialty: Vascular & Interventional Radiology.

Goli, krishna Jayanthi, Vicksburg; Specialty: Neurology.

o’kEEFFE, richard michaEl, Jackson; Specialty: Orthopedic Surgery.

Gray, Jim p., Pascagoula; Specialty: Radiology.

oVErstrEEt, raymond Gartin, Columbus; Specialty: Psychiatry.

thompson, ElainE allEn, Southaven; Specialty: Obstetrics & Gynecology.

hammock, brian a., Biloxi; Specialty: Psychiatry.

oWEn, robErt c., Hattiesburg; Specialty: Emergency Medicine.

thompson, GrEGory l., Oxford; Specialty: Anesthesiology.

harbour, kEVin c., Tupelo; Specialty: Internal Medicine.

pErnEs, calin, Hattiesburg; Specialty: Family Medicine.

VarEldzis, ramzi barnaba, Jackson; Specialty: Internal Medicine.

hill, ryan carl, Columbus; Specialty: Anesthesilogy.

pinkErton, Jay stuart, Lucedale; Specialty: Obstetrics & Gynecology.

WadsWorth, marGarEt E., Jackson; Specialty: Radiation Oncology.

harasty, hEathEr christinE, Jackson; Specialty: Internal Medicine. hollibauGh, bEcky, Diberville; Specialty: Family Medicine.

Jackson, ElicEia dionnE, Gautier; Specialty: Family Medicine.

poston, William mason, Oxford; Specialty: Anatomic Pathology. probst, charlEs Erickson, Ellisville; Specialty: Family Medicine.

January 2012 JOURNAL MSMA 19

• epicuritorial •

New Feature/ Old Favorite

I

can see the sticklers rolling their eyes. I think I can even hear a groan or two. “Why begin a feature on physicians’ favorite recipes? After all, this IS a medical journal.”

But this is MISSISSIPPI’S medical journal, and your Publications Committee, in a gesture of inclusivity, voted unanimously to provide this venue for the majority of our membership who will never submit a scientific article or produce an editorial. And if there’s a story connected with the recipe (again, Mississippi), so much the better.

For my family and me, it’s my 92-year-old father-in-law’s “Magnolia Pimento and Cheese.” It seems that the parents of my lovely bride of 43 years Whipping Up Some Famous Magnolia Pimento and Cheese— JMSMA Associate Editor Dr. Stanley Whipping Up Some Famous Magnolia Pimento and Cheese — JMSMA Associate Editor Dr. Stanley Hartness, right, looks on as his Hartness, right, looks on as his father-in-law Will father-in-law Will Parker McWilliams, left, stirs up his famous Pimento Parker McWilliams, left, stirs up his famous Pimento Cheese recipe. (Photo courtesy of the Magnolia Gazette) Cheese recipe. (Photo courtesy of the Magnolia Gazette) met in Magnolia, Mississippi, in 1942 when they both reported for work for the Farm Security Administration, now known as the Farm Service Agency. It was the first “real” job for my father-in-law, Will Parker McWilliams, an MSU alumnus, while my mother-in-law, Virginia Ann Mullen, was already a workforce veteran, having clerked at Lofton Clothing Store in Brookhaven after graduation from the “W.” Romance seemed inevitable. Not only were Ann and Will assigned as traveling work partners, they both had secured room and board with Misses Wilma and Lucille Vaughn for the tidy sum of about $30 a month. It was while enjoying the hospitality of the Sisters Vaughn that Will was introduced to “Magnolia Pimento and Cheese,” and from that point he was hooked! He persuaded the proprietors to share their secret recipe and their special ingredient…sugar! And now I’m letting all of you in on the secret.

Will’s Magnolia Pimento and Cheese Sharp cheddar cheese, grated (Will uses about 1/3 of a 2# Mississippi State block) 4 oz. jar pimento drained and chopped (Will uses a mini-prep processor to produce almost a puree) Dash of salt and pepper 3 heaping teaspoons of sugar Mayonnaise until the right consistency (Will uses Sauer’s Real Mayo and actually recommends the mixture be a little soupy) And did I mention, “Add more sugar to taste”?

Our family enjoys this treat many ways: when freshly made, it’s a tangy dip with chips; after it has “set up” in the refrigerator, it makes a delicious sandwich; for our traditional Thanksgiving and Christmas meals, it gives stuffed celery a whole new meaning. As a matter of fact, all this writing about it has prompted me to stir up a new batch!

So send in those longtime favorite family recipes…and their stories…to KEvers@MSMAonline.com. We look forward to hearing from lots of you throughout the year. Bon appétit!

—D. Stanley Hartness, MD Associate Editor 20 JOURNAL MSMA

January 2012

• perSonalS • olurotimi J. badero, md has successfully completed the first radial approach percutaneous coronary angioplasty and first left heart catheterization at Central Mississippi Medical Center (CMMC), utilizing an innovative procedure recorded in only 5-7 percent of interventional cardiology cases in the U.S. Dr. Badero, an interventional cardiologist and interventional nephrologist at CMMC, performed the coronary angioplasty procedure and diagnostic catheterization using the wrist rather than the groin as an entry point for the catheter used to thread through the blood vessels to the heart.

In addition to its use as a diagnostic tool to diagnose or evaluate coronary artery disease or other heart conditions, cardiac catheterization can also be used as an interventional procedure to treat heart attacks, open blocked arteries, and repair stenotic heart valves.

Dr. Badero said in the United States, the majority of cardiac catheterizations are performed through the femoral artery. A study conducted at Wake Heart Center in Raleigh, North Carolina, (Mann JT, III; Arrowood M, Cubeddu G.) found that although generally considered safe, this approach presents a higher risk of bleeding complications compared to radial artery catheterization that essentially has zero bleeding risks. Dr. Badero said the risk of stroke and TIA is also reduced with this approach, a significant observation since stroke is one of the potential complications of heart catheterization.

Radial cardiac catheterization offers a less invasive, lower-risk option because the procedure is performed through the wrist rather than the groin. This allows for a quicker recovery time and a shorter hospital stay.

Immediately after the procedure, patients are usually able to sit up, eat and walk. In contrast, after a traditional cardiac catheterization, patients must lie flat for two to six hours in order to ensure that bleeding will not occur from the site. Central Mississippi Medical Center is one of only two hospitals in Mississippi to offer radial cardiac catheterization.

The heart study also concluded the radial approach decreases the risk of vascular complications by four times. However, Dr. Badero notes not all patients are candidates for this procedure, and patients are evaluated at presentation to determine their suitability for the procedure. “In terms of reduced recovery time, cost

and complications, radial is the superior method of performing these life-saving interventional procedures,” Dr. Badero said.

In the U.S. today, Dr. Badero is part of a select group of fully-trained combined cardiologists and nephrologists. He completed 10 years of continuous post-graduate medical training. Dr. Badero is a specialist in internal medicine, nephrology and hypertension, interventional nephrology, cardiovascular medicine, interventional cardiology and peripheral vascular interventions. harriet l. Jones, md, a board-certified, infectiousdiseases-trained internist, has joined the University of Mississippi Medical Center (UMMC) as an associate professor in the Department of Medicine. She also has a dual appointment to the School of Nursing Advanced Practice Program. Dr. Jones specializes in the treatment of patients with complicated wounds, soft-tissue infections, including osteomyelitis, and postoperative complications.

After receiving the BSN from the University of Southern Mississippi in 1985, Jones earned the M.D. from UMMC in 1998. She completed residency training in internal medicine at UMMC in 2001 and served as a fellow in infectious diseases from 2001-03. She first joined the UMMC faculty as an assistant professor of medicine and surgery in 2003 and began the Outpatient Antimicrobial Service in the Division of Infectious Diseases.

In 2005, she joined River Oaks Hospital in Flowood as the sole physician and fulltime medical director of the Wound Care and Hyperbaric Medicine Center. She founded the Wound Management Group in 2008. In 2010, the group relocated its practice to Mississippi Baptist Medical Center in Jackson. An active member of the Wound Healing Society, the American Professional Wound Care Association, the American College of Physicians-American Society of Internal Medicine and the American Academy of Wound Care, she serves as a member of the editorial board for Today’s Wound Clinic.

January 2012 JOURNAL MSMA 21

lucius “luke” lampton, md has been appointed the Associate Editor of Medicine for the forthcoming Mississippi Encyclopedia, Dr. Ted Ownby, Director of the Center for the Study of Southern Culture at the University of Mississippi and chief editor of the Encyclopedia, recently announced. Dr. Lampton authored ten entries for the Encyclopedia, most dealing with medical topics, including an extensive overview of the history of medicine in the state. The Encyclopedia is scheduled for publication by the University Press of Mississippi in 2012. Dr. Lampton, a Magnolia family physician, serves as the Editor of the Journal of the Mississippi State Medical Association and Chair of the State Board of Health.

Wassim E. mouannes, md, a Heart Care Center physician, completed recertification in internal medicine through the American Board of Internal Medicine. Dr. Mouannes scored in the upper 10 percent of the nation.

Dr. Mouannes holds a medical degree from Saint Joseph University Campus of Science and Medicine in Beirut. He completed an internal medicine internship and residency at East Tennessee State University in Johnson City, Tennessee. He also completed a fellowship in cardiovascular disease at East Tennessee State University. He is board certified by the American Board of Internal Medicine in cardiovascular diseases, internal medicine, and nuclear cardiology. His professional affiliations include the Society of Cardiac CT, American College of Cardiology, Lebanese Medical Association, AMA, South Mississippi Medical Society.

J. preston parry, md, a specialist in reproductive endocrinology and infertility from the University of Wisconsin-Madison, has joined the UMMC Department of Obstetrics and Gynecology.

Dr. Parry will lead the in vitro fertilization (IVF) program in the IVF Clinic. This clinic is located at Women’s Specialty Care at Mirror Lake and operates through University Physicians, a part of UMHC. After earning his M.P.H. from Columbia University, New York, Parry received his M.D. from the New York Medical College in Valhalla. He finished 22 JOURNAL MSMA

January 2012

his residency training at Tufts University’s School of Medicine in Boston, Massachusets, and later completed his fellowship at the University of Louisville.

As the new director of reproductive endocrinology and infertility, he plans to focus on treating people who are having difficulty conceiving, helping sustain fertility in cancer patients, and assisting patients battling with recurrent pregnancy loss.

“I’m the type of person who will lie awake at night thinking about how to improve a woman’s chance of becoming a mother, even if just a few percents hangs in the balance. This commitment helped my previous program dramatically increase success rates and patient satisfaction,” Dr. Parry said.

Dr. Parry is an active member of several professional organizations, including the American College of Obstetricians and Gynecologists, the American Society of Reproductive Medicine and the European Society for Human Reproduction & Embryology. He is also involved with the Society for Assisted Reproductive Technology, the Society for Reproductive Endocrinology and Infertility and the Society for Reproductive Surgeons. mildred ridgway, md, a gynecologic oncologist who has practiced in Jackson for six years, has joined the medical faculty at the UMMC. She and dr. david mcintosh, chief of gynecologic oncology at UMMC, will see patients through University Physicians, a part of UMHC. They practice at UP Women’s Specialty Care at Mirror Lake and the UMMC Cancer Institute at the Jackson Medical Mall.

After receiving the B.A. in history from Tulane University, in 1992, Dr. Ridgway earned the M.D. at the Tulane University School of Medicine in 1998. She completed her internship in 1999 and residency training in ob-gyn in 2002 at the Duke University Medical Center, Durham, N.C., where she served as assistant chief resident from 2001-02. She completed a three-year fellowship in gynecologic oncology at the University of North Carolina, Chapel Hill, from 2002-05. Since moving to Jackson in 2005, Dr. Ridgway has been on the medical staff at Mississippi Baptist Medical Center, St. Dominic Memorial Hospital and River Oaks Hospital.

She has served as Robotics Surgery Program director at Baptist since 2009. She plans to continue her work in minimally invasive gynecologic surgery at UMMC.

ronald “andy” rimmer, do and tyree Winters, md have moved in a new clinic location, Care+ Pediatrics at the Reservoir. Dr. Andy Rimmer will be joining Dr. Tyree Winters at the location located at 1020 Spillway Circle, Suite 6, in Brandon. They will provide services such as primary care for newborns to young adults as well as wellbaby check-ups, well-child exams, illness care visits, childhood immunizations, sports physicals, osteopathic manipulative medicine and childhood obesity medicine.

Dr. Andy Rimmer completed his undergraduate degree at Mississippi State University followed by completing his medical degree at the Medical College of Georgia. His medical interests include allergies and asthma for pediatric patients. With family ties in Greenwood, Dr. Rimmer is no stranger to our state and brings 14½ years experience. He is board certified and a member of the American Board of Pediatrics.

Dr. Tyree Winters joined Crossgates River Oaks Hospital at Care+ Pediatrics in August of 2010 and will continue his pediatric practice at the new location. Dr. Winters received his Bachelor of Arts in psychology from the University of Michigan-Dearborn and his Doctorate of Osteopathic Medicine from Ohio University College of Osteopathic Medicine. He then went on to complete an internship and residency in general pediatrics at Nationwide Children’s Doctor West Hospital in Columbus, Ohio. While completing his residency, Dr. Winters was chosen and served as the pediatric chief resident. brent smith, md, a family physician in Jackson, has been elected to the board of directors of the American Academy of Family Physicians (AAFP). The AAFP represents 100,300 physicians and medical students nationwide.

Smith was elected to a oneyear term by the National Congress of Family Medicine Residents and confirmed by the AAFP’s governing body, the Congress of Delegates.

As the resident member of the board of directors, Dr. Smith is responsible for representing the interests and opinions of the National Congress of Family Medicine Residents to the AAFP Board of Directors and Congress of Delegates. In addition, he will advocate on behalf of family physicians and patients nationwide to inspire positive change in the U.S. health care system.

Dr. Smith, a Mississippi Rural Physician Scholar from Cleveland, has been an active leader in organized medicine throughout his medical education and

residency, including service in the following positions: student delegate to the AAFP Congress of Delegates, member of the AAFP Commission on Education and its subcommittees on Resident-Student Issues and International Family Medicine, AAFP resident delegate to the American Medical Association Resident-Fellow section, student leader and resident advisor for the University of Mississippi Family Medicine Interest Group, and resident member of the MSMA Board of Trustees and the MSMA Council on Legislation.

He is a Mississippi Rural Physicians Scholarship Program Committee member and member of the Vice Chancellor’s Resident’s group of HEALing Fellows, a community outreach program to identify and help correct the causes of health disparities and to improve resident training in serving the needs of the community.

In addition to his academic work, Dr. Smith contributed to his community as a volunteer with the Jackson Free Clinic from 2005 to 2010, with Habitat for Humanity from 2005 to 2008, with Ronald McDonald House in 2009 and 2010, and as a volunteer team physician for multiple local high school sports teams in 2009 and 2010.

Dr. Smith earned his medical degree from the UMMC School of Medicine and is completing his family medicine residency training at the UMC Family Medicine Residency Program in Jackson. In addition, he earned his Bachelor of Arts in History from Ouachita Baptist University, Arkadelphia, Arkansas, in 2010 and currently is completing his Master of Science in Clinical Education at the University of Edinburgh, Scotland. somprasong songcharoen, md of Mississippi Premier Plastic Surgery was recognized as Recertified in Surgery of the Hand by the American Board of Surgery. He was originally certified in 1990 and has been recertified twice since. There are only five other board certified hand surgeons in the Jackson Metropolitan area. “Recertification in this discipline is very prestigious and well-respected in the field of hand surgery,” said Eli Howell, MD, a staff surgeon with Mississippi Premier Plastic Surgery. Their associate Dotie Jackson, MD added that Dr. Song (as he his known by his patients) has demonstrated his commitment to increasing his professional knowledge and his dedication to his patients by achieving this recertification. Dr. Songcharoen is also certified by the American Board of Surgery and the American Board of Plastic Surgery.

January 2012 JOURNAL MSMA 23

neal suares, md recently opened a family practice clinic of Delta Regional Medical Center located at 334 Arnold Avenue in Greenville. Dr. Suares received his medical degree from St. Matthew’s School of Medicine in 2006 and completed his Family Practice Residency at University of Mississippi School of Medicine in 2009.

He has been in private practice since the completion of his studies. He is certified by the American Board of Family Medicine. Dr. Suares is a lifelong resident Greenville who is pleased to provide medical services in the community he has always called home. Dr. Suares says, “It is an honor to be part of the medical community here, and I am pleased to continue providing medical care to the people of the Delta, just as my father and grandfather have for the past 62 years.”

Jeffrey summers, md with NewSouth NeuroSpine was named one of the 70 “Best Pain Management Physicians in America” in the March 24 edition of Becker’s Orthopedic and Spine Review.

Dr. Summers is the director of the interventional pain management division of NewSouth NeuroSpine. He is a member of the American Board of Anesthesiology and treasurer of the International Spine Intervention Society. During his career, Dr. Summers has served as the director of the pain management service at William Beaumont Army Medical Center, medical director of the intensive care unit at University Hospital in Pensacola, Fla., and assistant professor in anesthesiology at the UMMC in Jackson.

Dr. Summers earned his M.D. at the UMMC in Jackson and completed his residency in anesthesiology at Brooke Army Medical Center in San Antonio. He also completed fellowships in pain management at the University of Texas Health Science Center in San Antonio as well as the Pain Relief Institute and Walton Centre for Neurosurgical Sciences in Liverpool, England. t. luke thompson, md has joined Ear, Nose & Throat, Associates, a service of Hattiesburg Clinic.

Dr. Thompson holds a medical degree from Louisiana State University Health Sciences Center in Shreveport, Louisiana. He completed a general surgery internship and otolaryngology residency at Tulane University in New Orleans, Louisiana. Dr. Thompson also completed a facial plastic and reconstructive surgery fellowship at Hedgewood Surgical Center in New Orleans.

His professional memberships include the American College of Surgeons, American Association of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy and American Academy of Otolaryngology – Head and Neck Surgery.

Dr. Thompson joins Michael J. Hammett, MD; James M. Hodges, MD; and John D. Sobiesk, MD. 24 JOURNAL MSMA

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m. stanton Ward, md, an associate professor of surgery and an orthopedic surgeon with fellowship training and sub-specialization in spine surgery, has joined University of Mississippi Health Care (UMHC). His practice is focused on adult decompressive and reconstructive spine surgery for degenerative and traumatic conditions as well as deformity, with an emphasis on minimally invasive approaches.

Dr. Ward was previously in private practice at Pinnacle Orthopedics in Marietta, Georgia. A summa cum laude graduate of Georgetown University, Washington, D.C., Dr. Ward earned the M.D. and the Ph.D. at the Columbia University College of Physicians and Surgeons, New York. He completed an orthopedic surgery internship and orthopedic surgery residency training at Columbia’s St. Luke’s-Roosevelt Hospital. During those years, he also had residency training in pediatric orthopedics at the A. I. duPont Hospital for Children in Wilmington, Del.; musculoskeletal oncology at Memorial SloanKettering Hospital in New York; and burn intensive care unit/plastic surgery at Jacobi Hospital in New York.

He completed a spine surgery fellowship at the Baylor College of Medicine/Texas Medical Center in 2007.

He has also completed additional training in minimally invasive spine surgery with neurosurgeon Dr. Anthony Salerni at the Northeast Institute for Minimally Invasive Spine Surgery. He is the first surgeon in Mississippi to become a member of the Society for Minimally Invasive Spine Surgery. ralph carlton daniel, md, Jackson; James W. holmes, md, Wiggins; William. b. larkin, Jr., md, Bude; and paul E. sheffield, md, Jackson recently received the AMA Physician’s Recognition Award (PRA). The PRA award recognizes physicians who earn at least an average of 50 credits per year from educational activities that meet the AMA standards.

The award is a way to demonstrate to your colleagues and patients that you are committed to continually expanding your knowledge and improving your skills by participating in continuing medical education. Please visit the AMA Web site at www.ama-assn.org/go/pra for more information about the AMA PRA and other topics of interest to the CME community. To obtain an application (print or online) for AMA PRA direct credit activities: Web: www.ama-assn.org/go/cme, e-mail: pra@ ama-assn.org or phone: (312) 464-5296.

The following physicians recently received a threeyear appointment as Cancer Liaison Physician for the cancer program at their respective facilities: John bailey, md of Pascagoula at Singing River Hospital System; paul Farabaugh, md, Facs, of Tupelo at North Mississippi Medical Center; david Gilliland, md, Facs, of Tupelo, at North Mississippi Medical Center John a. Johnson, iii, md of Hattiesburg at Forrest General Hospital and remi nader, md, of Gulfport at Memorial Hospital at Gulfport. Cancer Liaison Physicians are an integral part of cancer programs accredited by the American College of Surgeons Commission on Cancer (CoC).

Drs. Bailey, Farabaugh, Johnson and Nader are among a national network of over 1,600 volunteer physicians who are responsible for providing leadership and direction to establish, maintain, and support their facilities’ cancer program. These physicians have a significant interest in the diagnosis and treatment of patients with malignant diseases, and are members of the multidisciplinary cancer committee at their respective institutions which are dedicated to facilitating the delivery of comprehensive quality cancer care.

The NCDB currently contains patient demographics, tumor characteristics, treatment, and outcomes information for over 25 million malignant cancers diagnosed and treated at hospital-cancer programs in the United States between 1985 and 2008.

The Cancer Liaison Physician works with the cancer program staff to facilitate the submission, presentation, use, and interpretation of NCDB data. Analyzing and

sharing these data with the cancer committee can have a positive impact on cancer patient care at the facility.

In an effort to assist the more than 1.5 million Americans diagnosed with cancer each year, Cancer Liaison Physicians at CoC-accredited programs also facilitate participation in the Commission’s Facility Information Profile System (FIPS). FIPS provides the public with information about resources, services, and annual cancer cases diagnosed at CoC-accredited facilities. These data are shared with the public through the CoC Web site at www.facs.org/cancer.

The Commission on Cancer is a consortium of 50 professional organizations dedicated to improving the survival and quality of life for cancer patients. The Commission achieves its goal through standard-setting, cancer prevention, research, educational activities as well as monitoring comprehensive quality care. Its membership includes national organizations representing the full spectrum of cancer care and Fellows of the American College of Surgeons. The Commission’s core functions include establishing standards to ensure the delivery of quality, multidisciplinary, and comprehensive cancer care in health care settings; surveying facilities to assess compliance with those standards; collecting standardized data from accredited facilities to measure quality; using data to monitor treatment patterns, support cancer control, and enhance clinical surveillance activities; and developing effective educational interventions to improve outcomes at the national, state, and local level.

2012 Component Society Meeting Schedule Feb. 2 ....... North MS Medical Society, Location TBD, 6:30 pm Mar. 1 ....... Northeast Mississippi Medical Society, Location TBD, 6:30 pm Mar. 27 ..... Prairie Medical Society, Location TBD, 6:30 pm Apr. 11 ...... Delta Medical Society, Location TBD, 6:00 pm Apr. 26...... Coast Counties Medical Society, The Great Southern Club – Hancock Bank Bldg., Gulfport, MS, 6:00 pm

January 2012 JOURNAL MSMA 25

• obituarieS • William J. carr, Jr., md, age 77, resident of Gulfport passed away Thursday, December 22, 2011, in Gulfport.

Dr. Carr was born and raised in Gulfport. He was a member of Phi Beta Kappa at Vanderbilt University where he received a Bachelor’s Degree. After graduating from Vanderbilt, he served in the United States Navy for three years.

Upon finishing his military service, he entered Tulane Medical School and graduated with a concentration in Pediatrics. Dr. Carr returned to Gulfport to start his practice where he retired after 43 years of service to the Mississippi Gulf Coast in 2009.

Dr. Carr was a member of First United Methodist Church in Gulfport. During his retirement, he enjoyed traveling with his wife and spending time with his grandkids.

He was preceded in death by his parents, William J. Carr and Nannette Tomlinson Carr. Survivors include his wife, Anna Mae Carr; children, Bill (Suzannah) Carr, Jim (Delia) Carr, Mitzi Painter, Trudy (Bill) Bull, and Darrell (Susan) Painter; grandchildren, Billy and Charlotte Carr, Jane and Andrew Carr, Samantha York, and Kelly and Michele Painter; and numerous cousins, nieces, and nephews.

The funeral service was held Tuesday, December 27, 2011, at 11:00 a.m. at First United Methodist Church, Gulfport.

Burial followed at Evergreen Cemetery, Gulfport.

In lieu of flowers, donations may be made to First United Methodist Church, 2301 15th Street, Gulfport, Mississippi 39501. Tributes and condolences may be shared with the family at www.riemannfamily.com.

John b. Ederington, md passed away Saturday, December 10, 2011, in his home at the age of 74. Born and raised in Warren, Arkansas, he spent his childhood playing and working on the family farm. After attending Vanderbilt University, John went on to graduate from Tulane Medical School. He completed his internship at Baptist Medical in Nashville, Tennessee, before joining the United States Air Force for a 2-year stint. He served his residency at hospitals in New Orleans and Monroe, Louisiana. John and his family moved to Vicksburg in 1969 where he began practicing ophthalmology.

He retired from his practice in 1997. John was a fellow of the American College of Surgeons and a past member of MSMA. He was also involved with the Y’s Men’s Club at the YMCA for many years. In his free time, John enjoyed duck hunting with his friends at the Tupelo Break Duck Club and Riverland Properties and spent many hours in his woodworking shop.

His parents, Louis Wilson and Mary Catherine Bayliss Ederington, preceded him in death. John is survived by his loving wife of 49 years, Peggy Sue Marionneaux Ederington of Vicksburg; his daughter, Mary Elizabeth “Beth” Ederington of Saint Petersburg, Florida; a son and daughter-in-law, Charles Dixon and Deborah Herrod Ederington and two grandchildren, Courtney Elizabeth and Gage Dixon Ederington all of Vicksburg; a brother and sister-in-law, Louis Havis and Anne Jewell Ederington of Norman, Oklahoma.

A memorial service was held 2:00 p.m. Friday, December 16, 2011, at the Glenwood Funeral Home Chapel.

Memorials are requested to the Vicksburg YMCA, 2674 MCA Place, Vicksburg, MS 39183 or the American Cancer Society, Mid-South Division, 1380 Livingston Lane, Jackson, MS 39213.

26 JOURNAL MSMA

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There’s a lot going on in organized medicine so it’s easy to miss something if you’re on the go. To help you stay in touch no matter where you are, MSMA is now communicating via “Twitter.”

In about three minutes, you can set up a free Twitter account for yourself. Simply visit www.twitter. com and submit your name, email address and mobile phone number (optional, standard text messaging rates apply). Once you’re signed up with Twitter, you can add MSMA by going to the following web page http://twitter.com/ MSMA1 and clicking “Follow” next to the MSMA icon.

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Save the date: 144th MSMA Annual Session Grand Hotel Marriott Resort, Golf Club & Spa Point Clear, Alabama

June 7 - 10, 2012

Jackson Free Clinic needs you!

Requesting licensed physician volunteers for the Saturday of your choice (approximate time commitment: 1p-5p). As a registered 501(c)3 clinic, JFC provides medical care for uninsured/ underinsured patients. Come serve the community and help teach the next generation of physicians!

Please contact Rasheeda Crowell @ 601-4678981 or email rcrowell@ umc.edu for more information. www.JacksonFreeClinic.org

(404) 284-7855 tyrone@practicebrokers.com

10th Annual Summer CME Seminar Sandestin, Florida July 19-22, 2012 Contact: Jenny White (601) 853-6733 or jwhite@msmaonline.com

This forum is intended primarily for young physicians beginning their practice though all members of the MSMA are invited to attend. Its purpose is to convey up-to-date information to promote andAlliance skills that better Pay knowledge your MSMA statewill dues enhance $40 patient care and practice operations. before December 31, 2011 to beisentered in to a drawing The conference designed provide an avenue to win a freeformal weekend at theinformal for learning through lectures, Grand Hotel Point Clear Resort & Spa. of discussions with course faculty and exchange The drawing be held at theofJanuary ideas among peerswill related to issues interest to th MSMA Alliance board meeting. young20physicians.

2011-2012 Alliance Membership Drive

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

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

DISABILITY DETERMINATION SERVICES January 2012 JOURNAL MSMA 27

• InstructIons for Authors • The Journal of the Mississippi State Medical Association (JMSMA) welcomes material for publication submitted in accordance with the following guidelines. Address all correspondence to the Editor, Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS, 391582548. Contact Karen Evers, managing editor, with any questions concerning these guidelines: (601)853-6733, ext. 323.

Style: Articles should be consistent with JAMA/ JMSMA style. Please refer to explanations in the AMA Manual of Style: A Guide for Authors and Editors. 10th ed. New York, NY: Oxford University Press; 2007. JAMA and JMSMA style differs from APA style. JAMA: http://jama.ama-assn.org/misc/ifora.dtl Quick reference quide:http://www.docstyles.com/amastat.htm Any manuscript that does not conform to the AMA Manual of Style, 10th edition will be returned for revision.

ManuScriptS should be of an appropriate length due to the policy of the Journal to feature concise but complete articles.

(Some subjects may necessitate exception to this policy and will be reviewed and published at the Editor’s discretion.) The language and vocabulary of the manuscript should be understandable and not beyond the comprehension of the general readership of the Journal. The Journal attempts to avoid the use of medical jargon and abbreviations. All abbreviations, especially of laboratory and diagnostic procedures, must be identified in the text. Manuscripts must be typed, double-spaced with adequate margins. (This applies to all manuscript elements including text, references, legends, footnotes, etc.) the original and one duplicate hard copy should be submitted. in addition, the Journal also requires manuscripts in the form stated above be supplied in Windows OS-compatible digital format. you may email digital files as attachments to Kevers@MSMaonline.com or supply them on a portable memory storage medium. All graphic images should be included as individual separate files in TIFF, PDF or EPS format. Please identify the word processing program used and the file name. Pages should be numbered. An accompanying cover letter should designate one author as correspondent and include his/her address and telephone number. Manuscripts are received with the explicit understanding that they have not been previously published and are not under consideration by any other publication. Manuscripts are subject to editorial revisions as deemed necessary by the editors and to such modifications as to bring them into conformity with Journal style. The authors clearly bear the full responsibility for all statements made and the veracity of the work reported therein. revieWing prOceSS: Each manuscript is received by the managing editor, and reviewed by the Editor and/or Associate Editor and/or other members of the MSMA Committee on Publications and its review board. The acceptability of a manuscript is determined by such factors as the quality of the manuscript, perceived interest to Journal readers, and usefulness or importance to physicians. Authors are notified upon the acceptance or rejection of their manuscript. Accepted

28 JOURNAL MSMA

January 2012

manuscripts become the property of the Journal and may not be published elsewhere, in part or in whole, without permission from the Journal MSMA. title page should carry [1] the title of the manuscript, which should be concise but informative; [2] full name of each author, with highest academic degree(s), listed in descending order of magnitude of contribution (only the names of those who have contributed materially to the preparation of the manuscript should be included); [3] a one- to two-sentence biographical description for each author which should include specialty, practice location, academic appointments, primary hospital affiliation, or other credits; [4] name and address of author to whom requests for reprints should be addressed, or a statement that reprints will not be available. abStract, if included, should be on the second page and consist of no more than 150 words. It is designed to acquaint the potential reader with the essence of the text and should be factual and informative rather than descriptive. The abstract should be intelligible when divorced from the article, devoid of undefined abbreviations. The abstract should contain: [1] a brief statement of the manuscript’s purpose; [2] the approach used; [3] the material studied; [4] the results obtained. Emphasize new and important aspects of the study or observations. The abstract may be graphically boxed and printed as part of the published manuscript.

Key WOrdS should follow the abstract and be identified as such. Provide three to five key words or short phrases that will assist indexers in cross indexing your article. Use terms from the Medical Subject Heading list from Index Medicus when possible.

Available at: http://www.nlm.nih.gov/mesh/authors. html.

SubheadS are strongly encouraged. They should provide guidance for the reader and serve to break the typographic monotony of the text. The format is flexible but subheads ordinarily include: Methods and Materials, Case Reports, Symptoms, Examination, Treatment and Technique, Results, Discussion, and Summary. referenceS must be double spaced on a separate sheet of paper and limited to a reasonable number. They will be critically examined at the time of review and must be kept to a minimum.

You may find it helpful to use the PubMed Single Citation Matcher available online at: http://www.ncbi.nlm.nih. gov/ entrez/query/static/citmatch.html to find PubMed citations. All references must be cited in the text and the list should be arranged in order of citation, not alphabetically. Reference numbers should appear in superscript at the end of a sentence outside the period unless the text cited is in the middle of the sentence in which case the numeral should appear in superscript at the right end of the word or the phrase being cited. No parenthesis or brackets should surround the reference numbers.

Personal communications and unpublished data should not be included in references, but should be incorporated in the text.

References must conform to proper style to be eligible for review.

Contact managing editor Karen Evers for an easy-to-follow guide with examples of how to use JMSMA/ JAMA reference citation format. The following form should be followed: Journals: [1] author(s). Use the surname followed by initial without punctuation. The names of all authors should be given unless there are more than three, in which case the names of the first three authors are used, followed by “et al.” [2] title of article. Capitalize only the first letter of the first word. [3] name of Journal. Abbreviate and italicize, according to the listing in the current Index Medicus available online at http://www.nlm.nih.gov/bsd/aim.html.

[4] year of publication; [5] volume number: Do not include issue number or month except in the case of a supplement or when pagination is not consecutive throughout the volume. [6] inclusive page numbers. Do not omit digits. Do not include spaces between digits of the year, volume and page numbers. example: Bora LI, Dannem FJ, Stanford W, et al. A guideline for blood use during surgery. Am J Clin Pathol. 1979;71:680-692.

books: [1] author(s). Use the surname followed by initials without punctuation. The names of all authors should be given unless there are more than three, in which case the names of the first three authors are used followed by “et al.”

[2] title. Italicize title and capitalize the first and last word and each word that is not an article, preposition, or conjunction, of less than four letters. [3] edition number, [4] editor’s name. [5] place of publication, [6] publisher, [7] year, [8] inclusive page numbers. Do not omit digits. example: DeGole EL, Spann E, Hurst RA Jr, et al. Bedside Examination, in Cardiovascular Medicine, ed 2, Smith JT (ed).

New York, NY: McGraw Hill Co; 1986:23-27.

figureS require high resolution digital scans to be provided. Printed copies should also be submitted in duplicate in an envelope (paper clips should not be used on illustrations since the indentation they make may show on reproduction).

Legends should be typed, double-spaced on a separate sheet of paper. Photographic material should be high-contrast glossy prints. Patients must be unrecognizable in photographs unless specific written consent has been obtained, in which case a copy of the authorization should accompany the manuscript. All illustrations should be referred to in the body of the text. Omit illustrations which do not increase understanding of text. illustrations must be limited to a reasonable number. (Four illustrations should be adequate for a manuscript of 4 to 5 typed pages.) The following information should be typed on a label and affixed to the back of each illustration: figure number, title of manuscript, name of senior author, and arrow indicating top. tableS should be self-explanatory and should supplement, not duplicate, the text. The brief descriptive title, usually written as a phrase rather than a sentence, appears above to distinguish the table from other data displays in the article. Data should be aligned horizontally not to exceed 6.5". Tables should be numbered and supplied on individual pages separate from manuscript body text

with placement indicated within. See Section 4 of the "AMA Manual of Style" for specific Figure and Table components and proper presentation of data. acKnOWledgMentS are the author’s prerogative; however, acknowledgment of technicians and other remunerated personnel for carrying out routine operations or of resident physicians who merely care for patients as part of their hospital duties is discouraged. More acceptable acknowledgements include those of intellectual or professional participation. The recognition of assistance should be stated as simply as possible, without effusiveness or superlatives.

SubMiSSiOnS tO JMSMA Scientific SerieS top 10 facts you need to Know Series The purpose of this series of articles is to provide referenced information on clinical management of medical conditions in a concise fashion. The submissions should be directed toward practitioners who do not have specialty training on the specific topic as a matter of general information. The author of the best submission for each year will receive a prize. guidelines: 1) Articles should consist of 10 numbered paragraphs. Each of the paragraphs will begin with a fact that physicians need to know and a brief explanation of why. Facts will be referenced for each of the 10 points. 2) Suggested organization of manuscript is Introduction, Point 1, Point 2, etc., Conclusion, and References. 3) Articles will be about 3 pages (about 700 words) in length written at a level that can be easily understood by a practicing physician of any specialty. 4) A reference supporting the fact offered should be provided for each of the 10 points. Citations should not be review articles. 5) If there are specialty society guidelines in the area being discussed, the essential features of the recommendations should be included in the official guidelines cited in the references. uptodate Series The purpose of this series of articles is to provide brief reviews on topics of general interest to the practicing physicians of Mississippi in areas where recent developments in diagnosis or treatment have occurred. guidelines: 1) Articles should be practical and useful to physicians in office or hospital practice.

2) Suggested organization of manuscripts is Introduction, Diagnosis, Recent developments, Conclusion, and References. 3) Articles will be about 6 pages (1500 words) or so in length written at a level that can be easily understood by a practicing physician of any specialty. 4) Only include those references useful to physicians who desire further information in the area. Five to eight references that will be useful to those who desire further information should be included. 5) Figures are great as are “callouts,” i.e., boxes with key points to remember emphasizing the “take home” messages. 6) If there are specialty society guidelines on the topic, the essential features of the recommendations should be summarized in the text and the official guidelines should be cited in the references. galley prOOf - The principal author will receive a PDF via email to review. It is the author's responsibility to proof and approve it. Corrections should be clearly marked and returned promptly. If you desire reprints, inquire about prices to order. r

January 2012 JOURNAL MSMA 29

• the uncommon thread •

W

Welcome to 2012

ell, another year has rolled around and we are tumbling into 2012. It will be the last year we see a triple digit date (12/12/12) in our lifetimes unless something special comes up to extend the average human lifespan. While we may have a Methuselah among us, I’m not counting on it.

Over the past year or so, I’ve been involved in numerous activities of our MSMA. In talking to many of you I’ve sensed a developing current of dissatisfaction with the status quo. At this year’s annual session most were vocally expressed, but the murmurings have been persistent since as well.

The crux of the dissatisfaction seems to be that a core cadre of individuals tend to hold multiple positions in our association. Because they are well known, they act to deprive other members of our association who would r. Scott AnderSon, md like to serve at the upper levels of our organization a chance to do so. We need to find a way to give a voice to as many members of our association as possible. One way to do that is by establishing an editorial advisory board for our JOURNAL MSMA. The editors and the members of the MSMA Committee on Publications, with the blessings of our Board of Trustees, have accomplished that this year.

The Journal Editorial Advisory Board (JEAB) will help the Journal accomplish its mission to advance the art and science of medicine; promote the ideals of the MSMA; encourage scholarship and good will among Mississippi physicians; and disseminate information specifically applicable to the health care of Mississippians. JEAB advisors were selected from a cross section of our diverse membership based on their writing and editing experience and credentials as leaders in their fields of specialty. The members of the MSMA Committee on Publications believe these advisors’ expertise and involvement will help keep our Journal MSMA up to date on medicine’s best practices and topics. Furthermore, advisors will review scientific manuscripts related to their respective fields and have an opportunity to write for the Journal and contribute editorially as appropriate.

I have been named chair of this board and am pleased to announce the other members of our association that have been selected and agreed to serve: diane k. beebe, md.......................................................Family Medicine claude d. brunson, md ................................................Anesthesiology Jeffrey d. carron, md, Faap, Facs ..........................Otolaryngology & Communicative Sciences Gordon (mike) castleberry, md ..................................Urology mary currier, md, mph ..............................................Public Health thomas E. dobbs md, mph ........................................Public Health sharon douglas, md ......................................................Ethics & Judicial Affairs daniel p. Edney, md ......................................................Disaster Life Support & Internal Medicine owen b. Evans, md .......................................................Pediatrics and Neurology maxie l. Gordon, md ...................................................Psychiatry and Human Behavior scott hambleton, md ....................................................Addiction Medicine John Edward hill, md, FaaFp ...................................AMA & WHO, Family Medicine John d. isaacs, Jr., md ..................................................Ob/Gyn, Women’s Health & Infertility kent a. kirchner, md, Facp .......................................Nephrology brett c. lampton, md ..................................................Internal Medicine/Hospitalist philip l. levin, md ......................................................Emergency Medicine William lineaweaver, md, Facs ................................Plastic Surgery, Burns & Reconstruction John F. lucas, Jr., md ...................................................Surgery Gailen d. marshall, Jr., md, phd, Facp ....................Immunology and Allergy alan r. moore, md........................................................Neurophysiology paul “hal” moore Jr., md, Facr ...............................Radiology Jason G. murphy, md ...................................................Surgery ann myers, md..............................................................Rheumatology Jimmy l. stewart, Jr., md ............................................Internal Medicine & Pediatrics samuel calvin thigpen, md .........................................Hematology-Oncology thad F. Waites, md, Facc ..........................................Cardiology chris E. Wiggins, md ....................................................Orthopaedic Surgery John E. Wilkaitis, md, mba, cpE, ms ......................Psychiatry and Behavioral Health

I may be one of the people who have served in too many positions myself and, as such, after the initial term will happily step down at the will of the editor and the board. Until then, JMSMA Editor Dr. Luke Lampton and I are open to all suggestions for improving our publication. I think you will find the other editors, members of the publications committee and advisors receptive as well.

Respectfully, R. Scott Anderson, MD Chair, Journal Editorial Advisory Board

30 JOURNAL MSMA

January 2012

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January 2012 JOURNAL MSMA 31

• aSclepiad •

T

he name of this new JMSMA feature, Asclepiad, is an ancient term for physicians. This first portrait is William A. “Bill” Middleton, MD, of Winona. Dr. Bill, as he is known, is a Mississippi native and a graduate of Tulane School of Medicine. After further training at Jackson’s Baptist Hospital and Natchez’s old Charity Hospital, Bill began in July 1955 his long practice of family medicine in Winona. Over the years, he became a medical icon in the state, serving in many capacities including various positions in MSMA and as a member of the state Board of Health. After more than five decades of active medical practice, he retired on December 31, 2009.

“Medicine is a place one can give service and help others,” said Bill, reflecting on the essence of our profession, words which guided his own career.

Dr. Bill is shown in front of a recently completed statue of him, crafted by legendary Mississippi sculptor Sam Gore. It stands like a sentinel on a sloping hill in front of Winona’s Tyler Holmes Memorial Hospital where Bill admitted the first patient after it was built years ago. Interestingly, both Bill and artist Sam Gore are nephews of Dr. Wes Gore, the physician who delivered Bill in a farm house out from Alva in Webster County. Bill’s wife Nell advises that a presentation ceremony is planned in the spring. This photo is by Crawford Lampton.

— Lucius Lampton, MD, Editor

32 JOURNAL MSMA

January 2012

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