October 2011 JMSMA

October

VOL. LII

2011

No. 10

Lucius M. Lampton, MD Editor D. Stanley Hartness, MD Richard D. deShazo, MD Associate Editors Karen A. Evers Managing Editor

Publications Committee Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD, Ex-Officio Myron W. Lockey, MD, Ex-Officio and the Editors The Association Thomas E. Joiner, MD President Steven L. Demetropoulos, MD President-Elect J. Clay Hays, Jr., MD Secretary-Treasurer Lee Giffin, MD Speaker Geri Lee Weiland, MD Vice Speaker Charmain Kanosky Executive Director

Journal of the Mississippi State Medical Association (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual).

Periodicals postage paid at Jackson, MS and at additional mailing offices.

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

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

Advertising rates: furnished on request. Cristen Hemmins, Hemmins Hall, Inc. Advertising, P.O. Box 1112, Oxford, Mississippi 38655, Ph: (662) 236-1700, Fax: (662) 236-7011, email: cristenh@watervalley.net POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 391582548.

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

Copyright© 2011 Mississippi State Medical Association.

OCTOBER 2011

VOLUME 52

NUMBER 10

Scientific Articles

Neu-Laxova Syndrome: A Prenatal Diagnosis

307

Top 10 Facts You Need to Know About Head and Neck Cancer

310

Clinical Problem-Solving: A True Mystery Diagnosis

312

Pushpinder Dhillon, MD and James A. Bofill, MD

Tanima Jana, MD and Karen T. Pitman, MD

Martha Dempsey, MD

President’s Page

Reflections on Summer’s End

330

Thomas E. Joiner, MD; MSMA President

Special Articles

Mississippi County Health Rankings 2011: Improving Health in Your Community

322

Karen A. Evers, Managing Editor

Editorial

Elephant in tHe Exam Room

331

D. Stanley Hartness, MD; Associate Editor

Related Organizations

Mississippi State Department of Health MSMA Annual Session Survey MSMA Alliance

316 327 333

Departments

Correction New Members Images in Mississippi Medicine Poetry in Medicine The Uncommon Thread Placement/Classified

309 326 329 334 335 336

About The Cover:

“Boil Them Cabbage Down” — This photo was taken in Jonesborough, Tennessee, during the 2010 National Storytelling Festival. This annual event began in 1973 with about 60 in attendance and has grown annually to crowds approximating 10,000 to 15,000 during the first week of October each year. Mississippian Jerry Clower was the inspiration for the idea of a Storytelling Festival and an early performer there.

A Jonesborough schoolteacher and his students started the Festival which is now truly an international event. The lively gathering includes other performances, including regional music. This photo was made in front of the Jonesborough courthouse where buskers perform for passing crowds of festivalgoers. The handsome young man’s name is Todd Fishman Elliott. He and his father performed several old-time mountain tunes for the delighted audience. Photo by Dwalia South, MD; Ripley. r October

VOL. LII

Official Publication of the MSMA Since 1959

2011

No. 10

October 2011 JOURNAL MSMA 305

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Defense of Claims 306 JOURNAL MSMA

October 2011

• Scientific Articles • Neu-Laxova Syndrome: A Prenatal Diagnosis Pushpinder Dhillon, MD and James A. Bofill, MD

A

bstract

Neu-Laxova syndrome is a rare autosomal recessive congenital disorder.1 Prenatal diagnosis is possible via second trimester ultrasonography. Characteristic ultrasound findings include hydramnios, severe intrauterine growth restriction, craniofacial and CNS anomalies, limb contractures, skin lymphedema, skin restrictions, and akinesia.2 Fewer than 70 cases have been reported, and no survival beyond six months of age is known with most neonatal deaths occurring within the first few days of life. Overall, this is a lethal condition after birth secondary to severe lung hypoplasia and brain anomalies. Herein we report a recent case from our institution with prenatal diagnosis.

Key Words: Intrauterine growth restriction,

Case

polyhydramnios,

craniofacial anomalies

A 26-year-old African-American patient, gravida 5 para 2, presented to our tertiary referral institution at 30 weeks 6 days gestation secondary to preterm premature rupture of membranes with significant vaginal amniotic fluid loss over the last 24 hours. Ultrasound examination demonstrated normal amniotic fluid volume suspicious for hydramnios prior to rupture of membranes. Fetal biometry noted severe intrauterine growth restriction (estimated gestational age 23 weeks 3 days). Sonographic findings related to the fetal cranium included microAuthor Information: Dr. Dhillon - Fellow, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson. Dr. Bofill - Faculty, Department of Obstetrics and Gynecology, Fellowship Program Director, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson.

Corresponding Author: Pushpinder Dhillon, MD, Department of Obstetrics and Gynecology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216.

cephaly (fetal head circumference more than 4 standard deviations below the mean), absent cavum septi pellucidi and agenesis of the corpus callosum. The fetal cerebellum could not be clearly visualized or measured. The fetal face demonstrated a sloping forehead, micrognathia, a persistently open mouth (Figure 1), hypertelorism with protruding eyes and no visible eyelids. There was a corneal opacity of one eye which was suspicious for cataract formation. Other ultrasound findings included lymphedema (Figure 2) over all body surfaces and rocker-bottom feet. Most impressive was the lack of fetal activity (akinesia) throughout the course of the ultrasound examination.

An amniocentesis was performed to ascertain the fetal karyotype and to rule out an intrauterine infectious process.

The patient was counseled about our prenatal diagnosis of Neu-Laxova syndrome and the lethal nature of the disorder.

Induction of labor was initiated without fetal monitoring and with no plans for intervention for fetal indications. A stillborn female was delivered with a weight of 711 grams. Autopsy findings were entirely consistent with the prenatal diagnosis.

Detailed neuropathological examination demonstrated marked hypoplasia of the cerebral cortex with lissencephaly and a brain weight of only 19 grams (average for this gestational age is 163 grams). The cerebellar vermis was absent, and the hemispheres were hypoplastic. The pontine nuclei and crossing fibers were absent. The fetal face demonstrated that the eyelids were absent bilaterally as were the eyelashes. Exophthalmos was noted but was not as impressive as expected from the ultrasound images.

The fetal mouth was in a fixed open position. The hard palate was high arched but without defect. There was an impressive generalized edema and skin appeared shiny. A rocker-bottom foot and underdeveloped female genitalia were noted (Figure 3). The placenta weighed 190gms (478gms is normal for this gestation age) which is consistent with small placenta as reported by other authors. The final diagnosis was Neu-Laxova syndrome (Figure 4).

October 2011 JOURNAL MSMA 307

Discussion

The classic features of Neu-Laxova syndrome include severe IUGR, limb contractures, microcephaly, craniofacial abnormalities, CNS anomalies, skin edema, and absent or retracted eyelids which produce an exophthalmic appearance.2-5 The prenatal diagnosis can be made in second or third trimester of pregnancy with high-resolution ultrasound by an experienced examiner. A review of literature describes polyhydramnios and severe IUGR as the first signs of concern which should lead the primary level sonographer to seek further investigation and referral to a tertiary diagnostic center.5 In Neu-Laxova syndrome, IUGR and microcephaly will be nearly uniformly present.2 The typical CNS abnormalities include lissencephaly, agenesis of corpus callosum, and cerebellar hypoplasia.6 In this syndrome the facial appearance is striking, and features such as a slanting forehead, absent or retracted eyelids, exophthalmia, hypertelorism, a flat nose, and a persistently open mouth are typically visualized with ultrasound.2,4,9 Generalized skin lymphedema can give hands and feet an “inflated rubber gloves� appearance.3 Limb contractures are usually attributable to akinesia and skin edema since early development. 2 Rocker-bottom feet are commonly noted. Genitalia are usually underdeveloped.2,3 All these findings were present in our case.

In Neu-Laxova syndrome there are frequently multiple internal organ abnormalities including lung hypoplasia, a small or absent stomach, renal agenesis and other genitourinary abnormalities.3 However, the CNS and craniofacial findings are the most significant for differentiation from other maladies such as cerebro-oculo-facio-skeletal syndrome (COFS), PenaShokeir syndrome, Roberts syndrome, cerebroarthrodigital syndrome and Miller-Dieker syndrome. Many reported cases were significant for consanguinity or a history of previous affected sibling which suggested an autosomal recessive mode of inheritance for Neu-Laxova syndrome.7, 10 Arabic ethnicity may be a possible risk factor for Neu-Laxova syndrome, but consanguinity within these kindreds has not been well studied.

In our own case the patient denied any possibility of consanguinity, and her two previous children from the same partner were healthy.

Figure 1. Persistently open mouth

Figure 2. Scalp edema

Figure 3. Rocker-bottom foot, underdeveloped genitalia

Conclusion

Severe fetal IUGR, microcephaly, hydramnios, akinesia and lymphedema, singly or in any combination, demand a detailed fetal anatomic survey by a diagnostic team experienced in the prenatal diagnosis of congenital syndromes. Craniofacial and CNS abnormalities with akinesia are the hallmarks for the diagnosis of Neu-Laxova syndrome. Genetic amniocentesis for fetal karyotype is recommended to exclude any chromosomal aberrations. If the prenatal diagnosis of Neu-Laxova syndrome is made or strongly entertained the parents should be counseled regarding the lethal prognosis.

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References 1.

Neu RL, Kajii T, Gardner LI, Nagyfy SF. A lethal syndrome of microcephaly with multiple congenital anomalies in three siblings. Pediatrics. 1971;47:610-2.

Figure 4. Neu-Laxova syndrome

6.

7.

8.

9.

Ostrovskaya TI, Lazjuk GI. Cerebral abnormalities in the NeuLaxova syndrome. Am J Med Genet. 1988;30:747-56

Ugras M, Kocak G, Ozcan H. Neu-Laxova syndrome: a case report and review of the literature. J Eur Acad Dermatol Venereol.

2006;20:1126-8.

Hickey P, Piantanida E, Lentz-Kapua S, Kenner J. Neu-Laxova syndrome: a case report. Pediatr Dermatol. 2003;20:25-7.

Driggers RW, Isbister S, McShane C, Stone K, Blakemore K. Early second trimester prenatal diagnosis of Neu-Laxova syndrome. Prenat Diagn. 2002;22:118-20.

10. Dilli D, Yaşar H, Dilmen U, Ceylaner G. Neu-Laxova syndrome in an appropriate for gestational age newborn. Indian J Dermatol Venereol Leprol. 2008;74:487-9.

2.

3.

4.

5.

Manning MA, Cunniff CM, Colby CE, El-Sayed YY, Hoyme HE. Neu-Laxova syndrome: detailed prenatal diagnostic and post-mortem findings and literature review. Am J Med Genet A. 2004;125:240-9.

Coto-Puckett WL, Gilbert-Barness E, Steelman CK, Stuart T, Robinson HB, Shehata BM. A spectrum of phenotypical expression of Neu-Laxova syndrome: Three case reports and a review of the literature. Fetal Pediatr Pathol. 2010;29:108-19.

Mihci E, Simsek M, Mendilcioglu I, Tacoy S, Karaveli S. Evaluation of a fetus with Neu-Laxova syndrome through prenatal, clinical, and pathological findings. Fetal Diagn Ther.

2005;20:167-70.

Martín A, Eguiluz I, Barber MA, Medina N, Plasencia W, GarcíaAlix A, García-Hernández JA. A rare cause of polyhydramnios: Neu-Laxova syndrome. J Matern Fetal Neonatal Med. JNLMSMedBW-3 2006;19:439-42.

Correction Error in Text: In the Special Article entitled “When Time is Muscle: An Update on Mississippi’s STEMI System of Care Plan” published in the September 2011 issue of the JMSMA (2011;52[9]:295), the sixth sentence of the the photo legend for Robert Galli, MD addresses the Mississippi Task Force on Heart Disease and Stroke Prevention should read, “The stroke system is an example of the drip and ship coordinated system of care that is vital because if you have to drive 2 hours to get to a cath lab you’ve lost 2 of the 3 critical hours in which the new stroke meds must be administered,” he said.

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October 2011 JOURNAL MSMA 309

• Top 10 • Top 10 Facts You Need to Know About Head and Neck Cancer Tanima Jana, MD and Karen T. Pitman, MD

I

ntroduction

Head and neck cancers, whose multidisciplinary care is treated by otolaryngology-head and neck surgeons, encompass a heterogenous group of cancers and involve multiple sites, including the nasal cavity, nasopharynx, sinuses, oral cavity, oropharynx, lip, larynx, laryngopharynx, salivary glands, thyroid and skin (Figure 1). In the United States, approximately 30,000 of these cases are diagnosed annually with nearly 10,000 deaths per year.1 Conducting a thorough history and physical exam and identifying risk factors are the keys to early detection and reduction of treatment-related morbidity and disease-related mortality.

Figure 1. Key head and neck anatomy

1. Clinical Presentation Clinical symptoms reflect the anatomic site or origin.

While pharyngeal cancers may present with sore throat or dysphagia, laryngeal cancers often present with hoarseness.2 Other head and neck cancers may only present with lymph nodes in the neck or localized pain. While these symptoms may be the result of a benign condition, they should not be underestimated and should be thoroughly investigated.

2. Warning Signs The presence of “red-flag” signs or symptoms warrants immediate referral to a specialist for further evaluation. These “red flags,” which include 3 or more weeks of any of the following: unilateral otalgia, sores in the mouth, difficulty chewing, swallowing, or moving the tongue or jaw, persistent hoarseness, sore throat and neck masses,2-4 may be indicative of a serious underlying condition.

3. History and Physical Examination Head and neck primary cancers can be detected on routine physical examination in 80% of cases.5 A complete physiAuthor Information: Dr. Jana is a recent graduate of the University of Mississippi School of Medicine. Dr. Pitman is Professor in the Department of Otolaryngology and Communicative Sciences at the University of Mississippi Medical Center in Jackson.

Corresponding Author: Karen T. Pitman, MD, Department of Otolaryngology and Communicative Sciences, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216. Phone: (601) 984-5160.

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cal exam includes palpation of the entire neck for lymph nodes, examination of the scalp and entire oral cavity (tongue, floor of mouth, hard palate, gums, buccal mucosa, tonsils), removal of dentures, examination of the nose and ears, and flexible laryngoscopy.2 A thorough history and physical examination is integral to achieving early detection.

4. Smoking and Alcohol The biggest risk factors for head and neck cancers are smoking and alcohol.2,3,5-7 Seventy-five percent of head and neck squamous cell cancers (HNSCC) have been linked to smoking and alcohol,2,5 although non-smokers are also at risk.

The incidence of a second cancer has been reported as 6% in patients who stop smoking and as high as 40-60% in patients who continue to smoke.5 These are preventable risk factors, and cessation should be emphasized to patients not only to promote primary prevention, but also to decrease chances of recurrence.

5. Human Papillomavirus (HPV) HPV infection is a prominent risk factor in head and neck cancers, particularly oropharyngeal carcinoma. In the United States, HPV, primarily HPV-16,2-3,6-10 is responsible for 40-80% of oropharyngeal cancers.10 These patients tend to be younger in age (40-50 years), often do not have significant smoking or alcohol history, and usually present with a small primary tumor and large neck lymph nodes.2 This information is useful in promoting early detection and treatment by properly screening, evaluating, and educating patients who were not previously considered “at-risk” individuals.

6. Diet Diets high in fruits and vegetables may decrease the risk for head and neck cancers.2-3,6-8,11-13 Studies show that this may be due to the presence of antioxidant vitamins and carotenes in these foods.6-7,13 Diet is a modifiable risk factor and is important to address when counseling patients about the importance of maintaining a healthy lifestyle.

7. Genetics Patients with a family history of head and neck cancer in a first-degree relative have a 1.7 to 8-fold 2,7 increased risk of developing the disease themselves.2-3,7,10-11 Obtaining a complete family history is imperative to identify at-risk individuals and increase the chances of early detection.

8. Trends Up to 5.5% of HNSCC patients worldwide are less than 40 years of age.11 While many head and neck cancer patients have a significant history of smoking and alcohol usage, trends are changing, and many new diagnoses are being made of younger patients in the 30–50-year-old age group who have no smoking or alcohol history.2 It is crucial that physicians pay close attention to critical signs and symptoms in patients of this age group.

9. Prognostic Factors HPV-positive HNSCC are believed to have a better prognosis and respond better to treatment than those that are HPVnegative.3,6,8-10,14 This is an important factor to discuss when counseling and educating patients.

10. Mortality Death rates of head and neck cancers tend to be high, in part due to delays in diagnosis until disease advancement.15 Fiveyear survival rates for early stage (Stages I and II), localized tumors are in the range of 80-90%, yet only 33% of head and neck cancer patients are diagnosed in early stages.4 More commonly, patients show evidence of neck metastases at the time of diagnosis, which downgrades the overall prognosis by approximately 50%. About 10% of head and neck cancer patients will have evidence of distant metastases at the time of diagnosis and have less than 20% five-year survival rates. Early detection is the key

to reducing morbidity and mortality related to these cancers.

Conclusion

Primary care physicians play an enormous role in the evaluation and subsequent screening of patients with head and neck cancers. Most patients with head and neck cancers present to their dentist or internist first.5 A thorough history and physical exam is the key to recognizing risk factors and warning signs and symptoms. It is essential that primary care physicians urgently refer patients to a specialist if they have any “red flag” signs or symptoms (Table 1). Morbidity and mortality are closely linked to stage at diagnosis;1 therefore, early detection is the key to optimizing quality of life and increasing survival.

Table 1. “Red flag” Signs or Symptoms

Table 1. “Red flag” Signs or Symptoms Unilateral otalgia Sores in the mouth Difficulty chewing, swallowing, or moving the tongue or jaw

Persistent hoarseness Persistent sore throat Neck masses

References 1.

2.

3.

4.

5.

6.

7.

8.

9.

Shuman AG, Entezami P, Chernin AS, et al. Demographics and efficacy of head and neck cancer screening. Otolaryngol Head Neck Surg. 2010;143:353-360.

Mehanna H, Paleri V, West CML, et al. Head and neck cancer- part 1: epidemiology, presentation, and prevention. BMJ. 2010;341:663-666.

Day TA, Chi A, Neville B, et al. Prevention of head and neck cancer. Curr Oncol Rep. 2005;7:145-153.

Genden EM, Rinaldo A, Bradley PJ, et al. Referral guidelines for suspected cancer of the head and neck. Auris Nasus Larynx. 2006;33(1):1-5.

Jacobs C. The internist in the management of head and neck cancer. Ann Intern Med. 1990;113:771-778.

Döbrossy L. Epidemiology of head and neck cancer: magnitude of the problem. Cancer Metastasis Rev. 2005;24:9-17.

Sturgis EM, Wei Q, Spitz MR. Descriptive epidemiology and risk factors for head and neck cancer. Semin Oncol. 2004;31:726-733.

Goon PKC, Stanley MA, Ebmeyer J, et al. HPV & head and neck cancer: a descriptive update. Head Neck Oncol. 2009;1:36.

Chung CH, Gillison ML. Human papillomavirus in head and neck cancer: its role in pathogenesis and clinical implications. Clin Cancer Res. 2009;15:6758-6762.

10. Marur S, D’Souza G, Westra WH, et al. HPV-associated head and neck cancer: a virus-related cancer epidemic. Lancet Oncol. 2010;11:781-789.

11. Toner M, O’Regan EM. Head and neck squamous cell cancer in the young: a spectrum or a distinct group? Part 1. Head and Neck Pathol. 2009;3:246-248.

12. Freedman ND, Park Y, Subar AF, et al. Fruit and vegetable intake and head and neck cancer risk in a large United States prospective cohort study. Int J Cancer. 2008;122:2330-2336.

13. Suzuki T, Wakai K, Matsuo K, et al. Effect of dietary antioxidants and risk of oral, pharyngeal and laryngeal squamous cell carcinoma according to smoking and drinking habits. Cancer Sci. 2006;97:760-767.

14. Mehanna H, West CML, Nutting C, et al. Head and neck cancer- part 2: treatment and prognostic factors. BMJ. 2010;341:721-725.

15. Olli-Pekka A, Teppo H, Mäntyselkä P, et al. Head and neck cancer in primary care: presenting symptoms and the effect of delayed diagnosis of cancer cases. CMAJ. 2006;174:779-784.

October 2011 JOURNAL MSMA 311

• Clinical Problem-Solving • Presented and edited by the Department of Family Medicine, University of Mississippi Medical Center, Diane K. Beebe, MD, Chair

A True Mystery Diagnosis Martha Dempsey, MD A 14-year-old Caucasian male presented to his primary care provider in February with complaints of influenza type symptoms. A rapid influenza diagnostic test was positive so he was prescribed oseltamivir (Tamiflu).

Shortly after starting the medication, he began to exhibit bizarre behavior, confusion, excessive sleepiness, and initially he refused to eat. He did not have nausea, vomiting or headache, and his symptoms were constant with no fluctuation. His mother stated that he would sleep up to 24 hours a day and often only wake to go to the restroom.

He also experienced hyperphagia; once he began eating, he would eat only fruits, and it was often difficult to get him to stop. He also experienced paranoia, only talking to and trusting his mother. He seemed to be afraid of everything in his environment and even wanted his mother to sleep with him.

In a 14-year-old with these symptoms, I am concerned about an infectious process such as meningitis or encephalitis.

Given his age, I am concerned about possible ingestions or drug use. The paranoia is concerning for some sort of psychiatric disorder, such as schizophrenia or a personality disorder such as schizotypal or schizoid. Also, knowing that his mother is a nurse who has intimate knowledge of diseases and symptoms, I have to consider Munchausen’s syndrome by proxy as a possible explanation.

After 10 days the patient’s symptoms abated as he was recovering at home and no longer exhibited any of the odd and peculiar behaviors. He was able to return to school and resume his normal daily activities without any lasting effects. However, approximately 4 weeks after the initial problems began, he suddenly again exhibited his bizarre behaviors and his unusual symptoms. He was taken to his local hospital where he underwent a battery of tests including a lumbar puncture, electroencephalogram and a brain computed tomography (CT). A brain magnetic resonance imaging (MRI) was attempted but could not be obtained. He was discharged to the care of his mother. A Author Information: Dr. Dempsey is a Third Year Resident in the Department of Family Medicine at the University of Mississippi Medical Center, Jackson.

Corresponding Author: Martha Dempsey, MD; Family Medical Clinic of Orange Grove, 12330 Ashley Drive, Gulfport, MS 39503 Phone: 228-831-1572.

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blood test for West Nile virus, a lyme titer and a test for mononucleosis were negative.

Given the return of his symptoms, I have to worry about the possibility of a psychiatric illness. An intracranial structural lesion, such as tumor or abscess, also needs to be considered. He could also be suffering from an uncontrolled seizure disorder, and this could be repetitive absence seizures or status epilepticus. I need the scans and blood study results and a more detailed history from the mother, including any family or personal history of seizures or epilepsy.

Oseltamivir, an antiviral used to treat influenza, can cause neuropsychiatric events, such as confusion, delirium or self mutilation; however, these events are rare and are usually associated with encephalitis or encephalopathy.1 This patient did exhibit some confusion but no self mutilation, and there is some question as to whether this could actually be a delirium. Also, since his symptoms actually returned several weeks after resolving and several weeks after discontinuation of the oseltamivir, a drug reaction drops further down the list of my differential diagnoses. There is no documentation provided in the record of whether his flu symptoms resolved after taking the oseltamivir.

The results of his tests so far were negative for any abnormalities and results of a lumbar puncture were normal. There is no known family history of psychiatric illness, specifically schizophrenia or bipolar disorder. There are several family members that suffer from migraine headaches, including the patient’s father. There is no history of epilepsy in either the patient or his family members.

The normal lumbar puncture makes an infection such as meningitis or encephalitis less likely, and the normal head CT makes any structural abnormalities such as tumor or brain abscess less of a concern. An MRI would have also been helpful since it is a much better mode of imaging for showing structural abnormalities. At this point, a seizure disorder is still a possibility, so I would like to have a 24 hour video electroencephalogram (EEG). A drug test also needs to be performed since drug use is a possibility in this age group.

As before, the patient’s symptoms suddenly and spontaneously resolved after approximately 10 days without any lasting effect, but he again suffered another episode approximately 4 weeks from the last episode. The presentation and course of the illness were the same as the 2 previous episodes. In the interim, the patient was evaluated by a pediatric neurologist who was also perplexed. He

was concerned about possible delirium and psychosis as well, and the patient’s mother was advised to present to the emergency department of the children’s hospital for admission should he suffer another attack.

The patient and his mother presented for evaluation at the local children’s hospital 3 months after his initial presentation and beginning of symptoms. He was admitted to the children’s unit but a 24 hour video EEG failed to reveal any abnormalities. A repeat lumbar puncture was inconsistent with meningitis. Neurotransmitter studies returned normal. A urine drug screen was negative as was a test for urine porphyrins and mass spectroscopy.

With his normal video EEG, I am less concerned about a seizure disorder. Also given the normal interaction between the patient and his mother during the monitoring, the diagnosis of Munchausen’s syndrome by proxy is unlikely. The lumbar puncture did not indicate meningitis, and his negative mass spectroscopy and urine drug screen makes ingestion of drugs or other mind altering substance unlikely. The negative urine porphyrin makes the diagnosis of acute intermittent porphyria unlikely since this investigation is highly specific, even after a prolonged remission.2 He had a normal temperature, blood pressure, heart rate and respiratory rate. He also had a normal heart, lung and abdominal exam. On neurological exam, he was drowsy but arousable, with monotone, childlike speech. He appeared to be somewhat lethargic with a slow gait but he did respond appropriately when asked questions.

The patient had a normal electrocardiogram (EKG), and his Epstein-Barr virus titer was negative as was his streptozyme and anti-streptolysin O (ASO). His complete blood count was essentially normal with only a slightly elevated monocyte count of 14.1% on the differential.

Urinalysis was normal, and his chemistry panel showed an elevated alkaline phosphatase at 282 units per liter and essentially no other abnormalities.

His normal vital signs are reassuring, but his psychiatric exam is concerning. However, these findings do not shed any further light on this puzzling case. He does have a slightly elevated monocyte count of 14.1% (1%-10%). However, this is nonspecific and can be elevated in many conditions, including viral illnesses and malignancies. I am doubtful that he is suffering from a hematologic malignancy since all of the other complete blood count values are normal, and I would expect to see anemia or even pancytopenia in that case. His negative Epstein-Barr virus titer makes mononucleosis an unlikely possibility.

Pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANDAS) can cause neurologic abnormalities such as obsessive compulsive disorder (OCD) and tics in youth; however, it usually strikes patients who are prepubertal, usually between ages 3 and 12 years. It is marked by an abrupt onset, peaking in severity with complete resolution of symptoms after a period of several weeks. It is

always associated with group A streptococcal infections. Our patient does not fit this picture since he is older than 12 and has not exhibited any OCD behaviors or tics and his streptozyme and ASO titers were both negative.3 Serum ceruloplasmin and serum copper were both found to be normal. A psychiatric consultant did not think that he was suffering from a psychosis but was concerned that he was suffering from catatonia related to an unknown neurologic disorder.

Wilson disease is a disorder of copper metabolism that leads to accumulation of toxic concentrations of copper in various organs including the liver, nervous system and bones.

It can cause neurologic symptoms in a small percentage of adolescent patients but hepatic manifestations are invariably present. Since our patient’s liver function, ceruloplasmin and copper concentrations were all normal, Wilson disease is not a possibility either.4 The patient’s mother mentioned that a family friend watched a television episode entitled “Mystery Diagnosis” that described a similar situation in an adolescent girl. The patient in the program suffered from intermittent bouts of hypersomnolence, hyperphagia and confusion as well. The name of the disorder afflicting this girl was Kleine-Levin syndrome. Our patient’s mother asked if her son could be suffering from the same condition.

Kleine-Levin syndrome is an extremely rare disorder, usually affecting adolescent males. It is characterized by recurrent bouts of excessive sleepiness, cognitive and behavioral changes, as well as hypersexuality and polyphagia.5 The diagnosis of this disorder is made clinically, and brain imaging such as CT and MRI have been normal in all reported cases.6 The median age of onset is 15 years and episodes last approximately 10 days. The most common precipitating factor is an infection, and illnesses such as Epstein-Barr, varicella zoster, streptococcal infections, and Asian influenza virus have all been implicated. Hypersomnia is invariably present and is necessary for diagnosis.5 Since our patient did exhibit hypersomnolence, cognitive and behavioral changes and polyphagia, he fits the criteria so far. He is an adolescent male and his symptoms have followed the intermittent pattern, lasting exactly 10 days. His brain MRI was normal as were all of his other studies. He also began having symptoms very shortly after suffering from documented influenza. Our patient meets the diagnostic criteria for the diagnosis of Kleine-Levin syndrome, severe type.7 Since antiepileptics have been used with mild success in other cases and stimulants have also been shown to alleviate some of the sleepiness associated with the disorder,5 the patient was prescribed methylphenidate (Ritalin) 10 milligrams daily and oxcarbazepine (Trileptal) 600 milligrams twice daily. Per the recommendations of psychiatry, he was also prescribed lorazepam (Ativan) one milligram. After receiving these medications he slowly began to improve and was noted to be more conversant by his third day of hospitalization. He was

October 2011 JOURNAL MSMA 313

discharged home and on subsequent follow up visits to the neurology clinic was noted to have intermittent symptoms consistent with Kleine-Levin syndrome. He required hospitalization again approximately one year after his initial presentation with similar symptoms but responded promptly to treatment with lorazepam and oxcarbazepine.

There are no long term studies on Kleine-Levin syndrome, but all of the case reports indicate a prolonged yet self limited course. Each episode is less severe and less frequent than previous episodes until eventually ceasing altogether.7 The average duration of illness is 4-8 years. Less than 4% of cases showed patients with a permanent impairment of cognition several years after diagnosis.5 It is within reason to expect this patient to eventually achieve a full recovery from his disorder.

Today, patients and their families have access to a multitude of information from mass media sources. Although some information is not reliable, in this case the parent’s suggested diagnosis was correct. As physicians, we must be amenable to alternative answers. This case was truly a real mystery diagnosis.

References 1.

2.

3.

4.

5.

6.

7.

Tamiflu.com. Prescriber’s Information. Available at: http:// www.gene.com/gene/products/information/tamiflu/pdf/pi.pdf.

Accessed February 9, 2011.

Whatley S, Mason N, Woolf J, Newcombe R, Elder G, Badminton M. Diagnostic strategies for autosomal dominant acute porphyrias: retrospective analysis of 467 unrelated patients referred for mutational analysis of the HMBS, CPOX, or PPOX Gene. Clin Chem. 2009;55:1406-1414.

Snider LA, Swedo SE. PANDAS: current status and directions for research. Mol Psychiatry. 2004;9(10):900-907.

Nicastro E, Ranucci G, Pietro V, Vegnente A, Iorio R. Reevaluation of the diagnostic criteria for Wilson disease in children with mild liver disease. Hepatology. 2010;52(6):1948-1956.

Arnulf I, Zeitzer J, File J, Farber N, Mignot E. Kleine-Levin syndrome: a systematic review of 186 cases in the literature.

Brain. 2005;128(12):2763-2776.

Lisk DR. Kleine-Levin syndrome. Practical Neurology. 2009; 9(1):42-45.

International classification of sleep disorders, revised: Diagnostic and coding manual. Chicago, Illinois: American Academy of Sleep Medicine; 2001.

Key Words: Kleine-Levin syndrome, hyperphagia, hypersomnolence

be healthy. eat healthy.

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October 2011 JOURNAL MSMA 315

• MSDH • Mississippi Reportable Disease Statistics

July 2011 Figures for the current month are provisional

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

For the most current MMR figures, visit the Mississippi State Department of Health web site: www.HealthyMS.com.

316 JOURNAL MSMA

October 2011

An Academic Medical Center is a unique kind of health care.

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It is a place that offers the highest level of care to our mutual patients, every day.

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Learn more at umhc.com or call 888.815.2005.

October 2011 JOURNAL MSMA 317

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O’Brien & Family Law Group

James

P.O. Box 2623 682 Towne Center Blvd.

Ridgeland, Mississippi 39158 (601) 952-0050 (Office) •(601) 952-0904 (Fax) office@jamesandobrien.net James & O’Brien Family Law Group consists of five attorneys, L.C. James, Danna A. O’Brien, David E. James, Alicia C. Baladi and Kim D. McCormack, who specialize in domestic law cases of all types, with a particular emphasis on divorce and custody. The Firm has earned and maintained an “AV” rating (very highest) in Martindale-Hubble Law Directory for more than a quarter century, and its senior member, L.C. James, is one of only 1,397 attorneys in the nation and the only family law attorney in Mississippi who has been listed in every publication of “Best Lawyers in America” since its inception in 1983. The law firm is dedicated to each client as he or she deals with divorce. We strive to earn the respect and approval of each client, for we fully understand that our reputation for excellence has been established over these many years through the judges, our peer group of fellow attorneys, but most importantly, our clients.

Save the Date Second Annual

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320 JOURNAL MSMA

FOUNDATION, INC.

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What doctors have time to do...

Yeah, we get it. And we’d like to help.

The Delta Health Alliance (DHA) and the Mississippi State Medical Association (MSMA) can now help physicians in the Mississippi Delta: Take advantage of electronic health record (EHR) technology ∙ Connect EHRs to hospitals and clinics throughout the Delta ∙ Meet meaningful use criteria ∙ Qualify for financial incentives ∙ Improve patient outcomes.

Allow MSMA to introduce you to the BLUES (Better Living Utilizing Electronic Systems) Beacon Community!

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THIS OPPORTUNITY IS FUNDED THROUGH THE DHA WITH SUPPORT FROM DHHS ONC GRANT # 90BC0004‐01.

October 2011 JOURNAL MSMA 321

• Special Articles •

Mississippi County Health Rankings 2011: Improving Health in Your Community Karen A. Evers, Managing Editor

The Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute are pleased to present the 2011 County Health Rankings, a collection of 50 reports, that reflect the overall health of counties in every state across the country. For the second year in a row, counties can get a snapshot of how healthy their residents are by comparing their overall health and the factors that influence their health with other counties in their state. This allows communities to see county-to-county where they are doing well and where they need to improve.

The rankings, based on the latest data available for each county, is the only tool of its kind that measures the overall health of each county in all 50 states on the multiple factors that influence health.

It includes snapshots of nearly every county with a color-coded map that compares each county’s overall health with other counties in each of the 50 states.

People can compare how their county is doing in areas like diabetes screening rates or number of uninsured adults to national benchmarks.

Published on-line at www.countyhealthrankings. org by the University of Wisconsin Population Health Institute and the Robert Wood Johnson Foundation, the rankings help counties understand what influences how healthy residents are and how long they will live.

The rankings look at a variety of measures that affect health such as the rate of people dying before age 75, high school graduation rates, access to healthier foods, air pollution levels, income, and rates of smoking, obesity, and teen births.

For a more detailed explanation of the approach and methods used to compile the rankings, information on the action steps communities can take to improve their health, and examples of communities in action, see www.countyhealthrankings.org All images used with the permission of the Robert Wood Johnson Foundation.

322 JOURNAL MSMA

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2011 Mississippi

I

ntroduction

Where we live matters to our health. The health of a community depends on many different factors, including quality of health care, individual behavior, education, jobs, and the environment. We can improve a community’s health through programs and policies. For example, people who live in communities with ample park and recreation space are more likely to exercise, which reduces heart disease risk. People who live in communities with smoke-free laws are less likely to smoke or to be exposed to second-hand smoke, which reduces lung cancer risk. 1 The problem is that there are big differences in health across communities, with some places being much healthier than others. And up to now, it has been hard to get a standard way to measure how healthy a county is and see where they can improve.

Mississippi State Health Officer Dr. Mary Currier said, “It’s important that our physicians know how their county ranks so they can be the experts regarding the health of their

community and be advocates for improvement. Who better?” she added.

describe the current health status of a county. These health outcomes are influenced by a set of health factors. These County Healthand Rankings 2011: Mississippi health factors their outcomes may also be affected by Programs and Policies community-based programs and policies designed to alter The County Health Rankings model is grounded in their distribution in the community. Counties can improve The Rankings the belief that programs and policies implemented at the health outcomes by addressing all health factors with summary health outcomes rankings are based onand policies.

This report ranks countieslevels according local, Mississippi state, and federal havetoantheir impact on theOur variety effective, evidence-based programs anfor equal weighting of mortality and morbidity measures. summary measures health and health of factorsofthat, in outcomes turn, determine the health outcomes The summary health factors rankings are based on factors, as communities well as the components to create across theused nation.

All ofeach the County Health The R ankings weighted scores of fourThe types of factors: summary measure.

The the of population health Rankings arefigure basedbelow upondepicts this model rankings are behavioral, based on a model of population clinical, social and economic, and environmental. The structure of the Rankings model. Counties receive a rank improvement. health that emphasizes the many factors that, if improved, weights for the factors (shown in parentheses in the for each population health component; those having high In this model, health outcomes are measures that can help make communities healthier places to live, learn, figure) are based upon a review of the literature and ranks (e.g., 1 or 2) are estimated to be the “healthiest.” work and play. The report expert input, but represent just one way of combining Figure 1 Health Rankings Model1 — Building on the work of America’s Health ranks Mississippi counties these factors.

Rankings, the University of Wisconsin Population Health Institute has used this according to their summary model to rank the health of Wisconsin’s counties every year since 2003. measures of health outcomes and health factors as well as the components used to create each summary measure. Figure 1 depicts the structure of the rankings model. Counties receive a rank for each population health component; those having high ranks (e.g., 1 or 2) are estimated to be the “healthiest.”1 Summary health outcomes rankings are based on an equal weighting of mortality and morbidity measures.

The summary health factors rankings are based on weighted scores of four types of factors: behavioral, clinical, social and economic, and environmental.

The weights for the factors (shown in parentheses in the figure) are based upon a review of the literature and expert input but represent just one way of combining these factors.

Dr. Currier said, “It’s important to know that the County Health Rankings provide a standard way to compare counties within the state – using our own data – not calculated by using national numbers. The rankings provide counties with information to assist community leaders with making sound decisions regarding community health goals. The best way to affect

October 2011 JOURNAL MSMA 323

Figure 2. Mississippi’s counties divided into groups by health rank

HE ALT H O UT CO M E S

the community health outcomes is to improve the health factors through community engagement and health policy change.”

The Maps

The maps display Mississippi’s counties divided into groups by health rank (Figure 2). The lighter colors indicate better performance in the respective summary rankings. The green map shows the distribution of summary health outcomes.

The blue displays the distribution of the summary rank for health factors.

Maps help locate the healthiest and least healthy counties in the state. The health factors map appears similar to the health outcomes map, showing how health factors and health outcomes are closely related.

“It is important to note that, in general, the areas in the state that are doing better economically are also doing better with regards to health factors and outcomes,” Dr. Currier said.

“DeSoto County ranks number one for health outcomes, having the lowest mortality in the state and lower levels of self described ‘poor health’ than the rest of the state. In ‘health factors,’ DeSoto County ranks 5th, still having average rates

324 JOURNAL MSMA

October 2011

HE ALT H F ACT O R S

of adult smoking, obesity and excessive drinking compared to the rest of the state. So even in the county ranked number one for health outcomes, there are places where improvements can be made. On the other hand, the county with the lowest health outcomes ranking, Jefferson Davis County, is above average in those indicators associated with poverty, such as low rates of high school graduation, high levels of unemployment, and children living in poverty. Even in poverty stricken areas, however, improvements can be made through promotion of smoking cessation, education regarding healthy foods and exercise, and community policies that promote these such as healthy foods in schools and community use of school grounds for exercise through agreements between the school and the community (joint use agreements).” www.countyhealthrankings.org/mississippi 3

Summary Health Outcomes & Health Factors Rankings

Counties receive two summary ranks: • Health Outcomes • Health Factors Each of these ranks represents a weighted summary of a number of measures.

County Rankings 2011: Mississippi poor health, poor physical health days, poor mental mortality rank, representing length of life, is based on Health a health days, and the percent of births with low measure of premature death: the years of potential life birthweight. lost prior to age 75.

Health Outcomes Rankings

The summary health outcomes ranking is based on measures of mortality and morbidity. Each county’s ranks for mortality and morbidity are displayed here. The mortality rank, representing length of life, is based on a measure of premature death: the years of potential life lost prior to age 75.

The morbidity rank is based on measures that represent health-related quality of life and birth outcomes. We combine four morbidity measures: self-reported fair or poor health, poor physical health days, poor mental health days, and the percent of births with low birthweight.

The mortality and morbity ranks are shown in figure 3.

Figure 3. Mississippi County Ranks by Mortality and Morbidity Rank

Rank

Conclusion

Dr. Currier told the Journal, “We gather, analyze and use data on a daily basis to target interventions and to improve health. In the past, our priorities have been more focused on infectious disease prevention and control. These data help us to better help communities in the areas of chronic disease prevention.”

In closing, Dr. Currier said, “Every public school in the state has a school health council, and many communities have Mayor’s Health Councils, which assess school and city policies that affect health and try to change them for the better. Physicians across the state could help this process for improvement by becoming a member of these councils and providing the medical expertise needed for prioritizing goals and implementing change for better health in our communities.”

Everyone has a stake in community health. “We all need to work together to find solutions. The County Health Rankings serve as both a call to action and a needed tool in this effort,” Dr. Currier said.

6

Mortality

Morbidity

1

DeSoto

DeSoto

2

Lafayette

Madison

3

Rankin

Lamar

4

Pontotoc

Choctaw

5

Lamar

Rankin

6

Oktibbeha

Lafayette

7

Franklin

Oktibbeha

8

Greene

Sharkey

9

Lowndes

Hancock

10

Newton

Jackson

11

Clay

Lee

12

Alcorn

Tate

13

Monroe

Lowndes

14

Webster

Alcorn

15

Hancock

Lauderdale

16

Wayne

Warren

17

Kemper

Carroll

18

Chickasaw

Prentiss

19

Union

Jones

20

Tishomingo

Greene

21

Attala

Humphreys

22

Walthall

Yalobusha

23

Tate

Montgomery

24

Yazoo

Neshoba

25

Lincoln

Harrison

26

Tippah

Itawamba

27

Madison

Clay

28

Itawamba

Walthall

29

Perry

Pearl River

30

Covington

Pontotoc

31

Warren

Marshall

32

Jackson

Union

33

Forrest

Yazoo

34

Prentiss

Tishomingo

35

Noxubee

Forrest

36

Yalobusha

Coahoma

37

Amite

Bolivar

38

Hinds

Tunica

39

Harrison

Leake

40

Choctaw

George

www.countyhealthrankings.org/mississippi

References 1. County Health Rankings: 2011 Mississippi report.

Available at http://www. countyhealthrankings.org/sites/default/ files/states/CHR2011_MS.pdf. Accessed September 8, 2011.

2. University of Wisconsin Population Health Institute website. Available at http://uwphi.

pophealth.wisc.edu/pha/wchr.htm.

Accessed September 9, 2011.

Acknowledgement:

Images reproduced courtesy of the Robert Wood Johnson Foundation (RWJF).

Mortality

Morbidity

41

Lee

Hinds

42

Benton

Lincoln

43

Jones

Smith

44

Montgomery

Washington

45

Lauderdale

Newton

46

Winston

Panola

47

Lawrence

Stone

48

Pike

Quitman

49

Scott

Webster

50

Clarke

Monroe

51

Carroll

Perry

52

Calhoun

Lawrence

53

Simpson

Kemper

54

Pearl River

Winston

55

Marshall

Leflore

56

Copiah

Calhoun

57

Leflore

Chickasaw

58

Adams

Sunflower

59

Leake

Simpson

60

George

Benton

61

Stone

Marion

62

Wilkinson

Scott

63

Grenada

Clarke

64

Neshoba

Pike

65

Jefferson

Holmes

66

Jasper

Wilkinson

67

Claiborne

Jasper

68

Washington

Covington

69

Sharkey

Noxubee

70

Panola

Copiah

71

Tallahatchie

Franklin

72

Smith

Amite

73

Holmes

Grenada

74

Bolivar

Attala

75

Coahoma

Wayne

76

Tunica

Jefferson Davis

77

Sunflower

Tippah

78

Humphreys

Adams

79

Marion

Jefferson

80

Quitman

Claiborne

81

Jefferson Davis

Tallahatchie

F

or a more detailed explanation of the RWJF approach, the methods used to compile the rankings and information on the action steps communities can take to improve their health, and examples of communities in action, see www. www.countyhea countyhealthrankings.org.

October 2011 JOURNAL MSMA 325

• New Members • Aggarwal, Avichal, Jackson; Specialty: Pediatrics.

Allison, Shelton, Hattiesburg; Specialty: Psychiatry.

Bensler, James MICHAEL, Jackson; Specialty: Internal Medicine.

Berger, John, Jackson; Specialty: Pediatric Critical Care Medicine.

Brimhall, Bradley , Jackson; Specialty: Clinical Pathology.

Campbell, Mark E., Hattiesburg; Specialty: Internal Medicine.

Chaudary, Nauman , Jackson; Specialty: Pulmonary Disease.

Cruse, Julius M., Jackson; Specialty: Anatomic/Clinical Pathology.

Davis, Scott A., Jackson; Specialty: Family Medicine.

Flowers, W CRAIG, Jackson; Specialty: Pediatrics.

Freire, Maxime , Jackson; Specialty: Radiology.

Griffin, Kaisha R., Jackson; Specialty: Pediatrics.

Henley, Coleman , Laurel; Specialty: Obstetrics & Gynecology.

Hester, Deborah ANNE, Amory; Specialty: Emergency Medicine.

Islam, Nahid, Morton; Specialty: Family Medicine.

Jones, Alan E., Jackson; Specialty: Emergency Medicine.

Keeton, Kevin L., Brandon; Specialty: Pulmonary Disease.

326 JOURNAL MSMA

October 2011

Mayes, Charles E., Hattiesburg; Specialty: Internal Medicine.

Quin, Ernest M., Jackson; Specialty: Cardiac Electrophysiology.

McCaulley, Latasha M., Jackson; Specialty: Pediatrics.

Smith, Samuel ANTHONY, Jackson; Specialty: Pediatrics.

Mohammed, Rafat O., Brandon; Specialty: Psychiatry.

Sones, William D., Brookhaven; Specialty: Radiology.

Morris, R. Tim , Jackson; Specialty: Family Medicine.

Taylor, Jasmine P., Jackson; Specialty: Psychiatry.

Mullins, Laura B., Jackson; Specialty: Pediatrics.

Thigpen, Samuel C., Jackson; Specialty: Internal Medicine.

Nath, Dilip S., Jackson; Specialty: Cardiothoracic Surgery.

Windmill, Sue M., Jackson; Specialty: Otolaryngology.

Otworth, James R., Jackson; Specialty: Anesthesiology.

Wing, Denise LYNN, Tupelo; Specialty: Internal Medicine.

Patel, Ketan C., Ridgeland; Specialty: Psychiatry.

ONLINE JOB BANK Free position listings for MSMA members and for group clinics which employ at least 70% MSMA-member physicians • To list a position visit MSMAonlinejobs.com.

• For more information, contact Anna Morris: AMorris@MSMAonline.com, 601-853-6733, Ext. 324 My solo practice listed a free position on the MSMA online job bank, and within only a couple of weeks we received several inquiries from qualified candidates and were able to fill the position quickly and easily.

I highly recommend the job bank! —Tom Joiner, MD

MISSISSIPPI STATE MEDICAL ASSOCIATION

ANNUAL SESSION SURVEY

The MSMA Annual Session is an important membership event and we want to make sure that MSMA is meeting your needs when planning the Annual Session date, place, and agenda. Please take this short survey designed to evaluate your interest and our success in designing an annual meeting that addresses your interest and your needs. Thank you in advance for your open and honest evaluation of the MSMA Annual Session. We will use your responses to open discussions about the issues that influence your decision to attend MSMA meetings.

—The MSMA Board of Trustees

PERSONAL INFORMATION:

WAYS TO IMPROVE ANNUAL SESSION:

1.

8. Would you like any portion of the annual session program to be offered electronically? ____ CME ___ Virtual reference committee

___ Resident ___ Practicing Physician ___ Retired

2. How long have you been practicing in Mississippi? ____ 5 yrs. ____ 10 yrs. ____ 20 yrs. ____ 20 +yrs.

3. Have you ever been appointed or elected to an MSMA office? (Council on Legislation, CAP Committee) _____ Yes _____ No

9. Would you be interested in attending future Annual Sessions? _____ Yes _____ No Why? _______ _________________________________________

ANNUAL SESSION EXPERIENCE:

10. Would you like MSMA Annual Session and YPS CME meetings to be held back-to-back? ___ Yes ___ No

4. Did you attend the MSMA Annual Session in ____2009? _____2010? _____2011?

11. Please identify topics that would be of interest to you at future annual sessions: ____ Federal Health System Reform Updates

5. Was your decision determined by the location of the meeting? ____ Yes ____ No

____ Implementation of Health Reform by States

6. Are you more likely to attend the annual meeting if it is held in ___Mississippi or, ____ out-of-state?

____ Legislative updates on liability reform, scope of practice, and public health

7. Check any of the additional factors that may have influenced your decision:

____ Discussion of AMA matters ____ Information regarding participation in my component medical society

_____ Date was convenient.

_____ Date conflict

_____ Time of the Year

_____ Venue

_____ Social Events

_____ CME Topics

____ Other specific programs _________________________________________

_____ Elections

_____ Vendors

Thank you for your participation in this survey.

____ Cost of Travel/Room

_____Family Activities

_____ Participation in House of Delegates proceedings _____ Mississippi Medical Political Action Committee

Please return to MSMA: 

FAX : 601‐853‐6746



EMAIL: CKanosky@MSMAonline.com



MAIL: MSMA, PO Box 2548, Ridgeland, MS 39158‐2548

October 2011 JOURNAL MSMA 327

Calling all Mississippi Physician-Photographers for the 2012 COVER PHOTO CONTEST Load your camera or grab your digital. Shoot landscapes, people, animals, or anything else you can capture on film. Photos of subjects indicative of Mississippi will be given the highest consideration. Photos of original artwork are also acceptable. The Committee on Publications will judge the entries on the merits of quality, composition, originality and appropriateness to the JMSMA. Specifications: Color slides, digital files & photos. Size: Vertical format 5 x 7” or 8 x 10.” A hard copy print is required for judging.

Entry deadline: November 21, 2011 For more info contact: Karen Evers, JMSMA Managing Editor 601-853-6733, ext. 323 or KEvers@MSMAonline.com

MEA Medical Clinics Announces Openings for Board Certified Family Medicine Physicians in our Jackson and Laurel Area Clinics Guaranteed Base Compensation • Incentive Bonus Profit Sharing • Flexible Scheduling • CME Allowance Malpractice Insurance • Health Insurance • Life Insurance Disability Insurance • Much More!

BRANDON BYRAM CANTON CLINTON JACKSON LAUREL MADISON PEARL RICHLAND RIDGELAND

We look forward to hearing from you!

Toni Jordan 601-898-7535

Rachel Williamson 601-898-7527

1-800-844-6503 Recruiter@mms-ms.com

www.meamedicalclinics.com

328 JOURNAL MSMA

October 2011

• Images in Mississippi Medicine •

T

he Oath of Hippocrates—

“I swear by Apollo the physician…” begins one of the most important professional statements in world history and one of the most universally known Greek medical texts: The Hippocratic Oath. In it, a new physician swears upon a number of healing Greek gods that he, as an artist, will uphold numerous standards of professional conduct. The oath also clearly designates the obligation of the student of medicine to his teacher and to other physicians, and those obligations resemble that of a family. One historian even noted that the Oath’s creation “may have marked the early stages of medical training to those outside the first families of Hippocratic medicine, the Asclepiads of Kos, by requiring strict loyalty.” Note that the Oath does not contain the phrase, “First, do no harm,” which is often attributed to it. (There is Hippocratic writing similar to the phrase here and elsewhere!) This ancient broadside is taken from a copy of the 1964 “Clinic” annual of Jefferson Medical College of Philadelphia, Pennsylvania, one of the antebellum schools of choice for Mississippians. If you have an old or even somewhat recent photograph which would be of interest to Mississippi physicians, please contact the Journal or me at lukelampton@cableone.net.

—Lucius Lampton, MD; Editor October 2011 JOURNAL MSMA 329

• President’s Page •

Reflections on Summer’s End

W

ell, here it is the end of summer and so far things have been slow and manageable. The annual session was a success: we all had a good time, and we are now beginning to deal with the resolutions passed there. This is the time when board and staff catch up, prior to the start of the political sessions in Jackson. There are things going on at the national level that we keep an eye on, but, for the most part, our work starts when the State Legislature gets back into town.

This is not to say we have not been busy so far. Our Mississippi Medical Political Action Committee (MMPAC) has been hard at work interviewing candidates for the House and Senate seats, Lieutenant Governor and Governor, and has arrived at a slate of medicinefriendly candidates whom we can all expect to support patient and doctor-friendly legislation. I say “expect” because as you know Thomas E. Joiner, MD politicians “make strange bed fellows.” We have sent you, our 2011-12 MSMA President members, countless e-mails detailing this work and lists so you will be current on the issues and candidates. If you haven’t been reading the MSMA Lifeline, Physician’s Position, and the online edition of the Journal MSMA, please don’t delete them as spam. They contain important information beneficial to you and your practice.

We need everyone to become more politically savvy and take part in the process at all levels, from voters to candidates.

Things are changing and we want to make things happen, not have things “happen to us.” We want to be proactive as opposed to reactive. If you can’t run for office or help someone, a contribution to a campaign or MMPAC would go a long way in preserving quality medicine for years to come.

There are planned meetings of the CAP committee, a committee that is developing prominence. We are addressing formulary issues, payment issues, and any other issues that deal with third party payers. While we have had satisfactory resolutions to some issues, we remain frustrated with others but will continue to address them. What we do seem to do well is have a much bigger stick than a single physician alone. It is hard for these third parties to ignore us, but it seems to be easy to ignore a single physician or manager. For bigger influence, this committee plans to work with the group managers association also. All we need now is for our members to know we are there and use us. Bring us specifics we can use, not just complaints.

On a personal level, I expect things to pick up quickly also. We are planning to move our personal residence to the Brandon area, sell the one we are in, have a wedding for our oldest daughter, and maybe put in a trip to the Breeders’ Cup again at Churchill Downs. It was a little busy to make it to Saratoga this year. In the middle of all this, we are getting ready for the visits to the component societies where I can talk to each of you concerning the goings on here in the capital city. I plan to give updates on our activities, but do not expect a polished speaker at these events. After all, I am just a doctor!

As I have stated, things will pick up in November through the end of the legislative session. This is where your staff excels, in the halls of the State Capitol. I hope with the successes and efforts of the PAC we can again protect the quality of medicine delivered to the citizens of our great state.

Oh yeah, there is the interim meeting of the AMA in New Orleans in November. Your AMA delegation will be there representing the views of the physicians of our state, and I must say they do a great job voicing these views. This is a very dedicated and hard-working group. As I have written previously, not all goes the way we want it to. But we will return again and again to voice your views. Like I said, I am not ready to give up!

330 JOURNAL MSMA

October 2011

• Editorial •

Elephant in tHe Exam Room I

t was a summer of firsts for me.

I experienced my first dining experience at the Elite Restaurant on Capitol Street. I know, I know—but it had apparently dropped off my culinary radar screen until now. Delicious broiled calves liver with onions (either you love it or you don’t even want to hear it mentioned) and those unforgettable yeast rolls. In the words of that former California governor, “Ah’ll be bahck!”

If you’ve known me for longer than five minutes, you’ll find this next “first” hard to believe. Using complimentary tickets courtesy of a clinic associate (and not wanting to offend her), my curly-headed nine-year-old granddaughter and I joined the soldout coliseum throng for an evening of WWE—that’s wrastlin’ for you sophisticated uninitiated. What’s the word I’m looking for to describe this experience…surreal?...bizarre?...out of body? Ginny summed it up perfectly when, after about twenty minutes and only two matches, she tugged at my arm and whispered loudly, “GranStan, this is fake. Let’s go to Bop’s for some ice cream.” She WAS pleased that the lady wrestlers in pink with sparkles prevailed.

Although my final “first” began during the summer, it remains a work in progress: EHR…Electronic Health Records. As a gentle reminder, the Center for Medicare and Medicaid Services (CMS) has established guidelines for what they call “meaningful use” of this technology to ensure that physicians and hospitals are not only USING EHR’s but utilizing them to their full potential and for their intended purposes.

Broken down into three stages over a six year period so as to avoid overwhelming the participants, the 2011 implementation process focuses on electronically recording health history and treatment data and sharing such information with other “caretakers” and health organizations ostensibly to improve the quality and efficiency of healthcare.

The curtain is scheduled to rise in 2013 on Stage 2 which will call for practitioners to utilize previously recorded patient data to improve patient care (and to do so in a more structured format than was necessary in Stage 1). Stage 2 will also require the recording of lab results as well as other diagnostic tests (pathology, radiology).

The third and final stage will require practitioners to improve overall population health (nebulous enough, don’t you think?), provide patient access to self management tools, and identify situations of national priority through the compilation of report data.

October 2011 JOURNAL MSMA 331

According to the August 2011 Family Practice News article, confusion and frustration continue to be voiced by many physicians concerning the meaningful use criteria which spell out how they can receive incentive payments from Medicare and Medicaid for their use of EHR. Physicians in smaller practices are especially challenged. At the House of Delegates meeting in June, Dr. Michael L. Hodgkins, an AMA chief medical information officer, cited many obstacles to meeting meaningful use, including selecting from the more that 400 EHR products certified by the federal office of the National Coordinator (ONC) for Health Information Technology, part of the Health and Human Services Department. Another problem, according to Dr. Steve Waldren, director of the Center for Health Information Technology at the American Academy of Family Physicians, is the “aggressive” timeline set by the government. Dr. Waldren says it generally takes 6 to 18 months from purchase to active meaningful use of a system.

With my ear to the ground, I heard faint rumblings in the distance for many months only to look up to discover the beast upon me. To help us sidestep an ugly trampling, our “mothership” scheduled intensive IT training for our clinic personnel beginning mid summer (for some reason, physicians were allocated several extra sessions…). After a couple of “Mock Go Live” rehearsals, there was no turning back; we went “LIVE!” Even with on-site IT trainers and scaled-back appointment schedules, I felt like an astronaut who’d been shot into orbit without a game plan for re-entry, and , what’s worse, that one errant click of the mouse would totally annihilate my spacecraft!

Throughout medical school (at least the final two years), our focus was to be the patient in front of us. “Listen long enough and the patient will make the diagnosis…touch where it hurts.” These were our mantra. And for forty-plus years that was my modus operandi. Enter EHR, at this point the elephant in the room. Oh, it’s there all right, squarely between my patients and me…daring me to make one false move. And my patients can’t help but sense its presence (and my discomfiture). As of this writing, I’m told I’m doing quite well, thank you very much, with daily gold stars on my wee-wee chart. And it’s at this point that the classic response to the question “how do you eat an elephant?” comes to mind. One bite at a time!

— D. Stanley Hartness, MD Associate Editor

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October 2011

2011-2012 Alliance Membership Drive Pay your MSMA Alliance state dues $40 before December 31, 2011 to be entered in a drawing to win a free weekend at the Grand Hotel Point Clear Resort & Spa. The drawing will be held at the January 20th MSMA Alliance board meeting.

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• MSMA Alliance • Past President’s Spotlight: Mrs. Dewitt (Peggy) Crawford, Louisville Alliance President, 1993-1994

Dr. and Mrs. Dewitt Crawford MSMA Annual Session 1994

W

Peggy Crawford speaking at the 13th Annual BATTLE luncheon

here did you grow up? I was born in Louisville, delivered by a trusted general practice physician.

My dad laid natural gas lines throughout the U.S., and as a result, we moved frequently. I attended four schools during high school. This was a benefit because it developed my ability to meet people, to multitask, and to organize my time wisely. I returned to the “W” and graduated in three years with a degree in chemistry and bacteriology. After that, I spent a year in Little Rock getting a degree in medical technology. Later, back to school for a teaching certificate and a nursing home administrator’s license.

How did you meet your spouse? I was working at the local hospital, and Dewitt was on staff. We met, and one year later were married. He and I have a great family. Our girls are Beth (51), Jean (49), and Robin (45). They have blessed us with six grands. We have been a family for almost 36 years.

How did you become involved in the Alliance? Dewitt and I attended the Annual Session in Biloxi years ago when the meeting was held at the D’Iberville Hotel. I liked what I saw and heard, and joined East Mississippi Medical Society Alliance. The rest is history.

Peggy on a Honduras medical mission trip, 2008

What was the highlight of your year as Alliance president? I loved being president! It provided me with a new avenue for wonderful community projects, and a way to discover friends. Jevon Thompson, a motivational speaker for young people, traveled to five cities in the state and talked with the kids about drinking, drugs, teenage pregnancies, etc.

Our Alliance touched hundreds of young people with Jevon.

Do you have advice for anyone interested in the Alliance?

For years, we did not attend our medical meetings, but we discovered one cannot enjoy the lifelong friendships made in the Alliance unless they become involved. The Alliance provides each one an opportunity for friendship, for community service, and to play a vital role in the history of medicine.

What do you enjoy in your free time? I volunteer!

Presently, I sit on seven working boards. I read to the schoolchildren, and I’m very active in First United Methodist Church. I try to keep time to visit the BeeHive assisted living home and do a book review for the clients. We love golf, but sadly, there is not enough time to play, to read books, to RV (a little), and to keep the yard. r

October 2011 JOURNAL MSMA 333

• Poetry in Medicine • [This month, we print another poem by John D. McEachin, MD, a Meridian pediatrician and JMSMA’s unofficial poet laureate. This poem, written recently, is a tribute to the English or Shakespearean sonnet, which has a fixed form of 14 lines of 10 syllables each. Says Dr. McEachin, “There are two segments of this sonnet, consisting of three quatrains and a closing couplet. The rhyme scheme is abab, cdcd, efef, gg. (The less used sonnet form, preferred by Milton, used this rhyme scheme: abba, abba, cde, cde--- two quatrains, followed by two triplets, again 14 total lines.) I recommend the exercise!” The sonnet, from the Italian “sonneto,” meaning “little song,” dates to the early 1200s. The Italian sonnet is also termed Petrarchan, as the English form carries the name Shakespearian. (Neither Petrarch nor Shakespeare were the firsts in their language to use the form!) The form has persisted over the centuries in great verse by such later poets as John Keats and Edna St. Vincent Millay. For more of Dr. McEachin’s poetry, see past JMSMAs and look for more in coming months. Any physician is invited to submit poems for publication in the Journal, attention: Dr. Lampton or email me at lukelampton@cableone.net.] —Ed.

The Definitive Sonnet (Don’t Laugh, Will!)

The sonnet is a cute little ditty; It has ten syllables in every line.

With only fourteen lines, what a pity, But Mister Will Shakespeare felt this was fine!

Rhyme scheme in verse one is “ABAB;” “CDCD” is to come right behind.

Then “EFEF” is great for verse three; The final two lines, “GG”—blow your mind!

As you can see, I’m writing a sonnet; And we’re on that “EFEF” third verse.

To think up more rhymes is tough, “dog-gone-it,” But this is lots of fun; so could be worse!

Here come the “GG” lines, as you well know; Need a rhyme for “know!” Guess I better go!!

—John D. McEachin, MD Meridian

334 JOURNAL MSMA

October 2011

• The Uncommon Thread •

The Future of Books E

R. Scott Anderson, MD

veryone wants to predict the future. Nobody can, and nobody has a crystal ball. So, as always, we are left to try to define our beliefs based on opinions of experts we judge to be knowledgeable and trustworthy. One of the problems with this is that two equally intelligent individuals with an equal command of the facts at hand will often come to diametrically opposed conclusions. The problem is how to determine which one is correct or, to be precise, more correct, as no one is ever wholly right or wholly wrong. Think the Heisenberg Uncertainty Principle.

So what then is the future of books?…What is the future of art?…What is the future of music? Humankind, as a whole, places value on things based on availability: gold, diamonds, van Gogh oil paintings, oil. Virtually any commodity or service derives its value through the public’s perception of its “rareness” or exclusivity. Is a digital print as valuable as the aforementioned van Gogh? Of course not! Everyone can have a digital print. The same is not true for the painting. The devaluation of music and the shift from recorded music to live performances as the dominant source of musical artists’ income today are based on an unmitigated flood of digital musical output into the marketplace for little or no cost. There were gems in the flood somewhere, but a river of crap being offered for virtually nothing obscured them. The outcome was the demise of the local record shop most of us grew up knowing.

Self-publishing, e publishing, mass-market hardbacks and paperbacks, all of these things are a part of the flood of supply that is pushing the publishing industry to the brink. Our old pal Gutenberg didn’t sell 80,000 copies of his Bible a month, but he revolutionized the printed word and started us down the path that has led to digital downloads. With each step on that pathway, the unit price of “the book” has diminished. That’s good; a lot of us have learned to read because of it.

It is funny that the crisis in publishing follows so closely the crisis in the music industry. Writing followed song. Storytelling was, before the written word, an oral tradition, and the way those stories were remembered intact was to place them in a musical context. Those of you who are Jewish understand the role of the cantor in the preservation of the word. Biologically the human brain appears to be uniquely adapted to retain words placed to music. The need for the song was supplanted only by the recent development of the written word.

Books will survive. Books are not record albums nor are they eight-track tapes or CDs. They may become rarer as many flee to the simplicity of the digital download, but that very rareness will enhance their value. Perhaps at some point almost no one will be published, as we currently perceive it, and only those that have demonstrated value in the electronic sphere will ever be considered for paper publication. Who knows?

Hardback volumes will fare better than paperbacks; cheap and disposable paper loses to digital in a heartbeat. Textbooks and reference books are more difficult to predict. I still have my old copy of the first edition of Johns and Cunningham, a physics textbook covered with underlining and notes made in my own hand and decades out of print. Nevertheless, modern students will have different values I suspect.

I am an author that publishes only in e-format right now. A friend of mine, a book collector, asked, “What are you going to do, sign my Kindle?” I collect signed first editions, as do a lot of my friends. I love books. They have value to me, and I am willing to pay to own them. I think people always will.

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

October 2011 JOURNAL MSMA 335

general e-mail: info@msmaon kevers@msmaonline.co

• Placement/Classified • Jackson Free Clinic needs you!

1 2 Requesting licensed physician volunteers for the Saturday of your choice (approximate time 3 4 commitment: 1p-5p). As a registered 501(c)3 5 non-profit organization and UMMC student-run 6 clinic, JFC provides medical care for uninsured/ underinsured patients. Come serve the community 7 and help teach the next generation of physicians!

8 Please contact Rasheeda Crowell @ 601-4679 8981 or email rcrowell@ umc.edu for more 10 information. www.JacksonFreeClinic.org 11 12 13 14 15 144th MSMA Annual Session 16 Grand Hotel Marriott Resort, 17 Golf Club & Spa 18 Point Clear, Alabama 19 June 7 - 10, 2012 20 21 22 23 PHYSICIANS NEEDED 24 Physicians (specialists such as cardiologists, 25 ophthalmologists, pediatricians, orthopedists, neurologists, etc.) interested in performing consultative evaluations (according to Social Security guidelines) should contact the Medical Relations Office.

Save the date:

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DISABILITY DETERMINATION SERVICES 336 JOURNAL MSMA

October 2011

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Have You Considered a Life Settlement For Your Old Life Insurance Policy?

What is a Life Settlement?

A life settlement is the sale of an existing life insurance policy on the secondary market to a third party investor.

Who or What May Qualify?  If the person insured by the policy is age 70 or older  If the person insured has any major medical conditions  If the policy has a death benefit of $250,000 or more  Policies including, but not limited to, universal life, term insurance, variable life insurance or whole life insurance  If any cash value exists in the policy, the amount is relatively small

For More Information on Life Settlements, contact: H. Larry Fortenberry, CPA, CLU, ChFC Executive Planning Group, PA 1640 Lelia Drive, Suite 220 PO Box 16566 Jackson, MS 39216 (601) 982-3000

Why Use a Life Settlement?  Term life insurance policy will expire  Old policy that is no longer needed or premiums cannot be paid  A policy that was purchased for a business buy/sell and is no longer needed  A policy was purchased for a business that has been sold or is not needed  There may be a better policy available at a lower cost

 Estate value has changed and the policy is no longer needed

Securities Offered Through ValMark Securities, Inc. Member FINRA, SIPC Investment Advisory Services Offered Through ValMark Advisers, Inc. a SEC Registered Investment Advisor 130 Springside Drive, Suite 300 Akron, Ohio 44333-2431* 1-800-765-5201 Executive Planning Group is a separate entity from ValMark Securities, Inc. and ValMark Advisers, Inc. In a life settlement agreement, the current life insurance policy owner transfers the ownership and beneficiary designations to a third party, who receives the death proceeds at the passing of the insured. As a result, this buyer has a financial interest in the seller’s death. When an individual decides to sell their policy, he or she must provide complete access to his or her medical history, and other personal information, that may affect his or her life expectancy. This information is requested during the initial application for a life settlement. After the completion of the sale, there may be an ongoing obligation to disclose similar and additional information at a later date. A life settlement may affect the seller’s eligibility for certain public assistance programs, such as Medicaid, and there may be tax consequences. Individuals should discuss the taxation of the proceeds received with their tax advisor. ValMark Securities considers a life settlement a security transaction. ValMark and its registered representatives act as brokers on the transaction and may receive a fee from the purchaser. A life settlement transaction may require an extended period of time to complete. Due to complexity of the transaction, fees and costs incurred with the life settlement transaction may be substantially higher than other securities.