VOL. LVIII • NO. 8/9 • 2017 by Journal MSMA

VOL. LVIII • NO. 8/9 • 2017

William M. Grantham, MD · 2017-18 MSMA President

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VOL. LVIII • NO. 8/9 • AUGUST/SEPTEMBER 2017

SCIENTIFIC ARTICLES

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

THE ASSOCIATION President William M. Grantham, MD President-Elect Michael Mansour, MD

MANAGING EDITOR Karen A. Evers

Secretary-Treasurer W. Mark Horne, MD

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

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

JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. CORRESPONDENCE: Journal MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: 601-853-6733, Fax: 601-853-6746, www.MSMAonline.com. SUBSCRIPTION RATE: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available. ADVERTISING RATES: furnished on request. Cristen Hemmins, Hemmins Hall, Inc. Advertising, P.O. Box 1112, Oxford, Mississippi 38655, Ph: 662-236-1700, Fax: 662-236-7011, email: cristenh@watervalley.net POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 39158-2548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association. Copyright © 2017 Mississippi State Medical Association.

Official Publication

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Top 10 Facts You Need to Know about Feeding Disorders Dorothy Scattone, PhD

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Top 10 Facts You Need to Know about Palliative Care C. Christian Paine, MD; Angelle L. Klar, MD; Carole A. Ward, RN; J. Keith Mansel, MD; Keith M. Swetz, MD

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Repeated Cardiac Arrests due to Undersensing of Temporary 222 Epicardial Pacer After Coronary Bypass Grafting and Maze Procedure Sachin Bahadur, MD; Ben Ham, MD; Sirivalli Chamarti, BS; Tao Hong, MD Congenital Lobar Emphysema can Mimic Tension Pneumothorax Patricia Amolenda, MD; Douglas Maposa, MD; Madhankumar Sathyamoorthy, BMBS

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Connective Tissue Disease May Be a Significant Risk Factor 226 for Development of Nonuremic Calciphylaxis Shweta Kishore, MBBS; Max Harrigill; Amanda H Fowler, MD; Vikas Majithia MD, MPH DEPARTMENTS From the Editor – Is Nurse Staffing “the” Quality Issue? Lucius M. Lampton, MD, Editor

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President’s Page – Inaugural Address of William M. Grantham William M. Grantham, MD

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MSMA 149th Annual Session of the House of Delegates

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Special Article: An Interview with William M. Grantham, MD Karen A. Evers, Managing Editor

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Images in Mississippi Medicine – The Biloxi Sanatorium Lucius M. Lampton, MD

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Poetry and Medicine – Anytime: A Meditation for the Wounded Healer Dwalia S. South, MD

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RELATED ORGANIZATIONS Mississippi State Department of Health Reportable Disease Statistics

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ABOUT THE COVER Dr. William M. Grantham, a family physician who is the medical

director of the MEA Medical Clinic in Clinton, was inaugurated 2017-18 President of the Mississippi State Medical Association. He took office at the MSMA Annual Session of the House of Delegates in Jackson on August 11. Dr. Grantham is currently vice president of the Mississippi Academy of Family Physicians. A graduate of the University of Southern Mississippi, he received his medical degree from the University of Mississippi School of Medicine and performed both his internship and residency at the University of South Alabama. —Ed. n

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F R O M

T H E

E D I T O R

Is Nurse Staffing “the” Quality Issue?

hose physicians who still round at hospitals and other inpatient facilities such as nursing homes or skilled facilities recognize repeatedly what may be medicine’s most critical “quality” issue: nurse staffing or rather lack of staffing. The problem is the assertion of corporate mentality to hospital and nursing home management. “Quality care” has become Orwellian newspeak for “cost-control,” and any corporate administrator will tell you Lucius M. Lampton, MD that the profit-margin centers on Editor minimizing labor (i.e., employees). At all of these service entities (which must staff for both busy and slow periods, 24/7), nurses will tell you they are understaffed, undertrained, and underpaid, and that significant turnover is routine. Nurse staffing ratios to patients vary, but staffing should never be about census alone. Every patient is different, and nurse staffing must be patientcentered and ask: is the patient low acuity or high acuity? Some patients require more intensive nursing than others. When nurses complain about

unsafe patient ratios and work requirements, administrators usually turn a deaf ear. With frequent turnover, inexperienced new nurses take the place of old hands (and any hospital physician will tell you experience matters in these settings); the inexperienced not only don’t know the system they are stepping into, but often haven’t become competent at basic nursing skills. decade ago, nurse staffing was very different. At my small rural hospital, A with a census usually between 12 and 20, there were 3 RNs, a charge nurse, an IV nurse, 2 LPNs, 4 CNAs (2 to a hall), and 3 housekeepers. Nurses then spent time with patients. Fast forward to today: nurses are chained to a desk doing computer work, corporate medicine has eliminated 75% of the staff via ratios, and nurses complain about having to be “the nurse, housekeeper, and the aide.” hile the nurse on the front-line struggles to survive this ridiculous W environment, the state nursing board is oblivious to the key issue impacting their profession, instead focusing on the divisive issue of independent practice. Lack of appropriate nurse staffing is eroding the quality of patient care, and physicians must take up this battle for both our patients and our medical team. n Contact me at lukelampton@cableone.net.

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

EMERGENCY MEDICINE Philip Levin, MD

MEDICAL STUDENT John F. G. Bobo, M2

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

EPIDEMIOLOGY/PUBLIC HEALTH Mary Margaret Currier, MD, MPH Thomas E. Dobbs, MD, MPH

NEPHROLOGY Jorge Castaneda, MD Harvey A. Gersh, MD

ANESTHESIOLOGY Douglas R. Bacon, MD John W. Bethea, Jr., MD

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

OBSTETRICS & GYNECOLOGY Sidney W. Bondurant, MD Darden H. North, MD

GENERAL SURGERY Andrew C. Mallette, MD

OTOLARYNGOLOGY Bradford J. Dye, III, MD

HEMATOLOGY Vincent E Herrin, MD

PEDIATRIC OTOLARYNGOLOGY Jeffrey D. Carron, MD

INTERNAL MEDICINE Daniel P. Edney, MD W. Mark Horne, MD Daniel W. Jones, MD Brett C. Lampton, MD Jimmy Lee Stewart, Jr., MD

PEDIATRICS Michael Artigues, MD Owen B. Evans, MD

CARDIOVASCULAR DISEASE Cameron Guild, MD Thad F. Waites, MD CHILD & ADOLESCENT PSYCHIATRY John Elgin Wilkaitis, MD Nisha S. Withane, MD, Fellow CLINICAL NEUROPHYSIOLOGY Alan R. Moore, MD DERMATOLOGY Robert T. Brodell, MD Adam C. Byrd, MD

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ORTHOPEDIC SURGERY Chris E. Wiggins, MD

PLASTIC SURGERY William C. Lineaweaver, MD Chair, Journal Editorial Advisory Board PSYCHIATRY Beverly J. Bryant, MD June A. Powell, MD PULMONARY DISEASE Sharon P. Douglas, MD John R. Spurzem, MD RADIOLOGY P. H. (Hal) Moore, Jr., MD RHEUMATOLOGY Shweta Kishore, MD C. Ann Myers, MD UROLOGY W. Lamar Weems, MD

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Top 10 Facts You Need to Know about Feeding Disorders DOROTHY SCATTONE, PHD

1 2 3

Higher rates of eating problems occur in children with developmental disabilities. Children with special needs including autism have a higher incidence of feeding/eating disorders (30-80%) when compared with the general population. 1,2 Oftentimes these problems do not resolve with just time especially for those with autism and may require help from a professional.3 Professionals who provide feeding therapy: Feeding therapists usually consist of occupational therapists, speech therapists, behavior analysts (ABA therapy), behavioral psychologists, and/or nutritionists.4,5

4 5

Pediatric feeding disorders can be severe and may include: • Rigid preferences for certain brands, textures, colors, or types of food (Food Selectivity). • Eating little to no solid food (Food Refusal). • Problems chewing or swallowing (Dysphagia). • Refusal to pick up utensils and self-feed. • Refusal to drink all liquids (Adipsia). • Behavior problems during meals: screaming, crying, throwing food, spitting, gagging, vomiting, etc. 6,7

Many feeding problems occur for one of two reasons: The child is allowed to escape the meal contingent on behavior problems or the child receives attention (e.g., often in the form of a verbal reprimand) for inappropriate mealtime behavior. Allowing the child to escape the meal or providing attention for behavioral excesses may serve to strengthen problem behavior over time. 8

General suggestions for families to improve meal-time behavior: • Schedule family mealtimes with everyone sitting at the table. • Redirect children back to the table if they do not stay seated. • Turn off TV, cellphones, tablets, computers, videos, etc. • Focus on social topics rather than commenting on eating. 6 Most feeding interventions share a few common elements: • Structured meal and snack schedules (10-20 minutes for snacks; 20-30 minutes for meals). A timer could be used as a signal to end the meal. • Repeated exposure to nonpreferred foods. • Appetite manipulation (e.g., limiting fluids such as milk or Pediasure or snacks). • Reinforcement for consuming food (e.g., praise, preferred foods, access to toys). • Ignoring inappropriate behaviors. • Parent training. 6,9

Sensory integration is not evidenced-based. Sensory integration is often the first line of treatment recommended for children with feeding disorders despite no empirical support its use. There is one published study showing that exposing a child to sensory activities (e.g., brushing, crawling through tunnels, bouncing on a ball, for example) prior to meals was NOT effective for increasing food intake or decreasing behavior problems associated with eating (Addison, et al.). 4

Behavioral interventions are evidenced-based. Behavioral interventions have increasingly been shown effective in treating pediatric feeding disorders. These interventions establish a structured routine for meals and snacks, a data collection system for amount of food consumed (volume or number of

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bites), and systematic use of positive reinforcement. The following are just a few interventions that have been shown effective for some children with developmental disabilities who demonstrate mild food selectivity: 6,7,9,10

• Positive reinforcement for consuming food such as access to verbal praise, videos, television, iPads, computer games, or other items/activities.6

• Sequential Presentation Method: Presenting one pea sized bite of a nonpreferred food before giving access to a larger bite of a preferred food.9

• Simultaneous Presentation Method: Presenting a preferred food along with a nonpreferred food in the same bite. For example, putting a pea on top of a chip or condiments on top of vegetables, or embedding broccoli in an apple.10

• Mixing preferred food with a new food such as mixing ground vegetables in mashed potatoes or in spaghetti sauce beginning with a small amount and increasing over time.6

• R epeated exposure to new foods via taste sessions. Taste sessions may be conducted outside of regular mealtimes with the promise of a reward for trying a new food item. Once accepted, these foods can be reintroduced during regular meals.6,7

• R eintroduction of previously eaten foods. It may be easier for the child to eat a food he is familiar with than learning to eat a completely new food.6

Parent training often involves teaching parents to change their own behavior in order to change the child’s behavior by: • Providing directive statements (Take a bite) rather than questions (Will you take a bite?). • Beginning with an extremely small bite of food the size of a pea rather than an entire spoonful and gradually increase as child behavior problems decrease. • Providing strategic attention for consuming bites. • Being less reactive to inappropriate meal-time behavior. 5,6

A visit to a pediatric gastroenterologist should be the first step. Before starting any feeding program, a medical evaluation is always suggested to rule out medical reason for poor eating. Feeding problems may be caused by reflux, constipation, diarrhea, food allergies, dysphagia (problems swallowing), and oral motor problems. A gastroenterologist may recommend a swallow study for someone suspected of having dysphagia.5,6 n References 1. Ledford JR, Gast DL. Feeding problems in children with autism spectrum disorders: A review. Focus Autism Devel Disabil. 2006;21:153-166. 2. Sharp WG, Berry RC, McCracken C, et al. Feeding problems and nutrient intake in children with autism spectrum disorders: A meta-analysis and comprehensive review of the literature. J Autism Dev Disord, 2013;43:2159. 3. Williams KE, Gibbons B, Schreck KA. Comparing selective eaters with and without developmental disabilities. J Phys Devel Disabil. 2005;17:299-309. 4. Addison LR, Piazza CC, Bachmeyer MH, et al. A comparison of sensory integrative and behavioral therapist as treatment for pediatric feeding disorders. J Appl Behav Anal. 2012;45:455-471. 5. Silverman AH. Behavior management of feeding disorders of childhood. Ann Nutr Metab. 2015;66:33-42. 6. Williams KE, Fox RM. Treating eating problems of children with autism spectrum disorders. Austin, TX, Pro-ed. 2007;11-25,40-41,126-128. 7. Seiverling L, Williams K, Sturmey P, et al. Effects of behavioral skills training on parental treatment of children’s food selectivity. J Appl Beh Anal. 2012;45,97-2003. 8. Piazza CC, Patel MR, Santana CM, et al. An evaluation of simultaneous and sequential presentation of preferred and nonpreferred food to treat food selectivity. J Appl Behav Anal. 2002;35:259-270. 9. Piazza CC, Fisher WW, Brown KA. et al. Functional analysis of inappropriate mealtime behaviors. J Appl Behav Anal. 2003;36,187-204. 10. Ahearn W. Using simultaneous presentation to increase vegetable consumption in a mildly selectivity child with autism. J Appl Beh Anal. 2003; 36, 361-365.

Author Information: Dorothy Scattone, PhD, BCBA-D is an associate professor of pediatrics at the University of Mississippi Medical Center. Scattone is a licensed psychologist. Her primary area of clinical practice and research interests are in the area of autism spectrum disorders. Corresponding Author: Dorothy Scattone, PhD; University of Mississippi Medical Center, Center for Advancement of Youth (CAY), Department of Pediatrics, Division of Child Development, 2500 North State St., Jackson, MS 39216. (Ph) 601-815-3158 (Fax) 601-9845857 (dscattone@umc.edu). JOURNAL MSMA

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Top 10 Facts You Need to Know about Palliative Care C. CHRISTIAN PAINE, MD; ANGELLE L. KLAR, MD; CAROLE A. WARD, RN; J. KEITH MANSEL, MD; KEITH M. SWETZ, MD

Introduction Palliative care is a medical specialty that utilizes an interdisciplinary network to alleviate suffering in patients dealing with the stresses of advanced serious illness. Through aggressive symptom management and precise communication focused on clarifying and optimizing goals of care, Palliative care aims to treat the whole patient. Over the past decade, there has been increasing acceptance of and demand for specialty palliative care services with increased emphasis on primary palliative care by all clinicians. While availability of these services in the Southeastern U.S. has lagged behind other regions, there has been marked growth and increased access throughout Mississippi.1 Herein, we present ten essential facts about palliative care, highlighting the evidence that supports its integration in medical practice. Keywords: palliative care; quality of life, communication, interdisciplinary team

Palliative care is a specialty that offers expertise within the context of advanced serious illness. Although aspects of primary palliative care (PC), such as clarifying goals of care and symptom management, are essential aspects of practice for any medical provider, specialist PC providers are indispensable with the subset of cases requiring expertise with complex communication and prognostication, management of refractory symptoms and aligning goals of care with plan of care through skillful shared decision-making.2 Research demonstrates that specialist PC collaboration improves patient outcomes, provider and caregiver satisfaction, and leads to more appropriate resource utilization as defined by reduced length of stay and healthcare costs.3 (Reasons to consider specialist PC referral are listed in Figure).4

Figure 1. Reasons to Consider a Palliative Care Consultation

The interdisciplinary network is central to successful integration of palliative care. A board-certified, specialist PC physician understands the essential value of each member of the PC team and seeks out diverse insights and expertise to alleviate suffering in all of its forms. (Figure 2) Research demonstrates improved pain and symptom management, psychosocial measures of quality of life, and patient perceptions of quality of communication and treatment with interdisciplinary team input.5

Palliative care benefits patients of all ages grappling with From Strand, JJ, Mansel, JK, Swetz, KM. The growth of palliative care. Minn Med. any stage of advanced serious illness. Although the benefits of PC have traditionally been associated with 2010;97(6): 39-43. terminal illness, PC is an integral part of disease-directed and comfortfocused therapy. PC practices have been shown to improve quality of life including physical, emotional and interpersonal status, and spiritual outlook. Studies suggest that excellent PC may actually improve survival for some patients by improving symptom burden and quality of life.6,7

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Palliative care is most effective when integrated early in the course of illness. Patients and clinicians may have trepidation about PC practitioners’ involvement, remarking that patients are ‘not ready’ for PC yet or are not interested in ‘giving up’. On the contrary, early PC involvement insures comprehensive needs assessment and symptom management throughout an unpredictable course of serious illness. By developing treatment plans geared at meeting the goals of care of patients (and often their families or surrogates), attention can remain focused on quality of life as treatment plans evolve from disease-directed to comfort-centered. Early PC involvement has been shown to improve physical, functional, emotional and social well-being and decrease aggressive interventions at the end of life.7

Communication is a fundamental competency in palliative care and essential to patient-centered care. Poor communication impairs the development of a therapeutic relationship and limits accurate delineation of a patient’s goals, further impeding optimal treatment. Active listening is not only essential in gathering clinical data and strengthening the provider-patient relationship but, in and of itself, can be healing and therapeutic.8 Surveys have shown that (regarding information sharing) patients and families value timing, delivery and attitude as much as the information provided.9 PC specialists aim to model and teach skillful communication.

Using terms that clearly and accurately describe clinicians’ intent is crucial to effective palliative care. ‘The phrases ‘withdraw support’ or ‘withdraw care’ often give the impression of permitting suffering or abandoning patients in a time of need. The ‘do-not-resuscitate’ can inappropriately suggest that resuscitation is likely to be successful, when in fact the likelihood of restoring function and quality of life is extremely limited. ‘Comfort care’ is an ambiguous term which may not accurately portray the goals of care and may limit appropriate treatments. In fact, the word ‘hospice’ is often used synonymously with palliative care, leading to the false assumption that PC is reserved solely for patients at the end of life. However, hospice is a narrow subset of PC that is reserved for persons in the final 6 months of their lives. The specific words we choose can have a profound impact on perceptions of provider care and empathy, can affect a patient or family’s anxiety surrounding decision-making, and can leave a lasting image on patients and bereaved caregivers.10

Figure 2. Components of the Interdisciplinary Network

Palliative care improves quality of life by continually assessing and aggressively treating suffering in all its forms. Through focused; management of symptoms such as pain, nausea, dyspnea, fatigue, depression, anxiety, and delirium, PC seeks to ease physical suffering to allow the difficult work of emotional healing to occur. Research has shown that symptom intensity is improved with PC involvement through expert symptom management.11

Palliative care utilizes a ‘shared decision-making’ model to align patients’ goals-of-care with the clinical context. Goals of care can be defined broadly as the expectations and preferences of patients and families regarding future treatments, interventions, and outcomes. PC leverages skills in relationship building and communication to navigate difficult or contentious clinical situations to facilitate mutual treatment decisions between team and patient. Care planning, shared decision-making, and providerpatient relationships have been identified as of utmost importance in improving care by patients and families.12

A central aim of palliative care is fostering trusting relationships between healthcare teams and patients. Research suggests that patients are often most concerned about whether clinicians are honest, care about them as a person, and understand their goals and hopes.13 Such ideals are at the core of PC—namely, more fully understanding patients’ needs and values which may mollify the physical and emotional suffering that occur as illness progresses.

Palliative care focuses on treating the patient as a whole. PC aims to treat suffering in all its forms and thus must seek to know and treat the whole patient. In fact, comprehensive PC often necessitates treating a person’s loved ones’ needs as well. Suffering is a dynamic process that evolves over time. Recognizing and exploring patients’ background, culture, spirituality, and values builds rapport and trust. Furthermore, it can reveal critical information about a patient’s wishes and hopes and how they approach their illness journey. Patient surveys have suggested that respect for their hopes and beliefs is central to patients’ and families’ coping with illness from diagnosis through end of life.9

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Conclusion

Hunting?

Each of us is an individual with a story comprised by personal, cultural, and religious values that contribute to overall physical, psychological, spiritual and social needs that manifest and evolve throughout the course of advanced serious illness. By integrating Palliative Care into the lives of patients, it is possible to achieve a fuller understanding of the whole person, improve provider-patient relationships, clarify goals of care through shared decision making, and maximize quality of life for patients with advanced serious illness. n

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References 1. Dumanovsky T, Augustin R, Rogers M, et al. The growth of palliative care in U.S. hospitals: A status report. J Palliat Med. 2016;19:8-15. 2. Quill TE, Abernethy AP. Generalist plus specialist palliative care—Creating a more sustainable model. N Engl J Med. 2013;368:1173-1175. 3. O’Mahony S, Blank AE, Zallman L, Selwyn PA. The benefits of a hospital-based inpatient palliative care consultation service: preliminary outcome data. J Palliat Med. 2005;8:1033-1039. 4. From Strand, JJ, Mansel, JK, & Swetz, KM. The growth of palliative care. Minn Med, 2010;97(6):39-43. 5. Schrader SL, Brechtelsbauer D, Heins J, Holland P, Schroeder PA. A team approach in palliative care: Enhancing outcomes. S D Med. 2002;65:269-278. 6. Cohen SR, Boston P, Mount BM, Porterfield P. Changes in quality of life following admission to palliative care units. Palliat Med. 2001;15:363-371.

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7. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non–small-cell lung cancer. N Engl J Med. 2010;363:733-742. 8. Jogosh J, Donald Boudreau J, Steinart Y, Macdonald ME, Ingram L. The importance of physician listening from the patients’ perspective: Enhancing diagnosis, healing, and the doctor–patient relationship. Patient Educ Couns. 2011;85:369-374. 9. Kirk P, Kirk I, Kristjanson LB. What do patients receiving palliative care for cancer and their families want to be told? A Canadian and Australian qualitative study. BMJ. 2004;382:1343. 10. Curtis JR, Sprung CL, Azoulay E. The importance of word choice in the care of critically ill patients and their families. Intensive Care Med. 2014;40: 606-608. 11. Modonesi C, Scarpi E, Maltoni M, et al. Impact of palliative care unit admission on symptom control evaluated by the Edmonton Symptom Assessment System. J Pain Symptom Manage. 2005;30:367-373.

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12. Heyland DK, Cook DJ, Rocker GM, et al; Canadian Researchers at the End of Life Network (CARENET). Defining priorities for improving end-of-life care in Canada. CMAJ. 2010;182(16):E747-E752 . 13. Anderson R, Barbara A, Feldman S. What patients want: A content analysis of key qualities that influence patient satisfaction. J Med Pract Manage. 2007;22:255-261.

Author Information: University of Mississippi Medical Center, Palliative Care Program, Jackson, MS (Paine, Klar, Ward, and Mansel). University of Alabama at Birmingham, Birmingham, AL (Swetz). Corresponding Author: C. Christian Paine, II, MD; University of Mississippi Medical Center, Department of Pediatrics, 2500 N. State St., Jackson, MS 39216. Ph: (601)984-6562 (cpaine@umc.edu).

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Repeated Cardiac Arrests due to Undersensing of Temporary Epicardial Pacer after Coronary Artery Bypass Grafting and Maze Procedure SACHIN BAHADUR, MD; BEN HAM, MD; SIRIVALLI CHAMARTI, BS; TAO HONG, MD Abstract

during temporary epicardial pacing after cardiac surgery.

The R-on-T phenomenon is a well-known entity that may result in dangerous arrhythmias. This phenomenon can occur due to asynchronous pacing or to undersensing of a pacer’s intrinsic rhythm such that the generated QRS complex falls within a T wave of the preceding beat. This report involves a patient who was fitted with temporary epicardial pacing wires after coronary artery bypass grafting and Maze procedure. The patient experienced repeated episodes of pulseless polymorphic ventricular tachycardia. These episodes were caused by R-on-T phenomenon due to aberrant firing of a temporary pacemaker.

Case Presentation

Introduction Pacing wires are frequently inserted at the end of a cardiac surgical procedure to improve hemodynamic function in the presence of bradycardia and arrhythmias. Their use is generally considered safe and simple, however, rare but catastrophic complications have been reported. We describe an interesting case of R-on-T phenomenon

A 65-year-old man underwent three-vessel coronary artery bypass grafting (CABG) with modified Maze procedure under cardiopulmonary bypass. Temporary epicardial pacing wires were inserted for post-bypass junctional rhythm. His immediate postoperative course was uneventful; he was extubated within a few hours of arriving in the ICU. On the second postoperative day while waiting to be discharged from the ICU, he collapsed while eating and needed 30 minutes of resuscitation including multiple defibrillations for ventricular tachycardia (Figure 1). He was subsequently reintubated and stabilized. At the time of arrest his potassium was 4.7mmols/lt and his magnesium was 2.3 mmols/lt. His epicardial atrial pacer was checked and he was paced at 90 beats per minute with a threshold of 12mA. He underwent emergent cardiac catheterization and pulmonary angiography to evaluate and treat any potentially reversible causes of cardiac arrest. His coronary arteries were patent with no evidence of pulmonary embolism.

Figure 1. The strip reveals “R on T” phenomenon (black arrows) leading to subsequent ventricular tachycardia. Pacer spikes (red arrows) indicate pacemaker malfunction as preceding arrhythmia.

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Figure 1. The strip reveals “R on T” phenomenon (black arrows) leading to subsequent ventricular tachycardia. Pacer spikes (red arrows) indicate pacemaker malfunction as preceding arrhythmia.

causes of cardiac arrest was prioritized initially; however, a preliminary suspicion for pacer malfunction during the patient’s initial prandial syncopal episode could have averted significant morbidity.

The patient experienced a second cardiac arrest 9 hours after the initial event which required multiple defibrillations and 20 minutes of resuscitation, after which his rhythm again reverted to atrial fibrillation. The corrected QT interval before the second cardiac arrest was 440 ms. Telemetry recordings revealed an episode of sustained polymorphic ventricular tachycardia associated with the R-on-T wave phenomenon (Figure 2) due to asynchronous pacing from the temporary pacemaker. After the second event, the temporary pacemaker unit was switched off and he had no further episodes of cardiac arrest. He recovered completely without any neurological deficit and was later discharged to a skilled nursing facility.

Although the described phenomenon is relatively uncommon, it is possible that after CABG procedures and during temporary pacing, episodes of pacemaker-mediated ventricular fibrillation will occur unrecognized despite constant electrocardiographic monitoring. Recognition of the phenomenon is vital, as arrhythmias are potentially fatal, although when diagnosed early, a patient may easily be treated with good outcomes.

Figure 2. Second event of arrest preceded by “R on T” phenomenon (black arrow) with mid pacer spike (red arrow).

Discussion Although atrial and/or ventricular temporary pacing wires are frequently placed following cardiac surgery to prevent such perioperative arrhythmias as nodal or junctional arrhythmias, bradycardia, and atrioventricular block, that could result in significant hemodynamic compromise, there remains a paucity of data regarding their reliability, success, and complications.1 Atrial leads tend to fail more often than ventricular leads. Further, because the R waves have higher amplitudes compared to P waves, undersensing of ventricular activity by ventricular leads is much less common than the sensing malfunctions of atrial leads. Nevertheless, when they occur, there may be disastrous consequences. In a recent retrospective study of 217,365 patients undergoing surgery, 160 had perioperative cardiac arrest. Two of the patents were reported to have pacemaker-related cardiac arrest but the specific cause was not mentioned. This might be due to lack of knowledge or underreporting in this patient population.2 The R-on-T phenomenon due to intermittent loss of sensing by temporary ventricular pacing wires and leading to polymorphic ventricular tachycardia and cardiac arrest has been reported.3 This is nonetheless a unique cardiac surgery case of a coronary artery bypass and modified Maze surgery patient in which aberrant firing of the pacemaker resulted in the R-on-T phenomenon with subsequent ventricular fibrillation postoperatively. Ruling out more common

Repetitive ventricular activity is particularly common when a premature beat falls on the T wave of a beat with a preceding long cycle length. Physiologic factors that can increase cycle length include hypoxia, cardiac ischemia, myocardial disease, hypokalemia, hypothermia, hypothyroidism, digoxin therapy, and other drugs known to prolong the QT interval. Other causes of sensing malfunction can be related to lead connection and low battery so daily monitoring of the pacers for pacing and sensitivity is imperative. Other more common conditions frequently associated with repetitive ventricular activity that must be ruled out include hypoxia due to pulmonary embolus, cardiac ischemia, myocardial disease, acidosis, hypovolemia, tension pneumothorax, cardiac tamponade, metabolic disturbance including hypokalemia, hypothermia, hypothyroidism, and toxins/drugs. Conclusion Cardiac arrest after heart surgery is challenging and frequently leads to poor outcomes. It is imperative to diagnose the cause of arrest, which most commonly occurs secondary to coronary graft thrombosis and pulmonary emboli. However, critical consideration should also be given to cardiac arrest because of pacer malfunction caused by the undersensing of the epicardial leads, as it may easily be missed, even with patients on telemetry. A high index of suspicion and can be lifesaving, as can simply turning the pacer off. Of note, discontinuing backup pacing and temporary pacemaker generators when pacing support is not required could lead to improved patient prognosis. n References 1. Abu-Omar Y, Guerrieri-Wolf L, Taggart DP. Indications and positioning of temporary pacing wires. Multimedia Manual Cardio-Thoracic Surgery. 2006(0512). 2. Mantz J, Riou B. Introduction to the Anesthesiology Cardiac Arrest and Resuscitation Issue. Anesthesiology. 2014;120(4):829-838. 3. Chemello D, Subramanian A, Nanthakumar K. Cardiac arrest caused by undersensing of a temporary epicardial pacemaker. Can J Card. 2010;26(1):e13-e14. Corresponding Author: Tao Hong, MD; Associate Professor, Department of Anesthesiology, University of Mississippi Medical Center, 2500 N. State St., Jackson, MS 39216

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Congenital Lobar Emphysema Can Mimic Tension Pneumothorax PATRICIA AMOLENDA, MD; DOUGLAS MAPOSA, MD; MADHANKUMAR SATHYAMOORTHY, BMBS Abstract A 16-month-old female, born prematurely, required broviac catheter placement under general anesthesia for vascular access. The patient was in the intensive care unit (ICU), on mechanical ventilation due to respiratory failure. In the operating room, ventilation became difficult with high peak pressures. Based on fluoroscopy exam and rapidly developing hemodynamic instability, a tension pneumothorax was suspected; an emergency needle decompression was done to treat it. It was soon realized that the patient had pre-existing congenital lobar emphysema which was missed in the handoff communication. The patient underwent emergency lobectomy with improvement in ventilation and hemodynamic stabilization. This misadventure points out the need to develop a standardized in-person handoff report between providers to reduce errors and improve safety. Key Words: C ongenital lobar emphysema, Tension pneumothorax, Patient handoff, Cognitive bias Introduction Most medical errors can be prevented. They cause the most number of deaths in the US after heart disease and cancer.1 Communication failure between healthcare providers is a primary cause in a majority of sentinel events reported to the Joint Commission (JACHO).2 The following case report describes a misadventure in the perioperative management of a critically ill infant who was scheduled for a relatively minor procedure in the operating room under general anesthesia. This case highlights the need for a standardized handoff for patients that are transferred to the operating room for procedures.

for bibasilar crackles. A CT exam done two weeks prior showed left congenital lobar emphysema. The finding was missed in the hand off report when the patient was transferred from the PICU to the OR. In the OR before the start of the procedure, ventilation became difficult and required high peak inspiratory pressures. Her oxygen saturation started declining to 60s-50s. Direct laryngoscopy confirmed the proper position of the tracheal tube. Lung auscultation revealed decreased bilateral breath sounds more prominent on the left side, without any wheezing. A suction catheter was passed quickly through the tracheal tube and obtained only minimum secretion. Flexible bronchoscopy was also done to examine the airway and placement of the tube above the carina. Fluoroscopy of the chest revealed hyperlucency and absence of vascular markings on the left thorax (Figure). This finding in combination with difficult ventilation and hemodynamic instability, led to suspected tension pneumothorax. Emergency needle decompression at the left 2nd intercostal space with an 18 gauge angio-catheter was performed. There was minimal improvement in the patient’s ventilation. The oxygen saturation was in the 70s on 100% FIO2 and systolic blood pressure in the 40s. The patient was given an epinephrine bolus, and the infusion was started. The PICU attending physician arrived in the OR at this time and reported that the patient had congenital lobar emphysema on the left lung which was causing similar episodes of hypoxemia and difficult ventilation in the PICU. After discussing with the rest of the team and the parents, the surgeon proceeded to do a thoracotomy and left upper lobectomy. The patient had significant improvement in ventilation, oxygen saturation, and hemodynamics. Epinephrine was weaned off. The rest of the procedure was unremarkable, and the patient was transported back to PICU in stable condition.

Case Presentation A 16-month-old female admitted to the Pediatric Intensive Care Unit (PICU) was scheduled for broviac catheter placement in the operating room (OR) under general anesthesia. The patient was born prematurely at 25 weeks of gestational age. She had a history of chronic lung disease of prematurity, adrenal insufficiency, and pulmonary hypertension. She was intubated and on mechanical ventilation in Spontaneous Intermittent Mandatory Ventilation mode (SIMV) with a rate of 26, peak inspiratory pressure (PIP) of 30 cm H2O, and positive end-expiratory pressure (PEEP) of 9 cm H2O. Her oxygen saturation ranged from 88-95% on 60% FIO2, heart rate in the 140s and mean arterial pressure in 60s. Her lung auscultation was significant 224 VOL. 58 • NO. 8/9 • 2017

Discussion There are multiple challenges and pitfalls in this case. In a busy tertiary care center, patients with complex medical conditions can be added on to the operating room schedule late in the day. In this case, a child from PICU was posted as an add-on case for broviac catheter insertion. Her respiratory condition was treated as chronic lung disease of prematurity in the PICU. The recent CT scan finding of lobar emphysema was missed in the review of electronic medical record during pre-anesthesia evaluation. Also, the anesthesiologist did not receive in-person handoff report from the PICU attending during the transfer of care, as he was supervising another case with the resident in the OR. A standardized

handoff in person between providers during transfer of care from the PICU to the OR could have helped prevent the error in this case. A handoff, also known as a “handover” refers to the transfer of patient information and professional responsibility between individuals and teams, within the overall system of care. The primary function of handoff is to communicate essential patient data to provide safe and continuous patient care. Handoff procedures can vary widely from one institution to the next. The principles of effective handoffs remain consistent. The quality of a handoff can be assessed based on three aspects which include the handoff content, process, and outcome. It is important that the content information transmitted is accurate, precise and complete. The handoff process refers to environmental and behavioral aspects of the handoff. The handoff should be done in a place where there are minimal interruptions and decreased noise level. It is also ideal that there is an interactive communication between two providers. A handoff is not solely a passive transfer of information, rather, it is an opportunity for the recipient to critically review the information, ask questions and engage in the planning and decision-making in the patient’s care. Lastly, the outcome measures usually include the satisfaction with the handover and consequences on the subsequent patient care.3

Figure. Left lung is overinflated and hyperlucent consistent with lobar emphysema

Content omissions and poor communication processes can result in communication failures during handoffs. Content omissions can include, failure to report an ongoing/anticipated medical problem or rationale of a treatment/diagnostic test. Lack of face-to-face communication is a poor communication process.4 The lack of handoff education and training in medical professionals is also a significant barrier to giving an effective handoff.5

References

Multiple recommendations have been described for structuring the handover process. The process should be standardized with the use of checklists and protocols. Urgent clinical tasks should be completed before information transfer. The discussions should be focused on the particular patient. All relevant team members should be present during handoffs. Healthcare providers should be given continuous training in team skills and communication.6 Several mnemonics have been used in effective handoffs. Most commonly used are SBAR (Situation, Background, Assessment and Recommendations) and I-PASS (Illness Severity, Patient Summary, Action list, Situation awareness and contingency planning, and Synthesis by the receiver). In acute care settings, SBAR can help focus and improve effectiveness of information transfer.7, 8

4. Manser T, Foster S. Effective handover communication: An overview of research and improvement efforts. Best Prac Res Clin Anaesthesiol. 2011;25:181-191.

Conclusion There are many challenges and pitfalls in the anesthetic management of a critically ill child from the ICU. Standardized handoff report and inperson communication between physicians are critical in the transfer of care. Congenital lobar emphysema can present as sudden deterioration in ventilation and can be confused with tension pneumothorax.

1. Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016;353:i2139. 2. Joint Commission on Accreditation of Healthcare Organizations. Sentinel event statistics, August 1, 2016. https://www.jointcommission.org/sentinel_event_ statistics_quarterly/. 3. Jeffcott SA, Evans SM, Cameron PA, et al. Improving measurement in clinical handover. Qual Saf Health Care. 2009;18:272-276.

5. Riesenberg LA, Leitzsch J, Massucci JL, et al. Residents’ and Attending Physicians’ Handoffs: A Systematic Review of the Literature. Acad Med. 2009;84:1775-1787. 6. Segall N, Bonifacio AS, Schroeder RA, et al. Can We Make Postoperative Patient Handovers Safer? A Systematic Review of the Literature. Anesth Analg. 2012;115:102-115. 7. Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 2004 Oct;13 Suppl 1:i85-90. 8. Starmer AJ, Spector ND, Srivastava R, et al. Changes in medical errors after implementation of a handoff program. N Engl J Med. 2014;371:1803-12.

Author Information Resident in Anesthesiology, PGY4 (Amolenda). Associate Professor of Anesthesiology (Maposa). Associate Professor of Anesthesiology (Sathyamoorthy). All at the University of Mississippi Medical Center, Jackson, MS. Authors reported no conflicts of interest. Corresponding Author: Madhankumar Sathyamoorthy, MBBS, MS, BMBS; University of Mississippi Medical Center, Department of Anesthesiology, 2500 N State Street, Jackson, MS 39216. Ph: (601)984-5900, FAX: (601)984-6283 (msathyamoorthy@umc.edu).

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Connective Tissue Disease May Be a Significant Risk Factor for Development of Nonuremic Calciphylaxis SHWETA KISHORE, MBBS; MAX HARRIGILL; AMANDA H FOWLER, MD; VIKAS MAJITHIA, MD, MPH Abstract

Case Presentations

Calciphylaxis is a condition of generalized vascular and cutaneous calcification which may occur in the presence of normal renal function. Nonuremic calciphylaxis is a rare and poorly understood condition, and is usually associated with poor outcome. In this article, we present two patients with nonuremic calciphylaxis in association with connective tissue disease (CTD) and review literature. Both patients were female, had severe rheumatoid arthritis (RA), normal renal function and were treated with corticosteroids and TNF inhibitors. A systematic review of literature for reports of nonuremic calciphylaxis was also performed. A total of 78 patients of nonuremic calciphylaxis were identified, 18 (23 %) of which were associated with underlying CTD, suggesting a possible association between the pathogenesis of nonuremic calciphylaxis and connective tissue diseases.

Patient 1

Key Words N on-uremic calciphylaxis, Calciphylaxis, Connective tissue disease, Hyperparathyroidism, Review, Diagnosis, Treatment. Introduction Calciphylaxis is a syndrome of vascular calcification, thrombotic cutaneous ischemia and skin necrosis that has been well described in the setting of end stage kidney disease and renal transplantation. Calciphylaxis has been attributed to secondary hyperparathyroidism, calcium-phosphorus abnormalities and Vitamin D therapy in these patients. However, a definitive mechanism is not known. Calciphylaxis in the setting of normal renal function is often referred to as non-uremic calciphylaxis. Nonuremic calciphylaxis is a rare and poorly understood condition with limited or widespread calcium deposition in the soft tissues and has been associated with multiple underlying disorders, including connective tissue disease, malignancies, primary hyperparathyroidism and chronic liver disease. Attempts to treat nonuremic calciphylaxis have been met with varying rates of success and include parathyroidectomy, cinacalcet, surgical debridement, hyperbaric oxygen therapy, bisphosphonate therapy and sodium thiosulfate. Clear guidelines for treatment are lacking due to the relative rarity of calciphylaxis. Prognosis is generally poor, with oneyear mortality ranging from 45% to 80%.1,2 In this review, we present the two patients with nonuremic calciphylaxis in the setting of connective tissue disease and compare and contrast their findings with similar cases in the published literature.. 226 VOL. 58 â&#x20AC;˘ NO. 8/9 â&#x20AC;˘ 2017

A 35-year-old Caucasian female with rheumatoid arthritis for fifteen years had aggressive disease involving multiple small joints of the hands. Initial treatment with conventional disease modifying antirheumatic drugs such as methotrexate, hyd rox yc hl o ro q u ine and leflunomide failed to control her disease. She achieved good control of disease while she was on a combination of Figure 1: Post biopsy appearance of leflunomide, adalimumab and a large necrotic, punched out ulcer on low dose prednisone. Three shin in Patient 1. years into therapy she lost her job and could not continue adalimumab regularly. In 2011, she presented with cutaneous nodules and non-healing ulcers on her thighs and lower extremities (Figure 1). Upon biopsy, these nodules showed histopathology of calciphylaxis. Work up revealed a normal serum calcium 8.6 mg/dl, phosphorus 3.6 mg/dl, creatinine 0.7 mg/ dl and parathyroid hormone 51 pg/ml. The patient showed no improvement in the ulcers despite wound care and intravenous antibiotics and died due to sepsis after a prolonged hospitalization. Patient 2 A 70-year-old African American female with long standing rheumatoid arthritis and deep vein thrombosis on coumadin, hydroxychloroquine, low dose methotrexate, and prednisone was admitted for non-healing large deep ulcers on bilateral inner thigh (Figure 2). The initial diagnosis was pyoderma gangrenosum and

Figure 2: Extensive deep cutaneous ulcers on left thigh in Patient 2. The edges of the ulcer appear irregular and indurated. The margin of the ulcer is necrotic which can occur due to microthrombosis.

therapy was escalated to high dose steroids, azathioprine and Infliximab every four weeks. The ulcers failed to improve and a biopsy was done which showed calciphylaxis. Prednisone was tapered and infliximab and azathioprine were stopped. Laboratory workup revealed normal serum calcium 9.6 mg/dl, phosphorus 2.7 mg/dl, creatinine 0.85 mg/dl and parathyroid hormone 47 pg/ml. She was admitted for increasing pain and despite four months of aggressive wound care, debridement, intravenous antibiotics, intravenous sodium thiosulfate and alendronate died secondary to sepsis. Literature Review Materials and Methods Patients were identified using Pubmed and Google scholar using MeSH terms calciphylaxis and connective tissue disease or rheumatoid arthritis or lupus or sarcoidosis or giant cell arteritis. Reports included were of those who had a definitive diagnosis of connective tissue disease, the absence of end stage kidney disease, and had a histopathologic diagnosis of calciphylaxis. Additional case reports or case series were identified using the reference link provided in articles. The reports were reviewed and data regarding connective tissue disease, age, gender, race, prior use of glucocorticoids or warfarin (Coumadin), treatment, and outcome were recorded. Results In addition to the two patients reported here, we identified 15 citations including 16 patients with nonuremic calciphylaxis in the setting of connective tissue disease.3-16 These included 14 individual case reports and 1 case series. One report was written in Spanish and was excluded. All the patients had a histopathological diagnosis of calciphylaxis. Of the 17 patients, 9 had rheumatoid arthritis, 3 had systemic lupus erythematosus, 3 had polymyalgia rheumatica/giant cell arteritis, 1 had Crohnâ&#x20AC;&#x2122;s disease, and 1 had sarcoidosis (Table). Sixteen out of 17 patients were female. Four patients had elevated PTH out of which three had low vitamin D. Thirteen patients were on corticosteroids while eight patients were on other immunosuppressants prior to the diagnosis of calciphylaxis. Five patients were on warfarin. Ten out of 17 patients died, with sepsis as the most common cause of death. Two patients had an unknown outcome. Treatments included were sodium thiosulphate, bisphosphonate, hyperbaric oxygen, surgical debridement and glucocorticoids. Discussion Selye et al coined the term calciphylaxis in 1961, based on an animal model experiment by inducing calcification using Vitamin D and metallic salts.17 Calciphylaxis was first reported in a patient with uremia and secondary hyperparathyroidism.18 Initial lesions appear violaceous and progress to non-healing necrotic ulcerations.1 They may also develop nodules or plaques, some of which are indurated and extensive. It is often misdiagnosed as vasculitis.19 Histological studies describe a mural calcification of small dermal and subcutaneous blood vessels, with intimal fibroblastic proliferation causing luminal narrowing often accompanied by microthrombosis.5 The gross appearance and histopathology of uremic and nonuremic

calciphylaxis are the same. Suggested etiologies of calciphylaxis include chronic liver disease, chronic immunosuppression, autoimmune conditions, coumadin or corticosteroid use and proteins C & S deficiencies. Unlike uremic calciphylaxis, the majority of patients with nonuremic calciphylaxis do not have metabolic abnormalities like secondary hyperparathyroidism, hypercalcemia or hyperphosphatemia. Therapies associated with end stage renal disease like Vitamin D supplementation and phosphate binders can also precipitate calciphylaxis.20 Nuclear factor- kB is the key transcription factor for cellular function like activation of inflammatory cascade and bone mineral loss. Some studies suggest calciphylaxis occurs through a possible pathogenic mechanism involving imbalance of receptor activator nuclear factorkB (RANK), its ligand RANKL and osteoprotegerin pathway which is expressed on bone cells and vascular smooth muscle cells. Increased NF-kB activity results in transdifferentiation of vascular smooth muscle cells into osteoblast-like cells.21 Renal disease, liver disease, corticosteroids, warfarin, and chronic inflammatory conditions can increase the expression of RANK ligand and downregulate osteoprotegerin, thereby causing widespread calcification.22,23 Vascular calcification then produces localized pro-thrombotic state leading to ischemic necrosis seen with calciphylaxis.14 Fetuin-A is a ubiquitous extracellular glycoprotein which inhibits hydroxyapatite formation while matrix G1a-protein (MGP) is a vitamin K dependent protein which inhibits mineralization. It has been found that reduced levels of fetuin-A in renal failure and inhibition of MGP by warfarin also plays a role in vascular and extravascular calcification.24, 25 Another theory implicates hypercoagulable states like protein C and S deficiency in the pathogenesis of calciphylaxis.6 These theories are obviously not applicable to all the calciphylaxis patients due to complicated metabolic and coexistent comorbidities present in these patients and thus the pathogenesis of this grim condition remains poorly understood. In addition to excellent wound care, sodium thiosulphate and bisphosphonates have been used in patients with SLE and renal disease, but application in nonuremic calciphylaxis is limited to case reports.26,27 Pek EA, et al first reported the use of sodium thiosulphate in a patient with SLE and nonuremic calciphylaxis.15 Bisphosphonates have been utilized in calciphylaxis due to anti-inflammatory properties, as they can promote macrophage inhibition and suppression of inflammatory cytokines.28 Although the role of corticosteroids in the natural history of calciphylaxis is controversial, it is considered a risk factor and is generally not recommended therapeutically.15 Several other case series have been presented. In 2008, Nigweker et al reviewed 35 nonuremic calciphylaxis patients of which only 5 were associated with connective tissue diseases.29 Since then another 13 patients have been reported including our two patients. This indicates that reporting of nonuremic calciphylaxis associated with connective tissue disease has increased recently suggesting either an increase in incidence or an increased awareness of this extremely rare condition. Of the 76 nonuremic calciphylaxis patients identified in our literature search, 16 were found to be associated with underlying connective

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Table. Reported cases of calciphylaxis with connective tissue diseases Table. Reported cases of calciphylaxis associated withassociated connective diseases Author

CTD

Age

Sex

Ethnicity

M/F

Prior Steroid use

Other Medication Prior to Diagnosis

↑

Treatment

Outcome

PTH

Barri et al. 19973

Crohn’s Disease

Caucasian

Yes

Vit D, Allopurinol, Ca, Mg, Iron

Yes

High Dose Prednisone, Total Parathyroidectomy

Death due to Sepsis

Korkmaz et al. 20024

Unknown

Yes

Unknown

High Dose Steroids Stopped Later

Amputation of limb

Ozbalkan et al. 20055

Unknown

Yes

MTX

ABX

Death due to Sepsis

Brouns et al. 20076

GCA

Unknown

Yes

Coumadin, Vit D, Ca

Low

Stopped Steroid, Ca and Vit D. Switched Coumadin to Enoxaparin

Death due to Sepsis

Brouns et al. 20076

GCA

Unknown

Yes

Ca, Vit D and Alendronate

Low

Coumadin switched to Enoxaparin. Stopped Ca, Vit D. Alendronate

Death due to Sepsis

Ortiz et al. 20097

Unknown

Yes

MTX, LEF, Alendronate, Ca, Vit D

Wound care, ABX

Death due to Sepsis

Swanson et al. 20098

Sarcoidosis

Caucasian

Yes

Mycophenolate, cyclosporine

Unknown

Zechlinski et al. 20099

SLE

African American

Yes

Coumadin, Alendronate

Yes with Low Vit D

Prednisone and Vit D. Switched coumadin to Heparin.

Unknown

Malabu et al. 201110

Caucasian

Unknown

Yes with low Vit D

Wound care, Hyperbaric Oxygen, Vit D, STS, IV Ramidronate

Resolved

Aliaga et al. 201211

SLE

Caucasian

Yes

Unknown

ABX, Debridement, Steroids, CYC

Death due to sepsis

Hammadah et al. 201312

Caucasian

Yes

Unknown

High Dose Steroids, STS

Resolved

Dominguez et al. 201413

Unknown

Yes

LEF, Coumadin, Teriparatide

Stopped Teriparatide and Coumadin, STS

Death due to Sepsis

Spanakis et al. 201414

PMR

Caucasian

Yes

Coumadin, Teriparatide

Wound care, ABX. Stopped Teriparatide. IV Zoledronic Acid.

Resolved

Pek et al. 201615

SLE

Caucasian

Coumadin, Azathioprine, HCQ

Yes with Low Vit D

Steroids later tapered. Switched coumadin to Heparin, Vit D, Wound care, STS

Death due to sepsis

Ortiz et al. 201616

Unknown

Yes

MTX, LEF, Ca, Vit D

Local Supportive Care

Resolved

Case 1

Caucasian

Yes

Adalimumab, prednisone

Antibiotic, wound care

Death due to sepsis

Case 2

African American

Yes

HCQ, Azathioprine, Infliximab, prednisone

Wound care, STS, Alendronate, ABX

Death due to sepsis

Abbreviations: CTD (Connective Tissue Disease), Parathyroid Hormone (PTH), Giant Cell Arteritis (GCA), Polymyalgia Rheumatica (PMR), Rheumatoid Arthritis (RA), Systemic Lupus Erythematosus(SLE), Methotrexate(MTX), Hydroxychloroquine(HCQ), Leflunomide (LEF), Antibiotics (ABX), Calcium (Ca), Magnesium (Mg), Vitamin D (Vit D), Sodium Thiosulphate(STS), Intravenous (IV), Cyclophosphamide(CYC).

tissue disease. This suggests a significant association between the pathogenesis of nonuremic calciphylaxis and connective tissue

diseases. Our review also reveals a significant mortality in more than half patients with connective tissue diseases and nonuremic 228 VOL. 58 • NO. 8/9 • 2017

calciphylaxis. In addition, there were a disproportionate number of females, as there were 16 females to 1 male (Table). This is a significant association in patients developing nonuremic calciphylaxis in CTD, as the majority of uremic calciphylaxis patients are men. In

addition, there is a possible association between nonuremic calciphylaxis in patients with connective tissue diseases and corticosteroids and immunosuppressants, as 88.2% of the patients were on corticosteroids, while 47% were on other immunosuppressants. It must be noted, however, that these associations may be due to some present underlying diseases or other confounding factors. None of the patients were on anti-tumor necrosis factor therapy except two patients from our institution. Conclusion Nonuremic calciphylaxis is a rare and incompletely understood condition with a devastating outcome. It is associated with malignancies, primary hyperparathyroidism, liver diseases and connective tissue disease. Its presentation can be confused with vasculitis, antiphospholipid antibody syndrome and infections and thus nonuremic calciphylaxis should be considered in the differential diagnosis, particularly when additional risk factors are present.15 The reporting of nonuremic calciphylaxis cases associated with CTD is on a rise, likely due to awareness of this lethal condition. The lack of understanding of the complex pathogenesis has led to use of a variety of therapies with variable outcome. No single treatment has been effective so far. Additional studies are needed to understand the association between osteoporosis and vascular calcification for development of effective therapeutic intervention. n References 1. Weenig RH, Sewell LD, Davis MD, et al. Calciphylaxis: natural history, risk factor analysis, and outcome. J Am Acad Dermatol. 2007;56:569-579. 2. Meissner M, Gille J, Kaufmann R. Calciphylaxis: no therapeutic concepts for a poorly understood syndrome? J Dtsch Dermatol Ges. 2006;4:1037-1044. 3. Barri YM, Graves GS, Knochel JP. Calciphylaxis in a patient with crohnâ&#x20AC;&#x2122;s disease in the absence of end stage renal disease. Am J Kidney Dis. 1997;29:773-776. 4. Korkmaz E, Dundar E, Zubaroglu I. Calciphylaxis in a patient with rheumatoid arthritis without renal failure and hyperparathyroidism: the possible role of longterm steroid use and protein S deficiency. Clin Rheumatol. 2002;21:66-69. 5. Ozbalkan Z, Calguneri M, Onat AM, et al. Development of calciphylaxis after longterm steroid and methotrexate use in a patient with rheumatoid arthritis. Intern Med. 2005;44:1178-1181. 6. Brouns K, Verbeken E, Degreef H, et al. Fatal calciphylaxis in two patients with giant cell arteritis. Clin Rheumatol. 2007;26:836-840. 7. Ortiz A, Ceccato F, Roverano S, et al. Calciphylaxis associated with rheumatoid arthritis: communication of the second case. Clin Rheumatol. 2009;28(Suppl 1):S6568. 8. Swanson AM, Desai SR, Jackson JD, et al. Calciphylaxis associated with chronic inflammatory conditions, immunosuppression therapy, and normal renal function: a report of 2 cases. Arch Dermatol. 2009;145:723-725. 9. Zechlinski JJ, Angel JR. Calciphylaxis in the Absence of Renal Disease: secondary hyperparathyroidism and systemic lupus erythematosus. J Rheumatol. 2009;36:23702371. 10. Malabu UH, Roberts LJ, Sangla KS. Calciphylaxis in a morbidly obese woman with rheumatoid arthritis presenting with severe weight loss and vitamin D deficiency. Endocr Pract. 2011;17:e104-e108. 11. Aliaga LG, Barreira JC. Calciphylaxis in a patient with systemic lupus erythematosus without renal insufficiency or hyperparathyroidism. Lupus. 2012;21:329-331. 12. Hammadah M, Chaturvedi S, Jue J, et al. Acral gangrene as a presentation of nonuremic calciphylaxis. Avicenna J Med. 2013;3:109-111.

13. Dominguez AR, Goldman SE. Nonuremic calciphylaxis in a patient with rheumatoid arthritis and osteoporosis treated with teriparatide. J Am Acad Dermatol. 2014;70:e4142. 14. Spanakis EK, Sellmeyer DE. Nonuremic calciphylaxis precipitated by teriparatide [rhPTH(1-34)] therapy in the setting of chronic warfarin and glucocorticoid treatment. Osteoporos Int. 2014;25:1411-1414. 15. Pek EA, Joseph PL, Al Habeeb AS, et al. A Fatal Case of Calciphylaxis in a Patient with Systemic Lupus Erythematosus and Normal Renal Function. J Rheumatol. 2016;43:456-458 16. Ortiz A, Roverano S, Gallo J, et al. Calciphylaxis associated with rheumatoid arthritis: Communication of another case. Rheumatol Clin. 2016;12:158-160. 17. Seyle H, Gentile G, Pioreschi P: Cutaneous molt induced by calciphylaxis in the rat. Science. 1961;134: 1876-1877. 18. Anderson DC, Stewart WK, Piercy DM. Calcifying panniculitis with fat and skin necrosis in a case of uraemia with autonomous hyperparathyroidism. Lancet. 1968;2:323-325. 19. Lee JL, Naguwa SM, Cheema G, et al. Recognizing calcific uremic arteriolopathy in autoimmune disease: an emerging mimicker of vasculitis. Autoimmun Rev. 2008;7:638-643. 20. Budisavljevic MN, Cheek D, Ploth DW: Calciphylaxis in chronic renal failure. J Am Soc Nephrol. 1996;7: 978â&#x20AC;&#x201C;982. 21. Weenig RH. Pathogenesis of calciphylaxis: Hans Selye to nuclear factor kappa-B. J Am Acad Dermatol. 2008;58:458-471. 22. Huang L, Xu J, Kumta SM, et al: Gene expression of glucocorticoid receptor a and b in giant cell tumour of bone: Evidence of glucocorticoid-stimulated osteoclastogenesis by stromal-like tumour cells. Mol Cell Endocrinol. 2001;181:199-206. 23. Khoruts A, Stahnke L, McClain CJ, et al: Circulating tumor necrosis factor, interleukin-1 and interleukin-6 concentrations in chronic alcoholic patients. Hepatology. 1991;13:267-276. 24. Price PA, Faus SA, Williamson MK. Warfarin-induced artery calcification is accelerated by growth and vitamin D. Arterioscler Thromb Vasc Biol. 2000;20:317-327. 25. Ketteler M, Bongartz P, Westenfeld R, et al. Association of low fetuin-A (AHSG) concentrations in serum with cardiovascular mortality in patients on dialysis: a crosssectional study. Lancet. 2003;361:827-833. 26. Wendroth SM, Heady TN, Haverstick DM, et al. Falsely increased chloride and missed anion gap elevation during treatment with sodium thiosulfate. Clin Chim Acta. 2014; 431:77-79. 27. Mallet A, John G, Ranganathan D, et al. Sustained remission of systemic lupus erythematosus related calciphylaxis. Lupus. 2012;21:441-444. 28. Cecchini MG, Felix R, Fleisch H, et al. Effect of bisphosphonates on proliferation and viability of mouse bone marrow-derived macrophages. J Bone Miner Res. 1987;2:135142. 29. Nigweker SU, Wolf M, Strens RH, et al: Calciphylaxis from nonuremic causes: a systematic review. Clin J Am Soc Nephrol. 2008;3:1139-1143.

Author Information: Division of Rheumatology, Department of Medicine, University of Mississippi Medical Center, Jackson (Kishore, Fowler). Undergraduate student, Millsaps College, Division of Rheumatology, Department of Medicine, University of Mississippi Medical Center, Jackson (Harrigill). Senior author, Professor and Chief, Division of Rheumatology, Department of Medicine, University of Mississippi Medical Center, Jackson. Phone: (601)984-5540, Email: vmajithia@umc.edu (Majithia). Corresponding author: Shweta Kishore, MBBS; Division of Rheumatology, Department of Medicine, University of Mississippi Medical Center, 2500 N. State Street, Jackson, MS39216. Phone: (601)984-5540, Fax: (601)984-5535 Email: skishore@umc.edu.

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M I S S I S S I P P I

S T A T E

Marshall

Benton

Tishomingo

Alcorn

Tunica Tate

Prentiss

Tippah Union

Panola

Lafayette

Lee

Itawamba

Pontotoc Coahoma

Quitman

Bolivar

Yalobusha

Calhoun Monroe

Chickasaw Tallahatchie

Grenada Carroll

Washington

Montgomery

Clay

Attala

Humphreys

Issaquena

Lowndes Winston

Noxubee

Holmes Yazoo

Leake

Madison

Neshoba

Kemper

Newton

Lauderdale

Sharkey

Warren

Scott

Lincoln

Lawrence

Franklin

Amite

Wilkinson

Jasper

Smith

August 2017

Clarke

Simpson

Copiah

Jefferson Adams

Provisional Reportable Disease Statistics

Hinds

Rankin Claiborne

Mississippi

August 2017

Oktibbeha Choctaw

Covington

Jefferson Davis Lamar Marion

Pike

Wayne

Jones

Forrest

Perry

Greene

Walthall

Public Health District

George

Pearl River Stone

Northern Region Harrison

Central Region

H E A L T H

Provisional Reportable Disease Statistics

Webster

Sunflower Leflore

O F

Mississippi

Mississippi State Department of Health Public Health Regions DeSoto

D E P A R T M E N T

Jackson

State Totals*

Hancock

Southern Region

I Sexually Transmitted Diseases

Primary & Secondary Syphilis Early Latent Syphilis Gonorrhea Chlamydia HIV Disease Mycobacterial Diseases

Pulmonary Tuberculosis (TB) Extrapulmonary TB Mycobacteria Other Than TB Diphtheria Pertussis

Vaccine Preventable Diseases

Tetanus Poliomyelitis Measles Mumps Hepatitis B (acute) Invasive H. influenzae disease Invasive Meningococcal disease Hepatitis A (acute) Enteric Diseases

Salmonellosis Shigellosis Campylobacteriosis E. coli O157:H7/STEC/HUS

Zoonotic Diseases

Animal Rabies Lyme disease Rocky Mountain spotted fever

2 5 137 291 3 0 0 4 0 0 0 0 0 0 0 0 0 0 18 2 5 1 0 0 1 1

III

VII

VIII

0 1 2 8 0 1 2 2 7 0 13 4 2 2 103 47 79 268 109 118 117 238 276 241 660 192 144 245 5 3 4 14 0 0 1 0 1 1 3 0 0 1 0 0 1 0 0 0 0 13 1 1 5 5 4 2 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 33 3 17 24 14 4 11 2 5 1 0 0 0 0 9 4 5 2 2 1 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 1 2 0 0 1 1 3 1 3 7 2 1 0

Aug 2017

YTD 2017

6 22 25 196 1 36 48 310 102 1,080 597 5,538 254 2,541 1,615 12,537 3 33 38 325 1 7 4 32 0 1 0 4 6 41 35 266 0 0 0 0 0 2 1 24 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 21 1 2 2 24 1 2 2 38 0 0 0 2 0 0 0 2 15 139 194 675 3 13 9 100 10 42 28 328 0 1 1 14 0 0 1 1 0 0 0 1 2 10 24 106 0 18 9 47

West Nile virus *Totals include reports from Department of Corrections and those not reported from a specific District. 230 VOL. 58 â&#x20AC;˘ NO. 8/9 â&#x20AC;˘ 2017

Aug 2016

YTD 2016

214 335 4,419 12,939 299 27 7 254 0 2 1 0 0 1 17 41 0 3 706 43 152 13 2 0 84 20

State Board of Health Elects New Leadership

uring its quarterly meeting, the Mississippi State Board of Health elected new leadership in the positions of chairman and vice-chairman.

Ed “Tad” Barham, MD MSDH Board Chair

Ed “Tad” Dalton Barham, MD, FACR., was elected Board chairman. A Clinton resident, Dr. Barham has been a Board member since 2012 and currently serves as the Chief of Radiology and Director of Breast Imaging at Woman’s Hospital in Flowood.

“It has been a great privilege for me to be a member of the State Board of Health,” said Dr. Barham. “I am grateful for the opportunity to serve in a leadership position, and look forward to working with my colleagues to help promote public health in Mississippi.” Thad Fulton Waites, MD, was elected vice-chairman of the Board. Dr. Waites is a Hattiesburg physician who currently practices internal medicine at Hattiesburg Clinic and Forrest General Hospital. He is serving his second term with the Board, being first appointed in 2010. The new Board leaders replace Lucius M. Lampton, MD, FAAFP, who has served as chairman since 2007, and J. Edward Hill, MD, FAAFP, who has served as vicechairman since 2011.

Above, Outgoing Board Chair Dr. Luke Lampton presents long-time District Health Officer Dr. Alfio Rausa, Greenwood, with a resolution commending him for spending 50 years (“his whole life,” Lampton quipped) dedicated to public health. He is the longest serving District Health Officer in the history of the agency. Sadly, Dr. Rausa died shortly after this photo was taken. Below, Outgoing Board of Health Chair Dr. Lucius “Luke” M. Lampton and longtime Board Vice Chair Dr. J. Edward Hill were recognized for their leadership and contributions towards strengthening and improving public health for Mississippians. The hard hats were given to them by Dr. Mary Currier for the often difficult battles they fought over the years to protect public health in the state and for the agency.

“During the last decade, the Mississippi State Department of Health has emerged again as a national leader in public health. It has been an honor to serve my state in this capacity and a joy to work with the excellent staff at the department over the years,” said Dr. Lampton. “I am enthusiastic that our new election rules including term limitations for board leadership will encourage broader participation by all members in decision making,” Dr. Lampton added. The Board of Health is composed of 11 members appointed for staggered terms by the Governor. Their duties include providing policy direction for the agency, appointing a State Health Officer, and approving the State Health Plan and all agency rules and regulations. n

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M S M A

Grantham Inaugurated New MSMA President

Dr. Clay Hays, Chair of the MSMA Board of Trustees (right) gives the oath of office to MSMA President Dr. William Grantham (left) while his mother holds the Bible.

total of 23 resolutions were adopted by the MSMA House of Delegates during Annual Session, August 10-12, 2017, at the Hilton in Jackson. Summaries of the resolutions are below. Support Mississippi State Department of Health Immunization Policy This resolution reaffirms MSMA’s support for Mississippi’s robust and successful health policy regarding vaccinations. Antibiotic Stewardship MSMA resolves to support and promote antibiotic stewardship and to use the Journal MSMA and CME events to promote antibiotic stewardship.

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Required Information for PMP Database MSMA will work with the Board of Pharmacy and other medical licensing state boards to ensure the PMP database includes all current, relevant information on prescribers. Gap in Diagnosis and Treatment of Osteoporosis This resolution endorses MSMA’s use of the Journal MSMA to promote awareness of the health risks related to osteoporosis and its under diagnosis and under treatment. It also recommends more CME events on the disease. Commend MSMA Executive Director MSMA salutes the leadership and dedication of its Executive Director.

M S M A

H O U S E

Commend Hugh A. Gamble, II, MD MSMA recognizes and honors the lifelong work and leadership of Dr. Hugh Gamble in the practice of medicine. Physician Assisted Suicide MSMA further clarified and strengthened its opposition to physician assisted suicide. APRN Compact

O F

D E L E G A T E S

the matter. Also, that the insurance company should start paying for telemedicine under the law and retroactively pay for telemedicine services that have occurred since the law was passed in 2013. Educational Opportunities for Medical Students MSMA will give medical students free education on physician impairment, burnout and opioid prescribing. Anti-Tobacco Capitol Day for Students

This resolution opposes any APRN Compact legislation that might be introduced in the state and supports working with the AMA to develop a national strategy around the issue.

MSMA will work with students from the University of Mississippi School of Medicine and William Carey University College of Osteopathic Medicine to hold a Capitol Day to push for a tax increase on tobacco products.

Reporting Treatment for Depression and/or Burnout

Smoke-Free and Tobacco-Free Office for MSMA

MSMA will work with the State Board of Medical Licensure to make sure license renewal applications don’t discourage physicians from seeking treatment for burnout and/or depression and that the SBML gets the information it needs on the applications.

MSMA’s offices will continue to be tobacco-free.

Emergency Services for Out-of-Network Providers Should Be Covered Resolves that MSMA embrace AMA policy to make sure patients are protected and not penalized when getting emergency care from an outof-network provider. Developing Mechanisms for Physicians in Dealing with Insurance Companies Recommends that MSMA Board of Trustees enlist the Council on Legislation to study AMA recommendations on finding legislative solutions that would give physicians the power to collectively negotiate with insurance companies. Also, to analyze what the political climate might be in the state on this issue. Dr. Robert Smith, 2017 Recipient of the AMA Medal of Valor This resolution recognizes and congratulates Dr. Robert Smith for being awarded the 2017 AMA Medal of Valor. Educational Resources on the Topic of Opioids MSMA will use the Journal MSMA to publish articles on the responsible prescribing of opioids by examining a number of approaches and solutions to the matter. BCBS Telemedicine Reimbursement Resolves that MSMA will tell Blue Cross & Blue Shield of Mississippi that its policy on telemedicine reimbursement is outside state law on

Insurer Denials of Non-Emergent Care MSMA opposes insurance company denials of payment for nonemergency visits to emergency rooms by patients. Obesity Prevention Education MSMA supports the State Department of Health in preventing and treating obesity. Emphasizing Direct Clinical Care in Health Care Spending MSMA will tell Mississippi’s Congressional delegation that the U.S. health care system can be made more efficient by reducing red tape, spending more on direct care and less on bureaucracy and eliminating rules that create administrative burdens. Expand Medical Coverage This resolution supports the expansion of medical coverage for the uninsured and the underinsured, whether through state or federal funds. Strategies to Combat Burdensome MOC Requirements MSMA introduced a playbook to assist specialty societies when petitioning to make the MOC process less obtrusive and costly for physicians. The Problem of the Medically Uninsured in Mississippi This resolution recognizes that lack of medical insurance is a significant health risk and calls for MSMA to explore ways to improve access to care for uninsured Mississippians. n

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M S M A

Mansour Names President-Elect, Board of Trustees Welcomes New Members

Dr. William M. Grantham of Clinton was sworn in as the 150th president of MSMA at the Annual Session of the House of Delegates. Dr. Michael Mansour was named president-elect of MSMA. Names of new Trustees elected to the Board are italicized. Front seated left: YPS Representative Dr. John Cross, Dr. Joseph D. Austin, Dr. J. Clay Hays, Jr., (Dr. Timothy Beacham, who has since relocated. Dr. Roderick Givens now serves in this position.) and Dr. Brett C. Lampton. Rear standing: Resident/ Fellow Trustee Dr. Chelsea Rick, Dr. Geri Lee Weiland, Immediate Past-President Dr. Lee Voulters, Dr. John Pappas, Dr. Michael Mansour, Dr. John R. Mitchell, Dr. William Grantham, Student Trustee Avani Patel, and Dr. Jennifer J. Bryan. Not pictured above are Board Trustees Drs. Mark Horne, Steven W. Stogner, and J. Lee Valentine.

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STAT Students Receive Awards

Pictured left to right, front: Front: Kandice Bailey, Emily Bustin and Mary Elizabeth Butts. Back: Logan Ramsey, Tyler Howell, Jordan Rimes, Drew Desrosiers

he MSMA Student Advocacy Training (STAT) Program encourages medical students to get involved with organized medicine through advocacy, professional networking, and leadership training. These students, who have completed six of almost a dozen eligible activities during their medical school career, were recognized as STAT Scholars during the Annual Session. Numerous STAT activities are offered to give med students a variety of ways to gain advocacy experience and get plugged into MSMA. Students can choose from many activities. They can attend a meeting of a local medical society, the Mississippi Board of Medical Licensure, the Council on Medical Service, or MSMA Annual Session. They can participate in an MSMA legislative update conference call, an activity with the Medical Assurance Company of Mississippi, or an AMA recruitment event/AMA meeting grassroots effort. Or, they can write and submit an article for publication in the Journal MSMA or volunteer with an MMPAC event. Completion of this program is a great addition to any student resume. For more information on the STAT program, contact Conner Reeves at CReeves@MSMAonline.com or (601) 853.6733, ext. 309. n

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a n

i n t e r v i e w

w i t h

William M. Grantham, MD 150th MSMA President, 2017-2018 [Each year, the JMSMA interviews the incoming president. Here, we like to provide members with a glimpse of their new leader. The answered questions speak for the interview as a way of “getting to know” Dr. Grantham.] –Ed. Family I grew up in Hattiesburg with one sister- Alison. I was fortunate to be reared in a loving Christian home. We were very active and involved in our Methodist church. My parents were both very supportive of my activities. I was active in Boy Scouting (Boy Scouts of America) and became an Eagle Scout. As for my own family, I have one child, Taylor, 28, who was born during my residency. He is currently in PT school at St. Augustine in Florida. Education University of Southern Mississippi (USM), then University of Mississippi School of Medicine, 1984-1988. Residency: University of South Alabama, 1988-1991.

Milestones While a freshman at USM, my father suddenly died. Even though I was right there with him, I was not able to save him. This event solidified my desire to pursue medicine. My father was my greatest role model without question. My mother also has been such a wonderful role model. She continues to teach me so much, even to this day. Through scouting, knowing several physicians, working at the local hospital, and a desire to help others, I wanted to become a doctor. While still a teenager, I was interested in going to medical school. One of the best things about medical school was being able to rely on my best friends who were in my class, no matter how difficult the class or project was. The most difficult thing was trying to handle all of the material as it was so much more intense than was college. All of

149th Annual Session- Inauguration of MSMA’s 150th President William Grantham, MD – Dr. Grantham; his mother Rebecca Grantham, sister Alison and her husband, Cy Clarke

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Dr. Lee Voulters, MSMA Immediate Past-President, and Dr. Bill Grantham, MSMA President 2017-18

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us were successful, intelligent people so there was competition to prove yourself. Although medical school years were difficult, in hindsight those years were amazing because of not only achieving my dream, but creating such wonderful relationships. My proudest accomplishment was being chief resident of my residency. Following residency, Doug Perry, Chris Schwartz and I opened a clinic in McComb. The three of us had been together all through college, medical school and residency. Your MEA career Starting my career at MEA in 1993, I’ve since had the priveledge of serving on our all of our boards and I currently serve as the Chairman of three of them. We are trying to navigate the changes in health care just as everyone is; times are much more challenging and we all have so many demands with technology and evolving payment changes. Organized Medicine I immediately became involved in organized medicne when I moved to McComb. I joined South Central Medical Society and have been active in the Mississippi Academy of Family Physicians (MAFP) for many years. I have served as board member and all officer positions within Central Medical Society, and served as District 4 Board member for two terms. I have served on the board for MAFP, have been treasurer, and am currently vice-president. There always are issues we deal with, some expected, many that were not. In the past, issues encountered that stand out include malpractice reform, insurance regulations, scope of practice, immunization protection, and new payment reforms. As MSMA president, my agenda is to try and help physicians be informed of changes occurring in billing as the ACA changes occur and with the implementation of MACRA. I like that MSMA serves as the voice for all physicians and tries to fairly represent all to better help physicians to take care of Mississippians. Community Service I attend Madison United Methodist Church, and have helped as a volunteer for performing pre-participation physicals for student athletes and scout physicals. Balance I enjoy my interaction with and ability to help my patients the most. I get satisfaction from helping my group with the business side of medicine, but don’t like having to worry about how the new payment methods are making it so difficult for practices to stay in business. You just have to dedicate some time for yourself and family and stick to it. If not, the real risk of burn out significantly increases. When off, I enjoy spending time with friends, golfing, and fishing. Message to members Just, I really feel honored to serve as President and want to be effective in helping to articulate our positions to legislators and the public.

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FOR THE FUN OF IT – FILL IN THE BLANKS: You’re most likely to see me around at: MEA, MSMA, Castlewoods Country Club. On the weekends I love to: golf, fish, visit Destin, spend time with family and friends. The high school, college or pro sports teams I root for are: Certainly cheer for USM as an alumnus, but also all of our state schools since my medical degree is from the University of Mississippi and my son graduated from Mississippi State University. I love Mississippi, so it is easy to cheer for all of our collegiate teams at all levels. If I’m watching a movie or listening to music, it’s probably: Pandora various 70’s and 80’s artists My favorite books are: Harvey Penick’s Little Red Book, One Magical Sunday, The Devils Punchbowl Latest splurge: M2 Driver I am passionate about: Trying to help use technology to better deliver care to our patients and make it more efficient for our physicians Do you like to go out or stay in? I like to go out and be with others. Perfect meal: Fresh Redfish or Grouper that I have caught while sitting at the Marina Restaurant at Sandestin watching sunset Perfect day: Fishing out in the gulf as the sun rises and then returning to golf that afternoon, ending with the perfect meal. Favorite color: blue Cologne: Aqua DI GIO Text, email or cell phone: President@MSMAonline.com Pets: Rudy, long-haired dachshund MSMA Member since: 1991

Benefit tournament for UMMC’s Batson Children’s Hospital at Reunion, Fall 2017 – ( L to R) Conner Reeves; Ken Gresham, Senior V.P., Program Development, Mississippi Prescription Drug Card; Ken Gresham’s son, John; Dr. James Cady from Meridian and Dr. William Grantham.

Above, Dr. William Grantham after a hole-in-one on a Sandestin golf course in 2013. Top left, Dr. Grantham and his son Taylor.

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P A G E

The Inaugural Address of the 150th MSMA President William M. Grantham, MD

August 11, 2017 | The Hilton, Ridgeland

onight I want to start by talking about dreams. I attended my first MSMA meeting years ago; but, I never dreamed that I would be standing before you as the 150th president of the largest physician organization in the state. When I look at the list of all who have served before me, I realize this is an incredible honor and I will endeavor to serve you well But, back to dreams. The distance between a dream and reality is called ACTION. And, that’s what MSMA is best at, action. Action at the State Capitol, action on Capitol Hill and action here in our own House of Delegates. MSMA is the embodiment of physicians in action: liability reform in 2002 and 2004, the delayed implementation of ICD 10 in 2011. These are just a few examples of the kinds of great things we can accomplish together through MSMA.MSMA is strongest because this is the House of Medicine for all physicians of all specialties. This is where we all pull in the same direction, where we are united.

Dr. Tom Joiner and Becky Wells first encouraged me to run for a seat on the Board of Trustees; then for president. The Central Medical Society board and members have supported me. I have been inspired by my colleagues on the MSMA Board of Trustees and by the MSMA staff. I also must mention my specialty society, the Mississippi Academy of Family Physicians. You have been great role models. I have learned from and been inspired by so many of you. Thank you for all of your support, and know that I will continue to look for your advice and help this year. But, I would not be here tonight without all of my partners in the MEA family. Thanks to all my partners for helping cover shifts to free me up to participate, for encouraging me, and thanks for so many of you attending tonight. Drs. Chris and Robin Schwartz are here tonight. They are not only dear friends, but college and medical school classmates and Chris was my first partner in practice, and yes was a partner with us at MEA. I am so blessed that my mother, Rebecca Grantham, can be here tonight. She and my father inspired me as a

William M. Grantham, MD MSMA President 2017-2018

Unity does not mean sameness – it means oneness of purpose. And, our single purpose must always be to put patients first.

I would like to pause for a moment and talk about putting patients first. All of you here tonight are an inspiration to me. The work you do for MSMA inspires me. The care you give your patients inspires me. The students and residents with big dreams inspire me.

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I have learned from so many of you. Dr. Dan Edney encouraged me, years ago to become more involved. Dr. Eric Lindstrom, his wonderful wife Nancy, and Dr. Turner guided me when we went to Washington to leadership and advocacy meetings. Our own Dr. Edward Hill, as president of the AMA was very motivating. You all were my inspiration to get involved.

child to be the best person that I could possibly be. They helped me develop character and stood behind me all the way. I love you and thanks for being such a wonderful mother and supporter. My sister Alison Clarke and her husband, Cy, are here tonight. I cannot tell you how much it means to me that they traveled from Lexington, Kentucky to be here. I love you both. My son, Taylor, had conflicts with his PT school schedule in St Augustine, FL. Yet, he is here in my heart and I am so proud he is following his dreams. Like Taylor’s dream will bring challenges for him to face, the upcoming year will bring many challenges for the House of Medicine. Some of these challenges are predictable, others will surely be unexpected. Scope of practice will continue to be an issue. Nurse practitioners are pushing for independence. We must formulate strategies and articulate our position. The physician must be the leader of the healthcare team. We must exert physician oversight of quality, team-based care. We may want to consider a closer alignment with PAs. First, to demonstrate that the team care model works. Second, to create incentives to hire PAs, then, to inspire the nurse practitioners to join or stay on the health care TEAM. And, it may be time to look at creating a way for PAs to participate in MSMA – just a thought. Regardless, we must ensure the best care available for our patients. Changes in Medicaid will be challenging. A new managed care company, Molina, will be joining Magnolia and United. MPCN will credential the network for Molina and Magnolia which will benefit our physicians. We will look to MPCN as well as the Claims Advocacy Committee to work through the issues that come with that growth. Finally, we have a working Medicaid Advisory Committee chaired by Dr. Steve Demetropoulos to get some answers and make recommendations that will hopefully improve our Medicaid program. His tenacity has inspired me. It is important to promote changes so that more Mississippians have access to their insurance coverage. Too many patients have such a high deductible that their insurance is meaningless. The average Mississippian can never reach a $4,000 or $5,000 deductible. And, it is a travesty to allow insurers to sell a patient a policy that has a deductible

higher than a month’s pay. Surely Mississippi can find a way to sell an insurance policy that can be used by the patient who buys it. Speaking of insurance, let’s look at how the state ensures that all of us have a disease-free state. I’m talking about the Health Department. Funding for the Health Department is at a critical low. Programs have been cut, staff has been laid off, county clinics have been closed. The Health Department is at its lowest funded level in years. The reason, I’m afraid, is because the Health Department is a victim of its own success: No Legionnaires’ outbreak in Louisville. No salmonella in Sardis. No E. coli in Collins. No measles or mumps in Madison. So, we must stand up for that success. We must push for funding, hold the line on immunization laws, and tell the story of that success. We must work together at the state level through our MSMA and locally through our component medical societies. I want MSMA to help revitalize some of our component societies and engage more members to be involved in them. This might be achieved by offering more CME options and MSMA can help you do that. It may be prudent to merge some of the smaller societies into regional societies to encourage stronger programs and better participation. It may be that our MSMA can develop regional events with speakers and CME to bring more physicians together in one place. It’s certainly something I want to work on. In closing, I again would like to tell you what an honor it is to serve as MSMA’s 150th president. I am inspired by my responsibility to represent you. I am inspired by the dedication of our Board of Trustees and our MSMA staff. I am inspired by the eager students and residents who are making dreams come true. Why? Because a dream only seems impossible until its done. Together we will, once again, get the job done. God bless each of you and our MSMA. n

William M. Grantham, MD MSMA President 2017-2018

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HE BILOXI SANATORIUM, 1904, GULF COAST HEALTH RESORT, 1913 – These images, which date to 1904 and 1913, are of one of the Gulf Coast’s most important medical facilities: The Biloxi Sanatorium, which later became the Gulf Coast Health Resort. (The spelling on the postcard is sanitarium, however most other references to the facility spell it sanatorium. The difference between the two terms is subtle. The term “sanitarium” sometimes refers to a health resort where the term “sanatorium” usually refers to a hospital treating the sick.) Located on a 10-acre beach front site just west of the iconic Biloxi Lighthouse, the Sanatorium was chartered in June 1902 by Dr. Hyman M. Folkes (1871-1926), one of the most prominent Coast physicians who specialized in surgery and marine medicine. Its purpose, according to a contemporary ad, was the treatment and care of “every ill that human flesh is heir to.” Further, “The Biloxi Sanatorium is an institution for the care of convalescents from la grippe, pneumonia, typhoidal, and malarial fevers, etc.; insomnia, neurasthenia, asthma, bronchitis, heart, kidney, and liver troubles, and catarrhal troubles of all kinds. Tubercular patients are not taken…patients can remain nearly the entire time in the open air.” A promotional booklet outlined its offerings: “Electricity and Massage Treatment. Turkish, Russian, Salt Water, Mineral and other Baths. Complete X-ray Laboratory. Spacious Grounds Directly Upon the Gulf of Mexico.” Its X-ray machine was first used on a Pascagoula child who swallowed a pin! In January 1903, the institution opened “a school for training nurses and awarding diplomas.” In April 1904, the wooden structure housing the Sanatorium burned to the ground, and by November 24, 1904, the rebuilt Biloxi Sanatorium, seen above, was opened. By 1909, the Sanatorium changed its name to the “Gulf Coast Health Resort,” with Folkes forming a partnership with Dr. W. R. Card and later Dr. James Wallace. In November, 1913, R. L. White announced the end of the Health Resort and the opening of a first-class tourist hotel: The Hotel Biloxi. (See inset image, which reveals an east wing had been added to the facility.) Dr. Folkes and his wife Teresa would sell the property by 1923, and in May 1927, the old Sanatorium would be razed to make room for a new four-story $650,000 Hotel Biloxi, built in the Southern Colonial style with thirteen massive Corinthian columns. If you have an old or even somewhat recent photograph which would be of interest to Mississippi physicians, please send it to me at lukelampton@cableone.net or by snail mail to the Journal. n

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

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Anytime: A Meditation for the Wounded Healer [This month, we print a powerful poem by Dwalia S. South, MD, a Ripley family physician and long-time Chair of the Committee of Publications, which oversees this Journal. This poem, entitled “Anytime: A Meditation for the Wounded Healer” focuses on the role of woundedness in a healer’s profession. Dr. South writes: “Most of us labor under the delusion that we as physicians are scientists efficiently fighting disease with all the latest technology and medicines available, but that is an unreal and idealistic view. We are healers, hopefully compassionate ones, who possess a bit of knowledge and a few skills to help Nature get sick folks well. All of us are striving to ‘Do the Right Thing,’ the maxim of beloved Professor Peter Blake, to work our healing art for patients in a very uncertain medical climate. Sooner or later we are all patients ourselves. I wrote this meditation for all of us ‘Wounded Healers.’” Dr. South offered up two relevant and lovely quotations to introduce her poem. The first, by Abraham Verghese, M.D., states: “Few doctors will admit this, certainly not the young ones, but subconsciously, in entering the profession, we must believe that ministering to others will heal our woundedness. And it can. But it can also deepen the wound.” The other, by Henri J. M. Nouwen, comments: “When our wounds cease to be a source of shame and become a source of healing, we have become wounded healers…Our own experience with loneliness, depression and fear can become a gift…Our own bandaged wounds will allow us to listen to others with our whole beings.” Any physician is invited to submit poems by slow mail for publication in the Journal, attention: Dr. Lampton or email me at lukelampton@cableone.net.) — Ed.

Anytime it is hard for me to see clearly When my eyes are clouded by a thousand bitter tears I will ask God to be in my vision. Anytime it is hard for me to listen to good advice When my ears are filled with the murmuring of the crowd I will ask God to be in my hearing. Anytime it is hard to find my voice When my throat is scorched from swallowing the last embers of pride I will ask God to be in my speaking. Anytime it is hard for me to think straight When my brain is scrambled by invasive obsessions I will ask God to be in my thinking. Anytime is hard for me to feel When my once toughened heart has been ripped to pieces I will ask God to be in my understanding. “Beloved Father, hear, hear my lamentations. Timely is the cry of woe of this miserable wretch. O Heart of my heart, whatever befall me, O Lord of all, be Thou my vision.” *** — Dwalia S. South, MD, Ripley *** From the English translation of the old Irish hymn “Be Thou My Vision,” by Mary Byrne, 1905 244 VOL. 58 • NO. 8/9 • 2017

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