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Lucius M. Lampton, MD Editor D. Stanley Hartness, MD Michael O’Dell, MD AssociAtE Editors Karen A. Evers MAnAging Editor PublicAtions coMMittEE Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD, Ex-Officio Myron W. Lockey, MD, Ex-Officio and the Editors thE AssociAtion Randy Easterling, MD President Tim J. Alford, MD President-Elect J. Clay Hays, Jr., MD Secretary-Treasurer Lee Giffin, MD Speaker Geri Lee Weiland, MD Vice Speaker Charmain Kanosky Executive Director JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. CORRESPONDENCE: JOURNAL MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: (601) 853-6733, Fax: (601)853-6746, www.MSMAonline.com. SUBSCRIPTION RATE: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available. ADVERTISING RATES: furnished on request. Cristen Hemmins, Hemmins Hall, Inc. Advertising, P.O. Box 1112, Oxford, Mississippi 38655, Ph: (662) 236-1700, Fax: (662) 236-7011, email: cristenh@watervalley.net POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 391582548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association. Copyright© 2010, Mississippi State Medical Association.

MAY 2010

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Scientific ArticleS Blunt renal trauma and the Predictors of failure of non-operative Management

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Jon D. Simmons, MD; A. Neal Haraway, MD; Robert E. Schmieg, Jr., MD and Juan D. Duchesne, MD

clinical Problem-Solving: i See Dead People

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Janet M. Nielsen, MD

PreSiDent’S PAge Be Part of the Solution

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Randy Easterling, MD; MSMA President

eDitoriAl “Draumatized”

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Michael O’Dell, MD; Associate Editor

relAteD orgAnizAtionS Mississippi State Department of Health information and Quality Healthcare

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DePArtMentS Poetry in Medicine Physicians’ Bookshelf images in Mississippi Medicine the Uncommon thread Una Voce Placement/classified

145 146 148 149 151 152

ABoUt tHe coVer: “DUnleitH HiStoric inn” - Martin M. Pomphrey, Jr., MD, a semi-retired orthopaedic surgeon sub-specializing in sports medicine who practiced with Oktibbeha County Hospital (OCH) Bone and Joint Clinic, photographed this magnificent Greek Revival mansion located in the heart of Natchez. Known for its stately white colonnade that surrounds the exterior of the Southern VOL. LI

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home, Dunleith offers guests an escape from everyday life with luxurious accommodations, first rate amenities, and award-winning cuisine. An indelible

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icon, the white columns and rockers from Dunleith’s front porch call out, inviting one to take a journey back to a simpler time and place– a time without hectic schedules, deadlines and expectations. The Inn, located at 84 Homochitto Street, sits on 40 acres and features 26 rooms. Members and invited guests attending the 142nd MSMA Annual Session House of Delegates & Medical Affairs Forum can Official Publication of the MSMA Since 1959

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experience Dunleith at a welcome reception hosted by MSMA and the University of Mississippi Medical Center Medical Alumni Chapter on the grounds of this magnificent site. r

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• SCiENTiFiC aRTiCLES •

Blunt Renal Trauma and the Predictors of Failure of Non-operative Management Jon D. Simmons, MD; A. Neal Haraway, MD; Robert E. Schmieg, Jr., MD and Juan D. Duchesne, MD

A

BStrAct

Objectives: While non-operative management of renal trauma in selected patients is now an accepted management option, predictors of failure of this treatment strategy are still unclear. Methods: Fiveyear retrospective study of all patients with blunt renal injuries managed non-operatively at a Level I Trauma Center. Abstracted data included patient demographics, initial vital signs, base deficit, associated injuries, use of blood transfusion, management, and outcomes. Patients with successful non-operative management (S-NOM) and failure of non-operative management (F-NOM) were compared with twotailed Student’s t test, Fisher’s exact test, or chi-square analysis as appropriate. Results: Over five years, 271 patients out of 12,252 trauma cases (2.2%) had blunt renal injury; 239 (88%) were initially managed non-operatively, and ten (4.1%) of these patients later requiring operation or intervention. No differences in age, sex, initial vitals, or GCS were found between S-NOM and F-NOM. The F-NOM patients were more seriously injured than the S-NOM patients (ISS 31 vs. 21, p<0.001); had worse acidosis (ABG base deficit of -9.1 vs. -4.5, p<0.001); required more blood products (12 units PRBC vs. 2.6 units PRBC, p<0.001); and had significantly longer hospital lengths of stay (37 days vs. 12 days, p<0.001). Angiography was used more frequently in the F-NOM patients (40% vs 8.7%, p<0.02). In the F-NOM only 3 (30%) required direct kidney intervention: 1 nephrectomy, 1 open urinoma drainage and 1 open nephrostomy tube placement. All of these patients had grade V renal injuries. The rest of the F-NOM patients had operative interventions not directly related to their renal injuries: 1 splenectomy and 6 missed bowel injuries. Conclusion: Non-operative management of blunt renal injuries is successful in most cases. Patients with a high base deficit, ongoing transfusion requirements, and

AUtHor inforMAtion: Drs. Simmons, Schmieg, Jr. and Duchesne are in the Department of Surgery, Division of Trauma and Surgical Critical Care at the University of mississippi medical Center in Jackson, mS. Dr. Haraway is in the Department of General Surgery, Division of Urology at the University of mississippi medical Center in Jackson, mS. correSPonDing AUtHor: Jon D. Simmons, mD, Division of Trauma & Surgical Critical Care, University of mississippi medical Center, 2500 N State Street, Jackson, mS 39216, Phone: 601-984-5120, Fax: 601-815-1132, E-mail: jdsimmons@surgery.umsmed.edu

greater Injury Severity Scores have a higher likelihood of requiring operation, but these procedures most often are to address non-renal abdominal injuries. High-grade blunt renal injuries that are hemodynamically stable can be treated expectantly on an individual basis with close follow-up. Any patient with hemodynamic instability, renal pedicle injury, renal artery thrombosis, or urinary extravasation will likely require operative intervention.

KeY WorDS:

KIdNey LACeRATION; BLuNT ReNAL TRAuMA; NONOPeRATIVe MANAGeMeNT

introDUction While non-operative management in selected patients with renal trauma is now an accepted management option, predictors of failure of this treatment strategy are still unclear. The objectives of non-operative management include decreasing the nephrectomy rate while also decreasing mortality and morbidity. The current consensus is to manage all low grade (I-III) renal injuries non-operatively. Management of high grade (IV-V) injuries is still on an individual basis. emergent operative intervention has generally been reserved for renal associated hemodynamic instability or ureteral injury. We report a five-year experience in non-operative management of blunt renal trauma at a rural level 1 trauma center.

MAteriAlS AnD MetHoDS All patients 18 years of age or older presenting to the university of Mississippi Medical Center, an academic Level 1 Trauma Center, with blunt renal injuries during a five-year period from January of 2000 through december of 2005 were identified through the trauma registry. Patients who underwent initial operative management or who died in less than 24 hours were excluded. data abstracted from chart review and the institutional trauma registry for the patients undergoing initial non-operative management included demographic information, presenting vital signs, base deficit, Glasgow coma scale, blood transfusions received throughout the entire hospitalization, associated injuries, Injury Severity Score, management, complications, and outcome data. may

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Identified complications included sepsis, adult respiratory distress syndrome, multi-organ failure, renal failure (creatinine > 2), and active extravasation or hemoperitoneum found on a follow-up computed tomography scan. Renal injury was evaluated by computed tomography scan with delayed images. Injury grade was assigned by trauma surgeon review in accordance with the American Association for Surgery of Trauma kidney Anatomic Injury Score grading system.1 Nonoperative management was classified as a success or failure based upon need for later operation or intervention. Patients with successful nonoperative management (S-NOM) and failure of non-operative management (F-NOM) were compared with two-tailed Student’s t test, Fisher’s exact test, or chi-square analysis as appropriate. This study was approved by the university of Mississippi Institutional Review Board.

reSUltS In a five-year period at this academic level 1 trauma center, 271 patients out of 12,252 trauma cases (2.2%) had blunt renal injury. Initial non-operative management was chosen for 239 patients (88%). Ten (4.1%) of these patients required later operation or intervention. No differences in age, sex, initial vitals, or GCS were found between successful and failed non-operative management patients. tABle 1: STaTiSTiCaL SiGNiFiCaNCE bETwEEN S-NOm aND F-NOm Hospital LOS 12 days 37 days <0.001 PRBCs 2.6 12 <0.001 Base Deficit -4.5 -9.1 <0.001 ISS 21 31 <0.001 S-NOM F-NOM P-Value

ISS Base Deficit PRBCs Hospital LOS

S-NOM 21 -4.5 2.6

F-NOM 31 -9.1 12

12 days

P-Value <0.001 <0.001 <0.001

37 days

<0.001

Patients failing non-operative management (table 1) were more seriously injured (Injury Severity Score: 31 versus 21, p<0.001); had worse acidosis (initial arterial blood gas base deficit of -9.1 versus 4.5, p<0.001); required more blood product transfusion (12 units versus 2.6 units of packed red blood cells transfused, p<0.001); and had significantly longer hospital lengths of stay (37 days versus 12 days, p<0.001). Angiography was used more frequently in patients failing non-operative management (40% versus 8.7%, p<0.02). In the 10 patients requiring later intervention (table 2), only 3 (30%) required direct kidney intervention: 1 nephrectomy, 1 open urinoma drainage and 1 open nephrostomy tube placement; all of these patients had grade V renal injuries. The other 7 patients underwent operative interventions not directly related to their renal injuries: 1 splenectomy and 6 missed bowel injuries. tABle 2: RESULTS by RENaL aaST ORGaN iNJURy SCORES *Urinoma Drainage 0 *Neprectomy 0 F-NOM* S-NOM GRADE

0 0 0 2 0 0 0 1 (50%) 0(0%) 5(3%) 1(2%) 1(8%) 3 (100%) (97%) (98%) (92%) (50%) 14 152 59 11 3 I I I I IV V

GRADE S-NOM

I 14 (100%) F-NOM* 0 (0%) *Neprectomy 0 *Urinoma Drainage 0

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II 152 (97%) 5 (3%) 0 0

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IV 11 (92%) 1 (8%) 0 0

V 3 (50%) 3 (50%) 1 2

DiScUSSion Management of blunt renal trauma has evolved over the past five decades with popularization of non-operative management strategies initially in pediatric patients followed by the adult patient population. Selection of initial non-operative management for low-grade (grades IIII) renal trauma is now commonly accepted. Indications for surgical intervention have been narrowed to hemodynamic instability, pedicle avulsion, expanding retroperitoneal hematoma, renal artery thrombosis, and extravasation.2 Controversy remains over the role of non-operative management of high-grade (grades IV and V) renal injuries. Several series have demonstrated increased renal preservation after high grade injury blunt renal injury with initial non-operative management strategies.2-6 Proponents of early surgical intervention for higher-grade renal injury have advocated that debridement of devitalized segments and restoration of the collecting system maximize renal function and decrease complications, including the need for delayed nephrectomy.3 The late complications of post-traumatic renovascular hypertension and renal insufficiency after renal injury are often mentioned in concerns about non-operative management but are fortunately quite rare.23-24 In one small series, patients with high-grade renal injuries with devitalized segments did not develop renovascular hypertension.23 Recent literature has suggested that early surgical intervention may lead to increased unnecessary nephrectomies and complications.2 Santucci and Fisher’s2 review of renal trauma found widely varying management for grade II to IV injuries, with a consensus for expectant management in renal parenchymal injuries.7-20 They also suggested that higher operative rates conferred higher rates of iatrogenic nephrectomy. In comparing the management of blunt renal trauma between two large academic trauma centers, an operative rate of 63% was associated with an 11% nephrectomy rate in one center, while another center’s operative rate of 16% was associated with a 0% nephrectomy rate.21-22 These data support the stance that selection of initial non-operative treatment of blunt renal injuries can result in significantly fewer iatrogenic nephrectomies. Wright and colleagues examined renal and extra-renal predictors of nephrectomy in blunt trauma patients using the National Trauma data Bank.4 They found the strongest predictor of nephrectomy and operative intervention was severity of the renal injury. In their series, operations on other intra-abdominal organs imparted a higher risk of nephrectomy regardless of renal injury grade. Conclusions in the subset of patients with grade V blunt renal injuries have been hindered by the relative scarcity of such injuries in the series published to date. One study including six patients with grade V parenchymal injuries25 identified that non-operative management of grade V parenchymal injuries resulted in fewer intensive care days, fewer blood transfusions, and a lower mortality. These results were further supported in another small study.26 In our study reported here, predictors of failure for non-operative management were evaluated, including a subset of patients with high grade injuries. In twelve patients with grade IV injuries, none required a renal intervention. In six patients with grade V injuries, only one required later nephrectomy. Patients with failure of non-operative man-

agement had significantly worse Injury Severity Scores, worse base deficit, and increased number of packed red blood cells transfused compared to patients with successful non-operative management. Grade of renal injury was not predictive of failure of non-operative management in our study. Patients requiring eventual operative intervention in our study most commonly underwent operation for non-renal intra-abdominal injuries. Our results are in agreement with those of Ramsay6 and colleagues who found that blunt renal trauma patients requiring nephrectomy often present with high grades of renal injury, higher transfusion requirements and a higher Injury Severity Score. The length of hospital stay and outcome for these patients are usually related to the associated injuries rather than the injury of the kidney itself. Many of the past reported series have collected all renal injuries over ten to twenty-five years or more. evolving changes in diagnostic and treatment techniques over these prolonged time periods include increased availability of diagnostic angiography, angiographic embolization, and improvements in computed tomography scanning. Application of these past studies to current patients must take into account these advances. In this study, there were no significant institutional changes in the availability of these diagnostic and treatment modalities over the study period. As a potential limitation in this study, this retrospective review is based upon a recent five-year experience at an academic level 1 trauma center with a large rural catchment area. Logistical delays in transport were not examined but could potentially affect outcomes in that patients with injuries that might have been chosen for initial nonoperative management who failed to stabilize during transportation were selected out of our study population.

conclUSionS Non-operative management of blunt renal injuries is successful in most cases. Patients with a high base deficit, ongoing transfusion requirements, and greater Injury Severity Scores have a higher likelihood of requiring operation, but these procedures most often are to address non-renal abdominal injuries. High-grade blunt renal injuries that are hemodynamically stable can be treated expectantly on an individual basis with close follow-up. Any patient with hemodynamic instability, renal pedicle injury, renal artery thrombosis, or urinary extravasation will likely require operative intervention.

8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26.

Moudouni SM, Patard JJ, Manunta A, et al. A conservative approach to major blunt renal lacerations with urinary extravasation and devitalized renal segments. BJU Int. 2001;87:290–294. Thall eH, Stone NN, Cheng dL, et al. Conservative management of penetrating and blunt type III renal injuries. Br J Urol. 1996; 77:512–517. Heyns CF, Van Vollenhoven P. Selective surgical management of renal stab wounds. Br J Urol. 1992;69:351–357. Velmahos GC, demetriades d, Cornwell ee 3rd, et al. Selective management of renal gunshot wounds. Br J Surg. 1998;85:1121-1124. Wein AJ, Arger PH, Murphy JJ. Controversial aspects of blunt renal trauma. J Trauma. 1977;17:662–666. Altman AL, Haas C, dinchman KH, et al. Selective nonoperative management of blunt grade 5 renal injury. J Urol. 2000;164:27-30. Matthews LA, Smith eM, Spirnak JP. Nonoperative treatment of major blunt renal lacerations with urinary extravasation. J Urol.1997;157:2056– 2058. Haller JA, Jr., Papa P, drugas G, et al. Nonoperative management of solid organ injuries in children. Is it safe? Ann Surg. 1994;219:625–628. Tunberg T, Jona J. Review of multiple traumatic injuries in an urban pediatric population. Pediatr Emerg Care. 1985;1:116–119. Smith eM, elder JS, Spirnak JP. Major blunt renal trauma in the pediatric population: is a nonoperative approach indicated? J Urol.1993;149:546– 548. Gill B, Palmer LS, Reda e, et al. Optimal renal preservation with timely percutaneous intervention: a changing concept in the management of blunt renal trauma in children in the 1990s. Br J Urol. 1994;74:370–374. Kuzmarov IW, Morehouse dd, Gibson S. Blunt renal trauma in the pediatric population: a retrospective study. J Urol. 1981;126:648–649. Toutouzas KG, Karaiskakis M, Kaminski A, et al. Nonoperative management of blunt renal trauma: a prospective study. Am Surg. 2002;68:1097–1103. Matthews LA, Smith eM, Spirnak JP. Nonoperative treatment of major blunt renal lacerations with urinary extravasation. J Urol.1997;157:2056– 2058. Santucci RA, McAninch JW, Safir M, et al. Validation of the American Association for the Surgery of Trauma organ injury severity scale for the kidney. J Trauma. 2001;50:195–200. Husmann dA, Morris JS. Attempted nonoperative management of blunt renal lacerations extending through the corticomedullary junction: the short-term and long-term sequelae. J Urol. 1991;143:682-684. McGonigal Md, Lucas Ce, Ledgerwood AM. The effects of treatment of renal trauma on renal function. J Trauma. 1987; 27: 471-476. Altman AL, Haas C, dinchman KH, et al. Selective nonoperative management of blunt grade 5 renal injury. J Urol. 200; 164:27-30; discussion 30-21. Perego KL, Little dC, Kirkpatrick AK. Conservative nonoperative management of grade 5 blunt renal trauma. Journal of Urology. 2001; 165: 14-15.

referenceS 1. 2. 3. 4. 5. 6. 7.

Moore ee, Shackford SR, Pachter HL, et al. Organ injury scaling: spleen, liver, and kidney. J Trauma. 1989;29:1664-1666. Santucci, R. and Fisher, M. The Literature Increasingly Supports expectant Management of Renal Trauma- A Systematic Review. J Trauma. Aug, 2005;59(2):493-503. davis, K., Reed, L., Santaniello, J. et.al. Predictors of the Need for Nephrectomy After Renal Trauma. J Trauma. 2006;60(1):164-170. Wright, JL, Nathens, AB, Rivara, FP. Renal and extrarenal Predictors of Nephrectomy from the National Trauma databank. J Urol. 2006;175(3):970-975. Bozeman, C., Carver, B., Zabari, G. Selective Operative Management of Major Blunt Renal Trauma. J Trauma. 2004;57:305-309. Ramsay, L., Soumitra, e., Makhuli, M. Factors Affecting Management and Outcome in Blunt Renal Injury. World J Surg. 2002;26:416-419. Levy JB, Baskin LS, ewalt dH, et al. Nonoperative management of blunt pediatric major renal trauma. Urology. 1993;42:418–424.

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I See Dead People Janet M. Nielsen, MD

A

47-year-old African American male presented to the emergency department complaining of non-exertional chest pain and urinary frequency. He described the chest pain as dull, non-radiating, lasting only a few seconds and occurring after urination. He stated that these symptoms had been worsening over the past several months. The patient had a history of gastroesophageal reflux disease and obesity. During the history he also complained of two to three months of worsening vivid visual hallucinations of dead relatives. He became very tearful and perseverated hallucination details. He denied any other psychotic symptoms. He also denied any cardiac history. He was taking esomeprazole (Nexium) and metaxalone (Skelaxin) as needed. In a 47-year-old male with these peculiar symptoms, I wonder if substance abuse, metabolic derangement or an undiagnosed psychiatric disorder might be the cause. The hallucinations might be caused by a psychotic disorder such as schizophrenia or depression with psychotic features, a hallucinogen or delirium. The chest pain associated with urination may be due to a urinary tract infection or cardiac abnormality. I will obtain a complete blood count, complete metabolic panel, a urine drug screen and further psychiatric history. There may also be a cardiac component, considering his obesity. I will order an electrocardiogram (eKG), cardiac biomarkers (troponin, creatine phosphokinase (CK) – total and MB fraction) and a chest radiograph. On examination he had a normal temperature, pulse and respiratory rates. His blood pressure was elevated at 149/103 mm Hg, and his body mass index was 30.1. He was a tearful African American male with psychomotor retardation who was well groomed and obese. His cardiac, pulmonary and abdominal examinations were unremarkable. His musculoskeletal examination showed diffuse muscle tenderness, specifically over the thighs, lower legs and shoulders. His strength and range of motion were within normal limits, and his neurological examination showed normal patellar reflexes and slow gait. The patient had normal sensation in his arms and legs. He had dry skin. His mental status examination showed depressed mood with a blunted but congruent affect. His speech was slow, and his thought process was organized and focused on prior hallucinations of deceased relatives. He deAUtHor inforMAtion: Janet M. nielsen, MD is in the Department of Family medicine at the University of mississippi medical Center in Jackson. correSPonDing AUtHor: Janet m. Nielsen, mD, University of mississippi medical Center, Department of Family medicine, 2500 North State Street, Jackson, mS 39216, Phone: (601) 984-5426, Email: jnielsen@familymed.umsmed.edu

nied any auditory hallucinations or suicidal or homicidal ideation. An EKG showed normal sinus rhythm. The remainder of the requested laboratory studies was in process. The patient has an odd constellation of symptoms. diffuse muscle tenderness can be caused by overexertion, fibromyalgia, viral illnesses, dermatomyositis, polymyositis or a drug induced myopathy. I am less concerned about cardiac pathology, considering his normal eKG, normal cardiac examination and new finding of skeletal muscle tenderness. during a brief electronic health record review, I see that he had a normal echocardiogram 3 months earlier when he presented with similar complaints. At that visit he was prescribed metaxalone for his muscle aches and esomeprazole for his chest symptoms. The chest radiograph was within normal limits. His potassium was low at 3.3mEq/L. The remaining electrolytes, renal function, liver function tests and complete blood count were normal. Urinalysis showed trace blood only. His CK was elevated at 412 U/L (50-200 U/L), and his CK-MB was elevated at 5.94 % (0.10 – 4.94%). His troponin was negative at < 0.010 ng/nl. The negative troponin further lessens my concern for a cardiac cause of the chest pain. His urinalysis was not suggestive of infection, and I do not suspect a urinary cause of his pain. Given the elevated CK, I will start intravenous fluids to prevent renal function impairment. I will also obtain a more specific history from the patient including questions about exertion, statin use and dermatologic review of systems. exertion can cause transient elevations of CK. Myotoxicity is a common side effect of statins. Although the patient did not admit to statin use, one may have been prescribed, especially considering his obesity. Also, elevated CK can be associated with both dermatomyositis and polymyositis. The patient reported being a truck driver; this required heavy lifting while loading an unloading freight several times daily. He denied any statin use or recent rashes. While exertion from his job may account for some elevation in his CK, it seems unlikely to account for an elevation of the current magnitude. I rule out statin use as a cause of elevated creatine kinase as the patient continues to deny any statin use. Because he denies rashes, I put dermatomyositis and polymyositis lower on the differential. I also exclude fibromyalgia from the differential because he has diffuse muscle tenderness, not point tenderness which is seen in fibromyalgia. In addition, elevated CK is not seen in fibromyalgia. The patient stated that he was feeling better after the intravenous fluids. He also was happy when I suggested that he could see may

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a psychologist at clinic to discuss his visions. He denied any current visions or suicidal ideation. Feeling that the patient did not have an urgent condition, I discharged him from the emergency department with an appointment to follow up in clinic in 2 days. This patient has elevated creatine kinase and diffuse muscle aches. It could be due to exertion at his job, but I continue to wonder what disorder might link all of his odd symptoms together. While researching myositides, I discover that hypothyroid myopathy could be the cause of his elevated creatine kinase and muscle weakness.1 Hypothyroidism might also explain his psychiatric symptoms. I add a thyroid stimulating hormone (TSH) test to existing orders. The TSH was elevated at 47.2 mcIU/ml (0.27 – 4.2). His TSH concentration indicates that the patient likely has hypothyroid myopathy and hypothyroid psychosis. up to 70% of patients with hypothyroidism can have neuromuscular complaints including weakness and myalgias.2 Serum creatine kinase in usually elevated in patients with hypothyroidism but usually less than 1000 u/L.3 Psychiatric manifestations of hypothyroidism can include psychosis in 5-15% of patients. The psychiatric symptoms of hypothyroidism may be related to high concentrations of the T3 receptor in the amygdala and hippocampus. The most common neuropsychiatric sequelae in hypothyroidism include psychosis, depression and cognitive disorders. These symptoms usually occur after the manifestation on the physical symptoms of hypothyroidism.4 Rhabdomyolysis can be more profound with exertion in hypothyroidism.5 Both muscle symptoms and psychosis can resolve with thyroid hormone replacement therapy.2,4

The patient was prescribed levothyroxine (Synthroid) 112 mcg by mouth daily as replacement therapy. At his appointment two days later, he stated that he felt better but was still experiencing most of his symptoms. He was encouraged to stay well hydrated and to continue his levothyroxine. Six weeks later his TSH had decreased to 5.5 mcIU/mL, and his CK was normal at 105 U/L. His muscle pain, chest tightness and visions had resolved. His improvement with thyroid hormone replacement confirmed the diagnosis of hypothyroid myopathy and hypothyroid psychosis.

KeY WorDS:

HyPOTHyROIdISM, MyOPATHy, PSyCHOSIS

Acknowledgment: I thank Librarian Janet Bishoff, BS, MLS, for her assistance.

referenceS 1. 2.

3. 4. 5.

Sabatine MS. Pocket Medicine: The Massachusetts General Hospital Handbook of Internal Medicine. 3rd ed. Philadelphia, PA:Lippincott Williams & Wilkins; 2007 duyff RF, Van den Bosch J, Laman dM, Potter van Loon B, Linssen WH. Neuromuscular findings in thyroid dysfunction: a prospective clinical and electrodiagnostic study. J Neurol Neurosurg Psychiatry. 2000;(68):750-755. Scott KR, Simmons Z, Boyer PJ. Hypothyroid myopathy with a strikingly elevated serum creatine kinase level. Muscle Nerve. 2002;26:141-144. Heinrich TW, Grahm G. Hypothyroidism presenting as psychosis: Myxedema madness revisited. Prim Care Companion J Clin Psychiatry. 2003;5(6):260–266. Riggs Je. Acute exertional rhabdomyolysis in hypothyroidism: the result of a reversible defect in glycogenolysis? Mil Med. 1990;155:171-172.

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• mSDH • Mississippi Reportable Disease Statistics

March 2009

* Totals include reports from Department of Corrections and those not reported from a specific district NA - Not available (temporarily) for the most current MMr figures, visit the Mississippi State Department of Health web site: www.HealthyMS.com may

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• PRESiDENT’S PaGE •

Be Part of the Solution

M

arch 23, 2010: a date that will live in infamy. While certainly not as tragic as the events of december 7, 1941, in terms of lives lost in a matter of a few short hours, HR 3590 became public law 111-148 with the stroke of President Barack Obama’s 20-something pens. In my opinion, this culmination of 14 months of democratic deal cutting and back room negotiating will cast a shadow across our united States as long as any other sentinel event in our nation’s history. I continue to ask myself, “How did this happen?” Allow me a few moments to explain.

rAnDY eASterling, MD 2009-10 MSMA PreSiDent

For the past several years I have been privileged to travel across the united States and certainly to the far corners of our great state of Mississippi. In doing so, I have met very few physicians (and other private citizens for that matter) who have not embraced the idea of reforming our present system of delivering health care in the united States. Interestingly enough, I have met even fewer physicians and/or other Americans who are pleased with the method and/or manner by which this reform has come about. To add salt to the wound, complicit in this increasingly unpopular upheaval of our health care system were such groups as the American Medical Association, American Academy of Family Physicians, American College of Physicians and the list goes on. yet, when you talk to physicians who are members of the aforementioned organizations, very few say they support the present flavor of health system reform or, for that matter, their organization’s position on HR 3590. At this point, let’s all stop and collectively scratch our heads. did we not all wake up on Wednesday morning March 24th in a cold sweat? did we not all rub our eyes, splash cold water on our faces, and hope that we were awakening from a bad dream? We should have been as lucky as ebenezer Scrooge! While the idea of providing health care coverage to an additional 30 million Americans (what happened to the original 47 million we were told were uninsured a year ago?) is certainly a step in the right direction, I would remind you again that it is the manner in which this is being done that disturbs most Americans. For example, early in the health system reform game, liberal democrats insisted on a public option. The idea of a “government run insurance program” was so repugnant to most Americans that united States Congressmen and/or united States Senators were verbally and nearly physically accosted at “townhall” meetings all across America. yes, even in the liberal northeast and on the “left coast” (California), thousands of our fellow citizens sent a resounding message that further government control of our health care was not a viable alternative. under the guise of “listening to the electorate,” the public option was ditched. In its place, HR 3590 expands Medicaid by some 16 million. Overnight, with the stroke of a Presidential pen, we have entitled an additional 16 million Americans. Well, thank God we did not get that dreaded “public option” (which, by the way, would have insured only 15 million). What about expanding Medicaid is not growing an already-existing “government run health care plan”? Am I missing something? Well, at least we still have Medicare. This government run plan has been a Godsend to both physicians and patients. Medicare, by and large, takes care of our nation’s most vulnerable: those who have fought our wars, raised our children, gone to work every day, paid taxes, and woven the very moral, ethical, and financial fibers that hold our nation together. In spite of Medicare’s noble mission and outstanding record, it has been horribly mismanaged by our government and is scheduled to go under for the third time in about seven years. On top of that, HR 3590 is to be paid for in large measure by billions of dollars of cuts to our Medicare Program that is already on life support!

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To add insult to injury, efforts to fix the flawed Medicare payment system (SGR) allowing physicians to care for the elderly has repeatedly fallen on deaf ears in Congress. Let me get this straight! On March 23, 2010, the President of The united States signed into law a bill that expands healthcare coverage to an additional 16 million Americans who are, with notable exceptions, fairly young and healthy. Before the ink dried on the name Obama, this same bill diminished services and coverage to members of “the greatest generationâ€?. Some would wonder if we have in fact lost our moral compass in America. Not only does HR 3590 decrease services to the Medicare population, but for the first time in the united States history all of us will be required to pay Medicare tax on our lifetime of investments (capital gains and dividends) for the rest of our lives‌so much for that “nest eggâ€? idea. In addition, most feel that a value added tax is just around the corner. This would, of course, be a consumption tax that would further labor every social economic class in America. This tax would, by and large, place a disproportionate burden on the lower social economic groups and the elderly, and, if that were not enough, physicians, who tend to be in the higher income brackets, will most likely be taxed at levels never before seen in our nation’s history. What is that old saying? “If you think healthcare is expensive now, just wait until it is free.â€? When it is all said and done, the most disturbing development of the past 14 months of this democratic rule in Washington has been the massive growth of our federal government. Like the waistlines of many of our patients, the united States government continues to expand. While I feel strongly that all Americans who can afford health insurance should purchase same, where does the Constitution (remember from junior high civics, that is the document that has served us well for over 200 years) empower the federal government to force a single united States citizen to purchase any product, whether health insurance or anything else for that matter? So much for Ben Franklin, Thomas Jefferson, John Hancock, etc.; well, I guess they thought it sounded like a good idea at the time! I am reminded daily of the prophetic words of one of our constitutional framers, Thomas Jefferson, “A government big enough to give you everything you want is big enough to take everything you have.â€? While the Patient Protection and Affordable Care Act is now federal law, let’s hope that the “fat ladyâ€? has yet to sing. November 2010 elections are a few short months away. While I don’t want health system reform to be totally discarded, I do pray for a more sensible, equitable, physician-driven, patient-centered approach to restructuring the delivery of healthcare in America. If health system reform is to be physician driven and patient centered, it is incumbent on us as doctors to be the driving force. If history has taught us anything, it is that if we are not part of the solution, then we have become part of the problem. This is nothing short of a “call to arms.â€? We must organize, talk to our patients, give to our political action committees, and call our congressmen and senators. If you and I refuse to play a central role in health system reform, then the federal government will be more than happy to do it for us. Wait, I think they already have! yours in making Mississippi healthier,

Randy Easterling, MD President, Mississippi State Medical Association

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• EDiTORiaL •

“Draumatized”

M

ashup words can capture meaning wonderfully and sometimes hysterically. I want to introduce you to a new word, as reported to me by my wonderful and wise college professor wife. The new word, a mashup word, is “draumatized.” There may be some potential for research and even a new class of illness being discovered here.

So what is “draumatized?” Well, it is a combination of trauma and drama. The drama is of higher order than the trauma. “draumatized” was brought to the attention of the drs. O’dell as part of a plea invoked during earnest efforts by a relative. It seems the person she was pleading for had experienced a minor trauma. There was a full recovery in a brief period, but the circumstances were so dramatic as to be nearly unbelievable that some long lasting injury had not occurred. Telling the full story might disclose the guilty, so bear with me. Think of something like totaling your car and yet walking away with insignificant injuries. Well, it seems that for our subject a miraculous escape was not good enough. The story itself was too good to pass up so the event was being used liberally to explain all sorts of academic, social, and other failings on the part of our otherwise goodfortuned “victim.” The relative described the subject as having been “draumatized” and indicated the expectation that this victimhood status should absolve any failings in the program. empathy runs deep in the drs. O’dell household, but the obvious humor of this mashup of trauma and drama quickly overcame the more noble sentiment of empathy. We have found the new word useful in all sorts of ways. “draumatized” might even be a new diagnostic term for, say, the persons bringing me disability papers following a minor trauma on the job. Some of the “draumatized” even have hired drama coaches, usually procured at a local law office, to be certain they are convincing in their description of the trauma experienced. Let’s see, I wonder what the ICd-9M code would be? Would it fall into the 900-codes of injury? Maybe the 800- codes of brain injury? Or under the 301-codes of histrionic personalities? Can persons suffer from “draumatization” disorders? Maybe we are onto something here. “draumatization” disorder would certainly explain the constant issuance of work and school excuses at most primary care offices. If “draumatization” disorder is eventually recognized as a legitimate medical disorder then I might feel better about issuing such excuses for patients who do not come to the office to be seen for their work-interrupting illness but nevertheless desire my issuance of an excuse. Perhaps they were simply too “draumatized” to even come to the office. And maybe a patient with a “draumatization” disorder can be best treated in dramatic circumstances, perhaps explaining why patients with seemingly minor illness prefer the emergency room. As is the case with any new entity, I, like other scientific authors, recommend further study of “draumatized.” A new National Institute of Health should consider studying this potential disorder since it clearly is a unique entity not falling in the current silos of NIH investigation. doctors might find willing colleagues among actors who are expert in drama as we seek collaborative research in this new area of study. We should begin to recognize that drama is a co-morbid condition following trauma in some individuals. Certainly a scale for drama would be useful for the ongoing treatment of victims of trauma. Like Broadway plays, I suspect the best treatment lies in the box office. When the drama fails to bring in the crowds and receipts, it ceases to be produced. —Michael O’Dell, MD Associate Editor

The Pen is Mightier than the Sword! express your opinion in the JMSMA through a letter to the editor or guest editorial. The Journal MSMA welcomes letters to the editor. Letters for publication should be less than 300 words. Guest editorials or comments may be longer, with an average of 600 words. All letters are subject to editing for length and clarity. If you are writing in response to a particular article, please mention the headline and issue date in your letter. Also include your contact information. While we do not publish street addresses, e-mail addresses or telephone numbers, we do verify authorship, as well as try to clear up ambiguities, to protect our letter-writers.

you can submit your letter via email to Kevers@MSMAonline.com or mail to the Journal office at MSMA headquarters: P.O. Box 2548, Ridgeland, MS 39158-2548. may

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• iQH •

Patient Safety and Core Prevention

I

QH has successfully met performance requirements at the 18th month of our CMS 9th Statement of Work.

We recently received notification from dr. Barry M. Straube, CMS chief medical officer, director, Office of Clinical Standards and Quality, who stated: “We are pleased that your performance in the first evaluation period, focused on the theme areas of Patient Safety and Core Prevention, was in accordance with our expectations. On behalf of our QIO Program management and staff at CMS, I would like to congratulate you on successfully meeting performance requirements at the 18th month of 9th Statement of Work (SOW) core contract.” Our IQH staff works on patient safety and prevention projects focusing on improving the quality of health care for Medicare beneficiaries. We are very pleased with this 18th month evaluation. This accomplishment is important to us because it reflects improvement in quality care for our Medicare beneficiaries. To review, the projects include: Beneficiary Protection: Case Review and Reporting Hospital Quality data for Annual Payment update (RHQdAPu) Core Prevention: Working with physician offices and clinics to leverage certified electronic health record (eHR) systems in ways to help improve immunization rates for influenza and pneumonia as well as breast cancer and colorectal cancer screenings Patient Safety: Pressure ulcer Reduction in Nursing Home and Hospital Settings; Nursing Home Physical Restraints; Hospital Surgical Care Improvement Project (SCIP); Methicillin-resistent Staphylococcus Aureus (MRSA); Nursing Homes in Need; Medication Safety Sub-National Project: Focused disparities

Tobacco Quitline Updates

I

QH is now offering an alternative to telephone counseling for persons in Mississippi who want to quit using tobacco. An interactive Web site will offer online counseling to assist Mississippians who do not want to participate in telephone counseling. The Web site offers information on tobacco and its effect on health and gives other resource information. Healthcare providers can also take advantage of the resources on the Web site and download pamphlets and the fax referral form that will make referrals to the quitline quick and easy. The Web site is: www.QuitlineMS.com. Quitline hours have expanded to 7 a.m. to 7 p.m. Monday through Friday and on Saturday from 9 a.m. to 5:30 p.m. —James S. McIlwain, MD IQH President 144

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• POETRy iN mEDiCiNE • [Editor’s Note: This month, we print the poetry of Richard D. deShazo, MD, Chairman and Professor, Department of Medicine, Professor of Pediatrics, and Billy S. Guyton Distinguished Professor at the University of Mississippi School of Medicine. He is board certified in the medical specialties of internal medicine, allergy-immunology, rheumatology and geriatrics. He is also known to the listeners of Mississippi Public Radio as the host of “Southern Remedy,” a vibrant weekly program where his passion for serving his patients is clearly evident. This poem, entitled “Rhythms of Life,” came to deShazo one Saturday morning as he was trying to discover his proverbial “inner self.” He explains, “ I was sitting at the breakfast table when out of the recesses of my shrinking brain came a rush of thoughts about the yin and yang, ups and downs, ins and outs of life as a husband, father, grandfather and physician. The bottom line is that I have been more than blessed to serve in all of these roles and continue to be committed to them. Thus, I remain an aging heterosexual¬ with an aversion to tobacco and body odor. I hope the poem brings my colleagues a smile.” Any physician with Mississippi ties is invited to submit poems for publication in the journal, attention: Dr. Lampton or email to him at lukelampton@cableone.net.] —ED.

Rhythms of Life Some highs Some lows Some yeses Some noes.

Some by luck Some by will Some with help Some by skill.

Some good Some bad Some salmon Some shad.

Some with speed More by wait Some by plan Some by fate.

Some progress Some stalls Some homeruns Some foul balls.

Some with steel Some with planks Some with scars All with thanks.

Some sadness Some thrills Some solace Some bitter pills.

—Richard D. deShazo, MD Jackson

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• PHySiCiaNS’ bOOkSHELF • WITH SARAH WILEY SCHEIN, M.S., R.D., L.D.N.

CHAD RHODEN, M.D., Ph.D. • Information on the risks and benefits of medications • 70 delicious and healthy recipes • Practical advice on nutrition • Fitness plans and stress management tips • Immediate and long-term solutions

PRESSURE BLOOD HIGH DOWN BRINGING

BRINGING DOWN HIGH BLOOD PRESSURE

• Immediate and long-term solutions • Fitness plans and stress management tips • Practical advice on nutrition • 70 delicious and healthy recipes • Information on the risks and benefits of medications

“Bringing Down High Blood Pressure” By Chad Rhoden, MD, PhD with Sarah Wiley Schein, MS, RD, LDN ISBN-13 978-1-59077-159-4 304 pages. Includes graphs, tables, and index. $22.95, Distributed by National Book Network

O

ur own edward Hill, past president of both the Mississippi State Medical Association and the American Medical Association, offers a blurb on the back of Chad Rhoden's new book Bringing Down High Blood CHAD RHODEN, M.D., Ph.D. Pressure. He comments: “This book captures the essence of what WITH SARAH WILEY SCHEIN, M.S., R.D., L.D.N. must occur if we expect, as a society, to change successfully behavior that will prevent cardiovascular disease. everyone who expects to reach optimal health— whether patient or health care professional— should own, read, and treasure this book.” As usual, edward says it well and in a concise manner! This attractive hard bound book, which includes an index, seeks a national audience of both lay and professional readers. It is an excellent resource for physicians to offer to their patients who seek insight into their disease and who are serious about impacting positively their blood pressure. Over eight chapters and 5 appendices, dr. Rhoden gives readers straightforward solutions which can be utilized both short and long term in their lives. This book focuses on prevention, which is to be expected given Rhoden’s background. He opens with a chapter highlighting the causes and dangers of hypertension, this nation’s number one killer. With future chapters, he explores the benefits of a multifaceted approach to control and lower blood pressure, from exercise and weight loss, to diet and nutrition, to stress and emotional wellness, even to alternative approaches. Have no doubt he covers all of the bases. each of the chapters goes into extraordinary detail, which should allow most of the suggestions to be easily incorporated into a patient’s daily routine. He also stresses to the reader the need to discuss the book and suggestions with their physician before utilizing them. Rhoden extensively outlines the risks and benefits of various medications; he also emphasizes the important role lifestyle changes play in the disease process and how such lifestyle changes may result in a patient’s ability to reduce or eliminate medications. Impressive is the plentiful practical advice on nutrition, especially the multiple tips for healthy food selection and preparation. As well, more than 50 delicious recipes “for bringing down high blood pressure” are included over 75 pages, with each broken down from a nutritional standpoint. There is great variety for any palate, and food categories include appetizers, breads, salads, soups, vegetables, entrees, marinades, and desserts. The dishes do appear tasty, and include brandy apple crisp, herb marinated lamb chops, Louisiana-style shrimp creole, hummus, gazpacho, pupusas revueltas with chicken, crispy edamame, and pan-fried yucca. If physicians had two hours to spend with each patient, partnering with them to improve their health, Rhoden’s book is what we’d say. This book is a valuable and vital resource for both patients and physicians. It provides not only helpful information for bringing down high blood pressure, but also excellent advice on how to live a healthy life. Rhoden’s book begins the type of reflection each patient needs to garner insight in maximizing their health choices. My patients with hypertension will benefit from reading the book and adopting many of the innovative concepts for healthy living. 146

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Practicing physicians will want to utilize many of Rhoden’s strategies not only with their patients but also with themselves. How many of us are overweight, suffer from hypertension or hyperlipidemia, and need insight, suggestions, and encouragement to make changes in our life? There’s a great deal of good information here. Rhoden begins a conversation we need to have not only with our patients but with ourselves. This is an exemplary book by a fellow MSMA member, and I encourage you to give it a try. Chad A. Rhoden, Md, Phd, of Madison, is a one of our state’s emerging leaders in the field of disease prevention. His particular expertise is in prevention and management of cardiometabolic and infections disease occurring in the occupational setting. dr. Rhoden is board certified in preventive medicine/public health as well as family medicine. His Phd was in exercise science and nutrition. He lives in Madison, and comes from a family of physicians, including two great great uncles who served our MSMA as president. His co-author, Sarah Wiley Schein, MS, Rd, LdN is a registered dietitian, who resides in Wayne, Pennsylvania. — Lucius Lampton, Editor

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• imaGES iN miSSiSSiPPi mEDiCiNE •

HOSPITAL, ALCORN A & M, 1890s— These photos are of the original hospital for students at Alcorn Agricultural and Mechanical College. This was one of the earliest hospitals for African Americans in the state. Located in Claiborne County, four miles south of Port Gibson near the Jefferson County line, Alcorn State University was founded in 1871 as one of the nation’s first state-supported colleges for African American students. (The campus dates back to 1828 as Oakland College, a regional Presbyterian college which ceased operations by the time of the Civil War.) The college was named in honor of Reconstruction Governor and Senator James L. Alcorn. The college operated as a land-grant institution, and by 1875, the name Alcorn University was changed to Alcorn Agricultural and Mechanical College. At first the school was exclusively for black males but in 1903 women were admitted. In 1974 Alcorn Agricultural and Mechanical College became Alcorn State University. This hospital was not the first built for African American patients in Mississippi. In 1852, a Natchez newspaper (The Mississippi Free Trader) noted the erection of a small infirmary exclusively for African Americans, operated by future MSMA Vice President Luke Pryor Blackburn. (More about his later!) Anyone with additional information on the college hospital is asked to contact Dr. Lampton. If you have an old or even somewhat recent photograph which would be of interest to Mississippi physicians, please contact the Journal or me at LukeLampton@cableone.net. —Lucius Lampton, MD, Editor

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• THE UNCOmmON THREaD •

The Thomasine Confluence

W

r. Scott Anderson, MD

hen I posted my little story The Ghost on my blog it produced an interesting set of responses, which I shall post here, via the magic of cut and paste. The names have been changed to protect the innocent and the commentary left in blogger’s prose as seen on the computer screen.

Sis: Enjoyed the blog, Tom. Glad you answered when opportunity rang the bell” Frank: “Tom, are you sure it wasn’t UPS?...They ring once and run. And, we went to RMH for the Cardiac Unit’s 2 year anniversary this afternoon. Shook hands with my Surgeon, his PA, nurses etc., who remembered me well...when leaving, the Surgeon said ‘nice seeing you again you look great, Tom’.... When they made my name tag...they put Thomas (my middle name) instead of Frank....very - very spooky if you ask me...Tom...VERY SPOOKY....!!!!” Me: “the world is a spooky place, maybe he was in the wrong place.” Frank: “Which Tom was in the wrong place?” Ms CGS: “or maybe the surgeon is a closet writer/blogger/prf. of English?” Me: “Frank, since you're the only Tom here, I think the ghost was a bit south of where he intended to be.” Frank: “But, you see, I'm NOT the only Tom here...you have a Tom there....You are just as much of a Tom as I am....mistaken identity?” Ms CGS: “can I play? I'll be Tom the Editor. Frank: “hmmm...I think there are two impostors. Will the REAL Tom please stand up? (the quickest solution)” Frank: “OMG...we all stood up at the same time...back to square one....” I was planning to answer CGS with a suggestion that if we were going to cast an attractive woman as Tom the editor, that she would have to be comfortable being a “domin-ed-trix,” you know, an editor that was only was able to enjoy editing when she could dress up in clothes from Versace and edit writers really, really hard. But then something struck me. It was both the tone and the content of those final two posts which led me to the conclusion that there was something larger going on here. So that meant it was time for me to get in gear and look into it, in only the way a piercing mind such as mine can possibly do it. It was time for some…tat da da daaaaaah…(wait on it)… ReSeARCH. Research is always a good answer when you have a vexing problem or coincidence to investigate. The problem becomes how, and what to research? Clearly, this doesn’t appear to be a religious problem, although the Bible is replete with examples of Thomases who play a prominent role in Biblical history. And, there is always the possibility that we have all been simultaneously, because of our natural tendencies to scoff and distrust, transformed into visages of the Thomas who doubted Jesus’s resurrection, but after due consideration and running a few preliminary mathematical equations, I rejected this as the explanation. However, those of you that want to accept this as the answer on faith alone are welcome to do so. may

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Biology was always a consideration, and I had to consider the possibility that some genetic sequence that we all possess in common is the root of our mutual Thomasine misidentification. So, I went out to the garage and fired up my dNA sequencer, used a vacuum on my screen to suck dNA samples from each of the other Tom’s keyboards by visiting their Facebook profile using direct screen-to-screen transport to shove the vacuum nozzle against the keyboards. I knew they wouldn’t mind the intrusion. (Frank- I’m sorry about the mess. I pushed the blow button by mistake, but I changed the bag right after that. So the second time things went a lot better.) I looked at the recovered dNA, and yes almost ninety-percent of our dNA sequences were similar, but eighty-five percent of our dNA sequences match those of an earthworm, so I wasn’t able to draw any firm scientific conclusions from that. And while I don’t profess to speak fluent earthworm, I am unaware of any earthworms that refer to one another as Tom at all, much less it having some identifiable locus in their genome, so I was able to exclude those common sequences from consideration. The five percent remaining that the three of us Tom’s have in common with each other, but not with earthworms seems to code for stuff like arms and legs and a four chamber heart and things like that, and not for name specific identity. So I rejected biology. The answer then I reasoned must come from the realm of physics: specifically I gravitated to the subject of String Theory. Because it is such a fluid field, I adjusted and tweaked physical principles, added two unknown dimensions to account for Thomasine movement (a term I have now created) and voila there was the answer implicit in the very underpinnings of the science. We have only to look of the dual resonance model, first postulated by Veneziano in 1968 to see what is happening. In short, Veneziano observed that the s- and t-channel vibrations that occurred in meson scattering were of exactly the same amplitude. On further observation the exact phenomena was observed in N-particle amplitudes that gave us the idea of harmonic, opposing amplitudes like that occurs in a onedimensional model of linear string vibration. Obviously what is happening to us is an exact but opposite reaction, modulated through time by the presence of the two unseen dimensions of the great Brucine Confluence that effected Monty Python in the same years that Veneziano was developing his resonance model, and is only showing up now. I propose that we try to quantify B- (for Brucine) and T- (for Thomasine) confluent amplitudes and sit back and wait on the guys in Stockholm to send us that Nobel Prize I knew I was going to get some day. I’ll start working on the math.

— R. Scott Anderson, MD Meridian

R. Scott Anderson, MD, a radiation oncologist, is medical director of the Anderson Regional Cancer Center in Meridian and vice chair of the MSMA Board of Trustees. Additionally, he is an accomplished oil-painter and dabbles in the motion-picture industry as a screen-writer, helping form P-32, an entertainment funding entity.

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Dwalia South-Bitter, MD

m I the only person who is cheapskate enough to actually miss the free pens and note pads that physicians’ offices used to get from drug companies? It has been just over a year now since this practice has been banned, and I can almost see the bottom of my dwindling stockpile. The only gel pens we are given these days come from home health agencies and hospices. Thankfully they are almost as numerous in our region as Southern Baptist churches. you can’t swing a dead cat by the tail without hitting a new hospice that just opened up on the corner.

Someone sent me this e-mail photo with the caption… “I’m sure that you have seen pharmaceutical advertising in doctors’ offices on everything from tissues to exam table cover paper. Well, in my book, this one should get the prize. If the light stays on for more than four hours, call your electrician!” Although they are behind the times (since we no longer get ‘delightful’ free goodies such as this one), the e-mail only served to remind me of how revoltingly out of hand things had gotten in the pharmaceutical marketing realm. My feelings are hurt. My Pfizer rep never gave me one of these Viagra switch plates for my exam rooms. I did once receive a similarly tasteless marketing piece from the company who makes the competitive erectile dysfunction drug, Levitra. This drug rep stuck one on each of our exam room doors without permission, and the stupid things literally could not be pried off. (does the term ‘hard-on’ fail to come to mind here?) When their rapid removal ruined the finish on the doors, I got so mad. I told the nurses that I would not ever see that rep again. Apparently this happened in more than one office because he got fired or at least transferred to somewhere in the delta. He also left some of those bright plastic pens that unfold themselves slowly and expand into a reasonable semblance of virile manhood that could then actually be used to write a prescription for the ed drug named on the side. None of these things is as offensive to me as the television ads inflicted on the public, and unnecessarily exposing “children of all ages” to ideas and questions they would be just as well off not knowing…now or ever. There are also no “free lunches” any more. In reality there never were. I don’t remember ever enjoying any meal while I was engaged in inspecting Cytochrome P-450 interactions and Medicare-d formulary coverage. Goodbye to that! After listening to all that folderol, you need to ingest a few of those proton pump inhibiting acid reflux pills they were pushing while you scarfed your Subway sandwich. I have come to feel compassion for these pharmaceutical sales reps who went to college and earned a marketing or pharmacy degree but are forced by their companies into becoming lunch caterers to physician offices. There are things I will miss. I have a really nice collection of silk Viagra ties. And I have so many other astoundingly inane pharmaceutical gimmes that it would set your head spinning. I have a huge box of stuffed animals representing dozens of different drugs… among them, Zyrtec zebras and may

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Rhinocort rhinoceros beasts. They lie awaiting the day (like the misfit toys they truly are) when someone actually wants them and is actually willing to pay money for them… when some e-Bay aficionado becomes nostalgic for the tasteless trash that has been foisted upon the medical profession for the last quarter century. It appears that my collection’s value grows dearer with the new rules in place. I have a real problem with throwing things away. I am not quite a hoarder but sometimes come uncomfortably close. With these pharmaceutical marketing restrictions in place, I hope our office space will become at least a bit less cluttered. Now after all the years of their stupid shenanigans, drug company excesses have caused activists and lobbyists to convince Congress of the tawdry nature of these marketing practices. The drug reps are coming in and telling the doctors that… “If you don’t like the new regs, then you should blame the AMA. They are the ones who put a stop to us giving you all the freebies!” Good grief, what else is the AMA going to get the blame for? Sure, the Gulf oil spill was a dastardly AMA plot to raise gas prices.

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I know that I was never influenced to prescribe a drug by any of those expensive little doc-toys. A Caribbean cruise might have done the trick to entice me to write more Cialis, but shucks, now we’ll never know, will we? —Dwalia South-Bitter, MD Ripley

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