November 11 JMSMA

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Publications Committee Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD, Ex-Officio Myron W. Lockey, MD, Ex-Officio and the Editors The Association Thomas E. Joiner, MD President Steven L. Demetropoulos, MD President-Elect J. Clay Hays, Jr., MD Secretary-Treasurer Lee Giffin, MD Speaker Geri Lee Weiland, MD Vice Speaker Charmain Kanosky Executive Director

Journal of the Mississippi State Medical Association (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual).

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NOVEMBER 2011

VOLUME 52

NUMBER 11

Scientific Articles

T. Asahii Pulmonary Infection as A Complication of Tnf-Inhibitor and Steroids: Posaconazole Pharmacotherapy and Risk Analysis Somjade Songcharoen; John D. Cleary, PharmD., FCCP; John Jenkins, MD and Matthew DeShazo, MD

Top 10 Facts You Need to Know About About Febrile Seizures

346

Owen B. Evans, MD and John B. Ingram, MD

Special Article

Give Thanks, Give Back

354

Karen A. Evers, Managing Editor

President’s Page Times Change

357

Thomas E. Joiner, MD; MSMA President

Editorial

The Electronic Age

358

Ann Myers, MD

Related Organizations

Mississippi State Department of Health MSMA Alliance

344 363

Departments

Personals Poetry in Medicine Placement/Classified The Uncommon Thread

360 365 366 367

About The Cover:

Thomas E. Sheffield, MD, FACP captured this photo from his kitchen window in Columbus one morning in September of 2009. He says the fawn was having breakfast, and it was common to see deer in their backyard. The photo was taken with a Canon Power Shot SX1 IS, ISO 200, 100 mm, 0 EV, f/5.7, 1/25. Dr. Sheffield practiced internal medicine for 25 years. He now works at the G. V. (Sonny) Montgomery VA Medical Center in Jackson after retiring from his practice in Columbus in 2002. He is a past president of the Prairie Medical Society, a fellow of the American College of Physicians. While in the Jackson area, he and his wife Libba live at the Township at Colony Park in Ridgeland. r November

VOL. LII

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2011

No. 11

November 2011 JOURNAL MSMA 337

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• Scientific Articles • T. Asahii Pulmonary Infection as a Complication of Tnf-Inhibitor and Steroids: Posaconazole Pharmacotherapy and Risk Analysis Somjade Songcharoen, MD; John D. Cleary, PharmD, FCCP; John Jenkins, MD and Matthew DeShazo, MD

A

bstract

We report the first documented Trichosporon asahii infection in a patient with connective tissue disease treated with a Tumor Necrosis Factor (TNF) inhibitor and describe an institutional root cause analysis for TNF inhibitor-associated infections. Fourteen patients with incident fungal infections during TNF inhibitor treatment were identified. They were matched with uncomplicated patients receiving TNF inhibitors or with rheumatoid arthritis (RA) patients managed without TNF inhibitors. We found that patients acquiring fungal infections were more likely to have graft versus host disease (GVHD) (p<0.05).

Furthermore, infected patients were more likely (OR= 24.4) to have multiple immunosuppressive therapies over the controls as well as several risk factors identified by the Infectious Disease Society of America (IDSA). The 3 patient deaths in our study were associated with GVHD and infliximab. Trichosporon was isolated in 1 patient receiving adalimumab. Our results suggest that these high risk patients be monitored closely for fungal infection.

Key Words: Graft vs Host Disease, Rheumatoid Arthritis, Tumor Necrosis Factor-alpha, Fungal Infection

Introduction Rheumatoid arthritis is a chronic inflammatory arthritic disease that leads to deformity, disability, and early death if not treated aggressively.1 The anti-tumor necrosis factor-a biologics (TNF inhibitors) have become a mainstay of therapy in Author Information: Somjade Songcharoen, MD, Department of Medicine; John D. Cleary, PharmD., FCCP, Professor & ViceChairman of Research, Department of Pharmacy Practice, Schools of Pharmacy & Medicine; John Jenkins, MD, Associate Professor of Medicine, Division of Rheumatology/Molecular Immunology­­, School of Medicine and Matthew DeShazo, MD, House Officer, Department of Medicine are all affiliated with the University of Mississippi Medical Center, 2500 N. State Street, Jackson, MS 39216

rheumatoid arthritis (RA) in patients who do not respond well to nonsteroidials and traditional oral disease-modifying antirheumatic drugs.2 Five different molecules serve as functional TNF inhibitors: soluble receptors (etanercept, receptor-Ig construct), chimeric (infliximab) or humanized (golimumab, adalimumab) monoclonal antibodies, and pegylated humanized Fab’ fragment to TNF (certolizumab). All are currently available for use in RA, but their different mechanisms of TNF inhibition may be responsible for subtle differences in clinical effect and side effects. One of the primary concerns with TNF inhibitors (and with other biologic agents affecting other aspects of the immune or inflammatory system) is the risk of serious infection. In this report we will address invasive fungal infections.

Infliximab, approved by the Food and Drug Administration (FDA) in 1998, received its first black box warning associated with secondary infections in October 2001.3 This warning suggested an increased risk of tuberculosis and invasive fungal infections (histoplasmosis and Pneumocystis jirovecii added as a bolded warning) as well as other opportunistic organisms. In July 2004, coccidioidomycosis was added to the black box warning. Adalimumab, another TNF inhibitor, was approved by the FDA in 2002 with a black box warning regarding tuberculosis. Subsequently, invasive fungal and opportunistic infections were added and then strengthened to a bolded warning in 2007. Etanercept, FDA-approved in 1998, received a black box warning in April 2008 regarding serious infections. The differences in the mechanisms of tumor necrosis factor (TNF) inhibition might play a role in the varying susceptibilities to opportunistic infections and resultant FDA warnings. Regardless, each of these pharmaceuticals appears to increase the risk of fungal infections.4 Localized to severe infections with Trichosporon are being increasingly reported.5 Trichosporon infections can be invasive, usually occurring in immunocompromised patients.

Typical pathological findings of pulmonary Trichsporon

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infections reveal minimal inflammatory cell infiltration, necrosis, and hemorrhage. The diagnosis of a Trichosporon infection is usually based on several factors including blood cultures, tissue pathology or cytology, and non-specific clinical symptoms such as those of a yeast infection. Our purpose is to report the first case of Trichosporon asahii infection in a patient with connective tissue disease treated with a TNF inhibitor and to describe an institutional root-cause analysis for infections associated with TNF inhibitors.

Case Report A 48-year-old African-American male with a previous history of rheumatoid arthritis/mixed connective tissue disease overlap, diabetes mellitus, hypertension, gastroesophageal reflux disease, and opioid dependence presented to a tertiary care center with a chief complaint of right-sided chest pain for 5 days. He described the pain as a sharp anterior pain with intermittent radiation to his back. The patient stated that his pain was similar to a previous episode of pericarditis years ago. He also reported a cough that produced brown sputum but denied any significant hemoptysis. In addition, he reported night sweats, anorexia, and a fifteen pound weight loss over a 6 week period.

He denied fever, chills, and abdominal pain. The patient had recently been started on adalimumab 40 mg subcutaneously every other week and was on long term maintenance with prednisone 30 mg/day and methotrexate 20 mg orally once weekly, all for his connective tissue disease. One month previously, a plain chest radiograph and chest Computed Tomography (CT) indicated there was no active pulmonary disease.

At time of admission, the patient’s temperature was 98.2 F, blood pressure 154/108 mm Hg, supine 160/102 mm Hg, respiratory rate 20, and pulse 84 bpm. He was hypoxemic with a pAO2 of 69 torr. His white cell count was 12.3 th/cmm with 83.6% segmented neutrophils and 11.8% lymphocytes. Multiple pulmonary nodules were observed on chest x-ray and CT of his thorax. After a review of the patient’s history, it was noted that he had recent contact with a family member who was diagnosed with Mycobacterium tuberculosis (MTb). The patient was then placed on respiratory isolation, and his sputum was cultured for acid-fast bacteria (AFB). During his admission, his serum antinuclear and SS-B antibodies were both 184.0 (0-99) u/ml and his Westergren sedimentation rate 45 (1-9) mm/h. The patient was taken off of methotrexate, adalimumab was held, and his prednisone dose remained at 30 mg/day, the minimal dose tolerated by the rheumatologists. After serial sputum cultures for AFB were negative, the decision was made to perform a bronchoscopy.

Pathology identified a fungus in the sample from the bronchoscopic evaluation and bronchoalveolar lavage. Geimsa staining was initially positive for mold forms (Figure 1A, B). Cytology described a mold with septated hyphae and rare narrow based budding suggestive of Aspergillus. Confirmatory studies ruled out other fungal species, and an IgE precipitant was positive for Aspergillus. Unfortunately, cultures were

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not sent to microbiology, and initial therapy was empirically directed toward invasive A. fumagatus. Inpatient intravenous voriconazole 4mg/kg every twelve hours was initiated and after 48 hours stepped down to oral therapy which was continued after discharge for 18 days. He was closely followed by infectious disease and rheumatologists during therapy. Both agreed that he clinically and radiologically failed this therapy. At day 29 post discharge, posaconazole 400mg orally twice a day was started.

After hospital discharge, Trichosporon was ultimately identified as a probable pathogen by visual examination of cytology specimens. Trichosporon deoxyribonucleic acid (DNA) detection was performed by polymerase chain reaction (PCR) using biopsy tissue to confirm the T. asahii infection. The PCR and sequencing DNA of T. asahii was amplified with the primers TAAF (forward: 5’-GGATCATTAG TGATTGCCTTTATA-3’) and pITS4 (reverse: 5’-TCCTCCGCTTATTGATATG-3’).6 A 520 bp DNA fragment was produced from the tissue using T. asahii species-specific primers. The DNA sequence of this fragment was identical to that of internal transcribed spacer regions of T. asahii (GenBank accession number, AB018013).

Figure 1A, 1B . Geimsa staining was initially positive for mold forms.

Fig 1A.

Fig 1B.

Further studies revealed positive results using a monoclonal antibody against Trichosporon sp. (K-16, Cosmovio, Japan).

The patient was ultimately diagnosed with a localized pulmonary T. asahii infection after PCR confirmation of the fungal organism. After 6 months, his symptoms resolved and chest x-ray did not reveal any pulmonary infiltrates. His therapy was changed to posaconazole 200 mg daily for an indefinite time period to reduce the chances of relapse while on immunosuppressive drugs. Immunosuppressant medications were reinitiated and included rituximab 1000 mg IV twice 2 weeks apart every 6 months as per RA protocol, prednisone 10 mg daily, plaquenil 200 mg twice daily, and methotrexate 15 mg weekly.

His follow-up acid fast bacillus stains and cultures of sputum were negative for MTb. Repeat chest CT scan was negative for pulmonary infiltrates at 18 months post-discharge.

Root Cause Case Control Analysis TNF-a is a proinflammatory cytokine involved in the pathophysiology of rheumatoid arthritis, Crohn’s disease, and various other chronic inflammatory processes. An association between TNF inhibitors and the risk of infection also appears evident by many case reports.7-12 A PubMed search was performed for literature from 1969 through January 2008 to obtain information about TNF inhibitors and fungal infections. The literature search revealed 39 case reports implicating all 3 TNF inhibitors, with infliximab being implicated to the greatest extent. A wide range of organisms was isolated in these cases including Aspergillus spp., Candida albicans, Cryptococcus sp., Histoplasma sp., Mucor sp., Coccidioides sp., Sporothrix sp., Pneumocystis jirovecii.

Most patients in these reports received concomitant prednisone and methotrexate. The average onset of infection relative to the first dose of a TNF inhibitor was 26 weeks. Seven patients died from infections associated with or directly attributed to an opportunistic organism.7-29 In concordance with the literature search, FDA reports up to and including the first quarter of 2007 suggest that this adverse reaction is rare. For agents available in the United States, the following was found: twenty reports of fungal infection associated with infliximab (Remicade™), 23 for adalimumab (Humira™), and one for etanercept (Enbrel™).30 The number of patients treated worldwide was obtained from the manufacturer during the same time frame and was estimated to be 924,000, 250,000 and 500,000 doses for each of the agents, respectively. It is estimated that the United States accounts for about 85% of the total usage of these medications. A necdotally, our institution appeared to have relatively frequent fungal infections in TNF inhibitor users compared to FDA and literature reports, leading to the need for this root cause analysis.

In an attempt to assess the etiology of our fungal infections as well as the possibility of its association with the use of TNF inhibitors, we performed a Root Cause Case Control Analysis. Case patients included men or women identified by patient care services to have received a TNF inhibitor from Au-

gust 2004 to 2008. Case patients must have had a severe (invasive), a non-severe (cutaneous/subcutaneous), or a superficial yeast or mold infection. Diagnoses were classified by ICDM (International Classification of Diseases, Ninth Revision, Clinical Modification code 820.x) as determined by the primary care provider in the medical records. Control patients were selected from the same population. Patients treated with a TNF inhibitor who subsequently developed a fungal infection were matched 1 case to 4 controls with patients treated with a TNF inhibitor who had not acquired a fungal infection (Control I) and 1 case to 4 controls with patients receiving immunosuppressive therapy for rheumatoid arthritis (RA) that excluded TNF inhibitors (Control II). Demographic data, pharmacotherapy, risk factors for invasive fungal infections (as defined by IDSA), and infectious outcomes were collected and tested for associations by analysis of variance (ANOVA). This test was performed to evaluate for a significance (alpha = 0.05, beta = 0.2) of variables associated with the outcome of fungal infection using Sigma Stat (Aspire Software International; Ashburn, VA). Any missing data were not replaced.

Ultimately, we identified 14 cases of fungal infection (Cases). Patients were treated with infliximab (10, 71.4%) or adalimumab (4, 28.6%). Control patients were grouped based on TNF inhibitor use (Control I) or routine severe RA patient (Control II). One-hundred and eight subjects were identified, and 64 were randomly selected for Control group I. Control group I was selected in order to identify possible characteristics of TNF inhibitor use that could be discriminated as a risk factor and managed. Patients were treated with all 3 agents in this group: infliximab (41, 64%), adalimumab (10, 16%) and etanercept (13, 20%). There was 1 case each of ICDM code 696.0 (psoriatic arthritis) and 279.00 (arthritis due to or associated with hypogammaglobulinemia) in the original 108 patients who did not make the random selection for the study population.

Control group II was used to assess highly immunosuppressed patients with rheumatoid arthritis with similar risk yet not treated with TNF inhibitors. There were no significant differences in patient demographics. The average age was 45 years with a range of 15 through 64 with most being female (average 70%).

The racial distribution was nearly 50% Caucasian, 50% African American in all 3 groups, reflecting the ethnic mix of our clinics. However, the primary diagnosis of treatment was statistically different between groups. A patient who acquired a fungal infection (p < 0.05) was more likely to have been treated for graft versus host disease (GVHD) (43%) than RA (3% Control group I) (OR = 24.4).

Fungal infections in cases were distributed among mold infections (invasive aspergillosis, N=2), yeast infections caused

by Candida species (candiduria N=2, pneumonia N=2, sepsis N=2, orapharyngeal N=4), Trichossporon asahii (N=1) or yeast unidentified with associated empiric therapy (N=1). There were no cases in Control group I and 6 cases of vaginal candidiasis in Control group II. Patients who became infected were statistically more likely to have multiple immunosuppressive

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than two-fold higher mortality (39% vs 18% and 57% vs 24%, respectively). One might suspect that this relationship would be true for disseminated mold infections also.32-33 Immunosuppression associated with other newer agents, including TNF inhibitors, has been identified as a specific risk factor for invasive fungal infections. Disseminated histoplasmosis has been reported most commonly.34-36 Trichosporon spp. have been recognized as causative agents of fungemia, especially in patients who have neutropenia and cancer. Trichosporonosis may symptomatically Discussion resemble hematogenous candidiasis in clinical presentation.5 Our observations suggest that patients with GVHD reHistopathologic samples containing Trichosporon sp. have ceiving infliximab or adalimumab suffer a higher rate of funbeen reported to present with forms similar to Candida sp. or gal infection than patients being treated with TNF inhibitors even Aspergillus sp. In some reported cases, the yeast isolate for other indications. However, this is a high risk population was misidentified as Candida sp., only later to be identified as already. Published literature identifies high rates of fungal inTrichosporon asahii var. asahii.37 In our case, the cultures of fection in stem cell transplant patients. Once GVHD develops, blood and sputum were negative. Like most invasive yeast and these rates increase. This rate of infection is higher in patients mold infections, outcomes are linked to improvement in unreceiving higher risk transplantations like allogenic bone marderlying immunity. However, in our case immunosuppression row transplants.31 Risk factors for invasive yeast or molds continued due to the patientâ&#x20AC;&#x2122;s debilitating rheumatoid arthritis. include the following: central venous catheterization, total Trichosporon infections refractory to conventional anparenteral nutrition, antibiotic use (broad-spectrum, multiple, tifungal drugs are frequently reported. Optimal therapy for or prolonged administration), severe disease (Acute Physioltrichosporonosis has not yet been documented.5 Clinical Laboogy and Chronic Health Evaluation (APACHE) II score >20), ratory Standards Institute (CLSI) 2002 documents standardized neutropenia, prolonged time in the intensive care unit (ICU), antifungal susceptibility testing of Candida or Cryptococcus mechanical ventilation, diabetes mellitus, renal failure/hemoneoformans but does not include the genus Trichosporon. Howdialysis, immunosuppression (eg, due to advanced age, cancer, ever, studies suggest that T. asahii is more resistant to amphochemotherapy, corticosteroids), and acute pancreatitis. For distericin B (MICs > 2ug/mL) and more susceptible to triazoles.38 seminated yeast infections, lack of an infectious disease consult Multiple therapeutic failures associated with poor susceptibilior failure to follow IDSA guidelines was associated with more ties have been reported with amphotericin B, echinocandins, fluconazole, itraconazole and 5-fluorocytosine, alone or in combination.5 Triazoles Table 1.

Table 1: Data Summary tested in vitro or in vivo appear the most Cases Control Control Sample 14 64 64 effective.5, 38 Our patientâ&#x20AC;&#x2122;s infection was refractory to voraconazole, yet posaconPrimary PERCENT PER GROUP azole was effective in our case. There are ICDM many possible explanations for this, but 135.x Sarcoidosis 7 3 0 446 Arteritis, necrosing or necrotizing 0 2 0 we feel that our patient exhibited better 555.9 Gastroenteritis, ulcerative 14 27 0 absorption with posaconazole.

695.4 Lupus, erythematosus 0 2 0 714.x Rheumatism, rheumatic 36 64 100 996.8 Syndrome, graft-versus-host (bone marrow) 43 3 0 Conclusions: Patients receiving TNF inhibitors Risk Factors for Fungal develop fungal infections at a higher rate Immunosuppressive Therapy (>1 Agent) than comparable patients not receiving Azathioprine 0.0 1.9 0.0 Cyclosporine 14.3 0.0 1.6 such therapy. We report the first docuHydroxychloroquine 0.0 4.6 28.1 mented report of a Trichosporon infection Imuran 14.3 6.5 0.0 in a patient treated with a TNF inhibitor.

Leflunomide 0.0 4.6 28.1 In addition, patients with GVHD account 48.4 Methotrexate 35.7 43.5 14.3 4.6 0.0 Mycophenolate Mofetil for nearly fifty percent of all identified Plaquenil 0.0 0.0 1.6 TNF inhibitor-associated infections in our Prednisone 35.7 0.0 0.0 institution. These data suggest that these Tacrolimus 21.4 0.0 0.0 high risk patients should be monitored Central Venous 14.3 0.0 0.0 closely for fungal infection when initiated Broad Spectrum 28.6 0.0 0.0 on TNF inhibitors. therapies that were not utilized in the control groups. Specifically, an infected patient was more likely to be treated with cyclosporine, imuran, mycophenolate, tacrolimus or high dose prednisone (Table I). In addition, infected patients were significantly more likely to have several IDSA MSG identified risk factors (central venous catheter, broad spectrum antibiotics or total parenteral nutrition) compared to the control groups (p < 0.01). There were 3 patient deaths, all of whom were being treated for GVHD with infliximab.

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29. Kaur N, Mahl TC. Pneumocystis jiroveci pneumonia after infliximab therapy: a review of 84 cases. Dig Dis Sci. 2007;52(6):1481-1484.

12. Velayos FS, Sandborn WJ. Pneumocystis carinii pneumonia during maintenance anti-tumor necrosis factor-α therapy with infliximab for crohn’s disease. Inflamm Bowel Dis. 2004;10(5):657-660.

30. United States Food and Drug Administraiton (2008). MedWatch safety information website. www.fda.gov. Accessed November 2007.

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31. Michallet M, Ito JI. Approaches to the management of invasive fungal infections in hematologic malignancy and hematopoietic cell transplantation. J Clin Oncol. 2009; 27(20):3398-3409.

14. Mori S, Imamura F, Kiyofuji C et al. Pneumocystis jiroveci pneumonia in a patient with rheumatoid arthritis as a complication of treatment with infliximab, anti-tumor necrosis factor-α neutralizing antibody. Mod Rheumatol. 2006;16(1):58-62.

32. Ostrosky-Zeichner L, Pappas PC. Invasive candidiasis in the intensive care unit. Crit Care Med. 2006;34(3):857-863.

15. Montero JA, Ruiz-Moreno JM, Rodriguez AE, Ferrer C, Sanchis E, Alio JL . Endogenous endophthalmitis by propionibacterium acnes associated with leflunomide and adalimumab therapy. Eur J Ophthalmol. 2006;16(2):343-345.

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33. Pate1 M, Kunz DF, Trivedi VM, Jones MG, Moser SA, Baddley JW. Initial management of candidemia at an academic medical center: evaluation of the IDSA guidelines. Diagn Microbiol Infect Dis. 2005;52(1):29-34.

34. Humira [package insert]. Abbott Park, IL: Abbott Laboratories; 2008.

35. Remicade [package insert]. Horsham, PA: Centocor Inc; 2007.

36. Enbrel [package insert]. Madison, NJ: Wyeth; 2008.

17. Hoang JK, Burrus J. Localized cutaneous cryptococcus albidus infection in a 14-year old boy on etanercept therapy. Pediatr Dermatol. 2007;24(3):285-288.

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Moretti-Branchini ML, Fukushima K, Schreiber AZ et al.

Trichosporon species infection in bone marrow transplanted patients. Diagn Microbiol Infect Dis. 2001; 39(3):161-164.

18. Gottlieb GS, Lesser CF, King KH, Wald A. Disseminated Sporotrichosis associated with treatment with immunosuppressants and tumor necrosis factor-α antagonists. Clin Infect Dis. 2003;37(6):838-840.

38. Paphitou NI, Ostrosky-Zeichner L, Paetznick VL, Rodriguez JR, Chen E, Rex JH. In vitro antifungal susceptibilities of trichosporon species. Antimicrob Agents Chemother 2002; 46(4):1144-1146.

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â&#x20AC;˘ MSDH â&#x20AC;˘ Mississippi Reportable Disease Statistics

August 2011 Figures for the current month are provisional

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

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

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â&#x20AC;˘ Top 10 â&#x20AC;˘

Top 10 Facts You Need to Know About Febrile Seizures Owen B. Evans, MD and John B. Ingram, MD

I

ntroduction

sign of the fever. Usually the temperature is greater than 102 degrees Fahrenheit, although rapid rate of rise of the temperature is thought to be more significant than peak of temperature.1

Simple febrile seizures occur in about 3% of otherwise healthy children between the ages of 6 months to 5 years with a peak incidence at 2-3 years of age.1 The cause of a febrile seizure is unknown but there is often a familial history of febrile seizures. Complex febrile seizures are more likely to be associated with meningitis or encephalitis, epilepsy, underlying metabolic or electrolyte abnormalities, intoxications, trauma, brain tumors and other central nervous system disease.

Children with simple febrile seizures do not typically need an extensive evaluation such as brain imaging, lumbar puncture, and EEG. A complex febrile seizure is one that does not meet the criteria for a simple febrile seizure.2 These studies should be considered for children not meeting the criteria for a simple febrile seizure, especially those less than a year of age.

3. Febrile illness is caused by common pathogens: The most common causes for the febrile illness associated with febrile seizures are otitis media, roseola, and upper respiratory viral infections (particularly influenza).3 Meningitis and encephalitis are always concerns. A history of a preceding period of lethargy, irritability, nausea or vomiting suggest a central nervous system infection, and signs of meningismus on examination warrant a lumbar puncture. Because infants less than 12 months of age are more difficult to clinically evaluate, lumbar puncture is recommended.

1. Simple febrile seizures are brief: The seizure is a generalized tonic-clonic seizure that lasts several minutes and may be associated with a fall injury, tongue biting, and incontinence. Following the seizure, the child is obtunded and/or confused for a brief period of time but should return to baseline rather quickly. Status epilepticus (a seizure lasting longer than fifteen minutes OR subsequent serial seizures before the child awakens from the previous seizure) associated with fever, multiple seizures within the same febrile illness, and partial seizures are not consistent with simple febrile seizures. 1

4. Except for the febrile illness the child is normal: The child with a simple febrile seizure is developmentally normal, has a normal neurologic examination and has no evidence for trauma, central nervous system infection, metabolic disturbances (other causes for a seizure).1 Children of any age with epilepsy are prone to have seizures with fever, and children with developmental disorders and focal neurologic signs are at higher risk for epilepsy than the general population. Even if all other criteria are met for a simple febrile seizure, children with abnormal neurologic examinations and/or delayed development need a more extensive evaluation.

2. The fever is significant: A febrile seizure occurs in the first 24 hours of the febrile illness and may be the first Author Information: Dr. Evans is professor of pediatrics and neurology and Dr. Ingram is a senior resident in pediatric neurology at the University of Mississippi Medical Center in Jackson.

Corresponding Author: Owen B. Evans, MD; University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216 (bevans@umc.edu).

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5. Children with simple febrile seizures have only a few: Most children will only have one episode in their childhood. About one third will have a second and of these, one half will have a third. It is rare for a child to have more than three simple febrile seizures. A family history of febrile seizures, a febrile seizure that occurs before twelve months of age, and a child who has a seizure with a fever of less than 102 degrees Fahrenheit are more likely to have subsequent febrile seizures.4

6. Simple febrile seizures occur in the 6 month to six year age range: The child who has had more than three simple febrile seizures should be evaluated for epilepsy, especially if the seizures occur in a child who is younger than six months or older or persist beyond age five years.

Some of these children may have the â&#x20AC;&#x153;generalized epilepsy with febrile seizures plusâ&#x20AC;? syndrome. This is a genetic disorder with a variable phenotype but can be associated with intractable epilepsy. 5 Fever often causes a child with epilepsy to have a seizure and very often this is the first seizure. A child with a febrile seizure who has a history of one or more seizures without a fever has epilepsy. Some seizures, such as brief partial complex, myoclonic and absence seizures, may not be recognized as seizures by the caregivers and should be specifically asked about such activity.

7. Simple febrile seizures are unlikely to cause subsequent epilepsy: A child with simple febrile seizures has about the same risk of developing later epilepsy as the general population (1%).6 Children with complex febrile seizures, however, are at greater risk of subsequent epilepsy.7 This risk continues into adulthood.

8. Simple febrile seizures do not cause brain injury: A child with simple febrile seizures is not at risk for brain damage or subsequent neurologic complications from the seizure itself. Subsequent measures of intelligence, academic performance, attention, and behavior are not significantly different from children without a history of febrile seizures.8 9. Anticonvulsant medications are not recommended for the prevention of simple febrile seizures: The anticonvulsants phenobarbital, primidone, and sodium valproate are effective in reducing the risk of febrile seizures when given as prophylaxis at therapeutic doses.

However, there are significant risks associated with their use.9 Intermittent use of diazepam with febrile illnesses also reduces the risk of a febrile seizure but causes sedation as well.10 10. The acute management of a febrile seizure is the effort to keep the child safe from injury: Caregivers should be instructed to protect the childâ&#x20AC;&#x2122;s head and extremities, ensure there are no restraints to adequate respirations, and avoid putting anything in the mouth, especially their fingers.

Objects in the mouth may fracture teeth and cause more injury than the seizure itself. Although antipyretics may reduce pain and fever, they do not reduce the risk of febrile seizures.11 The child should be allowed to recover quietly, and attempts to awaken the child should be avoided.

Conclusion Fever is a common cause of seizures in children. A simple febrile seizure is one that: 1) lasts less than fifteen minutes; 2) is

a generalized tonic-clonic seizure; 3) occurs in the first 24 hours of the febrile illness; 4) is a single seizure within the febrile illness; 5) occurs in an otherwise healthy child who has a normal developmental history and normal neurologic exam. Children who meet the criteria of a simple febrile seizure are at no greater risk for subsequent epilepsy or neurologic impairment than other children. Children not meeting the criteria have complex febrile seizures and have a greater risk of having a serious underlying causation and subsequent epilepsy. A thorough history and physical examination separate the simple from the complex febrile seizure and those who need limited diagnostic evaluation from those who need more extensive diagnostic studies and possible referral to a neurologist. The National Institutes for Health website has useful information for families10, and the American Academy of Pediatrics has practice guidelines for the management of febrile seizures.11

References 1.

Nelson KB, Ellenberg JH. Prognosis in children with febrile seizures. Pediatrics. 1978;61 (1):720-727.

2.

Berg AT, Shinnar S. Complex febrile seizures. Epilepsia.

1996;37(2):126-133.

3.

Farwell JR, Blackner G, Sulzbacher S, Adelman L. Febrile seizures: Characteristics of the child, the seizure and the illness.

Clin Pediatr (Phila). 1994; 33(5):263-7.

4.

Berg AT, Shinnar S, Darefsky AS, et al. Predictors of recurrent febrile seizures: a prospective cohort study. Arch Pediatr Adolesc Med. 1997; 151(4):371-378.

5.

Scheffer IE, Berkovic SF, Generalized epilepsy with febrile seizures plus: A genetic disorder with heterogeneous clical phenotypes. Brain. 1997;120(PT 3):479-490.

6.

Nelson KB, Ellenberg JH. Predictors of epilepsy in children who have experienced febrile seizures. N Engl J Med. 1976;295(19):1029-1033.

7.

Annegers JF, Hauser WA, Shirts SB, Kurland LT. Factors prognostic of unprovoked seizures after febrile convulsions. N Engl J Med. 1987;316(9):493-498.

8.

Chang YC, Guo NW, Huang CC, Wang ST, Tsai JJ. Neurocognitive, attention and behavior outcome of school aged children with a history of febrile convulsions: a population study.

Epilepsia. 2000;41(4):412-420.

9.

Harranz JL, Armijo JA, Arteaga R. Effectiveness and toxicity of phenobarbital, primidone and sodium valproate in prevention of febrile convulsions, controlled by plasma levels. Epilepsia. 1984; 25(10): 89-95.

10. Rosman NP, Colton T, Labasso J, et al. A controlled trial of diazepam administered during febrile illness to prevent recurrence of febrile seizures. N Eng J Med. 1993; 329(9):79-84.

11. Van Esch A, Sreyerberg EW, Van Steneensel-Moll HA, et al. A study of the efficacy of antipyretic drugs in the prevention of febrile seizure recurrence. Ambul Child Health. 2000; 6(11):1926.

12. Febrile seizures. National Institute of Neurological Disorders and Stroke. http://www. ninds.nih.gov/disorders/febrile seizures/ detail febrile seizures.htm. Accessed June 2, 2011.

13. Committee on Quality Improvement, Subcommittee on Febrile Seizures, American Academy of Pediatrics. Practice parameter: long-term treatment of the child with simple febrile seizures.

Pediatrics. 1999;103(6):1307-1309.

November 2011 JOURNAL MSMA 347

Are you a PCP? “PHYSICIANS CARE” PROVIDER

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Strength in numbers – Our provider network is growing...currently over 3,500 physicians and allied providers, with new providers credentialed each month.

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MPCN’s Board of Directors is physicians only.

If you’re not a “Physicians Care” Provider, join today!

If you are... Congratulations, you’re with the right network.

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348 JOURNAL MSMA

November 2011

Introducing James B. Walker, MD Baptist Memorial Medical Group proudly introduces neurosurgeon James B. Walker, MD, to the Oxford community. Dr. Walker specializes in the minimally invasive treatment of degenerative spinal disorders, brain and spine tumors, peripheral nerve disorders, facial pain, hydrocephalus, and spasticity.

His comprehensive treatment and surgical care includes: •

Minimally invasive spine surgery

•

Surgical treatment for brain, spine, and pituitary tumors

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Medical and surgical management of traumatic brain injury

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Surgery for carpal tunnel syndrome and ulnar nerve entrapment

•

Endoscopic treatments for hydrocephalus

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Complex peripheral nerve surgery

•

Percutaneous and surgical treatments for facial pain/trigeminal neuralgia

•

Surgical treatment for Chiari malformation

Dr. Walker earned his medical degree from the University of Alabama-Birmingham, and completed his residency at The University of Mississippi Medical Center, where he also served a faculty appointment. He is a member of the Congress of Neurological Surgeons and the American Association of Neurological Surgeons.

Your neighborhood health care partner.

OXFORD NEUROSURGERY 2301 South Lamar, Suite 130 | Oxford, MS 38655 | 662-513-1300

November 2011 JOURNAL MSMA 349

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O’Brien & Family Law Group

James

P.O. Box 2623 682 Towne Center Blvd.

Ridgeland, Mississippi 39158 (601) 952-0050 (Office) •(601) 952-0904 (Fax) office@jamesandobrien.net James & O’Brien Family Law Group consists of five attorneys, L.C. James, Danna A. O’Brien, David E. James, Alicia C. Baladi and Kim D. McCormack, who specialize in domestic law cases of all types, with a particular emphasis on divorce and custody. The Firm has earned and maintained an “AV” rating (very highest) in Martindale-Hubble Law Directory for more than a quarter century, and its senior member, L.C. James, is one of only 1,397 attorneys in the nation and the only family law attorney in Mississippi who has been listed in every publication of “Best Lawyers in America” since its inception in 1983. The law firm is dedicated to each client as he or she deals with divorce. We strive to earn the respect and approval of each client, for we fully understand that our reputation for excellence has been established over these many years through the judges, our peer group of fellow attorneys, but most importantly, our clients.

350 JOURNAL MSMA

November 2011

ATTN DELTA DOCTORS:

Want to

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SAVE THE DATE: DECEMBER 6 at 12pm and 4pm

FREE INFORMATIONAL WEBINAR!

Learn how MSMA and the Delta Health Alliance can help you implement EHRs and connect to the Mississippi Health Information Network… at little cost to you!

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Participate in our webinar to learn how to ELECTRIFY your practice!

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Contact Toy Strickland at TStrickland@MSMAonline.com or 601-853-6733, Ext. 302.

This opportunity is funded through the DHA with support from DHHS ONC Grant # 90BC0004-01.

November 2011 JOURNAL MSMA 351

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352 JOURNAL MSMA

November 2011

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• Special Article •

Give Thanks, Give Back Karen A. Evers, Managing Editor The MSMA Foundation invites you to its second annual Give-Back Gala, Friday, December 2, at 7 p.m. at the South Warehouse in downtown Jackson. The Mardi Gras themed evening will be catered by Wendy Putt with Fresh Cut Floral and Catering. Tickets are $400 per couple (tax-deductible donation) and the purchase of a ticket enters you a chance to win an all-inclusive weekend getaway to New Orleans. The trip includes an optional private charter flight, two nights at The Roosevelt, and $400 gift card. The winner can choose the dates of trip.

The evening will begin with a cocktail reception with passed appetizers of corn-crab bruschetta and mini muffalettas.

A seated dinner will follow: mixed green salad with tri-color bell pepper, cucumber, tomato, and comeback dressing; shrimp and grits in martini glass; andouille sausage-stuffed pork loin with roasted garlic mashed potatoes; four-squash ratatouille and Gambino Bakery French bread with garlic butter. Dessert offers a choice of white chocolate whiskey bread pudding or praline brownie with pirouline and chocolate curls. The gala will offer dancing and a full open bar.

The gala will be hosted

by MSMA with music entertainment by Ned Fasullo and the Fabulous Big Band Orchestra. This same band played for the presidential inauguration of Dr. Tim Alford at annual session in Natchez two years ago. As a vocalist, Ned Fasullo’s singing embodies the feeling, persona, energy, and stage presence of the great crooners. Audiences from coast to coast have compared his look and style and phrasing to the Frank Sinatra, Dean Martin and Bobby Darin of the 50’s and 60’s at their career highs and swinging best. Ned and his group recently returned from their debut performance in New York City at Feinstein’s Supper Club in Manhattan and other performances in Miami, New Orleans and more. Ned’s musical arrangements are replicas of the original Nelson Riddle, Johnny Mandel, Neal Hefti, Count Basie, Duke Ellington, and more. Call it swing or call it crooning, his style is the continuation of the “art” now carried

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November 2011

on by other notables such as Harry Connick, Jr., Tony Bennett, Michael Buble, and others.

“In this season of thanksgiving and Christmas giving, it’s heartwarming to see so many friends turn out for the Give Back Gala,’’ said MSMA President Dr. Tom Joiner. “What a great time we had last year, and the funds raised will help accelerate the programs and services offered through the MSMA Foundation, Inc. It’s a worthy cause and a festive way to show appreciation for the benefits provided by our MSMA.” Last year, over 120 MSMA members and guests gathered at the Jackson Convention Complex for cocktails, dinner, dancing, and live jazz entertainment by New Orleans-based band “Swingaroux.” MSMA members and other supporters helped to raise nearly $15,000 to benefit the MSMA Foundation, Inc., a 501(c)3 charitable organization to which donations are fully taxdeductible.

All in attendance were there in an effort to help fund the the MSMA Foundation, Inc., a charitable, educational, and scientific trust organized to promote health education to the public, provide funding for medical research educational programs for Mississippi physicians, provide educational assistance for medical students, and provide grants to medical professionals whose practices have been impacted by disaster.

MSMA extends a big thank you to this year’s sponsors and donors: Children’s Health Center of Columbus, Medical Assurance Company of Mississippi, and Central Medical Society. MSMA Director of External Relations Anna Morris said, “We are in the midst of soliciting clinics, component societies, and other companies for sponsorships and those are just a few already on board.” Four sponsorship packages are available: Silver ($500), Gold ($1000), Platinum ($1500), and Table ($1800). All group clinics and component societies are encouraged to purchase a table (includes 5 couple’s tickets… admits 10 persons). To inquire about sponsorships contact or RSVP contact Anna Morris at 601-853-6733, Ext. 324 or AMorris@MSMAonline.com. r

Give-Back Gala 2010

Dr. Ric and Melanie Alexander

Dr. David Carroll and his wife Cassie with MSMA President Dr. Tom Joiner

Dr. Lee Giffin and his wife Dee Dee, Dr. William “Bill” Grantham and his wife Michelle

Therese and MSMA President elect Dr. Steve Demetropoulos with Rural Physician Scholarship Program Coordinator Janie Guice and her husband Daniel

Last year’s entertainment was provided by the New Orleans-based band Swingaroux. This year’s Give-Back Gala will feature Ned Fasullo and the Fabulous Big Band Orchestra.

November 2011 JOURNAL MSMA 355

This is my tort reform success story.

I knew I wanted to be a doctor. I wanted to help people right here in Mississippi. I stuck it out. I worked. I studied. I finished college, made it to medical school and my dream was within reach.

But, by 2000 Mississippi was being called a judicial hellhole and my dream of practicing medicine in my home state looked more like a nightmare.

I knew doctors who feared career‐ending lawsuits. I watched some of them just pack up and leave. I knew I had to make a decision and the thought of skyrocketing liability insurance filled me with dread. I had to ask, “If I couldn’t afford to practice here ‐ in Mississippi ‐ did I really even want to be a doctor?”

That was then. Today, ten years after tort reform passed, I’m a doctor ‐ an anesthesiologist. And, I’m right here in Mississippi.

That’s my tort reform success story.

What’s yours?

Timothy Beacham, MD Jackson, MS 356 JOURNAL MSMA

November 2011

• President’s Page •

Things Change

Y

ou have all heard me say over and over, “The times, they are a changing” (Dylan). I don’t need to stress this; anyone my age recognizes it. Some are better than others at accepting this, and some are better at adjusting to this; but one thing is for sure, it happens to us all. How we deal with change determines how well we do in life.

Thomas E. Joiner, MD 2011-12 MSMA President

As I have written before, the greatest influence on my life, and how I deal with it and its changes, would be my dad…just like most of you. In a conversation with my mom and brother, it dawned on me what his technique was. He would help when in unchartered waters but expect us to deal with our own problems our own way, to reach an acceptable conclusion. Never, but never, bring him our problem to deal with. He was always very supportive of any way we dealt with life. This instilled in each of us independence and a confidence that have served us all well. Still those unchartered waters are there, and I still long for his advice.

When I became secretary of Central Medical I found myself sitting in rooms with other docs I was only beginning to know, talking about things I knew nothing about, trying not to look stupid. I found myself sitting across from Carl Evers and watching his every move and expression. When we voted, more often than not, if Dr. Evers nodded yes I voted yes and if no I voted no. Looking back, I realize this was from the respect I had developed for him over the years. There were others in the room but none that I looked to more.

Well, life changes. One of the things I realize is that I am now in that phase where others look up to me as I did to my dad and Carl. We all have a responsibility to those coming along behind us not only to lead, but also to instill confidence and determination and to avoid discouragement. “Youngsters” can be discouraged easily. We all have a duty to lead.

This results in a much stronger MSMA with cooperation among members that allows more effective lobbying and advocating for all members. This has been my goal–to make MSMA relevant to all docs and not just some so no one has a reason not to be a member. In the coming months the strength of our organization will be tested, and we stand ready to meet those tests, especially with your support!

By the time you read this, the election will be over, and we will be moving forward with our legislative agenda. The AMA midterm meeting will be held in New Orleans, and our delegation will be there to voice our views loudly with results yet to be seen. But there is one thing you can count on, your voice will be heard.

Then there is important stuff like The Breeders Cup November 4th and 5th. One tip: Goldikova to win in the dirt mile.

It’s a gamble, but I am more sure of it than the AMA. Have a great Thanksgiving, and I will see you in December!

November 2011 JOURNAL MSMA 357

• Editorial •

The Electronic Age Ann Myers, MD

T

his article is written to any of you who, like me, are still trying to “enter the electronic age” and are struggling with the government’s push toward electronic records.

As a physician who entered practice just after the dark ages ended but certainly before computers took over medicine, I am still writing my notes, most of which are legible and tell me a story about that patient and our last decisions (in the old days referred to as SOAP notes). Like most of you who still use paper, I’ve been well aware of the push toward going paperless, have been reluctant to make the move primarily because of cost, and secondarily because I just didn’t want to.

Nevertheless, my partner and my office manager both have been urging, even cajoling at times, for me to “get with the program” and invest in an EMR. On the other hand, I’ve heard the horror stories from friends and colleagues about the perils of diving into electronic records, such as how disastrous the visit might be if the system is “down” and how long it took to really come up to speed. Therefore, I’ve been digging my heels in and resisting until I just “have to” which I had secretly hoped would never happen. However, since the government often gets what it decides it wants, and now with the carrot of money dangling out there to tempt even me, our office has decided to look for a system. So, I’ve been trying to adjust my attitude and “get on board.”

Now earlier this year, we decided to “dip our toes in the water” and start e-prescribing thanks to the financial incentive offered by Medicare. You know, that proverbial carrot they dangle for a short time before the hatchet falls if you don’t get in sync. That process had been going fairly smoothly and I actually had to admit I kind of liked sending prescriptions off into the web. So having e-prescribed for several months, I decided to try my hand at PQRI – those famous “quality measures” that somehow will tell the government how good a job I’m doing handling my arthritis patients. I found a registry that would let me put my data in without an EMR and yet still recoup the financial incentive this year. So how could I resist.

I had been slowly gathering my 30 patients, filling out the forms on paper, then planning to input the data on a “slow day.”

Since slow days don’t happen without some planning, I cleared the schedule and gathered the charts, ready to complete the task one afternoon. As I try to log on I discover that my password no longer works, and I am “locked out of the system.” After a few attempts to contact the person who can fix this problem (because you know that person is never available when you call the first three times), I get a new password. But it has taken more than an afternoon to get this problem fixed so I have to wait until I can schedule another afternoon “off” to input my data. The day arrives, and I again gather the 30 charts and log on. Unfortunately now I discover that the form previously posted requiring about seven questions answered has been changed to a form that now requires four pages of data about the patient, much of which I do not have in the current chart. You see, like some of you, I’ve been seeing patients for more than 20 years, and many of my patients I’ve been caring for almost that long. They are on their second or third chart. (I know, some of you “younger ones” are thinking if I just had an EMR I wouldn’t need a second or third chart.) Questions such as “when did you first see this patient” and “when was this diagnosis made” require a little more effort than the original 7 question for required. Hence, a task that I thought I could complete in one afternoon is now going to take quite a few more hours, a disappointment to say the least! However, I adjust my attitude and fire up the computer ready to tackle the task for a few hours. I get to the second page, and the second question on this page is the date of birth of that patient. Now, I know the answer to this so I’m still thinking I’m OK at this point but no: turns out that question is “grayed out” on the form, and I can’t input any date in the blocks. Still ready to proceed, I complete the next 17 or so questions and am ready to sign and attest that this one patient’s form is “complete.” But, silly me, a “critical error” red box pops up – and what do you think the error is?

You guessed it – missing date of birth. Feeling a little frustrated I scroll back up to that place on the form and try yet again to enter this patient’s date of birth. I scroll back to the first page (where incidentally I had already entered the patient’s date of birth) and, yes, that info is still there. So, I go to on to the second page and try once again to enter date of birth in the gray shaded boxes but with no luck.

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November 2011

Beginning to feel my blood pressure rise, I call the help line and enter the extension of the person listed who, of course it turns out, is not really in charge but who does give me the name of the person who is in charge of this form. However, of course, she’s not in at present. Is this beginning to sound to anyone like a call to get a prior approval for a drug or procedure?

Very frustrated now, I decide to at least save my data and begin again the next day when perhaps I can talk to the missing person who will surely re-appear by tomorrow to help clear up this confusion about the form. But as I try to save and exit – I’m rejected again because of – you guessed it – that dreaded critical error box - missing data: DATE OF BIRTH! So as you can guess, the $18,000 incentive offered by the government this year is beginning to look less attractive to me.

I’m thinking how many more patients I have to see to make that up, and I’m thinking 2015 sounds very far away and I might die or retire by then. Besides, when have those timelines ever held? I think I’d feel a little better about all this if I really thought I’d be a better doctor for my patients by going paperless (and yes I’ve heard all those arguments about sharing information but I think my fax works pretty well for that now). By tomorrow I’ll probably get a phone call from some 25-year-old who will try to understand my frustration and pretend to care (or not) and hopefully fix this glitch. Sometime before December 31 I’ll hopefully get my 30 patients entered without critical errors.

At least this PQRI info is still voluntary for now. I still have to worry about the RAC (is that spelled “rack”?) audits hoping that I haven’t forgotten to get a weight on a patient so that visit won’t be thrown out. But most of the time, I’ll still have the privilege and responsibility of caring for my patients, an honor I’ve had for the past 25 years and one that I still find very gratifying and fulfilling. Don’t most of us? Thank goodness for those precious human beings who still trust their health care issues to me. May I provide quality care to them for a while longer even if I can’t input their date of birth. r

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• Personals • Chris Anderson, MD, who specializes in adult and pediatric liver and kidney transplants, has joined the University of Mississippi Medical Center (UMMC) and will see patients through University of Mississippi Health Care (UMHC). Dr. Anderson, a Lucedale native who previously worked at Washington University in St. Louis, currently leads the kidney transplant program. Dr. Anderson has no doubt that the program will succeed. “I didn’t come here just to come home. The institution is committed to this growth from top to bottom.

There’s support here to make this happen. Our goal is that no one should leave the state to get excellent transplant care,” he said. A summa cum laude graduate of the University of Southern Mississippi, he earned the M.D. at Emory University in Atlanta. He completed residency training in general surgery at Vanderbilt University Medical Center where he also completed a fellowship in hepatobiliary surgical research. Dr. Anderson was a fellow in abdominal transplant surgery from 2006-2008 at Washington University. He served as a staff surgeon in Missouri at Barnes Jewish Hospital, Barnes Jewish West County Hospital, and Saint Louis Children’s Hospital.

Dr. Anderson’s immediate goal is to improve the kidney transplant program by promoting laparoscopic kidney surgery for living donor transplants. Dr. Anderson’s research interest is in fatty liver disease and how it impacts transplantation in donors and recipients. His research focus is driven, in part, by an increase in obesity and metabolic diseases nationally. He stated obesity-related illnesses may lead to liver diseases. “It will likely become a leading indication for liver transplant,” he said. He hopes to collaborate with researchers in the UMMC Obesity, Metabolism & Nutrition Center.

Alexander P. Auchus, MD, professor and McCarty Chair of Neurology, has been elected to the American Neurological Association, the world’s oldest neurological society and one of the earliest academic societies in the United States. Dr. Auchus also has been certified in the subspecialty of geriatric neurology by the United Council for Neurologic Subspecialties. Dr. Auchus, founding co-director of UMMC’s Comprehensive Stroke Center, holds degrees from

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Johns Hopkins University and Washington University in St. Louis and is an elected fellow of the American Academy of Neurology and of the American Geriatrics Society.

George Ball, MD, retired obstetrician/gynecologist and associate professor of ob/gyn at the University of Alabama, was selected keynote commencement speaker for the Hinds Community College nursing and allied health program graduates. Dr. Ball of Jackson has been retired since 2001 from his personal ob/gyn practice where he worked for more than 35 years and is currently serving as an associate professor at UMMC. Prior to beginning his personal practice, Dr. Ball was a major in the U.S. Air Force. He attended East Central Community College on a football scholarship before continuing on to Mississippi State University where he received his bachelor’s degree. He received his two-year medical certificate from the University of Mississippi School of Medicine and his M.D. from Tulane School of Medicine in New Orleans where he also completed his residency.

Dr. Ball is an active member of numerous health-related organizations including the American College of Obstetrics/ Gynecology where he has served as past president of the Mississippi chapter; the Tulane Obstetric and Gynecological Society, past president; Jackson Cancer Society, past president; Winfred Wiser Ob/Gyn Society; Central Association of Obstetrics/Gynecology; and many more.

He is a member of the Hinds Community College Foundation, chairman of the board of trustees of Central Mississippi Medical Center, member of the board of Christian World Missions, and founding chairman of Riggs Manor Methodist Retirement Home in Raymond. He and his wife of 56 years, Martha, have four sons, 12 grandchildren, and one great-grandchild.

Jennifer Barr, MD, a bone cancer specialist, has joined the medical faculty at the UMMC. As the sole provider of orthopedic oncology for children and adults in Mississippi, Dr. Barr will contribute vital expertise to the Department of Orthopedics and Rehabilitation. Dr. Barr, who treats bone and soft-tissue tumors, said 40 percent of bone cancers are found in children. She said she returned to Mississippi because she felt she could make a difference in the state. “I saw how much of a void there was and the desperate need of Mississippians to have this service available in the state,”

she said. A magna cum laude graduate of McNeese State University in Lake Charles, Louisiana, Dr. Barr earned the M.D. at Louisiana State University’s School of Medicine in 2005. She concluded her residency training in orthopedic surgery at UMMC and later completed an AO Trauma fellowship in Chur, Switzerland, in 2009. Barr fulfilled an additional fellowship in orthopedic oncology at the University of Washington Medical Center in Seattle in 2011.

Bryan N. Batson, MD, Hattiesburg Clinic physician, recently authored a study published in Ethnicity & Disease, the official journal of the International Society of Hypertension in Blacks, which examined trends in the treatment of hypertension in African American patients.

The study titled “Effect of African American Race on Hypertension Management: A Real-World Observational Study Among 28 US Physician Practices” included nearly 5,000 subjects from 28 physician practices between November 2006 and September 2008. Following four years of research and analysis, the study results demonstrated that although many providers across the country are aggressively treating hypertension in African American patients through methods such as increased medication, they are still facing difficulty controlling high blood pressure in these patients.

Dr. Batson holds a medical degree from UMMC, where he subsequently completed an internal medicine and pediatric residency. He holds board certification in internal medicine and is board eligible in pediatrics. He is a certified clinical hypertension specialist. He practices with Philip B. Mellen, MD and Elisha Woods, FNP at the Hypertension Center of Excellence, a service of Hattiesburg Clinic.

Sharon P. Douglas, MD is chair of the American Medical Association (AMA) Council on Ethical and Judicial Affairs (CEJA). The Council develops ethics policy for the AMA. Composed of seven practicing physicians, a resident or fellow, and a medical student who are nominated by the AMA’s President and elected by the House of Delegates, the Council prepares reports that analyze and address timely ethical issues that confront physicians and the medical profession. CEJA maintains and updates the 160-year-old AMA Code of Medical Ethics widely recognized as the most comprehensive ethics guide for physicians who strive to practice ethically. The Current Opinions of the Code can be found in PolicyFinder.

In addition, the Council has judicial responsibilities which include appellate jurisdiction over physician members’ appeals of ethics-related decisions made by state and specialty medical societies.

Dr. Douglas was elected to CEJA in 2005. Dr. Douglas is Professor of Medicine and Associate Dean for VA Education at the University of Mississippi School of Medicine (UMSOM). She graduated from the UMSOM where she also did residency training in internal medicine and fellowship training in pulmonary medicine. She is board certified in internal medicine and pulmonary medicine and a Fellow of the American College of Chest Physicians. At the G.V. (Sonny) Montgomery VA Medical Center she is staff pulmonologist, ICU/pulmonary clinician and teacher, and Associate Chief of Staff for Education and Ethics. Dr. Douglas received a Certificate in Healthcare Ethics from the University of Washington, Seattle. She currently teaches ethics to the medical students, internal medicine residents, and pulmonary fellows at the UMSOM. She serves as a member of the National Ethics Committee for the Veterans Healthcare Administration. Her main ethical interest is in end-of-life ethics. She gives community talks to local groups on Mississippi Advance Directives. Dr. Douglas is also an EPEC Trainer (Education for Physicians on End-of-life Care) for the AMA. She is certified in and an instructor for ACLS (Advanced Cardiac Life Support). She also has a special interest in palliative care.

Makram R. Ebeid, MD, pediatric cardiologist and professor of pediatrics, has successfully performed a transcatheter pulmonary heart valve replacement procedure for the first time in the state, a nonsurgical alternative to open-heart surgery.

UMMC is the first hospital in the region to offer the minimally invasive procedure that serves as a new tool in the treatment of congenital heart defects and damaged heart valves. Prior to the development of this capability, patients wanting to have this procedure would have to travel out of state.

“This is a great benefit for the patients, Mississippi, and UMMC. Families can stay in the state, and the recovery period with this procedure compared to open-heart surgery is shorter. Patients can have a one-day hospital stay instead of 5-7 days,” Dr. Ebeid said. Managing congenital heart defects that impact the function of the pulmonary valve has long-required multiple open heart surgeries throughout a patient’s lifetime.

Now, patients may be candidates for the procedure that allows a cardiologist to deliver a replacement valve through a catheter in the cardiovascular system, requiring only a small incision in the groin. The procedure is FDA approved under a special protocol for both pediatric and adult patients. “To reopen the chest many times is obviously uncomfortable for the patient but also comes with great risk. With this replacement valve, we can delay the patient’s next surgical intervention,” Dr. Ebeid said.

November 2011 JOURNAL MSMA 361

Joe Files, MD, professor of medicine and director of the Division of Hematology at UMMC, has received his mastership from the American College of Physicians, joining a select group of Mississippi physicians who have received the national organization’s highest recognition. Four Mississippians, all UMMC faculty, have received mastership since it was established in 1923. They include Dr. Robert Blount, Dr. Harper Hellums, Dr. Peter Blake, and Dr. James Achord. A native Mississippian and University of Mississippi graduate, Dr. Files earned the M.D. at the Medical Center in 1972. He completed his residency at UMMC in internal medicine, including a year as chief resident. He then attended the University of Washington in Seattle for his hematology fellowship where his primary focus was in the field of bone marrow transplant. He returned to join the Medical Center faculty in 1979. Dr. Files has been an active member in the ACP for more than 30 years and served as the governor of Mississippi for the college from 2001-05.

Philip L. Levin, MD debuted his latest book, Ndovu the Elephant – An African Tale. In this children’s book, baby elephant Ndovu is looking for adventure on the Kenyan Serengeti. Wandering away from his herd one morning, he realizes he has misplaced his family. The story shares the excitement of the elephant’s search for his home as he interacts with over a dozen native animals. The book’s photos were taken during one of his many medical missionary trips to Keumba, Kenya, where he works in a small rural hospital as a volunteer physician. A portion of each Ndovu book sale will be donated to the medical needs of the Kenyan population.

Books are available online at www.NdovuTheElephant.com.

Charles Kenneth Lippincott, MD of Tupelo, a psychiatrist and clinical director of North Mississippi State Hospital, received the highest honor bestowed in his specialty at a convocation during the 164th Annual Meeting of the American Psychiatric Association (APA) in Honolulu, Hawaii. Dr. Lippincott became a Distinguished Fellow of the APA based upon review of his accomplishments as a psychiatric physician, his service to community and his achievements in all areas of his career with the approval of the APA membership committee and the Board of Trustees. Nobel Peace Prize winner Archbishop Desmond Tutu delivered the

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lecture to the Fellows reminding them that excellence, not mere competence, is the hallmark of a Distinguished Fellow.

Nominated for this honor by the Mississippi Psychiatric Association, Dr. Lippincott was joined in Hawaii by his wife Lisa and their two sons and daughter.

Chad Rhoden, MD, PhD, has joined the medical staff at Madison River Oaks Medical Center as the new hospitalist, launching the hospitalist program, a new service line at the new facility which opened in May. Dr. Rhoden earned his M.D. from the University of Mississippi School of Medicine.

He completed his residency at North Mississippi Medical Center and is board certified by the American Board of Family Medicine and the American Board of Preventative Medicine.

Additionally, Dr. Rhoden is a certified nutrition specialist by the American College of Nutrition. He is a member of the AMA, Medical Fitness Association, Mississippi Alliance for School Health and the Partnership for a Healthier Mississippi. He is the co-founder and CEO of Flavor Doctor Foods and is the author of “Bringing Down High Blood Pressure” (2010, M. Evans).

James Martin, MD, professor of obstetrics and gynecology and member of the faculty of UMMC, was installed as president of the 53,000-member American Congress of Obstetricians and Gynecologists. Dr. Martin, a member of the UMMC faculty for 28 years, is the author of more than 500 scientific publications and communications, many of which address issues related to preeclampsia-eclampsia and atypical forms of this disease such as HELLP syndrome. The Preeclampsia Foundation presented Martin with its Hope Award in 2009 for lifetime achievement in preeclampsia research. He is a fellow of both the American Heart Association and the American Gynecological and Obstetrical Society. He is a past president of the North American Society for the Study of Hypertension in Pregnancy and the Society for Maternal-Fetal Medicine.

During his presidency of ACOG, Dr. Martin’s focus will be on preeclampsia and hypertensive complications of pregnancy. Despite being a leading cause of maternal death and sickness, the disease process is little understood after decades of research. “To conquer this disease, we must know how it begins as well as how it ends,” Dr. Martin said. The disease process, he said, remains among the most understudied and underfunded in research compared to other diseases.

“Such slow, underfunded research limits growth in evidencebased information and foments controversy surrounding the classification, diagnosis and management of the hypertensive disorders of pregnancy,” he said.

• MSMA Alliance • Past President’s Spotlight: Mrs. Eric (Nancy) Lindstrom, Laurel Alliance President, 1989-1990

W

here did you grow up? I was born in Bay Springs, Mississippi. I loved growing up in a small town where we knew almost everyone. Activities were centered on church and school.

Basketball was my favorite sport, and I graduated in 1955 from Bay Springs High School.

How did you meet your physician spouse? After attending Mississippi College for two years, I transferred to Florida State University (FSU) in Tallahassee. Eric came to FSU for a year of graduate work before going to Medical School at the University of Dr. and Mrs. Eric Lindstrom Nancy Lindstrom Maryland. We met during my senior MSMA Annual Session 2007 MSMA Alliance President 1989-90 year at the Baptist Student Union. Eric and I were married in 1960 between his freshman and sophomore years in Women, Mississippi State Medical Association (MSMA) and medical school, and we lived in Baltimore, Maryland. Eric Southern Medical Association Alliance (SMAA), etc., and did his internship at Madigan Army Hospital, Ft. Lewis, I love attending the sports activities of my grandchildren.

Washington, which started our 15-year active duty military Our family enjoys traveling and snow skiing together, and career. we spend time each summer at our cabin in Montana, Eric’s What are the names and ages of your children? We have two children. Our daughter, Laura, is presently teaching chemistry and physiology at Los Angeles Baptist Academy.

She has had a varied career, which has included counselor for Youth for Christ in California and teaching school in Germany and the Cayman Islands. Eric, Jr. (Ric) graduated from law school at Ole Miss, studied tax law at New York University, and is a certified public accountant. He is now pursuing a career in financial management. We have two grandchildren. Anna is a sophomore studying biochemistry at Mississippi State, and Alex is a sophomore at Laurel Christian High School.

How do you spend your free time? Free time? Is there such a thing? I enjoy church activities at First Baptist Church and community activities such as garden club, Republican

home state.

How did you come to join the Alliance? I participated in the Military Medical Alliance in various locations as we moved many times with the Army. Then I became active in the Jones County Medical Alliance when we settled in Laurel in 1976. After serving as president of our local alliance, Jo Waites asked me to serve as VP of Legislation on the state board. This started my journey to state president, several committees for the AMA Alliance, and serving on the AMPAC Board as the Alliance Representative for four years.

What is your favorite alliance memory? I was president the year that Jean Hill became President of AMAA. I took part in the installation and we had a wonderful year. Mississippi was given extra attention and Jean included us in the very special events.

November 2011 JOURNAL MSMA 363

Mrs. James (Jo) Waites presents a plaque to Mrs. Lindstrom in appreciation for her service to the auxiliary.

Nancy Lindstrom was president of the MSMA Auxiliary (now Alliance) when Mrs. Edward (Jean) Hill (front center) was installed as president of the AMA Alliance.

Photo on left: Nancy Lindstrom (center front) was 198990 MSMA Auxiliary President. Shown with her (from left) are Beth Hartness, Merrell Rogers, Peggy Crawford, Peggy Hoover, Kathy Carmichel, Sylvia Walker and Karen Stephens.

Calling all Mississippi Physician-Photographers for the 2012 What are the highlights of your presidential year? I enjoyed meeting the people while traveling throughout our state to visit the local alliances and attending Leadership Confluence in Chicago. The many friendships formed were invaluable. The theme for the year I served as president was “Because We Care.” We emphasized that support for our spouses and our involvement in health and legislative activities was because we truly did care! It was a thrill to present my report at the MSMA House of Delegates where I received a standing ovation. My presidential year also led to my involvement in the Southern Medical Association Alliance.

I attended my first SMA convention to represent Mississippi when Roberta Barnett was installed as Alliance president.

It was such great experience and fun that I stayed involved, serving as SMAA president in 2003-04.

Do you have any advice for fellow physician spouses?

Support your spouse and become involved in your physician spouse’s medical concerns. Medicine is being attacked on all sides. Your future as a medical family depends on your involvement in medical activities and politics. r

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COVER PHOTO CONTEST Load your camera or grab your digital. Shoot landscapes, people, animals, or anything else you can capture on film. Photos of subjects indicative of Mississippi will be given the highest consideration. Photos of original artwork are also acceptable. The Committee on Publications will judge the entries on the merits of quality, composition, originality and appropriateness to the JMSMA. Specifications: Color slides, digital files & photos. Size: Vertical format 5 x 7” or 8 x 10.” A hard copy print is required for judging.

Entry deadline: November 21, 2011 For more info contact: Karen Evers, JMSMA Managing Editor 601-853-6733, ext. 323 or KEvers@MSMAonline.com

• Poetry in Medicine • [This month, we print a poem by Ron Cannon, MD, a Jackson otolaryngologist. This poem, written recently, offers up a surgeon’s reflection on the hazards of his trade, not only for him but also, and mainly, for his patients. Ron explains about this poem: “It conveys the concerns that I have for my surgical patients.” Any physician is invited to submit poems for publication in the journal, attention: Dr. Lampton or email me at lukelampton@cableone.net.] —Ed.

The Surgeon’s Knot It is 2 a. m., and I am awake, Concerned about an incision in the morrow that I will make.

Her symptoms are right, the physical findings shed light, The labs confirm, but could I still learn?

It keeps me from my cot, this knot in my gut, This knot was small but grows bigger as I make the cut.

The scalpel is sharp, its line is fine, A small flood of the patient’s red blood.

The mass is found, for the microscope bound, The closing is right, each suture is tight, The catgut will hold, or so I have been told.

The knot is bigger, now up in my throat, It’s there even when I take off the white coat.

Without fail the patient awakens from the sleep doctor’s spell, But is there a smelly microbe? A dark clot? What will the future tell?

The wound is clean, and so are the cells, Now out of the woods with wind in her sails.

My reward is the patient’s thankful tone, Hallelujah! The knot is now gone!

The knot however lurks in the next exam room, Assuaged only by the avoidance of doom…

The Surgeon’s Knot!

—Ron Cannon, MD Jackson November 2011 JOURNAL MSMA 365

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• The Uncommon Thread •

The Turtle Rescue

I

f hurricane season is when orphan squirrels end up living in the Anderson household, spring is the season for turtle “rescues.”

Dogs are once again the primary reason for anything needing a rescue around here, and the most recent victim of canine playfulness has been named “Flippers” because he has three good ones left after Maddie succeeded in pulling him out of our Lab’s mouth.

R. Scott Anderson, MD I accept some responsibility for Flippers’s acquisition. I saw the little fellow walking up the driveway, his progress blocked by a four-foot retaining wall, and, not wanting to run over him, got out of my car and sat him on top of the impediment. As I drove off, I saw the dogs bounding out of the kitchen door. He was in a dog’s mouth before I got to work and living in the laundry room surrounded by floating lettuce and shrimp bits before lunch. By the time I got home, a care plan had been arrived at for his recovery.

Maddie showed him to me before I ever got out of the garage. She turned him over to show me his injuries and announced he was in shock.

In addition to the somewhat shredded flipper, his shell was injured from being chewed on and that was what was causing the shock, the shell injuries. She reckoned he’d recover, but he was going to need to be in “Maddie Lynn’s Turtle Hospital” for a few days.

She gets it honestly. I’m a sucker for a turtle in distress. I don’t know why I always stop to get turtles out of the road if I see them there, but for some reason I always do. Flip is the third or fourth one I’ve jumped out of the car to help this year. It’s not as if we’re having a turtle shortage or anything. They line the logs and shoreline of the lake behind our house like various sized helmets of some invading army. It’s just that I hate to see anything squashed in the roadway, even snakes. Char doesn’t allow snake rescues though, not since that unfortunate incident at the farm a few years ago.

She, Maddie, and I were in the Mule following the other kids who were all riding four-wheelers. Allison was in front of us, and for some reason she’s always thought that a throttle is simply an on-off switch that should be either on or off and not somewhere in between. Nevertheless, we were going across an open field when Allison ran over a chicken snake.

The soft paddle tires that allow her to get through swampy ground on the back of her four-wheeler also proved great for throwing snakes.

I’m sure you can picture the scene that unfolded. A flying yellow Honda, a little girl her curls blowing everywhere in the wind, a cloud of dust spreading out behind her, and a six and a half foot snake writhing as it rises in a lazy arc above it all… the screaming started almost immediately. I guess that’s how Maddie and Char spotted the snake in the first place.

Maddie did her best squirrel imitation by trying to climb on top of my head as I swerved to avoid the oncoming snake projectile. Maddie on top of my head must have impaired my judgment because I swerved to the left, putting Char directly in the path of the incoming reptile. That’s something I still haven’t heard the end of and something that’s used to question my bravery (and good judgment) to this day. Char, having none of it, grabbed the wheel and yanked back the other way. The result was we were facing the snake, head on, when it hit the front of the Mule between us.

Now I know that a chicken snake is a beneficial snake, good for the environment, a helpful predator, and totally harmless to humans. But I hadn’t really ever had a reason to practice making a positive identification on a flying snake on the wing, as it

November 2011 JOURNAL MSMA 367

were, in the past, so I wasn’t sure what exactly it was that we had just hit, nor was I exactly sure where it had gone. I didn’t really want it popping out from under the seat as we were crossing a creek or something, so I stopped to try to figure things out.

I always wear a pistol loaded with rat shot at the farm, so Char was of the opinion that the only reasonable course of action was for me to get our of the Mule and shoot the snake. I had the unfortunate lapse in judgment to suggest that I didn’t want to shoot the snake if it was a “good snake” because we needed all of those we could get to keep the rodent population down. Let us just say my argument did not prevail. Char is a snakeophobe. She has killed more than her share of rattlesnakes with a set of tongs and a 5-iron. After fishing them out of the pool, she wasn’t in the mood to discuss why she didn’t want her youngest daughter and a six and a half foot snake, of any description, anywhere near each other, much less in the same vehicle. While she was making this as clear as humanly possible, somehow, the snake disappeared.

“What’s he doing?” Char asked as I bent over looking under the Mule.

“I’m not sure,” I answered.

“What do you mean, you’re not sure?”

“He’s not under here,” I said and started to look around the back of the vehicle trying to catch some movement in the grass.

The tension level went up noticeably at that point.

“Maybe he went home,” Mat suggested.

“I think he must have,” I answered walking back and forth in semicircles to try to figure out where it was he’d actually disappeared. No luck.

I’d be less than honest if I didn’t admit that I had just a bit of trepidation as I reached down to loosen the latch under the bed of the Mule. I flipped it back half expecting the snake to pop out of the engine compartment at any second. He wasn’t there, or under the seat, or hung up in the frame. So off we went, uneasy, unsure, and very glad when we were finally back on the road.

Those were the good old days. I better stop for now; we’ll get back to the turtles next time.

R. Scott Anderson, MD, a radiation oncologist, is medical director of the Anderson Regional Cancer Center in Meridian and past vice chair of the MSMA Board of Trustees. Additionally, he is an accomplished author, oil-painter, and dabbles in the motionpicture industry as a screen-writer, helping form P-32, an entertainment funding entity.

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