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PUBLICATIONS COMMITTEE Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD, Ex-Officio Myron W. Lockey, MD, Ex-Officio and the Editors THE ASSOCIATION Randy Easterling, MD President Tim J. Alford, MD President-Elect J. Clay Hays, Jr., MD Secretary-Treasurer Lee Giffin, MD Speaker Gary Carr, MD Vice Speaker Charmain Kanosky Executive Director JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. CORRESPONDENCE: JOURNAL MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, ph.: (601) 853-6733, FAX (601)853-6746, www.MSMAonline.com. SUBSCRIPTION RATE: $73.00 per annum; $86.00 per annum for foreign subscriptions; $6.50 per copy, $7.00 per foreign copy, as available. ADVERTISING RATES: furnished on request. Cristen Hemmins, Hemmins Hall, Inc. Advertising, P.O. Box 1112, Oxford, Mississippi 38655, Ph: (662) 236-1700, Fax: (662) 236-7011, email: cristenh@watervalley.net POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 391582548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association. Copyright© 2009, Mississippi State Medical Association.
AUGUST 2009
VOLUME 50
NUMBER 8
SCIENTIFIC ARTICLES Acute Thermal Ulceration of the Epiglottis Vishwanath N. Shenoy, MD; Kiran Bettaiah Chandrashekar, MBBS and Sneha Pai, MBBS
259
Immunizations in Mississippi Mary Currier, MD, MPH
262
Multiplicity Rhonda Odom-Funches, MD
266
PRESIDENT’S PAGE Where Were You? Randy Easterling, MD; MSMA President
274
EDITORIAL Shame on Us W. Lamar Weems, MD
277
SPECIAL ARTICLE A Year Ago in Mozambique - The African Medical Mission Trip Philip L. Levin, MD
278
ORGANIZATIONS Mississippi State Department of Health Mississippi State Medical Association University of Mississippi Health Care Information and Quality Healthcare
270 272 281 287
DEPARTMENTS Personals Medical Legal Ease Placement/Classified
288 292 296
KOSCIUSKO WITH A “Z” - “Freedom shrieked the day Kosciuszko died.” These words were uttered about Polish patriot Tadeusz Kosciuszko who played a pivotal role for the colonies in the American Revolution. In 2006, Kosciusko, the only incorporated town in America with Kosciuszko as its namesake, finally realized a fitting memorial in the form of a life-sized bronze sculpture which stands in Redbud Springs (the City of Kosciusko’s original name) Bicentennial Park. Dr. Stanley Hartness, Kosciusko family physician, submitted this detail of Kosciuszko with an appropriate redbud foliage backdrop. ❒
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SCIENTIFIC ARTICLES
Acute Thermal Ulceration of the Epiglottis Vishwanath N. Shenoy, MD Kiran Bettaiah Chandrashekar, MBBS Sneha Pai, MBBS
A
Thermal injury to the epiglottis as a result of ingestion of hot food should be considered in the differential diagnosis of earache, severe throat pain and odynophagia. We report a case of a 48-year-old physician, who developed acute, severe throat pain, odynophagia and earache after inadvertent ingestion of hot food. This case is unique, as the physician performed the endoscopy on himself and diagnosed thermal epiglottitis. The epiglottitis responded to a short course of steroids and antibiotics. The physician has remained symptom free since treatment. BSTRACT
KEY WORDS:
THERMAL ULCERATION, EPIGLOTTITIS, ENDOSCOPY
INTRODUCTION Although injuries to the upper airway after inhalation of steam and hot gases is common, very few cases of thermal injury to the epiglottis after ingestion of hot food have been described in the literature. We report a case of a physician who presented with severe throat pain, odynophagia, and earache following ingestion of a hot spring roll. Endoscopy revealed solitary ulcer of the epiglottis which healed completely in seven days with antibiotic and steroid therapy. JOURNAL MSMA, August 2009 — Vol. 50, No. 8
CASE REPORT A 48-year-old male gastroenterologist of Asian origin was ingesting a spring roll at a restaurant. After swallowing the first bite, he realized that the contents of the spring roll were extremely hot. He developed immediate, severe pain in the throat which eased on ingestion of cold water. A day after the incident, the physician developed severe pain in the right side of the throat, radiating to the right ear. The pain intensified over the next 24-48 hrs and exacerbated with swallowing of saliva or food. The pain also impaired his sleep. There were no other symptoms. The physician was in good health otherwise. Visual examination of the oropharynx with a penlight was normal. The physician performed an upper endoscopy on himself under topical pharyngeal anesthesia after gargling with viscous 2% lidocaine. The physician sat in a chair facing the endoscopy video monitor and inserted the flexible gastroscope through a bite block into the mouth and advanced the endoscope into the laryngopharynx. Further advance was aborted because of intense gagging and pain. The endoscopy revealed a 1 cm superficial ulcer (arrow, fig. A) on the right side of the superior surface of the epiglottis consistent with a thermal injury. The physician took azithromycin tablet 500 mg on the first day, and then 250 mg for the next 4 days, by mouth. He also 259
Figure A
Figure B
took methyl-prednisolone (4 mg tablet) 32 mg on the first day, tapered over 7 days, all by mouth. His symptoms improved by the first day and resolved completely after completion of the above treatment. A repeat endoscopic examination done by the physician himself revealed complete healing of the epiglottic ulcer (fig. B) He has remained symptom free over the last 20 months.
described after use of crack cocaine.6 Microwave-heated food can cause serious injury if not allowed to cool before ingestion.7 Cases of laryngeal and pharyngeal burns after ingestion of microwave-heated potato, treacle tart has been described.7,8
DISCUSSION Thermal burn of the larynx after ingestion of hot food is uncommon in adults. Many cases of thermal injury to the epiglottis caused by ingestion of hot food or beverages have been described in children. Goto R et al described a case of a adult male who experienced a burn of the supra glottic area and epiglottis after ingestion of hot milk from a bottle.1 Kulick RM et al described two children who developed thermal epiglottitis after ingestion of hot beverages. They emphasized the same caution and preparedness for emergency airway management when thermal epiglottitis is suspected.2 Two young children who swallowed hot water and a corrosive agent developed thermal injuries to the epiglottis. Their clinical and radiological findings were similar to infectious epiglottitis. Both patients recovered quickly with parenteral antibiotics.3 A 3-yearold child developed thermal epiglottitis after ingestion of hot tea.4 Epiglottic burns should be suspected subsequent to thermal or caustic ingestion in mentally retarded adults who present with dysphagia, drooling and stridor.5,9 Thermal injury to the laryngopharynx has been 260
DIAGNOSIS The symptoms of thermal epiglottitis are similar to those of an infectious epiglottitis. The history of ingestion of hot food or caustic agent may not be forthcoming from the patients, as the patient might not recollect, or might have communication problems.5 The symptoms of severe throat pain, earache, drooling, odynophagia, dysphagia, change in voice or stridor all should lead to suspicion of epiglottitis.5,9,10,11,12 Patients might have cough and dyspnoea because of airway compromise and or aspiration pneumonitis. Patients may or may not have obvious burns of the oropharynx. The clinical, radiological and endscopic findings may be similar between infectious and thermal epiglottitis.5,10 Lateral x-rays of the neck may demonstrate a swollen epiglottis, aryepiglottic folds, and prominence of the retropharyngeal space.5,10 Indirect laryngoscopy or flexible nasolaryngoscopy may demonstrate swollen, inflamed, and/or an ulcerated epiglottis and adjacent structures.5.10 The differential diagnosis for thermal epiglottitis includes infections, smoke inhalation, foreign bodies, angioneurotic edema and crack cocaine use.6,9,10,11,12 JOURNAL MSMA, August 2009 — Vol. 50, No. 8
TREATMENT Adults with suspected airway compromise and children with thermal epiglottitis should be observed closely in the hospital setting and their airways managed appropriately. Expert personnel and emergency equipment should be available to treat acute airway obstruction as a result of swollen epiglottis. Antibiotics, especially to cover hemophilus influenzae type b strain, should be instituted. Corticosteroids have been used to hasten healing of the thermal burns, but their benefit is unproven.10 In summary, we present an uncommon case of thermal ulceration of the epiglottis after ingestion of a hot spring roll. REFERENCES 1.
Goto R, Miyabe K, Mori N. Thermal burns of the pharynx and larynx after swallowing hot milk. Auris Nasus Larynx. 2002;29(3):301-3. 2. Kulick RM, Selbst SM, Baker MD, Woodward GA. Thermal epiglottitis after swallowing hot beverages. Pediatrics. 1988;81(3):441-4. 3. Lai SH, Wong KS, Liao SL, Chou YH. Non-infectious epiglottitis in children: two cases report. Int J Pediatr Otorhinolaryngol. 2000 Sep 15;55(1):57-60. 4. Harjacek M, Kornberg AE, Yates EW, Montgomery P. Thermal epiglottitis after swallowing hot tea. Pediatr Emerg Care. 1992;8(6):342-4. 5. Kornak JM, Freije JE, Campbell BH. Caustic and thermal epiglottitis in the adult. Otolaryngol Head Neck Surg. 1996;114(2):310-2. 6. Ginsberg GG, Lipman TO. Endoscopic diagnosis of thermal injury to the laryngopharynx after crack cocaine ingestion. Gastrointest Endosc. 1993;39(6):838-9. 7. Offer GJ, Nanan D, Marshall JN. Thermal injury to the upper aerodigestive tract after microwave heating of food. J Accid Emerg Med. 1995;12(3):216-7. 8. Ford GR, Horrocks CL. Hazards of microwave cooking: direct thermal damage to the pharynx and larynx. J Laryngol Otol. 1994;108(6):509-10. 9. Sack JL, Brock CD. Identifyng acute epiglottitis in adults. High degree of awareness, close monitoring are key. Postgrad Med. 2002;112(1);81-2,85-6. 10. Ma OJ, Phelan MB. Adult thermal epiglottitis. Ann Emerg Med. 1996;27(5):675. 11. Ayache D, Amanou L, Manac’h Y, Roulleau P. Acute epiglottitis in adults. A series of 41 cases. Ann Otolaryngol Chir Cervicofac. 1996;13(1);40-4. 12. Kavanagh KR, Batti JS. Traumatic epiglottitis after foreign body ingestion. Int J Pediatr Otorhinolaryngol. 2008;72(6):901-3.
AUTHOR INFORMATION:
Vishwanath N. Shenoy, MD, Gastroenterologist, is affiliated with River Region Health System, Vicksburg, Mississippi.
Kiran B. Chandrashekar, MBBS, Physician Extern, is affiliated with River Region Health System, Vicksburg, Mississippi.
Sneha Pai, MBBS, Physician Extern, is affiliated with River Region Health System, Vicksburg, Mississippi.
CORRESPONDING AUTHOR & REPRINTS: Vishwanath N. Shenoy, MD River Region Health System 2100 Highway 61N. Vicksburg, MS 39183 Phone: (601) 883-5000 Email: vns59@yahoo.com
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JOURNAL MSMA, August 2009 — Vol. 50, No. 8
261
Immunizations in Mississippi Mary Currier, MD, MPH
B
In the early 1900s, infectious diseases were the most prevalent cause of death in the U.S. In 1920, 469,924 measles cases were reported, and 7575 patients died, diphtheria and pertussis were commonplace, and smallpox still occurred as the vaccine was not widely used. Huge progress has been made in many vaccine preventable diseases, with one disease, smallpox, being eradicated, and another, polio, now only found in the far reaches of very poor and remote areas.1 More recently, meningitis and sepsis due to Haemophilus influenzae type b (Hib) have almost disappeared, due to the Hib vaccine. In the late 1980’s and early 1990’s, prior to widespread use of the vaccine, Mississippi had 80 to 100 cases of Hib invasive disease reported yearly. The mortality rate for Hib meningitis was about 5%, with 15 to 30% of children who survived having long term consequences including deafness, developmental delay and behavioral abnormalities.2 Disease due to Streptococcus pneumoniae has also decreased of late. Invasive disease and hospitalization due to S. pneumoniae invasive disease have decreased among vaccinated children, and among children too young to be vaccinated, as carriage of this bacteria decreases and neonates are less frequently exposed to the bacteria.3,4 ACKGROUND
VACCINE COMPLETION RATES According to estimates from CDC’s National Immunization Survey (NIS), vaccine completion rates* among 2-year-olds in the U.S. have remained stable in the last five years at about 80%. In Mississippi, the rate of vaccine completion among children 19 to 36 months has fluctuated. In children who reached 24 months of age in 2007, the state’s completion rate was 78.7% while the national average was 80.1%.5 In addition, a study using NIS data from 2000 through 2002 showed Mississippi having the lowest rate of timely vaccination in
the nation. Only 2% of Mississippi children in the study had received all recommended DTaP, IPV, MMR, Hib and Hepatitis B vaccines, and had received them at the recommended intervals.6 So although almost 80% of the state’s 2-year-olds were completely vaccinated, most of those children received at least one dose of vaccine before or after the recommended time. The Mississippi State Department of Health (MSDH) performs a statewide immunization survey, separate from the NIS, which indicates that most of the state’s children who are not completely vaccinated by two years of age have all but one or two of their required shots.7 Reasons for undervaccination and for nonvaccination are many and varied. Children who are behind in their shots tend to be poor, minority, have more siblings and have more than one health care provider or no medical home. Another undervaccinated group, including those children who are completely unvaccinated, are more likely to have parents who are concerned about vaccine side effects.8,9,10
SCHOOL ENTRY REQUIREMENTS AND VACCINE CONTRAINDICATIONS Every state has a law requiring vaccination for school entry. Every state allows exemptions from this requirement for medical reasons.11 There are very few conditions that are true medical contraindications to vaccination. The following CDC chart summarizes the contraindications and precautions to vaccination and more information can be found online regarding specific conditions the may indicate a need to delay or not give a particular vaccine (http://www.cdc.gov/vaccines/recs/ vac-admin/contraindications.htm). There are only two vaccine contraindications that are usually considered to be permanent. When a person experiences a severe (anaphylactic) allergic reaction to
*rates of completion of 4 DTaP, 3 IPV, 1 MMR, 3 or 4 Hib, and 3 Hep B measured between the ages of 19 and 35 months
262
JOURNAL MSMA, August 2009 — Vol. 50, No. 8
Contraindications and Precautions to Vaccination† Condition
Live
Inactivated
Allergy to component
C
C
Pregnancy
C
V*
Immunosuppression
C
V
Severe illness
P
P
P**
V
Recent blood product
C = contraindication P = Precaution V = vaccinate if indicated *except HPV, **MMR and varicella-containing (except Zoster vaccine), and rotavirus vaccines only †
Adopted from: Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable
Diseases. Atkinson W, Wolfe S, Hamborsky J, McIntyre L, eds. 11th ed. Washington, DC: Public Health Foundation, 2009
a vaccine component or following a dose of vaccine, he or she should not receive that vaccine again. When a person experiences an encephalopathy with no other identifiable cause within 7 days of receiving pertussis containing vaccine, that person should no longer receive any vaccine containing pertussis antigen.12 All but 2 states allow exemptions from vaccinations for religious reasons. Mississippi is one of the two states that do not allow religious exemptions. Religious exemptions were allowed until 1979 when the Mississippi Supreme Court held that, “…provision of statute providing exception for immunization requirement based on religious beliefs was in violation of equal protection clause.”13 Although school vaccine requirements have no provision for timely vaccination prior to school entry, they do in fact improve rates of timely vaccination among toddlers as well as school age children.14
TRENDS IN REQUESTS FOR EXEMPTIONS Requests for exemptions from immunization requirements have increased across the country as fear regarding possible side effects increases. In geographic areas with elevated exemption rates there have been increases of vaccine preventable diseases such as measles and pertussis.15,16 In a retrospective cohort study using data from 1985 through 1992, unvaccinated children were 35 times more likely to contract measles than those JOURNAL MSMA, August 2009 — Vol. 50, No. 8
who were not exempt.17 Additionally, children who are unvaccinated are at increased risk for acquiring these diseases and transmitting them to other children who have conditions that keep them from being vaccinated or who are too young to get the vaccine. Most vaccines protect the person who is vaccinated, as well as the people around them through herd immunity, if the vaccination rates are high enough. In Minnesota in 2008 five cases of Hib meningitis were reported, three among children whose parents declined vaccine for them, one in an infant too young to be vaccinated and one in a child who had a previously undiagnosed immunodeficiency.18 Several issues have contributed to the growing number of requests for exemptions from school vaccination requirements. One is that the vaccines have done such a good job of preventing disease that the diseases are no longer experienced in many U.S. communities and therefore are no longer feared. For example, measles, which at one time killed thousands of children per year in this country, was reported in 134 cases in 2008.19 Parents may even fear the vaccine more than the preventable disease. As more vaccines are developed and added to the infant schedule, parents become more concerned about the number of shots given at one time. Parents are concerned, not just regarding the physical discomfort the shot itself causes, but due to a fear of multiple shots “overwhelming” the immune system. There is no evi263
dence that vaccines overwhelm the immune system. Vaccines today are cleaner and contain many fewer antigens than those used in decades past, so that multiple vaccines for multiple diseases expose children to fewer antigens than the fewer vaccines did in the past.20 Several “evidence resistant” theories regarding vaccines and autism have taken on lives of their own.21 In multiple studies with large numbers of children, no relationship between vaccines and autism could be found. The original papers by Andrew Wakefield purporting a relationship between MMR vaccine and autism have been shown to be inaccurate at best, and falsified at worst.22,23,24 Ten of twelve authors of the original paper (one author could not be contacted) published a formal retraction of the interpretation of the data in the Lancet.25 Thimerosal is a mercury containing preservative that until recently was used in most vaccines that do not contain live virus. It has been proposed that this preservative is related to autism. Many studies have been performed and there is no evidence to support a relationship between autism and thimerosal.22 The diagnosis of autism spectrum disorder continues to increase in spite of thimerosal being removed from almost all childhood vaccines.26
IMPROVING TIMELY VACCINATIONS Patients still get most of their vaccine information from their doctors.27 Discussing and addressing parental fears and responding in a reassuring way to their questions is an important step in reestablishing confidence in the safety and efficacy of vaccination and the importance for the community as well as the individual. Missed opportunities for vaccination contribute a great deal to decreased vaccination rates. Providing the immunization record on the front of the chart at each visit assists as a reminder to the physician and the nurse to assure the patient is up to date. Even if the reason for the visit is illness that precludes vaccination at that visit, a follow-up appointment can be made to provide vaccine. The reminder portion of reminder / recall is very important. Parents rely on providers to let them know when their children are due for their shots. Reminding parents before the child gets behind is preferred to recalling the patient to the clinic after he/she is already past due. The first step towards improving immunization levels, at the clinic level or statewide, is to determine a baseline level. MSDH representatives conduct site visits to assess immunization coverage levels on all Vac264
cine for Children participants throughout the state. The assessment is performed using the “CoCASA” software (Comprehensive Clinic Assessment Software Application). Non-VFC clnics may also request an assessment by calling their Public Health District Immunization Nurse. The Immunization Action Coalition (IAC), an organization dedicated to the distributing educational materials regarding vaccines to health professionals, has developed a short questionnaire that can be used to assess efficiency of vaccine delivery practices in clinics. It highlights standard practices that can be used to assure every child receives vaccines as close to the recommended schedule as possible, and assures that children and the community around them are protected. The survey as well as other useful patient and provider information can be found at the IAC’s website at www.immunize.org (specific survey site: http://www. immunize.org/catg.d/ p2045.pdf). A replacement for the current Mississippi Immunization Registry is being developed and should be fully in place by the summer of 2010. This improved system will allow immunization providers to review and track patient vaccine records online, to conduct automated reminder recall activities, to assess clinic immunization rates and to track vaccine inventory and doses administered. Through this improved technology, public and private providers will be better able to assure timely vaccination of children.
REFERENCES 1. 2. 3.
4. 5. 6.
Centers for Disease Control and Prevention. Achievements in Public Health, 1900-1999 Impact of Vaccines Universally Recommended for Children -- United States, 1990-1998. MMWR. 1999;48:243-248. Ward JI, Zangwill KM. Haemophilus influenzae. In: Feigin RD, Cherry JD, eds. Textbook of Pediatric Infectious Diseases. 4th ed. Philadelphia, PA: WB Saunders; 1471. Poehling KA, Ralbot TR, Griffin MR, et al. Invasive pneumococcal disease among infants before and after introduction of pneumococcal conjugate vaccine. JAMA. 2006; 295:1668-1674. http://www.jama.ama-assn.org/cgi/ content/full/295/14/1668 Accessed June 30, 2009. Centers for Disease Control and Prevention. Pneumonia hospitalizations among young children before and after introduction of pneumococcal conjugate vaccine- United States, 1997 – 2006. MMWR. 2009;58:1-4 National Immunization Survey. Centers for Disease Control and Prevention Web site; http://www.cdc.gov/vaccines/statssurv/imz-coverage.htm#nis; Updated April 13, 2009; Accessed June 30, 2009. Luman ET, Barker LE, McCauley MM, Drews-Botsch C. Timeliness of childhood immunizations: a state-specific analysis. Am J Public Health. 2005;95:1367-1374.
JOURNAL MSMA, August 2009 — Vol. 50, No. 8
7. 8. 9.
10. 11.
12. 13. 14. 15.
16.
17. 18. 19.
20. 21. 22.
23.
MSDH immunization survey Smith PJ, Chu SY, Barker LE. Children who have received no vaccines: who are they and where do they live? Pediatrics. 2004;114:187-195. Gust DA, Strine TW, Maurice E, Smith P, et al. Underimmunization among children: effects of vaccine safety concerns on immunization status. Pediatrics. 2004;114;e16-e22. http://www.pediatrics.org/cgi/content/ full 114/1/e16 Accessed June 30, 2009. Luman ET, McCauley MM, Shefer A, Chu SY. Maternal characteristics associated with vaccination of young children. Pediatrics. 2003;111:1215-1218. States with religious and philosophical exemptions from school immunization requirements. National Conference of State Legislatures Web site. http://www.ncsl.org/default. aspx?tabid=14376. Updated June, 2009. Accessed June 29, 2009. Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Atkinson W, Wolfe S, Hamborsky J, McIntyer L, eds. 11th ed. Washington DC: Public Health Foundation, 2009. Brown v. Stone, 378 So.2d 218 (1979). Omer SB, Salmon DA, Orenstein WA, et al. Vaccine refusal, mandatory immunization, and the risks of vaccinepreventable diseases. NEJM. 2009;360:1981-1988. Salmon DA, Haber M, Gangarosa EJ, et al. Health consequences of religious and philosophical exemptions from immunization laws: individual and societal risk of measles. JAMA. 1999;282:47-53 [Erratum, JAMA 2000;283:2241.] Omer SB, Enger KS, Moutlon LH, et al. Geographic clustering of nonmedical exemptions to school immunization requirements and associations with geographic clustering of pertussis. Am J Epidemiol. 2008;168:1389-1396. Feikin DR, Lezotte DC, Hamman RF, et al. Individual and community risks of measles and pertussis associated with personal exemptions to immunization. JAMA. 2000;284:3145-3150. Centers for Disease Control and Prevention. Invasive Haemophilus influenzae type b disease in five young children â&#x20AC;&#x201C; Minnesota, 2008. MMWR. 2009;58:58-60. Centers for Disease Control and Prevention. Provisional cases of infrequently reported notifiable diseases (<1,000 cases reported during the preceding year) â&#x20AC;&#x201C; United States, week ending January 10, 2009 (1st week). MMWR. 2009;58:11. Gerber JS, Offit PA. Vaccines and autism: A tale of shifting hypotheses. CID. 2009;48:456-461. Gross L. A broken trust: Lessons from the vaccine-autism wars. PLoS Biol 7:e1000114. Doi:10.1371/journal.pbio. 1000114 May 26, 2009. Accessed June 29, 2009 Institute of Medicine. Immunization safety review: Vaccines and autism. Board on Health Promotion and Disease Prevention. The National Academies Press, Washington DC. 2004 http://www.iom.edu/CMS/3793/4705/20155.aspx. Accessed June 30, 2009. Wakefield AJ, Murch SH, Anthony A, et al. Ileal-lymphoidnodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet.1998;351:637-641.
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24. Offit PA. Autismâ&#x20AC;&#x2122;s False Prophets. 1st ed. New York, NY: Columbia University Press; 2008:37-59. 25. Murch SH, Anthony A, Casson DH, et al. Retraction of an interpretation. Lancet. 2004;363:750 26. Schechter R, Grether JK. Continuing increases in autism reported to Californiaâ&#x20AC;&#x2122;s developmental services system. Arch Gen Psychiatry; 2008;65:19-23. 27. Salmon DA, Moulton LH, Omer SB, et al. Factors associated with refusal of childhood vaccine among parents of school-aged children: a case-control study. Arch Pediatr Adolesc Med. 2005;159:470-476. 28. Happe LE, Lunacsek OE, Kruzikas DT, Marshall GS. Impact of a pentavalent combination vaccine on immunization timeliness in a state Medicaid population. Pediatr Infect Dis J. 2009;28:98-101.
CORRESPONDING AUTHOR: Mary Currier, MD, MPH State Epidemiologist and Deputy State Health Officer for Medicine and Science Mississippi State Department of Health Post Office Box 1700 Jackson, MS 39215-1700 Phone: (601) 576-7725 Email: mcurrier@msdh.state.ms.us
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CLINICAL PROBLEM-SOLVING Presented and edited by the Department of Family Medicine University of Mississippi Medical Center Diane K. Beebe, MD, Chair
Multiplicity Rhonda Odom-Funches, MD
A
43-year-old black male was transferred from a rural hospital for further evaluation of a syrinx and a lung mass. Approximately one week prior to transfer, the patient had been hospitalized because of bilateral lower extremity (BLE) weakness. The patient had nodular changes in the right lung base on computed tomography (CT) of the chest and a syrinx at cervical vertebra 6 (C6) through thoracic vertebra 9 (T9) on magnetic resonance imaging (MRI) of the spine. As a result, the referring physician requested transfer of the patient for further evaluation. A syrinx is a fluid-filled cavity that can develop in the spinal cord-syringomyelia or the brainstemsyringobulbia. A syrinx usually develops from lesions that cause partial obstruction to cerebrospinal fluid (CSF) flow. About one-half of syrinxes occur in patients with congenital anomalies. It can also develop as a result of a spinal cord tumor, previous spinal trauma or there may be no known predisposing factors. Some of the presenting symptoms include pain and temperature sensory deficits, weakness, atrophy, spastic leg weakness, vertigo, nystagmus, loss of facial sensation, dysphagia and sometimes peripheral sensory or motor deficits.1 This patient is 43 years old with a lung mass and BLE weakness. My thought is that he probably has metastatic lung cancer or a spinal cord malignancy. Lymphoma is another possibility as it can metastasize to the central nervous system (CNS). Other diagnoses to consider are multiple sclerosis, lupus, rheumatoid 266
arthritis, or ascending paralysis, all of which could explain the BLE weakness. He could also have an infectious process such as pneumonia, tuberculosis (TB) or human immunodeficiency virus (HIV) given his CT chest results and neurological symptoms. Heavy metal poisoning may mimic ascending paralysis. Since multiple systems are affected in this patient, including pulmonary, CNS and musculoskeletal, a multisystem disease such as sarcoidosis is possible. I need more history, and I want to interview the patient and review the other hospital records. The patient had a past medical history positive for hypertension (HTN) and recent diagnosis of diabetes mellitus (DM). He complained of a threeweek history of progressively worsening BLE weakness, occasional cough (mostly dry) and urinary frequency. The patient had previously been in good health until 3 weeks ago when he reported having “weakness in both knees.” He was seen in a local emergency department and given a trial of a nonsteroidal anti-inflammatory drug which provided little improvement. He went to his primary care provider (PCP) 1 week later, and by this time, he was requiring assistance to ambulate and had started falling. As a result he had been admitted to the rural hospital. This is a very interesting history in a previously healthy young man. I would like to get more history from the patient, do initial laboratory studies and I want to know the results of studies done at the other hospital. JOURNAL MSMA, August 2009 — Vol. 50, No. 8
Records from the rural hospital included a chest radiograph (CXR) that showed abnormalities in the right lung. As a result, the patient had a computed tomography scan of the chest. His CT showed nodular changes in the right anterolateral lung base and alveolar consolidation with edema. He had 2 fine needle aspiration biopsies of the lung mass; both yielded inconclusive results. A right inguinal node biopsy showed no malignancy and no lymphoma. Sputum culture showed gram-positive cocci for which the patient was prescribed levofloxacin (Levaquin). He had a negative TB skin test and negative HIV test. The MRI of the spine indicated an abnormality at C6-T9 which was diagnosed as a syrinx. He had a family history of colon cancer, HTN and DM. He was single and worked as a steward in a casino; he denied tobacco (although I would suspect large exposure to second hand smoke in his work place) and illicit drug use. He reported drinking one to two quarts of beer per day but had stopped alcohol use one month prior to hospitalization. He denied chest pain, shortness of breath, fever, chills, night sweats, recent travel, insect bites, back pain, joint pain, heat or cold intolerance, bladder dysfunction, bowel dysfunction, numbness or tingling. Pertinent findings on examination were a spastic gait with poor control of BLE necessitating a walker. His reflexes were normal in both upper extremities; however, reflexes in both lower extremities were difficult to illicit. His sensation was intact. BLE motor function was 3-4/5 with the right lower extremity being somewhat weaker than the left. His breath sounds were clear bilaterally, and cardiac examination was within normal limits. Skin, rectal, abdominal and lymphatic systems were also normal. Initial laboratory findings were glucose 142 mg/dL (70-110 mg/dL), creatinine phosphokinase 257 u/L (35-232 u/L) and sedimentation rate 16 mm/hr (0-15 mm/hr). Results of the complete metabolic panel, complete blood count and urinalysis were essentially normal except for mildly elevated blood glucose. His CXR showed consolidation in the right lower lung base. There are very few abnormalities on initial evaluation except for the abnormal CXR that are consistent with the CT chest finding at the other hospital. The patientâ&#x20AC;&#x2122;s neurological examination is disturbing. Having a spastic gait, weakness and poor BLE reflexes, he very well could have a CNS mass. I will admit the patient and consult neurosurgery. Since JOURNAL MSMA, August 2009 â&#x20AC;&#x201D; Vol. 50, No. 8
the patient has an abnormal CXR, he could have a primary lung cancer with metastases, an infectious process, lymphoma or sarcoidosis; as a result, I want to get another CT of his chest and sputum studies. The patient was continued on levofloxacin to cover possible infectious disease. The patient continued to have a spastic gait and could not ambulate without a walker and even then, his movement was robotic. Neurosurgery evaluated the patient and noted this to be a very unusual presentation for syrinx. They recommended a repeat MRI of the spine, a neurology consultation and further investigation of the lung mass. Neurology recommended an autoimmune evaluation and a lumbar puncture. MRI revealed an abnormal signal within the thoracic cord, extending from the lower half of C7-T8 with an area of cord enhancement from T3-T6. These results were non-specific. His CSF analysis revealed an elevated protein concentration of 126 mg/dL (12-60 mg/dL), glucose 65 mg/dL (45-75 mg/dL), white blood cell (WBC) count 47 #/cmm (0-5 #/cmm) with 96% as lymphocytes and red blood cell (RBC) count 0 #/cmm (0-1 #/cmm). There were mature lymphocytes with no evidence of malignancy. CSF culture results showed no growth. The autoimmune investigation showed normal anti-nuclear antibody, rheumatoid factor and thyroid stimulating hormone studies. Serum angiotensin converting enzyme concentration was also normal at 49 u/L (9-67 u/L). Repeat TB skin test and HIV test were both negative. CT of the chest was reported as nonspecific overall with prominent mediastinal lymphadenopathy associated with nodular peripheral right infiltrate. Sputum cultures showed no growth. The results from these laboratory investigations do not pinpoint a diagnosis. The BLE weakness is explained by the abnormal MRI results but the cause of this abnormality is unknown as the MRI results are nonspecific. The available data does not indicate that the patient has TB or HIV. Autoimmune studies for rheumatoid arthritis, lupus and thyroid dysfunction are negative. There are some abnormal CSF studies but results do not indicate infection or malignancy. Sputum cultures do not indicate a pulmonary infection. Mediastinal lymphadenopathy with an associated pulmonary infiltrate is indicative of sarcoid, although the ACE concentration was normal. Have I missed something? After this extensive investigation, I do not have a definite diagnosis, and the patient is still weak and has spasticity. CT of the chest, although nonspecific, 267
does prompt a suspicion that this could be a primary pulmonary disease; therefore, I consult a pulmonologist for evaluation and bronchoscopy. Bronchial washings showed no malignancy, no fungi and no acid fast bacilli. Biopsy results revealed granulomatous inflammation, no caseous necrosis, no capillaritis or acute inflammation. The pulmonologist prescribed oral prednisone 20 mg three times a day. On day 2 of steroids the patient was noted to have some improvement in BLE weakness. Although he still required a walker to ambulate, his muscle strength was noted to be improved. In view of the lung biopsy results, the pulmonologist concluded that the patient had sarcoidosis. Neurology concurred with this diagnosis and also gave an additional diagnosis of probable neurosarcoidosis which accounted for the findings on the MRI. The patient was prescribed oral prednisone 60mg per day and discharged from the hospital with instructions to followup with the pulmonologist and neurologist in 2 weeks and his PCP in 1 week. Sarcoidosis is an inflammatory disease of unknown cause that can affect multiple systems. In this patient, pulmonary, CNS and musculoskeletal systems were affected. The prevalence of sarcoidosis is approximately 40 cases per 100,000 people. It occurs worldwide and can develop in any racial group. Sarcoidosis is most common in persons in their twenties or thirties, and women may have a greater risk for neurological and eye involvement. Non-necrotizing granulomas as seen in our patient are the hallmark of the disease.2 Nervous system involvement occurs in approximately 5-10% of patients affected with sarcoidosis.2,4 Neurosarcoidosis is a diagnostic consideration in patients with known sarcoidosis who develop neurological symptoms and signs, and in patients without documented sarcoidosis who present with an array of neurological findings. Approximately 50% of patients with neurosarcoidosis present with CNS involvement when first diagnosed with sarcoidosis; it is rare that patients have isolated neurosarcoidosis.2 The diagnosis of neurosarcoidosis is more evident in patients with multisystem sarcoidosis who develop neurological features that include cranial nerve palsies manifesting as facial muscle weakness, vision and hearing impairment, granulomatous meningitis, spinal cord involvement, peripheral neuropathy and myopathy.3,5 This patient’s physical examination was 268
consistent with lower extremity weakness and the absence of tendon reflexes. Typical CSF findings in patients with neurosarcoidosis reveal a high CSF opening pressure, pleocytosis and increased protein.5 Pleocytosis and elevated protein were noted in this patient’s CSF analysis. Spinal cord abnormalities due to neurosarcoidosis can present as an intramedullary spinal cord mass, an intradural extramedullary mass or an enhancing lesion with an associated syrinx.5 Findings of cord enhancement were noted on this patient’s MRI, and he had been given a diagnosis of syrinx at the rural hospital. A classification system has been developed to diagnose patients as having possible, probable and definite neurosarcoidosis.2,4 Based on the criteria, this patient was diagnosed as having probable neurosarcoidosis. He had typical clinical symptoms of neurosarcoidosis, other diseases had been excluded, and histopathological findings were indicative of systemic sarcoidosis. Further, his laboratory studies suggested an inflammation of the CNS (increased protein in the CSF and inflammatory changes on MRI). The patient was prescribed oral prednisone and was noted to have some improvement in muscle weakness. There are no rigorous studies to define the optimal treatment for sarcoidosis but the mainstay of therapy is the use of corticosteroids. Notable patient improvement has been seen with the use of immunosuppressive and immunomodulatory agents in combination with corticosteroids.2,4 However, most patients respond to oral steroids alone as this patient did. At 1 month follow-up with his PCP the patient was noted to be doing much better. He was still requiring some assistance with ambulation but his gait was not as spastic as before. Oral prednisone was continued by a community pulmonologist and at the patient’s five-month follow-up he could walk more erectly than before, although he still required walker assistance.
KEY WORDS:
SARCOID, PULMONARY SARCOIDOSIS, CORTICOSTEROIDS
REFERENCES 1.
2. 3.
Beers MH, Porter RS, Jones TV, Kaplan JL, Berkwits M, eds. The Merck Manual of Diagnosis and Therapy. 18th ed. Whitehouse Station, NJ: 2006. Stern BJ. Neurological complications of sarcoidosis. Curr Opin Neurol. 2004;17:311-316. Scola RH, Werneck LC, Prevedello DMS, Greboge P, Iwamoto M. Symptomatic muscle involvement in neurosarcoidosis: A clinicopathological study of 5 cases. Arq
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4. 5.
Neuropsiquiatr. 2001; 59(2-B):347-352. Kellinghaus C, Schilling M, Ludemann P. Neurosarcoidosis: Clinical experience and diagnostic pitfalls. Eur Neurol. 2004;51:84-88. Vinas FC, Rengachary S. Diagnosis and management of neurosarcoidosis. J Clin Neurosci. 2001; 8(6):505-513.
CORRESPONDING AUTHOR: Rhonda Odom-Funches, MD Grace & Mercy Family Medical Clinic 2106 Raymond Road, Suite A Jackson, MS, 39212 Phone: 601-373-1055 Fax: 601-373-1774 E-mail: Rhonda.funches@yahoo.com
Clinical Problem-Solving is a monthly feature of the Journal of the Mississippi State Medical Association. Clinical Problem-Solving manuscripts are case-based and portray the sequential process of clinical decision-making when the physician is faced with a diagnostic dilemma. Cases may be unusual presentations of common diseases or common presentations of unusual diseases. Patient problems must be based on actual patients from your practice, not contrived patients, and the problem must be solvable. Cases with interesting and educational differential diagnoses are most appropriate. Patient information is presented in segments (indicated in boldface type in the manuscript). The clinician then shares with the reader (regular type) how the new information is synthesized and the rationale for critical decisions. The decision making process continues as new information emerges until there is resolution of the problem. Authors from all medical and surgical specialties are encouraged to submit manuscripts for consideration in this monthly feature. Manuscripts and requests for Instructions to Authors should be addressed to Dr. Replogle at Department of Family Medicine, 2500 N. State St., Jackson, MS 39216. Review Committee:
Chris R. Arthur, PhD Diane K. Beebe, MD Judy Gearhart, MD Shannon D. Pittman, MD William H. Replogle, PhD
JOURNAL MSMA, August 2009 â&#x20AC;&#x201D; Vol. 50, No. 8
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MSDH Mississippi Reportable Disease Statistics
June 2009
* Totals include reports from Department of Corrections and those not reported from a specific district NA - Not available (temporarily)
For the most current MMR figures, visit the Mississippi State Department of Health web site: www.HealthyMS.com
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State Health Officer Receives National Award
S
tate Health Officer Dr. Ed Thompson has been named the 2009 State Health Officer of the Year by the National Association of Local Dr. Ed Thompson, State Health Officer Boards of Health (NALBOH). The award is given annually in recognition of outstanding contributions of time and energy in supporting state and local public health issues. Dr. Thompson was nominated by the Mississippi State Board of Health for his leadership. Dr. Luke Lampton, Board chairman, has called Dr. Thompson a “medical statesman.” “No state health officer in the country deserves this award more than Ed Thompson. He has made significant contributions not only to improving the health of Mississippians, but also the health of all Americans,” said Dr. Lampton. “The entire Board joins me in expressing our pleasure that Dr. Thompson has received this distinctive national honor, and they also join me in thanking him for his exemplary leadership of our department.” Thompson has been State Health Officer since 2007, having previously served in that position from 1993 to 2002. During that time, the Mississippi State Department of Health achieved the highest immunization rates in the country, lowered TB case rates below the national average for the first time in 30 years, and pushed the state’s syphilis rate below the national average for the first time since the Centers for Disease Control and Prevention (CDC) began keeping records. Dr. Lampton also praised Dr. Thompson for his most recent accomplishments. “Since his return in 2007, he has spearheaded construction for the new Public Health Lab, restored field staff and nurses to pre-2002 levels, and reconstituted the Epidemiology and Field Services divisions as strong units.” Under his leadership MSDH also received accolades for the agency’s response to swine flu and Hurricane Gustav. The agency has also renewed efforts to decrease TB rates and infant mortality rates in Mississippi including innovative pilot programs MIME (Metropolitan Infant Mortality Elimination) and DIME (Delta Infant Mortality Elimination) designed to reduce the state’s infant mortality numbers. Dr. Thompson has also served with distinction at the CDC in Atlanta and as Chair of Preventive Medicine at the University of Mississippi Medical Center. The presentation of the award was made during the organization’s annual conference in Philadelphia, Pennsylvania. NALBOH represents the grassroots foundation of public health in America and is dedicated to preparing and strengthening boards of health, empowering them to promote and protect the health of their communities through education, training and technical assistance.
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MSMA
Former State Senator Joins MSMA Staff
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xecutive Director Charmain Kanosky is pleased to announce that Neely C. Carlton has joined the MSMA staff after an exemplary career in public service and in the practice of law. “Neely has a unique background covering all three branches of state government and brings with her a wealth of contacts and experience in legal and public health policy matters,” said Ms. Kanosky.
Neely’s legal career began at the Mississippi Supreme Court while clerking for Justice Edwin Lloyd Pittman. She returned home to Greenville in 1995 to open a law firm, and she then threw in her hat for an open seat in the Mississippi State Senate. In November 1995, at age 25, Neely became the youngest person ever elected to the Mississippi State Senate. While transitioning a small town law practice into an established Delta defense firm, Lake Tindall LLP, in 1999 she focused on business law and litigation as well as insurance defense.
Neely’s legislative career had many highlights including serving as Vice Chair of the Senate Judiciary Committee and Chair of the Neely C. Carlton Interstate and Federal Cooperation Committee, as well as many notable legislative accomplishments covering education, workforce training, business, public health, domestic violence, and other criminal enforcement issues. As a member of the Senate Conference Committee on Medical Tort Reform in 2002, Neely championed new laws which laid the foundation for the sweeping changes in the Mississippi legal system that followed in 2004.
After starting a family in 2005, Neely made the decision not to seek re-election to the Senate; she and husband Dave Maatallah have a 6-year-old daughter, Marissa and 4-year-old twins, Adam and Joshua. The family moved to Jackson in 2003 where Neely accepted a job at Phelps Dunbar LLP in the firm’s business law section. This venture was cut short by an offer from newly-elected Governor Haley Barbour who asked Neely to join his staff when he took office in January 2004 as Counsel to the Governor and Legislative Liaison for his Administration. Beginning in 2008, she transferred to another branch of the administration as Chief of Staff for the Commissioner of the Department of Public Safety. “I have spent my public service career working to improve our state’s public health policies. MSMA is the premier public health advocate in this state. It is an honor to be able to combine my unique experience in the law and state government with the interest of MSMA and its members,” said Neely.
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Memphis Heart Clinic Provides Cardiac Care in Clarksdale, MS Memphis Heart Clinic is pleased to announce that Rajesh Subramanian MD, FACC, FSCAI and Amit Malhotra MD, FACC, FSCAI have opened a clinic in Clarksdale, MS.
Rajesh Subramanian MD, FACC, FSCAI
Amit Malhotra MD, FACC, FSCAI
R D C
Drs. Subramanian and Malhotra look forward to working with the local medical community and providing cardiology care to patients in need of treatment for heart disease. It is our goal to keep patients close to home, utilizing the excellent diagnostic services available to us though the NWRMC and local physician offices.
Clarksdale Clinic Suite 1G Professional Office Building Northwest Mississippi Regional Medical Center 662.349.1900
Helping Mississippi Families Every Step of the Way Scott Medical Imaging and Ridgeland Diagnostic Center offer state of the art MR imaging to the people of Mississippi in a friendly outpatient setting.
s Affordable for self pay patients. s Easy Payment Option available. s Scott Medical Imaging provides mobile MRI services at several locations throughout Mississippi. s Ridgeland Diagnostic is centrally located for patients in Jackson Metro Area. s State of the art Philips 1.5 Tesla scanner. s 2EPORTS AVAILABLE WITHIN HOURS OR SAME DAY IF REQUESTED
Scott Medical Imaging and Ridgeland Diagnostic Center Phone: 1-866- 853-3856 RDC RIDGELANDMRI COM s WWW RIDGELANDMRI COM JOURNAL MSMA, August 2009 â&#x20AC;&#x201D; Vol. 50, No. 8
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PRESIDENT ’S PAGE
WHERE WERE YOU?
Randy Easterling, MD 2009-10 MSMA President
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n often asked question— where were you on December 7, 1941? Where were you on November 22, 1963? Where were you on September 11, 2001? Where were you on June 15, 2009? Important dates, moments in time that will be forever burned into the pages of American history. Hey, wait a minute! We all recognize the first three dates (even if we were not alive for the first two), what is the deal with June 15, 2009? I submit to you
that this date will also live in infamy. On June 15, 2009, I and eleven other of your Mississippi colleagues (the Mississippi delegation to AMA) were at the Hyatt Hotel in Chicago sitting front and center when President Barack Obama delivered the longest address of his young presidency. Did you feel your world rock? For 55 minutes, the President of United States laid out a very logical and sound case for reforming the present healthcare system in America. “Make no mistake, the cost of our health care is a threat to our economy,” the President said, “It is an escalating burden on our families and businesses. It is a ticking time bomb for the federal budget and it is unsustainable for the United States of America.” The President’s text was predicated on the assumption that our healthcare system is too expensive, too complicated, too inefficient – does not cover all Americans, and most important of all, outcomes are less than desirable. “If comprehensive reform does not come about soon,” said the President, “America may go the way of GM; paying more, getting less, and going broke!” The President was warmly received by twelve hundred of your colleagues (delegates and alternate delegates to AMA) from all over the nation and world. During the almost hour-long address, he was interrupted no less than 20 times by applause, at least eight times by standing ovations. There was, however, a very timid boo from the audience when he mentioned that he did not support caps on non-economic damages. Overall, I walked away from the morning’s experience (we waited in line two hours and in our seats for one hour) better informed and with a clearer understanding of the task before us in American medicine. However, the thing which struck me most was not the principles and policies that President Obama laid out, but the confidence, conviction, and tenacity with which he delivered his message. It was clear to me that this is a man on a mission. Consider, if you will, the context. June 15, 2009 marked the first time a sitting United States President has addressed an annual meeting of the AMA House of Delegates since Ronald Reagan in the summer of 1983. While I was not there, one would assume that then President Reagan felt comfortable that he was addressing a room full 274
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of mostly conservative, middle/upper middle class physicians, most of who had supported and/or voted for him for President. Not so with this President. President Obama and his staff knew full well that he was in uncharted waters, entering into the lion’s den, if you will. Agreeing to address the AMA House of Delegates and take the message of healthcare reform face-to-face to those who benefit most from the status quo took guts. He did so with poise and confidence. His rock star mystique was obvious, but overshadowed in this incidence by what came across to all as a genuine desire to come up with a system that would better serve patients and physicians alike. I am of the opinion that the efforts of the President of United States on June 15, 2009 were in large measure successful. Allow me, if you will, to briefly outline the parts of the President’s plan.
1. Upgrade medical records by switching from a paper to an electronic system. 2. Invest more in preventive care in order to avoid illness and disease in the first place (an issue close to hearts of all Mississippi physicians). 3. Reform the way we compensate physicians and hospitals. Payments should be bundled. Payments for how we treat overall disease such as diabetes as opposed to reimbursement for each patient encounter (fee for service). 4. Rethink medical education. Reward medical students who choose primary care as a specialty and also those who choose to practice in rural and underserved areas (another issue close to the hearts of Mississippi physicians). 5. Improve the quality of medical education. Find the most effective methods of treatment and make them available to the physicians on the ground as soon as possible. 6. Health Insurance Exchange. This would allow Americans to one-stop-shop for the healthcare plan that benefits them the most. Central to this insurance exchange is a public option.
I apologize for the brevity with which I hit such crucial points – but time and space do not allow lengthy explanations. MSMA and AMA Web sites and updates will provide you and your patients with more facts and figures than you care to digest. However, more so than in any other situation I can think of in recent US history, “the devil is in the details.” If we are honest with ourselves, most of us agree that the healthcare system in America needs reform. Our present method of delivering health care is much too costly for the common good. The outcomes should be better. And, more Americans should be covered. But to make these statements without dissecting the reasons why these conditions exist does not do justice to the debate. Howard Fineman, political editor of Newsweek magazine, and regular on “Hardball with Chris Matthews,” CNBC and other major news outlets, spoke to the AMPAC club members in Chicago a day after President Obama gave his address. While informative, knowledgeable, and entertaining, Mr. Fineman was most of all insightful. He concluded his 30-minute discussion on President Obama and his desire to reform health care by saying, “It seems to me that what we need as much as health care reform – is a new American.” He went on to reflect that one of the reasons our system is less than desirable is that we as Americans have become too lazy, too fat, too self indulgent, and too dependent on others to solve our health care dilemma. On the flight back to Jackson, two days after the President’s address, what haunted me most were the words of Mr. Fineman: “What we need most is a new American.” Barack Obama’s plan is comprehensive, ambitious, and some parts of the proposal are needed. However, I fear that whatever the final product, we will in large measure be throwing good money, time, and effort after bad if we as Americans do not begin to assume more responsibility for our own health. Change is coming. We should not resist it, but embrace it. More so, we as physicians should be at the forefront doing what we can to assure that the changes are patient centered and physician driven. I am convinced by the end of President Obama’s first term, the healthcare system under which we apply our trade will be different. Will he get everything he wants? No! Will he get most of what he wants? Probably so! Let me restate my original question. Where were you on June 15, 2009? In large measure, the words of President Obama on June 15, 2009 were well thought out, politically scripted, and designed to make American JOURNAL MSMA, August 2009 — Vol. 50, No. 8
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physicians feel better about the tsunami that is about to wash over all of us. But the comments of Howard Fineman the following day were reflective, off the cuff, and terribly insightful. Maybe the take home message for MSMA and AMA is not so much a need to dismantle our healthcare system as much as to build a new American. The latter is a much more daunting task, but, I can assure you, it would bring about significantly more lasting and beneficial good. Your partner in making Mississippi healthier,
Mark Your Calendar!
The 142nd Annual Session of the MSMA House of
Delegates and Medical Randy Easterling, MD President, Mississippi State Medical Association
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Affairs Forum 2010 will be held
June 3-6, 2010 in Natchez.
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EDITORIAL
I
Shame on Us
want to begin with a proposition that should be both obvious to all and, in my opinion, indisputable: A strong consensus has developed, and is unlikely to change any time soon, that health care delivery today is flawed in this country and that the principal fly in the ointment is cost. This is not the exclusive view of liberal politicians and their constituents anymore. These old agitators are now joined by industrial leaders, senior citizen groups, many conservative politicians, and even by leaders of the American Medical Association and the American Hospital Association. Change is in the air, but the move toward change is where consensus evaporates. The scene now is one of mass confusion. Whatever plan is destined to emerge from existing chaos is anybody’s guess. One can safely predict, however, that it won’t embody both lowered cost and a lasting guarantee of free access and high quality. Sad to say, it didn’t have to be this way. Physicians are largely to blame. Consider, for example, a recent article in the New Yorker magazine of 1 June 2009 entitled “The Cost Conundrum.” The publication admittedly generally leans toward the left; but, nevertheless, the facts in this particular piece are indisputable. Medicare expenditures per person in the McAllen, Texas market are among the highest in the country—$15,000 per enrollee which is almost twice the national average. Up the road a piece [800 miles] in El Paso County, an area with similar demographics, Medicare expenditures are $7,500 per enrollee – approximately half as much as in her sister city. Many years ago, a friend of mine, Bill McRoberts, who later became head of Urology at University of Kentucky, studied the practice patterns of urologists in Seattle and comparable areas. He showed that per capita frequency of transurethral resection of the prostate in various market areas was proportional to the per capita number of urologists. Numerous studies and abundant data corroborate the relevancy of these anecdotes. The conclusion is ineluctable that such variances are largely due to the behavior of physicians. Many contributing factors may legitimately be recruited to explain escalating costs, including perverse incentives in public and private insurance contracts, malpractice claims, excessive paper work, proliferating new technology, etc. However, underlying all these issues, and where our culpability lies, is a climate within the profession which condones the unrestrained pursuit of mercenary interests and does little to discourage waste. It would be naïve to contend that the solution to the current crisis is simply to encourage individual physicians to “do right.” It is not too farfetched, however, to urge physician groups in the aggregate to acknowledge finally the prominent role that physicians as a group have played in enabling costs to get out of hand and to move forthrightly to change the culture within the profession in ways that promote cost-effective behavior. It may be too late to avert the damaging changes which are in the offing, but, such strategy probably is or has been the main hope to defend the system that has served patients and ourselves so well. I don’t wish to embarrass Ed Hill by holding him up as a paragon of medical virtue, but he will serve as a convenient and apt stereotype because he is well known. At the end of a roast which I delivered at a fund raiser a year or so ago, I made these remarks about Ed which could appropriately be applied to many other Mississippi physicians as well: “If all physicians had, in our generation, conducted their careers with the level of professionalism, competence, integrity, energy, and devotion to the public good as Ed has done, the health care system would not be an issue in the current Presidential election, there would be no need for medical political action committees, malpractice premiums would be a fraction of what they are, and third party payers would revert to their proper role as mere financial agents serving only to handle payments between patients and providers. In a word, physicians would be sovereign in the health care system. To paraphrase St. Paul: Not all the politicians, nor trial lawyers, nor hospital administrators, nor insurance executives, nor lobby groups, nor any other force in this free country could dislodge physicians in the aggregate from the position of power which they occupied in days gone by if all behaved like Ed Hill.” “Power” often carries a pejorative meaning in common parlance, but, it is to be coveted when cultivated and exercised responsibly. It is too bad that this vision of our role has too often been obscured, of late, by greed and apathy. W. Lamar Weems, MD MSMA Past President
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SPECIAL ARTICLE A Year Ago in Mozambique The African Medical Mission Trip Philip L. Levin, MD
W
ith the milieu of trauma, heart attacks, and unexplainable illnesses, one might presume the life of an emergency physician offers enough adventure. Yet every year or two I leave behind the luxuries of American life to experience the rigors of the medical missionary. These days spent among the neediest of our world reignite my joy of helping others, reminding me of the true purpose of being a healer. In August 2008 I joined a two-week trip under the direction of the Mercy Ships Organization to Mozambique in southern Africa. Once known as the “Jewel of Africa,” this country’s economy collapsed after the 1975 War of Independence. Portuguese nationals fled, and the country descended into anarchy. Her current GNP ranks 210th in the world. With their medical facilities catering to the rich, health care hovers out of reach for most of the population. Seventy percent of the natives live below the poverty level, suffering an infant mortality seventh highest in the world (greater than 10%). Even obtaining adequate food presents a constant challenge, with many residents suffering the effects of malnutrition. I prepared for my mission by studying tropical diseases and brushing up on my Portuguese. For supplies, I collected minor surgical equipment and purchased $200 of medicines: large bottles of antibiotics, anti-parasitics, and anti-diarrhetics. International travel allows only forty-four lbs (twenty kg) of suitcase weight. My case was thirty pounds of medical supplies, cushioned with a handful of clothing and toiletries. We flew into Maputo, Mozambique’s capital, where Gary, our dynamic organizer, gathered the two dozen participants as they arrived from the corners of the world. Herding us onto the minibus, he drove us along dirt roads overlooked by city MOTHER AND CHILD — This child suffered permanent neurological dump shantytowns. As we neared the gated damage from a yellow fever infection contracted in infancy. With compound of “Beacon of Hope,” a patchwork of an estimated age of three years, he functioned on a six-monthsimple homesteads spread out around us. old level. We saw very few chronic illnesses. Most often, we The Beacon was founded by Angie Walker, a surmised, when someone became seriously ill they recovered Texan nurse who felt the call of God. She created on their own, or they died. 278
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the compound by renting the space of a failed mission from the government at a dollar a year. Here she provides refuge for a dozen teenage boys; too young to live on their own, too old to remain in the homes of their overworked mothers or the few available orphanages. Eight years into her ninetynine year lease, ours was her first medical mission. In addition to me, we had one other physician, an Asian family doctor from Australia. The other members of our team included a pharmacist from Hawaii, a student from England, four nurses from the US Northwest, a teacher from Spain, staff from Texas, and a few other helpers. After we settled in, we walked through the BOY WITH ENLARGED SPLEEN — Malaria was so prevalent that our neighborhood to invite the locals to our afternoon history included “How many times have you had malaria, how recently, and did you have to be hospitalized?” This boy was clinic. Most of the lots were tiny, perhaps a recovering from his most recent bout, with residual marked hundred square feet, with boundaries marked by splenomegaly. hedges. Each held a tiny shack for shelter, a small plot of vegetable garden, a pit for garbage, and a blanket on the road border where the residents stacked items for sale; typically charcoal, bananas, or oranges. City pipes provided non-potable water. Electricity seemed a rarity. Our clinic on the lawn provided triage, nursing station, wound care, pharmacy, and our two doctor spots. We saw patients for about four hours, evaluating over two hundred. For many of them, we provided their first ever medical exam. Scalp and skin diseases were common; though otherwise the patients seemed surprisingly healthy, flourishing on a meager diet and plenty of exercise. My first patient was a seven-year-old boy with chronic osteomyelitis of his left ankle. Judging from the scars, the local witch doctors had been sticking him with a number of sharp instruments. We put him on amoxicillin for a month and hoped for the best. Another patient was an undersize three-year-old who couldn’t walk or talk. Further inquires revealed he had yellow fever as in infant, so probably had brain damage with permanent neurological disability. Without any testing available, all I could do was advise the mother that we had nothing to offer this child. Like all physicians, I rely on the medical history in making my diagnosis. In Africa, the language barrier proved especially difficult. Occasionally my Portuguese served, but it seemed most of our patients spoke Catalan or Swahili. I worked with a young male translator, who couldn’t get himself to discuss gynecological concerns. Clocks and calendars didn’t exist. Instead of assigning a time, we told the bus driver to pick us up at the first light of dawn. A boy whose mother reported as ten years old, might actually be six or sixteen. “How long has she had this rash?” I asked one mother of a child whose skin was scaling from neck to foot. “A few days.” “A few days?” I turned to my translator. “Ask again, this couldn’t have erupted in just a few days.” There ensued a long conversation between the two. He turned back to advise me, “Maybe a long time.” Making a diagnosis depended on physical exam and intuition. A middle age fellow with rotten teeth came to us complaining of a chronic cough. My differential stretched through tuberculosis, pneumocystis pneumonia, lung cancer, larvae migrans, asthma, sinus drainage, brucellosis and beyond. He wasn’t running a fever and didn’t seem too sick, so I prescribed some antihistamines and cough drops. Instead of asking, “Have you had malaria?” we asked, “How many times have you had malaria, how long ago, and did they have to hospitalize you?” For those who appeared gravely ill, there was a malaria clinic near Maputo sponsored by the Bill Gates Foundation. One of the Beacon Boys was recovering from malaria, and I examined his spleen, finding it to be a good ten centimeters below his rib margin. I advised him not to do anything active. A few minutes later I saw him out on the soccer field with his chums. Often we had nothing to offer, such as to the old farmer whose blinding cataracts had formed from years in JOURNAL MSMA, August 2009 — Vol. 50, No. 8
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the sun. Other times we could help, such as the fellow with the purplish rash overlying edema of both legs. We determined he lived on a cup of rice daily, diagnosed pellagra, and provided multivitamins. One infant, perhaps six months old, came with high fever and a stiff neck. We pleaded with the mother to allow us to take her and the baby to the hospital for further testing and antibiotics. “Tomorrow,” she said. “No. Right now. Your baby is very sick. We will pay for it.” She hesitated, clutching her baby to her chest, but shook her head. SURGERY IN THE OUTBACK — This young man had a large pedunculated “Tomorrow,” she insisted, turned, mole on his left cheek. I removed it on our first clinic day, and here I’m and rushed out through the gates. removing the sutures. Minor surgery, like most medical care, was “Why did she refuse?” one of the unavailable to most of the population. nurses asked. “She doesn’t trust the hospital and she doesn’t trust us,” Angie explained. “She has HIV and fears they’ll take her baby away.” We had no laboratory or x-ray. This hardly mattered, for we couldn’t treat most illnesses anyway. Our stocks included medications for impetigo, minor infections, skin tinea, vaginal moniliasis, and roundworm. We didn’t diagnose hypertension, diabetes, or angina, for we had no treatments to offer. Even children with heart murmurs, laborers with thyroid tumors, or women with breast cancer, could only be informed. We lived on native foods, mostly rice, beans, potatoes, and bread. The Beacon had a small garden, so we enjoyed occasional tomatoes, oranges, peanuts, bananas, and greens. Once a week we had two chickens mixed in with the food served for forty. The water had to be boiled for fifteen minutes before drinking or cooking. Electricity was spotty. For a few days the Internet worked. We slept under mosquito netting, though the first night I noticed I had several mosquitoes on the wrong side of my nets. I took my malaria prophylaxis and drank only prepared water. Of the fourteen in our group only one became ill, with a flare of her rheumatoid arthritis. She improved with a Prednisone bolus. One day we rented a bus and drove high into the mountains, setting up a clinic in a two-room concrete school. Within an hour fifty natives dressed in brightly colored wraps gathered under the papaya tree shade. For most of them it was their first exposure to western medicine, for many, their first view of a white man. People ask me why I put up with the inconvenience of missionary trips. After all, I can be more effective with the medications and facilities in my hometown E.R. Why not limit my travel to resorts, where I would enjoy better food, more comfortable beds, and more interesting sights? Because though I knew I wasn’t providing hightech medicine, without me, these people would have had no medical care at all.
Donations to “The Beacon of Hope” may be addressed c/o the Mercy Ships Organization, PO Box 2020, Garden Valley, TX, 75771.
Philip L. Levin has practiced in the Emergency Department of Memorial Hospital of Gulfport for the past seven of his thirty years as an E.R. doc. He currently serves as president of the Gulf Coast Writers Association and has published a few articles and books over the years. His missionary trips have included Honduras, Peru, and Africa. 280
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UMHC
T
Match Madness
ANTICIPATION, TENSIONS BUILD FOR SOM CLASS OF 2009 he narrow passage that connects four years of medical school with the bronzy, soon-to-be doctors is Match Day.
For more than half a century, Match Day, a nationwide event where residency locations are announced to fourth-year medical students, has remained half-Academy Awards and half-lottery jackpot drawing. Of the 96 students in the School of Medicine’s Class of 2009, most learned their match during a March 19 ceremony in the Norman C. Nelson Student Union. Picked at random, each student walked alone to a microphone at the front of a room crowded with classmates, family and faculty and read aloud his or her residency placement. At these ceremonies, tensions build. Nobody wants to go third from last – the runner-up and final students get prizes. Emotions get barely gauzed because some students place exactly where they hoped and others don’t, hence the references in event speeches to dealing with adversity and disappointment. At least half the 96 members of the 2009 class will remain in state. “Our whole purpose is to train physicians for Mississippi,” said Dr. LouAnn Woodward, associate dean for academic affairs at the time. The state’s physician-per-capita ratio remains the second-lowest in the U.S., a problem exacerbated by poverty, low health awareness and Mississippi’s largely rural population. It’s why Dr. Dan Jones, associate vice chancellor for health affairs and medical school dean (prior to being named Chancellor of the University of Mississippi), invited the students leaving the state to return after their residencies. “Let me ask you to consider coming to Mississippi to invest your career,” he said. “No other place in the world can better utilize your skills than here.” Fourth-year medical student Yakeyla Nave already knew that. A native of tiny Shuqualak, Nave tested into the Mississippi School for Math and Science and joined the junior ROTC in ninth grade. Medical school became a goal during high school when her grandmother began suffering from Parkinson’s disease. Enrolling in Xavier University of Louisiana, she served in the U.S. Army Reserves and Air Force Reserves, held two on-campus jobs and graduated summa cum laude in 2005. “With my grandmother, I was always taught to work hard,” Nave said. At the Match Day ceremony, her name was drawn third from last. No prize, but she got her wish: pediatrics at the Medical Center. With that squared away, Nave said she’ll concentrate the next couple weeks on pre-wedding details. Her fiancé, Theo Naylor, works for the Mississippi Department of Banking and Consumer Finance. Katy Rivlin, at the Match Day microphone for her turn, threw her arms into the air and yelled, “Ob-gyn at NYU!” Friends shrieked and family cheered. Joyful tears overwhelmed her face. Her boyfriend, Ari Glogower, will start this year at the New York University School of Law. “I was nervous because he got a scholarship there. So if I didn’t get placed in New York, then . . .” she said, trailing off. Beaming parents, spouses and siblings, so enwrapped they’d ditched teenage introspection, streamed out of JOURNAL MSMA, August 2009 — Vol. 50, No. 8
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the student union following the ceremony. Medical students lined up for snapshots, passing hugs and congratulatory handshakes. But letdown also punctured the scene. A few leaned quietly against railings, parents closed-mouthed nearby, happy for their classmates but not willing to discuss what just happened. At least 43 of the Class of 2009 will do their residencies in Mississippi. Preston McDonnell matched at the Medical Center in family medicine. Following his residency, he plans to join his family’s practice in his hometown of Hazlehurst. An avid outdoorsman, McDonnell earned a bachelor’s in business from the University of Mississippi but always wanted to become a doctor. “Medical school made sense to do, but I didn’t know if I could be successful,” he said. A critical-needs scholarship paid for his M.D., for which he’s required to practice six years in a medically underserved community. Coincidentally or not, Hazlehurst qualifies as such, so events worked out well for McDonnell. It was also during medical school that he and his wife, Candi, got married. McDonnell, whose father sponsors a diversity-related Barksdale Scholarship at the Medical Center, said the match puts him close to family, home in Flowood, the woods he hunts and the lakes he fishes. Dr. Woodward said McDonnell is a chief example of the School of Medicine’s goal. “His grandfather was a physician in Hazlehurst, his father is and he’s going to join them,” she said. “He’s exactly why we’re here.” -Jack Mazurak
University of Mississippi School of Medicine Class of 2009 Match List
Kevin Abel Family Medicine North Mississippi Medical Center Tupelo, Mississippi Khushboo Agrawal Internal Medicine Mayo School of Graduate Medical Ed. Rochester, Minnesota Holland Alday Internal Medicine University of Utah Affiliated Hospitals Salt Lake City, Utah
Nerma Bašić Anesthesiology University Hospitals Jackson, Mississippi
Stephen Bergin Internal Medicine Duke University Medical Center Durham, North Carolina 282
Marc Biggers Orthopedic Surgery University of Tennessee COM Memphis, Tennessee Barr Biglane Internal Medicine University Hospitals Jackson, Mississippi Ginny Blalack Internal Medicine University Hospitals Jackson, Mississippi Stewart Boyd Internal Medicine University Hospitals Jackson, Mississippi Kevin Bridges Internal Medicine University Hospitals Jackson, Mississippi
Ben Brock Medicine-Pediatrics University Hospitals Jackson, Mississippi
Chip Brooks Emergency Medicine Earl K. Long Medical Center Baton Rouge, Louisiana
Angel Brown Internal Medicine University of Tennessee COM Chattanooga, Tennessee Kathy Brown Pathology University Hospitals Jackson, Mississippi
Lauren Cantwell Internal Medicine Virginia Commonwealth University Health System Richmond, Virginia JOURNAL MSMA, August 2009 — Vol. 50, No. 8
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Will Cauthen General Surgery University Hospitals Jackson, Mississippi
Jennifer Chamberlain Surgery - Preliminary Oschner Clinic Foundation Urology â&#x20AC;&#x201C; Louisiana State University Oschner Medical Foundation New Orleans, Louisiana Seth Compton Internal Medicine University Hospitals Jackson, Mississippi
Jay Culpepper Surgery - Preliminary Greenville Hospital System University of South Carolina Greenville, South Carolina
Jay Derbort Emergency Medicine Earl K. Long Medical Center Baton Rouge, Louisiana
John Egger Psychiatry Rush University Medical Center Chicago, Illinois Angela Ethridge Internal Medicine University of Utah Affiliated Hospitals Salt Lake City, Utah Lindsay Ford Medicine-Pediatrics Tulane University SOM New Orleans, Louisiana Cindy Garrett Family Medicine University Hospitals Jackson, Mississippi
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Christina Giurintano Radiology University Hospitals Jackson, Mississippi
Miriam Gomez-Sanchez Internal Medicine University of Virginia Charlottesville, Virginia
Grant Guild General Surgery - Preliminary Maricopa Medical Center Phoenix, Arizona Jessica Gullung Otolaryngology Medical University of South Carolina Charleston, South Carolina
Marguerite Halphen Emergency Medicine Earl K. Long Medical Center Baton Rouge, Louisiana Claude Harbarger Otolaryngology Medical College of GeorgiaAugusta, Georgia
Nick Hendricks Surgery - Preliminary University of Virginia Health System Charlottesville, Virginia Radiology-Diagnostic (A), University of Virginia Hennessy Ann Howell Medicine-Pediatrics University of Alabama Birmingham, Alabama Josh Iles Pediatrics University Hospitals Jackson, Mississippi
Will Jennings General Surgery - Preliminary University of South Alabama Mobile, Alabama Russ Johnson Medicine - Preliminary University Hospitals Jackson, Mississippi Radiology-Diagnostic Baptist Memorial Memphis, Tennessee
Paxton Jones Transitional - Medical Center of Columbus, GA Radiology-Diagnostic Baptist Memorial Hospital Memphis, Tennessee Sarah Jones Pediatrics University Hospitals Jackson, Mississippi
Curtis Keller Neurology University of South Florida COM Tampa, Florida
Ben Kilman Family Medicine North Mississippi Medical Center Tupelo, Mississippi William Higdon King (Will) Radiology-Diagnostic Baptist Health System Birmingham, Alabama Michael Koury Surgery - Preliminary University Hospitals Jackson, Mississippi
Dustin LeBlanc Emergency Medicine University Hospital Cincinnati, Ohio Radiology-Diagnostic (A) University of Virginia JOURNAL MSMA, August 2009 â&#x20AC;&#x201D; Vol. 50, No. 8
Matt Lewis Orthopedic Surgery University of Missouri Kansas City Programs, Missouri
Samantha Morris Pathology University Hospitals Jackson, Mississippi
Nathan Maples General Surgery University Hospitals Jackson, Mississippi
Yakeyla Nave Pediatrics University Hospitals Jackson, Mississippi
David Macias Orthopedic Surgery Johns Hopkins Hospital Baltimore, Maryland
Christopher Martin Surgery - Preliminary Tulane University New Orleans, Louisiana Scott Martin Family Medicine University Hospitals Jackson, Mississippi Preston McDonnell Family Medicine University Hospitals Jackson, Mississippi Hamilton McGee Anesthesiology University Hospitals Jackson, Mississippi
Nathan McIntosh Emergency Medicine Transitional Emergency Medicine (A) University Hospitals Jackson, Mississippi
Will Meador Neurology University of Alabama Med Center Birmingham, Alabama Michael Michel General Surgery - Preliminary University of Florida Gainesville, Florida
Gary Nash Internal Medicine Baptist Health System Birmingham, Alabama
Claire Nettles Pediatrics University Hospitals Jackson, Mississippi
Neal Patel Emergency Medicine Henry Ford HSC Detroit, Michigan
Stuart Phillips Internal Medicine University of South Alabama Mobile, Alabama Sam Pierce Internal Medicine University Hospitals Jackson, Mississippi
Sarah Quilter Obstetrics-Gynecology University Hospitals Jackson, Mississippi
Jordan Ray Radiology-Diagnostic Baylor University Medical Center Dallas, Texas Wes Rayburn General Surgery - Preliminary Pys. Medicine & Rehab (A) University of Missouri Columbia, Missouri
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Breck Richardson Pediatrics University of Arkansas - Little Rock Little Rock, Arkansas Katy Rivlin Obstetrics-Gynecology New York University School of Medicine Manhattan, New York Pat Robbins Medicine - Preliminary Radiology - Diagnostic (A) University Hospitals Jackson, Mississippi Rob Robertson Orthopedic Surgery University Hospitals Jackson, Mississippi Rebecca Rose Family Medicine University Hospitals Jackson, Mississippi
Matt Sample Internal Medicine Vanderbilt University Medical Center Nashville, Tennessee Shawn Sanders Internal Medicine University Hospitals Jackson, Mississippi
Brandi Sartin Obstetrics-Gynecology University Hospitals Jackson, Mississippi
David Sayers Military - Pediatrics Wright Patterson AFB, Ohio Dayton, Ohio
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Jason Schwanebeck Emergency Medicine - Transitional Emergency Medicine (A) University Hospitals - Jackson, MS Sara Shrock Internal Medicine University Hospitals Jackson, Mississippi Kevin Sijansky Anesthesiology University Hospitals Jackson, Mississippi Brent Smith Family Medicine University Hospitals Jackson, Mississippi
Jason Smith Emergency Medicine University of Arkansas Little Rock, Arkansas
Taylor Smith Med-Prelim/Ophthalmology University Hospitals Jackson, Mississippi Amanda Smith Family Medicine University Hospitals Jackson, Mississippi
Josh Stevens Pediatrics Lackland AFB, Texas San Antonio, Texas
Matthew Stevens Otolaryngology University of Texas HSC San Antonio, Texas Patricia Stewart Internal Medicine University Hospitals Jackson, Mississippi
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Brad Suggs Family Medicine University Hospitals Jackson, Mississippi
Win Williams Internal Medicine University of Alabama Medical Center Birmingham, Alabama
Stephanie Tanner Pathology University Hospitals Jackson, Mississippi
Timbo Taylor Emergency Medicine University of Arkansas Little Rock, AK
Scott Therrien General Surgery University of Tennessee COM Memphis, Tennessee
Arthur Wood Family Medicine North Mississippi Medical Center Tupelo, Mississippi Lillian Zamora Anesthesiology University Hospitals Jackson, Mississippi
Brian Thompson Military - Pediatrics Wright Patterson AFB, Ohio Dayton, Ohio
Kyle Thompson Thoracic Surgery Medical University of South Carolina Charleston, South Carolina Scott Turner Emergency Medicine Baystate Medical Center Springfield, Massachusetts
Christy Walters Obstetrics-Gynecology University of Alabama Medical Center Birmingham, Alabama Jeremy Wigginton Family Medicine University Hospitals Jackson, Mississippi
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IQH
IQH ANNUAL SESSION
The current status of various IQH projects was shared with physicians convening for the IQH Annual Session Saturday, May 30, held during the 141st Annual Meeting of the Mississippi State Medical Association in Oxford. Dr. Jennifer Gholson, chief medical officer, presided and presented IQH’s medication safety project and the educational efforts to physicians about potentially inappropriate medications (PIMS) and drug-to-drug interactions (DDIs) from prescriptions for Medicare patients. She pointed out that Mississippi is currently number one in the nation in prescribing PIMs. Mary Helen Conner, project coordinator for IQH’s Health Information Security and Privacy Collaboration (HISPC), gave an update on the project which continues through July 2009. Dr. Gholson recognized Dr. Sid Bondurant and Michael Carney who completed their terms with the IQH board of directors. Newly elected board members are Dr. Melessa Phillips of Madison and Kathy Fender of Lucedale. They join board members Dr. Bill Jackson, Dr. Lee Greer, Dr. Peggy Davis, Dr. Charles Brock, Mary Curtis, Dr. Rodney Frothingham, Ricki Garrett, Dr. John Hassell, Walter Howell, Bill Oliver, Robert Pugh, Billy Sims and Lex Taylor.
DR. PEEPLES RECEIVES DERRICK QUALITY AWARD
Dr. Samuel H. Peeples of Jackson has been named the 2009 Derrick Physician Quality Award recipient by IQH. In presenting the award, Dr. James S. McIlwain, IQH president, pointed out that Dr. Peeples’ service to the quality organization is reflected by the fact that he was on the board of directors when the physician quality award was initiated in 1993 in memory of Dr. Arthur A. Derrick of Durant. Dr. Derrick was a longtime supporter of health care quality improvement in the state. In accepting the award, Dr. Peeples said, “I’ve always had an interest in improving quality in the state of Dr. James S. McIlwain, IQH president, left, presents Dr. Mississippi and around the nation. I appreciate this Samuel H. Peeples of Jackson a plaque recognizing him recognition from IQH.” as the 2009 Derrick Physician Quality Award recipient. Dr. Peeples serves as a consultant review physician Names of the physicians who have been honored with the in the CMS program. He served as a stakeholder in the award made in memory of Dr. Arthur A. Derrick of Durant IQH Doctor’s Office Quality Improvement Technology are on permanent display in the IQH office in Ridgeland. Project and has been a supporter of the adoption of electronic health records (EHRs). A native of Clarksdale, Dr. Peeples is with the Premier Medical Group of Mississippi. A graduate of Mississippi State University, he completed his internal medicine internship and residency at the University of Mississippi School of Medicine. He is a graduate of the Business of Medicine Executive Certificate program from the University of South Florida. From 2005 through 2009, he served as Mississippi governor for the American College of Physicians. He is past chairman of the Christian Medical and Dental Associations, Jackson Chapter, and is a member of the Mississippi State Medical Association and the Central Medical Society. He serves on the Board of Deacons at First Baptist Church in Jackson. Dr. Peeples participates in a student mentoring service and the Mission First Medical Clinic. A permanent display at the IQH offices lists names of physicians who have received the reward since its inception in 1993. JOURNAL MSMA, August 2009 — Vol. 50, No. 8
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PERSONALS
Beebe
Diane K. Beebe, MD, chair of the Department of Family Medicine, has been elected to the Board of Directors of the American Board of Family Medicine. The American Board of Family Medicine is a 40-year-old medical specialty notfor-profit that seeks to improve the quality of medical care available to the public. To do so, it establishes and maintains standards of excellence in the family medicine specialty, improves education standards in family medicine and evaluates practitioners who apply for and hold certificates. Beebe will serve a five-year term on the 15member board of directors. “This is terrific for Dr. Beebe and for our institution,” said Dr. Dan Jones, Chancellor of University of Mississippi. “I am proud of this accomplishment and grateful for the hard work over many years that went into this recognition. This is a great benefit to the Department of Family Medicine and to our organization for her to participate in a national organization. This will expose Dr. Beebe to lots of good ideas she can implement here at home.” Beebe said she’s honored and will use the opportunity to contribute her expertise to the field on a national level while learning ways to continue improving the Department of Family Medicine. Gary Carr, MD of Hattiesburg has been elected to serve as President of the Federation of State Physician Health Programs until April 2011. The Federation of State Physician Health Programs (FSPHP) is the national membership organization for the nation’s state physician health programs with 46 member states. Dr. Carr has served as Medical Director of the Mississippi Professionals Health Program (MPHP) since July 1999. Under his direction the MPHP has become nationally recognized as a model Physician Health Program. The MPHP assists physicians and other health care professionals with potentially impairing conditions such as alcohol and other drug dependencies, psychiatric illness, and other conditions which could result in professional impairment. FSPHP has developed guidelines for the effective monitoring of
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Glisson
potentially impaired physicians diagnosed with substance use disorders or psychiatric illnesses and is developing guidelines regarding maintenance of appropriate professional boundaries and physical impairments. James Glisson, MD, Assistant Professor of Medicine, has joined University of Mississippi Medical Center. He will see patients through University Physicians, part of University of Mississippi Health Care. A native of Corinth, Dr. Glisson earned the Pharm.D. cum laude in 1997 and completed a community pharmacy residency in 1998 at the University of Mississippi. While in pharmacy school, he was a member of the Rho Chi Pharmacy Honor Society and served as the organization's president. He received the M.D. from UMMC in 2002, where he served as an intern physician from 2002-03 and as a resident physician from 2003-05 in the Department of Internal Medicine. Since 2005 Dr. Glisson has served as clinic director of the Cross City Medical Clinic in Corinth, as a member of the medical staff at the Magnolia Regional Health Center in Corinth and as a member of the Pharmacy and Therapeutics Committee at the Magnolia Regional Health Center.
Walter Cornelius Gough, MD of Drew recently received the AMA Physician’s Recognition Award (PRA) for his twelfth time. The PRA award recognizes physicians who earn at least an average of 50 credits per year from educational activities that meet the AMA standards. The award is a way to demonstrate to your colleagues and patients that you are committed to continually expanding your knowledge and improving your skills by participating in continuing medical education. Visit the AMA Web site at www.ama-assn.org/go/pra for more information about the AMA PRA and other topics of interest to the CME community. To obtain an application (print or online) for AMA PRA direct credit activities: Web: www.amaassn.org/go/cme , e-mail: pra@ama-assn.org or phone: (312) 464-5296.
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Johnson
Keeton
John A. Johnson, III, MD has joined the Department of Surgery of Hattiesburg Clinic. Dr. Johnson received his M.D. from University of Mississippi School of Medicine in Jackson. He completed an internship in general surgery at the National Naval Medical Center, National Capitol Region, in Bethesda, Maryland. He completed his residency in general surgery at University of Mississippi Medical Center in Jackson. Dr. Johnson is a fellow of the American College of Surgeons. He is also a member of the American Society of General Surgeons, the Society of American Gastrointestinal Endoscopic Surgeons, the AMA, and the MSMA. He is a board certified Diplomate of the American Board of Surgery. Dr. Johnson joins Ralph E. Abraham, MD; Orlando J. Andy, Jr., MD; John W. Brahan, MD; Scott P. Guidry, MD; Charles E. Wall, Jr., MD; and William A. Whitehead, MD in the department of surgery.
Michael Hammett, MD; J. Michael Hodges, MD; and John Sobiesk, MD of Hattiesburg Clinic Ear, Nose, and Throat have begun seeing patients at Ear, Nose, and Throat Associates in Lucedale. This location is the former practice of Glenn Neel, MD. Dr. Hammett received his M.D. from Louisiana State University New Orleans. He completed his surgery internship at Medical Center of Louisiana in New Orleans, where he also completed his residency in otolaryngology head and neck surgery. He is board certified by the American Board of Otolaryngology. Dr. Hodges received his M.D. from the University of Alabama School of Medicine in Birmingham, Ala. He completed his internship at Keesler Medical Center at Keesler Air Force Base, Miss. He also completed a residency in otolaryngology, head and neck surgery at Walter Reed Army Medical Center in Washington, D.C. He is board certified by the American Board of Otolaryngology and the American Academy of Otolaryngic Allergy. Dr. Sobiesk received his M.D. from Louisiana State University School of Medicine in New Orleans. He completed an internship in general surgery at Louisiana State University/LSU Affiliated Hospitals, where he also completed his residency in general surgery and fellowship
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in otolaryngology, head and neck surgery. He is a fellow of the American Academy Otolaryngology. Appointments can be made by calling the Hattiesburg location at 601-579-3310. For appointments in Lucedale, call 601-947-9187. Ear, Nose, and Throat Associates is located at 1605 South 28th Avenue in Hattiesburg and 872 Winter Street in Lucedale.
James Keeton, MD and Lou Ann Woodward, MD have been named to interim leadership roles at the University of Mississippi Medical Center (UMMC). Effective July 1, Dr. James Keeton, the Vice Chancellor’s Chief of Staff at the UMMC, assumed responsibilities as Interim Vice Chancellor for Health Affairs, and Dr. Lou Ann Woodward, the medical school’s Vice Dean for Academic and Faculty Affairs, assumed responsibilities as Interim Dean, School of Medicine. Dr. Dan Jones, UMMC Vice Chancellor for Health Affairs, left the Medical Center July 1 to begin responsibilities as Chancellor of the University of Mississippi. “I have full confidence in the leadership of Dr. Keeton and Dr. Woodward. Just as I have reported to the Chancellor over the years, they will report to me in my role as Chancellor,” Dr. Jones said. Dr. Keeton is a Professor of Surgery and Pediatrics at UMMC. He graduated from the University of Mississippi in 1961 and earned his M.D. in 1965 at the University of Mississippi School of Medicine. He completed five years of residency in urology at UMMC, followed by a one-year pediatric urology residency in London, England. He then served for two years in the U.S. Navy Medical Corps. Dr. Keeton returned to Mississippi in 1970, where he has been in academic and private practice. Dr. Woodward is an Associate Professor of Emergency Medicine. She graduated from Mississippi State University in 1985 and earned her M.D. at UMMC in 1991. She completed an internal medicine internship and emergency medicine residency at UMMC. She joined the UMMC faculty in 1995.
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Brett Lampton, MD recently was elected Baptist Memorial Hospital-North Mississippi’s President of Medical Staff. In this position, Lampton, who was elected by his colleagues, will lead physician meetings and serve as a liaison between doctors and hospital leadership. He will work with hospital administration to help establish and maintain quality efforts. He also will communicate physicians’ wishes to Baptist North Mississippi’s administrative team. He will serve as President of the Medical Staff for one year. Dr. Lampton, board certified in Internal Medicine, also is the Medical Director of Baptist North Mississippi’s hospitalist program. “Dr. Lampton is a great choice to lead our medical staff,” said Don Hutson, Administrator and CEO of Baptist North Mississippi. “Under his leadership, our hospitalist program has been tremendously successful, and I believe he will continue to be successful as our Chief of Staff. I look forward to working with him.” Baptist North Mississippi is a 217-bed hospital that offers a variety of services including cardiovascular surgery, neurosurgery and a 24-hour emergency room. A recent expansion project brought a new emergency department, additional surgery suites and patient rooms and enhanced outpatient services. Since the hospital joined the Baptist system in 1989, Baptist has invested more than $140 million into the facility.
Manisha Sethi Malhotra, MD with Internal Medicine & Pediatric Associates of Ridgeland, PLLC in Jackson was named to Mississippi Business Journal’s “50 Leading Business Women.” She joins MSMA Executive Director Charmain Kanosky as an honoree in the Class of 2009. The annual honor, now in its 13th year, recognizes distinguished business contributions and talents.
Ben W. Seale, MD, has joined the medical practice of Grenfell, Evans and Dyess as an adult endocrinology physician. He is joining the medical staff of St. Dominic Hospital after having recently completed his fellowship at the University of Mississippi Medical Center. Seale’s previous experience includes teaching high school courses in math and science, serving as the Director of the Student Programming Board in Oxford and completing his Internal
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Medicine residency at UMC. Dr. Seale, a 2004 graduate of the University of Mississippi School of Medicine, obtained his undergraduate degree in biology from the University of Mississippi in 1999. Additionally, Dr. Seale is a member of numerous professional societies which include the American Association of Clinical Endocrinologists, the AMA and the MSMA. He also volunteers with many organizations including Habitat for Humanity, Mississippi Blood Services, United Way and Tar Wars, an anti-smoking program designed for elementary students. Grenfell, Evans, Dyess and Seale is located at 971 Lakeland Drive, St. Dominic West Tower, Suite 450, Jackson, MS 39216.
Chrystal Sumrall, MD, has joined Hattiesburg Clinic’s Immediate Care in Laurel. Dr. Sumrall received her M.D. from University of Mississippi School of Medicine in Jackson, where she also completed an internship and residency. She is board certified by the American Board of Family Practice and by the American Board of Family Medicine. She is a member of the American Academy of Family Physicians, the Mississippi Academy of Family Physicians, the American Medical Association, and the South Mississippi Medical Society. Dr. Sumrall joins Larry T. Holifield, DO, and Roger G. Meadows, DO/EM, at Immediate Care - Laurel. Immediate Care - Laurel is located at 2313 Highway 15 North in Laurel. Hours of operation are Monday through Friday, 8 a.m. to 5 p.m. and Saturday, 8 a.m. until 12 p.m. No appointment is necessary.
The Journal MSMA welcomes information and announcements readers would like included in an upcoming “Personals” section. Submit information on achievements and accolades of any MSMA member, such as awards, professional appointments or relocations, rankings, and grants, as well as special recognition earned to KEvers@MSMAonline.com. Photos submitted must be at least 300 dpi to be considered. For more information contact Karen Evers, JMSMA managing editor: (601)8536733.
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MEDICAL LEGAL EASE
Recovery Audit Contractors: Mississippi Physicians and Medicare Audits
M
THE RAC PROGRAM ississippi physicians who participate in Medicare’s fee-forservice program may begin receiving requests from Recovery Audit Contractors (RAC’s) for medical records as early as this month. RAC’s are employed by the Centers for Medicare & Medicaid Services (CMS) and charged with identifying improper payments on claims of health care services provided to Medicare beneficiaries—both overpayments and underpayments. Any provider who submits a claim for services or products under Medicare Part A or Part B, including physicians, hospitals, nursing facilities, and durable medical equipment suppliers are subject to RAC review. Section 302 of the Tax Relief and Health Care Act of 2006 requires a permanent and national RAC program to be in place by January 1, 2010. Mississippi’s program launches in August, 2009. RACs operate on a contingency fee basis and receive a percentage of the Peter A. Stokes improper overpayments or underpayments they collect from providers. CMS has divided the country into four RAC regions, and each region’s RAC is paid a different contingency fee. Mississippi’s RAC, Connolly Consulting Associates, Inc., is paid a 9% contingency fee for the improper payments they collect. The Medicare Modernization Act of 2003 established a three year RAC demonstration program that operated from March 2005 to March 2008 in California, Florida, New York, Massachusetts, South Carolina and Arizona. The program resulted in $992.7 million in overpayments being collected from providers and returned to the Medicare Trust Fund, and $37.8 million in underpayments returned to health care providers. Overpayments collected from physicians accounted for only 2%, or $19.9 million of overall collections. Overpayments occur typically when providers submit claims that do not meet Medicare’s coding or medical necessity policies or when providers fail to submit sufficient documentation to support a claim. Underpayments, when they do occur, are typically due to a provider’s submission of a claim for a simple procedure when a review of the medical record reveals a more complicated procedure was actually performed.
THE AUDIT PROCESS RACs use a review process similar to that of Medicare claims processing contractors. Audits are conducted using post payment review techniques and may be either automated or complex. Automated reviews are conducted through the use of proprietary software to discover obvious billing errors in violation of Medicare policy; these do not require production of medical records. Most audits, however, are complex and require production of records. For complex reviews the RAC will first contact the provider and give notice of the potential improper payment. The RAC may then obtain records by 292
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either going onsite to the provider’s location to copy them or by requesting that the provider mail, fax or securely transmit the records to the RAC. Providers have 45 calendar days plus 10 business days for mail delivery to respond to a RAC request for medical records. The RAC then has 60 days to review those records and inform the provider of the findings and initiate a discussion period. If the RAC insists the claim was an overpayment, the provider has a choice to do one of the following: (1) pay the RAC by check if the provider agrees with the determination, (2) allow recoupment from future Medicare payments, (3) request or apply for an extended payment plan, or (4) appeal the determination. Appeals must be filed within 120 days of the overpayment determination, and must comply with Medicare appeal rules. The appeals process involves multiple levels with minimum amount in controversy thresholds so retaining independent counsel to assist with the process is advisable to preserve your rights and halt recoupment. Also noteworthy is CMS’s determination that the success of the demonstration program was partly due to the low number of appeals. As of March 27, 2008 providers had chosen to appeal 14% (73,266) of the RAC determinations, and only about a third of these (24,376) were overturned on appeal. The American Medical Association has organized a quick flow-chart on appealing a RAC overpayment that can be reviewed online at http://interactive.snm.org/docs/RAC_Appeals.pdf.
PREPARING FOR AUDITS Physicians and physician groups should prepare ahead of time for RAC audits by developing and implementing procedures for responding to record requests in a timely manner, as well as educating employees on the audit process and documentation requirements. All medical records dating back to October 1, 2007 are subject to RAC review, so providers should determine where these records are stored and how to access them as well as ensure that they contain appropriate documentation. CMS has suggested providers conduct an internal assessment to verify that submitted claims are Medicare compliant. Providers are also encouraged to review the categories of claims denied during the RAC demonstration program to identify areas of increased scrutiny, and to ensure that an appropriate compliance plan has been adopted to reduce the chance of future RAC overpayment determinations. CMS has also identified several problem areas for physicians in which RACs found many of the improper payments. Nearly $6 million of the $19.9 million collected from physicians resulted from incorrect coding for injectable drugs physicians administered in the office. Preparing your practice now and designating staff to coordinate RAC audits can help protect your bottom line. View the full evaluation report online at http://www.cms.hhs.gov/RAC/Downloads/RAC Evaluation Report.pdf. Additionally, visit MSMAonline.com for articles and information providing a brief overview of the demonstration program, common mistakes physicians make in their claims, steps physicians should take to prepare for a RAC audit, and post-audit best practices. Peter A. Stokes is a law clerk for the Mississippi State Medical Association and a 2L student at Mississippi College School of Law.
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General Motors
Has Just Recognized Barksdale Cadillac as Mississippi’s Premier Cadillac Dealership. GM’s message is clear. Barksdale Cadillac is here to Stay. What that means to you, the consumer, is simply no matter where you bought your last new or pre-owned Cadillac,
Your Warranty and Service is Assured at Barksdale Cadillac. In fact, we offer the most lending options, including leasing. You see, our investment in you, our valued customer, began over a decade ago, and continues to serve the automotive needs of Mississippi as well as Louisiana. Our newly redesigned and renovated dealership is conveniently located at I-55 and County Line Road, on the North Frontage Road in Ridgeland directly beneath our American flag, which we fly proudly. There you will find the largest selection of new and Certified Pre-Owned Cadillacs in the state. Or for even more convenience, we invite you to see our inventory online at www.barksdalecadillac.com. Click on board and you can schedule service, pick out a vehicle, or even arrange financing.
It’s quick and it’s easy to do. We’ll even deliver the vehicle of your choice to your home or office. If you choose a traditional delivery of your new Cadillac, Certified Pre-Owned Cadillac, or one of our pristine pre-owned vehicles, just give us a call to let us know of your arrival at 601-519-0406. One of our GM factory trained sales professionals who knows your Cadillac inside and out will be happy to assist you. Or, if you are in the area, simply drop in. For our service customers, we also have a fleet of loaner Cadillacs ready for daytime or overnight use.
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Let us know what you think?
The Mississippi State Medical Association Alliance is conducting an online survey that will examine ways in which the MSMA Alliance can better serve your needs. We recognize that your time is valuable and thus have made the survey easy to complete. We would greatly appreciate your feedback in this important satisfaction survey. Alliance Members and Non-Members please log onto:
www.msmaonline.com/alliance.aspx then, click on Projects to access survey
Membership inquires please contact Mollie Pontius at mollius@hotmail.com or Sondra Pinson at twptupelo@comcast.net.
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Calling all Mississippi PhysicianPhotographers
SEEKING PHOTOS TAKEN BY MISSISSIPPI PHYSICIANS FOR 2010 COVERS OF THE
JOURNAL MSMA
• Load your camera. Shoot landscapes, people, animals, or anything else you can capture on film. Photos of subjects indicative of Mississippi will be given the highest consideration. Photos of original artwork are also acceptable. • The Committee on Publications will judge the entries on the merits of quality, composition, originality and appropriateness to the JOURNAL MSMA and select the best cover photos. All photos selected require the photographer and subjects contained therein to release “permission to reprint” and “publicize on the JOURNAL MSMA website.” • Specifications: Color slides, digital files and photos. Size: Vertical format 5 x 7" or 8 x 10". A print is required for judging.
Deadline: November 30, 2009 Send entries with a brief description of the subject as well as of yourself to:
Karen Evers, JOURNAL MSMA, P.O. Box 2548, Ridgeland, MS 39158-2548 or deliver to: MSMA headquarters 408 West Parkway Place, Ridgeland, MS 39157 or email to: KEvers@MSMAonline.com
For more information: contact Karen Evers, ph.:(800)898-0251 or (601)853-6733
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PLACEMENT / CLASSIFIED PHYSICIANS NEEDED Corporation seeking physician to conduct Independent Medical Evaluations. See patients 2 – 4 days a week. We provide referrals, scheduling, billing, transcription, logistic support and training. No call, no weekends, no holidays. Requires travel within MS. Contact information: Susan Gladys 1-866-929-8766. Fax: 1-866-712-5202 Email: susang@tsom.com
PHYSICIANS NEEDED
Physicians (specialists such as cardiologists, ophthalmologists, pediatricians, orthopedists, neurologists, etc.) interested in performing consultative evaluations (according to Social Security guidelines) should contact the Medical Relations Office. Toll Free 1-800-962-2230 Jackson 601-853-5487 Leola Meyer (Ext. 5487)
DISABILITY DETERMINATION SERVICES
1-800-962-2230
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