July 2014 JMSMA by Journal MSMA

July

VOL. LV

2014

No. 7

GET READY FOR

ICD-10

STAY ON THE ROAD TO 10 STEPS TO HELP YOU TRANSITION The ICD-10 transition will affect every part of your practice, from software upgrades, to patient registration and referrals, to clinical documentation and billing. CMS can help you prepare. Visit the CMS website at www.cms.gov/ICD10 and find out how to: •

Make a Plan—Look at the codes you use, develop a budget, and prepare your staff

•

Train Your Staff—Find options and resources to help your staff get ready for the transition

•

Update Your Processe—Review your policies, procedures, forms, and templates

•

Talk to Your Vendors and Payers—Talk to your software vendors, clearinghouses, and billing services

•

Test Your Systems and Processes—Test within your practice and with your vendors and payers

Now is the time to get ready. www.cms.gov/ICD10

Official CMS Industry Resources for the ICD-10 Transition

www.cms.gov/ICD10

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 James A. Rish, MD President Claude Brunson, MD President-Elect Michael Mansour, MD Secretary-Treasurer R. 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. Copyright© 2014 Mississippi State Medical Association.

JULY 2014

VOLUME 55

NUMBER 7

Scientific Articles Management of Preeclampsia When Diagnosed Between 34-37 Weeks Gestation: Deliver Now or Deliberate Until 37 Weeks? Michelle Y. Owens, MD; Brad Thigpen, DO; Marc R. Parrish, DO; Sharon D. Keiser, MD; Sandip Sawardecker, MD; Kedra Wallace, PhD; James N. Martin, Jr., MD

Top Ten Facts You Need to Know: About Liver Transplantation

212

Fauzia K. Butt, MD; Truman M. Earl, MD; Christopher D. Anderson, MD

Gulf Coast Tick Rash Illness in Mississippi Caused by Rickettsia parkeri 216 Okechukwu Ekenna, MD, MPH; Christopher D. Paddock, MD; Jerome Goddard, PhD

Up-To-Date Medicine in Mississippi: Avoiding Narcotic Analgesics in Young Children

President’s Page On Becoming a Doctor

237

James A. Rish, MD; MSMA President

Editorials Remaining a Great Physician in Tough Times: Learning from Business Principles

239

Robert T. Brodell, MD and Stephen E. Helms, MD

A Glimmer of Hope in the Electronic Medical Records Plague

241

John P. Hey, III, MD

Related Organizations Mississippi State Department of Health

246

Departments From the Editor: Katrina’s Lessons Learned in Louisville MSMA Annual Report 2013 Letters Poetry and Medicine Images in Mississippi Medicine

206 221 243 247 248

About The Cover:

“Rock Paper Scissors”- “In this challenging world of the ‘business of medicine,’ we should not compromise the core of what we have been trained to do. We must take the effort to stay involved in the crafting of political and legislative decisions for the sake of our patients. We must not allow the ‘business of medicine’ to be reduced to a ‘rock paper scissors’ decision-making game between players unable to reach a decision using other means,” writes creative photographer William (Bill) Pontius, MD of Ocean Springs. On a seperate note, his wife Mollie Pontius, president of the MSMA Alliance chapter in Ocean Springs, received the 2014 Prestige Award from the American Medical Association Alliance. This is a national award for community service in Health Awareness Promotion. Mississippi’s project was titled “Reaching the Finish Line With Dignity,” a brochure designed to address advanced directives and end-of-life planning. VOL. LV

of the MSMA Since 1959

235

Jeffrey D. Carron, MD

July

Official Publication

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2014

No. 7

July 2014 JOURNAL MSMA 205

From the Editor: Katrina’s Lessons Learned in Louisville

n April 28th, twenty-three tornadoes plowed through the heart of our state. The most catastrophic damage occurred in the central Mississippi city of Louisville, where an EF4 tornado was confirmed to have touched down. With Katrina-like brutality, that tornado left behind extensive devastation, thousands of injuries, and ten lives lost. Over 38 businesses were swept away, many of them essential medical institutions, such as clinics and nursing homes. Winston County’s hospital was also severely damaged and left unusable. The exemplary disaster response, coordinated by Governor Phil Bryant, may be remembered as his finest hour. With the hospital out of service, a 6 bed mobile ER staffed by UMMC opened to stabilize medical emergencies. However, it soon was obvious that Louisville would need a long-term temporary hospital. Mississippi’s leaders were able to obtain the nation’s Mobile Disaster Hospital, a federal asset located in North Carolina. (This was the first time it had been deployed on domestic soil.) Two dozen trucks delivered the hospital, with volunteers setting up the modular units on a large slab of concrete. Within 19 days of the storm, this 70,000 square

foot full-service acute care hospital opened in Louisville. The facility is expected to operate for the next 18 months, as local leaders plan for either restoring or replacing the old hospital facility. From Hurricane Katrina, Mississippi’s emergency responders learned many lessons. First, a hospital must become operational Lucius M. Lampton, MD promptly to preserve the local medical infrastructure. Doctors must have a place to work, or they will be forced to leave to support their families. As well, hospitals can’t bill Medicare if operating from tents, but they can bill if in modular structures. Bringing in other medical providers is not the solution in a disaster. Rather, the solution is keeping the community’s own physicians working and seeing their patients. After Katrina, many of the physicians impacted, unable to see their patients, had to leave their communities to find paying jobs. Louisville’s docs aren’t leaving because they can still see their patients and continue to make a living. Contact me at lukelampton@cableone.net. —Lucius M. “Luke” Lampton, MD, Editor

Journal Editorial Advisory Board Myron W. Lockey, MD Chair, JMSMA Editorial Advisory Board Journal MSMA Editor Emeritus, Madison Timothy J. Alford, MD Family Physician, Kosciusko Medical Clinic Michael Artigues, MD Pediatrician, McComb Children’s Clinic 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 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

Bradford J. Dye, III, MD Ear Nose & Throat Consultants, Oxford Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist, The Street Clinic, Vicksburg

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Paul “Hal” Moore Jr., MD Radiologist Singing River Radiology Group, Pascagoula

Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson

Jason G. Murphy, MD Surgeon Surgical Clinic Associates, 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

Ann Myers, MD Rheumatologist Mississippi Arthritis Clinic, Jackson

Scott Hambleton, MD Medical Director Mississippi Professionals Health Program, Ridgeland John Edward Hill, MD Family Physician, North Mississippi Medical Center Tupelo W. Mark Horne, MD Internist, Jefferson Medical Associates, Laurel Brett C. Lampton, MD Internist/Hospitalist, Baptist Memorial Hospital, Oxford

Philip L. Levin, MD President, Gulf Coast Writers Association Emergency Medicine Physician, Gulfport William Lineaweaver, MD Sharon Douglas, MD Editor, Annals of Plastic Surgery Professor of Medicine and Associate Dean for VA Medical Director Education, University of Mississippi School of Medicine, JMS Burn and Reconstruction Center, Jackson Associate Chief of Staff for Education and Ethics, G.V. Montgomery VA Medical Center, Jackson Michael D. Maples, MD Vice Preisdent, Chief of Medical Operations Baptist Health Systems, Jackson Thomas E. Dobbs, MD, MPH State Epidemiologist Mississippi State Department of Health, Hattiesburg

Alan R. Moore, MD Clinical Neurophysiologist Muscle and Nerve, Jackson

Darden H. North, MD Obstetrician/Gynecologist and Author Jackson Health Care for Women, Flowood 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 Clinical Cardiologist, Hattiesburg Clinic W. Lamar Weems, MD Urologist, Jackson Chris E. Wiggins, MD Orthopaedic Surgeon Bienville Orthopaedic Specialists, Pascagoula John E. Wilkaitis, MD Chief Medical Officer Brentwood Behavioral Healthcare, Flowood

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Knowing Our Insureds July 2014 JOURNAL MSMA 207

• Scientific Articles • Management of Preeclampsia When Diagnosed Between 34-37 Weeks Gestation: Deliver Now or Deliberate Until 37 Weeks? Michelle Y. Owens, MD; Brad Thigpen, DO; Marc R. Parrish, DO; Sharon D. Keiser, MD; Sandip Sawardecker, MD; Kedra Wallace, PhD; James N. Martin, Jr., MD

bstract

Objective: To evaluate maternal-newborn outcomes with immediate or expectantly managed preeclampsia first diagnosed at 34-37 weeks. Methods: Late preterm patients with preeclampsia without severe features were randomly assigned to immediate delivery (n=94) or expectant management (n=75) until 37 weeks gestation or earlier if severe features developed. Data were analyzed by appropriate tests for continuous or categorical outcomes with differences considered significant if p<0.05. Results: The two groups were similar at presentation. 41% of those expectantly managed developed severe features of preeclampsia within 72 hours versus 3% in the immediately delivered group (p<0.001). Immediate delivery did not significantly increase cesarean delivery or neonatal morbidity. Conclusion: Immediate delivery of the late preterm patient with preeclampsia significantly lessens her development of severe features without significantly increasing newborn risks. For the expectantly managed late preterm patient with preeclampsia, close surveillance for the first 72 hours following diagnosis and twice weekly thereafter appears prudent.

Key Words: Late Preterm Preeclampsia, Maternal Morbidity, Neonatal Morbidity

Author Affiliations: From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Winfred L. Wiser Hospital for Women and Infants, University of Mississippi Medical Center, Jackson, MS, USA. Corresponding Author: Michelle Owens, MD, Associate Professor, Division of Maternal-Fetal Medicine, Department of OB/GYN, University of Mississippi Medical Center, 2500 North State St., Jackson, MS 39216. Tel. 601-984-5358, Fax 601-984-6773, myowens@umc.edu). Disclosure: The authors report no conflict of interest. The Division of Maternal-Fetal Medicine in the Dept. of OB/GYN at the University of Mississippi Medical Center funded this study.

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Introduction Pregnant patients frequently develop gestational hypertension (GH) or preeclampsia (PE) during the late preterm pregnancy period spanning 34 0/7 to 36 6/7 weeks gestation. The recently released ACOG Guidelines for the management of patients with hypertensive disorders of pregnancy recommend delivery by 34 weeks gestation for patients with severe preeclampsia (“severe features” present) and delivery by 37 weeks for all patients with GH or PE.1 What to do for patients who develop either GH or PE between those two gestational milestones can be problematic for the practitioner. Balancing concern for the mother with her risk of preeclampsia progression versus concern that the newborn might suffer increased prematurity-associated risks if delivered before term is pivotal and pressing in importance. Uncertainty about the best course to follow in this clinical setting led us to undertake the present investigation which began in 2002. The objective was to estimate if immediate delivery of late preterm patients with PE but without severe features would prevent maternal disease progression without compromising neonatal outcome versus a policy of expectant management and surveillance until 37 weeks gestation was achieved. Methods and Materials Patient Enrollment. Patients admitted to The Wiser Hospital for Women & Infants at the University of Mississippi Medical Center (UMMC) from March 2002 through June 2008 who met ACOG 2002 criteria2 for mild preeclampsia (PE), had reliable gestational dating for 34-36 6/7th weeks (with an estimated fetal weight >2000g) and no other maternal-fetal-pregnancy complications were invited to participate in this IRB-approved trial.3 After informed consent, participants were randomized to immediate or expectant groups using stratified and random permuted blocks of 2 in consecutively numbered opaque envelopes. Those in the immediate arm were delivered via induction of labor or cesarean delivery within twelve hours of randomization. Those in the expectant management arm remained

Statistical Analysis. A total sample size of 220 patients (110 per group) was calculated to be necessary to ascertain statistically significant differences between the groups. Chi-square analysis, Fisher’s exact test and Student Ttest were used when appropriate to determine significance. Groups were also analyzed based on timing of PE diagnosis. Significance was defined as a p value < 0.05.

Fig 1. CONSORT flowchart of patients enrolled in trial. Enrolled and Randomized Consort Flow Diagram

Allocated to immediate delivery (n= 97) Received allocated intervention  Vaginal delivery (n=52)  Cesarean delivery (n=42)

183

Allocation

Allocated to expectant management (n=86) Received allocated intervention  Progression of disease (n= 31)  Delivery at term (n=44 )

Excluded (n=11) Not meeting inclusion criteria (n=7) Voluntarily withdrew from study (n=1) Met criteria but left AMA (n=3)

Excluded (n=3) Not meeting inclusion criteria (n=3)

Analyzed (n=75)

Analyzed (n=94) Excluded from analysis (n=0)

Analysis

Excluded from analysis (n=0)

as inpatients for twice daily assessment of signs, symptoms and laboratory values (every 3 days) suggestive of disease progression with severe features of PE. Twice weekly non-stress testing was used for fetal surveillance. Expectantly managed patients were carried to 37 weeks gestation unless there was spontaneous onset of labor or rupture of membranes, suspected placental abruption, development of severe features of PE or evidence of fetal compromise. Severe features include severe hypertension, thrombocytopenia, impaired liver function, epigastric pain, renal insufficiency, pulmonary edema, cerebral disturbances, or visual impairment. All study patients were treated with magnesium sulfate prophylaxis intrapartum and immediately post-partum.4 The primary maternal outcomes were a composite of maternal morbidity, mortality and maternal development of severe disease features as defined by ACOG.1,2 Other assessed outcomes included major neonatal morbidities and mortality.5

Results Patient demographics, laboratory values and clinical characteristics. Between March 2002 and June 2008, a total of 183 patients were enrolled before the study was stopped when discontinuation of the protocol as approved was no longer possible, leaving it underpowered with only 169 of the desired 220 study participants (Figure 1 flow chart). As illustrated in the Table, except for gestational age and weight at delivery, progression to severe PE, and length of hospitalization, there were no significant differences between groups with regard to demographics, laboratory values or clinical characteristics.

Progression to severe disease in expectant management group. The primary outcome of the current study was the occurrence of maternal mortality, maternal morbidity and progression of PE with the appearance of severe features. Forty-one % of women in the Expectant group developed severe features compared to 3% in the Immediate delivery group (p=0.001); RR = 2.79, 95% CI (2.15-3.64). The diagnosis of PE at an earlier gestational age did not significantly increase maternal risk of progression (p=0.16;Figure 2A). Severe hypertension was the most commonly observed feature indicative of disease progression (p=0.53), occurring on average 2.9+0.5 days following randomization in the Expectant group versus 0.83+0.12 days (p=0.22) in the Immediate delivery group; headache was second in frequency (Table). One expectantly managed patient developed HELLP syndrome and another developed postpartum eclampsia. As expected, there was significantly longer total hospitalization in the expectantly managed patient group (Table).

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Neonatal outcomes. Neonatal outcomes for study participants in both groups are also shown in the Table. The majority of newborns with neonatal morbidities (57%) were born to expectantly monitored mothers who developed severe features of PE although this did not increase risk for NICU admission (RR=0.96, 95%CI (0.79-1.19). Gestational age at diagnosis had a significant effect on the rate of NICU admission with the rate decreasing the closer to term that a patient was diagnosed (p=0.04, Figure 2B). There were no significant differences in NICU admission rates or length of stay between groups with 19% of newborns born to expectant mothers versus 21% in the immediate group (p=0.70) and 6.71+1.27days versus 6.85+1.23 days; p=0.94. Delivery of patients closer to 34 than 37 weeks gestation was not associated with an increased risk of NICU admission (RR=1.83, 95%CI(0.993.39).

Table. Summary table showing selected demographic, laboratory, clinical, delivery, postpartum and neonatal features of the EXPECTANT and IMMEDIATE delivery groups. TABLE. Study Variables

EXPECTANT (n=75)

ADMISSION Nulliparous 24 (36%) Maternal Age (years) 24.3 + 6.3 Gestational Age (weeks) At Enrollment 34.97 + .98 At Delivery 36.61 + 1.31 Ethnic Origin White 15 (20%) Black 54 (72%) Hispanic 1 (1%) Native American 5 (7%) MATERNAL OUTCOME Onset of Labor Vaginal 47 (63%) Cesarean 28 (37%) Elective 17 (61%) Failed Induction/Progress 6 (21%) Non-reassuring Fetal Indication 5 (18%) Progressed to Severe PE 31 (41%) Severe Hypertension 20 (68%) Cerebral Disturbances-Headache 8 (26%) Impaired Liver Function 4 (13%) Visual Impairment 1 (3%) Epigastric Pain/Nausea/Vomiting 2 (6%) Increasing Proteinuria 5 (16%) Postpartum Complications HELLP Syndrome 1 (1%) Eclampsia 1 (1%) Total Hospital LOS post delivery (days) 3.11 + 0.18 Total Hospital LOS (days) 18.11 + 14.81 NEWBORN Birthweight (grams) 2766.3+ 508.98 Small for Gestational Age 11 (15%) Arterial umbilical cord pH 7.24 + 0.01 NICU Admission 14 (19%) Reason for NICU Admission Asphyxia 4 (5%) Respiratory Distress Syndrome 6 (8%) Transient Tachypnea of Newborn 7 (9%) Apnea 1 (1%) NICU LOS (days) 1.25 + 3.3

IMMEDIATE (n=94)

P Value

38 (40%) 23.1 + 5.5

0.27 0.19

35.14 + .99 35.25 + .99

0.27 0.001* 0.52

21 (22%) 70 (75%) 1 (1%) 2 (2%) 52 (55%) 42 (45%) 21 (50%) 13 (31%) 6 (14%) 3 (3%) 3 (100%) 1 (33%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)

0.35 0.35 0.47 0.42 0.74 0.0001* 0.535 1 1 1 1 1

0 0 3.10 + 0.13 6.92 + 4.81

0.44 0.44 0.96 0.01*

Discussion The present findings about the implications of a diagnosis of PE first 2491.5+426.05 0.01* made during the late term period (be19 (20%) 0.08 tween 34-37 weeks gestation) in 169 7.24 + 0.01 0.48 20 (21%) 0.89 patients is complementary to other published findings. Barton and colleagues 3(3%) 0.70 reported that 52.1% of women with evi11(12%) 0.45 4 (4%) 0.21 dence of GH prior to 30 weeks of ges0 0.44 tation developed PE; 37.3% with first 1.45 + 3.76 0.72 evidence of GH around 34-35 weeks Data is represented as the number of patients (% of study population) or mean + standard error mean. LOS = length of stay. * denotes that P < 0.05 when the outcomes between the EXPECTANTLY managed and IMMEDIATE developed PE. These findings indicate delivery group are compared. that the earlier in gestation that GH is diagnosed, the greater is the chance is fetal condition of PE patients twice weekly up until delivery at for PE to develop.6 In the expectantly 37 weeks (in the absence of severe features) is consistent with managed PE patients from the current investigation, 41% deour findings.1 veloped severe features of PE within 3 days of diagnosis. This Induction of labor in women with PE diagnosed after suggests that patients with late term appearing PE will progress 36 weeks gestation versus expectant management in the Dutch in severity at a clinically significant frequency independent of HYPITAT trial reportedly decreased disease severity, maternal maternal age, parity or maternal race. Clearly it is important morbidity, and the rate of cesarean delivery without negatively to undertake enhanced inpatient or outpatient surveillance of impacting neonatal outcome.7 Findings from this and other patients in this clinical situation in order to detect and respond subsequent reports from the HYPITAT investigators are largely appropriately if and when severe features of PE present. In our responsible for the recent ACOG recommendation to deliver all experience, the first 72 hours following a late term PE diagnosis patients with GH or PE at 37 weeks).1 The present Mississippi was the most likely time to detect severe features as evidence of findings, reported despite the acquisition of only 77% of the disease progression to indicate delivery. The recently released desired patient numbers before issues of reimbursement and inACOG guidelines for physicians to monitor the maternal and

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Fig 2. Primary and Secondary outcomes based on gestational age at diagnosis. Women diagnosed at an earlier gestational age more often developed severe features with PE than women diagnosed at a later gestational age (A) and were more likely to have a baby admitted to the NICU (B).

for a substantial amount of severe obstetric morbidity.18 Data from the present study, while needing corroboration from a substantially larger number of participants and participating institutions, suggests that expectant management of the PE patient after 34 weeks gestation is undertaken at much greater risk of severe features of PE developing in the mother without significantly increased neonatal risk or a prolonged stay in the NICU. References

creased emphasis on outpatient management forced closure of the protocol, found similar results to HYPITAT when the gestational age ranged between 34-37 weeks at the time that PE was first diagnosed. Importantly a significant increase in cesarean delivery due to labor induction did not happen nor was there a significant risk associated with induction of labor vs. expectant management. The authors note, however, that when induction of labor is considered for the preterm patient with PE, there are other factors to consider such as cervical length and ripeness which our study did not examine.8-10 We did observe that women diagnosed at 35 weeks tended to need more cervical ripening compared to women diagnosed at other time periods. There are multiple recent publications which emphasize the increased morbidity that patients having late preterm and early term newborns can incur when delivered.11-14 It is important to emphasize that neonatal morbidity at any stage of gestation is significantly increased in newborns of mothers with PE.15,16 Buchbinder et al observed a 24% NICU admission rate in women with PE without severe features, a frequency that is similar to the 19-21% rate that we observed.17 The HYPITAT trial also found results similar to ours with no significant differences in neonatal outcomes between groups undergoing induction of labor and those expectantly managed.7 The increasing occurrence of patients suffering with a hypertensive disorder of pregnancy such as PE is responsible

Hypertension in Pregnancy: Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol 2013;122:1122-1131.

ACOG: Diagnosis and management of preeclampsia and eclampsia, Practice Bulletin. 2002.

Alexander G, Himes J, Kaufman R et al: A United States national reference for fetal growth. Obstet Gynecol 1996; 87: 163-168.

McDonald K, Lutsiv O, Dzaja N et al: A systematic review of maternal and infant outcomes following magnesium sulfate for pre-eclampsia/eclampsia in real-world use. Int J of Gynecol and Obstet 2012; 118: 90-96.

Cloherty J, Eichenwald E, Stark A: Manual of neonatal care. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. 2008.

Barton J, O’Brien J, Bergauer N et al: Mild gestational hypertension remote from term: progression and outcome. Am J Obstet Gynecol 2001; 184: 979-983.

Koopmans C, Bijlenga D, Groen H et al.: Induction of labour versus expectant monitoring for gestational hypertension or mild pre-eclampsia after 36 weeks gestation (HYPITAT):a multicentre, open-label randomised controlled trial. Lancet 2009; 374: 979-988.

Van der Tuuk K, Koopmans C, Groen H et al.: Prediction of progression to a high risk situation in women with gestational hypertension or mild pre-eclampsia at term. Australian and New Zealand Journal of Obstetrics and Gynaecology 2011; 51: 339-346.

Tajik P, van der Tuuk K, Koopmans C et al.: Should cervical favourability play a role in the decision for labour induction in gestational hypertension or mile pre-eclampsia at term? An exploratory analysis of the HYPITAT trial. British Journal of Obstetrics and Gynaecology 2012; 119: 11231130.

10. Caughey A, Sundaram V, Kaimal A et al.: Maternal and neonatal outcomes of elective induction of labor. Evid Rep Technol Assess 2009; 176: 1-257. 11. Escobar G, Clark R, Green J: Short-term outcomes of infants born at 35 to 36 weeks gestation: we need to ask more questions. Seminars in Perinatology 2006; 30: 28-33. 12. Melamed N, Klinger G, Tenenbaum-Gavish K, et al.: Short-term neonatal outcome in low-risk, spontaneous, singleton, late preterm deliveries. Obstet Gynecol 2009; 114: 253-260. 13. Bird T, Bronstein J, Hall R et al: Late preterm infants: birth outcomes and health care utilization in the first year. Pediatrics 2010; 126. 14. Consortium on Safe Labor, Hibbard J, Wilkins I, Sun L et al.: Respiratory morbidity in late preterm births. JAMA 2010; 304: 419-425. 15. Beke A, Rigo JJ, Paulin F: Effect of preeclampsia on neonatal morbidity. Orv Hetil 1995; 136: 1999-2003. 16. Abramovici D, Friedman S, Mercer B et al: Neonatal outcome in severe preeclampsia at 24 to 36 weeks’ gestation: does the HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome matter? Am J Obstet Gynecol 1999; 180: 221-225. 17. Buchbinder A, Sibai B, Caritis S et al.: National Institutes of Child Health and Human Development Network of maternal-Fetal Medicine Units. Adverse perinatal outcomes are significantly higher in severe gestational hypertension than in mild preeclampsia. Am J Obstet Gynecol 2002; 186: 66-71. 18. Kuklina E, Ayala C, Callaghan W: Hypertensive disorders and severe obstetric morbidity in the United States. Obstet Gynecol 2009; 113: 12991306.

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â&#x20AC;˘ Top Ten Facts You Need to Know â&#x20AC;˘ About Liver Transplantation

Fauzia K. Butt, MD; Truman M. Earl, MD; Christopher D. Anderson, MD ntroduction

In 1983, the National Institutes of Health concluded that liver transplantation was a legitimate, non-experimental treatment for end-stage liver 1 disease. Liver transplantation is the only therapy for a variety of chronic liver disease states which were previously considered to be universally incurable and resulted in death. Acute fulminant liver failure is another indication for transplantation. Well-compensated cirrhosis has a 10-year survival rate above 80%, but after complications develop (decompensation), the 5-year survival rate decreases to less than 50%.2 These complications may include the development of ascites, jaundice, variceal bleeding, hepatic encephalopathy, spontaneous bacterial peritonitis or hepatorenal syndrome. Timely referral for liver transplantation is essential, as a thorough evaluation takes time. Appropriate candidates are placed on a waitlist for a deceased donor organ. After listing, every patient must wait an additional undetermined period of time for a suitable donor organ to become available. The United Network for Organ Sharing (UNOS), a nonprofit organization under contract with the federal government as the National Organ Procurement and Transplantation Network (OPTN), allocates all deceased donor organs to ensure distribution in an equitable manner. Liver allocation has evolved over the years and is currently based on a calculated score, which reflects the likelihood of survival after transplantation. 1. Established guidelines exist for the evaluation of potential liver transplant recipients.2 Developed by the Practice Guidelines Committee of the American Association for the Study of Liver Diseases, these evidence-based recommendations facilitate the evaluation of liver transplant candidates by establishing some degree of uniformity for transplant programs. Potential recipients undergo extensive medical testing and a thorough psychosocial evaluation to determine their eligibility for transplantation. While specific selection criteria may vary slightly by transplant center, their main purpose is to ensure that potential candidates lack any unacceptable medical or psychosocial risks that would preclude a successful outcome. Repeat testing after initial listing Corresponding Author: Fauzia K. Butt, MD, FACS, Assistant Professor of Surgery, Division of Transplant and Hepatobiliary Surgery, Associate Director of Surgical Clerkship, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216. Tel. (601)815-3135 (fbutt@umc.edu).

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may be indicated for certain individuals, such as those with hepatocellular carcinoma or cardiovascular disease, in order to reconfirm continued suitability. Prospective candidates with substance abuse issues must demonstrate at least 6 months of sobriety before they can be listed for transplantation. Treatment of drug or alcohol addiction may require extensive counseling, including therapy in an inpatient program. In many cases, the inability to objectively demonstrate abstinence will exclude patients from listing. 2. Calculated Model for End-Stage Liver Disease (MELD) and Pediatric End-Stage Liver Disease (PELD) scores have been used to guide liver allocation for adult and pediatric patients, respectively, since February 27, 2002.3.4 The MELD score (Table 1) was initially developed to predict the 3-month mortality of patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) procedures and included laboratory values for serum creatinine, bilirubin, the international normalized ratio (INR) of prothrombin time and liver disease etiology. The MELD score was validated as a risk-stratification model by the Mayo Clinic and the etiology of liver disease was eventually eliminated, as it did not appear to contribute to the overall predictive power.4 The PELD score (Table 1), developed for pediatric patients with liver disease, includes bilirubin, INR, albumin, age < 1 year and growth failure (defined as height or weight more than 2 standard deviations below normal, for age and gender).4 The utilization of these scores allowed the liver allocation system to progress from a static, status-based algorithm based primarily on waiting time and urgency of need to a more dynamic process, using an objective severity score to stratify patients on the waitlist. Deceased donor livers are currently allocated based on MELD and PELD scores, independent of waiting time. Transplant centers are required to routinely update these scores to reflect any changes in disease severity.3 Since dialysis can artificially decrease serum creatinine levels, 4 mg/dL is uniformly utilized for MELD score calculation in patients on maintenance dialysis. The maximum achievable MELD score is 40.3 3. End-stage liver disease secondary to Hepatitis C virus (HCV) is the most common indication for liver transplantation in the United States.2,5,6 The primary etiology for 23.5% of all adult liver transplants performed in 2011 was HCV.7 It is estimated that cirrhosis will develop in 15-20% of patients with chronic HCV in-

of MELD and PELD scores fection within 20 years and concurrent Table 1: Calculation Table 1. Calculation of MELD and PELD scores alcohol abuse hastens this process.2 Pa- These scores are used to determine priority for recipients listed for a deceased donor liver. Laboratory tients with cirrhosis secondary to HCV values < 1 are set at 1; calculated score is multiplied by 10 and rounded to the nearest whole number. also have a 2-8% annual risk of developing hepatocellular carcinoma (HCC), MELD score calculation (for patients ≥ 12 years old) making HCV the leading cause of HCC MELD score = 0.957 x Loge(creatinine mg/dL) + 0.378 x Loge(bilirubin mg/dL) + 1.120 x Loge(INR) + 0.6431 For patients on dialysis, creatinine is automatically set at 4.0 mg/dL in the United States.2 Transplantation for HCV-related cirrhosis has 1-year PELD score calculation (for patients < 12 years old) and 5-year survival rates of 88% and PELD Score = 0.480 x Loge(bilirubin mg/dL) + 1.857 x Loge(INR) - 0.687 x Loge(albumin g/dL) + 0.436 if the patient is < 1 year old 69%, respectively.8 In patients with ac+ 0.667 if the patient has growth failure (<-2 Standard deviations) tive viral loads at the time of transplant, will develop decompensation within 7 years.13 The percentage HCV infection has a recurrence rate of of patients undergoing liver transplantation for NASH increased 100% in the transplanted liver.6 Cirrhosis may then subsequentfrom 1.2% in 2001 to 9.7% in 2009 and NASH is projected to ly develop in 20-40% of these patients within 5 years.6 The replace HCV as the leading indication for liver transplantation development of cirrhosis in the HCV post-transplant patient is within the next 20 years.12 The 1-year and 3-year patient survivassociated with decompensation in 40% within 1 year and has a al rates after transplantation were reported to be 84% and 78%, Liver‐Kidney Transplantation 50% mortality rate at 2 years.6 Historically,Table 2: Recommendations the outcomes of re- of Consensus Conference on Simultaneous respectively, which is comparable to that for other indications transplantation for HCV patients have been dismal. However, Due to the dismal prognosis of ESLD patients with renal 12 dysfunction and the limited supply of available for transplantation. However, NAFLD is closely linked to most centers have improved their selectiondeceased criteriadonor and organs, resultsguidelines were developed to determine which patients would benefit from the metabolic syndrome and many other comorbid conditions. simultaneous liver-kidney have improved.9 Currently, treatment of HCV recurrence after transplantation. Patients over 60 yearsgranted to: old with cirrhosis secondary to NASH, simultaneous liver‐kidney transplantation transplantation is difficult due to limited Approval for efficacy and severe hypertension, diabetes and a BMI ≥ 30 kg/m2 have a reported 1. ESRD patients with cirrhosis AND toxicity of the medications used. The development of effective, a. symptomatic portal hypertension OR 50% 1-year mortality after transplantation.13 Transplant centers non-toxic therapy for recurrent HCV will improve long-term b. hepatic vein wedge pressure with gradient > 10 mm Hg weigh such comorbid diseases heavily in the selection process transplantation success rates and newer treatment regimens 2. ESLD patientsofwith CKD AND GFR ≤ 30 mL/min for NASH patients. 10 fer the promise of improved efficacy. 3. Acute kidney injury, or HRS, with SCr ≥ 2.0 mg/dL AND dialysis ≥ 8 weeks 4. ESLD patients with evidence of CKD AND kidney biopsy demonstrating 6. Hepatocellular Carcinoma is an indication for liver 4. Biliary atresia is the most common indication a. for > 30% glomerulosclerosis OR 14 transplantation. 2 b. 30% fibrosis pediatric liver transplantation. annual incidence for the development of hepatocelAbbreviations: ESRD =of end-stage ESLD = end-stage liver disease, CKD = chronic kidney disease, GFR = glomerular Biliary atresia (BA) is the indication for 60-70% all renal disease,The lular SCr carcinoma (HCC) in cirrhotic patients is 3%.15 After liver = hepatorenal syndrome, = serum creatinine. pediatric liver transplants.2 Left untreated,filtration deathrate, is HRS certain by transplantation for HCC was widely abandoned in the 1990’s about 2 years of age. In contrast, early diagnosis and a Kasai due to high recurrence rates, the group from Milan, Italy, re2 portoenterostomy can increase survival in 70% of newborns. ported an 83% 4-year survival in 1996. This became known Successful outcome with a portoenterostomy procedure is as the Milan Criteria, defined as one tumor measuring ≤ 5 cm markedly decreased if the condition remains undiagnosed past in diameter or no more than three nodules, each measuring ≤ 3 months of age. Cirrhosis and portal hypertension may devel3 cm.15 Approximately 20% of liver transplants today are perop after a successful Kasai procedure and these children evenformed for a hepatic malignancy. Five-year patient survival has tually need transplantation for continued survival. After transbeen reported to be 70% with a 5-year disease-specific survival plantation, children with biliary atresia have an overall 1-year of 95%.16 This overall survival is similar to that of cirrhotic 11 survival of 93% and a 5-year survival above 85%. These expatients without HCC who undergo liver transplantation and cellent results are attributed to the lack of disease recurrence in more importantly, it is markedly improved compared to the BA patients after transplantation. 25% 3-year survival rate of cirrhotic patients with untreated, small HCCs.15 Currently, patients meeting the Milan Criteria 5. Nonalcoholic steatohepatitis is currently the third most are granted MELD exception points by UNOS in an effort to common indication for liver transplantation in the United expedite transplantation.14 States and is projected to become the leading indication within the next two decades.12 7. Toxicity secondary to acetaminophen overdose is the

Nonalcoholic fatty liver disease (NAFLD) resembles alcohol-induced liver injury histologically but occurs in the absence of alcohol ingestion. Nonalcoholic steatohepatitis (NASH) is the term used to describe hepatocellular necrosis and inflammation occurring in a steatotic liver, with or without accompanying fibrosis. NASH is estimated to progress to cirrhosis in 9-20% of patients and 50% of these cirrhotic patients

most common cause of fulminant hepatic failure in the United States.17

Fulminant hepatic failure (FHF) has been defined as the rapid onset of acute liver failure, characterized by encephalopathy and synthetic dysfunction, in the setting of previously normal liver function or well-compensated liver disease.18 Hypotension, renal insufficiency, sepsis and multisystem organ

July 2014 JOURNAL MSMA 213

failure may also develop in addition to coagulopathy and encephalopathy.19 The development of cerebral edema can lead to herniation and death. Intracranial pressure monitoring is occasionally utilized to maintain a cerebral perfusion pressure (defined as systemic blood pressure minus intracranial pressure) above 40 mm Hg.17 Patients presenting with FHF should be stabilized and transferred to the nearest transplant center. While some patients may be managed with supportive care until liver regeneration and complete recovery occurs, liver transplantation may be the only life-saving option for others. The ability to predict outcomes is challenging. Ideally, one would hope to avoid an unnecessary operation, particularly when the existing supply of donor organs is woefully inadequate to meet the demands of waitlisted patients. The Kingâ&#x20AC;&#x2122;s College criteria are used to help predict which patients will recover spontaneously and distinguish between acetaminophen overdose and other causes of acute hepatic failure.17, 18 For those patients with a life expectancy of < 7 days, UNOS has designated a special status 1 category to expedite transplantation.17 Status 1 designation is also assigned to patients with primary graft non-function or hepatic artery thrombosis within 7 days after transplantation.17 Transplantation has increased survival rates for acute hepatic failure from 15% to approximately 60 to 80 %.18 8. Solid organs and tissues may be recovered from deceased donors who are determined to have irreversible cessation of either neurologic or cardiac function.20 Neurologic criteria are used to determine brain death for a potential organ donor and the guidelines followed in the United States are clearly defined.21 In order to honor the wishes of patients with severe neurological injury without any possibility for meaningful recovery, donation after cardiac death (DCD) is an acceptable option for those patients who do not meet strict brain death criteria. The ventilator is discontinued and cardiac death must occur, which means complete cessation of circulatory function. Death is always declared by a physician independent of the organ recovery team to avoid any potential conflicts of interest. In order to demonstrate irreversibility, termination of circulatory and respiratory function must exist for at least 5 minutes before the organ recovery process can begin.20 Although DCD organs expand the donor pool, transplant surgeons must be highly selective. Livers recovered from DCD donors are associated with an increased risk of primary non-function after transplantation, as well as hepatic artery thrombosis and biliary complications, such as intrahepatic biliary strictures secondary to ischemic cholangiopathy.22 9. A living person may donate a portion of the liver after extensive screening for any medical conditions or psychosocial issues that would preclude donation.23 In contrast to living kidney donation, where one kidney can be removed without affecting the other, living donor liver transplantation (LDLT) entails division of the liver, with a

214 JOURNAL MSMA July 2014

portion given to the recipient, and has significant morbidity. It is essential that the donor be left with a large enough segment of liver to allow adequate liver function and regeneration.24 The advantages of living donation include the ability to thoroughly test the donor, electively schedule surgery and potentially prevent deaths on the waitlist, as recipients can be transplanted more rapidly. LDLT was initially described in pediatric transplantation, where the left lateral segment of an adult donor liver was transplanted into a pediatric recipient.25 Adult-to-adult LDLT utilizes either the full right, or left, lobe of the donor liver and carries considerably more morbidity than recovery of the left lateral segment.24 LDLT has inherent ethical concerns, as the living donor receives no direct benefit from the surgical procedure and is subjected to a certain degree of morbidity, including biliary complications, thromboembolic episodes and wound infections. Though rare, several living donor deaths have been reported.26 Estimated mortality for live donor lobectomy is approximately 0.5% for the right lobe and 0.1% for the left hepatic lobe.27 Therefore, when considering LDLT, donor safety must take precedence over any concerns about expediting transplantation. All prospective candidates for living donation are assigned an independent donor advocate who ensures that the interests of the living donor are not compromised and that the decision to donate is entirely voluntary. Excluding coercion may be challenging, especially when a parent is considering living donation in order to save a childâ&#x20AC;&#x2122;s life. 10. Hepatorenal syndrome is associated with an extremely poor prognosis.28,29 Hepatorenal syndrome (HRS) is a reversible but serious complication of advanced liver disease and fulminant hepatic failure. The renal impairment is functional in nature, as evidenced by successful renal transplantation using deceased donor kidneys from individuals with HRS30 and the correction of renal dysfunction after liver transplantation.31 The diagnosis of HRS is made according to criteria defined by the International Ascites Club.32 HRS is further characterized as one of two subtypes. Type 1 is defined by progressively rapid renal failure and is usually the result of a triggering event, such as spontaneous bacterial peritonitis. The initial serum creatinine doubles to a level above 2.5 mg/dL in less than 2 weeks, or the creatinine clearance decreases by 50% to a level less than 20 ml/ min.29 Type 2 HRS is usually associated with refractory ascites and follows a more indolent course, with a steady, continuous progression of renal failure, resulting in a serum creatinine above 1.5 mg/dL.29 Although the pathophysiology of HRS is not completely understood, it is typically associated with peripheral arterial vasodilation, hyperdynamic circulation and renal vasoconstriction. Untreated HRS has a dismal prognosis. Two-week mortality rates for type 1 HRS are estimated to be as high as 80% and 3-month survival is only 10 %.29 Type 2 HRS patients have a 50% 6-month survival.29 Liver transplantation is the preferred treatment and offers the best chance of survival

Table 2. Recommendations of Consensus Conference on Simultaneous Table 2: Recommendations of Consensus Conference on Simultaneous Liver‐Kidney Transplantation Liver-Kidney Transplantation

Due to the dismal prognosis of ESLD patients with renal dysfunction and the limited supply of available deceased donor organs, guidelines were developed to determine which patients would benefit from simultaneous liver-kidney transplantation. Approval for simultaneous liver‐kidney transplantation granted to: 1. ESRD patients with cirrhosis AND a. symptomatic portal hypertension OR b. hepatic vein wedge pressure with gradient > 10 mm Hg

• National Transplant Assistance Fund: www.ntafund.org • National Foundation for Transplants: www.transplants.org • Organ Procurement & Transplantation Network: http:// optn.transplant.hrsa.gov • Scientific Registry of Transplant Recipients: www.srtr.org • Transplant information provided by Astellas:www. transplantexperience.com • United Network for Organ Sharing: www.unos.org

References

1. Alqahtani SA, Larson AM. Adult liver transplantation in the USA. Curr Opin Gasteroenterol 2011; 27:240-247. 2. Murray KF, Carithers RL. AASLD Practice Guidelines: Evaluation of the Patient for Liver Transplantation. Hepatol 3. Acute kidney injury, or HRS, with SCr ≥ 2.0 mg/dL AND dialysis ≥ 8 weeks ogy 2005; 41: 1-26. 4. ESLD patients with evidence of CKD AND kidney biopsy demonstrating 3. Freeman RB, Wiesner RH, Harper A, McDiarmid SV, Lake J, Edwards E, et al. The New Liver Allocation System: a. > 30% glomerulosclerosis OR Moving toward Evidence-Based Transplantation Policy. b. 30% fibrosis Liver Transpl. 2002;8:851-858. 4. Freeman RB, Wiesner RH, Roberts JP, McDiarmid SV, Dyks- tra DM, Merion RM. Improving Liver Allocation: MELD and Abbreviations: ESRD = end-stage renal disease, ESLD = end-stage liver disease, CKD = chronic kidney disease, GFR = glomerular PELD. Am J Transplant 2004;4(Suppl 9):114-131. 5. Thuluvath PJ, Guidinger MK, Fung JJ, Johnson LB, Rayhill filtration rate, HRS = hepatorenal syndrome, SCr = serum creatinine. SC, Pelletier SJ. Liver Transplantation in the United States, 1999-2008. Am J Transplant 2010;10(Part 2): 1003-1019. 6. Burton JR, Sonnenberg A, Rosen HR. Retransplantation for recurrent hepatitis C in the MELD era: maximizing utility. Liver Transplantation 2004; 10[suppl 2]: S59-S64. 7. Organ Procurement and Transplantation Network (OPTN) and the Scientific Registry of Transplant Recipients (SRTR). OPTN/SRTR 2011 Annual Data Report. Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau, Division of Transplantation; 2012. Available at: http://srtr.transplant.hrsa.gov/annual_reports/2011/flash/03_liv28 er/index.html#/16/. Accessed February 4, 2013. 8. Doyle MBM, Anderson CD, Vachharajani N, et al. Liver Transplant for Hepatitis C virus: Effect of Using Older donor Grafts on Short- and Medium-Term Survival. Arch Surg 2008;143(7):679-685. 9. Kressel A, Therapondos G, Bohorquez H, et al. Excellent liver retransplantation outcomes in hepatitis C-infected patients. Clin Transplant 2013;27(4):E512-E520. 10. Coilly AC, Roche B, Samuel D. Current management and perspectives for HCV recurrence after liver transplantation. Liver International 2013;33[suppl s1]: 56-62. 33 11. Anderson CD, Tumelle YP, Lowell JA, et al. SPLIT Research Group. “The Effect of Recipient Specific Surgical Issues on Outcome of Liver Transplantation in Biliary Atresia” Am J Transplant. 2008; 8(6):1197-1204. 34 12. Charlton MR, Burns JM, Pedersen RA, et al. Frequency and outcomes of liver transplantation for nonalcoholic steatohepatitis in the United States. Gastroenterology 2011;141:1249-1253. 13. Malik SM, deVera ME, Fontes P, et al. Outcome after liver transplantation for NASH cirrhosis. Am J Transplant 2009;9:782-793. 14. Freeman RB, Gish RG, Harper A, Davis GL, Vierling J, Lieblein L, et al. Model for End-Stage Liver Disease (MELD) exception guidelines: results and recommendations from the MELD Exception Study Group and Conference (MESSAGE) for the approval of patients who need liver transplantation with diseases not considered by the standard MELD formula. Liver Transpl 2006;12:S128S136. 15. Mazzaferro V, Regalia E, Doci R, Andreola S, Pulvirenti A, Bozzetti F, et al. Liver Transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis. N Eng J Med 1996;334:693-699. 16. Doyle MBM, Vachharajani N, Maynard E, et al. Liver transplantation for hepatocellular carcinoma: 35 long-term results suggest excellent outcomes. J Am Coll Surg 2012; 215(1): 19-28. 17. Castaldo ET, Chari RS. Liver transplantation for acute hepatic failure. HPB 2006; 8: 29-34. 18. Gotthardt D, Riediger C, Weiss KH, et al. Fulminant hepatic failure: etiology and indications for liver transplantation. Nephrol Dial Transplant 2007; 22 [Suppl 8]: viii5-viii8. onclusion 19. Lee WM. Acute Liver Failure in the United States. Semin Liver Dis 2003; 23: 217-226. 20. Bernat JL, D’Alessandro AM, Port FK, et al. Report of a national conference on donation after cardiac death. Am J Transplant 2006;6:281-291. 36 21. Wijdicks EFM. Determining brain death in adults. Neurology 1995;45:1003-1011. 22. Chakravarty KD, Lee WC, Chen YC, Jan YY, Lee P. Liver Transplantation 2010. Jaypee Brothers Medical Publishers. New Delhi, India. 23. The Authors for the Live Organ Donor Consensus Group. Consensus statement on the live organ donor. JAMA 2000;284:2919-2926. 24. American Society of Transplant Surgeons Ethics Committee. American Society of Transplant Sur37 geons’ position paper on adult-to-adult living donor transplantation. Liver Transpl 2000; 6: 815-817. 25. Broelsch CE, Emond JC, Whitington PF, et al. Application of reduced-size liver transplants as split grafts, auxiliary orthotopic grafts and living related segmental grafts. Ann Surg 1990;212(3):368377. 26. Burra P, Freeman, R. Trends in Liver Transplantation 2011. J Hepatol 2012;56[suppl 1]:S101-S111. 27. Barr ML, Belghiti J, Villamil FG, Pomfret EA, Sutherland DS, Gruessner RW, et al. A report of the 38 Vancouver Forum on the care of the live organ donor: lung, liver, pancreas, and intestine data and medical guidelines. Transplantation 2006;81:1373-1385. 28. Salerno F, Gerbes A, Ginès P, et al. Diagnosis, prevention and treatment of hepatorenal syndrome in cirrhosis. Gut 2007; 56: 1310-1318. 29. Wadei HM, Mai ML, Ahsan N, et al. Hepatorenal syndrome: pathophysiology and management. Clin J Am Soc Nephrol 2006; 1: 1066-1079. 30. Koppel MH, Coburn JW, Mima MM, et al. Transplantation of cadaveric kidneys from patients with hepatorenal syndrome. Evidence for the functional nature of renal failure in advanced liver disease. N Eng J Med 1969; 280: 1367-1371. 31. Iwatsuki S, Popovtzer MM, Corman JL, et al. Recovery from “hepatorenal syndrome” after orthotopic liver transplantation. N Eng J Med 1973; 289: 1155-1159. 32. Arroyo V, Ginès P, Gerbes AL. Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis. International Ascites Club. Hepatology 1996; 23; 164-176. Available resources for additional information on transplantation: 33. Gonwa TA, Klintmalm GB, Levy M, et al. Impact of pretransplant renal function on survival after • American Association for the Study of Liver Diseases: www.aasld.org liver transplantation. Transplantation 1995;59:361-365. 34. Nair S, Verma S, Thuluvath PJ. Pretransplant renal function predicts survival in patients undergoing • American Liver Foundation: www.liverfoundation.org orthotopic liver transplantation. Hepatology 2002; 35: 1179–1185. • American Society of Transplant Surgeons: www.asts.org 35. Eason JD, Gonwa TA, Davis CL, et al. Proceedings of consensus conference on simultaneous liver kidney transplantation (SLK). Am J Transplant 2008;8:2243-2251. • American Society of Transplantation: www.a-s-t.org 36. HRSA/ OPTN website. Current U.S. waiting list, overall by organ type. Available at: http://optn. • Association for Multicultural Affairs in Transplantation: www.asmhtp.org transplant.hrsa.gov/latestData/rptData.asp. Accessed January 10, 2013. • Department of Health and Human Services: www.organdonor.gov 37. Scientific Registry of Transplant Recipients (SRTR) data. Based on data available as of 04/30/2012. Release at www.srtr.org on 07/13/2012. Accessed January 10, 2013. • Donate Life America: www.donatelife.net 38. Organ Procurement and Transplantation Network (OPTN) and the Scientific Registry of Transplant • Mississippi Organ Recovery Agency: www.msora.org Recipients (SRTR). OPTN/SRTR 2011 Annual Data Report. Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau, Division of • Minority Organ Tissue Transplant Education Program: www.nationalmottep.org Transplantation; 2012. Available at: http://srtr.transplant.hrsa.gov/annual_reports/2011/flash/03_liv-

2. ESLD patients with CKD AND GFR ≤ 30 mL/min

for those patients who are considered appropriate candidates. Patients with HRS tend to have increased complications after transplantation; 3-year survival rates after transplantation are 60%, as opposed to 70-80% for patients without HRS. A study performed by Gonwa, et al. reported that the incidence of endstage renal disease after liver transplantation for patients with HRS was 7%, as compared to patients without HRS who had an incidence of only 2%. Renal dysfunction has been shown to be an independent predictor of mortality after liver transplantation. In an effort to determine which patients would benefit from simultaneous liver-kidney (SLK) transplantation, a consensus conference was arranged to ensure optimal usage of scarce donor organs by preventing unnecessary transplant procedures while maximizing survival benefit. Their recommendations are summarized in Table 2. Approval of the Regional Review Board was recommended for SLK listing outside of these criteria. C

There are approximately 16,000 patients currently on the waitlist for liver transplantation in the United States. The 1-year and 3-year patient survival rates for adult recipients of a deceased donor liver transplant in the United States are reported to be 89.5% and 79.8%, respectively. Unfortunately, due to the shortage of available donor organs, 16% of the adult candidates listed for a liver transplant in 2011 died while awaiting transplantation. Maximal utilization of deceased donor organs can be achieved by encouraging everyone not only to register as an organ donor but also to inform one’s immediate family of this important, life-saving decision. Multiple resources regarding information on transplantation and donation are available for health care providers and their patients (see below).

July 2014 JOURNAL MSMA 215

• Scientific Articles • Gulf Coast Tick Rash Illness in Mississippi Caused by Rickettsia parkeri Okechukwu Ekenna, MD, MPH; Christopher D. Paddock, MD; Jerome Goddard, PhD

ntroduction

Despite cursory treatment by many medical references, tick-borne spotted fever group rickettsiae (SFGR) are a diverse group of bacteria that cause at least 20 distinct diseases in humans ranging in severity from relatively mild illnesses to life-threatening infections; surprisingly, most pathogenic SFGR have been identified within the last 25 years.1,2 Until 2004, Rocky Mountain spotted fever (RMSF) was the only recognized tick-borne SFG rickettsiosis in the United States.3 RMSF is of particular interest in Mississippi because it is among the top 10 states reporting this infection nationally.4 In addition, infection with Rickettsia parkeri, a newly determined human pathogen, has been reported throughout the southeastern U.S., with a large portion of confirmed or probable cases coming from Mississippi.5 This new disease has been variously named as “Rickettsia parkeri rickettsiosis,” “maculatum disease,” “tidewater spotted fever,” or “American boutonneuse fever” (ABF).6-8 Confounding clinical diagnosis is the fact that the causative agents of both of these diseases cross-react in serological tests used to diagnose RMSF. The primary vector of R. parkeri is the Gulf Coast tick, Amblyomma maculatum, from which the pathogen was first isolated.8 Ecological studies reveal that this tick is abundant in Mississippi, especially along the Gulf Coast, and that infection rates with R. parkeri in Mississippi are as high as 40%.9, 10 Author Affiliations: Infectious Diseases, Singing River Health System, Ocean Springs and Pascagoula, MS (Dr. Ekenna); Rickettsial Zoonoses Branch, Centers for Disease Control and Prevention, Atlanta, GA (Dr. Paddock); Department of Biochemistry, Molecular Biology, Entomology and Plant Pathology, Clay Lyle Entomology, Mississippi State University, MS (Dr. Goddard) Corresponding Author: Okechukwu Ekenna, MD, 3702 Jefferson Avenue, Pascagoula, MS, 39563. Tel. (228) 769-2588; (okekennaid@ cableone.net) Disclosure: The findings and conclusions in this article are those of the authors and do not necessarily reflect the views of the U.S. Department of Health and Human Services.

216 JOURNAL MSMA July 2014

Since the first diagnosis of disease due to R. parkeri, approximately 25 probable and confirmed cases have been reported throughout the Southeastern United States, including Mississippi; however, less than half of these cases have been carefully described or reported.5, 11, 12 Cases of the disease have also been identified in parts of Latin America, including Argentina and Uruguay.13,14 More detailed clinical and epidemiological information on R. parkeri rickettsiosis is needed and can assist physicians with more accurate and timely diagnosis for patients with spotted fever rickettsiosis. Herein we describe 1 confirmed and 4 probable cases of R. parkeri rickettsiosis identified by one physician (OE) between 2007 and 2012 and provide detailed clinical characteristics of this relatively new disease. Two of these patients are presented below in detail. Key Words: Rickettsia parkeri; Gulf Coast Tick Rash Illness; American Boutonneuse Fever; Clinical Characteristics; Mississippi.

Case Descriptions Case-patient 2 A 63-year-old Caucasian female was admitted to a hospital in southern Mississippi in April 2008 because of a rash and body aches [Table 1, case #2]. Six days prior to admission (PTA) she had noted the onset of severe head and body aches followed by an exacerbation of arthralgias. Four days PTA she noted the onset of a rash, beginning on the upper torso and spreading to involve other body parts within 24 hours. Two days later (and 2 days PTA) she came to the emergency department (ED) and was given doxycycline on suspicion for RMSF. She returned to the ED 2 days later because she was not feeling better and was admitted. A tick had been removed from her right ankle 10 days prior to the onset of symptoms. Her medical history included type 2 diabetes mellitus with neuropathy and degenerative joint disease involving the hands, knees and back. She also had hypertension and hypercholesterolemia. An infectious disease consultation was obtained. Physical examination was remarkable for low grade fever (99.6°F) and a diffuse mac-

Table 1. Characterization of patients with suspected or confirmed Rickettsia parkeri rickettsiosis* Characteristic (month/year of onset)

Case 1 (4/2007)

Case 2 (4/2008)

Case 3 (7/2008)

Case 4 (9/2008)

Case 5 (8/2012)

72/M

63/F

45/F

65/M

58/M

R groin

R ant. ankle

Abdomen & back

L chest & LE

R groin

>15 days

>17 days

>15 days

Unknown

≥ 21 days

7 days

10 days

3 days

14 days

Duration of Symptoms

> 8 days

> 7 days

> 10 days

≥ 10 days

Bite to onset of rash

13 days

12 days

14 days

> 14 days

≥ 14 days

Duration of rash

Unknown

> 7 days

> 5 days

≥ 5 days

Extent of rash: type

LE, UE, Torso, palms/soles: erythematousmacular

Generalized (no palms or soles): macular > nodular

Ant. chest, back, LE, esp. thighs: few scattered macules

Generalized, more intense in LE (no palms or soles): macular petechiae

Generalized: torso, UE, and LE (no palms or soles); papular > macular

Fever, chills, H/A, rash; T max 102.4

Gen. body & H/A, arthralgia, chills, nausea; T max 99.6°F

Severe H/A, body, neck & joint pains, low grade temp, chills, fatigue

Body aches, bitemporal H/A, fever & chills, rash; T max 103.5°F

Joint and body aches, H/A, fever, chills, fatigue, dry cough. T max 102.5°F

RPA-IgG IFA = 1:1024 on 5/7/08

RPA-IgG IFA: 7/9/08: < 32 8/18/08: 256

RPA-IgG IFA: 9/25/08: 1:1024 10/17/08: 1:64

Probable§

Eschar bx: IHC positive for SFGR and PCR positive for R. parkeri

NHL, recent chemotherapy 3 d PTA, neutropenia, DM

DM, DJD, overweight, heavy tobacco use

PM seizure, kidney stones, overweight

Gout, DJD, arthritis, overweight

HCV 20 yrs. ago, Appendectomy, Overweight

Treatment received

vancomycin, cefepime, doxycycline

doxycycline, ceftriaxone

doxycycline

doxycycline, ceftriaxone

doxycycline

Outcome

Full recovery

Exposure history & Epidemiology

Rider lawn mowing; tick in R groin

Gardening, handling flowers; tick in R ankle

Visit to rural site; 6-8 ticks on back & abdomen.

Weeding & planting grass in deer camp; 4 ticks L chest & LE

Tick in R groin. Rider lawn mowing. Walk in tall grass in old property

Age/sex Site of tick bite Duration of eschar Tick bite to onset of symptoms

Symptoms experienced by patients

Laboratory Diagnosis§

R. parkeri detected in attached Amblyomma maculatum tick by PCR

> 14 days

Probable§

Underlying Diseases

Confirmed§

ular and papular rash involving the anterior and posterior trunk and the upper and lower extremities, sparing the soles and palms (Fig. 1); a small, 5 mm crusted eschar was evident on the right anterior ankle (Fig. 1). The patient’s WBC count, hemoglobin, platelet count, serum sodium, and hepatic transaminases were within normal ranges. An erythrocyte sedimentation rate was elevated at 50 mm/hour (normal 0-20). Blood cultures were negative. A commercial serological test (IFA for IgG and IgM) for antibodies reactive to R. rickettsii was negative. The patient was discharged 2 days after admission on oral doxycycline and was seen in follow-up 3 weeks later. A serum sample sent to the Centers for Disease Control and Prevention (CDC) for indirect immunofluorescent antibody (IFA) testing demonstrated IgG titers of 1:1024 and 1:256 to R. parkeri and R. rickettsii respectively. The skin rash had faded upon follow-up but was not completely gone. By the next visit one month later the rash had completely resolved.

* DJD = degenerative joint isease; DM = diabetes mellitus; IFA = indirect immunofluorescent antibody assay; IHC = immunohistochemistry; NHL = non-Hodgkin’s lymphoma; PCR = polymerase chain reaction; RPA = Rickettsia parkeri. RR = Rickettsia rickettsii LE = lower extremity; UE = upper extremity; SFGR = spotted fever group rickettsiae. §A confirmed case of R. parkeri rickettsiosis is defined by PCR amplification of R. parkeri DNA from a clinical specimen. A probable case is defined as an epidemiologically and clinically compatible illness with a supportive serological or immunohistochemical test result, through use of group-specific assays for SFGR, or PCR amplification of R. parkeri DNA from an attached tick.5

July 2014 JOURNAL MSMA 217

Case-patient 5 A 58-year-old Caucasian male was admitted through the ED in August 2012 with a 7-day history of malaise, joint aches, cold sensation, and fatigue [Table 1, case #5]. He also had a non-productive cough, chest and body aches, and fever. Review of systems was significant for chest, joint and body aches, including the elbows, knuckles, and hands with symptoms ongoing for 7 days PTA. Headache was prominent on admission but was improved 3 days later. The maximal temperature was 102.5°F. Physical examination was remarkable for a temperature of 100.1 °F; multiple red non-pruritic papules generally distributed to the torso, abdomen, back, upper and lower extremities, including the dorsi of the feet, and an estimated 1.3 cm eschar in the right inguinal area. The remainder of the examination was otherwise unremarkable. CT scans of the head and chest x-ray were normal. Myocardial perfusion SPECT was normal with a left ventricular ejection fraction of 75%. Abdominal ultrasound showed fatty infiltration of the liver. Fluoroscopic lumbar puncture revealed reddish tinged CSF and was considered traumatic; CSF glucose was 68, protein 52, RBC 2106, and WBC 3/mm3: diff: 16% PMN’s, 36% L, and 48% mesothelial cells. The CSF Gram stain showed no organisms; the culture was negative. Two sets of blood cultures were negative. The patient was started on ceftriaxone and doxycycline intravenously. With negative blood and CSF cultures, infectious disease consult was sought 4 days after admission to address the fever of unknown origin. The patient recalled a tick bite 3 weeks PTA while walking in a field of tall grass. His medical history included a diagnosis of hepatitis C for which the patient had been treated, although he was not sure whether there was partial or complete remission. Complete blood count and chemistries on admission were unremarkable. Liver tests showed AST (SGOT) of 73 U/L, ALT (SGPT) 91 U/L with normal alkaline phosphatase, albumin, total protein, and bilirubin levels. Four days later, the AST had dropped to 48 U/L and the ALT to 57 U/L. An excisional biopsy of the right groin eschar (Fig. 2) was obtained and evaluated at CDC by histopathology, immunohistochemistry and PCR tests (Fig. 3) for spotted fever group Rickettsia species 9 and confirmed infection with R. parkeri. The patient was discharged home after the biopsy on oral doxycycline. At follow-up visit 2 weeks later, the patient had fully recovered and his rash had resolved. Results and Discussion This case series shows that patients with R. parkeri rickettsiosis typically present with fever and body aches beginning one week after tick bite (Table 1). Patients in this series were ill for several days before presenting for medical evaluation. This delay is not surprising, as most patients expect their initial symptoms to resolve and present only when these persist. Rash was noted approximately 2 weeks after the bite, and the eschar was usually still present when patients were first evaluated, often providing the most important diagnostic clue to this newly recognized illness.

218 JOURNAL MSMA July 2014

We suspect that during this time period there may have been more cases of this illness that did not generate a specific infectious disease consult. Such persons may have received antimicrobial therapy without a specific laboratory diagnosis or were treated presumptively for RMSF or other illness. A review of clinical characteristics in this small number of patients suggests that the duration of the eschar may be more than 14 days. Generalized myalgia and headache were identified frequently, and gastrointestinal manifestations were infrequent, with nausea reported by only one of the patients. This is compatible with previous clinical descriptions of this disease.5, 12 Time from tick bite to onset of symptoms ranged from a few days to 2 weeks. Time from tick bite to onset of rash in our 5 patients was between 12 and 14 days. Rash was usually present for 5 days or longer. Illness symptoms lasted for more than 7 days in all of our 5 patients, and all 5 of our patients made a full recovery from the illness. The illness was generally milder than that usually reported for RMSF. Conclusion It is important for clinicians to recognize this new rickettsial disease which may be more common along the Gulf Coast than previously appreciated for several important reasons. The first is that this illness resembles Rocky Mountain spotted fever which is a far more severe disease often requiring hospitalization. In general, since cases of R. parkeri rickettsiosis do not require hospitalization, accurate distinction between these illnesses may prevent an unnecessary or prolonged hospital stay. Second, familiarity with this disease may also prevent unnecessary procedures, such as lumbar punctures, which were performed during diagnostic evaluation of three patients in this series (case #3, #4, and #5). Finally, it is important to emphasize that the drug of choice for R. parkeri rickettsiosis and RMSF is doxycycline and that most other classes of broad-spectrum antibiotics, including penicillins, cephalosporins, aminoglycosides, sulfa-containing antimicrobials, and quinolones, have no activity against these diseases. Acknowledgements The authors thank Amy Denison, Sherif Zaki, and Joseph Singleton (CDC) for their assistance with the serologic, molecular, and pathologic evaluation of several patient specimens. References 1.

Parola P, Paddock CD, Socolovschi C, et al. Update on tick-borne rickettsioses around the world: a geographic approach. Clin Microbiol Rev. 2013; 26:657-702.

Kelly PJ, Beati L, Mason PR, Matthewman LA, Roux V, Raoult D. Rickettsia africae sp. nov.: the etiological agent of African tick bite fever. Int J Syst Bacteriol. 1996; 46:611-614.

Paddock CD, Sumner JW, Comer JA, et al. Rickettsia parkeri- a newly recognized cause of spotted fever rickettsiosis in the United States. Clin Infect Dis. 2004; 38:805-811.

CDC. Summary of notifiable diseases - United States, 2008: CDC, MMWR, 57(54):1-95; 2010.

compatible illness with > 1 supportive serological or immunohistochemical test result, through use of group-specific assays for SFGR, or PCR amplification of R. parkeri DNA from an attached tick5. Fig 1. Tick bite eschar in anterior right ankle; macular and papular rash on the left lower extremity, and upper back [Used with permission].

Fig 2. Tick bite eschar right groin; and papular nodular rash on the right thigh, and foot dorsum [Used permission]. Fig. 1:with Tick bite eschar in anterior right ankle; macular and papular rash on the left lower

extremity and upper back [Used with permission].

Fig 3. Histopathology and immunohistochemical staining for SFGR of right groin eschar of case 5.

Fig. 2: Tick bite eschar right groin; and papular nodular rash 6. [Used with permission].

A. Hematoxylin and eosin stain showing lymphocytic Fig. 3: Histopathology and immunohistochemical staining for SFGRdiffuse of right groin eschar of case 5. A. Hematoxylin & eosin stain showing diffuseOriginal lymphocytic perivascular inflammation: perivascular inflammation: magnification × 100. Original magnification × 100. B. Immunohistochemical for spotted fevergroup group rickettsiae B. Immunohistochemical stain forstain spotted fever (red). Original magnification × 258Original magnification × 258. rickettsiae (red).

Paddock CD, Finley RW, Wright CS, et al. Rickettsia parkeri rickettsiosis and its clinical distinction from Rocky Mountain spotted onfever. theClin right thigh foot dorsum Inf Dis. 2008;and 47:1188-1196. Goddard J. American boutonneuse fever -- a new spotted fever rickettsiosis. Infect Med. 2004; 21:207-210.

Goddard J. Historical and recent evidence for close relationships among Rickettsia parkeri, R. conorii, R. africae, and R. siberica: implications for rickettsial taxonomy. J Vector Ecol. 2009; 34:238242.

Parker RR, Kohls GM, Cox GW, Davis GE. Observations on an infectious agent from Amblyomma maculatum. Public Health Rep. 1939; 54:1482-1484.

Paddock CD, Fournier PE, Sumner JW, et al. Isolation of Rickettsia parkeri and identification of a novel spotted fever group Rickettsia sp. from Gulf Coast ticks (Amblyomma maculatum) in the United States. Appl Environ Microbiol. May 2010; 76(9):2689-2696.

10.

Ferrari FA, Goddard J, Paddock CD, Varela-Stokes AS. Rickettsia parkeri and Candidatus Rickettsia andeanae in Gulf Coast ticks, Mississippi. Emerg Infect Dis. 2012; 18:1705-7.

11.

Whitman TJ, Richards AL, Paddock CD, et al. Rickettsia parkeri infection after tick bite, Virginia. Emerg Infect Dis. 2007; 13:334335.

12.

Cragun WC, Bartlett BL, Ellis MW, et al. The expanding spectrum of eschar-associated rickettsioses in the United States. Arch Dermatol. 2010; 146:641-8.

13.

Conti-Diaz IA. Rickettsiosis caused by Rickettsia conorii in Uruguay. Ann NY Acad Sci. 2003; 990:264-266.

14.

Romer Y, Seijo AC, Crudo F, et al. Rickettsia parkeri rickettsiosis, Argentina. Emerging Infect Dis. 2011; 17:1169-73.

July 2014 JOURNAL MSMA 219

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220 JOURNAL MSMA July 2014

6/20/13 3:38 PM

2013 ANNUAL REPORT

A MESSAGE FROM THE EXECUTIVE DIRECTOR

Dear Doctor,

It’s never been done be fore. For the �irst time in its 156-year history, is presenting an annual your Association report to the members hip. Yes, we do report each year at Annual Se on many aspects ssion, yet this compreh ensive annual report is a �irst of its kind. If you are wondering, “Why now?” the answ er is easy: transparency. association. We pledge This is your to be good stewards on your behalf and be important for you to kn lieve that it’s ow what MSMA is doin g and why. Organized business. MSMA is a m medicine is big ulti-million dollar corp oration with many focu Annual Report gives ses. This 2014 you a closer look at wa ys your association wo physicians who care fo rks for the r Mississippi. MSMA is your voice an d your champion at th e State Capitol. This ye anniversary of the 20 ar is the 10th 04 tort reforms which m ade it possible for ph hospitals to keep their ysicians and doors open in our sta te. And, we’ve had a lo Capitol this year, too. t of wins at the Not just a mouthpiece, MSMA is ever listening to bring products and need in your own med services that you ical practice. You have told us that your prac roughly half of MSMA tice is changing: members are in priva te practice and the tre more of you are mov nd suggests that ing toward other prac tice arrangements. Th association developed at’s why your valuable services for th e growing number of ph “Not In Private Practic ysicians who are e.” MSMA has also pa rtnered with the Phys Institute to offer resour ician Advocacy ces as you navigate thro ugh complicated contra with sophisticated hosp ct negotiations ital/health organizatio ns. It’s going to be a tight rope walk to hold toge ther the coalition tradi organized medicine. As tionally known as important as it is to provide new resource practice arrangements, s for emerging it is perhaps more im portant to �ind the co unify physicians. Trul m m onalities that y, together we are str onger. MSMA is the glu physicians. e that unites all

Charmain Kanosky, Exec

utive Director

A PRESIDENTIAL PROFILE

James A. Rish, MD MSMA President 2013-2014 It has been my great pleasure to serve as President of the Mississippi State Medical Association this year. It has been a truly enlightening and rewarding experience.

This annual report summarizes the work of the association but, my no means, contains everything that your elected physician leaders and dedicated staff do to advance and protect our practices.

I urge you to be involved with MSMA. Our sole purpose is to become a valued part of the professional life of every Mississippi physician. Our voice is louder and stronger when we speak together. I heartily encourage your continued involvement in the interest of the profession and our patients. One of the most exciting elements – and certainly one of the most enlightening -- of being MSMA president is getting a front row seat for all of the action at the Capitol pushing good policy for the practice of medicine.

I am most proud of my part in getting legislation passed to ease the burden of our patients facing a terminal illness. Physician Orders for Sustaining Treatment (POST) legislation is a tremendous win for our patients who may be facing dif�icult decisions and will encourage physicians to have that dif�icult conversation with a patient about speci�ic preferences for care in his/her �inal days. This will allow the patient and physician to plan ahead before those decisions are further complicated for the family and the patient is no longer able to decide for himself. As MSMA works to get the word out I trust you will do your part to make POST available to patients across the state. Then, as your read further about the many accomplishments of our association, I urge you to get engaged in your future through MSMA. James A. Rish, MD; MSMA President 2013-2014

STRATEGIC PLAN PROGRESS REPORT 4

the vision:

to be an essential part of every Mississippi physician’s professional life GOAL 1

GOAL 2

Increase MSMA participation & engagement at all levels.

effectively communicate to members & other stakeholders.

GOAL 3

GOAL 4

GOAL 5

GOAL 6

make significant progress on workforce issue.

promote the physician as the leader of the medical care team.

advocate for quality healthcare

organizational improvement.

Weekly reports keep MSMA successfully Projects like Physicians for Smoke-Free Cities physicians informed and secured funding for the Office of Physician are designed for local a new mobile app for Workforce and the medical societies to iPad, smart phones and Rural Physician stimulate community androids engages other Scholarship Program. participation. CME-in- stakeholders. MSMA is the exclusive source in Exploring a new idea to the-Sand was expanded harness state funding Mississippi for the to attract young secure medical for additional residency physicians and the slots is a cooperative experienced alike. To messaging system effort between MSMA known as DocBook. get more members and the University of involved in Annual Mississippi Medical Session activities, the business meeting was Center. MSMA comoved to Jackson and sponsorship of the broadcast so any Governor’s annual member can monitor Health Summit also the proceedings of the furthers this goal House of Delegates focusing on the and the reference importance of committee hearings. physicians and medical Online CME 24/7 care to spur economic eliminates travel costs development. and registration fees.

MSMA vigorously monitors the regulations of licensure boards agencies insisting on strict oversight and proper collaborations. We continue to press for a physician medical director at the Division of Medicaid. To identify and equip younger physicians with tools needed thrive in the new world of medicine, MSMA is launching a leadership program. MSMA publicly positions the physician as the leader of the medical team using social media and earned media. Physicians are encouraged to participate on local civic boards, school wellness committees and to lead local Smoke-Free efforts.

To strengthen the association’s influence MSMA promotes ways physicians can improve the quality of care at the local level. Opportunities are maximized for the association’s leaders to be featured in print, broadcast and internetbased outlets. MSMA continues to be the voice of Mississippi physicians at the State Capitol.

Reserve funds were increased. Staff was added to assist members with payment issues with government and private payers. Three iPASS Summits introduced payer reps to trouble shoot claims for clinic staff. The Strategic Plan also cited growth of the Alliance as a priority and MSMA is assisting with recruitment activities, encouraging physician membership in the Alliance and opening leadership development opportunities to Alliance members.

4,732

MEMBERSHIP CATEGORY

JUNE 30

2005 2006

2007

PHYSICIANS 2,889 2,887 2,890 PAID ACTIVE RETIRED DUES EXEMPT

STUDENTS DUES EXEMPT

2008

2009 2010

2,872 2,691 3,059

2011 2012

2013

2014

3,141 3,146 3,129 3,023

455

444

468

444

511

505

486

461

495

523

234

328

353

377

433

596

532

554

570

633

148

149

103

469

476

449

541

586

RESIDENTS DUES EXEMPT

TOTAL 3,673 3,807 3,860

3,796 3,709 4,629

TOGETHER WE ARE STRONGER

2013 MEMBERSHIP

4,635 4,610 4,732 4,765

ANNUAL SESSION 2013 The new Jackson location and abbreviated schedule attracted physicians from across the state. The central

location shortened the drive for most delegates and

the high tech capabilities available at UMMC allowed

any member to monitor the House of Delegates proceedings

online

through

video

streaming.

Governor Phil Bryant and AMA President Dr. Ardis

Hoven opened the House of Delegates afterwhich Dr.

James A. Rish was ofďż˝icially inaugurated as the 146th MSMA President.

MSMA FINANCIAL REPORTS

2013 REVENUE IN REVIEW REVENUE Membership Dues Event Revenue

225,675

Subsidiary Services

205,094

MACM Sponsorship

150,000

Rental Income

72,348

Management Fees

66,000

CME Accreditation

54,381

Journal, MSMA

40,285

MPCN Dividend

35,000

Misc Revenue

12,600

Total MSMA Revenue

2013 EXPENSE BREAKDOWN EXPENSES

Administrative & General

948,738

Government AďŹ&#x20AC;airs

320,746

Event Expenses

300,435

Journal, MSMA

181,665

Building & Equipment

159,117

Travel & Meetings

133,806

Communications

127,922

CME Accreditation

106,792

Specialty Society Mgt.

37,509

MPHP Support

20,000

Total MSMA Expenses

2,336,730

1,526,088

2,387,471

The Claims Advocacy for Physicians (CAP) Committee assists MSMA members to resolve claims issues and disputes with insurance companies, HMOs, Medicare, Medicaid, other third party payers, and utilization management/quality review organizations. Below are just a sample of issues worked by the committee to bene�it all physicians.

Improper Use of CPT 99050: In response to audits and recoupment for improper use of CPT 99050, the CAP Committee found the only “afterhours” CPT code covered by the Medicaid program is 99050 and it allows reimbursement at times other than regularly scheduled hours. As a result, the CAP Committee requested Medicaid open additional codes to provide reimbursement for services provided during regularly scheduled extended evening, weekend, or holiday of�ice hours, in addition to the basic service. Medicaid opened CPT 99051 effective March 1, 2013, for billing and reimbursement.

Dif�iculty with Prior Authorizations in MississippiCAN program: Physicians were faced with guessing the criteria that had to be met in order to get certain services prior authorized. The CAP Committee has worked diligently with Magnolia Health Plan to provide the Guidelines and Tip Sheets for advanced imaging procedures to all physicians. The work will continue to reduce the burden of obtaining prior authorizations.

icd10

MSMA partners with Holmes Community College to equip physicians and clinic staff with the training necessary to understand the complex new ICD-10-CM code set. One participant said the workshop was “very informative and gave me a new con�idence to tackle the ICD-10 Monster.”

PRACTICE MANAGEMENT

CLAIMS ASSISTANCE

iPASS Named iPASS for “Insurance Payment Advocacy Solutions Summit,” regional forums provide clinic staff with resources to resolve claims issues for quicker payments, to become more ef�icient in handling claims issues, and to identify personal contacts at each major healthcare payer. Attendees told us “Great having all payers under one roof,” and “Very, very informative.” MSMA hosted 2014 insurance forums in Hattiesburg, Oxford, and Pearl.

uninsured

To ensure broad and varied discussions, MSMA focused the Solutions for Covering the Uninsured of Mississippi forum focused on options for covering the uninsured. Three issues were presented. First, facts about the uninsured population of Mississippi; second, how Medicaid expansion could bene�it the state; and third was a discussion on alternative ways to cover the uninsured. MSMA members discussed the issues as a group.

ADVOCACY

MSMA is the voice of medicine at the State Capitol. The year 2014 marks the 10th anniversary of landmark tort reform legislation which made it possible for Mississippi physicians and hospitals to keep their doors open. MSMA continues to tackle the big issues for you at the Capitol. Highlights of the 2014 session follow.

• •

•

The new POST bill – Physician Order for Sustaining Treatment – protects the patient’s right to determine end-of-life options with the physician.

With support from the National Football League a new Return-to-Play bill protects a student athlete who sustains a head injury on the playing �ield and requires a health professional to evaluate his condition before the athlete can return to play.

MSMA squared off against the big insurance company to prohibit discrimination and allow network participation to any physician willing to meet credentialing standards and accept the network reimbursement fees set by the insurer. When the bill died on the House �loor, your MSMA asked Governor Phil Bryant to appoint a special oversight committee to examine issues of network adequacy and the importance of protecting Mississippi physicians with “any willing provider” legislation.

When that same big insurer refused to honor a patient’s assignment of bene�its for more than one visit, MSMA went back to the Capitol. The new law requires all insurers to honor the patient’s assignment of bene�its for at least one year or until revocation. When Blue Cross Blue Shield tried to drive a wedge between the doctor and his patient, MSMA stopped the practice at the State Capitol. The big insurer threatened to withhold prescription bene�its from patients whose physician was not in the Blue network – even when the patient had prescription coverage. The new law puts a stop to this practice and prohibits the insurer from denying medically necessary prescriptions based solely on network distinctions. When MSMA’s bill passed both chambers unanimously BCBS withdrew its policy to deny medicine prescribed by an out of network physician.

Scan for more information on each bill.

COUNTDOWN TO ICD-10

To appease physicians frustrated with yet another temporary SGR fix, Congress delayed ICD-10 implementation from October 1, 2014 until October 1, 2015. MSMA’s 2012 resolution to the AMA focused organized medicine to oppose ICD-10. MSMA continues to work to stop its implementation altogether.

REPEAL UN-SUSTAINABLE GROWTH RATE FORMULA MSMA works diligently with the federation of medicine to repeal and replace the Sustainable Growth Rate (SGR) formula. With the aide of Congressman Gregg Harper, MSMA pushed legislation to repeal the onerous SGR formula this year. MSMA leaders met regularly with each of Mississippi’s congressional delegation imploring Congress to stabilize the uncertainty when SGR was debated and eventually patched. MMPAC Chair Dr. Hugh Gamble and Cong. Harper had detailed and frank discussions about the seriousness of this issue. Throughout the process, Cong. Harper stood �irm in his support to repeal the SGR formula. Following Dr. Gamble’s successful Capitol Hill visits, the MSMA Delegation to the AMA including Drs. Sharon Douglas, Tom Joiner, Claude Brunson, Jim Rish and Clay Hays, secured key co-sponsors in both the House and Senate. When the delegates met in November with Mississippi’s four House members and both senators, they continued to push compromise legislation to replace the SGR formula.

MSMA AND THE AMA Three resolutions were submitted by the MSMA delegation for consideration by the AMA House of Delegates. Mississippi’s request that the AMA work to reimburse all hospital-billed physician services and their facilities at equal rates (AMA 807) reaf�irmed by existing policy. The AMA’s Council on Medical Education will consider MSMA’s suggestion that training in a physician’s of�ice counts toward residency requirements. The AMA also adopted policy to ask Joint Commission to use only recognized performance measures when evaluating a patients vital signs. MSMA actively assists the federation of medicine with national regulatory issues and with Mississippi’s members of Congress.

When both sides reached a historic bi-partisan agreement on legislation to repeal the SGR formula the bill was strongly supported by organized medicine. It was �irst time all parties agreed on a new Medicare physician payment structure that emphasizes value and quality over quantity and encourages physicians to measure new, patient-centered outcomes. In the end, leaders in both the House and Senate balked at the agreement and instead imposed the 17th temporary patch on Medicare Jackson Trustee Dr. Clay Hays, Jr. and MSMA President Dr. Jim Rish of Tupelo met in Washington with Senator payments to physicians. Thad Cochran.

FEDERAL ADVOCACY

YOUR MSMA IN D.C.

MAXIMIZE YOUR MEMBERSHIP

CME

Committed to the practice of medicine, MSMA supplies management tools, continuing education opportunities, and legislative advocacy. For over 150 years, MSMA has been an advocate for its members, their patients, and the public health. The association promotes ethical, educational, and clinical standards for the medical profession and the enactment of just medical laws.

MSMA’s twenty accredited CME providers sponsored over 2,370 hours of CME programming in 2013 and awarded more than 15,000 hours of AMA Category 1TM credit. CME conferences designed for and by physicians feature hot topics for your practice population. CME in the Sand combines education with a beach vacation over Memorial Day weekend in Sandestin for physicians of all ages and specialties. More CME is available 24/7 at MSMAonline.com. Get credits when it is convenient for you – with no travel cost or conference registration.

NOT IN PRIVATE PRACTICE? MSMA knows that physicians who are not in private practice need tools and resources to thrive in a competitive corporation. We have the tools to help you navigate the legal system, negotiate a contract, lead the collaborative medical team and implement progressive quality measures. The Physician Leadership Academy is designed to help you thrive in the new world of medicine outside the private practice parameters. Experts teach innovation and creative problem solving so you maximize your leadership and hone communication skills that ensure success in an advanced management role.

MSMA FOUNDATION

The MSMA Foundation is proudly the philanthropic arm of your association that allows a contributor to ful�ill charitable commitments to medicine by promoting medical education for members, educating the public, publishing scienti�ic research and empowering Rural Physician Scholars. Visit MSMAfoundation-com.webs.com to contribute online and sign up now for the third annual “Cadaver Course 5k” Halloween fun run. Just outrun the zombies to win a prize. 2014 Race Dates: Ridgeland on Saturday, November 1, 2014; Tupelo on Saturday, October 11, 2014. Register online at MSMAFoundation.org.

GET INVOLVED

mmpac LET’S MAKE MISSISSIPPI SMOKE FREE During the 2013 legislative session, MSMA worked diligently on a statewide smoking ban. Strong opposition thwarted the Clean Air Coalition for many years. The tone of the conversation had to change. Anticipating strong resistance, MSMA implemented a new strategic campaign prior to session which included rebranding the issue as the “Clean Air Act.” Messaging centered on the positive economic impacts of a statewide smoking ban, and bringing other interested parties (such as casinos and the restaurant industry) into the conversation. MSMA held meetings with the Governor, Lt. Governor, Speaker plus House and Senate Public Health Chairs before session began to outline and push for a ban on smoking in indoor public spaces.

Physicians have “MMPAC.” The Mississippi Medical Political Action Committee (MMPAC) is one of the largest and most in�luential political organizations. Each year MMPAC advances physician-friendly and patient-driven legislation by supporting candidates proven to be pro-patient and a "Healthy Choice" for Mississippi. To learn more about MMPAC and to get involved visit MMPAConline.com.

doctor of the day Dozens of MSMA members volunteer as the “Doctor of the Day” at the Mississippi State Capitol. This gives MSMA a unique opportunity to affect policy-making as members talk to legislators and their staff. Physician participants report this experience to be rewarding and educational, as they truly are the “boots on the ground.”

GET CONNECTED

Keep up-to-date on the latest happenings at the nation’s Capitol and in our own backyard in Mississippi. Connect with MSMA on social media, through your monthly Journal MSMA in your mailbox, or weekly email newsletters. MSMA sends weekly emails to keep you abreast of the latest information in the �ield of medicine. Update your contact information so you don’t miss any news from the Capitol in The MSMA Advocate, pertinent practice information in Lifeline or Mississippi medical headlines in Physician’s Position. $SULO

The Journal MSMA is a peer-reviewed scien�itic journal edited by Mississippi physicians for Mississippi physicians. Each issue features popular commentaries, scienti�ic research and timely editorials.

Scan and read the Journal MSMA online

92/ / 9

MISSISSIPPI STATE MEDICAL ASSOCIATION 12

408 West Parkway Place  Ridgeland, Mississippi 39157 601-853-6733  MSMAonline.com

A RECORD YEAR IN MEDICINE MSMA 146th Annual Session of the House of Delegates

August 15-16, 2014  Jackson

THURSDAY AUG 14 JACKSON HILTON

12:00 at UMMC UMMC Medical Students Lunch with AMA President

FRIDAY  AUG 15 UMMC STUDENT UNION

SATURDAY  AUG 16 UMMC STUDENT UNION

7:30 – 11:00 Board of Trustees Meeting

8:00-10:00 Board of Trustees Meeting

……………………………………

11:00-12:00 CME Transitioning to ICD-10

10:00-10:45 Excellence Awards

2:00 -3:00 Hilton lobby Clean Air Coalition news conference

12:00-1:00 CME Physicians for Smoke-Free Air

10:45-11:45 Candidate Speeches

3:00-5:00 Hilton amphitheater American Cancer Society Palliative Care Policy Forum

Boxed lunch available

5:00-7:00 Jackson Hilton Welcome Reception with AMA President Robert M. Wah, MD Host: Central Medical Society

Late resolutions, President’s Address

Secretary of State Delbert Hosemann

1:00-2:00 House of Delegates

2:00-5:00 Reference Committee Hearings

10:45 Friday, Fairview (invitation only) Past Presidents’ Luncheon 2:00 Friday, UMMC Alliance Board Orientation 8:30 Saturday, Jackson Hilton Alliance House of Delegates 11:00 Saturday, Jackson Hilton Installation Luncheon

11:45-1:00 Caucuses 1:00-4:00 House of Delegates 4:00-4:30 Board of Trustees Meeting

………………………………

……………………………………….

ALLIANCE SCHEDULE

Boxed lunch available

FRIDAY  AUG 15 JACKSON HILTON



OFFICIAL INAUGURATION

CLAUDE D. BRUNSON, MD 147TH PRESIDENT OF MSMA 

6:30 Jackson Country Club UMMC Alumni Dinner

……………………………… Reference committee orientation will be held prior to Annual Session via Go-to-Meeting.

7:00-8:00 Alliance Scholarship Fundraiser

The reference committee hearings and both sessions of the House of Delegates will be distributed by streaming video.

8:00–11:00 Gala with Soul

Delegates must be present to introduce late resolutions and speak at the reference committee hearings.

Dinner Dance tickets $100 pp

Delegates must be present to vote.

PATIENT QUALITY OF LIFE FORUM

Thursday, August 14, 2014

Hilton Hotel | 1001 E County Line Road | Jackson, MS 39157 3:00 pm - 5:00 pm Reception following

Please join us for the Patient Quality of Life Forum, a policy discussion on quality of life and palliative care. This forum will highlight how palliative care provided throughout the course of any type of serious illness achieves the triple aim of better patient experience, better quality of care, and lowered health care costs. Palliative care honors patient choice about treatment goals and helps bring the family into the care process. This is a unique opportunity to hear from other health care organizations and share your views and concerns.

To register to attend or for more information, please contact Anita Bales at anita.bales@cancer.org or 601-321-5519, or visit http://www.acscan.org/patientforum

PATIENT QUALITY OF LIFE FORUM

THANK YOU TO OUR SPONSORS

What is palliative care?

Thursday, August 14, 2014

Palliative care, also called supportive care, is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness. Hilton The goalHotel is to improve quality of life forLine both Road the patient and the family. Palliative | 1001 E County | Jackson, MS 39157 care is provided by a team of doctors, nurses, and other specialists who work with the patientâ&#x20AC;&#x2122;s other doctors to 3:00inpm - 5:00 pmand provide an extra layer of support. Palliative care is appropriate at any age and at any stage a serious illness, can help patients get well faster and easier. 234 JOURNAL MSMA July 2014

• Up-To-Date Medicine in Mississippi • Avoiding Narcotic Analgesics in Young Children Jeffrey D. Carron, MD

bstract

Recent warnings regarding the use of codeine in young children have triggered changes in postoperative pain management with a trend toward over the counter pain medicines. A summary of the recent FDA warnings and current pain protocols is contained within. In August 2012, the FDA released a warning advising against the administration of codeine following tonsillectomy and/or adenoidectomy in children.1 It was revised to a Black Box Warning in February 2013.2 This warning was in direct response to an article which appeared in the the journal Pediatrics

concerning 4 cases, 3 fatal, of respiratory depression resulting from acetaminophen/codeine elixir given to children after adenotonsillectomy.3 The primary reason for ...continued next page.... Author Information: Dr. Carron is Professor of Otolaryngology and Pediatrics at the University of Mississippi Medical Center in Jackson. Corresponding Author: Jeffrey D. Carron, MD, FAAP, FACS; Department of Otolaryngology and Communicative Sciences, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216 Ph: (601) 984-5456, Fax: (601)815-3062.

FDA advice on the use of codeine in children1 

Life-threatening adverse events and death have occurred in certain children who received codeine after tonsillectomy and/or adenoidectomy for obstructive sleep apnea syndrome. These children had evidence of being “ultra-rapid metabolizers” of substrates of cytochrome P450 2D6 (CYP2D6), including codeine.



If prescribing codeine-containing drugs, use the lowest effective dose for the shortest period of time on an as-needed basis (i.e., not scheduled around the clock).



Counsel parents and caregivers on how to recognize the signs of morphine toxicity, and advise them to stop giving the child codeine and to seek medical attention immediately if their child is exhibiting these signs.



FDA-cleared tests are available for determining a patient’s CYP2D6 genotype.



The estimated number of ultra-rapid metabolizers varies among different racial/ethnic groups.



Consider prescribing alternative analgesics for children undergoing tonsillectomy and/or adenoidectomy for obstructive sleep apnea syndrome.



Report adverse events involving codeine to the FDA MedWatch program.

July 2014 JOURNAL MSMA 235

the respiratory depression is not the underlying surgical pathology but variations within the liver enzymes, specifically CYP2D6. Patients who are phenotypic ultra-rapid metabolizers of codeine will quickly convert the drug to high serum levels of morphine, causing CNS depression.1 While hydrocodone (Lortab®) was not mentioned by the FDA as dangerous in children, it is metabolized to hydromorphone by the CYP2D6 pathway and can theoretically cause similar CNS effects as codeine/morphine. If the primary reason for the toxicity is that individuals may genetically be ultra-rapid metabolizers, why not caution against using codeine in young children period? Why single out one surgical procedure? Obviously, this warning was in response to several reports after tonsillectomy, one of the most common surgical procedures performed in children. Furthermore, upper airway edema and altered respiratory patterns in some children with obstructive sleep apnea could place them at higher risk compared to other patients; however, when choosing to prescribe opiates to young children, regardless of the procedure or indication, physicians should consider the possibility for variable metabolism and err on the lower side of the therapeutic range. The FDA also reports 1-6% prevalence of the ultra-rapid metabolizer (UM) phenotype based on ethnic variations.1 Considering my own prior experience in performing or supervising over 2500 tonsillectomies with postoperative narcotic prescriptions, mathematically I should have seen UM effects 25-300 times. I have seen none but heard of two possible cases (not confirmed with any sort of testing) prior to my fellowship in Seattle. Fortunately, post-tonsillectomy pain management has been thoroughly studied, and pediatric otolaryngologists have been aggressively altering their pain management strategies. At the Blair E. Batson Hospital for Children at UMMC, we have devised a protocol of over-the-counter (OTC) pain medication only for children under age 7. All children receive intraoperative steroids, and a single dose of steroid 3 days later may be given as well. Older children are encouraged to use ibuprofen the day after surgery but may use narcotic elixir for rescue. Our department has experienced a slight increase in postoperative phone calls but no increase in emergency room visits for pain-related complaints. Numerous studies have confirmed equivalent pain control with oral acetaminophen and/or ibuprofen compared to acetaminophen with codeine or hydrocodone.4,5 Furthermore, the use of ibuprofen postoperatively has not shown to increase the risk of post-tonsillectomy bleeding.6-9 In some studies, children using OTC analgesics alone had better fluid intake due to less nausea and less sedation.6,9 In summary, narcotic pain medication is seldom necessary following tonsillectomy and/or adenoidectomy in young children. Primary care providers should be aware of changing protocols as patients often turn to them for postopera-

236 JOURNAL MSMA July 2014

tive complaints, particularly if the surgeon is in another part of the state. Practitioners performing surgery on young children should look critically at whether narcotic pain medication is necessary and take extra time to explain to parents the risks of opiates. Often when individuals are counseled about side effects such as nausea, constipation, and CNS depression, they are happy to avoid them. References 1.

FDA Drug Safety Communication: Codeine use in certain children after tonsillectomy and/or adenoidectomy may lead to rare, but life-threatening adverse events or death. FDA website: http://www.fda.gov/drugs/drugsafety/ucm313631.htm.

FDA Drug Safety Communication: Safety review update of codeine use in children; new Boxed Warning and Contraindication on use after tonsillectomy and/or adenoidectomy. FDA website: http://www.fda.gov/Drugs/ DrugSafety/ucm339112.htm.

Kelly LE, Rieder M, van den Anker J, Malkin B, Ross C, Neely MN, et al. More codeine fatalities after tonsillectomy in North American children. Pediatrics 2012;129:e1343-7.

Moir MS, Bair E, Shinnick P, Messner A. Acetaminophen versus acetaminophen with codeine after pediatric tonsillectomy. Laryngoscope. 2000;110(11):1824-7.

St Charles CS, Matt BH, Hamilton MM, Katz BP. A comparison of ibuprofen versus acetaminophen with codeine in the young tonsillectomy patient. Otolaryngol Head Neck Surg. 1997 Jul;117(1):76-82.

Cardwell M, Siviter G, Smith A. Non-steroidal anti-inflammatory drugs and perioperative bleeding in paediatric tonsillectomy. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD003591.

Krishna S, Hughes LF, Lin SY. Postoperative hemorrhage with nonsteroidal anti-inflammatory drug use after tonsillectomy: A meta-analysis. Arch Otolaryngol Head Neck Surg. 2003;129(10):1086-1089.

Riggin L, Ramakrishna J, Sommer DD, Koren G. A 2013 updated systematic review and meta-analysis of 36 randomized controlled trials; no apparent effects of non steroidal anti-inflammatory agents on the risk of bleeding after tonsillectomy. Clin Otolaryngol. 2013 Apr;38(2):115-29.

Lewis SR, Nicholson A, Cardwell ME, Siviter G, Smith AF. Nonsteroidal anti-inflammatory drugs and perioperative bleeding in paediatric tonsillectomy. Cochrane Database Syst Rev. 2013 Jul 18;7.

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• President’s Page • On Becoming A Doctor

James A. Rish, MD 2013-14 MSMA President

hen I was preparing for my medical school interview, the first question I pondered was what exactly drove me to want to become a physician. I often find myself refocusing on the answer to this question as I approach 20 years of private practice. When determining my career, it seemed that of all my high school courses I enjoyed the science related courses the most. I viewed the body as an amazing feat of God’s engineering and had an insatiable quest to better understand just how the body worked. I admired the knowledge base that physicians possess. The detective aspect of examining the evidence, labeling the pathology, and developing a treatment plan fascinated me. Physicians have been, and continue to be, among the most highly respected community members and are in a unique position to serve mankind.

My father grew up very poor and worked with a general surgeon in Houston, Mississippi, to help make ends meet. He did so when it could be done without a bunch of initials after your name or numerous factions being concerned about scope of practice. He, too, wanted to become a doctor but did not have the financial means to do so. I grew up wanting to become the physician that my father could not be, and I was often dumbfounded at the discouraging response from firmly entrenched practicing physicians when discussing my desire to become a physician. “Why was this?” I thought. I have certainly gained a better understanding of these tepid responses as I have advanced my career. Little did I know that the admirable abilities of physicians that drew me to the profession were just a small part of what being a physician actually involves. It is sad that it has become increasingly difficult to care for patients. Yet, it is not because insufficient information exists; quite the opposite is true. The difficulty exists because government agencies and the insurance industry have unleashed a tsunami of regulations that often does little to improve the care of our patients or the efficiency with which we deliver care. We have now been called upon not only to provide high quality care to our patients (which is exactly what we should be doing) but also to be ward clerks, transcriptionists, and coders. We are mandated to utilize EHR (Electronic Health Records) systems that lack the technological infrastructure to efficiently document the care of our patients in an understandable fashion. Many patients become frustrated when staring at the back of a computer screen while yearning to communicate their health issues with their physician. The abundance of mandates and regulatory measures forces physicians to spend more time with a computer than with the patient; this ultimately limits the patient’s access to his physician. It does not make sense when society would benefit from expanded access to physician care. Another source of physician dissatisfaction stems from the continuous devaluation of our services by CMS and other third party payers. Reimbursement rates are often set at or below the cost to provide the service. I am not aware of any other profession or business involving the sale of goods and services in which the purchaser can not only decide the amount they will pay but also whether or not they will pay at all, despite services being rendered. The common theme is a relentless intrusion of the physician-patient relationship. Take insurance network adequacy for example. Patients can no longer count on the physician, whom they have come to know and trust, being there for them in their time of need when a third party can arbitrarily decide to exclude the physician from the insurance network. Ultimately, it is our patients who suffer. This is a sad commentary. It is now easy for me to understand why the grey haired established physicians I consulted were less than enthusiastic when discussing my desire to become a physician. So how do we address these important issues? Even if we physicians find politics distasteful, it behooves us to become political. We must actively participate in organized medicine to rectify these shortcomings. This means not only joining MSMA

July 2014 JOURNAL MSMA 237

but also actively working within the organization at the state level. It is also critical that we be engaged at the national level by membership in our national specialty societies, and yes, the AMA. I have been criticized for my previous endorsement of the AMA. The fact remains that there is simply no other organization of this magnitude with the resources needed to get our voice heard on Capitol Hill. There has been a progressive erosion of our influence and relevance on Capitol Hill because we physicians have been unable or unwilling to recognize this fact. Currently only approximately 14% of the nation’s physicians are members of the AMA which, in my opinion, is shameful. I can assure you that the Congress is keenly aware of this fact. The net result is that our arguments get less traction than the powerful, well organized and funded insurance industry. I don’t always agree with the stance of AMA on many issues, most prominently the Patient Protection and Affordable Care Act (PPACA). The truth of the matter is that I do not always agree with my spouse on various issues either. However, I do not walk away when these disagreements occur. Similarly, we cannot afford to turn our back on the AMA when we disagree with its position on any particular issue. I just returned from the annual AMA House of Delegates meeting and, I assure you, the AMA is working diligently on our behalf on a myriad of issues that are critical to physicians, and more importantly, to the patients of our state. There is good news: despite the current status of health care delivery in our state and nation we do have a wealth of intelligent students who are eager to become physicians. This is evident by an increase in medical school applications across the nation. Most assuredly, health care delivery will look very different as each new generation of physicians enters the work force. We must stay focused on what led us to become physicians. As we pass the torch to our new colleagues we must emphasize the importance of being involved in the political process as it pertains to our profession. If we are complacent in this responsibility, it is to our own peril.

Advocacy, Leadership, Quality and Professional Identity

AnnuAl Scientific ASSembly October 30-November 1, 2014

SAndeStin Golf And beAch ReSoRt, deStin, fl bAytowne confeRence centeR

Assembly Highlights and Events

How to Register Online: sma.org/assembly Telephone: 800.423.4992, ext. 620 Mail or Fax -Download Form: sma.org/assembly

238 JOURNAL MSMA July 2014

Education!

Alliance Activities!

w Pulmonary Diseases w Cardiovascular Diseases w New Drugs Update w Risk Management w Health Reform Update w “Watson” in Healthcare w Quality of Care/Medical Necessity w Abstract Presentations w Poster Presentations

w Raffle w General Sessions w State and County Project Exhibits w Celebrating its 90th Anniversary

Collegiality and Networking! w Welcome Reception w Hospitality Area w SMA/SMAA Presidents’ Installation Luncheon

Halloween Family Fun! w Trick or Treat in Sandestin’s Village Streets w DJ Music – Events Plaza Stage w Spooky Fireworks

• Editorial • Remaining a Great Physician in Tough Times: Learning from Business Principles Robert T. Brodell, MD and Stephen E. Helms, MD

hat makes a really good doctor is not only what they know but how they think. This is particularly important in the current challenging economic environment marked by decreased payments to physicians from insurance companies and Medicare that may encourage physicians to engage in Herculean efforts to protect their bottom line (profit margin). Staff can be laid off, salaries can be cut, purchases of needed supplies can be delayed, face-time with patients can be decreased, and continuing medical education (CME) can be curtailed. Unfortunately, all of these options have the potential for unintended consequences and may lead to a decrease in the overall quality of care received by our patients. Subsequently, this may have the paradoxical result of a decrease in gross income which can have a snowball effect limiting the quality of care even further. An economic death spiral can eventuate in the destruction of a medical practice, including those built with care over many years. We would never have written this article except for stumbling upon one written for businessmen entitled “Three Rules for Making a Company Truly Great.”1 While in the past businessmen often looked to the medical profession for examples of caring and compassion, perhaps in these tough economic times the medical profession should now look to evolving business models. With a combined 62 years of private practice experience, we believe that this “secret sauce” of business success is as valuable for private practice (a small company) or a group practice (middle-sized company) as it is for an academic medical center (a big company). (Table 1) Ethical Principle 1: Put the interests of patients ahead of all else (Better before Cheaper). It is not easy to ignore the steady erosion of practice income, but patient autonomy and non-malfeasance are the cornerstones of our profession and should drive the mission of our lives. Physicians must have the necessary support staff to operate their practices even when staff salaries are an increasingly larger percentage of operating expenses.

Physicians must reward exceptional staff with both kind words and pay raises or risk losing them. The interests of patients require that you keep your staff happy. Thus, profit margins are inevitably shrinking. Some experts have suggested that physicians should never do anything that they would be ashamed of doing if it appeared on the front page of the New York Times. We favor the more positive approach of meeting the expectations of your family or perhaps your children. Will your children or grandchildren think better of you because you made a little more money and pinched every penny? More likely, they will think most highly of a parent or grandparent who answered the call of patients even when it sometimes intruded on their free time, performed community service that was not required, and gave them an extra hand with their homework even when they were tired after a long day’s work. In fact, helping others has an unintended consequence. Patients will return to your practice and bring their family and friends. The willingness to help others is also the single most important characteristic of hyper-efficient people.2 When you treat colleagues, staff, and students in the manner you would wish to be treated, they often find ways to repay your kindness in unexpected ways and at unexpected times.2 In some cases this is an investment in time (helping medical students, residents, or a colleague) and in others an investment in money for staff that lowers the profit margin but helps you to maintain a high level of service. This is the reflection of your practice to the world. Table 1: Three Rules for Making a Company and a Physician Truly Great1 Rule #1: Better before cheaper Rule # 2: Revenue before cost Rule # 3: There are no other rules From Raynor ME and Ahmaed M. Three Rules for Making a Company Truly Great.

July 2014 JOURNAL MSMA 239

• Editorial • Ethical principle 2: Revenue before cost. The days of the “mom and pop” medical practice and totally research-based academic departments are gone. Physicians are rapidly joining large multispecialty groups or specialty specific group practices; most feel overwhelmed with the prospect of “going it alone” in solo practice as they try to meet the requirements of a score of regulatory agencies and resident physicians are faced with extraordinarily high start-up costs. Many have massive educational loans to be repaid. University departments are seeing more patients and providing less “protected time.” Neither solo private practice nor academic medicine is dead! It just costs more to run a practice or a department and revenue streams are changing! Overhead expenses may be 50% to 60% or more in a 21st century practice. Attempting to save money rather than invest in staff to handle patient services, submission of insurance claims, resubmission of rejections, call-backs to pharmacies about step-protocols, non-covered medications, etc. will lead to practice failure. This is on top of the concerns physicians and their personnel must deal with related to Health Insurance Portability and Accountability Act of 1996 (HIPAA), Occupational Health and Safety Administration (OSHA) Rules and Regulations, Clinical Laboratory Improvement Amendments (CLIA), Recovery Audit Contractors (RAC) audits. In fact, team-based care is essential to enhance revenue, even recognizing the cost is great. Perhaps the government will come to realize that the unintended consequences of their regulatory habits are impacting the care of our patients and they will ease their oversight. If not, at some point some physicians and academic departments will need to close their doors. Until then, the physician, in my opinion, should earn his/her way to greatness with the best quality product that can he/she can produce. Ethical Principle #3: Don’t follow any other rules. It is easy to imagine other approaches that might promise the financial success that underpins our ability to care for patients. One could cheat or lie to increase insurance reimbursement. Any short-term financial gain is fraught with severe legal and financial risks. One could focus on trivial things like the color of the office walls, the style of staff outfits, the ratio between level 2 and level 3 office visits. Rather than worrying about taking the right risks, just do the right thing for each patient (Principle # 1). One could try to please staff. Before giving your staff what they want, consider if it is what they need to be a cohesive patient-focused workforce. One could get bogged down in a consideration of the motives of office staff or leaders in an academic organization. Don’t worry about the motivation of these individuals as long as they do the right thing.

240 JOURNAL MSMA July 2014

Of course, there are tradeoffs in our lives when we act honorably. Did the time you spent helping a community organization infringe on time with your family or patients? Did the patient you added to your schedule with an acute problem cause other patients to wait longer for their care? Did education of a medical student at the bedside make a patient feel a little uncomfortable? Conclusion As we think about the private practices we left behind and our work at an academic institution, simple guiding principles help us to keep focus. While the economic milieu of medical practice has been bastardized to the point that it is hardly recognizable as a capitalist enterprise, business realities do impact the physician’s ability to care for patients, and business decisions must be made quickly and confidently. We believe these simple business principles will help to ensure our survival. Furthermore, this approach does not conflict with the core foundation of our profession as elucidated by the Hippocratic Oath. Perhaps many of the readers of the Journal of the Mississippi State Medical Association will agree! Author Information Dr. Brodell has 27 years of experience in the solo private practice of dermatology in Warren, Ohio, a small town in northeast Ohio where he grew up. He has been Professor and Chair of the Department of Dermatology and Professor of Pathology at the University of Mississippi Medical Center for 2 years. He now considers himself to be a proud southerner. Dr. Helms has 35 years of private practice experience in the same small town, Warren, Ohio. He joined the faculty at the University of Mississippi Medical Center as Professor of Dermatology in the fall of 2013. His subspecialty interest is in the area of occupational dermatology.

References 1. Raynor ME and Ahmaed M. Three Rules for Making a Company Truly Great. Harvard Business Review. April 2013: 108-117. 2. Grant AM. Give and Take: A Revolutionary Approach to Success. Viking (New York) 2013.

The editorial comments expressed in this publication reflect the opinions of the authors and do not necessarily state the views or policies of the Mississippi State Medical Association.

• Editorial •

A Glimmer of Hope in the Electronic Medical Records Plague John P. Hey, III, MD; Greenwood

et me say up front that I love computers. I have them all over my house and all over my office. My wife says I spend so much time on my laptop that I can’t get around to her or the various jobs that she has for me! I certainly love our electronic billing programs that make it possible to deal with insurance companies, Medicare and Medicaid. In fact, without these electronic aids, I don’t know how we would ever get the claims processed. However, we must remember that it took at least 15 years to get these systems developed where they are user friendly and profitable to us. We have seen a recent development in medical care whereby the government community of politicians and bureaucrats has demanded huge amounts of data from the medical system. They are almost like “data hoarders,” about which there are many entertaining reality TV programs. They want this data, but unfortunately, even if it is garbage in, we don’t have very good programs to give us garbage out. It is very difficult to use this data or to access it, and it takes huge amounts of time to enter it into these dysfunctional systems. Under the Unavailable Care Act mandates, big corporate developers have scrambled to cobble together these electronic health records to meet artificial deadlines and provide satisfaction to non-medical people and the bean counters who have attached themselves to the medical system. The AMA authorized a review by the Rand Corporation, which found that the electronic health records are an absolute disaster and just about failed at every test. Doctors hate them, and patients don’t like the lack of attention while the doctor is hunched over a computer. I used to get nice, succinct notes from specialists that I referred to, but now I get voluminous print outs (in fine print!) of all sorts of useless information. I usually ask my nurse “What did he say was wrong and what is he going to do?” while she pores over it. Most of the time these go straight into the garbage can as unusable. This has all been done at a huge expense, especially for hospitals and large medical units. Financially, EHRs are virtually unreachable for individual, small practices. Therefore, we are being fined by various CMS rules every year for not falling in line with these plans.

There have been voluminous reports on the ineffectiveness, inefficiency, and pain involved in the socalled electronic health records systems. Now we are starting to see some interesting reports on the innovative ideas that help alleviate this problem. The Wall Street Journal has had several articles about medical scribes. These are individuals who are trained to be medical information technicians (MIT). They follow the physician around and take down the notes he dictates, go through the check boxes and so forth, and review past records, lab, and medications for the physician, all as they travel making rounds and seeing patients. Patients seem to like this, especially the part where the doctor now looks at them instead of a keyboard. This system has been shown to almost double productivity and increase income by most companies who use it. It is a shame that we have to have another layer of personnel and staff to carry out something that feeds the bureaucratic machine and doesn’t add much to actual medical care. The scribe system mostly protects the doctor and patient from having valuable assets drained away with little to show for it. It doesn’t actually produce anything beyond a nice computerized record. I think as a medical profession we need to stand up and insist that we only practice medicine, and we are not trained in data management, computers, government regulations, coding and other paper work foolishness that are being foisted upon us. There are those who can go and specialize in these skills. We live in an age of division of labor and specialization. We certainly don’t expect our physicians to run their own lab work, mix their own IVs, or dispense medications. I’ve done all of these things, but I’m glad I don’t have to do them now. Doing so would certainly cut into my ability to see so many patients well. I have had hospital administrators tell me that even though they spent millions of dollars keeping this dysfunctional system up and running, they just cannot afford to hire scribes for $10-20 hour. So, what they are really saying is that they want to take a $400 an hour surgeon and convert him into a $10 an hour clerk typist. Now he may be a brilliant surgeon and do wonderful waterproof anastomoses and sewing lines, but I very seldom see these same people perform well

July 2014 JOURNAL MSMA 241

as very good clerk typists or data-entry keypunch operators. We have not been trained and really don’t have any desire to learn in that special area. I think that we, as a medical profession and certainly as the state medical society, should pass resolutions to help remedy this problem and put the force of our organizations behind some solutions. I would recommend that these resolutions at least contain the following: 1. As a medical association, we need to go on record that the medical scribe system or additional nurses to accompany the physician must be implemented, paid for, and supported by hospitals and medical facilities. We need to begin bringing pressure on the hospital associations, etc., to make this happen. 2. No physician should have to work overtime or stay late at night doing keypunch work. When he finishes his schedule for the day, he should go home. If records start backing up, then the facility should hire additional help to get the paperwork done and not depend on physicians working overtime. 3. Physicians should be encouraged not to enter into contracts with medical facilities that do not include provisions for iPhone, iPad, Android, and all web-enabled mobile devices mandating that adequate nursing and staff, including scribes, will be provided. I will list a few of the very interesting articles recently published. They have a great deal of excellent data in them that Put the Journal MSMA in the palm of your hand. should be a great encouragement to us all. We don’t have to allow non-medical people to orchestrate tinkering with or the Full color. Flip-page. Every month. destruction of our medical system. Ethically, we owe it to our patients to do what is best for them and do it in accordance with scientific evidence basedmedicine and ethics. If we are not able to do this, I think we will see more and more retirements, more and more alternative medical systems, and generally poorer health care in our country. All of this, of course, may serve a “good purpose,” in that it will cut down on utilization and availability. Patients will just have to learn that in the Unavailable Health Care regime, there is a lot of care that they simply will not be able to get anymore. Bibliography 1. Bank, Allen J. “In Praise of Medical Scribes,” Op-ed, Wall Street Journal, April 7, 2014. 2. Gregg, H. “The Case for Medical Scribes in Emergency Care,” Becker’s Hospital Review, May 9, 2014. Available at: http://www.beckershospitalreview.com/ 3.

healthcare-information-technology/the-case-for-medical-scribes-in-emergency-care.html.

Wilkinson, S. “Medical Scribes Are More of a Symptom Than a Solution,” Opinion - Letters, Wall Street Journal. Available at: http://online.wsj.com/news/ articles/SB10001424052702303603904579494340866436798.

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242 JOURNAL MSMA July 2014

• Letters •

ear JMSMA Editor:

You Have A Voice in Mississippi Medicine; Attend the Annual Session in Jackson

I read with interest your opening to the May issue [From the editor: Has Jackson taken over our MSMA? J Miss Med Assoc. 2014;55(5):138]. The dominance of our state association by a limited geographic sub-population is an obvious problem, and I share your concern, but you are incorrect in attributing the problem solely to the location of the annual session. The origins of this situation actually stem from the period of time following the de-unification of our association with the AMA. In the wake of that moral abyss, there was an almost hysteric need on the part of the leadership and staff of our association to bolus membership numbers. In part, to prove to those members that hadn’t already resigned their membership over the AMA endorsement of Obamacare, that things were just fine now that we’d suceded from the union, and that membership was recovering. But how, oh how to do that? Well, we found a way. We could achieve that membership bolus and increase our MPCN network participation if we could just get every physician on the faculty of the University of Mississippi Medical Center to become a member of both entities. We just needed a way to convince them to do that. There was very little hope of coercing every single physician on the UMMC faculty that it was in their best interest to do such a thing out of their own pockets. But, there was still a way. We just needed to bypass individual volition and appeal directly to the institution, so we did. A deal was cut to offer membership in the MSMA and participation in the MPCN to every physician of the UMC faculty at a discounted rate, with those dues to be paid by the institution (UMMC) in order to get 100% participation. In return UMMC would contribute directly to the bottom line of both entities. It doesn’t really take an intellect much greater than a potato to see the potential outcome of such a decision. We had sold controlling interest of our association to a single institution. The issue was not UMMC but altered membership dynamics. I do understand the fiscal implications, we went to UMMC they did not come to us, we did it for several reasons, but the outcome is the same: a geographically univocal influx of membership. But hey, we got to stand up at the board meetings and at annual session and trumpet our new membership numbers and how well we had survived the de-unification fight. Members were flocking back to the fold. We have now exacerbated that potential problem by moving our annual session to the very institution to which we have given an improbable numeric advantage. There is nothing to prevent a senior UMMC official from, say, sending out e-mails to department heads strongly encouraging voter participation in favor of a particular candidate, and in this situation, as it now exists, that would constitute undue influence on the electoral process. As soon as that happens the physicians of the rest of the state become disenfranchised, and their input rendered moot. To quote Dr. South, I have a terrible problem with my memory...it still works. Respectfully, R. Scott Anderson, MD; Meridian

n response: Statement of the Board of Trustees

One of the primary goals of MSMA’s 2008 Strategic Plan was to increase membership in our organization. Membership dues are our primary source of income, and we want every physician involved in our state medical association. In fact, the vision statement from that Strategic Plan is for “MSMA to be an essential part of every Mississippi physician’s professional life.” Areas where we had little penetration for membership were among academic physicians, medical students, and residents. The Board of Trustees made a concerted effort to encourage membership in those areas and we have had good success. We offered free membership to students and residents and put more emphasis on YPS functions to get our next generation of physicians involved. We are proud that the University Medical Center values MSMA membership and pays (full dues rate) for their physicians to be members. They are valued members of our association. Membership continues to be an important priority for the Board of Trustees. We hope that all physicians in our state find value in being MSMA members. We encourage all MSMA members to attend the Annual Session House of Delegates in Jackson on August 15-16. We need everyone’s input to address the many challenges we face as the doctors who care for Mississippi. Lee Voulters, MD; Chair, Gulfport MSMA Board of Trustees

July 2014 JOURNAL MSMA 243

• Letters • Dear JMSMA Editor,

read with interest Dr. Trotter’s excellent article in the Journal MSMA on the Mississippi State TB Sanatorium (MSTS). While it is of some interest because our company insures a number of thoracic surgeons in Mississippi, I have a more personal connection to the MSTS. Both of my parents were patients there immediately after World War II. My father was diagnosed with tuberculosis upon his discharge from the Army and my mother while a sophomore at Ole Miss. My father used to tell a story about Dr. Boswell letting him take my mother on a date in Dr. Boswell’s car toward the end of their time at MSTS. My mother claims Dr. Boswell even told them when they could have their first child, my older brother. In the late 1940’s, my grandmother moved to Sanatorium and became director of the nurses’ dormitory, which can be seen in the background of the photo on page 181. I spent many a night in that dorm and played all over the nearby grounds. She also played the piano in the chapel on the campus. I remember fresh milk in glass bottles being delivered to the back steps of the dorm. I cannot remember whether MSTS’s 9-hole golf course was still in use at that time. While my parents’ treatment at MSTS was a difficult time in their lives, they always talked very highly of the care provided to them and the dedication of its physicians and staff. You have probably read the wonderful 1979 MDAH interview of Mrs. Boswell, but here is the link in case you have not: http://mdah.state.ms.us/arrec/digital_archives/vault/projects/OHtranscripts/AU125_099091.pdf Best wishes, Rob Jones, JD Chief Executive Officer Medical Assurance Company of Mississippi

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DISABILITY DETERMINATION SERVICES 1-800-962-2230 244 JOURNAL MSMA July 2014

Dear JMSMA Editor,

enjoyed reading MSMA’s June Journal— it’s one of my favorites! It was nice seeing Dr. Scott Hambleton and Physicians’ Health Corner in there and the articles on TB and the Veterans Administration were great. Seeing Benjamin Rush’s name [J Miss Med Assoc. “Images in Mississippi Medicine” Death of Benjamin Rush (1746-1813) 2014;55(6):204] brought back memories of reading about him in one of my old books, “Slaying the Dragon” by William White. Not only was Rush considered the father of psychiatry, he was also considered the “first American authority on alcohol and alcoholism.” Dr. Rush’s father was an alcoholic, so there was the family history, and as surgeon general during the Revolution he became concerned about the Continental Army’s drunkenness. Interestingly, Dr. Rush was the first prominent physician of his time (and for many years beyond his time) to see alcoholism as a disease and as a problem that required treatment. Donna Hopkins, Jackson

The PEN is greater than the SWORD

xpress your opinion in the Journal MSMA through a letter to the editor or guest editorial. Letters for publication should be less than 300 words. Guest editorials or comments may be longer, with an average of 600 words. All letters are subject to editing for length and clarity. If you are writing in response to a particular article, please mention the headline and issue date in your letter. Also include your contact information. While we do not publish street addresses, e-mail addresses or telephone numbers, we do verify authorship, as well as try to clear up ambiguities, to protect our letter-writers. You may submit your letter via email to KEvers@MSMA online.com or mail to: P.O. Box 2548, Ridgeland, MS 39158-2548.

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July 2014 JOURNAL MSMA 245

• Mississippi State Department of Health •

246 JOURNAL MSMA July 2014

• Poetry and Medicine • [“A frightening episode for new or experienced parent– the brightest, greenest, fluorescent stool in a perfectly healthy child, but which evacuation just happened to catch Mom by surprise. Conjured up are visions of Shigella, parasites, and even cancer. There indeed is no other stool like this. Word of mouth eventually gets around and the next door neighbor becomes an expert diagnostician. As a college chemistry major, I am amazed at the resources of gastrointestinal HCL, bile, microbial, or enzymatic mechanism that can alter the original dye and lavish us with this beautiful piece of art. As is usual, a good history can yield this diagnosis over the phone!” writes Dr. John D. McEachin, a Meridian pediatrician. Any physician is invited to submit poems for publication in the JMSMA, attention: Dr. Lampton or email me at lukelampton@cableone.net.] —Ed.

A Little Gut Magic A mom came bursting through the door, Her panic adorned with a cry. “Doc, examine this boy of mine; He’s all I’ve got! Don’t let him die!” “Now, now Mrs. Brown, please calm down; He’s alert, and his color’s great!” Mother Brown, not to be outdone, “Doc, hold on a sec! You just wait!” Producing two kiddie diapers, Sure evidence to make her case: “Look at this stool, just look at it!”— Expecting my smile to erase. “Yes, mother dear, I see your point; This stool color is quite the scene! There is none other quite like it— This fluorescent lime, spinach green! But to help you feel much better, I’ll ask you a question or two. Any Grape Icee or Kool-Aid, In the last day or so—or Blue?” To learn from this common story, A script fit for Hollywood screen: All that glitters may not be gold— Blue and purple just may be green! — John D. McEachin, MD; Meridian

July 2014 JOURNAL MSMA 247

• Images in Mississippi Medicine •

SMA ANNUAL SESSION MEETS IN 1928 AT ELKS CLUB, MERIDIAN– The Sixty-first Annual Session of the Mississippi State Medical Association met at the Elks Club in Meridian on May 7 to 10th, 1928. At that time, the annual session was the premier medical event for physicians in the state, with most specialty medical societies meeting in unison and extensive medical education and lectures offered. The Radiological Society of the state met at the Lamar Hotel with 5 essayists, including Dr. Henry Boswell. The President that year was Dr. John Darrington of Yazoo City; with three Vice-Presidents Drs. Edwin Benoist of Natchez; E. S. Bramlett, Oxford; and E. L. Posey of Jackson. Acting Treasurer was Dr. I. W. Cooper of Meridian, and Dr. T. M. Dye of Clarksdale, ancestor of our own Ford Dye of Oxford, served as longtime Secretary. The Women’s Auxiliary also was meeting. Interestingly, Section 4 of the By-laws stressed that “no address” before the association, except that of President or a special orator, “shall occupy more than fifteen minutes in delivery; and no member shall speak more than five minutes, nor more than once on any subject.” Seems even then, they had long-winded physicians speaking on the floor of the House of Delegates! This photograph was taken at that annual convention back in 1928 by the famed Mississippi photographer Hammond. (Apparently, the photograph was brought to the 1963 annual session and “created such a sensation.”) Among past leaders I recognize are the then President Dr. Darrington, bearded on the front row; and past Presidents: Dr. W. W. Crawford of Hattiesburg; Drs. Hugh and Paul Gamble of Greenville; Dr. W. H. Anderson of Booneville; Dr. J. J. Haralson of Forest; Dr. G. S. Bryan of Amory; and others. The big issue of that session was a proposed dues increase of 33%. Despite keen discussion by the House, the dues increase carried the day. If you have an old or even somewhat recent photograph which would be of interest to Mississippi physicians, please send it to me at lukelampton@cableone.net or by snail mail to the Journal. — Lucius M. “Luke” Lampton, MD; JMSMA Editor

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