Journal MSMA • VOLUME LXI • NO. 3 • 2020 by Journal MSMA

VOLUME LXI Ū ISSUE NO. 3 Ū MARCH 2020

MISSISSIPPI STATE MEDICAL ASSOCIATION

18 th ANNUAL

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VOL. LXI Ū NO. 3 Ū MARCH 2020

SCIENCE ARTICLES

EDITOR Lucius M. Lampton, MD

THE ASSOCIATION President J. Clay Hays, Jr., MD

ASSOCIATE EDITORS D. Stanley Hartness, MD Philip T. Merideth, MD, JD

President-Elect W. Mark Horne, MD

MANAGING EDITOR Karen A. Evers

Secretary-Treasurer Joe Austin, MD

PUBLICATIONS COMMITTEE Sheila Bouldin, MD, Chair Dwalia S. South, MD, Chair Emeritus Thomas C. Dobbs, MD Wesley Youngblood, M4 and the Editors

Speaker Geri Lee Weiland, MD Vice Speaker Jeffrey A. Morris, MD Executive Director Claude D. Brunson, MD

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.

Amnion/Chorion Allografts in the Treatment of a Deep Plantar Burn in a Child Kristen L. Stephens, M4; Somjade J. Songcharoen, MD; Carolyn Cushing, MD

Pen Perforating the Retropharyngeal Space: A Case Report Savannah Stockton, M4; Brian McManus, MD, PGY-3; Jeffrey Carron, MD

“My Bones Have Been Aching”: A Clinical Problem-Solving Case Susan F. Williams, MD; Sarah E. Barowka, MD; Karen Hughes, MD

DEPARTMENTS From the Editor – Novel Coronavirus and a New Age of Quarantine Lucius M. Lampton, MD

President’s Page – Pea Size J. Clay Hays, Jr., MD

Images in Mississippi Medicine – The Infirmary/Hospital at Ole Miss, 1908 Lucius M. Lampton, MD

Editorial – The Importance of Humanism and Compassion in Medicine Avani Patel, M4

Poetry and Medicine – Happy Birthday to Me John D. McEachin, MD

New Members – Welcoming Our Newest Members

Una Voce – We Simply Must Start Growing Our Own: No, It Isn’t What You’re Thinking Dwalia S. South, MD

RELATED ORGANIZATIONS American Medical Association – Digital Health Tools Gain Momentum Among Physicians

Centers for Medicare and Medicaid Services – MIPS 2019 Data Submission Period Now Open

Mississippi State Department of Health Reportable Disease Statistics

MSMA Alliance – Alliance Hosts 14th Annual Capitol Screening Initiative (CSI-14)

University of Mississippi Medical Center – Medical Scribe Program Strives to Deliver the “Write” Fit Gary Pettus, UMMC Public Affairs

ABOUT THE COVER ADVERTISING RATES: furnished on request. Karen A. Evers, ext. 323. Email: KEvers@MSMAonline.com POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 39158-2548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association. Copyright © 2020 Mississippi State Medical Association.

Official Publication

.4." r Since 1959

A Mississippi Family Tradition, Sciple’s Water Mill has been in the family for 230 years. Tucked away in rural Kemper County on the bank of the Running Tiger Creek sits one of Mississippi’s oldest businesses operating since it was built in 1790. Not only is it one of Mississippi’s most historic sites, but the mill is actually the “the oldest commercially operated water mill in the U.S.” Its weathered clapboard exterior and rusted metal roof speak of its age. Inside, old farm implements, hand tools and other antiques have a coating of dust from the grain that is milled there. An American flag provides color amid the worn gray siding and tin rooftop of ’ this 18th-century industry. The mill operates much as it did back then . It is powered by creek water that is dammed with gates. The water turns a Leffel turbine that replaced the original wooden turbine when the mill was renovated in 1880. Corn and wheat are ground into grits, cornmeal and flour between two round 42-inch-diameter stones. The bottom stone is stationary and weighs 2,100 pounds. The upper stone rotates and weighs 1,600 pounds. The mill’s huge grinding stones are housed in a wooden encasement. Before that, a wood turbine was used. Amazingly, Sciple’s Mill charges growers precisely what the original owners did in 1790: one-eighth of the corn or wheat being ground, which the mill can then bag and sell. Eddie Sciple, who is the fifth-generation operator/owner, welcomes guests for a “grinding” tour that can produce grits, whole wheat flour, fish fry mix, and meal. The longrunning mill is now open to the public on Saturdays only because Eddie works weekdays as an East Mississippi Community College instructor. Regardless of when you visit, you can purchase some of the mill’s flour and grits thanks to a product cabinet with an “honor box.” Sciple’s Mill is located at 525 Sciples Mill Road in De Kalb. If you’re in town on a Saturday night, the mill’s grounds also include the Water Mill Opry, the place to go for live music, home-cooked food, and an old-fashioned atmosphere. For more information, call (601) 416-2860. The Sciple’s Water Mill was photographed by Joe R. Bumgardner, MD, a retired general surgeon from Starkville. Q

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F R O M

T H E

E D I T O R

Novel Coronavirus and a New Age of Quarantine T

he 2019 novel coronavirus (COVID-19) that debuted on the world stage in December after originating in Wuhan, China, has at press time multiplied more quickly than any infectious disease of recent memory with more than 91,783 confirmed cases and at least 3,123 deaths, according to the latest figures from the World Health Organization (WHO). The outbreak has spread to 73 countries beyond China, and here in the U.S., there are more than 100 confirmed cases in 15 states with six deaths. Around the Lucius M. Lampton, MD world, millions are confined in quarantine, Editor thousands remain trapped on cruise ships, and a global shortage of surgical masks has arisen, crises with potential implications for the practice of medicine, surgery, and dentistry around the world. This new, highly contagious coronavirus causes a respiratory illness with such symptoms as fever, cough, shortness of breath, and, in some cases, a deadly acute respiratory syndrome, which can lead to pneumonia, respiratory failure, or septic shock. Infected persons have shown a range of symptoms from mild

to severe illness and death. Symptoms may appear in as few as a couple of days to as long as 14 days after exposure. Genetic analysis of the virus indicates that it originated in bats, although it is still unclear whether it jumped directly from bats or an intermediary host existed. There remains much to be learned about the basics of this emerging disease. COVID-19 is spreading rapidly from person to person internationally and appears to be headed toward a status as a global pandemic. In response, the U.S. government has issued federal quarantine orders for the first time in more than 50 years. (The last use was for smallpox in the 1960s.) The hope is that the use of quarantine will delay its spread, providing time for more research and work on a vaccine. Mississippians are currently considered at low risk from this coronavirus, but individuals with the possibility of complications due to infection, such as the elderly and those with chronic medical issues, may be at higher risk if community transmission occurs. Our state health department has prepared guidelines for physicians and healthcare facilities on identifying, reporting, and safely handling any suspected cases of COVID-19 that may occur in Mississippi. Q

Contact me at lukelampton@cableone.net. — Lucius M. Lampton, MD, Editor

JOURNAL EDITORIAL ADVISORY BOARD ADDICTION MEDICINE Scott L. Hambleton, MD ALLERGY/IMMUNOLOGY Richard D. deShazo, MD Stephen B. LeBlanc, MD Patricia H. Stewart, MD

FAMILY MEDICINE Tim J. Alford, MD Diane K. Beebe, MD Jennifer Bryan, MD J. Edward Hill, MD GASTROENTEROLOGY James Q. Sones, MD

MEDICAL STUDENT John F. G. Bobo, M4

PLASTIC SURGERY William C. Lineaweaver, MD, Chair

NEPHROLOGY Harvey A. Gersh, MD Sohail Abdul Salim, MD

PSYCHIATRY Beverly J. Bryant, MD June A. Powell, MD

NEUROLOGY Mary Alissa Willis, MD

PUBLIC HEALTH Mary Margaret Currier, MD, MPH PULMONARY DISEASE Sharon P. Douglas, MD John R. Spurzem, MD

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

GENERAL SURGERY Andrew C. Mallette, MD

CARDIOVASCULAR DISEASE Thad F. Waites, MD

HEMATOLOGY/ONCOLOGY Carter Milner, MD Kelly Wilkinson, MD

OBSTETRICS & GYNECOLOGY Sidney W. Bondurant, MD Sheila Bouldin, MD Elizabeth A. Lutz, MD Darden H. North, MD

INFECTIOUS DISEASE Rathel "Skip" Nolen, III, MD

ORTHOPEDIC SURGERY Chris E. Wiggins, MD

INTERNAL MEDICINE Richard D. deShazo, MD Daniel P. Edney, MD Daniel W. Jones, MD Brett C. Lampton, MD Kelly J. Wilkinson, MD

OTOLARYNGOLOGY Bradford J. Dye, III, MD

CHILD & ADOLESCENT PSYCHIATRY John Elgin Wilkaitis, MD CLINICAL NEUROPHYSIOLOGY Alan R. Moore, MD DERMATOLOGY Robert T. Brodell, MD Adam C. Byrd, MD EMERGENCY MEDICINE Philip Levin, MD

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INTERNAL MEDICINE/EPIDEMIOLOGY Thomas E. Dobbs, MD

PEDIATRIC OTOLARYNGOLOGY Jeffrey D. Carron, MD PEDIATRICS Michael Artigues, MD

RADIOLOGY Justin Lohmeier, MD P. H. (Hal) Moore, Jr., MD RESIDENT/FELLOW Cesar Cardenas, MD UROLOGY Charles R. Pound, MD VASCULAR SURGERY Taimur Saleem, MD

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Amnion/Chorion Allografts in the Treatment of a Deep Plantar Burn in a Child KRISTEN L. STEPHENS, M4; SOMJADE J. SONGCHAROEN, MD; AND CAROLYN CUSHING, MD

Abstract Objective: This case report addresses the use of human amnion/ chorion membrane to conservatively manage pediatric burns compared to the traditional approach of early excision and grafting. Case Presentation: We present a case involving nonaccidental trauma in a 3-year-old boy who presented with a deep plantar burn. After initial debridement and 2 weeks of amnion/chorion allograft, he was ambulatory and tolerating dressing changes every other day at home without use of pain medication. His wound was healed by 8 weeks and without symptomatic scarring at a 1-year follow-up. Conclusions: In this novel case, we were able to conservatively treat a clinically deep plantar burn in a child with a biologically active dressing. Further, the amnion/chorion allograft may have played a role in the comfort of the child as well as in healing a prolonged wound without a symptomatic scar. Keywords: Dehydrated human amnion chorion membrane; plantar; burn; pediatric Background The treatment of plantar burns in the pediatric patient is challenging. There is a demand to address the developmental and psychosocial needs of children as well as the compliance of their caregivers. When combined with the requirement for frequent dressing changes and rehabilitation, each pediatric burn case requires a complex approach to tackle the multiple barriers that must be overcome for successful burn treatment. Consequently, the logistics of burn treatment are highly specialized and localized. Indeed, much of the scientific literature on the subject consists of small case series with many focused on locoregional experiences. In Mississippi, the Joseph M. Still (JMS) Burn and Reconstruction Center is the only burn center designated by the State Department of Health and Trauma Care System. Dr. William Lineweaver, JMS medical director, reported that the center had treated nearly 1500 pediatric burn patients in the past 9 years, citing a 0.6% mortality rate and 1.2% outof-state transfer rate for those with inhalational injuries or who were candidates for cultured epithelial autografting.1 The standard of care for full-thickness burns is early excision and grafting, though exceptions are often made for burns involving

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glabrous skin. This tissue is extremely thick and highly specialized, with a propensity to heal with conservative management. Current strategies involve dressing changes for up to 3 weeks, possibly followed by surgical debridement and grafting to prevent late sequelae.2 Tissue engineering continues to be a strong driver for advancements in burn care. More recently, amniotic membrane-derived tissue has reemerged as a compelling treatment option. Dehydrated human amnion/chorion membrane (dHACM) is a commercially available allograft that is being explored for its ability to retain growth factors and regulatory molecules that are naturally found in placental tissues.3 It has been postulated that dHACM may reduce pain, time to closure, and perhaps obviate the need for grafting in many cases.4 The current use of dHACM in plantar burn treatment has been limited to a handful of case reports showing favorable results in hostile wound beds, including partial-thickness burns.5 However, its use on deep burns on the plantar surface has been limited to a single case report on a chronic wound in a diabetic patient many weeks after the burn.6 We report a case where dHACM was utilized to heal an acute deep burn on the entire weight-bearing plantar surface of a 3-year-old. Case Presentation A 3-year-old boy with a history of seizures and developmental delay was admitted to the pediatric trauma service with a subdural hematoma after stepping on a hot iron and falling down a flight of stairs. He was brought to the pediatric emergency department in a delayed fashion with altered mental status. Physical exam was significant for a Glasgow Coma Scale of 12, burns and bruises of varying ages scattered over his body, and an acute burn on his left foot. Computed tomography scans revealed acute left frontal and right parieto-occipital subdural hematomas with mass effect on the adjacent parenchyma. Scans were also significant for a possible duodenal injury, fluid in the perihepatic space, and a superior endplate compression fracture at T4. He was admitted to the pediatric intensive care unit, and a nonaccidental trauma workup was initiated. On hospital day 2, the plastic surgery service was consulted for the burn to the left foot. On exam, his left foot was covered with a large blister over the entire weight-bearing plantar surface, including his big toe. The blister was filled with cloudy-appearing fluid. Soft tissue underneath

was not tender to palpation. It was blanched and surrounded by a ring of nonblanching dark, hemorrhagic-appearing zone of erythema. His physical exam was consistent with a full-thickness burn to a large percentage of the wound. He was taken to the operating room for debridement on the following day. Upon incision, the blisters immediately drained foulsmelling purulent fluid. After cultures were sent, the blister roof was excised. The wound bed was then sharply debrided with the aid of a VERSAJET™ Hydrosurgery device (Smith & Nephew, St. Petersburg, FL) until healthy bleeding tissue at the level of the subcutaneous fat was encountered. The wound measured 12 cm × 5.5 cm in its widest dimensions. A dHACM allograft (AmnioFix; MiMedx Group, Inc., Marietta, GA) was then applied to the wound bed as an interim stage to later definitive soft tissue coverage. Two 2 cm × 12 cm sheets were utilized and secured using chromic sutures. The graft was then covered with a negative pressure therapy dressing using a silver sponge, followed by a posterior based splint. Cultures were positive for Streptococcus Viridans, and antibiotics were tailored appropriately. On postoperative day 6, he underwent a dressing change under anesthesia. The wound had healthy granulation tissue with greater than 95% adherence to the dHACM and now measured 12 cm × 5 cm in its widest dimensions. Given the healthy granulation tissue and potential to avoid a more invasive surgery, a second dHACM layer was applied to the wound bed after gentle irrigation and then dressed in a similar fashion. After another 6 days, he underwent a dressing change under conscious sedation with continued progression of his wound bed. He was discharged 4 days later, ambulatory with a walking boot. His dressings were changed with xeroform every other day until healed. He did well in subsequent outpatient visits and was discharged from clinic just 2 months after his original injury. On his one-year follow-up visit, he had an asymptomatic scar and was ambulatory with normal gait. The figure depicts the progression of his healing. Discussion and Conclusions Burns to the feet are classified as a major burn by the American Burn Association.7 Classically, full-thickness burns are treated aggressively with early excision and grafting.8 In glabrous skin, however, sweat glands have been shown to participate in skin regeneration in wounds of the lower skin layer.9 Thus, even with the absence of hair follicles, glabrous skin may re-epithelialize the skin surface after a deep cutaneous injury because of the densely packed sweat glands.10 Consequently, burns that are clinically assessed as full-thickness often heal with conservative treatment because of the many deep structures that remain intact.11 However, even conservative treatment dictates frequent dressing changes, topical ointments, and antibiotics, which are all extremely difficult to do with consistency in a child. Although wounds in healthy children tend to heal regardless of treatment, the long-term functional outcome of their scars is often the limiting factor and should be of paramount importance to the

provider. In a retrospective review of 233 isolated foot burns with nearly half in the pediatric population, Hemington-Gorse et al. cited a complication rate of 18% and an association with prolonged hospital stay. Hypertrophic scarring was the most common complication, with 68% of these occurring in children.11 Moreover, these late sequelae are associated with delayed healing. In a retrospective study of isolated plantar burns in 40 pediatric patients, Barret and Herndon found that all patients with late sequelae were younger and treated conservatively with a healing time of longer than 24.4 days.2 For this reason, the authors recommend excision and autografting in burns that do not heal within 3 weeks. Conservative treatments on these studies, however, utilized hydrocolloid dressings. Dehydrated human amnion/chorion membrane seems to be effective for the treatment of difficult wounds. These amnion/chorion allografts have been shown to contain immunomodulatory chemokines and tissue growth-promoting factors, all of which are associated with an increase in the number of microvessels in vivo.4 Despite being a dehydrated product, the dHACM retains biologically active substances that cause human dermal fibroblast proliferation and migration of human mesenchymal stem cells in vitro. Similar results were also found in vivo with mouse models. Assays on the amnion/chorion allograft show quantifiable levels in more than 10 growth or stimulating factors in addition to the confirmed presence of a handful of interleukins and tissue inhibitors of metalloproteases. Thus, dHACMs are implicated in affecting cell proliferation, inflammation, metalloproteinase activity, and the recruitment of progenitor cells.12 In addition, an amniotic membrane stromal matrix has been shown to suppress DNA synthesis and subsequent differentiation of myofibroblasts by suppressing growth factor signaling systems. These actions help explain not only the antiscarring results of amniotic membrane transplantation but also why fetal wound healing is scarless.13 These properties have made the use of dHACMs an increasingly popular adjunct to all stages of burn reconstruction. Further, as we saw in our patient, they may help reduce the risk of hypertrophic scarring and contractures that frequently complicate burn wounds with prolonged healing. Many burns are typically treated in the outpatient setting; however, our patient was hospitalized for an extended period of time due to other injuries and social issues. As an inpatient, we had the opportunity to use negative pressure therapy. With the vacuum dressing in place, we minimized the burden of dressing changes to a once-weekly basis for the first 2 weeks. Although the negative pressure therapy may have played a role in improving the quality of the wound bed through microdeformation,14 we chose to use it primarily for the protection of our graft and for the comfort of the child. To our knowledge, this is the first reported case utilizing a dHACM to conservatively treat a clinically deep burn to the plantar surface in a pediatric patient. As with any case report, it is difficult to generalize our results to others. Further, we should be cautious about making hard implications between the amnion/chorion allograft and our final result. Nonetheless, we were pleased and somewhat surprised with our outcome, considering we achieved complete healing conservatively and asymptomatically despite our initial preparations for surgical soft tissue coverage. Q

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Figure. A) Initial presentation. B) Day 6, first dressing change. C) Day 12, second dressing change. D) 1-week post discharge. E) 1-month post discharge. F) 1-year follow-up.

Acknowledgments

9. Miller SJ, Burke EM, Rader MD, et al. Re-epithelialization of porcine skin by the sweat apparatus. J Invest Dermatol. 1998;110(1):13-19.

Conflict of Interest Disclosures: The authors have nothing to disclose.

10. Chang S-C, Hsu C-K, Tzeng Y-S, et al. Deep sole burns in several participants in a traditional festival of the firewalking ceremony in Kee-lung, Taiwan: Clinical experiences and prevention strategies. Burns 2012;38(7):1079-1083.

References

11. Hemington-Gorse S, Pellard S, Wilson-Jones N, et al. Foot burns: Epidemiology and management. Burns 2007;33(8):1041-1045.

1. Lineaweaver WC. Burn care in Mississippi. CME presentation, Central Mississippi Medical Society, Jackson, MS, April 24, 2018.

12. Grube BJ, Engrav LH, Heimbach DM. Early ambulation and discharge in 100 patients with burns of the foot treated by grafts. J Trauma. 1992;33(5):662-664.

2. Barret JP, Herndon DN. Plantar burns in children: Epidemiology and sequelae. Ann Plast Surg. 2004;53(5):462-464.

13. Kılıç T, Krijnen P, Tuinebreijer WE, et al. Epidemiology of foot burns in a Dutch burn centre. Burn Trauma. 2015;3:5.

3. Tenenhaus M. The use of dehydrated human amnion/chorion membranes in the treatment of burns and complex wounds: Current and future applications. Ann Plast Surg. 2017;78(2 Suppl 1):S11-S13.

14. Koob TJ, Rennert R, Zabek N, et al. Biological properties of dehydrated human amnion/ chorion composite graft: Implications for chronic wound healing. Int Wound J. 2013;10(5): 493-500.

4. Glat PM, Davenport T. Current techniques for burn reconstruction: Using dehydrated human amnion/chorion membrane allografts as an adjunctive treatment along the reconstructive ladder. Ann Plast Surg. 2017;78(2 Suppl 1):S14-S18. 5. Reilly DA, Hickey S, Lineaweaver W, et al. Clinical experience: Using dehydrated human amnion/chorion membrane allografts for acute and reconstructive burn care. Ann Plast Surg. 2017;78:S19-S26. 6. Chua W. Dehydrated human amnion/chorion membrane for the treatment of full-thickness plantar burn in a diabetic patient: A case report. J Diabet Foot Complicat. 2014;6(3):67-71. 7. Zachary LS, Heggers JP, Robson MC, et al. Burns of the feet. J Burn Care Rehabil. 1987;8(3):192-194. 8. Liu H-F, Zhang F, Lineaweaver WC. History and advancement of burn treatments. Ann Plast Surg. 2017;78(2):S2-S8.

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Author Information: M4, School of Medicine, University of Mississippi Medical Center, Jackson (Stephens). Resident, Department of Surgery, Division of Plastic Surgery, University of Mississippi Medical Center, Jackson (Songcharoen). Assistant Professor, Department of Surgery, University of Mississippi Medical Center, Jackson (Cushing). Corresponding Author: Somjade J. Songcharoen, MD, Department of Surgery, Division of Plastic Surgery, University of Mississippi Medical Center, 2500 N. State St., Jackson, MS 39216 (sjsongcharoen@ gmail.com).

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Pen Perforating the Retropharyngeal Space: A Case Report SAVANNAH STOCKTON, M4; BRIAN MCMANUS, MD, PGY-3; AND JEFFREY CARRON, MD

Abstract Background: Esophageal foreign body is a common complaint of psychiatric patients presenting to the emergency department. The management of these patients usually consists of imaging to confirm the presence of the foreign body, followed by endoscopy to retrieve it. Dissection and implantation into the retropharyngeal space is a rare complication of foreign body ingestion.

Figure 1. Initial x-ray image showing pen extending from approximately the level of the C3 vertebral body to the upper esophagus.

Case presentation: We report a case where an initial endoscopic foreign body retrieval failed to detect an additional foreign body in the posterior hypopharyngeal mucosa of a 30-year-old female psychiatric patient. Radiographic images post-retrieval showed a foreign body still present that had not been seen on esophagogastroduodenoscopy (EGD), and the patient underwent a direct laryngoscopy for retrieval. Conclusion: This case highlights the importance of a thorough review of imaging prior to endoscopy when multiple foreign bodies are present and remembering that they can penetrate submucosally, making visualization difficult. Keywords: Complication of esophageal foreign body, hypopharyngeal mucosa, ingestion, psychiatric Case Report A 30-year-old woman with a history of psychiatric illness, deafness, and multiple foreign body ingestions presented to the emergency department after reportedly swallowing a ballpoint pen. The patient was a resident at a psychiatric hospital and reported swallowing the pen after becoming angry with her doctor. On physical examination, vital signs were stable, and the patient complained of trouble swallowing. No object was visible in the posterior oropharynx. Radiographic images of the neck and chest showed a radiopaque foreign body in the esophagus as well as an additional foreign body at the level of the gastroesophageal junction (Figure 1). Examination with flexible laryngoscopy revealed the top of a foreign object appearing in the esophagus but difficult to visualize with secretions; there was no airway compromise. She then underwent flexible esophagogastroduodenoscopy (EGD) with successful removal of a pen ink cartridge from the proximal esophagus and a plastic spoon from the stomach.

The next day, despite broad-spectrum antibiotic coverage, the patient developed persistent fever with tachycardia. The patient complained of diffuse throat pain that prevented her from swallowing. Vital signs were significant for a temperature of 103sF and a heart rate of 111 beats per minute. Laboratory studies revealed an elevated white blood cell count (WBC) of 11,900/mm3 with differential counts of neutrophils 88.5%, lymphocytes 5.7%, monocytes 5.3%, eosinophils 0%, and basophils 0.1%. Hematocrit value was 31.6%, and platelet count was 163,000/mm3. A follow-up neck computed tomography (CT) scan showed a persistent foreign body measuring an estimated 16 cm extending from the hypopharyngeal region into the proximal thoracic esophagus (Figure 2). She was taken back to the operating room where examination with a laryngoscope revealed the tip of a metallic foreign body embedded in

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Figure 2. CT image after initial EGD showing retained foreign body. An arrow points to the top of the pen.

Figure 4. Pen post-removal from retropharyngeal space measuring approximately 14 cm.

Figure 3. Direct laryngoscopy image showing top of pen embedded in the posterior hypopharyngeal mucosa and into the retropharyngeal space.

considering the location in the retropharyngeal space. Ampicillin/ sulbactam and vancomycin were chosen for empiric coverage. On postoperative day (POD) 2 a gastrograffin swallow study and esophagram showed an approximately 3 cm retroesophageal false passage beginning at the level of C3 and ending in a blind pouch. A repeat swallow study performed 5 days later showed resolving of the false passage that was improved from the previous exam.

the posterior pharyngeal wall of the hypopharynx with an associated laceration (Figure 3). A 14 cm writing pen foreign body was found to be nearly totally embedded in the posterior hypopharyngeal mucosa and into the retropharyngeal space with only the top showing (Figure 4). No other foreign bodies were seen. An intraoperative chest x-ray confirmed that the foreign body was no longer present. The patient was subsequently monitored in the intensive care unit for signs of mediastinitis,

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The patient’s status regarding the foreign body removal continued to improve. Additional issues, including heart arrhythmia and pleural effusion, delayed the patient’s discharge, but she was ultimately discharged on POD 31. At the 2-week follow-up visit, the patient reported tolerating a normal diet with the occasional feeling of food getting stuck in her throat that was relieved with drinking liquids. Discussion Foreign body ingestion is a common complaint of psychiatric patients presenting to the emergency department. Most foreign bodies are

identified by neck radiograph and subsequently retrieved from the lumen of the esophagus via endoscopy. There have been multiple case reports of foreign body ingestions that cannot be located on endoscopy and are found to be extraluminal. These cases are usually caused by ingestion of a sharp object with the ability to penetrate the mucosal lining. One case reports ingestion of a fishbone that caused traumatic perforation of the hypopharynx and subsequent retropharyngeal abscess.1 Other cases report retropharyngeal foreign bodies secondary to external traumatic entry.2,3 Sharp foreign bodies have the potential to penetrate the mucosa and embed in the retropharyngeal space. Early diagnosis with a neck radiograph is key, as there are many potentially life-threatening complications associated with ingestion of a foreign body including mediastinitis, retropharyngeal abscess, esophageal perforation, pneumomediastinum, and pneumothorax.1,4–6 Management of foreign body ingestion is case dependent, ranging from observation to surgery for removal.

Acknowledgments Conflict of Interest Disclosures: The authors have nothing to disclose. References 1. Berger S, Elidan J, Gay I. Retropharyngeal abscess caused by traumatic perforation of the hypopharynx by fish bone. Ann Otol Rhinol Laryngol. 1990;99:927-928. 2. Mishra A, Shukla G, Bhatia N. Oropharyngeal foreign body. J Laryngol Otol. 2000;114:469-470. 3. Ahmad R, Pampori R, Wani A, et al. Transcervical foreign body. J Laryngol Otol. 2000;114:471-472. 4. Chio E, Agrawal A. Esophageal foreign body causing retropharyngeal abscess. Otolaryngol Head Neck Surg. 2007;137:156-157. 5. Sewell DL. Retropharyngeal abscess secondary to foreign body in hypopharynx. BMJ. 1928;2(3546):1135. www.jstor.org/stable/25330960. Accessed February 6, 2020. 6. Rumbold H. Retropharyngeal abscess secondary to a foreign body. Emerg Med J. 2009; 26(10):723.

Author Information There are unique problems inherent in the management of psychiatric patients who harm themselves by deliberately ingesting foreign bodies. As evident in our patient’s case, intraoperative x-rays to confirm the successful removal of the object may be useful when the number of objects ingested is unknown. Also, since the gastroscope was inserted beyond the hypopharynx during the first procedure by the gastroenterologist and the subsequent procedure was done with different instruments by the otolaryngology team, collaboration among teams may have avoided the need for two procedures and shortened her length of stay. Q

M4 at the University of Mississippi Medical Center, Jackson (Stockton). PGY-3, Otolaryngology resident, the University of Mississippi Medical Center, Jackson (McManus). Professor of Otolaryngology and Pediatrics, the University of Mississippi Medical Center, Jackson (Carron). Corresponding Author: Jeffrey Carron, MD, University of Mississippi Medical Center, Department of Otolaryngology and Communicative Sciences, 2500 N. State St., Jackson, MS 39216 Ph: (601) 984-5160 (jcarron@umc.edu).

PHYSICIANS NEEDED Internists, Cardiologists, Ophthalmologists, Pediatricians, Orthopedists, Neurologists, Psychiatrists, etc. interested in performing consultative evaluations according to Social Security guidelines.

OR Physicians to review Social Security disability claims at the Mississippi Department of Rehabilitation Services (MDRS) in Madison MS.

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“My Bones Have Been Aching”: A Clinical Problem-Solving Case SUSAN F. WILLIAMS, MD; SARAH E. BAROWKA, MD; AND KAREN HUGHES, MD

Abstract A 50-year-old male presented with acute body aches, diffuse weakness, and persistent fever despite antibiotic therapy. After evaluation for fever of unknown origin, he was ultimately diagnosed with adult-onset Still’s disease. This case study will discuss his presentation, workup, broad differential diagnoses, and outcome. Keywords: Still’s disease, adult-onset, fever of unknown origin, arthralgia A 50-year-old man presented to our emergency department (ED) with complaints of fever, sore throat, body aches, and generalized weakness during an active flu season. Of note, he had been seen at an outside facility 2 weeks prior and was given intramuscular Ceftriaxone and a prescription for oral Amoxicillin. He was diagnosed with suspected streptococcal pharyngitis (no records that cultures were obtained) and discharged. He stopped taking the antibiotics after a few days as he felt there was no improvement in his symptoms. He then presented to the ED 4 days later with similar symptoms and fever (Tmax 103°F, Table 1). At that time, his urinalysis was suspicious for infection, so he was given 2 g of Ceftriaxone and discharged with oral Ciprofloxacin. He was Table 1. Maximum Temperature Per Hospital Day Listed in Degrees Fahrenheit

Hospital day

Tmax (°F)

100

101.2

101.6

101.8

102.6

102.8

102.9

97.6

98.4

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scheduled for follow-up the next day with his primary care clinic. At the clinic visit, he reported an itchy rash that had been on his face and scalp for an unknown amount of time. He reported he had been taking the antibiotic and was afebrile. His family member reported a new complaint of difficulty walking, and he was complaining of diffuse body pain, aching joints, and dizziness. He reported having received a flu shot this year. He denied known sick contacts. He denied abdominal pain, nausea, vomiting, diarrhea, headache, or urinary symptoms. The differential diagnosis for fever of unknown origin (FUO) includes infection, neoplasm, and connective tissue disorders. Classic fever of unknown origin is defined as temperature ≥100.9°F (38.3°C) for at least 3 weeks with no identified cause after 3 days of hospital evaluation or 3 outpatient visits1 (Table 1). At this point, he had been evaluated at an outside hospital once, twice in our hospital’s ED, then was seen in an outpatient clinic without resolution of reported symptoms and fever for 6 days. Although there were visits without recorded fever, including the office visit, this could have been affected by antipyretic use or due to fever variation. At this point in the course of illness, the suspected cause was an undetermined infection resistant to the above-listed antibiotics. The patient had been disabled from an accident while working as a truck driver in 2007 and did not work. He denied current tobacco or drug use but was a former smoker. He admitted to occasional alcohol use. He was not using assistive devices and was independent in his activities of daily living (ADLs) at baseline. His home medications were ferrous sulfate, metformin, gabapentin, pravastatin, torsemide, aspirin, carvedilol, and lisinopril-hydrochlorothiazide. His past medical history was significant for class III obesity, hypertension, obstructive sleep apnea/obesity hypoventilation syndrome (OSA/OHS) on home bilevel positive airway pressure (BiPAP), gastroesophageal reflux disease, iron deficiency anemia, controlled noninsulin dependent diabetes mellitus type II with polyneuropathy, venous stasis dermatitis, and chronic low back pain. On physical exam in the ED, he was afebrile (Tmax 100°F), had no tachycardia, no tachypnea, and his oxygen saturation was 95% on room air. He did not appear to be in distress and was alert on examination (Table 1). He had no scleral icterus or conjunctival injection and no rhinorrhea. His oral mucosa was moist without lesion and his oropharynx showed bilateral tonsillar exudates with erythema. There was 1+ pitting lower extremity edema, and his

abdomen was tense but nontender to palpation. Due to body habitus, it was difficult to appreciate if there was any hepatosplenomegaly. He had scattered scaling, erythematous plaques on his cheeks and throughout his scalp with no appreciable cervical adenopathy. He had thickened and discolored toenails bilaterally with evidence of venous stasis dermatitis to lower extremities: pretibial hair loss and some induration but no sign of secondary infection or erythema. He had no focal neurological deficits but exhibited generalized fullbody weakness with diminished strength throughout. Sensation was intact. His recent and remote memory was intact. After obtaining a history and performing a physical examination, his clinical presentation was most consistent with an acute viral or bacterial infection, causing pharyngitis and generalized somatic complaints. He was admitted for failed outpatient therapy and started on intravenous Levaquin. In a patient with fever of unknown origin, minimum investigation includes a complete blood count, electrolytes, blood urea nitrogen (BUN)/creatinine, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), creatinine phosphokinase, liver function panel, urinalysis (with culture if pyuria is present), 3 sets of blood cultures, antinuclear antibodies (ANA), antineutrophil cytoplasmic antibodies (ANCA), rheumatoid factor (RF), human immunodeficiency virus (HIV) antibody, purified protein derivative (PPD) or interferon-gamma release assay, chest x-ray (CXR), and abdominal ultrasound or computed tomography (CT) with contrast.1 Initial laboratory results were notable for decreased hemoglobin and hematocrit of 10.4 g/dL and 33.8%, respectively, with an elevated white blood cell count (WBC) of 19.9 and 92% polymorphonuclear cells. Aspartate aminotransferase (SGOT/ AST) was elevated at 70 U/L, and rapid strep antigen with reflex culture was negative. Urinalysis was significant for 2+ protein, 1+ leukocytes, 57 WBC, 6 RBC, and few bacteria. A urine culture with Antimicrobial Removal Device (ARDS) and two sets of blood cultures with ARDS were obtained in the emergency department and were pending. Influenza A/B antigen, Monospot, and HIV tests were negative, and creatinine kinase was normal. The ESR and CRP were elevated at 63 and >20, respectively. The CXR was concerning for mild bilateral peribronchial cuffing, suggestive of a bronchial infectious or inflammatory process. The electrocardiogram (ECG) was sinus rhythm with a rate of 85, no acute ST T-wave ischemic changes, and normal QRS. The diagnosis becomes less apparent here. Overall, the leukocytosis (≥10,000/mm3) with ≥80% polymorphonuclear cells suggested an infectious etiology, but no readily apparent infection was identified on initial laboratory results and did not meet sepsis criteria. However, the decision was made to start antibiotics to cover for possible pneumonia. At the time, our differential diagnosis included urinary tract infection, bacteremia, streptococcal pharyngitis, viral pharyngitis, bronchitis, or pneumonia. With the negative rapid flu test, influenza was low on our differential; however, with the elevated CRP and ESR, we added rheumatologic disorders to our differential.

The patient was admitted to the general medical floor as an inpatient. Further history was obtained, and he denied family history of rheumatoid arthritis, lupus, or sarcoidosis. He denied history of sexually transmitted diseases (STDs), recent sexual activity, or penile discharge. Urine Neisseria gonorrhoeae (GC) Chlamydia trachomatis screening was ordered for completeness. With the elevated AST, a hepatitis panel was ordered, and because of his history of confusion, a head CT without IV contrast and a brain MRI without IV contrast were ordered in addition to basic rheumatology work-up: FANA, RF, TSH, and EBV and CMV titers. He was found to have a vitamin D deficiency, and replacement was initiated. His vitamin B12 and folate levels were normal; however, he continued to complain of joint pain, and his Tmax on hospital day 1 and 2 was 100°F and 101.6°F, respectively (Table 1). Due to continued fevers despite antibiotic therapy, multiple comorbidities, and no definite source of infection, his antibiotic therapy was expanded with the addition of intravenous Vancomycin to Levofloxacin given. In the meantime, Epstein-Barr Virus and cytomegalovirus titers showed no active infection but suggested past infection, and head imaging was unremarkable. Rheumatoid factor, urine GC Chlamydia, chronic hepatitis panel, RPR, FANA, and TSH were all negative. An Infectious Disease (ID) specialist was consulted at this time due to the lack of a clear source of infection with continued leukocytosis and fever. With this acute febrile illness with a sore throat, myalgias, arthralgias, leukocytosis, and pyuria, we added adult-onset Still’s disease (AOSD) to our differential diagnoses. This is typically a diagnosis of exclusion. On hospital day 3, he was seen by ID specialist working with differential diagnoses that included AOSD, endocarditis, occult pulmonary or abdominal infection, rheumatology condition, or occult malignancy. Ferritin was ordered at this time along with repeat liver function tests, transthoracic echocardiogram (TTE), and a CT of the chest/abdomen/pelvis without IV contrast for further evaluation. His antibiotics were adjusted due to the development of acute renal insufficiency, but the plan was for these to continue until an infectious process could be ruled out. His Tmax was 101.3°F throughout day 3 of hospitalization (Table 1). AOSD is generally considered a diagnosis of exclusion in the workup of fever of unknown origin. It is characterized by four cardinal symptoms: spiking fever, an evanescent salmon-pink maculopapular rash, arthralgia or arthritis, and a white-blood-cell count (WBC) ≥10,000/mm3, mainly polymorphonuclear cells (PMNs). Elevated CRP and ESR are common and can be found in 90%–100% of cases. Increased serum ferritinemia with glycosylated fraction ≤20% appears as one of the more suggestive findings.2 However some case studies are suggesting that atypical cutaneous manifestations have been seen.4 CT of the chest/abdomen/pelvis without IV contrast showed enlarged nodes: right paratracheal, right subcarinal, right inguinal, and right femoral. He is a former smoker, but chest imaging did not show evidence of a pulmonary mass, and abdominal imaging

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did not show any colonic masses. Infectious disease ordered a lymph node biopsy on hospital day 4 with pathology and cultures for further evaluation. At this time, all cultures (strep, urine, and blood cultures) were ultimately negative. Transthoracic echocardiogram showed normal-appearing valves despite a technically challenging study due to patient’s morbid obesity. Antibiotics were stopped as there was no evidence of infection. However, Tmax was now 101.8°F (Table 1). At this time, our differential diagnosis began to narrow: adult-onset Still’s disease, sarcoidosis, lymphoma, tuberculosis (TB), or endemic fungal disease. A purified protein derivate was placed to test for silent (latent) TB infection. Additionally, his ferritin level was elevated at 3,830 ng/mL. On further review of his fever curve, the patient consistently had twice daily fevers. At this point, our most likely diagnoses were adult-onset Still’s disease, sarcoidosis, or lymphoma, and we were awaiting the results of the lymph node biopsy to rule out malignancy. The addition of naproxen twice daily was considered, but with the patient’s continued acute renal insufficiency, this was avoided. The increased ferritin level was consistent with AOSD, but glycosylated fraction was not obtained. On hospital day 7, the patient’s acute renal insufficiency resolved, and naproxen was added as needed for fever. The fungal culture from the right inguinal lymph node biopsy was negative, while the anaerobic culture from the lymph node was positive for S. pasteuri, which was thought to be a contaminant; antibiotics were not resumed. Lymph node biopsy was negative for malignancy and did not show evidence of granulomatous inflammation, making lymphoma and sarcoidosis less likely. At this time, rheumatology was consulted for suspected AOSD. Patient was given one dose of Solumedrol 80 mg intravenously on hospital day 8, after which he remained afebrile. Yamaguchi’s criteria are the most sensitive diagnostic tool for AOSD compared to other classification criteria.3 Our patient presented with 3 major criteria (fever, arthralgia, and neutrophilic leukocytosis) and 4 minor criteria (absence of ANA and RF, sore throat, lymphadenopathy, and hepatic dysfunction). Thus, our patient fulfilled Yamaguchi’s criteria for the diagnosis of AOSD. Requiring 5 or more criteria, including 2 or more major criteria, yielded 96.2% sensitivity and 92.1% specificity8 (Table 2). Atypical cutaneous manifestations have been observed to occur in addition to the typical evanescent rash.4 Cutaneous symptoms alone could significantly lengthen the average time of diagnosis. Based on a review of 81 case reports, there was an overall prevalence of atypical cutaneous manifestations in this AOSD population of 14%, including persistent pruritic papules and/or plaques, urticarial or urticarial-like eruptions, generalized nonpruritic persistent erythema, vesiculopustular eruptions, and widespread peau d’orange appearance.3 Our patient initially reported a skin rash involving his face and scalp of unknown duration. It was presumed to be tinea capitis and tinea corporis

68 LEB$ ŝŘ DE$ Ś řŗřŗ

Table 2. Yamaguchi’s Criteria3

At least 5 criteria, including ≥2 major criteria and no exclusion criteria, are required for diagnosis Major criteria

Fever ≥102.2°F lasting ≥1 week Arthralgia lasting 2 weeks Typical skin rash: maculopapular, nonpruritic, salmon-pink rash with concomitant fever spikes Leukocytosis ≥10,000 cells/mm3 with polymorphonuclear count ≥80%

Minor criteria

Pharyngitis or sore throat Lymphadenopathy and/or splenomegaly Abnormalities in liver enzymes (aminotransferases) Negative for rheumatoid factor or antinuclear antibodies

Exclusion criteria

Infectious, especially sepsis and Epstein-Barr viral infection Malignant diseases, especially lymphomas Inflammatory disease, especially polyarteritis nodosa

and treated empirically. Skin biopsy was not obtained. He had multiple risk factors for the development of diffuse cutaneous fungal infection (class III obesity, diabetes mellitus, presence of onychomycosis), but this could have potentially been an atypical skin manifestation. Although no reported incidences of fungal infection appear associated with AOSD, this could be an area for more investigation in the future. Rheumatology evaluated the patient and believed his presentation could be due to sarcoidosis with inflammatory arthritis or adultonset Still’s disease. However, the right inguinal node biopsy did not show evidence of granulomatous inflammation. He responded to prednisone therapy and has been afebrile since it was begun. He started on scheduled Naproxen twice daily. The plan was to monitor his response and consider adding the immunosuppressant Anakinra outpatient if there was no response to NSAIDs and prednisone. Additional rheumatology studies were obtained: CK (62), ESR (64 mm/hour), CRP (>20 mg/dL), c-ANCA/p-ANCA (negative), C3 (131), C4 (24), total Ch50 (57 U/mL), Histoplasmosis urine (negative), Histoplasmosis Ag (negative), and Blastomyces serum Ab (negative). The tuberculin skin test and Quantiferon gold returned negative for tuberculosis. Angiotensin-converting enzyme (ACE) level was obtained for evaluation of sarcoidosis and was within normal range. Serum electrophoresis was obtained, showing a polyclonal increase in gamma globulins. Numerous tests can be ordered in the evaluation of a patient such as this. In review of the patient’s workup so far, infectious workup was negative, and malignancy was of low concern. At this step, we

continued his autoimmune and rheumatologic workup. Heightened immunological activity was reflected in his elevated acute phase reactants (ESR and CRP) and serum ferritin levels. Serum creatinine kinase was useful in the evaluation of polymyositis in the setting of arthralgias and myalgias, but his level was normal. Antineutrophil cytoplasmic antibodies (c-ANCA and p-ANCA) are useful in the evaluation of patients suspected of having autoimmune vasculitides such as Wegener granulomatosis, microscopic polyangiitis, or pauciimmune necrotizing glomerulonephritis; these were negative.2 Next, complement function evaluation can be helpful if there is concern for collagen-vascular disease. Measurement of total CH50 tests the ability of proteins in a classic pathway from membrane attack complexes to lyse antibody-coated complexes. This is useful as a screening test for diseases of the complement system, since low or high C3 and C4 titers can help determine if the complement system is acting abnormally. Based on these results, it was less likely he had a complement deficiency. Since pulmonary infection was possible, testing for Histoplasmosis and Blastomycosis as well as tuberculosis were ordered and were negative, completing the workup for an infectious cause of his multisystem illness. Sarcoidosis was another possibility, so ACE was obtained. One of the classic features of sarcoidosis is the development of granulomas, leading to damage and inflammation of surrounding tissues. The tissues can then release increased amounts of this enzyme. The negative lymph node biopsy for granulomatous inflammation and normal ACE made sarcoidosis seem less likely, and AOSD appeared more probable. Serum protein electrophoresis is used to identify patients with serum protein disorders, and clinical interest is generally focused on the gamma region of the serum protein spectrum. Increased gamma globulins can be seen in chronic granulomatous infections, lymphoma, multiple myeloma, connective tissue disorders, and so on. When interpreting serum protein electrophoresis results, it is important to differentiate between monoclonal and polyclonal gammopathies as monoclonal gammopathies are associated with potentially malignant processes. This patient had evidence of polyclonal gammopathy, which can be seen in connective tissue diseases such as sarcoidosis. It can also be seen in lymphoma, but, as we previously discussed, this was effectively ruled out.2 With resolution of fever after steroids, rheumatology planned to follow up with the patient after hospital discharge. The patient planned to go to a short-term rehabilitation facility for physical therapy for his general debility. The pathogenesis is not entirely understood, but most proinflammatory cytokines [IL-1β, IL-6, IL-18, tumor necrosis factor (TNF)-α, and interferon (IFN)-γ] have been found to be elevated in AOSD. This is further supported by the clinical response to interleukin (IL)-blocking therapies, especially IL-1β. It is proposed that environmental triggers such as viruses, bacteria, and so on cause pathogen-associated or damage-associated molecular patterns (PAMPS or DAMPs) to initiate and perpetuate a noninfectious inflammatory response that leads to macrophage activation. This leads to increased production of the abovelisted proinflammatory cytokines. Increased cytokine production leads

to acute-phase reaction, increased neutrophils, increased ferritin, and decreased glycosylated ferritin.2 These are thought to be responsible for the major clinical and biological features of AOSD. However, unrestrained macrophage activation can lead to life-threatening uncontrolled hemophagocytosis and reactive hemophagocytic lymphohistiocytosis (RHL), previously known as macrophage activation syndrome. This is thought to be secondary to excessive activation and proliferation of T lymphocytes and macrophages. RHL is characterized by pancytopenia, liver dysfunction, coagulopathy, and neurological symptoms.5 There is evidence that nonsteroidal antiinflammatory drugs (NSAIDs) can accelerate macrophage immune responses through chronic cyclooxygenase inhibition.6 Thus, the risks and benefits of NSAID use should be considered in the treatment of fever of unknown origin and especially AOSD. Treatment options for AOSD include NSAIDs, corticosteroids, conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), and biologic agents (bDMARDs). Studies have shown that only 15–20% of AOSD patients respond to NSAID therapy. Systemic oral corticosteroids are first-line agents (effective in approximately 60% of trials7), but long-term use has been associated with multiple possible side effects. When disease activity is uncontrolled on corticosteroids or flares are experienced during tapering of corticosteroids, csDMARDs such as methotrexate or cyclosporine can be utilized. Methotrexate (MTX) is effective in approximately 70% of patients. The combination of MTX and systemic corticosteroids should be considered as initial treatment in active disease. Patients refractory to systemic corticosteroids and csDMARDs sometimes require bDMARDs therapy. Examples include anti-TNF agents (e.g., infliximab, etanercept), anti-IL-1 therapy (e.g., anakinra, rilonacept, canakinumab), anti-IL-6 therapy (e.g., tocilizumab), CTLA-4-Ig fusion protein (e.g., Abatacept), and chimeric anti-CD20 monoclonal antibody (e.g., rituximab).7 However, treatment should be individualized and disease activity measured during long-term follow-up. Ultimately, the patient was seen by rheumatology after inpatient rehabilitation discharge, where he reported he had finished his prednisone taper without fever or joint pains. At that time, he was told that AOSD was less likely as he tapered and stopped his prednisone therapy without any flare-up or fever. However, before leaving the office visit, the patient became hypotensive and dizzy. He was re-admitted to the hospital and treated for sepsis secondary to Proteus urinary tract infection (UTI) with acute kidney injury. At admission, he was febrile to 104°F (Table 1). Laboratory results were as follows: ESR 102, CRP 16, and ferritin 11,000. An extensive laboratory workup was obtained at the request of rheumatology as part of the AOSD workup. Rheumatology did not recommend resuming steroids. There was concern for bacteremia with blood cultures positive for gram-positive cocci, but infectious disease was consulted and felt this was a contaminant as Staphylococcus epidermidis was ultimately grown. He was discharged home once medically stable with oral antibiotics. At the hospital follow-up visit, rheumatology was convinced that his presentation was consistent with AOSD. His length of time

LEB$ ŝŘ DE$ Ś řŗřŗ 69

from symptom onset to definitive diagnosis was approximately 3 months. He started on methotrexate 10 mg by mouth (PO) once per week as well as folic acid 1 mg PO daily. The plan was to add Anakinra if his symptoms were not controlled. Over the next year, the patient required MTX to be increased to the current dosage of 20 mg once per week. He has had no further hospital admissions. In research, as in life, hindsight is 20/20. As I reviewed charts and re-examined this patientâ&#x20AC;&#x2122;s hospital course, I realized that there were some limitations in confirming the diagnosis of adult-onset Stillâ&#x20AC;&#x2122;s disease. As discussed earlier, the time required for diagnosis of FUO is 3 weeks. I cannot indubitably say that he had fever for precisely this period as he was ill before presenting in the outpatient setting. Yamaguchiâ&#x20AC;&#x2122;s criteria state that fever should last â&#x2030;Ľ1 week. As I reviewed the patientâ&#x20AC;&#x2122;s fever curve throughout his hospitalization, he consistently had fevers >102.2Â°F for 4 days until he received systemic corticosteroids, after which his fever resolved (Table 1). We can extrapolate that the patientâ&#x20AC;&#x2122;s fever trend would have continued if systemic corticosteroids had not been given, but as we already suspected AOSD, we treated him. Many tests were obtained during this patientâ&#x20AC;&#x2122;s workup, but the addition of glycosylated ferritin would have been useful, in hindsight, as well as trending of ferritin. The estimated length of time from presentation in outpatient setting to definitive diagnosis of AOSD was approximately 2 months.

6. Na YR, Yoon YN, Son D, Jung D, Gu GJ, Seok SH. Consistent inhibition of cyclooxygenase drives macrophages towards the inflammatory phenotype. PLoS One. 2015;10(2):e0118203. 7. Yoo DH. Treatment of adult-onset Stillâ&#x20AC;&#x2122;s disease: Up to date. Expert Rev of Clin Immunol. 2017;13(9):849-866. 8. Yamaguchi M, Ohta A, Tsunematsu T, et al. Preliminary criteria for classification of adult Stillâ&#x20AC;&#x2122;s disease. J Rheumatol. 1992;19(3):424-430.

Author Information Family medicine physician, Hattiesburg Clinic (Williams). Faculty physicians, North Mississippi Medical Center Family Medicine residency program (Barowka, Hughes). Corresponding Author: Susan F. Williams, MD, Hattiesburg Clinic, The Family Clinic - Purvis, 101 Weems Street Purvis, MS 39475 Ph: (601-794-2224) (susan.williams@hattiesburgclinic.com).

While it is important to follow diagnostic criteria to reach the correct diagnosis, it is also essential to recognize that our patients do not always follow the criteria exactly and that treatment itself can impact some of the presenting signs. As a family physician, our role is often to ensure that the information from each specialist is communicated, so all see the whole picture. Teamwork allows diagnosis of a complex and confusing illness to be made and treatment to begin as soon as possible. Acknowledgments Conflict of Interest Disclosures: The authors have nothing to disclose. References 1. Varghese GM, Trowbridge P, Doherty T. Investigating and managing pyrexia of unknown origin in adults. BMJ. 2010;341:C5470-C5470. 2. Mitrovic S, Fautrel B. New markers for adult-onset Stillâ&#x20AC;&#x2122;s disease. Joint Bone Spine. 2018;85(3):285-293. 3. Pak S, Pham C. Delay in diagnosis of adult-onset Stillâ&#x20AC;&#x2122;s disease. Cureus. 2017;9(6):1321.

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4. NarvĂĄez Garcia FJ, Pascual M, LĂłpez de Recalde M, et al. Adult-onset Stillâ&#x20AC;&#x2122;s disease with atypical cutaneous manifestations. Medicine. 2017;96(11):e6318.

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5. Raj PB, Harikrishnan BL, Mampilly R, Anand R. Macrophage activation syndrome. J Assoc Physicians India. 2017;65(5):91-92.

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or almost a quarter of a decade, I have had the pleasure of seeing patients with heart disease. Most people worry about how to prevent a heart attack, a stroke, high blood pressure, high cholesterol, congestive heart failure, or atrial fibrillation. The public has been encouraged to “know your numbers.”1 Knowing your blood pressure, lipid values and glucose levels is extremely important, and we should continue to find ways to improve the health of our citizens. We should also continue J. Clay Hays, Jr., MD to encourage people to exercise, avoid all MSMA President tobacco, follow a healthful diet, and to keep 2019–2020 their weight down. Because of our efforts, the rate of heart disease deaths continues to decline.2 That’s good for everybody! Recently, cardiologists have turned their attention toward valvular heart disease and, more specifically, aortic stenosis. In years past, our only options for treatment were surgical aortic valve replacement (SAVR) and basically palliative balloon valvuloplasty. However, over the past few years, a new option of therapy has become available in the form of percutaneous transaortic valve replacement (TAVR). The TAVR procedures initially were used only for patients who were too high-risk for surgery. Published reports3 showed that TAVR was not inferior to SAVR regarding survival and so research was done on low-risk patients. Last year, several trials4 also showed that TAVR was not inferior to SAVR in low-risk patients. Following publication of these important trials, Medicare approved payment for TAVR, and this has opened the flood gates for treatment using TAVR at hospitals all around the country. The importance of rapid diagnosis and treatment of severe aortic stenosis is critical to the well-being of our patients with this disease. The survival rate of untreated severe aortic stenosis is 3% at 5 years. This is worse than many cancers.5 When the public learns of this poor prognosis, I expect they will be asking their physicians a lot of questions on what to do if they are found to have a heart murmur. The American College of Cardiology (ACC) publishes guidelines on various cardiac illnesses every year. The last published valvular heart disease guideline was in 2014.6 I expect the ACC will update these guidelines this year, and the criteria for classifying aortic stenosis as severe will change. The 2014 ACC guidelines classify severe aortic stenosis as an aortic valve area of ≤1.0 cm2 with a mean gradient of 40 mm Hg and/or an echocardiogram peak jet velocity of 4.0 m/s in a patient with a normal left ventricular ejection fraction. If the patient does not have a normal left ventricular ejection fraction, there are ways to reassess the gradient after the use of such agents as dobutamine. Other low-flow, low-gradient aortic stenosis patients represent a smaller population of severe aortic stenosis cases and require additional evaluation. Several recent studies have reported that moderate aortic stenosis patients have the same mortality rates as patients with severe

aortic stenosis. This has made the cardiology world think that we may need to change the criteria for classifying severity. This brings me back to properly identifying patients with severe aortic stenosis. Symptoms worrisome for severe aortic stenosis include, but are not limited to, chest fullness, dyspnea, near syncope, or syncope. When patients don’t express these symptoms and their echo findings suggest severe aortic stenosis, the 2014 ACC guidelines recommend exercise echo stress testing for further evaluation. Often patients will change to a sedentary lifestyle when they start noticing dyspnea and fatigue. When they are questioned about these types of symptoms, they often respond by saying, “I don’t have any of those symptoms, but I don’t do much.” This type of response can mislead the physician, and the patient may suffer an unintended consequence. Physicians should consider a referral to a cardiologist for further evaluation of these types of patients if there is any question or concern. The other question I get from patients when they learn they have aortic stenosis is, ”How big is my valve?” I try to use simple analogies through the use of readily identifiable objects such as coins. A normal aortic valve opening is the size of a silver dollar. Mild aortic stenosis is represented by an opening the size of a quarter, moderate aortic stenosis is an opening the size of a nickel, and severe aortic stenosis is an opening the size of a dime. I tell patients who have critical stenosis, the opening is about the size of a pea. On a recent office visit, I had a patient ask me what kind of pea– an English pea, field pea, or black-eyed pea! Bless him. Treatment of aortic stenosis has definitely changed, and the options of therapy have improved survival with less morbidity. Many centers around the state have developed valve clinics and teams composed of cardiologists, cardiac surgeons, cardiac anesthesiologists, nurse practitioners, nurses, and echocardiographic technicians. Physicians need to continue to be vigilant in properly identifying patients with severe aortic stenosis. These patients depend on you! Q

References 1. American Heart Association. Know your numbers. https://www.goredfor women.org/en/know-your-risk/know-your-numbers. Accessed January 9, 2020. 2. Centers for Disease Control. Heart disease statistics and maps, heart disease facts. https://www.cdc.gov/heartdisease/facts.htm. Accessed January 9, 2020. 3. Leon MB, Smith CR, Mack MJ, et al. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N Engl J Med. 2016;374:16091620. 4. Kolte D, Vlahakes GJ, Palacios IF, et al. Transcatheter versus surgical aortic valve replacement in low-risk patients. J Am Coll Cardiol. 2019;74(12):15321540. 5. Campo J, Tsoris A, Kruse J, et al. Prognosis of severe asymptomatic aortic stenosis with and without surgery. Ann Thoracic Surg. 2019;108(1):79-80. 6. 2014 AHA/ACC. Guideline for the management of patients with valvular heart disease. J Am Coll Cardiol. 2014;63(22):e57-e185. 10.1016/j. jacc.2014.02.536.

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THE INFIRMARY/HOSPITAL AT OLE MISS, 1908 — This postcard image from 1908 (top) features the Ole Miss Infirmary, also called the Hospital, which served as the student infirmary and hospital from 1904 to 1934, after which the new Hospital building (now Guyton Hall) was completed. This one story brick building (on the left) was the first official infirmary on the Oxford campus, later called Brady Hall, and was located next to the Sigma Chi chapter house (right). The correspondent, apparently a nurse or teacher named Mabel, who is residing in the structure, placed markings on the front of this postcard and writes on the back in June, 1908: “We are beginning to get started in the work. Look closely and you will find our rooms marked. Alice’s is the first on the left side of entrance and mine is third.” The Infirmary was built as part of the original plan for the two-year Ole Miss School of Medicine, then called the Department of Medicine, which opened in 1903. (See related Images in JMSMA issues November/December 2019 and February 2020, as well as future Images for more on the Oxford Medical School.) In its 1904 session (the first after the medical school opens), the Mississippi Legislature approved $10,000 for “building…and furnishing for infirmary.” In the 1908 session, $1,500 more was provided for “furnishing hospital.” Besides this additional furnishing, the infirmary would also be enlarged after 1908 with further rooms and a covered front porch (see bottom photo from 1912). This would be the site of the student hospital until the erection of Guyton Hall in the 1930s. If you have an old or even somewhat recent photograph which would be of interest to Mississippi physicians, please send it to me at lukelampton@cableone.net or by snail mail to the Journal. — Lucius M. “Luke” Lampton, MD; JMSMA Editor

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E D I T O R I A L

The Importance of Humanism and Compassion in Medicine AVANI PATEL, M4

To the patient who taught me the meaning of true compassion,

will never forget you. I remember looking through the list of patients, and I saw your name. I thought, What a pretty name; I began to read through your chart and realized the difficulties you’ve gone through. And here you are at our hospital with an exacerbation of congestive heart failure. I was warned by the residents that you would rather not be seen by the team most days as you’d prefer to be alone; however, we needed and wanted to see you every day. I remember walking into your door early in the morning. I woke you up, all bright-eyed with a full smile. I could tell you weren’t very happy to see me, but I was hopeful that one day you’d smile back. When I performed the physical exam, I had never seen or felt severe edema until that day; it started from your feet all the way up to your back. It was heartbreaking knowing you could barely move, and I could only imagine how frustrated you must have felt. But day after day, I remained hopeful. I called you “my sunshine” during every morning and afternoon visit, and I knew one day you would warm up to me. A few days into your hospital stay, you started asking me questions about medical school and started calling me your doctor. You smiled every time I walked into the room, and you became my favorite patient. What a privilege it was to take care of you as your physician-in-training. When you knew I had an exam coming up, you always prayed for me, encouraged me, and told me that my best would always be enough because I was already a great doctor-to-be. About two weeks into your hospital stay, we were beginning to prepare for discharge. Who knew this would be the most difficult discharge I would have to make; however, I was so happy that you would be able to reunite with family in the Carolinas. During your last morning with

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us, I walked into your room, and as soon as I finished performing the physical exam, tears started streaming down my face. You held my hand, and I will never forget your words of encouragement as you began to cry. You said to me, “I truly believe that God puts angels on this earth. When I didn’t want to have anything to do with anyone here, He sent me you. You are an angel on earth, and you will make a difference in many peoples’ lives, as you have mine. Work hard, and do your best on exams. You will make the best doctor, I know. Just promise me you won’t forget me because I will never forget you.” Tears continued to stream down my face uncontrollably. We began rounding as a team, and you were our last stop. My attending and I entered your room for one last check-in before discharge. We were all in tears. You continued to say some of the kindest things anyone has ever said about me. I had to step out of the room to hold my composure because I knew this would be a difficult goodbye. My attending notified me that you didn’t want me to know your time of discharge as you didn’t have the heart to see me in tears. I will never forget you, sunshine. You will always be my favorite patient. Thank you for giving me the best gift I could have asked for—teaching me the true meaning of humanism and compassion in medicine. Avani Patel is an MD candidate at the University of Mississippi School of Medicine and MHA Candidate at Oklahoma State University Graduate College. She grew up in Columbia, Mississippi, and hopes to train and practice medicine in her home state. She enjoys advocating for patients serving in a variety of capacities at both the state and national levels with the MSMA and the AMA. One of Avani’s notable accomplishments is that she has blogged for Merck Manuals for the last four years. She enjoys writing, traveling, photography, and other artistic outlets. Q

F E ; J H O 7 D : C ; : ? 9 ? D ;

Edited by Lucius Lampton, MD; JMSMA Editor

[This month, we print a fun poem by John D. McEachin, MD, FAAP, a Meridian pediatrician and the Journal’s unofficial poet laureate. He penned this witty tribute to his eighty-third birthday experience. Dr. McEachin writes: “Luke, I am blessed with recurring renal stones! We are in Franklin, Tennessee, celebrating Christmas, my birthday, my 55-year-old youngest son’s birthday, New Year’s Day, and my 6th-day post-removal of a ureteral stone. We split time between Meridian and Franklin, so my local Franklin urologist, Matt Hassan, met me early Christmas Eve morning at Williamson County Hospital for surgery. (My last stone removal was also by Dr. Hassan two years ago.) I jotted down a silly, witty, ditty as a memorial to this most recent event!” For more of Dr. McEachin’s wonderful poetry, see past issues of JMSMA. To contact the poet, email him at mceachinmd@bellsouth.net. Any physician is invited to submit poems for publication in the Journal either by email at lukelampton@cableone.net or regular mail to the Journal, attention: Dr. Lampton.] —Ed.

Happy Birthday to Me Happy birthday to me! Today, I’m eighty-three! All the family is here, Which brings cheer and a tear. Matt Hassan brought a toy— Three days early! What joy! He took my “stone” away With scope and laser play! But just before he went, He left behind a stent— Which sure ain’t a real treat, But a stone! It does beat!! —John D. McEachin, MD, Meridian *Dr. Matt Hassan, my urologist, removed a kidney stone, early a.m., Christmas Eve, December 24, 2019.

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Digital Health Tools Gain Momentum Among Physicians

New AMA survey illustrates tech expectations of a growing number of physicians

Adoption of digital health tools has grown significantly among all physicians since 2016 when the american medical association (AMA) first benchmarked the integration of emerging health technology into clinical practice. New AMA research released today shows more physicians than ever recognize digital health tools as an advantage for driving improved efficiency and safety in health care. “The rise of the digital-native physician will have a profound impact on health care and patient outcomes and will place digital health technologies under pressure to perform according to higher expectations,” said AMA board chair Jesse M. Ehrenfeld, MD, MPH. “The AMA survey provides deep insight into the emerging requirements that physicians expect from digital technologies and sets an industry guidepost for understanding what a growing number of physicians require to adopt new technology.” The AMA Digital Health Research investigates shifts in physician adoption of digital health tools during the last three years, along with current attitudes and expectations among physicians. The research examines seven categories of digital health tools that engage patients for clinical purposes, interpret and use clinical data, and manage outcomes and other measures of care quality. According to the AMA survey, adoption trends in the following seven categories are helping to propel the digital transformation of health care. Tele-visits/virtual visits – Physician adoption doubled from 14% in 2016 to 28% in 2019, the largest growth among the digital health tool categories. This category includes audio/video connections used to see patients remotely. Remote monitoring and management for improved care – Physician adoption jumped from 13% in 2016 to 22% in 2019. This

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category includes mobile applications and devices for use by chronic disease patients for daily measurement of vital signs, such as weight, blood pressure, blood glucose, and so on. Readings are visible to patients and transmitted to the physician’s office. Alerts are generated as appropriate for missing or out of range readings. Remote monitoring for efficiency – Physician adoption grew modestly from 12% in 2016 to 16% in 2019. This category includes smart versions of common clinical devices such as thermometers, blood pressure cuffs, and scales that automatically enter readings in the patient medical record. Clinical decision support – Physician adoption climbed from 28% in 2016 to 37% in 2019. This category includes modules used in conjunction with the electronic medical record (EHR), or mobile applications integrated with an EHR, that highlight potentially significant changes in patient data, such as weight gain/loss, change in blood chemistry, and so on. Patient engagement – Physician adoption rose from 26% in 2016 to 32% in 2019. This category includes solutions to promote patient wellness and active participation in their care for chronic diseases, such as adherence to treatment regimens. Point of care/workflow enhancement – Physician adoption modestly increased from 42% in 2016 to 47% in 2019. This category includes communication and sharing of electronic clinical data to consult with specialists, make referrals, and/or transitions of care. Consumer access to clinical data – Physician adoption rose from 53% in 2016 to 58% in 2019, the highest adoption rate among the digital health tool categories. This category includes secure access allowing patients to view clinical information such as routine lab results, to receive appointment reminders and treatment prompts, and to ask for prescription refills, appointments, and to speak with their physician.

While all digital health tools have seen increases in physician adoption since 2016, the biggest growth in adoption was among digital tools in the categories of tele-visits/virtual visits and remote monitoring for improved patient care. Driving this adoption is a significant increase in the importance physicians place in providing remote care to patients. To speed implementation of remote patient monitoring, the AMA’s Digital Health Implementation Playbook packages the key steps, best practices, and resources to help physicians extend care beyond the examination room. Improved efficiency and increased patient safety remain the most important factors driving physician interest in digital health tools, although addressing patient adherence, convenience, and physician burnout have increased in importance as factors driving physician interest. Liability coverage remains the most important requirement for physician adoption of digital health tools, and this requirement has significantly increased in importance during the last three years. Electronic medical record (EHR) integration and data privacy rounded out the three most important physician requirements for digital health tools. There was a notable increase in the importance of peer review validation as a physician requirement for digital health tools.

Immediate Opportunity in Laurel!

For the first time, the AMA research surveyed physicians about their awareness and current usage of emerging technologies, such as augmented intelligence, blockchain, and precision medicine. While levels of awareness greatly exceed adoption rates, more than one-third of physicians intended to adopt emerging technologies within the year. Interest is highest for use with chronic care patients. The AMA is dedicated to shaping a future where digital health tools are evidence based, validated, interoperable, and actionable. Through its ongoing work, the AMA is committed to ensuring physicians play a greater role in leading trustworthy and equitable tech-enabled innovation that enhances patient care, shapes a better health care system, and improves the health of the nation. Through our research, collaborations, advocacy, and leadership, the AMA is working to make the patient–physician relationship more valued than paperwork, preventive care the focus of the future, technology an asset and not a burden, and physician burnout a thing of the past. Learn more on how the AMA is assisting physicians in using advanced technologies by visiting our digital health website. Q

Helping you build a more secure future. We invest our own money alongside yours, so we are invested in your success.

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MEDLEY & BROWN F I N A N C I A L

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MIPS 2019 Data Submission Period Now Open MIPS Eligible Clinicians Can Start Submitting Data for 2019 through March 31

Small, Underserved, and Rural Practice Support

The Centers for Medicare & Medicaid Services (CMS) has opened the data submission period for Merit-Based Incentive Payment System (MIPS) eligible clinicians who participated in the 2019 performance period of the Quality Payment Program. Data can be submitted and updated from 9:00 AM CST on January 2, 2020, until 7:00 PM CST on March 31, 2020.

Clinicians in small practices (including those in rural locations), health professional shortage areas, and medically underserved areas may request technical assistance from organizations that can provide no-cost support. To learn more about this support or to connect with your local technical assistance organization, we encourage you to visit our Small, Underserved, and Rural Practices page on the Quality Payment Program website.

Please note that the data submission period through the CMS Web Interface for ACOs, preregistered groups and virtual groups also opens on January 2, 2020, and closes on March 31, 2020. Quality measures reported via Medicare Part B claims have been submitted throughout the 2019 performance period. Sign in to qpp.cms.gov for your preliminary feedback on Part B claims measure data processed to date. This feedback will be updated at the end of the submission period with claims processed by your Medicare Administrative Contractor within the 60-day run-out period.

For More Information

How to Submit Your 2019 MIPS Data

r To

Clinicians will follow the steps outlined below to submit their data:

r Watch our series of data submission demo videos:

1. Go to the Quality Payment Program website 2. Sign in using your QPP access credentials (see below for directions) 3. Submit your MIPS data for the 2019 performance period or review the data reported on your behalf by a third party. How to Sign in to the Quality Payment Program Data Submission System To sign in and submit data, clinicians will need to register in the HCQIS Authorization Roles and Profile (HARP) system. For clinicians who need help enrolling with HARP, please refer to the QPP Access User Guide. Note: Clinicians who are not sure if they are eligible to participate in the Quality Payment Program can check their final eligibility status using the QPP Participation Status Lookup Tool. Clinicians and groups that are opt-in eligible will need to make an election before they can submit data. (No election is required for those who don’t want to participate in MIPS.)

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learn more about how to submit data, please review the resources available in the QPP Resource Library. o

Introduction and Overview of 2019 Data Submission

File Upload and Quality Scoring

Manual Attestation of Improvement Activities

Manual Attestation of Promoting Interoperability Measures (coming soon)

Questions? Please contact the Quality Payment Program at 1-866-288-8292, Monday through Friday, 7:00 AM–7:00 PM CST or by e-mail at QPP@ cms.hhs.gov. To receive assistance more quickly, consider calling during nonpeak hours—before 9:00 AM and after1:00 PM CST. We also encourage you to contact us earlier in the year, as response times often increase with heavier demand as the March 31 data submission deadline approaches.

r Customers who are hearing impaired can dial 711 to be connected to a TRS Communications Assistant.

Check Your Initial 2020 MIPS Eligibility on the QPP Website You can now use the updated CMS Quality Payment Program Participation Status Lookup Tool to check on your initial 2020 eligibility for the Merit-Based Incentive Payment System (MIPS). Just enter your National Provider Identifier (NPI) to find out whether you need to participate in MIPS during the 2020 performance period.

If you do not exceed all three of the above criteria for the 2020 performance period, you are excluded from MIPS. However, you have the opportunity to opt-in to MIPS and receive a payment adjustment if you meet or exceed one or two, but not all, of the low-volume threshold criteria. Alternatively, you may choose to voluntarily report to MIPS and not receive a payment adjustment if you do not meet any of the low-volume threshold criteria or if you meet some, but not all, of the criteria.

Low Volume Threshold Requirements Find Out Today To be eligible to participate in MIPS in 2020, you must:

r Bill more than $90,000 a year in allowed charges for covered professional services under the Medicare Physician Fee Schedule (PFS), AND

r Furnish covered professional services to more than 200 Medicare Part B beneficiaries, AND

r Provide more the PFS.

than 200 covered professional services under

Find out whether you’re eligible for MIPS today. Prepare now to earn a positive payment adjustment in 2022 for your 2020 performance. Note: The 2020 Eligibility Tool Update for QPs/APMs will be updated at a later time. Additionally, the tool will be updated in late 2020 to indicate final MIPS eligibility. For More Information

r Visit the How MIPS Eligibility is Determined webpage on the Quality Payment Program website.

r View the 2020 QPP Final Rule Overview Fact Sheet. Q

Help and Hope At Heart of Hospice our mission is to serve all hospice eligible patients the way they desire to be served. We work with each patient to develop a plan of care that is unique to their specific situation. Physical therapy, IV therapies, radiation and other comforting treatments approved by the physician may be included in the patient’s plan of care. Our Heart of Hospice team works 24/7 to help eligible patients and families who need our care. For more information please call 1.844.464.0411 or visit heartofhospice.net

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Mississippi WƌŽǀŝƐŝŽŶĂů ZĞƉŽƌƚĂďůĞ ŝƐĞĂƐĞ ^ƚĂƟƐƟĐƐΎ December 2019 ΎDŽŶƚŚůǇ ƐƚĂƚŝƐƚŝĐƐ ĂƌĞ ƉƌŽǀŝƐŝŽŶĂů͘ ŝƐĞĂƐĞ ƚŽƚĂůƐ ŵĂǇ ĐŚĂŶŐĞ ĚĞƉĞŶĚŝŶŐ ŽŶ ĂĚĚŝƚŝŽŶĂů ƌĞƉŽƌƚŝŶŐ ĨƌŽŵ ŚĞĂůƚŚĐĂƌĞ ƉƌŽǀŝĚĞƌƐ ĂŶĚ ƉƵďůŝĐ ŚĞĂůƚŚ ŝŶǀĞƐƚŝŐĂƚŝŽŶ͘ dŚĞƐĞ ŶƵŵďĞƌƐ ĚŽ ŶŽƚ ƌĞĨůĞĐƚ ƚŚĞ ĨŝŶĂů ĐĂƐĞ ĐŽƵŶƚƐ͘

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Public Health District

State Totals*

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VII

VIII

Dec 2019

Dec 2018

YTD 2019

YTD 2018

Primary & Secondary Syphilis

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Early Latent Syphilis

ϭϬ

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925

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ϭϴϲ Ϯϰϯ 1,770 ϭ͕ϱϳϴ Ϯϱ͕Ϯϴϳ ϮϮ͕Ϭϴϲ

Gonorrhea Chlamydia HIV Disease

ϯϯ

ϰϴϭ

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Pulmonary Tuberculosis (TB)

ϭϭ

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Extrapulmonary TB

ϭϬ

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Mycobacteria Other Than TB

ϯϯ

ϯϯϰ

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Diphtheria

Pertussis

ϱϰ

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Tetanus

Poliomyelitis

Measles

Mumps

ϰϲ

ϭϬ

Hepatitis B (acute)

ϰϵ

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Invasive ,͘ ŝŶĨůƵĞŶǌĂĞ disease

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Invasive Meningococcal disease

Hepatitis A (acute)

ϭϮ

ϭϯϮ

ϭϯ

Salmonellosis

ϰϭ

Shigellosis

Ϯϯ

ϭϴϬ

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Campylobacteriosis

ϰϱ

ϱϵϵ

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͘ ĐŽůŝ O157:H7/STEC/HUS

ϵϯ

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Animal Rabies (bats)

Lyme disease

Rocky Mountain spotted fever

ϭϭϱ

ϭϱϱ

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Alliance Hosts 14th Annual CSI On January 15, Mississippi Health Awareness Day, the MSMA Alliance held its 14th Annual Capitol Screening Initiative, or CSI-14, for legislators. The event included vision screening for glaucoma and diabetic retinopathy and testing for blood glucose/cholesterol, body composition, grip strength, bone density, carbon monoxide, and stress management counseling with popular stress dots. Other health screenings included abdominal aortic aneurysm, peripheral vascular, atrial fibrillation, and carotid intima-media thickness test to diagnose the extent of carotid atherosclerotic vascular disease.

MSMA Alliance members: (top row) Lauren Reed, Teresa Floyd, Angela Ladner; (middle) Karen Morris, Rebecca Martin, Heather Rifkin; (front) Shannon Warnock, Danita Horne, Nancy Smith, and Mary Elizabeth Monaghan.

University of Mississippi Medical Center (UMMC) resident physician Dr. Jonathan Glaze provides a glaucoma screening for Missy McNeese, Senate Appropriations Committee assistant.

Mississippi Rural Physicians Scholarship Program (MRPSP) medical scholars participated in the Capitol Initiative Screening sponsored by the MSMA Alliance in the rotunda of the Capitol on January 15, 2020.

Kayla Seranthus, with MEA, checks Sturgis Senator Gary Jackson’s blood pressure.

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Garland Baugh of the Diabetes Care Group (Vigilant Health) checks House Representative Tracy Arnold’s blood glucose.

Dr. William Watkins of UMMC Ophthalmology teaches medical students while examining Senator Hillman Frazier.

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Exhibitors for MEA Primary Care Plus Clinics (front) with the MSMA Alliance members (rear).

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The price for membership will not change whether you wish to receive the print version or not.

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Medical Scribe Program Strives to Deliver the “Write” Fit GARY PETTUS, UMMC PUBLIC AFFAIRS

An up-and-coming education program in the School of HealthRelated Professions (SHRP) is grounded partly on the notion that a key cause of physician burnout is a computer keyboard—an essential tool in the era of electronic health records. This is a serious proposition considering that family physicians and other specialists often link dissatisfaction and stress with the demands of digital documentation which have meant less time for meaningful contact with patients at work and with loved ones at home.

“God bless Matt,” said Glover, professor of medicine and director of the Division of Digestive Diseases at UMMC. She has also worked scribeless, she said. “Yes, it was horrible. I hated it. I was always behind on my charting,” she said.

SHRP’s new Medical Scribe Specialist Program is designed to, among other things, supply physicians with experts explicitly trained to relieve those documentation burdens and recover that lost time, said Dr. Cynthia Casey, associate professor of health sciences and chair of the Health Sciences Program.

Her arithmetic was part of a study she presented at the University of Florida in Gainesville, where she started a pilot medical scribe program before arriving at UMMC a year ago.

“Physicians are seeing more and more patients; documentation is so important now. Having a scribe helps with billing and coding issues and frees up the physician to be more one-on-one with patients. It increases patient satisfaction and physician satisfaction. Having a scribe is another layer to ensure more accurate coding. When coding is not done correctly, hospitals lose revenue,” Dr. Casey said. Accepting only students with bachelor’s degrees makes SHRP’s program a first-of-its-kind in the arena of formal medical scribe training, which isn’t offered anywhere else in the state, Dr. Casey said. Right now, there are few education requirements, beyond a high school diploma, for applicants to such programs as ScribeAmerica, a company that “prefers” a college degree and computer and typing skills. “Having a post-baccalaureate degree increases the quality of the scribes who will be working out there,” said Britney Reulet, director of the Health Sciences Program and part of the program’s trio of instructors that also includes Dr. Casey and Dr. Pamela Jones, assistant professor of health sciences at SHRP. Working right now for Dr. Sarah Glover is her current scribe, Matt McCoy, who earned a microbiology degree at Mississippi State University.

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Dr. Glover hated it enough to figure out the average number of “clicks” she made on her computer keyboard to document one gastrointestinal patient visit: “Four hundred.”

Dr. Glover’s report, which introduced the program at UF, swarmed with such tantalizing findings as these: with a scribe, clinic appointment length dropped by 13.5 minutes; between the first quarters of fiscal years 2015 and 2016, total charges billed rose by $71,439; the extra revenue for the first quarter was 536 percent higher than the salary of the scribe. “Documentation stress decreased,” she wrote. “The use of scribes improved the physician-patient relationship, clinical efficiency, physician productivity, bone density screening, and vaccinations for flu and pneumonia,” the report concluded. When Dr. Glover was hired at UMMC, she had a provision for a scribe written into her contract. “Scribes catch a lot of things I might miss,” Dr. Glover said. “They improve the quality of care.” Enter Matt McCoy. “Matt is technologically savvy,” Dr. Glover said. “He made changes to templates and streamlined forms, all of which helped improve patient flow in our clinic.” McCoy is apparently only one of two Medical Center employees with “scribe” officially attached to their titles, as in “Epic Scribe,” a reference to the electronic health record system in place at UMMC since 2012. Employed by Dr. Glover, McCoy works in the clinic and lab with the physician, documenting on his laptop her spoken observations during gastrointestinal procedures, or a patient’s history, symptoms, etc. in

“The electronic health record has benefits,” Dr. Brodell said, “but it also makes you 30 percent less efficient.” Faculty members spend an average of 60 to 90 minutes daily on EHR after work, Dr. Brodell said. For evidence, he cites an article for which he is listed as a co-author, and its conclusion: adding assistants to perform a scribe’s tasks allows physicians to “see more patients and generate more income.”1 In fact, there are other scribes at the Medical Center, although you probably shouldn’t call them that. Often, their “real” jobs are nurses or nurse practitioners or, in many cases, students in medical school or on the way there. Turner, for one, will begin pursuing her medical degree at UMMC this coming fall; her job as a scribe has enabled her to shadow a physician.

Scribe Emily Turner, left, works on a patient’s chart alongside MSMA member Dr. Pegah Hosseini-Carroll.

the examination room. Later, he types up an after-visit summary and a patient plan of action, which uploads to MyChart. “I can book more cases because I have more downtime,” Dr. Glover said. “It almost doubles my productivity.” Emily E. Turner, the other medical scribe at UMMC, works for Dr. Pegah Hosseini-Carroll, assistant professor of medicine in the Division of Digestive Diseases. “Having a scribe beside me allows me to focus more on the patient; I can make more eye contact,” said Dr. Carroll. She reviewed patient-visit notes with Turner, an MSU graduate with an accounting degree. “Emily saves me a lot of time. I’m faster when she is with me.” Still, Dr. Carroll is not 100 percent scribed-up because Turner splits her time among various doctors. This may explain why Dr. Carroll spent 10 hours over the Thanksgiving holiday catching up on her charting work at home. “I was on Epic the other night until 11,” she said.

The person who trained Turner, Matt McCoy, trained himself on the job. He has applied for a physician assistant program he hopes to enter by early summer. As a scribe, he is able to meet that program’s admissions requirement for clinical hours accrued. In other words, for McCoy and Turner, their current occupation allows them to literally write their own tickets as they journey toward other careers. As a physician, Dr. Brodell has dealt with this dynamic of transience. Last year, he hired a prospective UMMC medical student as a scribe, who was then accepted to a different school and left. “That tells me that this is not the correct way to use medical scribes in a clinic,” Dr. Brodell said. A better way, instructor Reulet and others say, is to put in place an education program that encourages its students to embark on medical scribe careers. SHRP’s course, which offers classes online, had five applicants by year’s end, and Dr. Casey hopes to double that. “In our program, students can do their clinical work at Merit Health hospitals, Baptist Medical Center and at any site where UMMC has a clinical affiliation,” Reulet said. “We hope that will be an advantage.

Typing fatigue has certainly taken hold among dermatologists, said Dr. Robert Brodell, chair of dermatology at UMMC. “Until about five years ago, dermatology had the happiest doctors in America,” said Dr. Brodell. “But in a recent survey, we’re now in the middle of the pack. There’s only one logical reason—EHR, he said. Robert Brodell, MD

When the survey asked physicians how they have improved their work life, one replied: “Say(ing) no to unreasonable requests to function as a data-entry clerk.”

As a medical scribe, Matt McCoy, left, has helped “improve the quality of [patient] care,” said Dr. Sarah Glover, right.

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â&#x20AC;&#x153;This gives those sites students that can be molded there and then hired when they graduate.â&#x20AC;? As Dr. Glover put it, â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s a return on your investment to have a scribe. Do you really want to pay a physician, say, $100 an hour to do charting?â&#x20AC;?

It is only the Medical Centerâ&#x20AC;&#x2122;s second project developed from a workforce need. The first, also a SHRP objective that blossomed at Baileyâ&#x20AC;&#x2122;s behest, was a histotechnology program, which graduated its first trainee in 2018.

Pay for a medical scribe, nationwide, averages $12.33 an hour. Dr. Casey hopes that the new crop of specially trained scribes, with the promise of greater health records accuracy, will merit $16 to $17 an hour, she said. Which begs the question: With higher pay, will scribes still be desirable as an investment returner?

â&#x20AC;&#x153;This is how we anticipate other positions will be created in the future,â&#x20AC;? Dr. Didlake said. The medical scribes training program allows a certain segment of the workforce to advance themselves into a meaningful role in the clinic. â&#x20AC;&#x153;It can provide a career ladder for much of our workforce.â&#x20AC;?

That is one of the questions not answered yet, said Dr. Ralph Didlake, associate chancellor for academic affairs and chief academic officer. Another unanswered question: Is there a shortage of people available to do the work of a scribe?

In the meantime, Dr. Glover is â&#x20AC;&#x153;trollingâ&#x20AC;? for a potential replacement for McCoy. She knows of a drug representativeâ&#x20AC;&#x2122;s daughter who may fill the opening, word of which spread rapidly. â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s a network,â&#x20AC;? Dr. Glover said. â&#x20AC;&#x153;Scribes beget scribes.â&#x20AC;? And so it was written. Q

What is known: â&#x20AC;&#x153;The need for this function is out there,â&#x20AC;? Dr. Didlake said. Apparently, that means everywhere: The American College of Medical Scribe Specialists estimates 20,000 scribes were at work by the end of 2014, a number it expects to balloon to 100,000 by 2020. At UMMC, it was Dr. Jessica Bailey, the dean of SHRP, who helped Didlake appreciate the need for a Dr. Ralph Didlake formal training course. â&#x20AC;&#x153;She was the primary driver of the idea to start a medical scribe program,â&#x20AC;? he said, â&#x20AC;&#x153;and made a very strong case for it.â&#x20AC;? Dr. Didlake became a â&#x20AC;&#x153;strong supporter,â&#x20AC;? then remained one after he realized how the course touches all three Medical Center missions, not just education. The health care mission is satisfied because graduates will be able to go to work immediately, including at the Medical Center. Regarding research: â&#x20AC;&#x153;The program provides opportunities for us to test how these graduates function in a real clinical environment,â&#x20AC;? Dr. Didlake said. Those findings will be part of a pilot study, which Dr. Casey believes will take a couple of years as it measures productivity, patient and doctor satisfaction, and more. It should also answer those hanging questions about scribe shortages and investment returns, said Dr. Didlake. And for anyone wondering if an official definition for â&#x20AC;&#x153;medical scribeâ&#x20AC;? is forthcoming, the answer to that is â&#x20AC;&#x153;yesâ&#x20AC;&#x201D;once the clinical world expresses an interest in it,â&#x20AC;? Dr. Didlake said. â&#x20AC;&#x153;We have a high confidence it will.â&#x20AC;? There is confidence also that the creation of the Medical Scribe Specialist Program represents a new blueprint for breeding other education courses, Dr. Didlake said.

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Reference 1. Kindley KJ, Jackson JD, Sisson WT, et al. Improving Dermatology Clinical Efficiency in Academic Medical Centers. Int J Health Sci (Qassim). 2015;9(3): 351-354.

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We Simply Must Start Growing Our Own: No, It Isn’t What You’re Thinking GROUNDHOG DAY, February 2, 2020 – Tomorrow is Groundhog Day, and the old legend says that if this critter sees his shadow, he will get frightened and crawl back into his burrow for 6 more weeks of winter weather. Thoughts of Groundhog Day reminded me of the 1993 fantasy movie of the same name. The protagonist, comedian Bill Murray, is a TV newsman covering Punxsutawney Phil’s annual February 2 appearance on Gobbler’s Knob. The reporter becomes caught in a time loop, waking up each morning to find himself forced to relive that same day, endlessly. The film is ultimately an allegory of redemption as Murray could not escape his trapped existence and find happiness until he began placing the needs of others over his own selfish desires. There are times in primary care medical practice when these gloomy winter workdays can give us this groundhog sense of never being able to truly and satisfactorily accomplish the day’s mission, and we must return to the clinic the following morning to go through the motions again. As the scope of practice of Family Medicine has become whittled down by several forces beyond our control, it is easy to feel ensnared in a never-ending loop of recycled and unsolvable problems. Days seem to be spent gently but repeatedly scolding noncompliant hypertensives into taking their medicine correctly… days of failing to convince folks with a common cold that they don’t need antibiotics… and days of working the flesh-and-blood Sudoku puzzle of safely balancing the 12 meds of the chronically ill diabetic/ renal failure/atrial fibrillation patient while simultaneously finding ways to help them pay for it all. Oh, and I neglected to mention enduring our constant dread of threats and punishment from the duly appointed wardens of medical practice whenever we contemplate prescribing pain medication for our patients. (Very often it is the only thing that can be safely done to make a pain-racked arthritic’s life a bit more bearable, but I digress.) To this mix, add the time-consuming translation of patient care into the dreaded electronic medical record gobbledygook that now suffices for a chart. The obstacles often seem to be insurmountable. Some days I lament to my patients that medical practice has become a lot like housework. We do it today, and then we have to do it all over again tomorrow, from sun to sun, and never quite done! While we certainly hope we are not yet “burned out” from our life’s calling, there are some days the long-simmering crock-pot seems to be over-heating. What then is the best remedy for the healer who needs some healing? Sometimes, it can be as simple as “seeing your shadow.”

Me and My Shadow Just a few weeks back, I had the opportunity to spend time with a Tippah County boy as “my shadow,” a fine young man whom I have known all his life and who has long expressed a desire to become a physician in his home community. Cole Chapman is a fellow to watch for the future of healthcare in our local area. He is a self-starter who did not wait for a college career advisor to tell him that he needed to shadow mentors in practice to see if Medicine was the thing to which he would want to commit as his life’s calling.

Cole Chapman

Cole is in his third year at Freed-Hardeman University in Henderson, Tennessee. He is a double major in Biological Sciences and Religion and is making excellent grades. Over the years, I have mentored several students at his scholastic level, and I must say that it is extremely rare today to see them arrive as prepared and focused as this 20-year-old. He called me one day while on his winter break and got the okay to come and observe what we do. I didn’t give him any specific instructions other than to show up at the clinic first thing the next week. I was certainly impressed by several things about Cole. Without having to be told, he arrived that first morning all geared up looking as though he belonged in our clinic. He wore neat scrubs and had donned a photo name tag. In his pocket was a small notebook for writing down things he wanted to read about later. He had a cell phone that he did not fool around with unless I asked him to look something up for us. (There was none of that endless and apparently obsessive texting and Tweeting behavior that I see so many young folks exhibiting these days.) He met patients easily, and we would always ask if it was okay for him to be in the room for the exam. Because he so naturally projected an air of trustworthiness, no patient refused. His roots in Tippah County run deep and wide, thus almost every patient we encountered knew of his family. Many knew his dad, Rodney, who is a local carpenter by trade and with whom Cole has worked during his summers and vacations. Many older men we saw together remembered running hunting dogs with his great-grandpa,

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“Mig” Chapman, who served as a Tippah County District Supervisor for many years. A few men recalled a day long before Cole was born when his paternal grandfather C.H. Chapman was accidentally killed while dynamiting beaver dams on Hatchie River. C.H.’s wife (and Cole’s granny) Brenda was my own clinic nurse and constant companion from the time I began practicing until her retirement a couple of years back. Cole’s mother, Dana, and maternal grandmother Sandra Graves are both registered nurses. Dana teaches nursing at our local vocationaltechnical school. His uncle Dr. Patrick Chapman is our Tippah County Hospital Administrator. One of his cousins is Ripley’s steadfast family physician, Dr. Troy Cappleman. But enough of this name dropping, my point about his local connections is well-made. Cole’s eyes seemed to light up when a patient would exhibit some interesting or unusual symptoms or quietly said something intriguing. Even in what otherwise would be potentially embarrassing situations for a novice, he kept his equanimous cool. You can always gauge a fellow’s real understanding of a situation by the questions he asks after a visit ends. In Cole’s discussions, you could hear compassion and common sense, two precious qualities for a physician. At the end of each day, he would thank me very sincerely for allowing him to be there and remark that he could not believe how much he learned that day. And as seems the norm, I felt as if I had received far more benefit from Cole than I gave. On the last day, he recalled several of our more interesting cases and requested that I let him know how things turned out for the patient. “Did the suspicious lesion on the chest x-ray prove to be lung cancer? Did the severely depressed patient respond to the medicine we chose for her? Did our chest pain patient with an abnormal EKG require a bypass?” In those parting questions, I heard not just his youthful curiosity but real caring and concern for the individuals he had been privileged to meet. Also on that last day, he started inquiring about when he might return to shadow some more. We settled on Good Friday as the next rendezvous point. I am thrilled to see someone with his natural abilities and work ethic making the right steps toward becoming a hometown physician. I am strongly encouraging him to apply for the Mississippi Rural Physicians Scholarship. To watch a young student thrive–to laugh, to learn, and to love what he is experiencing under my direction and watchful eye–allows me to come once again to work with confidence and pleasure. Mentoring and teaching students never fails to revive my love for the spirit of medical practice. This recent experience was no exception. I fully intend to do everything in my power to help this talented young man, Cole Chapman, to achieve his dream.

to practice medicine. The academic enrichment, physician mentoring, and solid medical school financial support through the MRPSP will enable more talented young Mississippians to meet the challenge of what has truly become a healthcare crisis in our state. Since its inception, the state legislature has allocated $12.6 million in scholarships. As of 2020, the program will have helped place approximately 60 practicing primary care physicians in rural Mississippi towns. In addition to providing much-needed healthcare for our citizens, the addition of one physician to a community contributes a total annual average of $2 million in additional economic output and an addition of 21 jobs. Each MRPSP scholar will become eligible to receive $30,000 per year for medical training. After med school, the MRPSP endowed student must enter residency training in one of the five primary care specialties: Family Medicine, General Internal Medicine, Internal Medicine-Pediatrics (Med-Peds), Obstetrics/Gynecology, or General Pediatrics. In return, they will then practice their chosen profession in the Magnolia State. Our own Tippah County Hospital should soon be unveiling exciting plans for the construction of a brand-new facility. This is an astounding feat for us in today’s healthcare environment, which favors the construction of massive urban medical centers. Some have questioned why we are building this new hospital when there are so few local physicians available to staff it. Honestly, this is a valid question. New construction for rural hospitals in Mississippi has been virtually nonexistent in recent years. There are far fewer primary care doctors practicing in Tippah and Benton counties today than there were a hundred years ago, and those of us still standing are not spring chickens. If you think about it, every physician currently practicing in our county was reared here, came back here to practice, and stayed here. If we seize these fantastic opportunities to identify qualified students and then help them succeed and take root at home, the future of medical care in our community can and will flourish again. We have, over recent years, very regrettably missed several opportunities to recruit and retain our local medical graduates back home to practice. Bringing in physicians with no ties to this community, paying back their student loans, paying them a nice guaranteed salary for a few years, and then expecting them to stay here permanently when they finally must make their own way is not a strategy that has ever worked out for Tippah County Hospital. This obviously has to change and change very soon. For the future of Tippah and Benton Counties, we simply must begin once again to “Grow Our Own.” Q

Growing Our Own The Mississippi Rural Physicians Scholarship Program (MRPSP) was authorized by the Mississippi Legislature in 2007 to identify rural college students who aspire to return to their hometown roots

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Dwalia S. South, MD Member, Mississippi State Board of Health Past-President, Mississippi Academy of Family Physicians Past-President, Mississippi State Medical Association

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