Journal MSMA • VOLUME LXI • NO. 5 • MAY 2020

VOLUME LXI • NO. 5 • MAY 2020

RESCHEDULED WITH NEW DATE! MISSISSIPPI STATE MEDICAL ASSOCIATION

18 th ANNUAL

CME IN THE SAND JULY 3–7, 2020 DESTIN , FLORIDA 16 CME HOURS TOPICS INCLUDE: Dermatology GI Pediatrics OBGYN Robotics History of Medicine in MS

REGISTRATION Register at www.MSMAonline.com.

For more information contact: Becky Wells

West Nile

601.853.6733, Ext. 340 • BWells@MSMAonline.com

Prescribing Controlled Substances

or

Vaping

Kim Mathis 601.853.6733, Ext. 302 • kmathis@MSMAonline.com

AND MORE

SANDESTIN GOLF & BEACH RESORT Reserve your room at www.Sandestin.com or by calling 850-320-8115. Use the group code 23P27.

VOL. LXI • NO. 5 • May 2020

SCIENCE ARTICLES

EDITOR Lucius M. Lampton, MD ASSOCIATE EDITORS D. Stanley Hartness, MD Philip T. Merideth, MD, JD

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

Pediatric Pharmacokinetic Studies Inform Children’s Standard Care: Pharmacokinetics of Understudied Drugs Administered to Children per Standard of Care (POPS) Joy Holmes, BSN; Lacy Malloch, BS; Eugene Melvin, MS; Joseph Marc Majure, MD; David Josey, MD; Crystal S. Lim, PhD; Lauren C. Tucker, MD; and Robert D. Annett, PhD

124

President-Elect W. Mark Horne, MD

Outpatient Antibiotic Prescribing: Time to Rethink Our Approach?

Peter W. Pendergrass, MD, MPH; Desiree B. Pendergrass, MD, MPH; and Paul Byers, MD

128

Mumps Orchitis in an 18-Year-Old Male Admitted for Severe Sepsis Secondary to Community-Acquired Pneumonia: A Case Report Jordan Sexe, OMS4 and Matthew Wade, MD

133

Opioid Use in Patients Undergoing Thyroidectomy C. Ron Cannon, MD, MHSA; William Replogle, PhD; Bobby Cumberland, BA

136

Top Ten Things You Need to Know about Asthma and COPD Taylor Mabry, MD; Cheshil Dixit, MD; and Patricia Stewart, MD

139

MANAGING EDITOR Karen A. Evers

Secretary-Treasurer Joe Austin, MD

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

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

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

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

SUBSCRIPTION RATE: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available.

ADVERTISING RATES: furnished on request. Karen A. Evers, ext. 323. Email: KEvers@MSMAonline.com POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 39158-2548.

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

Copyright © 2020 Mississippi State Medical Association.

Official Publication

MSMA • Since 1959

DEPARTMENTS From the Editor – The Loneliness of COVID-19 Lucius M. Lampton, MD

122

President’s Page – For Such a Time as This J. Clay Hays, Jr, MD

143

Letters – MSMA Caught Up in Major Hypocrisy: Physicians Have Failed to Formulate an Alternative to Expansion of Medicaid Which Would Fulfill Our Professed Ethical Commitment

144

New Members – Welcoming Our Newest Members

145

Images in Mississippi Medicine –The Lyceum at Ole Miss and Oxford: First Location of University of Mississippi School of Medicine, 1903-08 Lucius M. Lampton, MD

146

Poetry and Medicine – Death Happens Merrill Moore, MD

147

Una Voce – Chief Complaints: Part Three Dwalia S. South, MD

150

RELATED ORGANIZATIONS Rural Study Begins Outreach and Community Engagement in North Mississippi Karen Bascom, Science Writer, UMMC

148

ABOUT THE COVER “Southern Azaleas”– Rhododendron, Encore Azalea ‘Autumn Twist’ photographed by Ron Cannon, MD, Brandon. Rhododendrons and azaleas are arguably the South’s favorite shrubs. They both belong to the genus Rhododendron, which comprises more than 800 species and 10,000 named selections. Azalea plants delight gardeners with a profusion of blooms in a wide range of colors, flower size, and form. Most bloom in the spring with the beautiful blossoms lasting for several weeks, although some bloom three times per year as in the case of the continuous flowering Encore family of Azalea.

The “Autumn Twist” on the cover has a unique twist to every flower. They are light purple, but streaked, striped, and spotted in dark purple so that every flower is a little different. Some have white margins, and others are solid dark purple. Blooming from April to the first frost, the blooms cover almost the entire plant making them a welcome and colorful part of the landscape.

Even to the untrained eye, one difference between rhododendrons and azaleas is obvious: rhododendrons have much larger leaves. From a technical standpoint, rhododendron flowers are bell-shaped and have ten or more stamens, while azalea blooms are typically funnel-shaped and have five stamens. They were first introduced to the outdoor landscape in this country at a plantation in Charleston, South Carolina, in the 1830s. There are many azalea festivals throughout the world, including the well-known Mobile Azalea Trail Festival in Alabama.

Dr. Cannon writes, “We have several beds of azaleas at our home in Brandon. These are planted beneath several oak trees where they seem to enjoy the dappled sunlight. Thanks to God for these lovely shrubs and to my wife, who nurtures them.” Dr. C. Ron Cannon is in the private practice of otolaryngology at Head & Neck Surgical Group in Flowood. n

MAY • JOURNAL MSMA

121

F R O M

T H E

E D I T O R

The Loneliness of COVID-19 C

entral to a physician’s art is the laying on of hands: the touching and examining of the patient. This tactile aspect of our art seems even more important in those who are sicker or dying.

A physician’s touch conveys our concern and empathy, helping establish an ancient bond of trust so critical in the physician/ patient relationship. The stethoscope, one of our most important diagnostic tools, symbolizes this connection, directly Lucius M. Lampton, MD linking the physician and patient together Editor as an umbilical cord for the healing process.

While the physical examination yields diagnostic value for the physician, the exam also provides therapeutic benefit for our patients.

Living a COVID-19 life is marked by an extraordinary sense of loneliness.

This plague’s only proven preventions are quarantine, isolation, personal protective equipment, and social distancing, all of which emphasize our isolated condition. Our society is experiencing a shared emotional trauma, with evidence emerging that the reduction in social interaction associated with school closures, lockdowns, and sheltering in place is

increasing depressive and anxiety symptoms throughout our population in all age groups. This national anxiety also appears to be associated with more suicides. Although our social restrictions at nursing homes are slowing the pandemic’s spread, the restrictions may also be contributing to more progressive cognitive decline in our elderly.

Masks, gloves, gowns, and eye shields may protect us from the plague but are obstacles to our art, placing barriers difficult to overcome in the physician/patient relationship. Combine these with physical distancing from our patients. How does one have a relationship while keeping six feet away and talking through a mask? When we dare to get closer, garbed in full PPE, our voices muffled by an N95, our goggles fogged, our bodies sweating in a gown, how do we transmit our concern and empathy? How do we relieve the panic in our patient’s eyes? How do we console them as they are dying, making them feel not so alone and abandoned? To touch and be touched is part of the healing process for both patients and physicians. We all miss human contact. We must seek ways to surmount these many obstacles, even if by telemedicine or telephone, to connect with others. n Contact me at lukelampton@cableone.net.

— Lucius M. Lampton, MD, Editor

JOURNAL EDITORIAL ADVISORY BOARD ADDICTION MEDICINE Scott L. Hambleton, MD ALLERGY/IMMUNOLOGY Richard D. deShazo, MD Stephen B. LeBlanc, MD Patricia H. Stewart, MD ANESTHESIOLOGY Douglas R. Bacon, MD John W. Bethea, Jr., MD CARDIOVASCULAR DISEASE Thad F. Waites, MD CHILD & ADOLESCENT PSYCHIATRY John Elgin Wilkaitis, MD CLINICAL NEUROPHYSIOLOGY Alan R. Moore, MD DERMATOLOGY Robert T. Brodell, MD Adam C. Byrd, MD EMERGENCY MEDICINE Philip Levin, MD

122 VOL. 61 • NO. 5 • 2020

FAMILY MEDICINE Tim J. Alford, MD Diane K. Beebe, MD Jennifer Bryan, MD J. Edward Hill, MD

MEDICAL STUDENT John F. G. Bobo, M4

PLASTIC SURGERY William C. Lineaweaver, MD, Chair

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

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

NEUROLOGY Mary Alissa Willis, MD

PUBLIC HEALTH Mary Margaret Currier, MD, MPH

HEMATOLOGY/ONCOLOGY Carter Milner, MD Kelly Wilkinson, MD

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

PULMONARY DISEASE Sharon P. Douglas, MD John R. Spurzem, MD

INFECTIOUS DISEASE Rathel "Skip" Nolen, III, MD

ORTHOPEDIC SURGERY Chris E. Wiggins, MD

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

OTOLARYNGOLOGY Bradford J. Dye, III, MD

GASTROENTEROLOGY James Q. Sones, MD GENERAL SURGERY Andrew C. Mallette, MD

INTERNAL MEDICINE/EPIDEMIOLOGY Thomas E. Dobbs, MD

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

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

Do Not Enter the Courtroom Without the Protection of MACM Regardless of merit, thousands of medical malpractice claims are filed each year. Some say it is not a question of IF you will be sued; it is a question of WHEN. Call MACM today for your professional liability needs and to join so many others who have placed their trust with a company that has been physician owned and physician governed for over 40 years.

601-605-4882 | macm.net

S C I E N C E

O F

M E D I C I N E

Pediatric Pharmacokinetic Studies Inform Children’s Standard Care: Pharmacokinetics of Understudied Drugs Administered to Children per Standard of Care (POPS) JOY HOLMES, BSN; LACY MALLOCH, BS; EUGENE MELVIN, MS; JOSEPH MARC MAJURE, MD; DAVID JOSEY, MD; CRYSTAL S. LIM, PHD; LAUREN C. TUCKER, MD; AND ROBERT D. ANNETT, PHD

Abstract Limited information is known about the safety, efficacy, and pharmacokinetics of many medications used in the standard of care of children. Due to the lack of data, drug dosing in pediatrics is often extrapolated from adult studies. In fact, pharmacologic research in adults has been extrapolated to provide recommendations for dosing specifications for approximately 80% of the medications used in standard care in pediatric populations. The Best Pharmaceuticals for Children Act (BPCA) prioritizes therapeutic needs, including support for pediatric labeling, sponsoring pediatric trials, and submitting data leading to labeling changes in pediatric medications. The Pharmacokinetics of Understudied Drugs Administered to Children per Standard of Care (POPS) utilizes information from medications given in routine care of children to identify the pathophysiologic factors causing changes in the dose-concentration relationship and the extent of changes so that medication labeling can be modified.

This article describes POPS, its implementation, and characterizes implementation challenges and successes.

Keywords: Pharmacokinetics, children, standard of care Introduction Approximately 80% of medications used in the standard care of children have not been studied for safety, efficacy, and dosing.1 Pharmacologic research with adults has often been extrapolated to provide dosing specification recommendations for children based on the Food and Drug Administration’s (FDA’s) pediatric study decision tree.2 The most recent reauthorization of the Best Pharmaceuticals for Children Act (BCPA) recognizes the need for the industry to conduct pediatric studies to improve labeling of medications used to treat children. A significant gap exists in our understanding of how medications developed in adult trials can safely be used in the care of

124 VOL. 61 • NO. 5 • 2020

children. With this legislation in mind, the National Institute of Child Health and Human Development initiated the Pharmacokinetics of Understudied Drugs Administered to Children per Standard of Care, or POPS, study. This study is designed to increase our understanding of medications used to care for children through the power of population pharmacokinetics. Specifically, the purpose of POPS is to characterize the pharmacokinetics, explore the pharmacodynamics, and explore biomarkers associated with understudied drugs administered to children as prescribed per standard of care. Thus, findings from POPS will advance the care for children with increased understanding of how medications work among different age groups and may result in modifying labeling for drugs currently widely used in the pediatric population.

In an effort to expand recruitment sites, POPS investigators forged a collaboration with the National Institutes of Health (NIH) Environmental Influences on Child Health Outcomes program (ECHO) and specifically the Institutional Development Award (IDeA) program’s pediatric clinical trials network initiative. Mississippi and the University of Mississippi Medical Center (UMMC) have been recipients of funding to establish a local site for the IDeA States Pediatric Clinical Trials Network (the Network), making POPS one of the first pediatric studies to be launched as a result of our local network resources.

UMMC is currently one of 17 network sites recruiting participants for POPS, which has been enrolling since 2011. By linking multiple clinical sites, sufficient enrollment of children can occur more efficiently, and the resulting knowledge gained can be rapidly translated and thus provide information for children’s care.

In this article we describe the POPS study, how it is being implemented at UMMC, and characterize the challenges and successes related to implementation.

What is POPS? The POPS study seeks to increase knowledge of understudied drugs commonly administered to children, with this information resulting in FDA labeling changes. With increased understanding of pharmacokinetics in child age cohorts and among children with special healthcare needs, pediatricians can utilize drugs commonly administered to children according to best practices. While the study may find that current practices for some cohorts and considerations are recommended, current literature shows that there is a great need for studies to fill the gap for information that is missing or limited.

Off -label use should not be considered best practice in this large and vulnerable population.

How Does POPS Work?

While common drugs for diseases in children have been available, the safety, efficacy, and dosing for these drugs has predominantly been extrapolated from studies in adults.1 As these drugs have been used to treat children for many years, there is little impetus for the pharmaceutical industry to conduct clinical trials to characterize the pharmacokinetics and pharmacodynamics of these drugs in children. Certain patient demographical (pediatric population), pathophysiological (disease state), and therapies (extracorporeal membrane oxygenation [ECMO]) can alter concentration-response relationships.3-4 Population pharmacokinetics offers the advantage of using relatively sparse data obtained from a variety of unbalanced designs in populations and settings that otherwise would be excluded from traditional pharmacodynamic studies.5 An additional advantage is that by using multiple-site study centers, information can be accumulated quickly and the results presented that inform current practice.

With POPS, a drug of interest (DOI) is identified through the coordinating center (Duke Clinical Research Institute) and age-linked to one of 10 child age groups. A DOI cohort is defined by the drug, child age, and health status. Child cohorts range from premature infants to under 21 years of age. Health status conditions include children receiving inpatient care who, for example, are being treated with ECMO. An example of an outpatient cohort of interest would include children who are obese. The DOI list is updated frequently as cohort ages of interest complete enrollment. Subsequently, new DOIs are then open for enrollment.

Within a POPS cohort, no DOI is prescribed by the study; rather children who are eligible are receiving the DOI as standard of care by their treating physician. Inclusion criteria include children who are receiving a DOI, ability of the parent/guardian to provide informed consent, and assent (depending on age). Exclusion includes lack of consent/assent and known pregnancy. Other exclusions include kidney transplant within thirty days, kidney rejection, liver transplant, stem cell transplant, continuous veno-venous hemodialysis, ventricular assistive device, ECMO (unless specified by cohort), continuous renal replacement therapy, peritoneal dialysis, topical route, route by

patch, or extended release preparation. Sample collection includes a fresh standard of care blood collection, thereby eliminating additional procedures or sticks for study purposes. For antimicrobials, a paired sample is required which consists of standard of care cerebrospinal fluid collection (CSF) and blood collection that may be fresh or scavenged from the laboratory. Depending on the type of sample being obtained, there are blood volume limits in place per protocol for standard of care laboratory versus nonstandard of care laboratory.

Once a potential participant is identified, the treating physician approaches the family to inform them about the study and ask if a member of the research team can speak with the family about their possible participation. With family agreement, the study team discusses participation and requests consent/assent. Once informed consent/assent is obtained, a signed copy is given to the parents and a time for any additional sample collection is scheduled. Once drawn, the samples are taken to the UMMC Biobank, appropriate regulatory documentation is maintained, and samples are frozen until they are shipped to the POPS central repository twice annually.

Implementation at UMMC: Challenges and Successes The UMMC site was opened in October 2018 and as a quality metric, both screening and enrollment efforts were tracked. At UMMC, the screening for eligibility process includes a nurse research coordinator running a twice-daily report in our electronic health record (EHR) EPIC. This report queries the electronic medical record for children meeting inclusion criteria. At the time of activation, screening for participants was a time intensive process. In our first month, the time spent running EPIC reports was over 40 hours. Following the report for eligibility, subsequent research nurse screening time was an additional 16 hours. In month 2, the report run time decreased, largely driven by changes made to the report generation process and increased coordinator efficiency. Research coordinator time for supplemental eligibility screening has been observed to vary based upon the length of the screening report. When the EPIC reports fail to run, additional coordinator time is needed to review patient lists. Our quality metrics have revealed that the average length of time to screen by patient list has been 42 minutes in month 2.

In order to increase our efficiency, UMMC’s Center for Informatics and Analytics (CIA) and Division of Information Systems (DIS) met with our study team to brainstorm solutions and streamline the current reporting and screening process. As a result of this collaboration, the average daily report run time of 2 hours and 7 minutes before intervention was reduced to an average of 3 minutes to run the improved report.

The study team has ownership of the EPIC report and can make necessary changes when DOIs are closed and/or added. Now that we have significantly improved the report run time, we will be concentrating improvement efforts on decreasing the amount of time the nurse coordinator spends screening for eligible participants.

Our CIA/DIS team is currently adjusting the EPIC report to include

VOL. 61 • NO. 5 • 2020 125

valuable inclusion criteria at a glance without having to search within the child’s individual chart. This important step will be crucial in reducing screening time.

One major challenge to the implementation of POPS at UMMC has been utilizing the EHR to identify potentially eligible patients. As discussed above, the time spent obtaining EPIC reports decreased over time. However, after a routine EPIC upgrade, the cache system running the reporting workbench became inefficient. This led to a large amount of data being pulled and compiled into a report which caused the run time to dramatically increase. The data could be gathered quickly but then stall while preparing the information to be downloaded into a report. This caused the report to sit for 30-60 minutes or produce no result at all. As part of our capacity building efforts, we were able to utilize our collaboration with the UMMC CIA/DIS to effect change.

Application analysts were able to run diagnostics on the report and find the faulty index issue created by the EPIC upgrade. The report was changed to not search by index but instead to search by criteria, allowing for a more efficient run time because the search is now more defined.

Other measures are being implemented to decrease the amount of screening time. Currently the report identifies children who are the correct age and receive a DOI. A separate CSF report is run to cross reference for antimicrobials. However, the patient medical record has to be reviewed to determine if they qualify under the obese or ECMO category. Currently, CIA/DIS is building a category report at the bottom of the generated EPIC report. These smaller reports will show whether CSF has been ordered or collected, ECMO status, BMI, and current medication information. This is a detailed view created through a print group allowing more information to be viewed without entering the patient’s medical record. Developing relationships with the CIA/DIS has been integral for effective communication and efficient problem-solving, which will lead to overall improved enrollment.

Liaison with UMMC Pediatric Providers In order to enhance engagement within the UMMC environment, we distributed informational flyers to inpatient providers and nurses which led to successful contacts for participant enrollment. At this time, few children have CSF collected after receiving a DOI. When they do, the timing of finding them and getting consent/assent before the sample expires has proven to be challenging. Our successes have come with nurses identifying and notifying the research team when a CSF sample has been drawn or if CSF collection is being planned. Our nurse coordinator has been critical in establishing these relationships with inpatient nursing teams.

Our study team is also exploring avenues of reaching possible participants who are scheduled for outpatient visits or surgical procedures. Through relationships with our UMMC providers, we are reaching out and introducing the study for collaboration with the appropriate faculty and staff.

126 VOL. 61 • NO. 5 • 2020

Need for Pediatric Pharmacokinetic Study Pharmacokinetic (PK) studies examine how the body absorbs, distributes, metabolizes, and excretes medications, all of which are impacted by child age and development. Children are not small adults; therefore, the current practice of modifying adult dosing recommendations and safety information for children can no longer be considered standard of care or best clinical practice. Each child age group has challenges that potentially make current practice unsafe.

POPS has 10 child age cohorts ranging from preterm to age 20 and four additional cohorts (preterm, obese, ECMO, and an infant special population). These four additional cohorts address compounding concerns for pediatric populations. While research including pediatric participants is limited, research including pediatric participants with these special considerations is even more limited.

Preterm infants exhibit different drug absorption rates, distribution, metabolizing, and excretion when compared to normal term physiology.6 Increased extra cellular fluid volume and immature renal, hepatic, and metabolic systems contribute to these differences.

Preterm infants also have extremely permeable blood brain barriers.

The infant age cohort is a separate cohort to evaluate infants with a known congenital heart defect undergoing surgical repair that will include placing the infant on cardiopulmonary bypass (CPB) and methylprednisolone being administered per standard of care 24-hours before and/or during CPB. Additional data of special interest is collected regarding this process.

Similar to the infant cohort is the ECMO cohort. ECMO is used as a life support system during the treatment of the following conditions: congenital diaphragmatic hernia repair (CDH), meconium aspiration syndrome (MAS), acute respiratory distress syndrome (ARDS), persistent pulmonary hypertension (PPHN), and pneumonia, as well as transplant and graft surgeries.

During the ECMO process blood is pumped from the body’s venous system through an artificial lung system. Once the oxygen has been added and carbon dioxide has been removed from the blood, the blood will be returned to body through the venous or arterial system, venovenous versus veno-arterial.

Obese children have been included in some hypertension studies but have been otherwise excluded. Physiological aspects that make this population of particular interest include adult studies that show more rapid perfusion of lean tissue as opposed to nonlean tissue.6 Drug toxicity is potentially reached much quicker when toxic levels are reached by nonlean body weight versus lean body weight. As referenced in the protocol, in the article, “Predicting Pediatric Age-Matched Weight and Body Mass Index,” it is observed that drug dosages used during cardiopulmonary resuscitation may be inadequate for obese children as shown by “obesity being an independent post-resuscitation risk factor for death.”10 Summary and Conclusions POPS has been very successful at starting to inform pediatricians and other pediatric health care providers of pharmacokinetics of commonly

used drugs as evident in recent publications.7-9 There are significant challenges in implementing a study like POPS; these include technical issues of identifying eligible participants within a large children’s hospital setting, being able to obtain samples with minimal disruption to a child’s clinical care, and creating a working relationship with care providers to assist with the smooth study operation.

In this presentation we have selected elements of POPS to highlight the importance of pharmacokinetic/pharmacogenomic studies to inform pediatric health care. We believe that it is important for health care providers and families to understand how participation in POPS advances care for infants and children and, through implementation at multiple sites across the US, will contribute to overall improvements in pediatric health care. We are indebted to the UMMC physicians, nurses, and Mississippi families that have helped make POPS successful. n Acknowledgments The Best Pharmaceuticals for Children Act–Pediatric Trials Network Publication Committee: Phyllis Kennel, Duke Clinical Research Institute (DCRI), Durham, NC; Danny Benjamin, DCRI, Durham, NC; Edmund Capparelli, University of California San Diego, San Diego, CA; Gregory L. Kearns, Arkansas Children’s Hospital Research Institute, Little Rock, AR; Ian M. Paul, Penn State College of Medicine, Hershey, PA; Christoph Hornik, DCRI, Durham, NC; Kelly Wade, Children’s Hospital of Philadelphia, Philadelphia, PA. The Eunice Kennedy Shriver National Institute of Child Health and Human Development: David Siegel (retired) and Perdita Taylor-Zapata.

The Emmes Corporation Company, LLC (Data Coordinating Center): Ravinder Anand and Gina Simone.

Pediatric Trials Network’s Pharmacokinetics of Understudied Drugs Administered to Children per Standard of Care Study Team: DCRI: Chiara Melloni (PI), Barrie Harper (PL), Adam Samson (L-CRA)/Gary Gong (L-CRA), Tammy Day (CRA), and the Emmes Corporation: David Lipscomb (Data manager).

This work was supported by NIH Grant UG1HD090848-01. The contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. Conflict of Interest Disclosures: The authors have nothing to disclose.

References 1. Drug Research and Children. Food and Drug Administration. Updated May 4, 2016. Accessed March 20, 2019. https://www.fda.gov/drugs/drug-informationconsumers/drug-research-and-children.htm 2. Pediatric Science and Research Activities. Food and Drug Administration.

Updated March 22, 2018. Accessed March 20, 2019. https://www.fda.gov/ scienceresearch/specialtopics/pediatrictherapeuticsresearch/ucm106614.htm 3. Yoki T. Essentials for starting a pediatric clinical study: Pharmacokinetics in children. J Toxicol Sci. 2009;34(Suppl 2):SP307-SP312.

4. Zuppa AF, Zane NR, Moorthy G, et al. for Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Group. A Population pharmacokinetic analysis to study of the

effect of extracorporeal membrane oxygenation on cefepime disposition in children. Pediatr Crit Care Med. 2019;20(1):62-70.

5. Nechuta S, Mudd LM, Elliott MR, et al. Attitudes of pregnant women towards collection of biological specimens during pregnancy and at birth. Paediatr Perinat Epidemiol. 2012;26(3):272-275.

6. Spittle AJ, Spencer-Smith MM, Eeles AL, et al. Does the Bayley-III Motor Scale at 2 years predict motor outcome at 4 years in very preterm children? Dev Med Child Neurol. 2013;55(5):448-452.

7. Tremoulet A, Le J, Poindexter B, et al. Characterization of the population pharmacokinetics of ampicillin in neonates using an opportunistic study design. Antimicrob Agents Chemother. 2014;58(6):3013-3020.

8. Smith MJ, Gonzalez D, Goldman JL, et al. Pharmacokinetics of Clindamycin in Obese and Nonobese Children. Antimicrob Agents Chemother. 2017;61(4): e02014-e02016.

9. Hornik CP, Benjamin DK, Jr., Smith PB, et al. electronic health records and pharmacokinetic modeling to assess the relationship between ampicillin exposure and seizure risk in neonates. J Pediatr. 2016;178:125-129.1.

10. Srinivasan V, Nadkarni VM, Helfaer MA, et al. Childhood obesity and survival after in-hospital pediatric cardiopulmonary resuscitation. Pediatrics. 2010;125, 481-488.

Author Information Pediatric Research Division, University of Mississippi Medical Center (Holmes, Malloch). Center for Informatics and Analytics, University of Mississippi Medical Center (Melvin). Professor of Pediatrics, University of Mississippi Medical Center (Majure, Annett). Assistant Professor, University of Mississippi Medical Center (Josey, Lim, Tucker).

Corresponding Author: Joyce Y. Holmes, BSN, Department of Pediatrics, Translational Research Center, University of Mississippi Medical Center, 2500 N. State St., Jackson, MS 39216 Ph: (601) 815-4179 (jyholmes@umc.edu).

Pen > Sword

E

xpress your opinion in the JMSMA through a letter to the editor or guest editorial. The Journal MSMA welcomes letters to the editor. Letters for publication should be less than 300 words. Guest editorials or comments may be longer, with an average of 600 words. All letters are subject to editing for length and clarity. If you are writing in response to a particular article, please mention the headline and issue date in your letter. Also include your contact information. While we do not publish street addresses, e-mail addresses, or telephone numbers, we do verify authorship, as well as clarify ambiguities, to protect our letterwriters. You can submit your letter via email to: KEvers@MSMAonline.com or mail it to the Journal office at MSMA headquarters: P.O. Box 2548, Ridgeland, MS 39158-2548.

VOL. 61 • NO. 5 • 2020 127

S C I E N C E

O F

M E D I C I N E

Outpatient Antibiotic Prescribing: Time to Rethink Our Approach?

PETER W. PENDERGRASS, MD, MPH; DESIREE B. PENDERGRASS, MD, MPH; AND PAUL BYERS, MD

Background: Antibiotic Resistance Antibiotics are not like other drugs. Even with appropriate use, they become less effective over time as organisms develop resistance to them, impacting both individuals and the community at large.1,2 The problem is compounded by the fact that antibiotic development is no longer keeping pace with the development of resistance.2 This is why the Centers for Disease Control (CDC) and Prevention and the World Health Organization have identified antibiotic resistance as a significant worldwide public health issue.3–5 Antibiotics are a valuable tool; however, their use is not without consequences. Antibiotics can lead to poorer health outcomes and increased healthcare costs.6,7 More than 2 million antibioticresistant illnesses and 23,000 deaths associated with antibiotic use occur each year in the United States with an associated cost of 30 billion dollars.8 Adverse reactions to antibiotics lead to 140,000 emergency department visits each year.9 In addition, antibiotic use leads to alteration of normal gut flora which may persist for months and put individuals at increased risk for infections ranging from infectious diarrhea to sepsis.9,10 The CDC estimates that each year at least 250,000 illnesses and 14,000 deaths are caused by Clostridium difficile alone.4

population was 786/1000 members, much lower than the national rate published by the CDC.11 Overprescribing: How Much is Too Much?

Determining an appropriate level of antibiotic prescribing is difficult; however, current U.S. rates are significantly higher than other developed nations such as Scandinavian countries that have a rate of 400 prescriptions per 1000 population.9,12 When prescribing is compared to national guidelines, the rates of overprescribing are even more apparent. Based on guidelines, the CDC estimates 30% of the more than 47 million antibiotic prescriptions written each year in outpatient offices and emergency departments are unnecessary.9 That rate rises to 50% when the analysis is restricted to respiratory conditions, which are the most common reasons for outpatient visits.9 Variations exist by age, with the highest rates occurring in adults ages 20–64 years (35% of visits for all conditions and 70% of visits for acute respiratory conditions) and the lowest in children ≤ 19 years of age (29% of visits for all conditions and 34% of visits for acute respiratory conditions).9 In 2015, the National Action Plan for Antibiotic Resistance set a goal of a 50% reduction in inappropriate antibiotic prescribing by the year 2020.13 Different methods have been proposed for reaching this goal, including setting targets at those of the lowest prescribing state or region or targeting those conditions with the highest rates of inappropriate prescribing (i.e., respiratory conditions).

Prescribing Rates: U.S. and Mississippi Prescribing: Choosing the Right Antibiotic In 2016, outpatient pharmacies in the United States filled 207.2 million antibiotic prescriptions, a fill rate of 836 prescriptions for every 1000 individuals.10 Rates vary by state and region with the lowest rate found in Alaska (511/1000) and the highest in Kentucky (1270/1000).10 Regionally, the highest rates occur in the South (937/1000) and the lowest in the West (607/1000).10 Mississippi ranks third overall with a rate of 1235/1000 or a fill rate of 1.23 prescriptions for every man, woman and child in the state yearly.10 Of note, this represents a 4.1% increase in prescribing in Mississippi since 2011 compared to a 4.9% decrease for the U.S. as a whole (see Figure 1).10 A Blue Cross/Blue Shield study of 2016 data found similar rates (1233/1000) for its commercially insured population in Mississippi; however, the median overall prescribing rate for this

128 VOL. 61 • NO. 5 • 2020

Equally important to prescribing only when indicated is choosing the correct antibiotic. Currently, only 52% of patients prescribed an antibiotic for sinusitis, suppurative otitis media, or pharyngitis received a first line agent.14 The percentage is even lower for adults (37%). While second line therapy is warranted for some (e.g., history of allergy, recent antibiotic treatment with first line agent, failure to respond, etc.), an expert panel has determined that at least 80% of patients with these conditions should be receiving first line agents.14 Inappropriate use of azithromycin is common despite the fact that it is not a recommended treatment for sinusitis or suppurative otitis media and is appropriate only for pharyngitis in penicillin allergic patients.14

Figure 1. Outpatient Antibiotic Prescriptions

Improving Antibiotic Prescribing: The Keys Are Commitment and Communication Decreasing the amount of antibiotics prescribed will positively impact the quality of care by decreasing the number of C. difficile infections, lowering the rate of adverse events, decreasing the development of resistance, and ultimately leading to decreased costs of care.9,15–18 Antibiotic stewardship programs (ASP) are able to affect these changes; however, they have historically been focused on facilities (e.g., hospitals, long-term care facilities). Given that the majority of antibiotics are prescribed in the outpatient setting, efforts must be shifted into this arena in order to optimally address the problem.13,14 Commitment is the first step to reducing inappropriate antibiotic use. Providers must be committed to learning and following the latest evidence-based guidelines to ensure appropriate antibiotic use. A good place to begin is to choose at least one area (e.g., respiratory illnesses) to improve prescribing practices. To this end, the CDC has developed summaries of current evidence-based guidelines for the treatment of common adult and pediatric respiratory conditions. These recommendations can be accessed easily online using the following links:19,20 • https://www.cdc.gov/antibiotic-use/community/for-hcp/ outpatient-hcp/adult-treatment-rec.html • https://www.cdc.gov/antibiotic-use/community/for-hcp/ outpatient-hcp/pediatric-treatment-rec.html It also is important to make this commitment known. A good tool for this is the use of a commitment poster that is signed by all providers and placed in the waiting and exam rooms (Figure 2). This simple

intervention has been shown to decrease inappropriate prescribing by 20%. 9,16 Measuring what is being done and providing feedback to providers is critical to successfully facilitate change.

Effective communication with patients is another critical element.21 As noted in the “Four-Es”22 (Figure 3), it is important for the provider to discuss physical findings and a specific diagnosis with patients, demonstrate empathy, describe why antibiotics are not warranted, prescribe symptomatic relief, and develop a contingency plan if things do not progress as expected.

Patients do not necessarily want antibiotics, but they do want their symptoms addressed. As such, it is important to give them specific advice including drinking plenty of fluids, using a saline nasal spray for congestion, using ice chips, sore throat spray or lozenges for a sore throat, or specific over the counter medicines to address fever, pain or other symptoms. Written prescriptions or instructions are preferred over verbal ones.

Two approaches to contingency planning are watchful waiting and delayed prescribing.23 Watchful waiting is a good approach when you believe a patient has a viral respiratory infection (e.g., acute rhinosinusitis). With this technique, the provider gives guidance on symptom relief and explains the likely course of the illness. The patient is asked to call or come back into the office if symptoms do not begin to improve within a set timeframe, typically 72 hours, or if symptoms worsen. Delayed prescribing is similar to watchful waiting and is especially useful for episodes of acute otitis media.

Instead of asking the patient to call or come back, patients are given a prescription for an appropriate antibiotic and asked not to fill it unless symptoms worsen or fail to improve within a given time frame, typically 48 to 72 hours. Additional clinical tools have been

VOL. 61 • NO. 5 • 2020 129

Figure 2. Commitment Poster

developed for providers to use in educating patients and improving their communications regarding their care of respiratory illnesses.

These tools can be found on the CDC website at https://www. cdc.gov/antibiotic-use/community/materials-references/printmaterials/index.html. The adoption of even small steps can and will

130 VOL. 61 • NO. 5 • 2020

produce positive changes for patients and the communities in which they live. Refusing to prescribe unwarranted antibiotics is consistent with one of the foundations of medicine, “to first do no harm.”

Provider commitment and improved communication are the means to achieving this important end.

Figure 3. The 4 E’s of Patient Communication

References

7. Sanchez GV, Fleming-Dutra KE, Roberts RM, et al. Core elements of outpatient antibiotic stewardship. MMWR Recomm Rep. 2016;65(6):1-12.

1. Srinivasan A. Antibiotic stewardship: Why we must, how we can. Cleveland Clin JMed. 2017;84(9):673- 679.

8. Harris AM, Hicks LA, Qaseem A. for the High Value Care Task Force of the American College of Physicians and for the Centers for Disease Control and Prevention. Appropriate antibiotic use for acute respiratory tract infection in adults: Advice for high-value care from the American College of Physicians and the Centers for Disease Control and Prevention. Ann Intern Med. 2016;164:425-434.

2. Zetts RM, Stoesz A, Smith BA, et al. Outpatient antibiotics use and the need for increased antibiotic stewardship efforts. Pediatrics 2018;141(6):e20174124.

3. Pew Charitable Trust. The Critical Need for New Antibiotics. September 2018.

Accessed. April 22, 2020. https://www.pewtrusts.org/-/media/assets/2020/ 04/the_critical_need_for_new_antibiotics_apr2020.pdf 4. Center for Disease Control and Prevention, United States Department of Health and Human Services. Antibiotic Resistance Threats in the United States, 2013 [online]. Accessed March 28, 2017. https://www.cdc.gov/drugresistance/ threat-report-2013/pdf/ar-threats-2013-508.pdf 5. World Health Organization. Antimicrobial Resistance: Global Report on Surveillance. June 2014. Accessed October 2, 2014. http://apps.who.int/iris/bitstream/ handle/10665/112642/9789241564748_eng.pdf ?sequence=1 6. Fishman N. Antimicrobial stewardship. Amer J Infect Cont. 2006;34(5):S55-S63.

9. CDC: Antibiotic Use in the United States, 2017. Progress and Opportunities.

Atlanta, GA: US Department of Health and Human Services, CDC; 2017. (PDF) 10. Center for Disease Control and Prevention, Outpatient Antibiotic Prescriptions – United States, 2016. Accessed April 22, 2020. https://www.cdc.gov/antibi otic-use/community/pdfs/Annual-Report-2016-H.pdf 11. Blue Cross/Blue Shield. The Health of America Report: Antibiotic Prescription Fill Rates Declining in the U.S. 2017. Accessed March 6, 2019. https://www. bcbs.com/sites/default/files/file-attachments/health-of-america-report/HoA. Antibiotics.Report.pdf 12. Pew Charitable Trust. Trends in U.S. Antibiotic Use. March 2017. https://www. pewtrusts.org/-/media/assets/2017/03/trends-in-us-antibiotic-use.pdf

VOL. 61 • NO. 5 • 2020 131

13. The Pew Charitable Trusts. Antibiotic Use in Outpatient Settings. May 2016.

Accessed August 29, 2018. http://www.pewtrusts.org/~/media/assets/ 2016/05/antibioticuseinoutpatientsettings.pdf 14. The Pew Charitable Trusts, Health Experts Establish National Targets to

Improve Outpatient Antibiotic Selection. October 2016. Accessed August 29, 2018. http://www.pewtrusts.org/~/media/assets/2016/10/health_experts_ establish_national_targets_to_improve_outpatient_antibiotic_selection.pdf 15. Dantes R, Mu Y, Hicks LA, et al. Association between outpatient antibiotic prescribing practices and community-associated Clostridium difficile infection. Open Forum Infect Dis Soc. 2015;2(3):ofv113.

16. Meeker D, Knight TK, Friedberg MW, et al. Nudging guideline-concordant antibiotic prescribing: A randomized clinical trial. JAMA Intern Med. 2014;174:425-431.

17. Meeker D, Linder JA, Fox CR, et al. Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices: A randomized clinical trial. JAMA. 2016;315:562-570.

18. Gerber JS, Prasad PA, Fiks AG, et al. Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians: A randomized trial. JAMA. 2013;309:2345-2352.

19. CDC. Adult Treatment Recommendations. Online. Accessed November 1, 2018. https://www.cdc.gov/antibiotic-use/community/for-hcp/outpatient-hcp/ adult-treatment-rec.html 20. CDC. Pediatric Treatment Recommendations. Online. Accessed November 1, 2018. https://www.cdc.gov/antibiotic-use/community/for-hcp/outpatient-hcp/ pediatric-treatment-rec.html 21. Fleming-Dutra KE, Mangione-Smith R, et al. How to prescribe fewer antibiotics: talking points that work with patients and their families. Am Fam Physician.

2016;94(3):200-202.

22. New England QIN-QIO, the Medicare Quality Innovation Network-Quality Improvement Organization for New England. Talking to Patients about Viral Illnesses Use the Four E’s. CMSQIN_C310_010518 _1279. Accessed April 21, 2019. https://www.lsqin.org/wp-content/uploads/2018/05/Antibiotic_stewardship_patients_VRI.pdf 23. CDC. Antibiotic Prescribing and Use in Doctor’s Offices: Print Materials for Healthcare Providers. Online. Accessed March 19, 2019. https://www.cdc.gov/ antibiotic-use/community/materials-references/print-materials/index.html

Author Information Epidemiologic Consultant, MSDH; Associate Professor of Preventive Medicine, University of Mississippi Medical Center, Jackson (P. Pendergrass). Epidemiologic Consultant, Mississippi State Department of Health; Associate Professor of Preventive Medicine and Pediatrics, University of Mississippi Medical Center, Jackson (D. Pendergrass). State Epidemiologist, Mississippi State Department of Health (Byers).

MEA thanks its staff and all the healthcare professionals statewide who are working tirelessly on the frontlines to move us through this pandemic.

MEAMedicalClinics.com Where you need us. When you need us.

Helping you build a more secure future.

We invest our own money alongside yours, so we are invested in your success.

Corresponding Author: Desiree B. Pendergrass, MD, MPH; 4330 Bull Creek Road, Apt #1408; Austin, TX 78731. Ph: (806) 500 – 0462 (dbpendergrass@sbcglobal.net).

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

601-982-4123

M&B MSMA 4'17'17.indd 1

132 VOL. 61 • NO. 5 • 2020

A D V I S O R S

medleybrown.com

4/17/17 2:21 PM

S C I E N C E

O F

M E D I C I N E

Mumps Orchitis in an 18-Year-Old Male Admitted for Severe Sepsis Secondary to Community-Acquired Pneumonia: A Case Report JORDAN SEXE, OMS4 AND MATTHEW WADE, MD

Abstract Mumps is a largely preventable viral illness with a concerning re-emergence in recent years. Routine childhood vaccines have effectively prevented and controlled mumps infections in the United States since 1967. This re-emergence is suspected to be related to factors such as lower than anticipated vaccine efficacy, vaccine strains not sufficiently covering wild strains, waning neutralizing antibodies, lack of vaccination, and underestimation of the herd immunity threshold.

We describe the clinical course of a partially vaccinated 18-year-old male who exhibited mumps orchitis during hospital admission for severe sepsis secondary to community-acquired pneumonia.

Keywords: Mumps, orchitis, sepsis, pneumonia Introduction Mumps is a re-emerging and vaccine-preventable viral illness that classically presents during childhood with fever and parotid gland swelling. However, only 60–70% of mumps infections have been shown to present with the classic parotitis.1 Other potential manifestations are orchitis, pancreatitis, hearing loss, and meningitis.2 This re-emergence has been attributed to factors such as lower than anticipated vaccine efficacy, vaccine strains not sufficiently covering wild strains, waning neutralizing antibodies, lack of vaccination, and underestimation of the herd immunity threshold.3 This report describes a patient who initially presented to his primary care provider (PCP) complaining of a cough and low-grade fever but was eventually admitted to the hospital for severe sepsis secondary to communityacquired pneumonia. On day 3 of hospital admission, the patient developed acute left testicle pain, and mumps serology was drawn and later confirmed as positive. This case serves to bring increased awareness to this re-emerging viral infection and how such infections may present.

Case Report DAY 1: In January 2019, an 18-year-old male with a past medical history of asthma, pneumonia, and attention deficit/hyperactivity

disorder (ADHD) presented to his PCP with a cough and fever of 1 day duration. He was diagnosed with pneumonia and prescribed a 5-day course of levofloxacin and hydrocodone-homatropine syrup.

DAY 4: The patient presented to the local emergency department (ED) complaining of worsening cough, fever, sore throat, and shortness of breath (SOB). The patient had received an at-home ipratropium bromide and albuterol (duo-neb) treatment due to pleuritic chest pain the prior day. The patient was afebrile, tachycardic at 110 bpm, and had decreased breath sounds in the right middle and right upper lung fields. Screening for strep A, influenza A, and influenza B was negative.

A posterioranterior/lateral (PA/Lateral) chest x-ray showed a nodular infiltrate throughout the right upper lung field and calcified lymph nodes in both hila. The patient was treated with 1 g IV ceftriaxone, 125 mg IV methylprednisolone, 1 L IV normal saline, and 2.5 mg of nebulized albuterol.

The patient reported improvement in symptoms and was diagnosed with right upper lung pneumonia, hypovolemia, and moderate asthma.

He was discharged home with instructions to continue the previously prescribed levofloxacin, use his home nebulizer every 4–6 hours, and given a prescription for a methylprednisolone 4 mg tablet dose pack.

DAY 5: The patient returned to the local ED with worsening SOB and fever. The patient reported a maximum temperature of 103 F prior to arrival. On examination, the patient had a blood pressure of 144/84 mmHg, a heart rate of 120 bpm, an SpO2 of 98% on room air, and an oral temperature of 101.3 F approximately 3 hours after taking ibuprofen at home. There were rales in the right upper lobe. Blood cultures and repeat lactic acid were ordered. An AP/Lateral chest x-ray showed worsening of the right upper lobe infiltrate and a new perihilar infiltrate (Figure). The patient was treated in the ED with 1 g IV cefepime, 2 L normal saline, and 1 g oral acetaminophen and admitted to the general medical floor for severe sepsis secondary to communityacquired pneumonia with failed outpatient therapy.

DAY 6: The patient remained on 2 g IV cefepime every 8 hours in addition to DuoNeb inhalations every 8 hours. The patient continued to acknowledge pleuritic chest pain and SOB.

VOL. 61 • NO. 5 • 2020 133

Figure. Patient’s Chest X-ray on Day 5, Showing Worsening of the Right Upper Lobe Infiltrate and a New Perihilar Infilrate

Discussion In this report, we described the clinical course of a partially vaccinated 18-year-old male who developed mumps orchitis during a hospital admission for severe sepsis secondary to community-acquired pneumonia. Mumps is a rare but re-emerging viral disease in the United States, which has raised concern among health care officials.

Factors hypothesized to be instigating this re-emergence are lower than anticipated vaccine efficacy, vaccine strains not sufficiently covering wild strains, waning neutralizing antibodies, lack of vaccination, and underestimation of the herd immunity threshold.3 Approximately one-third of mumps cases will display extra-salivary manifestations without the classic parotitis, with epididymo-orchitis being the most common in adults.4 Additionally, mumps infections may also present with isolated respiratory symptoms.2,5 This patient initially presented with respiratory symptoms and fever, while orchitis occurred later in the hospital course (day 8). This patient was only partially vaccinated against mumps, having received only 1 of the 2 recommended MMR doses. Receiving 1 of the 2 MMR vaccines has been reported to provide a 78% reduction of risk against mumps infection, while receiving 2 doses confers an 88% reduction.2

IMAGING: A CT angiogram pulmonary embolus with contrast was ordered. The CT showed no evidence of pulmonary embolism, a dense consolidating infiltrate in the right upper lobe, areas of consolidated infiltrates in the superior left lower lobe and right middle lobe, trace pleural fluid bilaterally, no suspicious mediastinal or hilar pathology, and an irregular enhancement pattern of the spleen.

DAY 8: The patient reported near resolution of chest pain and SOB but acknowledged new onset left testicle pain. On exam, the left testicle did not exhibit rotation, elevation, or outward physical changes but was significantly tender to light palpation. The right testicle was normal.

We elected to draw mumps serology when it was determined that the patient received only 1 of the 2 measles, mumps, and rubella (MMR) vaccines. The patient remained on IV cefepime and DuoNeb every 8 hours.

DAY 9: The patient reported resolution of his testicle pain and acknowledged continued improvement of his chest pain and SOB. DAY 11: The patient reported resolution of all complaints and was discharged home in good condition with an outpatient pulmonology referral.

DAY 24: The mumps IgM and IgG antibody results became available and were reported as mumps IgM 5.56 (reference range 0–0.79) and mumps IgG 49.7 (reference range 0–8.9). The Mississippi Department of Health and the patient’s PCP were notified and initiated follow-up.

134 VOL. 61 • NO. 5 • 2020

It is uncertain whether our patient contracted mumps or pneumonia first. The patient did not have an underlying immune deficiency or risk factors for HIV. However, initial infection with either pathology could compromise host immune defenses and promote a secondary infection. Since the incubation period for mumps has been reported to be 12–25 days5 and this patient developed orchitis on day 8, it is more likely that the patient contracted mumps before pneumonia. The concurrent findings may also represent a coincidence of having both diseases simultaneously. However, we believe that a mumps infection initially compromised our patient’s immune defenses and promoted a lower threshold for pneumonia.

Though extremely rare, mumps has been reported to precipitate pneumonia.6–8 However, there are very few reported cases in the literature, and this tends to present in the newborn period. We feel the need to discuss this possibility due to the patient having 2 negative blood cultures. The radiographic findings of mumps pneumonia have not been well established but have been reported to show multifocal involvement with rare consolidations or pleural effusions.9 Although the radiographic findings of mumps pneumonia are poorly understood, this patient’s chest CT showed multiple consolidations and trace fluid bilaterally favoring a bacterial etiology.

The Mississippi State Department of Health reported 46 cases of mumps in 2019 and 10 cases in 2018.10 Mumps typically presents as a flu-like illness with fever, headache, myalgias, anorexia, and subsequent swelling of one or both parotid glands several days later. Diagnosis can be made with RT-PCR, viral culture, or IgM serology. However, it should be noted that a negative IgM result in a vaccinated individual does not rule out infection.2 There is no specific therapy for mumps, but supportive care with acetaminophen may help reduce fever and

pain. Orchitis symptoms may benefit from testicle support, cold compresses, and NSAIDs. Possible complications from mumps are meningitis, encephalitis, hearing loss, orchitis, and pancreatitis.11 Conclusion Mumps is a vaccine-preventable disease that has shown a concerning re-emergence in recent years. Rarely, mumps can present with orchitis in the absence of the classic parotitis. This report serves to bring increased awareness to the re-emergence of mumps infections and how these infections may manifest.

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

5. Kutty PK, Kyaw MH, Dayan GH, et al. Guidance for isolation precautions for mumps in the United States: A review of the scientific basis for policy change. Clin Infect Dis. 2010;50(12):1619-1628.

6. Facts about mumps. ecdc.europa.eu. Accessed October 5, 2019. https://www. ecdc.europa.eu/en/mumps/facts 7. Jones JF, Ray CG, Fulginiti VA. Perinatal mumps infection. J Pediatr.

1980;96(5):912-914.

8. Groenendaal F, Rothbarth PH, Van Den Anker JN, et al. Congenital mumps pneumonia: A rare cause of neonatal respiratory distress. Acta Pædiatrica.

1990;79(12):1252-1254.

9. Koo HJ, Lim S, Choe J, et al. Radiographic and CT features of viral pneumonia.

Radiographics. 2018;1438(3):719-739.

10. Mississippi Provisional Reportable Disease Statistics. msdh.ms.gov. Published January 2020. Accessed February 9, 2020. https://msdh.ms.gov/msdhsite/_ static/resources/8436.pdf 11. Albrecht MA. Mumps. In: Post T, ed. UpToDate. Waltham, MA. Updated May 17, 2019. Accessed January 23, 2020. www.uptodate.com

References Author Information 1. Davis NF, McGuire BB, Mahon JA, et al. The increasing incidence of mumps orchitis: A comprehensive review. BJU Int. 2010;105(8):1060-1065.

2. Mumps – for healthcare providers. cdc.gov. Updated March 15, 2019. Accessed October 4, 2019. https://www.cdc.gov/mumps/hcp.html 3. Quinlisk MP. Mumps control today. J Infect Dis. 2010;202(5):655-656.

4. Singh R, Mostafid H, Hindley RG. Measles, mumps and rubella–the urologist’s perspective. Int J Clin Pract. 2006;60(3):335-339.

Fourth-year medical student, William Carey University College of Osteopathic Medicine, Hattiesburg, MS (Sexe). Internal medicine physician, Baptist Memorial Hospital- Golden Triangle, Columbus, MS. Associate Clinical Professor, William Carey University College of Osteopathic Medicine (Wade).

Corresponding Author: Jordan Sexe, Ph: (515) 890-8532 (jordanmichaelsexe@ gmail.com).

THE 152ND ANNUAL SESSION OF THE MSMA

AUGUST 13-15, 2020 AT THE JAckSon WESTIN Now accepting nominations for the following awards to be presented at the Excellence in Medicine Awards ceremony at the Annual Session of the MSMA House of Delegates: • The MSMA Community Service Award honors a member of the association who is actively engaged in the practice of medicine and has rendered service “above and beyond the call of duty” for the betterment of his/her community and the state.

• The Excellence In Wellness Promotion Award recognizes an individual or entity for promoting public health and wellness through media or with a unique and effective program/ event.

Complete the nomination form at MSMAonline.com. For more information, contact Kathy Wade-Butler at KWadeButler@MSMAonline.com or (601) 853.6733, ext. 307. Nominations must be submitted by June 25, 2020.

VOL. 61 • NO. 5 • 2020 135

S C I E N C E

O F

M E D I C I N E

Opioid Use in Patients Undergoing Thyroidectomy C. RON CANNON, MD, MHSA; WILLIAM REPLOGLE, PHD; BOBBY CUMBERLAND, BA

Abstract This study is a prospective evaluation of 31 consecutive patients undergoing thyroidectomy. Seven patients were excluded from the study as they were chronic users of opioids (most commonly for back pain), one for allergy to opioids, and one for incomplete report of demographic data.

The remaining 24 patients who underwent 25 thyroidectomy procedures and constitute the study group. The patients were given a standardized regimen of Hydrocodone/Tylenol (Norco) in pill form. Nineteen of these patients experienced cessation of pain by postoperative day #3 and did not require further opioids for pain, and only two patients reported pain at postoperative day #7.

The patients were given a standardized regimen of hydrocodone/ Tylenol (Norco) in pill form. Five of the patients did not take any opioids for pain. Nineteen of the patients took six or less tablets for pain. Only two of the patients in the study group asked for a refill of pain medication at postoperative day #7.

In this series of patients, postoperative pain had largely resolved by postoperative day #3. The number of doses of pain medication was six tablets or less in the majority of patients. Patients undergoing thyroidectomy had limited pain postoperatively and subsequently low risk of becoming opioid dependent after surgery.

Introduction There is an opioid crisis in the United States, most likely due to the treatment of chronic pain. This opioid crisis has resulted in unnecessary deaths and has also increased the use of other illicit drugs.

Not surprisingly, patients undergoing surgery often report severe pain postoperatively.1 From a surgical perspective, there is a need to treat the acute pain associated with surgical procedures while avoiding progression to chronic pain and opioid dependence.

vital sign. In 2000, the Joint Commission on Hospital Accreditations adopted pain as the fifth vital sign.4 Assessment of pain then became a requirement of patient care just as the assessment of temperature, blood pressure, respiratory rate, and pulse are standards of care. Because of this recommendation, physicians have been encouraged to give as much pain medication as needed to alleviate patients’ subjective complaints of pain.5 This recommendation, however, has not been without risk.

For example, a study by the American College of Surgeons found that overmedication with sedatives and narcotics contributed to many needless deaths in patients admitted to the hospital with trauma.6 The other factor in the opioid epidemic is the marketing of opioids by pharmaceutical manufacturers who have overemphasized the effectiveness of opioids and underemphasized their addictive potential.3 Opioids are natural, semisynthetic, or synthetic substances with morphinelike properties that cause analgesia as well as a sense of euphoria.7 Opioids have different potencies depending on the drug and are measured in morphine milligram equivalents (MME). The MME for both morphine and hydrocodone equals 1. For oxycodone, the MME is 1.5, and for fentanyl, it is 7.2, while codeine is less than 1.

The Drug Enforcement Administration (DEA) has classified these drugs as schedule II. Schedule II drugs are defined as having a high potential for abuse, with use potentially leading to severe psychological or physical dependence.

The purpose of the current study is to evaluate the postoperative thyroidectomy patient in terms of the patterns of opioid use, the number of tablets taken after surgery, the number of days the tablets were taken, and the number of refills. Other objectives are to assess correlations between age, sex, pathology, estimated blood loss, length of surgery, and other factors such as education level associated with hydrocodone use.

Methods

Opioids are potent analgesics and are highly addictive. In the United States, there have been over 200 000 opioid-related deaths since the 1990s.2 Currently, Americans consume 99% of the world’s supply of hydrocodone. There were 249 million prescriptions for opioid pain medication written in 2013, enough for every adult in this country to have a bottle of pain pills.3

Patients underwent thyroidectomy in standard fashion via a minimally invasive technique using a nerve integrity monitor to assess recurrent laryngeal nerve function. Patients were evaluated for their use of hydrocodone. Upon discharge, they were given a prescription for 20 tablets of hydrocodone 7.5 mg/Tylenol 325 mg (Norco) along with instructions on the proper use of opioids.

There seem to be 2 factors associated with the opioid epidemic.

Beginning in 1995, an effort was made to declare pain as a measurable

Data are summarized as means and minimum and maximum values or as frequencies and percentages. Correlation coefficients shown in the

136 VOL. 61 • NO. 5 • 2020

Table. Correlation Coefficients1 Between Demographic and SurgeryRelated Variables and the Number of Days Pain Medicine Taken and the Total Number of Pills Taken Postsurgically

Sex Race

2

Number Days Medication Taken

Total Pills Taken

−.043

.003

.367

.350

Education

−.076

.170

Age3

−.389

−.429

.198

.236

−.211

−.239

Blood loss

.021

−.088

Pathology

−.048

−.193

Lobectomy Length of surgery

1

Correlation coefficients range in value from -1 to +1. The absolute numerical value of the coefficient indicates the strength of the relationship, with absolute values closer to 1 indicating stronger relationships and absolute values closer to 0 indicating weaker relationships. The sign indicates the direction of the relationship, either positive or negative (inverse) relationships.

2 Race correlated with the number of days pain medication was taken (rpb = .367, P = .071) and the total number of pills taken (rpb = .350, P = .086).

3 Age correlated with number of days medication was taken (r = -.389, P = .055) and total pain medication taken (r = -.429, P = .032).

Table between both the number of days medication was taken and total number of pills taken and demographic and surgery-related variables were derived by Pearson (r) or Point-Biserial (rpb) statistical procedures.

Pearson correlation was used to test for association between 2 intervalscaled variables, and Point-Biserial correlation was used to test for an association between an interval-scaled variable and a dichotomous variable.

Results This prospective study evaluated 31 consecutive patients undergoing thyroidectomy. Seven patients were excluded from the study as they were chronic users of opioids (most commonly for back pain), 1 for allergy to opioids, and 1 for incomplete report of demographic data.

The remaining 24 patients underwent 25 thyroidectomy procedures.

There were 21 (87.5%) females and 4 (12.5%) males with a mean age of 52.4 years. Thirteen patients (54.2%) were Caucasian and 11 (45.8%) African-Americans. Fifty-three percent had completed high school and 41% had a college level education; 6% indicated other educational levels.

A thyroid lobectomy was carried out in 68% of the surgical procedures while a total thyroidectomy was performed in 32% of the procedures.

Mean length of surgery was 123 minutes (range 72-240) with a mean blood loss of 41 ml. Fourteen (56%) were found to have benign pathology while 44% were found to have a thyroid malignancy. All patients were found to have normal vocal cord function at follow-up laryngeal exam.

Five (20%) patients required no pain medicine after hospital discharge, 13 (52%) used hydrocodone for 1–3 days, 5 (20%) used hydrocodone for 4–5 days, and 2 (8%) used hydrocodone at days 6–7 postoperatively.

The mean number of pills taken was 5.0 (range, 0-18) with 2 (8%) patients requiring 1 refill of their pain medicine.

We found a significant correlation between patient age and both the total number of pills taken (r = -.43, P = .032) and the number of days pain medication was taken (r = -.38, P = .055 [marginally]), with younger patients tending to take more doses of the hydrocodone and for more days compared to older patients. Additionally, we found a marginally significant correlation between patient race and both the total number of pills taken (r = .35, P = .086) and the number of days that pain medication was taken (r = .36, P = .07), with African American patients tending to take more doses of the hydrocodone and for more days compared to Caucasian patients. We failed to find significant statistical associations between hydrocodone use and gender, educational level, length of surgery, blood loss, and final pathology.

Comment In patients undergoing thyroidectomy, there are other methods beyond those of opioids that are used for postoperative pain relief.

Dexamethasone given to patients undergoing thyroidectomy decreases postoperative nausea and vomiting, but has no pain relief or opioidsparing effect.8 Sore throat after thyroidectomy is common and has been found to be associated with the use of an endotracheal tube. In a study of patients intubated with either a #6 or a #7 endotracheal tube and treated with intravenous (IV) lidocaine during the procedure (1.5 mg/kg), there was an association with use of the smaller #6 endotracheal tube and the use of IV lidocaine in terms of decreased postoperative sore throat.9,10 Infiltration of the thyroid capsule with local anesthetic leads to decreased use of fentanyl during the surgery procedure and a shorter arousal time postoperatively.11 A prospective double-blind randomized control trial of patients treated with bilateral superficial cervical plexus block with 0.75% ropivacaine did not show any improvement in post operative analgesic requirements after total thyroidectomy.12 However, a similar study related decreased pain and frequency of opioid use after thyroidectomy whether the superficial plexus block was performed preoperatively or in the postoperative period.13 Another question is how much of an opioid should be prescribed after surgery. A systematic review of 810 patients undergoing 7 different surgical procedures found unused opioid tablets in 67% to 92% of the patients.14 In another study, up to71% of the prescribed opioid tablets went unused, and only 6.3% of the patients disposed of their extra pain medication. Additionally, 29% of those patients reported adverse effects from using opioids.15 Another 34% admitted that they shared or diverted opioids to family or friends.15 Dispensing the proper amount of an opioid results in lower cost to the patient and decreased risk of illicit use of opioids by the patient or others.16 In a study of 313 patients undergoing thyroidectomy or parathyroidectomy, 83% of patients took less than 10 oral morphine

VOL. 61 • NO. 5 • 2020 137

equivalents (OMEQ), and 93% took less than 20 OMEQ. Risk factors for increased use of opioids are related to age and also to previous narcotic use. Patients younger than 45 years old used greater amounts of opioids whether they had thyroidectomy or parathyroidectomy. As a result, the authors recommend that prescriptions be given to patients for 20 OMEQ or less. In the current study, there was also an increased use of opioids by patients age 45 and younger.

The net effect of this project has been that the senior author has decreased the number of opioid pain doses prescribed after thyroidectomy by 50%. There has been no corresponding increase in patient requests for stronger pain meds, requests for refills on pain meds, or after-hours calls for opioid pain medication.

Limitations of the current study are the limited number of patients and low statistical power. Currently, more patients are being accrued for further analysis and higher statistical power.

Summary Opioid requirements after thyroidectomy in the postoperative period are limited in the number of doses of pain meds and duration of analgesic treatment. In this series of patients, pain had largely resolved by postoperative day 3, and the number of doses of pain medication was 5 tablets on average. There is a low risk of becoming opioid-dependent following thyroidectomy.

9. Xu YJ, Wang SL, Ren Y, Zhu Y, Tan ZM. A smaller endotracheal tube combined with intravenous lidocaine decreases postoperative sore throat – a randomized controlled trial. Acta Anaesthesiol Scand. 2012; 56:1314-1320.

10. Jaensson M, Olowsson L, Nilsson U. Endotracheal tube size and sore throat following surgery: A randomized controlled study. Acta Anaesthesiol Scand. 2010; 54:147-153.

11. Vach B, Kurzova. A, Ma.lek J, Fanta J, Pachl J. Infiltration of local anesthesia into the thyroid gland capsule for surgery and the postoperative period. Rozhl Chir. 2002; 81:519-522.

12. Herbland A, Cantini O, Reynier P. The bilateral superficial cervical plexus block with 0.75% ropivacaine administered before or after surgery does not prevent postoperative pain. Reg Anesth Pain Med. 2006; 31:34-39.

13. Kale S, Aggarwal S, Shastri V, Chintamani. Evaluation of the analgesic effect of bilateral superficial cervical plexus block for thyroid surgery: A comparison of ­presurgical with postsurgical block. Indian J Surg. 2015; 77:1196-2000.

14. Bicket MC, Long JJ, Pronovost PJ, Alexander GC, Wu CL. Prescription opioid analgesics commonly unused after surgery: A systematic review. JAMA Surg. 2017; 152:1066-1071.

15. Lewis E, Cucciare M, Trafton J. What do patients do with unused opioid medications? Clin J Pain. 2014; 30:654-62.

16. Lou I, Chennell TB, Schaefer SC, et al. Optimizing outpatient pain management after thyroid and parathyroid surgery: A two institution experience. Ann Surg Oncol. 2017; 24:1951-1957.

Author Information Head & Neck Surgical Group, Flowood, MS (Cannon, Cumberland). Professor, School of Nursing, University of Mississippi Medical Center, Jackson (Replogle).

Corresponding Author: C Ron Cannon MD, FACS, MHSA; 500 Hwy 468, Brandon, MS 39042 Ph: (601)832-4455 (crcannonhn@bellsouth.net).

More efficient postoperative prescribing of analgesics in this setting leads to efficient pain control for the patient and less wasted medication, decreased illicit sharing of these pain meds with others (family, friends), and lower potential for becoming opioid-dependent.

Acknowledgment

OR

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

References 1. Rawal N. Current issues in postoperative pain management. Eur J Anesthesiol.

2016; 33:160-71.

2. deShazo R, Johnson M, Eriator I, Rodenmeyer K. Good intentions gone bad, an industry gone rogue and watchdogs gone to sleep. J Miss Med Assoc. 2019; 60:56-62.

3. CDC Guideline for Prescribing Opioids for Chronic Pain. Accessed March 31, 2020 . https://www.cdc.gov/drugoverdose/prescribing/guideline.html 4. Olsen Y. The CDC Guideline on Opioid Prescribing: Rising to the Challenge.

JAMA. 2016; 315;1577-1579.

5. Walid MS, Donahue SN, Darmohray DM, et al. The fifth vital sign – What does it mean? Pain Pract. 2008; 8:417-422.

6. Lucas CE, Viahos AL, Ledgerwood AM. Kindness kills: The negative impact of pain as the fifth vital sign. J Am Coll Surg. 2007; 205:101-107.

7. Analyzing Prescription Data and Morphine Milligram Equivalents. The Center for Disease Control and Prevention. Accessed March 31, 2020. https://www. cdc.gov/drugoverdose/media/ 8. Doksrød S, Sagen Ø, Nøstdahl T, Raeder J. Dexamethasone does not reduce pain or analgesic consumption after thyroid surgery; a prospective, randomized trial.

Acta Anaesthesiol Scand. 2012; 56:513-519.

138 VOL. 61 • NO. 5 • 2020

PRINT or ONLINE The choice is yours...

F

ree online access to the Journal MSMA is available to current members of the Association. If you would prefer to receive only the online version and not the print version of the JMSMA let us know. If you would like to opt out of receiving the print version, please contact Managing Editor Karen Evers, KEvers@MSMAonline.com or 601.853.6733, ext. 323.

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

S C I E N C E

O F

M E D I C I N E

Top Ten Things You Need to Know about Asthma and COPD TAYLOR MABRY, MD; CHESHIL DIXIT, MD; AND PATRICIA STEWART, MD Asthma is one of the most common chronic diseases and affects approximately 300 million people worldwide. Chronic obstructive pulmonary disease (COPD) affects more than 10 million people in the United States, and estimates suggest that it will be the third leading cause of death worldwide by 2020.1 Here are 10 things of importance about these two diseases.

The criteria for the diagnosis of asthma are unchanged.

Although symptoms like shortness of breath and dyspnea are features of asthma, the gold standard for diagnosis remains the demonstration of reversible airways obstruction by pulmonary function testing (PFTs). Diagnostic findings show a pattern of reversible obstruction: FEV1/FVC ratio <70% (obstruction) along with >12% increase and >200 ml increase in FEV1 15 minutes after short-acting beta agonist, or SABA (reversibility)2 (Figure 1).

Figure 1. Recordings during the forced vital capacity maneuver

(A) in a healthy person and (B) in a person with partial airway obstruction. (The “zero” on the volume scale is residual volume.)

FEV1, forced expiratory volume during the first second; FVC, forced expiratory vital capacity.

Asthma should be classified by severity and frequency of symptoms.

Before initiating therapy, asthma is classified based on the severity and frequency of symptoms, as defined by the National Heart, Lung, and Blood Institute and National Asthma Education and Prevention Program Expert Panel Report 3 (EPR-3).3 The classes include intermittent, mild-persistent, moderate-persistent, and severepersistent, which are further categorized by age 0–4 years, 5–11 years, and ≥ 12 years. This classification is the basis for present asthma treatment guidelines. These guidelines are readily available online and should be referenced as options for asthma treatment are rapidly changing.3 Current treatment options for asthma are rapidly changing.

While the prevalence of asthma has increased in developed countries since 1988, the past 10 years have shown a steady decline in asthma-related deaths. This is due to advancements in medical therapies, including the widespread use of inhaled corticosteroids (ICS) as directed by guidelines.

The current treatment approach is a stepwise approach.

Based on the patient’s symptoms, stratified by the EPR-3 guidelines (Figure 2), the recommended approach to the treatment of asthma is a stepwise approach. Treatment begins with albuterol as needed. If this does not manage symptoms, schedule and start low dose ICS. If symptoms are still uncontrolled, increase the ICS dose. If necessary, add Montelukast or a long-acting beta-agonist (LABA). If symptoms remain uncontrolled, up titration to high dose ICS (with the same Montelukast or LABA) should be considered. Consider expert consultation with an asthma specialist if symptoms are still uncontrolled.3

Reprinted with permission from Hall et al.2

Newer targeted therapy.

Omalizumab is a monoclonal antibody that targets the IgE receptor that has been shown effective in patients with persistent asthma who also have a positive skin test to perennial aeroallergens and elevated IgE levels.4 Recently, other biologic therapies approved for asthma, include mepolizumab, reslizumab, benralizumab and dupilumab. Fevipiprant, an oral prostaglandin antagonist, is in

VOL. 61 • NO. 5 • 2020 139

Figure 2. Stepwise Approach to Managing Asthma

Reprinted with permission from NHLBI.3

development, and if approved, it will be the first oral drug approved for the treatment of asthma in more than 20 years.5 The Global Iniative for Chronic Obstructive Lung Disease (GOLD) committee publishes gold standards in the diagnosis and classification of COPD. The gold standard for the diagnosis of COPD comes from the GOLD Committee. A yearly GOLD report guides health care professionals on COPD diagnosis, management, and prevention. The clinical

140 VOL. 61 • NO. 5 • 2020

picture (signs, symptoms, history) drives suspicion of COPD, which is then confirmed with spirometry. The criterion for diagnosis is a post-bronchodilator FEV1/FVC ratio of <70%, as opposed to the PFT criteria for asthma. Beyond this, GOLD classifies COPD into mild, moderate, severe, and very severe based on FEV1 (Figure 3).6 Inhaled anticholinergics have great efficacy in COPD. Anticholinergics originate from the deadly Nightshade family of plants. These plants have been used for centuries for their

Figure 3. Classification of Airflow Limitation Severity in COPD

Steroids are helpful, but more is not always better.

In 1999, glucocorticoid use among hospitalized patients with a COPD exacerbation was shown to be efficacious.8 Since then, intravenous and oral steroids have been commonplace in the treatment of COPD exacerbation. However, corticosteroids are not without side effects or risks. A 2013 study published in JAMA showed that 5 days of steroids were noninferior to 14 days with a standard COPD exacerbation.9 Asthma and COPD are distinct diseases, or are they?

For years, asthma and COPD were thought to be separate entities. In 2015, a study described Asthma and COPD Overlap (ACO).10 ACO is characterized by persistent airflow limitation with several features usually associated with asthma and several features usually associated with COPD. ACO is more common than previously thought. It is a distinct clinical phenotype with more frequent exacerbations, hospitalizations, quality of life, and health care costs than either disease alone. There is a critical need to define the optimal management and treatment of this syndrome.

Reprinted with permission of Decker et al.6

effects on the lungs. Inhaled ipratropium bromide was introduced and found to be effective as a bronchodilator.7 At that time, bronchodilators had been demonstrated to only have benefits in the short-term management of COPD. However, extended administration of ipratropium appears to be associated with improved baseline lung function and improved response to acute bronchodilation by a β-agonist. Extended administration of β-agonist, in contrast, appears to have little effect on baseline lung function, but may decrease response to acute bronchodilation. In 2015, tiotropium was approved for the use of asthma. Other inhaled anticholinergics are on the market now as well.

The Global Initiative for Asthma (GINA) and the GOLD committee have come together on ACO. In their packet published in 2015, a joint communication from GINA and GOLD offered a stepwise approach to diagnosis of asthma, COPD, and ACO. For diagnosis, they advise to first confirm obstructive disease is present based on history, physical, and radiology. They suggested features that point toward asthma alone, COPD alone, or ACO. They also provided a chart with spirometry results that point toward asthma alone, COPD alone, or ACO (Table 1). If the diagnosis is asthma or COPD alone, they recommend

Table 1. Features of Asthma, COPD, and Overlap

Spirometric variable

Asthma

COPD

Overlap

Normal FEV1/FVC pre- or post-BD

Compatible with asthma

Not compatible with diagnosis (GOLD)

Not compatible with diagnosis

Post-BD FEV1/FVC <0.7

Indicates airflow limitation; may improve

Required for diagnosis of GOLD criteria

Usual in asthma-COPD overlap (ACO)

FEV1 > 80% predicted

Compatible with asthma (good control, or interval between symptoms

Compatible with GOLD category A or B if post-BD FEV1/FVC <0.7

Compatible with mild ACO

FEV1 < 80% predicted

Compatible with asthma. A risk factor for exacerbations

Indicates severity of airflow Indicates severity of airflow limitation and risk of exacerbations limitation and risk of exacerbations and mortality and mortality

Post-BD increase in FEV1 > 12% and 200 mL from baseline (reversible airflow limitation)

Usual at some time in course of asthma; not always present

Common in COPD and more likely when FEV1 is low

Common in ACO, and more likely when FEV1 is low

Post-BD increase in FEV1 > 12% and 400 mL from baseline

High probability of asthma

Unusual in COPD. Consider ACO

Compatible with diagnosis of ACO

Reprinted with permission from 2015 GINA Guidelines.11

VOL. 61 • NO. 5 • 2020 141

the therapy previously discussed for each disease. For ACO, they recommend treating as if it were asthma while further workup can be performed due to the recognized pivotal role in ICS preventing morbidity and mortality in asthma.11 n

7. Rennard SI, Serby CW, Ghafouri M, et al. Extended therapy with Ipratropium is associated with improved lung function in patients with COPD. Chest.

1996;110(1):62-70.

References

9. Leuppi JD, Schuetz P, Bingisser R, et al. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: The REDUCE randomized clinical trial. JAMA 2013;309(21):2223-2231.

1. Barnes PJ. Harrison’s Principles of Internal Medicine. 20th ed. McGraw-Hill; 2018.

2. Hall JE. Guyton and Hall Textbook of Medical Physiology. 12th ed. Elsevier; 2010.

3. NHLBI. National Heart, Lung, and Blood Institute National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma Full Report 2007. Accessed October 10, 2018. https:// www.ncbi.nlm.nih.gov/books/NBK7232/pdf/Bookshelf_NBK7232.pdf 4. Strunk RC, Bloomberg GR. Omalizumab for Asthma. N Engl J Med. 2006;354(25):2689-2695.

8. Niewoehner DE, Erbland ML, Deupree RH, et al. Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease. N Engl J Med. 1999;340(25):1941-1947.

10. Alshabanat A, Zafari Z, Albanyan O, et al. Asthma and COPD overlap syndrome (ACOS): A systematic review and meta analysis. PLoS One. 2015;10(9):e0136065.

11. 2015 Asthma, COPD and Asthma-COPD Overlap Syndrome (ACOS). Glob Initiat Asthma. 2015:1-18. Accessed July, 2018. http://ginasthma.org/asthma-copdand-asthma-­copd-overlap-syndrome-acos/

Author Information

5. Gonem S, Berair R, Singapuri A, et al. Fevipiprant, a prostaglandin D 2 receptor 2 antagonist, in patients with persistent eosinophilic asthma: A single-centre, ­randomised, double-blind, parallel-group, placebo-controlled trial. Lancet Respir Med. 2016;4(9):699-707.

Department of Medicine, Division of Allergy, Asthma and Clinical Immunology, University of Mississippi Medical Center, Jackson (Mabry, Dixit, Stewart).

6. Decker, et al. Global Initiative for Chronic Obstructive Lung Disease. A Guide for Health Care Professionals Global Initiative for Chronic Obstructive Disease. Glob Initiat Chronic Obstr Lung Dis. 2010;22(4):1-30.

Corresponding Author: Taylor Mabry, MD, Department of Medicine, University of Mississippi Medical Center, 2500 North State St., Jackson, MS 39216. Ph: (601) 9845600 (tmabry@umc.edu).

Help and Hope At Heart of Hospice our mission is to serve all hospice eligible patients the way they desire to be served.

We work with each patient to develop a plan of care that is unique to their specific situation. Physical therapy, IV therapies, radiation and other comforting treatments approved by the physician may be included in the patient’s plan of care.

Our Heart of Hospice team works 24/7 to help eligible patients and families who need our care.

For more information please call 1.844.464.0411 or visit heartofhospice.net

142 VOL. 61 • NO. 5 • 2020

P R E S I D E N T ’ S

P A G E

before proceeding with the planned procedure is imperative. Careful anesthetic management, especially airway management and avoiding a pulmonary hypertensive crisis, is critical. Avoiding multiple procedures and anesthetics may be helpful. n

Table 2. Five Star Approach to the Anesthetic Management of Trisomy 18

For Such a Time as This

Table 2. Five Star Approach to the Anesthetic Management of Trisomy 18

1. Pre-anesthetic evaluation

2. Logistics Readiness

3. Intraoperative anesthesia management

J. Clay Hays, Jr, MD MSMA President 2019–2020

4. Immediate post-operative management

5. General risk reduction strategy

Ø Complete examination including cardiac evaluation, airway assessment Ø Multidisciplinary meeting involving surgeon, anesthesiologist, & intensivist to discuss perioperative plan Ø Open and honest discussion with family about the risks, expectations, and treatment plan

Acknowledgment

I

We would the like importance to thank Khalid Altirkawi,and MD, for to giving understand of teamwork canFAAP delegate otherus permission to use pictures the figure. team members whathisneeds to befordone efficiently.

t has been said that every generation needs a crisis. I believe we have found ours. The COVID-19 pandemic has Øspared Completeno anesthesia readiness,on including country the immediate globe availability and no of difficult airway equipment and emergency vasoactive drugs state in our union.

No one could have Ø Pediatric anesthesiologist with experience in difficult airway management and cardiac anesthesia anticipated the amount of destruction that it caused on humanity as well as our economy. Thousands have died, and Ø “Tight” physiological control during anesthetic, including meticulous of attention to ventilation prevention of the trillions dollars haveandbeen lost, at least pulmonary hypertensive crisis on paper. Most of us have experienced feelingsin intensive of fear Øsignificant Post-operative monitoring care and unit andconcern. possible ventilatoryare support.

People afraid for their families, their jobs, and their retirement. They look for Ø Employ “one-stop shopping” strategy: performing more than one leaders provide solutions and hope. procedureto under one anesthetic to reduce multiple anesthesia

References It has been wonderful to see how Mississippi physicians have pulled 1. BaumI VC, JE. Anesthesia Genetic, Metabolic, Dysmorphic together. haveO’Flaherty been fortunate to beforinvolved with theand Governor’ s Syndromes of Childhood.

Third edition.

Philadelphia: Wolters Kluwer; 2015.

COVID-19 advisory committee. Under experienced physician 2. Cereda A, Carey JC. The trisomy 18 syndrome. Orphanet J Rare Dis. 2012;7:81. leadership, the Liu Mississippi Stateet Medical hastrisomy been 13able 3. Meyer RE, G, Gilboa SM, al. SurvivalAssociation of children with and to work with18:theA multi-state Mississippipopulation-based Department study. of Health, the Genet Mississippi trisomy Am J Med A. 2016 Apr;170A(4):825-37.

Medical Licensure Board, the Mississippi Hospital Association, the 4. Banka S, Metcalfe K, Clayton-Smith J. Trisomy 18 mosaicism: report of two cases.

Mississippi Nursing Association, the University of Mississippi Medical World J Pediatr. 2013;9(2):179-181.

Center, Medical Assurance of Mississippi, Governor’ s staff,Y.and the 5. Kosho T, Nakamura T, Kawame H, Baba A, the Tamura M, Fukushima Neonatal management of trisomy 18: clinical details ofof24the patients receiving intensive Mississippi Healthcare Alliance.

The purpose advisory committee treatment.

Am J Med Genet 2006;140(9):937-944. is to guide the Governor withA.knowledge about allocating resources and 6. Batees H, Altirkawi KA. Trisomy 18 syndrome: Towards a balanced approach. staff toSudan the right centers as we take care of the citizens of our state.

J Paediatr.

2014;14(2):76-84.

procedures

7.

exacerbating pulmonary hypertension.

Muscle rigidity after use of succinylcholine has been reported in these patients.12 However, there is no known risk for malignant hyperthermia in children with Trisomy 18. Brief surgical procedures such as myringotomies can be managed by laryngeal mask airway (LMA).9 Regional nerve block techniques such as an epidural catheter or single shot caudal can be considered for lower abdominal or extremity procedures in combination with general anesthesia. Pain assessment in older patients in the post-operative period can be challenging due to severe mental retardation.

Conclusion

8

We propose several strategies for safe perioperative management Fortunately, physicians well-trained to navigate challenging of these patients.

Theseare patients should undergo a thorough presituations.

They use their training and experience to make educated anesthetic evaluation and be managed by a pediatric anesthesiologist decisions when they do not have complete information.

They do not with experience in managing the difficult airway and cardiac anesthesia. panic and rely on eachwith other make about the best decisionsoptions possible.

Detailed discussion thetofamily treatment andWith risks their ability to sift the wheat from the chaff, physicians are quickly able to place the right resources for the right patients at the right time. They

Boss RD, Holmes KW, Althaus J, Rushton CH, McNee H, McNee T. Trisomy 18

and complex congenital heart disease: aseeking the threshold benefit.

Pediatrics.

The advisory committee developed COVID task force system of 2013;132(1):161-165. care, similar to the way the STEMI and trauma systems of care were 8. Courreges P, Nieuviarts R, Lecoutre D. Anaesthetic management for Edward’s established.

Each member the advisory committee took their role syndrome.

Paediatr Anaesth.of 2003;13(3):267-269.

9. seriously Bailey C, Chung R. Use of the laryngeal mask a patient with Edward’ very and expertly assembled theirairway care inteams.

Critical care s syndrome. Anaesthesia. 1992;47(8):713. positions worked on a protocol for different level hospitals depending 10. Miller C, Mayhew JF. Edward’s syndrome (trisomy 18). Paediatr Anaesth. on what resources they had available to them at their location.

1998;8(5):441-442.

11.

Friesen RH, Twiteon MD, CS, ettelemedicine al. Hemodynamic response to ketamine They also worked a Nichols statewide consult system.

Thein children with pulmonary hypertension.

Paediatr Anaesth.

2016;26(1):102-108. emergency medical transport companies worked with the Mississippi 12. Matsuda H, Kaseno S, Gotoh Y, Furukawa K, Imanaka K. Muscle rigidity caused State Department of Health to develop plan to move patients safely to by succinylcholine in Edwards’ syndrome.aMasui.

1983;32(1):125-128. available facilities. The licensure boards granted emergency licenses to Author make sureInformation personnel could be credentialed quickly to meet needs. The hospitals quickly developed a statewide surge plan to meet the future Assistant professor, Department of Anesthesiology, Texas Tech University Health demands of sick Lubbock, patients. TX The(Fishkin).

Governor’Associate s staff worked with insuranceof Sciences Center, professor, Department companies to ease the burden of regulation and liability.

All groups Anesthesiology, Levine Children's Hospital, Charlotte, NC (Sathyamoorthy).

CRNA, Department of Anesthesiology, University of Mississippi Medical Center, Jackson, MS worked in concert against the common coronavirus enemy.

(Wardlaw). Professor, Department of Otolaryngology and Communicative Sciences, University of Mississippi Medical Center, Jackson, MS (Reed). The authors report no As I pen disclosures this article, major surge of COVID-19 has not hit our state financial or the conflict of interest.

yet, but I am confident that our efforts will pay off. We will bend the Corresponding Author: Semyon Fishkin, MD; Department of Anesthesiology, curve, andUniversity many lives willSciences be saved.

I am we will talk8182, about the Texas Tech Health Center, 3601sure 4th Street, STOP Lubbock, heroes of this time,743-2981 and I’m (semyonfishkin@gmail.com). also sure that many physicians will be on TX 79430.

Ph: (806) the list of champions. I am proud that our profession could step up during our time of greatest need. Well done! n

@JournalMSMA Like us on Facebook

@JournalMSMA

Follow us on Twitter VOL. 61 • NO. 5 MSMA • 2020 143 OCTOBER • JOURNAL 469

L E T T E R S

MSMA Caught Up in Major Hypocrisy: Physicians Have Failed to Formulate an Alternative to Expansion of Medicaid Which Would Fulfill Our Professed Ethical Commitment Dear JMSMA Editor, Clay Hays was a guest speaker of Central Medical Society a couple of months ago. Clay is a good guy, my wife’s cardiologist, and he comes from good stock to boot—his maternal grandfather was a urologist!

He gave a good talk, a polished message, and presented well.

After we finished bashing optometrists (for about the 40th year in a row), the discussion focused on the Medicaid Program, a discussion which was dominated by a litany of damning anecdotes, generally castigating the program for a variety of faults. That discussion came to an abrupt halt when I suggested the following hypothetical resolution: “Persons who get sick or injured should be denied access to health care if they can’t pay for it.” When I asked for a show of hands, nobody—I repeat, NOBODY—voted for the resolution.

My take-home message from that little experiment is that our MSMA is caught up in major hypocrisy. Whether by action or failure to act, organized medicine, at both state and national levels has resisted, or not promoted, expansion of Medicaid and, at the same time, has failed to formulate an alternative which would fulfill our professed ethical commitment.

RightTrack

MEDICAL GROUP

Even so, I don’t want to appear too sanctimonious in this argument.

This issue presents a huge conundrum for the medical profession and society. For instance, just today (April 2), two articles appeared in The W all S treet J ournal t hat a ttracted m y a ttention b ecause, though about disparate subjects, both were central to this debate.

The headline for one: “stress rises for hospitals in rural areas” (related to the Coronavirus). The other: “stimulus deal fuels boom for lobbyists.” Imagine the job opportunities for lobbyists when federal bureaucrats and politicians are empowered to spend trillions of dollars annually on health care and are given the authority to decide who gets what. Even medical organizations will be forced to gear up to compete. The American Association of Clinical Urologists, of which I was President in 1987, has one lobbyist. They will need more if we have to contend that a prostatectomy is worth more than nailing a hip.

“Is a puzzlement” —Yul Brynner in “The King And I”

Katherine G. Pannel, DO

Psychiatrist & Medical Director ®

Quality outpatient mental healthcare in Mississippi ✔ PSYCHIATRIC EVALUATION ✔ MEDICATION MANAGEMENT

✔ INDIVIDUAL & FAMILY THERAPY ✔ COPING SKILLS GROUPS

e m a i l : i n f o @ R i g h t Tr a c k M e d i c a l . c o m

144 VOL. 61 • NO. 5 • 2020

— W. Lamar Weems, MD MSMA Past-President, Jackson

CLINIC LOCATIONS:

• Oxford • Tupelo • Corinth • Olive Branch • Starkville

M S M A

Welcoming Our Newest Members

ADAMS, JEREMY, Tupelo, Foot & Ankle, Orthopedics

MOSS, JASON, Hattiesburg, Internal medicine

ALCIVAR FRANCO, DIEGO, Hattiesburg, Cardiovascular Disease

NOWACKI, NATHANIEL, Hattiesburg, Neurology OFFIAH, MAUREEN, Hattiesburg, Dermatology

BARBER, PATRICK, Meridian, Family Medicine

OWENS, JENISUS, Ellisville, Family Medicine

CAMPBELL, LUKE, Saltillo, Family Medicine

PETZINGER, CATHERINE, Cleveland, General Surgery

FOLSE, JACOB, Hattiesburg, Orthopedic Surgery GILLIAM PIERRE, ARDARIAN, Jackson, Family Medicine

RAMSEY, CARL, Biloxi, Anesthesiology REDMANN, GREG, Jackson, Neurology

GLOVER, PORTER, Hattiesburg, Gastroenterology HARRELL, STEPHANIE, McComb, Pediatrics KENNEDY, DANIEL, Ridgeland, Radiology

ROYALS, THOMAS, Hattiesburg, Orthopedic Surgery SCHEXNAYDER, KAITLEN, Hattiesburg, Urology SIMS, JALEEN, Flowood, Obstetrics & Gynecology

LIDDELL, THOMPSON, Hattiesburg, Infectious Disease

STEVENS, CLAYTON, Gulfport, Ophthalmology

MASTERSON, CHESTER, Tupelo, Anesthesiology

TULLOS, JESSICA, Hattiesburg, Family Medicine

MATANI, SARA, Hattiesburg, Internal Medicine

VESA, TELCIANE, Hattiesburg, Internal Medicine

MITCHELL, BARBARA, Hattiesburg, Internal Medicine

WILLIAMS, SUSAN, Purvis, Family Medicine

MOORE, ALLEN, Tupelo, Orthopedic Surgery

YEHYA, AHMAD, Hattiesburg, Endocrinology

MOORE, JOHN, Hattiesburg, Urology

MISSISSIPPI STATE MEDICAL ASSOCIATION MSMAonline.com

VOL. 61 • NO. 5 • 2020 145

I M A G E S

I N

M I S S I S S I P P I

M E D I C I N E

THE LYCEUM AT OLE MISS AND OXFORD: FIRST LOCATION OF UNIVERSITY OF MISSISSIPPI SCHOOL OF MEDICINE, 1903-08 — After its creation in the fall of 1903, the University of Mississippi School of Medicine, then called the Department of Medicine, was first housed in the historic Lyceum building in one of its two newly constructed wings. The top image, with a postmark of August 3, 1908, reveals the Lyceum and its fresh appendages during the medical school’s period there. The wings, built in the same year as the birth of the medical department, would be forever linked in their mutual creation in that ambitious year of 1903. This first “home” of the department was termed “cramped quarters” by one historian and included at least two classrooms and an office. As well, the department utilized a small frame structure (perhaps visible in the back left of this image) behind the Lyceum for dissection purposes.

The medical department’s sixteen students were taught here, and its professors had their offices here for more than 3 years, until Science Hall was completed and occupied, which occurred between 1906 and 1908. The Department joined the American Association of Medical Colleges in 1904, which allowed them the ability to issue certificates to its two-year graduates which permitted them to enter the third year of any affiliated medical school’s regular four-year course. The Lyceum, easily the most iconic structure on the campus, was the first building erected at the Oxford school, with construction beginning in 1846 and ending by 1848. (The bricks utilized in its building are believed to have been made from clay at the site.) It served initially as a library and housed several classrooms. Designed by the eminent architect William Nichols in Greek Revival style (inspired by an Ionic temple on the Illisos River near Athens), the structure is one of the most important in the state’s medical history, serving as a hospital during the Civil War, the first home of the medical school, and also as a hospital and emergency-aid station during the Ole Miss riot of 1962. Although the building was lengthened in 1858, the major addition to the structure were these two flanking north and south wings constructed in 1903. The bottom image, postmarked June 25, 1911, shows a different view of the Lyceum of that period, with a later fountain and walkway. If you have an old or even somewhat recent photograph which would be of interest to Mississippi physicians, please send it to me at lukelampton@cableone.net or by snail mail to the Journal.

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

146 VOL. 61 • NO. 5 • 2020

P O E T R Y

A N D

M E D I C I N E

Edited by Lucius Lampton, MD; JMSMA Editor

[This month, I return to the poetry of the physician-poet Merrill Moore, MD (1903-1957).

This poem’s subject is our own mortality and the inevitability of death, and Moore seems almost indifferent about death’s gravity: “Death happens,” he begins. My friend Dr. Ed Thompson once told me something similar (quoting an old Wesson doctor he rotated with as a medical student), “All of your patients are going to die.” Such is not meant as an embrace of the futility of our work, but simply an understanding of the ground rules of what we can and can’t do as physicians. We shouldn’t have unrealistic expectations. We can’t end death.

We can prevent needless or premature death or morbidity and improve the quality and length of our patients’ lives. As COVID-19 dances across the United States, reflections on death may be seen as either appropriate or hysteria. My favorite line in this poem is Moore’s under his breath reference to the Greek physician Galen: “Dew falls: men die.” Claudius Galenus of Pergamum (129–216), better known as Galen, was a Greek physician and a prolific writer on medicine and philosophy who lived six hundred years after Hippocrates. His theories dominated the practice of European medicine for well over a millennium. Galen’s patients included some of the Roman Empire’s most powerful individuals and their families. He is credited as advocating the best of the Greek medical tradition which had preceded him and conveying it to after ages. This poem is from “M: One Thousand Autobiographical Sonnets” published in 1938 (see page 914). Any physician is invited to submit poems for publication in the Journal either by email at lukelampton@cableone.net or regular mail to the Journal, attention: Dr. Lampton.]—Ed.

Death Happens It brooks no vengeance; it extorts no pay.

It comes no matter what the preachers say Or poets preach. After the dew has fallen (Dew falls: men die– that was observed by Galen) The dew sinks into the earth and disappears As do men’s excrement and women’s tears, The blood of beasts, all nature’s offertory, The ancient and inexorable story.

Men die; death is no fancy; it is fact, The one same scene that you too must enact Who say, “Here is my new role and created For me of all God’s creatures the mismated Of elements.” Death happens and transpires Like dawn’s quick flaming embers, sunset fires.

—Merrill Moore, MD (1903-1957)

VOL. 61 • NO. 5 • 2020 147

U N I V E R S I T Y

O F

M I S S I S S I P P I

M E D I C A L

C E N T E R

RURAL Study Begins Outreach and Community Engagement in North Mississippi KAREN BASCOM, SCIENCE WRITER, UMMC

In May 2019 researchers from the University of Mississippi Medical Center (UMMC) and partner institutions announced the Risk Underlying Rural Areas Longitudinal Study, or RURAL, which will examine the causes of high-burden of heart, lung, blood, and sleep (HLBS) disorders in the Southern Appalachia and Mississippi Delta regions.

With funding from the National Heart, Lung, and Blood Institute and led by Boston University, the six-year, $21.4 million multisite prospective cohort study plans to recruit 4,000 participants from 10 of the most economically-challenged rural counties in those areas.

“We are going to look at a rural population cohort—a cohort that has never been studied successfully at this scale,” said Dr. Ervin Fox, professor of medicine and principal investigator for the Mississippi sites. Additional RURAL investigators in Mississippi include Dr. Frances Henderson, consultant; Dr. Felicia Caples, project administrator; Dr. Sonja Fuqua, consultant; and Abril Grant, research specialist.

“There are critical gaps in knowledge on why those living in rural areas are at highest risk for death due to heart disease and stroke. This problem is true for both blacks and whites living in these regions.”

“The RURAL study is poised to find the distribution and determinants of HLBS disorders in a multiethnic population living in rural areas, to determine how different risk factors contribute to disease in this population, and what risk factors are specific to those living in these communities,” — Ervin Fox, MD explained.

“Additionally, the study will look at resilience and identify solutions by understanding the differences in higher risk and lower risk counties.

These solutions can then be used to implement helpful communitybased interventions. Finally, there is a strong community engagement

The RURAL study plan is to use a mobile examination unit and wearable activity monitors and smartphones to assess familial, lifestyle, behavior, and medical histories. In addition to considering environmental and economic factors, standard and novel risk factors for HLBS disorders will also be studied.

Recruiting the Mississippi cohort for the RURAL study is planned from Oktibbeha and Panola counties.

A mobile exam unit will visit each county and serve as the site where RURAL investigators will conduct the participant exams.

“We hope to recruit people from Como, Crenshaw, Courtland, Sardis, Pope, Maben, Sturgis, and throughout all Panola and Oktibbeha counties.

We want this study to be representative of these communities,” Dr. Fox said.

148 VOL. 61 • NO. 5 • 2020

Ervin R. Fox, MD

Frances Henderson Consultant

Felicia Caples Project Administrator

Sonja Fuqua Consultant

Abril Grant Research Specialist

component to the study, allowing for educational and health-related activities throughout the span of the study,” Dr. Fox said.

The Mississippi Core Team for the RURAL study has engaged the community through focus groups, stakeholder meetings, and the formation of a community advisory board for each county. The board members will serve as liaisons between the RURAL study and the community.

In addition, the RURAL study and community advisory boards co-hosted Go Red for Women heart health events in Panola and Oktibbeha counties in February, which introduced attendees to RURAL and its goals.

The community advisory boards and the Mississippi Core of RURAL will continue participating in health education events, connecting with community partners and businesses, and working with faith-based organizations and health care facilities to promote the study. There will be periodic public announcements regarding the RURAL study. The study plans to start recruitment and expects the arrival of the mobile exam unit to Oktibbeha and Panola counties in 2021.

For more detailed information, physicians should contact Dr. Ervin Fox at UMMC at efox@umc.edu or by phone at (601) 984-1000. n

COVID-19 Personal Protective Equipment (PPE) for Healthcare Personnel Preferred PPE – Use N95 or Higher Respirator Face shield or goggles

N95 or higher respirator

Acceptable Alternative PPE – Use Facemask Face shield or goggles

When respirators are not available, use the best available alternative, like a facemask.

One pair of clean, non-sterile gloves

Facemask N95 or higher respirators are preferred but facemasks are an acceptable alternative.

One pair of clean, non-sterile gloves

Isolation gown

Isolation gown

cdc.gov/COVID19 CS 315838-C 03/23/2020

VOL. 61 • NO. 5 • 2020 149

U N A

V O C E

Chief Complaints: Part Three Have you just about had a belly-full of the constant onslaught of the gloom and doom reports that are our nightly news?

2. “If you are giving me any biotics, you might as well give me some East infection medicine to go along with it. Any time I take them biotics, I need a wire brush to scratch with before it is over.”

Those of us who were simply worrying about having the neverending Mississippi crud and trying to avoid the flu bug a couple of weeks ago, are now near panic mode over the Coronavirus threat.

4. “ I read the package insertion on that Metformin, and I had every symptom of that Latick Acidophilus it can give you . . . . plus enough gas to drive to Kalamazoo.”

Have you had just about enough endless political haggling to last you a lifetime? Enough of watching the stock market and your 401K take a major nose-dive?

Dwalia S. South, MD

Enough missed sleep from watching our fellow Mississippians float away, Tennesseans get blown away, and Australians get burned out?

Which new cancer scare frightens you more– realizing that for the past thirty years you have taken good old Zantac every single day or that you have liberally squirted gallons of Round-Up on everything in your yard that didn’t move?

Do you have “Iron-poor Tired Blood”?

Do you need “Fast, Fast, Fast relief ”?

Do you want to hear “plop-plop, fizz-fizz, oh, what a relief it is?”

Is your medicine cabinet still stocked with Geritol, Anacin, and AlkaSeltzer? If not, perhaps this month’s “Una Voce” will be a good change of pace. These are actual quotes from my patients… pearls, which I have written down and squirreled away for just such an opportunity as this. Hopefully, they will lighten your mood brought on by these recent depressing days. Here goes my third compilation of “Chief Complaints”:* 1. “I’ve got old, and I’m losing ground, so I bought me some Ensurance, and I been a drinking it every day. It tastes like stump water, and it is as high as a cat’s back to buy, but I think it has hope me some.” * “Chief Complaints: Parts One and Two” were previously published in the Journal MSMA and the book UNA VOCE (China Grove Press-2011).

150 VOL. 61 • NO. 5 • 2020

3. “I don’t like your new weighing scales; they flatulate too much.”

5. “ Doc, we can’t put Momma in a nursing home. Her and Daddy are so close that if you give one of them a laxative, why, they both have a BM.” 6. “ Dr. Stone told me I had ‘romantic fever’ when I was little; reckon I still have it?”

7. “ The bone doctor told me the cartridge in my knees is completely shot.” (Time to reload.)

8. “I had a stroke and died for a little bit. They had to incubate me.”

9. “ Doc, I am feeling so bad, I think I just need for you to seduce me into a coma.”

10. “ Little old Dr. Mauney told us our Daddy was a High-Condrack. I know what that means. You think you are sick when you are not. I reckon she was right because he has told us at least once a day for the last 40 years he was dyin’, but he has outlived us all.”

11. “I am just old and wore out and disabilitated.”

12. “ That nerve medicine you gave me is not working…I am still having panickintacks. I get mad, and then I squall till I pass out.”

13. “ Please check my son for AIDS when he comes in to see you. He is one more Hotty Toddy Poddy Boy.” (Ole Miss Party boy is all I can figure on this) 14. “ I know my husband must have that emezema because I can’t sleep for him wheezling all night.”

15. “ What do you mean, I have the gouch? I thought that was something you caught between your legs?” (gout) 16. “ My Daddy may be old, but he is in such good shape, they’ll have to knock him in the head on judgment day.”

17. “ My momma died of compulsive heart failure.” (Are all OCD folks predisposed to this?)

18. “My boyfriend needs that camera run up him, you know, for man stuff.”

27. “ My bladder has dropped, and they said I was too old to put to sleep, so here I am wearing a patsy.”

19. “ That last doctor I saw gave me a bunch of Viagra, and I told him that was like putting a flag pole on a condemned building.”

28. “ I am supposed to be in my golden years, but the only damn thing I got that’s gold is pee.”

20. “My husband has seen a specialist in Tupelo. I think he was a­ 29. “On my bill, it said that I had an ‘exacerbation of COPD.’ What is that urin-o-cologist.” exactly?” I told the patient that it was a $2.00 word for worsening in your breathing troubles. She said, “Well, now you remember you 21. “I’m about ready to get rid of my old man; he ain’t nothing but an are dealing with a 50 cent gal, so from now on, just give me the 50 obitual liar.” cent word.”

22. “My ears feel really wearied lately.” (Weird? Or tired ears?)

30. “My sister in Memphis told me I had too much wrong with me to 23. “I have been looking on the computer, and I am pretty sure I have be messing around with regular doctors. She said I needed to go see that sleep acne.” an eternal medicine specialist. Well, I just told her that I am going to 24. “My technicals are about to kill me.” (testicles, as near as I can stick with Dr. South until I die.” guess) 25. “In the passed, I have been diagnosed as biopolar sexsophenic. I just love it, and that last one will do to quit on until next time.

Meanwhile, pass me that Geritol bottle so I can wash down this BC I also have anexity attacks…insomia…blood pressure…

Powder and “Come back strong!” fibroalligynia…osteoarthis really bad…knees bone to bone… takin shots of rooster combs…don’t help…need Loratabs and —Dwalia S. South, MD nobody won’t help me anymore.” (This was an actual note handed Ripley to me.)

26. “My Medicaid is supposed to be radioactive for three months.”

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

OR Physicians to review Social Security disability claims at the

Mississippi Department of Rehabilitation Services (MDRS) in Madison MS.

Contact us at: Gwendolyn Williams 601- 853-5449

DISABILITY DETERMINATION SERVICES 1-800-962-2230

VOL. 61 • NO. 5 • 2020 151

Cold or Allergies

Flu

Coronavirus

Itchy Eyes Stuffy Nose Sneezing Fever Fatigue Body Aches Shortness of Breath Coughs History of Travel Exposure Worsening Symptoms Sources: CDC, Mayo Clinic. For more information: www.cdc.gov/COVID19-symptoms

Mississippi Drug Card can help you save up to 80% on your prescriptions.

Compliments of:

For more information contact:

info@mississippidrugcard.com

Proud Supporter of:

Learn more at

MISSISSIPPIDRUGCARD.COM and get your Free Prescription Savings Coupon Card

A donation will be made to your local CMN hospital each time a prescription is processed using this coupon.

What’s Your Specialty?

Our specialty is NETWORKING...

TPAs Physicians

Hospitals

M

I

S

S

I

S

S

I

P

P

I

Physicians Care N E T WO R K

Employer Groups

Ancillary Providers Insurance Companies

MPCN - THE OBVIOUS CHOICE Change Networks. Not Doctors.

601-605-4756 • www.mpcn-ms.com Sponsored by the Mississippi State Medical Association

download the issuu app to read the Journal

24/7/365

anytime, anywhere...