VOL. LVIII • NO. 5 • 2017

VOL. LVIII • NO. 5 • 2017

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VOL. LVIII • NO. 5 • MAY 2017

SCIENTIFIC ARTICLES

EDITOR Lucius M. Lampton, MD ASSOCIATE EDITORS D. Stanley Hartness, MD Richard D. deShazo, MD

THE ASSOCIATION President Lee Voulters, MD President-Elect William M. Grantham, MD

Top 10 Facts You Need to Know about ADHD Barbara S. Saunders, DO

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Top 10 Facts You Need to Know about Chest Radiography of Lines 154 and Tubes in the Intensive Care Unit J. Michael Brewer, DO; Dominique J. Pepper, MD; Charles S. White, MD

Establishing A Continuum of Care for Evidence-Based 158 Behavioral Treatment for Youth with Disruptive Behavior Kathryn E. Parisi, MA; Nina Wong Sarver, PhD; Dorothy Scattone, PhD; Dustin E. Sarver, PhD Change In Meropenem Utilization Following the Implementation 162 of a Targeted Antimicrobial Stewardship Audit and Feedback Program David A. Cretella, PharmD; S. Travis King, PharmD; Jason J. Parham, MD; Kayla R. Stover, PharmD

MANAGING EDITOR Karen A. Evers

Secretary-Treasurer Michael Mansour, MD

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

Speaker Geri Lee Weiland, MD

Vice Speaker Jeffrey A. Morris, MD

Nonketotic Hyperglycemic Chorea-Hemiballismus, 168 A Unique and Treatable Manifestation of Diabetes Mellitus Ashley Buice, MD and Tanvir Rizvi, MD

Executive Director Charmain Kanosky

DEPARTMENTS

JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices.

CORRESPONDENCE: Journal MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: 601-853-6733, Fax: 601-853-6746, www.MSMAonline.com.

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Copyright © 2017 Mississippi State Medical Association.

Official Publication

MSMA • Since 1959

From the Editor – The Lost Art of Nursing Lucius M. Lampton, MD, Editor

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President’s Page – Opioid Abuse: A Comprehensive Problem 175 Demands a Comprehensive Solution Lee Voulters, MD MSMA Physicians Leadership Academy - Dr. Ann Roberson and Dr. LaFarra Young

176

Images in Mississippi Medicine – The New Hospital, Beauvoir

177

Poetry and Medicine – Doc Hill Edgar Lee Masters

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RELATED ORGANIZATIONS Mississippi State Department of Health – Reportable Disease Statistics

170

Mississippi Medical Political Action Committee – Thanks to the 2017 I.V. League and MMPAC Members

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Medical Assurance Company of Mississippi – Telemedicine Checklist: How to Get Started

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ABOUT THE COVER

Lantana camara, (Verbenaceae) — One of the hardiest Lantana on the market, “Miss Huff ” thumbs her nose at cold weather all the way to zone 7. This wonderfully free flowering Lantana, whose clusters of flowers open yellow, fade to orange, coral, and finally pink, blooms from summer to frost. Durable and reliable, this perennial is moderately drought-tolerant, deer-resistant, and is generally pest free.

Scientists have studied the repellency of Lantana camara (Verbenaceae) flowers against Aedes mosquitoes. One application of Lantana flower can provide more than 50% protection up to 4 hours against the possible bites of Aedes mosquitoes. https://www.ncbi. nlm.nih.gov/pubmed/8887218 VOL. LVIII • NO. 5 • 2017

Dr. Michael Davis, who took the cover photo, is a recently retired nephrologist in Vicksburg.—Ed. n

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E D I T O R

The Lost Art of Nursing

A

ninety-year-old nurse/patient recently lamented the “lost art of nursing,” expressing to me that “this younger generation” of nurses is failing in both patient care and professional behavior. “I would never hire a nurse under the age of fifty,” she complained. “The younger ones simply don’t get what nursing is supposed to be about: caring for the patient.”

While many of these bygone rules seem antiquated, my nurse friend perceptively asserted that younger nurses seem less focused on the critical ethic of selfless patient care. Older physicians have told me the same thing about the “lost art of medicine” and the younger generation of physicians.

The arts of nursing and medicine are not really lost, just not emphasized and stressed as essential. These arts are not what one wears but rather what is in one’s heart and head. I daily see selfish young nurses and doctors who see their work as simply a job and not a calling. I also see other young nurses and physicians keenly dedicated to their patients, keeping the art and calling of healing alive.

Reflecting on her five decades of nursing, she recalled sentimentally the strict rules observed at the beginning of her career: “Your white dress uniform must be starched and ironed. You must wear a white cap, white stockings, and white laced-up, polished shoes. Absolutely no ear rings or jewelry, no nail polish, and no or very little perfume. When a physician walks up to the nurse’s station, you stand up promptly and offer him a cup of coffee or tea. You follow a doctor on his rounds with a clipboard, taking any orders. The nurse opens the door for the doctor outside the patient’s room and then goes in after him. You never get on the elevator with a doctor, you wait for the next one.”

Medicine and nursing go hand in hand; no professions are more dependent on each other. The modern physician/nurse teams need to cultivate the art of their professions to care best for their patients. Never have our patients needed the art of their healers more than now! n

Lucius M. Lampton, MD Editor

Contact me at lukelampton@cableone.net.

— Lucius M. Lampton, MD, Editor

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

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

Michael Artigues, MD Pediatrician, McComb Children’s Clinic

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

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

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

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

J. Edward Hill, MD Family Physician, Oxford

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

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

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

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

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

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

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

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

Paul “Hal” Moore Jr., MD Radiologist, Singing River Radiology Group, Pascagoula Ann Myers, MD Rheumatologist , Mississippi Arthritis Clinic, Jackson Darden H. North, MD Obstetrician/Gynecologist , Jackson Health Care-Women, Flowood Jack D. Owens, MD, MPH Neonatologist, Newborn Associates, 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 Shou J. Tang, MD Professor and Director, Division of Digestive Diseases, University of Mississippi Medical Center, Jackson Samuel Calvin Thigpen, MD Hematology-Oncology Fellow, Department of Medicine, University of Mississippi Medical Center, Jackson Thad F. Waites, MD Clinical Cardiologist, Hattiesburg Clinic W. Lamar Weems, MD Urologist, Jackson Chris E. Wiggins, MD Orthopaedic Surgeon, Bienville Orthopaedic Specialists, Pascagoula John E. Wilkaitis, MD Chief Medical Officer, Brentwood Behavioral Healthcare, Flowood Sloan C. Youngblood, MD Assistant Medical Director, Department of Anesthesiology, University of Mississippi Medical Center, Jackson

CME WITH MICKEY MOUSE NOVEMBER 18–21, 2017 | WALT DISNEY WORLD® Register now at MSMAonline.com/CMEDisney For more information call Becky Wells at (601) 853.6733, ext. 340.

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Top 10 Facts You Need to Know about ADHD BARBARA S. SAUNDERS, DO Individuals with Attention-Deficit/Hyperactivity Disorder (ADHD) may daydream frequently, have difficulty focusing on the task at hand, be fidgety, talk too much, act impulsively, and/or make careless mistakes. ADHD is more commonly diagnosed in Mississippi than in some other states, and because it affects children, adolescents, and adults, it is important for all physicians in Mississippi to know about ADHD.

1

ADHD is the most common neurobehavioral disorder of childhood.

It affects approximately 11% of school-age children in the United States. Based on a meta-analysis of 175 research studies worldwide on the prevalence of ADHD in children 18 years of age or younger, Thomas et al. estimates that the worldwide prevalence of ADHD is about 7.2%.1 The Deep South has a higher than average prevalence of children diagnosed with ADHD. In Mississippi, approximately 14% of school-aged children have ever been diagnosed with ADHD.2

2 3

It’s all ADHD now.

With the latest revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the diagnostic terminology changed.

We no longer refer to children as having ADD or ADHD. Everyone who meets criteria is said to have ADHD, and the subtype is then specified. Subtypes include: inattentive type, hyperactive-impulsive type, and the most common, combined type.3 The prevalence of ADHD varies based on a child’s gender, race/ethnicity, and age.

ADHD occurs more commonly in boys than in girls; a study by Pastor et al. showed the prevalence of ADHD to be 13.3% in boys and 5.6% in girls. The same study showed a prevalence of 11.5% in non-Hispanic white children, while the prevalence in nonHispanic black children was 8.9% and in Hispanic children 6.3%. Pastor’s study found that ADHD was most common in the 12-17 year age range (11.8%),4 and the National Survey of Children’s Health 2003-2011 found ADHD to be most common in the 11-14 year age range (11.4%).5

4

The cause of ADHD is not known.

The current literature shows that genetics play a role in ADHD. Researchers are investigating brain injury, exposure to environmental toxins (such as lead) in utero or at an early age, exposure to alcohol in utero, and prematurity as possible risk factors and/or causes of ADHD. Current literature indicates that ADHD is not caused by consuming too much sugar, excessive screen time, poor parenting, or other social factors.6

5 6

The primary care physician should evaluate for ADHD in children ages 4 to 18 years old who present to clinic with learning and behavior problems and who also have symptoms of inattention, hyperactivity/impulsivity, or both.

This recommendation was made in the updated guidelines for the diagnosis, evaluation, and treatment of ADHD published by the American Academy of Pediatrics (AAP) in 2011.7 The evaluation for suspected ADHD is multifaceted and should include comprehensive medical, developmental, educational, and psychosocial evaluations.

The medical portion of the evaluation should include obtaining histories on any prenatal exposures (alcohol, tobacco, and illicit drugs), perinatal and/or neonatal complications, head trauma, sleep disturbances, medications, and alcohol/illicit drug use/abuse.

Obtaining a family history of ADHD and/or other behavior or learning problems is very important, as ADHD is thought to have a strong genetic component.8

7

Behavior rating scales are very important in both the initial evaluation of suspected ADHD and in the ongoing monitoring of ADHD symptoms.

“Broadband scales” evaluate for an array of behavior and/or mood symptoms including symptoms of ADHD, oppositional defiant disorder (ODD), conduct disorder, anxiety, and depression. Commonly used scales in this category include the Conners 3rd Edition, Child Behavior Checklist, and Teacher Report Form. “Narrow-band scales” evaluate for all diagnostic criteria of ADHD and often screen (but do not include all diagnostic criteria) for other behavior disturbances. Commonly used scales in this category include the Vanderbilt

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Assessment Scales and ADHD Rating Scale. Of note, only the Conners Comprehensive Behavior Rating Scales and the ADHD Rating Scale IV have been validated in preschool-aged children.8

8

Management recommendations for ADHD depend on age.

In the updated guidelines for the treatment of ADHD published by the AAP in 2011, recommendations were made based on three age groups: preschool-aged children (4-5 years old), elementary school-aged children (6-11 years old), and adolescents (12-18 years old). For preschool-aged children, the first line treatment is evidence-based parent- and/or teacher-administered behavior therapy. If behavior interventions do not adequately improve symptoms and symptoms continue to be moderately to severely impairing, methylphenidate can be prescribed. For elementary school-aged children, FDA-approved medications for ADHD and/or evidencebased parent- and/or teacher-administered behavior therapy are recommended. The first line treatment for adolescents is FDA-approved medication for ADHD, and behavior therapy may be prescribed if needed.7

9

Children and adolescents with ADHD are at increased risk for other behavioral, mood, and/or developmental disorders when compared to peers without ADHD. Common comorbid mood and behavioral disorders include depression, anxiety, oppositional defiant disorder, and conduct disorder.

Children and adolescents with ADHD should be screened for these and other mood/behavior disorders. Common developmental disorders include developmental delay/intellectual disability, writing and learning disabilities, and speech/language problems.9,10

10

Children with ADHD can receive increased academic and/or behavioral support at school if needed.

Children with ADHD who attend public schools, including charter schools, may be entitled to regular or special education services and/or accommodations and modifications designed to meet his/her educational needs under Section 504 of the Rehabilitation Act of 1973. These services are often referred to as a “504 Plan.” Children who attend public schools who have more significant learning and/or behavioral problems may qualify for an individualized education plan (IEP) under the Individuals with Disabilities Education Act 2004.11,12 n References 1. Thomas R, Sanders S, Doust J, et al. Prevalence of attention-deficit/hyperactivity disorder: a systematic review and meta-analysis. Pediatrics. 2015;135:e994-e1001. doi:10.1542/peds.2014-3482.

2. State-based prevalence data of parent reported ADHD diagnosis by a health care provider. Centers for Disease Control and Prevention: Attention-Deficit/Hyperactivity Disorder (ADHD). https://www.cdc.gov/ncbddd/adhd/prevalence.html. Published February 13, 2017. Accessed May 14, 2017.

3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th edition. Arlington, VA: American Psychiatric Association; 2013:59-65.

4. Pastor PN, Reuben CA, Duran CR, et al. Association between diagnosed ADHD and selected characteristics among children aged 4-17 years: United States, 20112013. NCHS Data Brief. 2015;201.

5. Visser SN, Danielson ML, Bitsko RH, et al. Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United States, 2003–2011. J Am Acad Child Adolesc Psychiatry. 2014;53:34-46. doi:10.1016/j.jaac.2013.09.001.

6. Division of Human Development and Disability, National Center on Birth Defects and Developmental Disabilities. Attention-deficit / hyperactivity disorder (ADHD).

Centers for Disease Control and Prevention. https://www.cdc.gov/ncbddd/adhd/facts.html. Published November 16, 2016. Accessed May 18, 2017.

7. Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011;128:1007-1022. doi:10.1542/ peds.2011-2654.

8. Krull KR. Attention deficit hyperactivity disorder in children and adolescents: clinical features and diagnosis. https://www.uptodate.com/contents/attention-deficithyperactivity-disorder-in-children-and-adolescents-clinical-features-and-diagnosis#H1. Accessed May 14, 2017.

9. Larson K, Russ SA, Kahn RS, et al. Patterns of comorbidity, functioning, and service use for US children with ADHD, 2007. Pediatrics. 2011;127:462-470. doi:10.1542/ peds.2010-0165.

10. Yoshimasu K, Barbaresi WJ, Colligan RC, et al. Written-language disorder among children with and without ADHD in a population-based birth cohort. Pediatrics.

2011:e605-e612. doi:10.1542/peds.2010-2581d.

11. Know your rights: students with ADHD. United States department of education, office for civil rights. https://www2.ed.gov/about/offices/list/ocr/docs/dcl-knowrights-201607-504.pdf. Accessed May 16, 2017.

12. IDEA 2004 Statute and Regulations. IDEA 2004: law and regulations - Wrightslaw. http://www.wrightslaw.com/idea/law.htm. Accessed May 15, 2017.

Author Information: Dr. Saunders is an Assistant Professor of Pediatrics and Chief of the Division of Child Development at the University of Mississippi Medical Center. Dr. Saunders is a developmental-behavioral pediatrician and practices in the Center for Advancement of Youth (CAY Center) at the University of Mississippi Medical Center in Jackson.

Corresponding Author: Barbara S. Saunders, DO, FAAP, Department of Pediatrics, Division of Child Development, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216. (bsaunders@umc.edu)

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Top 10 Facts You Need to Know about Chest Radiography of Lines and Tubes in the Intensive Care Unit J. MICHAEL BREWER, DO; DOMINIQUE J. PEPPER, MD; CHARLES S. WHITE, MD Introduction Almost one-fifth of new major findings among intubated, mechanically ventilated patients in the intensive care unit (ICU) are discovered only by routine chest radiography.1 The following describes ten key facts for every intensivist and intensivist-in-training about correct placement and positioning of common lines and tubes that traverse the adult thorax.

1 2 3

Always confirm the correct patient, date and time of the chest radiograph, as well as assess the quality of the image (rotation, penetration, and degree of inspiration).

Endotracheal Tube In adults, the ideal position of the endotracheal tube is within the trachea with the tip located 2 cm (minimum distance) to 7 cm above the carina (T4–T5 interspace) – Image A.

Tracheostomy Tube In adults, the ideal position of the tip of a tracheostomy tube is 3 – 5 cm above the carina. Although routine post-tracheostomy chest radiographs are of low yield, tracheostomy patients with high-risk features should be imaged. High-risk features include post-operative signs and symptoms of complications, emergent or ‘difficult’ tracheostomies, and tracheostomy cases performed without bronchoscopic guidance.2

4 5 6 7 8

Feeding Tube The ideal position of the tip of a naso- or orogastric tube is within the distal duodenum.3 A well-placed feeding tube should extend below the diaphragm and should not coil within the stomach – Image D. Thoracostomy Tube An interruption in the radio-opaque line delineates the last side-hole in a thoracostomy tube – Images B and C. Clinicians should suspect a misplaced tube if the last side-hole lies outside the thoracic cavity or if subcutaneous air is evident on the chest radiograph.4

Central Venous Catheter Central venous catheters should be placed with ultrasound guidance into the internal jugular or subclavian veins.5 The catheter tip is ideally positioned 1–2 cm above the cavoatrial junction (superior vena cava and right atrium) – Image C.6 The catheter tip should not abut the wall of the superior vena cava at an acute angle as this increases the risk of vessel wall erosion.

Midline Catheter and Peripherally Inserted Central Catheter Midline catheters and peripherally inserted central catheters (PICC) are inserted via the brachial or ante-cubital veins. A midline catheter is 3 to 10 inches in length and does not require confirmatory positioning with chest radiography as it is designed to lie above the vena cava.7 The tip of a PICC is ideally positioned 1–2 cm above the cavoatrial junction – Image E. Pulmonary Artery Catheter The tip of a pulmonary artery catheter is pulled back into the pulmonary artery after wedging and is ideally positioned within the mediastinal or hilar shadow – Image G.8

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A

B

E

F

C

D

G

H

Image A: Endotracheal tube correctly positioned within the trachea with the endotracheal tip (white arrow) located 2 to 7 cm above the main carina (white asterisk).

Image E: Right peripherally inserted central catheter (PICC) extending from the antecubital fossa and correctly terminating above the cavoatrial junction (white arrow).

Image B: Two thoracostomy tubes positioned within the right pleural space, one angled to the lung apex while the other is angled toward the lung base. Note the interruption in radio-opaque lines (white arrows) of the thoracostomy tubes within the thoracic cavity.

Image F: Right sub-clavian CVC seen crossing over the midline (white arrow). Pressure tracings after transducing the CVC indicated pulsatile flow and CT angiography confirmed that the CVC was inadvertently inserted into the right subclavian artery and terminated in the aorta.

Image C: Right subclavian central venous catheter, CVC (thick white arrow) with its tip correctly positioned above the cavo-atrial junction (thin white arrow). Left internal jugular CVC (thick black arrow) crossing the midline with its tip extending into the right internal jugular vein (thin black arrow). Also seen are three thoracostomy tubes located within the right pleural cavity.

Image D: Two pigtail catheters (thin white arrows) located within the right pleural cavity of a patient with acute respiratory distress syndrome and a large right pneumothorax. The patient required extracorporeal membrane oxygenation (ECMO) and the ECMO catheter (thick black arrow) is seen extending from the right internal jugular vein to above the cavo-atrial junction. A left internal jugular CVC is also seen terminating within the left brachiocephalic vein (thin black arrow). The feeding tube extends below the diaphragm and courses toward the gastric pylorus (thick white arrow).

Image G: Pulmonary artery catheter extending from the right internal jugular vein (thick white arrow) and optimally terminating within the mediastinal shadow (thin white arrow).

Image H: Left internal jugular CVC (thick white arrow) correctly terminating above the cavo-atrial junction (thin white arrow). The patient also has a Blakemore tube located in the esophagus that terminates in the stomach with the gastric balloon inflated (black arrow). Also seen are radio-opaque devices (Kelly clamp and grill of a football helmet) used to secure the Blakemore tube.

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Intra-Aortic Balloon Pump The tip of an intra-aortic balloon pump catheter is ideally located just distal to the left subclavian artery in the descending thoracic aorta, at the level of the sterno-manubrial joint – Image I.9

Implantable Cardioverter Defibrillator The implantable cardioverter defibrillator is usually composed of a single lead with two shock coils. One shock coil is located at the brachiocephalic vein–superior vena cava junction and the other in the right ventricle – Image J.9 Extension of the lead beyond the epicardial fat stripe may indicate myocardial perforation.

Conclusion Studies have failed to identify any subgroup in which performing daiI J ly routine chest radiography was beneficial.10,11 However, abandoning routine for restrictive chest radiographs in the intensive care unit may Image I: Radio-opaque stripe indicating the tip of an intra-aortic compromise patient safety.12 n balloon pump catheter (white arrow). The balloon pump is ideally

References 1. Hall JB, White SR, Karrison T. Efficacy of daily routine chest radiographs in intubated, mechanically ventilated patients. Crit Care Med. 1991; 19(5):68993.

located at the level of the sterno-manubrial joint, where the second rib inserts anteriorly. Also seen is an optimally placed pulmonary artery catheter.

Image J: Implantable cardioverter defibrillator with ventricular lead extending from the left subclavian vein to the right ventricle. One 2. Yeo WX, Phua CQ, Lo S. Is routine chest X-ray after surgical and percutaneous shock coil is located at the brachiocephalic vein–superior vena cava tracheostomy necessary in adults: a systemic review of the current literature. junction (thick white arrow) and the other in the right ventricle (thin white arrow).

Clin Otolaryngol. 2014; 39(2):79-88.

3. Metheny NA, Meert KL. Monitoring feeding tube placement. Nutr Clin Pract.

2004; 19(5):487-95.

4.

Gross SB. Current challenges, concepts, and controversies in chest tube management. AACN Clin Issues Crit Care Nurs. 1993; 4(2):260-75.

5. Milling TJ, Rose J, Brigs WM, Birkhahn R, Gaeta TJ, Bove JJ, Melniker LA. Randomized, controlled clinical trial of point-of-care limited ultrasonography assistance of central venous cannulation: The Third Sonography Outcomes Assessment Program (SOAP-3) Trial. Crit Care Med. 2005;33(8):1764-69.

6. Pikwer A, Bååth L, Davidson B, Perstoft I, Akeson J. The incidence and risk of central venous catheter malpositioning: a prospective cohort study in 1619 patients.

Anaesth Intensive Care. 2008; 36(1):30-7.

7.

Gorski LA, Czaplewski LM. Peripherally inserted central catheters and midline catheters for the homecare nurse. J Infus Nurs. 2004; 27(6):399-409.

8.

Kaye W. Invasive monitoring techniques: arterial cannulation, bedside pulmonary artery catheterization, and arterial puncture. Heart Lung. 1983; 12(4):395-427.

9.

Hunter TB, Taljanovic MS, Tsau PH, Berger WG, Standen JR. Medical Devices of the Chest. Radiographics. 2004; 24(6):1725-46.

10. Oba Y, Zaza T. Abandoning daily routine chest radiography in the intensive care unit: meta-analysis. Radiology. 2010; 255(2):386-95.

11. Pikwer A, Bååth L, Perstoft I, Davidson B, Akeson J. Routine chest X-ray is not required after a low-risk central venous cannulation. Acta Anaesthesiol Scand. 2009; 53(9):1145-52.

12. Ganapathy A, Adhikari NK, Spiegelman J, Scales DC. Routine chest x-rays in intensive care units: a systematic review and meta-analysis. Crit Care. 2012; 16(2):R68.

Author Information: (Dr. Pepper) Fellow, Critical Care/ Pulmonary Medicine, Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda MD. (Mr. Brewer) Fellow, Critical Care/ Pulmonary/ Sleep Medicine, Department of Medicine, University of Mississippi Medical Center, Jackson MS. (Dr. White) Professor of Radiology and Chief of Thoracic Imaging, Department of Radiology, University of Maryland Medical Center, Baltimore MD Corresponding Author: Dominique J. Pepper, Critical Care Medicine Department 2C145, 10 Center Drive Bethesda MD, 20892, email: dominiquepepper@gmail.com

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Establishing A Continuum of Care for Evidence-Based Behavioral Treatment for Youth with Disruptive Behavior KATHRYN E. PARISI, MA; NINA WONG SARVER, PHD; DOROTHY SCATTONE, PHD; DUSTIN E. SARVER, PHD

Abstract Disruptive behavior problems are a common and impairing condition among youth. Evidence-based behavioral interventions for behavioral problems in Mississippi are scarce. The present manuscript details the current diagnostic criteria for disruptive behavior disorders, reviews treatment guidelines and current treatment service use trends both nationally and in Mississippi. Overall, national surveys of behavioral treatment use indicate a disparity between treatment guidelines and typical service provision. Based on this disparity, this report introduces and reviews the establishment of a new evidence-based behavioral treatment for Mississippi families that embraces a continuum of care approach: Parent-Child Interaction Therapy (PCIT) and its prevention-based and supportive companion Child-Adult Relationship Enhancement (CARE). Guidelines for evidenced-based treatment practices that physicians may use to monitor and ensure that children are receiving evidenced-based behavioral care for behavioral disorders are also presented. Improving access to such evidence-based behavioral interventions is crucial to maximize long-term outcomes for Mississippi families.

Key Words: disruptive behavior problems, behavioral treatment, children, evidence-based practice, parent-child interaction therapy Introduction Disruptive behavior problems are among the most common mental health concerns affecting children. The estimated national lifetime prevalence rate of disruptive behavior disorders among children under age eight is 10-18%. Commonly observed impairments include family conflict and dysfunction, decreased school performance, social difficulty with peers and victimization, and difficulty with emotion regulation. Longitudinal findings indicate that early behavioral disturbances also place children at substantial later risk for other forms of impairment and disturbance during adolescence and adulthood including co-occurring mental problems (e.g., depression, suicidality), delinquency/criminality, substance use, and financial and relational difficulties. The management of behavioral problems is also associated with large financial and societal costs, with an estimated total annual cost of $247 billion. The treatment of behavior problems in children is, therefore, an important public health priority in the United States, and in Mississippi because of their high prevalence, early age of

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onset, and impact on the individual child, family, and community.

This manuscript, therefore, has several key aims: (1) review of the phenomenology of childhood disruptive behavior disorders, (2) review of current national treatment guidelines and recent service trends in treating behavioral problems, and (3) explanation of the introduction of a new evidence-based behavioral treatment program for families in Mississippi.

Phenomenology of Child Disruptive Behaviors Disruptive behavior disorders are characterized by repeated, maladaptive problems with oppositional behaviors toward others, including peers and authority figures. Clinical presentations include Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD). ODD is defined by a pattern of angry/irritable mood, argumentativeness, defiance, and vindictiveness towards others. CD is defined as a repetitive and persistent pattern of behavior that violates the rights of others, major societal/age norms, or rules. In younger children, significant tantrums, outbursts, reflexive defiance (i.e., “No!”), and acts of aggression are frequent symptoms.

Notably, disruptive behavior in children with neurodevelopmental disabilities occurs at a much higher rate than among neurotypical children and constitutes a major source of impairment.

Neurodevelopmental disorders as a group are common and encompass a range of developmental issues encountered by physicians, including speech/language delays, motor delays, cognitive/learning delays, attention-deficit/hyperactivity disorder (ADHD), and autism spectrum disorder, as well as other specific conditions affecting development (e.g., Fetal Alcohol Syndrome). Addressing co-occurring behavioral disturbances in these children is especially important as disturbances have the potential to interfere with progress in treatments for the disorder itself (e.g., speech/occupational therapy) may be an additional source of impairment.

Treatment Guidelines and Service Trends National treatment guidelines. Behavioral interventions are the first-line treatments recommended for childhood disruptive behavior in preschool-aged youth. Guidelines from the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, the American Psychological Association, and the Centers for Disease Control uniformly advise physicians to facilitate referral for or initiate behavioral treatments for children < 5 years prior to the introduction of

medication, if possible.1-3 Recent data on national service use trends, however, have raised questions over the quality of medical care for behavioral problems and whether families are receiving treatment that corresponds to these consensus practice guidelines.

Trends in treatment practice. The concern that practice guidelines are followed less frequently than recommended is largely based on the increased use of psychotropic medications for the treatment of childhood disruptive behavior in outpatient care in recent years. For example, rates of psychotropic use rose significantly from 1994-2006, and antipsychotic prescriptions used to treat aggression increased 7.6 fold in youth between 1993-1998 and 2005-2009.4 A similar pattern emerges for children with neurodevelopmental disorders. For instance, pediatric stimulant use for ADHD experienced an annual growth rate of 3.4% annually from 1996-2008 before leveling off.5 Moreover, the presence of disruptive behavior is known to increase the likelihood that children with autism will be prescribed psychotropic medication.6 Overall, these national patterns suggest that effective behavioral interventions may be underutilized.

The underutilization of behavioral interventions occurs prominently in Mississippi, particularly among children diagnosed with ADHD, the most common neurodevelopmental disorder. Nationally, Mississippi ranks 6th in the number of children with ADHD currently receiving medication treatment (74%) but ranks 48th in the number of children receiving behavioral interventions (44%).7 Based on 2011 Medicaid data, the Centers for Disease Control indicates that Mississippi children ages 2-5 years with ADHD are significantly more likely to receive medication (73.2%) than behavioral treatment (56.4%).7 The gap is even larger among families with private insurance (89% and 22.8% received medication and behavioral therapy respectively).7 There are several factors and barriers that may explain this sizable gap. In Mississippi, qualified providers remain scarce, and evidencebased behavioral treatment options are often unavailable and/or are poorly integrated into community-based care, whereas medications are comparatively more accessible, available, and may offer acute symptom relief.8 These trends are striking given recent evidence that behavioral interventions have greater cost-effectiveness than medications when sequenced consistent with consensus guidelines.9 Status of contemporary behavioral interventions. Behavioral interventions for disruptive behavior teach parents new skills and reorganize dysfunctional family interaction patterns to better manage problematic behavior. Best practice advisories recommend that physicians engage in evidence-informed discussions with parents of disruptive children to advise them on the benefits and components of effective behavioral interventions.1-3 Key evidenced-based elements addressed in behavioral management that physicians and parents should be aware of to ensure receipt of standard of care behavioral treatment are displayed in the Table. For preschool-aged children, behavioral therapy is often superior to medication in reducing problematic behavior and increasing compliance, with treatment gains maintained even after treatment is over.10 Thus, increasing access and availability to behavioral interventions for preschool children in Mississippi is one critical step in reversing the underutilization of behavioral interventions.

Introduction of an Evidence-based Behavioral Intervention to Mississippi Parent-Child Interaction Therapy. Parent-Child interaction Therapy (PCIT) is a specialized evidence-based treatment initially developed for children with ODD, CD, or related behavior problems.

Borrowing from social learning theory, operant conditioning, and attachment theory, PCIT works to improve the parent-child relationship and provides parents with effective, non-physical discipline techniques. Extensive research demonstrates the efficacy of PCIT in children ages 2-12 years old, and children who receive PCIT have decreased problem behaviors and improved family relationships with less parental stress and negativity.11 Long-term benefits include reductions in delinquency risk and related outcomes in adolescence and later adulthood.12 PCIT treatment consists of two phases: Child-Directed Interaction (CDI) and Parent-Directed Interaction (PDI). In CDI, parents follow the childâ&#x20AC;&#x2122;s lead during structured play sequences and acquire positive interaction skills that help foster a warm, healthy relationship.

Skills include the use of positive praise, reflection of the childâ&#x20AC;&#x2122;s speech, imitation of appropriate behavior, behavioral descriptions, and enthusiasm/enjoyment during play. During child-led play interactions, parents are also coached to avoid asking questions, giving commands, or making negative/critical statements. In PDI, parents learn discipline skills including selective attention and giving effective time outs that are generalized from the clinic to the home setting.

PCIT is unlike talk-therapy and is set apart by its use of live therapist coaching to the parent through an audio communication earpiece.

This provides parents with real-time feedback in acquiring parenting skills while observing play interactions through a one-way mirror.

Importantly, PCIT is data-driven and involves ongoing assessment of behavioral change or progress. Treatment is discontinued only after parents reach quantifiable mastery of CDI/PDI skills and gain confidence with independently implementing behavior management techniques.

Establishing PCIT in Mississippi. In October 2015, The Mississippi Council for Developmental Disabilities (MSCDD) sponsored the initiation of a PCIT program through the Center for Advancement of Youth (CAY) at UMMC. This project provided the opportunity to establish the first PCIT program in Mississippi. Five therapists (four Ph.D. level clinical psychologists and one social worker) underwent formal PCIT training certification in the Jackson area. The clinical service began in February 2016 and rapidly filled a critical treatment service gap, particularly for pre-school aged children. Assessment of clinical outcomes occur each session and are ongoing, but preliminary program evaluation results are highly promising.

Continuum of Care through CARE. The program received additional funding to expand services to children and adolescents who may be at risk for but subclinical for behavior problems. This effort results in a continuum of care supporting intervention of behavioral problems in youth. Certified PCIT therapists will become master trainers in Child-Adult Relationship Enhancement (CARE), an extension of PCIT that can be disseminated to any adult who interacts JOURNAL MSMA

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Table. Key evidenced-based elements in behavior management Element

Description

Example

Modeling & Imitation

Demonstrate prosocial behavior including getting along and handling conflict calmly. Smile and praise others and children may be more likely to do the same with peers.

Follow the child’s lead in play, mimic actions.

Praise

Positive comments to motivate specific pro-social behavior or compliance.

“Nice job making your bed!” “Great job minding so quickly!” instead of a vague “Good job”

Strategic Attention

Enthusiastic praise for appropriate behavior

“I like how you are playing quietly!” “Awesome sharing!”

Selective Ignoring

Turn or walk away contingent on minor misbehaviors such as whining, sassing, protesting, and crying.

Give no eye contact or comments and return attention once behavior stops.

Prompt

A cue or hint for someone to initiate a target behavior.

“When we walk in the hall, we keep our hands to ourselves”.

Effective Instructions

Specific instructions given one at a time and directly rather than indirect, vague or general.

“Put your backpack in your room” instead of “Let’s clean your room”.

Positive Practice

Practice the correct behavior after a misbehavior.

Pick up crayons after the child scattered crayons on the floor. Next require the child to pick up crayons in other areas.

Response Cost

Remove access to a valued object, privilege, or activity contingent on misbehavior.

Removing earned tokens after a misbehavior; loss of screen time for violating rule.

Time Out

Removal of attention for misbehaviors. In adolescents, may take form of grounding that varies in time according to misbehavior.

Place child in a designated area without access to privileges or attention for a given time period.

Restitution

Return the environment to its original condition.

Picking up crayons that were scattered all over floor.

House Rules

A list of 3-5 rules stated positively.

“Play gently”/“Safe hands” instead of “No hitting”.

Token Economy, Point System, Sticker Charts

Provide the child with tokens, stickers, or points contingent upon task completion or other specified activity. The child then may exchange tokens for an object or activity.

Rewards can be normalized, to which child has access regularly, do not need to cost money: TV time, later bedtime, choose family dinner if possible, dessert.

Behavioral Contract

Specifies expectations, rewards, and consequences in the form of a written contract.

Allowance contract, cell phone usage contract, chore contract.

Communication Skills & Conflict Management

Explicit instructions on listening, communicating parental expectations, providing youth choices, and conflict resolution.

Discuss turn taking rules before beginning an activity. Explain in advance that noncompliance does not earn privileges.

Daily Report Card

List of 4-6 behavior expectations at school that is tracked by teacher. Privileges are earned for positive school behavior.

Child will participate in all reading activities; Child will raise hand before speaking.

with children (e.g., paraprofessionals, teachers, child advocates, and daycare providers). CARE trainings provide complementary techniques derived from PCIT that can be easily disseminated into community-based settings. In this way, CARE resembles a primary and secondary prevention model designed to improve adults’ interactions with youth, as one mechanism to reduce problematic child behavior.

Conclusions Childhood behavior problems create substantial impairments for children and their families, interfering with healthy psychosocial development. Adverse outcomes associated with behavior problems can be mitigated by evidence-based behavioral interventions, but

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such treatment is lacking in Mississippi. This contributes to the underutilization of behavioral interventions. The PCIT program at UMMC is making headway to address this gap by developing an evidence-based continuum of care for youth with behavioral problems through the provision of PCIT treatment services and the introduction of CARE trainings that target prevention of behavioral problems in at risk populations (i.e., neurodevelopmental disorders).

Mississippi physicians will be crucial to help parlay this evidence-based service into local communities by supporting policies and expansions, calling for local dissemination of evidence-based interventions, and directing patients to behavioral health practitioners who demonstrate adherence to behaviorally-focused treatment for disruptive behavior. Such cooperation across medical and behavioral services is imperative to maximizing the positive outcomes for families. Practitioners who are interested in clinical services or establishing of a continuum of care in their area are encouraged to contact the PCIT program for more information (Figure).

Acknowledgements

The PCIT project was funded by a grant to the senior corresponding author (DES) by MS 4680-DD15-HE from the Mississippi Council for Developmental Disabilities and in part through a grant to The Children’s Collaborative from the Mississippi Division of Medicaid.

The authors gratefully acknowledge the contributions of Genevieve Garrett, Patricia Logan, Joshua Masse, and lastly, the children and families who have participated in the PCIT program at UMMC. n

References 1.

Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management. Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/

hyperactivity disorder in children and adolescents. Pediatrics. 2011 Nov; 128(5): 1007–1022. Published online 2011 Oct 16. doi: 10.1542/ peds.2011-2654.

2. Ghuman J, Arnold L, Anthony B. Psychopharmacological and other treatments in preschool children with attention-deficit/hyperactivity disorder: current evidence and practice. J Child Adolesc Psychopharmacol.

2008;18,413–47.

3. Gleason MM, Egger HL, Emslie GJ, et al. Psychopharmacological treatment for very young children: contexts and guidelines. J Can Acad Child Adolesc Psychiatry. 2007;46,1532–72.

4. Olfson M, Blanco C, Liu S, et al. National trends in the office-based treatment of children, adolescents, and adults with antipsychotics. JAMA Psychiatry [serial online]. 2012;69:1247-1256.

5. Safer, DJ. Recent trends in stimulant usage. J Attent Disorders. 2016;20,471477.

6. Aman MG, Lam KS, Van Bourgondien ME. Medication patterns in patients with autism: Temporal, regional, and demographic influences. J Child Adolesc Psychopharmacol. 2005;15,116-26.

7. Centers for Disease Control and Prevention. Mental health surveillance among children – United States, 2005-2011. Morbidity and Mortality Weekly Report. 2013;62(Suppl;May 16, 2013):1-35.

8. Elkin, TD, Sarver, DE, Wong Sarver, N, et al. Future directions for the implementation and dissemination of statewide developmental-behavioral pediatric integrated health care. J Clin Child Adolesc Psychol. 2016;4416,1– 12. http://doi.org/10.1080/15374416.2016.1152551.

9. Page, TF, Pelham III, WE, Fabiano, GA et al. Comparative cost analysis of sequential, adaptive, behavioral, pharmacological, and combined treatments for childhood ADHD. J Clin Child Adolesc Psychol. 2016;4416,1–12. http://doi.org/10.1080/15374416.2015.1055859.

Child Interaction Therapy (PCIT) project at the Center for Advancement of Youth at the University of Mississippi Medical Center. Her interests include child maltreatment and predicting outcomes of PCIT, parent training, and other treatments for children and families (Ms. Parisi). Assistant professor of pediatrics at the University of Mississippi Medical Center. Licensed clinical psychologist and a co-investigator for the PCIT project at UMMC. Her clinical and research interests include enhancing and disseminating evidencebased treatments for anxiety, mood, and related disorders (Dr. Wong Sarver). Associate professor of pediatrics at the University of Mississippi Medical Center. Licensed clinical psychologist and a co-investigator for the PCIT project at UMMC. Her primary area of clinical practice and research interests are in the area autism spectrum disorders (Dr. Scattone). Assistant professor of pediatrics at the University of Mississippi Medical Center. Dr. Sarver is licensed clinical psychologist and is the Principal Investigator for the PCIT project at UMMC. His clinical and research interests focuses on developmental psychopathology broadly, with specialization in the assessment and treatment of ADHD, neurodevelopmental and behavioral disorders (Dr. D. Sarver).

Author Correspondance: Dustin E. Sarver, PhD; University of Mississippi Medical Center Center for Advancement of Youth (CAY), Department of Pediatrics, Division of Child Development, 2500 North State Street, Jackson, MS 39216. (Ph) 601-984-5863 (Fax) 601-984-5857 Email: dsarver@umc. edu.

10. Thomas, R, & Zimmer-Gembeck, MJ. Behavioral outcomes of parent-child interaction therapy and Triple P—Positive Parenting Program: a review and meta-analysis. J Abnormal Child Psychol. 2007;35,475-495.

11. Hood, KK & Eyberg, SM. Outcomes of Parent-Child Interaction Therapy: mothers’ reports of maintenance three to six years after treatment. J Clin Child Adolesc Psychol. 2003;32,419-429.

12. Piquero, AR, Farrington, DP, Welsh, BC, et al. Effects of early family/parent training programs on antisocial behavior and delinquency. J Exp Criminol.

2009;5,83-120.

Author Information: Center for Advancement of Youth, Department of Pediatrics, University of Mississippi Medical Center, Jackson. Research coordinator for the ParentFigure. Objectives of PCIT and contact information Parent Child Interaction Therapy (PCIT) is an empirically based treatment for families of children ages 2-7 years with behavioral problems Treatment goals in PCIT include:

✓ Reductions in child disruptive behavioral symptoms ✓ Improved parent-child relationship/attachment, increased physical warmth ✓ Increased parental authority/age-appropriate discipline and child compliance ✓ Increases in parenting confidence Referrals to the PCIT program at UMMC can be made by contacting CAY at (601) 984-4465.

For questions or inquiries about PCIT or CARE training, please contact the senior, corresponding author at dsarver@umc.edu.

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Change In Meropenem Utilization Following the Implementation of a Targeted Antimicrobial Stewardship Audit and Feedback Program DAVID A. CRETELLA, PHARMD; S. TRAVIS KING, PHARMD; JASON J. PARHAM, MD; KAYLA R. STOVER, PHARMD Abstract Purpose: To evaluate the impact of an antimicrobial stewardship audit and feedback intervention on meropenem use.

Methods: A daily program of prospective, post-prescriptive audit with feedback targeting meropenem was implemented by the institutional antimicrobial stewardship program (ASP). The goal of this intervention was to reduce inappropriate meropenem use by recommending alternative therapy. To assess this intervention, adult medicine patients with meropenem orders active for ≥ 24 hours from June 1, 2013-August 31, 2013 (pre-intervention (PRE)) or June 1, 2014-August 31, 2014 (post-intervention (POST)) were reviewed. The primary objective was the change in appropriate use of meropenem.

Results: 111 PRE and 91 POST courses were reviewed. Appropriate meropenem use rates were 22.5% and 31.9%, respectively. Reasons for inappropriate use included allergy (35% vs. 37%) and escalation (16% vs. 10%). Meropenem days of therapy/1000 patient-days significantly decreased by 37.5% (24 vs. 15 in PRE vs. POST, respectively, p<0.01).

There were more short (1-3 day) courses of therapy in POST (28 vs.

32 courses, respectively), but fewer extended (>3 day) courses of therapy (83 vs. 59).

Conclusions: Implementation of a targeted stewardship audit and feedback intervention reduced the duration of therapy and consumption of meropenem despite an overall high percentage of inappropriate use. These results demonstrate the effect that audit and feedback can have on identifying drivers of inappropriate prescribing and reducing inappropriate use.

Key Words: persuasive intervention, carbapenem, quasiexperimental, antibiotics Introduction There is growing momentum across the United States in support of increased antimicrobial stewardship, evidenced by the White House’s National Action Plan for Combating Antibiotic-Resistant Bacteria and proposed Joint Commission stewardship requirements.1,2 It is widely anticipated that health systems will be required to track antimicrobial use and regularly conduct activities to improve antimicrobial prescribing.2 The Infectious Disease Society of America (IDSA) recommends that acute care hospitals establish antimicrobial stewardship programs 162 VOL. 58 • NO. 5 • 2017

(ASPs) to improve prescribing practices.3 Their recommendations for influencing prescribing include a combination of mechanisms, such as persuasive interventions and restrictive prescribing policies.

Meropenem is a carbapenem ubiquitously employed in the management of gram negative infections. This use stems from its retained stability in the setting of most beta-lactamases, include extended-spectrum beta-lactamases (ESBLs) and Ambler Class C beta-lactamases (AmpCs).4-6 Widespread use of this agent has hastened the emergence of resistance, most notably that caused by the production of carbapenemases and porin alterations.4 Infections with these carbapenem-resistant Enterobacteriaceae (CRE) are steadily increasing and associated with significant morbidity and mortality in hospitalized patients (Table 1).7,8 High rates of institutional use and patient exposure to these agents has been well-documented as propagating the spread of these pathogens throughout health systems.4 As such, it is imperative that health systems implement mechanisms to improve utilization of broad-spectrum antimicrobials, including carbapenems through stewardship and other quality improvement initiatives.

Table 1. Clinically Significant Carbapenem Resistant Mechanisms Mechanisms of Carbapenem Resistance Carbapenemase production

KPC, NDM, OXA, IMP, VIM

Hydrolyze all betalactam antibioticsa

Reduced expression of outer membrane porins

OprD, OmpC, OmpK, OmpF

Reduced entry of carbapenems into periplasmic space

Over-expression of efflux pump systems

MexAB-OprM, MexXY-OprM

Increased expulsion of beta-lactams from target site

a. Aztreonam may retain susceptibility in the presence of NDM, VIM, IMP enzymes. b. Multiple mechanisms may be present in a single organism.

ASPs serve as critical elements in optimizing institutional antimicrobial utilization. Additionally, ASPs have been shown to reduce costs, shorten length of stay, and optimize patient care.3 In April 2014, after unsuccessful attempts to restrict meropenem use to the intensive care unit, the ASP at this center implemented a prospective audit with feedback system targeting meropenem in non-critically ill adult patients. The goal of this intervention was to improve utilization of

meropenem by reducing inappropriate use. This institutional review board-exempted quasi-experimental study was performed to evaluate the effects of the intervention.

Objective The primary objective was to assess the change in appropriate utilization of meropenem. Secondary objectives included drug utilization and consumption data.

Methods Study Setting The hospital is a 722-bed tertiary care facility that serves as the state’s only academic medical center. The ASP at this institution conducts a number of interventions including review of pertinent positive blood cultures, medical intensive care unit rounds, tracking of antimicrobial usage and audit with feedback. It also regularly conducts audit and feedback on targeted antimicrobials, including vancomycin, daptomycin, linezolid, and the echinocandins. This program of audit and feedback is modeled after current recommendations regarding antimicrobial stewardship programs3 and consists of a complete review of antimicrobial therapy by a stewardship clinician (infectious disease physician or infectious disease-trained Pharm.D.) followed by recommendations to optimize care if it can be improved. The review, assessment, and recommendations, are made using the stewardship clinician’s judgement without formalized criteria or guidance and are patient-specific. Stewardship interventions are communicated through patient-centered discussion in a form of “academic detailing”. Regularly communicated recommendations include changes to antimicrobial regimens, additional laboratory testing and consultations. Theradoc® (Premier) decision support software is utilized for patient identification and analysis as well as a tool to follow drug consumption. Stewardship personnel includes one infectious disease physician (0.4 full time equivalent (FTE)) and indirect, voluntary support from two infectious disease pharmacy faculty and an infectious disease pharmacy resident totaling nearly 0.5 FTE. Stewardship Intervention In April 2014, the stewardship team created an alert for any active meropenem orders on adult medicine patients. The stewardship clinician reviewed the electronic medical records of patients on the alert list in order to determine whether meropenem was being used appropriately. Alerts were reviewed once daily on the day following order placement. Orders placed on weekends were reviewed the following Monday. If the meropenem use was determined to be inappropriate by the reviewing clinician, the stewardship team member contacted the primary team to recommend alternative therapy following the same process for audit and feedback as earlier described. Correspondence between stewardship and prescribers did not use a standardized form and was outside of the medical record.

The acceptance of this recommendation was voluntary, as there is no formal pre-prescription guidance or restriction for meropenem at this institution.

Study Design This quasi-experimental review before and after intervention initiation was completed at a 722-bed tertiary care academic facility in compliance

with Institutional Review Board requirements. The pre-intervention patient group included all adults on medicine floors who had an active meropenem order for >24 hours from 06/01/2013-8/31/2013. The post-intervention group included adults on medicine floors with an active meropenem order for > 24 hours from 06/01/2014-8/31/2014.

Patients entering the intensive care unit (ICU) at any time during their stay were excluded. Data collected included demographics, allergy information, prescriber information, lab values, vitals, medication use data (duration of therapy, dose, indication), culture data, and infection risk factors such as Human Immunodeficiency Virus (HIV) or chronic immunosuppression. To assess acute disease severity, the rapid emergency medicine score (REMS) at time of drug initiation was calculated.9 In this scoring system, a REMS >10 indicates greater than 10% chance for inpatient mortality.

Each course of meropenem that met inclusion criteria was evaluated by a single investigator to determine appropriateness of use. Appropriate use criteria were created by the stewardship team members to facilitate objective course assessment after intervention implementation and were not specified or formally recognized during either study period.

Appropriate use criteria for meropenem are listed in Table 2. The stewardship team members believed these criteria clearly merited continuation of meropenem after review and that alternative therapy would not have been recommended. Meropenem utilization that was not appropriate was assessed via review of patient chart to determine the rationale for selection, with special consideration for use to avoid drug allergies, critically ill patients, and use in presumed high-risk populations such as patients taking chronic immunosuppressive agents. Additionally, days of therapy were calculated for 4 additional broad-spectrum antimicrobials (cefepime, piperacillin-tazobactam, ceftriaxone, and vancomycin) to determine if there was any change in prescribing practices as a consequence of the targeted meropenem intervention.

Usage data were generated using the Theradoc® system (Premier, Inc, Salt Lake City, UT) and courses were evaluated for duplication.

Table 2. Appropriate Meropenem Use Criteria • Definitive treatment of an organism resistant to third generations cephalosporins • E mpiric therapy in a patient with a history of infection with an organism resistant to third generation cephalosporins • C linical treatment failure, defined as persistent signs and symptoms of infection for 48 hours, requiring escalation to a carbapenem from another broad-spectrum antimicrobial icrobiologic treatment failure, defined as persistently positive cultures requiring • M escalation to a carbapenem from another broad-spectrum antimicrobial

Statistics were performed using SAS software v. 9.4 (SAS Institute Inc., Cary, NC). Average duration of therapy and length of stay in the two study periods were compared using the Mann-Whitney U test, as length of stay data did not have a normal distribution. Days of therapy of meropenem were calculated using the sum of meropenem days (calculated by specific start and stop times) divided by the total patient-days in the adult medical wards during the study period. It was compared by assuming the count data followed a Poisson distribution and analyzed using a generalized linear model. Other results are reported demonstratively.

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Results A total of 111 meropenem courses in the pre-intervention period and 91 meropenem courses in the post-intervention period met inclusion criteria. The groups were well balanced in regards to demographics and comorbid conditions (Table 3).

FIGURE 1. Duration of meropenem courses stratified by course duration. Pre-intervention data are represented by solid bars, postintervention data by striped bars. Data presented as number of courses.

Table 3. Patient Characteristics

Age (years) Any Antimicrobial allergy PCN Allergy Cephalosporin Allergy Past Medical History DM Cancer ESRD on HD/PD Immunosuppression Received Other Antimicrobials >3 days in Last Week Average REMS High REMS (>10) Infectious Disease Consult Death During Admission

PRE (n=111) 56 ± 18 46 (41.4%) 31 (27.9%) 5 (4.5%)

POST (n=91) 57 ± 20 46 (50.5%) 31 (34%) 7 (7.7%)

39 (35.1%) 30 (27%) 10 (9%) 29 (26.1%)

22 (24.1%) 27 (29.6%) 6 (6.6%) 31 (34%)

34 (30.6%)

34 (37.4%)

4.8 ± 2.8 1 (0.9%) 13 (11.7%) 8 (7.2%)

4.6 ± 2.8 0 14 (15.4%) 5 (5.5%)

FIGURE 2. Identified rationale of evaluator-identified inappropriate courses in pre- and post-intervention periods. Pre-intervention data are represented by solid bars, post-intervention data by striped bars.

Data presented as number of courses.

PCN = penicillin; DM = diabetes mellitus; ESRD = end stage renal disease; HD = hemodialysis; PD = peritoneal dialysis; Immunosuppression = Human Immunodeficiency Virus (HIV), organ transplant, or neutropenia; REMS = rapid emergency medicine score.

Data presented as mean ± standard deviation or number (%).

There was a statistically significant reduction in overall meropenem use of 37.5% (24 versus 15 days of therapy/1000 patient-days in the pre- and post-intervention periods, respectively, p<0.01). When comparing the pre- and post-intervention periods, the average meropenem treatment duration was reduced (6.2 days vs. 4.9 days) but was not statistically significant (p = 0.11). A higher number of patients in the post-intervention group received short courses while fewer received courses longer than 3 days. (Figure 1). The length of hospitalization in the post-intervention group was longer (16.4 vs 14.2 days), but this difference was not statistically significant (p = 0.38).

Of the meropenem courses evaluated, 25 (22.5%) in the preintervention group and 29 (31.9%) in the post-intervention group were considered appropriate. The most common appropriate indication was treatment of a drug-resistant organism (13 (11%) vs. 22 (24.1%) in the pre- and post-intervention group, respectively). Appropriate escalation of therapy was seen in 11 (9.9%) and 7 (7.7%) courses, respectively. Inappropriate indications included drug allergies (35% vs. 37%), particularly to the beta-lactams, presumed “high risk of death”, escalations after <48 hours on previous therapy, pancreatitis and failure to narrow therapy based on culture results (Figure 2). Meropenem was most commonly used by a medicine service (56 courses in the preintervention period and 33 courses in the post-intervention period), followed by hematology/oncology (20 and 17 courses, respectively).

Evaluation of other broad-spectrum antimicrobials during the study period revealed a reduction in use of all examined antimicrobials except for ceftriaxone which was essentially unchanged (Figure 3).

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FIGURE 3. Total consumption of evaluated broad-spectrum antimicrobials in the medical wards during the study periods. Preintervention data are represented by solid bars, post-intervention data by striped bars. Data presented as days of therapy (days/1000 patient-days).

Discussion In this study a stewardship initiative consisting primarily of a meropenem-targeted audit and feedback program led to a significant (37.5%) reduction in meropenem use, including fewer total or extended courses of therapy. Other reviewed antimicrobials also showed a reduction, signaling a broader trend of reduced antimicrobial use. This adds to the body of evidence suggesting that persuasive interventions can have a significant impact on prescribing practice and identify drivers in inappropriate use that can facilitate future improvements.

In the current climate of increasing drug resistance and with a limited number of new drugs on the horizon, the implementation of successful antimicrobial stewardship initiatives is imperative.

Published Data A Cochrane review evaluated various stewardship efforts to modify antimicrobial prescribing and found that restrictive interventions had a greater initial impact, but persuasive interventions, including audit and feedback, achieved similar results over time. Experience has shown that restrictive interventions alone are easier to circumvent and fail to contain inappropriate antimicrobial use.10 These results are similar to what we have anecdotally found: antimicrobial restrictions alone are not sustainable without significant resources (unpublished data). To optimize antimicrobial stewardship efforts, a combination of restrictive and persuasive interventions appears to be the most effective.

Published results from audit and feedback studies vary in their methods and have shown generally positive but inconsistent results. A 72-hour standardized review of intravenous antimicrobials in medicine patients resulted in a reduction in consumption of antimicrobials for included patients but failed to reduce overall antimicrobial consumption.10 In another study, a review of critical-care patients on the third or tenth day of broad-spectrum antimicrobials by an infectious disease pharmacist followed by feedback to prescribers yielded a decrease in broadspectrum antimicrobial use, reduced rate of C. difficile infections and increased meropenem susceptibility.11 Another ASP initiative reviewed new orders of broad-spectrum antimicrobials, including carbapenems, and was associated with an increase in ASP-defined appropriateness and reduction in overall use of targeted antimicrobials.12 In contrast, a program of broad-spectrum antimicrobial prescription review by an infectious disease physician followed by standardized recommendations for therapeutic modification failed to reduce antimicrobial consumption.13 It is encouraging that our program, utilizing persuasive intervention in combination with patient-level reviews, including those on broad-spectrum antimicrobials, was able to show successes similar to those detailed above. In contrast to those studies above, we were able to reduce utilization of meropenem with a more rapid review (within 24 hours during the week or 48 hours after a weekend). It is possible that quicker review might yield further reduce inappropriate antimicrobial use.

Stewardship Program Guidance This institution has no formal prescribing guidance for carbapenems, so appropriate use was determined by the stewardship team. It is important to note that course appropriateness was assessed a day after order placement, with no active stewardship intervention guiding initial antimicrobial selection. It was very common that courses were subsequently modified after review to yield a 1-day inappropriate course of meropenem therapy in the post-intervention period, compared to longer inappropriate courses in the pre-intervention period. The increased number of short meropenem courses consisted of many of these promptly modified regimens.

This system relies on provider education to guide future prescribing and reinforce stewardship initiatives. To objectively define cases as inappropriate for the study, narrow criteria were developed for assessment in settings where all members agreed meropenem would be the most appropriate antimicrobial. As a result, appropriateness criteria used in the evaluation of meropenem courses in this study were more limited than other studies that have assessed appropriate use.12,13

Neither severe sepsis nor use in patients with beta-lactam allergy was deemed appropriate in this study, despite being accepted uses in other studies. The retrospective nature of this study makes it difficult to interpret prescriber rationale, but the narrow appropriate use criteria and lack of pre-prescription guidance provide likely reasons for the overall low rate of appropriate meropenem use. This is evidenced by the high rate of inappropriate use due to penicillin allergy, which may have been considered “appropriate” by some clinicians.

Use Analysis In identification of reasons for inappropriate use, the largest driver was drug allergy. The high rate of drug allergy in patients reviewed (41% and 50%) revealed a correlation between this allergy and the choice of meropenem. These results underscore the major role that drug allergies play in prescribing practices and warrant further exploration and prescriber education. Our health system has no standardized process for allergy documentation and assessment and this often contributes to confusion regarding identification of allergies or intolerance. We do not currently have a system for allergy testing to assess for “true” allergies. Hospitals should consider a more robust evaluation of drug allergies on admission, making an effort to document specific agent allergy and reaction types.

The services with the highest drug use were medicine and hematology/ oncology. However, the services responded differently to the intervention; prescriptions dropped dramatically in the medicine group (56 to 33) but very little in the hematology/oncology group (20 to 17). This reinforces the importance of targeting stewardship to varying clinical scenarios. Interventions promoting de-escalation are more challenging in higher risk patients and/or those less likely to have identified microbiologic pathogens, such as those managed by an inpatient hematology service. Stewardship programs should work with key leaders on those services to construct a unified approach to improving antimicrobial use despite difficult scenarios.

Stewardship Program Focus While the stewardship program at this institution was active in both 2013 and 2014, there was a shift in focus in the two time periods.

Dedicated time was moved away from initiatives that had shown quick success, including intravenous to oral conversion, towards initiatives requiring more intensive chart review and communication. The addition of meropenem to the list of reviewed antimicrobials and strong focus to reduce its inappropriate use, even in situations where it had previously been softly accepted (i.e. drug allergy), led to an increased amount of provider interaction. Unlike many previously published studies, this ASP initiative used chart review followed by patientspecific recommendations communicated through verbal dialogue to individual providers as its process to modify prescribing11-15 This format of intervention allowed for great flexibility in patient discussion with an emphasis on education, interactivity and prescriber autonomy.

The comprehensive discussion including individualized patient information may have contributed to the positive effect of this study and may explain limitations of previously published experiences.13 The overall pattern of reduced broad-spectrum antimicrobial use examined in this time period shows there was no compensatory increase due to the intervention on meropenem and is a promising result.

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Study Limitations As with other quasi-experimental studies, our review is not without limitations. First, the evaluation of the intervention was conducted over a short period of time, limiting the sample. Next, patients who entered the ICU at any time during hospitalization, who may be more likely to receive meropenem at this institution, were excluded because the ASP did not monitor or regularly contribute to ICU care during this period. In this study, the intervention’s effect on drug resistance was not evaluated, in part because of lack of ICU intervention but also because breakpoints for many beta-lactams were recently lowered, creating an inaccurate comparison of ESBL infection rates. Finally, not all providers in our institution agreed with our appropriate use criteria for meropenem; some believed erroneously that carbapenems are the safe alternative in cases of reported penicillin allergy.

Conclusion Regulatory requirements, increasing gram negative resistance and rising healthcare costs will motivate health systems to further scrutinize healthcare prescribing. While health systems will be compelled to implement an increasing number of stewardship activities and interventions, they should not neglect the value of patient-centered audit and feedback. This study demonstrates that an ASP audit and feedback intervention conducted within 24 hours of initial prescription had a significant impact on prescribing of meropenem, resulting in reduced meropenem consumption, reduced long courses of therapy, and improved appropriate use, without increasing use of other broad-spectrum beta-lactams. These results demonstrate the significant effect that audit and feedback can have on identifying drivers of inappropriate prescribing and reducing inappropriate use.

Audit and feedback remains a valuable tool for ASP personnel to influence prescribers through education and to build relationships for further stewardship initiatives. Stewardship personnel should continue to prioritize accurately confirming and documenting drug allergies, identifying high-use services and recognizing problematic prescribing habits to tailor interventions for maximal benefit. n Acknowledgements Data were previously presented as an abstract at the Interscience Conference on Antimicrobial Agents and Chemotherapy (Abstract S410) September 18-22, 2015 in San Diego, California. Financial support: No specific funding was received for this work. This study was conducted in compliance with Institutional Review Board requirements. All authors report no conflicts of interest relevant to this article.

References 1. National Action Plan for Combating Antibiotic-Resistant Bacteria. (March 2015). https://www.whitehouse.gov/sites/default/files/docs/national_ action_plan_for_combating_antibotic-resistant_bacteria.pdf.

Accessed January 19, 2016.

2. The Joint Commission. Proposed Standards for Antimicrobial Stewardship in AHC, CAH, HAP, NCC, and OBS. https://jointcommission.az1.qualtrics. com/CP/File.php?F=F_5tDHGzIVDMHenDn. Accessed January 19, 2016.

3. Dellit TH, Owens RC, McGowan JE Jr, et al. Infectious Disease Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis. 2007;44:159-77.

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4. Kanj SS, Kanafani ZA. Current concepts in antimicrobial therapy against resistant gram-negative organisms: extended spectrum beta-lactamaseproducing enterobacteriaceae, carbapenem-resistant enterobacteriaceae, and multidrug-resistant Pseudomonas aeruginosa. Mayo Clin Proc. 2011;86:250-9.

5. Vardakas KZ, Tansarli GS, Rafailidis PI, Falagas ME. Carbapenems versus alternative antibiotics for the treatment of bacteraemia due to enterobacteriaceae producing extended-spectrum beta-lactamases: a systematic review and metaanalysis. J Antimicrob Chemother. 2012;67:2793-803.

6. Kaye KS, Pogue JM. Infections caused by resistant gram-negative bacteria: epidemiology and management. Pharmacotherapy. 2015;35:949-62.

7. Gasink LB, Edelstein PH, Lautenback E, et al. Risk factors and clinical impact of Klebsiella pneumoniae carbapenemase-producing K. pneumoniae. Infect Control Hosp Epidemiol. 2009:30:1180-5.

8. Schwaber MJ, Klarfeld-Lidji S, Navon-Venezia S, et al. Predictors of carbapenemresistant Klebsiella pneumoniae acquisition among hospitalized adults and effect of acquisition on mortality. Antimicrob Agents and Chemother. 2008:52:1028-33.

9. Olsson T, Terent A, Lind L. Rapid Emergency Medicine score: a new prognostic tool for in-hospital mortality in nonsurgical emergency department patients. J Intern Med. 2004;255:579-87.

10. Davey P, Brown E, Charani E, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev. 2013;4:CD003543.

11. Elligsen M, Walker SA, Pinto R, et al. Audit and feedback to reduce broadspectrum antibiotic use among intensive care unit patients: a controlled interrupted time series analysis. Infect Control Hosp Epidemiol. 2012;33: 354-61.

12. Seah X, Ong Y, Tan S, et al. Impact of an antimicrobial stewardship program on the use of carbapenems in a tertiary women’s and children’s hospital, Singapore.

Pharmacotherapy. 2014;34:1141-50.

13. Masià M, Matoses C, Padilla S, et al. Limited efficacy of a nonrestricted intervention on antimicrobial prescription of commonly used antibiotics in the hospital setting: results of a randomized controlled trial. Eur J Clin Microbiol Infect Dis. 2008;27:597-605.

14. Manuel O, Burnand B, Bady P, et al. Impact of Standardised Review of Intravenous Antibiotic Therapy 72 Hours after Prescription in Two Internal Medicine Wards. J Hosp Infect. 2010;74:326-331.

15. Standiford H, Chan S, Tripoli M, et al. Antimicrobial stewardship at a large tertiary care academic medical center: cost analysis before, during, and after a 7-year program. Infect Control Hosp Epidemiol. 2012;33:338-45.

Author Information: Infectious Diseases Clinical Specialist, Department of Pharmacy, University of Mississippi Medical Center, 2500 N. State Street Jackson. PGY2 Infectious Diseases Resident at the University of Mississippi Medical Center when this work was completed (Dr. Cretella). Assistant Professor, Department of Pharmacy Practice, University of Mississippi School of Pharmacy, 2500 N. State Street, Jackson. Adjunct Faculty, Department of Medicine-Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (Dr. King). Associate Professor, Department of Medicine-Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (Dr. Parham). Associate Professor, Department of Pharmacy Practice, University of Mississippi School of Pharmacy, 2500 N. State Street Jackson, Mississippi 39216; Adjunct Faculty, Department of Medicine-Division of Infectious Diseases, University of Mississippi Medical Center (Dr. Stover).

Corresponding Author: Kayla R. Stover, Associate Professor, University of Mississippi School of Pharmacy, 2500 North State Street, Jackson, MS 39216. Phone: 601-984-2615; Fax: 601-984-2751; Email: kstover@umc. edu.

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S C I E N T I F I C

Nonketotic Hyperglycemic Chorea-Hemiballismus, A Unique and Treatable Manifestation of Diabetes Mellitus ASHLEY BUICE, MD AND TANVIR RIZVI, MD Summary Nonketotic hyperglycemic chorea-hemiballismus is a treatable cause of chorea. It is a rare and unique presentation of diabetes mellitus. Imaging findings of T1 hyperintensity in the basal ganglia in the clinical context of nonketotic hyperglycemia can help confirm the diagnosis and alert the treating physician for the presence of this entity.

FIGURE 1. T1 weighted MR images through the level of the lentiform nucleus (1a) and caudate (1b) demonstrating T1 hyperintensity in the left caudate and putamen.

Background Nonketotic hyperglycemic chorea-hemiballismus is a rare and unique manifestation of diabetes mellitus. Chorea is a disorder of jerky involuntary movements, while hemiballismus is a type of unilateral chorea. These disorders have a myriad of causes in addition to diabetes (Table 1). When associated with nonketotic hyperglycemia, choreahemiballismus is often association with lesions in the subthalamic nucleus, corpus striatum, thalamus, or brainstem.1 As choreahemiballismus can be debilitating and even life threatening in some cases, recognition of nonketotic hyperglycemia as a treatable cause is paramount, particularly since it can be an initial presentation of diabetes.1 Increasing awareness of this rare entity would aid in rapid diagnosis and treatment, and recognition of typical imaging findings can aid in differentiating nonketotic hyperglycemia induced chorea from other causes.

Table 1. Common causes of chorea • Infection • N eurodegenerative disorders • M etabolic derangement • I atrogenic/medication effects

Case Presentation Our patient was a 56-year-old female with a known prior history of diabetes and remote ischemic infarct with mild residual right upper extremity weakness. She was referred to a general neurologist by her primary care physician after complaining of an 8 week history of uncontrolled involuntary right-sided tremors which had recently worsened to the point of interfering with daily tasks and causing injury. The chorea-hemiballismus started acutely. She experienced a syncopal episode inciting the chorea which had been constant since.

At that time, workup revealed severe hypertension with systolic levels 168 VOL. 58 • NO. 5 • 2017

1a

1b

in the 200s and severe hyperglycemia with blood glucose levels greater than 600 mg/dL. She had hemoglobin A1C drawn by her primary care physician at the time of referral which was elevated to the level of 12.5. After starting oral antihypertensives (lisinopril, clonidine, chlorthalidone, and amlodipine), oral and injectable hypoglycemics (metformin, insulin degludec, and insulin glargine), and benztropine, she was seen by neurology approximately one month later where right arm greater than right leg jerking was noted while walking. Magnetic resonance imaging several weeks later demonstrated T1 shortening/ hyperintensity (bright signal) involving the left caudate and putamen without evidence of hemorrhage or infarct, and nonketotic hyperglycemic chorea-hemiballismus was suggested (Figures 1a and 1b). Subsequently she was started on medical management including Amantadine 100mg BID with improvement of symptoms. The management was mainly focused on control of hyperglycemia and symptomatic tremor control with gradual improvement of symptoms.

Follow-up magnetic resonance imaging after symptom improvement demonstrated decreased T1 hyperintensity in the left basal ganglia (Figures 2a and 2b).

Discussion Nonketotic hyperglycemic chorea-hemiballismus has certain classic imaging appearances, though there can be a slight variation on the common theme. Computed tomography appearance can range from normal to increased density in the caudate and putamen or in the putamen alone while magnetic resonance imaging typically

FIGURE 2. Follow up T1 weighted MR through the level of the lentiform nucleus (2a) and caudate (2b) demonstrating improvement with decreased T1 hyperintensity in the left caudate and putamen.

subsequent magnetic resonance imaging demonstrating the typical T1 hyperintensity in the contralateral basal ganglia. In this case, the imaging features in the context of diabetes and hyperglycemia were able to suggest the diagnosis. Following subsequent medical treatment, the patientâ&#x20AC;&#x2122;s symptoms improved with follow-up imaging demonstrating the expected improvement in the basal ganglial T1 hyperintensity. This case illustrates the importance of awareness of this rare manifestation of diabetes. Our patient had been suffering with symptoms for a few months which had worsened to the point of severe impairment of her daily tasks, but following imaging and correct diagnosis, appropriate treatment was able to be initiated with improvement of her symptoms.

Conclusion

2a

2b

demonstrates increased T1 hyperintensity in the basal ganglia, even in the setting of a normal CT.1 There is a narrow differential of these computed tomography and magnetic resonance imaging findings.

Basal ganglia hyperdensity may also reflect hemorrhage or calcification while T1 hyperintensity in the basal ganglia may reflect manganese toxicity in the clinical setting of long term parenteral nutrition, chronic liver failure, hypoxemia, neurofibromatosis, and certain metabolic disorders.1 Single photon emission computed tomography is of little diagnostic use as findings are highly variable.2 Laterality of imaging findings on computed tomography or magnetic resonance imaging correlates well with laterality of symptoms, which are contralateral from the site of involvement on imaging.1 Imaging findings also typically reflect the clinical course with resolution over time with correction of hyperglycemia, although imaging resolution lags clinical resolution.1 The typical patient suffering from nonketotic hyperglycemic choreahemiballismus is older and of Asian descent with a slight female predominance.2 Chorea primarily involves the extremities, but some patients may also exhibit focal deficits or facial involvement.2 Symptoms typically resolve with medical therapy.1 Recurrence may occur in a minority of patients with recurrent hyperglycemia.2 The etiology of nonketotic hyperglycemic chorea-hemiballismus is unknown, though several mechanisms have been postulated. These range from chronic cerebrovascular disease compounded by acute blood/brain barrier dysfunction and reduced cerebral blood flow, to postanoxic petechial hemorrhage, or decreased acetylcholine synthesis secondary to anaerobic metabolic shift causing basal ganglia dysfunction.1,2 There is most likely a synergistic effect of uncontrolled nonketotic hyperglycemia and vascular insufficiency related to chronic poorly controlled diabetes that causes incomplete transient dysfunction of the striatum resulting in chorea. Previous postmortem examinations have demonstrated changes in the striatum and areas of selective neuronal loss, gliosis, and reactive astrocytosis but no apparent hemorrhage.2

Nonketotic hyperglycemic chorea-hemiballismus is a unique manifestation of a common illness. It can be an extremely debilitating condition with a readily treatable cause. Recognition of this rare entity which may even be the initial presentation of diabetes can ensure appropriate treatment. Imaging can aid in making the appropriate diagnosis with magnetic resonance imaging being the preferred modality as computed tomography findings may be variable. The magnetic resonance imaging findings associated with nonketotic hyperglycemic chorea-hemiballismus have a narrow differential, but in the clinical context of hyperglycemia these findings can strongly suggest the diagnosis. n References 1. Lai PH, Tien RD, Chang MH, et al. Chorea-ballismus with nonketotic hyperglycemia in primary diabetes mellitus. AJNR Am J Neuroradiol.

1996;17:1057â&#x20AC;&#x201C;1064.

2.

Oh SH, Lee KY, Im JH, Lee MS. Chorea associated with nonketotic hyperglycemia and hyperintensity basal ganglia lesion on T1-weighted brain MRI study: a meta-analysis of 53 cases including four present cases. J Neurol Sci. 2002;200:57â&#x20AC;&#x201C;62.

Author Information: Radiology resident in the School of Medicine, University of Mississippi Medical Center, Jackson (Dr. Buice). Assistant professor of radiology in the division of Neuroradiology at University of Mississippi Medical Center, Jackson (Dr. Trivni).

Corresponding Author: Ashley L. Buice, MD; University of Mississippi School of Medicine, Department of Radiology, 2500 N. State St., Jackson, MS 39216. Phone: (601) 984-1000.

Our case mirrors the expected findings and course of nonketotic hyperglycemic chorea-hemiballismus documented in the literature.

It demonstrates the features of this unusual presentation of diabetes.

Following development of chorea, our patient was found to have extremely elevated blood glucose and hemoglobin A1c levels with JOURNAL MSMA

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M I S S I S S I P P I

S T A T E

D E P A R T M E N T

O F

H E A L T H

Mississippi State Department of Health Public Health Regions DeSoto

Marshall

Benton

Tishomingo

Alcorn

Tunica Tate

Prentiss

Tippah Union

Panola

Lafayette

Lee

Itawamba

Pontotoc Coahoma

Quitman

Bolivar

Yalobusha

Monroe

Chickasaw Tallahatchie

Grenada Carroll

Montgomery

Washington

Clay Webster

Sunflower Leflore Attala

Humphreys

Issaquena

Oktibbeha Lowndes

Choctaw Winston

Noxubee

Holmes Yazoo

Madison

Leake

Neshoba

Kemper

Newton

Lauderdale

Sharkey Scott

Warren

Hinds

Adams

Jasper

Smith

Rankin Claiborne

Lincoln

Covington

Lawrence

Franklin

Marion

Pike

Wilkinson

Wayne

Jones

Jefferson Davis Lamar

Amite

Clarke

Simpson

Copiah

Jefferson

Mississippi

Calhoun

Forrest

Perry

Mississippi Provisional Reportable Disease Statistics

May 2017 Provisional Reportable Disease Statistics May 2017

Greene

Walthall George

Pearl River Stone

Northern Region Harrison

Central Region

Jackson

Hancock

Southern Region

Public Health District I

Sexually Transmitted Diseases

Primary & Secondary Syphilis Early Latent Syphilis Gonorrhea Chlamydia

Mycobacterial Diseases

HIV Disease Pulmonary Tuberculosis (TB) Extrapulmonary TB Mycobacteria Other Than TB Diphtheria Pertussis

Vaccine Preventable Diseases

Tetanus Poliomyelitis Measles Mumps Hepatitis B (acute) Invasive H. influenzae disease Invasive Meningococcal disease

Enteric Diseases

Hepatitis A (acute) Salmonellosis Shigellosis Campylobacteriosis

Zoonotic Diseases

E. coli O157:H7/STEC/HUS

*

Animal Rabies Lyme disease Rocky Mountain spotted fever West Nile virus

3 0 82 205 5 0 0 2 0 3 0 0 0 1 0 0 0 0 8 5 2 0 0 0 0 0

II

III

4 1 2 4 103 92 149 158 1 1 0 0 0 1 5 2 0 0 0 0 0 0 0 0 0 0 1 0 2 0 0 1 1 0 1 0 24 2 1 2 14 3 0 0 0 0 0 0 0 0 0 0

IV

2 1 39 96 2 0 0 0 0 0 0 0 0 0 0 0 0 0 5 3 2 0 0 0 0 0

V

VI

3 4 10 4 165 58 413 126 10 3 5 0 0 0 10 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 17 4 3 0 5 5 0 0 0 0 0 0 1 5 0 0

State Totals* VII

1 0 27 85 1 0 0 0 0 0 0 0 0 0 0 0 0 0 7 1 1 0 0 0 1 0

VIII

IX

May 2017

YTD 2017 YTD 2016

4 5 27 32 122 3 1 25 39 175 81 112 759 518 2,985 151 209 1,592 1,510 6,556 3 5 31 24 196 0 1 6 5 18 0 0 1 0 1 3 5 28 33 174 0 0 0 0 0 0 0 4 0 13 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 4 0 18 0 1 3 0 19 1 1 4 6 28 0 0 1 0 2 0 0 1 0 2 10 13 90 82 248 0 3 18 9 60 4 9 45 13 179 0 0 0 1 5 0 0 0 0 1 0 0 0 0 0 1 0 8 13 20 0 0 0 0 0

Totals include reports from Department of Corrections and those not reported from a specific District.

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May 2016

119 208 2,555 7,875 193 15 4 164 0 1 1 0 0 0 8 32 0 3 246 29 76 7 0 0 27 1

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John D. Belknap, MD Donald W. Benefield, MD Allison Derrick Bennett, MD Louis W. Benton, MD Craig D. Berteau, MD Barry D. Bertolet, MD Yashashree L. Bethala, MD John W Bethea, Jr., MD John G. Biggs, MD Wm. Morgan Billington, Jr., DO Cindy Bishop Arthur Dewayne Black, MD Don J. Blackwood, MD Mark E. Blackwood, MD Thomas H. Blake, Jr., MD Danielle Denice Blakeney, MD Earl J. Blanchard, Jr., MD Kevin Paul Blanchard, MD Benjamin D. Blossom, MD James J. Blount, III, MD Gregory H. Boling, MD Gary G. Bolton, MD Michael J. Borne, MD Charles D. Borum, MD Douglas E. Bowden, DO Wm. Brent Bowling, MD Daniel L. Boyd, MD J. Jeffery Boyd, MD Judith L. Bradley, MD Scott T. Bradley, MD K. Page Branam, MD Steven C. Brandon, MD Eric W. Bridges, MD Charles F. Brock, Jr., MD James M. Brock, Jr., MD David J. Brooks, MD John Carl Brooks, MD Brett O. Brown, MD James S. Brown, III, MD James Jay Brown, MD Kimberly Latisha Brown, MD Claude D. Brunson, MD, MS, CPE Joel R. Brunt, MD Jennifer J. Bryan, MD Stephen E. Buckley, MD J. David Bullock, MD Derrick Burgess, MD John D. Burk, MD James L. Burkhalter, MD Christopher Burks, MD Walter M. Burnett, MD Robert B. Burns, MD Jamey Walcott Burrow, MD Melanie Burrow Dudley S. Burwell, Jr., MD William G. Bush, MD Lisa Clark Bushardt, MD Joel Alan Butler, MD R. Allen Butler, II, MD Stephen D. Butler, MD Patrick S. Bynum, MD Kirk Caddell, MD Kenneth Brent Cain, DO William B. Calhoun, MD

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Graham C. Calvert, MD Meredith Calvert Joe H. Campbell, Jr., MD Mark E. Campbell, MD Teresa Camp-Rogers, MD C. Ron Cannon, MD Susan Strong Cannon, MD John E. Cantrell, MD Christopher Conrad Capel, MD Troy R. Cappleman, MD Frederick B. Carlton, Jr., MD Scott A. Carlton, MD William Steven Carroll, MD Edward L. Carruth, MD James M. Carter, MD Michael H. Carter, Jr., MD Patti Carter W. Larkin Carter, III, MD Ann Castleberry G. M. Castleberry, MD Jack Q. Causey, II, MD Arthur Lloyd Chambers, III, MD Virginia Chambers Rickey L. Chance, DO J. Kevin Kevin Chandler, MD Lisa L. Chandler, MD Geraldine B. Chaney, MD J. Patrick Chaney, MD Louis R. Chanin, DO Clyde Chapman, MD Christine K. Chard, MD Christopher M. Charles, MD Constantine D. Charoglu, MD Bertin C. Chevis, MD Gregory W. Childrey, MD Sushma Chowdhary, MD Yashwant Chowdhary, MD Michael J. Christie, MD Gary A. Cirilli, MD Roger C. Clapp, Jr., MD, FACS Cheryl G. Clark, MD Jeffrey G. Clark, MD Kathy Clark Steven G. Clark, MD Richard E. Clatterbuck, MD John C. Clay, MD J. Anthony Cloy, MD Stephen Coachys, MD Thomas J. Cobb, MD Thomas P. Cole, MD Timothy L. Cole, MD James P. Coleman, II, MD Lee Walker Coleman, MD Michael W. Coleman, MD Larry L. Collins, MD N. Karen Collins, MD David C. Collipp, MD Stephen W. Commiskey, MD Nathan Lyle Compton, MD Stephen L. Conerly, MD John J. Cook, MD David T. Coon, MD James M. Cooper, MD Kevin S. Cooper, MD

Robert F. Cooper, III, MD Tom S. Cooper, MD Fred A. Corder, MD, AGAF Robert Stephen Corkern, MD F. Alan Covin, MD Mary Ann Cowart, MD Barbara Craft, MD Jason A. Craft, MD E. Howell Crawford, Jr., MD Virginia M. Crawford, MD Samuel J. Creekmore, III, MD John Cross, MD Beverly Crossen Karl J. Crossen, MD Andrew Crothers, MD Rowe S. Crowder, III, MD E. Thomas Cullom, III, MD Amanda Cunningham, MD Jeffrey J. Cunningham, MD Jerry M. Cunningham, MD Steven G. Cunningham, MD Mary Currier, MD, MPH Robert L. Curry, IV, MD Willis Norwood Dabbs, Jr., MD Edward F. Daly, III, MD J. Shay A. Daly, MD C. Ralph Daniel, III, MD Suman K. Das, MD Zaineb Daud, MD Stephen F. Davidson, MD John D. Davis, IV, MD Margaret Miller Davis, MD Ronald D. Davis, MD Christopher Hale Decker, MD Lawrence E. Deese, MD Steve Demetropoulos, MD Sanjay Derhgawen, MD James Dew, MD Robert C. Dews, MD Jayant Dey, MD Michael J. Diaz, MD Kimberly G. Dobbs, MD Thomas E. Dobbs, MD Catherine N. Donald, MD Jeffery S. Doolittle, MD, FACS Sharon P. Douglas, MD W. Wade Dowell, MD John K. Drake, MD Patricia L. Dudley, MD David L. Dugger, MD James L. Duncan, III, MD T. Jason Dunn, DO Joanna Therese Dupont, MD Bradford J. Dye, III, MD Eric M. Dyess, MD Janie Easterling S. Randy Easterling, MD Quenyatta Echols-Williams, MD Henry L. Edmondson, MD Marshall G. Edmondson, MD Daniel P. Edney, MD Lori A. Edney Kenny Bernard Edwards, MD Maroun Elie El-Hayek, MD

Charles M. Elliott, MD Mark S. Elliott, MD Mark L. Ellis, MD Leslie E. England, MD Calvin S. Ennis, MD Diana L. Entrekin, MD Stephen Paul Epperson, MD James W. Ervin, Jr., MD Joan Ervin Kimberly J. Estes, MD Timothy D. Estes, MD Dottie Estess J. Murray Estess, Jr., MD John M. Estess, MD Chris P. Ethridge, MD Patty Ethridge Robert M. Evans, MD T. Keith Everett, MD Michael C. Farmer, DO William M. Farmer, DO Nicholas Fayard, MD Linda Fenter Thomas C. Fenter, MD Cindy Field, MD Larry D. Field, MD J. Keith Fisher, MD Geoffrey J. Flattmann, MD F. Henry Flautt, Jr., MD Jeff A. Fletcher, MD Rafael D. Florez, MD Herbert B. Floyd, MD John David Floyd, MD Teresa Floyd Arthur N. Fokakis, MD Ben P. Folk, III, MD Y. Susi Folse, MD Daniel Benjamin Fore, MD Thomas P. Forks, DO John E. Foropoulos, MD H. Creed Fox, MD Randall P. Frazier, MD Tijuana L. Freeman, MD Terry M. French, DO Richard B. Friedman, MD Kristen T. Fyke, MD Ira E. Gaddy, III, MD George Galjour, MD Richard J. Galloway, MD Hugh A. Gamble, II, MD S. DeWayne Gammel, MD Cynthia Gandy David J. Gandy, MD Diego Fernandez Garcia-Roves, MD Justin M. Garner, MD Rachel C. Garner, MD Thomas C. Garrott, MD Gerard Frantz Germain, MD Michelle J. Gibson, MD R. Lee Giffin, MD Hilton L. Gillespie, Jr., MD J. Barry Gillespie, MD Wm. M. Gillespie, III, MD James Gilmore, MD

Wesley G. Girod, MD Roderick C. Givens, MD Cheryl L. Gladney, MD A. Lamar Glaze, MD Sara Hanak Gleason, MD E. Chad Gnam, III, MD Robbie B. Godwin, DO Barbara B. Goodman, MD Perry Jay Goodman, MD Felix Gordon, Jr., MD Lloyd J. Gordon, III, MD Carolyn Gorton Mary Katherine Gorton S. Carlton Gorton, II, MD W. Mack Gorton, MD Otis Gowdy, Jr., MD Michael C. Graeber, MD Jacob Martin Graham, MD William M. Grantham, MD Fernanda Gray Jim P. Gray, MD Laura A. Gray, MD Jennifer L. Grayson, MD Michael Lewis Greene, DO Bradley N. Greenhaw, MD Frederick O. Gregg, DO Avit J. Gremillion, III, MD Raymond F. Grenfell, Jr., MD Raymond F. Grenfell, III, MD Joshua G. Griffin, MD Meredith Griffin, MD D. Frank Guedon, MD Shy Guedon Daryl P. Guest, MD John M. Guice, MD Donald C. Guild, MD Richa Gupta, MD Barney J. Guyton, MD Douglas C. Guyton, MD Faseeh Hadidi, MD DeGail J. Hadley, DO Felica Hadley Kenneth A. Hahn, MD Maribeth Haire W. C. Haire, Jr., DO Bethany Hairston, MD, F.A.A.D Barry J. Hall, MD Justin M. Hall, MD J. Mack Haltom, III, MD James R. Haltom, MD Scott L. Hambleton, MD George M. Hammitt, III, MD Dabney J. Hamner, MD Karen Emily Hand, MD Burnett Hanson, MD Lillie Hanson R. Houston Hardin, MD Cheryl Hardy, PhD Merrill D. Hardy, Jr., MD Stephen L. Harless, MD F. E. Harman, Jr., MD Donnis K. Harrison, MD Aamir Hashmat, MD John F. Hassell, MD Arlin Hatfield, MD Landall C. Hathorn, MD Michael R. Havens, MD J. Clay Hays, Jr., MD Richard K. Heard, MD

Robert F. Heath, MD Marc C. Hellrung, MD Stephen E. Helms, MD Samuel D. Hensley, Jr., MD Joel H. Herring, MD Lee E. Herring, MD John L. Herzog, Sr., MD Deanne Hester, MD John P. Hey, III, MD Cassie B. Hill, MD Douglas L. Hill, MD J. Edward Hill, MD Jean Hill Ryan Carl Hill, MD Brenda P. Hines, MD Kenneth L. Hines, MD Randall S. Hines, MD Hoat Minh Hoang, MD E. Rhettson Hobgood, MD Katie Habgood, RN Chip D. Holbrook, MD Daniel Holland, MD John G. Holland, MD John J. Hollister, MD Amy J. Hollman, MD Edward H. Holmes, MD John T. Hontzas, MD W. Briggs Hopson, Jr., MD Danita Horne W. Mark Horne, MD Jason Hosey, MD Jeffrey C. Houin, Jr., MD James R. House, III, MD A. Archie Howard, Jr., MD Craig Howard, MD Jan Howard William P. Howard, MD Antoinette M. Hubble, MD Jeffrey L. Hudson, MD Roger Lee Huey, MD Karen A. Hughes, MD Vernon Thomas Hughes, Jr., DO Noel K. Hunt, MD A. Eugene Hutcheson, MD Braxter P. Irby, Jr., MD Kris Ivancic M. Edward Ivancic, MD Dena W. Jackson, MD Paul D. Jackson, MD Wm. G. Jackson, MD David L. Jameson, MD Arjun Jayaraj, MD Cynthia Jean-Pierre, MD B. Thomas Jeffcoat, MD Chester W. Jenkins, MD John C. Jennings, MD David S. Joe, MD Robert L. Johansen, MD Tamela Johansen Brian P. Johnson, MD Daryl A. Johnson, MD Dean Johnson, JD James C. Johnson, Jr., MD Jeff N. Johnson, MD John Jeffrey Johnson, MD Kurt D. Johnson, MD Sidney A. Johnson, Jr., MD Wayne C. Johnson, Jr., MD Richard L. Johnston, MD

Word M. Johnston, MD Debbie Joiner Thomas E. Joiner, MD Angela M. Jones, MD David Franklin Jones, MD G. Scott Jones, MD Stephen Craig Jones, MD Eric Wayne Jordan, MD Terry T. Jordan, MD Clarence Allen Justice, MD Azad Kabir, MD Ralph C. Kahler, MD Charmain Kanosky Michael G. Kanosky, MD Arvinder Kaul, MD Dwight S. Keady, Jr., MD Candace E. Keller, MD John L. Kennedy, Jr., MD Charles A. Kergosien, MD Manpreet Khemka, MD Pavel L. Khimenko, MD Daniel K. Kim, MD Kirk L. Kinard, DO Mary Ann King, DO Kent A. Kirchner, MD David Kirk Jimmy Lamar Kittrell, Jr., MD Joel M. Knight, MD Frank G. Koe, MD John H. Kosko, MD Libby Y. Kot, MD Kurt G. Kratz, MD Pamela R. Lacy, MD Angela Ladner Mark E. Ladner, MD Stephen C. Lambert, MD Brett C. Lampton, MD Lucius M. Lampton, MD Charles Laney, MD Jeffrey T. Laseter, MD Carlos Latorre, MD John F. Laurenzo, MD Wright Lauten, MD Penny J. Lawin, MD Eric D. Lawson, MD James C. Leak, II, MD Clifton T. Leatherbury, MD Christopher J. LeBrun, MD David C. Lee, MD John P. Lee, MD Grif Alan Leek, MD Lisa Loughman Leek, MD Henry T. Leis, MD Erik Paul Lessmann, MD Philip Levin, MD Bettye Lewis Eric Lewis, MD Henry L. Lewis, III, MD Matthew W. Lewis, MD W. Mark Lewis, MD Holly Liberatore, MD Hal T. Liddell, MD Lawrence L. Line, MD William C. Lineaweaver, MD Russell C. Linton, MD C. Kenneth Lippincott, MD Nelson K. Little, MD Steven B. Liverman, MD William B. Lobrano, MD

William R. Locke, MD Lori Longest T. Bruce Longest, Jr., MD William E. Loper, III, MD R. H. Lopez-Santini, MD Chester C. Lott, MD Frank A. Lovell, MD Rodney N. Lovitt, MD Slater B. Lowry, MD Kurre T. Luber, MD John F. Lucas, III, MD Marsha G. Lucas, MD, PhD Brenda Luethje Ronald H. Luethje, MD Miguel Luna Russo, MD David Macias, MD Richard L. Mackey, MD Steven D. Major, MD John H. Mallett, MD Presley D. Mallett, MD J. Michael Manning, MD Michael Mansour, MD Danett Maples, MD Don E. Marascalco, MD William L. Marcy, MD Lori H. Marshall, MD Andrew A. Martin, MD, JD,FACP Charles Cecil Martin, IV, MD Frederick R. Martin, MD Irvin L. Martin, III, MD N. Sharon Martin, MD S. Gail Martin, MD J. Lawrence Mason, Jr., MD F Mitchell Massey, MD Robert C. Masterson, DO Paul G. Matherne, MD Arthur M. Matthews, Jr., MD Wanda Matthews W. Maret Maxwell, MD D. Cameron May, MD Elizabeth H. May, MD Wm S. Mayo, DO Susan Fleming McAllister, MD Marvin B. McCay, MD W. David McClendon, Jr., MD Trish McCluney Jamie D. McCollum, MD Phillip W. McDill, MD Fred J. McDonnell, MD Robert McEachern, MD, FCCP Ryan McGaughey, MD Brandi S. McGehee, MD Joseph B. McGehee, MD Robert A. McGuire, Jr., MD W. Blair McIver, MD David L. McKellar, MD Everett C. McKibben, MD Laura McKinney Robert H. McKinney, MD John R. McPherson, MD J Thomas McReynolds, MD Liz Mehrle Robert Kersey Mehrle, MD Charles V. Menendez, Jr., MD Margaret Menendez Courtney E. Meredith, MD Roland J. Mestayer, MD Suzie Mestayer Cary N. Mettetal, DO

Kay E. Midler, DO Wm. Hughes Milam, MD Johnny F. Miles, Jr., MD Sonya Mitchell Miles, MD Laura J. Miller, MD Regina C. Mills, MD Blane A. Mire, MD Elizabeth W. Mitchell, MD John R. Mitchell, MD Elizabeth K. Mize, MD Michael W. Montesi, MD Nancy Colette Montz, MD David L. Moody, MD Alan R. Moore, MD Charles R. Moore, MD Danny D. Moore, MD Jonathan H. Moore, MD Melanie Moore P. H. (Hal) Moore, Jr., MD David B. Morgan, MD Dennis P. Morgan, MD Jeffrey A. Morris, MD Karen Morris Michael Burch Morrison, MD Wm. A. Morrison, MD C. Troy Morrissette, MD Louis Jeff Moses, MD Walter C. Moses, Jr., MD Britney Moss James A. Moss, Jr., MD Rebekah W. Moulder, MD Paul E. Mullen, II, MD Jonathan Barry Mullins, MD Teresa G. Mulvihill, MD Erin Murphy, MD Donald S. Murray, MD Mark Garry Murray, MD John C. Mutziger, DO Andrew J. Myrick, Jr., MD John H. Nading, MD Krishna R. Nalluri, MD Yoshinobu Namihira, MD Kelly E. Nation, MD Robin D. Nations, MD Charles L. Nause, Jr., DO Brittanie Ingram Neaves, MD John C. Nelson, MD Virginia C. Nelson, DO Samuel D. Newell, Jr., MD Heather Newlon, MD Elliott B. Nipper, MD Jeffrey Dean Noblin, MD Steven D. Nowicki, MD W. Thomas Oakes, Jr., MD John P. O’Brien, MD W. Garrett Ogg, MD Richard O’Keeffe, Jr., MD James W. O’Mara, Jr., MD Shawn O’Mara Christy T. Oswalt, MD Stephen K. Otey, MD Joseph Sam Owen, Jr., MD Robert C. Owen, MD James M. Pace, MD Mary Ellis Pace, MD Leena Pande, MD Victor G. Pang, MD John F. Pappas, MD Kamlesh H. Parekh, MD

JOURNAL MSMA

173

Billy D. Parsons, MD Amita N. Patel, MD Chandanbala Patel Pravinchandra P. Patel, MD Gregory A. Patino, MD Brandy R. Patterson, MD Joseph J. Patterson, III, MD Katherine T. Patterson, MD Michael C. Patterson, MD George E. Patton, Jr., MD Gregory O. Patton, MD Jason A. Payne, MD Eric J. Pearson, MD Thomas H. Pearson, Jr., MD Edward Pellerano, MD Sharon M. Pennington, MD Calin Pernes, MD Terry Ray Perrine, MD Clyde B. Phillips, MD Douglas C. Phillips, MD Edward K. Phillips, MD John Phillips, MD, PhD, FACG Joshua F. Phillips, MD Julie Phillips Trevor R. Pickering, MD Sondra Pinson Terry W. Pinson, MD Larry B. Poe, MD Janet Polchow T. Neal Polchow, MD James D. Polk, MD Joseph L. Pratt, MD Charles K. Pringle, Jr., MD Meg Puckett Thomas Glenn Puckett, MD Joe S. Pulliam, MD Purnima Ramesh Purohit, MD Ramesh Chandra Purohit, MD Jani L. Purvis, MD Fauzia F. Quddus, MD Syed S. Rafique, MD Milton R. Raines, MD Jeremy T. Rainey, DO Seshadri Raju, MD Amy Ramsey J. Randall Ramsey, MD Arun R. Rao, MD Gutti J Rao, MD Donald W. Ratliff, MD Mark A. Ray, MD J. Ann Rea, MD John E. Reed, Jr., MD, FACP Kim Reed Lauren Reed W. Ray Reed, Jr., MD David L. Reeves, MD Eric Lee Reimund, MD Jerald A. Reinshagen, MD D Brian Remley, MD William L. Reno, III, MD Ben T. Rester, MD Judd Reynolds, DO Richard E. Rhoden, MD Charles David Richardson, MD David R. Richardson, MD Harry Lee Richardson, Jr., MD Rebecca Richardson Sharon Richardson Steven Thomas Richey, MD Brian S. Rifkin, MD

Edward E. Rigdon, MD Angela Marie Riley, MD James M. Riser, MD James A. Rish, MD Antoine B. Rizk, MD Brett D. Robbins, MD James E. Roberts, Jr., MD Jennifer Rebecca Roberts, DO Joseph F. Roberts, MD Elliott B. Robertson, MD George H. Robertson, III, MD Jeremy Stephen Rogers, DO Merrell Rogers Elizabeth R. Rose, MD Claire B. Rosenblatt, MD April Michelle Ross, MD Diane Ellen Ross, MD Randolph J. Ross, MD Douglas W. Rouse, MD Louis A. Rubenstein, MD Denise Rubino, MD R. Scott Runnels, Jr., MD Rudolph S. Runnels, Sr., MD E Lane Rushing, MD Jennifer V. Russ, MD Dave A. Russell, MD Vishal Sachdev, MD Mark V. Sandefur, MD Andrea Sanders Deborah Sanders, MD H. Jay Sanders, IV, MD Vanessa L. Sandifer, MD Bharat H. Sangani, MD David N. Sawyer, MD Philip A. Schaeffer, MD Amanda R. Schiefer, MD Eric J. Schmidt, MD Robin H. Schwartz, MD Ronald Bradley Scott, DO Lisa Scruggs Massey Ben W. Seale, MD Bradley N. Secrest, MD David R. Segrest, MD Robert G. Sexton, MD Manojkumar P. Shah, MD Nathan P. Shappley, III, MD Misty T. Sharp, MD Libba Sheffield Paul E. Sheffield, MD Thomas E. Sheffield, MD, FACP Beverly Shelton Walter R. Shelton, MD John G. Shields, Jr., MD Roderick A. Shields, MD James Byron Shipp, MD Jason Lee Shives, MD Robert M. Shows, MD W. Fletcher Shrock, Jr., MD Timothy D. Shumaker, MD Obaid A. Siddiqui, MD Kevin L. Sijansky, MD James N. Sikes, MD Keith M. Simnicht, MD Shane M. Sims, MD Jamie D. Sisk, MD Trishna Sisodraker, MD B. Todd Sitzman, MD, MPH Larry W. Sivils, MD Jacob Skiwski, MD Victoria Skiwski

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Neil B. Sloan, MD Wayne A. Slocum, MD Yvette Slocum Charles E. Slonaker, III, MD Barbara D Smith David L. Smith, MD Dennis Earl Smith, Jr., DO Gary L. Smith, MD George V. Smith, MD Jason V. Smith, MD Mary Kelli Smith, MD Mary A. Smith Nancy Smith P. Brent Smith, MD Perrin N. Smith, MD Prentiss E. Smith, Jr., MD Robert B. Smith, MD Taletha B. Smith, MD W. Todd Smith, MD Wm. H. Smith, Jr., MD Adam Smitherman Neil J. Solomon, MD William D. Sones, Jr., MD Somprasong Songcharoen, MD Suthin Songcharoen, MD Augustus P. Soriano, MD C. Dallas Sorrell, MD Hubert E. Spears, Jr., MD Steven E. Speights, MD David L. Spencer, Sr., MD A. Patrick Sprabery, MD Arthur C. Sproles, MD Hugh W. Stancill, III, MD David R. Steckler, Jr., MD Michael Edward Steuer, MD Carl W. Stevens, II, MD John S. Stewart, DO Rebecca Stewart Steven W. Stogner, MD Charles T. Stokley, MD Beth Stone James E. Stone, Jr., MD R. Harper Stone, MD Michael J. Stonnington, MD W. Lynn Stringer, MD Marcella Strong Mark H. Strong, MD, FACC William B. Strong, Jr., MD Kenneth W. Stubbs, MD Robert N. Suares, MD Bradley J. Suggs, MD Margie J. Suggs, MD, PHD Sabra Sullivan, MD,PhD William B. Sullivan, MD Wm David Sullivan, MD Ralph E. Sulser, MD, FACP Jeffrey T. Summers, MD Dawn M. Sumrall, MD Doyle F. Sumrall, MD Stephen R. Sumrall, MD J. Dean Tanner, MD Stephanie Tanner Crystal L. Tate, MD Greg Tavai, MD Pami Jo Taylor, MD Cooper L. Terry, MD Joe W. Terry, III, MD William G. Thaggard, MD Abhash C. Thakur, MD Gregory Thalken, MD

Chrisitie H. Theriot, MD Kenneth R. Thomas, MD William O. Thomas, III, MD Allen Hale Thompson, MD Gregory L. Thompson, MD Martha Thompson Will P. Thompson, MD Wm. O. B. Thompson, MD Lee Kinsey Thornton, MD George M. Thurber, MD Carolyn Vardaman Tingle, MD Ancel C. Tipton, Jr., MD Raymond E. Tipton, Jr., MD Alan J. Torrey, MD B. Scott Torrey, MD Meredith M. Travelstead, MD Ara B. Travers, MD Brian K. Tsang, MD B. Shane Tucker, MD J. Martin Tucker, MD Joel A. Tucker, MD Sam C. Tumminello, MD Lee Harris Turk, MD D. Michael Turner, Jr., MD Gerald A. Turner, MD Helen R. Turner, MD Kristen Y. Turner, MD Sherry Denise Turner, DO John U. Uhl, MD Timothy G. Usey, MD Richard C. Vallette, MD George Karl Van Osten, III, MD Gregory A. Vance, MD Cynthia A. Vaughn, MD Daniel L. Venarske, MD Satish C. Verma, MD Ken Vick Laura R. Vick, MD Gregory N. Vickers, MD Juan P. Villani, MD Dimitrios Virvillis, MD Dana S. Vitale, DO Rahul Vohra, MD Robert D. Voller, Jr., MD Christie Voulters Lee Voulters, MD David I. Waddell, MD Frank C. Wade, Jr., MD Stanley A. Wade, Jr., MD Terry Wade Margaret E. Wadsworth, MD David A. Wahl, MD Thad F. Waites, MD Dexter Winn Walcott, MD Sue Dudley Walker, MD Wm E. Walker, MD Mark Burnette Wall, MD Richard E. Waller, MD William L. Waller, MD David L. Walt, MD Marcia Walt D. Ross Ward, MD George L. H. Ward, MD Wm. C. Warner, Jr., MD Shannon Warnock James E. Warrington, MD Pat Warrington Paul W. Warrington, MD Clinton L. Washington, MD Eric D. Washington, MD

D. Eric Webb, MD LeeAnne Webb Mark C. Webb, MD Geri Lee Weiland, MD Roger D. Weiner, MD Bert A. Welch, III, MD Jerry W. Welch, MD Thomas E. Weldon, MD Jeremy B. Wells, MD Peggy J. Wells, MD Willie Lee Wells, MD Matthew B. Wesson, MD Thomas W. Wesson, Jr., MD Bobbie Britt West, MD Flavia West-Huddleston, MD Terry A. Westmoreland, MD Raun Wetzel, MD Benton M. Wheeler, MD Patrick D. Whipple, MD Chester K. White, MD James L. White, MD M. Neil White, III, MD Mary White Kary G. Whitehead, MD Richard S. Whitlock, MD Robert August Wiemer, MD Chris E. Wiggins, MD James Wilde, MD Brian L. Wilkinson, MD Barry William Willbrandt, MD A. Terrel Williams, MD J. Barton Williams, MD Diane Williamson Karen Williamson Nathan A. Williamson, MD Stoney Williamson, MD Todd David Williamson, DO Edward R. Willis, Jr., MD James P. Wilson, MD Julie Wilson Paschal Wilson, MD Woodie Jeff Wilson, Jr., MD B. Pearson Windham, MD Angela B. Wingfield, MD Peter F. Wisniewski, DO John E. Witcher, MD Daniel A. Wittersheim, MD Rose Wittersheim Duke J. Wood, DO E. Greg Wood, III, MD James W. Woodall, Jr., MD Katherine Woodall James S. Woodard, MD Sandra C Woodard Trent A. Woods, MD Anna Woodson, MD Benjamin Woodson, MD Darwin Beshan Wooten, MD Christopher H. Wyatt, MD Ben W. Yarbrough, MD William E. Yoe, MD Ronald S. Young, MD Ronald A. Young, MD Teresa Young William D. Young, MD Steven E. Zachow, MD Constantine P. Zouboukos, MD

P R E S I D E N T ’ S

P A G E

Opioid Abuse: A Comprehensive Problem Demands a Comprehensive Solution

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hysicians and others on the front lines of the opioid abuse crisis in the U.S. have a very different view from the average American. We see a burgeoning problem with no sign of slowing down. Consider a few sobering facts:

• I n 2013, 43,982 people in America died from drug overdoses, 25% than the 32,719 who died in car crashes.

• Prescription drug overdoses account for nearly 60% of drug overdose deaths in the U.S. and 73% of those deaths stemmed from opioid use.

• Sales of prescription painkillers have quadrupled since 1999, and deaths from them have similarly increased.

• The rate of painkiller prescriptions in Mississippi is the sixth highest per capita in the nation, with 120 prescriptions for every 100 people.

This is tragedy writ large. In fact, there’s a good chance that everyone reading this issue of the Journal has a patient struggling with opioid addiction. Most of us also have a friend or loved one grappling with opioid addiction. You don’t have to be an alarmist to see something is terribly wrong here. This crisis didn’t happen overnight and it is going to take a long-term, comprehensive plan to address it.

Agreeing that physicians have a professional duty to help reverse the opioid tragedy, the American Medical Association created the Task Force to Reduce Opioid Abuse that set goals to increase physician education and use of effective Prescription Drug Monitoring Programs (PDMPs), promote comprehensive assessment and treatment of substance use disorders and expand access to naloxone in the community and through co-prescribing.

Here in Mississippi, MSMA has hailed our legislature for increasing access to naloxone and promoting the PDMP. I am also steering an MSMA committee of physicians on the front lines reviewing the CDC prescribing guidelines and making recommendations to the Governor’s Opioid Task Force. This is bringing physicians together with law enforcement, pharmacists, and counselors.

We’ve been addressing substance abuse among our profession for years now. The Mississippi Physician Health Program (MPHP) offers an anonymous track for physicians to overcome substance abuse with detection, evaluation, and treatment. The program focuses on monitoring recovery and returning physicians to a safe and productive medical practice.

Recovery is a tough, long, complex journey. Addressing the opioid abuse issue statewide is even more problematic. To find meaningful solutions, we must work together. n

Lee Voulters, MD; Gulfport MSMA President 2016-2017 JOURNAL MSMA

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M S M A

This is part of a spotlight series on the MSMA Physician Leadership Academy class of 2017.

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or Dr. Ann Chancellor Roberson, being a physician is a blending of science and compassion. An early interest in science led to fascination with research and, eventually, a desire to use that knowledge base to reach out and help people.

As an anesthesia student in med school, Dr. Roberson enjoyed applying her specialty to a variety of rotations, from pediatrics to obstetrics to surgery and critical care. In anesthesia, interaction with patients is brief but intense. And it’s in that intensity that Dr. Roberson sees the chance to make a difference.

“I love the challenge of having a limited amount of time to get their history and medical information all while calming and reassuring them,” she said. “I am motivated to be an advocate for the patient safety and satisfaction so that patients have a good experience overall.”

Ann Roberson, MD

As a medical student and resident, Dr. Roberson had many physicians and teachers helping her hone her skills and find her way in a complex profession. One standout was Dr. LouAnn Woodward, current vice chancellor at UMMC.

“I remember stepping into Dr. Woodward’s office sick with nerves and jitters,” she said. “Her warm smile and engaging personality put me right at ease. It was also great to have a strong female physician that served her hospital in so many leadership roles.”

Dr. Roberson said the Physician Leadership Academy has been a useful tool in developing the skills she needs to be an advocate for medicine, as well as a skillful, caring physician.

“Organized medicine is crucial to the perpetuation of our field,” she said. “We are busy caring for patients, trying to balance our work load with family life, and advocacy was something we as a profession didn’t have time for. We now recognize the need for our involvement to protect the way we want to practice and for the benefit of our patients.”

Dr. Roberson lives in Oxford with her husband, Rowland, and their three daughters Lillie, Rainey and Virginia.

L

ike many young physicians, Dr. LaFarra Young started her path to medicine as a lover of science. As early as high school, she knew she wanted to be a physician to use science and discovery to learn more about the human body and how to help patients.

Dr. Young narrowed in on her specialty of pediatric pathology as a way to put her innate curiosity and her training to work in service to those who come to her for help.

“There’s always something else to be seen under the microscope,” she said. “There’s always the potential to see something new. My job requires a lot of attention to detail, like a private investigator.”

As a medical student, Dr. Young was strongly influenced by Dr. Kenneth Edelin, Dean of Minority Affairs at Boston University School of Medicine. He helped her find her confidence and her voice.

“He encouraged me to be more assertive,” Dr. Young said. “I grew to respect the power I could have to make a difference by practicing what I learned.”

LaFarra Young, MD

As a participant in the Physician Leadership Academy, Dr. Young hopes to broaden her network and join other physicians who want to be a voice for the profession. As she has grown in her practice, she has seen the importance of advocating for professionals in medicine.

While discovering the necessity of professional leadership, Dr. Young has also seen her career expand thanks to hard work.

“Creating my own career path as a minority pathologist in Mississippi has been a challenge,” she said. “I started out as the only board-certified pediatric pathologist at UMMC and have had a few other firsts in my field in the state. But I continue to rise to meet my challenges.” n 176 VOL. 58 • NO. 5 • 2017

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HE NEW HOSPITAL, BEAUVOIR, 1907— This image, which dates to 1907, is of the first Beauvoir Hospital, one of the state’s first efforts to provide hospital services for its veterans, who were then termed the “dwindling gray line.” The turn of the last century was a progressive period in Mississippi politics, with much interest expressed for supporting public health initiatives such as charity hospitals and the state’s “benevolent” institutions, serving the blind, deaf, and insane. The Legislature had established as early as 1901 a “Confederate Hospital Annex” at the Vicksburg Charity Hospital, the state’s first effort to provide medical care specifically for veterans. More than a decade after the death of ex-Confederate President Jefferson Davis, his wife in 1902 sold his house Beauvoir, located facing the Gulf near Biloxi in Harrison County, to the Mississippi Sons of Confederate Veterans to create a home for Confederate soldiers and sailors, as well as their wives, widows, and servants. The home opened on Dec. 10, 1903, and by 1904, the state directed $10,000 for the benefit of its residents, called “inmates.” In 1906, the Beauvoir’s legislative appropriation included $7,500 for “a thirty-bed, general hospital having a small, but modern operating room with needful accessories, sun parlor for convalescents, several small rooms for patients about to die, lavatories, diet kitchen, rooms for nurses, drugs, and surgical supplies, modern plumbing, steam or hot water heater, all outside openings to be screened.”(This request for screens was directed at yellow fever and its recently proven vector the mosquito!) A Biloxi “Daily Herald” article, dated April 24, 1907, indicates that this original “electric lighted” hospital opened in March 1907 and was located on the west side of Beauvoir house facing the Gulf. House surgeon for the hospital was Dr. H. M. Folkes (1871-1926), a prominent Biloxi physician, and head nurse was Mrs. M. C. Ansley. “New and white and spotless, as a hospital should be, it yet lacks the severity which so many institutions of this character bear about them, and with its long piazza running from east to west and its many sunlit windows is by no means an unattractive place,” wrote the Herald in 1907. By 1920, Beauvoir Superintendent Elnathan Tartt initiated a successful effort to replace this wooden structure, then in decline and considered a “firetrap,” with a state of the art “modern fireproof brick” hospital. By 1924, a 48-bed brick hospital was constructed on the east side of Beauvoir house and the old hospital converted into the “ladies’ hospital.” On January 23, 1930, this original hospital was totally destroyed by fire. My thanks to historian Charles L. Sullivan of Perkinston for his assistance with this article. If you have an old or even somewhat recent photograph which would be of interest to Mississippi physicians, please send it to me at lukelampton@cableone.net or by snail mail to the Journal. n — Lucius M. “Luke” Lampton, MD; JMSMA Editor JOURNAL MSMA

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Kathy Stone, BSN, RN Vice President of Risk Management, Medical Assurance Company of Mississippi

C O M P A N Y

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M I S S I S S I P P I

TELEMEDICINE CHECKLIST: HOW TO GET STARTED

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n recent years, there has been tremendous growth in telemedicine, ranging from online consultations with patients to a breakthrough system that links remote monitoring of vital signs (such as temperature and blood pressure). As the use of these technologies expand to increase access to care, the risk of liability likewise expands.

When considering the use of telemedicine in your practice, consider the following to improve your liability risks.

3 1. Review the Mississippi State Board of Medical Licensure Telemedicine Regulations (and Mississippi Board of Nursing q Regulations, if working with APRNs).

3 2. Decide on the following: q a. Type of service you want to provide,

b. Locations of service – at both ends, c. Telemedicine practice times (how many hours each day and how many days each week), d. Personnel needed – at all sites.

3 3. Choose appropriate technology to accomplish your plan. q a. View several options.

b. Discuss with other providers using same technology. c. Make site visits to see technology in action.

3 4. Review all contracts thoroughly. Look for the following: q a. Who will “own” the medical records?

b. Will the records be easily accessible at both sites? c. Is there an indemnity clause? d. What assurances are made by vendor regarding maintenance and problem solving? e. Have a healthcare attorney review the contract before you sign it.

3 5. Ensure privacy protection of all medical information and related data. q a. This should be addressed in contract.

b. Must apply to both the use of the technology and the medical records generated. c. Is transmitted data encrypted or otherwise protected? d. Will vendor be responsible for privacy and security of system?

3 6. Train all staff involved – at all sites. q a. Include clinicians and support staff in training – everyone who will be involved in the telemedicine process.

b. Document all training, including who was present and the content covered. c. Document dates of both training and re-training that occurs after the program is running.

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3 7. Set up policies and procedures for telemedicine practice, including: q a. Policy for HIPAA compliance,

b. Criteria for patient selection, c. Process for managing urgent/emergent situations identified during a telemedicine encounter. d. Share all policies and procedures with staff at all sites.

3 8. Determine how you will decide which patients to see via telemedicine. Consider the following when deciding who you q want to treat:

a. Established patients only or new patients? b. Patients established only with you or also with your partners? c. Follow-up visits only or new onset problems too? d. Follow-up only on certain diagnoses, e.g. DM, HTN, ADHD, etc.? e. No telemedicine for certain complaints, for instance, those that may require urgent care, a hands- on exam, or further diagnostic studies unavailable via a telemedicine visit. Be specific with a list of diagnoses or symptoms you will not treat via telemedicine. f. For new patients, what types of complaints or issues will you see in telemedicine? g. Any age limits on patients? Are any too young or too old to be seen via telemedicine? h. Location of patient? Limited to a structured environment, such as another clinic, or will you see patient in her home or even if she is on vacation?

3 9. Refuse to provide care if technology is not working properly or patientâ&#x20AC;&#x2122;s condition is not suitable for telemedicine. q 3 10. Have a plan to transition visits from telemedicine to in-person. q 3 11. If patient refuses, document refusal for transition to in-person visit. q 3 12. Document a telemedicine encounter to the same extent that an in-person visit would be documented. q 3 13. Be sure all paperwork completed at remote site is entered into medical records and practice administration files. q 3 14. Obtain informed consent from patient for a telemedicine visit using a consent form which includes the following info: q a. Basic explanation of how the telemedicine encounter will be performed,

b. ID of patient, provider, and providerâ&#x20AC;&#x2122;s credentials, c. Provider will determine if patientâ&#x20AC;&#x2122;s condition is appropriate for telemedicine visit, d. Details on security measures taken, e. Possibility of loss of information due to technology failures, f. Assurance of availability of appropriate follow-up care, g. Complete medical record will be maintained and available to patient per usual request procedures, h. Limitations of telemedicine, as well as risks and benefits, i. How patients can access care in the event of an adverse response to treatment or failure of the technology or equipment.

3 15. Patients must still sign the usual forms for consent to treat, privacy, and release of information. n q This checklist is for informational purposes only and is in no way intended to amount to a representation regarding insurance coverage. Further, it is not intended and should not be construed to be or to establish the standard of care applicable to physicians practicing in Mississippi. This information should not be regarded as legal advice. We encourage physicians to seek the advice of their own legal counsel. Finally, this list is not exhaustive, and there may be additional areas which require your consideration prior to beginning a telemedicine practice.

Source: The Risk Manager, Medical Assurance Company of Mississippi About the Author: As the Vice President of Risk Management for Medical Assurance Company of Mississippi, Kathy Stone has over 15 years of experience working with insured physicians and clinics throughout Mississippi to identify and address issues and concerns related to patient safety and medical liability. Additionally, Ms. Stone develops and coordinates risk programs and regularly presents educational programs to physicians and their staffs.

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Doc Hill [This month’s poem is the final of my favorites from “Spoon River Anthology” about physicians. Most of these poetic portraits paint physicians as frail, well-intentioned humans subjected to tragic stress. The anthology’s author, Edgar Lee Masters (1868-1950), wrote other books, but his 1915 “Spoon River Anthology” remains his masterpiece, offering a collection of free-verse poetry as confessional epitaphs of the dead residents of the fictional American village Spoon River. The poem below, “Doc Hill,” relates the story of an altruistic physician with a tragic home-life who works late into the night caring for his patients. The night-watchman Andy describes his “weary steps” as sounding “like one who walks in his sleep.” There is much conjecture about who is “Em Stanton,” but Doc reveals a probable deep love relationship with or for her by his emotion. I encourage you to read the volume, especially the poems related to this one. Chief among my other favorites is the soliloquy of Lucinda Matlock, who was based on Masters’s own frontier grandmother, which describes her work rearing twelve children, “eight of whom we lost.” The poem concludes: “What is this I hear of sorrow and weariness, / Anger, discontent and drooping hopes? / Degenerate sons and daughters, / Life is too strong for you---/ It takes life to love Life.” Any physician is invited to submit poems for publication in the journal, attention: Dr. Lampton or email me at lukelampton@cableone.net.]—Ed.

I went up and down the streets Here and there by day and night, Through all hours of the night caring for the poor Who were sick.

Do you know why?

My wife hated me, my son went to the dogs.

And I turned to the people and poured out my love to them.

Sweet it was to see the crowds about the lawns on the day of my funeral, And hear them murmur their love and sorrow.

But oh, dear God, my soul trembled, scarcely able To hold to the railing of the new life When I saw Em Stanton behind the oak tree At the grave, Hiding herself, and her grief !

—Edgar Lee Masters, 1915

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