May 2015 JMSMA

May

VOL. LVI

2015

No. 5

Coming in the June issue...

This special educational resource will be dedicated to the state’s growing HIV/ AIDS crisis. Contains articles on:

New Medications

Treatments Timely Medical

Information on the disease to educate physicians as you care for a changing patient base

Guest editor: Thomas Dobbs III, MD, MPH, State Epidemiologist.

Articles from Mississippi State Department of Health and other leading experts in the fields of epidemiology, infectious disease, HIV/AIDS, and pharmacology.

Lucius M. Lampton, MD Editor D. Stanley Hartness, MD Richard D. deShazo, MD Associate Editors Karen A. Evers Managing Editor Publications Committee Dwalia S. South, MD

Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD, Ex-Officio and the Editors

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.

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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.

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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© 2015 Mississippi State Medical Association.

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The Association Claude D. Brunson, MD President Daniel P. Edney, MD President-Elect Michael Mansour, MD Secretary-Treasurer Geri Lee Weiland, MD Speaker Jeffrey A. Morris, MD Vice Speaker Charmain Kanosky Executive Director

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MAY 2015

VOLUME 56

NUMBER 5

Scientific Articles An Assessment of Emergency Department Use among 120 Mississippi’s Medicaid Population Benjamin H. Walker, MS; John S. McCown, MS; Diana Bowser, ScD, MPH; Alison Patev, BA; Frances Shechter Raede, MPH; Moaven Razavi, PhD; David Dzielak, PhD; Linda H. Southward, PhD

Top 10 Facts You Should Know about Synthetic Cannabinoids: 125 Not So Nice Spice Ann Kemp, RPh, MD; Molly Clark, PhD; Thomas Dobbs, MD; Robert Galli, MD; Justin Sherman, Pharm D; Robert Cox, MD, PhD

Clinical Problem-Solving Case: A Rash Decision

139

Laura J. Miller, MD

Just Off the Press- Info You Want to Know: Vitamin C in the Prevention 147 of Complex Regional Pain Syndrome Richard L. Ogletree, Jr., PharmD and Sarah Hill Davidson, PharmD

MSMA Spotlight 2: Physician Leadership Academy Scholars

133

Kara Kimbrough, MSMA Director of Communications

President’s Page There is “Power in Numbers”

138

Claude D. Brunson, MD; MSMA President

Editorial It’s About Time

143

D. Stanley Hartness, MD; Associate Editor

Special Article Attitudes Toward Diversity in the Health Care Environment

144

Ralph H. Didlake, MD, FACS; Caroline E. Compretta, PhD

Departments From the Editor: Bye-bye SGR, Hello MACRA and MIPS UMMC- Dr. Dan Jones Will Help Lead Obesity Research Efforts Poetry and Medicine- “Enter Patient”

Physician’s Bookshelf- Dr. Chris Wiggins on Ocean Springs and Gautier Images in Mississippi Medicine - Veterans’ Hospital Gulfport, 1924

About The Cover:

Kamp Kaleidoscope — Each day after a delicious lunch featuring veggies grown on the farm across the highway and picked the “morning of,” Strong River campers are invited out of Magnolia’s Dining Hall to play “small games” under the majestic oak trees in the center of camp before retiring to their cabins for rest period.

As camp doctor, I always pack my camera, ready to capture interesting sights. This collection of brightly colored hula hoops and other “small game” items caught my attention as they waited to be grabbed up by the kids. —Stanley Hartness, MD, Family Physician, Premier Patient 1st Clinic, Jackson. r May

VOL. LVI

Official Publication of the MSMA Since 1959

118 149 150 151 152

2015

No. 5

May 2015 JOURNAL MSMA 117

O

From the Editor: Bye-bye SGR, Hello MACRA and MIPS

n April 16th, President Barack Obama signed into law the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the socalled “permanent doc fix.” This act is the largest and most expansive healthcare bill signed into law since the Affordable Care Act was enacted five years ago. Many physician advocates are still amazed at the miracle of its passage. The AMA’s chief lobbyist commented, “No one believed SGR [Sustainable Growth Rate] could be repealed a year ago, but the stars aligned, and the logjam was broken.”

The Medicare SGR had been in place since 1997 and had been enacted to control costs. It soon became apparent that utilizing this “growth in GDP” formula would punish physicians annually with massive double digit payment cuts, thus annually requiring the so-called “doc fix” by Congress to suspend SGR and not implement a massive fee reduction. (This year docs were facing a 23.7% pay reduction.) For ten to fifteen years, physician advocates have had the “repeal of SGR” as a high priority, only to accomplish annual fixes but no permanent solution. Finally, SGR is no more.

MACRA repealed permanently that formula and established a new way to pay physicians, ending fee-for-

service over time. For the short term, physician compensation remains in a holding pattern, with annual increases of a mere .5% for the next five years.

Then comes MIPS, the Merit-Based Incentive Payment System, designed to shift Medicare reimbursement from fee-for-service to pay-for-performance.

MIPS will be assessing physicians in four categories, with “quality” largely determined by system cost and EHR Lucius M. Lampton, MD use.

In the end, the repeal of SGR is a hollow victory for physicians. Very soon, the army of medicine will be fighting the punitive flaws yet to be discovered in MACRA and MIPS. Past MSMA President Hugh Gamble whispered skeptically as AMA leadership was rejoicing at the repeal of SGR: “A few more victories like this and the private practice of medicine will be dead.” Go ahead and get your signs ready: “Repeal MIPS!” It’s never too early to start!

Contact me at LukeLampton@cableone.net.

—Lucius M. Lampton, MD, Editor

Journal Editorial Advisory Board Timothy J. Alford, MD Family Physician, Kosciusko Medical Clinic Michael Artigues, MD Pediatrician, McComb Children’s Clinic

Maxie L. Gordon, MD Assistant Professor, Department of Psychiatry and Human Behavior, Director of the Adult Inpatient Psychiatry Unit and Medical Student Education, University of Mississippi Medical Center, Jackson

Diane K. Beebe, MD Professor and Chair, Department of Family Medicine, University of MS Medical Center, Jackson

Scott Hambleton, MD Medical Director Mississippi Professionals Health Program, Ridgeland

Jennifer J. Bryan, MD Assistant Professor, Department of Family Medicine University of Mississippi Medical Center, Jackson

J. Edward Hill, MD Family Physician, North Mississippi Medical Center Tupelo

Jeffrey D. Carron, MD Professor, Department of Otolaryngology & Communicative Sciences, University of Mississippi Medical Center, Jackson

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

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

Thomas E. Dobbs, MD, MPH State Epidemiologist Mississippi State Department of Health, Hattiesburg

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

Philip L. Levin, MD President, Gulf Coast Writers Association Emergency Medicine Physician, Gulfport Sharon Douglas, MD

Professor of Medicine and Associate Dean for VA William Lineaweaver, MD Education, University of Mississippi School of Medicine, Editor, Annals of Plastic Surgery Associate Chief of Staff for Education and Ethics, Medical Director G.V. Montgomery VA Medical Center, Jackson JMS Burn and Reconstruction Center, Brandon Bradford J. Dye, III, MD Ear Nose & Throat Consultants, Oxford Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist, The Street Clinic, Vicksburg Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson

118 JOURNAL MSMA

May 2015

Jason G. Murphy, MD Surgeon, Surgical Clinic Associates, Jackson Ann Myers, MD Rheumatologist Mississippi Arthritis Clinic, Jackson Darden H. North, MD Obstetrician/Gynecologist Jackson Health Care-Women, Flowood Michelle Y. Owens, MD Associate Professor, Vice-Chair of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson Jimmy L. Stewart, Jr., MD Program Director, Combined Internal Medicine/ Pediatrics Residency Program, Associate Professor of Medicine and Pediatrics University of Mississippi Medical Center, Jackson Samuel Calvin Thigpen, MD Hematology-Oncology Fellow, Department of Medicine University of Mississippi Medical Center, Jackson Thad F. Waites, MD Clinical Cardiologist, Hattiesburg Clinic W. Lamar Weems, MD Urologist, Jackson

Michael D. Maples, MD Vice President and Chief of Medical Operations Baptist Health Systems

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

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

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

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

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

May 2015 JOURNAL MSMA 119

• Scientific Articles • An Assessment of Emergency Department Use among Mississippi’s Medicaid Population Benjamin H. Walker, MS; John S. McCown, MS; Diana Bowser, ScD, MPH; Alison Patev, BA; Frances Shechter Raede, MPH; Moaven Razavi, PhD; David Dzielak, PhD; Linda H. Southward, PhD

A

Key Words: Medicaid, Delivery of Health Care, Emergency Medical Services

bstract

Background

National trends in Emergency Department (ED) use suggest Medicaid recipients visit the ED more frequently and make more non-emergent ED visits than those uninsured and privately insured. Given the absence of data on Medicaid beneficiaries in Mississippi, it is important to explore their ED utilization, particularly frequent and non-emergent ED visits.

Method

Medicaid claims data were used to calculate ED visit rates and identify common diagnoses within the Mississippi Medicaid population. Non-emergent ED visits were classified using the NYU ED algorithm.

Results

In 2012, 605,555 ED claims were made by 290,324 Medicaid beneficiaries in Mississippi, representing 43.7% of the Medicaid population (664,583). Twelve percent of ED users were frequent users (4 or more claims per year). Most claims (57.5%) were non-emergent, meaning they could have been treated in a primary care setting.

Conclusion

High rates of non-emergent ED visits suggest gaps in primary care delivery for Mississippi Medicaid beneficiaries.

Author Affiliations: Research Associates (Walker, McCown), Graduate Research Assistant (Patev), Research Professor (Southward), Mississippi State University, Social Science Research Center; Scientist, Lecturer and Director, MS Program in International Health Policy and Management (Bowser), Graduate Research Assistant (Raede), Senior Research Associate (Razavi), Brandeis University, The Heller School for Social Policy and Management; Executive Director (Dzielak), Mississippi Division of Medicaid.

Corresponding Author: Benjamin H. Walker, Social Science Research Center, Mississippi State University, 1 Research Blvd., Suite 103, P.O. Box 5287, Mississippi State, MS 39762. Telephone: 662-325-2099, Fax: 662-325-7966, E-mail address: ben.walker@ssrc.msstate.edu

Conflicts of Interest/ Funding Support: None.

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Introduction

In the general population, Emergency Department (ED) visits in the United States have increased 23% from 1997 to 2007.1 This increase in overall ED use is a concern as is the disproportionate use of the ED by a small proportion of the Medicaid population. Nationwide, roughly 8% of all ED users account for 28% of ED visits, suggesting systemic reasons behind frequent use.2 The ED is an expensive place to receive care and it should therefore be avoided when possible, particularly when care by a primary care provider (PCP) is more appropriate.

In the literature, the definition of frequent use varies. In this study, we use the definition provided by Weber and colleagues as four or more visits to an ED over a 12-month period.3 Although it is widely believed that most frequent ED users are uninsured individuals, recent research indicates that frequent users of the ED are more likely to be Medicaid recipients.4 A randomized control trial conducted in Oregon found that obtaining Medicaid coverage increased the likelihood of making ED visit by 40%, as compared to use by the eligible non-covered population.5 Frequent use of EDs by Medicaid recipients raises concerns about whether frequent users are using the ED appropriately or not. Individuals who visit the ED frequently, such as the severely or chronically ill, are not necessarily using these services inappropriately, as they often require emergency level care.6 Other individuals may use the ED for services that could have been treated in a primary care setting, which would make the use of the ED inappropriate. One goal of this study is to determine if ED users in the Mississippi Medicaid population are using the ED inappropriately, which could have implications for spending. Such an analysis is particularly important in Mississippi which has more room for improvements in health and economic outcomes compared to most other states.

A common method used to determine the appropriate use of EDs is by assessing the urgency of the ED visit based on classifying the reason for the visit into non-emergent and emergent categories.7 Non-emergent conditions are illnesses that can

be treated in a primary care setting, while emergent conditions require immediate emergency care. Medicaid recipients have been shown to have higher rates of non-emergent ED use than other individuals.5 Higher non-emergent ED use in an area may be linked with lower access to primary care providers.8 Results from an assessment of ED use in North Carolina suggest the lack of access to a PCP as the reason behind an increase number of nonemergent ED visits.9 The Utah Department of Health’s analysis of ED visits in the state also found that more non-emergent ED visits were related to less access to PCP’s.10 Additionally, patients whose PCP was closer in proximity than an ED and more often available were less likely to make non-emergent ED visits.12 Therefore, non-emergent ED use may indicate inadequate PCP access in a given area.8 Moreover, areas with higher concentrations of PCPs tend to have fewer ED visits for ambulatory-care sensitive conditions (ACSH), also known as potentially preventable hospitalizations.11 Therefore, examining non-emergent ED use in Mississippi may also help to understand access to primary care.

There has been minimal research examining ED use by Medicaid recipients in Mississippi. The only other published figure on ED use by Medicaid recipients is a figure from 2002 reporting that 26% of Medicaid beneficiaries had visited an ED during that year.13 This publication is timely, because as Mississippi continues to expand its Medicaid programs, it will be important to understand why Medicaid recipients are using EDs and for what type of conditions. The goal of this study is to examine ED outpatient visits using Medicaid claims data, and identify the populations that use the ED frequently and/or unnecessarily. Through analysis of diagnoses, focusing on type, severity and frequency of outpatient ED visits, we were able to identify groups within the Medicaid population that should be target of future policies. This study is an initial step towards better understanding and improving the health delivery system.

Methods

This study used Mississippi Medicaid Claims data for the year 2012 to analyze the use of emergency departments (ED) among the Medicaid population. In the year 2012, there were a total of 664,583 Medicaid beneficiaries. Of this number, 290,324 used the ED for a total of 605,555 ED claims. Using the Medicaid Claims data for Mississippi, we calculated ED usage rates and common diagnoses by age categories, gender, and race categories.

Classification of Diagnoses Claims data often contains multiple diagnostic codes.

The primary diagnosis was considered to be the main reason for admission to the ED, while the secondary diagnoses reflected co-existing clinical conditions. These diagnoses were coded according to the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). The Clinical Classifications Software (CCS) developed by the Agency for

Healthcare Research and Quality (AHRQ) was used to collapse the 14,000 diagnoses and 3,900 procedure codes into a manageable number of clinically meaningful categories.

Frequency of Usage Claims were grouped and ranked by diagnoses (ICD-9 code). This process was first completed for all Medicaid beneficiaries and was then repeated for different age groups and race categories. In order to allow for comparisons across groups, claim rates per 1,000 Medicaid population beneficiaries were also calculated. This was important because different groups comprise different proportions of the state’s Medicaid population. In addition, using claims per 1,000 population accounted for the different population sizes within cohorts, which could bias the total claims numbers.

Determining Claim Severity The NYU algorithm was used to determine the severity of the ED claim.7 The NYU algorithm assigned the probability that a given ICD-9 code fell into one of four categories: 1) nonemergent (NE); 2) emergent (requires medical attention within 12 hours) but primary care treatable (PCT); 3) emergent but not treatable in primary care but preventable or avoidable (EPA); and 4) emergent and not preventable or avoidable (ENPA). The algorithm categorized rare diagnoses and treated mental health, substance abuse, and injuries separately. We used the probabilities derived from the algorithm to classify the claim as being emergent, non-emergent, or intermediate, consistent with the methodology used by Ballard and colleagues.14 It was important to note that since patients who were hospitalized were not captured in the Medicaid outpatient data, the proportion of emergent claims for this analysis was not truly representative of all Medicaid ED visits—only those that did not result in an admission.

Results

Classification of Primary Diagnoses Table 1 shows the most frequent reasons for ED claims for each age group. For beneficiaries ages 18-44, complications of pregnancy (8%) was the most common diagnosis for an ED claim. For beneficiaries ages 45-64, spondylosis or other back problems (6.4%) was the most frequent concern. For older adults ages 65-84, nonspecific chest pain (5.5%) was the most common reason for ED treatment, while for adults ages 85 and older, superficial injury or contusion was the most frequent cause for an ED claim.

Table 2 shows the most frequent reasons for children’s ED claims for each age group. The most common reason for an ED claim for all groups of children was upper respiratory infection.

Otitis media was the second most common for children ages 0-5; for older children (ages 6-17) the second most common was superficial injuries and contusion. Asthma appeared as the fourth leading diagnosis for children ages 6-11.

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Frequency of Usage Figure 1 shows the claim frequency (per 1,000 Medicaid beneficiary population) by race # Diagnosis (% within each age category) Claims Percentage and age categories. As is shown in Figure 1, the Medicaid beneficiary claim rate for all benefiAges 18-44 ciaries is 911 per 1,000 beneficiaries. Both black 1 Other complications of pregnancy 14,477 8.0% and white beneficiaries claim rates are simi2 Other upper respiratory infections 12,131 6.7% lar to the overall rate, with black beneficiaries 3 Abdominal pain 8,646 4.8% 4 Headache; including migraine 8,443 4.7% making 910 claims per 1,000 and whites mak5 Urinary tract infections 7,205 4.0% ing 890 per 1,000. Children less than one year Ages 45-64 of age had the highest claim rate (1,433/1,000) 1 Spondylosis; intervertebral disc disorders; other back problems 6,264 6.4% of any age group followed by adults ages 18-44 2 Nonspecific chest pain 5,715 5.9% (1,283/1,000).

3 Abdominal pain 4,272 4.4% The 290,324 Medicaid ED users represent 4 Superficial injury; contusion 4,138 4.3% 5 Headache; including migraine 3,718 3.8% 43.7% of the average number of beneficiaries Ages 65-84 (664,583) in 2012. As shown in Table 3, the 1 Nonspecific chest pain 2,193 5.5% majority of Medicaid beneficiaries who visited 2 Superficial injury; contusion 2,018 5.0% an ED made only one claim that year (23.1%).

3 Urinary tract infections 1,631 4.1% Frequent use of the ED is often defined as four 4 Spondylosis; intervertebral disc disorders; other back problems 1,540 3.8% 5 Chronic obstructive pulmonary disease and bronchiectasis 1,513 3.8% or more visits per year (Weber et al., 2005).

Ages 85+ Using this threshold, 5.7% (38,218) of all ben1 Superficial injury; contusion 764 7.6% eficiaries qualified as frequent users, or 12% 2 Urinary tract infections 631 6.3% of all ED users. Although not shown in Table 3 Other gastrointestinal disorders 419 4.2% 3, the proportion of beneficiaries who made at 4 Nonspecific chest pain 402 4.0% least one ED visit for 18-64 year olds in 2012 is 5 Fluid and electrolyte disorders 336 3.4% 47.6%. Payment data shows that frequent users accounted for over one-third (34%) of fee-forservice expenditures, approximately $36 million.

Table 2. Five Most Frequent Reasons for Emergency Figure 1. ED Claim Rate by Race and Age (per 1,000) Department Claims for Children by Age Table 1. Five Most Frequent Reasons for Emergency Department Claims for Adults by Age

#

Diagnosis (% within each age category)

Ages < 1 year 1 Other upper respiratory infections 2 Otitis media and related conditions 3 Fever of unknown origin 4 Acute bronchitis 5 Viral infection Ages 1-5 1 Other upper respiratory infections 2 Otitis media and related conditions 3 Superficial injury; contusion 4 Fever of unknown origin 5 Influenza Ages 6-11 1 Other upper respiratory infections 2 Superficial injury; contusion 3 Sprains and strains 4 Asthma 5 Open wounds of extremities Ages 12-17 1 Other upper respiratory infections 2 Superficial injury; contusion 3 Sprains and strains 4 Abdominal pain 5 Skin and subcutaneous tissue infections

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Claims

Percentage

10,108 5,301 2,804 2,398 2,096

22.7% 11.9% 6.3% 5.4% 4.7%

25,303 11,768 6,657 6,071 3,988

21.3% 9.9% 5.6% 5.1% 3.4%

10,508 4,879 2,325 2,135 2,131

17.4% 8.1% 3.9% 3.5% 3.5%

6,287 4,719 4,597 1,943 1,885

11.5% 8.6% 8.4% 3.6% 3.4%

Claim Severity As shown in Table 4, approximately 57.5% (348,242) of ED claims made by Medicaid beneficiaries were non-emergent; that is, their conditions did not necessitate ED treatment and could have been taken care of safely by a primary care provider.

Of the outstanding claims, 9.1% (55,256) were emergent; that is, their conditions needed to be treated in an ED setting. The remaining 33% (202,057) were intermediate, mental health or injury related claims, or were unclassified. Analysis of payment data shows that non-emergent claims by fee-for-service beneficiaries represented $54 million in fee-for-service payments.

Table 3. Frequency of Claims Frequency Beneficiaries

Percent (Beneficiaries)

Percent (Only ED Users)

0 Claims 1 Claim 2 Claims 3 Claims 4 Claims 5-7 Claims 8+ Claims

56.3% 23.1% 10.1% 4.7% 2.4% 2.5% 0.8% 100.0%

--52.9% 23.0% 10.8% 5.6% 5.6% 1.9% 100.0%

374,259 153,723 66,894 31,489 16,232 16,398 5,588 664,583

Table 4. Proportion of ED Outpatient Claims by Severity Emergency Status

Claims

Percentage

Non-Emergent Emergent Intermediate Injury diagnoses Mental health diagnoses Drug and alcohol-related diagnoses Unclassified Total

348,242 57.5% 55,256 9.1% 8,119 1.3% 102,371 16.9% 7,588 1.3% 1,736 0.3% 82,243 13.6% 605,555 100%

Table 5. Non-Emergent Claims by Demographics Characteristic

Non-Emergent Claims

Non-Emergent %

Age < 1 year 29,203 65.7% 1-17 years 138,327 59.2% 18-44 years 107,260 59.5% 45-64 years 50,882 52.4% 65-84 years 18,640 46.5% 85+ years 3,930 39.2% Sex Male 120,555 53.2% Female 227,643 60.1% Race White 111,732 54.0% Black 210,264 59.7% Other/Unknown 26,246 56.2%

In order to better understand non-emergent use of the ED, percentages were calculated for different ages, sex and race categories. Table 5 shows that that children under one year of age had the highest percentage of non-emergent use (65.7%) when compared to other age groups (range of 39.2% to 59.5%).

Our results also showed that females had a higher percentage of non-emergent use when compared to males (60.1% vs. 53.2%), and blacks had a higher percentage of non-emergent use when compared to whites (59.7% vs. 54%).

Discussion

To our knowledge, this is the first in-depth study of emergency department use in the Mississippi Medicaid population. According to the data presented in this report,

290,324 Medicaid beneficiaries used the ED for outpatient services at least once during the year 2012 for an ED visit rate of 43.7%. Although a minority of these ED users in 2012 (12%) were frequent users (4+ claims per year), payment data shows they had a disproportionate economic impact, accounting for over one-third (34%) of fee-for-service expenditures or approximately $36 million.

With regard to national figures of ED use among Medicaid beneficiaries, the Mississippi rate of beneficiaries (ages 18-64) who visited the ED one or more times in 201215 is higher at 47.6% compared to 39.7% nationally. Analyzing ED claims by demographics has revealed several important findings.

Although national ED visit rates by Tang and colleagues show that blacks and whites vary widely (721.3/1,000 vs.

360.6/1,000)1, in our study blacks and whites had similar rates, 910/1,000 and 890/1,000 respectively. The differences in these findings are likely due in part to differences in socioeconomic and insurance status. Because our study consisted entirely of Medicaid recipients, blacks and whites in our study all qualify for Medicaid which means they are in a similar socioeconomic bracket, whereas in Tang et al., the ED visit rates by race were collapsed across insurance status (i.e., private, Medicaid, Medicare, uninsured), which could then bias the results due to difference in income levels. This finding suggests that, given similar health insurance and hence socioeconomic status, blacks and whites visit the ED at a similar rate in Mississippi.

The high ED visit rates for children under one year of age (1,433 claims/1,000 beneficiaries) and ages 1-5 years old (982 claims/1,000 beneficiaries) could suggest certain failures in care delivery in Mississippi for this population. Our examination of the principal reasons for ED visits in these age groups suggests that many of these children are using the ED for conditions that could be treated or managed by effective primary care. For example, the top two reasons for ED visits in these age groups were upper respiratory infections (i.e., common cold) and otitis media (i.e., inner ear inflammation). These findings underscore important policy considerations for the state of Mississippi, particularly in terms of the need for increasing preventive care among children and assessing the utilization and effectiveness of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program in Mississippi.

The results of our analysis also show that a large proportion of ED visits is for non-emergent conditions which contribute to unnecessary Medicaid costs. In fact, these nonemergent claims represent nearly $54 million in fee-for-service payments in 2012. It is likely that many of these non-emergent visits are due to a lack of access to primary care. Medicaid beneficiaries frequently cite lack of availability and access to a PCP as reasons to use ED services.16,17 In Mississippi, there is evidence to suggest that Medicaid beneficiaries have greater barriers to accessing PCPs than the privately insured.

Cossman and colleagues found that 38% of PCP offices in Mississippi were not accepting new Medicaid patients, while

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only 7% were not accepting privately insured patients.18 That is, being enrolled in Medicaid alone does not ensure access to primary care. This highlights the need for further investigation into possible shortcomings of the infrastructure and provision of primary care for Medicaid recipients in the state. However, a lack of access to primary care does not completely explain why Mississippi Medicaid recipients are reliant on the ED for care. Therefore, additional methodologies (e.g., surveys, field studies) should be used to better understand the reasons that Medicaid beneficiaries have for visiting the ED for nonemergent conditions (i.e., convenience, perceived severity of illness, availability of specialist care).

As mentioned above, while the analysis of outpatient ED visits for the Medicaid population is interesting and has important policy implications, the larger impact on costs in Mississippi can only be studied by examining the events and encounters that follow the ED visit as they move through inpatient and the referral process. For example, it is important to know how many of those who come to the ED are then admitted for inpatient hospital services. The national figure shows that 47% of Medicaid hospital admissions come from the ED which could lead to significant spending in Mississippi, as hospital inpatient care (among all insurance groups) accounts for approximately one-third of healthcare spending across the country.19 A limitation of the analysis above was the inability to identify the key characteristics of the individuals in the Medicaid population. The authors did not have access to a comprehensive database that included detailed information on individual beneficiaries in the Medicaid population who did not use the ED. As an approximation in the analysis above, we used the age, race, and gender reported in Medicaid enrollment files. However, an ideal linking between the claim files and the enrollment file at the beneficiary level is necessary to analyze through causal pathways between demographic and ED usage patterns as well as to compare the utilization measures with other states and national benchmarks.

In summary, the findings from this study show high rates of ED use in the Mississippi Medicaid population, particularly among young children. Much of this is for non-emergent conditions which can be reduced by removing potential barriers to primary care. Future research should investigate the reasons for over-reliance on the ED, including more research to understand the potential contribution of convenience, perceived severity, availability of providers, or geographic location. Such research will help identify risk factors for frequent and nonemergent ED use in order to coordinate care within specific populations and geographies.

References 1.

Tang N, Stein J, Hsia RY, Maselli JH, Gonzales R. Trends and characteristics of US emergency department visits, 1997-2007. JAMA. 2010;304(6):664-670. doi:10.1001/jama.2010.1112.

2. Hunt KA, Weber EJ, Showstack JA, Colby DC, Callaham ML.

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Characteristics of frequent users of emergency departments. Ann Emerg Med. 2006;48(1):1-9. doi:10.1016/j.annemergmed.2005.12.030.

3. Weber EJ, Showstack JA, Hunt KA, Colby DC, Callaham ML. Does lack of a usual source of care or health insurance increase the likelihood of an emergency department visit? Results of a national populationbased study. Ann Emerg Med. 2006;45(1):4-12. doi:10.1016/j. annemergmed.2004.06.023.

4. Peppe, EM, Mays, JW, Chang, HC; Kaiser Family Foundation.

Characteristics of frequent emergency department users. http:// kaiserfamilyfoundation.files.wordpress.com/2013/01/7696.pdf.

Published October 2007. Accessed April 14, 2014.

5. Taubman, SL, Allen, HL, Wright, BJ, Baicker, K, Finkelstein, AN. (2014).

Medicaid increases emergency-department use: Evidence from Oregon’s health insurance experiment. Science. 2014;343:263-268. doi:10.1126/ science.1246183.

6. Pines JM, Asplin BR, Kaji AH, et al. Frequent users of emergency department services: Gaps in knowledge and a proposed research agenda. Acad Emerg Med. 2011;18(6):64 – 69. doi: 10.1111/j.1553-2712.

2011.01086x.

7.

Billings, J, Parikh, N, Mijanovich, T; The Commonwealth Fund.

Emergency department use: The New York story. In: Issue Brief. http:// www.commonwealthfund.org/usr_doc/billings_ nystory.pdf. Published November 2000. Accessed August 18, 2014.

8. Ansari, Z, Laditka, JN, Laditka, SB. Access to primary health care and hospitalization for ambulatory care sensitive conditions. Med Care Res Rev. 2006;63(6):719-741.

9. McWilliams, A, Tapp, H, Barker, J, Dulin, M. Cost analysis of the use of emergency departments for primary care services in Charlotte, North Carolina. N C Med J, 2011;72(4):265-271.

10.

Utah Department of Health. Primary care sensitive emergency department visits in Utah, 2001. Salt Lake City, UT: Utah Department of Health Center for Health Data; 2004.

11. Laditka, JN, Laditka, SB, Probst, JC. More may be better: Evidence that a greater supply of primary care physicians reduces hospitalization for ambulatory care sensitive conditions. Health Serv Res. 2005;40(4):11481166.

12.

Villani, J, Mortensen, K. Nonemergent emergency department use among patients with a usual source of care. J Am Board Fam Med. 2013;26(6):680 – 691.

13. Cossman, J, Sansing, W, Burson, I, Crudden, A; Mississippi Health Policy Research Center. The demographics of emergency room visits for Mississippi Medicaid beneficiaries. http:// www.nemsahec.msstate.edu/ publications/policybriefs/ERDemo graphics.pdf. Published July 2007.

Accessed April 14, 2014.

14. Ballard, D W, Price, M, Fung, V, et al. Validation of an algorithm for categorizing the severity of hospital emergency department visits. Med Care. 2010;48:1-15. doi: 10.1097/MLR.0b013e3181bd49ad.

15. National Center for Health Statistics (NCHS), U.S. Department of Health and Human Services. Health, United States, 2013. Table 87. http://www. cdc.gov/ nchs/hus/contents2013. Accessed April 18, 2014.

16. Gindi, RM, Cohen, RA, Kirzinger, WK; Center for Disease Control and Prevention. Emergency room use among adults aged 18-64: Early release of estimates from the National Health Interview Survey, January - June 2011. http://www.cdc.gov/nchs/data/nhis/earlyrelease/emergency_ room_use_january-june_2011.pdf. Published May 2012. Accessed April 14, 2014.

17. Wang, L, Tchopev, N, Kuntz-Melcavage, K, Hawkins, M, Richardson, R. (2014). Patient-reported reasons for emergency department visits in the urban Medicaid population. Am J Med Qual. 2014;29:1-5. doi:10.1177/1062860614525225.

18. Cossman, RE, Cossman, JS, Rogers, S, et al. Access to primary care physicians differs by health insurance coverage in Mississippi. South Med J. 2014;107(2):87-90. doi: 10.1097/SMJ.0000000000000057.

19. Morganti, KG, Bauhoff, S, Blanchard, JC, et al. The Evolving Role of Emergency Departments in the United States Research Report. Santa Monica, CA: RAND Health; 2013.

• Top 10 Facts You Should Know • Synthetic Cannabinoids: Not So Nice Spice Ann Kemp, RPh, MD; Molly Clark, PhD; Thomas Dobbs, MD, MPH; Robert Galli, MD; Justin Sherman, Pharm D; Robert Cox, MD, PhD

I

ntroduction

Recent outbreaks of synthetic cannabinoid-related emergency department visits across the country have been in the news lately, most notably in Alabama, Louisiana, Texas, and close-to-home here in Mississippi. As of May 11, 2015, in Mississippi there have been over 1000 emergency department visits with 9 % requiring ICU admission, 11% requiring nonICU admission, and at least 14 possibly related deaths.1 During April and into May, 25-50 patients per day were presenting to the emergency departments across the state because of these exposures,1 so the numbers when this article goes to press may well be much, much higher than the ones cited. Because of the growing prevalence of this problem, providers should be aware of the facts.

1. Synthetic cannabinoids are not marijuana/cannabis.

Also known as Spice, these illegal substances are commonly referred to in publications and the news as synthetic cannabinoids, cannabinoid receptor agonists, cannabimimetic agents, synthetic marijuana or even legal marijuana; however, they should not be confused with marijuana/cannabis or the legal synthetic cannabinoids/ cannabinoid receptor agonists such as Cesamet® (nabilone) or Marinol® (dronabinol; Δ9-tetrahydrocannabinol). Synthetic cannabinoids are not marijuana/cannabis but rather a collection of numerous laboratory chemicals that interact with the cannabinoid receptor in the brain to mimic marijuana to induce a marijuana-like high. The synthetic chemicals designed to mimic marijuana bind to the same cannabinoid receptors in the brain as delta 9-tetrahydrocannabinol (Δ9-THC), the primary psychoactive component of marijuana.2 Author Affiliations: Associate Professor and Family Medicine Associate Residency Director, Department of Family Medicine, Clinical Associate Professor of Pharmacy Practice, School of Pharmacy (Kemp); Assistant Professor and Psychology Fellowship Director, Department of Family Medicine (Clark); Professor, Executive Director Telemergency (Galli); Associate Professor of Pharmacy Practice, School of Pharmacy, Affiliate Faculty Family Medicine Department (Sherman); Professor, Medical Toxicology Service Director, Medical Director, Mississippi Poison Control Center (Cox), University of Mississippi Medical Center, Jackson, MS; State Epidemiologist, Mississippi State Department of Health (Dobbs).

Corresponding Author: Thomas Dobbs, MD, MPH; State Epidemiologist, Mississippi State Department of Health, 570 East Woodrow Wilson Drive, Jackson, Mississippi 39215. Phone: 601-576-7725 (Thomas.

Dobbs@msdh.ms.gov)

2. Synthetic cannabinoids are often more potent than marijuana/cannabis.3 One of the reasons spice may be more potent than marijuana is because the chemical components bind more strongly to the cannabinoid receptor in the brain and they also may interact with other receptors in the brain that marijuana does not.3 Patients’ symptoms with synthetic cannabinoid intoxication may resolve spontaneously and without intervention. Symptoms vary including mild to moderate intoxication-like symptoms, nausea, vomiting, weakness, tachycardia, hypertension, and agitation.1,3 Many of the symptoms suggest some degree of amphetamine-like activity. Several news reports have described users in a state of “excited delirium,” significantly agitated, tearing off their clothes and sweating profusely. Some patients have had severe symptoms such as significant cardiac arrhythmias, myocardial infarction, psychosis, respiratory depression, flaccid paralysis, hyperthermia, rhabdomyolysis, seizures, coma and even death.1,3,4 Management of synthetic cannabinoid intoxication depends on presentation and usually centers on addressing the airway, breathing, and circulation (ABCs) and life-threatening issues first, followed by supportive care.3,4 Fluid resuscitation may be needed as well as electrolyte correction.3 Benzodiazepines are usually first line treatment for anxiety and agitation.4,5 The use of physical restraints may be necessary.3 Some patients may have significant psychosis with behavioral disturbances and cannot be calmed with typical methods; in these instances, antipsychotics may be helpful.4,5 Anecdotally, some of the patients in the recent emergency department visits presented with significant psychotic behaviors and were “out of control;” the atypical antipsychotics seemed to assist more than the benzodiazepines in those cases. Note, however, that caution should be used with antipsychotics and other medications that can decrease seizure threshold since there have been reports of synthetic cannabinoids causing seizures.3,4 Because the presentations of synthetic cannabinoid intoxication are so varied, the treatment is individualized by scenario; therefore, the specific treatments used, how long to observe the patient in the emergency department and whether or not to admit (non-ICU or ICU) should be decided on a case-by-case basis and depend on

May 2015 JOURNAL MSMA 125

the severity of the symptoms and co-morbid conditions.

The Mississippi Poison Control Center (800-222-1222) can assist with management questions. All cases should be reported to the Mississippi Poison Control Center.

3. Synthetic cannabinoids are ever-changing.

In 2012, the Synthetic Drug Abuse Prevention Act was passed and made 26 synthetic chemicals Schedule I, among them 15 fifteen synthetic cannabinoids.6 The Drug Enforcement Administration (DEA) continues to designate active chemicals and their analogs most frequently found in Spice as Schedule I controlled substances; this makes these products illegal to sell, buy, or possess.7 One of the latest expansions of the law occurred in January 2015 with the addition of three more chemical formulations of synthetic cannabinoids; AB-CHMINACA was one of three added 8 (Figure 1). However, the clandestine manufacturers of these products continue to change the chemical formulations to evade law enforcement.2 MAB-CHMINACA is an example of one Figure 1: of the newer formulations; one can see how the chemicals have been tweaked Δ9-THC resulting in the difference between AB-CHMINACA and MAB-CHMINACA (Figure 1).

Like all of these emerging synthetic AB-CHMINACA cannabinoids, the full extent of their physiological and toxicological effects is unknown at this time. Some states have enacted MAB-CHMINACA broad/generic lanSource: Courtesy of Cayman Chemical Company guage describing synthetic cannabinoids and analogs; for example, in Mississippi, all synthetic cannabinoids are currently illegal per the Mississippi Controlled Substance Act (MS Code 4129-113). However, because synthetic cannabinoids are not marijuana, they will not show up as marijuana on a typical urine drug screen.2 Confirmation testing such as gas chromatography/ mass spectrometry (GC/MS) will detect some specific synthetic cannabinoid compounds; however, because the chemical components of these synthetic cannabinoids are changing so rapidly, they will more than likely be undetectable even with confirmation since “their identification and quantitative analysis are limited by the availability of Figure 1 with THC,

AB and MAB.pdf

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pure reference samples.”9 The latest chemical components that led to the recent emergency department visits were identified because they were specifically sent for toxicology investigation.10 Of course, this does not happen on routine drug screening. Some patients have even stated that part of the reason that they used the products was to avoid detection through routine drug screens.3,11 4. Synthetic cannabinoid research was “hijacked.”12 Synthetic cannabinoid research began over 40 years ago to evaluate their use as pharmaceutical agents.13 These synthetic cannabinoids were never designed to be abused as they are today but were legitimate scientific and medical research. One such example is the research of synthetic cannabinoid analogs developed by Dr. J. W. Huffman, a chemist at Clemson Figure 2: University in the 1990s, to explore the cannabinoid Acsystem.11,13 cording to an news interview in April 2015, Dr. Huffman JWH-018 never intended the compounds he developed for human c o n s u m p t i o n . 14 U n f o r t u n a t e l y, HU-210 clandestine manufacturers began ilSource: Courtesy of Cayman Chemical Company legally synthesizing some of the compounds and distributing for illicit use. Early examples of legitimate research compounds that started showing up in illegal products include JWH-018 (named for Dr. Huffman) and HU-210 (from Hebrew University research) as well as other analogs (Figure 2).11, 12, 13 The products were seen in Europe as early as 2004 and the first DEA forensic lab detection of these products was in 2008.12 Thus emerged the abuse of the original research.

Figure 2 JWH-018 and HU-210.pdf

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5. Synthetic cannabinoids are dangerous chemicals with unknown human toxicity.

Because they are rapidly changing products sprayed on unknown varied herbs, they can be very dangerous. The user does not really know what he/she is inhaling or consuming because the amount of drug is unknown, the herbs used are unknown, and there are no quality controls used in the production process. The vast majority of these chemicals have never been evaluated in a controlled setting with laboratory animals or humans. Many of these products are laced with a variety of substances ranging from simple flavors to more dangerous substances such as other drugs, rat

poison, and embalming fluids.15 Numerous adverse events in the medical literature have been reported after a single inhalation.

6. Synthetic cannabinoids have many street names.

Examples of common street names/“trade names” for synthetic cannabinoids include Spice, “K2,” “Angry Birds,” “Bhang,” “Bliss,” “Dr. Feel Good,” fake weed, “Gangsta,” “Killa Gorilla,” “Mojo,” “Outer Space,” “Scooby Snax,” “Mr. Nice Guy,” “Sexy Monkey,” and “Tomcat.”3,15 According to the Mississippi Bureau of Narcotics, “Scooby Snax” and “Mojo” are two common street names in Mississippi among others (Figures 3, 4, and 5) and the trade names along with catchy packaging are constantly emerging as dealers try to market and sell their products.15 Part of marketing and trying to increase sales can include adding different flavors or other drugs to the mix such as methamphetamine, ecstasy, bath salts, or PCP, making the products even more dangerous.15 Trade names are not necessarily indicative of a specific synthetic cannabinoid, and any available type could be present in any labeled package.

Synthetic cannabinoids can also be purchased in unlabeled plastic bags (Figure 6). Newly introduced synthetic cannabinoids, with unknown toxicities, may be sold under previously used names. It is important for providers to be aware of the vernacular being used and try to keep abreast of the changing terms. The best way to do this is to ask patients specifically what they are using, and if a patient uses an unfamiliar term, ask for clarification.

Figure 4

Figure 5

All figures on this page are used with permission of the Mississippi Bureau of Narcotics.

Figure 3

Figure 6

May 2015 JOURNAL MSMA 127

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7. Synthetic cannabinoids usage is not limited to young people.

According to the 2014 Monitoring the Future Survey, although spice is #3 on the top drugs used by 12th graders at 5.8% using in the past year,16 it has fallen in use steadily since 2012.17 Its overall decline nationally with young people according to the National Institute on Drug Abuse (NIDA) stems from increased perception of risk.17 But the recent outbreak could represent that the perception of risk is reversing and that its use is not limited to young people.

Based on Mississippi Emergency Medical Services Information System which tracks Emergency Medical Service calls, the ages for the recent synthetic cannabinoid emergency department visits have ranged from 12-69. When patients have been asked why they would choose to try these products, perceived safety and availability may have played a role; however, the fact that the product is not picked up on random work drug screens has also been cited.3 Furthermore, the stereotypes of who may be abusing drugs may change by the year 2020.18 The need for substance abuse treatment in those 50 years of age and older is estimated to triple due to the impact of baby boomers aging and this age group’s experiences of drug use in the past.18 8. Synthetic cannabinoids are easily obtained.

According to the Mississippi Bureau of Narcotics, the majority of cases of synthetic cannabinoids in Mississippi involved individual drug dealers who are likely selling chemicals that are being manufactured overseas (i.e. China or India) and being imported into the United States. A recent article in the The Guardian stated that the majority of these chemicals are being produced in China which is now being called the “new front in the global drug war.”10 The chemicals used are usually white mixed with acetone and then typically sprayed onto a concoction of herbs; they can also be in a liquid form, dissolved in propellant intended for e-cigarette use/vaping.8 The “herbal” products resemble potpourri and may be marketed as incense.7 Most of the time the products are labeled “not for human consumption”3 with no instructions/doses for human use, but the product is intended to be either smoked like marijuana, “vaped” or mixed as a herbal infusion to be drunk.2,8 Although, the majority of the spice in the cases in Mississippi was obtained from independent drug dealers,15 spice can also be found at head shops (shops that sell smoking paraphernalia), at gas stations, and on the internet. According to the Mississippi Bureau of Narcotics, cost of spice is usually $10 per gram but can be cheaper in bulk.15 It is big business. An April 2015 news report stated over $8 million dollars of synthetic cannabinoids was seized from a Jackson, Mississippi, apartment.19

9. Synthetic cannabinoids can be addicting with unknown long term consequences.

Proposed factors that contribute to their addiction potential include the increased binding affinity, full agonism of the receptor (THC partially agonizes the receptor), and active metabolites; some bind over 100 times more tightly than THC.9,20 Cannabinoid-1 (CB1) and CB2 receptors are found mainly in the central nervous system and immune tissues, respectively. While both receptor types are affected by synthetic cannabinoids, stimulation of CB1 causes a greater psychoactive effect through its modulation of glutamate and gamma-aminobutyric acid neurotransmitters.21 Due to the unknown chemical content of synthetic cannabinoids and varying activity of related metabolites, effects are unpredictable. Long term consequences and addiction potential are unclear. Long-term users may be vulnerable to new-onset or relapse of psychosis and cognitive deficits including reduced attention span and memory. Withdrawal potential can be unpredictable as well. One case report of a daily user of “Spice Gold” in Germany over an eight-month period reported the patient experiencing drug cravings, sweating, hypertension, headache, restlessness, and nightmares.22 10. Provider Education is key.

Numerous misconceptions about synthetic cannabinoids exist in the community, including erroneous beliefs that these products are safe or that they are a simply a version of marijuana. Any synthetic cannabinoid product is likely to be of different chemical composition and of varying potency at different points of sale, leading to inconsistency in effect. Synthetic cannabinoids can be unsafe in any quantity or frequency of use; using these products is a big risk. It may seem to be a daunting task for providers to keep up with all of the changes in substance abuse trends. However, the NIDA website (www.drugabuse.gov) is a great resource for information on specific substances and trends. The medical and health professionals section of the NIDA website also provides practice resources such as screening tools, patient handouts and continuing education modules. In addition, the Substance Abuse and Mental Health Services Administration (SAMHSA) website (http:// store.samhsa.gov) provides free print resources aimed at assisting physicians in detecting substance abuse, brief interventions, screening, and referral resources for substance abuse. Providers can also use resources that are closer to home. The Mississippi Department of Health Services posts information on its website (http://www.msdh.state. ms.us/) on important new trends and sends out alerts on the Mississippi Health Alert Network. The Mississippi Poison Control Center (800-222-1222) can help with management questions. With the April/May 2015 outbreak of emergency department visits in Mississippi, medical personnel, local and state officials collaborated to identify the compounds

May 2015 JOURNAL MSMA 129

being used locally. Another recent example was cited in the New England Journal of Medicine as providers used similar tactics to help with a synthetic cannabinoid outbreak in Colorado.23

Conclusion

Synthetic cannabinoids have emerged as a significant problem in Mississippi resulting in many emergency department visits and even fatalities. To counter this growing problem, it is imperative that providers be aware of these dangerous substances and their effects on patients. Providers need to keep the use of synthetic cannabinoids in the differential for any patient who presents as described above. Educational tools such as the ones mentioned here are available for physicians to be self-informed. It is important for providers to stay abreast of local trends and, when necessary, partner with pharmacists, law enforcement, toxicologists and mental health providers to discuss trends and treatment options in your area that may be most beneficial as there are regional variations with substance abuse and available resources.

References 1. Source: Mississippi Department of Health and Mississippi Health Alert Network.

2.

National Institute on Drug Abuse.http://www.drugabuse.gov/publications/drugfacts/k2spice-synthetic-marijuanahttp://www.drugabuse.gov/ drugs-abuse/emerging-trends#spice.

12. An Introduction to Synthetic Drugs. http://www.namsdl.org/library/ 2FCED5EA-65BE-F4BB-A59EF19FEBC462FF/.

13.

Seely KA, Lapoint J, Moran JH, Fattore L. Spice drugs are more than harmless herbal blends: a review of the pharmacology and toxicology of synthetic cannabinoids. Progress in Neuro-Psychopharmacology & Biological Psychiatry. 2012;39(2):234-243.

14. WCNC news. http://www.wcnc.com/story/news/local/2015/02/13/ storied-clemson-professor-is-grandfather-of-synthetic-marijuana/23373291.

15. Mississippi Bureau of Narcotics.

16. Monitoring the Future Survey. http://www.monitoringthefuture.org/.

17. National Institute on Drug Abuse. http://www.drugabuse.gov/relatedtopics/trends-statistics/monitoring-future/monitoring-future-surveyoverview-findings-2014.

18. Gfroerer J, Penne M, Pemberton M, Folsom R. Substance abuse treatment need among older adults in 2020: the impact of the aging babyboom cohort. Drug and Alcohol Dependence, 2003; 69 (2): 127-135.

19. Clarion-Ledger. http://www.clarionledger.com/story/news/2015/04/10/ around-million-spice-seized-jackson-apartment/25587753/.

20. Rosenbaum CD, Carreiro SP, Babu KM. Here today, gone tomorrow… and back again? A review of herbal marijuana alternatives (K2, Spice), synthetic cathinones (bath salts, kratom, Salvia divinorum, methoxetamine, and piperazines. J Med Toxicol, 2012; 8: 15-32.

21. Rech MA, Donahey E, Dziedzic JMC, Oh L, Greenhalgh E. New drugs of abuse. Pharmacother, 2015; 35(2): 189-197.

22. Zimmermann US, Winkelmann PR, Pilhatsch M, Nees JA, Spanagel R, Schulz K. Withdrawal phenomena and dependence syndrome after the consumption of “spice gold.” Dtsch Arztebl Int, 2009; 106:464-467.

23. Monte AA, Bronstein AC, Heard KJ, Iwanicki JL. An outbreak of exposure to a novel synthetic cannabinoid. NEJM 2014; 370: 389-390.

3. Lisi, Donna M. Patients May Be Using Synthetic Cannabinoids More Than You Think. JEMS 2014 Sep;39(9):56-9.

4. Wang et al. Synthetic Cannabinoids: Acute Intoxication. Up To Date.

March 2015.

5. Castellanos D, Thornton G. Synthetic cannabinoid use: recognition and management. J Psychiatr Pract. 2012 Mar;18(2):86-93.

6. DEA Office of Diversion Control. http://www.deadiversion.usdoj.gov/ fed_regs/rules/2013/fr0104.htm.

7. DEA Fact Sheet: K2 or Spice. http://www.dea.gov/druginfo/drug_data_ sheets/K2_Spice.pdf 8. DEA Office of Diversion Control. http://www.deadiversion.usdoj.gov/ fed_regs/rules/2015/fr0130.htm.

9. Synthetic cannabinoids and “Spice “ profile; European Monitoring Centre for Drugs and Drug Addiction: http://www.emcdda.europa.eu/publications/drug-profiles/synthetic-cannabinoids.

10. The Guardian. http://www.theguardian.com/society/2015/may/01/chinese-labs-legal-highs-west-drugs.

11. Wiley, JL, Marusich, JA, Huffman JW, Balster RL, Thomas BF. Hijacking of Basic Research: The Case of Synthetic Cannabinoids. Methods Rep RTI Press. 2011 Nov; 2011.

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SPOTLIGHT ON:

Physician Leadership Academy

By Kara Kimbrough

2

Part of the ongoing series of features on the participants in MSMA’s first Physician Leadership Academy.

Series of life changes led TIMOTHY BEACHAM, MD to medicine

G

rowing up in the small Copiah County town of Hazlehurst, Timothy Beacham had ordinary goals. Like most Hazlehurst Middle School students, Copiah-Lincoln Community College just down the road was the likely next step after high school. The untimely death of his mother necessitated a move to Canton, where he graduated from high school. Enrolling in nearby Tougaloo College was the fortuitous next step that put him on the road to becoming a physician. Looking back, he realizes his life would have taken a different path had the series of events not occurred.

“It wasn’t until I was an undergrad at Tougaloo that I even had any contact with a physician,” said Dr. Beacham, now an anesthesiologist at Comprehensive Pain Specialists in Greenville. “I’d always done well in high school math and science courses and enrolled in a summer science camp at Tougaloo before my freshman year. I knew chemistry was something I wanted to pursue, then many of my instructors began talking to me about a medical career. I went along with their suggestions and today am glad that I did.”

Meeting medical pioneer Robert Smith, MD, and Tougaloo chemistry professor Richard McGinnis, PhD solidified his foray into the medical field. The two mentors provided advice and offered encouragement that gave the small town boy the confidence to set the lofty goal of becoming a physician.

After working on research projects for two years at University of Mississippi Medical Center and National Institutes of Health, he was accepted to University of Mississippi School of Medicine. At UMMC, he met Claude Brunson, MD and UMMC Chancellor Wallace Conerly, MD. After learning of his initial desire to become a neurosurgeon both physicians advised the older student to channel his interest into the field of anesthesiology.

“I was still interested in the central nervous system, but as an older student, I realized how long it would take for me to become a neurosurgeon,” he said. “Instead, Dr. Brunson

Joining Dr. Beacham at the State Capitol during his Doctor of the Day service were, front row from left: sons Tim Jr. and Jonathan; back row, daughter Gabbi and wife Drew. The children were out of school for spring break and emjoyed seeing their dad at work.

advised me to look at anesthesiology, which combined my interest in the central nervous system and in pain management. I was able to go into the OR and view the process and I knew I was in the right place. It’s turned out to be a great marriage of the two areas in which I had the most interest.

I’ve loved every minute of it. ” In another successful marriage arena, Dr. Beacham tied the knot with his wife Drew during his third year of mediMay 2015 JOURNAL MSMA 133

cal school. The couple welcomed their daughter during his final year, then added two sons to the family in following years.

“It was extraordinarily important for me to have a career that allowed me to spend time with my family,” said Dr. Beacham. “I’m fortunate in that I settled on a specialty that allows me to keep my priorities in order.”

Dr. Beacham completed his internship and residency in anesthesiology at UMMC, then completed a multidisciplinary pain fellowship there. Spending a good amount of time around Dr. Brunson provided “lots of time to pick his brain,” Dr. Beacham recalls.

Dr. Beacham is now double Board Certified in Interventional Pain Medicine and Anesthesiology. Before joining CPS he served as medical director of Delta Regional Chronic Pain Clinic as well as director of acute pain services at DRMC.

He is the President of the Mississippi Society of Inteventional Pain Physicians. He also serves as President-elect of Mississippi Medical and Surgical Association (MMSA) and former Chairman of the Board of Trustees.

Perhaps from his years at UMMC, which he calls “the best possible learning environment and place to improve skills,” Dr. Beacham continues to strive to become a better physician. Learning to improve communication skills has been one of the most valuable sessions in MSMA’s Physicians Leadership Academy, he says.

“It’s important that physicians serve as leaders and patient advocates,” he said. “We can’t do that if we can’t present our thoughts in an effective, professional manner. The mock interviews and other communication exercises will help me as I strive to speak for myself and others in professional settings.”

PAGE BRANAM, MD toyed with the idea of treating animals before humans

G

rowing up in Miami, Page Branam, MD, felt it was expected that she’d enter the family business. Her mother was a nurse practitioner and many family members and friends were attorneys. Naturally, they assumed she’d follow in their footsteps. Instead, she chose the same path as her mother and went a step further by obtaining her medical degree.

“You could have heard a pin drop when I told my family I was planning to enter the medical field,” said Dr. Branam, now a Jackson-area anesthesiologist. “They really wanted me to become an attorney. It was simply not a field in which I could envision myself.”

As a student at the University of Miami, she enjoyed the math and science courses and was named top bio-chemistry student. Excelling in the prerequisites for medical school gave her the assurance she’d made the right career choice.

A love of animals sent her on a brief detour to the field of veterinary medicine. After one year, the negative aspects of dealing with pet owners who chose not to extend sick animals’ lives became too much to handle. She decided to move full-steam ahead into the field of medicine.

Dr. Branam earned a bachelor’s degree in biochemistry from the University of Miami and a medical degree at St George’s School of Medicine. She completed clinical rotations at Methodist Hospital in Brooklyn, followed by an internship and residency in anesthesiology at Louisiana State University Health Science Center in Shreveport.

During her internship at LSU she met her husband, Juan Villani, MD, also a practicing anesthesiologist in Jackson.

Her chosen field provides regular affirmation she chose 134 JOURNAL MSMA May 2015

the right specialty, Dr. Branam says. Becoming a patient while dealing with an illness during medical school provided insight into the mindset of those undergoing treatment.

It’s a lesson she carries with her and utilizes in day-to-day patient interactions.

“Anesthesiology has a long history of patient advocacy,” she said. “The mind-body connection is so important. Presurgery, it’s my job to make sure patients are reassured they are in good hands and that I will be there with them in the OR and when they wake up. It’s a rewarding part of my job and one I take very seriously.”

Dr. Branam says engaging with different personalities and gaining immediate gratification from seeing the outcome of the surgeon’s work makes her job one of the most rewarding in the healthcare setting.

She is quick to single out MSMA President Claude Brunson, MD as a mentor that entered her life early in her career. A chance meeting at an American Society of Anesthesiologists (ASA) meeting solidified information she had read about him. Finding out he was the “real deal” established his place as an important person in her career.

“Dr. Brunson is someone that has meant a great deal to me and to my career,” she said. “I feel very fortunate to have met him and to continue to benefit from his guidance and advice.”

She applied for a spot in the first Physician Leadership Academy after deciding it was time to strengthen certain skills not offered in a traditional medical school curriculum.

“Physicians are expected on a daily basis to resolve conflict, negotiate contracts and lead others, but we aren’t given the tools to accomplish these things,” she said. “Learning these skills and many other components as part of the Phy-

sician Leadership Academy has been very beneficial.”

The mother of two small children, Dr. Branam and her husband enjoy water sports, barbecues, spending time with friends and traveling to Argentina to visit family.

Trip across the pond spurred

KENNETH THOMAS, MD’S interest in medicine

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rowing up as the son of a high school teacher and electrician in the community of Kewanee near Meridian, Kenneth Thomas had minimal contact with anyone working in healthcare. After graduating from Columbus’ Mississippi School for Mathematics and Science, his career path was set. He enrolled in engineering at Mississippi State University with the firm belief he’d depart as a chemical engineer. A chance meeting with two English physicians during a junior year study-abroad trip to Bristol, England presented a fork in the road that led him to the final destination: a career in medicine.

“Staying with the couple, both of whom were physicians, and observing their lives, was literally my first introduction to medicine,” said Dr. Thomas, a board-certified urologist at Urology Specialist of Mississippi in Starkville. “The experience caused me to think this might be something I would like to do. I came back to State and realized I had already taken all the prerequisites except for two biology courses.

I took the MCAT and was accepted into medical school.

Looking back, it was really a quick process from engineering to medicine.”

Dr. Thomas describes the first two years at UMMC School of Medicine as “mentally-challenging.” At the same time, the climate at UMMC was supportive and prepared him for the rigorous road ahead.

“My years of residency at University of Virginia were the most physically-challenging ones of the process,” he recalls.

“With long work hours and odd shifts, it was extremely rigorous. But the end result was worth the effort it took to get through those years.”

Looking back, Dr. Thomas feels the cumulative experience of studying for the MCAT and enduring medical school and residency, was excellent preparation for his chosen career.

“I remember missing out on movies, ball games and other things my friends were doing,” he recalls. “However, I realized a medical career takes discipline and hard work.

The short-term trials of those years were excellent preparation for this field and helped me reach my long-term goal of becoming a physician.”

Choosing urology as a specialty was a natural fit for his desire to put “church and family first without jeopardizing patient care.”

“I received some excellent advice early on that urology was a specialty in which a physician can have a rewarding family life while providing quality medical care to patients,” said Dr. Thomas. “It was a challenging process and not an easy specialty to get into, but I find my career very rewarding.”

When weighing their options on places in which to practice, Dr. Thomas says he and his wife, a fellow chemical engineer major he met at MSU, couldn’t imagine living anywhere but Mississippi. Starkville was an area they already knew and loved. As a result, it was one of only a few places they considered.

“I called several hospitals before my residency and Starkville was a city looking for a urologist,” he recalls. “We kept that in mind and always planned to come back to Mississippi and possibly the area. Besides being a great place to live and work, it was close to our families. We have not regretted the decision.”

Despite the demands of a busy practice and a hectic family life filled with four children involved in numerous sporting activities, Dr. Thomas was eager to sign up for MSMA’s Physician Leadership Academy. He feels it’s been a worthwhile investment in strengthening his leadership skills.

“There are many changes occurring right now in the healthcare arena and unfortunately, many physicians don’t always have as strong of a voice as they need to,” he said.

“It’s important to foster leadership qualities among physicians, including myself, so that we can make necessary changes that are in the best interests of our patients.”

Dr. Thomas’ advice for those considering the medical field, including his own children, is simple.

“Don’t go into the medical field for pride or money,” he stated emphatically. “Become a physician because you feel strongly it’s your calling to help others. I tell my kids, ‘if you want to be a physician, that’s fine. But do it because it’s your passion and for no other reason.’”

May 2015 JOURNAL MSMA 135

William Carey medical student VIOLET YEAGER enjoys exposure to physicians in PLA

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ngaging in leadership training alongside 11 other physicians with impressive medical degrees and years of experience under their belts might intimidate another medical student. For Violet Yeager, MSPH, a DO student enrolled in the William Carey College of Osteopathic Medicine, the cumulative experience of overseas mission work in countries such as Thailand, Vietnam, West Africa, Haiti and Mexico combined with a strong educational background provided a level of confidence not found in most of her peers. Her instructors at William Carey agree.

“Violet is one of those students who comes to you with answers, not problems, said James Turner, DO, MPH, Dean of the College of Osteopathic Medicine and professor of clinical sciences. “She’s always willing to help others and is a great representative of the student body.

Growing up in Texas as one of 11 children, Violet felt her destiny was to help others. Specifically, a career in medicine in some form or fashion was one of her goals.

She graduated from the Tulane University School of Public Health and Tropical Medicine with a master’s in tropical

medicine. Passionate about disaster response and international medical service, she parlayed her degree into helping others in the overseas mission field. She also gained experience in logistical operations with the American Red Cross.

Taking her desire to help one step further, she enrolled at WCU and is already looking down the road at pediatrics and psychiatry as possible specialty areas. She hopes to complete her residency in Mississippi, with an eye toward practicing overseas or in the states, wherever the greatest need exists, she says.

The training she has received as the first medical student in the Physician Leadership Academy has not gone unnoticed by her instructors.

“Physicians are thrust into leadership roles from the moment they begin practicing,” said Dr. Turner. “I’ve already noticed a change in Violet’s presentations and in her confidence level.”

For her part, Violet considers it a privilege to be in the company of physicians.

“Meeting the other physicians has been a great side benefit of the leadership academy,” she said. “I’ve been expected to excel at their level and that fact in itself has been a valuable learning experience. They have all been very helpful and of course, accepting of my presence. In the end, we all have the same goal and that’s to become better leaders, regardless of our status.”

To learn more about becoming a member of the next Physician Leadership Academy class, contact Phyllis Williams at 601-853-6733.

Violet Yeager is pictured in a classroom in William Carey University in Hattiesburg, now the site of a College of Osteopathic Medicine.

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May 2015 JOURNAL MSMA 137

• President’s Page • Because You Want To

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f I had to guess, I would say many of you joined MSMA because your partner, mentor or medical director suggested – or maybe even told you – that you needed to become a member of our association. But you may not have been fully sold on MSMA. We might not have explained all of the benefits. Or maybe you never got fully involved but rather rejoined each year out of habit. As such, we’ve fostered a culture where some members JOIN rather than BELONG to MSMA. We are now embarking on a path to change that. Besides our already strong goals of offering professional advocacy, education and representation, a new one is to provide additional tools and resources that are a benefit to you and to your patients. Ultimately, we want you to consider MSMA a vital resource and support network that helps you grow your Claude D. Brunson, MD practice, connect with your colleagues, foster better relationships with patients and has a positive impact on the state’s medical arena collectively.

2014-15 MSMA President To that end, we are proud to be partnering with key industry-related organizations to bring members first class benefits and services. Through a new initiative spearheaded by MSMA’s general counsel Conner Reeves, members will benefit from an array of cost savings, products and services offered by our new member benefit partners. We look forward to the relationships and opportunities that will develop as a result.

One of the newest benefits offered to members is Mississippi Drug Card. It’s a discount drug card that is free to all Mississippians. The discount card generates savings of up to 75 percent on prescription drugs to uninsured and under-insured patients in need of assistance with the cost of prescription medications.

The cards are being distributed now to members to give to patients. Additionally, any patient can print a free prescription assistance card from MSMA’s website.

Mississippi Drug Card is the latest member benefit partner to join the growing list of companies and organizations with whom MSMA has teamed to strengthen your membership benefits.

Having a membership base of physicians that belong because they recognize the personal and professional benefits of an association formed by physicians for physicians to effect lasting change in their patients’ lives and Mississippi as a whole is something of which we can all be proud.

So, urge other physicians to join us – and continue to remain a vital, active part of our association – because you want to. r

Download the issuu app Read the JMSMA online

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May 2015

• Clinical Problem-Solving Case • A Rash Decision Laura J. Miller, MD

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A 57-year-old Caucasian female presented to clinic with a left palmar rash. She had a history of rheumatoid arthritis, osteoporosis, emphysema and depression. She had been evaluated in an emergency department multiple times for the same complaint of left hand rash. Two months prior to this clinic presentation, a three-view radiograph of her left hand showed no abnormality. She had been prescribed oral clindamycin, oral doxycycline, topical triamcinolone cream and topical mupirocin ointment. She had completed the oral antibiotics and reported diligent use of the topical drugs as well as over-the-counter moisturizers and emollient preparations but there was no improvement in the rash. She admitted to trying a home remedy that involved placing her hand in “bleach water.” She had been referred to dermatology by the emergency department but did not obtain an appointment. She was also taking daily aspirin, a calcium supplement, alendronate sodium (Fosamax) and bupropion hydrochloride (Wellbutrin SR). She had no prior hand or arm surgery and denied tobacco, alcohol and drug use. She reported a 5-6 year history of dry and scaly skin on her hand and also stated that she had injured her left palm with a knife several months ago. She stated that the lacerated area never properly healed and now caused her pain with constant redness and inflammation.

On review of systems, she reported difficulty grasping items with her left hand secondary to pain, described a feeling of generalized weakness and fatigue but denied other issues. Physical examination revealed a normally developed, well-nourished female who was alert and in no distress. Her temperature was 97.6°F, weight 132 pounds, blood pressure 140/76 mmHg, heart rate 87 beats per minute and respiratory rate 16 breaths per minute. Her physical examination was unremarkable except for the palmar aspect of her left hand, which was erythematous with diffuse scaling. There was no apparent abscess formation or drainage, and the rash did not extend past the wrist. The patient was unable to tolerate palpation and manipulation of the hand secondary to pain.

The differential at this point is quite broad. Due to her history of dry scaling skin on her hand for greater than 5 years, Author Affiliations: Dr. Miller is at the Family Medical Clinic of Crystal Springs, 104 West Railroad Avenue South, Crystal Springs, MS 39059, laurajacksonmiller@gmail.com

it would be reasonable to establish a differential diagnosis that included chronic prolonged skin conditions such as psoriasis, a chronic contact dermatitis, atopic dermatis or xerotic eczema, a drug eruption or nonspecific dermatitis. Given her history, there could be a superimposed cellulitis or dermatitis due to hygiene or bleach exposure. Due to the patient’s reported history of rheumatoid arthritis and weakness, and possibility of an infectious process, laboratory investigation is warranted. We order a complete blood count to investigate for an infectious process or anemia as contributing causes to her rash and fatigue. We order a thyroid stimulating hormone to evaluate hypothyroidism as cause of her fatigue.

Blood tests were performed to evaluate her weakness.

Thyroid stimulating hormone and a basic metabolic profile were normal. A complete blood count was normal except for mean platelet volume 9.9 mcm3, (11.5-14.5) and mean corpuscular hemoglobin 31.4 pg (27-31).

Given these laboratory findings, we do not have a clear cause for her weakness and will continue to focus on rash treatment. Since she has been treated with oral antibiotics previously with no improvement and did not have an abnormal white blood cell count or fever, we think the rash is likely due to a chronic condition. At this point, psoriasis and xerotic eczema are highest on our differential diagnosis. Psoriasis is a common disease in the United States, affecting 2 percent of the total population.9 It is characterized by red, scaly plaques and can range from localized areas of inflammation or wide-spread cutaneous involvement. There are several types of psoriasis, including plaque-type and pustular localized psoriasis.9 Plaque-type psoriasis usually presents with thick red scaly lesions and is often confused with atopic, irritant, and seborrheic dermatitis, cutaneous T-cell lymphoma or pityriasis rubra pilaris.6,9 Pustular localized psoriasis usually presents with erythematous papules or plaques studded with pustules often on palms or soles and is often confused with drug eruption or dyshidrotic eczema.9 Both types of psoriasis are usually treated with topical corticosteroids, calcipotriene, coal tars, anthralin or tazarotene as well as phototherapy and systemic agents.6,9 Given her red scaly lesions, we thought the patient’s rash to be plaque-type as she did not have pustules.

She was diagnosed with suspected psoriasis, continued on her topical treatments, and given an oral prednisone taper. She followed up in clinic 6 weeks later and had completed her prednisone taper with no improvement in her left hand pain or appearance. She denied fevers and in the

May 2015 JOURNAL MSMA 139

interim had visited a wound care clinic where bandages were applied to her hand over her topical treatments. She reported worsening of the rash with migration onto the dorsal aspect of the left hand as well as worsening of the existing palmar rash. She had developed multiple open wounds on the palm and on the dorsal aspect of the fifth digit. She had improvement in her weakness in the interim.

Photographs were taken with plans to send them to dermatology for review. She was prescribed clobetasol cream to apply topically to the rash. Biopsy was discussed with the patient who vehemently refused secondary to fear of pain and complications from the procedure.

Our greatest concern at this point due to the patient’s lack of improvement is that the rash may be a malignant process.

We think that it may be a skin cancer or cutaneous lymphoma and would like pathologic analysis of a skin biopsy. Due to its unilateral presentation on one extremity and gradual worsening, we want to obtain a diagnosis quickly so that we may adjust our treatment regimen to target the correct pathophysiology. Given the patient’s staunch refusal to pursue biopsy for a more definitive diagnosis and her inability to see a dermatologist, we think that it is prudent to schedule her for frequent followup visits to monitor the rash as well as to take photographs to document evolution of the rash.

One month later, she reported that her rash was worsening in appearance, size and pain. She stopped wound care in the interim but reported compliance with her topical medications. She denied swelling of the hand and denied weakness in the hand but admitted not grasping things with her left hand secondary to pain. She was continued on her current treatment and was again referred to dermatology. She agreed to schedule a biopsy in the future. Due to her enlarging rash with worsening cracking of the skin as well as continued diffuse erythema and serous yellow drainage, she was admitted to the hospital for treatment with intravenous antifungals and antibiotics for suspected cellulitis superimposed on a psoriatic rash.

While hospitalized, we believe that the patient will benefit from a dermatology consult given that the rash has not improved with appropriate treatment. We review our treatment plan with a dermatologist who recommends continuation of our current plan and agrees to see her as an outpatient. We continue to think that the patient would most benefit from biopsy due to the extensive treatments that have not improved her symptoms.

We make another effort to convince the patient that a biopsy would give us the best chance to have a definitive diagnosis of the cause of the rash, which would direct our treatment course.

During her inpatient hospital stay, she was given intravenous clindamycin and oral terbinafine (Lamisil). She had minimal improvement of her left hand rash and pain.

A complete blood count revealed all values within reference ranges, and an erythrocyte sedimentation rate was elevated at 17 mm/hr (ref range 1-9 mm/hr) and C-reactive protein

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of 0.1 mg/dL (reference range 0-1.0 mg/dL). Wound cultures showed light growth of coagulase-negative staphylococcus while a fungal culture grew penicillium species. She completed a course of IV medication and was discharged home with an additional week of oral clindamycin and terbinafine. She was to follow up in 1 week at the outpatient clinic for her biopsy.

Despite hospital wound cultures showing a superimposed infection with bacteria and fungus, the patient’s white blood cell count remains normal. She does have an elevated ESR, and we think this is possibly related to her history of osteoarthritis and rheumatoid arthritis, as well as a suspected inflammatory skin condition with a superimposed infectious process.

We chose not to biopsy the rash while she is inpatient due to the superimposed infection and prefer to get a tissue sample after she completes her antibiotic and antifungal medications. Given the lack of improvement during her inpatient stay, our suspicions are heightened that a rarer process is the cause of this rash. Since we diagnosed and treated suspected psoriasis and she has had no improvement, a diagnostic biopsy is indicated.

Biopsy can differentiate psoriasis from similar conditions.4 Over 1 month later, she presented to clinic for followup. She continued to have no improvement of the rash, and the rash had continued to spread, now involving the entire palmar and dorsal aspects of her left hand and wrist.

During the interim between hospital discharge and her clinic followup, she had been evaluated by another hospital’s emergency department and wound care clinic and had received IV vancomycin. At this clinic visit, the physician consulted with a dermatologist who recommended griseofulvin (Grifulvin V) twice daily and scheduled the patient for an outpatient appointment. She was also given oral clindamycin and sulfamethoxazole/trimethoprim (Bactrim DS) and rescheduled for a biopsy.

At this point, we are more concerned that the patient has a more aggressive or serious condition such as a skin cancer or other malignant process. We also will want a definitive diagnosis of psoriasis prior to starting systemic treatment.

We think this patient has very poor insight into her condition and the benefits of biopsy. She also expresses continual concern and fear for painful procedures and financial burdens of specialty appointments. As the patient’s rash is continuing to worsen, we again discuss with her that we recommend a biopsy and explain that it may give a definitive diagnosis, which will then lead to appropriate treatment.

One week later, a punch biopsy of the lesion was performed. She was admitted to the hospital 1 week later for cellulitis of her left hand with biopsy results pending. Lab work at time of admission to the hospital showed complete blood count components within normal limits, a basic metabolic panel that was normal except for a potassium concentration of 2.7 mEq/L (reference range 3.5-5.0).

Erythrocyte sedimentation rate was again 17 mm/hr and

C-reactive protein of 0.5 mg/dL. She was given vancomycin intravenously and was discharged home with oral clindamycin and oral griseofulvin with plans to be seen in clinic or notified regarding the biopsy pathology.

She returned to clinic to review her biopsy pathology that revealed atypical lymphoproliferative infiltrate concerning for mycosis fungoides (cutaneous T-cell lymphoma) in transformation to CD-30 positive T-cell lymphoma. The pathology report indicated that the neoplastic cells were relatively small and uniform and did not express ALK-1 protein, favoring a primary cutaneous lymphoma.

Two months later, the patient had a lymph node biopsy taken from her left axillary region suspicious for involvement

by T-cell lymphoma.

Cutaneous T-cell lymphoma, also known as mycosis fungoides, is a malignancy that involves CD4+ T-helper cells.10 It often imitates benign skin conditions, and it can be very difficult to definitively diagnose early in the disease process without a biopsy.10 It can manifest as patch, plaque or tumor. It can also diminish in intensity with topical corticosteroids or phototherapy.10 It should be considered in the differential diagnosis if a chronic psoriatic-type lesion or eczema has not responded appropriately to treatment. One of the reasons cutaneous Tcell lymphoma was not immediately high on our differential diagnosis is that it is a rare condition. United States data from 1992 through 2001 showed an annual incidence of 4.5 cases

per million, with palmoplantar keratoderma observed in only 11.5% of mycosis fungoides cases.5,8 Palmoplantar involvement is generally a secondary presentation in people who have skin involvement of their trunk or extremities.8 Only in 0.6% of cases is the prevalent presentation on the palms or soles, forming what has been designated “mycosis fungoides palmaris et plantaris.”7,8 The patient had a computed tomography scan of the chest, abdomen and pelvis which showed an enhancing fluid-filled cystic structure in the left axilla with inflammation and stranding at the site of the prior lymph node biopsy. It also revealed an increased number of small left-sided lower cervical and supraclavicular lymph nodes with no lymphadenopathy or metastatic disease in the abdomen or pelvis seen. The patient was referred to hematology where she began undergoing chemotherapy treatments before moving out of state and transferring her care.

Cutaneous T-cell lymphoma is often diagnosed in people in their 50s or 60s.1 It often presents as pruritic, inflammatory patches that can be present for years without severe worsening.1,10 We think that this patient had scaly lesions for multiple years before these worsened and caused concern that led her to present for treatment. The prognosis of patients with cutaneous T-cell lymphoma is based upon the presence or absence of extracutaneous disease and type and amount of skin involvement.1 Key Words: Cutaneous T-cell Lymphoma, Mycosis Fungoides, Rash, Palmar Rash

References 1. Duhovic C, Child F, Wain EM. Management of cutaneous T-cell lymphoma. Clin Med. 2012; 12(2):160-164.

2. Elmer KB, George RM. Cutaneous T-cell lymphoma presenting as benign dermatoses. Am Fam Physician. 1999; 59(10):2809-2813.

3. Femiano F, Buonaiuto C, Heulfe I. What news are on mycosis fungoides. J Stomatological Investigation. 2008; 2:57-65.

4. Luba KM, Stulburg DL. Chronic plaque psoriasis. Am Fam Physician.

2006; 73(4):636-644.

Medical Clinic and Office Space for Lease.

Hwy 49 S. Richland MS. High traffic and visibility located across the street from Richland Medical Plaza that contains Richland Primary Care Center and Care Plus Pediatrics which can be referral base. Ideal location for cardiology, pulmonology, GI, ObGyn, DME, home healthcare, etc. Motivated landlord. Below market rate for long-term tenants.

5. Morton LM, Wang SS, Devesa SS, Hartge P, Weisenburger DD, Linet MS. Lymphoma incidence patterns by WHO subtype in the United States, 1992-2001. Blood. 2006; 107(1): 265–276.

6. Pardasani AG, Feldman SR, Clark AR. Treatment of psoriasis: an algorithm-based approach for primary care physicians. Am Fam Physician. 2000; 61(3):725-733.

7. Smoller BR. Mycosis fungoides palmaris et plantaris [Letter to the Editor]. Arch Derm.1996;132:468.

8. Topf S, Luftl M, Neisius U, et al. Mycosis fungoides palmaris et plantaris- an unusual variant of cutaneous T-cell lymphoma. Eur J Derm.

2006; 16(1):84-86.

9. Weigle N, McBane S. Psoriasis. Am Fam Physician. 2013; 87(9):626633.

10. Zackheim HS, McCalmont TH. Mycosis fungoides: the great imitator.

J Am Acad Derm. 2002; 47(6):914-918.

Contact: Wayne Johnson 601-955-5906.

May 2015 JOURNAL MSMA 141

Pen > Sword

YOUR FRIEND IN OXFORD REAL ESTATE

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POLINA WHEELER, Realtor速 2092 Old Taylor Rd. Suite 101 Oxford, MS 38655 Contact: (662)401-4632 Office: (662)234-5344 polina@tmhomes.com

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xpress 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 clarify ambiguities, to protect our letterwriters. You can submit your letter via email to: KEvers@MSMAonline.com or mail it to the Journal office at MSMA headquarters: P.O. Box 2548, Ridgeland, MS 39158-2548.

• Editorial •

It’s about Time D. Stanley Hartness, MD; Associate Editor

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’ve discovered that working at a walk-in clinic is a lot like Forrest Gump’s box of chocolates: you never know what you’re “gonna” get! On top of that, I recently felt as if I’d been assigned one of our Journal MSMA’s clinical pathology cases.

Late on a Friday afternoon a 34-year-old previously healthy black female patient from a neighboring county signed in as a new patient with a one-week history of swelling, progressive weakness, and numbness and tingling of her legs to the point that she had begun to have difficulty walking. About ten days before, she had been treated for a severe sore throat by her LMD (is that term still used?). She had begun to notice that even coughing produced an “electric shock” down both legs. She also was experiencing urinary frequency and urgency but no change in bowel habits. She had undergone a hysterectomy for a benign condition several years ago but still had both ovaries.

The weakness was clearly evident as she struggled to move from chair to exam table. While vital signs, distal pulses, DTR’s, chest and abdominal exams were normal, the 2-3+ pitting edema of her lower extremities from thigh distally was impressive. Lab data were normal save for ESR 48, ALT 72, and ANA screen 2.3. Thinking I might be dealing with some sort of obstructive process, I ordered CT scans of the abdomen and pelvis (which were performed the following Monday): normal. I then opted for an MRI L-S spine (which was scheduled for later that week): normal.

As I’ve often opined, being a doctor is a lot like being a detective, and since I’d fairly well exhausted my list of usual suspects going on at least two weeks into this acute process, a referral to an appropriate specialist was made…only to be informed that the doctor would review the records and decide when (or even if) this well-insured school secretary could be seen. After another week passed, I checked on the status of her appointment only to be told that the information was still on the busy doctor’s desk. When I contacted the patient to let her know what was going on, it was bothersome to hear that, although the swelling had subsided somewhat, the weakness and paresthesias had worsened.

One week after that (now four weeks into the problem), the specialist’s office called with the recommendation (and no explanation) that the patient be referred to University of Mississippi Medical Center (UMMC) instead. Then when UMMC Neurology gave my office staff an appointment three to four weeks out, I called back personally to plead my case. The kind secretary said she knew it must be important if the doctor himself called so she moved the time forward by two weeks, still some six weeks after the onset of these perplexing symptoms.

My concerns at this point were threefold: 1) what was the diagnosis 2) would there be any permanent sequelae and 3) whose office would the trial lawyers be contacting. Untimely appointments for evaluation of acute medical problems, regardless of the specialty, are perceived by our patients are off-putting and self-serving at best and potentially debilitating (if not life-threatening) and litigious at worst. And we all know that perception is reality. It would be sort of like me as a family physician telling a patient who showed up with 103 temp, cough, shortness of breath, and chest pain to come back next week to be seen.

I realize we all have our “druthers” when it comes to scheduling appointments and by no means am I trying to tell you how to manage your practices. But every now and then, it becomes necessary to inconvenience ourselves for the sake of our patients—and for our profession—and work in an extra patient or two. Hey, this soapbox is beginning to feel pretty comfortable. So while I’m at it, if you’ve promised a patient to call at a time certain about a report or an appointment, make sure you or your staff completes this task to avoid the appearance of indifference or incompetence.

In this day of that intrusive, ubiquitous interloper a.k.a the computer, it’s about time that we re-infuse our practices with the common courtesy and proper professionalism which our patients deserve and for which they hunger. r

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• Special Article • Attitudes Toward Diversity in the Health Care Environment Ralph H. Didlake, MD, FACS; Caroline E. Compretta, PhD

Key Words: Race Relations, Mississippi,

Professional Ethics, Medical Education

Introduction

In celebration of the 50th Anniversary of the Freedom Summer, the First Marston Symposium on Race and Medicine was held at the University of Mississippi Medical Center (UMMC) in June 2014. Presenters, panelists, and participants explored both historical and current race relations within Mississippi’s medical community to highlight activists’, institutional, and public accomplishments toward racial equity and to discuss additional steps needed to improve professional and educational diversity across the state. UMMC’s Center for Bioethics and Medical Humanities was invited by the symposium organizers to offer a data-driven analysis of racial attitudes that inform current professional behavior and interactions. Several approaches to gathering this type of data were considered, each fraught with its own limitations, biases, assumptions, and preconceptions.

After review of numerous options for collecting new data, a decision was made to analyze an existing data set that was convergent with the needs of the symposium. The Diversity Engagement Survey (DES), conducted in 2011 at UMMC as well as 13 other academic medical centers across the US, was chosen because it assessed faculty, student, and staff perceptions regarding workplace inclusion and employee engagement. The DES, developed by the University of Massachusetts Medical School and sponsored by the Association of American Medical Colleges, includes quantitative and qualitative data in 22 areas grounded in workforce engagement theory.1 The DES was intended to give institutions rich data and analysis from which to evaluate inclusion in the work environment.

Author Affiliations: Dr. Didlake is Associate Vice Chancellor of Academic Affairs and Director of the Center for Bioethics and Medical Humanities. Dr. Compretta is an anthropologist and assistant professor in the UMMC Center for Bioethics and Medical Humanities. Both are at University of Mississippi Medical Center, 2500 N. State Street, Jackson, MS. Corresponding Author: Ralph H. Didlake, MD, FACS, University of Mississippi Medical Center, 2500 N. State St., Jackson, MS 39216. Tel: (601)984-5009. Email: rdidlake@umc.edu.

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Selection of the DES, for the purposes of the symposium, was based on the observation that this data set not only provides a sampling of prevailing racial attitudes across the entire health care workforce but also reflects attitudes within the student and trainee learning environment wherein professional perspectives and behaviors are both informed and developed. As trainees move into healthcare careers, they bring with them professional attitudes regarding race and diversity that are shaped within their programs of study. Thus, the DES not only offers data regarding the UMMC community but also provides information about racial attitudes that can be found across the Mississippi health care community among graduates and trainees of the institution.

The DES assessed perceptions about professional diversity using three specific content domains: Appreciation, Camaraderie, and Vision & Purpose. Appreciation was defined as the contributions and values an individual attributes to an institution; Camaraderie as an individual’s sense of institutional belonging; and Vision and Purpose as the reasons an individual furthers institutional missions. UMMC further customized the survey to include questions regarding learning environments, observations of insensitive or exclusionary behaviors, and institutional participation.

Out of 5000 surveys deployed, 2284 UMMC employees responded, resulting in a 45% response rate. Initial review of these data identified a single qualitative question that yielded rich sets of responses within the Camaraderie cluster. Using a 5-point Likert scale (5=strongly agree to 1=strongly disagree), respondents were asked to score the following statement: “The effort made by this institution to create an inclusive education and learning environment that value individuals with diverse backgrounds.” After completing the question, survey participants were invited to provide further open-ended comments regarding how they perceived the institution’s commitment to diversity. Of the 2284 survey respondents, 287 provided additional comments. These qualitative comments are the basis for this analysis and reveal a range of attitudes regarding diversity within the clinical care and medical education communities.

Methods

Using methods of thematic coding, comments were first

High

Neutral

Low

Unrelated

Figure 1. Respondent‟s reported “value” of diversity and inclusion in the workplace (n =

Results

According to the overall value categories, 38% of respondents placed a high value on diversity, 14% were neutral, 31% placed a low value on diversity, and 15% provided additional comments unrelated to the scope of this analysis [Figure 1].

This initial analysis revealed that respondents were polarized according to their views on diversity with over a third of respondents expressing a high value on diversity and inclusion and a third placing little value on these issues.

Figure 1: Respondent’s reported “value” of diversity Figures and inclusion in the workplace (n = 287).

40

80 70

Percent

60 40 30 10

0

Neutral

Low

Unrelated

40 3: Value of diversity and inclusion reported by Figure black or African American men.

30 50 20 40 10 30 0 20 10

10

High

14% were value neutral, and 3% expressed low value [Figure 2]. African American males valued reported diversity of comFigure 2. Value of diversity and inclusion bywith black40% or African American women ments coded as “high value” and 40% expressing neural sentiments [Figure 3]. White female responses were differentiated with 32% placing a high value on diversity and 31% expressing low diversity values [Figure 4]. Finally, 22% of White male respondents’ comments were coded as “high value” while 56% placed a low value on diversity [Figure 5].

This analysis is limited by the survey’s sampling bias.

While the survey had a positive response rate (45%), respondents50were predominately white, female, heterosexual, Chris-

20

0

50

20

Percent

Percent

30

Figure 2: Value of diversity and inclusion reported by black or African American women.

Percent

examined without demographic data and analyzed according to six categories that assessed the value respondents placed on diversity and inclusion. The six categories included (1) overt experiences of discrimination, (2) more diversity needed, (3) status quo, (4) dissonant responses, (5) meritocracy rather than ‘diversity,’ and (6) overt anti-diversity. These themes were then further clustered into three overall categories which identified comments as expressing a high value, neutral value, or low value on diversity and inclusion. For example, the following comment was identified as placing a high value on diversity: “…it is essential to highlight the importance of diversity competence in clinical settings.” Neutral values were expressed in such comments as “I have never observed any obvious discrimination against anyone for any reason.” Finally, the following comment illustrates statements coded as expressing a low value for diversity: “… to constantly have diversity crammed down our throats is OFFENSIVE to ME.” (Respondents emphasis)

High

Neutral

Low

Unrelated

Figure 3.

Value of diversity and inclusion reported by black or African American me 0 High

High

Neutral

Low

Unrelated

Neutral

Low

Unrelated

Figure 4: Value of diversity and inclusion reported by white women.

Figure 3. Value of diversity and inclusion reported by black or African American me 40

Figure To 1. Respondent‟s reported “value” of diversity and inclusion in the workplace (n = 287). further investigate this polarization, survey comments

10

0

High

Neutral

Low

Unrelated

Percent

30 40 20 30 Percent

Percent

were reanalyzed using demographic information for gender and race/ethnicity to determine how different groups at UMMC 80 diversity and inclusion. Given the Marston Sympoviewed sium’s 70 focus on traditional Southern race relations, the analysis concentrated on White and African American respondents 60 and divided each racial group by gender resulting in analyses 50 for respondents who self-identified as Black/African Ameri40 can women, Black/African American men, White women, and White30men. According to this analysis, 67% of African American female respondents placed a high value on diversity while 20

10 20

0

10

High

Neutral

Low

Unrelated

May 2015 JOURNAL MSMA 145

Figure 4. Value of diversity and inclusion reported by white women.

0

High

Neutral

Low

Unrelated

Figure 5: Value of diversity and inclusion reported by white men.

60

Percent

50 40 30 20 10

0

High

Neutral

Low

Unrelated

Figure 5. Value of diversity and inclusion reportedanalysis by white men. tian, and English-speaking.

Our initial reveals that

diversity continues to be a polarizing issue, but further studies should be undertaken to expand the sampling limitations of the DES to better understand diversity issues in a range of healthcare settings across the state. Such research could examine additional areas of inclusion such as gender discrimination, selection of specialty, choice of practice environment, and participation in organized medicine, and help to further the goals of the Marston Symposium.

Discussion

While the Marston Symposium illuminated numerous ways in which Mississippi has made progress in its move beyond legacies of racial violence and inequality, the data brought forward in this report, despite their limitations, suggest that polarization regarding race, diversity, and engagement remains in some sectors of the health care community. Stratification of these data shows the degree to which a respondent values diversity in the health care workplace is strongly correlated with their self-identified race/ethnicity and gender. There can be little doubt that such attitudes affect both education and practice environments. Further work is required to understand the relationship between such racial and gender attitudes among providers and the increasingly complex and persistent issue of health outcome disparities.

Given the complex backdrop of our medical community’s troubled racial past 2, the American Medical Association’s 2008 apology for prior racial discrimination3, and our state’s only academic health science center’s commitment to train “committed health care professionals who work together to improve health outcomes and eliminate health care disparities,”4 these data strongly support the need for additional education programs and awareness campaigns about the value and benefits of an inclusive and diverse health care community. This work does not diminish the value of prior or ongoing diversity and inclusion efforts but suggests that more work needs to be done.

This was a recurrent theme among other presenters at the 2014 Marston Symposium. However, at our present juncture, fifty years since Freedom Summer, perhaps an additional approach

146 JOURNAL MSMA

May 2015

to polarized attitudes is in order. Specifically, we propose to transform efforts toward diversity and inclusion and the language in which they are framed from multiculturalism or cultural competence into issues of medical professionalism. This shift would bring these discussions into the light of professional ethics which inform our day-to-day interactions with patients and colleagues. For the medical profession, the ethical values, norms, and standards that define boundaries for these interactions have deep historical roots which extend from Hippocrates and Maimonides, run through the works of Thomas Percival, and find modern expression in the AMA Code of Ethics.5 These norms demand collegiality, deference, and respect among members of the medical profession across all groups of care provider professionals. All physicians who accept the mantle of professional are obligated to maintain the integrity of the profession in which they claim membership. Such an obligation is foundational to the ethics of any profession and requires its members to work against any force, situation, movement, or circumstance that degrades professional integrity either individually or collectively. Polarization of racial attitudes, such as those seen in the qualitative comments analyzed in this study, is an undeniable threat to professional integrity. It is for this reason that we strongly suggest augmenting discussions about diversity and inclusion with discussions of professional ethics and integrity.

Translating narratives of emotionally weighted and politically-charged topics such as race, disparity, and inclusion into the common language of professional ethics and integrity gives the medical community a lingua franca through which universally accepted goals can be more readily recognized and mutually productive solutions more readily crafted.

Achieving such a reframing will require a deliberate cognitive approach but one justified to reach the important goals of diversity and inclusion across the healthcare workforce while not only preserving but actively fostering professional integrity.

Acknowledgments

The authors would like to thank Roderick Gilbert and Juanyce Taylor 13 for their contributions to this work.

References

1. American Association of Medical Colleges. Diversity and inclusion survey; https://www.aamc.org/initiatives/diversity/portfolios/349308/diversityengagementsurveypage.html; Accessed, March 18, 2015.

2. Dittmer, J. Race and health care in Mississippi during the civil rights years. J Miss State Med Assoc. 2014.50:11 3. American Medical Association Web site. http://www.ama-assn.org/go/ apology. July 7, 2008. AMA apologies for history of racial inequality and now works to include and promote minority physicians [press release.]

4. University of Mississippi Medical Center Vision Statement. Available from: http://www.umc.edu/Administration/Strategic_Plan/7__Mission_ and_Vision.aspx. Accessed, April 1, 2015.

5. American Medical Association. Code of Medical Ethics: Current Opinions with Annotations. American Medical Association Press; 2012.

• Just Off the Press - Info You Want to Know • Vitamin C in the Prevention of Complex Regional Pain Syndrome Richard L. Ogletree, Jr., PharmD and Sarah Hill Davidson, PharmD

Article

Design

Shibuya N, Humphers JM, Agarwal MR, Jupiter DC. Efficacy and safety of high-dose vitamin C on complex regional pain syndrome in extremity trauma and surgery – systematic review and meta-analysis. J Foot Ankle Surg. 2013 JanFeb;52(1):62-6.1

Systematic review of 4 studies on surgically and traumatically induced CRPS in both upper and lower extremities was carried out. The intervention analyzed was the daily use of vitamin C of more than 500 mg, as recommended by guidelines.

Background

The original search identified 414 articles through EMBASE, MEDLINE, CINAHL, and the Cochrane Database, respectively. After screening, 4 studies remained that qualified for inclusion. Three of the 4 studies involved wrist fractures and surgeries. Only one article (Besse) investigated the use of vitamin C in foot/ankle trauma.4

Complex Regional Pain Syndrome (CRPS) causes diffuse extremity pain not isolated to the area of injury or surgery. It usually initiates from trauma, including injury and/or surgical intervention, and is divided into Type I and Type II CRPS. Type 1 is chronic, usually develops after tissue trauma, and often the nerve injury cannot be immediately identified. Type 2 develops within the area of the affected nerve but may spread outside the nerve distribution. CRPS is common after foot and ankle injuries and surgeries, and after wrist fractures. Use of high-dose vitamin C has been endorsed by the Evidence Based Guidelines for Type 1 CRPS and the American Academy of Orthopedic Surgeons.2,3 It has been recommended to prevent CRPS following a wrist fracture.

Objective

The purpose of this study was to evaluate the effectiveness of vitamin C in preventing occurrence of CRPS in trauma and surgery.

Methods

Results

Three studies involved distal radial fractures and the fourth foot and ankle surgeries.4-7 All four studies favored the use of prophylactic high-dose vitamin C for the prevention of CRPS. The calculated relative risk (RR) for this quantitative synthesis was 0.22 (95% CI =0.12, 0.39), which was statistically significant. An RR of 0.22 means that the risk of CRPS in a patient using vitamin C was only 22% that of a patient who was not using it.

CI = Confidence interval, the result was considered statistically significant if 95% CI did not include 1 M-H = Mantel-Haenszel, the method used for calculating risk ratio and CI Figure used with permission from reference 1

May 2015 JOURNAL MSMA 147

Conclusion

Vitamin C, when taken in a daily dose of more than 500mg for 45 to 50 days post trauma or surgery, may help reduce the occurrence of CRPS in the extremities. It is also inexpensive and safe with gastrointestinal complaints the most common side effect.

Reviewer’s comments

More randomized-control trial data would be helpful.

Use of the raw data to calculate a number needed to treat (NNT) resulted in an NNT of approximately eleven. In other words, treating eleven extremity trauma patients with vitamin C could prevent a case of CRPS. Looking at the wrist data alone, the NNT was 10. With vitamin C being affordable (100 ct bottle ~$7.00) and the potential impact of CRPS being substantial, serious consideration should be given to the use of vitamin C for the prevention of CRPS in patients presenting with wrist fractures.

References 1. Shibuya N, Humphers JM, Agarwal MR, Jupiter DC. Efficacy and Safety of High-dose Vitamin C on Complex Regional Pain Syndrome in Extremity Trauma and Surgery—Systematic Review and Meta-Analysis. J. Foot Ankle Surg. 2013 Jan;52(1):62– 6.

2. Perez RS, Zollinger PE, Dijkstra PU, Thomassen-Hilgersom IL, Zuurmond WW, Rosenbrand KC, et al. Evidence based guidelines for complex regional pain syndrome type 1. BMC Neurol.

2010;10:20.

3. The treatment of distal radius fractures - guideline and evidence report [Internet]. [cited 2013 May 29]. Available from: http:// www.aaos.org/research/guidelines/drfguideline.pdf 4. Besse J-L, Gadeyne S, Galand-Desmé S, Lerat J-L, Moyen B. Effect of vitamin C on prevention of complex regional pain syndrome type I in foot and ankle surgery. Foot Ankle Surg. Off. J. Eur. Soc. Foot Ankle Surg. 2009;15(4):179–82.

5. Zollinger PE, Tuinebreijer WE, Kreis RW, Breederveld RS. Effect of vitamin C on frequency of reflex sympathetic dystrophy in wrist fractures: a randomised trial. Lancet. 1999 Dec 11;354(9195):2025–8.

6. Zollinger PE, Tuinebreijer WE, Breederveld RS, Kreis RW. Can vitamin C prevent complex regional pain syndrome in patients with wrist fractures? A randomized, controlled, multicenter doseresponse study. J. Bone Joint Surg. Am. 2007 Jul;89(7):1424–31.

7. Cazeneuve JF, Leborgne JM, Kermad K, Hassan Y. [Vitamin C and prevention of reflex sympathetic dystrophy following surgical management of distal radius fractures]. Acta Orthop. Belg.

2002 Dec;68(5):481–4.

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DISABILITY DETERMINATION SERVICES 1-800-962-2230 148 JOURNAL MSMA

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• University of Mississippi Medical Center • Dr. Dan Jones Will Join UMMC to Help Lead Obesity Research Efforts

F

or over two years, Dr. John Hall has conducted a national search for the right person to lead the development of clinical obesity research programs at the University of Mississippi Medical Center.

He interviewed five high-profile scientists, but the search stalled. Then it occurred to him that the person whom he describes as “uniquely qualified” to fill the role was closer than he could have ever imagined: University of Mississippi Chancellor Dan Jones.

Hall, the Arthur Guyton Professor and Chair of Physiology and Biophysics and director of the Mississippi Center for Obesity Research (MCOR), announced today that Jones will join the Medical Center faculty next fall as the MCOR’s director of clinical and population sciences.

In that role, Jones will be asked to tackle Mississippi’s most pernicious and consequential health problem, one that costs the state an estimated $1 billion in annual direct health-care expense. And yet the science of obesity is still poorly understood, and the means of preventing it or safely treating it have proven largely ineffective.

An internal medicine physician by training and a tenured professor at UMMC, Jones is currently on leave from his position as UM chancellor and will officially end his tenure after six years at the helm when his contract expires Sept. 14. He will join UMMC on Sept. 15, Hall said.

“Because Dan Jones has been in university administration for the last 13 years, not everyone remembers that he is an eminent physician-scientist who was the original principal investigator of the Jackson Heart Study and served as president of the American Heart Association,” said Hall. “He is uniquely qualified for this position in so many different ways.”

A graduate of its medical school, Jones joined the UMMC faculty in 1992 and was heavily involved in clinical and population research related to hypertension and other cardiovascular risk factors until he became associate vice chancellor for health affairs in 2002. He was named vice chancellor and dean of the medical school in 2003 and left Jackson to become chancellor of the university in 2009.

“This is a welcome opportunity for the next stage of my career,” said Jones. “Over the last several weeks, I have explored several good opportunities in universities outside Mississippi. As I examined options, it became clear to me that my first priority was to seek a position where I could work on important issues where there was a real need. The invitation from Dr. Hall to fill this position in the center allows me to do this in the state of Mississippi I love so much.”

Jones’ primary faculty appointment will be in the Department of Physiology and Biophysics reporting to Hall, with a joint appointment in the Department of Medicine. Jones will be the first person to hold the Mr. and Mrs. Joe F. Sanderson, Jr. Endowed • Comprehensive Management Chair in Obesity, Metabolic Diseases and Nutrition.

• Comprehensive Consulting Hall said although Jones is best known in the scientific community for his work in hypertension, obesity and weight management • Billing & Accounts Receivable Management are common threads in his published papers and the clinical trials • Coding & Documentation he has overseen. “He has great expertise on clinical aspects of obe• Practice Assessments & Revenue Enhancement sity management and why this is an effective approach to prevent• Profitability Improvement ing and treating many chronic diseases such as hypertension, heart attack, stroke, kidney disease, diabetes and dementia,” Hall said.

• Practice Start-ups Beyond his scientific and research expertise, Jones has a proven • Personnel Management ability to build programs, win grant support and private funding, and establish collaborative relationships that will be critical to making inroads against obesity in Mississippi and elsewhere, Hall said.

“When I worked as an administrator on the formation of this center, I never dreamed I would have the opportunity to return to the Medical Center in my role as a physician scientist,” Jones said. “I’m grateful to Dr. Hall and Dr. LouAnn Woodward for their confidence in asking me to fill this role and to make a difference in Mississippi.”

1600 North State Street Suite 400 “I completely support Dr. Hall’s decision and consider this a crucial step forward in our state’s efforts to battle the public health Jackson, MS 39202 epidemic of obesity,” said Woodward, vice chancellor for health Telephone: 601.944.1717 affairs and dean of the School of Medicine at UMMC. “This is a WATS: 1.800.355.4231 difficult, challenging job, and we are extremely fortunate that a scientist and leader of Dr. Jones’ caliber is willing to take it on.” www.mpsbilling.com

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May 2015 JOURNAL MSMA 149

• Poetry and Medicine • [This month, we print a poem by British journalist William Ernest Henley (1849-1903) from his famous twenty-eight-poem sequence, “In Hospital,” which is noteworthy for being among the first free verse ever published in England. It is also historic for its subject matter in the Victorian age. From the age of 12, Henley suffered from tuberculosis of the bone that resulted in the amputation of his left leg below the knee in 1868–69. “In Hospital” is a collection of poetry he wrote during a three year stay at the Royal Infirmary of Edinburgh. He went there seeking a consultation with the pioneering surgeon Joseph Lister (1827–1912) with hopes of preventing a second amputation. After three years in the hospital (1873–75), during which Henley wrote and published these poems, he was discharged. Although Lister’s treatment had not cured him, Henley enjoyed three decades of relatively stable health. His best-remembered work is his poem “Invictus,” written in 1888. An interesting literary footnote is that Henley inspired his friend Robert Louis Stevenson’s idea for the character of Long John Silver. Stevenson’s stepson, Lloyd Osbourne, described Henley as “... a great, glowing, massive-shouldered fellow with a big red beard and a crutch; jovial, astoundingly clever, and with a laugh that rolled like music; he had an unimaginable fire and vitality; he swept one off one’s feet.” In a letter to Henley after the publication of “Treasure Island,” Stevenson wrote, “I will now make a confession: It was the sight of your maimed strength and masterfulness that begot Long John Silver... the idea of the maimed man, ruling and dreaded by the sound, was entirely taken from you.” Over the next few issues, I plan to run several more of Henley’s poems from “In Hospital.” His description in “Enter Patient” describing the hospital as “half-workhouse and halfjail” seems particularly insightful. Any physician is invited to submit poems for publication in our Journal MSMA, attention: Dr. Lampton or email me at lukelampton@cableone.net.]—Ed.

Enter Patient

T

he morning mists still haunt the stony street; The northern summer air is shrill and cold; And lo, the Hospital, grey, quiet, old,

Where Life and Death like friendly chafferers meet.

Thro’ the loud spaciousness and draughty gloom A small, strange child — so aged yet so young! — Her little arm besplinted and beslung, Precedes me gravely to the waiting-room.

I limp behind, my confidence all gone.

The grey-haired soldier-porter waves me on, And on I crawl, and still my spirits fail: tragic meanness seems so to environ These corridors and stairs of stone and iron, Cold, naked, clean — half-workhouse and half-jail.

—William Ernest Henley, England, written 1873-1875

150 JOURNAL MSMA

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• Physician’s Bookshelf • What You Always Wanted To Know About Ocean Springs and Gautier, but…

CreateSpace Independent Publishing, 2015 ISBN-10: 1511465115 / ISBN-13: 978-1511465113 (Hardcover $20.00, Kindle $9.99) 270 pages includes photos, illustrations, introduction, bibliography, index

Chris E. Wiggins, MD

A

new book by a Mississippi physician and a member of the JMSMA Editorial Advisory Board has appeared on the scene. Dr. Chris Wiggins, an orthopaedic surgeon in Pascagoula, has penned his second book in the Jackson County local history series. It is not simply a repetition of facts and dates as is so common in history chronicles. Instead, the work is a historical odyssey of the people and times—their foibles and peculiarities included. “What You Always Wanted To Know…” is a tale full of heroes and scoundrels, explorers and fisherman, people of great ideals, and people on the lam from the law.

The story begins in 1699 when Iberville landed on the Mississippi coast and ends…yesterday. While Ocean Springs and Gautier are featured in the title, the scope is not confined to those locales. The first five chapters deal primarily with the early coastal Indians, how they lived, and how they were influenced by the early French explorers. The book conveys serious history but with particular attention given to the ironic and out of the ordinary—making for entertaining reading.

As might be expected from a physician author, there are plenty of medical asides. Yellow Fever was the scourge of the Coast until modern times. By the late 1800s tuberculosis had taken over as a focus of concern.

Sanatoriums came into vogue. Mississippi’s earliest were in Biloxi and Ocean Springs. The facilities were as much health resorts as places to receive medical treatment.

These are just a few of the health issues touched upon.

All sale proceeds go to the Jackson County Historical and Genealogical Society. The book is available online in softcover at Amazon.com, as an e-book download at Amazon.com/Kindle, and as a hardcover from lulu.com.

May 2015 JOURNAL MSMA 151

• Images in Mississippi Medicine •

H

ISTORIC U. S. VETERANS’ HOSPITAL, GULFPORT, 1924--- This image dates to the mid1920s and features the then recently built U. S. Veterans’ Hospital, which had been erected at the hefty cost of $2,000,000. The core of this hospital would be built between 1923-1946 and is now known as Centennial Plaza, located at 200 E. Beach Blvd in Gulfport and listed on the National Register of Historic Places. Shaded by hundreds of live oak trees, this 92 acre beachfront property was utilized to celebrate Mississippi’s statehood centennial in 1917 (although most of the centennial events were cancelled due to World War I.). With the coming of that war, the property came into the hands of the U. S. Navy for military training. After the war, the U. S. Public Health Service acquired the property and by 1921 opened a hospital for the neuropsychiatric care of servicemen. By 1923, the U. S. Veterans’ Bureau purchased the property, with the site becoming the Veterans’ Administration Medical Center, Gulfport Division. The postcard’s back further explained: “View of United States Veterans’ Hospital No. 74, located at Gulfport, Miss. Spacious grounds and buildings facing the Gulf of Mexico. Located on the Old Spanish Trail.” The Spanish Colonial Revival architectural style, perhaps inspired by its location on the Old Spanish Trail, added a distinctive environment for its staff and patients. The historic campus sustained extensive damage from Hurricane Katrina’s storm surge in 2005, which resulted in its closing and transfer of services to the Biloxi VA system and the property to the city of Gulfport. Currently, there are plans to redevelop the property into a mixed use vacation community (hotels, retail outlets, and restaurants). 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

152 JOURNAL MSMA

May 2015

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