Journal MSMA Volume LXI | No 6/7 | June/July 2020

volUME lXI • no. 6 / 7 • JUNE / JULY 2020

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vol. LXI • no. 6/7 • June/July 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 President-Elect W. Mark Horne, MD

Managing Editor Karen A. Evers

Secretary-Treasurer Joe Austin, MD

Publications Committee Sheila Bouldin, MD, Chair Dwalia S. South, MD, Chair Emeritus Thomas C. Dobbs, MD Wesley Youngblood, MD 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.

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

Copyright © 2020 Mississippi State Medical Association.

Official Publication

MSMA • Since 1959

In-Vitro Virucidal Effect of a Benzalkonium Chloride Hand Sanitizer on Coronavirus 156 Sidney W. Bondurant, MD and Ronny Jackson, MD Treatment of Critical Hand Ischemia with Atherectomy and Balloon Angioplasty in a Hemodialysis Patient

Abdul Bahro, MD, FACC, FSCAI; Connie Williams, AGACNP-BC; and William C. Lineaweaver, MD, FACS

158

Huntington’s Disease Care in Mississippi: The Challenge and the Hope on the Horizon Liana Singh, MD; Scott Gibson, MD; Netrali Patel, MD; and Juebin Huang, MD, PhD

161

Top 10 Facts You Need to Know About Dyslexia Twila W. Rawson, PhD

165

departments From the Editor – The Pandemic’s Enduring Lesson: Better Fund Public Health Lucius M. Lampton, MD

154

President’s Page – It’s Time J. Clay Hays, Jr, MD

167

Letters – Vitamin D for Enhanced Immuno-Protection Against Covid-19

169

Editorial – Social Determinants of Health Sheila D. Bouldin, MD

170

Editorial – A Flashlight While Stumbling Around in the Dark: Organized Medicine Meets the COVID-19 Pandemic and Physician Burnout H ead On Jennifer Joiner Bryan, MD

171

New Members – Welcoming Our Newest Members

174

Images in Mississippi Medicine – The Science Hall in July 1908: Another View of the First Medical School Building at Ole Miss Lucius M. Lampton, MD

175

Poetry and Medicine – Ode de Corona Dwalia S. South, MD

176

COVID to Billie Joe Philip Merideth, MD, JD

177

ABOUT THE COVER “Doing His Part” – A mask cleverly placed on the statue of Kosciusko’s namesake, Polish general Tadeusz Kosciuszko (1746-1817), serves to remind passersby of our “new normal” courtesy of COVID-19. Our cover photo was provided by our longtime JMSMA Associate Editor Dr. Stanley Hartness, whose vision helped make the bronze monument sculpted by Tracy Sugg a reality. The statue stands in Redbud Springs Bicentennial Park in downtown Kosciusko.

This photo also possesses a timeliness as Black Lives Matter protests have swept the country following the tragic death of George Floyd while being arrested by Minneapolis police officers.

These protests have often focused on the removal or destruction of statues of historical figures associated with colonialism and slavery. There has emerged a renewed discussion about what statues represent, both in the past and in this current moment. Although Kosciuszko possesses local significance as the namesake of one of central Mississippi’s loveliest cities, he also should be remembered by all for his extraordinary contributions to the creation of our country and his passionate early leadership to eradicate slavery. This Polish patriot became enamored with the values of the French Enlightenment and felt the American struggle for independence was the world’s great hope for freedom. His military skills included engineering, and he is credited with designing the colonial defenses in some of the Revolution’s most critical battles.

Thaddeus Kosciuszko (pronounced cuz-CHOOSE-co) became both respected and befriended by many of America’s most prominent Revolutionary leaders, whom he held to the highest ideals of equality on the issue of slavery. Thomas Jefferson, perhaps his closest friend, said “General Kosciuszko, I see him often…He is as pure a son of liberty as I have ever known, and of that liberty which is to go to all, and not to the few or rich alone.” He took freedom and liberty so seriously that he frequently expressed his disappointment with close friends like Jefferson and George Washington for owning slaves. During his service in both the American and Polish revolutions, he employed black men as his aides-de-camp: Agrippa Hull in America and Jean Lapierre in Poland. In May 1798, Kosciuszko composed a will. In it, he gave the entirety of his American assets – $18,912 and 500 acres of land in Ohio – for Jefferson to use to purchase the freedom and provide education for enslaved blacks. The final version called on “my friend Thomas Jefferson” to use Kosciuszko’s assets “in purchasing negroes from among his own as [well as] any others…giving them liberty,” and “giving them an education in trades and otherwise.” Jefferson stumbled in executing his friend’s will, largely due to his own financial collapse. However, the abolitionist perspective behind this will bestows a moral status upon Kosciuszko as an early voice of American conscience. A historian recently asserted that Kosciuszko was “fighting next to people who believed they were fighting for independence, but not doing it for all. Even before Americans themselves fully came to that understanding, he saw it.”—Ed. n

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F R O M

t h e

e d i t or

The Pandemic’s Enduring Lesson: Better Fund Public Health W

hen Germany invaded Poland in September 1939, the media reported from the Battle of Krojanty that the brave Polish cavalry charged with their lances and sabers against German Panzers. Although the story was mostly fiction, this mythical image of men on horseback rushing armored tanks came to mind as I watched our own health care heroes, the nation’s physicians and nurses, run out of gowns and masks, and yet still choosing to risk their lives wearing garbage bags belted by tape, snorkel masks, Lucius M. Lampton, MD swimming goggles, motorbike helmets Editor with visors, plastic raincoats, and other homemade personal protection equipment (PPE) in order to care for their COVID-19 patients. Like the Polish cavalrymen, physicians were going into battle without appropriate armor or adequate weaponry to face a deadly, better-armed foe. In this and countless other ways, this pandemic reveals the tragedy of our nation’s chronic underinvestment in public health and its health care system, especially in rural areas. It also underscores the need to look at public health funding differently in the future than we have in the past.

Here in Mississippi, our State Health Officer, Dr. Thomas Dobbs, has emerged as a heroic and trusted public health leader in this time of crisis. Similar to Dr. Anthony Fauci at the national level, Dobbs has led in a dignified, transparent, and competent manner, calming a stressed general population. Among the many heroes assisting him at our Department of Health are Dr. Paul Byers, State Epidemiologist; Jim Craig, Senior Deputy and Director of Health Protection; Daphne Ware, PhD, Lab Director; and Victor Sutton, PhD, Director of Preventive Health and Health Equity. This line of honor is assisted by many other dedicated staff who deserve our thanks and praise.

Hopefully, an enduring consequence of this crisis will be a greater respect for the importance of public health and a conscious decision to fund it appropriately.

Operating the Department of Health on a shoestring budget is not a tenable plan going forward. My message to Americans: Don’t give health care workers a free Happy Meal at McDonald’s. Don’t ring the church bells at dusk, or bang pots and serenade us from your balconies. Instead, in the future just fund public health more robustly. Why does it take the hysteria of a pandemic for citizens to appreciate the importance health care plays in their very survival? 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

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

FAMILY MEDICINE Tim J. Alford, MD Diane K. Beebe, MD Jennifer Bryan, MD J. Edward Hill, MD GASTROENTEROLOGY James Q. Sones, MD GENERAL SURGERY Andrew C. Mallette, MD

INTERNAL MEDICINE/EPIDEMIOLOGY Thomas E. Dobbs, MD

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

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

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In-Vitro Virucidal Effect of a Benzalkonium Chloride Hand Sanitizer on Coronavirus Sidney W. Bondurant, MD and Ronny Jackson, MD

Abstract A commercially available hand sanitizer containing 0.12% benzalkonium chloride as the active ingredient was tested in the laboratory for its ability to inactivate Human Coronavirus Strain 229E (a surrogate for SARS-CoV-2) in an in-vitro cell culture test. The results showed a >99.9% inactivation of the test virus with 30 seconds, 60 seconds, and 120 seconds of exposure to the test product.

Standard Test Method to Assess the Activity of Microbicides against Viruses in Suspension. The percent and log10 reductions from the initial population of the viral strain was determined following exposure to the test product for 30 seconds, 60 seconds, and 120 seconds. The host cells were American Type Cell Culture Collection (ATCC) MRC-5 (CCL171). Five parameters were evaluated: virucidal suspension test, virus control, cytotoxicity control, neutralization control and cell culture control.

Introduction

Results

The public health emergency of international concern caused by the novel coronavirus (SARS-CoV2) has, as of May 4, 2020, resulted in 1,158,341 cases of infection (COVID-19) and 67,686 deaths in the United States of America. Trials are currently underway to evaluate medical treatments for this infection with several appearing to be promising options for recommended therapy. Vaccine development is also underway, but availability is many months away.

The results showed a > 3.00 log10 reduction in the test product’s virucidal suspension parameter as compared to the virus control parameter, showing significant inactivation (> 99.90%) of the test coronavirus strain by the test product at 30 seconds exposure, 60 seconds exposure, and 120 seconds exposure. The cytotoxicity control and neutralization control showed no effect on the cell line (see Table).

For now, prevention is the most effective way of attacking this epidemic.

The World Health Organization (WHO) recommends handwashing with soap and water and using alcohol-based hand sanitizer if there is no visible soiling of the hands.1 In the United States, the FDA allows only 3 active ingredients for hand sanitizers, ethyl alcohol, isopropyl alcohol, and benzalkonium chloride. We evaluated the effect of a commercially available hand sanitizer (DAB, Three Kings Corp., Corinth, MS) using 0.12% benzalkonium chloride as its active ingredient on Human Coronavirus, strain 229E (ATCC #VR-740).

Strain 229E, like other coronaviruses, including SARS-CoV2, is a large enveloped virus. Composition and structures of the envelope are not strain-specific, and sanitizers that are effective against 1 strain of an enveloped virus representing the virus family are likely to be effective against the whole family of viruses.2 Strain 229 E is a health authority recommended surrogate for SARS-CoV2.3 Methods The study evaluated the virucidal properties of the test product when challenged with Human Coronavirus based on ASTM E1052-11

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Discussion Although numerous studies on medical treatments for COVID-19 are underway and vaccine research is ongoing, it may be some time before accepted treatments are in widespread use. Prevention of person to person spread in health care facilities involves the use of mask respirators and personal protective equipment along with adherence to hand hygiene protocols. For the general public, the WHO has published several recommendations for protection, one of which is the use of alcohol-based hand sanitizer when the hands are not visibly soiled.1 Since there are situations where alcohol-based hand sanitizers are not appropriate, we tested a benzalkonium chloride (the only other FDA allowed active ingredient) hand sanitizer to see if it was effective against coronavirus. In a recent review article of disinfectants on surfaces and their effects on coronavirus, Kampf found the data on benzalkonium chloride “conflicting” and also stated there was no study found on hands and coronavirus.4 Our research showed that the test product we studied was highly effective in inactivating coronavirus.

Previous studies of this test product have shown that it has persistent antibacterial effects against Staphylococcus aureus for at least 4 hours.5,6 Our study did not address any persistence of antiviral effects. This question should be addressed in follow-up studies.

Table. Test Formulation #1: DAB Protects BZK @ 0.12% (Lot #20027). Virus: Coronavirus strain 229E (ATCC #VR-740). Host Cell Line: MRC-5 (ATCC #CCL-171). Volume Plated per Well: 1.0 mL.

Dilution (–Log10)

Virus Control

30 Seconds

Test 1 Minute

–2 –3 –4 –5 –6 –7 TCID50 (log10)

NT ++++1 +0++ ++++ 00+0 0000 5.50

CT 00002 0000 0000 0000 0000 ≤2.50

CT 0000 0000 0000 0000 0000 ≤2.50

CT 0000 0000 0000 0000 0000 ≤2.50

Log10 reduction

N/A

≥3.00 ≥99.90

≥3.00 ≥99.90

≥3.00 ≥99.90

Percent reduction

NTC

2 Minutes

NC

CTC

CC 0000

NT ++++ +00+ ++0+ 0000 0000 4.75

NT ++++ 0+++ ++0+ 0000 0000 5.00

++++ 0000 0000 NT NT NT 2.50

N/A

N/A

+ = CPE (cytopathic/cytotoxic effect) present.

0 = CPE (cytopathic/cytotoxic effect) not detected.

CC = cell control; CTC = cytotoxicity control; NC = neutralization control; NTC = neutralizer toxicity control; NT = Not tested; N/A = Not applicable; and TCID50 = tissue culture infective dose – 50%.

1 2

Conclusions A 0.12% benzalkonium chloride hand sanitizer was highly effective in inactivating Human Coronavirus Strain 229E (ATCC- #VR-740) in vitro. Given the known lack of persistence on the skin of alcoholbased hand sanitizers (unless organic acids are added to the product)7 and the previous research showing at least 4 hours of antibacterial persistence of this test product, additional studies are recommended to see if benzalkonium chloride hand sanitizers have a persistent antiviral effect. n Acknowledgments This study was funded by Three Kings Corporation, Corinth, MS, who also furnished the test product for the study. Dr. Bondurant discloses he and Medical Spark Biologics, LLC, are consultants to Three Kings Corporation.

Dr. Jackson discloses he is a consultant to Three Kings Corporation.

References 1. World Health Organization, Diseases, coronavirus disease (COVID-19) advice for the public. Accessed May 4, 2020. https://www.who.int/emergencies/ diseases/novel-coronavirus-2019/advice-for-public 2. McDonnell G, Russell A. Antiseptics and disinfectants: Activity, action, and resistance. Clin Microbiol Rev. 1999;12(1):147-179.

3. Surrogate viruses for use in disinfectant efficacy tests to justify claims against COVID-19. Accessed May 4, 2020. https://www.tga.gov.au/surrogate-virusesuse-disinfectant-efficacy-tests-justify-claims-against-covid-19 4. Kampf G. Potential role of inanimate surfaces for the spread of coronaviruses and their inactivation with disinfectant agents. Accessed May 4, 2020. https://doi. org/10.1016/j.infpip.2020.100044 5. Bondurant S, Duly C, Harbell J. Demonstrating the persistent antibacterial efficacy of a hand sanitizer containing benzalkonium chloride on human skin at 1, 2, and 4 hours after application. Accessed May 4, 2020. https://www.ajicjournal. org/article/S0196-6553(19)30008-2/fulltext 6. Bondurant S, McKinney T, Bondurant L, Fitzpatrick L. Evaluation of a benzalkonium chloride hand sanitizer in reducing transient Staphylococcus aureus on the hands of health care workers. Am J Infect Cont. 2020;48(5):522-526.

7. Gold NA, Avva U. Alcohol Sanitizer. StatPearls [Internet]. StatPearls Publishing, Treasure Island (FL). Updated February 6, 2020. Accessed May 4, 2020. https:// www.ncbi.nlm.nih.gov/books/NBK513254/

Author Information Senior Medical Officer at Medical Spark Biologics and Professor Emeritus, University of Mississippi School of Medicine (Bondurant). Retired Rear Admiral in the US Navy Medical Corps. Past service as medical adviser and White House physician for Presidents G. W. Bush, B. H. Obama, and D. J. Trump (Jackson).

Corresponding Author: Sidney W. Bondurant, MD, Senior Medical Officer, Medical Spark Biologics, Suite 150, 4400 Old Canton Rd., Jackson, MS 39216 (sbondurant@ medicalspark.com).

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Treatment of Critical Hand Ischemia with Atherectomy and Balloon Angioplasty in a Hemodialysis Patient Abdul Bahro, MD, FACC, FSCAI; Connie Williams, AGACNP-BC; and William C. Lineaweaver, MD, FACS

Abstract A patient with critical arteriosclerotic ischemia of his left upper extremity was treated with angiographic atherectomy and balloon angioplasty, resulting in restoration of circulation to his hand, resolution of pain, restoration of function, and healing of ischemic finger necrosis.

Keywords: upper extremity ischemia; angiography; angioplasty Introduction A common problem plaguing diabetic and end-stage renal disease patients is the development of calcified peripheral artery disease of the forearm and hand. Severe pain and critical hand ischemia can develop, leading to amputations. Unfortunately, only sparse data are available for therapeutic treatments of calcified lesions distal to the elbow.1-4 Studies have proven that heavily calcified lesions are effectively treated with atherectomy followed by balloon angioplasty below the knee, but below the elbow lesions are often excluded from therapeutic consideration because of small vessel size.5-6 We present a case of upper extremity critical ischemia treated with atherectomy and angioplasty, illustrating the utility of this strategy in the forearm and hand.

Case Report The patient was a 69-year-old man with a past medical history of hypertension, diabetes mellitus, hyperlipidemia, and end-stage renal disease on hemodialysis. He was referred from his dialysis center for resting ischemia to the left hand. He had an arteriovenous fistula for dialysis in his proximal left arm. He developed severe pain, discoloration, and necrotic areas to the tips of his fingers. He was previously admitted to another local hospital for 12 days and treated with anticoagulation with no improvement in his ischemic symptoms.

His pain progressively worsened, and necrotic areas were increasing in size. The pain was so severe he was unable to move his fingers (Figure 1).

He was then referred to our facility.

An arterial Doppler study review of the left upper extremity showed severe peripheral arterial disease, and the patient was scheduled for angiography. The images revealed severe disease in the proximal and

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mid-left radial artery with an occluded segment just proximal to the wrist, along with an occluded ulnar artery distal to the wrist (Figure 2).

The recommendation was to proceed with endovascular intervention to the radial artery.

Figure 1. Resting Ischemic Changes to the Left Hand

Figure 2. Severely calcified Disease Below the Elbow

Figure 4A. Atherectomy Left Radial Artery

Figure 3. Guidewire Crossing Occluded Distal Segment of Radial Artery

Figure 4B. Balloon Angioplasty Left Radial Artery

A 5-French sheath was used to cannulate the right femoral artery. A 5-French manufactured Bernstein catheter and an Advantage wire were used to advance the catheter into the proximal brachial artery. Selective angiography was then performed. To perform intervention, a long NaviCross catheter was advanced over the Advantage wire to the distal brachial artery. A long 6-French Destination sheath was advanced to the midbrachial artery. Heparin and Aggrastat were given intravenously. Using a PT Choice guidewire and a Seeker catheter, the occluded segment in the distal radial artery was crossed (Figure 3). The wire was then exchanged to a Viper wire. Atherectomy was performed using 1.25 solid crown followed by balloon angioplasty using 2.0 × 40 mm in the distal segment of the radial artery. A 2.5 × 150 mm balloon was utilized in the proximal and midportion of the vessel. Each balloon was inflated between 4–6

atmospheres for 2–3 minutes (Figure 4). The final angiogram revealed excellent flow through the treated segment (Figure 5).

The day after the procedure, the patient was able to move his fingers, and the pain was completely resolved. Color had returned to his fingertips, and he was discharged home that day.

The patient returned to the clinic 6 weeks after the procedure. The ischemic ulcerations had healed entirely. His pain had resolved, allowing full mobility of his hand. Coloration had returned to normal (Figure 6). The outcome was successful in restoring blood flow to his fingertips, allowing proper healing, and preventing amputation.

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Figure 5. Angiogram Results

be caused by arteriosclerosis or a variety of other processes including emboli, thrombi, arteritis (Buerger’s disease), connective tissue diseases, and chronic vasospasm (Raynaud’s disease).7 Arteriography is a definitive study for evaluation for treatment of upper extremity ischemia. For arteriosclerotic ischemia, arteriography can include revascularization procedures such as the one described in this case report. In cases where bypass grafting, sympathectomy, and venous arterialization are considered, arteriography can provide a map for the planning of such procedures.7-10 n Acknowledgment Conflict of Interest Disclosures: The authors have nothing to disclose.

References 1. Ferraresi R, Palloshi A, Aprigliano G, et al. Angioplasty of below-the-elbow arteries in critical hand ischaemia. Eur J Vasc Endovasc Surg. 2012;43:73–80.

Figure 6. Improvement of Hand Soft Tissues

2. Ferraresi R, Frlini M, Sozzi F, et al. Images in cardiovascular medicine. Percutaneous transluminal angioplasty for treatment of critical hand ischemia. Circulation 2006;114:e232-4 3. Gandini R, Angelopoulos G, Da Ros V, et al. Percutaneous transluminal angioplasty for treatment of critical hand ischemia with a novel endovascular approach: “The radial to ulnar artery loop technique. J Vasc Surg. 2010;51:760–762.

4. Itaya H, Nakamura M. Novel strategy for percutaneous transluminal angioplasty for complex critical hand. Cardiovasc Interv Ther. 2012;27:52–56.

5. Rocha-Singh KJ, Zeller T, Jaff MR. Peripheral arterial calcification: Prevalence, mechanism, detection, and clinical implications. Cathet Cardiovasc Intervent.

2014;83: E212–E220.

Technical Fine Points When performing endovascular procedures, it is important to maintain activated clotting time at or over 250 seconds. Gentle wire manipulation should be utilized when working with heavily calcified lesions. A small Diamondback crown is appropriate for atherectomy.

Vasodilators such as Verapamil may be administered through the exchange catheters. The angioplasty balloon should be the same size as the diameter of the vessel. Long and low inflations are recommended initially with progression to a smaller balloon with higher inflation pressures for resistant lesions.

Discussion This case study shows that upper arm critical limb ischemia can be effectively treated with endovascular techniques such as atherectomy.

Upper extremity revascularization is increasingly recognized as a valuable intervention for upper extremity ischemia. Such ischemia can

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6. Shammas NW, Lam R, Mustapha J, et al. Comparison of orbital atherectomy plus balloon angioplasty vs. balloon angioplasty alone in patients with critical limb ­ischemia: Results of the CALCIUM 360 randomized pilot trial. J Endovasc Ther.

2012;19:480–488.

7. Ahn HC, Jones NF. Ischemia of the hand In: Plastic Surgery, ed 6, Neligan P (ed).

London: Elsevier; 2013:6, 467–485.

8. Kitzinger H, Schoonhoven J, Schmitt R, et al. Hypothenar hammer syndrome.

Ann Plast Surg. 2016;76:40–45.

9. Smith BP, Koman L. Microsurgical revascularization and sympathectomy In: Operative Microsurgery, Boyd JB, Jones F (eds). New York: McGraw Hill; 2015:1015– 1022.

10. Zeng W, Hammert WG. Arterialization of the venous system for treatment of chronic ischemia of the hand. Plast Reconstr Surg. 2016;137:1213–1220.

Author Information Interventional Cardiology, Merit Health Central Hospital (Bahro, Williams).

Medical Director, JMS Burn and Reconstruction Center at Merit Health Central Hospital (Lineaweaver).

Corresponding Author: Abdul Bahro, M.D., F.A.C.C., F.S.C.A.I.; Interventional Cardiology Merit Health Central Hospital, 1850 Chadwick Dr., Jackson, MS, 39204.

Ph: (601)376 1394. Fax: (601)376 1684 (abdulbahro@hotmail.com).

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Huntington’s Disease Care in Mississippi: The Challenge and the Hope on the Horizon Liana Singh, MD; Scott Gibson, MD; Netrali Patel, MD; and Juebin Huang, MD, PhD

Case Report A 68-year-old woman presents to a memory clinic with her longtime friend for evaluation of memory loss. She has been experiencing problems with her memory for approximately five years. Symptoms include repeating herself, difficulty recalling people’s names or recent events, and misplacing personal belongings. She is otherwise grossly independent with most of her activities of daily living (ADL). She lives alone and has one adult son that lives across the street. She is managing her own finances without any problems such as paying bills, depositing and/or withdrawing money. She drives daily to see her mother who is 92 years old and lives about a mile away. Her friend reported that two months ago she became lost driving to a familiar place.

There is conflicting information regarding depressive symptoms. Her friend noticed that she is tearful, agitated at times, and irritable with some personality changes, which the patient denies. Her spouse had a myocardial infarction and passed away unexpectedly two years ago.

In addition, her dog passed away a year later. She only socializes with her friend at either of their homes, in contrast to approximately two years ago when she used to enjoy going to the bingo hall. She has seen another provider who thought she was depressed and wanted to start an antidepressant; however, the patient refused medication at that time.

The patient denies any difficulty with her mobility, and no falls were reported. However, her friend endorses that she is walking more slowly and with a slight limp. Her past medical history is significant for untreated depression. There is no family history of dementia or surgical history. She denies drinking alcohol, but admits to smoking two packs of cigarettes per day for 40 years. She completed high school and worked in the auditing department of a local bank until she retired five years ago.

The initial physical examination by her geriatrician revealed a calm, thin white female with normal vital signs. She was noted to have some involuntary jerking, twitching movement in her right arm and face.

Gait assessment indicated a slowed pace and decreased length of stride. However, the remainder of the examination was unremarkable.

Cognitive screening was conducted. She scored 15 out of 30 (normal = 27–30) on Montreal Cognitive Assessment (MOCA), including significant impairment in visuospatial/executive function, attention

and memory. Her Geriatric Depression Screen (GDS) score was 3/15, which indicated no depression.

Further evaluation for her cognitive impairment, including routine laboratory studies (completed blood count, basic metabolic panel, and urinalysis), along with thyroid stimulating hormone (TSH), vitamin B12, and folate were all essentially normal. Records from the outside hospital indicated that the patient had a head computed tomography (CT) completed a year ago that showed prominent ventricles and cortical sulci compatible with atrophic change.

At this point, her subjective cognitive complaints together with the objective, moderately severe cognitive impairment evident by the low MOCA score, would suggest a dementia syndrome, although her activities of daily living have been grossly intact except the concern of her driving. The initial unremarkable ancillary tests, including depression screening, serum chemistry and metabolic markers, as well as brain imaging, suggested that her cognitive impairment is most likely due to a neurodegenerative process such as Alzheimer’s disease. However, an alternate diagnosis other than Alzheimer’s disease cannot be ruled out, particularly given the neurological examination findings of involuntary movement and gait disturbance. A neurology referral was then made.

A thorough neurological examination done by the consultant neurologist (J-H) revealed abnormal, slow saccadic eye movements, subtle but diffuse chorea-like involuntary movement involving her eyes, face, distal arms and legs, and a slightly wide-based unsteady gait. The diffuse chorea-like involuntary movement, together with the cognitive impairment, raised the concern of movement disorders such as Huntington’s disease (HD) vs. tardive dyskinesia. However, the patient denies any family history of HD or similar presentation of involuntary movement or dementia. She also denies any history of using antipsychotics in the past. A Huntington’s genetic test was eventually obtained and reported positive for Huntington’s disease [cytosine-adenine-guanine (CAG) repeats 45/17, which indicates full penetrance].

Huntington’s Disease (HD) HD is a hereditary neurodegenerative disorder caused by an expansion of a repeating CAG triplet series in the Huntingtin gene on

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chromosome 4, which results in the expression of abnormal Huntingtin protein with an abnormally long polyglutamine peptide sequence.1 It is a rare disease with a prevalence of 5 to 8 per 100,000 in North America.2 The age of onset is usually between 30 and 50 years old but can be as early as 2 and late as 80 years old.1 Between 4.4% and 11.5% of individuals with HD have a late-onset (over 60 years of age).3 There is a loose correlation of CAG repeat length and age of symptom onset/ rate of disease progression.4 It has a variable course with survival rates between 10 and 40 years.1 HD is inherited in an autosomal dominant pattern so that each child of an affected parent has a 50% chance of developing the disease. Diagnosis of HD is based on clinical features, a positive family history, and a positive HD genetic test for CAG repeats.

However, up to 8% of patients with genetically confirmed HD don’t have a family history.1 The hallmark features of HD are motor symptoms (typically choreiform involuntary movements), cognitive impairment, psychiatric, and behavioral symptoms. Initial presentation is usually motor symptoms (mostly chorea), although up to 29.2% of HD patients may present with nonmotor manifestations as the first clinical feature.1 Cognitive impairment usually occurs at a later stage of the disease, rarely as the initial presentation. However, cognitive impairment rather than chorea may be the major source of disability in late-onset HD.3 The disease process can be grouped into early, middle, and late stages.5 Cardinal features of the early stage are incoordination, involuntary extremity movements, abnormal saccades, and psychomotor symptoms such as irritability, disinhibition and/or depression.

However, patients are still independent in ADLs, and the symptoms are generally mild.

In the middle stage, ADLs become impaired with patients needing increased assistance. Cognitive complaints are more apparent. Chorea

is more pronounced with an increased fall risk. Swallowing becomes impaired. Therefore, dietary changes are often instituted.

Patients who progress to the late stage will require attendants providing around-the-clock, hands-on care. They lose the majority of voluntary control of motor skills. Those that are retained are termed “ballistic and high amplitude,”1 which often leads to injury of the extremity.

Unfortunately, the patient is most often confined to the bed. The inability to swallow leads to enteral nutrition with a percutaneous endoscopic gastrostomy (PEG) tube.

Genetic testing should be offered to symptomatic individuals who display chorea. Testing may be offered to asymptomatic offspring of HD gene confirmed patients, but a genetic counseling referral is often required.1 Typical findings of magnetic resonance imaging (MRI) of the brain in Huntington’s patients are features of head of caudate atrophy that results in augmentation of the frontal horns (Figure).1 HD Treatment and Clinical Care Symptomatic Treatment There is currently no cure for HD, and treatment is geared toward symptom management. Traditionally, dopamine receptor blockers such as haloperidol and risperidone have been used to treat chorea, but these neuroleptics have a variety of serious side effects including weight gain, metabolic syndrome, drowsiness, Parkinsonism and tardive dyskinesia. There are two FDA-approved medications (Tetrabenazine and Deutetrabenazine) for symptomatic treatment of the chorea in HD. Both Tetrabenazine and Deutetrabenazine are vesicular monoamine transporter 2 (VMAT2) inhibitors, which

Figure. MRI findings in HD. MRI T2 coronal images show the normal head of caudate contour (right panel, red arrow) and atrophic head of caudate contour (left panel, red arrow).

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reduce dopamine storage and release. The VMAT2 inhibitor has the advantage over the dopamine blocking drugs in that it does not cause tardive dyskinesia.1 For behavioral/psychiatric symptoms, the most studied drugs are quetiapine (Seroquel) and aripiprazole (Abilify) for irritability, aggressiveness, and psychosis. However, Selective Serotonin Reuptake Inhibitors (SSRIs) and mood stabilizers (i.e., carbamazepine, valproic acid, etc.) are widely used for different behavioral/psychiatric symptoms. Acetylcholinesterase inhibitors such as Donepezil are commonly used (off-label) for cognitive impairment in HD. The Interdisciplinary Approach Given the broad spectrum of clinical presentation and disability, HD care usually requires a multidisciplinary team, including neurologist, psychiatrist, psychologist, geneticist/genetic counselor, social worker, physical therapist, occupational therapist, speech therapist, dietitian, specialty pharmacist, and dedicated nursing staff. Interdisciplinary evaluations targeting key functional, quality of life, and safety concerns are relevant across all HD stages.

HD Care in Mississippi It is estimated that more than 30,000 Americans have HD. As a result, the projected number of HD patients is approximately 300 in Mississippi. Although the impact of the disease to HD family and community is way more serious than the number can tell.

Due to the lack of resources for specialized HD care in Mississippi, traditionally, HD patients have often been taken care of by primary care providers, internists, and to a less extent, general neurologists and psychiatrists. Since 2018, a HDSA (Huntington’s Disease Society of America) funded HD Clinic has been established at the University of Mississippi Medical Center (UMMC) as a partner site for the HDSA center of excellence located at the University of Alabama at Birmingham (http://hdsa.org/hdsacoeums/). The goal of the UMMC HD clinic is to bring a higher level, multiple disciplinary HD care to Mississippians suffering this devastating neurological disease, to improve patient access to specialized care, to raise awareness and recognition of HD to the general practitioner in Mississippi, and to promote cutting-edge research and community education.

RNA and thereby reduce concentrations of the mutant Huntingtin protein. Results of the trial were published recently in the New England Journal of Medicine and reported that HTTRx treatment resulted in a dose-dependent reduction in the concentration of mutant Huntingtin in CSF.6 A multicenter phase 3 study is now ongoing in the United States. A variety of viral vector delivered and other RNA interference approaches are also under preclinical development. Research on gene therapy to slow down the progression of HD or even cure the disease is the hope on the horizon for many patients and families suffering HD. Summary of the Case Our case represents a diagnostic challenge due to the fact that the patient is late-onset, with no family history, and with cognitive impairment as the initial presentation. Diagnosis of late-onset HD can be easily missed, due to the perceived low likelihood of HD in the over 60-year-olds, especially when the patients present to clinical services that, in general, are not familiar with HD. A thorough history and physical exam, including a comprehensive neurological exam, should always be conducted when a patient presents with cognitive complaints.

Although Alzheimer’s disease (AD) is the dominant diagnosis made in patients presenting to a memory clinic, clinicians should always remain vigilant and keep non-AD conditions in the differential diagnosis. Any abnormal or focal neurological findings warrant further investigation, including a neurology referral.

The patient, in this case, was brought back to the clinic after the HD genetic test came back positive. Counseling for the diagnosis, prognosis, and a care plan were offered, as well as pharmaceutical treatment for her involuntary movement. She was also referred to psychiatry for further counseling and management of cognitive-behavior disturbance related to her HD. Counseling was also offered to her son. He was encouraged to discuss options of presymptomatic genetic counseling, including genetic testing with his family and his primary care provider, as he is at risk of developing HD. Acknowledgments Funding: None.

Hope on the Horizon While the newest FDA-approved compounds focus on chorea, there are novel therapeutics being tested against more general motor signs and symptom outcomes. Developing neuroprotective and diseasemodifying therapeutics has also been an active area of research.

As HD is caused by a single gene mutation, a major current therapeutic development focus is impacting the level of mutant Huntingtin (HTT). Gene silencing techniques are in the frontline of trial development. The first antisense oligonucleotides (ASO) against HTT mRNA (HTTRx) trial in human HD patients was launched in 2015. In this randomized, double-blind, multiple-ascending-dose, phase 1–2a study, the HTTRx was designed to inhibit HTT messenger

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

References 1. Testa CM, Jankovic J. Huntington disease: A quarter century of progress since the gene discovery. J Neuro Sci. 2019;396:52–68.

2. Pringsheim T, Wiltshire K, Day L, et al. The incidence and prevalence of Huntington’s disease: A systematic review and meta-analysis. Mov Disord. . 2012;27:1083– 1091.

3. Chaganti SS, McCusker EA, Loy CT. What do we know about late onset Huntington’s disease? J Huntington’s Dis. 2017;6:95–103.

4. Maat-Kievit A, Losekoot M, Zwinderman K, et al. Predictability of age at onset in Huntington disease in the Dutch population. Medicine (Baltimore) 2002;81:251– 259.

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5. Roos RAC. Huntington’s disease: A clinical review. Orphanet J Rare Dis. . 2010;5:40.

6. Tabrizi SJ, Leavitt BR, Landwehrmeyer GB, et al. Targeting Huntingtin expression in patients with Huntington’s disease. N Engl J Med. 2019;380:2307–2316.

Author Information Division of Geriatrics, Department of Medicine, University of Mississippi Medical Center, Jackson, MS (Singh, Gibson). Center of Excellence in Adult and Geriatric Medicine, Jacksonville, FL (Patel). Department of Neurology and the MIND Center, University of Mississippi Medical Center, Jackson, MS (Huang). *Corresponding author: Dr. Juebin Huang, MD, PhD, Associate professor, Director of the HDSA Center of Excellence Partner, Department of Neurology, University of Mississippi Medical Center, 2500 N. State St., Jackson, MS, 39216. Ph: (601) 9845500; Fax: (601) 984-5503 (jhuang@umc.edu).

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Top 10 Facts You Need to Know About Dyslexia Twila W. Rawson, PhD

Introduction Individuals with dyslexia have difficulty with the phonological component of language which may affect reading, speaking, and writing. It is a specific learning disability that can be remediated but is a life-long condition. Physicians were the first to report findings of dyslexia, but it is not a medical diagnosis. As Margaret Rawson and Roger Saunders, psychologists/educators, have stated: “The differences are personal. The diagnosis is clinical. The treatment is educational. The understanding is scientific.”1 As parents often discuss concerns regarding their child’s learning difficulties with the child’s physician, it is important for physicians to understand what dyslexia is and how to address parents’ concerns in this area.

Dyslexia is a neurobiological, language-based learning disability, contrary to the belief it is seeing letters or numbers backward.

The following definition was adopted by the Board of Directors of the International Dyslexia Association on November 12, 2002: Dyslexia is a specific learning disability that is neurobiological in origin. It is characterized by difficulties with accurate and/or fluent word recognition and by poor spelling and decoding abilities. These difficulties typically result from a deficit in the phonological component of language that often is surprising considering other cognitive abilities and the provision of effective classroom instruction. Secondary consequences may include problems in reading comprehension and reduced reading experience that can impede the growth of vocabulary and background knowledge.2 Dyslexia is a reading disorder and is not the result of developmental delay, visual deficits or poor motivation.

Problems associated with dyslexia are language-based.

Dyslexia is caused by difficulties in the phonological component of language that cause problems with decoding and single word reading. There may also be difficulties with reading fluency and spelling.

Individuals with reading difficulty often have poor comprehension skills, and as they struggle with reading, they often choose not to read, which can result in weak vocabulary skills and poor background knowledge.3 Dyslexia affects individuals across all races, socioeconomic levels and gender.

Dyslexia occurs in 1 in 5 individuals and occurs nearly equally in males and females. It exists on a continuum of mild to severe, and many individuals with mild dyslexia may never be diagnosed. Eighty percent of students ruled eligible for special education for a learning disability have dyslexia.4 Dyslexia often coexists with other developmental disorders.

Thirty percent of children with dyslexia also have ADHD.3,5 Other learning disabilities may also exist with dyslexia including dyscalculia (math disorder) and dysgraphia (writing disorder).

Executive functioning may also be an area of difficulty for people with dyslexia. Individuals with dyslexia may have language disorders which may affect how well they respond to dyslexia therapy. Children with dyslexia often deal with anxiety and depression as a result of their struggle with reading and may have poor self-esteem and feelings of helplessness. They are often teased by other children and feel that adults are frustrated with them. In addition to appropriate educational therapy, behavioral therapy or counseling may be needed. It is important to encourage parents and teachers to help children with dyslexia find their strengths and encourage them in those areas.3,6 Dyslexia can be diagnosed in kindergarten with characteristics often noted in the preschool years.

Preschool children who do not enjoy looking at or following along when being read to and/or who are late in learning to talk, may be at risk for reading difficulty. Kindergarteners who have difficulty with phonemic awareness and rhyming may also be at risk for reading difficulty.3 Mississippi state law mandates screening for dyslexia in kindergarten and first grade.

HB 1031 requires that children be screened for dyslexia in the spring of kindergarten and in the fall of first grade.

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Parents are to be notified of the results of the screening process. The school district is not mandated to evaluate children, but must recognize a diagnosis of dyslexia when it is made by a licensed psychologist, psychometrist, or speech pathologist.7 Evaluation of dyslexia requires a comprehensive assessment.

The following areas should be included as a part of a comprehensive evaluation for dyslexia: phonological awareness, phonological memory, rapid automatic naming, receptive vocabulary, oral reading fluency, spelling, processing speed, and writing.

Assessment of intellectual functioning and math skills is often included in a comprehensive assessment.8,9 Remediation of dyslexia requires a structured, multisensory, language-based approach by a certified therapist.

Research has shown that intense, structured remediation can rewire the brain and mitigate the effects of dyslexia though the condition is not cured. Five percent of those with the most severe form of dyslexia will have enduring difficulties that do not generally respond to therapy.3,8 Accommodations for dyslexia are helpful in the classroom.

Classroom accommodations allow the student diagnosed with dyslexia to be on equal footing with other students during classroom instruction and times of assessment. Classroom accommodations may include, but are not limited to, extended time for completing assignments or tests, alternative presentation format of information during instruction time, alternative format for responding to assignments or tests, reduction of distractions in the classroom and use of devices/strategies to aid in organization.8,10 Individuals with dyslexia often have talents and abilities that allow them to be successful.

People in all occupations and professions have dyslexia and have been successful.3,8 Among them are Thomas Edison, Agatha Christie, Henry Winkler, Steve Jobs, Will Smith, and Steven Spielberg. Many of those individuals state that their dyslexia has allowed them to be innovative and think outside the box. They often have strengths in areas of critical thinking and problem solving and find ways to meet their challenges and achieve success using their creativity and perseverance.

References 1. Maryland Women’s Hall of Fame. Margaret Byrd Rawson (1899-2001). Accessed October 15, 2019. http://msa.maryland.gov/msa/educ/exhibits/womenshall/ html/rawson.html 2. Lyon GR, Shaywitz SE, Shaywitz BA. A definition of dyslexia. Ann of Dyslexia.

2003;53:1–14.

3. Moats LC, Dakin KE. Basic Facts about Dyslexia and Other Reading Problems. Baltimore, Maryland: The International Dyslexia Association; 2008.

4. The Yale Center for Dyslexia and Creativity. Dyslexia FAQ. Accessed December 5, 2019. http://dyslexia.yale.edu/dyslexia/dyslexia-faq 5. The Dyslexia Center of Utah. 5 Steps for Identifying Dyslexia in Your Child.

Accessed December 5, 2019. http://dyslexiacenterofutah.org/statistics 6. Tridas EQ. From ABC to ADHD. Baltimore, Maryland: The International Dyslexia Association; 2007.

7. 2012 Cumulative Supplement to Mississippi Code, Vol 10A 73-173-15, MS Legislature, 2012.

8. Shaywitz S. Overcoming Dyslexia. New York, NY: Random House, Inc.; 2003.

9. Mather N, Wendling BJ. Essentials of Dyslexia Assessment and Intervention. Hoboken, New Jersey: John Wiley & Sons; 2012.

10. International Dyslexia Association. Accommodations for students with dyslexia.

International Dyslexia Association, Accessed November 14, 2019. https://dyslex iaida.org/accommodations-for-students-with-dyslexia

Author Information Associate Professor in Psychology (Pediatrics), Center for Advancement of Youth (CAY) (Rawson).

Corresponding author: Twila Rawson, PhD, CALT; University of Mississippi Medical Center, 2500 North State St., Jackson, MS 39216. Ph: (601) 984-5236 Fax: (601) 984-2975 (trawson@umc.edu).

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Conclusion A better understanding of dyslexia will allow physicians to more adequately discuss concerns with parents and refer them for an appropriate assessment. Parents may be assured that, though dyslexia cannot be cured, there is therapy to remediate the effects of dyslexia.

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Acknowledgment Conflict of Interest Disclosures: The author has nothing to disclose.

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It’s Time

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rowing up as a kid in Jackson, Mississippi, I used to love to go to Ole Miss football games to watch my beloved Rebels play. Witnessing players like Archie Manning, Norris Weese, John Fourcade, and Buford Magee running all over the field was exciting. I can vividly remember the crowd cheering and waving their confederate flags when my childhood heroes would make a great play or score a touchdown. The whole spectacle J. Clay Hays, Jr, MD of the event including listening to the MSMA President band, watching the crowds wave their flags, 2019–2020 and the team playing was exhilarating, uplifting, and contagious. Those great memories of fun, friends, family and football are something I will treasure and never forget! It was just a game to me.

It became more than a game when I went to Ole Miss. How I felt on Monday depended on whether the Rebels won or lost on Saturday.

I also developed a relationship with my future wife during the many weekends we spent together at the ball games. It was a tradition to dress up and carry your flag to show your support for the team and our school. It became a source of pride for us to be unified as we battled teams from other states. We sang Dixie, waved our flags, and cheered for our team. We all felt great. We thought everyone from Mississippi felt that way. What's the big deal? We couldn’t believe anyone would feel differently.

However, many people did feel differently. They saw the symbols of Ole Miss as symbols of racism and oppression. How could anyone be supportive of a confederate flag, the playing of Dixie, or a confederate soldier as its mascot? Were we racist? Were we mean spirited? Did we care about anyone else particularly African Americans? Why would we do such a terrible thing? They could not understand and we couldn’t either. They had not been in our shoes as we viewed these symbols through a different lens. We saw those symbols as symbols of unity and fun. We did not know how it hurt others. We really didn’t know much about civil rights. We did not know because many of us weren’t around African Americans much.

Yes, we saw black people but we didn’t know black people. They did not go to our schools, our churches, or our homes. We were in one big bubble. We were ignorant about the plight they endured.

Then Chucky got hurt.

Chucky Mullins was a great defensive back from Alabama. He was scrappy, played hard, and had an infectious smile. Everybody loved him.

We thought he would be the anchor of a tough defense until he broke his neck one Saturday against Vanderbilt. He would never be the same and we would never be the same. Chucky became the symbol of unity for the Ole Miss family. People raised money for him, wrote letters to him, and cheered him at every event. He tragically lost his life at too young of an age. A bust of him is placed at the entrance to the field at Vaught Hemingway stadium. Below the bust, the words “It’s Time” are prominently displayed. We loved Chucky but his memories became distant. A statewide referendum on the flag was put on the ballot in the early 2003 but the current flag was reaffirmed. I voted to keep the flag because of my childhood memories. I voted for the flag because I didn’t want outsiders attacking Mississippi. I was wrong but I didn’t know it.

Nevertheless, a seed of change had been planted. Chancellor Robert Khayat took a bold move to basically get rid of the confederate flag at ball games by banning sticks. Chancellor Dr. Dan Jones stopped the playing of Dixie and changed the mascot. A concerted effort to increase the number of African American students was implemented and a statue of James Meredith was erected on campus. Rod Barnes was hired as the head basketball coach. Other schools in Mississippi also followed suit including Mississippi State by hiring Sylvester Croom as head football coach. University of Southern Mississippi hired Rodney Bennett as President. Traditionally all white private schools started to have black students enrolled. Educational institutions had taken the lead but the field of medicine would be quick to follow.

I also got to see others in a different light. My medical school class had many people from diverse backgrounds. I got to see how they felt when we talked about racial differences. I got to treat patients who came from really tough places. Even during my residency at the Mayo Clinic in Minnesota, I witnessed a white man from Tennessee tell a brilliant hematologist that he could not be his physician because he was black. I was stunned when this same physician used me as his tool to still help this man. What a testimony to professionalism! It is something that I will never forget.

I also was exposed to humble physicians here at home. Dr. Claude Brunson moved his way up through the ladder of academia leading the Anesthesiology department at the University of Mississippi Medical Center. He later would become the first African American President of the Mississippi State Medical Association (MSMA). Dr. Rod Givens and Dr. Loretta Jackson were elected to the MSMA Board of Trustees and Dr. Roger Huey was elected to the board of Medical Assurance Company of Mississippi. Because of education and relationships, barriers have been knocked down and bridges are being built. To hear of their struggles toward success, I have developed a better understanding of what it must be like to be black. My mind has changed and I feel differently about what is the right thing to do.

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Now back to the barrier of the state flag. Flags are supposed to be the current flag, the Legislature has given us an opportunity to look beforetoproceeding with making a new kindthe of planned history. nprocedure is imperative. Careful symbols of unity not signs of division. Just like any team, whether it forward Table 2.

Five Star Approach to the Anesthetic Management of Trisomy 18 anesthetic management, especially airway management and avoiding a is a sports team or a hospital team, we should understand what we are Table 2. Five Star Approach to the Anesthetic Management of Trisomy 18 hypertensive crisis, is critical. Avoiding multiple procedures trying to accomplish. My belief is that we all want one goal, that is to be It’spulmonary time. and anesthetics may be helpful. n better. We want our citizens to have better. We want better education, Ø Complete examination including cardiac evaluation, airway better jobs, better healthcare, assessment better services, better highways, and Acknowledgment Ø Multidisciplinary surgeon, anesthesiologist, better government.

As Mississippians, we meeting want involving all of our patients and& 1. Pre-anesthetic evaluation intensivist to discuss perioperative plan their families to have a betterØ tomorrow today.

Thataboutcan only be Open and honestthan discussion with family the risks, We would like to thank Khalid Altirkawi, MD, FAAP for giving us expectations, and treatment plan accomplished when we are unified. Just like when the Ole Miss family permission to use his pictures for the figure. rallied around Chucky Mullins, I believe our state wants to rally around a unifying symbol. Not the current state flag, but a better flag. One flag References Ø Complete anesthesia readiness, including immediate availability Clay Hays, Jr, MD that signifies future opportunities andairway hope.

It would not bevasoactive a flagdrugs for of difficult equipment and emergency 2. Logistics Readiness 1.

Baum VC, O’Flaherty JE. Anesthesia for Genetic, Metabolic, and Dysmorphic Ø Pediatric anesthesiologist with experience in difficult airway President, Mississippi State Medical Association passing legislation removing some of us. It would be a flag formanagement all of us.andBycardiac anesthesia

Syndromes of Childhood. Third edition. Philadelphia: Wolters Kluwer; 2015.

Cereda A, Carey JC. The trisomy 18 syndrome. Orphanet J Rare Dis. 2012;7:81.

T:7” Meyer RE, Liu G, Gilboa SM, et al. Survival of children with trisomy 13 and trisomy 18: A multi-state population-based study. Am J Med Genet A. 2016 Ø “Tight” physiological control during anesthetic, including 3. Intraoperative anesthesia Apr;170A(4):825-37. meticulous attention to ventilation and prevention of the management pulmonary hypertensive crisis 4. Banka S, Metcalfe K, Clayton-Smith J. Trisomy 18 mosaicism: report of two cases.

STAYING CONNECTED World J Pediatr. 2013;9(2):179-181.

5. Kosho T, Nakamura T, Kawame H, Baba A, Tamura M, Fukushima Y. Neonatal 4. Immediate post-operative Ø Post-operative monitoring in intensive care unit and possible THE UNEXPECTED JOYSofOF management ventilatory support. management of trisomy 18: clinical details 24CAREGIVING patients receiving intensive treatment. Am J Med Genet A. 2006;140(9):937-944.

6. Batees H, Altirkawi KA. Trisomy 18 syndrome: Towards a balanced approach. Ø Employ “one-stop shopping” strategy: performing more than one 5. General risk reduction strategy procedure under one anesthetic to reduce multiple anesthesia Sudan J Paediatr. 2014;14(2):76-84. procedures 7. Boss RD, Holmes KW, Althaus J, Rushton CH, McNee H, McNee T. Trisomy 18 and complex congenital heart disease: seeking the threshold benefit. Pediatrics.

2013;132(1):161-165.

8. Courreges P, Nieuviarts R, Lecoutre D. Anaesthetic management for Edward’s exacerbating pulmonary hypertension. syndrome. Paediatr Anaesth. 2003;13(3):267-269.

9. Bailey C, Chung R. Use of the laryngeal mask airway in a patient with Edward’s Muscle rigidity after use of succinylcholine has been reported in these syndrome. Anaesthesia. 1992;47(8):713. patients.12 However, there is no known risk for malignant hyperthermia 10. Miller C, Mayhew JF. Edward’s syndrome (trisomy 18). Paediatr Anaesth. in children with Trisomy 18. Brief surgical procedures such as 11. 1998;8(5):441-442.

Friesen RH, Twite MD, Nichols CS, et al. Hemodynamic response to ketamine in myringotomies can be managed by laryngeal mask airway (LMA).9 children with pulmonary hypertension. Paediatr Anaesth. 2016;26(1):102-108.

Regional nerve block techniques such as an epidural catheter or single 12. Matsuda H, Kaseno S, Gotoh Y, Furukawa K, Imanaka K. Muscle rigidity caused by succinylcholine in Edwards’ syndrome. Masui. 1983;32(1):125-128. shot caudal can be considered for lower abdominal or extremity 2.

3.

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procedures in combination with general anesthesia. Pain assessment in older patients in the post-operative period can be challenging due to severe mental retardation.

Author Information

Assistant professor, Department of Anesthesiology, Texas Tech University Health Sciences Center, Lubbock, TX (Fishkin). Associate professor, Department of Anesthesiology, Levine Children's Hospital, Charlotte, NC (Sathyamoorthy). CRNA, Conclusion 8 Department of Anesthesiology, University of Mississippi Medical Center, Jackson, MS (Wardlaw). Professor, Department of Otolaryngology and Communicative Sciences, We propose several strategies for safe perioperative management University of Mississippi Medical Center, Jackson, MS (Reed). The authors report no of these patients. These patients should undergo a thorough pre- financial disclosures or conflict of interest.

anesthetic evaluation and be managed by a pediatric anesthesiologist with experience in managing the difficult airway and cardiac anesthesia.

Detailed discussion with the family about treatment options and risks

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L E T T E R S

Vitamin D for Enhanced Immuno-Protection Against Covid-19 Dear Editor, In my lifetime, I have seen 15 epidemics come through, two of which tried to kill me!

It seems that every winter, some plague flu disorders come in from China. Usually, by hot summertime, though, they disappear.

We need to acknowledge that in this current epidemic, all of our experts have been wrong in what they have predicted. In fact, there is no real scientific evidence that the different lockdown-type actions have altered the course of the epidemic at all.

However, there are some peculiar patterns that are suggestive of environmental differences. Certain parts of our country, such as the sunny states with beaches along the ocean, seem to have lower infection rates than the rest of the states. Southern and western states with hot summers also seem to have lower incidence rates.

In our community, the three nursing homes have drastically different COVID-19 infection rates. Golden Age, the largest of the three, has had only one COVID-19 patient, who has since tested negative for infection. However, according to the Mississippi State Department of Health’s daily COVID-19 update for Saturday, May 9, there are 43 additional positive cases at other nursing homes in Leflore County, and 8 nursing home patient deaths.

Could vitamin D be the difference between our results and those of other nursing homes? Most nursing home patients receive far less sunlight than ordinary individuals, and sunlight on bare skin is the way vitamin D is naturally produced. Additionally, darker-skinned individuals have more difficulty making adequate vitamin D. Thus, it seems possible that in less sunny environments, such as is found in the northern and eastern states, and in metropolitan areas where people travel by subway and buses in the dark and work all day in skyscrapers with limited access to sunlight, a vitamin D deficiency might explain higher COVID-19 infection rates.

Vitamin D is already shown to help down-regulate dangerous immune responses, including the “cytokine storm” that does so much lung damage in COVID-19 cases. It has also been shown to help suppress other respiratory infections as well.

Indeed, after I wrote the first draft of this letter, I became aware that at least two late-breaking medical studies have just found a correlation between low vitamin D levels and high COVID-19 infection rates.

Of course, correlation doesn’t prove causation. No doubt, it will take some big grants over several years to perform a double-blind, crossover, placebo-controlled study that will give us solid scientific proof one way or the other.

I am sure that all of our local nursing homes have been following the standard preventive rules, but why the large difference?

I think it would be good to compare infection rates of outdoor workers such as roofers and gardeners with people who are confined to nursing homes and offices.

Several years ago, a group of doctors specializing in geriatrics (treatment of the elderly) began to study disease processes in nursing homes and discovered that some patient symptoms, especially weakness, musculoskeletal problems, and failure to thrive, were all related to extremely low vitamin D levels. Furthermore, these patients quickly improved when treated with vitamin D.

Because of all these facts and observations, I routinely recommend that all of my patients, family, and friends take 5000 units of vitamin D3 every day. This can be found at all the local drug stores at a low cost and without a prescription.

As a result, at Golden Age, where I am the medical director and half of the patients are my own, I have insisted that each patient receive 5000 units of vitamin D daily. I have delivered lectures on this subject to physicians over the last few years, and the use of supplemental vitamin D has provided great results in our patients.

And, take your vitamin D daily. What do you have to lose?

Of course, we must continue to wash our hands and clean off surfaces.

We must also get plenty of outside fresh air, exercise, sunlight.

— John Hey, MD; Greenwood

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Social Determinants of Health Sheila D. Bouldin, MD “Health inequalities and the social determinants of health are not a footnote to the determinants of health. They are the main issue.” —Michael Marmot

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s a physician in a primary care specialty, I see patients daily with at least one or more preventable chronic health conditions such as type 2 diabetes, hypertension, obesity, and heart disease. A majority of patients with chronic diseases are among the five groups classified as vulnerable populations: chronically ill and disabled; low-income and homeless individuals; specific geographical communities such as rural populations; the LGBTQ+ population; and, the very young and very old.1 Social factors may exacerbate the health and health care needs of these populations.

What are social determinants of health? Social determinants of health are a combination of personal, social, environmental, and economic factors that all play a role in one’s health. Physicians, other health care providers, and health care institutions should be cognizant of and address social determinants of health when providing patient care.

As physicians, we should address these social determinants of health, including economic stability, education, social and community context, access to health care, and neighborhood and built environment.

Acknowledging these social determinants could change how we practice medicine and the health outcomes for our state.

The COVID-19 pandemic has shed additional light on the many health care disparities that exist in the African-American community. In Mississippi and across the U.S., more African-Americans were infected

RightTrack

MEDICAL GROUP

with the coronavirus and died as a result of the coronavirus than any other race. Could addressing social determinants of health earlier have made a difference in the mortality and morbidity associated with COVID-19? There are vast opportunities to close these gaps in health care. n Reference 1. Joszt L. 5 Vulnerable populations in healthcare [blog post]. Am J Man Care. Published July 20, 2018. Accessed April 20, 2020. https://www.ajmc.com/newsroom/5-vulnerable-populations-in-healthcare

Dr. Bouldin is a board-certified obstetrician and gynecologist at the University of Mississippi Medical Center and chair of the MSMA Committee on Publications. She has over 20 years of experience taking care of the overall health care needs of women throughout all phases of their lives. This includes care across several generations, starting from adolescence to the menopausal years. Her experience has been as a private community physician and as an academician in the university setting, providing general obstetrics and gynecology care.

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

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CLINIC LOCATIONS:

• Oxford • Tupelo • Corinth • Olive Branch • Starkville

E D I T O R I A L

A Flashlight While Stumbling Around in the Dark: Organized Medicine Meets the COVID-19 Pandemic and Physician Burnout Head On Jennifer Joiner Bryan, MD

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oronavirus – One word has turned the entire world upside down. As I watched this virus escape Wuhan, China, and spillover quickly to other nations, my mind raced. It was raging like wildfire and moved so quickly that it felt like an alternate reality. As I interacted with the public, I grieved that they did not yet realize the tidal wave was coming– the new normal. We are now living in the new normal.

Most physicians realize that we are finding our new normal through this and that the old normal isn’t returning anytime soon… if ever.

administrators stop short of telling physicians where to refer patients.

However, reminders are often given for those clinics that are recommended to use and currently practicing within or financially supporting the system.

Many physicians are given little say in their own time management and clinic flow, and there is significant micromanagement (little of which has anything to do with actual medical care and most designed around billing practices). Physicians are deemed “providers” and witness first-hand the death of medical expertise.

Prior to the pandemic, physician burnout was at an all-time high.

Physicians, taught to put others first, have been attacked from every direction, and yet remain resilient. Depression, substance abuse, and suicide are serious threats to our workforce, and regulatory issues have become quite a burden. Physicians, who in years past had kept a box of index cards that listed things such as “strep throat, gave penicillin” slowly became data entry clerks. “Click here or don’t get paid…” “Make sure you meet your patient’s ‘quality’ measures even though you just spent a halfhour listening to them cry over their divorce.” “Didn’t code that visit right?”

Fraud. Did you call in a refill on your neighbor’s blood pressure pill when they ran out while out of town? Well, that might threaten your license.

Medical school? Why did you waste all that time and money? Everyone knows you can go online to become a nurse practitioner and do nearly the same thing. Look at your patient and hold their hands as they weep?

There’s no time. Type. Click the boxes. Get it done. As the regulatory burdens increased, physicians slowly gave up autonomy. Just before the pandemic, 51% of United States physicians were employed. With Centers for Medicare and Medicaid Services (CMS) requirements and an everchanging regulatory environment, it is not feasible for most to own their own practice. Or it hasn't been feasible until recently when regulations were slashed in the name of easing the burdens of the pandemic crisis.

As practices shifted to outpatient care separate from inpatient care provided by hospitalists, an even greater disconnect began. It affected medical care, and we all knew it. Doctors in the hospital cared for gravely ill people whom they had never met before. Why didn’t outpatient doctors want to go to the hospital anymore? The answer was simple.

Their lifestyle could no longer sustain it. Many could not keep up with the quality measures and charting systems, which were again designed primarily for billing purposes, and still care for their patients in their hours of greatest need. Doctors who had to type and “button click” quality measures began to employ nurse practitioners and physician assistants just to keep up. The scope of practice battles waged and burnout taskforces were created across the country to determine what was causing this “mysterious” burnout. At national physician-run meetings, the message was clear. Physicians knew why they were burned out (a hint for the nonphysicians reading this: it is all of the above things and more), but there has been too much money at stake for stakeholders to stop the current processes and rethink what we have been doing in health care. And then the coronavirus pandemic happened.

Over the past 15 years, health administration became big business.

Physicians became employees but still held that medical decision making was autonomous. In reality, that autonomy looked like, “You can order what you want, doctor, but we (the insurance company) are just telling you what we’ll pay for. The patient can have the test, but we’ll bill them the thousands of dollars for the test unless you order what we tell you we will pay for.” That same policy goes for prescriptions.

Health systems have grown their own networks of clinics to support their hospitals. To get around Stark Law issues on self-referral, etc.,

Despite what some may think, physicians are generally nurturing people who went into medicine to help people. They are peoplepleasers, and somewhere along the way became so wrapped up in trying to juggle all the balls in the air that they gave up a lot of autonomy.

They realized they were caught up in a system of prior authorizations, insurance denials, disruption of care between outpatient and inpatient, devalued expertise, and it was all too BIG. It was so big that no one really knew how to change it, and so they quietly burned out. At the dawn of the pandemic, the health care workforce found itself at a critical point of experiencing burnout, and some even have called it moral injury. Physicians who took an oath knew that there were fundamental differences between what drove them and what drove other stakeholders, but never was it so exposed until the pandemic.

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In 2005, President George W. Bush devised the National Strategy for Pandemic Influenza, followed by an implementation plan the next year in 2006. It was updated in 2009 following H1N1 influenza and again in 2017, and these plans outlined what would be needed in a time of a pandemic. President Bush famously said, “If we wait for a pandemic to appear, it will be too late to prepare.” These plans included a robust stockpile of supplies, and after a strong initial effort, the plans were abandoned. Just five short years ago, in April 2015, in the Clinical Infectious Diseases publication, a scientific assessment was published. This was the background of the article titled “Potential Demand for Respirators and Surgical Masks During a Hypothetical Influenza Pandemic in the United States,” which stated, “To inform planning for an influenza pandemic, we estimated the United States demand for N95 filtering facepiece respirators (respirators) by health care and emergency services personnel and need for surgical masks by pandemic patients seeking care.” It outlined how much personal protection equipment (PPE) would be needed for a pandemic. Bill Gates promoted our lack of preparedness often, and his TED talk from 2015 titled “The next outbreak? We’re not ready” is eerily telling.

Others increasingly sounded alarms to be prepared for a pandemic, but most stakeholders operated on a “just enough to get through a few days” supply. Our only real defense against a pandemic was to hope one didn’t happen.

As the virus spread earlier this year, physicians across the United States began to voice concerns to many of the hospital systems and other healthcare stakeholders about the fact that COVID-19 was coming to the United States based on the early available science and the R0 (“R naught”), which indicates how easily a disease spreads. They spoke to their business-minded colleagues and tried to teach and to advocate.

They attempted to keep themselves, their staff, and the public as safe as possible. If they were not terminated, they were ridiculed. Across the country, it was the same story. “Don’t talk about it.” “Here is the new policy.” “Wear a surgical mask for a week or until it is visibly soiled.”

Physicians were communicating in real time with colleagues in other countries. From their own scientific backgrounds, many assessed that this would be a significant event and that testing and PPE would be critical. These physicians watched in shock as they heard messages that the virus would not be a big deal or would be contained. When they tried to explain the early science to others, they were chastised for fear-mongering or being political. The psychology was obvious and detrimental. People did not want to believe that something horrible was actually happening.

Physicians attempted to educate, but that depended on the approval of their public relations department to approve educational posters.

Common-sense suggestions such as baby monitors to monitor COVID-19 patients to preserve the PPE for frequent staff checks were shot down or lost in red tape. Many clinic staff could work remotely while performing telemedicine, but this decision was not left to the physicians. Despite physician warnings that many already suspected COVID-19 was present and replicating in our country, the lack of testing caused physicians across the United States to be “flying blind” as to what the true disease prevalence actually was, and day to day business rolled on. There was no focus on education or prevention.

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Many took to social media to try to forewarn the public, while the early public messages they heard indicated that the virus would be contained were incongruent with reality. They knew health care workers were dying at a greater rate overseas and that it was likely due to increased exposure to high viral loads and increased length of time around the sickest people. They also knew that health care workers were getting sick and succumbing to the illness due to the lack of PPE and that the PPE acquired overseas was faulty many times. While publicly called heroes, physicians were being silenced and left unprotected. Many said they felt stabbed in the back, and indeed, in ways, they had been.

Plenty of physicians were proactive and bought PPE for themselves, but were not allowed to wear it because institutions or employers told them that it would scare the patients. One Mississippi physician stated he was terminated because of trying to discuss proper infection control with his hospital administration and that he had his mask pulled from his face by an infectious disease nurse. Perhaps, if asked, many physicians would have shared their individual PPE supplies if they had been more included in the various task forces, run primarily by executives.

Perhaps they could have developed a network to ensure that PPEs never stopped flowing until production ramped up or re-use protocols were found to be safe. Our national lowering of safety standards would never have occurred. As physicians began to change their collective management of COVID-19, utilizing ventilating as a method of last resort, the American Hospital Association and their executives across the nation were working closely with Washington, D.C., on ventilator production and distribution. While ventilators were definitely needed then, and are still needed going forward, many doctors were scratching their heads as the need for PPE remained dire. Without PPE, health care workers would either get sick, die, or spread the disease to others, including their own families or their community.

On April 25, the Prime Minister of Canada, Justin Trudeau stated, “I don’t think we should be reopening any sector of the economy until there is enough personal protective equipment for businesses to fight the coronavirus.” He alluded to “planeloads” of PPE being delivered soon and domestic production being ramped up. Where is this conversation in the United States, and where is the focus on the American health care worker? While the timeline for the economy to be opened up is one that can be debated, the fact is, that at the time the ventilators were being mass-produced, PPE could have been produced as well in anticipation of reopening the economy. Yet, it was not, and in fact, our PPE was still being shipped to countries overseas. This was alarming to many American physicians.

Everyone wanted to help, but organizations and governments were left to compete with people all over the globe for the PPE they did not have. Our United States health care structure was such that physicians had a difficult time leading medical decision making as well as public messaging, as politicians and hospitals primarily generated the verbiage regarding our nation’s COVID-19 response. It is hard to convince the public that this is a deadly virus, and they need to take it seriously and change their behaviors when they hear constant mixed messaging. Currently, personal liberties are of concern, and protests are ongoing, and most physicians who also value freedom and a thriving

economy also see the continued spread of disease. A graduated return of the economy will come, but it will be a return to a new normal.

There is currently not enough PPE to protect the United States health care workforce, to take care of all the people who would fall sick from an immediate return to prepandemic activity without safeguards in place, and this would likely lead to catastrophic economic failure and subsequent secondary health effects. Effective re-use strategies are gaining steam, and production is finally increasing. We are currently at what has been dubbed by the health department as “modified crisis level PPE” in our daily jobs using single-use PPE for a week or longer, etc. Once properly protected to fight COVID-19, which will unfortunately and undoubtedly occur once we are in a plateau phase and not before any peak, contact tracing and testing will be an important piece in managing outbreaks. This will allow us to get by until there is a reasonable therapy and/or vaccine.

The power of physician foresight is important in realizing this is a marathon and not a sprint. We should stop stumbling around in the dark and turn on the flashlight of organized medicine. We are taught to put ourselves last, but now we must evaluate our priorities. First, identify who you are and what is important to you. What is going to happen next? What do we, the physicians, want the new normal to be?

Your family and your health are important. It is not now and has never been ok for anyone to ask you to work in an unsafe environment or to do something that endangers your health and wellbeing or that of your family. We should make sure we know what we are comfortable with and what our boundaries are ahead of time, and then respect them. As things are shifting, practice saying, “No” and setting personal boundaries. It is good medical decision making and absolutely acceptable to say, “No” to unsafe practices. Even if we as health care workers contract the virus and are asymptomatic, we can infect. We should study the things we thought were necessary in life versus what really is.

We all recognize the economic crisis is real and will affect us in many ways. Many physicians are concerned about the Relative Value Unit (RVU) model of pay and coding. While these are extremely important concerns, telemedicine is here to stay in some capacity and will be an important social distancing tool in dealing with COVID-19. We know there is surgery that has to happen, and we need to decide what that will look like and how we will serve our patients first. The economics of medicine is important to public health but cannot be the primary driver during an infectious health crisis. Financial times will be tight, and hospitals and other employers will be significantly strained. The government is trying to mitigate that impact as much as possible by opening up as much as they can and as safely as they can, but we know that the virus will still be around, and people will not be spending money like they were for a long time. There will be significant financial difficulty, and we need to start now deciding how we will move medicine forward and stand up for our profession and redefine it. Now is the time to work on getting rid of what was negatively affecting medicine and add back the things that make it better. We have a golden opportunity to make medicine better for all involved parties but, most importantly, for the patients. As we attempt to return to some semblance of normal with a graduated return and a heavy focus on social distancing, masks, public health expertise, technology, etc., we should be thinking about

what makes us happier people and better physicians. Then we should be working to improve and expound on that. There will always be a role for physicians, but what do we want the practice of medicine to be?

Never again will physicians wear garbage bags and bandanas to fight such a horrible virus. Never again will we wear masks meant for a single use for a week or until they are visibly soiled. Never again will our altruism be used against us. We will lead. We lost precious time in our nation’s response because the health care experts at the table, in most instances, were not physicians. The CDC published crisis regulations based on available supplies and not standard regulations based on safety. This caused many to lose trust that anyone cared about their safety or the safety of their families. It was a defining moment in modern medicine. In the eye of the storm, we face a moment of clarity right now. Physicians, I encourage you to think about who and what is important, and then to go after those things! While we advocate against the negatives, it is up to us to make a joyful, functional return to the basics of a doctor/patient relationship where physician expertise is respected, and burnout is nonexistent.

In closing, I urge you to take the time to proactively determine what your boundaries are in taking care of COVID-19. Will you treat without proper PPE? Think through what it means to code a COVID-19 patient, or to perform an aerosol-generating procedure without PPE and how infectious that is to yourself and surrounding staff without standard protection. Assess the situation beforehand and make sure you have appropriate protection and that you will wear it before rushing in because you can help no one if you are quarantined or sick.

Please decide before that emotional moment happens what your plan will be and stick to it. All of that is practicing good and ethical medicine for the benefit of the patient and others. If antibody testing rolls out without evidence as a purported means for those infected to return to work, how will you respond? We cannot abandon our evidence-based medicine approach to disease as we simultaneously attempt to restart the economy with a cautious and measured approach following the advice of our public health experts and our elected officials. We cannot rush forward without proper PPE and turn our backs on the safety of the entire health care team and the public. This is the time for physicians to LEAD. I look forward to being with you on the journey as we seek the new normal of the physician-led team who not only leads through a pandemic, but is healthy, happy, and professionally fulfilled on the other side of it. A healthy physician is one who makes good medical decisions. We CAN stop the culture of burnout. Keeping patients first, we must find a way to forge a new normal that makes sense. You are so cherished as an individual and as a physician. Society needs you, and we need the BEST you. Our crystal balls are dark. We cannot see the future, BUT we can turn on the flashlight of organized medicine and take a much-needed look around as we move forward together. I invite you to join us as we stand up for physicians and patients. Organized medicine has your back. n Jennifer Joiner Bryan, MD Chairman of the Board of Trustees, Mississippi State Medical Association

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M S M A

Welcoming Our Newest Members

Chelsea Mockbee, Jackson, Internal Medicine

Frederick Sailes, Madison, Plastic Surgery

Casey Murphy, Pascagoula, Physical Medicine & Rehabilitation

Miguel Villalobos, Jackson, Vascular Surgery

Charles Richardson, Hattiesburg, Psychiatry MISSISSIPPI STATE MEDICAL ASSOCIATION MSMAonline.com

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

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M I S S I S S I P P I

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The Science Hall in July 1908: Another View of the First Medical School Building at Ole Miss — After the Legislature appropriated $40,000 for the construction of a “science hall” in 1906, this four-story brick structure was erected in Oxford and soon occupied by the Department of Medicine. (The designation “School of Medicine” rather than department first appears in the 1924-5 Ole Miss catalog.) This frontal view, dated July 1908, features the freshly constructed Science Hall, which served as the home of the Medical Department and School from 1906-1907 to 1934 when the two-year school moved to Guyton Hall (which would serve as its home until it moved to Jackson in 1955 becoming a four-year school).

During the writing of his famous 1910 report on “Medical Education in the United States and Canada,” Abraham Flexner visited the school in November 1909. He noted that there were 8 professors, 3 of whom gave their entire time to the Department of Medicine, as well as 3 assistants. Flexner also described the laboratory facilities at that time: “Laboratories, adequate to the needs of instruction offered, are provided for physiology, pharmacology, histology, and anatomy; pathology and bacteriology are less satisfactory. Chemistry is well cared for in the university laboratory. The teachers need a larger number of competent assistants and helpers; a beginning has been made toward a departmental library.” The Science Hall had modern laboratories and a prominent basement that was crafted to contain a large concrete vat to store and preserve human cadavers. An elevator shaft, which had no elevator, was utilized with the aid of a block and tackle to hoist cadavers from their basement storage to the thirdfloor gross anatomy laboratory. In 1906 legislation was passed, which allowed unclaimed bodies at Mississippi hospitals to be given to the university for anatomical study. By 1918, the “Ole Miss” annual would refer to this massive structure as the “Medical Building.” This building no longer stands and photographs show it during its more than fifty-year life in the heart of the Ole Miss campus, on University Circle south of the Confederate statue, near present-day Hume and Shoemaker Halls. (See related image of Science Hall in JMSMA Vol. 60, 11/12, 2019, page 364.) This month concludes my several issues focus on Ole Miss’s two-year School of Medicine. If you have an old or even somewhat recent photograph which would be of interest to Mississippi physicians, please send it to me at lukelampton@cableone.net or by snail mail to the Journal.

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

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P o e t r y

a n d

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Edited by Lucius Lampton, MD; JMSMA Editor

[This month, we print a double truck poetic tribute to the impact of COVID-19 on our lives. Double truck, a journalism term, refers to a pair of facing pages, with content that stretches over both pages. Both poems are parodies of other more famous odes, both inspired by the recent arrival of coronavirus on our shores. An ode is a lyric poem, sometimes meant to be sung , which is an address to a particular subject or person, often elevated in style and feeling and written in varied or irregular meter. The first is offered up by the one and only Dr. Dwalia South of Ripley, past MSMA president, past JMSMA Associate Editor, Publications Committee Chair Emeritus, and current member of the State Board of Health. South gives her apologies to Dr. Seuss for this Seussian fun, and notes, “It was tough to find 20 rhyming words for everywhere!” The second ode is a clever take on a haunting Mississippi classic by JMSMA Associate Editor Philip Merideth of Jackson. He explains: “These lines were inspired by the number one hit song (and movie) ‘Ode to Billie Joe’ that was written and recorded by Mississippi Delta native Bobbie Gentry in 1967. These lines are offered in solemn tribute to the victims of the COVID-19 pandemic and to the health professionals who cared for them.” In 2001, Rolling Stone magazine listed “Ode to Billie Joe” among the 500 Greatest Songs of All Time. 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.

Ode de Corona Long before spring was in the air We were told we should beware Of a tiny little virus, once new and rare, That now seems to be almost everywhere.

At first, folks didn’t seem to care…

“That bug is in China, way over there!”

“No harm will come to us!” they’d swear.

But quickly we soon became aware That coronavirus is a sho’nuff BEAR! Though social distancing seems so unfair This virus gone ‘VIRAL’ is easy to share— From eyes, mouth, noses and even our hair; Hugging and kissing should give you a scare.

Of sneezes and squeezes you must beware…

And masks and gloves we all now must wear…

Leaving them off is like being bare!

So now that you’ve got time to spare Just sit down in your easy chair— Sanitize those hands and send up a prayer, ‘Cause Jesus and germs are everywhere!

—Dwalia South, MD Ripley

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COVID to Billie Joe (with apologies and credit to singer/songwriter Bobbie Gentry) It was the sixth of June, another sticky, steamy Delta day I was shoppin’ for some Charmin and Brother was lookin’ for some pay At dinner time we drove back to the house, and oh lands, Mama hollered out the back door, y’all remember to wash your hands And then she says, I got some bad news this mornin’ from Choctaw Ridge ‘Cause Billie Joe McAllister’s low sick at Tallahatchie Bridge Then papa says to mama, as he touched his face and tried not to sneeze Billie Joe’s a sickly boy, never had a lick of immunity; pass the Kleenex, please There’s only five more rolls of toilet paper we’ve got left in the house now And mama said it was a shame about the folks in New York, anyhow Seems like nothin’ ever comes to no good durin’ the COVID anyway And now Billie Joe’s caught it at Tallahatchie Bridge today Next off, Brother said he recollected when he, Cousin Tom, and Billie Joe Poured a Co’ Cola down my back at the midnight picture show And he says wasn’t that me Zoomin’ with Billie Joe after video church last Sunday night?

I’ll have another Lysol wipe, please; you know, if I got it right I saw him not mindin’ the social distancin’ last week on Choctaw Ridge And now Billie Joe’s fell out at Tallahatchie Bridge And then mama says to me, child, you lost your appetite?

You been coughin’ all mornin’, and you haven’t eaten a single bite That nice young Gov’nor was on the news again today Said he’d be pleased to re-open the schools in August, and oh, by the way Cousin Tom said he heard yesterday a girl that looked a lot like you was up on Choctaw Ridge And she and Billie Joe were talkin’ mighty close at Tallahatchie Bridge Well, a year has come and gone since we heard ‘bout the President election and Uncle Joe And Brother married that ER nurse; they’re sellin’ medical stuff online in Tupelo There was another bunch of the COVID and papa was saved by that breathin’ machine Billie Joe’s not the same and doesn’t want to do much of anything And me - I’m OK now; spendin’ a lot of time daydreamin’ up on Choctaw Ridge Just hopin’ to see Billie Joe feelin’ better again at Tallahatchie Bridge —Philip Merideth, MD, JD Jackson

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Join the

MISSISSIPPI TELEMEDICINE NETWORK

Mississippi physicians in need of a telemedicine solution to treat patients have a new option thanks to a partnership between the Mississippi State Medical Association (MSMA) and telehealth platform, AZOVA. The COVID-19 pandemic has emphasized the need of both physicians and patients to have safe and reliable access to care at a distance.

Physicians who use AZOVA’s digital health system will be able sign up and create a telemedicine presence in as little as 20 minutes. Many Mississippi physicians may already have access to telemedicine platforms through their hospital or health system, but several are not in an existing telemedicine network or one that meets their needs. Through this partnership with AZOVA, MSMA can leverage the Mississippi network to negotiate contracts with payers, government agencies, and other entities to more appropriately reimburse Mississippi physicians for services offered through the digital network.

In addition to providing this critical resource for physicians, the AZOVA digital health network allows patients to find physicians online and register for eVisits and in-office services. AZOVA provides physicians and patients a reliable marketplace to access healthcare remotely, including specialists who they may have otherwise traveled great distances to see for an office visit.

“Access to telemedicine systems has been a significant barrier for many of our physicians, particularly those working in rural areas of the state,” said Claude Brunson, MD, executive director of MSMA. “This partnership with AZOVA will enable physicians to safely evaluate patients with COVID-19 symptoms and reduce risks for medical staff and other patients, especially those with chronic diseases and conditions that make them high risk.”

AZOVA awarded MSMA a generous grant which covers the cost of subscriptions to establish a digital physician telemedicine network that will connect physicians across the state through digital collaboration and communication technology. This offering will allow all physicians access to robust, user-friendly tools to enhance their practice. According to a recent survey of Mississippi physicians conducted by MSMA, telemedicine equipment and subscriptions is one of the primary expenses physicians have incurred during the COVID-19 pandemic.

“There is an urgent and immediate need to implement telemedicine systems across the state to keep patients safe and ensure they get the treatment they need,” said Jennifer Bryan, MD, chair of the MSMA Board of Trustees. “We also believe this partnership is an important step for Mississippi as we seek to improve long-term health outcomes. When more physicians are able to use telemedicine, more patients have access, and, ultimately, our state is healthier.”

MSMA is encouraging all physicians join the network for a number of reasons, including: 1. When the Mississippi Telehealth Network has representation across the state, physicians develop stronger negotiating power to get reimbursement for services, which allows physicians to compete with the national telemedicine companies.

2. A larger digital provider network means more opportunities for Mississippi physicians to participate.

3. MSMA can connect the entire state through a single technology to offer telehealth services to any patient or facility who needs care, and physicians can securely message, share records, and collaborate in patient care together.

AZOVA has waived initial sign-up fees for physicians to help all physicians access the platform. Instead, the company will charge a nominal fee per patient encounter to physicians for the service. For more information on this partnership or MSMA, visit www.msmaonline.com. For more information on AVOZA, visit www.azova.com.

Small Town Mississippi Greenwood Leflore Hospital, a 208 bed, Level IV trauma center has proudly served the heart of t he Mississippi Delta since 1906. We serve as a regional referral center for a range of medical specialties including Anesthesiology, Cardiology, Diabetes Education, Emergency, Family Practice, Gastroenterology, General Surgery, HIV, Internal Medicine, Interventional Radiology, Medical Oncology, Neurology, Neurosurgery, Obstetrics/Gynecology, Orthopedic Surgery, Otolaryngology, Pain Management, Pathology, Pediatrics, Podiatry, Pulmonology, Radiation Oncology, Radiology, Rehabilitation, Sleep Disorders, Vascular Surgery, Urology, and Wound Care.

Greenwood Leflore Hospital is expanding services and is seeking physicians in the following specialties. We are interested in physicians who are immediately available or those who are near completion of training in: • • • • •

Emergency Medicine Family Medicine General Surgery Hospitalist Internal Medicine

• • • • •

OB/GYN Orthopedic Surgery Otolaryngology Pediatrics Urology

The city of Greenwood and our community hospital offer: • Balance of Work and Life • Community Events • Historic Downtown Rich in Blues, Arts, Culinary Experiences • Abundance of Outdoor Recreation (hunting & fishing) • Loan Repayment • Competitive Salary • Sign On Bonus • Moving Expenses

For information regarding career opportunities, please contact physician recruiter, Lea Denton at 662-459-7113 or ldenton@glh.org.

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