VOL. LVIII • NO. 6/7 • 2017 by Journal MSMA

VOL. LVIII • NO. 6/7 • 2017

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VOL. LVIII • NO. 6/7 • JUNE/JULY 2017

SCIENTIFIC ARTICLES

EDITOR Lucius M. Lampton, MD

THE ASSOCIATION President Lee Voulters, MD

Top 10 Facts You Need to Know about Negative Aspects of Treatment with Benzodiazepines Roy R. Reeves, DO, PhD and Sara H. Gleason, MD

184

Top 10 Facts You Need to Know About Contact Dermatitis Hannah R. Badon, M2 and Stephen E. Helms, MD

187 190

ASSOCIATE EDITORS D. Stanley Hartness, MD Richard D. deShazo, MD

President-Elect William M. Grantham, MD

MANAGING EDITOR Karen A. Evers

Secretary-Treasurer Michael Mansour, MD

Speaker Geri Lee Weiland, MD

A Retrospective Analysis of Thyroid Cancer Prevalence among Thyroid Nodules at the University of Mississippi Medical Center Jeremy Taylor, MD and Shema Ahmad, MD

192

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

Transcatheter Aortic Valve Replacement in Treatment of Aortic Stenosis John Schmidt, MS and Josiah Laite, MS

195

Mississippi Hospital Stroke Readiness Mary Helen Conner, PhD; Elgenaid Hamadain, PhD; Ellen Jones, PhD

198

Vice Speaker Jeffry A. Morris, MD Executive Director Charmain Kanosky

JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. CORRESPONDENCE: Journal MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: 601-853-6733, Fax: 601-853-6746, www.MSMAonline.com. SUBSCRIPTION RATE: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available. ADVERTISING RATES: furnished on request. Cristen Hemmins, Hemmins Hall, Inc. Advertising, P.O. Box 1112, Oxford, Mississippi 38655, Ph: 662-236-1700, Fax: 662-236-7011, email: cristenh@watervalley.net POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 39158-2548.

DEPARTMENTS From the Editor – The Politics of Public Health Crises Lucius M. Lampton, MD, Editor

182

President’s Page – The Address of the 2017-18 MSMA President Lee Voulters, MD

202

Editorial – Has the Time Come for Democracy at our MSMA? Michael “Mike” Artigues, MD

204

Editorial – You Can Change a Village: Lessons Learned on a Medical Mission to Honduras Philip Merideth, MD, JD

205

New Members

210

Images in Mississippi Medicine – The Second Hospital, Beauvoir, 1924-2005

211

Poetry and Medicine – Alpha to Omega John D. McEachin, MD

212

RELATED ORGANIZATIONS Mississippi State Department of Health – Reportable Disease Statistics

208

Mississippi State Department of Health – Department of Health Earns Coveted National Accreditation

209

The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association. Copyright © 2017 Mississippi State Medical Association.

Official Publication

MSMA • Since 1959

ABOUT THE COVER

“Come into my parlor…” Framed by a vine-covered arbor, this historic cottage sits barely visible on one of Kosciusko’s main streets. Dr. Stanley Hartness, Kosciusko native and friend of the owners, has always been intrigued by the enigmatic setting which seems both welcoming and cautionary.—Ed. JOURNAL MSMA

VOL. LVIII • NO. 6 • 2017

181

F R O M

T H E

E D I T O R

The Politics of Public Health Crises

T Lucius M. Lampton, MD Editor

he state’s political leadership, the press, and even medical leaders have recently asserted that the current opioid epidemic is “the number one public health crisis” in Mississippi. While I don’t want to understate the tragedy and enormity of the opioid crisis in our state and the important role physicians must play in its elimination, such a statement is pure poppycock: politics and demagoguery are at play in selecting one public health crisis wrongly as “number one,” while other crises more deserving of attention receive only neglect.

According to Mississippi Bureau of Narcotics statistics, in 2013, there were 140 prescription opioid related deaths in Mississippi. By 2016, a significant decline occurred, with only 63 prescription opioid related deaths occurring, a more than 55% decrease in a 3-year period. By any standard, this is a positive trend: physician education requirements and increased use of the Prescription Monitoring Program may be having a dramatic impact on opioid prescribing, diversion, and deaths. While 63 deaths in a year is still 63 too many, let’s look at the other public health crises impacting our state. Obesity, easily Mississippi’s number one

public health crisis, impacts two out of three Mississippians and contributes to one out of every eight deaths. State CDC data on other diseases reveals that last year: 3,576 people died of heart disease, 1,315 from hypertension, 1,580 from stroke, 698 from renal disease, and 1,014 from diabetes. Road traffic accidents claimed 648 people, ten times the opiate deaths, in a year when our political leadership underfunded our fragile trauma system. Various cancers claimed multiple thousands of citizens last year, while our state allowed 15% of our population to be uninsured and receive no preventative care. Suicide deaths in the state were 377, six times more than opioid deaths, in a year in which historic legislative cuts were made to the mental health system. Infant mortality here remains among the highest in the nation, with 354 infant deaths in 2015, while anemic funding annually undermines the work of our Department of Health. Where is the public outrage about these crises? Where are the task forces and the regional meetings? Where is the daily press coverage? While the epidemic of fatal opioid overdoses is a serious crisis for Mississippi, physicians should demand of the state’s political leadership similar attention and alarm for other legitimate public health issues which are claiming countless more lives. Q Contact me at lukelampton@cableone.net.

— Lucius M. Lampton, MD, Editor

JOURNAL EDITORIAL ADVISORY BOARD Timothy J. Alford, MD Family Physician, Kosy Direct Care

Bradford J. Dye, III, MD Ear Nose & Throat Consultants, Oxford

Michael Artigues, MD Pediatrician, McComb Children’s Clinic

Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist, Medical Associates of Vicksburg

Diane K. Beebe, MD Professor and Chair, Department of Family Medicine, University of Mississippi Medical Center, Jackson Rep. Sidney W. Bondurant, MD Retired Obstetrician-Gynecologist, Madison Jennifer J. Bryan, MD Assistant Professor, Department of Family Medicine University of Mississippi Medical Center, Jackson Jeffrey D. Carron, MD Professor, Department of Otolaryngology & Communicative Sciences, University of Mississippi Medical Center, Jackson

Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson Nitin K. Gupta, MD Assistant Professor-Digestive Diseases, University of Mississippi Medical Center, Jackson Scott Hambleton, MD Medical Director, Mississippi Professionals Health Program, Ridgeland

Philip L. Levin, MD President, Gulf Coast Writers Association Emergency Medicine Physician, Gulfport Lillian Lien, MD Professor and Director, Division of Endocrinology, University of Mississippi Medical Center, Jackson William Lineaweaver, MD Editor, Annals of Plastic Surgery, Medical Director, JMS Burn and Reconstruction Center, Brandon Michael D. Maples, MD Vice President and Chief of Medical Operations, Baptist Health Systems Heddy-Dale Matthias, MD Anesthesiologist, Critical Care Internist, Madison

J. Edward Hill, MD Family Physician, Oxford

Jason G. Murphy, MD Surgeon, Surgical Clinic Associates, Jackson

Gordon (Mike) Castleberry, MD Urologist, Starkville Urology Clinic

W. Mark Horne, MD Internist, Jefferson Medical Associates, Laurel

Matthew deShazo, MD, MPH Assistant Professor-Cardiology, University of Mississippi Medical Center, Jackson

Daniel W. Jones, MD Sanderson Chair in Obesity, Metabolic Diseases and Nutrition Director, Clinical and Population Science, Mississippi Center for Obesity Research, Professor of Medicine and Physiology, Interim Chair, Department of Medicine

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

Thomas E. Dobbs, MD, MPH Chief Medical Officer, VP Quality, South Central Regional Medical Center & Infectious Diseases Consultant, Mississippi State Department of Health, Hattiesburg Sharon Douglas, MD Professor of Medicine and Associate Dean for VA Education, University of Mississippi School of Medicine, Associate Chief of Staff for Education and Ethics, G.V. Montgomery VA Medical Center, Jackson

Ben E. Kitchens, MD Family Physician, Iuka Brett C. Lampton, MD Internist/Hospitalist, Baptist Memorial Hospital, Oxford

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Michelle Y. Owens, MD Associate Professor, Vice-Chair of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson Jimmy L. Stewart, Jr., MD Program Director, Combined Internal Medicine/ Pediatrics Residency Program, Associate Professor of Medicine and Pediatrics University of Mississippi Medical Center, Jackson Shou J. Tang, MD Professor and Director, Division of Digestive Diseases, 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

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

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

Ann Myers, MD Rheumatologist , Mississippi Arthritis Clinic, Jackson

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

Darden H. North, MD Obstetrician/Gynecologist , Jackson Health Care-Women, Flowood

Sloan C. Youngblood, MD Assistant Medical Director, Department of Anesthesiology, University of Mississippi Medical Center, Jackson

Jack D. Owens, MD, MPH Neonatologist, Newborn Associates, Flowood

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S C I E N T I F I C

Top 10 Facts You Need to Know about Negative Aspects of Treatment with Benzodiazepines ROY R. REEVES, DO, PHD AND SARA H. GLEASON, MD Benzodiazepines are among the most commonly prescribed medications and are the most widely used of all psychotropic drugs. It has been estimated that during the last 25 years over 500 million people have taken a course of benzodiazepine treatment.1 However, although beneficial in a number of conditions, almost from their introduction the use of benzodiazepines has been controversial. Advocates point out their efficacy and patient acceptability, while opponents are concerned about their adverse effects and abuse and dependence liability. This paper will explore the negative aspects of treatment with benzodiazepines, particularly long-term usage. All benzodiazepines are CNS depressants and can cause sedation. Tolerance may develop after a few weeks of treatment with benzodiazepines, but residual effects often persist.2 Drowsiness can also be present during the day after the use of a benzodiazepine for insomnia the previous night (residual daytime sedation). Some individuals also experience ataxia (about 2%) and dizziness (about 1%). These symptoms may result in falls and have caused fractures in some patients.3

Benzodiazepines may impair cognition. Memory for information acquired pre-drug administration (retrograde memory) is not impaired but acquisition of new material post-drug (anterograde memory) is consistently impaired by benzodiazepines, 4 all of which can cause interference with new learning.3 Long term treatment with benzodiazepines has been reported to cause impairment in several cognitive domains such as visuospatial ability, speed of processing, and verbal learning. A meta-analysis of peer-reviewed studies found that, although cognitive dysfunction improved after benzodiazepines were withdrawn, patients did not return to levels that matched benzodiazepine-free controls.5

Benzodiazepines may cause psychomotor impairment and studies suggest that using these medications while driving approximately doubles the risk of motor vehicle accidents. Impairment of driving caused by a single dose of diazepam 10 mg is equivalent to impairment caused by a blood alcohol level sufficient to qualify for a citation for driving under the influence. Patients whose driving is impaired often are not aware of the problem.6 Tolerance to psychomotor impairment does not occur as readily as does tolerance to sedation.3

Physical dependence, tolerance, and risk of withdrawal may develop quickly. Dependence may occur after relatively short-term use of alprazolam (Xanax) at dosages recommended to treat anxiety, and abrupt discontinuation, dosage tapering, or missed doses may result in rebound anxiety or withdrawal symptoms (anxiety, hypertension, sweating, tremor, and sometimes convulsions).7 Persons who misuse benzodiazepines are often those who appropriately seek help for anxiety or insomnia but continue to use their medication beyond the recommended duration of treatment or at higher than recommended doses. Another group of patients who actively seek benzodiazepines for intentional misuse are those with an underlying substance use disorder.2

Dangerous interactions may occur when benzodiazepines are taken with other medications. There is a significant risk of respiratory depression when benzodiazepines are taken with other CNS depressants such as alcohol. Of particular danger is the combination of benzodiazepines and opiates.8 The metabolism of benzodiazepines is delayed when combined with certain drugs, resulting in increased levels. Caution should be taken about interactions between benzodiazepines and SSRIs, antiepileptic drugs, macrolide antibiotics, antimycotics, and cimetidine.9 Death has occurred when parenteral lorazepam was given with parenteral olanzapine (an antipsychotic).3

Certain persons are especially vulnerable to adverse effects of benzodiazepines, particularly the elderly and patients with hepatic disease. Usual clinical doses can produce toxic levels in such individuals. Benzodiazepines have been placed on the list of potentially inappropriate medications (PIMs) for use in older adults in the American Geriatric Society Beerâ&#x20AC;&#x2122;s Criteria.10 Demented patients may

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become more confused when they take benzodiazepines because further depression of the reticular activating system produces delirium.3 Benzodiazepines can also produce clinically significant impairment of respiration in persons with COPD and sleep apnea.3,11 A recent study in Finland showed that benzodiazepine use was associated with an increased risk of pneumonia among patients with Alzheimer’s Disease and concluded that risk of pneumonia should be considered when weighing the benefits and risks of benzodiazepines in this population.12 Benzodiazepines have been associated with the development of dementia; the greater a person’s cumulative dose, the greater the risk. A study of patients with Alzheimer’s Disease showed that taking a benzodiazepine for three to six months increased the risk of dementia by 32%, and taking one for more than six months increased the risk by 84%. People who were on long acting benzodiazepines were at a greater risk than those on short acting preparations.13 Enlargement of cerebrospinal fluid spaces has also been demonstrated to occur in long term benzodiazepine abusers.14

Paradoxical excitation after benzodiazepine administration is well documented. Benzodiazepines may cause agitation, disinhibition, and even aggression and violence in certain patients. While rare, violence in some cases has been severe. Risk factors include concurrent alcohol use, benzodiazepine dosage, a history of aggression and impulsivity, and pre-existing brain damage.15

8 9

Most benzodiazepines were classified FDA Pregnancy Category D. Benzodiazepines cross the placenta. Studies concerning their teratogenicity have produced conflicting results, with some investigations citing an increased risk and others showing no danger of harm to the fetus. Benzodiazepines may increase rates of preterm birth, low birth weight, and small for gestational age infants.16 Occurrence of withdrawal symptoms in newborns of mothers exposed to benzodiazepines during pregnancy has been well documented. Benzodiazepines are secreted in breast milk in sufficient concentrations to cause drowsiness, hypotonia, dyspnea, and bradycardia in nursing babies.3 Withdrawal may occur in nursing infants when the mother stops taking benzodiazepines or stops breastfeeding. Benzodiazepines can make counseling/psychotherapy less effective for certain psychiatric disorders, particularly Post Traumatic Stress Disorder. Benzodiazepines interfere with the natural decrease in anxiety that comes from talking through and facing fearful memories and thoughts. Benzodiazepines may also prevent patients from engaging with therapy by making them less able to concentrate on or connect with how a trauma has affected them.1

Conclusion The risk-benefit ratio of the benzodiazepines is positive for most patients in the short term (i.e., weeks) but is unestablished beyond that time.2 Patients taking benzodiazepines should be warned about the risks of sedation, impaired psychomotor performance, and other adverse effects. Considering the extent to which benzodiazepines are prescribed (often not adequately based on scientific evidence17) and the number of potentially adverse effects in this drug class, indiscriminate widespread use should be cautioned against. Q References 1.

Bernardy NC. The role of benzodiazepines in the treatment of posttraumatic stress disorder (PTSD). PTSD Res Quart. 2013;23(4):1-9.

Lader M. Benzodiazepines revisited-will we ever learn? Addiction. 2011;106:2086-2109.

Dubovsky SL. Benzodiazepine receptor agonists and antagonists. In: Sadock BJ, Sadock VA, Ruiz Peds. Comprehensive Textbook of Psychiatry, 9th ed. Philadelphia: Wolters Kluwer. 2009:3044-3056.

Barker MJ, Greenwood KM, Jackson M, Crowe SF. Cognitive effects of long-term benzodiazepine use: a meta-analysis. CNS Drugs. 2004;18:37-48.

Stewart SA. The effects of benzodiazepines on cognition. J Clin Psychiatry. 2005;66 Suppl 2:9-13.

Thomas RE. Benzodiazepine use and motor vehicle accidents. Systematic review of reported association. Can Fam Physician. 1998;44:799-808.

Medical Letter Inc. Alprazolam (Xanax, and others) revisited. Medical Let. 2005;47 (Issue 1200) January 17:5-6.

Webster LR, Reisfield GM, Dasgupta N. Eight principles for safer opioid prescribing and cautions with benzodiazepines. Postgrad Med. 2015;127(1):27-32.

Tanaka E. Clinically significant pharmacokinetic drug interactions with benzodiazepines. J Clin Pharm Ther. 1999;24:347-355.

10. American Geriatrics Society. American Geriatrics Society updated Beer’s Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60:616-631. 11. Ekstrom MP, Bornefalk-Hermansson A, Abernethy AP, Currow DC. Safety of benzodiazepines and opioids in very severe respiratory disease: national prospective study. BMJ. 2014;348:g445 doi: 10.1136/bmj.g445. JOURNAL MSMA

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12. Taipale H, Tolppanen AM, Koponen M, Taskanen A, et al. Risk of pneumonia associated with incident benzodiazepine use among community-dwelling adults with Alzheimer Disease. CMAJ. 2017 Apr 10;189(14):E519-E529. doi: 10.1503/cmaj.160126. 13. Billioti de Gage S, Moride Y, Ducruet T, et al. Benzodiazepine use and risk of Alzheimer’s Disease: a case-control study. BMJ. 2014 Sep 9;349:g5205. Doi: 10 1136/ bmj.g5205. 14. Schmauss C, Krieg JC. Enlargement of cerebrospinal fluid spaces in long-term benzodiazepine abusers. Psychol Med. 1987;17:869-873. 15. Jones KA, Nielsen S, Bruno R, et al. Benzodiazepines - their role in aggression and why GPs should prescribe with caution. Aust Fam Physician. 2011;40:862-865. 16. Okun ML, Ebert R, Saini B. A review of sleep-promoting medications used in pregnancy. Am J Obstet Gynecol. 2015 Apr;212(4):428-441. doi 10.1016/j. ajog.2014.10.1106. 17. Dell’osso B, Lader M. Do benzodiazepines still deserve a major role in the treatment of psychiatric disorders? a critical appraisal. Eur Psychiatry. 2013;28:7-20.

Author Information: Clinical Director at South Mississippi State Hospital and Adjunct Professor of Clinical Sciences at William Carey University College of Osteopathic Medicine, Hattiesburg MS (Reeves). Associate Professor, Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, MS (Gleason). Corresponding Author: Roy R. Reeves, DO, PhD; South Mississippi State Hospital, 823 Highway 589, Purvis, MS 39475. Ph: 601-7940169 (rreeves@smsh.state.ms.us).

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Top 10 Facts You Need to Know About Contact Dermatitis HANNAH R. BADON, M2 AND STEPHEN E. HELMS, MD Contact dermatitis, both allergic and irritant, is a frequent diagnosis made by both dermatologists and other medical practitioners. In the case of irritant contact dermatitis, which is more common, the skin becomes irritated after repeated exposure to any number of irritating chemicals or repeated exposure to water.1 If an allergic reaction is the case, this delayed hypersensitivity (Type IV) reaction occurs after previous exposure to the allergen and manifests itself either as an acute or chronic eczematous eruption. The inciting allergen or allergens can be identified by patch testing the patient and treatment includes topical and or systemic corticosteroids.2 Furthermore, one obviously must avoid the allergen or allergens in order to avoid a future or chronic rash. Contact dermatitis is the most frequently reported dermatologic disease by non-dermatologist practitioners, noted at 12% of outpatient visits. In fact, twice as many contact dermatitis cases are seen by non-dermatologists than by dermatologists. Yearly, over 76 million combined cases of irritant and allergic contact dermatitis are reported by physicians.3

1 2 3

Not all contact dermatitis is due to an allergy. Irritant contact dermatitis can be easily misdiagnosed as allergic contact dermatitis. Studies show that up to 80% of cases are due to irritants as opposed to allergens.1 Furthermore, approximately 9% of these cases are occupationally related.4 Potential irritants primarily include frequent wet work (soap and water), harsh chemicals, solvents, cosmetic products, some medications, and many others.

Potential allergens change over time with new chemicals being reported or become more frequent with increased exposure. For example, methylisothiazolinone, a newer preservative found in wipes and many personal care and cosmetic products, has more than doubled its incidence of positive reactions when compared in the 2011-2012 to 2013-2014 studies published by The North American Contact Dermatitis Group (NACDG). This group studied thousands of patients in 13 centers in the U.S. and Canada, demonstrating that the positive reaction rate for methylisothiazolinone increased from 5% to 10.8% in the short time period between the two studies.4 The prevalence of allergic contact dermatitis is reported every 2 to 3 years so that we may note increases and decreases in those allergens most often showing positive reactions (Table 1).

We as medical personnel, as well as hairdressers, custodians, and all who work in “wet” environments, are more likely to develop contact dermatitis.5 Once again, irritant contact dermatitis is usually the case, but allergens can play a significant role as well.

An FDA approved commercial product (TRUE Test™ -Thin-Layer Rapid Use Epicutaneous Patch Test) is available and generally useful for screening for allergic contact dermatitis; however, it may miss up to 1/3 of potential allergens.6 The TRUE TestTM consists of 35 allergens and a petrolatum control that is available from Smart Practice in Canada (Table 2).7 Some of the most important allergens that may be missed include: methylisothiazolinone, iodopropynyl butylcarbamate, additional fragrance materials, and propylene glycol. Therefore, it may be necessary to expand to larger screening series or include some of the patient’s personal products to effectively reveal relevant allergens.8

Table 1. Top 10 Most Frequent Allergens Per the North American Contact Dermatitis Group4 Substance

Nickel sulfate hexahydrate Fragrance mix I Neomycin sulfate Myroxylon pereirae resin (balsam of Peru) Bacitracin Cobalt (II) chloride hexahydrate Formaldehyde Quaternium-15 4-Phenylenediamine base Fragrance mix II

Positive Reaction Percentage 18.5% 12.1% 9.1% 7.9% 7.8% 7.3% 6.6% 6.4% 6.4% 5.2%

As shown in Table 1, nickel sulfate hexahydrate elicited the greatest amount of positive reactions in the recent study by the North American Contact Dermatitis Group. The allergens are ranked by the greatest number of positive reactions.

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Allergic contact dermatitis is being recognized with an increasing frequency in patients with atopic dermatitis. Multiple studies have indicated that practitioners should patch test children with “stubborn or resistant” eczema more frequently. Studies show that nearly 20% of children suffer from atopic dermatitis, and a significant number of these patients may have their eczema aggravated by allergens found in medications or other topical products.9 In fact, patch testing has been listed as a preventative measure in a recent review series for current guidelines of care for atopic dermatitis.10

Table 2. TRUE Test Allergens7 PANEL 1.3

PANEL 2.3

PANEL 3.3

Allergens ug/cm2 1. Nickel Sulfate .................... 200 2. Wool alcohols ................... 1000 3. Neomycin sulfate ............. 600 4. Potassium dichromate ..... 54 5. Caine mix ........................... 630 6. Fragrance mix.................... 500 7. Colophony ......................... 1200 8. Paraben mix....................... 1000 9. Negative control 10. Balsam of Peru ................ 800 11. Ethylenediamine dihydrochloride ............... 50 12. Cobalt dichloride ............ 20

Allergens ug/cm2 13. p-tert-Butyphenol formaldehyde resin......... 45 14. Epoxy resin ...................... 50 15. Carba mix ......................... 250 16. Black rubber mix ............. 75 17. Cl+Me Isothiazolinone ... 4 18. Quatemium-15 ................ 100 19. Methyidibromo glutaronitrile ................... 5 20. p-Phenylenediamine ...... 80 21. Formaldehyde ................. 180 22. Mercapto mix .................. 75 23. Thiuram mix .................... 7 24. Thiuram mix .................... 27

Allergens ug/cm2 25. Diazolidinyl urea............. 550 26. Quinoline mix .................. 190 27. Tixocortol-21-pivalate... 3 28. Gold sodium thiosulfate ....................... 75 29. Imidazolidinyl urea ......... 600 30. Budesonide...................... 1 31. Hydrocortisone-17 butyrate ........................... 20 32. Mercaptobenzothiazole ... 75 33. Bacitracin......................... 600 34. Parthenolide ................... 3 35. Disperse blue 106 ........... 50 36. 2-Bromo-2-nitropropane-1, 3-diol................................ 250

Allergic contact dermatitis due to rubber materials today is more likely due to rubber accelerators instead of actual latex. This is an especially important fact when treating medical personnel for hand dermatitis.11 In fact, individuals, such as health care workers, who regularly wear sterile or non-sterile rubber gloves are prone to develop an allergy to a chemical in the production of the glove, most commonly a rubber accelerator, and not a latex protein.12 Therefore, if the allergy is due to one of the rubber accelerators, these patients can still display reactions to “latex-free” products.

The FDA does not regulate “hypoallergenic” products. Many patients, as well as practitioners, feel anything labelled as hypoallergenic could not possibly cause or aggravate a dermatitis. A surprising study revealed that over 80% of 187 products advertised as hypoallergenic contained at least one allergen. Furthermore, 63% of the examined products contained more than two allergens and 11% contained as many as five or more allergens.13

8 9 10

Any dermatological problem can be exacerbated by the use of over-the-counter or prescribed topical medications. Commonly used antibiotic OTC ointments, such as bacitracin and neomycin, have the potential to cause allergic reactions in quite a few patients. In fact, these commonly used topical antibiotics were included in the top 10 most frequent allergens in patients studied during 2013-2014.4

Treating extensive contact dermatitis with a 4-6 day regimen of systemic steroids can cause rebound dermatitis. If the reaction is moderate to severe, treatment should extend over a 10-14 day period rather than a short-term, rapidly-tapered Methylprednisolone Dose Pack.2 Relatively higher doses of Methylprednisolone in the 40-60 mg range should be initiated in adults and slowly tapered to prevent rebound as the Dose Pack regimen is not effective after just 3 to 4 days. This is because the Type IV hypersensitivity reaction may continue to be active for up to 2 weeks or more if left untreated. For more information regarding contact dermatitis and its treatment, readers are directed to the biannual publication of allergen frequency studies from the North American Contact Dermatitis Group4 and the review article by Mowad et al. in the Journal of the American Academy of Dermatology.14 Q

References 1.

Afsaneh A, Sibbald GR, Ladizinski B, et al. Wound-related allergic/irritant contact dermatitis. Adv Skin Wound Care. 2016;29:278-286.

Usatine RP, Riojas M. Diagnosis and management of contact dermatitis. Am Fam Physician. 2010;82:249-255.

Wilmer EN, Gustafson CJ, Ahn CS, et al. Most common dermatologic conditions encountered by dermatologists and nondermatologists. Cutis. 2014;94:284-292.

DeKoven JG, Warshaw EM, Belsito DV, et al. North American contact dermatitis group patch test results 2013-2014. Dermatitis. 2017;28:33-46.

Carøe TK, Ebbehøj NE, Agner T. Occupational dermatitis in hairdressers - influence of individual and environmental factors. Contact Dermatitis. 2017;76:146-150.

Spiker A, Mowad C. Patch test negative generalized dermatitis. Dermatitis. 2016;27:259-262.

SmartPractice. http://www.smartpractice.com/Apps/WebObjects/SmartPractice.woa/wa/content?f=product-truetest.html&m=SPA. 2017. Accessed June 6, 2017.

Millitello G, Woo DK, Kantor J, et al. The utility of the TRUE Test in a private practice setting. Dermatitis. 2006;17:77-84.

Moustafa M, Holden CR, Athavale P, et al. Patch testing is a useful investigation in children with eczema. Contact Dermatitis. 2011;65:208-212.

10. Eichenfield LF, Wynnis TL, Chalin SL. Guidelines of care for the management of atopic dermatitis: Section 1. Diagnosis and assessment of atopic dermatitis. J Am Acad Dermatol. 2014;70:338-351. 188 VOL. 58 • NO. 6/7 • 2017

11. Geier J, Lessmann H, Mahler V, et al. Occupational contact allergy caused by rubber gloves--nothing has changed. Contact Dermatitis. 2012;67:149156.

12. Buttazzo S, Prodi A, Fortina AB, et al. Sensitization to rubber accelerators in Northeastern Italy: The Triveneto patch test database. Dermatitis. 2016;27:222-226. 13. Hamann CR, Bernard S, Hamann D, et al. Allergens in cosmetic pediatric products marketed as hypoallergenic, fragrance free, paraben free, and dermatologist recommended. Presented at the 25th Annual Meeting of the American Contact Dermatitis Society, Denver, Colorado. 2014. 14. Mowad CM, Anderson B, Scheinman P, et al. Allergic contact dermatitis: Patient management and education. J Am Acad Dermatol. 2016;74:1043-1054.

Author Information: M2 in the Department of Dermatology, University of Mississippi Medical Center (Badon). Professor, Department of Dermatology, specializing in contact dermatology, University of Mississippi Medical Center (Helms). Corresponding Author: Stephen E. Helms, Department of Dermatology, University of Mississippi Medical Center, 2500 N. State St., Jackson, MS 39216. Ph: (330)-550-1285.

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Cervical Spine Immobilization Associated with an Increased Risk of Death in Patients Transferred to the University of Mississippi Medical Center with Gunshot Wounds to the Head JOSEPH GARAGLIANO, M4; ADAM TURNOCK, PGY-1; RACHEL N. SAUNDERS, MD; WESLEY B. VANDERLAN, MD Introduction Prophylactic Cervical Spine Immobilization (c-spine immobilization) has been associated with an increased risk of death in penetrating cervical and thoracic trauma without neurologic benefit.1,2,3 Cervical spine fracture has not been shown to result from penetrating cranial trauma.4 This study hypothesized that c-spine immobilization was associated with an increased risk of death in penetrating cranial trauma without attendant neurologic benefit. Key Words: Cervical Spine Immobilization, Cervical Spine Fracture, Gunshot Wound, Penetrating Cranial Trauma Method Retrospective chart review of the University of Mississippi Medical Center (UMMC), a State of Mississippi Verified Level I Trauma center. The trauma registry at UMMC was queried for penetrating head trauma from January 1, 2001, through July 1, 2007. Only isolated gunshot wounds (GSW) to the head were examined. Patients with penetrating trauma into the cranial vault were categorized as cranial. Patients with penetrating injury not entering the cranial vault were categorized as extracranial. Data abstracted included age, sex, race, mechanism of injury, admission Glasgow Coma Scale (GCS), radiographic imaging, the presence and type of vascular injury, the presence or absence of cervical spine fracture, cervical spinal cord injury, c-spine immobilization, and pre–hospital times. Patient data were entered into a database and described statistically using inherent computational software (Microsoft Excel 2010, Redmond, WA). Comparison of the proportion difference between two groups was performed by chi-square (χ2) analysis using SAS v9.1 (SAS Institute Inc., Cary, NC). Significance was accepted for p < 0.05.

to 89 years with a standard deviation of 18.7 years. Sixty-five subjects were transferred from an outside hospital and 66 were primary arrivals to UMMC. Fourteen patients could not be categorized as either primary arrival or transfer and were therefore excluded. The sixty-six primary arrivals comprised 14 DOA, 32 deaths prior to discharge and 20 alive at discharge. Of the primary arrivals, 33 received c-spine immobilization and 19 did not. Of those receiving c-spine immobilization, 13 were alive at discharge and 20 were deceased. Of those not receiving c-spine immobilization, 7 were alive at discharge and 12 were deceased. The sixty-five transfer arrivals included 1 DOA, 29 deaths prior to discharge and 35 alive at discharge. Of the transfer arrivals, 36 received c-spine immobilization and 28 did not. Of those receiving c-spine immobilization, 15 were alive at discharge and 21 were deceased. Of those not receiving c-spine immobilization, 20 were alive at discharge and 8 were deceased. DOAs were excluded for analysis and no imaging was performed on these individuals. No patients with penetrating cranial trauma incurred cervical spine fracture. Two of the 37 extracranial gunshot wounds incurred cervical spine fracture. Both of these patients with cervical spine fracture received c-spine immobilization and were transfers. One cervical spine fracture involved a stable C4 fracture. The other patient had comminuted fractures of C1 and C2 with complete neurologic devastation. Data were summarized on the Table and the Figure. C-spine immobilization was not associated with an increased risk of death in penetrating cranial GSW for all alive patients arriving at UMMC (p = 0.08), and for non–transfer patients (p = 0.86). C-spine immobilization was associated with a significant risk of death in the transfer group (p = 0.024, OR 3.50, 95%CI 1.085 – 11.600). Discussion

Results One hundred and forty-five subjects were identified. One hundred and sixteen were male and 29 were female. Seventy-nine were of African American descent and 66 were Caucasian. One hundred and eight patients incurred cranial wounds and 37 incurred extracranial wounds. Eighty-one arrived with c-spine immobilization in the form of a cervical collar and 64 arrived without a cervical collar. Fifteen arrived dead on arrival (DOA), 66 died prior to discharge, and 64 were alive at the time of discharge. Average age was 33 years and ranged from 1 year 190 VOL. 58 • NO. 6/7 • 2017

Patients with penetrating gunshot wound injury to the head receiving prophylactic c-spine immobilization showed an increased risk of death when transferred to UMMC from outside hospitals compared to primary arrivals to UMMC (p = 0.024, OR 3.50, 95%CI 1.085 – 11.600). This increased mortality may be due to consequences of c-spine immobilization including, but not limited to, increased intracranial pressure, respiratory compromise, treatment delay, impaired delivery of care, and impeded control of hemorrhage.5,6,7,8,9,10,11 Furthermore, this study did not demonstrate neurologic benefit of

Barkana Y, Stein M, Scope A, Maor R, Abramovich Y, Friedman Z, Knoller N. Prehospital stabilization of the cervical spine for penetrating injuries of the neck – is it necessary? Injury. 2000;31:305 – 9.

Medzon R, Rothenhaus T, Bono CM, Grindlinger G, Rathlev NK. Stability of Cervical Spine Fractures After Gunshot Wounds to the Head and Neck. Spine. 2005;30(20):2274–9.

Table. Patient Demographics of Primary and Transfer Arrivals to UMMC Following Isolated Gunshot Wounds to the Head. Signiﬁcance was accepted for p < 0.05. PATIENT DEMOGRAPHIC Average age GENDER Male Female ETHNICITY White African American LOCATION OF INJURY Cranial Extracranial PATIENT SOURCE Primary Arrival Transfer Not Recorded CERVICAL SPINE FRACTURE CSFx No CSFx

% N/A

CSI+ 32

No CSI 35

p 0.320

80 20

66 15

50 14

0.678 0.678

46 54

35 46

31 33

0.615 0.615

Kennedy FR, Gonzalez P, Beitler A, Sterling – Scott R, Fleming AW. Incidence of Cervical Spine Injury in Patients with Gunshot Wounds to the Head. South Med J. 1994;87(6):621–3.

74 26

65 16

43 21

0.086 0.086

Bauer D, Kowalski R. Effect of spinal immobilization devices on pulmonary function in the healthy, nonsmoking man. Ann Emerg Med. 1988;17(9):915– 8.

40 36 9

40 36 5

26 29 9

0.086 0.086 0.086

Schafermeyer RW, Ribbeck BM, Gaskins J, Thomason S, Harlan M, Attkisson A. Respiratory effects of spinal immobilization in children. Ann Emerg Med. 1991;20(9):1017–9.

1 99

2 79

0 64

0.500 0.500

UMMC: University of Mississippi Medical Center; CSI+: Received cervical spine immobilization; No CSI: Did not receive cervical spine immobilization; CSFx: Cervical spine fracture present; No CSFx: Cervical spine fracture absent

prophylactic c-spine immobilization as no cervical spine fractures occurred with isolated penetrating cranial trauma. Previous studies have demonstrated no role of c-spine immobilization in decreasing morbidity or mortality following gunshot wounds to the head.4 UMMC is the only Level 1 trauma center in Mississippi and 66% of the penetrating trauma treated by UMMC arrives via transfer. Consideration should be given to deferring c-spine immobilization in patients with isolated GSW to the head due to the increased risk of death without attendant neurologic benefit. Further study is necessary to confirm these findings. Q References 1.

10. Kolb JC, Summers RL, Galli RL. Cervical Collar – Induced Changes In Intracranial Pressure. Am J Emerg Med. 1999;17(2):135–7. 11. Hunt K, Hallworth S, Smith M. The effects of rigid collar placement on intracranial and cerebral perfusion pressures. Anaesthesia. 2001;56(6):511–3.

Author Information: M4, Tulane University School of Medicine, New Orleans, LA (Garagliano). Intern/PGY-1, University of Arizona (Turnock). Department of Surgery, Division of Trauma, Surgical Critical Care and Acute Care Surgery, University of Mississippi Medical Center, Jackson, Mississippi, (Saunders and Vanderlan). Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland (Vanderlan). Corresponding Author: Wesley B. Vanderlan. Department of Surgery, Uniformed Services University of the Health Sciences. 4301 Jones Bridge Rd., Bethesda, MD 20814. Email: blakevanderlan@yahoo.com. Phone: 985230-1870.

FIGURE. Summary of Hospital Course of All Subjects with Penetrating Head Trauma

Vanderlan, WB, Tew BE, McSwain NE, Jr. Increased Risk of Death with Cervical Spine Immobilization in Penetrating Cervical Trauma. Injury. 2009 Aug;40(8):880-3. doi: 10.1016.

13 3 Alive at Discharge 33 R Received ecei ece eceived ce ved eed d Cervica C Cerv Cervical erv ervica icaaall SSpine p Immobilization 20 Deceased

Haut ER, Kalish BT, Efron DR, Haider AH, Stevens KA, Kieninger AN, Cornwell EE, III, Chang DC. Spine Immobilization in Penetrating Trauma: More Harm Than Good? J Trauma. 2010 Jan;68(1):115-20; discussion 120-1. doi: 10.1097. Seamon MJ, Fisher CA, Gaughan J, Loyd M, Bradley KM, Santora TA, Pathak AS, Goldberg AJ. Prehospital Procedures Before Emergency Department Thoracotomy: “Scoop and Run” Saves Lives. J Trauma. 2007;63(1):113 – 20. Lanoix R, Gupta R, Leak L, Pierre J. C-spine injury associated with gunshot wounds to the head: retrospective study and literature review. J Trauma. 2000;49(5):860 – 3.

66 Primary Arrivals to UMMC

7 Alive at Discharge 19 9D Did id d Not Nott Receive R Recei ecei ece ec cei e vve C Cervical errv ervi ervica rvi vica c Spine Immobilization 12 Deceased 14 Dead on Arrival

15 Alive at Discharge

145 45 Tota 4 Total otal Subjec o Su SSubjects ubjec bje jjecttss with with th h Penetrating Head Trauma

36 R Received eceeiived ec ecei ve Ce Cerv Cervical eerv rvviical rvical ica ccaal Sp SSpine p Immobilization 21 Deceased

65 Transfers nsfers ns e s fro ers from rro om O Outside Hospitals

20 Alive at Discharge 28 8D Did id d not not ot Receive R Recei ecei ecei ece ce vve C Cervical ervvica ervi ca ca Spine Immobilization

14 Excluded

8 Decesased 1 Dead on Arrival

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A Retrospective Analysis of Thyroid Cancer Prevalence among Thyroid Nodules at the University of Mississippi Medical Center JEREMY TAYLOR, MD AND SHEMA AHMAD, MD Key Words: thyroid nodule, thyroid cancer, molecular markers Abstract Rationale: The incidence of thyroid nodules and thyroid cancer has continued to rise as more imaging modalities are used, but the overall mortality rate from thyroid cancer remains unchanged. Fine needle aspiration (FNA) of thyroid nodules has also increased with utilization of ultrasound guided techniques, but approximately 15-30% of these aspirations will not confirm or exclude a malignancy. Historically, such patients were referred for a thyroidectomy. Sixty-six percent of these cases resulted in surgically proven benign disease, and surgery may not have been necessary.1 Because an estimated 60-70% of thyroid cancers will harbor at least one known genetic mutation, molecular testing is now common practice to determine whether to pursue surgical intervention for cytologically indeterminate thyroid nodules.2 Objectives: Our goal was to determine the prevalence of malignancy for each thyroid nodule cytologic category at our institution. For those nodules with indeterminate cytology, we aimed to ensure our institution could properly apply the results of molecular markers based on each cytologic category’s prevalence of malignancy. Methods: A retrospective review of cytopathology specimens for thyroid nodules from June 2012–December 2015 was performed. We reviewed the clinical courses of those cases which required additional testing with molecular markers or had corresponding surgical pathology. The cases with surgical pathology allowed us to determine the prevalence of thyroid malignancy within each cytologic category. Data and Main Results: Six hundred sixty-two thyroid nodules were included in this study. Only 12 of these specimens were confirmed to contain malignant cells on surgical pathology. The prevalence of malignancy among indeterminate cytology categories III and IV were respectively, 11.5% and 42.8%. When molecular testing was used in these cases, it did not yield results consistent with the surgical pathology. Conclusion: Our study suggests that molecular testing provides beneficial information only when the population prevalence of thyroid malignancy is known. Otherwise, the results only cloud discussions of risk and benefit regarding thyroidectomy with these patients. Introduction Clinicians are tasked to thoroughly inform patients about their medical conditions and advise them on the available treatments. It is now known that many patients with indeterminate thyroid nodule cytology 192 VOL. 58 • NO. 6/7 • 2017

could have avoided the risk and cost of undergoing a surgery. Centers for Medicare and Medicaid Services (CMS) data from 2010 estimates the mean cost for a total thyroidectomy was $11,265.26 (ranging from $6,907-$25,824) compared to the mean of $3,200 (ranging from $2,000-5,000) for molecular testing on thyroid nodule aspirates.3 Regarding thyroid nodules with indeterminate cytology after fine needle aspiration (FNA), there are three options available: (1) proceed with surgical resection of the thyroid gland, (2) observe and repeat a surveillance thyroid ultrasound in 6-12 months or (3) repeat FNA after a specified time interval. Which option to pursue depends on the cytopathologic category of the thyroid nodule and a patient’s preference. Fine needle aspirate cytopathology of thyroid nodules is currently described using the Bethesda classification system, established in 2007.4 Cytopathologic categories range from I-VI (Table 1).

Table 1. Bethesda Classiﬁcation of Thyroid Nodule Pathology Bethesda Class I II III

IV V VI

Overall Malignancy Risk Diagnostic Category Nondiagnostic or Unsatisfactory 1 to 4 % Benign 0 to 3 % 5 to 15 % Atypia of undetermined signiﬁcance (ACUS) or Follicular lesion of undetermined signiﬁcant (FLUS) Follicular neoplasm or suspicious for 15 to 30 % follicular neoplasm 60 to 75 % Suspicious for malignancy Malignant 97 to 99 %

It is the specimens that fall into Bethesda classes III, IV and V that require more scrutiny as cancer risks in these categories are not definitive. This discrepancy exists in large part due to an individual institution’s volume of thyroid nodule cytopathology. This may be explained by observations that lower volumes in some centers result in categorization of a nodule as indeterminate due to intra and interobserver variability.5 Using molecular tests which identify oncogenes associated with thyroid cancer has been recommended as an adjunct tool by the American Thyroid Association to better determine overall malignancy risk of a nodule that falls into Bethesda classes III-V.6 There are different commercial tests with collection kits provided by their respective companies available for thyroid nodule molecular testing (Table 2).7

Table 2. Comparison of the available thyroid molecular testing Test Name

Aﬁrma

ThyGenX/ThyraMIR

Thyroseq

Methodology

mRNA microarray, classiﬁes as either “benign” or “suspicious” gene expression proﬁle

ThyGenX: PCR detection of mutations (BRAF, NRAS, KRAS) and rearrangement (RET-PTC1, RET-PTC3, and PAX8-PPARG) by sequence speciﬁc probes ThyraMIR: microRNA expression analysis; classiﬁes as either “negative” or “positive”

Next generation sequencing to detect mutations (AKT, BRAF, CTNNB1, GNAS, HRAS, KRAS, NRAS, PIK3CA, PTEN, RET, TP53, TSHR, TERT, and EIF1AX) and rearrangements (RET, PPARG, NTRK1, NTRK3, BRAF and ALK)

Strengths

High NPV (95%), validated in blinded multicenter prospective trial

High NPA (94%) and PPV (74%), ability to startify risk based on mutation, validated in blinded multicenter study

High NPV (96%) and PPV (83%); ability to stratify risk based on the mutation

Limitations

Low PPV, concern about performance in Hurthle cell lesions

ThyraMIR is a newer test with limited data to date

Newer test with limited data to date

Sample Required

2 dedicated FNA passes

1 dedicated FNA pass with at least 50 ng of cellular material

1-2 drops from ﬁrst pass, if suﬃciently cellular

During the time frame of this data analysis, our division was using Afirma (Veracyte Inc. in San Francisco, CA) a gene expression classifier (GEC) that amplifies mRNA from FNA specimens to test for an assay signature of 167 genes that can separate a nodule as “benign” or “suspicious for malignancy”. The Afirma test also supplies a commercial cytologic evaluation on the FNA specimen. It was designed as a “rule out test” and has been validated to have a 95% negative predictive value and a 38% positive predictive value,1 see Figure 1. Thus the results can be interpreted with greater confidence in institutional populations with a lower thyroid cancer frequency. FIGURE 1. Eﬀect of prevalence change on test predictive value5

category. The cases which utilized molecular markers were reviewed further to see if their results corresponded to surgical pathology diagnoses. Results There were a total of 662 thyroid nodules that underwent FNA at UMMC from June 1, 2012, through December 31, 2015. Only 12 of these specimens were confirmed to be malignant by surgical pathology. Among these FNA specimens there was a 1.8% prevalence of thyroid cancer. There were six cases of papillary thyroid cancer (PTC) which were diagnosed on surgical pathology without a prior FNA. Including these additional cases, the overall prevalence of thyroid cancer was determined to be 2.4%. While the overall prevalence of thyroid cancer is low, applying these values when interpreting molecular marker testing would be misguided. One must use the specific prevalence for the corresponding Bethesda category. Regarding FNA samples that were characterized as Bethesda categories III and IV, there was a respective 11.5% and 42.8% prevalence of thyroid cancer confirmed by surgical pathology (Table 3). For further analysis of specimens sent for thyroidectomy and Afirma testing refer to Tables 4 and 5. Table 3. Cytopathology results from UMMC, June 1, 2012 – December 31, 2015 Bethesda Class

Test performance based on population disease prevalence: If disease prevalence is 25%, then NPV=92%, PPV=38% If disease prevalence decreases to 10%, then NPV=96%, PPV=17% If disease prevalence increases to 40%, then NPV=85%, PPV=54%

Materials and Methods We performed a retrospective review of cytopathology and surgical pathology records available via Epic (electronic medical record) selecting cases labeled “thyroid nodule” at the University of Mississippi Medical Center (UMMC) in Jackson, MS. Cases were queried from June 1, 2012, through December 31, 2015. This timeframe excluded cases prior to the utilization of Epic at UMMC. This data was used to determine the prevalence of thyroid cancer in each cytopathologic

I II III IV V VI

Total Number of Cases 8 613 26 14 0 1

Total Malignant by Surgical Pathology

Percentage Malignant by Surgical Pathology

1 1 3 6 n/a 1

12.5% 0.2 % 11.5% 42.8% n/a 100%

*Select cases of FNA samples in Bethesda classes III and IV were sent for Aﬁrma testing while others were sent directly for thyroidectomy (Tables 4 and 5).

There were no Bethesda Class V cytopathologic diagnoses during the time of our investigation. Six Bethesda Class III specimens were analyzed; three returned suspicious for malignancy. With this diagnosis, a total thyroidectomy was recommended; however, only JOURNAL MSMA

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Alexander EK, Kennedy, GC, Baloch, ZW et al. Preoperative diagnosis of benign thyroid nodules with indeterminate cytology. N Engl J Med. 2012; 367:705-715.

Li H, Robinson KA, Anton B, et al. Cost-effectiveness of a novel molecular test for cytologically indeterminate thyroid nodules. J Clin Endocrinol Metab. 2011;96:E1719-E1726.

Cibas ES, Ali SZ. The Bethesda system for reporting thyroid cytopathology. Am J Clin Pathol. 2009;132:658–665. doi: 10.1309/AJCPPHLWMI3JV4LA.

Cibas ES, Baloch ZW, Fellegara G, et al. A prospective assessment defining the limitations of thyroid nodule pathologic evaluation. Ann Intern Med. 2013;159:325-332.

Ferris RL, Baloch Z, Bernet A, et al. American Thyroid Association statement on surgical application of molecular profiling for thyroid nodules: current impact on perioperative decision making. Thyroid. 25(7),760-768. doi: 10.1089/thy.2014.0502.

Nishino, M. Molecular cytopathology for thyroid nodules: A review of methodology and test performance. Cancer (Cancer Cytopathol). 2016;124:14– 27.

Table 4. Bethesda Classes III and IV sent to thyroidectomy Bethesda Class III n = 26 IV n = 14

Direct to Thyroidectomy 10

Malignant by Surgical Pathology 3*

6**

*1 microscopic PTC, 1 PTC with microscopic follicular variant foci, 1 follicular carcinoma **3 follicular variant PTC, 2 microscopic PTC, 1 follicular carcinoma

Table 5. Bethesda Classes III and IV sent for Aﬁrma testing Bethesda Class

Total sent for Aﬁrma® Analysis

Benign

Suspicious for Malignancyy

III n = 26 IV n = 14

two of the patients agreed to the operation. Both of these patients had benign thyroid nodules on final surgical pathology. Among the two Bethesda class IV specimens analyzed by Afirma, both were confirmed to be benign by surgical pathology. Discussion In our patient population, we found a moderate prevalence of thyroid cancer in Bethesda categories III and IV. When Afirma was applied to select samples from these cohorts, the data was inconsistent with surgical pathology. Similar discordance can be expected with this molecular test due to the frequency of thyroid cancer in these indeterminate cytopathologic categories at UMMC. The analysis of molecular markers for indeterminate (Bethesda Classes III-V) thyroid nodule FNA specimens is a valuable tool in perioperative counseling when used in the appropriate context. If a patient’s goal is to avoid thyroidectomy for definitive treatment, then molecular testing can help provide the proper counseling with targeted discussion and risk stratification for the presence of a thyroid malignancy. However, if a patient’s goal is to pursue thyroidectomy, there would be no reason to do additional testing on an indeterminate thyroid nodule.

Author Information: Clinical endocrinology fellow at the University of Mississippi Medical Center in Jackson. Served as chief endocrine fellow in the final year of his training. Following completion of his fellowship he will enter private practice with the Diabetes and Endocrine Center of Mississippi located at St. Dominic’s in Jackson (Taylor). Associate Professor and Director of the Thyroid Center in the Division of Endocrinology at the University of Mississippi Medical Center. Practices general endocrinology with a personal interest in thyroid pathology and is an active member of the American Thyroid Association (Ahmad). Corresponding Author: Jeremy Taylor, 696 Hazelton Drive, Madison, MS 39110. Email: jstaylor95@gmail.com, Cell: 228-861-7393.

Molecular testing continues to evolve in the field of endocrinology. As demonstrated in previous trials, molecular testing is not as reliable in populations with a higher prevalence of thyroid cancer. Owing to this reason, molecular testing on thyroid nodules is not something to be done on a routine basis. Intra-and inter-observer variability of cytopathology specimens will always factor into the prevalence of thyroid malignancy at each medical institution which affects the negative predicative value of the test. The results of a molecular test should always be associated with other cytologically similar thyroid nodules at the same institution in order to get the most accurate and cost effective result. Q References 1.

Wang CC, Friedman L, Kennedy GC, et al. A large multicenter correlation study of thyroid nodule cytopathology and histopathology. Thyroid. 2011;21(3):243-251.

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Transcatheter Aortic Valve Replacement in Treatment of Aortic Stenosis JOHN SCHMIDT, MS AND JOSIAH LAITE, MS Background Surgical aortic valve replacement (SAVR) has been the accepted procedural method in the replacement of the aortic valve.1 SAVR is used as an invasive surgical technique for the treatment of aortic stenosis (AS) which, until recently, if treated by non-invasive methods only, leads to heart dysfunction, failure, and ultimately the death of the patient.2 AS has the highest prevalence rate of all valve related heart diseases. Commensurate with the disease is the calcification of the aortic valve and the tissues of the ascending and descending aorta as well as its branch points in the subclavian and carotid arteries.2,3 Diagnosis of this disease is symptomatically seen with angina, heart failure, and syncope; AS prognosis carries a survival rate of just two years without intervention. In 2002, a new non-surgical intervention titled Transcatheter Aortic Valve Replacement (TAVR) was developed by Cribier.4 Since inception in 2002, the technique has been successfully used more than 50,000 times with a total success rate upwards of 95%.4 Over the last decade TAVR has emerged as the accepted alternative to surgical treatment for high risk patients, and is now considered the standard of care for patients deemed inoperable.5 Patient Selection Due to insidious onset, AS often manifests with comorbid conditions, making selecting patients for aortic valve replacement difficult. Determining the course of treatment requires great consideration of many factors: age, cardiovascular health, condition of arteries, stroke, rejection, and clotting. Due to any number of these concerns, many patients are precluded from surgical treatment and deemed inoperable; which accounts for up to 50% of AS patients.6 At present, TAVR represents a last resort treatment for these patients.. Location selection for TAVR Upon selection of the patient for TAVR, the location of access must be determined. TAVR has evolved to become less invasive. Early procedures were delivered anterograde from venous flow by transseptal puncture into the left ventricle. The transcatheter valve was then passed through the mitral valve and placed into position in the aorta.2 Improvements have spawned the retrograde trans-arterial approach, which includes four preferred locations of access: trans-femoral, transsubclavian, trans-apical, and trans-aortic.7 A hierarchy exists among location selection for TAVR. The transfemoral approach is preferred unless this method of access is deemed not suitable due to calcific atheroma or vascular unsuitability.8

The trans-subclavian method is next preferred followed by trans-apical and finally trans-aortic. All three sites of entry reduce the postoperative complications associated with surgical replacement including, sternal dehiscence, infection, pulmonary dysfunction and pain.9 Non-surgical TAVR Trans-femoral TAVR: The trans-femoral approach represents the most common method of retrograde TAVR deployments.9 This approach requires minimum invasion, reduces or eliminates the need for cardioplegia and significantly reduces recovery time.9,10 In this method, the common femoral artery is assessed by fluoroscopy and ultrasound. The specific inguinal side of access is based on imaging observed during assessment. The determining factors for assessing access are the size (minimum luminal diameter of 7 mm),12 and compressibility of the artery as well as an examination of the amount of calcification, disease, and tortuosity of the artery.10,11 After access is determined, a percutaneous puncture is made and the TAVR sheath apparatus is inserted into the artery. An additional percutaneous puncture or surgical cut down is made on the contralateral femoral artery. Into the contralateral artery, a pigtail catheter is inserted and maneuvered up to the ascending aorta for angiographic imaging of the procedure.10,12 After all accommodations have been completed, the valve is navigated up to the aorta, and the self-expanding valve is deployed across the aortic valve. During the deployment of the valve, the ventricular pacing is intentionally increased to a range of 160-220 beats per minute This manipulates individual stroke volume and curtails unintentional movement of the implant valve during the procedure.10 The delivery system is retrieved from the femoral artery, and the puncture is closed. Subsequently, after angiographic imaging is completed, the pigtail in the contralateral artery is removed and the artery puncture or cut down is repaired. This procedure can be completed under local or general anesthesia.10 Axillary/Subclavian TAVR: This procedure follows a similar protocol to the trans-femoral method. Subclavian access is selected as alternate route when the femoral or iliofemoral artery has been deemed unsuitable due to vascular issues, blockage or calcification related problems.12 In similar manner to trans-femoral TAVR, a percutaneous puncture is made into the subclavian artery, and the sheath is navigated into the aorta and deployed in similar fashion to trans-femoral TAVR.13,14 Partial Surgical TAVR When imaging reveals peripheral arterial disease that precludes transfemoral or subclavian methods of access, a partial surgical solution JOURNAL MSMA

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is required. The two current methods, trans-apical and trans-aortic TAVR, are used in less than 30% of all TAVR procedures.15 Of the two partial surgical procedures, trans-aortic is preferred. In trans-aortic TAVR, a minithoractomy or ministernotomy is performed, wherein incisions are made in second or third intercostal on the right side. The TAVR device is placed directly into the ascending aorta and delivered via the same method as the non-invasive trans-femoral or subclavian TAVR protocols.16,17 This method is preferred over the alternative minimally invasive trans-apical method due to reduced bleeding and myocardial injury.17 The trans-apical approach follows a similar protocol to trans-aortic TAVR, but carries greater risk as it requires entry directly through the left ventricle.18,19 This method is used only when all other methods are not suitable due to numerous concomitant conditions.

huge benefit, as the cardiologist will be able to non-invasively correct any issues of paravalvular regurgitation resulting from post procedure movement of the valve. Additionally, a fully retrievable valve will allow for easy removal and replacement of a poor functioning or malfunctioning valve. While long term studies need to be completed prior to establishing TAVR as a preferred method for younger healthier patients, this method shows great promise for the future. Q References 1.

Bach DS, Siao D, Girard SE, et al. Evaluation of patients with severe symptomatic aortic stenosis who do not undergo aortic valve replacement: the potential role of subjectively overestimated operative risk. Circ Cardiovasc Qual Outcomes. 2009 Nov;2(6):533–9.

Ross Jr J, Braunwald E. Aortic stenosis. Circulation. 1968 Jul;38(1) (suppl):61–7.

Bonow RO, Carabello BA, Chatterjee K, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2006 Aug 1;114(5):84–231.

Cribier A, Eltchaninoff H, Bash A, et al. Percutaneous transcatheter implantation of an aortic valve prosthesis for calcific aortic stenosis: first human case description. Circulation. 2002 Dec 10;106(24):3006–8.

Smith CR, Leon MB, Mack MJ, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Eng J Med. 2011 Jun 9;364(23):2187–98.

Siddiqui Y, Moore S, Ghosh S, et al. Common cardiac pathologies associated with aortic stenosis. In: Min J, Berman D, Leipsic J, eds. Multimodality Imaging for Transcatheter Aortic Valve Replacement. Berlin, Germany: Springer-Verlag London; 2014.

Conduction disturbances: New pacemakers are required in 4.9-28.9% of patients depending on the specific brand of valve chosen.24

Other complications of lower occurrence: Several other complications have been reported at similar rates to surgical replacement including myocardial injury, coronary obstruction, and acute kidney failure.19-21

Webb JG, Chandavimol M, Thompson CR, et al. Percutaneous aortic valve implantation retro-grade from the femoral artery. Circulation. 2006 Feb 14;113(6):842–50.

Leon MB, Smith CR, Mack M, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Eng J Med. 2010 Oct 21;363(17):1597–607.

Fontana GP, Ruiz CE, Kliger C. Transcatheter aortic valve replacement: a surgeon’s view. In: Min J, Berman D, Leipsic J, eds. Multimodality Imaging for Transcatheter Aortic Valve Replacement. Berlin, Germany: Springer-Verlag London; 2014.

Procedural complications and outlook As TAVR has evolved, the risk of procedural complication has decreased significantly,20 but as with any procedure, risk of complication requires note. Associated risks are noted as follows: Stroke: 8.4% in early generation procedure. The data on stroke occurrence has been reported as low as 1.7% in later TAVR procedures.8 Paravalvular regurgitation: Has been reported in approximately 80-96% of patients, but is noted as minor or not consequential.22 Approximately 12% of TAVR patients show a regurgitation grade higher than 2% which is the current threshold of clinical significance.8 Vascular complications: At an occurrence rate of 1.9-14%,22 with some studies indicating this number to be as low as 1%.23

Conclusion Since conception in 2002, TAVR has shown excellent promise; the technique has been successfully used more than 50,000 times with a total success rate exceeding 95%24 TAVR prosthesis has comparable short term durability to the invasive surgical counterpart method and comparative results measurable to time frames greater than three years.21 Early data indicates TAVR valves may reduce patient-prosthesis mismatch and rejection.25

10. Freeman M, Webb JG. Transcatheter aortic valve replacement: an interventionist’s view. In: Min J, Berman D, Leipsic J, eds. Multimodality Imaging for Transcatheter Aortic Valve Replacement. Berlin, Germany: SpringerVerlag London; 2014.

While surgical methods are still the treatment of choice in aortic valve replacement, TAVR is quickly gaining in popularity. TAVR remains the method of choice in high risk and non-operable patients and will likely become a preferred method of choice for aortic valve replacement after long term outcomes and studies have been completed during the next decade.

11. Jilaihawi H, Chakravarty T. Transcatheter aortic valve replacement: what the near-term future holds and what evidence is needed? In: Min J, Berman D, Leipsic J, eds. Multimodality Imaging for Transcatheter Aortic Valve Replacement. Berlin, Germany: Springer-Verlag London; 2014.

The accumulated mortality rates are not of great consequence as the rates reflect death by any cause in elderly patients.

13. Modine T, Obadia JF, Choukroun E, et al. Transcutaneous aortic valve implantation using the axillary/subclavian access: feasibility and early clinical outcomes. J Thorac Cardiovasc Surg. 2011 Feb;141(2):487–91.

Future directions and goals

14. Bruschi G, Fratto P, De Marco F, et al. The Trans-subclavian retrograde approach for transcatheter aortic valve replacement: single-center experience. J Thorac Cardiovasc Surg. 2010 Oct;140(4):911–5.

As TAVR evolves, future models will likely include fully retrievable valves which can be manipulated after insertion. This function is of 196 VOL. 58 • NO. 6/7 • 2017

12. Abdulla R, Blew GA, Holterman MJ. Cardiovascular embryology. Pediatr Cardiol. 2004 May-Jun;25(5):191–200.

15. Eltchaninoff H, Prat A, Gilard M, Leguerrier A, et al. Transcatheter aortic valve implantation: early results of the FRANCE (FRench Aortic National CoreValve and Edwards) registry. Eur Heart J. 2011 Jan;32(2):191–7. 16. Lefevre T, Kappetein AP, Wolner E, et al. One year follow-up of the multicentre European PARTNER transcatheter heart valve study. Eur Heart J. 2011 Jan; 32(2):148–57. 17. Petronio AS, De Carlo M, Bedogni F, et al. Safety and efficacy of the subclavian approach for transcatheter aortic valve implantation with the CoreValve revalving system. Circ Cardiovasc Interv. 2010 Aug;3(4):359–66. 18. Grube E, Laborde JC, Gerckens U, et al. Percutaneous implantation of the CoreValve self-expanding valve prosthesis in high-risk patients with aortic valve disease: the Siegburg first-in-man study. Circulation. 2006 Oct 10;114(15):1616–24. 19. Bosmans JM, Kefer J, De Bruyne B, et al. Procedural, 30-day and one year outcome following CoreValve or Edwards transcatheter aortic valve implantation: results of the Belgian national registry. Interact Cardiovasc Thoracic Surg. 2011 May; 12(5):762–7. 20. Leon MB, Piazza N, Nikolsky E, et al. Standardized endpoint definitions for transcatheter aortic valve implantation clinical trials: a consensus report from the Valve Academic Research Consortium. Eur Heart J. 2011 Jan; 32(2):205– 17. 21. Rodes-Cabau J, Webb JG, Cheung A, et al. Transcatheter aortic valve implantation for the treatment of severe symptomatic aortic stenosis in patients at very high or prohibitive surgical risk: acute and late outcomes of the multicenter Canadian experience. J Am Coll Card. 2010 Mar 16; 55(11):1080–90. 22. Piazza N, Grube E, Gerckens U, et al. Procedural and 30-day outcomes following transcatheter aortic valve implantation using the third generation (18 Fr) corevalve revalving system: results from the multicentre, expanded evaluation registry 1-year following CE mark approval. EuroIntervention. 2008 Aug;4(2):242–9. 23. Toggweiler S, Gurvitch R, Leipsic J, et al. Percutaneous aortic valve replacement vascular outcomes with a fully percutaneous procedure. J Am Coll Cardiol. 2012 Jan 10;59(2):113–8. 24. Généreux P, Head SJ, Van Mieghem NM, et al. Clinical outcomes after transcatheter aortic valve replacement using Valve Academic Research Consortium definitions: a weighted meta-analysis of 3,519 patients from 16 studies. J Am Coll Cardiol. 2012 Jun 19; 59(25):2317–26. 25. Abdel-Wahab M, Zahn R, Horack M, et al. Aortic regurgitation after transcatheter aortic valve implantation: incidence and early outcome. Results from the German transcatheter aortic valve interventions registry. Heart. 2011 Jun;97(11):899–906.

Acknowledgements The authors want to thank Thad Waites, MD and Christopher Douglas, MD for their guidance preparing this manuscript.

Calling All Mississippi Physician-Photographers Enter the 2018 JMSMA Cover Photo Contest

Film or Digital Shoot anything you can capture as a high-resolution image. Subjects given the highest consideration are those indicative of Mississippi. Photos of original artwork are also acceptable. The MSMA Committee on Publications will judge the entries on the merits of quality, composition, originality, and appropriateness to the JMSMA. Specifications: Color slides, digital ﬁles & photos (at least 300 DPI/PPI). A hard copy print is required for judging. Please include a brief description of the image and information about the physican/photographer.

Size: Vertical format 5 x 7” or 8 x 10” Deadline: January 1, 2018

For more info contact: Karen Evers, Managing Editor 601-853-6733, ext. 323 or KEvers@MSMAonline.com

Author Information William Carey College of Medicine, MS in Biotechnology and BS in Premedical Biology from Florida Institute of Technology (Schmidt). MS in Biotechnology and BS in Biology from Florida Institute of Technology (Laite).

Mail to: P.O. Box 2548 Ridgeland, MS 39158-2548 or deliver to MSMA headquarters 408 W. Parkway Place, Ridgeland, MS 39157

Corresponding Author: John Schmidt, Ph: (321)298-0308, Email: Johnschmidt300@live.com. JOURNAL MSMA

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Mississippi Hospital Stroke Readiness MARY HELEN CONNER, PHD; ELGENAID HAMADAIN, PHD; ELLEN JONES, PHD Abstract Introduction: During 2014, there were 1,710 deaths due to stroke in Mississippi. Stroke accounted for 5.3% of total deaths, with an ageadjusted rate of 56.2 deaths per 100,000 persons.1 This study was designed to evaluate and report the readiness of Mississippi hospitals to diagnose and treat stroke; to provide professional and public education; and to offer stroke support groups. Methods: Mississippi acute care and critical access hospitals were surveyed in 2005, 2008, and 2016. In 2016, the stroke readiness criteria for level 1 was met by 3 Mississippi hospitals, 8 hospitals met level 2 criteria, 25 hospitals met level 3 criteria, and 19 met level 4 criteria. Results: The 2005 survey response rate was 100%, the 2008 survey response rate was 77%, and the 2016 survey response rate was 63%. Conclusions: Despite improvements in stroke readiness, Mississippi hospitals need to expand capacity to diagnose and treat stroke. Ancillary services including support groups, education for stroke survivors, families and caregivers is important to survivorship. Introduction In the United States, stroke is the fifth leading cause of death for both men and women and the leading cause of long-term disability. Each year about 800,000 people living in the United States will experience a stroke.1 Approximately 610,000 of these are first or new strokes, and about 185,000 individuals who survive the first stroke eventually have another stroke. On average, a stroke occurs every 40 seconds, and someone dies of a stroke every 3 to 4 minutes. Furthermore, stroke is the cause of approximately one out of every 20 deaths, killing more than 130,000 Americans per year.2 Stroke is an expensive disease, with lifetime rehabilitation costing over $140,000 per ischemic stroke with higher costs for subarachnoid hemorrhage.3 Disparities exist in stroke incidence and survival. African Americans are more impacted by stroke than any other racial group within the American population.4 Stroke in Mississippi In 2010, stroke was the fifth leading cause of death in Mississippi, with 1,520 people dying from stroke. During that year, Mississippi also had the highest death rate from cardiovascular disease in the country, with 7,542 Mississippians dying of heart disease.5 Mississippi had the highest burden of chronic disease in the United States in 2011, reported in data from CDC’s 2011 Behavioral Risk Factor Surveillance System (BRFSS), Mississippi ranked second in the nation for adult obesity, second for hypertension and diabetes, and 198 VOL. 58 • NO. 6/7 • 2017

fifth for adult tobacco use. Mississippi had the highest death rate from heart disease in the country for 2010. Medical expenses from chronic disease alone cost the state $4 billion dollars annually.6 Teenage Years in the “Stroke Belt” Drive Up Risk The impact of stroke in Mississippi as one of the states in the Stroke Belt is further emphasized by the findings of a large population-based study funded by the National Institute of Neurological Disorders and Stroke (NINDS). This study found that persons who lived in the Stroke Belt during their teenage years (ages 13-18) had a 17% higher risk of stroke than those who had not lived in the Stroke Belt area. The study also found that black persons (33%) were harmed more by living in this area during their adolescence than white persons (15%).7 These findings further emphasize the importance of focusing on education and prevention of stroke risk factors in childhood and adolescence. The goal of this study was to identify and categorize current Mississippi acute care and critical access hospitals as to their capability or readiness to treat acute ischemic stroke in one of the 4 Levels of Care. Additionally, the study assessed the current availability of stroke support groups, the provision of education for professionals and the public regarding how to identify a stroke and what to do if a stroke occurs. This information is critical in facilitating a Stroke System of Care in Mississippi so that emergency personnel, when called by an educated public, will be able to access appropriate referral hospitals for emergency treatment of acute ischemic stroke patients. Methodology The methodology used to carry out this research included conducting 3 surveys of Mississippi acute care and critical access hospitals in the years 2005, 2008, and 2016. The survey questions were answered by the hospitals’ quality improvement, case management and or stroke contacts. The data were collected by the co-investigator from the completed Hospital Stroke Readiness Surveys for all three years. The comparison and analysis of the 3 surveys are based on the components and resources that confirm the level of stroke hospital standards of Mississippi acute care and critical access hospitals to rapidly treat acute ischemic stroke. These surveys were also designed to identify the current number of acute care and critical access hospitals providing stroke support groups for stroke survivors/caregivers. An additional important objective of the 3 surveys was the level of stroke education being provided by the hospitals for their professionals, their patients and the public. Survey Instruments The data for this research were collected from Mississippi Hospital

Stroke Readiness Survey conducted in 2005 as baseline data compared to two additional stroke readiness surveys conducted in 2008 and 2016. The first two surveys were based on the brain attack coalition criteria for primary stroke centers. The third survey was updated but was compatible with the previous surveys containing questions related to level of stroke care, provision of professional education, provision of public education and offering stroke support groups for patients/ caregivers. The stroke hospital standards criteria used in the 2016 hospital stroke readiness survey are levels of care that have been approved by the Mississippi State Department of Health in relation to the creation of a stroke system of care for Mississippi. Hospitals must be ready to treat and manage stroke. This readiness is based on several components, including resources, protocols, equipment and trained personnel. The levels listed below include the required components for the hospital to be designated at the appropriate category of stroke preparedness. “Stroke Centers” in the state categorized as level 1 and level 2 provide comprehensive diagnostic and treatment services designated by the Mississippi Department of Health. Hospitals categorized as a level 3 are labeled as “Stroke Ready Hospitals.” These hospitals have the ability to rapidly diagnose an ischemic stroke, provide lab and CT, but do not have neurology personnel or definitive stroke care treatment component.8 Level 4 hospitals in this system of care are hospitals that must be ready to transition a patient to a higher level of care for treatment. These hospitals may be bypassed by EMS to facilitate rapid treatment of the patient experiencing a stroke.8 The inclusion criteria for this study involved all Mississippi acute care and critical access hospitals with operating emergency rooms. One acute care hospital had two locations and was counted as two different acute care hospitals. Results of the 2005 and 2008 Surveys The 2005 survey response rate was 100% of all acute care and critical access hospitals (n =95) meeting the inclusion criteria. The 2008 survey response rate (n = 72) was 77% of all acute care and critical access hospitals (n =94). Only six Mississippi hospitals (n = 95) were identified in 2005 as having some of the most critical components of the Brain Attack Coalition criteria required for the rapid diagnosis and treatment of persons having a stroke. These components included: a designated stroke team available 24 hours a day, 7 days a week; written stroke protocols; CT/MRI available 24 hours a day, 7 days a week; timely completion of the CT/MRI; and timely interpretation of the CT/ MRI by a physician with experience in acute stroke. Comments from this survey documented that in some of the hospitals with no formal stroke team, emergency room personnel and code grey protocols were being used for the acute care of ischemic stroke patients. One facility stated that they were in the process of completing an application to be certified as a Primary Stroke Center by the Joint Commission. A great deal of work remained to be completed in Mississippi in 2008 to treat acute stroke patients rapidly. The results of the 2008 survey compared to the 2005 survey documented that there was very little change and some actual decrease in the initiation of the Brain Attack

Coalition components and criteria related to providing quality stroke care in Mississippi hospitals. While many Mississippi hospitals reported following some of the Brain Attack Coalition criteria for primary stroke centers, very few currently had all of the relevant identified components for providing quality acute stroke care. Response to the 2016 Survey Fifty seven of the ninety hospitals completed the survey for a response rate of 63%. Approximately one third in the target groups were critical access hospitals (n=31) and two thirds were acute care hospitals (n=59). Two responses were not included in stroke center criteria analysis due to incomplete survey responses. The final analysis included 55 surveys. Hospitals meeting Level 1 Stroke Center Criteria The findings from this survey show that out of the responding acute care or critical access hospitals (n = 55) there are 3 facilities that met all of the criteria for being a comprehensive stroke center or a level 1 stroke center. Level 1 stroke centers offer all of the characteristics listed by the Brain Attack Coalition for both non-invasive and invasive care and all phases of acute and rehabilitative definitive stroke care (Mississippi State Department of Health, 2016).8 The specific criteria for level 1 includes an adequate helicopter landing site on campus; neurology, neurosurgery, and endovascular specialists available 24/7; and a fully staffed operating room available 24/7 for emergency surgery when necessary. Hospitals meeting Level 2 Stroke Center Criteria Eight acute care hospitals met the criteria for being a level 2 stroke center. A level 2 stroke center is labeled as a primary stroke center and is required to have the same exact components as a level 1, comprehensive stroke center with the exclusion of endovascular capabilities. Hospitals meeting Level 3 Stroke Center Criteria Twenty-five acute care or critical access hospitals met the criteria for being capable to treat stroke or are designated as level 3 stroke centers. At this level a hospital must have the ability to diagnose and stabilize the patient for transfer to a comprehensive (level 1) or a primary (level 2) referring stroke center. Hospitals meeting Level 4 stroke center criteria are designated as nonstroke hospitals, 19 hospitals met the criteria for this level of stroke readiness. Hospitals in this level are able to assess and evaluate for possible stroke, but lack essential components to treat patients with IV thrombolytics. Transition plans must be established by level 4 hospitals to facilitate rapid transfer of patients to level 1 or 2 stroke centers. Additional survey findings indicated that only 11 of the 55 (19.3%) facilities offer a stroke support group for their patients, caregivers and family members; 32 of the 57 or 56% of responding hospitals answered yes to providing public education at least twice a year. At least 8 hours of professional education for nurses and doctors are being offered by 31 (55%) of the responding hospitals. Of interest is the fact that only 56 of the survey respondents (n = 57) answered this survey question.

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Discussion In 2016, the burden of stroke in Mississippi continues to be greater than in other states in the nation. Mississippi leads the nation in stroke risk factors and stroke mortality rate. A tremendous need and urgency exist for Mississippi hospitals to be ready to treat and diagnose stroke. This research also found that there is a continued need for hospitals to offer continuing education for the public and for professionals (physicians and nurses). These hospitals also need to provide stroke support groups for their stroke patients, their families and caregivers. Although about half of the hospitals in Mississippi provide continuing medical education for their professionals, there is a need to reach out to those facilities not providing this type of education. There is an immediate need for the provision of speaker bureaus with experts on stroke prepared to present at stroke-related conferences, webinars, and web-based continuing medical education (CME) programs for the professionals in Mississippi. Numerous professional websites offer CME programs for professionals treating stroke. The National Stroke Association, the American Stroke Association, the National Institute for Health, and the Internet Stroke Center have information and CME opportunities on the treatment of stroke. This type of education offers additional hours of convenient education for nurses and physicians. The Mississippi Healthcare Alliance, American Stroke Association, the Governorâ&#x20AC;&#x2122;s Task Force on Heart Disease and Stroke Prevention, the Mississippi State Department of Health, the Hypertension Coalition and many other similar organizations serve as resources for professional education. The need for increased stroke education of professionals will be of interest to these groups in Mississippi that direct their focus on increasing the quality of medical care related to stroke. Summary Because of the increased readiness of hospitals in Mississippi to treat stroke, now is the time to focus on educating the public to ensure that persons experiencing a stroke understand the immediate need to recognize stroke signs and symptoms and to call 911 so they will have an opportunity to benefit from hospitals being ready to treat stroke. Q References 1.

Centers for Disease Control and Prevention. Stroke Facts. http://www.cdc. gov/stroke/facts.htm. Accessed March 24, 2015.

National Center for Chronic Disease Prevention and Health Promotion. Division for Heart Disease and Stroke Prevention 2013. http://www.cdc. gov/stroke/about.htm. Accessed April 11, 2014.

Alberts MJ, Latchaw RE, Jagoda A, et.al. Revised and Updated Recommendations for the Establishment of Primary Stroke Centers. A Summary Statement from the Brain Attack Coalition. STROKEAHA. 2011; 42:2651-2665.

American Stroke Association 2017. Impact of Stroke (Stroke Statistics). http://www.strokeassociation.org/STROKEORG/AboutStroke/Impactof-Stroke-Stroke-statistics_UCM_310728_Article.jsp#.V65Hf U0dRMw. Accessed March 15, 2017.

American Heart/Stroke Association 2010. Mississippi State Fact Sheet. http://www.heart.org/idc/groups/heart- public/@wcm/@adv/documents/ downloadable/ucm_307186.pdf. Accessed June 6, 2014.

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Mississippi State Department of Health 2014. Report on the Burden of Chronic Diseases in Mississippi 2014. http://msdh.ms.gov/msdhsite/_ static/resources/4775.pdf. Accessed March 16, 2017.

National Institute of Neurological Disorders and Stroke 2013. Teenage Years in the â&#x20AC;&#x153;Stroke Beltâ&#x20AC;? Drive up Risk. http://www.ninds.nih.gov/news_and_ events/news_articles/stroke_belt_teen_risk.htm. Accessed September 27, 2016.

Mississippi Healthcare Alliance. Stroke System of Care Plan. https://www. mshealthcarealliance.org/wp-content/uploads/Stroke_System_of_Care_ Plan_BOH_adpted_2015_07_06-1.pdf. Accessed July 10, 2016.

Author Information Doctor of Philosophy in Clinical Health Sciences (Conner) University of Mississippi Medical Center. Professor and Biostatistician, School of Health Related Professions (Hamadain). Doctor of Health Administration, School of Health Related Professions, University of Mississippi Medical Center (Jones). Corresponding Author: Mary Helen Conner, PhD, Quality Improvement Advisor, Information & Quality Healthcare, 385B Highland Colony Parkway, Suite 504, Ridgeland, MS 39157. Ph: (601)957-1575, ext. 219. Mary.Conner@area-g.hcqis.org.

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Help Us Hold The Memories

As we prepare to celebrate the 150th Anniversary of our Annual Session, we are looking for stories, historical items and insights that you may have. We would love to have input and anecdotes from you on: â&#x20AC;˘ /% % , %*) â&#x20AC;˘ Little-known Historical Facts â&#x20AC;˘ Medical Milestones in Mississippi â&#x20AC;˘ Pioneers in Mississippi Medicine â&#x20AC;˘ And More! If you have something to share or if you want to donate money to the celebration, just email &+( % % *&( ( % , () , () &%# % &$

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P R E S I D E N T ’ S

P A G E

The Address of the 2017-18 MSMA President Lee Voulters, MD August 11, 2017 • Jackson, Mississippi

t is hard to believe it has been one year since I started as your president. It went by incredibly quickly. It was very busy, educational, interesting and extremely rewarding. I want to thank all of you for the wonderful support you gave me this year. The amazing responses I received at all of the component medical societies. I was humbled by the great turnouts and warm reception you gave Christie and me. One of my favorite duties as president was traveling around the state and meeting all of you on your home turf, discussing your concerns and issues on a local level. One of the most important functions as president is spearheading the legislative agenda of the MSMA. I would like to give you an overview of this. My legislative experience started with giving testimony to the Senate public health committee on telemedicine. I explained how telemedicine can be appropriately utilized in a practice and how many physicians are using this technology already. I also expressed our opposition to telemedicine corporations who promote audio-only deliveries of care and those that don’t adhere to our State Board of Medical Licensure’s regulations on telemedicine. We sent a very loud and definitive “no” to this and gave many reasons why audio-only telemedicine is not good medicine. We also outlined the right way to deliver telemedicine. Subsequent to this hearing we gave the Speaker of the House a private demonstration of the way telemedicine should be performed, courtesy of Dr. Clay Hays. We also cited as an example the outstanding telemedicine program we have at the University Medical Center. Following these events telemedicine did not come up as an issue in the legislature this year. During the actual legislative session four anti-vaccination bills were introduced to weaken the wonderful vaccination policies in Mississippi which are the envy of the country and which we at MSMA support 100%. All four of these bills would have significantly weakened our vaccination policy and put thousands of our school children at risk of infection. I am pleased to tell you that all were successfully defeated. Six scope of practice bills also were successfully defeated. In addition, we supported the re-authorization of licensed acupuncturists with some new guidelines in place. We always have to be vigilant, as scope of practice issues are always one of the most important things we have to fight every year. We must protect the practice of medicine on behalf of our patients, to ensure the highest quality of medicine is practiced in the state. And, scope battles don’t stop when the legislative session ends. This summer the State Board of Pharmacy proposed a new rule to let pharmacists make therapeutic substitutions for the prescriptions we write without consulting the prescribing physician. Dr. Bill Grantham and I explained our objections to several of the pharmacy board members and within 24 hours this proposed rule was withdrawn. This meeting also served to open a dialogue between MSMA and the pharmacy board which will need to continue. We will be in a better position if we can deal with important prescribing issues with such a combined approach. We were asked to let pharmacists prescribe oral contraceptive pills bypassing the physician. This proposal was actually made by a pharmacist working for the Health Department. I made our opposition to the State Health Officer in no uncertain terms. Let’s talk more about the Health Department. In my inaugural speech one year ago I cited the crisis of funding for our department of health as one of my greatest concerns. We have a wonderful Health Department which performs miracles in public health on a shoestring budget. Every year the agency faces more budget cuts. This year was no exception. The bottom line was inevitable budget cuts for all state agencies. Dr. Currier told me that if the legislature would restore $5

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million of these cuts the Health Department could survive and continue the key public health programs. We in turn launched a vigorous effort with newspaper articles and guest editorials, aggressive lobbying and many phone calls to lawmakers. In the end the agency did get the $5 million restored and Dr. Currier is dedicated to using the appropriation to save core public health services. But, the Health Department was still in the cross-hairs of those who wanted to make the Health Department an executive agency reporting to the Governor. This scheme would have stripped all authority from the physician-led Board of Health making them advisory to the Governor. Again, MSMA aggressively opposed this bill. It would have politicized the Department of Health and ultimately threatened the health of our citizens. Thanks to our amazing lobbying group, we met with the Lieutenant Governor on very short notice and, this bill died a quick death. Just as an aside, we have great access to our legislators. Thanks to our administrative staff for all of the greatÂ work the medical society has done over the years, supporting our legislators through our MMPAC. Medicaid is another major issue that I mentioned in my inauguration speech. I want to help expand Medicaid. More accurately stated, I want to expand medical care coverage for our citizens. I did meet with the medical directors of both Mississippi CAN managed careÂ plans. We discussed a number of issues including the need for greater transparency and the need for the agency to provide physicians with outcomes data. I also met with the Medicaid Director and I asked him to provide articles for the Journal specifically aimed at physicians to better inform us of issues and topics that are most important to us. Again, stressing the need for transparency and information, I cited two accomplishments: Dr. Tami Brooks is now the Medical Director working at Medicaid, and the Medicaid Medical Care Advisory Committee is now meeting regularly and is chaired by Dr. Steve Demetropoulos. I do want to talk about expanding medical coverage for all Mississippians. The legislature this last session was not at all interested in discussing any type of expansion of any type of medical coverage whether it is done through Medicaid expansion or any other program. However, I suspect the next legislative session will be different and that changes in Medicaid will be on the table. We just do not know what the national landscape is going to look like. Will there be federal matching funds? If so, how much? Will it be block grants for states? It is very difficult for any of us to predict what is going to happen. We did get some traction on a plan which is based on a Medicaid waiver to cover the 300,000 working poor in the state. This group is defined as earning up to 138% of the Federal poverty level. This plan is based on the Indiana plan in which the lieutenant governor may have interest. It would add about 9,000 health care jobs, reduce uninsured costs by over 60% and improve the financial viability of small healthcare facilities over twofold. One of the greatest challenges we are facing in health care is the opioid crisis. When he was president Dan Edney convened a prescribing committee under the direction of Dr. Timothy Beacham who reviewed national guidelines that would be most relevant as a reference for Mississippi physicians. I chaired the MSMA Opioid Committee and over the past two years we have studied many aspects of prescribing and opioid misuse. These strategies were channeled to the Governorâ&#x20AC;&#x2122;s Study Task Force on Opioids through our three representatives Drs. Randy Easterling, Claude Brunson, and Scott Hambleton. We suggested more education for prescribers on opioids and alternatives for chronic pain, more education on prescribing for doctors in training and more detailed guidelines for treating chronic pain and treating patients referred to pain clinics. We recommended better insurance coverage and better funding for addiction treatment, rehab programs and research. Our list included expanding MPHP and developing similar programs for other professionals. We are also emphasizing safe disposal of unwanted, unused and expired prescriptions. More education and interaction with legislators. I further hope to see a series of articles in our Journal that covers educational topics for physicians and information for our patients. In conclusion, I would like to thank all of you again for your support and confidence that you have shown me. It has been an amazingly rewarding and humbling experience - one I will never forget. I will continue to fight for my colleagues and my patients in any capacity I can, to ensure that we maintain the highest quality of medicine possible here in Mississippi and protect the physician/patient relationship that we all hold so dear as the cornerstone of our practice of medicine. Thank you all so very much for an incredible experience. Q

Lee Voulters, B.Pharm, MD, FRCPC, MBA MSMA President 2016-2017 JOURNAL MSMA

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Has the Time Come for Democracy at our MSMA? MICHAEL “MIKE” ARTIGUES, MD

Over the course of my 22 years in practice since residency, I have attended at least a half dozen MSMA annual sessions. Early on, I had three partners in my clinic with at least two free weekends per month and a generous allowance to attend CME meetings. One of my former partners, Dr. Tom Carey, was (and is) active in the politics of medicine and he was always encouraging me to attend the sessions. I’m also a member of the South Central Medical Society where Dr. Luke Lampton, our esteemed MSMA Journal editor and a tour de force in medical politics, does a bang-up job of soliciting attendees from our chapter as Secretary. Despite all the opportunities and encouragement I have had over the years, like most of my fellow MSMA members I have had obstacles preventing my attendance at most annual sessions. In the past, I was a young physician trying to establish my practice. I had a growing Michael Artigues, MD family (and growing debt). I practice in McComb, and the annual sessions I attended were held in Jackson, Tupelo, and on the Coast. Most importantly, I’m both naive and generally unenthusiastic about politics - medical or otherwise. Mind you, the proceedings were often interesting, and even legislatively ignorant people like me can enjoy a productive caucus meeting discussing topics of interest to my patients and my practice. Still, most years, for one reason or another, I did not attend. Why am I saying all of this? When this nation was founded, there was no federal law dictating who could and could not vote. Most states limited voting rights to white male property owners. Over the following 200 years or so, various amendments to the Constitution were passed that expanded rights along racial (1870), gender (1920), socioeconomic (1964), and age (1971) lines. Most people would view that as progress. In our Mississippi State Medical Association, however, there is a very simple voting rule: if you want to vote for state medical leadership or ANY of the multitude of resolutions presented you MUST attend the annual session. Period. The year is 2017. I can immediately contact my son in Shanghai, China via the internet. I can transfer money to another child in New York City using an app on my cellphone in a matter of seconds. I can pay my car tag, shop for groceries, and have a video conference with my siblings all without leaving my home. In this era of internet technology and virtual reality, there is absolutely no reason why a dues-paying member of the Mississippi State Medical Association should have to leave his/her practice and travel perhaps across the state to attend a weekend of political meetings in order to have a vote. Though I didn’t attend this year’s session, with the help of Dr. Lampton, I wrote a resolution proposing to give MSMA members a vote regardless of whether they attend the annual session. The resolution did not pass. The time has come, however, for our medical association to broaden its approach and to reach out to ALL of its members. By doing so, more of them can participate in the political process of the organization and, most importantly, have a say in its leadership and decision-making. I have witnessed ﬁrst hand the many dedicated physicians who make the wheels of the MSMA go ‘round at the annual session. By giving the majority of members unable to attend the session a vote, physicians in our state are more likely to gain an interest and feel they have a say (i.e., ownership) in the political process. It could even inspire a future state medical presidential candidate or two. In any case, it’s the right thing to do…and its time has come! Q About the author: Dr. Mike Artigues is a practicing pediatrician in McComb and a longtime member of our MSMA. He also serves as a member of the JMSMA Editorial Advisory Board. He can be contacted at artiguesm@bellsouth.net. 204 VOL. 58 • NO. 6/7 • 2017

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You Can Change a Village: Lessons Learned on a Medical Mission to Honduras PHILIP MERIDETH, MD, JD Since 1983, a group of churches in Mississippi has sponsored a medical, dental, and veterinary mission to the remote village of San Joaquin in the northwestern mountains of Honduras. From February 18-25 of this year, five MSMA members and one former member worked as a team to see 2714 patients during five clinic days in the village. During that time, the team learned some lessons that may be of interest to our MSMA colleagues. In no particular order, they are: 1.

“You can change a village.” A Honduran woman made this offhand comment to a small group of us shortly after our arrival in the city of San Pedro Sula, the second largest city in Honduras (population 719,000). The words passed with little comment at the time but stayed with me during the entire mission, and still do. Without intention, the woman’s casual statement echoes the urging of Mahatma Gandhi for his followers to “Be the change that you wish to see in the world.”

The team of physicians on the 2017 Honduras Medical Mission included (left to right) MSMA members Paul Perry, Holly Peeples, Kent Kirchner, Philip Merideth, and Frank Criddle, and former member Addie Henderson. The inscription on the wall indicates that the clinic is named in honor of the late Gene Lee, MD, JD, who served on many Honduran medical missions.

Important ingredients in the recipe for success of this mission included preparation, communication, flexibility, compassion, humor, team spirit, and enthusiastic leadership. Having a good support team at home and work helps, too. Special thanks for all of the assistance provided to this mission “newbie” by the members of the medical clinic team, including Drs. Holly Peeples (the clinic leader), Kent Kirchner, Frank Criddle, Paul Perry, and Addie Henderson. Dr. Criddle and Dr. Perry were accompanied in the medical clinic by their spouses, Janie Criddle, R.N. and Amanda Perry, O.T. Prior to the mission, two frequent quotes from mission veterans about what to expect from the experience were, “It’ll change your life” and “You’ll get more from the Hondurans than they get from you.” Trite phrases? Maybe so, but trite phrases can also be true, and those are. 3. Pack lightly for a medical mission, and leave your ego at home. There are no MVP’s on a medical mission team. Here is most of what you need: scrubs, comfortable shoes, bedding, toiletries, water bottle, stethoscope, otoscope, flashlight, airline ticket, passport, a little cash, a good book, and a sense of adventure. Throw in a deck of cards for off-line entertainment in the many areas where no internet service is available. Tuck away a personal supply of comfort meds to keep handy in case you or a team member get sick at the end of the mission, after the clinic supplies have been packed away (it happened…. twice). The team optometrist, Dr. William Strickland, packed his satellite radio and treated us to the broadcast of the Ole Miss v. Mississippi State basketball game, an exciting contest won by the Rebels in overtime.

Amanda Perry worked with her husband, Dr. Paul Perry (seated in background), to provide medical care to patients of all ages.

4. Meal times are a source of physical and emotional nutrition that increase team morale. The team enjoyed delicious food that was cooked on a wood burning stove by our Honduran hosts. However, the third world shower and toilet facilities were a challenge that made us appreciate the comforts of home. Best to bring your own toilet paper. And pack flip flops for the shower.

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5. The idea that roosters crow at dawn is a myth, at least in Honduras. The free-range village roosters start crowing as early as 10 PM and hit a rousing peak at about 2 to 4 AM. One team member observed that the crow of a rooster with a hoarse voice (“cock ahhrr rhoodle rhoo!”) is even more annoying than a melodic one. The team pharmacists recommended Ambien and earplugs to provide some relief to the cackle just outside of our dorm windows.

Drs. Philip Merideth, Kent Kirchner, and Paul Perry together saw up to 15 patients at a time in this room in the medical clinic.

6. Some Honduran families rise at 5 AM to walk the dusty mountain roads for up to three hours and then wait in a long line to spend just a few minutes with “the American doctors.” In addition to the limited prescription medications that are available, they all receive a “family pack” (while supplies last) of over-the-counter medications that Americans can buy for about ten dollars at their neighborhood pharmacy. They tolerate without complaint the lack of privacy in the medical clinic where up to fifteen patients at a time are seen in a small room staffed by as many as three physicians and three translators. The command to say “Ahhh” and the tongue-thrusting mouth movement associated with it are not part of a Honduran’s understanding, even with the assistance of a very capable and determined translator. After unsuccessful attempts at a throat exam on several patients, I gave up unless there was a specific complaint of sore throat.

7. The villagers of San Joaquin and the surrounding areas seem to be in generally good health and genuinely happy, in spite of having only basic nutrition, limited educational opportunities (sixth grade for most), minimal access to health care, and an average weekly wage for agricultural work of about 168 Lempiras (about seven U. S. dollars). The children are well behaved and the diagnosis of ADHD seems to be rare. Of the roughly estimated 150 children that I saw in the medical clinic, only one appeared to have symptoms that in the United States would be diagnosed as ADHD. After the mission ended, I wondered if future missions could also focus on disease prevention and health education in addition to acute medical care. With that in mind, I relearned the lessons of the 1895 poem “The Fence or the Ambulance” by Joseph Malins that was published in the Iowa Health Bulletin in 1912 and often recited by professor Wilbrod St. Amand to his biology classes at Ole Miss in the 1970’s and 1980’s. The poem ends with this quote from an old sage, opining that it is better to aim at prevention rather than repair of injury: “Better put a strong fence ‘round the top of the cliff, than an ambulance down in the valley!” (The poem is printed in its entirety on page 175 of the June 2005 volume of the Journal.)

As the medical school saying goes, “Common things occur commonly.” It was a challenge for me, as a child psychiatrist, to evaluate for the first time in many years such common conditions as hypertension, diabetes, rheumatoid arthritis, heart murmur, hypothyroidism, conjunctivitis, cataracts, carpal tunnel pain, esophageal reflux, and a myriad of skin conditions and musculoskeletal complaints. One of the most puzzling diagnostic challenges of the week turned out to be a simple case of hypoglycemia in a young woman who had a reported “seizure” during a tooth extraction in the dental clinic. With no labs or intravenous medications available, the semi-conscious patient was eventually diagnosed by the medical team late in the afternoon from the clinical history provided by her sister that she had not eaten all day. A call for empiric treatment carried the day and the patient was spoon fed under her tongue with a sugar paste that was hastily prepared by the team veterinarian, Dr. Stephen King. Within minutes, the woman was fully alert and able to walk back to her dirt-floored home located down the mountain on the bank of a dry creek bed.

During my childhood, complaints to my parents were often answered with the proverb, “I once complained that I had no shoes until I met a man who had no feet.” In San Joaquin, the medical clinic team met the proverbial man with no feet in the form of a four year old boy with the ironic name of Jesus. Born with no feet or hands, he was remarkably agile and happy to play with a smiley-faced balloon made from an inflated exam glove. Of all the patients that we encountered that week, he touched me the most. I hope he gets the prosthetic feet that his mother came seeking from the clinic.

10. After Action Report, unofficial totals for services provided during the mission: 1.

Medical clinic—2714 patients seen, including 336 procedures

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Dr. Frank Criddle and his wife Janie are on a break from their work in the medical clinic.

Pharmacy—19,123 medications dispensed

Dental clinic— 1127 teeth extracted from 388 patients, plus 361 sealants and cleanings

Eye clinic—624 glasses dispensed after 1000 eye exams

Veterinary clinic—857 animals treated (many horses, some scrawny dogs, and the only 2 cats surviving in the village)

Pastoral services—2 church services conducted in Spanish, including the blessing of an electric guitar that a team member donated to the local church. Never seen an electric guitar blessed before, at least not in church.

11. After Action Report, official totals for critters seen (this writer’s personal totals only): 1.

5 mosquitoes

1 housefly

1 lizard

1 scorpion (the good kind, dead)

0 snakes (in spite of a pre-mission warning to be wary that came from Dr. William Lushbaugh, Professor Emeritus of microbiology at UMMC. He still works there at the age of 72.)

Dr. Holly Peeples wants more MSMA members to go on future medical missions to Honduras. The sign on the clinic wall translates to, “We will be back next year.”

12. After a medical mission to a third world country, plan time for yourself for re-entry and adjustment to our “first world problems.” The daily journal that I kept with plans to write a longer article, alas, resulted in only these twelve lessons learned due to limited time for writing. Many thanks to the other 32 members of the team who worked together to make the medical mission a big success. Special recognition goes to the unsung heroes of the mission, the dental clinic team. Drs. Hal Winn, Chip Leggett, and Karen Crews and their support team worked tirelessly to provide dental care to the villagers under very spartan clinical conditions. Lesson Number 1 above, “You can change a village,” remains with me as the number one lesson learned from the mission. It is also a stirring metaphor, a call to action for all of us to be an agent for change in our own communities. Without leaving your comfort zone, you can change a village. Will you? Q Postscript: The Honduras Medical Mission Mission is recruiting team members for future medical missions, which usually occur in February of each year.. More information is available by sending an email to hondurasmedicalmission@earthlink.net. MSMA members who are unable to travel to Honduras may support the mission by making financial contributions or donations of medicine and supplies.

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M I S S I S S I P P I

DeSoto

Marshall

Benton

S T A T E

D E P A R T M E N T

O F

H E A L T H

Tishomingo

Alcorn

Tunica Tate

Prentiss Tippah Union

Panola

Lafayette

Lee

Itawamba

Pontotoc Coahoma

Quitman

Chickasaw Tallahatchie

Grenada Carroll

Mississippi

Calhoun

Yalobusha

Bolivar

Montgomery

Monroe

Clay Webster Oktibbeha

Washington Sunflower Leflore

Lowndes

Choctaw Attala

Humphreys

Issaquena

Winston

Noxubee

Holmes Yazoo Madison

Leake

Neshoba

Kemper

Newton

Lauderdale

Sharkey

Warren

Scott Hinds

Jasper

Smith

Clarke

Rankin Claiborne

Simpson

Copiah

Jefferson Covington Adams

Lincoln

Wayne

Jones

Lawrence

Franklin

Amite

Wilkinson

WƌŽǀŝƐŝŽŶĂů ZĞƉŽƌƚĂďůĞ ŝƐĞĂƐĞ ^ƚĂƟƐƟĐƐ

Jefferson Davis Lamar Marion

Pike

Forrest

Perry

Greene

Walthall George

Pearl River Stone

Northern Region Harrison

Central Region

Jackson

Hancock

Southern Region

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July 2017

M I S S I S S I P P I

S T A T E

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Department of Health Earns Coveted National Accreditation

State Health Oﬃcer Dr. Mary Currier explains the signiﬁcance of accreditation by the Public Health Accreditation Board.

he Mississippi State Department of Health (MSDH) has become a nationally accredited public health department, joining a select group of state health departments that meet rigorous standards of policy, practice and quality improvement. This accreditation is the culmination of an effort that began over three years ago with statewide community collaborations, in-depth assessment of the strengths and weaknesses of agency policies and procedures, and a renewed focus on quality improvement initiatives.

Accreditation by the Public Health Accreditation Board (PHAB) means that the MSDH provides primary and expert leadership in promoting and protecting the health of communities throughout the state, and that the agency meets or exceeds national standards of public health practices and performance. “This is an incredible achievement for our agency, and it’s important for the state as a whole because it means we are more accountable and credible to the public, our funders, elected officials and community partners,” said MSDH State Health Officer Dr. Mary Currier. Dr. Luke Lampton, who served as Chairman of the Board of Health during the department’s efforts to achieve accreditation, commented, “This is hugely important to receive this. Accomplishing national accreditation has been a long, but essential, journey for the department. It was the dream of Dr. Ed Thompson when he was state health officer, and Dr. Currier’s dedicated leadership over several years in achieving this dream, with the assistance of her excellent staff and the board, has been impressive. Despite the department’s persisting anemic funding, all Mississippians can know that this public health agency and its employees are meeting the highest quality standards in the nation.” PHAB officials have spent the last nine months thoroughly reviewing thousands of pieces of documentation demonstrating MSDH’s full range of processes and procedures, from disease investigation and chronic disease prevention to public information and education, community collaboration and partnerships, and quality improvement planning. “Continuous quality improvement is the keystone of national accreditation. It involves measuring and monitoring all of our programs and discovering ways to be more effective in our mission. This will make us better able to address rates of chronic disease and communicable diseases such as HIV and STDs, and certainly our response in emergencies or disasters,” said Dr. Currier. “All Mississippians will benefit because accreditation affects the entire range of the services that we provide 24 hours a day, seven days a week. It means the highest standards for operations that contribute to the quality of your life each and every day – from the water you drink, to the restaurant where you eat, to the daycare or nursing home where your loved ones may be,” she said. “National accreditation demonstrates that the MSDH uses data to make decisions, that we analyze outcomes, and that we continually monitor and improve all of our programs to best serve Mississippians,” said Dr. Currier. “We are an agency of evidence-based practices and have proved with this accreditation that we are a safe bet for further investment.” PHAB was created in 2007 to serve as the national public health accrediting body. The national accreditation program was actually launched in 2011. PHAB is jointly funded by the Centers for Disease Control and Prevention and the Robert Wood Johnson Foundation. Q JOURNAL MSMA

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ANAZIA, GREGG, Hattiesburg; Internal Medicine

MCGEE, HAMILTON, Greenville; Anesthesiology

ANAZIA, TASHEITHA, Hattiesburg: Psychiatry

MOHAMED, EMAD, Corinth; Cardiovascular Disease

BANAHAN, JOHN, Pascagoula; Diagnostic Radiology

MOTANYA, DAVID, Hattiesburg; Anesthesiology

BANAHAN, TAYLOR, Pascagoula; Obstetrics & Gyn.

NORTH, WILLIAM, Flowood; Plastic Surgery

BATH, KARAN, Southaven; General Surgery

PERCY, RAECHEL, Flowood; Physical Medicine & Rehab.

BAYMILLER, SCOTT, Hernando; Psychiatry

PROTOS, ADAM, Jackson; Cardiothoracic Surgery

BECKHAM, JAMES, Columbus; General Surgery

RICKS, KEVIN, McComb; Family Medicine

BERRY, JOHN, Hattiesburg; Orthopedic Surgery

ROBERTSON, ELLIOTT, Flowood; Anesthesiology

BOLER, PATRICK, Clinton; Dermatology

ROLAND, MALCOLM, Oxford; Neurology

BOLES, PEGGY, Tupelo; Anesthesiology

SANDERS, SHAWN, Jackson; Interventional Cardiology

BURMAN, KABEER, Hattiesburg; Internal Medicine

SCARFF, TIFFANY, Whitfield; Neurology

CANNON, ROB, Vicksburg; Family Medicine

SCHMIDT, ERIC, Ocean Springs; Ophthalmology

CHOATE, CODY, Columbia; Family Medicine

SCOGGIN, DARREN, Jackson; Pediatrics

CONFAIT, CASSIE, Meridian; Ophthalmology

SELLERS, AMANDA, Hattiesburg; Obstetrics & Gyn.

CUMBIE, TODD, Jackson; Vascular Surgery

SINGH, AMANDEEP, Laurel; Psychiatry

DOBBS, SHANNON, Ackerman; Family Medicine

SLOAN, RICHARD, Hattiesburg; Family Medicine

FOSTER, MICHAEL, Olive Branch; General Surgery

SMITH, STEPHEN, Jackson; Psychiatry

FRIEDLANDER, EDWARD, Hattiesburg; Anat./Clin. Pathology

SMITH, STEVEN, Columbus; Otolaryngology

GAUTAM, SAMIR, Natchez; Nephrology

SMITHERMAN, ADAM, Jackson; Orthopedic Surgery

GRISHAM, JENNIFER, Saltillo; Pediatrics

STONE, W. ROSS, Tupelo; Internal Medicine

HAMILTON, JAMES, Jackson; Cardiac Electrophysiology

SUBBARAO, ITALO, Hattiesburg; Emergency Medicine

HENDRIX, S TAL, Flowood; Orthopedic Surgery

TINGLE, CAROLYN, Jackson; Child & Adolescent Psych.

HUNT, HARRY, McComb; Family Medicine

VIRVILLIS, DIMITRIOS, Gulfport; Vascular Surgery

HURT, CHRISTIN, Clinton; Dermatology

WALKER, MARSHALL, Pascagoula; Radiology

KELLER, CURTIS, Biloxi; Neurology

WHITTINGTON, ALEXANDER, Jackson; Ophthalmology

KULPA, JANUS, Ocean Springs; Family Medicine

WILSON, MARK, West Point; Pediatrics

MAROM, ZVI, Houston; General Practice

WOOTTON, JAMES, McComb; Family Medicine

MARTIN, CHARLES, Hattiesburg; Cardiovascular Disease 210 VOL. 58 • NO. 6/7 • 2017

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HE SECOND HOSPITAL, BEAUVOIR, 1924-2005— These images are of one of the early

efforts of our state to provide hospital services for its veterans. The wife of ex-Confederate President Jefferson Davis sold in 1902 his house Beauvoir, located facing the Gulf near Biloxi in Harrison County, to the Mississippi Sons of Confederate Veterans to create a home for Confederate soldiers and sailors, their wives and servants. The property was used as a veterans’ home from 1903 to 1957; more than 2,000 veterans, widows and servants resided there, with 780 of the inmates buried in the Beauvoir cemetery. In 1907 a 30-bed, general hospital was erected to care for the inmates. (See last month’s JMSMA.) By 1920, Beauvoir Superintendent Elnathan Tartt initiated a successful effort to replace the original wooden hospital, then in decline, with a state of the art “modern fireproof brick” hospital. Leading the effort to raise the necessary $60,000 was my great-great-grandfather Walter M. Lampton, a Magnolia banker who retired to Biloxi and took an interest in improving the lives of the veterans living at Beauvoir. By 1924, a 48-bed brick state of the art hospital was constructed on the east side of Beauvoir house and the old hospital converted into the “ladies’ hospital.” The large image shows the brick Confederate Soldiers Home Hospital soon after it was built. It contained three wards with ten beds each, one ward with six beds, and twelve single rooms. (There was also a separate isolation ward north of the structure.) Annual appropriations from the Legislature paid the operational expenses of the hospital during its busiest period in the 1920s and 1930s. After years of active service as a hospital, on June 3, 1957, the structure was converted into a Confederate Soldiers Museum and filled with rare Civil War artifacts. Although this brick structure survived Hurricane Camille in 1969, the battering waves of Hurricane Katrina on August 29, 2005, totally destroyed not only this structure but most of the Beauvoir property. The smaller photo, taken by historian Charles L. Sullivan on September 8, 2005 shows the rubble of the Beauvoir Brick Hospital Museum; a 12-pound Howitzer, with one wheel still attached but shattered, can be seen among other destroyed artifacts in the ruins. My thanks to Dr. Sullivan, Jay Peterson, and Dr. Tom Payne for their assistance with this article. 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. Q

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

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Alpha to Omega (A True Story) [This month, we print an insightful poem by John D. McEachin, MD, a Meridian pediatrician and the Journalâ&#x20AC;&#x2122;s XQRIÂżFLDO SRHW ODXUHDWH 7KLV SRHP HQWLWOHG Âł$OSKD WR 2PHJDÂ´ IRFXVHV RQ WKH VHULRXV GLOHPPD RI KD]LQJ DQG DOFRKRO DEXVH RQ RXU FROOHJH FDPSXVHV 'U 0F(DFKLQ ZULWHV Âł8QLYHUVLWLHV KDYH D GLIÂżFXOW WDVN DWWHPSWLQJ to broaden minds, while acting as parenting surrogates. In many ways this is similar to addressing the needs RI WKH \HDU ROG Â˛RU WKH WHHQDJHUÂ˛ ZKR LV DPELYDOHQW LQ UHVLVWLQJ ERXQGDULHV ZKLOH DVWRQLVKLQJO\ GHPDQGLQJ WKHP 7KH XQLYHUVLW\ PXVW PDNH LW YHU\ FOHDU WR LWV HQWHULQJ IUHVKPDQ DQG WR LWV UHWXUQLQJ XSSHU FODVVPDQ ZKDW LV H[SHFWHG LQ WHUPV RI EHKDYLRU ERWK RQ DQG RII FDPSXV ,Q DGGLWLRQ KD]LQJ RI DQ\ W\SH LV XQDFFHSWDEOH 8QLYHUVLWLHV PXVW HQIRUFH VWULFW UXOHV LQ WKLV UHJDUG 6WXGHQWVÂś OLYHV DUH RQ WKH OLQH Â´ )RU PRUH RI 'U 0F(DFKLQÂśV SRHWU\ VHH SDVW DQG IXWXUH -060$V $Q\ SK\VLFLDQ LV LQYLWHG WR VXEPLW SRHPV E\ VORZ PDLO IRU SXEOLFDWLRQ LQ WKH MRXUQDO DWWHQWLRQ 'U /DPSWRQ RU HPDLO PH DW OXNHODPSWRQ#FDEOHRQH QHW @â&#x20AC;&#x201D;ED.

They told me how much they liked meâ&#x20AC;&#x201D; The boys in the fraternityâ&#x20AC;&#x201D; I would learn the Greek alphabet, And run a few errands, for sure. Maturity ruled this college band; There would be no infantile pranks. Since liquor was banned on campus, I felt they would keep their wordâ&#x20AC;&#x201D; (Their founders â&#x20AC;&#x201C;all men of honor.) I was a teen, and I was naĂŻve; Yes, I was â&#x20AC;&#x153;wet behind the ears.â&#x20AC;? I soon learned that sophomores Are not to be trusted at all. Some want to act as â&#x20AC;&#x153;pseudo-sadists,â&#x20AC;? Using pledges as their private toys! Water was my beverage of choiceâ&#x20AC;&#x201D; That just wonâ&#x20AC;&#x2122;t do for a man! My â&#x20AC;&#x153;fratâ&#x20AC;? friends would introduce me to A drink that would make me â&#x20AC;&#x153;that man.â&#x20AC;? I was blindfolded for a start, Then taken to a basement cold.

The guys began to drink some beer; Frivolity ruled the scene. The drinking went on for a while; Then they set me down in a chair. â&#x20AC;&#x153;How much waterâ&#x20AC;&#x2122;d you say you can drink?â&#x20AC;? Now they were taking off my clothes. A ceiling fan was on high speed, Poured water was splashing my face. Forced to swallow more and more water, I am getting weaker and weaker. No longer can I hear the laughter; Lord save me, or I die! I am so cold, so very cold. I gasp! No! I cannot gasp at all! Senseless, I am slumping to the floorâ&#x20AC;&#x201D; A faint voice, â&#x20AC;&#x153;Heâ&#x20AC;&#x2122;s just asleep!â&#x20AC;? Their judgment long since departed-Credit their subtle associate, the beer. These young men meant no harm, Insulted if thought murderers; But hazing is a dastardly deviceâ&#x20AC;&#x201D; Add liquor and it is deadly!

:DWHU LQWR[LFDWLRQ DQG K\SRWKHUPLD ZHUH WKH FDXVHV RI WKLV \RXQJ PDQÂśV GHDWK +D]LQJ DOFRKRO DQG LQFLYLOLW\ DUH WKH FHUWDLQ XQGHUO\LQJ DJHQWV IRU LWV RFFXUUHQFH (YHU\ FROOHJH DQG XQLYHUVLW\ LQ WKLV FRXQWU\ VKRXOG incorporate in orientation a session on mutual respect for fellow students as well as for school properties â&#x20AC;&#x201D;an HWKRV WR SDUDOOHO DFDGHPLFV

â&#x20AC;&#x201D;John D. McEachin, MD Meridian 212 VOL. 58 â&#x20AC;˘ NO. 6/7 â&#x20AC;˘ 2017

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