VOL. LX • NO. 1 • 2019 by Journal MSMA

VOLUME LX • NO. 1 • 2019

Regularly priced at $80, the book is on sale now! Imag sin Mi issippi Medicin . horographi Hi mry f · edidne i

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Order three or more to receive a discount at: http://tinyurl.com/yb7ab974 “Images In Mississippi Medicine by Dr. Luke Lampton and Karen Evers is a handsome and impressive book, filled with stories and scenes ranging from primitive operating rooms and rows of hospitalized tornado victims a century ago to the new teaching complex at the University of Mississippi Medical Center with its modern breakthroughs. The volume is a piece of our history that every Mississippian can appreciate.” – Curtis Wilkie, journalist, author, and professor at Ole Miss

Images in Mississippi Medicine: A Photographic History of Medicine in Mississippi; MSMA; Jackson, MS: 2018.

OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION VOL. LX • NO. 1 • JANUARY 2019

SCIENCE OF MEDICINE

EDITOR Lucius M. Lampton, MD

THE ASSOCIATION President Michael Mansour, MD

ASSOCIATE EDITORS D. Stanley Hartness, MD Philip T. Merideth, MD, JD

President-Elect J. Clay Hays, Jr., MD

MANAGING EDITOR Karen A. Evers

Secretary-Treasurer W. Mark Horne, MD

PUBLICATIONS COMMITTEE Dwalia S. South, MD Chair Richard D. deShazo, MD Sheila Bouldin, MD Wesley Youngblood, M3 and the Editors

Speaker Geri Lee Weiland, MD Vice Speaker Jeffrey A. Morris, MD Acting Executive Director Scott Hambleton, MD

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.

Foot Drop Associated with A Pulsatile Leg Mass William C. Lineaweaver, MD, FACS; Rachel Ratliff, FNP-C; Craig Adams, MD

Provider Perceived Barriers to HPV Vaccination in Mississippi Mildred Ridgway, MD; Sukhpreet S. Multani, MD; Kedra Wallace, PhD; Bethany Sabins, NP

The Top 10 Facts You Need to Know about Antibiotic Stewardship Desiree B. Pendergrass, MD, MPH; Peter W. Pendergrass, MD, MPH; Paul Byers, MD; Thomas Dobbs, MD, MPH

Cerebral Venous Thrombosis and Escitalopram: A Case Report and Review of Literature Lakeshia C. Gibson, M3; Disha Kohli, MD; Christa O’Hana S. Nobleza, MD

DEPARTMENTS From the Editor – Relish the Joy of Healing Lucius M. Lampton, MD

President’s Page – Professionalism and Advocacy - The Physician Citizen Michael Mansour, MD

Editorial – A New Person to Push the Boulder Philip Merideth, MD, JD; Associate Editor

New Members

In Memoriam

Images in Mississippi Medicine – Mississippi Baptist Hospital Lucius M. Lampton, MD

Poetry and Medicine – Yockanookany Stanley Hartness, MD, JMSMA Associate Editor

Una Voce – Good Riddance Day Dwalia South, MD

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POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 39158-2548. 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 © 2019 Mississippi State Medical Association.

ABOUT THE COVER “The Horse with No Leg” – Dr. Stanley Hartness has always been fascinated with the exquisite Italian fountain at the Renaissance in Ridgeland, Mississippi. Handcrafted of quarried marble in the likeness of another fountain in Rome, the 16-foot-tall structure features 40 jets that spray 1,400 gallons of water per minute into the lower bowl. His cover photo happens to focus on one of the magnificent sea horses inexplicably vandalized in 2015. When officers arrived, they found the culprit with a hammer in his hand and the legs of several horses scattered around him. Stay tuned for our February issue which may shed light on his actions. VOLUME LX • NO. 1 • 2019

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Relish the Joy of Healing T

he Methodist minister of my smalltown church cannot restrain his bliss for his job. As he conducts our church service, his words dance with enthusiasm. As he officiates prayer, offering, communion, and scripture, he does so with unbridled passion. Tears or a broken voice stream in the midst of his sermons. Preferring the old Methodist Cokesbury Hymnal rather than the modern one, he revels in every word of Lucius M. Lampton, MD those classics of long ago. He asks his Editor congregation to sing all of the verses, and his own fully-engaged voice, occasionally off-key, can be heard fortissimo throughout the hymns. No PA system is needed to amplify his voice: his exuberance is more than enough! My minister’s infectious zeal for his ministry is not only one of the reasons I am so fond of him but also why he is so effective at what he does. He truly loves what he does. His love of his ministry triumphs over any hiccups or problems which present themselves. His example provides helpful insight for we asclepiads.

The first step towards success as a physician is to relish the joy of healing. Too often we focus on the woes of our daily practice rather than its delights. We gripe about rip-off insurance companies, ridiculous paperwork, time-consuming EHRs, staff who haven’t done their jobs, or late-in-the-day work-ins who keep us working after hours. Rather, physicians need to recognize and savor the unique joys of our profession. What a wondrous thing it is to be a physician! Every time a physician opens a door and walks into a patient’s room, we open a door pregnant with opportunity for fire and fondness for our chosen work. Realize the glee of solving difficult problems very few can and of using our years of study and experience to change lives for the better. Celebrate the diverse personalities of our patients and staff and the privilege of being able to share in their happiness and sorrows. What a blessing to use one’s mind, hands, and skills in an ancient art of service and beneficence while working with others committed to those same goals. Q Contact me at LukeLampton@cableone.net. — Lucius M. Lampton, MD, Editor

JOURNAL EDITORIAL ADVISORY BOARD ADDICTION MEDICINE Scott L. Hambleton, MD

EMERGENCY MEDICINE Philip Levin, MD

MEDICAL STUDENT John F. G. Bobo, M3

ALLERGY/IMMUNOLOGY Stephen B. LeBlanc, MD Patricia H. Stewart, MD

FAMILY MEDICINE Tim J. Alford, MD Diane K. Beebe, MD Jennifer J. Bryan, MD J. Edward Hill, MD Ben Earl Kitchens, MD

NEPHROLOGY Harvey A. Gersh, MD Sohail Abdul Salim, MD

ANESTHESIOLOGY Douglas R. Bacon, MD John W. Bethea, Jr., MD CARDIOVASCULAR DISEASE Thad F. Waites, MD CHILD & ADOLESCENT PSYCHIATRY John Elgin Wilkaitis, MD

GENERAL SURGERY Andrew C. Mallette, MD HEMATOLOGY Carter Milner, MD INFECTIOUS DISEASE Rathel "Skip" Nolen, III, MD

CLINICAL NEUROPHYSIOLOGY Alan R. Moore, MD DERMATOLOGY Robert T. Brodell, MD Adam C. Byrd, MD

INTERNAL MEDICINE Daniel P. Edney, MD Daniel W. Jones, MD Brett C. Lampton, MD Kelly J. Wilkinson, MD INTERNAL MEDICINE/EPIDEMIOLOGY Thomas E. Dobbs, MD

2 VOL. 60 • NO. 1 • 2019

OBSTETRICS & GYNECOLOGY Sidney W. Bondurant, MD Sheila Bouldin, MD Darden H. North, MD ORTHOPEDIC SURGERY Chris E. Wiggins, MD OTOLARYNGOLOGY Bradford J. Dye, III, MD PEDIATRIC OTOLARYNGOLOGY Jeffrey D. Carron, MD PEDIATRICS Michael Artigues, MD Owen B. Evans, MD

PLASTIC SURGERY William C. Lineaweaver, MD Chair, Journal Editorial Advisory Board PSYCHIATRY Beverly J. Bryant, MD June A. Powell, MD PUBLIC HEALTH Mary Margaret Currier, MD, MPH PULMONARY DISEASE Sharon P. Douglas, MD John R. Spurzem, MD RADIOLOGY P. H. (Hal) Moore, Jr., MD RESIDENT / FELLOW Cesar Cardenas, MD UROLOGY W. Lamar Weems, MD

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Foot Drop Associated with a Pulsatile Leg Mass WILLIAM C. LINEAWEAVER, MD; RACHEL RATLIFF, FNP-C; CRAIG ADAMS, MD

Case Presentation An otherwise healthy 12-year-old girl presented to our clinic with right foot drop. Two months earlier, she tripped over an open dishwasher door and sustained a puncture wound to her anterolateral right leg from a steak knife. Subsequently, she lost ability to dorsiflex her right foot and her right great toe, although she continued to be able to dorsiflex her right second, third, fourth, and fifth toes. She also developed progressive swelling and induration at the site of the stab wound. Motor and sensory examination confirmed loss of ankle and great toe dorsiflexion of the right foot. She had decreased sensation to light touch at her right dorsal second web space. Palpation of the swelling at the site of the puncture wound detected a strong pulse. Pedal pulses were palpably intact, and no other motor or sensory deficits were noted. Computed tomographic angiography (CTA) revealed a pseudoaneurysm of the anterior tibial artery in the area of the puncture wound. (Figure) What Would You Do Next? A. Obtain nerve conduction and electromyographic (NCS/EMG) studies. B. Aspirate the mass. C. Proceed to surgical exploration. D. Proceed to angiographic embolization of the anterior tibial artery. Diagnosis Compression neuropathy of the right deep peroneal nerve secondary to anterior tibial artery pseudoaneurysm. What to Do Next: C. Proceed to surgical exploration The patient had suffered a puncture of the anterior tibial artery as a component of her stab wound. The progressive blood loss at this site created an expanding pseudoaneurysm, i.e., an extension of the arterial lumen contained by a fibrin wall.1 The pseudoaneurysm compressed the deep peroneal nerve, resulting in foot drop and loss of dorsiflexion of the great toe. Persistent dorsiflexion of the lateral four toes was consistent with innervation of the extensor digitorum longus from the common peroneal nerve proximal to the zone of compression.2 4 VOL. 60 â&#x20AC;˘ NO. 1 â&#x20AC;˘ 2019

Figure. Pseudoaneurysm of the anterior tibial artery in the region of the puncture wound on computed tomographic angiography.

Discussion

Traumatic pseudoaneurysms can result from penetrating or blunt injuries.1,3 When the mass of a pseudoaneurysm is contained within an anatomic space that includes a nerve, compression neuropathy can develop as a secondary process.4

Wang TN, Lineaweaver WC, Scott T, Feldman R. Internal pudendal pseudoaneurysm complicating an ischial pressure sore. Ann Plast Surg. 1987;19(4):381-383.

Megalopoulos A, Vasiliadis K, Siminas S, et al. Pseudoaneurysm of the popliteal artery complicated by peroneal mononeuropathy in a 4-year-old child: report of a case. Surg Today. 2007;37(9):798-801.

Colen DL, Yeh JT, Colen LB. Anatomical basis and clinical application of synovial flaps in the wrist and distal forearm. Plast Reconstr Surg. 2017;139 (5):1165-1174.

Following a diagnosis of pseudoaneurysm with secondary nerve compression, surgical exploration and repair are indicated. NCS/EMG studies in this case would not add information not already available from physical examination.5 Aspiration of the pulsatile mass would be at the minimum useless and could lead to “explosive bleeding.”1 Embolization can be considered for pseudoaneurysms involving vessels whose occlusions do not risk significant distal ischemia.3,6,7 In this case, however, such a procedure could not predictably relieve the mass effect of the pseudoaneurysm and its compression of the deep peroneal nerve. Patient Outcome In surgery, the anterior tibial artery was isolated above and below the pseudoaneurysm. The damaged portion of the artery and the fibrin capsule were resected. The artery was repaired with a reversed saphenous vein graft.8 The nerve was explored and found to be grossly intact. All investing scar and fibrin residue were excised as a neurolysis, and the epineurium was reconstructed with a wrap of dehydrated human amnionic-chorionic membrane.9,10 At a final clinic visit 6 months following surgery, the patient demonstrated full active dorsiflexion of the foot. She could extend the great toe to neutral and had paraesthetic sensation to touch at the foot web space. Q

10. Reilly DA, Hickey S, Glat P, Lineaweaver WC, Goverman J. Clinical Experience: Using dehydrated human amnion/chorion membrane allografts for acute and reconstructive burn care. Ann Plast Surg. 2017;78(2 Suppl 1):S19-S26.

Author Information Medical Director of the branch of the JMS Burn and Reconstruction Center based at Merit Health Central Hospital, Jackson, MS; Chief Research Officer, Joseph M. Still Research Foundation, Augusta, GA; Editor-in-Chief of the Annals of Plastic Surgery (Lineaweaver). Nurse practitioner, JMS Burn and Reconstruction Center based at Merit Health Central Hospital in Jackson, MS (Ratliff). Director of Cardiothoracic and Vascular Surgery, Southwest Mississippi Regional Medical Center, McComb, MS (Adams). Corresponding Author: William C. Lineaweaver, MD, Medical Director, JMS Burn and Reconstruction Center at Merit Health Central, 1850 Chadwick Drive, Suite 1427, Jackson, MS, 39204. Ph: (601)824.3977 (william.lineaweaver@burncenters.com).

Helping you build a more secure future.

References 1.

Zitsman JL. Pseudoaneurysm after penetrating trauma in children and adolescents. J Pediatr Surg. 1998; 33(10):1574-1577.

Hollinshead WH. Anatomy for Surgeons: The Back and Limbs. Vol 3. 3rd ed. Philadelphia, PA: Harper & Row, Publishers, Inc.; 1982.

We invest our own money alongside yours, so we are invested in your success.

Khera G, Shea AJ, Parkinson R, Lambrianides AL. Delayed diagnosis of a gluteal pseudoaneurysm caused by blunt trauma: review of the literature and presentation of a case report. J Trauma. 2006; 60(3):644-647.

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Ersozlu S, Ozulku M, Yildirim E, Tandogan, R. Common peroneal nerve palsy from an untreated popliteal pseudoaneurysm after penetrating injury. J Vasc Surg. 2007; 45(2):408-410.

Callaghan BC, Burke JF, Feldman EL. Electrodiagnostic tests in polyneuropathy and radiculopathy. JAMA. 2016;315 (3):297-298.

Ge PS, Ng G, Ishaque BM, Gelabert H, de Virgilio C. Iatrogenic pseudoaneurysm of the superior gluteal artery presenting as pelvic mass with foot drop and sciatica: case report and review of literature. Vasc Endovascular Surg. 2010;44:64-68.

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Provider Perceived Barriers to HPV Vaccination in Mississippi MILDRED RIDGWAY, MD; SUKHPREET S. MULTANI, MD; KEDRA WALLACE, PHD; BETHANY SABINS, NP

Abstract Cervical cancer is the most common cancer in women and remains the cancer with the fifth highest mortality rate, worldwide. A 24-item questionnaire administered to primary care physicians in Mississippi was designed to consist of three primary components: practice identifiers, practitioner knowledge base concerning the human papilloma virus (HPV) vaccine, and practitioner observed obstacles to administering the vaccination. Practice identifiers consisted of demographic questions regarding participant educational background, medical specialty, length of time practicing, and patient population. Barriers to vaccination were noted to be associated with patient compliance and provider perceived barriers in education of patients. Future increases in human papilloma virus vaccination can be achieved by addressing these particular issues. Key Words: Cervical cancer, human papilloma virus, immunization, cervical dysplasia, genital warts Introduction Cervical cancer is the most common human papillomavirus (HPV)associated cancer in women and remains the cancer with the fifth highest mortality rate worldwide.1 HPV is also believed to be responsible for more than 90% of anal cancers, 60% of penile cancers and 70% of vaginal and vulvar cancers. In short, HPV infection annually causes more than 26,000 new cases of cancer in the United States and 600,000 cases in worldwide.1,2 In 2006, Merck first introduced the Gardasil vaccine for immunization of females between ages 9-26 against the high-risk HPV subtypes. This was later followed by Gardasil 9, a vaccine that protected against an additional 4 strains of HPV.3 Several studies over the years have examined the efficacy of the HPV vaccine and have demonstrated that with early vaccination clinical efficacy is present up to age 45.4,5 Recent studies have noted that HPV vaccination rates nationwide are not meeting the expected benchmark. The most recent data reports that Mississippi ranks fiftieth in HPV vaccination completion among females ages 13-17, despite the high incidence of cervical cancer in Mississippi, and 48th or higher when both sexes are compared.6,7 More alarming is that the rate of HPV vaccinations in Mississippi

6 VOL. 60 â&#x20AC;˘ NO. 1 â&#x20AC;˘ 2019

has been declining based on the most recent information from the Mississippi Department of Health and Human Services.7 Several reasons have been stated for the low number of HPV vaccinations, not just in Mississippi but across the country, ranging from unclear recommendations for the administration of HPV vaccinations to parental barriers.8,9 As Mississippi has a high incidence of HPV-associated cancers such as cervical cancer and low completion of HPV vaccination, we examined some of the obstacles that may be associated with utilizing the HPV vaccination among practitioners in Mississippi. Methods Study Setting and Population A survey was administered to practitioners of obstetrics/gynecology (ob/gyn), family medicine, internal medicine, and pediatrics in Mississippi. The Human Subjects Review Board at the University of Mississippi Medical Center approved the study, and written informed consent was not required. An invitation to participate in the survey was emailed to practitioners listed in the Mississippi Physicians Directory. Survey Design and Administration A 24-item questionnaire was designed to consist of three primary components: practice identifiers, practitioner knowledge base concerning the HPV vaccine, and practitioner-observed obstacles to administering the vaccination. Practice identifiers consisted of demographic questions regarding participant educational background, medical specialty, length of time practicing, and patient population. Participants were also asked about their knowledge base regarding any formal training about the HPV vaccine and what they currently know about it. Questions about participant practices regarding HPV counseling ranged from in depth counseling patients about HPV vaccination, patient understanding and compliance with vaccination recommendations, and office practice surrounding HPV vaccination. Participants were also asked to select what they believed to be the greatest obstacles to patients receiving the vaccination. The Internet survey was administered using Survey Monkey. The group received an initial email with one reminder to complete the survey. The study was conducted over 2 months.

Results Ύ

- ·- --

Of the 650 surveys we emailed, Ύ we received 113 (17%) responses Ύ Ύ Ύ Ύ with representation from 47 Ύ Ύ Ύ Ύ (57%) of the counties of Ύ Ύ Ύ Mississippi (Figure). The Ύ Ύ ..... Ύ Ύ Ύ Ύ majority of the respondents Ύ Ύ were MD/DOs (96%) with Ύ the remainder of the population Ύ Ύ Ύ Ύ Ύ Ύ responding as NP/MSN/RN. Ύ Ύ Ύ Ύ Ύ The characteristics or practice Ύ identifiers of the survey Ύ Ύ ...,Ύ Ύ Ύ Ύ respondents are presented ..... Ύ in Table 1. There were Ύ Ύ Ύ Ύ no clear trends among Ύ specialty groups in the number of years practiced or in the practice type. Ύ Very few providers saw patients who were “self- Figure. The * represents counties pay” and neither ob/gyn where respondents indicated they nor pediatric providers saw physically administer HPV vaccines. patients who were “no pay.” Family medicine and ob/gyn providers saw mostly self-identified Caucasian and African-American patients whereas pediatric and providers in the Other category saw mostly self-identified AfricanAmerican patients.

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in Table 2, most respondents were knowledgeable about HPV vaccination. The greatest disparity in knowledge concerned the benefit of vaccination in vulvar and vaginal dysplasia as well as genital warts. Barriers surrounding HPV Vaccination Responses regarding barriers to administering the HPV vaccine are presented in Figure 2. The most frequently reported barriers were patient compliance (65%), patient understanding (52%), followed by parental refusal (47%), and the cost of medication (30%). There were no overall differences in the perceived barriers between the different subspecialties. Figure 2. Perceived barriers to HPV vaccination by subspecialty

....

Knowledge Regarding HPV Vaccination The majority of the providers had received HPV formal training or education (in the form of lectures, CME credit, presentations, or education through a journal article). There were 2 ob/gyns, 4 pediatricians and 3 internal medicine providers that had not received any HPV formal training or education before the survey. As shown

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When barriers surrounding HPV vaccination were examined, we found that more than 80% of practitioners felt comfortable counseling their patients. When we examined the 16 practitioners who did not feel comfortable (answered neutral, disagree or strongly disagree), we found that 63% of them had received education on the HPV vaccine and 75% (n=12) of the 16 respondents worked in a university setting. Conclusion

Table 1. Practice identiﬁers of survey participants by specialty (%). Other is Patient and physician-oriented outreach programs composed of internal medicine and public health providers. regarding the HPV vaccination have been implemented Characteristic Response Family Other Ob/Gyn Pediatrics on local and national levels. However, individual state Medicine (n=12) (n=44) (n=38) based disparities can only be addressed by recognizing (n=19) systems issues for the particular region of interest. Our <5 15.7 66.8 29.5 26.3 6 -10 21 16.6 15.9 2.6 survey identifies patient and physician compliance as Years in Practice 11 -20 26.3 0 13.6 44.8 common themes in missed vaccination opportunities. > 20 37 16.6 41 26.3 These issues can be more easily addressed with the integration of electronic medical records into our Solo 26.3 0 7 5.2 Group 31.5 16.6 45.4 42.1 health care system as well as electronic outreach to our Practice Type Academic 42.2 75.1 38.6 50.1 patients. Other

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0 52.7 36.8 10.5

8.3 16.6 16.6 58.5

0 55.9 44.1 0

0 92.2 7.8 0

Caucasian African-American equal proportion

42.1 57.9 0

16.6 83.4 0

45.4 54.6 0

15.8 78.9 5.3

What ethnicity comprises a majority of your patient population?

The results of our survey, while not inclusive of all of the providers within Mississippi, do suggest that more education is needed on the benefits of the HPV vaccine to improve both patient compliance and parental approval. Recently, Louisiana, which also struggles with many of the same health and socioeconomic problems as Mississippi, has published its success JANUARY • JOURNAL MSMA

Table 2. Respondent knowledge regarding HPV vaccination (n=113) True/False/I Don’t Know Statements (correct responses are indicated in parentheses) The HPV Vaccine is only reserved for patients that have never had sex (False) Patients are required to have a pap smear before administering the HPV vaccine (False) The HPV Vaccine does not protect against vulvar or vaginal cancers caused by HPV (False) Gardasil is given as 3 injections over 3 months, the 2nd dose comes 2 months after the 1st dose, and the 3rd dose comes 6 months after the 1st dose (True) Patients do not need any pap smears in the future once they have received the HPV vaccine (False) The HPV Vaccine protects against genital warts and cervical cancer (True)

in increasing HPV vaccination rates.10 Through coupling the HPV vaccine with other adolescent vaccines, advertising the benefits of the vaccine’s protection against cancer and genital warts, and implementing a reminder system to schedule future shots, Louisiana has been able to improve the vaccination rates within its higher performing clinics. While the cost of the vaccine can be a concern, it did not appear to be a significant factor in the current study. Perhaps, this is because HPV vaccination is covered under Medicare, a public children’s vaccine program, and by most commercial insurance plans. As the cancers associated with HPV along with HPV itself are higher in Mississippi when compared with other states, administration of the HPV vaccine can have a positive impact on patient morbidity in Mississippi. To reduce this morbidity and the resultant burden on patients and the healthcare system, Mississippi’s healthcare providers should work together to reduce the barriers to patient access to the HPV vaccine. Better effort should be made not only to educate patients, parents, and guardians about the health benefits of the HPV vaccine, but the healthcare providers themselves must make this mission a priority. Q

Family Medicine 95 100 84 89

Correct Response % Internal Ob/Gyn Pediatrics Medicine 94 100 100 81 100 97 100 84 76 81 93 88

100

3, double-blind, randomized controlled VIVIANE study. Lancet. 2014 Dec 20;384(9961):2213-27. doi: 10.1016/S1473-3099(16)30120-7. 6.

Rimer B, Harper H, Witte O. Accelerating HPV vaccine uptake: Urgency for action to prevent cancer; A report to the President of the United States from the President's Cancer Panel. Bethesda, MD: National Cancer Institute; 2014.

Mississippi State Department of Health. Immunization for Human Papillomavirus in Mississippi - Room for Improvement. Mississippi Morbidity Report. 2015; 31(6):1-2.

Raley J, Followwill K, Zimet G, Ault K. Gynecologists' attitudes regarding human papilloma virus vaccination: A survey of Fellows of the American College of Obstetricians and Gynecologists. Infect Dis Obstet Gynecol. 2004;12(3-4):127-133. doi: 10.1080/10647440400020661.

Rutten L, St Sauver J, Beebe T, et al. Clinician knowledge, clinician barriers, and perceived parental barriers regarding human papillomavirus vaccination: Association with initiation and completion rates. Vaccine. 2017;35(1):164169. doi: 10.1016/j.vaccine.2016.11.012.

10. Williams DL, Wheeler CS, Lawrence M, Hall S, Hagensee M. Louisiana Physicians are increasing HPV vaccination rates. J La State Med Soc. 2017;169(3):63-67.

References 1.

Centers for Disease Control and Prevention. HPV-Associated Cancer Statistics. https://www.cdc.gov/cancer/hpv/statistics/. Accessed January 22, 2018.

Freeman HP, Wingrove BK. Excess Cervical Cancer Mortality: A Marker for Low Access to Health Care in Poor Communities. Rockville, MD: National Cancer Institute, Center to Reduce Cancer Health Disparities, May 2005. NIH Pub. No. 05–5282.

Joura E, Pils S. Vaccines against human papillomavirus infections: protection against cancer, genital warts or both? Clin Microbiol Infect. 2016;22(5):S125-S127. doi: 10.1016/j.cmi.2016.12.017.

Castellsague X, Munoz N, Pitisuttithum P, et al. End-of-study safety, immunogenicity, and efficacy of quadrivalent HPV (types 6, 11, 16, 18) recombinant vaccine in adult women 24-45 years of age. Br J Cancer. 2011; Jun 28 105(1):28-37. doi: 10.1038/bjc.2011.185.

Wheeler C, Skinner S, Rosario-Raymundo R, et al. Efficacy, safety, and immunogenicity of the human papillomavirus 16/18 AS04-adjuvanted vaccine in women older than 25 years: 7-year interim follow-up of the phase

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Author Information Principal Investigator on study; Obstetrics & Gynecology, Division of Gynecologic Oncology, University of Mississippi Medical Center, Jackson (Ridgeway). Investigator on study; Obstetrics & Gynecology Department, St. Vincent’s Medical Center, Indianapolis, IN (Multani). Investigator on study; Obstetrics & Gynecology, Division of Research, University of Mississippi Medical Center, Jackson (Wallace). Investigator on study; Obstetrics & Gynecology, Division of Gynecologic Oncology, University of Mississippi Medical Center, Jackson (Sabins). Corresponding Author: Mildred Ridgway, MD; Department of Obstetrics & Gynecology, University of Mississippi Medical Center, 2500 North State St., Jackson, MS 39216.

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The Top 10 Facts You Need to Know about Antibiotic Stewardship DESIREE B. PENDERGRASS, MD, MPH; PETER W. PENDERGRASS, MD, MPH; PAUL BYERS, MD; THOMAS DOBBS, MD, MPH

Introduction

TABLE. Core elements of hospital antibiotic stewardship5 1.

The use and misuse of antibiotics is an important factor in the development of resistant organisms and negatively impacts patient outcomes.1 Antibiotic stewardship has been defined as coordinated efforts to improve antibiotic and antimicrobial use which lead to a decrease in the development and spread of drug-resistant organism and improve patient outcomes.2

Inappropriate antibiotic use is a public health crisis. Its associated costs are large. Inappropriate use of antibiotics is estimated to account for 2 million antibiotic-resistant illnesses and 23,000 deaths each year in the United States at the cost of approximately 30 billion dollars.3 The Centers for Disease Control and Prevention (CDC) has identified three organisms, C. difficile, Carbapenem-resistant Enterobacteriaceae (CRE) and drugresistant Neisseria gonorrhoeae, as urgent public health threats and an additional twelve conditions as serious public health threats including Vancomycin-resistant Enterococcus (VRE), Methicillin-resistant Staphylococcus aureus (MRSA), drug-resistant Streptococcus pneumoniae and drug-resistant tuberculosis.1 It is important to note that antibiotics are unique medications in that even when used appropriately they become less effective over time, and their use by individuals also impacts the population at large through the development and spread of resistant organisms.4

2. 3. 4. 5. 6. 7.

FIGURE. Community antibiotic prescriptions per 1,000 population by state - 2015 Conwm.1n11y Ant,olouc Pr<l$0'1J)l10rni per 1.000 ?op<Aatlon b~ Smie • 2015

Prescriptions per 1,000

D D D

Mississippi lags behind the nation in its antibiotic stewardship efforts. The CDC has developed seven core elements for antibiotic stewardship in the hospital setting (Table). In 2016, 64% of U.S. hospitals were compliant with all seven core elements, but only 50% of Mississippi hospitals were compliant with these measures.6 The Mississippi State Department of Health and its Healthcare Acquired Infections Advisory Committee continue working to help facilities improve compliance with all core elements.

Antibiotic prescribing varies by region and is highest in the South. Of note, southern states, including Mississippi, have the highest rates of antibiotic prescribing in the U.S. (Figure).8 In 2015, there were 1254 prescriptions written per 1000 population in Mississippi. This is in comparison to the national average of 838 prescriptions per 1000. This increase was true for penicillin, cephalosporin, fluoroquinolones and macrolide antibiotic classes.7

Hospital Leadership and Commitment: dedicated humans, financial and IT Resources Program Leadership (Accountability): a specific person who is responsible for outcomes Drug Expertise: at least one pharmacist responsible for improving antibiotic use Act: performance of at least one prescribing improvement action Track: monitoring prescribing and antibiotic resistance patterns. Report: regularly report to staff prescribing and resistance patterns Educate: clinicians and relevant staff should receive education on antibiotic resistance and improving prescribing practices.

511-668

696-759 769-845 864-915 918-1,016 1,018-1,319

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Most antibiotics are prescribed in the outpatient setting, and 30% of these are unnecessary. In 2015, about 269 million antibiotic prescriptions were filled in the United States by outpatient pharmacies.8 The CDC estimated that at least 30% of these antibiotics were unnecessary and that number reached 50% when evaluating visits for respiratory conditions.9 The CDC also noted that

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of the 70% of prescriptions that were necessary, there was a need to focus on improving drug selection, drug dose and drug duration.8

Antibiotics are commonly prescribed for diagnoses where they are never or rarely indicated. These diagnoses include upper respiratory infections (URIs), bronchitis, sinusitis, and pharyngitis. Most cases (98%) of sinusitis and rhinosinusitis are viral in origin, yet 80% of the 4.3 million annual adult visits for this diagnosis resulted in an antibiotic prescription.3 Similarly, 60% of patients seen for pharyngitis and 70% of adults seen for bronchitis receive antibiotics3 even though most cases are viral. Historically, antibiotics were prescribed for all cases of acute otitis media; however, current guidelines endorse the practice of “watchful waiting” for those without severe symptoms and initiating antibiotics only if symptoms fail to improve.10 Summaries of evidence-based treatment and clinical practice guidelines for common outpatient illness for both adults and children are available at the CDC website at https://www.cdc.gov/ antibiotic-use/community/for-hcp/outpatient-hcp/index.html.11

Broad-spectrum antibiotics are often used when narrowspectrum antibiotics are indicated. The use of broadspectrum antibiotics when not indicated is common.12 Examples include the use of fluoroquinolones for uncomplicated UTIs or azithromycin for respiratory illnesses. Broad- spectrum antibiotics are prescribed in 61% of cases where guidelines call for the use of a narrowspectrum agent.3 While amoxicillin is the preferred agent for children with community-acquired pneumonia, it was prescribed only 40.7% of the time, and broad-spectrum agents, such as macrolides or cephalosporins were prescribed in the majority of cases.13 Review of clinical factors did not typically explain this variation.

Antibiotics are often prescribed for the wrong duration, increasing the risk of complications such as C. difficile and the development of resistant organisms. Antibiotics are often prescribed for longer periods than needed. Patients with uncomplicated infections are routinely prescribed 10-day courses of antibiotics. Numerous studies support the efficacy of shorter courses for a number of infections occurring in children and adults including UTIs,16,15 community-acquired pneumonia,16,17 and otitis media.18 Of note, short-course treatment (5 – 7 days) for acute otitis media in young children (< 24 months) has been shown to be no less effective than traditional lengths of therapy. However, short courses may not be appropriate for the treatment of higher risk patients such as those with recurrent or chronic otitis, ruptured tympanic membranes or with underlying chronic conditions. Evidence-based clinical practice guidelines of the Infectious Disease Society of America recommend treating acute bacterial rhinosinusitis for only 5 to 7 days in most children and adults.19 Despite this, a recent study of provider prescribing habits for adults with sinusitis found that the median duration of treatment was 10 days and most courses (69.6%) were for 10 or more days. Of note, when excluding prescriptions for azithromycin, where a 5 day course typically provides 10 days of antibiotic coverage, that number rises to 91.5%.20

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Barriers to inappropriate use include concerns over patient perceptions and its negative impact on patient satisfaction. Many providers believe that not prescribing antibiotics for patients seen with an acute illness will negatively impact patient satisfaction. Studies evaluating this concern have been mixed,21,22 but it has been shown that provider communication, not antibiotic prescribing, has a more significant impact on patient satisfaction.23 Brief educational interventions and materials on why antibiotics were not needed/prescribed along with a discussion of what can be done to provide symptomatic relief and when to follow-up if symptoms worsen/fail to improve have all been found to positively impact patient satisfaction.22,24-27

There are some ongoing efforts to improve antibiotic stewardship, many of which are focusing on the outpatient setting. Clinicians knowing and following published practice guidelines for common ambulatory conditions is an important first step in improving outpatient antibiotic stewardship. The Choosing Wisely Campaign29 is a broad-based intervention of medical specialties to educate the public and providers on the appropriate use of various medical interventions including the use of antibiotics. More information on this initiative can be found at http://www.choosingwisely.org. Be Antibiotics Aware: Smart Use, Best Care (formerly Get Smart About Antibiotics) is a national initiative led by the CDC to fight antibiotic resistance through improved antibiotic stewardship.30 More about this initiative and educational materials for both providers and patients can be found at https://www.cdc.gov/antibiotic-use. In conjunction with these efforts, the CDC has training available for healthcare professionals on this topic. They can be accessed at https://www.cdc. gov/antibiotic-use/community/for-hcp/continuing-education.html.

Resources exist to help implement antibiotic stewardship in your practice. Similar to their efforts around inpatient antibiotic stewardship, the CDC has outlined 4 Core Elements for Outpatient Antibiotic Stewardship.31 They are: 1) Commitment: from both clinicians and organizational leadership, 2) Action: implementation of at least one policy or practice that supports these efforts, 3) Tracking and Reporting: measurement of how the organization is performing and feedback on these efforts to providers, and 4) Education and Expertise: education of both clinicians and patients on appropriate antibiotic use and access to experts on this topic. Included in the guide are checklists to aid clinicians and outpatient facilities in implementing these efforts within their practices. Information for healthcare providers on the appropriate diagnosis and treatment of common outpatient conditions is available on the CDC website32 at https://www.cdc.gov/antibiotic-use/community/

for-hcp/index.html. Finally, the CDC has developed resources and educational materials on appropriate antibiotic use for both providers and patients which can be found on the CDC website33 at https:// www.cdc.gov/antibiotic-use/community/materials-references/ print-materials/index.html. Q References 1.

4. 5.

8. 9.

10.

11.

12.

13.

14.

15.

16.

17.

CDC, United States Department of Health and Human Services. Antibiotic Resistance Threats in the United States, 2013. https://www.cdc.gov/ drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf. Accessed March 28, 2017. Association for Professional in Infection Control and Epidemiology. Antimicrobial Stewardship. https://apic.org/Professional-Practice/PracticeResources/Antimicrobial-Stewardship. Accessed February 6, 2018. Harris AM, Hicks LA, Qaseem; A. High value care task force of the American College of Physicians and for the Centers for Disease Control and prevention appropriate antibiotic use for acute respiratory tract infection in adults: advice for high-value care from the American College of Physicians and the Centers for Disease Control and Prevention. Ann Intern Med. 2016;164(6):425-434. Srinivasan A. Antibiotic stewardship: why we must, how we can. Cleve Clin J Med. 2017;84(9):673–679. CDC. Core Elements of Hospital Antibiotic Stewardship Programs. Atlanta, GA: US Department of Health and Human Services, CDC; 2014. http://www. cdc.gov/getsmart/healthcare/ implementation/core-elements.html. Accessed February 7, 2018. CDC. Antibiotic Stewardship in Acute Care Hospital by State, 2016. AR Patient Safety Atlas. https://gis.cdc.gov/grasp/PSA/STMapView.html. Accessed February 6, 2018. CDC. Antibiotic Prescriptions Dispensed in U.S. Community Pharmacies per 1000 Population | All Antibiotic Classes | 2015. https://gis.cdc.gov/grasp/ PSA/AUMapView.html. Accessed February 8, 2018. CDC. Antibiotic Use in the United States, 2017: Progress and Opportunities. Atlanta, GA: US Department of Health and Human Services, CDC; 2017. Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. Prevalence of Inappropriate Antibiotic Prescriptions Among US Ambulatory Care Visits, 2010-2011. JAMA. 2016;315(17):1864-1873. Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics. 2013:131(3): e964–e999. http://pediatrics. aappublications.org/content/pediatrics/131/3/e964.full.pdf. Accessed June 14, 2017. CDC. Antibiotic prescribing and use in doctor’s offices: outpatient healthcare professionals. https://www.cdc.gov/antibiotic-use/community/for-hcp/ outpatient-hcp/index.html. Accessed March 13, 2018. Hersh AL, Kronman MP. Inappropriate antibiotic prescribing: wind at our backs or flapping in the breeze? [published online ahead of print March 7, 2017]. Pediatrics. http://pediatrics.aappublications.org/content/early/2017/03/03/ peds.2017-0027. Accessed May 9, 2017. Handy LK, Bryan M, Gerber JS, Zaoutis T, Feemster KA. Variability in antibiotic prescribing for community-acquired pneumonia. [published online ahead of print March 7, 2017]. Pediatrics. Accessed July 5, 2017. http://pediatrics. aappublications.org/content/early/2017/03/03/peds.2016-2331. Katchman EA, Milo G, Paul M, Christiaens T, Baerheim A, Leibovici L. Threeday vs. longer duration of antibiotic treatment for cystitis in women: systemic review and meta-analysis. Am J Med. 2005;118(11):1196–1207. Michael M, Hodson EM, Craig CJ, Martin S, Moyer VA. Short compared with standard duration antibiotic treatment for urinary tract infection: a systematic review of randomized controlled trials. Arch Dis Child. 2002;87(2):118–123. Dimopoulos G, Matthaiou DK, Karageorgopoulos DE, Grammatikos AP, Athanassa Z, Falagas ME. Short- versus long-course antibacterial therapy for community-acquired pneumonia: a meta-analysis. Drugs. 2008;68(13):18411854. Greenberg D, Givon-Lavi N, Sadaka Y, Ben-Shimol S, Bar-Ziv J, Dagan R. Shortcourse antibiotic treatment for community-acquired pneumonia in ambulatory children: a double-blind, randomized, placebo-controlled trial. Pediatr Infect Dis J. 2014;33(2):136–142.

18. Hoberman A, Paradise JL, Rockette HE, et al. Shortened antimicrobial treatment for acute otitis media in young children. NEJM. 2016;375(25):2446–2456. 19. Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012;54(8):1041– 1045. https://academic.oup.com/cid/article/54/8/1041/364141. Accessed March 29, 2018. 20. King LH, Sanchez GV, Bartoces M, Hicks LA and Fleming-Dutra KE. Research Letter - Less is more: antibiotic therapy in us adults with sinusitis. JAMA Intern Med. 2018;178(7):992-994. https://jamanetwork.com/journals/ jamainternalmedicine/fullarticle/2674867. Accessed March 29, 2018. 21. Stearns CR, Gonzales R, Camargo CA, Maselli J, Metlay JP. Antibiotic prescriptions are associated with increased patient satisfaction with emergency department visits for acute respiratory tract infections. Acad Emerg Med. 2009; 16(10):934–941. 22. Ashworth M, White P, Jongsma H, Schofield P, Armstrong D. Antibiotic prescribing and patient satisfaction in primary care in England: cross-sectional analysis of national patient survey data and prescribing data. Br J Gen Pract. 2016; 66(642):40–e 46. 23. Mangione-Smith R, McGlynn EA, Elliott MN, McDonald L, Franz CE, Kravitz RL. Parent expectations for antibiotics, physician-parent communication, and satisfaction. Arch Pediatr Adolesc Med. 2001;155(7):800-806. 24. Francis N, Butler C, hood K, Simpson S, Wood F and Nuttall J. Effect of using and interactive booklet about childhood respiratory tract infections in primary care consultations on reconsulting and antibiotic prescribing: a cluster randomized controlled trial. BMJ. (Clinical research ed.). 2009;339:b2885. https://www.bmj.com/content/bmj/339/bmj.b2885.full.pdf. Accessed July 12, 2018. 25. Mangione-Smith R, Zhou C, Robinson JD, Taylor JA, Elliott MN, Heritage J. Communication practices and antibiotic use for acute respiratory tract infections in children. Ann Fam Med. 2015;13(3):221-7. 26. Tonkin-Crine S, Anthierens S, Francis NA, et al. on behalf of the GRACE INTRO team. Exploring patients’ views of primary care consultations with contrasting interventions for acute cough: a six-country European qualitative study. NPJ Prim Care Respir Med. 2014; 24:14026. doi:10.1038/ npjpcrm.2014.26. Published online July17, 2014. 27. Welschen I, Kuyvenhoven MM, Hoes AW, Verheij TJ. Effectiveness of a multiple intervention to reduce antibiotic prescribing for respiratory tract symptoms in primary care: randomised controlled trial. BMJ. 2004; 329(7463): 431. 28. Gonzales R, Steiner JF, Maselli J, Lum A, Barrett PH Jr. Impact of reducing antibiotic prescribing for acute bronchitis on patient satisfaction. Eff Clin Pract. 2001;4(3):105-11. 29. Choosing Wisely: An Initiative of the ABIM Foundation. Choosing Wisely Website. http://www.choosingwisely.org/. Accessed June 28, 2017. 30. Antibiotic Prescribing and Use: Be Antibiotics Aware. CDC website. https:// www.cdc.gov/antibiotic-use/. Accessed March 8, 2018. 31. Sanchez, GV, Fleming-Dutra, KE, Roberts, RM, Hicks, LA. Core elements of outpatient antibiotic stewardship. MMWR Recomm Rep. 2016;65(No. RR6):1–12. 32. Antibiotic Prescribing and Use in Doctor’s Offices: For Healthcare Professionals. CDC website. https://www.cdc.gov/antibiotic-use/community/for-hcp/ index.html. Accessed March 8, 2018. 33. Antibiotic Prescribing and Uses in Doctor’s Offices. Print Materials. CDC website. https://www.cdc.gov/antibiotic-use/community/materials-references/ print-materials/index.html. Accessed February 13, 2018.

Author Information Author Information: Epidemiologic Consultant, Mississippi State Department of Health; Associate Professor of Preventive Medicine and Pediatrics, University of Mississippi Medical Center (DB Pendergrass). Epidemiologic Consultant, MSDH; Associate Professor of Preventive Medicine, UMMC (PW Pendergrass). State Epidemiologist, MSDH (Byers). State Health Officer, MSDH (Dobbs). Corresponding Author: Desiree B. Pendergrass, MD, MPH; Associate Professor of Preventive Medicine and Pediatrics, UMMC, 2500 North State Street, CR 103 -02, Jackson, MS 39216. Ph: (601) 815-9063, (dpendergrass@umc.edu).

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Cerebral Venous Thrombosis and Escitalopram: A Case Report and Review of Literature LAKESHIA C. GIBSON M3; DISHA KOHLI MD; CHRISTA O’HANA S. NOBLEZA MD Introduction Selective serotonin reuptake inhibitors (SSRI) are some of the most common treatments for depression. Escitalopram is widely used owing to its favorable side effect profile. We describe escitalopram use and its potential link to veno-thrombotic events, especially of the cerebral venous system. We present the case of a 34-year-old African American woman with superior sagittal sinus (SSS) thrombosis while on therapy for depression with escitalopram. The patient had a history of lower extremity and pelvic deep venous thrombosis (DVT) nine years prior while being on therapy with escitalopram for post-partum depression. Although escitalopram’s thrombotic effect has been previously reported. This is only the second report showing an association with cerebral venous thrombosis. Key Words: Escitalopram, sagittal sinus thrombosis, cerebral venous thrombosis Case Report A 34-year-old, gravida 1, para 1, obese, right-handed African American female presented from another institution for new right-hand weakness. She was diagnosed 17 days prior to admission with sagittal sinus thrombosis (SSS) and right parietal venous infarction in another hospital where she presented with acute left-hand weakness, gait instability, and headache. During that hospitalization a thrombophilia workup performed included partial thromboplastin time, prothrombin time, international normalized ratio (INR), Factor V Leiden, Protein S and Protein C antigen, lupus anticoagulant, methylenetetrahydrofolate reductase mutation, homocysteine, lipoprotein A, antithrombin III antigen, Factor II G20210A gene, and dilute Russell viper venom time. All were within normal limits except for antithrombin III antigen, which was slightly low at 76% (normal 80%-120%). The patient was started on enoxaparin sodium 120 mg twice a day, warfarin 12 mg daily and was discharged home. On the day of admission to our institution, she developed acute righthand weakness and presented to our emergency department. Her active medications included escitalopram (10 mg), warfarin (12 mg one tablet at night), enoxaparin (120 mg subcutaneous twice daily), and fioricet. Enoxaparin was used to bridge warfarin because the patient was subtherapeutic (INR 1.8). She had an intrauterine device for contraception. Her past medical history was remarkable for a history of deep venous thrombosis (DVT) in 2006 when she presented with hip and pelvic pain. At that time, she had been taking escitalopram for 12 VOL. 60 • NO. 1 • 2019

post-partum depression for a few weeks prior to her diagnosis. She stated a thrombophilia work-up at that time was unremarkable. She has a history of chronic migraines, but there was no history of recent head trauma, infection, malignancy, chronic inflammatory diseases or dehydration. She denied any family history of lupus, miscarriages, and hypercoagulable states. Her INR in the emergency department was noted to be 1.8. On exam, she had decreased strength (4/5) in her right hand and decreased sensation to light touch and temperature. She had no sign of dehydration, and vital signs were within normal range. A computed tomography (CT) of the head without contrast showed no new infarcts or hemorrhages. A magnetic resonance image (MRI) with contrast revealed SSS thrombosis and left parietal cortical vein thrombosis (Figure). During this hospitalization, an additional autoimmune and coagulation work-up to include homocysteine, antinuclear antibody, human immunodeficiency virus, sedimentation rate, and C-reactive protein level was within normal limits (Table 2). Due to the recurrence of the event on a similar medication without any other significant abnormality indicating a primary thrombophilia and because anti-thrombin III activity may be decreased transiently in the setting of acute thrombosis, it was thought that her hypercoagulable state was due to escitalopram. Psychiatry service evaluated the patient, and escitalopram was discontinued per their recommendation. She was then discharged home with appointments for follow up with psychiatry and hematology. Figure. T1 Magnetic resonance imaging sequence and reconstructed venogram demonstrating our patient’s sagittal venous thrombosis. (Red arrows indicating areas of thrombosis.)

Discussion Our patient developed cerebral venous thrombosis (CVT) in the setting of escitalopram use. To our knowledge, this is only the second

Table 1. Comparison of prior cases of thrombotic events in the setting of escitalopram use. Case Report

Clinical Presentation

Evaluation

Kurne A et al. 1

53-year-old, male, with major depression for which escitalopram 10mg/day was started and increased to 20mg/day in 4 days. After escitalopram was started, posterior left lower extremity pain started which increased to affect mobility. He was found to have a DVT. Hypercoagulable work-up done was within normal limits. 44-year-old, gravida 2, para 2, presented with right hand, arm and leg. She was found to have an acute stroke in the parietal cortex and brainstem. She also had a history of right hand tremors and worsening fine motor movement. She was then admitted for further work-up and developed left face and hand numbness and left arm ataxia. A repeat MRI revealed a new superior sagittal sinus thrombosis.

CBC, renal function tests, LFT, TFT, sedimentation rate, fibrinogen, protein C activity, protein S activity, antithrombin III activity, antiphospholipid IgM, antiphospholipid IgG, anti-dsDNA, antinuclear antibody, activated protein C resistance, international normalized ratio, aPTT, homocysteine levels, Factor V Leiden and prothrombin 20210A mutation.

Nasrazadani D and Jensen R.2

Moore W, Cannon M and O’Neill J.3

11-year-old, female, found down in prone position with head resting on her arms pulseless and apneic. CPR ensued for 10 minutes until EMS arrival where ROSC was achieved. She was then admitted to the PICU. Toxicology revealed tramadol and citalopram levels which the family was unaware that the patient was taking. After the investigation, it was concluded that the medications were taken in a suicide attempt. Repeat MRI 4 months after the admission still revealed the left transverse sinus thrombus and pan paranasal sinus disease

MRI showed brainstem and right parietal strokes, carotid duplex showed minimal atherosclerotic disease. Echocardiogram showed an ejection fraction 55-60%, CSF studies showing lymphocytic predominance, WBC 18, RBC 253, protein and glucose were normal, no OCB, infectious titers were negative, TFT, Chest and abdomen CT, repeat MRI showed a new superior sagittal sinus thrombosis. Blood and urine homocysteine, prothrombin G20210A, antithrombin III activity, protein C and S, B6, folate and B12 levels were normal, Factor VIII was elevated 227 (normal 50-150), with a MTHFR heterozygozity gene mutation. CT head showed hyperdensity in the region of the left transverse sinus. MRI of the brain revealed a left transverse sinus thrombosis, bilateral cerebellar infarction, bilateral mastoid effusions, paranasal sinus disease and mucosal thickening of bilateral maxillary, ethmoid, sphenoid and frontal sinuses. “Thrombophilia studies” were performed but not specified and were unremarkable. Toxicology screen revealed tramadol and citalopram levels.

Past Medical History, Home Medications Unavailable. Medications include: alprazolam with escitalopram.

Management and Patient outcome Treatment not mentioned, but patient admitted to psychiatry due to suicidal attempt.

Oral contraceptive use 5 years prior to admission, Atorvastatin, escitalopram, omeprazole and trazodone, divalproex sodium then decadron, topiramate, minocycline were started for possible demyelination

Heparin drip and Coumadin was started, neurologic symptoms improved, venous thrombosis attributed to Factor VIII elevation and MTHFR heterozygosity, prior pregnancy and prior contraceptive use.

Past medical history of asthma, seasonal allergies, gastroesophageal reflux, OsgoodSchlatter disease and depression. Medications included escitalopram oxalate and aripiprazole started 1 month prior to admission. Other medications include montelukast sodium, omeprazole and occasional acetaminophen and ibuprofen.

Heparin was started with warfarin. She was also started on intravenous cefotaxime and clindamycin for pansinusitis and mastoiditis. Venous thrombosis attributed to infection, cardio-respiratory arrest, citalopram and tramadol through the mechanism of low-flow states.

CBC=complete blood count, LFT= liver function test, TFT= thyroid function test, DVT= deep venous thrombosis, MRI=Magnetic Resonance Imaging, CSF= cerebrospinal fluid, WBC= white blood cells, RBC= red blood cells, CT=computed tomography scan, MTHFR=Methylene tetrahydrofolate reductase, CPR=cardiopulmonary resuscitation, ROSC=return of spontaneous circulation, PICU=pediatric intensive care unit., OCB = , anti-dsDNA =, anti-double stranded deoxyribonucleic acid, aPTT=activated partial thromboplastin time

Table 2. Hypercoagulable laboratory evaluation Hypercoagulable Panel MTHFR Mutation Homocysteine Lipoprotein A Antithrombin III Antigen Prothrombin Gene 20210/Factor II, DNA Analysis Prothrombin Time INR D-dimer, quant Factor 5 Leiden Protein S deficiency profile Protein S, Total Protein S, Free Protein C antigen, total dRVVT Mix Interpretation Lupus Anticoagulant PTT Lupus Anticoagulant Additional Testing

Value No variant detected 9.32 26 76 Not detected

Reference Range 4.50 – 12.00 umol/L < 75 nmol/L 80 – 120 %

16.1 1.4 216.0 Not detected

23.0 – 35.0 seconds 2.0 – 3.0 <= 230.0 ng/mL

93 62 78 33 Not detected 38

70 – 140 % 50 – 147 % 70 – 140 % <= 45 seconds Not Detected =< 49 seconds

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report linking escitalopram to a hypercoagulable state1 and the third linking this class of anti-depressant to cerebral venous thrombosis (CVT).1,3 Three published reports of similar patients are summarized in Table 1. Only one of these reports directly mentions escitalopram as a potential etiology for the venous thrombus,1 while one mentions citalopram overdose as one of the potential causes of the venous thrombus due to low flow state.3 In the first report, DVT occurred with escitalopram use in a male with major depression disorder at a dose of 10mg/day then increased to 20 mg/day.1 He presented with lower extremity pain after starting escitalopram following which he was subsequently found to have a popliteal DVT with a negative workup for thrombophilia.1 Interestingly, the two other reports of CVT have included use of escitalopram for depression.2,3 The second reported case was a patient with a history of pregnancy and contraceptive use 5 years prior to admission who was found to have a CVT attributed to Factor VIII elevation, MTHFR-gene mutation heterozygosity complicated by her prior pregnancy and contraceptive use.2 However, unlike the patient in this reported case, our patient had a slightly abnormally low anti-thrombin antigen which can be the case in the setting of an acute thrombus. The third patient was an 11-year-old girl with a history of depression on escitalopram, who was found to be unconscious and pulseless from a possible drug overdose.3 Workup after the return of spontaneous circulation revealed a CVT, which was attributed partially to possible bacterial sinusitis and drug overdose with citalopram and tramadol and cardiopulmonary arrest. The mechanism of CVT development proposed was a low-flow state and sinusitis. The patient was anticoagulated, antibiotics were administered, and the patient fully recovered.3 Symptoms of CVT may include severe “thunderclap” headache that may mimic a ruptured subarachnoid hemorrhage or migraine3,4 with or without a focal neurologic symptom or seizure-like presentation with or without coexisting thrombophilia.3,5 The SSS is the most commonly affected site.2 There are numerous risk factors including Factor V Leiden mutation, oral contraception, pregnancy, and post-pregnancy states, anticardiolipin antibodies, lupus anticoagulant, deficient protein C, protein S or antithrombin III, increased homocysteine levels, postsurgical states, malignancy, immobility, inflammatory or infection states.5 In our patient, although her past DVT could be attributed to her post-partum state, her most recent SSS thrombosis could not be. We could not fully associate the development of her SSS thrombosis from escitalopram; however, given that she was not on oral contraception nor did her hypercoagulable workup (Table 2) reveal any significant abnormality, we believe that escitalopram use contributed to a thrombophilic state.

activation is decreased because serotonin storage is depleted moreso after repeated doses.8,10 Our patient had her first thrombotic event a few weeks after escitalopram use and the most recent SSS thrombosis while on escitalopram for a similar duration. She may have been in the “first phase” of platelet dysfunction, which could have precipitated a hypercoagulable state leading to SSS thrombosis. In the other 2 reported cases1,3 the duration of escitalopram use was less than 6 months. In a prior study, SSRI use greater than 6 months was reported to increase bleeding risk because of lowered platelet 5-HT content and reduced platelet aggregation while a second study showed that after 5 weeks, the platelet aggregating effect of SSRIs is decreased.11,12 Our patient was still likely in the window of platelet aggregation effect of escitalopram.12 It is important to note that our patient had a mild decrease in antithrombin III activity in the setting of acute thrombosis which has been reported to occur.13 This report highlights the importance of the possible link of escitalopram to prothrombotic events. We have presented the second case of CVT in the setting of escitalopram use, which may suggest a possible link that may be further explored. Caution in the use of this drug class in patients with preexisting hypercoagulable states is recommended. Q References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

12. 13.

Escitalopram, like its enantiomer citalopram, is well tolerated. It is approved for the treatment of major depressive disorder (MDD) and generalized anxiety disorder (GAD) in adults and children older than 12 years old.6,7 Serotonin plays a role in platelet function.8 Selective Serotonin Reuptake Inhibitors (SSRI), such as escitalopram, by their mechanism of action, reduce reuptake of serotonin centrally; however, they also affects peripheral serotonin possibly in “two phases”.9 The “first phase” may be the time when reuptake is initially inhibited, and serotonin’s platelet activating effect is working.1 The duration of this phase is unclear. Better studied is the “second phase” wherein platelet 14 VOL. 60 • NO. 1 • 2019

Kurne A, Ertugrul A, Anil yağcioğlu AE, Yazici KM. Venous thromboembolism and escitalopram. Gen Hosp Psych. 2004;26(6):481-3. Nasrazadani D and Jensen R. Case Report: diagnosis and treatment of superior sagittal sinus thrombosis. Kansas J Med. 2015:8(4)153-159. Moore WN, Cannon ML, O'Neill JC. An unusual case of cerebral venous sinus thrombosis in a pediatric patient. J Emerg Med. 2011;40(3):283-6. De Bruijn SF, Stam J, Kappelle LJ. Thunderclap headache as first symptom of cerebral venous sinus thrombosis. CVST Study Group. Lancet. 1996;348(9042):1623-5. Sasidharan PK. Cerebral vein thrombosis misdiagnosed and mismanaged. Thrombosis 2012;2012:210676. Höschl C, Svestka J. Escitalopram for the treatment of major depression and anxiety disorders. Expert Rev Neurother. 2008;8(4):537-52. American Psychiatric Association, Practice Guideline for the Treatment of Patients With Major Depressive Disorder. 3rd ed. Washington, DC American Psychiatric Association Press 2010. Hackam DG, Mrkobrada M. Selective serotonin reuptake inhibitors and brain hemorrhage: a meta-analysis. Neurology. 2012;79(18):1862-5. Hardisty AD, Hemmerdinger CM, Quah SA. Citalopram-associated central retinal vein occlusion. Int Ophthalmol. 2009;29(4):303-4. Markovitz JH, Shuster JL, Chitwood WS, May RS, Tolbert LC. Platelet activation in depression and effects of sertraline treatment: An open-label study. Am J Psychiatry. 2000;157(6):1006-8. Bismuth-evenzal Y, Gonopolsky Y, Gurwitz D, Iancu I, Weizman A, Rehavi M. Decreased serotonin content and reduced agonist-induced aggregation in platelets of patients chronically medicated with SSRI drugs. J Affect Disord. 2012;136(1-2):99-103. Lederbogen F, Gilles M, Maras A, et al. Increased platelet aggregability in major depression? Psychiatry Res. 2001;102(3):255-61. Damus PS, Wallace GA. Immunologic measurement of antithrombin III-heparin cofactor and alpha2 macroglobulin in disseminated intravascular coagulation and hepatic failure coagulopathy. Thromb Res. 1975;6(1):27-38.

Author Information University of Mississippi School of Medicine, Jackson, Mississippi (Gibson). Department of Neurology University of Mississippi Medical Center, Jackson, Mississippi (Kohli, Nobleza). Corresponding Author: Lakeshia C. Gibson, Department of Neurology, 2500 North State St., Jackson, MS 39216 (csanluis@umc.edu). Conflicts of Interest: None

P R E S I D E N T ’ S

P A G E

Professionalism and Advocacy The Physician Citizen

ll physicians have a primary ethical and professional responsibility for the health of the community members they serve. Successful advocacy requires clarity of purpose, good data, and effective strategies. It relies on the promotion of the skills and attitudes of good citizenship and medical practice that are ultimately in the interest of patients, physicians, and society as a whole.1 The basic credo of physicians, to put the interest of patients before their own, reflects a form of solidarity. Government and politics is the avenue for the expression of that sense of solidarity. Physicians who want politics out of healthcare are going to be disappointed. Ignoring politics will be at the peril of physicians and their patients.

We do not exist in a vacuum. We need our partners. There is strength in numbers. Influencing and changing health policy may not occur in one meeting or over a few days or even in the course of a legislative session. Changes often occur over years thanks to Michael Mansour, MD the groundwork that has been laid and relationships developed over long periods. Membership in the Mississippi State Medical Association (MSMA) matters because we are stronger together.3

Advocacy, especially in Medicine, is a team sport. With a Healthcare comprises almost one-fifth of the US economy demanding day job, it is nearly impossible for physicians and consists of an enormously complex system of healthcare to have a meaningful effect in legislative advocacy without payment. This presents the opportunity for every single collaborating with others. We must learn from and organization with an economic stake in healthcare whether collaborate with professionals who track major health motivated by private interest or the public interest to find issues that come before the Legislature and who form multiple pressure points for influence. Healthcare is an relationships with requisite lawmakers on given issues. inevitable battlefield for the contention that is the public These professionals are lobbyists who understand the discourse of individual responsibility and the role of entire legislative and budget process necessary to enact 2 compassion in public affairs. successfully legislation.4 Public engagement requires clear roles, reasonable limits to what can be expected, and clearly outlined tasks that are compatible with busy medical practices. Greater engagement of physicians in the public arena is necessary for three compelling reasons. First, community and socioeconomic characteristics affect many health problems and access to healthcare. Second, physician expertise is essential for properly addressing major quality issues, access to care, public health, and policy concerns. Third, visible leadership in the interest of the public’s health is regarded by many as the best way for the medical profession to retain the public trust.1

Physicians must learn how to influence people using social media, relationship building, and “storytelling” (the technique of getting your message across successfully and succinctly).3 Stories matter more than statistics. As physicians, we are taught to make evidence-based decisions, but in politics, dramatic stories spark change more often than do numbers. Physicians can tell patient stories that can make the difference in the ultimate success of a legislative agenda.4 Issues on the Mississippi State Medical Association's legislative agenda come from a number of sources. Some JANUARY • JOURNAL MSMA

originate in the House of Delegates; specialty societies promote others. Some are left over from a previous year, and others are proactive efforts to address an issue before it becomes a problem. Some current issues include maintaining and promoting physician-led team-based care in the best interest of optimal care and patient outcomes. MSMA continues to protect the nation’s most comprehensive law requiring pre-school vaccinations and to pursue legislation to ban the use of tanning beds by minors. MSMA and a coalition of 30 public health-related organizations will support legislation to reduce the burden of tobacco use in Mississippi through an increase in the state’s tobacco tax. The Association will pursue amending state law to prohibit firearms in public hospitals. Among other efforts, MSMA will support funding for the Mississippi Department of Health, the Rural Physician Scholarship Program, the Office of Physician Workforce, as well as other efforts supporting medical education in Mississippi. The Mississippi State Medical Association is well prepared to advocate for improved outcomes, better care, lower costs, and clinician wellbeing. We continue this mission during the annual session of the Mississippi Legislature and throughout the year. Every physician has a role in this process because all politics is local. Developing relationships and educating local legislators and policymakers can help to effect significant change. We are stronger together, and to be the most effective we need every physician engaged in this process. Q

rSAVE THE DATE CME in the SAND Destin, Florida May 24-28, 2019

Annual Session Jackson, MS August 16-17, 2019

CME with Mickey Orlando, Florida November 24-26, 2019

CME 24/7 www.MSMAonline.com

Questions? Michael Mansour, MD President, Mississippi State Medical Association References 1. Gruen RL, Pearson SD, Brennan TA. Physician-citizen–Public roles and professional obligations. JAMA. 2004;291:94-98. 2. Berwick DM. Politics and healthcare. JAMA. 2018;320:1437-1438. 3. Valentine CM, Waites TF. The ACC is your advocate. J Am Coll Card. 2018;72:1870-1871. 4. Griffiths EP. Effective Legislative advocacy—Lessons from medical trainee campaigns. N Eng J Med. 2017;376:2409-2411.

16 VOL. 60 • NO. 1 • 2019

Contact Becky Wells, 601.853.6733 Ext. 340 Bwells@MSMAonline.com

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E D I T O R I A L

A New Person to Push the Boulder PHILIP MERIDETH, MD, JD; ASSOCIATE EDITOR

he Mississippi State Department of Health has a new leader, or as Marshall Ramsey depicted the scene in his editorial cartoon, “a new person to push the boulder.” The new boulder-pusher is MSMA’s own Dr. Thomas Dobbs, who in December 2018 was appointed by the Board of Health to serve in the important leadership role of State Health Officer. Dr. Dobbs will step into the shoes of another one of our own, the recently retired and much beloved Dr. Mary Currier, who served with distinction as State Health Officer from 2010 to 2018. In succeeding Dr. Currier as the new State Health Officer, Dr. Dobbs will follow in the footsteps of other great public health leaders in Mississippi, including Drs. Alton Cobb and the late Ed Thompson.

Dr. Dobbs came to this position as a highly Reprinted from the Clarion-Ledger, December 14, 2018, with permission from cartoonist Marshall qualified physician and dedicated public servant. Ramsey. He holds a master’s degree in public health and board certifications in internal medicine and infectious disease. He has served as a District Health Officer, the State Epidemiologist, and recently as Deputy State Health Officer. He has a faculty appointment as an Associate Professor in the new School of Population Health at UMMC, where he teaches epidemiology and health policy. Dr. Dobbs’ academic qualifications and leadership experience in public health will be assets in his work at the Department of Health. He is the right man for the job, as there are many boulders to push up the public health hills in Mississippi. Those challenges include addressing well-known public health issues such as obesity, diabetes, and communicable disease, and the less recognized, but the devastating effects of mental health issues such as depression and suicide. In their efforts to address Mississippi’s public health needs, Dr. Dobbs and his team would do well to heed the advice of our former MSMA and AMA President, Dr. Edward Hill, himself a member of the Board of Health, who noted many times in speeches on the floor of our House Of Delegates that most U. S. health care dollars are spent on seven preventable behaviors: smoking, obesity, substance use, teen pregnancy, gun violence, suicide, and motor vehicle accidents. Dr. Currier is commended for her graceful efforts to ensure a successful transition in leadership at the Department of Health. The Journal wishes Dr. Currier a happy retirement from public service and a much-deserved return to her life as a self-described “introvert.” The Board of Health, whose membership includes Journal leaders Dr. Dwalia South and Dr. Luke Lampton, is also to be commended for making this wise appointment of a new State Health Officer. Dr. Dobbs, your colleagues at MSMA stand ready to join you in pushing boulders, and we are confident that you will show us how to help you. Here’s to continued success at the Mississippi State Department of Health and a healthier Mississippi for all in 2019.

JANUARY • JOURNAL MSMA

M S M A

Welcoming Our Newest Members

ASH, TOLAND, Lucedale, Family Medicine

PACE, BENJAMIN, Hattiesburg, Ophthalmology

BENN, SONIA, Southaven, Medical Oncology

PLOTT, ERIC, Meridian, Gastroenterology

CUDWORTH, RACHEL, Laurel, Obstetrics & Gynecology

QUINN, ADAM, Hattiesburg, Ophthalmology

DERANEY, SARAH, Tupelo, Diagnostic Radiology

RAY, HANNAH, Indianola, Family Medicine

DOWELL, CHAD, Indianola, Family Medicine

SALEEM, TAIMUR, Jackson, Vascular Surgery

DOWELL, KELSEY, Indianola, Family Medicine

SEMAAN, WALID, McComb, Internal Medicine

DULLI, AMMAR, Greenville, Pulmonary Disease

SHAW, CHRISTOPHER, Hattiesburg, Emergency Medicine

FLOWERS, JONATHAN, Ridgeland, Family Medicine

SPEIGHTS, JOHN, Saltillo, Internal Medicine

HOUSTON, SAMANTHA, Oxford, Internal Medicine

TERRELL, MERCEDES, Starkville, Internal Medicine

KENDRICK, BRIANNA, Starkville, Family Medicine

WEBB, KIMBERLY, Oxford, Family Medicine

LANDRUM, EMILY, Starkville, Family Medicine

WILE, ANNA, Meridian, Dermatology

MILLER, JOHN, Magee, Family Medicine

WOODS, AMY, Byhalia, Internal Medicine

MOORE, JOEL, Meridian, Family Medicine

MISSISSIPPI STATE MEDICAL ASSOCIATION MSMAonline.com

22 VOL. 60 • NO. 1 • 2019

I N

M E M O R I A M

Honoring the Lives and Legacies of our Fellow Physicians wife Kim of Union. He is survived by 7 grandchildren: Alex Lawhorn and wife Catherine of Nashville, TN, J. D. Lawhorn and wife Kelli of Nashville, TN, Mary Morgan Wade and husband Todd of Oxford, Sadler Alexander of Jacksonville, FL, Will Price and Walker Price of Madison, and Beth Price of Union. He is also survived by four great grandchildren: Lucy Lawhorn and William Lawhorn, both of Nashville, Cooper Lawhorn of Nashville and McLaurin Wade of Oxford.

Dr. William “Bill” Rutledge Lockwood died on August 18, 2018, in Ocean Springs, MS, at the age of 89. After serving in the U.S. Navy during the Korean War, Dr. Lockwood graduated from the University of Tennessee School of Medicine in 1957. He completed his Post-Doctoral Fellowship in infectious diseases at the University of Mississippi Medical Center in Jackson in 1961.

William Lockwood, MD

Dr. Lockwood settled in Jackson to raise his family and spent his career as a Professor of Medicine at UMMC (1962-1985). He was also Associate Chief of Staff for Research at the MS Veterans Administrative Center (1968-1973). Preceded in death by his wife Mary Lou (Butler) Lockwood, Dr. Lockwood is survived by two daughters, Margaret L. Davis of Mobile, AL, and Anna B. Lockwood of Ocean Springs, MS; three grandchildren, Alexander A. Alston IV of Ridgeland, MS, Mary T. Winder of Alpharetta, GA, and Elise L. Rogers of Ocean Springs, MS; and four great-grandchildren. Dr. John Gilbert Alexander died on August 21, 2018, in Union, MS, at the age of 90. Dr. Alexander graduated from received his BS Degree from Millsaps College. In 1954, he received his MD Degree from Tulane University and completed his internship at Charity Hospital in New Orleans, LA, and practiced Family Medicine. He was a member John Alexander, MD of The Mississippi Academy of Family Practice, Mississippi Medical Association and Southern Medical Association. He practiced at Laird Hospital/Family Medical Group at the time of his retirement. The Mississippi Chapter of the American Family Practice Association selected Dr. Alexander as its “Physician of the Year.” He was very instrumental in the establishment of the J.G. Alexander Nursing Home in 2006. In 2008, Dr. Alexander retired from his clinic duties but remained active on the Laird Hospital staff as Senior Medical Advisor. The Union Chamber of Commerce named Dr. J. G. Alexander as Citizen of the Year in 2005 and the Lifetime Achievement Recipient Award in 2014. Dr. Alexander is survived by four children: Karen Alexander Lawhorn and husband Bill of Germantown, TN, David Alexander of Hattiesburg, Ross Price and wife Stephanie of Madison, Mike Price and

He is also survived by two special friends, Jennifer McElhenney and Nona Griffin. Dr. Alexander was preceded in death by wives: Sue Sadler Alexander and Billie Price Alexander; parents, H.C. and Essie Mae Alexander and one brother, Harold C. Alexander. Dr. Robert W. Jarrett died on September 8, 2018 in Meridian, MS, at the age of 77. Dr. Jarrett earned his undergraduate degree in chemistry from Vanderbilt, and his medical degree from the University of Tennessee in Memphis. He completed his residency training at Baptist Memorial Hospital in Memphis. He practiced pathology. Dr. Jarrett came to Mississippi in 1976 to join Dr. Charles L. Wilkinson in practice at Medical Pathology Laboratory (MPL). Dr. Jarrett and Dr. Wilkinson, who had trained together in Memphis, were partners in practice for twenty years, during which time MPL grew to serve many hospitals in Mississippi and Alabama, employing more than 80 people at the time of his retirement. Besides his wife, the former Patricia Ann Dunn of Mobile, Alabama, his two younger sisters Jean (Milnor) and Leila (Hosley) and their families, Dr. Jarrett is survived by a son, Rob, of Roanoke, VA, his wife Emily, and their children Wilkes and Margaret; and a daughter, Kelly, of Carrboro, NC, her husband Mike DeFranco, and their daughter Ryan. Following in their father's footsteps, both Rob and Kelly chose careers in health care. Dr. Milton Reed York died on September 27, 2018, in Vicksburg, MS, at the age of 86. Dr. York graduated from Mississippi College and received a medical degree from the University of Mississippi Medical Center. He enlisted in the US Navy and was discharged as a full lieutenant. He also served in "D" Medical Company (USMC). He practiced Anesthesiology. He was Milton York, MD a member of Alpha Kappa Kappa, the American Medical Association, and the Mississippi State Medical Association. He was a former Assistant Professor of Anesthesiology, University of Mississippi Medical School and was a member of the team that JANUARY • JOURNAL MSMA

performed the first heart transplant ever done in the world. He practiced in Greenville, MS for 30 years. Dr. York is preceded in death by his parents Milton York and Ruby Leigh York, and a brother Robert Wayne York. He is survived by his wife Adele Blackburn York of Vicksburg, a daughter Tara Leigh York of Conifer, CO, four sons Reed York of Dothan, AL, Eric York of Cape Coral, FL, James York of Vicksburg and Bill York of Diamondhead, MS, one brother Gale York of Hattiesburg, and his 13 grandchildren. Dr. Merlos Ricardo died on October 13, 2018, in Meridian, MS, at the age of 73. Dr. Ricardo began his career in medicine at the University in El Salvador and served as personal physician to a Salvadorian President for three years. He completed his residency and internship in anesthesiology at the Medical College of Wisconsin in Milwaukee. After Merlos Ricardo, MD graduation, he was an esteemed professor at MCW. He moved to Pascagoula, MS, in 1981 and worked on staff at Singing River Hospital for 36 years. In 2016, he began working at Anderson Regional Medical Center in Meridian and served as the Medical Director of Anesthesia. He retired as a Colonel from the United States Army and served in the Army Reserves for 20 years. He was thrilled to repay and serve his country for his citizenship. He served in Operation Desert Shield, Operation Desert Storm, & Operation Enduring Freedom. Dr. Merlos is preceded in death by his beloved Grandmother Aminta “Mama Aminta” Aguilar de Guevara and his parents, Jose Fermin Merlos and Dolores De Jesus Guevara de Merlos. He is survived by his wife of 30 years, Darlene Altom Merlos; sister Angela Merlos (Oscar) de Mendoza; his sons, Ricardo Jose Merlos, R Ernesto (Antonieta) Merlos; two step-children, Josiah (Monica) Overstreet and Mysteria (Fiancé Aaron Wells) Guthery; grandchildren, Marietta Guthery, Luke, Elijah, & Rhys Overstreet; cousin, Dr. Ben (Late Wife Gloria) Simo; niece, Aura Lucia Mendoza; best friends, Dr. John (Phyllis) McCloskey, Edward (Mary) Jones; and numerous cousins, nieces, nephews, and friends. Dr. Roland "Butch" Guest died on November 6, 2018, in Tupelo, MS, at the age of 73. Dr. Guest briefly attended Mississippi State University before returning home to serve as a medic attached to an armory unit of the Mississippi National Guard. This led him to pursue a medical career and he enrolled at Delta State University before attending medical school at the University of Mississippi.

Roland Guest, MD

After finishing his cardiology fellowship in 1980, he moved to Tupelo and was the first cardiologist at North Mississippi Medical Center. He performed the first heart catheterization at North Mississippi 24 VOL. 60 • NO. 1 • 2019

Medical Center in 1981. He pioneered the heart program and served as the only interventional cardiologist in Tupelo until Dr. Jack Foster joined him in 1983. In 1983, he went to St. Luke Mid America Heart Institute and did a further specialization in interventional cardiology. He performed the first percutaneous angioplasty at North Mississippi Medical Center in 1984. As the pioneer in his field, Dr. Guest was one of the only three cardiologists in North Mississippi doing interventions at the time. Under his leadership, the cardiology practice expanded to become the leading and largest program in the Northern part of the state. He practiced in Tupelo at the time of his retirement. Dr. Guest was preceded in death by his parents. He is survived by his life partner and guardian angel, Carol Etheridge of Tupelo; his brother, Charles Guest (Rubye) of Starkville; his three daughters, Mary Alice Cafiero of Dallas, TX, Sarah Grace (John) of Belden, and Noel Cameron (Jacob) of Saltillo. He is also survived by his six grandchildren, Caitlin, Matty, and Joe Cafiero; Ellis Watts; and Riley and Peyton Cameron; as well as a host of nieces and nephews. Dr. Blair E. Batson died on November 26, 2018, at the age of 98. Dr. Batson earned his BA and MD at Vanderbilt University, where he completed a residency in pediatrics. He served in the U.S. Army during World War II and in the U.S. Army Medical Corps from 1946-48 in Giessen, Germany, as ward officer for contagious diseases and pediatrics for the 388th Station Hospital.

Blair E. Batson, MD

He served as chief resident at Vanderbilt from 1949-50 and had a faculty appointment there from 1949-1952. He completed a one-year residency at the Johns Hopkins Hospital and was on the faculty of the Johns Hopkins School of Public Health and the Johns Hopkins School of Medicine from 1952-55. He also received a Master of Public Health degree from Johns Hopkins University. At 34, he was named chair of the Department of Pediatrics at UMMC just two months after the Medical Center opened its doors to patients in 1955. Batson was an examiner for the American Board of Pediatrics from 1963-90, a member of the executive board of the American Academy of Pediatrics from 1974-80 and president of the pediatric section of the Southern Medical Association. He was the recipient of the 2000 Humanitarian of the Year tribute from the Epilepsy Foundation of Mississippi. In 1996, he was selected Vanderbilt’s Distinguished School of Medicine Alumnus of the Year. In 1995, he was inducted into the University of Mississippi Alumni Hall of Fame. Batson was honored often for his contributions to the health of children in Mississippi. He received awards for outstanding service from the March of Dimes, the National Easter Seal Society and the American Academy of Pediatrics District VII. He received an award for leadership and devotion to child health care from the Mississippi Academy of Pediatrics. He officially retired in 1989, although he still taught for years afterward.

During his long career, he taught more than 3,500 medical students and 240 pediatric residents. Among those was the late Dr. Aaron Shirley, who, under Batson’s leadership, in 1965 became the first African-American learner in any program at UMMC. In 1997, the new children’s hospital was named the Blair E. Batson Hospital for Children in recognition of his lifetime contributions to the health of children in Mississippi. A new addition to the hospital is currently under construction and due to be completed by 2020. During a memorial at UMMC on Friday, January 11, 2019, former students, colleagues, and patients paid tribute to Dr. Batson. “His most enduring legacy is in teaching thousands of medical students and residents,” said Dr. Owen B. Evans, who became chair of pediatrics at UMMC following Batson’s retirement. “The ripple effect of Batson’s teaching,” said Evans, “is enormous, and it will continue.” Dr. Batson was married twice, first to Dr. Margaret Batson, a distinguished pediatrician in her own right and member of the original pediatric faculty, and then to Blanche Batson, a well-known artist, both of whom are deceased. Survivors include Batson’s only brother, John O. Batson II; six nieces and nephews: John O. Batson III of Lake Oswego, OR; Molly Batson Smith of Atlanta, GA; Blair Batson of Portland, OR; Bryan Batson Jauregui of Todos Santos, Mexico; Andrew Graves Batson of Seattle, WA and Virginia Batson of Collingswood, NJand four great nieces and nephews: Bryan Smith of Athens, GA; Annie Smith of San Francisco, CA and Griffin Batson Grant and Tristan Batson Grant of Collingswood, NJ.

founded the Urology Center, P.A., in 1976, where he practiced until his retirement. As a physician, his skills were peerless; in a career of over fifty years, countless men and women came under his care. A tireless innovator to his colleagues and his patients alike, he pioneered among numerous other techniques the use of lithotripsy in urologic practice in Mississippi, transforming the management of kidney stones in the greater Hattiesburg region. Among his professional honors were his service as President of the Mississippi Urologic Society (two terms), a term on the Board of Directors of the Southeastern Section of the American Urological Association (SESAUA), and a term as Chairman of the Membership Committee of the SESAUA. Recognizing his contributions, the SESAUA awarded Dr. Morris its Outstanding Achievement and Service Award in 2007, as well as its Distinguished Member Recognition Award in 2018. He was a member of the Mississippi State Medical Association, the American Medical Association, and a Fellow of the American College of Surgeons, as well as a volunteer physician for the American Red Cross, the United States Coast Guard Auxiliary, and other organizations. Dr. Morris is preceded in death by his parents, Toxey M. Morris and Dorothy C. Morris, a daughter, Mary Catherine Morris, and his sisterin-law, Laura W. Blackwell. He is survived by his wife of 45 years, Virginia W. Morris; his two sons, Robert M. Morris and Dr. Benjamin A. Morris; his brother and sister-in-law, John Alan and Ann Morris; his grandchildren, Ashton and Alexander Hill; his daughter-in-law, Sabree Hill; his brother- and sisterin-law, A.F. and Mary Joe Wicke; and his niece and nephew, Stephanie Morris and John Wilson Morris.

Dr. Toxey Michael Morris died on November 24, 2018, at the age of 80.

Dr. James Leighton Pettis died on November 15, 2018, in Memphis, TN, at the age of 85. He formerly resided in Tupelo, MS.

After studying microbiology at Vanderbilt University in Nashville, TN, Dr. Morris entered Tulane University School of Medicine in New Orleans, LA, where he earned his MD in 1963. Following his internship at Confederate Memorial Hospital in Shreveport, LA, his Toxey Morris, MD residency in general surgery was interrupted by the conflict in Vietnam. As a young surgeon, Dr. Morris joined the United States Navy as First Medical Officer aboard the USS Tripoli (LPH-10), proudly serving one tour of duty from 1967-1968 in the waters of North Vietnam. Commanding the hospital wing of that vessel during combat operations, he and his team treated wounded servicemembers and civilians alike, for which he received the Navy Commendation Medal among other awards. Following this tour, he was honorably discharged with the rank of Lieutenant Commander, and maintained his commitment to the armed forces for many decades afterwards.

Dr. Pettis attended the University of Mississippi and received his medical degree from the University of Tennessee Medical School in 1958.

Following his return to civilian life in 1968, Dr. Morris completed his residency in urology at the University of Mississippi Medical Center in Jackson, MS, and returned to his hometown of Hattiesburg to enter private practice.

Dr. Fitten Lamar McMillen, Jr. died on December 3, 2018, in Vicksburg, MS, at the age of 74.

In 1971, he joined the Hattiesburg Urology Clinic, after which he

He completed his residency in ophthalmology at Tulane University Medical School. He was a member of the Mississippi State Medical Association. He practiced in Tupelo at the time of his retirement. He is survived by son, Jim Pettis (Susan); three daughters, Brenda Warren (John), Libby Maloch (Roger), Leigh Anne Luther (Gripp); ten grandchildren, Elizabeth Pettis, Catherine Pettis, Caroline Pettis, Scott Warren (Elizabeth), Ashley Stanford, Keller Carlock, Leighton Carlock, Thomas Carlock, Neill Luther and Leighton Luther; two great grandchildren Lawson and McRae; one brother, Ben Pettis (Adalene). He is preceded in death by his parents, Mr. and Mrs. Leighton Pettis and his loving wife of 53 years, Jean Greene Pettis.

Dr. McMillen, Jr. received a BA degree from the University of the South in Sewanee, Tennessee, and a MA degree from the University of Arkansas in Fayetteville, Arkansas. JANUARY • JOURNAL MSMA

He received his medical doctorate from the University of Arkansas Medical Center in Little Rock. His post-graduate medical training was at the University of Minnesota in Minneapolis. He practiced Family Medicine in Vicksburg, MS, at the time of his retirement. Dr. McMillen, Jr. is survived by his wife of 44 years, Carol Lee Ellingson McMillin, his three children, Ashley McMillin Moomaw (Charlie), David Lamar McMillin (Grace Lo), and Stephen Lee McMillin (Jennifer Lynne), and his six grandchildren, Grayson McMillin Moomaw, McMillin Strum Moomaw, Baby Moomaw (due date of March 7, 2019), Ethan Lamar McMillin, Lynlee Rhodes McMillin, and Lyla Elizabeth McMillin. Dr. John Benjamin Milam died on December 15, 2018, in Jackson, MS, at the age of 71. Dr. Milam received a BA degree from University of Mississippi in 1969 majoring in math and chemistry. He graduated from the University School of Medicine with an MD degree in 1973. He completed an internship in internal medicine at Baptist Memorial Hospital in Memphis, TN, and a residency in opthamology at the University of Mississippi School of Medicine. He completed two fellowships in pediatric opthamology, and cornea and external diseases at Baylor College of Medicine in Houston, TX. He practiced opthamology for 38 years in the Jackson area before retiring in January 2018. Dr. Milam was preceded in death by his sister, Lynn Milam Granberry, and his parents, John T. and Helen Milam. Survivors include his wife, Sherry of Jackson; his daughter, Mary Amanda Milam of Jackson; his brother, James Thomas Milam of Tupelo (Nancy Brown); four nieces, two nephews, and two great nephews. Dr. A. Wayne Sullivan died on December 17, 2018, in Athens, GA at the age of 96. He formerly resided in Meridian, MS. Dr. Sullivan received a BS from Mississippi College and an MD from the University of Virginia. He completed his internship at the Medical College of Georgia Hospital and his residency in Radiology at Emory University Hospital.

Over the course of his career, he was certified as a diplomate of the American Board of Radiology, and held the positions of President of Lauderdale County Medical Society, Secretary of the East Mississippi Medical Society, President of the Mississippi Radiology Society, East Mississippi representative to the Mississippi Medical Society, and Chief of Staff of Anderson Regional Medical Center, Meridian, MS. He practiced in Meridian at the time of his retirement. Dr. Sullivan is survived by his three children: Patrick (Julie) Sullivan of Knoxville, TN, Dr. David Sullivan of Memphis, TN, and Erin Sullivan of Athens, GA; grandchildren: Lauren Sullivan, Kiley Aguar, Nathaniel (Karen) Aguar, Gabriel Sullivan-Brugger, and Lyndon SullivanBrugger. Dr. Otrie Bertrelle Hickerson-Smith died on December 19, 2018, in Jackson, MS, at the age of 82. Dr. Hickerson-Smith graduated from Howard University with a degree in Chemistry and a medical degree at Howard University College of Medicine in 1962. She completed an internship at Kings County Hospital in Brooklyn, NY, Otrie Bertrelle residency in psychiatry at Mental Health Institute Hickerson-Smith, MD in Independence, IA, and post-graduate training and a staff appointment at the prestigious Menninger Foundation in Topeka, KS. She accepted an appointment to be Chief Psychiatrist in the Outpatient Department of Public Health and Clinical Instructor in Psychiatry at Howard University College of Medicine. She came to Jackson, MS, in 1969 to take an appointment as a Staff Psychiatrist with the Mississippi Veteran Administration Center and a staff appointment as an instructor in Clinical Psychiatry and Attending Physician at the University of Mississippi Medical Center. In taking the appointment, she became the first female and the first AfricanAmerican psychiatrist in the State of Mississippi and one of the few in the South, as well as the first African-American to join the Mississippi Psychiatric Association. In 1972, she was certified in psychiatry by the American Board of Psychiatry and Neurology.

He served among the enlisted ranks in the US Navy during WWII. During the Korean War, he served in the US Army as a Radiologist with the 25th Evacuation Hospital. After his Korean War service, he held the post of Associate Radiologist at Baylor University Hospital in Dallas, TX, and at the Veterans Administrations Hospital in Jackson, MS.

A founding member of the Committee of Black Psychiatrists of the American Psychiatric Association, she helped push the APA to diagnose PTSD. She further served as a Psychiatrist and Psychology instructor at Tougaloo College, founding Director of Mental Health at Jackson-Hinds Comprehensive Health Center which was the first mental health center in a community health center in the country, now FQHCS, Private Practice Psychiatrist at Mississippi Family Health Center, and retired as a Staff Psychiatrist with the Department of Veterans Affairs Medical Center in Jackson, MS.

Dr. Sullivan was the first Radiologist to practice in Meridian, conducting both a diagnostic practice and radiation therapy in private practice and at all the Meridian hospitals. He also established the School of X-Ray Technology at what is now Meridian Community College, and he was the cofounder of the Southern Radiology Conference.

She served as Observer Consultant for the Council of Mental Health Services of the American Psychiatric Association, on the Initial Review Committee of the Minority Mental Health Center of the National Institute of Mental Health, a member of the Advisory Committee of the Mississippi State Department of Mental Health, as a consultant for Special Education Services with Jackson Public Schools, and as a

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A. Wayne Sullivan, MD

consultant for Mental Health of Job Corps for Minact, Inc. Her professional memberships included being a Life Member of the APA Jackson Medical Association, Mississippi Medical and Surgical Association, National Medical Association, Central Mississippi Medical Association, Mississippi State Medical Association, American Medical Association, and the Mississippi Psychiatric Association.

Dr. Curtis W. Caine, Sr. died on January 1, 2019, in Chattanooga, TN, at the age of 97. He formerly resided in Jackson, MS. Dr. Caine, Sr. graduated from Tulane University and Tulane Medical School. He served in the Navy during WWII in New York and Virginia.

Dr. Hickerson-Smith is survived by husband Dr. Robert Smith, son Claude Alexander, Jr. (Kim), daughters Donna Elizabeth Smith and Pamela Broadnax (Columbus), brothers Willis Hickerson and Ernest Hickerson (Norma), brother-in-law George, sisters-in-law Jackie, Margie Ree, grandchildren Camryn Renee Alexander, Carsyn Richelle Alexander, Nigeana Broadnax, Ottire Johnson (Isaac) and Sandra Broadnax, beloved nieces/surrogate daughters Laura Powell, Valerie Cooper, Ann Therese Johnson, a host of nieces, nephews, other relatives, and dear friends.

He started his practice in Jackson, MS, as the first anesthesiologist in Mississippi, where he practiced for 60 years.

Dr. John Carl Passman, Jr. died on December 24, 2018, in Natchez, MS, at the age of 90.

Dr. Ansel Caine, his father, graduated from the School of Medicine in 1907 and went on to become the first full-time practicing anesthesiologist in the city of New Orleans and the first chief of anesthesia at Southern Baptist Hospital.

Dr. Passman, Jr. joined the U.S. Navy in 1946 after graduating from high school. Following his naval service, Dr. Passman attended LSU in Baton Rouge and New Orleans, LA. In 1955, he graduated from LSU New Orleans Medical School.

Curtis Caine, MD

Tulane Medical Center's School of Medicine celebrated the dedication of the Caine Anesthesiology Library in December 2009. The Caine Library represents a "quantum leap in the resources available for our anesthesiology students," said Dr. Frank Rosinia, chair of the Department of Anesthesiology at Tulane Medical Center. Dr. Caine, Sr. helped fund the library in honor of the three generations of his family who left indelible marks on the field of anesthesiology.

Curtis Caine Sr. followed in his father's footsteps. His son, the late Curtis Caine, Jr., another Tulane alumnus, continued the family tradition in anesthesiology as well. John Carl Passman, MD

That same year, he began a general medicine practice in Jonesville with his mentor and brother, Dr. Charley Fred Passman. In 1964, Dr. Passman completed his residency in orthopedics at CMMC in Shreveport. He began his career in orthopedics in Natchez, which covered a span of fifty two years. He served the people of the Miss-Lou area for an entirety of 61 years with total devotion to his patients. This included opening Passman Orthopedic and Physical Therapy Clinic with his wife Marcia at the time of his retirement. He was a member of the American Medical Association, Southern Orthopedic Medical Association, and the Homochitto Valley Medical Society. Preceding him in death were his parents John Carl Passman and Nina Stringer Passman, his siblings Charley Fred Passman, Maudell (Helen Louise), Monez, Wanda Sue and his youngest son, Charles Bradley Passman. Dr. Passman is survived by his beloved wife and companion of 36 years, Marcia Kay Hubbard Passman, his children, Carlane Passman, Paul Gavin Passman and wife Susan, and Carl Frederick Passman; Mary Girlinghouse Passman, mother of his children; grandchildren Samantha Gail Passman, Colby Joseph Passman, Sydney Claire Passman, Eliot Osborne Passman, Alton Joseph Passman, Luke Alexander Passman, Breanna Kathleen Little, and Ian Michael Little. Other survivors include nieces, nephews, cousins, other relatives and many wonderful close friends.

Dr. Caine, Sr. is preceded in death by his wife, Lynn Johnson Caine; his five siblings; his children, Gertie Pearl Caine, Curtis Caine, Jr., and Gary Caine; and his grandchild Curtis Caine, III. He is survived by his children, Edsel (Joan) Caine and Carol Caine Guess; grandchildren, Michael Caine, David Caine, Jason Caine, Brandon Caine, Jordon Caine, Hannah Campbell, Becca Susong, and Debra Klein; and 16 great grandchildren. Q

HOT OFF THE PRESS! Images in Mississippi Medicine: A Photographic History of Medicine in Mississippi

Lucius “Luke” M. Lampton, MD and Karen A. Evers

Get your copy today @ msmaonline.com

JANUARY • JOURNAL MSMA

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Invest in a Healthier Future More than 70 Percent of Mississippi Voters Support a Cigarette Tax Increase At Capitol, Over 30 Organizations Ask Lawmakers to “Invest in a Healthier Future”

n a November 28 press conference at the Mississippi State Capitol, supporters from the more than 30 diverse organizations calling for an increase in the state cigarette tax of $1.50 per pack announced that an overwhelming majority of Mississippi is with them: More than 70% of voters in the state support the measure. The Invest in a Healthier Future Coalition is asking lawmakers to take action on this increase to help Mississippi save lives, improve the health of citizens and support the economy.

“The polling results released confirmed what we know and regularly hear in conversations with Mississippians,” said Katherine Bryant, director of government relations for the American Heart Association in Mississippi. “Tobacco-related illnesses are expensive and harmful for all of us. In Mississippi, tobacco remains the No. 1 cause of preventable death. Tobacco is an addictive and deadly product, and higher cigarette taxes are proven to help people quit and help young people never start.” Mississippi’s cigarette tax is 68 cents per pack, ranking it 40th in the nation, contributing to the state’s very high adult smoking rate and low life expectancy. The average state cigarette tax is $1.78 per pack. It has been nearly 10 years since Mississippi last raised its cigarette tax, with the state missing opportunities to improve the health of its citizens. Results from a newly released poll showed solid support throughout Mississippi for a tobacco tax increase, with every region showing support ranging between 67-78%, and overall state support at 73% in favor. Mississippians across party lines support a $1.50 increase in the tobacco tax, with 69% of independents, 71% of Republicans and 80% of Democrats in favor of the measure. The statewide telephone survey of 500 registered voters, October 27-29, 2018, was conducted by Public Opinion Strategies with a margin of error of +/-4.38%. Glen Bolger, a partner with Public Opinion Strategies, was the principal researcher on the project. “Mississippi supports raising the cigarette tax more than the possibility of increasing other taxes,” said Bogler. “Support is wide and deep. We found the $1.50 cigarette tax increase is much more palatable than other options, with this being a policy that would save lives and help the state budget.” MSMA President Dr. Michael Mansour spoke at the press conference to announce the ﬁndings of a new poll regarding a potential increase in Mississippi’s cigarette tax. “The direct cost to the Medicaid program in Mississippi from the eﬀects of tobacco use is $320 million a year,” he explained. 28 VOL. 60 • NO. 1 • 2019

Smoking kills an estimated 5,400 in Mississippians annually, and 1,400 children under 18 become new daily smokers each year, according to “Toll of Tobacco, Mississippi, Tobacco-Free Kids.” Smoking costs the state $1.23 billion in direct health care costs, including $319.7 million in Medicaid costs every year. Additionally, Mississippi experiences $1.8 billion in productivity losses because of tobacco use annually. Meanwhile, the state spends just $8.4 million on tobacco prevention and cessation

annually, far below funding levels recommended by the U.S. Centers for Disease Control and Prevention. The Invest in a Healthier Future Coalition says the projected health benefits from a $1.50 increase in the state cigarette tax make it a great investment. According to the American Cancer Society Cancer Action Network, the Campaign for Tobacco-Free Kids, and the Tobacconomics research group, the $1.50 increase is projected to prevent 13,200 smoking-caused deaths, prevent 21,700 kids under 18 from becoming adult smokers, and help 25,100 current adult smokers quit. Financially, the $1.50 increase can generate $169.7 million in much-needed revenue annually for Mississippi, saving $987.8 million in long-term health care costs through adult and youth smoking declines. Every state that has significantly increased its cigarette tax has seen increases in revenue despite any resulting reductions in smoking. The poll also found the majority of smokers in Mississippi support the $1.50 per pack increase. “I quit smoking 23 years ago, after 25 years of heavy smoking,” said Ron Schnoor, Mississippi resident, and former smoker. “I stopped abruptly after being diagnosed with Type 1 diabetes and am convinced my heavy smoking contributed to my health problems. But I’m fortunate it was not worse. I wholeheartedly support the $1.50 increase. Cigarettes are lethal. They are killers. This is a necessary step to save lives.” To learn more, share your story or support this initiative, visit investMS. org. Q

ANNUAL HEALTH CARE EXPENDITURES IN MISSISSIPPI DIRECTLY CAUSED BY SMOKING ARE $1.23 BILLION.* FOR THIS REASON, THE INVEST IN A HEALTHIER FUTURE COALITION IS PROPOSING A $1.SO PER PACK CIGARETTE ~

About the Invest in a Healthier Future Coalition

INCREASE AND AN EQUIVLENT TAX ON OTHER TOBACCO PRODUCTS, THE USE OF TOBACCO PRODUCTS REMAINS THE #1 CAUSE OF PREVENTABLE DEATH. IN MISSISSIPPI, AN ESTIMATED S,400 DEATHS ARE CAUSED BY SMOKING EACH YEAR. ONE OF THE BEST THINGS MISSISSIPPI CAN DO TO IMPROVE THE HEALTH OF ITS CITIZENS AND SUPPORT ITS ECONOMY IS TO SIGNIFICANTLY INCREASE THE TAX RATE ON CIGARETTES BY $1.SO PER PACK AND INCREASE A TAX ON OTHER TOBACCO

Invest in a Healthier Future is a broad-based coalition of more than 30 organizations leading the effort to reduce the preventable death and chronic disease of tobacco use in Mississippi through an increase of $1.50 per pack on the state’s cigarette tax. Our vision for the future is a healthier Mississippi with fewer children starting to smoke, more people who smoke quitting, and increased revenue for the state. The use of tobacco products remains the #1 cause of preventable death in Mississippi. We can save lives, improve the health of citizens and support the economy through an increase in the state cigarette tax.

PRODUCTS (OTP) TO NEW PARALLEL LEVELS.

PREMATURE SMOKING-CAUSED DEATHS PREVENTED.

KIDS PREVENTED FROM BECOMING ADULT SMOKERS.

CURRENT ADULT SMOKERS WHO WOULD QUIT.

SAVE LIVES

REDUCE HEALTH CARE COSTS

GENERATE NEW REVENUE! $200 MILLION+ JANUARY • JOURNAL MSMA

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Dr. Thomas E. Dobbs Named New State Health Officer

n December 13, 2018, the Mississippi State Department of Health announced that Interim State Health Officer and former State Epidemiologist Thomas E. Dobbs, MD, MPH, has been appointed Mississippi’s new State Health Officer. Former State Health Officer Mary Currier, MD, MPH, retired October 31, 2018, after almost nine years as State Health Officer. Dobbs’ appointment came during a regularly scheduled State Board of Health meeting. Dr. Dobbs is a board certified Infectious Diseases and Internal Medicine physician with extensive training in public health and epidemiology. Dr. Dobbs recently joined MSDH as the Deputy State Health Officer after two years working in Laurel as a practicing physician but also as Vice President for Quality and Chief Medical Officer of South Central Regional Medical Center. Before this, he served 4 years as a District Health Officer in southern Mississippi and then 4 years as the State Epidemiologist with MSDH.

Dr. Dobbs is a graduate of Emory University and received his medical degree and his Master’s degree in Public Health at the University of Alabama at Birmingham. He has been active in public health research and advocacy, working globally through the Gorgas Tuberculosis Initiative in Russia and Cambodia, and in the U.S. through appointments at UMMC and the University of Florida (as regional clinical consultant with the Southeastern Regional TB Center). He has an appointment at the John D. Bower School of Population Health at UMMC, teaching Epidemiology and Health Policy. “The Mississippi State Department of Health is privileged to have someone of Dr. Dobbs’ experience and caliber to lead our health department as we continue to face challenges and changes,” said Chairman of the Mississippi State Board Health Ed D. “Tad” Barham MD, FACR. “Dobbs’ knowledge of infectious diseases, his work both in the field and in the administrative arm, and his community involvement will all be a great asset to the department.” “I am grateful for this opportunity to help address the health needs facing all Mississippians. Although we have many challenges, we have great people, institutions, and resources in our state to meet those challenges” said Dobbs. “The Mississippi State Department of Health has a long, proud history, as a potent force of change and as an innovator. I am humbled to step into a role previously held by some of our nation’s public health leaders.” Q

30 VOL. 60 • NO. 1 • 2019

U M M C

Heart-liver transplant one for UMMC history books

avis Beasley had no inkling his heart was on borrowed time until he passed out at work, which happened to be at the oil well he was helping to drill that day. “They took me to the local ER, and they said I had an irregular heartbeat,” said Beasley, 48, a resident of Millry, Alabama, population 510. “It went from there.” That was almost a decade ago. On November 15, 2018, he made history at the University of Mississippi Medical Center, where a transplant team replaced his damaged heart, which had strained his liver to the point that it, too, was barely functioning.

Minutes after giving him a donor heart, a second transplant team placed a new liver into Beasley’s abdomen, making him the Medical Center’s first combined heart-liver recipient. It’s a rare procedure; the latest data from the United Network for Organ Sharing (UNOS) shows it has been completed just 35 other times nationally this year. The transplant surgeons were Dr. Christopher Anderson, professor and chair of the Department of Surgery and chief of the Abdominal and Transplant Division; Dr. Mark Earl, professor of abdominal transplant surgery; Dr. Brian Kogon, professor of pediatric and congenital heart surgery; and Dr. Hannah Copeland, assistant professor of cardiothoracic surgery. Dr. Larry Creswell, associate professor of cardiothoracic surgery, removed the donor heart; Dr. Felicitas Koller, assistant professor of transplant surgery, removed the donor liver. Anderson and Earl led the liver team; Kogon and Copeland led the heart team. Kogon has performed one other combined heart-liver transplant and one combined heart-liver-kidney transplant, both at Emory University. “The liver team and the heart team at UMMC had to mature to the point where they felt confident in taking on something like this,” said Anderson, who was recruited to UMMC in August 2011 with a mission: Bring back the liver transplant program following a 20year hiatus, and build an abdominal transplant team to keep that momentum going. The surgery also was made possible by a skillful anesthesia team, one for each organ transplanted; a stellar OR support team; and excellent work by the abdominal and heart transplant coordinators and intensive care and nursing support teams, Anderson said. “Our operating room capabilities are at the point where we can do this, and do this well,” he said.

Davis Beasley, center, visits with members of his transplant teams, from left, Dr. Mark Earl and Dr. Christopher Anderson, liver; and Dr. Brian Kogon and Dr. Hannah Copeland, heart.

The combined transplant is most often performed on patients with end-stage liver and cardiac failure, or for certain patients who have a genetic condition that can cause heart failure and can be cured with a liver transplant. The two organs almost always come from the same donor. So far this year, just 14 other hospitals have performed one or more simultaneous heart-liver transplants, UNOS says. The first heart-liver transplant was performed in 1984 on a 6-year-old girl who survived for 10 weeks. Survival rates have skyrocketed since then, with a one-year rate of greater than 80% and a 10-year rate of greater than 70%, a 2016 national transplant study showed. Between 1992 and this year to date, 269 heart-liver transplants have been performed, UNOS reports. Nationwide, there were 18 in 2016 and 29 in 2017. Beasley’s heart condition is called arrhythmogenic right ventricular dysplasia. It’s a rare disease, sometimes inherited. “Scar tissue forms in the right ventricle and prevents the heart from pumping properly,” Kogon said. Beasley deteriorated to the point that “his medical options were exhausted,” Kogon said. “The next step is a transplant.” The dad of two “wasn’t a candidate to have a transplant of either organ without the other,” Anderson said. Anderson began caring for Beasley more than a year ago for his liver issues. His cardiologists are Dr. Craig Long, associate professor of

JANUARY • JOURNAL MSMA

cardiology, and Dr. Charles Moore, professor of cardiology. “He was being followed for his heart failure at that point, and as it progressed, it became clear that he wouldn’t survive without a transplant of both organs,” Anderson said. “Both transplant teams agreed.” But first, surgeons had to get him well enough to get through the double transplant. Beasley was in a wheelchair when he saw Copeland a year ago for his heart issues, “and he was completely jaundiced. He was yellow,” she said. “I said, ‘He needs a heart-liver.’ ” Copeland, who completed a heart and lung transplant and mechanical circulatory fellowship at Indiana University, said Beasley’s medical team optimized his medications to improve his heart function enough to withstand surgery. Beasley went on the transplant list in spring 2018. He had no qualms. “I trusted them,” he said of his surgeons. “I wanted to continue living. I wanted to do what was necessary to save my life. I got to where I couldn’t walk sometimes, or get out of bed. The week before the surgery, it was pretty rough.” The eight-hour procedure began at 6:30 a.m. The teams worked in tandem to transplant first the heart, and then the liver. “You had two heart surgeons, two liver surgeons, the heart team, the liver team, the anesthesiology team, the nurses and other assistants,” Anderson said. “Each team had some of its residents and students. “Even in our biggest OR here, it was a tight squeeze,” he said. “But it was very coordinated. We followed the strategy that we all followed at our prior institutions, with the heart transplant going first. “That transplant is finished, and the patient comes off cardiopulmonary bypass. Then, we proceed to the liver transplant. Once that’s done, the heart team comes back and looks at the chest to make sure there is no bleeding and makes a decision about closing

the chest. Then, the liver team comes back.” The transplanted heart and liver had immediate good function, Anderson said. “The time it took was probably a little quicker than normal for a heart and liver together, but it’s certainly indicative of the smooth operations and coordination by the teams.” The organs came from the same donor, but it was more important that the heart is suited to the size of Beasley’s chest than the liver be a perfect fit into his abdomen. “This is a prime example of the positive effect that organ donation can have,” Anderson said. “The difference that one donor can make is huge, and I am always humbled to see patients like Mr. Beasley improve because of this gift of life.” Almost two weeks after his surgery, Beasley walked – his own choice -- from his intensive care room to a bed on the cardiovascular care hospital floor. “It’s getting better every day,” he said of how he feels with his new organs. “I’ve just got to get through all this.” Beasley has received the directions that all transplant recipients receive to steer clear of infection and germs: Avoid crowds and places where large groups gather, like shopping malls or churches. Wash your hands, and ask those around you to wash theirs, too. “We always tell them to tell people that they can’t hug and kiss on you,” Anderson said. “We never want someone to be locked in their home, or live in a bubble, but we do educate them on the proper processes. We want them to live their lives smartly.” A number of UMMC milestones have followed the 2013 jump-start of the abdominal transplant program: the first transplant of both a pancreas and a kidney in 2013; the first transplant of an isolated pancreas in 2014; in 2015, the 50th liver transplant since Anderson’s arrival; and a record number of transplants in each of kidney, liver and heart in 2016. In June, the transplant teams together performed UMMC’s first heart-kidney transplant, with the organs being transplanted into the same recipient one day apart. Although 2018 might not surpass 2016 on total transplants, it’s already been the busiest year for livers – 42 through November 21. All told, the Medical Center has transplanted 188 livers since 2013. The history-making of the heart-liver transplant “is another example of us following up on the vision that Mississippi patients in need of a transplant shouldn’t have to leave the state for expert care,” Anderson said. “I’m glad we reached this milestone. I had no doubt that we would. But, it boils down to the transplant team we’ve built, the transplant coordinators, the OR teams and hospital administration. We have confidence in them.”

Beasley poses with the surgeons, anesthesiologists, nurses, operating room support staff, abdominal and heart transplant coordinators, intensive care staff and others who helped make his heart-liver transplant a success.

32 VOL. 60 • NO. 1 • 2019

Said Kogon: “A heart transplant alone is a monster operation. A liver transplant is a monster operation. A combination of the two is huge. For our program to accomplish that is pretty special.” Q

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JANUARY • JOURNAL MSMA

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ISSISSIPPI BAPTIST HOSPITAL, JACKSON, 1914 – Jackson’s Mississippi Baptist Hospital was established in 1909 at the corner of North State and Manship streets as a private hospital and clinic operated by Drs. John Farrar Hunter and Harley Roseborough Shands. The year before, the two had acquired the Eckles property and converted the eight-room frame residence into a well-equipped small hospital. With the initiative of Rev. Warren Furman Yarborough of Jackson’s First Baptist Church, the Mississippi Baptist Convention took charge of the hospital as part of its mission on January 1, 1911, with a nursing education program beginning in 1912. Memphis architect John Gaisford developed the plans for a new brick hospital (made of brick both as a sign of being modern and also to be more fireproof!). By 1913, the old house was moved back in the lot and turned sideways to face Manship Street and the foundation for the new brick hospital was laid, with two adjoining lots on North State Street donated to the property. This new facility cost $150,000.00 to construct and was dedicated on December 22, 1914, with 50 patient beds and a much-enlarged medical staff serving multiple specialties: Pediatrics, Medicine, Surgery, Obstetrics, Eye-Ear-Nose and Throat, Neurology, Gastroenterology, Rectal and Genitourinary Surgery, Electrotherapy, and Dental. By 1939, the four-story Green Annex was created as a segregated hospital within the larger hospital to care for African-American patients. The respected nurse training school also included African-Americans as students. The hospital would continue to expand over decades into a massive medical center, extending along North State Street to Carlisle Street and across North State Street into a 564-bed hospital, one of the largest in the state. This Jackson landmark, seen here from Manship Street between 1914 and 1920, would be razed in 1985 to make room for a new multi-story Medical Arts Plaza. If you have an old or even somewhat recent photograph which would be of interest to Mississippi physicians, please send it to me at lukelampton@cableone.net or by snail mail to the Journal. Q — Lucius M. “Luke” Lampton, MD JMSMA Editor 34 VOL. 60 • NO. 1 • 2019

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Yockanookany EDITED BY LUCIUS LAMPTON, MD, JMSMA [This month, we print lovely verse by my fellow JMSMA editor, Dr. Stanley Hartness, a family physician, once of Kosciusko, now of Jackson. Heâ&#x20AC;&#x2122;s a gifted and meticulous writer who possesses an artist's vision with anything he does. He returns to his Attala County roots with this poem, which refers to the legendary Yockanookany River, which pierces the central Mississippi landscape (Choctaw, Attala, and Leake Counties) on its seventy-mile southwestwardly trek to embrace the Pearl Riverâ&#x20AC;&#x2122;s journey to the Gulf of Mexico. He relates with a smile: â&#x20AC;&#x153;The Yockanookany formed one of the boundaries of my fatherâ&#x20AC;&#x2122;s farmland Dà§¼HFWLRQDWHO\ NQRZQ E\ XV IDPLO\ PHPEHUV DV Âµ'DGG\Â¶V ERWWRPÂ¶ Â´ 7KH GLVWLQFWLYH QDPH Â³<RFNDQRRNDQ\ Â´ SURQRXQFHG ORFDOO\ Â³\RFN DK 122. DKQHH Â´ LV RI &KRFWDZ RULJLQ WKH Â¿UVW HOHPHQW Â³\DNQLÂ´ PHDQV Â³ODQG Â´ EXW WKH UHVW RI LWV PHDQLQJ LV GHEDWHG 'HVSLWH WKH VLPLODU VRXQG WR )DXONQHUÂ¶V P\WKLFDO Â³<RNQDSDWDZSKDÂ´ &RXQW\ WKH IDPRXV ZULWHU ZDV LQVSLUHG E\ D GLà§¼HUHQW QRUWK 0LVVLVVLSSL ULYHUÂ¶V IXOO &KLFNDVDZ QDPH IRU KLV Â¿FWLRQDO KRPHSODFHÂ¶V DSSHOODWLRQ WKH <RFRQD SURQRXQFHG <RN QD 7KH -060$ LQYLWHV DQ\ SK\VLFLDQ WR submit poems for publication in the Journal either by email at lukelampton@cableone.net or regular mail to the Journal, attention: Dr. Lampton.] â&#x20AC;&#x201D; Eà¨&#x201E;.

Moccasined souls single file stealthily Along its banks Dodging the fruits of melancholy bald cypress branches Chahta, bring my people home. Gnarled fingers pick clean bones of our dead Colorfully woven baskets belie their funereal fate Spirits ascend encouraged by festooned poles encircling new graves Chahta, bring my people home. Sacred earth salted by my trail of tears Sacred earth cleansed by your Yockanookany waters Forever healed Chahta, I am home at last! â&#x20AC;&#x201D; Stanley Hartness, MD JMSMA Associate Editor (Authorâ&#x20AC;&#x2122;s note: The Yockanookany River, a tributary of the Pearl which meanders through central Mississippi, was sacred to the Choctaws, an original people of the American southeast who took their name from Chahta, a legendary leader.) JANUARY â&#x20AC;¢ JOURNAL MSMA

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Good Riddance Day

s has become the touchstone start to every morning after getting my coffee pot cranked up, I grabbed my ‘Our Daily Bread’ devotional book. While the brown potion which gets the blood flowing was hissing, I learned that Friday, December 28, was “Good Riddance Day.” This is a real live annual occurrence, based on a Latin American tradition, where people write down on paper some unpleasant part of their lives, embarrassing memories, bad issues, or the names of toxic people from the recent past and destroy these either by shredding or taking a sledgehammer to them. One group I read about stuff their “goodbye-to” notes inside a cloth doll (not a voodoo doll of course) and throws them in a ceremonial fire. Since 2006, there has been a celebration of “Good Riddance Day” at this time each year in New York City’s Times Square. This year countless hundreds of people gathered there for the annual event. People wrote down everything they did not want to bring with them into the New Year, old paid bills, empty medicine bottles, cigarette packs, copies of divorce decrees, etc. and brought them to a giant shredder truck for final dispensation. Of course, as with all things in Times Square, a party ensued and all of this went on well before the ball dropped at midnight a couple of days later. At that point, refrains of Guy Lombardo’s “Should Old Acquaintance Be Forgot,” hugging and kissing, and other frivolities became the order of the evening. In his recent Tupelo Journal column, Marty Russell said it best, “Good riddance to that stink bomb of a year 2018. I guess nature has a way of balancing out the good and the bad so maybe that means in 2019 we’ll come to our senses and stop the bleeding from poor past decisions about everything from politics to the environment to deficit spending to whatever social media app is the privacy-stealing must-have of the day.” Could not have said it better myself! I have asked around about what folks I know specifically want to say good riddance to. Here are some that friends came up with. Some, reported exactly as they are, may make no sense to you. 1. 2. 3. 4. 5.

Albanian boyfriends Endless campaign mudslinging commercials on TV A nagging pain in my right side A nosy next-door neighbor Two hundred pounds of unwanted fat. (Is that the same as #1?) 6. Cats in my backyard (?) and too short daylight hours 7. Renters and rental property in general 8. A never-ending car payment 9. An outlaw/ in-law and an EX! 10. Smoking! My husband Roger’s list includes intensive care units, hospitals in general, hospital food in particular, being awakened and punctured for lab six times a day, for wheelchairs, walkers, adult 36 VOL. 60 • NO. 1 • 2019

diapers, and pressure sores. I say AMEN to all these wishes of his for saying “good riddance.” And, I would like to wish a belated GOOD RIDDANCE to something that has been in my attic for the past ten years. When I was treated for a parotid gland malignancy in the fall of 2008, I took radiation therapy to my head and neck for two months. The actual critter is called an Aquaplast™ immobilization device, Dwalia S. South, MD but basically was the plastic mesh head and neck mask that they manufactured to reliably clamp me in the exact position needed for my daily radiation treatments. I was given the white plastic headpiece as a souvenir of sorts after the treatments were done and kept it in my attic. I would bring it out on Halloween to scare kids with in Freddy Kruger fashion! While I was fumbling around upstairs this fall, looking for some home hospital equipment for my husband, I ran across it, picked it up and noted that the darn thing was dry-rotted! Wherever I would touch it, it would disintegrate. This was my cue that it was time to say good riddance to it. So, exactly ten years after it did the job for which it was created, I decided to burn the ghastly thing. (See photos.) When the flame went out and the ghostly visage became nothing more than a fizzled memory, we stoked the fire with some fresh wood and celebrated with a marshmallow and weenie roast! There are many more things including a few people to whom I would like to say GOOD RIDDANCE. But, at this juncture, I will have to quote the steadfast Auntie Em from the Wizard of Oz… “Elmira Gulch, just because you own half the county doesn’t mean you have the power to run over the rest of us. For 23 years, I’ve been dying to tell you what I thought of you, and now…well, being a Christian woman, I can’t say it.” Yes, let’s start 2019 with fresh new beginnings and throw some water on all the wicked witches and their henchmen who have long bedeviled us. Q

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