July 2012 JMSMA by Journal MSMA

July

VOL. LIII

2012

No. 7

New Platforms, New Products, New Ways to Reach MSMA Members! The Mississippi State Medical Association has now partnered with Naylor, LLC. The company will coordinate and produce MSMAâ&#x20AC;&#x2122;s weekly Lifeline eNewsletter and MSMAonline.com website advertising sales and the Directory of Mississippi Physicians 2012-2013.

The Directory of Mississippi Physicians 2012-2013 is a key networking tool and purchasing guide for our members. Available in print and in a fully interactive digital version, the directory brings all the benefits of a printed directory to our members while also being viewable online, on most smartphones and on iPads. Whether in the office or on-the go our easy-to-use weekly Lifeline eNewsletter and MSMAonline.com website advertisingÂ sales helps get your company in front of our members. Get your message in front of our member physicians throughout the year. Participate in one of our communication pieces today! To advertise contact:

SaraCatherine Sedberry Print Publication Directory | Naylor, LLC (770) 810-6977 | ssedberry@naylor.com

Troy Dempsey Online Project Leader | Naylor, LLC (770) 810-6978 | tdempsey@naylor.com

Lucius M. Lampton, MD EDITOR D. Stanley Hartness, MD Richard D. deShazo, MD ASSOCIATE EDITORS Karen A. Evers MANAGING EDITOR 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 Steven L. ThDemetropoulos, omas E. Joiner, MD President Steven L. Demetropoulos, James A. Rish, MD President-Elect J. Clay Hays, Jr., MD Secretary-Treasurer Lee Giffin, MD Speaker Geri Lee Weiland, MD Vice Speaker Charmain Kanosky Executive Director JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION ISSN 00266396 is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. CORRESPONDENCE: Journal MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: (601) 853-6733, Fax: (601)853-6746, www.MSMAonline.com. SUBSCRIPTION RATE: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available. ADVERTISING RATES: furnished on request. Cristen Hemmins, Hemmins Hall, Inc. Advertising, P.O. Box 1112, Oxford, Mississippi 38655, Ph: (662) 236-1700, Fax: (662) 236-7011, email: cristenh@watervalley.net POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 39158-2548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association.

S SI

PPI S T

I L A SSOC

MED

E AT

Oﬃcial Publication of the MSMA Since 1959

JULY 2012

VOLUME 53

NUMBER 7

SCIENTIFIC ARTICLES

Current Use of Intrapleural Tissue Plasminogen Activator in the Treatment of Complex Pleural Processes: A Review of the Literature and Report of 9 Cases

216

Caleb R. Dulaney, BS; Walter H Merrill, MD; Stephanie Tesseneer, PharmD; Lora Jenkins-Lonidier, DNP and Curtis G. Tribble, MD

Top 10 Facts You Should Know about How to Improve Compliance for Obstructive Sleep Apnea

220

Sadeka Tamanna, MD, MPH and M. Iftekhar Ullah, MD, MPH

Clinical Problem-Solving: Too Old for this Joint

222

Carlos A. Latorre, MD

Just Off the Press- Info You Want to Know: Don’t Forget the Stethoscopes 235 Jasmine Mckee, PharmD and Richard L. Ogletree, Jr., PharmD

PRESIDENT’S PAGE

Inaugural Address

225

Steven L. Demetropoulos MD; MSMA President

MSMA

Report and Highlights of the 144th Annual Session of the MSMA House of Delegates 2012

227

Karen A. Evers, Managing Editor

RELATED ORGANIZATIONS

Mississippi State Department of Health University of Mississippi Medical Center

237 238

DEPARTMENTS

Uncommon Thread Placement / Classified

239 242

ASCLEPIAD

William F. Pontius, MD

244

ABOUT THE COVER:

SUMMER RAINBOW — C. Ron Cannon, MD, who is in practice at Head and Neck Surgical Group in Flowood, photographed this rainbow seen over the ski lake at his home following a summer afternoon rain. Dr. Cannon explains, “To see the brilliant arc of colors the sun must be behind you with the area of moisture in front. The drops of moisture reflect, refract, and diffract the sun’s rays resulting in the multicolored rainbow. The red band measures about 42 degrees from the line formed by the sun’s rays, the other color bands occur at less than 42 degrees.” Scientifically, Aristotle was the first to study the rainbow about 350 BC. Others include Descartes, who described the primary and secondary bows of the rainbow, and Isaac Newton, who demonstrated that white light is composed of all of the colors of the rainbow. In mythology, the rainbow has been described as a path between heaven and earth as a supernatural bridge, or to represent the belt of the sun, a war bow, or a necklace. Perhaps the best known is the Irish leprechauns’ legend that one could find a pot of gold at the end of the rainbow. Dr. Cannon notes, from a biblical perspective, in Genesis 9:13-17, God put the rainbow in the sky as a promise to Noah that the earth would not be destroyed again by flood. r -XO\

92/ /,,,

JULY 2012 JOURNAL MSMA 213

From the Editor

he creation by the Mississippi Legislature this year of the Office of Physician Workforce is one of the major accomplishments of our profession over the last decade. An anemic and maldistributed physician workforce has plagued this state since its founding. The issue was the driving force for the creation of both the two year medical school at Oxford in 1903 and the full four year school at Jackson in 1955. The rise of the Mississippi Regional Medical Program facilitated workforce strategy and assessment in the 1960s and 70s with federal funding, which resulted in the enlargement of UMMC’s class size to 150. However, since that federal program was defunded in the late 1970s, little data collection and strategic planning have occurred with our professional workforce. In the mid 1980s and early 1990s, various physician leaders, Drs. Edward Hill and Tim Alford among them, advocated the creation of a physician workforce office to assess the needs of our underserved state. The first meeting of the office occurred on July 11 at UMMC. A fuller sketch of office’s activities will be forthcoming. However, two outstanding physicians were selected as chair and vice-chair, Drs. John Mitchell of Tupelo and Hugh Gamble of Greenville. Dr. Diane Beebe, current Chair of the Department of Family Medicine at UMMC, will be acting Executive Director of the office until a full time director is selected. Many good things will be coming from this office for Mississippi!

This Journal welcomes our new President, Steve Demetropoulos, and directs you to his energized inaugural address and the recap of our recent annual session. Our readers should not miss the Asclepiad portrait of Dr. Bill Pontius of Ocean Springs at the issue’s end. Bill is a gifted man of many talents: photography, flying, scuba diving, sailboat racing, and trawler cruising. After he retired, he and his wife cruised the East Coast from the Chesapeake Bay Lucius M. Lampton, MD Editor to Key West for two years, including a trip to Toronto, Canada and the west coast of Florida. From his years of practice, what does he advise Mississippi docs? “If you work diligently to make the diagnosis of your patients’ problems, your rewards will follow: your patients will love you, and you will feel happy at the end of the day.” He adds, quoting Hippocrates, “For where there is love of man, there is love of the art of medicine.” Bill asserts, “Today’s doctors must not lose the ‘center of effort’ in the practice of medicine.” He concludes, “Medicine is a calling and an art. It is where one makes a difference. I have been blessed to be a part of it.” And Mississippians have been blessed to have such physicians in practice as Bill Pontius. —Lucius M. Lampton, MD, JMSMA Editor

Journal Editorial Advisory Board R. Scott Anderson, MD, FACR Chair, Journall Editorial Advisory Board Radiation Oncologist and Medical Director, Anderson Regional Cancer Center, Meridian Diane K. Beebe, MD Professor and Chair, Department of Family Medicine, University of MS Medical Center, Jackson Claude D. Brunson, MD Senior Advisor to the Vice Chancellor for External Affairs, University of Mississippi Medical Center, Jackson Jeffrey D. Carron, MD, FAAP, FACS Associate Professor, Department of Otolaryngology & Communicative Sciences, University of Mississippi Medical Center, Jackson Gordon (Mike) Castleberry, MD Urologist, Starkville Urology Clinic Mary Currier, MD, MPH State Health Officer Mississippi State Department of Health, Jackson Thomas E. Dobbs, MD, MPH Health Officer, District VII/VIII Mississippi State Department of Health, Hattiesburg Sharon Douglas, MD Chair, AMA Council on Ethical & Judicial Affairs Professor of Medicine and Associate Dean for V A Education, University of Mississippi School of Medicine, Associate Chief of Staff for Education and Ethics, G.V. Montgomery VA Medical Center, Jackson Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist The Street Clinic, Vicksburg

214 JOURNAL MSMA JULY 2012

Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson Maxie L. Gordon, MD Assistant Professor, Department of Psychiatry and Human Behavior, Director of the Adult Inpatient Psychiatry Unit and Medical Student Education, University of Mississippi Medical Center, Jackson Scott Hambleton, MD Medical Director Mississippi Professionals Health Program, Ridgeland John Edward Hill, MD, FAAFP Residency Program Director North Mississippi Medical Center, Tupelo John D. Isaacs, Jr., MD Infertility Specialist, Mississippi Fertility Institute at Women’s Specialty Center, Jackson Kent A Kirchner, MD Chief of Staff G.V. Montgomery VA Medical Center, Jackson Brett C. Lampton, MD Internist/Hospitalist Baptist Memorial Hospital, Oxford Philip L. Levin, MD President, Gulf Coast Writers Association Emergency Medicine Physician, Gulfport

Gailen D. Marshall, Jr., MD, PhD, FACP Professor of Medicine and Pediatrics, Vice Chair for Research, Director, Division of Clinical Immunology and Allergy, Chief, Laboratory of Behavioral Immunology Research The University of Mississippi Medical Center, Jackson Alan R. Moore, MD Clinical Neurophysiologist Muscle and Nerve, Jackson Paul “Hal” Moore Jr., MD, FACR Radiologist Singing River Radiology Group, Pascagoula Jason G. Murphy, MD Surgeon Surgical Clinic Associates, Jackson Ann Myers, MD Rheumatologist Mississippi Arthritis Clinic, Jackson Jimmy L. Stewart, Jr., MD Program Director, Combined Internal Medicine/ Pediatrics Residency Program, Associate Professor of Medicine and Pediatrics University of Mississippi Medical Center, Jackson Samuel Calvin Thigpen, MD Hematology-Oncology Fellow, Department of Medicine University of Mississippi Medical Center, Jackson Thad F. Waites, MD, FACC Clinical Cardiologist, Hattiesburg Clinic

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

Chris E. Wiggins, MD Orthopaedic Surgeon Bienville Orthopaedic Specialists, Pascagoula

John F. Lucas,III, MD Surgeon Greenwood Leflore Hospital

John E. Wilkaitis, MD, MBA, CPE, MS Chief Medical Officer Brentwood Behavioral Healthcare, Flowood

Medical Assurance Company of Mississippi An outside perspective and appreciation of MACM

“

My position on the American Board of Family Medicine’s credentials committee gives me new insight and appreciation for the critical role that MACM plays in the lives of our state physicians. MACM’s involvement with its insureds — from risk management to liability and scope of practice issues — has their best interest, and that of the public they serve, at heart. Particularly at the level of the Risk Management Committee, many of these issues are handled constructively and effectively to improve and ensure quality care for patients, while guiding physicians from potential hazards. In many states, without the commitment of an organization like MACM, physicians and patients are far less protected and similar issues result in adverse actions that often result in licensure and practice restrictions.

“

All insureds of MACM should be grateful for the role MACM and their experts in Risk Management play in keeping us (physicians and patients) safe.

Diane Beebe, MD Family Medicine Jackson, Mississippi

For over 30 years, Mississippi physicians have looked to Medical Assurance Company of Mississippi for their professional liability needs. Today, MACM is an integral part of the health care community through its dedication to risk management services for our insureds. A dedicated staﬀ and physician involvement at every level guarantees that the interests of our policyholders remain the top priority. This, combined with the many years of loyalty and support from our insureds, is what allows us to be the carrier of choice in Mississippi. Please call on us to assist with your professional liability needs.

1.800.325.4172 • www.macm.net

In Partnership with Insureds JULY 2012 JOURNAL MSMA 215

â&#x20AC;˘ SCIENTIFIC ARTICLES â&#x20AC;˘ Current Use of Intrapleural Tissue Plasminogen Activator in the Treatment of Complex Pleural Processes: A Review of the Literature and Report of 9 Cases

Caleb R. Dulaney, BS; Walter H Merrill, MD; Stephanie Tesseneer, PharmD; Lora Jenkins-Lonidier, DNP, ACNP, CFNP, CCRN; Curtis G. Tribble, MD

BSTRACT

Intrapleural tissue plasminogen activator is increasingly being utilized to treat complex pleural processes, such as complicated pleural effusions and empyemas, without surgical intervention. This technique is especially useful for patients with numerous co-morbidities or who are poor surgical candidates. We present our experience in treating nine adult patients with intrapleural tissue plasminogen activator for complex pleural processes. Patients were treated with one to eight doses until their condition resolved or surgical intervention was necessary. Seven patients had complete resolution, two patients required surgical intervention, and there were no complications from therapy. A review of all available literature on the use of intrapleural tissue plasminogen activator in adults is presented, comparing the various methods and techniques used by others.

KEY WORDS: EMPYEMA, PLEURAL EFFUSION, TISSUE PLASMINOGEN ACTIVATOR

INTRODUCTION Complex pleural processes, including complicated pleural effusions and empyemas, are a significant source of morbidity and mortality and require prompt drainage by chest AUTHOR INFORMATION: Third-year medical student at the University of Mississippi School of Medicine (Mr. Dulaney); Professor and Chief of the Division of Cardiothoracic Surgery and Vice-chair of the Department of Surgery at the University of Mississippi Medical Center (Dr. Merrill); Pharmacist in the Cardiac Critical Care Unit at the University of Mississippi Medical Center (Dr. Tesseneer); Clinical Instructor and Nurse Practitioner in the Division of Cardiothoracic Surgery at the University of Mississippi Medical Center (Mrs. Lonier); Professor of Surgery and Medical Director of Transplantation in the Division of Cardiothoracic Surgery at the University of Mississippi Medical Center (Dr. Tribble). CORRESPONDING AUTHOR: Curtis Tribble, Department of Surgery, University of Mississippi Medical Center, 2500 N. State Street, Jackson, MS 39216.

216 JOURNAL MSMA JULY 2012

tube or thoracentesis. However, the fibrinopurulent nature of complex pleural processes sometimes prevents adequate drainage and necessitates additional intervention to drain the pleural space. If a complex pleural process reaches the empyema stage, mortality rates can be as high as 20%, even with surgical intervention.1 Currently, there are few evidencebased guidelines on the treatment of complex pleural processes. The available guidelines are based on insufficient evidence, and they only apply to parapneumonic pleural effusions.2,3 These guidelines recognize intrapleural fibrinolytics, videoassisted thoracoscopic surgery (VATS), and open thoracotomy as effective interventions for pleural effusions that do not properly drain by thoracentesis or thoracostomy tube. In 1949, Tillet and Sherry first described the use of an intrapleural fibinolytic agent, streptokinase, to aid in the drainage of infected pleural spaces and prevent the need for surgical intervention.4 This form of treatment for pleural infection was based upon the theory that an overabundance of fibrinous material in the pleural space during the fibrinopurulent stage of pleural effusion prevents fluid drainage. It is thought that fibrinolytics can be used to break up fibrinous material and drain the pleural space without surgical intervention. Tissue plasminogen activator (tPA) has been used as an intrapleural fibrinolytic for only the last decade.5 tPA is a natural enzyme that binds to plasminogen and converts it to plasmin. In turn, plasmin binds to and degrades fibrin. The action of tPA is most notably used in ischemic stroke to degrade fibrinous clots. In the pleural space, it breaks up fibrinous material and allows for improved drainage. tPA came into use as a pleural fibrinolytic primarily because of concerns over the safety of streptokinase and urokinase. tPA may be a more appropriate fibrinolytic agent because the lack of endogenous tPA and overabundance of plasminogen activator inhibitors allows an infected pleural space to accumulate fibrinous material and progress to empyema.6,7

Table 1. Experience with Intrapleural tPA at the University of Mississippi Medical Center (h= hours; d= days) Patient

Condition

Type of Drainage

Dose and Schedule

Duration

Totals

Empyema

Chest tube followed by Catheter

25mg/24h (Day 1) 50mg/24h (Days 2-4) 25mg/24h (Day 5)

Until Resolved (5d)

200mg, 5 doses

Empyema

4mg/12h

Until Resolved (2.5d)

20mg, 5 doses

Empyema Parapneumonic Effusion

6mg/24h

Until Resolved (3d)

18mg, 3 doses

Catheter

6mg/12h

Until Resolved (4d)

48mg, 8 doses

Chest tube followed by 2 Catheters Chest tube

2 Empyemas

Chest tube

6mg/24h

Empyema

Catheter

Empyema

Catheter

6mg/12h 2mg/24h (Day 1) 6mg/24h (Days 2-3) 6mg/12h (Day 4) 6mg/24h (Day 5)

8 9

Malignant Pleural Effusion Loculated Pleural Effusion

Condition Worsened (1d), Surgical Decortication Until Resolved (4d)

48mg, 8 doses

Until Resolved (4d)

32mg, 6 doses

6mg, 1 dose

Catheter

4mg/12h

No Improvement (36h), VATS

12mg, 3 doses

Catheter

2mg/24h

Until Resolved (4d)

8mg, 4 doses

Many patients with complex pleural processes have serious underlying conditions, chronic diseases, or other comorbidities that can make interventions to drain the pleural space difficult or risky. Our first experience using intrapleural tPA was in a patient with an empyema that failed to drain by chest tube and required surgical intervention. However, this patient was morbidly obese, immune deficient, and had a number of other co-morbidities that made for a poor surgical candidate. After reviewing the literature, we decided to initiate a course of intrapleural tPA that successfully resolved the empyema without surgical intervention. We present our experience in treating nine patients with complex pleural processes using intrapleural tPA. tPA completely resolved seven of these cases. In two cases tPA therapy was unsuccessful and surgical intervention was necessary to drain the pleural space. We also present a brief review of the available literature regarding the use of tPA in the treatment of complex pleural processes in adults.

TREATMENT AND TECHNIQUE Nine patients were treated in the Division of Cardiothoracic Surgery at the University of Mississippi Medical Center with intrapleural tPA for complex pleural processes. The treatment protocol and dosage was modified from that described by Gervais, et al.8 However, no strict protocol was followed and tPA doses and schedules were varied according to patient factors and experience. The most common dose was 6mg diluted in 60mL of normal saline. Doses ranged from 2mg to 50mg. Five patients were treated for empyema, one patient for two empyemas, one patient for malignant pleural effusion, one patient for parapneumonic effusion, and one patient for loculated pleural effusion. In all cases, the indication for tPA administration was failure of chest tube or catheter drainage of a complex pleural process in a patient that was determined to be a poor surgical candidate. The diagnosis, type of drainage, dosage and

schedule, and outcome for each patient is presented in Table 1. In five patients, 8-12 French (Fr) pigtail catheters were used to drain the pleural space. Two patients had 24-32 Fr chest tubes, and two patients had chest tubes that were replaced with pigtail catheters during treatment. Chest tubes were placed at the bedside, and all pigtail catheters were placed by Interventional Radiologists using computed-tomography (CT) image guidance. tPA was administered through the existing chest tube or catheter and allowed to dwell in the pleural space before resuming drainage. All patients were monitored with daily chest x-rays, and some patients had follow-up CT scans to assess their condition. There were two indications for terminating tPA treatment: resolution of the complex pleural process, and no improvement or worsening of the patientâ&#x20AC;&#x2122;s condition. The latter case was an indication for surgical intervention.

RESULTS The condition treated, type of drainage, dose of tPA, schedule of administration, duration, and total amounts of tPA administered for all patients can be found in Table 1. Seven patients had complete resolution with intrapleural tPA. The average duration of treatment in successful cases was 4 days. Of note, as little as 8mg total of tPA in four doses was successful in one patient. Two patients did not respond to intrapleural tPA, patient 5 and patient 8. Of note, patient 5 suffered from multiple pleural effusions, and two gas containing empyemas. Chest tubes were placed in the larger empyemas and tPA was administered. Of note, the empyemas that were treated with intrapleural tPA decreased in size on interval chest x-ray and CT. However, this patientâ&#x20AC;&#x2122;s condition continued to deteriorate requiring surgical decortication. All other patients were treated successfully with intrapleural tPA without complication. In our experience, intrapleural tPA offers an effective alternative in treating complex pleural processes in patients with significant co-morbidities.

JULY 2012 JOURNAL MSMA 217

Table 2. Previous Experiences with Intrapleural tPA (h= hours; d= days; CPE= Complicated Pleural Effusion; HTx= Hemothorax; CMPE= Complicated Malignant Pleural Effusion; MPE= Malignant Pleural Effusion; PPE= Parapneumonic Pleural Effusion) Study

Dose and Schedule

Duration

Totals

Overall Effectiveness

Specific Effectiveness

Walker Emerson

16mg/24h 10mg/24h

Until Resolved (6d) Until Resolved (6d)

96mg, 6 doses 60mg, 6 doses

100% (1/1) 100% (1/1)

Skeete

2-50mg/24h

Until Resolved or Intervention

N/A

78% (30-38)

Gervais Levinson

4-6mg/12h 2mg/8h

3d Cycle 3d Cycle

24-36mg, 6 doses 18mg, 9 doses

86% (57/66) 100% (21/21)

Thommi

10-100mg/24h

Until Resolved or Intervention

3 doses (avg.)

93.3% (112/120)

Froudarakis

25mg/24h

Until Resolved or Intervention

75mg, 3 doses (avg.)

95% (19/20)

Ben-Or

25mg/24h

Until Resolved or Intervention

25mg (1 dose)200mg (8 doses)

69.5% (83/118)

100% CPE 100% Empyema 67% (5/8) HTx 82% (18/22) Empyema 82% (10/12) LPE N/A 100% (21/21) 85% (44/52) Empyema 100% (41/41) CPE 100% (10/10) HTx 100% (7/7) CMPE 100% (15/15) CPE 80% (4/5) Empyema 78.1% (25/32) Empyema 61.5% (8/13) HTx 100% (8/8) MPE 71.4% (30/42) CPE 48% (12/25) PPE

DISCUSSION The first use of intrapleural tPA was described in a case report by Walker, et al in 2003.5 Since that time, the use of tPA to treat complex pleural processes in adults has been reported in 2 case reports, 3 retrospective reviews, and 3 prospective, non-controlled, non-randomized trials.8-14 These studies are presented in table 2. A total of 139 patients with empyema, 198 with malignant or parapneumonic pleural effusion (PPE), 39 with hemothorax (HTx), 12 with loculated PPE, and 4 with post-operative pleural effusion were reported. The primary indication for tPA treatment in most of these studies, and in our cases as well, was decreased chest tube drainage despite clinical and radiographic evidence of continued pleural effusion over a period of twenty-four hours. Only in one retrospective review did patients receive tPA immediately upon chest tube placement.8 All authors agree that timing is critical in initiating tPA treatment. The only large, prospective, randomized control trial using intrapleural fibrinolytics showed that intrapleural fibrinolytics provide no additional benefit as a broad, first line treatment for all patients with pleural effusions.15 However, it seems that tPA is of greatest benefit in resolving pleural processes if initiated as soon as they enter the fibrinopurulent stage if there is failed or inadequate chest tube drainage. In our cases and in most other studies, pre-existing chest tubes were used for tPA treatment. A variety of placement techniques were used ranging from bedside placement with no image guidance in one review to all image-guided chest tube placement in two other studies.8,11,13 Generally, tubes placed by interventional radiologists were small pigtail catheters ranging in size from 8-12 French (Fr). Other reported chest tube sizes were 24-32Fr. Our cases included a mix of drainage techniques with some patients even receiving both chest tube and catheter. No studies reported any significance in chest tube sizes or

218 JOURNAL MSMA JULY 2012

placement techniques on outcomes. Initial chest drainage by large-bore tubes (24-32Fr) is currently recommended because there is a lack of evidence comparing the use of different size tubes.2,16,17 However, an important factor in chest tube drainage is proper placement. Tubes inserted without image guidance are less than 50% successful at draining the pleural space, and one expert has stated that image guided chest tube placement is the most important factor in effective drainage.18-21 The doses and schedules of tPA administration can be seen in Table 2. Overall, there were two different styles of tPA treatment observed in all studies: daily tPA administration until resolution or intervention, and three day treatment cycles with assessment after each cycle. tPA is generally administered intrapleurally in a saline solution and the chest tube is closed to allow adequate dwell time before draining the pleural space. Of the studies describing specific procedures for tPA instillation, tPA dwell times ranged from 30 minutes to 4 hours. All studies used some form of imaging to assess pleural effusion resolution. Those who gave tPA on a daily basis until resolution used some form of imaging, usually chest x-ray, each day to assess the status of the patient. However, one study used daily chest ultrasound (US) to assess pleural effusion status before administering tPA.13 In another, no imaging was done until after the three-day cycle. At the end of the cycle, CT was performed to assess the pleural space.8 The consensus seems to be that some form of imaging should be done after each cycle of tPA treatment to assess the patientâ&#x20AC;&#x2122;s pleural space before proceeding to either another cycle of treatment or surgical intervention. Otherwise, no study compared different imaging modalities in assessing patient status. The overall effectiveness and effectiveness for specific diagnoses for each study can be found in Table 2. These studies

consistently show that there is a very high success rate for tPA treatment of complex pleural processes. Empyema generally has lower success rates in these studies and in studies using other fibrinolytics. This may be attributed to the timing of treatment in the progression of the pleural process. Fibrinolytics in general have been shown to be most effective during the fibrinopurulent stage of pleural effusion. However, most of the patients in our cases had empyemas that still resolved with tPA treatment. In our cases, there were no complications or deaths associated with tPA treatment. Overall, intrapleural tPA treatment has been associated with pain and local bleeding.8-14 There is an increased risk of minor bleeding in patients receiving therapeutic anticoagulation.8,14 However, tPA is still effective in these patients and should not be contraindicated. Pain associated with tPA administration generally resolved after instillation and did not interfere with treatment.

SUMMARY Intrapleural tPA is a safe and relatively effective means of resolving complex pleural processes without surgical intervention. At our institution and at a number of others, there has been positive experience using tPA in this manner. However, there has yet to be a large trial to establish the proper indications, doses, and schedules for intrapleural tPA administration. Until such a trial occurs, clinicians must rely on their own clinical judgement and small studies and reports to guide therapy for complex pleural processes.

10. Skeete DA, Rutherford EJ, Schlidt SA, et al. Intrapleural tissue plasminogen activator for complicated pleural effusions. J Trauma. 2004;57:1178-1183. 11. Levinson GM, Pennington DW. Intrapleural fibrinolytics combined with image-guided chest tube drainage for pleural infection. Mayo Clin Proc. 2007;82:407-413. 12. Thommi G, Nair CK, Aronow WS, et al. Efficacy and safety of intrapleural instillation of Alteplase in the management of complicated pleural effusion or empyema. Am J Ther. 2007;14:341-345. 13. Froudarakis ME, Kouliatsis G, Steiropoulos P, et al. Recombinant tissue plasminogen activator in the treatment of pleural infections in adults. Respiratory Medicine 2008;102:1694-1700. 14. Ben-Or S, Feins RH, Veeramachaneni NK, et al. Effectiveness and risks associated with intrapleural alteplase by means of tube thoracostomy. Ann Thorac Surg. 2011;91:860-864. 15. Maskell NA, Davies CW, Nunn AJ, et al. UK Controlled trial of intrapleural streptokinase for pleural infection. N Engl J Med .2005;352:865-874. 16. Yim AP. Paradigm shift in empyema management. Chest 1999;115:611-612 17. Rosenberg ER. Ultrasound in the assessment of pleural densities. Chest 1983; 84:283-285. 18. Storm HK, Krasnik M, Bang K, et al. Treatment of pleural empyema secondary to pneumonia: thoracentesis regimen versus tube drainage. Thorax 1992;47:821-824. 19. Moulton JS. Image-guided management of complicated pleural fluid collections. Radiol Clin North Am. 2000;38:345-374. 20. Ali I, Unruh H. Management of empyema thoracis. Ann Thorac Surg. 1990; 50:355-359. 21. Heffner JE, Klein JS, Hampson C. Interventional management of pleural infections. Chest 2009;136:1148-1159.

REFERENCES 1. 2. 3.

Peters RM. Empyema Thoracis: Historical Perspective. Ann Thorac Surg. 1989; 48:306-308. Davies CW, Gleeson FV, Davies RJ. BTS guidelines for the management of pleural infection. Thorax 2003;58(suppl):ii18-ii28. Colice GL, Curtis A, Deslauriers J, et al. Medical and surgical treatment of parapneumonic effusions: an evidence based guideline. Chest 200;118:1158-1171. Tillet WS, Sherry S. The effect in patients of streptococcal fibrinolysin (streptokinase) and streptococcal deoxyribonuclease on fibrinous, purulent, and sanguinous pleural exudations. J Clin Invest. 1949;23:173-179. Walker CA, Shirk MB, Tschampel MM, et al. Intrapleural alteplase in a patient with complicated pleural effusion. Ann Pharmacother. 2003;37:376-379. Idell S, Girard W, Koenig KB, et al. Abnormalities of pathways of fibrin turnover in the human pleural space. Am Rev Respir Dis. 1991;144:187-194. Philip-Joet F, Alessi MC, Philip-Joet C, et al. Fibrinolytic and inflammatory processes in pleural effusions. Eur Respir J. 1995;8:1352-1356. Gervais DA, Levis DA, Hahn PF, et al. Adjunctive intrapleural tissue plasminogen activator administered via chest tubes placed with imaging guidance: effectiveness and risk for hemorrhage. Radiology 2008;246:956-963. Emerson CR, Bercume CM, Antonopoulos MS, et al. The administration of rt-PA (Activase) for the treatment of empyema in an adult patient. J of Pharmacy Practice. 2009;22:117-123.

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JULY 2012 JOURNAL MSMA 219

• TOP 10 FACTS YOU SHOULD KNOW •

About How To Improve CPAP Compliance for the Treatment of Obstructive Sleep Apnea Sadeka Tamanna, MD, MPH and M. Iftekhar Ullah, MD, MPH

NTRODUCTION

Obstructive sleep apnea (OSA) is a major sleep disorder affecting about 25% of American adult population. It is characterized by loud snoring, observed apneas, choking or snorting during sleep, morning headache and feeling tired or sleepy despite spending adequate time in bed. The complications of untreated sleep apnea include poorly controlled hypertension and diabetes, atrial fibrillation, increased risk of stroke and motor vehicle accidents, along with overall increase in mortality. Polysomnography is the gold standard for diagnosis of sleep apnea while continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP) are the major treatment modalities available at this time. CPAP/BiPAP has to be used nightly to achieve the full benefit of treatment of sleep apnea. Because of its cumbersomeness, CPAP compliance among OSA patients is only about 60-70%.1 This can improve to 85% only with consistent follow up and trouble shooting by the providers.2 In this article, we will discuss the key issues faced by the patients while using CPAP, and how to address them. KEY WORDS: OBSTRUCTIVE SLEEP APNEA, CPAP, COMPLIANCE

1. Motivation: Lack of risk perception is one of the major causes of non-adherence to CPAP therapy.3 Discussing the risks of untreated obstructive sleep apnea with patients help them to be motivated to use the therapy.

2. Finding the right mask: Selecting the appropriate mask is one of the most important steps in being compliant. Patients, who are mouth breathers usually do well on full face mask which covers both nose and mouth, but those with claustrophobia may opt for a nasal mask or nasal pillows that fit under the nose. Addition of a chin strap may minimize the mouth breathing.

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3. Getting used to the mask: Adherence to CPAP use in the first 4 nights can determine the overall CPAP compliance in the future.4 Patients usually have difficulties sleeping well for the first few nights with the new mask on. They need to be encouraged to wear it nightly and be reassured that most people eventually get used to it if used regularly.

4. Nasal dryness: CPAP may cause significant nasal dryness which can be prevented by using a heated humidifier attached to the CPAP unit and can be adjusted as needed. Use of normal saline nasal spray prior to sleep as well as steroid nasal spray may be helpful.

5. Dryness of mouth: People who breathe through the mouth or sleep with the mouth open can suffer from dryness of mouth. A full-face mask or adding a chin strap with the nasal mask can solve the problem.

6. Tolerating the air pressure: “Ramp” button is a unique feature in the CPAP device which helps to start CPAP at a low pressure and increases gradually towards the prescribed setting. The ramp time can be adjusted if the patient needs longer time to fall asleep.

7. Mask leak: A leaky mask fails to deliver the optimal pressure and trying to adjust them inappropriately can cause skin irritation, bruises on the face and irritation of the eyes. This should be fixed by adjusting the pads and straps to get a better fit and by changing the mask if adjustment fails.

8. Involuntary removal of CPAP at night: It is not uncommon for patients to wake up at night and find the CPAP mask displaced. Patients may involuntarily remove the device during sleep, or it may become

displaced during movements in sleep. Nasal dryness and mask leakage can cause irritation, prompting the removal, and should be addresses accordingly.

10. Noise from CPAP unit: Noise produced by the CPAP unit, especially the older models, may interfere with the sleep of the patients or their spouses. Older units should be replaced by newer ones if noise is a problem. If the machine still makes noise, it needs to be checked and air filter may need to be replaced. If the noise is still bothersome, use of ear plugs or a white noise sound machine can be effective.

9. Claustrophobia: A feeling of claustrophobia is one of the most common complaints about wearing a CPAP. Changing a full face mask to a nasal mask or nasal pillows and practicing to use the mask while awake (while watching TV, for example) may desensitize the patients. Short term use of anxiolytics may be helpful. Figure 1. Different types of masks and head gears used in CPAP/BiPAP treatment of sleep apnea.

CONCLUSION Poor compliance to CPAP therapy is a major obstacle in the treatment of OSA. Patients are very commonly hesitant to discuss the initial difficulties dealing with the CPAP unit and thus may become non-compliant. Physicians must actively seek and address with compassion the issues faced by the patients. This will lead to better compliance and help improve overall morbidity and mortality resulting from the complications of untreated OSA.

REFERENCES

Nasal pillow: the headgear is connected to the nasal airway by a soft but thick cannula fitting firmly with the nasal opening Full face mask

Waldhorn RE, Herrick TW, Nguyen MC, Oâ&#x20AC;&#x2122;Donnell AE, Sodero J, Potolicchio SJ. Long-term compliance with nasal continuous positive airway pressure therapy of obstructive sleep apnea. Chest. 1990;97(1):33-38.

Sin DD, Mayers I, Man GC, Pawluk L. Long-term compliance rates to continuous positive airway pressure in obstructive sleep apnea: a population-based study. Chest. 2002;121(2):430-435.

Archbold KH, Parthasarathy S. Adherence to positive airway pressure therapy in adults and children. Curr Opin Pulm Med. 2009;15(6):585-590

Weaver TE, Kribbs NB, Pack AI, et al. Night-to-night variability in CPAP use over the first three months of treatment. Sleep. 1997;20(4):278-283.

AUTHOR INFORMATION: Assistant Professor, General Internal Medicine and Sleep Medicine, University of Mississippi Medical Center, Medical Director, Sleep disorders laboratory, G.V (Sonny) Montgomery VA Medical Center, Jackson, MS. E-mail: stamanna@umc.edu; sadeka.tamanna@ va.gov (Dr. Tamanna); Assistant Professor, Division of General Internal Medicine, University of Mississippi Medical Center, E-mail: mullah@umc.edu (Dr. Ullah).

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Full face mask fitted on the face along with head gear JULY 2012 JOURNAL MSMA 221

• CLINICAL PROBLEM-SOLVING • Presented and edited by the Department of Family Medicine, University of Mississippi Medical Center, Diane K. Beebe, MD, Chair

Too Old for this Joint! Carlos A. Latorre, MD

63-year-old African-American male presented to clinic for evaluation of worsening right knee pain and swelling. The symptoms had begun 6 weeks earlier and gradually worsened, requiring use of a wheelchair. Several months before presenting for care, he had experienced pain in his left knee, followed by an onset of pain and swelling in his wrists, hands and fingers. The pain in his joints was worsened with movement. He reported mild to moderate morning stiffness. He denied any recent trauma, fever, tick bites, rash, travel, recent sexually transmitted diseases or viral illness. He had a history of progressive joint pain and swelling that started at least 2 years earlier. He was evaluated at a local hospital for the same complaint, diagnosed with knee pain and treated for pain 2 weeks prior to this clinic visit. The patient was a retired construction worker. Onset of monoarticular knee pain in an older male is most commonly due to osteoarthritis (OA) or trauma,1 especially in someone who works in the construction field. However, the history of progression from a monoarticular to a polyarticular pattern suggests an underlying systemic inflammatory disorder. My initial differential diagnosis includes one of the seronegative spondyloarthropathies, such as a reactive arthritis, as well as rheumatoid arthritis (RA), crystal-induced arthritis and septic arthritis. In this case, septic arthritis is the less likely due to the prolonged course and lack of systemic indications.2 The patient had a medical history of hypertension, hypercholesterolemia, cerebrovascular accident and a history of trauma to the right knee 20 years ago. The patient's medications included hydrocodone-acetaminophen (Lortab), ibuprofen, aspirin, simvastatin (Zocor), furosemide (Lasix), potassium chloride (Klor-Con) and lisinopril (Zestril). He had no known drug allergies. He had never smoked cigarettes and reported occasional beer consumption. There was no family history of autoimmune disease or cancer. We have few clues to explain the worsening joint pain of the upper and lower extremities, and the patient's medical history does not suggest a predisposition to a specific musculoskeletal disorder. His history of right knee trauma and surgery could suggest OA of the knee, but it would not explain pain AUTHOR INFORMATION: Dr. Latorre is a family physician with River Region Health Systems in Vicksburg. CORRESPONDING AUTHOR: Carlos A. Latorre, MD, DABFM, 1907 Mission 66, Vicksburg, MS 39216. (Carlos.Latorre@riverregion. com)

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and inflammation in other joints. Crystal-induced inflammatory arthropathies could also explain the knee and wrist pain. The patient drinks beer, and alcohol use, especially beer consumption, is a major contributor to gout and increases uric acid. His use of aspirin may cause hyperuricemia and, over time, could increase the risk of gouty arthritis. On physical exam the patient was afebrile, had a normal respiratory rate of 16 breaths per minute, blood pressure of 128/85 mm Hg and a heart rate slightly elevated at 101 beats per minute. The results of the cardiac, pulmonary and abdominal exams were unremarkable. The patient was unable to ambulate due to right knee pain. He had diffused bilateral knee swelling. No erythema, subcutaneous nodules or digital vasculitis were observed. Warmth and crepitus were felt on palpation, but minimal pain elicited during the exam. He had decreased range of motion in both knees and ankles, and experienced pain with active and passive motion. He had no hip joint abnormalities identified on physical exam. He also had swelling of fingers and metacarpophalangeal joints with ulnar deviation of fingers bilaterally; swan-neck and boutonniere deformities were also present bilaterally. He had periarticular swelling and reduced range of motion and pain with active and passive motion in his hands and fingers bilaterally. Examination of the skin revealed no abnormalities. There were no varicosities or peripheral edema. The rest of the physical exam was within normal limits. These findings are suggestive of an inflammatory polyarthritis. Involvement of the wrist, fingers and ankle, along with the presence of warm, swollen knees, could be consistent with a reactive arthritis. However, patients presenting with reactive arthritis typically have had a preceding symptomatic infection several days to weeks prior to the onset of arthritis; our patient reported no antecedent infectious illness. The typical arthritis pattern is an asymmetrical mono- or oligo- arthritis, predominantly of the lower extremities. The other spondyloarthropathies, such as psoriatic arthritis and arthritis associated with inflammatory bowel disease, are unlikely in the absence of a history of these conditions. The findings of morning stiffness and symmetric, peripheral polyarthritis of unknown origin are more suggestive of RA,3 although this condition usually presents in the middle years. However, we cannot rule out OA or gout without further laboratory investigation. Serology should be ordered to aid in the confirmation or exclusion of these conditions. The patient’s white cell count, hematocrit, liver function, electrolytes and renal function were normal. He had

Table 1. ACR/EULAR 2010 classification criteria for rheumatoid arthritis

At present, the main clinically useful biologic markers in patients with RA A. Joint involvement§ Score are rheumatoid factors and 1 large joint¶ 0 antibodies to citrullinated 2-10 large joints 1 peptides for both diagnosis 1-3 small joints (with or without involvement of large joints)# 2 4-10 small joints (with or without involvement of large joints) 3 and prediction of functional >10 joints (at least 1 small joint) 5 ** and radiographic outcomes. B. Serology (at least 1 test result is needed for classification) Erythrocyte sedimentation Negative RF and negative Anti-citrullinated Protein Antibody (ACPA) 0 Low-positive RF or low-positive ACPA 2 rate and C-reactive protein High-positive RF or high-positive ACPA 3 ** are useful for ongoing asC. Acute-phase reactants (at least 1 test result is needed for classification sessment of disease activity Normal C-Reactive Protein and normal Erythrocyte Sedimentation Rate 0 and also predicting funcAbnormal C-Reactive Protein or abnormal Erythrocyte Sedimentation 1 ** Rate tional and radiographic outD. Duration of symptoms §§ comes.3,5 < 6 weeks 0 Anti-cyclic citrul> 6 weeks 1 ** The diagnosis of RA is based on the confirmed presence of synovitis in at least 1 joint, absence of an linated peptide (Antialternative diagnosis that better explains the synovitis, and achievement of a total score of 6 or greater CCP) was greater than (of a possible 10) from the individual scores in categories A-D.7 60 units, strongly posi** Indicates criteria met by current patient. The criteria are aimed at classification of newly presenting patients. tive. Radiologic examina◄ Differential diagnoses vary among patients with different presentations, but may include conditions tions were reviewed from such as systemic lupus erythematosus, psoriatic arthritis and gout. his emergency room visit § Joint involvement refers to any swollen or tender joint on examination, which may be confirmed by 2 weeks prior to his iniimaging evidence of synovitis. ¶“Large joints” refers to shoulders, elbows, hips, knees and ankles. tial visit. Radiograph of # “Small joints” refers to the metacarpophalangeal joints, proximal interphalangeal joints, second the left knee, two views, through fifth metatarsophalangeal joints, thumb interphalangeal joints and wrists. §§ Duration of symptoms refers to patient self-report of the duration of signs or symptoms of synovitis showed severe tricom(e.g., pain, swelling, tenderness) of joints that are clinically involved at the time of assessment, partmental disease of the regardless of treatment status. left knee with significant Please refer to the following link for additional info: http://www.rheumatology.org/practice/clinical/ joint space narrowing, classification/ra/2010_revised_criteria_classification_ra.pdf osteophyte formation and subchondral sclerosis. There was no evidence of joint effuan elevated uric acid concentration of 8.4 mg/dL, elevated sion, and no acute abnormality was demonstrated. RadioC-reactive protein of 6.4 mg/dL and elevated rheumatoid graph of the right knee, two views, also showed no acute factor of 842 IU/mL. His antinuclear antibody reflex was osseous abnormality, but did demonstrate severe tricomnegative. partmental osteoporosis without joint effusion and diffuse The results of serologic testing support a diagnosis of osteopenia. Erosions of cartilage and bone, two cardinal feacrystal-induced arthropathy and RA. I would be more inclined tures of RA,3 were not described. to attribute the left knee pain to an acute gout or pseudo gout The laboratory studies and clinical findings are suggestive exacerbation. This diagnosis is most secure when supported of RA. The radiographic results are more suggestive of OA and by visualization of urate crystals in a sample of fluid aspirated crystal-induced arthropathy. To confirm the diagnosis of RA, I from an affected joint or bursa.4 The patient declined this test should compare my clinical and serologic findings with estabdue to financial reasons, and a provisional diagnosis was made lished criteria available for the diagnosis of RA. based on clinical data, including history, physical examination The current diagnostic criteria for rheumatoid arthriand uric acid concentrations. tis were developed and validated by the American College of The patient was treated symptomatically with indoRheumatology (ACR) and European League Against Rheumethacin (Indocin) 50 mg 1 tab PO daily and was asked matism (EULAR) in 2010. (Table 1) The diagnosis of RA is to return to clinic in 1 week for follow-up. The symptoms based on the confirmed presence of synovitis in at least 1 joint, improved dramatically over the next 2 to 3 days. absence of an alternative diagnosis that better explains the syThe patient returned to clinic 4 weeks later for further novitis, and achievement of a total score of 6 or greater (of a evaluation. His left knee pain had improved to the point that possible 10) from the individual scores in categories A-D.7 My he was able to ambulate with a cane. He was still experiencpatient met all the criteria of the ACR/EULAR 2010 classificaing some bilateral knee pain and stiffness in the morning. tion. Based on the these results he was diagnosed with RA.6,7 His wrists, hands and finger pain and swelling remained unchanged. Target population (Who should be tested?): Patients who 1) have at least 1 joint with definite clinical synovitis (swelling) ** 2) with the synovitis not better explained by another disease ◄ **

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The majority of individuals develop RA in early to middle adulthood, but my patient is in his sixties. He might have developed RA years earlier but remained undiagnosed until now. Late-onset RA (LORA) is defined as RA occurring after age 60.8 In this age group, the correct diagnosis may be more elusive and is often delayed. LORA may be confused with entities such as polymyalgia rheumatica, crystalline arthritis or OA. The onset may be acute or slow and insidious. Patients are frequently misdiagnosed because of comorbid conditions. Patients with LORA represent a diagnostic and therapeutic management challenge. Trends in RA prevalence by age and calendar year show increasing prevalence with older age and decreasing prevalence for most other age groups in more recent time periods.9 Based on clinical, radiologic, laboratory and ACR/ EULAR criteria the patient was diagnosed with crystal-induced arthropathy and rheumatoid arthritis. The patient was referred to a local rheumatology clinic for further evaluation and treatment.

KEY WORDS:

Knee pain, Osteoarthritis, Rheumatoid Arthritis, Crystal-induced inflammatory arthropathy

REFERENCES: 1.

Schwarzberg AB, Alexander CB, DeAngelo DJ, Helfgott SM. A joint venture. N Engl J Med. 2008;358:2496-2501.

Calmbach WL, Hutchens M. Evaluation of Patients Presenting with Knee Pain: Part II. Differential Diagnosis. Am Fam Physician. 2003 Sep 1;68(5):917-922.

Pincus T, Callahan LF. How many types of patients meet classification criteria for rheumatoid arthritis? J Rheumatol. 1994;21(8):1385-1389.

Zhang W, Doherty M, Pascual E, et.al. EULAR evidence based recommendations for gout. Part I: Diagnosis. Report of a task force of the Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis. 2006;65(10):1301-1311.

Nishimura K, Sugiyama D, Kogata Y, et. al. Meta-analysis: diagnostic accuracy of anti-cyclic citrullinated peptide antibody and rheumatoid factor for rheumatoid arthritis. Ann Intern Med. 2007;146(11):797-808.

Arnett FC, Edworthy SM, Bloch DA, et. al. The American Rheumatism Association 1987, Revised Criteria for the Classification of Rheumatoid Arthritis. Arthritis Rheum. 1988;31:315-324.

Aletaha D, Neogi T, Silman AJ, et.al. 2010 Rheumatoid Arthritis Classification Criteria, An American College of Rheumatology/European League Against Rheumatism Collaborative Initiative. Arthritis Rheum., 2010 Sep;62(9):2569-2581

Olivieri J, Pipitone N, Dâ&#x20AC;&#x2122; Angelo S, et.al. Late-onset rheumatoid arthritis and late-onset spondyloarthritis. Clin Exp Rheumatology. 2009 Jul-Aug; 27 (4 Suppl 55): S139-45.

Gabriel SE, Crowson CS, O'Fallon WM. The epidemiology of rheumatoid arthritis in Rochester, Minnesota, 1955-1985. Arthritis Rheum. 1999 Mar;42(3):415-420.

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William C. Lineaweaver, MD

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• PRESIDENT’S PAGE • Inaugural Address

STEVEN L. DEMETROPOULOS, MD 2012-13 MSMA PRESIDENT

would like to welcome everyone to this inaugural celebration. I would like to thank each of you for coming. In the past our goal has been to increase the numbers at the annual session and I am here to give you the numbers for this annual session. This is the largest number that we have had in the last five years and I would like to thank each of you for being a part of this. I want to also thank a few people and then I want to introduce you to some folks and then I will do my presentation. First I would like to give you a little bit of historical reference. The last time someone from the Coast was elected President of the Mississippi State Medical Association was in 1980-81 and that was Dr. Paul Moore, Sr. and he is here with us tonight. Prior to that, it was Dr. Thompson from Moss Point and that was in ’65 and ’66. I am honored and humbled to follow in the footsteps of two great physicians from my area.

I would like to thank my local medical society. Many of my colleagues are here tonight celebrating this event with me. Thank you so much for supporting me. It means a lot when you are able to celebrate a special event with friends. The second group I want to acknowledge is my partners. As many of you know, you can’t do any job in which you volunteer your time unless you have people who are willing to cover for you or switch with you. They have been great partners and great friends and I appreciate them being here tonight with me as well. I would like to recognize my MACM family. That’s the Medical Assurance Company of Mississippi. I have been the youngster on that board for the last ten years. I appreciate them coming out and supporting me as I take on the presidency role with the State Medical Association. There are a few other people I would like to acknowledge. In your life there are always those people who give you direction and feedback. Locally those two people were Dr. Jack Hoover and Dr. Paul Moore. They encouraged me to get involved in organized medicine and so I would like to thank them for that. I was reading a book about leadership recently and it was talking about the importance of having mentors in your life. I don’t know if I ever really had a mentor but I did have people who were encouragers and who gave me good advice and I would like to recognize those folks. They are Dr. Steve Parvin and Dr. Michael Carter. Both have been good friends to me and I appreciate their direction over the years. I would like to introduce a few people here tonight. First of all, both sisters are here. Lisa Jones and her husband Michael, and their two daughters, Sophia and Andria Gray made the trip down from Montgomery, Alabama. My sister Nadine and her husband Sam McLemore are here with us as well. My mother is here from Florida with her husband Lowell Piper. My family has always been supportive of all the big events in my life. My daughters and son are here. I would like to introduce them to you. Katie is 24. She is a nurse in Memphis at the Methodist emergency department. Ari, 22 is next to her. She will be starting dental school this summer at UMC. Victoria, 18, will begin her freshman year at Ole Miss this fall. She is interested in physical therapy. Steven, who is 14, likes sports and hunting and fishing and he is also a good student. And, last but not least, my wife Therese. She has been such a great supporter and I would not be here if it were not for her. She has allowed me to go on the trips and go to meetings and everything was always handled at home. She really deserves this honor as much as I do. She should be standing right here by me because without her I couldn’t have done this. That is all of my family, with the exception of one person.

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If you will allow me just a few minutes of your time I would like to tell you about my Dad. He died about 13 years ago. He was the son of a Greek immigrant who grew up on a dairy farm. He went away to college but needed to come back and help his family and so he came home after just one year of college. He worked on the dairy farm and later had a small farm of his own on which we grew up. He was a person who would have been a great college history professor. He had an excellent mind. He remembered everything that he read and he had a great way of relating it back to you in a story-like fashion so that you could remember it as well. When I moved back to Pascagoula after training, we started a purebred cattle operation together and we had twelve years of just father and son running a business that we both really enjoyed. We bought cattle all over the United States and developed a nice herd and had a thoroughly enjoyable time doing this. When I was growing up, I had always been his helper at work on the farm. It seems our roles had changed when I came back. He became my helper in whatever project we were working on, whether it was with cattle or building a fence or a barn. He would help me do that and, in turn, tell me about all the recent books he had read or the shows he had seen on The History Channel. On my days off when I would go to the farm to work, he would take off a little bit early to go in and fix my lunch and call me in and we would eat together. Not many men can say that, but he did that for me as an act of service. As soon as my children were big enough, I would take them to the farm and he would love to see them. We would carry them around to our different work places and they would play and we would watch them. So from about two-years old to five-years old, they really spent most of their days at the farm when I was off. We had a great time doing that. When he died, it was too much to keep the herd together by myself so we ended up selling our herd. Mother was a great help in this. She actually took over his position as the herdsman doing all the things she had learned from him, and helped get things together for our dispersal sale. I like to remember my Dad this way: It’s a beautiful April afternoon. The rye grass is deep and thick. The cows are fat with big calves by their sides. He comes walking to the field. He has his coveralls on and is holding one of my daughters on his hip. He calls me in to dinner. He says, “Oh by the way, I want to tell you about a new book I just finished.” And that’s the way I would like to remember him today. Thank you all for that moment of indulgence. I know he would have been proud of me and I know he would have liked to have been here today. continued on p. 233, see President’s Agenda....

Dr. Steve Demetropoulos and family on the eve of his inauguration as the 145th president of the Mississippi State Medical Association, with his wifeTherese and children Ari, Katie, Victoria and and Steven.

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• MSMA • Report and Highlights of the 144th Annual Session of the MSMA House of Delegates and Medical Affairs Forum 2012 Karen A. Evers

Three years of the association’s presidency are represented, from left, Dr. James A. Rish of Tupelo, president-elect 2013-14; newly inaugurated president 2012-13 Dr. Steven L. Demetropoulos of Pascagoula, and Dr. Thomas E. Joiner of Jackson, immediate past president, 2011-12.

he 144th Annual Session of the MSMA House of Delegates and Medical Affairs Forum 2012 was held June 7 – 10 at the Grand Hotel Resort and Spa in Point Clear, Alabama. Our MSMA inaugurated its president and chose its president-elect and other leadership for the 2012-2013 term. Pascagoula emergency medicine physician Dr. Steve L. Demetropoulos, who served as president-elect over the past year, was inaugurated as president succeeding Dr. Thomas E. Joiner of Jackson. James (Jim) A. Rish of Tupelo was elected to serve as president-elect and will represent MSMA as president in 2013-2014. Dr. Demetropoulos took his oath of office to lead the association for the next year during a “Big Fat Greek Gala”

themed inaugural dinner-dance held Saturday evening. Despite inclement weather, flooding, and conducting closing business of the House of Delegates on generator-power by candle and flashlight, a successful meeting was held with increased attendance. A total of 342 physicians, spouses, medical students and exhibitors attended the meeting.

HOUSE OF DELEGATES ACTIONS During the meeting, the MSMA House pased several resolutions which will affect the future operations of the association, including a directive to work with the Department of Mental Health on various reforms. continued on p. 229....

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MSMA member John D. McKee, MD, (with his wife, Karen and their two sons) accepted the MSMA Award for Excellence in Wellness Promotion given to Mariner’s Village, Long Beach, Miss. Developers say it’s the first Optimal Health Community in the nation. Many of the amenities are designed by physicians to focus on health. “The Optimal Health Community means that we’re going to actually work with the residents to help them achieve better health by providing better amenities and by helping them be aware of community activities that are going to promote better health,” said Dr. McKee who helped develop the community.

Though sunset-showers relocated the President’s (MDs & Mudbugs Crawfish Boil) Reception indoors from Julep Point overlooking Mobile Bay, guests danced to tunes by Splash Trio and celebrated “Life’s A Beach with Tort Reform.” Following the casual seafood dinner, Southern Medical Association hosted their annual ice cream sundae social. Shown l. to r.: Doctors Jennifer Gholson, Scott Anderson, Tom Joiner, Randy Easterling, John Cook, Ford Dye, Bill Grantham, Jeff Morris and Clay Hays, Jr.

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Recipient of the Dr. James C. Waites Leadership Award - Jeffrey A. Morris, MD. His wife Karen is a past president of the MSMA Alliance.

Dr. Helen Turner and Dr. Rick Carlton — In addition to tackling the issues surrounding the practice of medicine, the House also honored one of its own. Resolution 9, commends the career of Helen Turner, MD, who, among many other accomplishments, served as the Associate Vice Chancellor for Academic Affairs at UMMC. Additionally, she served our MSMA as secretary, board of trustees member, president-elect, president, and as a delegate to the AMA for 10 years.

...House Actions continued from p. 227 Resolutions 5 and 13, both passed by the House of Delegates, dealt with reform of the Mississippi Department of Mental Health. Resolution 5, which was adopted by the House, recommended that the Mental Health Department Executive Director be a psychiatrist and that the Board Chair be a physician. Resolution 13, which was referred to the MSMA Board of Trustees (BOT), encouraged dialogue with the Department to evaluate commitment laws and involuntary commitment laws. Other resolutions passed by the MSMA House include:

Resolutions 4 and 11 - Hold three of every four Annual Session meetings in Mississippi beginning in 2017 (adopted); MSMA to honor contracts already in place for Sandestin (May 26 - 28, 2013), Biloxi (2014), Natchez (2015) and Point Clear (2016).

Resolution 2 - Reaffirm financial support for public health (adopted); MSMA to work with Health Department for increaed state funding to improve public health.

Recommendation A - Increase active member dues by up to $50 in 2013 (referred to the BOT); Referred to BOT for implementation of dues increase for active members starting in 2013.

Resolution 3 - Support Affordable CME (adopted); MSMA to continue offering low cost CME and AMA delegation to support reconsideration of fee hikes.

Recommendation C - Urge component societies to use Southern Remedy obesity management program (adopted); MSMA to encourage component societies to use Southern Remedy at the local level;

Resolution 6 - Repeal the Patient Protection and Affordable Care Act (adopted); MSMA to seek repeal of PPACA and to take resolution to the AMA to this effect.

Recommendation D - Empower component societies to pursue smokefree cities (adopted); MSMA to support and encourage component societies to pursue smokefree city ordinances in their respective areas.

Resolution 7 - Add a Young Physician Section member to the MSMA BOT (adopted); Lays resolution on the table for vote at 2013 Annual Session.

Resolution 8 - Support physician freedom from reporting immigration status of patients (referred to BOT); MSMA to oppose any effort to limit care given to patients and oppose any directive to report immigration status.

Resolution 10 - Encourage AMA to study practice drift (adopted); MSMA to ask AMA to study and report back at AMA 2013 annual meeting on policy recommendations and model legislation.

Resolution 12 - Support free flu shots for pregnant women (adopted); MSMA to support efforts of Health Department to budget free flu shots for uninsured pregnant women.

Resolution 15 - Explore regional determination of Health Professional Shortage Area designation or HPSA (adopted); MSMA to work with Health Department to explore Rural Workforce Area submission to maximize HPSA designation and compensation.

DID YOUR LAST MEETING LEAVE YOU FEELING A TAD

“ECTOPIC” If so, you should consider having your next meeting in Tupelo!

We’re right in the middle of the MidSouth and Tupelo is the headquarters of the North Mississippi Medical Center, the largest non-metropolitan hospital in the United States, and is a winner of the prestigious Malcolm Baldrige National Quality Award! And we promise you won’t feel out of place here! For information about setting up your next meeting, give Linda Elliff a call at 800-533-0611.

ll of the above resolutions may be viewed and commented upon online in the membersonly section of www.MSMAonline.com. Visit the website, sign in as a member, select the Issues/ Discussions link, then select the 2012 Annual Session online forum.

JULY 2012 JOURNAL MSMA 229

uring the meeting, physicians elected officers, trustees, and council members to open positions for terms beginning in 2012.

Council on Medical Education District 8: David McClendon, MD

Council on Medical Service District 6: Robert Brahan, MD

Council on Medical Service District 7: Geri Lee Weiland, MD

Council on Medical Service District 8: Joseph Mitchell, MD

ELECTION RESULTS ARE AS FOLLOWS: ·

President-Elect: James A. Rish, MD

Trustee District 1: Carlton Gorton, MD

Trustee District 3: Steven Brandon, MD

Trustee Resident/Fellow: Andrews Weeks, MD

Council on Medical Service Resident: Jason Stacy, MD

Trustee Student: Richard Robertson

Council on Medical Service Student: Emily Brandon

Associate Editor, Journal MSMA: Stanley Hartness, MD

Council on Budget and Finance: Mark Horne, MD

Council on Public Information District 7: Joe Austin, MD

Council on Budget and Finance: Scott Carlton, MD

Council on Constitution and Bylaws: Eric Lindstrom, MD

Council on Public Information District 8: Greg Patino, MD

Council on Legislation District 4: Michael Kanosky, MD

Council on Legislation District 5: Dee Dee Price, MD

Council on Legislation Resident: Tal Hendrix, MD

Council on Legislation Student: Luke Ainsworth

Council on Medical Education District 6: Thomas Dobbs, MD

Council on Medical Education District 7: Carlos Latorre, MD

MSMA AWARDS: LEADERSHIP, COMMUNITY SERVICE, AND WELLNESS PROMOTION PROJECT

ur MSMA honored two South Mississippi physicians and a Gulf Coast residential community at a ceremony for the 2012 Excellence in Medicine Awards. Recipients and respective honors include:

FRAUD &ABUSE: A TERMINAL DIAGNOSIS.

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(601) 856-7200 www.cctb.com

230 JOURNAL MSMA JULY 2012

Jeffrey A. Morris, MD – Dr. James C. Waites Leadership Award

he Dr. James C. Waites Leadership Award honors one physician under the age of 50 who is an outstanding leader in organized medicine and community affairs. The Waites Award recipient for 2012, Jeffrey A. Morris MD, of Hattiesburg, is a partner and internal medicine physician at HubSouth Medical Clinic in Hattiesburg and is the Medical Director for the South Mississippi State Hospital, Mississippi Home Care, and Perry County Nursing Home. He is also a staff physician at Forrest General Hospital and at Wesley Medical Center, where he serves on the Continuing Medical Education Committee, Ethics Committee, Medical Executive Committee, and Peer Review Committee. Dr. Morris is a member of the Board of Trustees for Hub Health of South Mississippi, Inc. and member of the Board of Directors for Mississippi Physicians Care Network. In addition to serving on the MSMA Board of Trustees, he has been dedicated to his local component medical society through holding positions of President and Secretary/Treasurer. He is also a member of the Mississippi Medical Political Action Committee, Southern Medical Association, American Medical Association, and American Medical Political Action Committee. His wife Karen is an office holder in the MSMA Alliance organization, and together the Morrises have dedicated many hours to support pro-medicine and community service efforts, including organizing annual 5K charity races sponsored by the Alliance in the Hattiesburg area.

Robert Travnicek, MD – Recipient of the MSMA Community Service Award

r. Robert Travnicek, recipient of the 2012 MSMA Community Service Award, earned his medical, bachelor’s degree and doctorate from the University of Nebraska School of Medicine. After 21 years in private practice as a family physician in rural Nebraska, Dr. Travnicek, who was by this time married to his wife Lora and had two young daughters, completed a Masters of Public Health degree at Harvard School of Public Health in 1990 and subsequently moved to Mississippi to become the District Director of Coastal Plains Public Health District IX, where he has served with distinction for over 20 years. His role during the

Hurricane Katrina response in 2005 was legendary; he worked tirelessly for two consecutive months without a break in the immediate wake of the worst natural disaster in American history. This service led to his being recognized in 2009 by the Harrison County Emergency Management Agency for “Outstanding Service and Dedication.” He has provided high risk obstetric consultative care in the Harrison County Health Department and has served in several community service capacities. Dr. Travnicek supervised and directed a nationally recognized Stroke Belt Grant Project offering hypertension screening to Coast residents; partnered with the Healthier Communities Alliance Association, Memorial Hospital of Gulfport, local schools, Rotary clubs, churches, and Boards of Supervisors to establish and supervise a mobile medical unit which is currently providing health care screening and immunizations throughout Mississippi coastal counties; helped Memorial Hospital of Gulfport establish school-based clinics; helped to establish a Hazard Analysis and Critical Points checklist for food service facilities to improve environmental health; and served as a guest speaker for Harrison County Chamber of Commerce leadership conferences and U.S. Food and Drug Administration training programs. In addition to the 2012 MSMA Community Service Award, Dr. Travnicek has received the 2004 Felix Underwood Award (given by the Mississippi Public Health Association as the top award for public health service in Mississippi); the 2003 Dean College Presidents Award for Leadership; the 1997 Donald Evans Sutter Award (given by Memorial Hospital of Gulfport for leadership abilities and contributions to community development); the 2007 Orange Grove Rotary Service Award; and the 2009 Gulfport Rotary Service Award.

Mariner’s Village; Long Beach– MSMA Award for Excellence in Wellness Promotion

he 2012 MSMA Excellence in Wellness Promotion award winner, Mariner’s Village in Long Beach, is a residential community with a mission to promote wellness and healthy living for its residents. Following Hurricane Katrina, MSMA member John D. McKee, MD, wanted to help residents of the Coast recover and felt that a community focused on health was the best way to start. He collaborated with award-winning developers at Miami-based Pinnacle Housing Group to create a $12 million, state-ofthe-art residential community focused on promoting optimal health for its residents. Partially funded by the Mississippi Development Authority, the residence offers health-promoting amenities including a community center, gymnasium, beach volleyball court, walking track, and playground with splash area for children. The community center includes a computer business office, full kitchen, virtual kid’s gymnasium, and group meeting area. The center also serves as the gathering place for healthy cooking classes, morning exercise programs,

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232 JOURNAL MSMA JULY 2012

...continued from p. 231 MSMA Excellence in Wellness Promotion and childrenâ&#x20AC;&#x2122;s health and educational activities. The housing is designed so that even the busiest person can take advantage of better health. Throughout the campus are exercise stations, just steps from the apartments, and employees can help residents get involved in community activities. Developers suspect that the idea of using a community to promote better health will quickly catch on across the nation. â&#x20AC;&#x153;As a physician, I see the ravages of diabetes and obesity and many of the conditions are preventable. And, thatâ&#x20AC;&#x2122;s what weâ&#x20AC;&#x2122;re targeting,â&#x20AC;? said Dr. McKee. The residentsâ&#x20AC;&#x2122; response to the healthy living community is manifested by their markedly improved health and neighborhood pride. Tremendous motivation has been spawned, as residents continue to organize and participate in volunteer activities, giving back to others in the form of blood drives and helping their community become focused on better health. Marinerâ&#x20AC;&#x2122;s Village is a great success story, showing how a motivated Mississippian produced a unique development that promotes the highest level of wellness for its residents which in turn inspired citizens to make meaningful contributions to their own community. r

President’s Agenda, continued from p. 226.... want to talk about my agenda for this upcoming year. I’m a “list” kind of guy and so I like to have a list of goals that I want to try to accomplish. I like setting goals and I like working to accomplish those goals during the course of the year. I want to tell you about three different things that I am really interested in working on this year and I am going to ask for your help as we work on them. Then after we do that, we will have all of the business of the evening over and we will be able to crank up the Greek band and have the dancers start. We will open up the dessert bars and the cocktail bars so we will have a nice relaxed evening together.

MEMBERSHIP

The first thing I would really like to look at is our membership. At this point, our total membership is 4,600 and this is the highest that it has ever been. The problem that we are seeing is that even though our membership is the highest it has ever been, we don’t have the involvement that we had in the past even with lower numbers. I want to focus on involvement of our membership in this next year. Obviously I am “preaching to the choir” for those of you who are here tonight; but, let me tell you why I think it’s important for each of us here to go back and get our own local component society enthused and active and engaged. The argument that I will make is that if we are not engaged, someone else will make decisions regarding medicine for us. We all see that on a daily basis. We see the scope of practice issues where you have everyone who’s not a doctor wanting to be able to diagnose and treat patients independently or wanting to do more outside their practices than what we feel they were trained for. That includes everything from optometry to chiropractics to nurse practitioners. So many want to gain through legislation what we have gained through education. We see the state and federal government putting more regulatory burdens on physicians such as pre-certification for tests or visits with a specialist. We see more whittling away of our financial reimbursement in the face of rising practice costs. If we do not engage the next generation of physicians to take an active role in defending, promoting and protecting our patients’ wellbeing, no one else will. That is why we have to have our next generation of doctors engaged. What I would like each of you to do when I come to your component society for a visit over this next year, is to invite people who are not members. Please open it up to non-members because I would like to make a pitch to them of why they need to be a member of the Mississippi State Medical Association. Also try to invite all those people who have not been engaged in the past and let me make a pitch to them on why they should be engaged. The first step for anybody in an organization is to become a member. Now, we really need members and the reason we need them is that 4,600 doctors speak louder than 1,000 doctors. Our numbers matter so it is important for us to have every physician in the state to be a member of the State Medical Association. The money that you pay for membership matters. It allows us to fund our legislative agenda. It allows us to defend scope of practice issues, to work on reshaping Medicaid and to work on public health initiatives. So membership and dues are important. If you have physicians in your area who aren’t members, we really need their membership and we can make a good argument why what we do as an organization benefits every single physician in this state. Things like CME accreditation, the recovering physician program, and protecting tort reform, just to name a few. We don’t just want our membership. We want to earn it.

ENGAGEMENT

The second level of involvement with an organization is called engagement. That is when we have physicians who are members going to the component society meetings. They start volunteering for a role in the local component society as an officer. This is where we really need to make the big push in our organization to get more people engaged. One of the problems I’ve noticed is that there is not really a project to get behind. I am going to suggest to you a project that is one of the best ones that we ever did in our local component society. Component societies across the state could do this. It would enhance your influence with your community leaders and would give them a great insight into our practices. That project is called the mini-internship. The program works like this: You invite community leaders to join you for two days of work. They start on a Sunday evening with the orientation. They work a Monday and Tuesday and then they have a debriefing on Tuesday evening. It’s a great project. I will have some information about it tomorrow morning. If you are a leader with your local component society, pick it up and consider doing it. We did it for about twelve years in our local component society. It was so well received we had every one of our legislators go through it. We had judges, CEOs, members of the board of trustees of the hospital, and healthcare decision-makers for all the local industries. The two things that everyone walked away with from that event were these: 1) “We didn’t know that you guys worked so hard. Our feet are so tired and we are exhausted.” 2) “You have an incredible job that touches the lives of people in such a unique way.” This program helps you to develop more relationships and more influence within our community. It is a great way to allow others to see a side of medicine that they would not see any other way.

LEADERSHIP

The final level of involvement is called leadership and that is when we get people volunteering to be a leader at the statewide level. They volunteer to sit on the reference committees when we have our annual session. They volunteer to be on committees. It has been hard for us to find interested people recently. This is where we need our next level leaders to step up and say, “Yes, it is important to me to donate my time, it is important enough for medicine, it is important enough for my wellbeing and for the colleagues who I represent for me to be engaged and involved.” The fact of the matter is that if every one of us did just a little, the burden would be light for all of us.

JULY 2012 JOURNAL MSMA 233

The second issue that I would like to work on is Medicaid reform. As many of you know, we have been working on this for about two years at the direction of the House of Delegates. It was initially started by President Tim Alford who focused on the patient-centered medical home. Under this model, as many of you know, the physicians’ offices get much more back office support so the patients get much more education and social support. An example would be someone who has congestive heart failure who normally would be a frequent visitor to the emergency department, consequently admitted, and if they were severe enough, admitted to the ICU. The medical home model would have much closer follow-up at the patient’s home. The patients would be taught to weigh themselves. If they don’t have a scale, a scale would be provided. When they gain more than a certain amount of weight they know to take an extra dose of Lasix. They focus on their diet and compliance with their medications. They can even reduce multiple visits to their doctor’s office. This prevents further visits to the emergency department and hospitalizations. Under this model there is much more focus on trying to keep the patient healthy and prevent further hospital admissions. Our current President Tom Joiner has spent multiple hours presenting this model to the Legislature as well as to the Department of Medicaid. We think that this is our best opportunity to push forward with this model which has higher satisfaction for the doctors and for the patients and actually saves the state money. We are in a unique position in that we have really good relationships with the Governor, Lieutenant Governor and the Legislature, as well as the State Medicaid Director, so I am going to continue to push ahead on behalf of the organization and continue to present our argument for the patient-centered medical home as being the model of choice by both the doctors and patients. The third item on my agenda is public health. Public health issues are our biggest opportunity to make the greatest impact on our patients’ health and the health of our fellow Mississippians. When I met with Dr. Currier, the State Health Officer, we discussed opportunities for improvement. One that seemed like it would be a particularly good project to work on with our spouses in the MSMA Alliance is vaccinations for adolescents. Mississippi ranks number 51 in the vaccination of teenagers 13 to 17-years old for tetanus, diphtheria and pertussis as well as meningococcal vaccinations. We rank number 48 in the United States in human papilloma virus vaccination. All of these are preventable diseases with vaccinations. I look at this as being a “mom issue” and by that I mean that in general the moms are the adults who are responsible for seeing the kids are vaccinated. Amy Gammel, incoming Alliance President, and I are going to work very closely together on promoting this issue. The first step obviously is to raise awareness, both with parents and primary care doctors, of vaccination schedules and perceived risk of the disease. The second thing that we can do is to make parents aware that if they don’t have a medical home, CHIPS and Medicaid both will pay for these vaccinations and they can receive them at the health department. If they don’t have any other form of insurance, they can receive them at the health department for $10. The second area that I am going to continue to address is the statewide law prohibiting smoking in indoor workplaces, restaurants or bars. There are some very good studies done here in Mississippi that show that heart attack rates for individuals exposed to secondhand smoke are much higher than those who are not exposed to secondhand smoke. The rates of asthma and respiratory disease are also much higher. If you didn’t realize it, there are 53 cities in Mississippi that are already smoke-free and 12 more that are partially smoke-free. In fact if you look at the demographics, it’s about 23% of our state population. The areas that still allow secondhand smoke are mainly in the areas where there are casinos. Although on the Coast, the Palace Casino went smoke-free and it has not affected the revenue of their business so I am going to continue to push our state to becoming a smoke-free state since a substantial number of our cities are already smoke-free. This one issue represents our best opportunity to improve the health of our fellow Mississippians. One of the most important leadership qualities any person can have is pursuit. That is a persistent drive to achieve a goal. It’s important for an individual and important for an organization. So these are the goals I’ll be pursing this year: Engage the membership. Continue to work on the patient-centered medical home model in the Medicaid system. Work with public health issues, specifically the vaccination rates in adolescents and a smoke-free state. I would like to end with one of my favorite quotes. It is from the Book of Micah, Chapter 6, and Verse 8. It says, “I showed you oh man what is good and what does the Lord require of you? That you do justice, that you love mercy and that you walk humbly before your God.” So how do we do justice? We do justice every time we fight on behalf of our patients. When there is a test or medication that they need that they are being denied and we advocate on their behalf or a hospitalization that we feel is necessary and again we fight on their behalf. That is how we do justice. We do justice as an organization and collectively as physicians when we try to increase physician access by enlarging medical class sizes or funding rural scholarship programs and by working in the public health arena to decrease obesity and increase vaccination rates. How do we love mercy? We love mercy individually when we take care of that alcoholic patient who is having his fifth presentation because he has fallen off the wagon or we take care of the diabetic patient who is being readmitted for DKA because they have been noncompliant, or we take care of the COPD patient who continues to smoke. That’s how we show mercy. We show mercy collectively as a group every time we serve in a free clinic or go on a medical mission trip. Continued on p. 242, see Humility....

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• JUST OFF THE PRESS - INFO YOU WANT TO KNOW •

Don’t Forget the Stethoscopes Richard L. Ogletree, Jr., PharmD

Article: Bhatta D.R., Gokhale S., Ansari M.T., Tiwari H.K., Gaur A., Mathuria J.M., Ghosh A.N. Stethoscopes: A Possible Mode for Transmission of Nosocomial Pathogens. Journal of Clinical and Diagnostic Research 2011 November; 5:1173-1176. Available from http://www.jcdr.net/back_issues.

asp?issn=0973-709x&year=2011&month=November&volum e=5&issue=6&page=1173-1176&id=1596 Background: Stethoscopes are tools that are universally used in the healthcare world. Could they also be fomites involved in transmission of infection?

ȋΨȌ ȋ Ȍ ȋ Ȍ Micrococcus ͵ʹ ͶͲ ͳͲ ͳͺ ȋͷͷǤͳ͹ΨȌ ȋ͸ͺǤͻ͸ΨȌ ȋͳ͹ǤʹͶΨȌ ȋ͵ͳǤͲ͵ΨȌ Ͳͺ ʹͳ ͳͲ ͳʹ ȋͳ͵Ǥ͹ͻΨȌ ȋ͵͸ǤʹͲΨȌ ȋͳ͹ǤʹͶΨȌ ȋʹͲǤ͸ͺΨȌ Ͳͺ ͳͺ ʹʹ ͳ͸ ȋͳ͵Ǥ͹ͻΨȌ ȋ͵ͳǤͲ͵ΨȌ ȋ͵͹Ǥͻ͵ΨȌ ȋʹ͹ǤͷͺΨȌ Ͳʹ Ͳͷ Ǧ Ǧ StreptococcusǦ ȋ͵ǤͶͶΨȌ ȋͺǤ͸ʹΨȌ

Staphylococcus Ͳͳ Ͳ͵ Ǧ Ͳͳ aureus ȋ Ȍ ȋͳǤ͹ʹΨȌ ȋͷǤͳ͹ΨȌ ȋͳǤ͹ʹΨȌ Staphylococcus Ͳͳ Ͳʹ Ǧ Ǧ aureus ȋͳǤ͹ʹΨȌ ȋ͵ǤͶͶΨȌ ȋ Ȍ Pseudomonas Ǧ Ͳʹ Ǧ Ǧ ȋ͵ǤͶͶΨȌ Enterobacter Ǧ Ͳʹ Ǧ Ǧ ȋ͵ǤͶͶΨȌ Escherichia Ǧ Ͳͳ Ǧ Ǧ coli ȋͳǤ͹ʹΨȌ ͷʹ ͻͶ Ͷʹ Ͷ͹ ʹͲ Ͳ͸ ͳͺ ͳͶ ͳǣ ǡ ȋΨȌ ͲͶ ȋ͸ǤͺͻΨȌ Ͳͷ ȋͺǤ͸ʹΨȌ Ͳ͹ ȋͳʹǤͲ͸ΨȌ ͳͲ ȋͳ͹ǤʹͶΨȌ ͲͶ ȋ͸ǤͺͻΨȌ Ͳͺ ȋͳ͵Ǥ͹ͻΨȌ Ͳͷ ȋͺǤ͸ʹΨȌ ʹǣ

Objective: The purposes of this study were to assess the contamination of stethoscopes, to evaluate methods of disinfecting them, and to recommend measures for improvement. Design: Prospective, cross-sectional study at two teaching hospitals in Nepal. Methods: 58 physicians and nurses completed questionnaires between April and October 2010. They also allowed their stethoscopes to be cultured (diaphragm, bell, and both earpieces). Results: According to the questionnaires, 96.55% of the participants were aware that stethoscopes could transmit infectious agents, and 100% felt that stethoscopes should to be disinfected. 79.31% of the participants used stethoscopes directly on the skin of the patients while 20.69% used them through the clothing of the patients. The same amount (79.31%) cleaned their stethoscopes by some method, compared to 20.69% who never cleaned them at all. Conclusion: Stethoscopes can transmit nosocomial pathogens and should be cleaned regularly. r Figures adapted from: Bhatta D.R., Gokhale S., Ansari M.T., Tiwari H.K., Gaur A., Mathuria J.M., Ghosh A.N. Stethoscopes: A Possible Mode for Transmission of Nosocomial Pathogens. Journal of Clinical and Diagnostic Research 2011 November; 5:1173-1176.

JULY 2012 JOURNAL MSMA 235

• SCIENTIFIC • Article: Vajravelu RK, Guerrero DM, Jury LA, Donskey CJ. Evaluation of Stethoscopes as Vectors of Clostridium difficile and Methicillin-Resistant Staphylococcus aureus. Infection Control and Hospital Epidemiology 2012 Jan;33(1):96-98. Background: Stethoscopes are potential vectors for transmission of micro-organisms but are not always routinely cleaned. Objective: The purposes of this study were to quantify the potential risk for transmission of C. difficile and MRSA and to evaluate stethoscope cleaning methods. Methods: Stethoscope diaphragms were tested for efficacy of direct and indirect transmission of C. difficile (35 samples) or MRSA (57 samples). Diaphragms were either directly or indirectly inoculated with MRSA or C. difficile spores. Indirect transmission involved skin exposure to the contaminant (the forearm of a human volunteer for C. difficle spores or processed pigskin for MRSA).

Cleaning methods assessed included alcohol wipes, ethanol soaked gauze, and water soaked gauze. Results: The number of colonies of C. difficile transmitted by stethoscopes compared to a gloved hand was statistically similar. There was less transmission of MRSA, but there was still substantial transmission. Gauze was better than alcohol wipes for cleaning C. difficile spores (98-99% vs 92 -94%). Alcohol wipes or ethanol soaked gauze was better than water soaked gauze for decontaminating MRSA (100% vs 94%). Conclusion: Stethoscopes can transmit nosocomial pathogens and should be cleaned regularly. Friction can get rid of most C. difficle spores while alcohol is a better decontaminant for MRSA. Comments: Cleaning the stethoscope should be emphasized as a part of the examination process. r

This was compared to transmission of contaminants via gloved hands.

Transfer of Clostridium difficile spores (A) and methicillin-resistant Staphylococcus aureus (MRSA; B) by stethoscopes. Direct transfer (solid bars) indicates organisms directly inoculated onto the stethoscope diaphragm, air dried, and diaphragm imprinted onto selective agar. Indirect transfer from skin (open bars) indicates organisms inoculated onto skin and air dried, contacted by stethoscope diaphragm, and diaphragm imprinted onto selective agar. Nontoxigenic C. difficile spores were inoculated onto a human forearm, and MRSA was inoculated onto pig skin. CFU, colony-forming unit. — Figure used with permission.

236 JOURNAL MSMA JULY 2012

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

May 2012 Figures for the current month are provisional

Totals include reports from the Department of Corrections and those not reported from a specific District. For the most current MMR figures, visit the Mississippi State Department of Health website: www.HealthyMS.com.

JULY 2012 JOURNAL MSMA 237

•• L UMMC ETTERS •• The University of Mississippi Medical Center Division of Multicultural Affairs Jasmine Taylor, M.D. and Matt Westerfield

n the fall of 2010, representatives from the University of Mississippi Medical Center joined educators and lawmakers from around the state in celebrating the launch of a formal partnership between the Medical Center and Franklin Academy Health Sciences and Wellness Magnet School in Columbus. This partnership, now under the name Project REACH (Reaching Education and Changing Healthcare) is thriving and impacting the lives of over 500 K-5 students. Forged by the Division of Multicultural Affairs, this relationship will equip Franklin Academy with classroom enrichment and exposure to healthcare mentors to nurture the hopes and dreams its young students have of becoming the next generation of medical professionals. While this is not the first pipeline program established by Multicultural Affairs, it does target younger students than ever before. In partnering with Franklin Academy, Multicultural Affairs now offers outreach programs that run the spectrum from kindergartners all the way through current students of health professions. Our goal is to support the Medical Center’s efforts to train a diverse healthcare work force dedicated to serving the needs of Mississippians and to have an environment that supports an inclusive university community. We believe that it is a worthwhile goal to have a diverse community of healthcare providers that reflects the wonderfully diverse people of our state, one that appreciates the benefits we derive from the variety of insights, perspectives and experiences which such diversity brings. This broad-scope attitude has been molded and enhanced over time, as the Division of Multicultural Affairs has changed with the times. Established in 1974, the Division was originally known as the Office of Minority Student Affairs and focused on recruiting and supporting minority medical students. While that remains very much part of its missions, the Division has evolved to keep pace with the changing culture. The American Association of Medical Colleges reports that in 2004, Blacks, Hispanics/Latinos, and Native Americans comprised 6.4% of all physicians. In comparison, the 2000 U. S. Census data showed Blacks, Hispanics/Latinos, and Native Americans comprised nearly 26% of the U. S. population. Asian physicians were the largest group of racial and ethnic minority physicians at 5.7%. Today, we are reaching out to a wider variety of students than ever before, with a special focus on recruiting students from underserved areas of the state, rural backgrounds, educationally and financially disadvantaged, as well as, students from underrepresented groups in medicine. In 2010, the pipeline participants totaled 153, excluding the K-5 participants. Participants were predominantly female, 15% American-Indian, and 9% White. In 2010, the participants in the very popular Prematriculation pipeline program were 48% White, 19% rural, 38% underserved, and 33% economically disadvantaged. The Prematriculation Program is the final stage of the enrichment pipeline program and offers accepted medical and dental students the opportunity to spend seven weeks in the summer prior to matriculation engaged in intensive coursework in preparation for the fall. The students do not receive academic credit and may participate in the program upon referral by the admission committees. Brief descriptions of selected programs offered within the Division of Multicultural Affairs, including pipeline programming, are included below. Our Science Training and Enrichment Program (STEP) is a Saturday institute held one Saturday each month during the school year. It focuses on bolstering math, science and critical thinking skills in students grades 5-8. Program participants include, but are not limited to, students from Choctaw Tribal Schools, Jackson Public Schools, and Humphreys County Schools. We offer undergraduate initiatives that provide enrichment and shadowing opportunities to college students. Our eight-week Health Careers Development Program targets undergraduates as well, allowing them to explore career opportunities in healthcare fields through volunteering and observing to gain first-hand experience of their potential careers. We offer cultural and diversity training for our current UMMC students, including a cultural simulation experience during orientation and a variety of presentations during the academic year. Our Health Equity Lecture Series offers exposure to local and national experts on issues related to health equity and racial and ethnic health disparities. Dr. Marc Nivet, chief diversity officer for the American Association of Medical Colleges (AAMC) was the inaugural speaker. On April 25, 2012, Dr. Somnath Saha, associate professor of Medicine at the Portland VA Medical Center, presented a lecture on racial and ethnic disparities in the quality of health care. Our Mini Medical School aims to improve health literacy and education among residents of the Delta through a partnership with Mississippi Valley State providing health career exposure to selected middle school students and undergraduates, and free seminars to the public on selected Saturdays. The goal of this program is to increase the number of undergraduates who seek enrollment in a health professional school and increase the number of healthcare professionals providing health care in underserved areas of the Delta. These outreach activities are based on our belief that efforts to sustain a diverse and culturally inclusive campus environment will ultimately lead to a more diverse healthcare work force prepared to join the fight to eliminate health disparities in the state of Mississippi. r 1. 2.

Diversity in the Physician Workforce: Facts & Figures 2006. AAMC Data Warehouse: Minority Physician Data, Applicant-Matriculate File, and AMA Physician Masterfile, as of March 16, 2006. “Underrepresented in Medicine” means those racial and ethnic populations - - underrepresented in the medical profession relative to their numbers in the general population. – American Association of Medical Colleges.

238 JOURNAL MSMA JULY 2012

• UNCOMMON • UNA VOCE THREAD • • Anderson Family Driving School (Under New Management)

olton and Allison are both driving now. Allison has her learner’s permit. Holton has a regular license. I didn’t know if he was going to survive to get there. Several times he almost didn’t. Several times I almost killed him myself. He was not the quickest learner with a permit. R. SCOTT ANDERSON, MD

Holton is the fifth boy I’ve taught to drive. Since all of our prior kids that had to learn to drive were boys, it fell to me to teach them how to do it. At least that was what Charlene said. So, I already had sixteen years experience to steady my nerves before Holton ever slipped behind the wheel of a car. Once you’ve had a fifteen-year-old turn left into the far right lane directly in the path of an oncoming tractor-trailer, then freeze with his foot on the accelerator, everything else is small change. (I grabbed the wheel and ran us over a strip of grass into a parking lot.) Generally, what has given them all the most trouble has been the issue of left-hand turns. From the exalted position of the passenger’s seat for sixteen years I got to have a wonderful unobstructed view of the oncoming traffic that was about to run into my side of the car. I knew right away if it was a Hyundai or a Honda that was going to send me to the afterlife if it didn’t have good brakes. Fortunately, for me and for Holton, for the last year we only pulled in front of alert, aware drivers that weren’t preoccupied with texting or making calls on their cell phones. To my great good fortune they all reacted wonderfully to a car sitting in the left-turn lane pulling directly out in front of them and then slamming on its brakes and sitting still. This is apparently a common reaction in new drivers, recognize impending disaster…freeze. Not the best course for a good outcome. But, my days as a driving instructor apparently have ended with Holton. The last two children that still need instruction are girls, so the ball is firmly in Charlene’s court now. I did try once, but it didn’t go well. We never made it out of the garage. Allison dissolved into tears and stomped into the house wailing, “Daddy yelled at me and called me a name.” “Why would you call her a name? She hasn’t even backed out,” Charlene asked. “ Just because I started backing up without looking at the mirrors,” Allison huffed. “She almost hit the dog,” I explained. “Well you can’t get mad and holler at her, she’s a girl. See how upset you have her?” Charlene insisted. “Then you teach her. Hollering is part of how I teach kids how to drive.” See I’m not the “stop, please stop, baby you need to stop” kind of guy. It’s more like, “stop, STOP, DAMN IT. I SAID STOP THE CAR.” So it was obvious at this point that it was better if I got out while I was only a little bit behind. With that, the Anderson Family Driving School was under new management. Anyway, a few days later I was at work sitting at the nursing station, looking through a chart to get ready for my next consult, when my cell phone rang.

JULY 2012 JOURNAL MSMA 239

I’ve gone back to the simple ring. I used to give everyone his or her own song, but that was too much trouble. I never could remember whose song was whose. I would forget that the song had anything to do with the phone at all and would hum along with whatever great song just mysteriously piped up out of nowhere. And sometimes it can be quite socially uncomfortable. The average cancer patient does not want to hear Warren Zevon sing out “Life’ll Kill Ya” in the middle of a consultation, even if it is your son’s favorite song. Anyway, as Alice Cooper sings, “The Telephone is Ringing.” When I answer it, it’s Charlene, but a very quiet Charlene. “What’s up?” I asked, in a hurry to return to my review. “Your daughter tried to kill me.” “So, the driving isn’t going well?” I asked. “How’d you know? And, no, it isn’t. She can’t drive at all.” “Just a hunch. She does great at the farm. Traffic throws them.” Allison can drive anything anywhere off-road. She never gets stuck. At three she could throw her Barbie jeep into a controlled slide, bounce it up the front steps and get out on the front porch without missing a beat or losing a doll baby. “Do you know what she did?” Char asked breathlessly. “Did it have anything to do with a left-turn?” I asked. “Yes. We were pulling into the left-turn lane, Bella Gs. The light turned green. There isn’t an arrow there and cars were coming. She kept saying, ‘Can I go yet?’ and I’d say ‘no.’ I explained to her, ‘These cars are going straight. You have to wait until all of them go through.’ One car went through then another then another and all of the cars that had been sitting there had gone through. She asked ‘Can I go now?” and before I could answer, she just hits the gas. Right in front of a car that’s trying to make the light. I screamed…I’m not kidding, I freaked out and started screaming. My brains wouldn’t let any words come out I was so scared. I thought we were going to die. That car was coming right at me. Do you know what she did?” I pretty much did, but I didn’t want to interrupt. “She stopped, well she slowed down. She slammed on the brakes. I started hollering, ‘Go, go, go, don’t stop now. Get through as far as you can.’ I was just hoping the lady’d only hit the back of the car. Not my door.” “Did she hit you?” Obviously she hadn’t hit Charlene, or we wouldn’t be talking. “No. Allison hit the gas and the lady swerved and hit her brakes and somehow, thank God, we missed each other. We get through the intersection, and I asked her what in the world she was thinking. She just looked over and said, ‘Sorry Mom, my bad.’ My bad! My bad! She almost kills me and it’s, ‘My bad.’ Then she shrugged her shoulders and asked ‘Can we still go to Bella Gs?” “What did you say?” I asked, truly curious. “I told her yes, yes. I just wanted her to stop the car. I couldn’t talk. I didn’t have any saliva in my mouth to talk. She’s in there shopping now. I couldn’t even go in. My knees are shaking. I couldn’t even go in there.” I guess I’m happy to give up the role of driving instructor for the girls in the house. I tend to get bored at a dress shop. See ya next time, Scott

240 JOURNAL MSMA JULY 2012

B LUE S

B EACO N

A PROGRAM OF THE DELTA HEALTH ALLIANCE

CO MMU N I TY SOLUTIONS FOR A HEALTHY TOMORROW

Delta Health Alliance Presents the Beacon Q&A Q: What in the world is Beacon? A: Beacon is a federal d ggrantt program providing communities commu with funding fu to o build and strengthen n their health care systems. s The Delta Health Al Alliance received one of the 17 gran grants ants the federal government awarded two yea years ago. The total three year grant gra is for $14.7 million. million

Q: What are you hoping to accomplish? A: We are focusing oonn diabetes. diabetes Wee want to show how physicians and hospitals tals can use the latest latesst health information technology techno and clinical practices in innovative vative ways to help get a handle on diabetes in the th Delta. We want to demonstrate monstrate ways to redirect redirrect existing resources out of administration and record keeping and d into patient care. c

Q: Are you just focusing on physicians and hospitals? A: Good question. No iis the short answer. We are also developing programs that work directly with diabetic patients, to help them understand the causes of the disease, how it can be treated, and how it can be prevented.

Q: So, what are you actually doing? A: I’ll give you one of what could be many examples.

We have a program that works with individual patients to assess prescription drug related needs and medication experience to identify, resolve and prevent medication-related problems. The grant pays a pharmacist to work directly with patients in our partner clinics to provide education, screenings and medication management. One outcome of this project is to avoid hospitalizations in a region with some of the highest hospital readmission rates in the country. For example, one inpatient hospital day costs $1,853 for a patient with diabetes. An oﬃce visit where diabetes is the primary diagnosis costs $132. That’s ’ a potential savings of $1,721 for one patient for one day by avoiding a hospital admission and directing care to the primary care provider’s clinic. Multiply that by the thousands of diabetic patients in the Delta and you see what Beacon can do.

For more information about Beacon in Mississippi, contact Delta Health Alliance.

POST OFFICE BOX 277, STONEVILLE, MS 38776 • 662-686-7004

www.deltahealthalliance.org

The Delta Health Alliance receives funding support for health information initiatives through the Beacon Community Program from the Ofﬁce of the National Coordinator, U.S. Department of Health and Human Services.

JULY 2012 JOURNAL MSMA 241

• PLACEMENT / CLASSIFIED • Humility, continued from p. 234.... How do we walk with humility? We walk with humility when we realize the very special privilege that we have as physicians to be invited into the most intimate parts of a person’s life both physically, mentally, and emotionally. We realize that we are not invited in just because of what we have done personally, but because of what doctors have done over thousands of years by conducting themselves with honor and respect, and putting their patients’ interests above their own. So we walk with humility when we realize that we are standing on the shoulders of the giants who have come before us. We walk with humility when we acknowledge that we have an obligation to continue to act with honor and compassion to our patients so that we can pass on this very special privilege that we have to the generation that comes after us. That’s how we walk with humility as doctors. So, when you leave here today, go out and do justice. Love mercy and walk humbly before your God. It is an honor for me to be your president. Thank you for this opportunity.

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• ASCLEPIAD • W. F. PONTIUS OF OCEAN SPRINGS —This month’s physician portrait is of Dr. William Frederic “Bill” Pontius, MD, of Ocean Springs, long a member of our MSMA. Born in Tiffin, Ohio, he spent his early years in Lincoln, Nebraska; Memphis, Tennessee; and Atlanta, Georgia, before moving to Pass Christian, Mississippi, and finally, Flora. His pre-med studies at Mississippi State were interrupted by a stint in the U. S. Navy, after which he obtained his MD from UMMC. After an internship at Mobile General Hospital (now University of South Alabama), he practiced general medicine and surgery for eight years in Canton, delivering sixty to seventy babies a year and serving as President of Central Medical Society in 1971-72. He then performed a residency in Diagnostic Radiology at the University of Florida in Gainesville before beginning his practice of Radiology in Biloxi at Biloxi Regional Medical Center (Howard Memorial) in 1976. There he served as Chief of Staff in 1981 and 1982. One might surmise that the practice of diagnostic radiology after his years as a GP would have been somewhat “prosaic or hum drum.” However, it was just the opposite, for Bill was entering radiology at a time of exponential technological advancement, with new exciting modalities emerging. He notes: “During my residency, we trained in ultrasound, and thus I became the first ultrasonographer on the Mississippi Gulf Coast. I also trained in angiography where mini-catheters were the norm instead of the standard large caliber catheters which had more complications. We also had CT training in Florida, but it took a couple of years to acquire a scanner here on the Coast.” As well, interventional radiology had its beginning about that time, and nuclear medicine, which had been thought to be withering on the vine, began a renewed life with 3D and SPECT scanning. MRIs continued further imaging advancement without radiation and with exquisite detail. He also was among the first radiologists to implement teleradiology and by 1980 had pioneered “computerized” billing in the office. During his period of practice, a radiologist was a renaissance man, seeing most every patient that entered the hospital and participating significantly in most diagnoses and treatment. He reflects, “I always loved the practice of medicine; it’s the business of medicine that is abominable.” He has been married almost 23 years to wife Mollie, who has served our alliance as local president and is currently serving as MSMAA President-Elect. They have three children, Mike (American Medical Response) married to Lori, Amy (Vascular Lab Nurse, Ocean Springs Hospital), and Regina (accountant, City of Biloxi). They have five grandchildren: Taylor, Madison, Shelby, Drew, and Grayson. For more on Dr. Pontius, see “From the Editor,” page 214. This photo is by Karen Evers. — Lucius M. Lampton, MD, Editor

244 JOURNAL MSMA JULY 2012

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