VOL. LVIII • NO. 1 • 2017

VOL. LVIII • NO. 1 • 2017

t Register a .org!

A E C W M

Workers’ Recovery The Umbrella of Solutions

MWCEA

Mississippi Workers’ Compensation Educational Conference

April 19th - 21st 2017 Beau Rivage Resort • Biloxi, MS The 2017 Annual Mississippi Workers’ Compensation Educational Conference is an exciting gathering of employers, insurers, TPA’s, legal professionals, healthcare professionals, rehabilitation providers and others involved in the workers’ compensation field in Mississippi. An expected 700, or more, professionals will attend the conference over the three-day period. Up to 12 hours of continuing education credits have been applied for the following: Physical Therapists, Occupational Therapists, CLE (MS, AL & LA), CRC, CCM, CDMS, MS Adjusters, MS P&C Agents.

The conference includes multiple topics and presenters. Specific interest within the medical field that you do not want to miss include:

Using Evidence Based Medicine to Analyze Medical Issues Commonly Encountered in Workers’ Compensation Claims David Gandy, MD - Jackson Orthopedic Clinic, PA - Jackson, MS Christopher Burks, MD - Bienville Orthopedic Specialists - Ocean Springs, MS Daniel Boyd, MD - Oxford Orthopedics & Sports Medicine - Oxford, MS

Tapering Patients Off Multiple Prescription Drugs

Mark Pew, Senior Vice President - Prium - Atlanta, GA Mel Pohl, MD, Medical Director and Founder - Las Vegas Recovery Center - Las Vegas, NV Dr. Aaron Wolfson, PhD - Jefferson Neurobehavioral Group - New Orleans, LA For a complete list of programming, the list of final CEU credits approved, as well as to register for the conference, visit MWCEA.org. Early registrants will be entered into drawings for special prizes. You must be registered as an attendee to receive continuing education credits.

Hosted by: Mississippi Workers’ Compensation Commission Mississippi Workers’ Compensation Educational Association, Inc. (MWCEA)

Mississippi Workers’ Compensation Educational Association PO Box 13508, Jackson, MS 39236 • info@MWCEA.org • MWCEA.org

VOL. LVIII • NO. 1 • JANUARY 2017

THE ASSOCIATION President Lee Voulters, MD

SCIENTIFIC ARTICLES Precision Medicine in Cancer Prevention: Exploring Applications in Mississippi and Beyond in Health?

Srinivasan Vijayakumar, MD; Paul Russell Roberts; Satyaseelan Packianathan, MD

President-Elect William M. Grantham, MD

Top 10 Facts You Need to Know about Carotid Artery Disease Daniel J. Robbins, BM and Marc E. Mitchell, MD

MANAGING EDITOR Karen A. Evers

Secretary-Treasurer Michael Mansour, MD

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

Speaker Geri Lee Weiland, MD

EDITOR Lucius M. Lampton, MD ASSOCIATE EDITORS D. Stanley Hartness, MD Richard D. deShazo, MD

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

JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices.

CORRESPONDENCE: Journal MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: 601-853-6733, Fax: 601-853-6746, www.MSMAonline.com.

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Emergency Physician-Performed Bedside Ultrasound 10 in the Evaluation of Acute Appendicitis in a Pediatric Population Brian Tollefson, MD, RDMS; Jaryd Zummer, MD; Phillip Dixon, MD, MPH

DEPARTMENTS From the Editor – Word Salad: What Our Patients Hear Lucius M. Lampton, MD, Editor

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President’s Page – Free Drug Discount Card Can Help Your Patients Get Meds Lee Voulters, MD

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Editorial – Primordial and Primary Prevention: Addressing Non-communicable Diseases in Mississippi Jennifer Mansour and Michael Mansour, MD

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Letters

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New Members

22

Images in Mississippi Medicine – Newton Sanatarium

25

Poetry and Medicine – Our Little Blind Boy 28 Dwalia South, MD RELATED ORGANIZATIONS MSDH – Reportable Disease Statistics

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

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

Copyright © 2017 Mississippi State Medical Association.

Official Publication

MSMA • Since 1959

ABOUT THE COVER

This is a tree that stands just off the road at the back entrance to

Grand Gulf Nuclear Power Plant in Claiborne County, MS. The picture was taken March of 2015 just as the leaves were coming back to the landscape. It has a lonely but sturdy appearance, even when her foundation seems to be slipping away. Dr. Randy Easterling of Vicksburg who has been the Fitness for Duty Officer and Medical Review Officer at the power plant for 29 years took this photo. – Ed. n

JOURNAL MSMA

VOL. LVIII • NO. 1 • 2017

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F R O M

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Word Salad: What Our Patients Hear

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ur medical patois bounces off our patients’ ears as an alien language, at times frightening and pregnant with intimidation. Patients often venture into our dangerous vernacular fearlessly at times, with humorous results. One of my elderly female patients once told me, “I got to show you my pajama,” pointing down to her female area. “Dr. Lampton, my pajama has been jumping!” (This Lucius M. Lampton, MD ended up a simple case of vaginal Editor candidiasis.) A male patient not too long after stated his “peanut was swollen” (which ended up being acute epididymitis). Another patient had a seizure disorder and had run out of her Dilantin. As I walked into the room, she expressed her fear that she would have a “conversion” (rather than a convulsion) if she didn’t get her refill soon. (I do like the idea of patients having conversions in our offices!)

Sometimes the words patients use are close enough to understand.

One patient mentioned her “limp nob” was swollen, and another

referred to her recent “knee transplant.” Another told me the ER doctor had informed her she had “puff on her kidneys” (puss), another described needing an “acid reflex” pill, and another told me she was “dibetical.” Recently, a patient’s daughter asked if her mother had received her “ammonia shot” and within days a cirrhosis patient asked if I would draw a “pneumonia level.” Another inquired if it was ok if she took “subliminal B12” (sublingual). “Of course,” I told her, “You can have all the subliminal B12 you want!”

There are many lessons in these verbal forays of our patients. First, physicians need to appreciate the wonders and joys of humanity in our medical practices. Every single day, we can revel in our love of our patients and their comments. Second, our patients are desperately seeking ways to connect with their physicians. Physicians need to reach out to patients as they seek this connection and help them along by speaking not only our language but their language too. Health care literacy is a two-way street: patient and physician must work as a team to communicate effectively. n Contact me at lukelampton@cableone.net.

— Lucius M. Lampton, MD, Editor

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

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

Michael Artigues, MD Pediatrician, McComb Children’s Clinic

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

Diane K. Beebe, MD Professor and Chair, Department of Family Medicine, University of Mississippi Medical Center, Jackson Rep. Sidney W. Bondurant, MD Retired Obstetrician-Gynecologist, Madison Jennifer J. Bryan, MD Assistant Professor, Department of Family Medicine University of Mississippi Medical Center, Jackson Jeffrey D. Carron, MD Professor, Department of Otolaryngology & Communicative Sciences, University of Mississippi Medical Center, Jackson Gordon (Mike) Castleberry, MD Urologist, Starkville Urology Clinic Matthew deShazo, MD, MPH Assistant Professor-Cardiology, University of Mississippi Medical Center, Jackson Thomas E. Dobbs, MD, MPH Chief Medical Officer, VP Quality, South Central Regional Medical Center & Infectious Diseases Consultant, Mississippi State Department of Health, Hattiesburg Sharon Douglas, MD Professor of Medicine and Associate Dean for VA Education, University of Mississippi School of Medicine, Associate Chief of Staff for Education and Ethics, G.V. Montgomery VA Medical Center, Jackson

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Brett C. Lampton, MD Internist/Hospitalist, Baptist Memorial Hospital, Oxford Philip L. Levin, MD President, Gulf Coast Writers Association Emergency Medicine Physician, Gulfport

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

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

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

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

Nitin K. Gupta, MD Assistant Professor-Digestive Diseases, University of Mississippi Medical Center, Jackson Scott Hambleton, MD Medical Director, Mississippi Professionals Health Program, Ridgeland J. Edward Hill, MD Family Physician, Oxford W. Mark Horne, MD Internist, Jefferson Medical Associates, Laurel Daniel W. Jones, MD Sanderson Chair in Obesity, Metabolic Diseases and Nutrition Director, Clinical and Population Science, Mississippi Center for Obesity Research, Professor of Medicine and Physiology, Interim Chair, Department of Medicine Ben E. Kitchens, MD Family Physician, Iuka

Michael D. Maples, MD Vice President and Chief of Medical Operations, Baptist Health Systems Heddy-Dale Matthias, MD Anesthesiologist, Critical Care Internist, Madison Jason G. Murphy, MD Surgeon, Surgical Clinic Associates, Jackson Alan R. Moore, MD Clinical Neurophysiologist, Muscle and Nerve, Jackson Paul “Hal” Moore Jr., MD Radiologist, Singing River Radiology Group, Pascagoula Ann Myers, MD Rheumatologist , Mississippi Arthritis Clinic, Jackson Darden H. North, MD Obstetrician/Gynecologist , Jackson Health Care-Women, Flowood

Jack D. Owens, MD, MPH Neonatologist, Newborn Associates, Flowood Michelle Y. Owens, MD Associate Professor, Vice-Chair of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson Jimmy L. Stewart, Jr., MD Program Director, Combined Internal Medicine/ Pediatrics Residency Program, Associate Professor of Medicine and Pediatrics University of Mississippi Medical Center, Jackson Shou J. Tang, MD Professor and Director, Division of Digestive Diseases, University of Mississippi Medical Center, Jackson Samuel Calvin Thigpen, MD Hematology-Oncology Fellow, Department of Medicine, University of Mississippi Medical Center, Jackson Thad F. Waites, MD Clinical Cardiologist, Hattiesburg Clinic W. Lamar Weems, MD Urologist, Jackson Chris E. Wiggins, MD Orthopaedic Surgeon, Bienville Orthopaedic Specialists, Pascagoula John E. Wilkaitis, MD Chief Medical Officer, Brentwood Behavioral Healthcare, Flowood Sloan C. Youngblood, MD Assistant Medical Director, Department of Anesthesiology, University of Mississippi Medical Center, Jackson

Your patients can enjoy a healthier life.

They just need a little extra motivation.

Motivated to Live a Better Life is a free six-week workshop designed to help Mississippians better manage chronic conditions and take the right steps to lead a healthier, more active life. Learn more about this evidence-based approach to health management by calling the Mississippi State Department of Health Office of Preventive Health at 601-206-1559 or visiting HealthyMS.com/MLBL.

JOURNAL MSMA 3 Motivated to Live a Better Life is licensed by the Stanford University Chronic Disease Self-Management JOURNAL Program.

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Precision Medicine in Cancer Prevention: Exploring Applications in Mississippi and Beyond SRINIVASAN VIJAYAKUMAR, MD; PAUL RUSSELL ROBERTS; SATYASEELAN PACKIANATHAN, MD Introduction Precision medicine has been defined as “the right … treatment for the right patient at the right time”.1 It is the latest term meant to convey the concept of “personalized medicine,” although some argue that precision medicine and personalized medicine are different concepts.

Our current approaches to managing diseases are designed for the “average patient”, which then leads to problems when treating an actual, individual patient. For example, any given treatment will have a greater effectiveness in some patients compared to others; only a fraction of patients who receive a treatment or drug will respond at all. Unfortunately, a consequence of using this “average treatment for the average patient” approach can lead to situations where side effects occur in patients who see no benefit from their medical therapy.1-7 Recent biological and technological advances, such as the human genome project, “Big Data” initiatives, and electronic medical records (EMR) have changed the way physicians approach disease treatment.1-7 In a recent review, Cardon and Harris point out the need for a term that aptly describes what had been previously stated in various ways: precision medicine, personalized medicine, stratified medicine, and targeted therapies.3 They define the modern approach as “prevention and treatment that takes individual variability into account.”3 Precision medicine is not new. For instance, physicians have been matching individual blood groups in transfusions for decades, an early form of precision medicine. Customized spectacles is another form of precision medicine. By using advances in genomic medicine, EMR, and “Big Data” initiatives, precision medicine applications are now feasible.9 As Cardon and Harris also point out, “Precision medicine has moved beyond the early phase of hope and hyperbole to a practical reality.”1-7 The Precision Medicine Initiative (PMI) announced by

President Barack Obama in his 2015 State of the Union Address further heightened the interest of the people and scientists on the possibilities of precision medicine and its potential to save lives, improve the quality of lives, prevent diseases, and improve the health of populations. In this paper we focus on 6 related issues which are listed in Table 1.

Hypothesis Cancer is a complex, chronic, genetic, mutational disease in most cases. Genomic Medicine, “Big Data” initiatives, and electronic health records (EHRs) are already being leveraged to provide personalized oncological care to improve outcomes. To decrease the worldwide cancer burden, we suggest that future efforts can and should be extended to prevention and early detection of the multi-step carcinogenic process (Figure).

FIGURE - Using Precision Medicine Concepts in Cancer Prevention: Conceptual Framework

Table 1. Issues Reviewed in This Paper 1.

Differences between genomic and precision medicine

2.

Potential uses of Big Data Initiatives in human health and disease

3. Applications of EMRs to revolutionize current approaches to disease management and patient health 4.

Extension of these concepts to prevention and early disease detection

5.

Reasons why cancer has led in the application of precision medicine

6.

Methods to inidividualize cancer prevention and early diagnosis

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Genomic Medicine The National Human Genome Research Institute (NHGRI) defines “Genomic Medicine” as, “an emerging medical discipline that involves using genomic information about an individual as part of their clinical care (e.g., for diagnostic or therapeutic decision-making) and the health outcomes and policy implications of that clinical use.”10 Without a doubt, ‘new doors’ to genomic medicine were opened with the advent of the

Human Genome Project (HGP) and its ongoing discoveries.12-15 The HGP lasted from 1990 to 2003 and was an international, publiclyfunded, collaborative effort to map the entire human genome.13 The human genome has about 3 billion base pairs with approximately 30,000 functioning genes. Since the first publication in 2001,20 human genome sequencing has led to many important new medical paradigms.15 Comprehensive genomic catalogs have been generated and led to the discovery of specific genes for roughly 3,000 Mendelianmonogenic diseases. Genetic associations between over 900 genomic loci and complex multigenic (disease) traits have been mapped. Our current understanding of the importance of the non-coding regions of the human genome has vastly improved; these include gene regulation, chromosome function, and the generation and purpose of untranslated RNAs. The HGP has shown that health and disease are influenced by the interactions of genetic variations, environmental agents, health behaviors, and epigenetic contributors.

Molecular taxonomy, advances in pharmacogenomics, and new gene therapy strategies seem to be obvious future advances deriving from genomic medicine.15 Most importantly, for complex diseases, “genomic information will also lead to newer therapeutic approaches based on dietary, behavioral and lifestyle interventions, modification of environmental exposures, and other population-based or societal interventions that have genotype-specific effects.”15 This last sentence crystalizes the crucial difference between genomic and precision medicine. Genomic medicine can be a component of precision medicine; however, precision medicine encompasses many more facets of health and disease.

“Big Data” in Human Health and Diseases “Big Data” refers to the “extremely large data sets that may be analyzed computationally to reveal patterns, trends, and associations, especially those relating to human behavior and interactions.”16 These complex data sets have immense potential to impact patient care but also generate unique new problems of their own.17,21 For instance, traditional data processing techniques are unable to handle adequate analysis, storage, search, data curation, data transfer, visualization, and querying of “Big Data.” Nonetheless, new data management technologies and research have led to the beneficial application of information derived from “Big Data”’ in many spheres of human endeavors, and healthcare is no exception.

Murdoch and Detsky predicted the “inevitable application of ‘Big Data’ to healthcare.”17 Their review showed that data management and analysis in other industries made them more efficient and productive.

Although the health care industry was ahead of other non-healthrelated industries in using evidence-based decision making, it has lagged behind in applying “Big Data” to improve patient care and outcomes.

Widespread adoption of EMRs are expected to make significant contributions in generating “Big Data,” and the health care industry should learn from other industries and prepare itself to take advantage of this opportunity. In Table 2, we list five main ways in which the quality, efficiency, and outcomes of the health care can be potentially improved by using “Big Data.”

Table 2. Opportunities to Improve Health Care Using “Big Data” 1.

Generation of new knowledge

2.

Knowledge dissemination

3. Transformation of personalized medicine initiatives to practical applications 4.

Informing patients and the public

5. Empowering them to play a more active role in the improvement of personal and population disease management and health.

Electronic Medical Records/Electronic Health Records Lately, health policymakers have indicated a preference for the term “Electronic Health Records” to “Electronic Medical Records”.18 The Office of the National Coordinator for Health Information Technology (ONC) makes succinct arguments to prefer EHR to EMR. EMRs are generally used for diagnosis and treatment of diseases among patients.

They help track data over time and help multiple caregivers within a medical facility share patients’ information to make coordinated care possible. However, an EHR can do even more. For instance, an EHR must contain all information from all caregivers caring for a patient. In theory, such health information moves with the patient, regardless of city, state, or country. Also, patients will have personal access to their own medical record, so that he/she can follow, monitor, direct, and assess his/her progress.

The real potential of EHR, however, is in its ability to contribute to disease prevention, health promotion, and population health research.

Kite et al., reviewed the utility of EHR in cardiovascular (CV) research, CV disease prevention, and CV health promotion.19 They divided the EHR’s uses into active and passive categories: passive when the flow of information is unidirectional – from the EHR to outside and active when information flowed two ways – in and out of the EHR. Both active and passive uses can be further utilized in areas like CV health promotion, population-based research strategies, and CV health outcomes improvement. Similar possibilities also exist for cancer prevention, early diagnosis, and outcomes research. In another example, Kurian et al., linked the EHR data from two different medical systems and state registries to perform outcomes research.23 Additionally, in a cluster randomized controlled trial in primary care centers of Barcelona, Spain, Guiriquet et al., showed that by including an alert in the EHR, more subjects participated in a colorectal screening program.24 These examples illustrate the potential utility of linking EHRs with disease prevention, early diagnosis, and outcomes research.

Precision Medicine in Cancer Cancer is a disease of genetic mutations, a complex and multifactorial disease, a spectrum of diseases, a chronic disease, a disease of aging, and needs multidisciplinary care. Its overarching complexity means that for optimal care, Genomic Medicine, “Big Data”-based interventions, and EHR-linked tools should all be used, not only in its treatment, but also in its prevention and early detection. Such a comprehensive combination of cancer care and cancer prevention will yield great dividends.25

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A Therapeutic Perspective of Precision Oncology Klement et al., point out the following that supports the hypothesis of this paper. They argue that cancer is a heterogenic disease with intraand inter-tumoral variabilities and individually unique molecular signatures and profiles. They suggest that this will make traditional histopathological diagnoses largely irrelevant in the future and a molecularly-based tumor taxonomy will emerge, necessitating a paradigm shift in how patients will be diagnosed and treated – a shift driven by newly available genomic, proteomic and metabolomics information.26 We believe that the future outlined by these authors will require application of the concepts we have presented in this paper: applying the advances of genomic medicine, using the tools developed for “Big Data” analyses, and effective intra- and inter-EHR communication. We have outlined some of the steps which we believe will help us make that transition (Table 3).26 Once those concepts are accepted and implemented in therapeutic clinical trials, it is but ‘one short step’ to their application in cancer prevention paradigms.

Table 3. Necessary Steps to Shift Current Diagnosis and Treatment Paradigm.

1.

Implementation of N = 1 clinical trials.

2.

Generate and interpret large data sets with outstanding integrity.

3. Develop novel mathematical models to investigate the genomic hierarchy in an individual patient’s cancer.

4. Design combination therapies based on genomic, proteomic, and metabolomicpathway determinations.

Conclusion In this commentary, a new paradigm has been proposed: the idea that “precision medicine concepts can be applied to cancer prevention initiatives (Figure).” These initiatives would apply state of the art ideas from Genomic Medicine, “Big Data” and EHR to a new area, cancer prevention.

To implement these concepts, we will need to assemble experts to help set priorities, generate funding, create directed taskforces, and influence legislative and administrative policymakers. If implemented successfully, such a plan could lead to sizeable benefits. These include a decrease in cancer incidences, improvements in cancer outcomes and quality of life, and reductions in health care costs by alleviating the need to take care of patients with cancer through primary, secondary, and tertiary cancer treatment paradigms. n References 1. NIH:NLM Genetics Home Reference. What is precision medicine? https://ghr.nlm.nih.gov/primer/precisionmedicine/definition. Accessed January 29, 2017.

2. Peer D. Precision medicine--delivering the goods? Cancer Lett. 2014 Sep 28;352(1):2-3. doi: 10.1016/j.canlet.2014.04.011.

3. Cardon LR, Harris T. Precision medicine, genomics and drug discovery Hum Mol Genet. 2016 Oct 1;25(R2):R166-R172. Epub 2016 Aug 18.

4. Brennan P, Wild CP. Genomics of Cancer and a New Era for Cancer Prevention. PLoS Genet 11(11):e1005522. doi: 10.1371/journal. pgen.1005522.

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5. Kensler TW, Spira A, Garber JE, Szabo E, et al. Cancer Prev Res (Phila).

2016;9(1):2-10. doi: 10.1158/1940-6207.

6. Feero WG, Guttmacher AE, Collins FS. Genomic medicine — An updated primer. N Engl J Med. 2010;362(21):2001-2011. doi: 10.1056/ nejmra0907175.

7. Schott, AF, Perou CM, Hayes DF. Genome medicine in cancer: What’s in a name? Cancer Res. 75(10), 1930-1935. DOI: 10.1158/0008-5472.

8. White house precision medicine initiative. https://www.whitehouse.gov/ precision-medicine. Accessed January 29, 2017.

9. Topol EJ. The creative destruction of medicine: How the digital revolution will create better health care. New York: Basic Books, 2011. ISBN: 0465029345 10. National human Genome Research Institute. What is Genome Medicine? https://www.genome.gov/27552451/what-is-genomic-medicine/ Accessed January 29, 2017.

11. Duffy, DJ. Problems, challenges and promises: Perspectives on precision medicine. Brief Bioinform. 2016;17(3):494-504. doi:10.1093/bib/bbv060.

12. Guttmacher AE, Collins FS. Genomic medicine–a primer, N Engl J Med. 2002; 347:1512-1520. doi:10.1056/nejmra012240 13. The Editors of Encyclopædia Britannica. Human genome project | scientific project. Encyclopædia Britannica; June 23, 2016. https://www. britannica.com/event/Human-Genome-Project. Accessed January 29, 2017.

14. National Human Genome Research Institute (NHGRI). https://www. genome.gov/27552451/what-is-genomic-medicine/ Accessed January 29, 2017.

15. Green ED, Guyer MS, Green ED, Guyer MS, Manolio TA, & Peterson JL. Charting a course for genomic medicine from base pairs to bedside.

Nature. 2011;470(7333), 204-213. doi:10.1038/nature09764.

16. Google. https://www.google.com/?gws_rd=ssl#q=big+data. Accessed January 29, 2017.

17. Murdoch TB, & Detsky AS (2013). The inevitable application of big data to health care. JAMA. 309(13), 1351. doi:10.1001/jama.2013.393.

18. EMR vs EHR – what is the difference? - health IT buzz. Electronic Health & Medical Records. http://www.healthit.gov/buzz-blog/electronichealth-and-medical-records/emr-vs-ehr-difference/. Accessed January 29, 2017.

19. Kite BJ, Tangasi W, Kelley M, Bower JK, Foraker RE. Electronic Medical Records and Their Use in Health Promotion and Population Research of Cardiovascular Disease. Current Cardiovascular Risk Reports, 9(1). doi:10.1007/s12170-014-0422-5.

20. Human genomes, public and private. Nature, 2001;409(6822), 745-745. doi:10.1038/35057454.

21. Big data. Wikimedia Foundation; January 27, 2017. https://en.wikipedia. org/wiki/Big_data. Accessed January 29, 2017.

22. Weiss I. EHR vs. EMR | definition, benefits and usage trends. EHR updates. http://www.practicefusion.com/blog/ehr-vs-emr/. Accessed January 29, 2017.

23. Kurian AW, Mitani A, Desai M, Yu PP, et al. Breast cancer treatment across health care systems: Linking electronic medical records and state registry data to enable outcomes research. Cancer. 2014 Jan 1;120(1):103-11. doi: 10.1002/cncr.28395.Cancer. 2014 Jan 1;120(1):103-11. doi: 10.1002/ cncr.28395.

24. Guiriguet C, Munoz-Ortiz L, Buron A, Rivero I, et al. Br J Gen Pract.

2016;66(648): e483–e490.

25. Stewart BW, Bray F, Forman D, Ohgaki H, et al. Cancer prevention as part of precision medicine: Plenty to be done. Carcinogenesis. 2016;37(1):2-9. doi:10.1093/carcin/bgv166.

Journal of the Mississippi State Med 1 2 3 4 Author Information: 5 Corresponding Author: Srinivasan Vijayakumar MD, DMRT, FACR, 6 Professor and Chairman, Department of Radiation Oncology, 2500 N State 7 St., Jackson, MS 39216. svijayakumar@umc.edu.

8 9 To be presented as a poster for research day: George Washington University, 10 Washington, DC. 11 12 13 14 15 16 17 18 19 20 Journal of the Mississippi State 21 22 23 24 The University of Mississippi Medical 25 Center Hospitalist Division in Jackson, MS is seeking BC/BE Hospitalist. Faculty 26 candidates should submit a CV via fax to 27 28 601-984-5608. EOE, M/F/D/V. 29 30 26. Klement GL, Arkun K, Valik D, Roffidal T, et al. Future paradigms for precision oncology. Oncotarget. 2016;19(7)29:46813-46831. doi: 10.18632/oncotarget.9488.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

The Division of Infectious Diseases in the Department of Medicine, at The University of Mississippi Medical Center, is recruiting a full-time infectious diseases academic physician at the assistant professor level.

Job Description: The Division of Infectious Diseases in the Department of Medicine, at The University of Mississippi Medical Center, is recruiting a full-time infectious diseases academic physician at the assistant professor level. This position is focused on the establishment of a service dedicated to treatment of bone and joint infections and expansion of an existing service dedicated to outpatient antibiotic administration at our 650 bed tertiary referral medical center. The position also requires participation on inpatient consultative services with teaching/supervision of fellows and residents.

The University of Mississippi Medical Center is an

Medical equal Association opportunity employer, M/F/D/V. DirectAssoc Contact Information: Keith Robinson, HR-Service Partner

Please send your resume to Dr. Rathel L. Nolan, UMMC Talent Acquisition Professor of Medicine, DivisionMedical of Infectious Diseases, University of Mississippi Center The University of Mississippi Medical Center, 2500 North State Street 2500 North Street, Jackson, MS 39216: Jackson, MS State 39216-4505 Fax (601) 815-4014 or email: rnolan@umc.edu

KRobinson5@umc.edu

Dear Mr. Robinson:

2017 MSMA “CMEThankinyou the Sand” for your interest in the

MACM Golf Tournament

JOURNAL MSMA. Your ad is typeset for a 7 line b/w ad at the rate of $5.50 per line ($38.50) plus an additional typesetting charge of $25 for a rate of $63.50 for the current insertion; $38.50 should you wish to run again Sandestin thereafter.

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Top 10 Facts You Need to Know about Carotid Artery Disease DANIEL J. ROBBINS, BM AND MARC E. MITCHELL, MD Carotid artery disease (CAD) occurs when atherosclerotic plaque builds up within the carotid arteries resulting in stenosis, most commonly at the carotid bifurcation. If the disease becomes severe enough, ischemic strokes can ensue, leading to long-term disabilities or death. As cardiovascular disease, including stroke, is the leading cause of death in Mississippi, it is important for all Mississippi physicians to know about CAD.

1 2 3 4

The prevalence of CAD increases with age and is greater in men than women.

The prevalence of moderately severe CAD increases from 0.2% in men aged <50 years to 7.5% in men aged >80 years, and for severe CAD increases from 0.1% to 3.1%. Similar trends are seen in women across these age groups, although the disease is less prevalent: 0% to 5.0% for moderate CAD and 0% to 0.9% for severe CAD.1

Risk factors for and history of other cardiovascular diseases are associated with CAD. Men and women with CAD have higher levels of cholesterol, fibrinogen, and systolic blood pressure, and lower HDL cholesterol levels compared to controls. Smoking and a history of cardiovascular disease, including angina pectoris, myocardial infarction, claudication of the lower extremities, stroke or transient ischemic attack, are all associated with CAD.2 There are genetic links to CAD. The Bogalusa Heart Study examined the association of specific genes with carotid intima-media thickness (IMT) in a biracial sample. Their findings included two novel genetic markers associated with IMT in whites and blacks, one gene-smoking interaction identified in blacks only, and three genes that showed gene-based associations with IMT levels.3

The structure of atherosclerotic plaques in CAD contributes to the occurrence of ischemic stroke.

The fibrous cap of the plaque can ulcerate or rupture leading to the formation of a thrombus in the artery. The majority of strokes are the result of emboli originating from the unstable plaque, although if the thrombus is occlusive blood flow to the brain can be compromised resulting in a stroke. Pathologic studies of carotid plaque from patients who had suffered a major stroke found 74% to be thrombotically active.4

5

Duplex ultrasonography is the recommended initial diagnostic test to detect significant carotid stenosis.

Carotid Duplex ultrasonography is a widely available, noninvasive technology that imparts little risk and discomfort to patients. It is useful in evaluating asymptomatic patients with known or suspected CAD, asymptomatic patients with risk factors for CAD and symptomatic patients with focal neurological symptoms. Carotid Duplex ultrasonography is not recommended for the routine screening of patients without symptoms or risk factors for atherosclerosis.5

6

Magnetic resonance angiography (MRA) and computed tomography angiography (CTA) are useful in evaluating CAD. MRA is noninvasive, requires no ionizing radiation, and is accurate in diagnosing carotid occlusion. MRA has a tendency to overestimate the degree of stenosis making it difficult to distinguish moderate from severe stenosis. MRA also evaluates plaque morphology which is helpful in assessing the risk of stroke based on the structure of the plaque, such as the distinction between a thick, thin, or ruptured fibrous cap. CTA is less likely to overestimate the degree of stenosis, and better visualizes the soft tissue and bone.6

7

Risk factor modification, anti-platelet agents and statins are the mainstays of medical therapy for CAD. Risk factor modification and anti-platelet drugs are the primary treatment for atherosclerosis, including CAD. Statin drugs reduce atherogenic lipoproteins and decrease cardiovascular morbidity and mortality. The intensive administration of atorvastatin (80 mg/day) slows the progression of atherosclerosis in patients suffering from cardiovascular disease7 and is effective in reducing the occurrence of stroke in patients who have suffered a previous stroke or transient ischemic attack.8

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Surgical intervention is indicated for patients with significant CAD. In both asymptomatic and symptomatic patients with severe carotid stenosis (>70%), carotid endarterectomy (CEA) is effective in reducing complications and death due to stroke. In symptomatic patients with moderate stenosis (50% - 69%) surgery is also beneficial. Careful evaluation of cardiovascular risk factors and a skilled surgeon are essential if excellent surgical outcomes are to be achieved.9,10

9

CEA is the gold standard for the treatment of CAD. This procedure involves opening the artery, removing the atherosclerotic plaque, and repairing the artery, and can be performed under local or general anesthesia. CEA has produced excellent results in a variety of practice settings with 30-day stroke/death rates remaining low across multiple studies. Additionally, it is effective in both low and high-risk surgical candidates, including patients aged 80 years or more.11,12

10

Carotid Angioplasty and Stenting (CAS) is an alternative option for the treatment of CAD. CAS is a catheter based technique involving balloon dilatation of the artery and placement of a stent and was initially introduced as an alternative to CEA for patients who were considered too high risk for surgery. Recent studies have shown similar procedural complication rates, recovery time and stroke/death rates when comparing CEA and CAS. The most appropriate treatment is chosen based on the individual patientâ&#x20AC;&#x2122;s history, overall medical condition and the anatomy of the carotid stenosis.12,13 n References 1. De Weerd M, Greving JP, Hedblad B, et al. Prevalence of asymptomatic carotid artery stenosis in the general population: An individual participant data meta-analysis.

Stroke. 2010;41(6):1294-1297.

2. Mathiesen EB, Joakimsen O, Bonaa KH. Prevalence of and risk factors associated with carotid artery stenosis: The Tromsø study. Cerebrovasc Dis. 2001;12(1):44-51.

3. Li C, Chen W, Jiang F, et al. Genetic association and gene-smoking interaction study of carotid intima-media thickness at five GWAS-indicated genes: The Bogalusa Heart Study. Gene. 2015;562(2):226-231.

4. Spagnoli LG, Mauriello A, Sangiorgi G, et al. Extracranial thrombotically active carotid plaque as a risk factor for ischemic stroke. JAMA. 2004;292(15):1845-1852.

5. Brott TG, Halperin JL, Abbara S, et al. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/ SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. Circulation. 2011;124(4):489-532.

6. Ricotta JJ, AbuRahma A, Ascher E, Eskandari M, Faries P, Lal BK. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease. J Vasc Surg. 2011;54(3):832-836.

7. Nissen SE, Tuzcu EM, Schoenhagen P, et al. Effect of intensive compared with moderate lipid-lowering therapy on progression of coronary atherosclerosis: A randomized controlled trial. JAMA. 2004;291(9):1071-1080.

8. Amarenco P, Bogousslavsky J, Callahan A, et al. High-dose atorvastatin after stroke or transient ischemic attack. N Engl J Med. 2006;355(6):549-559.

9. Barnett HJ, Taylor DW, Eliasziw M, et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. N Engl J Med. 1998;339(20):14151425.

10. Halliday A, Mansfield A, Marro J, et al. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomized controlled trial. Lancet. 2004;363(9420):1491-1502.

11. Kang JL, Chung TK, Lancaster RT, LaMuraglia GM, Conrad MF, Cambria RP. Outcomes after carotid endarterectomy: Is there a high-risk population? A National Surgical Quality Improvement Program report. J Vasc Surg. 2009;49(2):331-339.

12. Ballotta E, Toniato A, Da Roit A, Lorenzetti R, Piatto G, Baracchini C. Carotid endarterectomy for asymptomatic carotid stenosis in the very elderly. J Vasc Surg.

2015;61(2):382-388.

13. Groeneveld PW, Yang L, Greenhut A, Yang F. Comparative effectiveness of carotid arterial stenting versus endarterectomy. J Vasc Surg. 2009;50(5):1040-1048.

Author Information: Mr. Robbins is a medical student in the graduating class of 2018 at the University of Mississippi Medical Center. Dr. Mitchell is Professor of Surgery at the University of Mississippi Medical Center.

Corresponding Author: Marc E. Mitchell, MD, Department of Surgery, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, memitchell@umc.edu.

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Emergency Physician-Performed Bedside Ultrasound in the Evaluation of Acute Appendicitis in a Pediatric Population BRIAN TOLLEFSON, MD, RDMS; JARYD ZUMMER, MD; PHILLIP DIXON, MD, MPH Abstract

Introduction

Background/Objective

Acute appendicitis remains one of the most common surgical emergencies in the pediatric population. Although appendicitis is traditionally a clinical diagnosis, history and physical exam alone have provided only moderate diagnostic accuracy.2-5 Suboptimal clinical diagnostic accuracy is especially true of patients with atypical presentations and in the pediatric population who cannot always verbalize or sufficiently describe their symptoms.5 Historically, relying heavily on clinical diagnosis has contributed to higher negative appendectomy rates, that are not without risk.6-8 Due to its high sensitivity and specificity, CT has gained favor in the diagnosis of acute appendicitis.9,10 CT does have significant disadvantages including relatively high cost, prolonged time needed to complete and interpret the study, and exposure to ionizing radiation. The exposure to ionizing radiation with CT is of particular concern in the pediatric population in whom risk of malignancy increases with lifetime radiation exposure.11,12

Many pediatric emergency departments in the United States have adopted a staged ultrasound and CT pathway for the diagnosis of acute appendicitis. However, most algorithms only include radiologyperformed ultrasound (RUS) and not emergency physicianperformed bedside ultrasound (BUS). Our objective was to determine if emergency physician-performed BUS provides sufficient diagnostic accuracy for acute appendicitis in a pediatric population, thereby limiting additional cost and/or delays in disposition.

Methods This is a single-center prospective study of pediatric patients with concern for and requiring further work-up for acute appendicitis.

Each patient had a focused bedside ultrasound (BUS) performed by an emergency physician with training in BUS. Diagnostic accuracy was compared with surgical pathology standard, as well as radiologyperformed ultrasound (RUS), computed tomography (CT), and clinical follow-up.

Results Among 46 enrolled patients, 12 were diagnosed with acute appendicitis (26%). There were no negative laparotomies in those who had surgery.

There was one case of missed appendicitis at 4-week follow-up. BUS had a sensitivity of 100% (95% CI: 72% to 100%) and a specificity of 81% (61% to 93%) when the appendix was visualized (37). This resulted in positive likelihood ratio of 5.2 and a negative likelihood ratio of 0. In the cases where the appendix was not visualized on BUS (9), 1 patient was diagnosed with appendicitis, and the other 8 patients were negative for appendicitis. In RUS both the sensitivity and specificity was 100% when the appendix was visualized. The sensitivity and specificity of CT in our study was 90% and 100% respectively.

Conclusions Emergency physicians can perform bedside ultrasound with high accuracy for acute appendicitis in a pediatric population. When the appendix is not visualized by ultrasound, a staged ultrasound and CT pathway should be considered.

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In comparing ultrasound and CT for the diagnosis of appendicitis, pooled data form meta-analysis suggest that CT has a higher sensitivity while the specificity of the two imaging modalities is equivalent.9 Many pediatric emergency departments in the U.S. have established a staged ultrasound and CT pathway. This ultrasound first pathway has proven to have similar diagnostic accuracy for acute appendicitis, while decreasing the radiation exposure, negative appendectomy rate and perforation rate in children.13-15 The role of emergency physician-performed BUS continues to expand within U.S. emergency rooms, but its use in pediatric emergency rooms lags behind those with an adult-only population.

The underutilization of BUS in the pediatric ER setting may in part result from the lack of formal BUS education in pediatric trained physicians. Decreased disposition time is one of the main benefits of the emergency physician-performed BUS. Many hospitals do not have readily available sonographers, and time delays often occur for an oncall sonographer to be called in from home to perform the exam. This ultimately delays diagnosis and disposition. One objective of our study is to compare the accuracy of emergency physician-performed BUS with radiology-performed ultrasound (RUS). Similar results have been demonstrated in other areas, such as evaluating for gallstones and for hemoperitoneum in blunt abdominal trauma.16,17 The primary goal

of our study is to determine if emergency physician performed BUS alone provides sufficient diagnostic accuracy for acute appendicitis in a pediatric population.

Methods Study Design This is a single-center prospective study evaluating the diagnostic accuracy of emergency physician-performed bedside ultrasound (BUS) for acute appendicitis when compared with radiologyperformed ultrasound (RUS), CT, and/or surgical pathology results.

The University of Mississippi Medical Center Institutional Review Board (IRB) approved the study and all study participants and guardians were provided written informed consent and assent when age-appropriate.

Study Setting and Population The study took place in a single urban, academic tertiary care institution with both ACGME-accredited Emergency Medicine, Pediatrics, and General Surgery residency programs, as well as a Pediatric Emergency Medicine Fellowship. The annual census of the pediatric emergency department is roughly 40,000 visits per year, with approximately 5-15 cases of acute appendicitis seen in the PED per month. The study population included patients 0-16 years of age presenting to the PED with concern for and requiring further work-up for acute appendicitis, as determined by the attending pediatric emergency physician. A convenience sample of patients presenting to the PED meeting the inclusion and exclusion criteria were enrolled.

Participant Inclusion Criteria Any patient less than 17 years of age who presents to the pediatric emergency room at UMMC with concern for and requiring further work-up (blood tests, radiologic studies, surgical consultation, or surgery) for acute appendicitis, as determined by the attending pediatric emergency physician.

Participant Exclusion Criteria Patients greater than 16 years of age, pregnancy, prisoners, parents unable to give consent or patients unable to assent, patients who did not receive any of the three reference criterion for final diagnosis of acute appendicitis (radiologist performed ultrasound, CT, surgical pathology result), patients who had radiologic studies (ultrasound, CT) performed at an outside facility prior to arrival, or patients determined not to require further diagnostic work-up for acute appendicitis as determined by the attending pediatric emergency physician were excluded.

Data Collection and Quality Control The study team involved in ultrasound scanning was comprised of 1 emergency medicine (EM) attending physician and 3 EM residents.

The resident scanners were upper-level EM residents that had completed at least 2 months of emergency ultrasound training as part of residency. Before the start of the study, each member was required to read a review article (Quigley et al.22), and undergo a short training session on how to perform a BUS exam for appendicitis by the director of the emergency ultrasound training program. After demonstrating the ability to accurately identify the appendix on 10 patients, training

was deemed complete. The total training time for each resident was less than 4 hours. A uniform scanning technique was used to locate the appendix. Each exam began by scanning the right lower quadrant (RLQ) of the abdomen at the point of maximal tenderness. The probe was moved incrementally throughout the RLQ until the appendix was located. Moderate probe pressure was applied to the abdomen to move bowel out of the visual field. Typically the appendix can be found in the RLQ just anterior to the external iliac artery cephalad to the inguinal ligament.

Eligible patients were identified after initial triage and evaluation by the attending pediatric emergency physician, who determined whether or not the patient required further diagnostic work-up for acute appendicitis. Those patients meeting inclusion and exclusion criteria had a BUS performed by one of the study personnel. Once a patient was scanned using the ultrasound device, the results were documented by the investigator on a data collection form. The BUS was always performed prior to any knowledge of formal radiographic imaging studies. The patients were assigned a specific number and labeled as such throughout the study.

The ultrasound equipment used for each study participant was a Sonosite X-Porte model, with both 5-2 MHz curvilinear and 13-6 MHz linear probes used for scans. This machine was routinely serviced using a standard protocol.

Follow-up and Outcome Assessment After all diagnostic work-up and (if necessary) surgery was completed, a member of the research team reviewed each patientâ&#x20AC;&#x2122;s chart within 1 week of initial presentation. Results of RUS, CT scan, and surgical pathology were recorded. Additionally, for those patients in whom additional diagnostic work-up did not reveal evidence of acute appendicitis, a chart review and phone follow-up was performed at least 4 weeks after initial presentation to determine if the patient was readmitted or had other radiologic studies or surgery performed at UMMC or at an outside facility.

The primary outcome was the diagnostic accuracy of BUS for acute appendicitis. This was compared to the gold standard of appendiceal surgical pathology. Those who had not undergone surgery within the above follow-up period were deemed not to have a missed diagnosis of acute appendicitis. A secondary outcome measure was the direct comparison of the diagnostic accuracy of BUS with RUS and CT scan. As such, we used a tiered standard criterion to assess the primary and secondary objectives of our study. A positive BUS result for appendicitis was defined as visualizing a non-compressible, nonperistalsing tubular structure attached to the tip of the cecum measuring >6mm in diameter. A negative result was defined as visualizing a compressible, non-peristalsing tubular structure measuring <6mm in diameter and without other concerning features for appendicitis including wall thickness >3mm, appendicolith, periappendiceal fluid, and wall hyperemia. The exam was documented as equivocal if neither of the above results could be obtained or the appendix could not be visualized. The ultrasound images in figures 1 and 2 are examples of a normal appendix and appendicitis, respectively.

At our institution, radiology department ultrasounds are performed by trained sonographers and interpreted by attending radiologists.

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Table 1. BUS with appendix visualized: Statistic

Value

95% CI

Sensitivity

100%

72% to 100%

Specificity

80.8%

61% to 93%

+LR

5.2

2.4 to 11.4

-LR

0

Prevalence

29.7%

15.9% to 47%

+PV

68.8%

41.3% to 89%

-PV

100%

84% to 100%

Likewise, CT scans are interpreted by attending radiologists. As such, we defined RUS or CT results as positive, negative, or equivocal for appendicitis based on an attending radiologist report “consistent with appendicitis,” “normal appendix identified,” or “non-visualized appendix” respectively. Surgical pathology was defined as positive if the report stated “consistent with appendicitis” and negative if it stated “not consistent with appendicitis”.

Data Analysis The primary outcome was analyzed by performing calculations using MedCalc Software 2017 and Microsoft Excel. Sensitivity, specificity, positive likelihood ratio (+LR), and negative likelihood ratio (-LR) for ED BUS were calculated using the outcomes previously described as the gold standard. The analysis of secondary outcomes was conducted similarly.

Results

Table 2. BUS with equivocal scans assumed positive: Statistic

Value

95% CI

Sensitivity

100%

74% to 100%

Specificity

62%

44% to 78%

+LR

2.6

1.7 to 4.0

-LR

0

Prevalence

26%

14.3% to 41.1%

+PV

48%

27.8% to 68.7%

-PV

100%

84% to 100%

Table 3. BUS with equivocal scans assumed negative: Statistic

Value

95% CI

Sensitivity

92%

62% to 100%

Specificity

85%

69% to 95%

+LR

6.2

2.7 to 14.3

-LR

0.1

0.01 to 0.7

Prevalence

26.1%

14.3% to 41.1%

+PV

68.8%

49% to 83.4%

-PV

96.7%

81.5% to 99.5%

Table 4. Image modality comparison: Image Modality

Sensitivity

Specificity

BUS

100%

81%

RUS

100%

100%

CT

90%

100%

From September 2015 through June 2016, a total of 46 patients meeting inclusion and exclusion criteria were enrolled in our study. Of these, 12 underwent surgery (26%), all of which had surgical pathology consistent with acute appendicitis. Only one of these patients that was initially discharged with a negative work-up had acute appendicitis on 4-week followup, which was confirmed by surgical pathology. All 46 patients had a BUS performed by one of the study investigators, while 27 had RUS and 31 had CT performed. Additionally, 12 patients underwent staged RUS followed by CT scanning when the appendix was not visualized on the RUS ultrasound exam.

The appendix was visualized with BUS in 37 of the 46 patients enrolled in the study (80.4%).

Of the appendixes visualized on BUS, there were 5 false positive and 0 false negative results.

This yielded a sensitivity of 100% (95% CI: 72% to 100%), specificity of 80.8% (61% to 93%), positive likelihood ratio of 5.2 (2.4 to 11.4), and negative likelihood ratio of 0 (Table 1).

Due to sample size and number of equivocal scans, we conducted a post hoc sensitivity and specificity analysis using 2 different scenarios. We treated equivocal BUS (non-visualization of the appendix) as either positive (most conservative) or negative (least conservative).

We believe that analyzing equivocal cases by this method, which has been demonstrated in previous studies,23 allowed us to make inferences on the true diagnostic accuracy of BUS. Considering all equivocal BUS scans as positive yielded a sensitivity of 100% (74% to 100%), specificity of 62% (44% to 78%), positive likelihood ratio 2.6 (1.7 to 4.0), and negative likelihood ratio 0 when compared with the reference standard (Table 2). Considering all equivocal BUS scans as negative yielded a sensitivity of 92% (62% to 100%), specificity of 85% (69% to 95%), positive likelihood ratio 6.2 (2.7 to 14.3), and negative likelihood ratio 0.1 (0.01 to 0.7) when compared with the reference standard (Table 3).

The appendix was visualized in 19 of the 27 patients that underwent RUS (70.4%). All RUS exams were correctly identified as negative and positive when compared with the reference standard, yielding both a sensitivity and specificity of 100%. There were 3 patients with an equivocal BUS that had RUS performed. In all 3 of these cases, RUS was also unable to visualize the appendix. Additionally, there were 5 studies in which RUS failed to visualize the appendix that were identified on BUS. Of these, 4 of the 5 were correctly interpreted, and 1 proved to be a false positive result.

Of the study patients, 31 had a CT scan performed, 19 as the primary imaging modality and 12 as part of a staged US-CT algorithm. CT scanning resulted in 1 false negative and 0 false positives when compared to the reference standard. This yielded a sensitivity of 90% and specificity of 100%.

Table 4 highlights the accuracy of BUS, RUS, and CT when compared to the reference standard.

Discussion Based on our results, we believe that BUS has sufficient diagnostic accuracy for acute appendicitis in a pediatric population, but only if the results are applied appropriately. This should primarily be based on whether or not the appendix was visualized. When visualized, BUS was 100% sensitive, and can therefore accurately rule out the diagnosis and allow for safe discharge. BUS was only 80.8% specific, and thus a positive result should be cautiously considered. Depending on provider experience and confidence in the result, as well as clinical pre-test probability, one may determine if a confirmatory diagnostic test or surgical consultation is appropriate.

When the appendix was not visualized, BUS missed one case of appendicitis. This specific patient had a case of retrocecal appendicitis that was 12 VOL. 58 • NO. 1 • 2017

FIGURE 1. Longitudinal ultrasound image of a normal appendix with a diameter of 4.6mm.

FIGURE 3. Proposed Diagnostic algorithm for acute appendicitis:

is equivocal. In our study, every patient whose appendix was not visualized on BUS also had an equivocal RUS. As such, we propose a staged BUS-CT pathway when clinical suspicion for the disease is high, which could obviate the need for RUS and decrease the time until CT scan is obtained. Based on these results, we propose the clinical algorithm shown in figure 3.

FIGURE 2. Longitudinal ultrasound image of non-compressible, 10mm appendix with surrounding inflammation. Surgical pathology confirmed appendicitis.

When BUS visualized the appendix, we found no false negative results; however, multiple false positive findings occurred. These cases were reviewed by the emergency ultrasound director after study completion, and were determined to be loops of bowel and tubo-ovarian structures incorrectly identified as the appendix. These findings occurred more frequently earlier on in the study, and gradually declined with increasing provider experience. Additionally, they occurred more commonly in larger female patients. Further sub-group analyses based on age, gender, and BMI may provide insight into which patients may benefit most from a staged BUS-CT pathway.

There are several limitations of our study that deserve consideration.

Two of the major limitations are the relatively small sample size and convenience sampling. It was not practical for study team personnel to be available at all times, thus not all suspected cases of appendicitis were included in the study. Convenience sampling coupled with the relatively small sample size could limit the ability to detect small differences in the population and affect the validity of our results.

confirmed by surgical pathology. In this instance, RUS also failed to visualize the appendix, while CT accurately identified the pathology.

Given that a missed case of acute appendicitis carries risk of significant complications, further imaging should be considered when ultrasound

The post hoc analysis looked at the result of assigning BUS exams with non-visualized appendixes as either all positive or all negative.

This comparison between the most conservative versus the least conservative scenarios gives an idea of sensitivity and specificity when the appendix was not visualized. If the appendix was non-visualized but assumed to be positive, the sensitivity approaches 100% (but can be as low as 74% with a 95% CI). A more comprehensive study with a larger sample size would help narrow the 95% confidence interval.

If the appendix was non-visualized but assumed to be negative, the specificity increased to 85%; however, sensitivity decreased to 92% (with a confidence interval of 62% to 100%). Because of the consequences of undiagnosed appendicitis, we feel it is more important to have a higher sensitivity in order to effectively rule out disease.

Another limitation of our study was selection bias. Patients were

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included in the study only if the attending pediatric emergency physician had clinical concern for acute appendicitis. Thus, variation in emergency physician judgment of who required an evaluation and work-up for the condition may have selected in or out certain patients.

Given that the study occurred at only one center with a single highquality ultrasound machine, it is possible that these results may not be reproduced in other clinical settings. By providing standardized training and reading material to the study personnel, we attempted to establish a minimum knowledge base. All investigators involved in scanning had previous interest and training in bedside ultrasound. Nonetheless, the experience levels of the 4 investigators were not uniform and evolved throughout the study. In addition, the investigators were not blinded to the physical appearance and condition of the patients, which may bias them in their clinical suspicion of the appendicitis. We believe, however, that this provides a more realistic scenario of emergency physician-performed bedside ultrasound.

Conclusion Our study results demonstrate that there is a strong probability that bedside ultrasound performed by emergency physicians could play an important role in the diagnosis of appendicitis in children. Further studies in larger numbers of patients should be done to confirm our results. n References 1. Von Titte SN, McCabe CJ, Ottinger LW. Delayed appendectomy for appendicitis: causes and consequences. Am J Emerg Med. 1996 Nov;14(7):620-2.

2. Paulson EK, Kalady MF, Pappas TN. Clinical practice. Suspected appendicitis. N Engl J Med. 2003 Jan 15;348(3)236-42.

3. Andersson RE. Meta-analysis of the clinical and laboratory diagnosis of appendicitis. Br J Surg. 2004 Jan;9(1):28-37.

4. Wagner JM, McKinney WP, Carpenter JL. Does this patient have appendicitis? JAMA 1996 Nov 20;276(19)1589-94.

5. Gamal R, Moore TC. Appendicitis in children aged 13 years and younger.

Am J Surg. Jun;159(6)589-92.

6. Hernandez JA, Swischuk LE, Angel CA, Chung D, Chandler R, Lee S. Imaging of acute appendicitis: US as the primary imaging modality. Pediatr Radiol. 2005 Apr;35(4):392-5.

7. Rao PM, Rhea JT, Noveline RA, Mostafavi AA, McCabe CJ. Effect of computed tomography of the appendix on treatment of patients and use of hospital resources. N Engl J Med. 1998 Jan 15;338(3):141-6.

8. Izbicki JR, Knoefel WT, Wilker DK, Mandelkow HK, Muller K, Siebeck M, Schweibere L. Accurate diagnosis of acute appendicitis: a retropspective and prospective analysis of 686 patients. Eur J Surg. 1992 Apr;158(4):22731.

9. Doria AS, Moineddin R, Kellenberger CJ, Epelman M, Beyene J, Schuh S, Babyn PS, Dick PT. US or CT for Diagnosis of appendicitis in children and adults? A meta-analysis. Radiology. 2006 Oct;241(1):83-94. Epub 2006 Aug 23.

10. Rao PM, Rhea JT, Novelline RA, McCabe CJ, Lawrason JN Berger DL, Sacknoff R. Helical CT technique for the diagnosis of appendicitis: prospective evaluation of a focused appendix CT examination. Radiology.

1997 Jan;202(1):139-44.

11. Brenner D, Elliston C, Hall E, Bergdon W. Estimated risks of radiationinduced fatal cancer from pediatric CT. AJR Am J Roentgenol. 2001 Feb;176(2):289-96.

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12. Brenner DJ, Hall EJ, Phil D. Computed Tomography – An increasing source of radiaion exposure. N Engl J Med. 2007;357;2277-84.

13. Ramarajan N, Krishnamoorthi R, Barth R, Ghanouni P, Mueller C, Dannenburg B, Wang E. An interdisciplinary initiative to reduce radiation exposure: Evaluation of appendicitis in a pediatric emergency department with clinical assessment supported by a staged ultrasound and computed tomography pathway. Acad Emerg Med. 2009 Nov;16(11):1258-65.

14. Pena BM, Taylor GA, Fishman SJ, Mandl KD. Effect of an imaging protocol on clinical outcomes among pediatric patients with appendicitis. Pediatrics.

2002 Dec;110(6):1088-93.

15. Russell WS, Schuh AM, Hill JG, Hebra A, Cina RA, Smith CD, Streck CJ. Clinical practice guidelines for pediatric appendicitis evaluation can decrease computed tomography utilization while maintaining diagnostic accuracy. Pediatr Emerg Care. 2013 May;29(5):568-73.

16. Scruggs W, Fox JC, Potts B, Zildenny A, McDonough J, Anderson CL, Larson J, Barajas G, Langdorf MI. Accuracy of ED bedside ultrasound for identification of gallstones: retrospective analysis of 575 studies. West J Emerg Med. Jan 2008;9(1):1-5.

17. Brooks A, Davies B, Smethhurst M, Connolly J. Prospective evaluation of non-radiologist performed emergency abdominal ultrasound for hemoperitoneum. Emerg Med J. Sep 2004;21(5):e5.

18. Chen SC, Wang HP, Hsu HY, Huang PM, Lin FY. Accuracy of ED sonography in the diagnosis of acute appendicitis. Am J Emerg Med. 2000 Jul;18(4):449-52.

19. Fox JC, Hunt MJ, Zlidenny AM, Oshita MH, Barajas G, Langdorf MI. A Retrospective analysis of emergency department ultrasound for acute appendicitis. Cal J Emerg Med. May 2007; 8(2): 41–45.

20. Fox JC, Solley M, Anderson CL, Zlidenny A, Laham S, Maasumi K. Prospective evaluation of emergency physician performed bedside ultrasound to detect acute appendicitis. European J Emerg Med. April 2008; 15(2): 80-85.

21. Tollefson B, Nichols J, Fromang S, Summers RL. Validation of the sonographic Ottawa foot and ankle rules (SOFAR) study in a large urban trauma center. J Miss State Med Assoc. 2016;57(2):35-8. DOI: http:// dx.doi.org/10.1016/j.annemergmed.2012.06.069.

22. Quigley AJ, Starfrace S. Ultrasound assessment of acute appendicitis in pediatric patients: methodology and pictorial overview of findings seen.

Insights Imaging. 2013 Dec;4(6):741-51.

23. Bachur RG, Dayan PS, Bajaj L, Macias CG, Mittai MK, Stevenson MD, Dudley NC, Sinclair K, Bennett J, Monuteaux MC, Kharbanda AB, for the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. The Effect of Abdominal Pain Duration on the Accuracy of Diagnostic Imaging for Pediatric Appendicitis. Ann Emerg Med. 2012 Nov;60(5):582-590.

24. Stephen AE, Segev DL, Ryan DP, Mullins ME, Kim SH, Schnitzer JJ, Doody DP. The Diagnosis of Acute Appendicitis in a Pediatric Population: To CT or Not To CT. J Pediatr Surg. 2003 Mar;38(3):367-71.

Author Information: Dr. Tollefson is the Director of Emergency Ultrasound and Associate Professor of Emergency Medicine at the University of Mississippi Medical Center (UMMC) in Jackson, MS. Dr. Zummer is a former Chief Resident in Emergency Medicine at UMMC and current Pediatric Emergency Medicine Fellow at CHU St. Justine Hospital in Montreal, Canada. Dr. Dixon is a Chief Resident in Emergency Medicine at UMMC. Corresponding Author: Brian Tollefson, MD, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216. Ph: (601) 9845144. Email: btollefson@umc.edu.

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MSMA Supports Immunizations with GiveMeAShot.org

“G

ive-Me-A-Shot” is the web-based, public health campaign launched by the Mississippi Immunization Task Force to promote immunizations against preventable childhood diseases.

Television spots and radio ads feature happy children saying “Give Me A Shot; I deserve a safe school.” The campaign was designed to educate and inform parents as well as the community at large.

The MSMA Board of Trustees committed $50,000 from the Association’s legislative action fund to the public health campaign because we want to support Mississippi’s strong childhood immunization law that requires school age children to be vaccinated. And, we want everyone to know that MSMA supports the State Health Department immunization program and good public health policy.

The Give-Me-A-Shot campaign emphasizes the importance of timely vaccinations and empowers families to stay informed and stay on schedule getting children immunizations to protect themselves and others. The website features science-based facts and opportunities to get involved.

MSMA was instrumental in activating the Mississippi Immunization Task Force. It is a coalition of health care leaders who support immunizations against preventable childhood diseases. Member organizations include the State Department of Health, MSMA, Mississippi Academy of Pediatrics, March of Dimes, Mississippi Academy of Family Physicians, UMMC, Blair E. Batson Children’s Hospital, Pfizer, Griffith Media, and Maris, West & Baker.

The goal is to spotlight outbreaks of preventable diseases so we can demonstrate the safety and efficacy of scheduled immunizations based on physicians’ guidelines for healthy children and safe communities. We need all physicians to participate in the campaign. Visit Give-Me-A-Shot.org. Send your patients to the website to get the facts.

We have also enlisted the help of the MSMA Alliance and physician families to take a “vaccine selfie” and send it in for the social channels and the campaign site GiveMeAShot.org. Encourage your family, friends, and your patients to “#ShowYourShot. Post on Facebook or Twitter with the hashtag #ShowYourShot or send it via email to info@GiveMeAShot.org.” n

Lee Voulters, MD; Gulfport MSMA President 2016-2017

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Primordial and Primary Prevention: Addressing Non-communicable Diseases in Mississippi JENNIFER MANSOUR AND MICHAEL MANSOUR, MD In August 2015, the Mississippi State Medical Association (MSMA) adopted the World Health Organizationâ&#x20AC;&#x2122;s (WHO) call for a 25% reduction in mortality for non-communicable diseases among persons between the ages of 30 and 70 by the year of 2025. This goal requires preventive measures aimed at increased physical activity, reduced sodium intake, reduction in tobacco use, improved hypertension control, and halt the rising incidence of obesity and diabetes.

The MSMA should be admired for promoting this position and presenting this goal at the state legislature as part of the MSMA State Health report card. Non-communicable diseases, however, are not just a Mississippi problem but represent a global epidemic that poses challenges not only for poor regions of this country but represent the predominant global public health challenge of the 21st century.1 Focusing on persons between the ages of 30 and 70 as called for in the WHO 25x25 project as adopted by MSMA may be a missed opportunity to make even greater impact through primary prevention beginning at younger ages. The biggest potential effect for prevention may come from efforts aimed at children. Habits related to diet, physical activity, and smoking are established early in life.2 We have evidence from the Bogalusa Heart Study and the Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Study that suggests a lifelong effort beginning with preventing development of risk factors in youth may make the greatest impact in preventing atherosclerosis and coronary heart disease later.3,4,5,6 This concept of preventing risk factors from developing has come to be known as primordial prevention since it goes beyond the primary prevention of managing cardiovascular risk factors to prevent the development of clinical cardiovascular disease.

The PDAY study indicates that risk factor control is likely to be beneficial regardless of the stage of disease since risk factors are associated with atherosclerosis from the teenage years. Risk factors measured early in life predict advanced lesions later in life. It is also well established that major risk factors of atherosclerosis in the teenage years and their effects are cumulative. Preventing or controlling risk factors in youth will help to prevent atherosclerosis and cardiovascular disease later in life.3,4,6 A recent high school science fair project designed to determine if body mass index affects blood pressure in teenagers demonstrates opportunities for screening, education, and treatment that are readily available in teenagers.

Twenty high school students randomly selected with an average age of 15 years, with 50% girls and 50% boys, 45% African American and 55% of non-African Americans were divided into groups based on BMI. The normal group had a BMI 18.5-24.9 and the obese group had a BMI>29.9. A significant difference was seen between the normal and obese groups with higher average blood pressure (p<0.01) and higher rate pressure product (p<0.05).

The Expert Panel of Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: Summary Report outlines the approach and goal set in addressing teenagers such as those with obesity and hypertension.7 The obese group is also at risk for corresponding atherosclerosis development by developing diabetes and metabolic syndrome.7,8,9,10 The student data from the high school science fair project illustrate an opportunity for prevention of risk factor development (primordial prevention) and prevention of future cardiovascular disease by effective management of identified risk factors (primary prevention).4 In overweight and obese youth, the combination of diet and a specific physical activity intervention is universally more effective at achieving decreases in weight and BMI. Lower dietary sodium intake is associated with lower BP levels in all age groups. The DASH-style diet rich in fruit, vegetables, low-fat or fat-free dairy products, whole grains, fish, poultry, beans, seeds, and nuts is one dietary intervention that can be utilized in addressing hypertension and obesity treatment and prevention. These evidence-based recommendations for diet and nutrition are also reflected in the CHILD-1 recommendations heart-healthy eating.6,7,8 Preventive programs such as the Mississippi Public Broadcasting sponsored Southern Remedy Healthy Living Program and information at the Mississippi State Department of Health make guidance for healthy living readily available.

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The Center for Medicare and Medicaid Services’ Million Hearts Campaign to prevent 1 million myocardial infarctions over five years has been embraced and promoted by the Mississippi Chapter of the American College of Cardiology and by the Mississippi Task Force on Heart Disease and Stroke Prevention. The Million Hearts campaign focuses on lower blood pressure, ending a smoking habit, and implementing a statin and aspirin regimen.

State level policies can have major effects on such factors as early screening for cardiovascular disease, smoking and healthy eating.

Effective policies are in place in many states regarding smoke-free environments, tobacco marketing restrictions, taxation of unhealthy food, improved school lunches, and physical and nutritional education programs. These and other policies can be championed at the level of local municipalities and state legislatures. Mississippi is one of only six states to require gym classes to be provided at every grade level.2 Many efforts have been undertaken in approaching atherosclerosis risk factors in children in Mississippi. Among these are ordinances against smoking in public places. The Mississippi Healthy Students Act of 2007 was created by the office of Healthy Schools and the Coordinated School Health Program funded in part by the Bower Foundation. This act mandated improved physical fitness programs and improved nutrition standards in schools.

The follow up evaluation of the Mississippi Healthy Students Act of 2007 following overweight and obesity rates among public school students 2005-2011 showed obesity rates among all elementary students decreasing from 40.3 to 37.3%. A disparity was seen in rates with obesity in Caucasian students falling from 40.6 to 34.8% while the rates of African American children were rising not falling. At this same time the obesity prevalence in the United States was 16.9% in youth and 34.9% in adults and remained unchanged from 2003.11 Efforts in Mississippi schools must be fundamental to the long-range goal of achieving a further reduction in cardiovascular disease in Mississippi. Risk factors for atherosclerosis can be identified in childhood and tracked from childhood to adulthood. Progression of disease is related to the number and intensity of risk factors. Mississippi schools hold great promise for instilling and enhancing good health in young people.

Our ability to meet these goals and successfully improve cardiovascular health outcomes and the cost of health care delivery is dependent on successfully changing the environment that Mississippians exist in and creating a culture of primary and primordial prevention.

Confronting the challenge presented by the global epidemic of non-communicable diseases by adopting the WHO 25x25 here in Mississippi in combination with opportunities and efforts aimed at primordial prevention holds great promise for Mississippians and must remain a primary focus of healthcare providers and society as a whole. n References 1.

Mansour M., Health Disparities, Population Health, and Preventive Medicine. J Miss Sate Med Assoc. 2014Apr;55(4):128-9.

2.

Mansour M, Shor R. Health Care in Transition: Primary Prevention and Health Disparities in Focus. J Am Coll Cardiol. 2015;66(16):1837-1838.

3. McGill HC, McMahan CA, Giddung SS. Preventing Heart Disease in the 21st Century. http://dx.doi.org/10.1161/CIRCULATIONAHA.107.717033. March 4, 2008.

4. McGill HC Jr, McMahan CA, Henderick EE, et al. for the Pathobiological Determinants of Atherosclerosis in Youth (PDAY) Research Group. Obesity accelerates the progression of coronary atherosclerosis in young men. Circulation. 2002; 105:2712-2718.

5. Li S, Chen W, Srinivasan SR, et al. Childhood cardiovascular risk factors and carotid vascular changes in adulthood: the Bogalusa Heart Study. JAMA. 2003 Nov 5;290(17):2271-6.

6. Berenson GS, Srinivasan SR, Bao W, et al. for the Bogalusa Heart Study. Asssociation between multiple cardiovascular risk factors and atherosclerosis in children and young adults. N Engl J Med. 1998;338:1650-1656.

7. Expert Panel on Integrated Guidelines for Cardiovascular health and Risk Reduction in Children and Adolescents. Expert Panel on Integrated Guidelines for Cardiovascular health and Risk Reduction in Children and Adolescents: Summary Report. Pediatrics.2011 Dec; 128(Suppl 5 ): S213-S256.

8. Watanabe M, Yokotsuka M, Yamaoka K, et al. Effects of a lifestyle modification programme to reduce the number of risk factors for metabolic syndrome: a randomized controlled trial. Public Health Nutr. 2016 Jul 29:1-12.

9. West NA, Hamman RF, Mayer-Davis EJ, et al. Cardiovascular Risk Factors Among Youth With and Without Type 2 Diabetes. Diabetes Care. 2009 Jan; 32(1): 175-180.

10. Ferdinand KC, Rodriguez F, Nasser SA, et al. Cardiorenal Metabolic Syndrome and Cardiometabolic Risks in Minority Populations. Cardiorenal Med 2014;4:111.

11. Ogden CL, Carroll MD, Kit BK, et al. Prevalence of childhood and Adult Obesity in the United States, 2011-2012. JAMA, 2014 Feb 26: 311(8): 806-814.

18 VOL. 58 • NO. 1 • 2017

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L E T T E R S

Rural Hospital Survival Depends on Infusion of Monies, Especially to Cover Uncompensated Care: Could Medicaid Expansion Provide Critical Relief?

Dear JMSMA Editor: In a recent editorial, Dr. Lampton identified a grim prospect for health care in Mississippi. As many as 31 of the state’s 94 hospitals are reported to be “at risk of closure.”1 Such closures compromise the advantages of accessible local care as well as threaten to overload other hospitals and specialty centers.

Dr. Lampton proposes that these possible closures are consequences of a “war on small hospitals” intrinsic to the implantation of the Affordable Care Act. While elements of this legislation offered some incentives to consolidations and elimination of duplicate services, the law does not clearly create any circumstances mandating the closing of smaller facilities. None of the ACA replacement proposals clearly recognizes hospital closures as a problem, and none of them explicitly offers any defined relief.2,3 I work in a practice that accepts referrals from all over all our state, ranging from the smallest health centers to the state’s Level I trauma center. In addition, I serve on state trauma committees and subcommittees. In these capacities, I have heard many hospital administrators describe difficulties facing their facilities.

Such discussions almost always include the financial burdens associated with providing uncompensated care. As of 2012, 15% of Mississippi’s citizens did not have health insurance.4 Costs of such care can be crippling to large institutions, and they can be fatal to smaller facilities with fragile budgets.

Medicaid expansion, a provision of the Affordable Care Act, can provide substantial relief to hospitals that could critically benefit from reductions in losses and increases in revenue. A study of 19 states that expanded Medicaid in January, 2014, showed that hospitals in those states reduced mean annual compensated care costs by $2.8M ($1.6M-4.1M) and increased mean annual Medicaid income by 3.2 M ($0.9M-5.6M).5 Hospitals in states without Medicaid expansions showed no decreases in cost or increases in revenue.

Mississippi, despite a high uninsured population and woeful health statistics, has declined to implement Medicaid expansion.4 Could such an expansion, with possible increases in budget balances of $6M annually, provide critical relief for Mississippi’s at risk hospitals? n —William Lineaweaver, MD Jackson References 1. Lampton L. ObamaCare’s war on small and rural. JMSMA 2016; 57:276.

2. Obama B. United States health care reform. JAMA 2016; 316: S25-532.

3. Carroll AE. A look at Republican plans for repealing and replacing Obamacare. JAMA 2017; 317:348-349.

4. Lineaweaver W. Segregation then, poverty now: Disparities forever? JMSMA 2015; 56:320-321.

5. Blavin F. Association between the 2014 Medicaid expansion and US hospital finances. JAMA 2016; 316:1475-1483.

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Physicians Should Support Universal Healthcare Dear JMSMA Editor: Several articles have come out recently regarding the efficacy of Medicaid expansion and ObamaCare. [Sommers, BD et al.

“Changes in Utilization and Health Among Low-Income Adults After Medicaid Expansion or Expanded Private Insurance.” JAMA Intern Med. 2016;176(10):1501-1509.] It is clear that this is dramatically improving the lives of patients. I do hope you can find some way to work this into the Journal and that the Journal can, as well as the State Medical Association, get on the right side of history of strongly supporting universal healthcare for United States citizens. This is the single most important issue for United States physicians and patients.

There are many ways that ObamaCare certainly needs to be improved; the emphasis should be on improvement rather than the idea that poor people do not need and/or deserve healthcare. n —David L. Smith, MD Flowood

Sandbagging Medicaid is a Futile Weapon Against the ACA and Short-Changes Mississippians Hundreds of Millions Dear JMSMA Editor: Sand-bagging Medicaid as a weapon against the Affordable Care Act is futile, in the first place, and damaging to the health care system and to the economy of the State·, as well. Medicaid was here well before the ACA and will be here after the demise of ACA. The people, all people, of Mississippi have benefitted greatly from the Medicaid legislation but have been short-changed by hundreds of millions of dollars a year by politicians who have been penny-wise and pound-foolish from the outset.

This was far and away the most important issue before the House of Delegates during the 2016 Session. The House, and the Reference Committee, got it right.* n —W. Lamar Weems, MD, MSMA Past President Jackson *Resolution 12 as adopted by the House of Delegates reads as follows: “RESOLVED, that MSMA support the expansion of medical coverage as allowable under the Affordable Care Act to cover uninsured Mississippians under the age of 65.”

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M E M B E R S

ACHARYA, PRAKRATI, Jackson; Internal Medicine

GONG, STEPHANIE, Madison; Obstetrics & Gynecology

AHUJA, SHRADHA, Jackson; Internal Medicine

GRANT-SPENCER, TELITHA, Sebastopol; Internal Medicine

AL-BAYATI, ALHAMZA, Jackson; Neurology

GRUNES, DIANNE, Jackson; Anatomic/Clinical Pathology

ALDRED, LEWIS, Brandon; Internal Medicine

GUILD, DONALD, Philadelphia; Family Medicine

ALLEN, SUMMER, Gulfport; Internal Medicine

HALL, JUSTIN, Columbus; Obstetrics & Gynecology

AMANKONAH, THOMAS, Jackson; Internal Medicine

HASLER-JONES, SARAH, Jackson; Pediatrics

BAILEY, THOMAS, Laurel; Emergency Medicine

HENEGAN, JOHN, Jackson; Hematology

BAKDASH, TARIF, Jackson; Pediatric Neurology

HIERLMEIER, BRYAN, Jackson; Anesthesiology

BAROWKA, SARAH, Tupelo; Family Medicine

HOSCH, RICHARD, Jackson; Internal Medicine

BASS, ERICA, Jackson; General Surgery

HOSSEINI-CARROLL, PEGAH, Jackson; Gastroenterology

BAYLES, JOANNA, Diamondhead; Family Medicine

HUBBARD, JAMES, Oxford; Occupational Medicine

BEASON, KEVIN, Philadelphia; Emergency Medicine

HULETT, WILLIAM, Jackson; Anesthesiology

BIGGERS, MARCUS, Olive Branch; Orthopedic Surgery

JAYARAJ, ARJUN, Jackson; Vascular Surgery

BLAKENEY, DANIELLE, Laurel; Emergency Medicine

JORNS, JACOB, Gulfport; Urology

BOYLES, JON, Philadelphia; Emergency Medicine

KALIKKOT THEKKEVEEDU, RENJITHKUMAR, Jackson; Pediatrics

BRASHIER, MATTHEW, Pascagoula; General Surgery BREWER, SARA, Jackson; Pediatrics BURNHAM, JORDAN, Brandon; Ophthalmology BYDALEK, MARTIN, Pascagoula; Emergency Medicine BYRD, ADAM, Jackson; Dermatology CABEZA RIVERA, FRANCO, Jackson; Nephrology CADDELL, KIRK, Amory; General Surgery CAMP-ROGERS, TERESA, Laurel; Emergency Medicine CARROLL, JONATHAN, Jackson; General Surgery CHAPMAN, CLYDE, Lexington; Pediatrics CHEEMA, YASER, Southaven; Interventional Cardiology COMPTON, ASTRID, Hattiesburg; Pediatrics COMPTON, NATHAN, Hattiesburg; General Surgery DABBS, WILLIS, Oxford; Family Medicine EDWARDS, CEDRIC, Jackson; Internal Medicine EL-ASHRY, AWAD, Meridian; Vascular Surgery ELKINS, CAMILLE, Ocean Springs; Clinical Pathology FOWLER, AMANDA, Jackson; Rheumatology GANGADHARA, SHREYAS, Jackson; Neurology GARCIA-ROVES, DIEGO, Laurel; Anesthesiology GARG, PARVESH, Jackson; Neonatology GARG, PADMA, Jackson; Pediatric Critical Care GARLA, VISHNU, Jackson; Endocrinology GLOVER, CHRISTINA, Jackson; Endocrinology 22 VOL. 58 • NO. 1 • 2017

KING, WILLIAM, Oxford; Radiology KISHORE, SHWETA, Jackson; Rheumatology KLAR, ANGELLE, Jackson; Neonatal Perinatal Medicine KRENTEL, ROD, Gulfport; Radiology KUTCHER, MATTHEW, Jackson; Trauma Surgery LARES ROMERO, CLAUDI, Jackson; Pediatric Emergency Medicine LAVENDER, JESSICA, Jackson; Internal Medicine LEBLOND, LAWRENCE, Memphis; Emergency Medicine LEMAY, THOMAS, Natchez; Cardiovascular Disease LOWRY, MARY, Flowood; Pediatric Gastroenterology LUCAR LLOVERAS, JOSE, Jackson; Infectious Disease MACIAS, DAVID, Columbus; Emergency Medicine MADDUX, ROBERT, Whitfield; Child & Adolescent Psychiatry MALLETTE, ANDREW, Jackson; General Surgery MANDALAPU, KAMAL, Biloxi; Hematology/Oncology MANEJWALA, FAZAL, Southaven; Obstetrics & Gynecology MARKS, CHRISTINA, Brandon; Radiology MASON, CHAWLA, Jackson; Anesthesiology MATHIS, TAYLOR, Tupelo; Orthopedic Surgery MCINTYRE, BENJAMIN, Jackson; Diagnostic Radiology MCKEY, SUSAN, Jackson; Reconstructive Surgery MCLEOD, MARY, Jackson; Pediatrics

MEDAURA, JUAN, Jackson; Pediatrics

ROGERS, JEREMY, Laurel; Emergency Medicine

MITCHELL-SILVER, KIM, Picayune; Family Medicine

ROSE, REBECCA, Biloxi; Family Medicine

MITEMA, DONALD, Jackson; Nephrology

ROSENBLATT, CLAIRE, Jackson; Allergy Immunology

MITRA, SRIPARNA, Jackson; Pediatrics

SAAD, ALI, Jackson; Anatomic Pathology

MIZE, ELIZABETH, Oxford; Public Health

SCOTEGAGNA, EDUARDO, Jackson; Radiology

MONAGHAN, D. KIRK, Tupelo; Anesthesiology

SHAH, NIRAJ, Jackson; General Practice

MOORE, SHENITTA, Greenwood; Psychiatry

SHARMA, RAJESH, Jackson; Neurology

MOREMEN, JACOB, Jackson; Cardiothoracic Surgery

SHIAO, RENEE, Ocean Springs; Gastroenterology

MOSS, JAMES, Jackson; Orthopedic Surgery

SHORES, JOEL, Laurel; Internal Medicine

MOUTON, CYNTHIA, Lucedale; Family Medicine

SILVER, SARA, Jackson; Pediatrics

MUKHERJEE, SOURABH, Tupelo; Vascular Surgery

SIMEUNOVIC, KOSANA, Hattiesburg; Internal Medicine

MUKHI, NIKHIK, Laurel; Hematology/Oncology

SISODRAKER, TRISHNA, Ocean Springs; Pediatrics

MURRAY, MATTHEW, Pascagoula; Family Medicine

STACY, JASON, Tupelo; Neurosurgery

MYLES, BENITA, Sebastopol; Family Medicine

STEUER, MICHAEL, Southaven; Pain Management

NANDI, UTSAV, Jackson; Emergency Medicine

SUGGS, MARGIE, Jackson; Radiation Oncology

NATION, KELLY, Ocean Springs; Pediatrics

SYKES, LEON, Jackson; Trauma Surgery

NICKERSON, ASHLEY, Corinth; Internal Medicine

TAVAI, GREG, Hattiesburg; Emergency Medicine

NOOR, RAHAT, Jackson; Internal Medicine

TAYLOR, MONTOYA, Jackson; Cardiovascular Disease

NUTT, JOEL, Jackson; Anesthesiology

TAYLOR, FUNMINIYI, Jackson; Maternal & Fetal Medicine

OBEROI, GULSHAN, Laurel; Neurology

THERIOT, CHRISITIE, Tupelo; Family Medicine

PACE, REBECCA, Jackson; Endocrinology

THOMAS, KATHRYN, Grenada; Pediatrics

PANDIT, AMIT ANIL, Jackson; Critical Care Medicine

THOPPIL, DEEPU, Hattiesburg; Internal Medicine

PANOS, ANTHONY, Jackson; Internal Medicine

TOPALOGLU, ALI, Jackson; Pediatric Endocrinology

PARDEN, JUSTIN, Tupelo; Cardiovascular Disease

TORRENCE, CHASITY, Whitfield; Psychiatry

PARKS, LAURA, Jackson; Internal Medicine/Pediatrics

TORRES, FRANK, Jackson; Anatomic Pathology

PATEL, MINAL, Jackson; Thoracic Surgery

UBAIDULHAQ, MUHAMMAD, Jackson; Child Neurology

PATNANA, SRIKRISHNA, Pascagoula; Gastroenterology

URIBE, JUAN, Madison; Neurosurgery

PERKINS, JESSICA, Jackson; Pediatrics

VAITLA, PRADEEP, Jackson; Internal Medicine

PERKINS, RYAN, Jackson; Pediatrics

VANLANDINGHAM, MATTHEW, Flowood; Neurosurgery

POWELL, STELLA, Jackson; Internal Medicine

VILLACORTA, JENNIFER, Jackson; Physical Medicine & Rehabilitation

PRESLEY, MARC, Jackson; Radiology RAGLAND, TIMOTHY, Jackson; Diagnostic Radiology RAGLAND, KATHERINE, Jackson; Radiology REDMOND, PAUL, Jackson; Pediatrics REYNOLDS, CHARLES, Brookhaven; General Surgery RHINEWALT, J. MATTHEW, New Albany; Pediatrics RICHEY, STEVEN, Southaven; Pain Management RIZVI, TANVIR, Jackson; Diagnostic Radiology ROBERTSON, HESS, Jackson; Anesthesiology

WALKER, LEE, Tupelo; Ophthalmology WALTERS HAYGOOD, CHRISTEN, Jackson; Obstetrics & Gynecology WELLS, RICHARD, Jackson; Internal Medicine WILKINSON, KELLY, Jackson; Internal Medicine WILLIAMS, JONATHAN, Starkville; Orthopedic Surgery YERGAW, DANIEL, McComb; Internal Medicine YORK, JAMES, Jackson; Diagnostic Radiology n

ROBERTSON, SARA, Jackson; Anesthesiology

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Hattiesburg: Friday, May 5 | Raymond: Wednesday, May 10 | Oxford: Friday, May 12 Working effectively with payers is the key to a profitable medical practice, but you have to know how.

Make plans now for you or your billing staff to attend iPass 2017 in your area, and get the inside track on maximizing your payments. To register, go to www.MSMAonline.com/iPASS

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EWTON SANITARIUM, 1908--- This image, from 1908, shows 4 nurses standing in front of

Newton Sanitarium in Newton, Mississippi. Located in Newton County, the city was established in the mid-1850s as the Vicksburg to Jackson railroad pushed east towards Meridian. The city and the downtown hospital site have a long medical history. In 1863, Willis R. Norman received a Confederate government contract to build the hospital, which opened under the supervision of a Dr. Bozeman and Dr. Blount. Of more than 1000 Confederate soldiers treated here it was said only about 100 died (and those were buried on the nearby Doolittle family burying ground). It was apparently one of the many “wayside” Confederate hospitals located along major Southern rail lines. That hospital closed by war’s end, but more than 4 decades later the next hospital opened on the site, seen in the image above. Newton Sanitarium, which would later become Newton Hospital, and then Rush Hospital-Newton, was built and opened in 1908 by Dr. J. T. B. Berry, who came to Newton from Brandon. Around 1912, Dr. W. Greg Gill bought the hospital from Dr. Berry and a few years later started the nursing school, which was called the Newton Sanitarium Training School. Drs. M. L. Flynt, Sr., and Hilliard McMullan bought the hospital from Gill around 1927 and added a wing, bringing the number of patient beds to 25. Later owners included: Drs. Dudley Stennis, Omar Simmons, M. L. Flynt, and Mayo Flynt. A new 40 bed hospital, built with Hill-Burton funds and which “piped oxygen to every room,” was opened October 1, 1954. Rush Corporation, based in Meridian, acquired the Newton Hospital in 1982. In 2005, the hospital moved from downtown into a $6.5 million new building on Hwy. 15 and was renamed Newton Regional Hospital. In Sept. 2010, it was acquired by Magee-based Pioneer Health Services and renamed Pioneer Community Hospital of Newton. Sadly, due to CMS’s reinterpretation of its Critical Access Hospital status, the hospital was forced to close on Dec. 1, 2015. If you have an old or even somewhat recent photograph which would be of interest to Mississippi physicians, please send it to me at lukelampton@cableone.net or by snail mail to the Journal. n

— Lucius M. “Luke” Lampton, MD; JMSMA Editor

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Committee Seeks Candidates for Vacancies in MSMA Offices Delegates attending the 149th MSMA Annual Session August 10 - 12, 2017 in Jackson will cast ballots to fill new terms of office for a number of association posts. The Nominating Committee is seeking input from the membership as the committee prepares a slate of candidates. The slate developed by the Nominating Committee will be published to the entire membership in June. All nominees must be active members of the association. No physician may be put forth on the ballot unless that physician has expressed a willingness to serve. The chart below lists the vacancies that will be filled by election in 2017. The names of incumbents and the incumbent’s eligibility to be re-elected are indicated. Terms of Office: President-elect: 1 year 2017-2018; Officers, Trustees & Councils (physicians): 3 years 2017-2020; Trustees & Councils (students & residents): 1 year 2017-2018.

Journal Editor: 3 years 2017-2020; Journal Associate Editor: 2 years 2017-2019. Incumbents NOT eligible for re-election are noted in gray type.

AT LARGE POSITIONS President-elect at large Speaker of the House Vice-Speaker of the House Journal Editor Journal Associate Editor Board of Trustees, YPS AT LARGE COUNCILS Accreditation at large Accreditation at large Budget & Finance at large Constitution & Bylaws Ethical & Judicial Affairs MSMA_2x3_DivisionsBoard_pr.pdf

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

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

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

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

26 VOL. 58 • NO. 1 • 2017

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M E D I C I N E

Our Little Blind Boy [This month, we print a poem by Dr. Dwalia S. South, Chair of the Committee of Publications, which oversees the Journal.

She’s a family physician in Ripley and a gifted writer known and loved by our readers. Asked about the inspiration of the poem, her dog Mickey, she commented, “Over a year ago Roger [her husband] and I went on a trip and boarded our dog Mickey at the groomer’s. When we retrieved him, he was a certified basket case, acted like he’d had a stroke, could barely stand to walk, got lost in the house repeatedly, became incontinent of B and B, moaned...etc. He was so pitiful for 3-4 days that I actually made an appointment at the vet to have him put down. I chickened out the last minute and didn’t do it. He finally started to improve to his baseline status, and life went on. I suppose he was delirious, but not demented! (May have had a UTI or simply in shock from all the noise there.) I thought about all this recently when after sitting at the kitchen table one morning for too long drinking coffee. I could barely straighten up to walk with my sciatica to go fetch my $2.00 reading glasses so that I could then focus on the morning paper. I grunted loudly with the effort. It made me mad to feel so dogged old! Then when I got up again later to take him outside, I yelped again, Mickey was placidly sleeping in his doggie bed... he got up and stumbled but followed my ‘muching-up’ and clicking as we both limped to the back porch! He didn’t grunt! I thought, ‘if I could only be so content with my lot in life and ailments that time hath inflicted upon me!’ I suppose it helps that dogs have no concept of time or of their ultimate downhill slide and demise as do we. They take one day, no one moment, at a time. As Roger says, ‘Dogs don’t think, they simply react to stimuli.’ At any rate, this was the nidus of the poem. I hope the readers can either enjoy it or at least appreciate the sadness of it. My dear friend Tommy Covington posted the rough version on his facebook page with a photo of Mickey with his cataracts shining....he is now the most famous senile dog in Tippah County.” Any physician is invited to submit poems for publication in the journal, attention: Dr. Lampton or email me at lukelampton@cableone.net.]—Ed.

“Come on Little Boy, you can make it…” cautiously descending the makeshift handicap accessible steps toenails clicking on the concrete porch winded and wheezing from the effort of going out to do his morning business missing the steps and tumbling as often as not is our Mickey Boy, our bench-legged Yorkie… his twelve dog years become 85 in human time… why then do we still see him as our child, our Little Blind Boy? talk baby talk to him? because he never grew big? because we would keep our children small if we could somehow? about right, 85 making that downhill slide in almost every way… although our Blind Boy never whines as do we in our decrepitude broken-down, feeble arthritic and unbalanced near blind as a bat from cataracts he follows his master’s voice and the light he is given… his business done, back up the steps his little pot-belly swaying painfully and slowly ambulating requiring much encouragement in his ascent and looking for all the world like a furry turtle with no shell

28 VOL. 58 • NO. 1 • 2017

he nudges the curious cats aside “Come on Little Boy, you can do it!” he knows the way back to the kitchen but bumps a few misplaced chair legs with a bit more spring in his waddle knowing that breakfast comes next… another morning ritual traversed he then peacefully and without complaint sleeps the whole day through… at the close of day at our return home we are greeted by the excited yapping of our Little Blind Boy sounding alert and young once more thrilled as if he thought never to see us again…

Teach us, our Little Blind Boy, how to traverse our own disintegration our days of earthly waning and decay… of missing steps and stumbling with hobbling gait and clouded eyes teach us to make it through our days by following our Master’s voice and the light He has given us.

—Dwalia South, MD Ripley

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