October 2014 JMSMA

October

VOL. LV

2014

No. 10

Calling All Mississippi Physician-Photographers Enter the JMSMA 2015 cover photo contest Load your camera or grab your digital. Shoot anything you can capture as a high-resolution image. Subjects given the highest consideration are those indicative of Mississippi. Photos of original artwork are also acceptable. The MSMA 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 (at least 300 DPI/PPI). A hard copy print is required for judging. Please include a brief description of the image and information about the physician/ photographer.

Size: Vertical format 5 x 7” or 8 x 10” Deadline: November 29, 2014 Mail to: P.O. Box 2548 Ridgeland, MS 39158-2548 or deliver to MSMA headquarters 408 W. Parkway Place, Ridgeland, MS 39157

For more info contact: Karen Evers, Managing Editor 601-853-6733, ext. 323 or KEvers@MSMAonline.com

SAVE THE DATE FOR

CME in the Sand M A Y 22-26, 2015 Sandestin Golf and Beach Resort Destin, Florida ALL physicians are invited to attend this fun, family – oriented event, hosted by the MSMA Young Physicians Section

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

Publications Committee Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD, Ex-Officio and the Editors The Association Claude D. Brunson, MD President Daniel P. Edney, MD President-Elect Michael Mansour, MD Secretary-Treasurer Geri Lee Weiland, MD Speaker Jeffrey A. Morris, MD Vice Speaker Charmain Kanosky Executive Director

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 39158-2548.

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

Copyright© 2014 Mississippi State Medical Association.

OCTOBER 2014

VOLUME 55

NUMBER 10

Scientific Articles Basic Skin Care: A Pragmatic Approach to Better Skin Using Over-the-Counter Cosmeceuticals

316

James L. Griffith, MD; Nancye K. McCowan, MD

Clinical Problem-Solving: All Dressed Up with No Place to Go

322

Ana-Maria Hubert, MD; Jennifer J. Bryan, MD

Top Ten Facts You Need to Know - About Smoking Cessation

325

Lucius M. Lampton, MD; William Lee Vail, M3

The James D. Hardy Lectureship in Surgery- Surgical Forum Abstracts

President’s Page The MSMA Physician Leadership Academy

327

Claude D. Brunson, MD; MSMA President

Editorial Round and Round She Goes...

333

D. Stanley Hartness, MD; Associate Editor

Related Organizations Mississippi Assurance Company of Mississippi MSMA Alliance

346 347

Departments From the Editor: Awaiting Ebola at our Posts MSMA: Excellence in Medicine Awards Images in Mississippi Medicine

313 330 348

About The Cover:

Heron at the Mississippi Gulf Coast- With the sun’s shimmer one might wonder if this could be a tricolored heron, a marsh bird that can be found around ponds, lakes, and ditches. It is a large heron although smaller than the great blue heron. As the name suggests, it displays a variety of colors in its plumage. The great blue heron is the biggest heron on the Gulf Coast, a common sight along the beaches especially around fishing piers where they hope to snag trash fish anglers may throw their way.

Photograph by JMSMA Editor Emeritus Myron W. Lockey, MD†. A special tribute to Dr. Lockey is forthcoming in the December issue. Please contact Managing Editor Karen Evers if you have memorable stories to share or thoughts to contribute. †Died September 11, 2014. r October

VOL. LV

Official Publication of the MSMA Since 1959

334

Marc E. Mitchell, MD; James D. Hardy Professor and Chair, Department of Surgery

2014

No. 10

October 2014 JOURNAL MSMA 313

From the Editor: Awaiting Ebola at our Posts

N

othing speaks more of the inherent hazards of our profession than a grave inscription at Lake, Mississippi. It reads: “To the memory of Dr. G. C. McCallum, Died of Yellow Fever in 1878, Aged 33 years, AT HIS POST HE DIED.” [Lampton LM. Images in Mississippi Medicine, J Miss State Med Assoc. 2007:48(11);356] Young Dr. McCallum joined dozens of Mississippi physicians who died in that 1878 epidemic, including 4 of the 15 members of the State Board of Health. The phrase “at his post he died” underscores that like the military and law enforcement, physicians are the front line of a war of life and death. Despite being masked, gowned, and gloved, we are exposed daily to death and disease and possess no more immunity than our patients. Ebola, too, reminds us of this important lesson and essential requirement of our art.

Since the nation’s first “patient zero” with Ebola presented in Texas (with resulting infections of some hospital workers who cared for the patient), public health response has been evolving. The CDC is assisting with active screening on the ground in West Africa, and then all travelers from affected

countries are routed through five major airports, screened, then referred to local health officials, including those in Mississippi, for direct monitoring for 21 days. These ongoing Department of Health screenings of all those who come into the state with a travel history should preclude a Lucius M. Lampton, MD “pop-up” case here. However, Mississippi physicians should be cognizant of when to consider the possibility of Ebola.

Primarily, remember that any Ebola suspects must have a travel history. Only if a patient visited Sierra Leone, Guinea, or Liberia in the past 21 days (or had direct contact with a confirmed Ebola case) are they at risk of contracting Ebola. If physicians happen to encounter a patient with such a history and a fever, they should identify and isolate the patient, then call the Department of Health on its Ebola Hotline: 1-877-222-9358. A team will then arrive and assume management of the case.

Contact me at lukelampton@cableone.net.

—Lucius M. “Luke” Lampton, MD, Editor

Journal Editorial Advisory Board Timothy J. Alford, MD Family Physician, Kosciusko Medical Clinic Michael Artigues, MD Pediatrician, McComb Children’s Clinic Diane K. Beebe, MD Professor and Chair, Department of Family Medicine, University of MS Medical Center, Jackson Claude D. Brunson, MD Senior Advisor to the Vice Chancellor for External Affairs, University of Mississippi Medical Center, Jackson Jennifer J. Bryan, MD Assistant Professor, Department of Family Medicine University of Mississippi Medical Center, Jackson Jeffrey D. Carron, MD Professor, Department of Otolaryngology & Communicative Sciences, University of Mississippi Medical Center, Jackson

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

Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson

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

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

Jason G. Murphy, MD Surgeon

Surgical Clinic Associates, Jackson

Scott Hambleton, MD Medical Director Mississippi Professionals Health Program, Ridgeland J. Edward Hill, MD Family Physician, North Mississippi Medical Center Tupelo W. Mark Horne, MD Internist, Jefferson Medical Associates, Laurel Ben E. Kitchens, MD Family Physician, Iuka Brett C. Lampton, MD Internist/Hospitalist, Baptist Memorial Hospital, Oxford

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

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

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

314 JOURNAL MSMA October 2014

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

Ann Myers, MD Rheumatologist Mississippi Arthritis Clinic, Jackson Darden H. North, MD Obstetrician/Gynecologist Jackson Health Care-Women, Flowood Michelle Y. Owens, MD Associate Professor, Vice-Chair of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson Jimmy L. Stewart, Jr., MD Program Director, Combined Internal Medicine/Pediatrics Residency Program, Associate Professor of Medicine and Pediatrics University of Mississippi Medical Center, Jackson Samuel Calvin Thigpen, MD Hematology-Oncology Fellow, Department of Medicine University of Mississippi Medical Center, Jackson Thad F. Waites, MD Clinical Cardiologist, Hattiesburg Clinic W. Lamar Weems, MD Urologist, Jackson Chris E. Wiggins, MD Orthopaedic Surgeon Bienville Orthopaedic Specialists, Pascagoula John E. Wilkaitis, MD Chief Medical Officer Brentwood Behavioral Healthcare, Flowood

Medical Assurance Company of Mississippi With his help, MACM puts risk management in practice.

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Managing the Risks October 2014 JOURNAL MSMA 315

• Scientific Articles • Basic Skin Care: A Pragmatic Approach to Better Skin Using Over-the-Counter Cosmeceuticals James L. Griffith, MD; Nancye K. McCowan, MD [I have been very confused about what proprietary, over-the-counter, dermatologic products are useful for cleansing, moisturization, sunscreen protection, and treatment of sun damaged skin. Most patients who complain of these problems do not need referral Types of OTCwhat to recommend. Dr. McCowan, who is director of the new dermatology training proto dermatologists, if we physicians know Skin Products gram at the University of Mississippi Medical Center, and Dr. Griffith, one of our recent graduates now training at the Henry Ford Department of Dermatology, 1.haveCleansers put together a paper on basic skin care which solves my dilemma. I hope you will be as pleased 2.

Moisturizers to have this information as I am.]

—Richard D. deShazo, MD; Associate Editor

A

3.

4.

Sunscreens Rejuvinators

bstract

Environmental exposures to ultraviolet radiation, wind, and tobacco smoke progressively damage the skin’s cellular and extracellular structures resulting in wrinkles, sagging skin, irregular pigmentation, and skin cancers. These undesirable effects can be minimized with avoidance of the sun, tanning salons, and smoking. The topical application of prescription and non-prescription agents (cosmeceuticals) can provide additional benefits.

Considering the vast array of topical non-prescription agents marketed to protect or repair damaged skin, it is difficult for consumers and physicians to choose the best options.

Therefore, this article discusses recommendations from a dermatologist concerning the choice and use of over-the-counter cleansers, moisturizers, sunscreens, and rejuvenators to create individualized, daily skin care regimens for patients.

Key Words:

skin care, cosmeceutical, over-the-

counter

Introduction

Everyone wants perfect skin! Unfortunately, genetic properties over which we have no control and environmental exposures to ultraviolet radiation, wind, and chemicals (such as tobacco smoke) lead to cellular and extracellular changes in the

Types of OTC Skin Products 1.

2.

3.

4.

Cleansers Moisturizers Sunscreens Rejuvinators

Author Affiliations: Dr. McCowan is Dermatology Residency Program Director and an Associate Professor in the Division of Dermatology at the University of Mississippi Medical Center in Jackson. Dr. Griffith is a graduate from the University of Mississippi School of Medicine, who is continuing his medical training at the Hernry Ford Department of Dermatology in Detroit, Michigan.

Corresponding Author: Nancye K. McCowan, MD, Department of Otolaryngology and Communicative Sciences, The Face and Skin Center of University Physicians, 201 Northlake Avenue, Suite 211, Ridgeland, MS 39157.

316 JOURNAL MSMA October 2014

skin’s structure that accelerate skin aging. This results in wrinkles, sagging, irregular pigmentation, decreased skin elasticity, and skin cancer. The topical applications of non-prescription agents called cosmeceuticals can minimize these changes. Considering the large number of cosmeceuticals that claim to offer healthier, more youthful skin, it is almost impossible for laypeople to confidently choose the product that is best for them. It is worth noting that the Food and Drug Administration does not have purview over agents Skin Type and Cleanser that contain vitamins and Recommendations Dry Skin Cold Cream minerals,1 and even phy♣ Noxema Cream sicians have difficulty ♣ Pond’s Cold Cream Lipid-free analyzing the claims of ♣ CeraVe Foaming Facial these products in a scien♣ Cetaphil Gentle Skin ♣ Neutrogena Ultra Gentle tific manner. This article Normal *Sydnet bar/liquid will discuss recommen(Face) ♣ Cetaphil Gentle Cleansing Bar dations from a dermatolo♣ Dove White Beauty Bar gist who has no ties to the ♣ Oil of Olay Bar ♣ Oil of Olay Foaming pharmaceutical industry.

Face Wash These are simple, overOily Lipid-free Skin ♣ CeraVe Foaming Facial the-counter routines of & ♣ Cetaphil Antibacterial cleansing, moisturizing, Acne Gentle Cleansing Bar ♣ Cetaphil Gentle Skin protecting from the sun, ♣ Neutrogena Ultra Gentle and rejuvenating to mainSalicycilic acid ♣ Neutrogena Oil-free Acne tain healthy skin in men Face Wash and women.

Benzyol peroxide

Cleansing

Proper cleansing of the skin requires a fine balance between removal of excess dead skin cells, sweat, oil, bacteria, and fungus while retaining substances vital to the

♣ PanOxyl Acne Creamy Wash Normal Bar soaps Skin ♣ Ivory bar soap (Body) Combars ♣ Dial soap ♣ Irish Spring Bar Soap Body Wash ♣ Dial Antibacterial Moisturizing Body Wash *Sydnet: cleansers contain synthetic detergents and <10% soap to retain a more normalized skin pH, 5.5‐7.2

Skin Type and Cle Recommendatio Dry Skin

Cold Cream ♣ Noxema Crea ♣ Pond’s Cold C

Moisturizing Products only in environments where the ambient humidity exceeds barrier function of the skin. Healthy skin prevents the entry of OTCskin Humectant Occlusive Moisturizing Sunscreens 3,4 70%.

Both types of moisturizers theoretically provide maxiinfectious agents and minimizes trans-epidermal water loss. ♣ Amlactin ♣ CeraVe PM Cream ♣ Lubriderm Advanced ♣ CeraVe AM Cream mum benefit when applied 5-10Daily minutes bathing or showTypical household and shower soaps are either true alkali salt Therapy Ultra cream ♣ Cetaphil Moisturizing Lotion ♣ Cetaphil Facialafter Moisturizer Cream Lubriderm Advanced Therapy SPF 30 soaps or combars - soaps containing deodorants, fragrances,♣ Vanicream ering.Skin ThisCream is the point ♣when the water content within theLotion skin is ♣ Curel Daily Moisture ♣ Vasoline Total 5Moisture ♣ Neutrogena Healthy Defense Liquid and sometimes, harsh detergents. While♣ these soaps effective- Bodygreatest.

(Another optionMoisturizer is to wet the skin with a fine spray of Curel Ultra Healing Lotion ly remove dirt and oil, they often have a supraphysiologic pH water immediately prior to applying a moisturizer.) that disrupts the skin leaving the face and other sensitive areas Sunscreen susceptible to dermatitis, irritation, and a feeling of tightness.2 Choosing the appropriate cleanser depends upon the area of the Ultraviolet (UV) radiation is the Alcohol based body, dirt content, and skin type (dry, normal, or oily). primary environmental cause of skin sunscreens “burn” when applied to For dry, cracked areas, lipid-free or cold cream cleansdamage, including: wrinkle formation, compromised or ers are generally recommended. Lipid-free cleansers do not loss of elasticity, irregular pigmentation, “cracked” skin. Oilformulations, include the long-chain fatty acids found in most soaps, while and skin cancer. For its role in the for- based Blue Lizard and cold creams combine waxes and oils with a detergent, borax.3 mation of melanoma and non-melanoma CeraVe AM are Both of these compounds are excellent cleansers for dry, irriskin cancers, the World Heath Organiza- advantageous in these situations. tated skin. However, they are a poor choice for oily, acne-prone tion has classified UV radiation in the skin as they clear only limited amounts of dirt, oil, and bactesame carcinogen class as uranium.6 Although the UV waveria.3 Waxes/oils of cold creams can also contribute to acne by length spectrum is divided into UVA, UVB, and UVC, UVC blocking pores (comedone formation). A few mild, lipid-free is irrelevant to this discussion as it is entirely absorbed or recleansers contain the antibacterial agent triclosan, which is a flected by the earth’s atmosphere. Long-wave UV radiation, useful agent for controlling acne in people with sensitive skin.

UVA, induces most of the effects associated with aging, such Chemical or mechanical exfoliant cleansers may be useas wrinkle formation and easy bruising (UVA=Aging). These ful adjuvants in topical acne regimens. Cleansers with salichanges occur through the destruction of collagen and other excylic acid or benzoyl peroxide chemically disrupt adhesion tracellular matrix components in the dermis, a deep layer of the between corneocytes (skin cells),3 accelerating their removal skin.7 In contrast, short wave, higher energy UVB radiation is to prevent pore blockage. Mechanical exfoliants rely upon primarily absorbed in the epidermis, the superficial layer of the abrasive particles to remove skin cells. Chemical exfoliants skin,7 causing the immediate changes of warmth and sunburns are generally preferred over mechanical cleansers, as mechani(UVB=Burns). Tanning beds primarily emit the deeper pencal exfoliants are frequently used too aggressively resulting etrating UVA radiation to stimulate melanin generation – the in skin irritation that does more harm than good. This is espigment responsible for skin coloration - while avoiding sunpecially true for acne prone-skin. If a mechanical exfoliant is burns.8 chosen, the smoother particles of polyethylene beads or aluMelanin production (tanning) is the body’s response to minum oxide cleansers are recommended over irregular, jagDNA damage from UVA and UVB irradiation.9 When damged ground fruit pits. Both chemical and mechanical exfoliants aged, cellular pathways are activated to repair DNA and melamay irritate and excessively dry sensitive or non-oily skin. nin is produced to absorb future UV radiation.10 Melanin, however, provides only limited protection from UV radiation. This Moisturizers protection is approximately equivalent to wearing a thin, white Are moisturizers only for dry skin?

Moisturizers serve as an eft-shirt.11,12 Tanning beds emitonly high-dose UVA radiation, which Are moisturizers for No. Moisturizers reduce drythe skin? fective method of decreasing skin roughness & flaking in greatly increases risk of developing deadly melanoma, the No. Moisturizers reduce roughness and flaking by hydrat- normal to dry skin and most serious form of skin cancer. In fact, both the frequency roughness & flaking in decrease oil production in ing the skin. Contrary to popular oily skin. and duration ofnormal tanning bedskin useand increase the risk of melanoma.13 to dry decrease production in belief, moisturizers do not add exLimiting exposure to oilUV radiation, especially from tanning oily skin. ternal “moisture” to the surface of the skin nor are they incorpobeds, also reduces the risk of non-melanoma skin cancer and rated as intracellular lipids.4 Instead, moisturizers either retard maintains the skin’s vitality and youthful appearance. evaporative loss (occlusive) or attract moisture (humectants).

Sunscreens contain either organic or inorganic ingrediDuring the dry winter season, occlusive agents, such as petroents offering varying degrees of UVA and UVB protection. latum products, are recommended because they block transepiSunburn Protection Factor, SPF, was developed to protect soldermal water loss.

Humectants, on the other hand, hydrate the diers from UVB sunburns during World War II. A SPF 30 or OTC Moisturizing Products greater provides exOcclusive Moisturizing Sunscreens OTC Moisturizing Products m ♣ Lubriderm Advanced ♣ CeraVe AM Cream cellent UVB protecMoisturizing Sunscreens zing TherapyHumectant Lotion ♣ Cetaphil DailyOcclusive Facial Moisturizer tion. It is important ♣ Amlactin PM CreamAdvanced ♣ Lubriderm Advanced ♣ CeraVe AM Cream ♣ Vanicream Skin Cream ♣ CeraVe ♣ Lubriderm Therapy SPF 30 Lotion Ultra cream ♣ Cetaphil Moisturizing Therapy Lotion ♣ Cetaphil Daily Facial Moisturizer for people to test a ure ♣ Vasoline Total Moisture ♣ Neutrogena Healthy Defense Liquid Cream Moisturizer ♣ Vanicream Skin Cream ♣ Lubriderm Advanced Therapy SPF 30 Lotion ng Body Lotion number of products ♣ Curel Daily Moisture ♣ Vasoline Total Moisture ♣ Neutrogena Healthy Defense Liquid and find one that they ♣ Curel Ultra Healing Body Lotion Moisturizer

October 2014 JOURNAL MSMA 317 Alcohol based sunscreens “burn” when applied to

Alcohol based

Blocked UPF 5-7

80-86%

White cotton t-shirt 14, 15 Predominant Protective Spectrum of Active Compounds in Sunscreen UPF 10 like to use since it will be R estoration of S un damaged S kin with T90% opical UVA 16, 17 UVB UVA & UVB RetiGreen cotton t-shirt UPF Rating & UV Blockage a recommended on a daily noids, H♣ ydroxy Acids, and Antioxidants ♣ Avobenzone ♣ Cinoxate Octyl salicylate ♣ Titanium dioxide UPF 15 ♣ UPF % of UV basis in the spring and ♣ Ecamsule (Mexoryl ♣ Dioxybenzone ♣ Oxybenzone Zinc oxide Prevention of skina damage through the93.3% use of proper SX) Blocked ♣ Homosalate ♣ Padimate O summer. The SPF, howevcleansing, skin hydration, and daily of sunscreen is UPF 30 application96.7% 80-86% Octocrylene ♣ Sulisobenzone UPF 5-7 er, ♣provides no indication the best method for ensuring healthy skin in the future. HowWhite cotton t-shirt ♣ Octyl Methoxycinnamate (OMC) UPF 50 98%

of the level of UVA protec-

a

UPF 10

ever, several cosmeceuticals are available to help repair and/or been caused by damage in the past.Dark Denim shirt

The combination of avobenzone and oxybenzone, commonly called Helioplex (Neutrogena) and Active Photobarrier Complex 90%provides broad-spectrum tion. Therefore, products UPF 1,700 aesthetically improve skin imperfections that 99.9% may have (Aveeno), UV coverage (UVA & UVB).

Green cotton t-shirt

offering UVA and UVB protection now advertise Which rejuvenator type should I choose? “broad-spectrum protecRetinoids are generally the most effective restoratives and UPF 30 96.7% limited to only “rejuvenating” products. To minimize the tion” as mandated by the number and cost of OTC products, purchase a retinoid and UPF 50 98% FDA. Consumers should choose a moisturizer with AHA’s (CeraVe PM) or antioxidants UPF 1,700 99.9% be aware this labeling sys(Neutrogena Naturals Multivitamin Nourishing Moisturizer).

Dark Denim shirt tem does not indicate the Retinoids extent of UVA protection. WhilePredominant the combination of specific Protective Spectrum of Active Compounds in Sunscreen14, 15 Retinoids are synthetic or natural derivatives of vitamin UVA UVB UVA & UVB compounds, such as avobenzone with oxybenzone, will provide A that are important in cellular replication and turnover. a OTC HA & Retinol♣ Products ♣ Avobenzone ♣ Cinoxate ♣ Octyl salicylate Titanium dioxide While excellent broad-spectrum (UVA & UVB) coverage, physical Retinol Hydroxy deliver Acids high cona other prescriptions retinoic acid (tretinoin) and ♣ zinc Ecamsule (Mexoryl Dioxybenzone ♣ Oxybenzone ♣ Zinc oxide blocks, such as oxide and titanium♣oxide, deliver equiva♣ Glow by Dr. Brandt Overnight ♣ Amlactin Ultra cream SX) ♣ Homosalate ♣ of Padimate O centrations therapeutically active retinoids, non-prescription lent broad-spectrum protection and may be easier for patients Resurfacing solution ♣ Pond’s Rejuveness

♣ Octocrylene ♣ Sulisobenzone retinoids (retinol and retinyl esters) rely upon a controlled conto remember.14,15 A few products sold in♣the United States have ♣ Neutrogena Healthy Skin Anticream Octyl Methoxycinnamate (OMC) version to the active metabolite, retinoic acid. Both prescription mpounds in Sunscreen14, 15 a wrinkle cream - Night started marketing their level of UVA protection with Europe’s The combination of avobenzone and oxybenzone, commonly called Helioplex (Neutrogena) and Active Photobarrier Complex UVA & UVB and non-prescription retinoids cause (1) epidermal thickening of (Aveeno), coverage (UVAbe & UVB). new 4-star UVA rating provides system.broad-spectrum A 3 or 4 star UV product should tyl salicylate ♣ Titanium dioxide thin, atrophic skin, (2) dermal regeneration, (3) reduced brown ybenzonea chosen. ♣ Zinc oxide pigmentation, and (4) desquamation of the superficial skin laydimate O Sunscreen application is generally recommended thirtyWhich rejuvenator type should I choose?

In addition, retinoids a vital component ers.20-23 Retinoids are generally the mostare effective restoratives and of acne isobenzone minutes before UV exposure with two finger lengths of sunlimited regulating to only “rejuvenating” products.

To minimize the regimens: follicular epithelial proliferation, reducscreen for every two-by-two foot area of the body. Reapplicanumber and cost of OTC products, purchase a retinoid and Neutrogena) and Active Photobarrier Complex ing sebaceous gland sebum production, and preventing clogged tion is needed every three to four hours with shorter intervals choose a moisturizer with AHA’s (CeraVe PM) or antioxidants 24 pore (Neutrogena formation Naturals by desquamation.

RetinoidsMoisturizer). may thin the skin Multivitamin Nourishing during water-activities or heavy sweating. The duration of UPF Rating & UV Blockage16, 17 slightly and increase the propensity for sunburns.

Therefore, water-resistant venator type should I choose? sunscreens varies between 30-90 minutes and is sun-precautions are routinely recommended with retinoid use.

UPF % of UV e generally thestated most effective restoratives and now on the product’s label. For those with dry, cracked Blocked nly “rejuvenating” products. To minimize the skin, alcohol-based sunscreens (Bullfrog) may burn when apcost of OTC products, purchase a retinoid and OTC HA & Retinol UPF 5-7 80-86% Products isturizer with AHA’s (CeraVe or antioxidants plied and an PM) oil-water emulsion based product (such as Blue Hydroxy Acids WhiteRetinol cotton t-shirt Naturals Multivitamin Nourishing Lizard or CeraVeMoisturizer).

AM) may be preferred. ♣ Glow by Dr. Brandt Overnight ♣ Amlactin Ultra cream UPF solution 10 90% ♣ Pond’s Rejuveness Resurfacing Sun-avoidance efforts, hats, umbrellas, and protective Green cotton t-shirt ♣ Neutrogena Healthy Skin Anticream clothing will provide additional protection and decrease the forwrinkle cream - Night 93.3% UPF 15 mation of Products skin cancer, wrinkles, and irregular pigmented areas.

OTC HA & Retinol Retinol Hydroxy Acids Clothing marketed as sun-protective, UPF - Ultraviolet ProtecUPF 30 96.7% Hydroxy acids r. Brandt Overnight ♣ Amlactin Ultra cream tion Factor, is generally a lighter weight, cooler-to-wear fabric UPFacids 50 98%commonly used in cosmetic g solution ♣ Pond’s Rejuveness Hydroxy (HAs) are than traditional clothing with equivalent UV protection. These a Healthy Skin Anticream products andUPF chemical they first surged onto the mar1,700 peels since 99.9% fabrics should not replace the application of sunscreen but are le cream - Night 25 Dark Denim shirt ket in the 1990’s. Although naturally found in sugarcane (glyuseful adjuvants. We recommend applying a base layer of suncolic acid), sour milk (lactic acid), and fruits (citric, malic, and screen underneath dark, tight-weave fabric or UPF 30+ clothtartic acids), HAs found in prescription and cosmetic products ing. Finally, the use of sunglasses may reduce the deleterious are predominantly synthetic compounds.26 These compounds effects of UV radiation on the eyes, including retinal melanoma decrease roughness and irregular pigmentation, enhance dermal and cataract formation.18,19 vascular perfusion, and rebuild the skin’s extracellular matrix by increasing the Predominant Protective Spectrum of Active Compounds in Sunscreen14, 15 density of dermal UVA UVB UVA & UVB collagen, hyal♣ Avobenzonea ♣ Cinoxate ♣ Octyl salicylate ♣ Titanium dioxide uronic acid, and ♣ Ecamsule (Mexoryl ♣ Dioxybenzone ♣ Oxybenzonea ♣ Zinc oxide the quality of the SX) ♣ Homosalate ♣ Padimate O

♣ Octocrylene ♣ Sulisobenzone elastic fibers.27-28 ♣ Octyl Methoxycinnamate (OMC) The exact moleca The combination of avobenzone and oxybenzone, commonly called Helioplex (Neutrogena) and Active Photobarrier Complex ular mechanisms (Aveeno), provides broad-spectrum UV coverage (UVA & UVB).

UPF 15

93.3%

318 JOURNAL MSMA October 2014

Which rejuvenator type should I choose?

Retinoids are generally the most effective restoratives and limited to only “rejuvenating” products. To minimize the number and cost of OTC products, purchase a retinoid and

behind these changes are not entirely clear.

Depending upon the condition being treated and the desired effect, higher concentration (>10% HA), dermatologic applications may be preferred over low concentration, 4-10% HA, cosmeceuticals. Due to exfoliation, HAs may increase the skin’s sensitivity to the sun and possibly lead to further sun-damage and burns. Patients should be certain to employ adequate sun protection strategies (sunscreen, sun-protective clothing including hats, and sun avoidance) while they use HAs.

and safety in humans.

It is important to restate the FDA has no oversight on these OTC compounds, and product availability does not imply efficacy or safety. For example, gold, which is found in some OTC anti-aging creams, is a relatively common cause of allergic contact dermatitis.39

Discussion

Consider consulting a

Given the large number of dermatologist prior to these regimens commercially available cosmeceu- beginning in patients with: Antioxidants tical products and ubiquitous ad- ♣ Atopic Dermatitis vertisements claiming to offer im- ♣ Cystic Acne A number of cosmeceuticals include antioxidants to de♣ Rosacea crease free radical damage to DNA and other cellular compoprovements in the skin’s appearance, nents. Cellular stress, UV irradiation, and smoking generate consumers and physicians are often confused as to which OTC highly reactive oxygenated species (ROS), which possess an products produce the best results. Simple, effective skin care regimens combine cleansers, moisturizers, sunscreens, and if unpaired electron, also known as a free radical. Enzymes and for starting a routine: desired anti-agingSuggestions products containing retinoids, hydroxyl acantioxidants, such as glutathione, vitamin C, vitamin E,Regimen and Basic Facial Skin Care ubiquinone (CoQ10), remove these free radicals by donating ids, and antioxidants.

The use of prescription retinoids or hya A 1) Wash with appropriate cleanser for skin type • Wash your face with an appropriate cleanser b one of their electrons but become depleted or temporarily indroxy acid chemical peels at the dermatologist’s office may M 2) Apply moisturizer for your skin type after brushing your teeth b 3) Apply sunscreen activated in the process. Replenishing these reducing agents is provide greater improvements of skin imperfections (acne, (morning and evening) c the theoretical basis for the topical application of or antioxidants. wrinkles, and•irregular cosmeceuticals.

P 1) Wash with a dry normal skin cleanser After pigmentation) washing, applythan a moisturizing Applyabundant, Retinoid orwater-soluble Rejuvenator product Vitamin C: Vitamin CMis the2)most sunscreen in the morning and a moisturizer, 3) Apply Moisturizer HA, or retinoid in the evening antioxidant in the body. In addition to its antioxidant role in the a • Basic If you wear makeup, choose makeup with for each skin type management of free radicals, Appropriate vitamin C iscleansers a required enzyme co- are listed Facial Skin CareRegimen Regimen Example Skin Care above in Cleansing. broad-spectrum UVA-UVB coverage. factor in the production of collagen and vitamin E regeneration. b a Step 2 & 3 may be combined if a moisturizing A 1) •WashIfwith appropriate cleanser for skin type you work outside, keep a bottle of zinc or • While oral, vitamin C supplementation does(CeraVe not increase cutane-Daily Facial M 2) Apply moisturizerb sunscreen is used AM, Cetaphil titanium sunscreen in your lunch box. It will Neutrogena Healthy Defense ous levels in those without aMoisturizer, pre-existing deficiency, topical for- Liquid 3) Apply sunscreenb both remind you and provide a refreshing Moisturizer). mulations can lead to an (1)c increase in Vitamin skin concenc Salicylic acid or benzoylCperoxide washes may over- P when reapplied at lunch.

1) Washcoolness with a dry or normal skin cleanser • dry the skin if used twice daily. peroxide also M tration, (2) decrease in deep skin furrows (wrinkles), (3) Benzyol repair of 2) Apply Retinoid or Rejuvenator product will inactivate retinoids, as will ultraviolet exposure.

3) Apply Moisturizer elastic tissue, and (4) enhanced photoprotective effects of sunConsider consulting a 29-31 screen.

Since the biologically active form, L-ascorbic acid, is a prior to • Appropriate cleansers for eachdermatologist skin type are listed easily oxidized in air, heat, or alkaline pH, topicals often employ beginning these regimens above in Cleansing. b patients with: Step 2 & 3 may be combined ifin a moisturizing a more stable, Vitamin C derivative in their formulations.32 L• AtopicDaily Dermatitis sunscreen is used (CeraVe AM, ♣ Cetaphil Facial ascorbate and tetrahexyldecyl ascorbate (THD) have been extenMoisturizer, Neutrogena Healthy Liquid ♣ Defense Cystic Acne sively studied and are effective penetrators of the epidermis.

Moisturizer). ♣ Rosacea c Salicylic acid or benzoyl peroxide washes may overVitamin E: Tocopherol, commonly called Vitamin E, is dry the skin if used twice daily. Benzyol peroxide also another antioxidant that has been extensively studied in the will inactivate retinoids, as will ultraviolet exposure. skin. At least, eight tocopherols exist with alpha-tocopherol being the most common form in animals. Similar to vitamin C, oral supplementation of alpha-tocopherol restores Vitamin Suggestions for starting a routine: Basic Facial Skin Care Regimen E’s photoprotective effects less effectively than topical adminA Topical 1) Wash with appropriate for skin typea istration.33,34 formulations reduce cleanser extracellular matrix • Wash your face with an appropriate cleanser b M 2) Apply moisturizer degradation, UVB-induced sunburns, and UV-induced tumor for your skin type after brushing your teeth 3) Apply sunscreenb formation.34-36 However, topical vitamin E may cause a contact (morning and evening) 37 dermatitis in individuals.

P some 1) Wash with a dry or normal skin cleanserc • After washing, apply a moisturizing MAntioxidants: 2) Apply Retinoid or Rejuvenator Other A number of additionalproduct ingredients, sunscreen in the morning and a moisturizer, 3) Apply Moisturizer which are not mentioned above, are marketed in OTC anti-agHA, or retinoid in the evening a ing formulations.

Of thecleansers more commonly advertised antioxi• If you wear makeup, choose makeup with Appropriate for each skin type are listed dants, Camella (green tea), Vitis vinifera (grape seed abovesinensis in Cleansing. broad-spectrum UVA-UVB coverage. b Step 2 & 3 may be combined if a(kinetin), moisturizing extract), Soy extract, N6-furfuryladenine and Nico• If you work outside, keep a bottle of zinc or (CeraVehave AM, Cetaphil Daily Facial tinamide (asunscreen Vitamin isBused derivative) shown promising retitanium sunscreen in your lunch box. It will Moisturizer, Neutrogena Healthy Defense Liquid 38 sults in biochemical and/or animal studies.

However, these both remind you and provide a refreshing Moisturizer). compoundsc Salicylic currentlyacid cannot be recommended due to a lack or benzoyl peroxide washes may over-of coolness when reapplied at lunch. randomized, therapeutic benefit drycontrolled the skin iftrials used demonstrating twice daily. Benzyol peroxide also will inactivate retinoids, as will ultraviolet exposure.

October 2014 JOURNAL MSMA 319

Sugges

Wash y for you (mornin After w sunscre HA, or If you w broad-s If you w titanium both re coolnes

References 1. U.S. Food and Drug Administration. FDA 101: Dietary Supplements [Internet]. 2013. Available from: http://www.fda.gov/forconsumers/consumerupdates/ucm050803.htm.

2. Wortzman M, Scott R, Wong P, Lowe N, Breeding J. Soap and detergent rinsability. J Soc Cosmet Chem. 1986;37:89-97.

3. Draelos Z. Cosmetics and Cosmeceuticals. In: Bolognia J, Jorizzo J, Rapini R, editors. Bolognia Textbook of Dermatology. 2nd ed. Spain: Molsby Elsevier Publishing; 2008:2301-2303.

4. Rieger M, Deem D. Skin Moisturizers. II. The effect of cosmetic ingredients on human stratum corneum. J Soc Cosmet Chem. 1974;25(5):253-62.

5. Stender I, Blichmann C, Serup J. Effects of oil and water baths on the hydration state of the epidermis. Clin Exp Dermatol. 1990;15(3):206-209.

6. WHO International Agency for Research on Cancer. IARC monographs on the evaluation of carcinogenic risks to humans [Website]. 2012. Available from: http://monographs.iarc.fr/ENG/Classification/index.php.

7.

Beitner H. Clinical and experimental aspects of longwave ultraviolet (UVA) irradiation of human skin. Acta Derm Venereol Suppl (Stockh).1986;123:1-56.

25. U.S. Food and Drug Administration. Guidance: Labeling for Cosmetics Containing Alpha Hydroxy Acids [Internet]. 2005. Available from: http:// www.fda.gov/Cosmetics/GuidanceComplianceRegulatoryInformation/ GuidanceDocuments/ucm090816.htm.

26. Kneedler J, Sky S, Sexton L. Understanding alpha-hydroxy acids. Dermatol Nurs. 1998; 10(4):247-54,259-62; quiz 265-6.

27. Bergfeld W, Tung R, Vidimos A, Vellanki L, et al. Improving the cosmetic appearance of photoaged skin with glycolic acid. J Am Acad Dermatol.

1997; 36(6 Pt 1):1011-3.

28. Ditre C, Griffin T, Murphy G, Sueki H, et al. Effects of alpha-hydroxy acids on photoaged skin: a pilot clinical histologic and ultrastructural. J Am Acad Dermatol. 1996; 34(2 Pt 1):187-95.

29. Pinnell S, Yang H, Omar M, Monteiro-Riviere N, et al. Topical L-ascorbic acid: percutaneous absorption studies. Dermatol Surg. 2001; 27(2):13742.

30. Humbert P, Haftek M, Creidi P, Lapiere C, et al. Topical ascorbic acid on photoaged skin. Clinical, topographical and ultrastructural evaluation: double-blind study vs. placebo. Exp Dermatol. 2003; 12(3):237-44.

31. Eberlein-Konig B, Ring J. Relevance of vitamins C and E in cutaneous photoprotection. J Cosmet Derm 2005;4(1):4-9.

8. Brady M. Public health and the tanning bed controversy. J Clin Oncol.

2012;30(14):1571-3.

32. Morris A, Barnett A, Burrows O. Effect of processing on nutrient content of foods. Cajanus. 2004; 37(3):160-64.

9. de With A, Greulich K. Wavelength dependence of laser-induced DNA damage in lymphocytes observed by single-cell gel electrophoresis. J of Photochem and Photobiol B. 1995;30(1):71-6.

33. Wernighaus K, Meydani M, Bhawan J, Margolis R et al. Evaluation of the photoprotective effect of oral vitamin E supplementation. Arch Dermatol.

1994;130(10):1257-61.

10. Nylander K, Bourdon J, Bray S, Gibbs N, et al. Transcriptional activation of tyrosinase and TRP-I by p53 links UV irradiation to the protective tanning response. J Pathol. 2000;190(1):39-46.

34. Trevithick J, Xiong H, Lee S, Shum D, et al. Topical tocopherol acetate reduces post-UVB, sunburn-associated erythema, edema, and skin sensitivity in hairless mice. Arch. Biochem Biophys. 296(2):575-82.

11. Honigsmann H. Erythema and pigmentation. Photodermatol Photoimmunol Photomed 2002;18(2):75-81.

35. Gensler H, Magdaleno M. Topical vitamin E inhibition of immunosuppression and tumorigenesis induced by ultraviolet irradiation. Nutr Cancer. 1991;15(2):97-106.

12. Sayre R, Hughes S. Sun protective apparel: advancements in sun protection. Skin Cancer J. 1993;8:41-7.

13. Ratanaprasatporn L, Neustadter J, Weinstock M. Scientific developments in indoor tanning and melanoma. J Am Acad Dermatol. 2001;64(4):783-5.

14. DeLeo, V. Sunscreens. In: Bolognia J, Jorizzo J, Rapini R, editors. Bolognia Textbook of Dermatology. 2nd ed. Spain: Molsby Elsevier Publishing; 2008:2038.

15. United States Environmental Protection Agency. Sunscreen: The Burning Facts. Air and Radiation (6205J). 2006;EPA 430-F-06-013.

16. Gies P, McLennon A. Everyday and High-UPF Sun-Protective Clothing.

The Melanoma Letter [Internet]. 2012. Available from: www.skincancer. org/publications/the-melanoma-letter/summer-2012-vol-30-no-2/clothing.

17. American Association of Textile Chemists and Colorists (AATCC). Test Method 183 – Transmittance or blocking of erythemally weighted ultraviolet radiation through fabrics. In AATCC technical manual. 2001: 349351, AATC, Research Triangle Park NC 2001.

36. Chung J, Seo J, Lee M, Eun H, et al. Ultraviolet modulation of human macrophage metalloelastase in human skin in vivo. J Invest Dermatol.

2002;119(2):507-12.

37. Kosari P, Alikhan A, Sockolov M, Feldman S. Vitamin E and allergic contact dermatitis. Dermatitis. 2010;21(3):148-53.

38. Cronin H, Draelos Z. Top 10 botanical ingredients in 2010 anti-aging creams. J Cosmet Dermatol. 2010; 9(3):218-25.

39. Katta R. Common Misconceptions in Contact Dermatitis Counseling.

Dermatol Online J. 2008. 14(4):2.

Extensively screened.

Carefully matched.

Compassionate, Professional Home Care

18. Tucker MA, Shields JA, Hartge P, Augsburger J, et al. Sunlight exposure as a risk factor for intraocular malignant melanoma. N Engl J Med. 1985;313(13):789–92.

19. Neale R, Purdie J, Hirst L, Green A. Sun Exposure as a risk factor for nuclear cataract. Epidemiology. 2003;14(6):707-12.

20. Creidi P, Vienne M, Ochonisky S, Lauze C, et al. Profilometric evaluation of photodamage after topical retinaldehyde and retinoic acid treatment. J Am Acad Dermatol. 1998;39(6):960-5.

21. Cho S, Lowe L, Hamilton T, Fisher G, et al. Long-term treatment of photoaged human skin with topical retinoic acid improves epidermal cell atypia and thickens the collagen band in papillary dermis. J Amer Acad Dermatol. 2005;53(5):769-74.

22. Nyirady J, Bergfeld W, Ellis C, Levine N, et al. Tretinoin cream 0.02% for the treatment of photodamaged facial skin: a review of 2 double-blind clinical studies. Cutis. 2001.68(2):135-42.

23. Hakkinen L, Westermarck J, Johansson, et al. Suprabasal expression of epidermal alpha 2 beta 1 and alpha 3 beta 1 integrin in skin treated with topical retinoic acid. Br J Dermatol. 1998; 138(1):29-36.

24. Hsu P, Litman G, Brodell R. Overview of the treatment of acne vulgaris with topical retinoids. Postgrad Med. 2011;123(3):153-61.

320 JOURNAL MSMA October 2014

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October 2014 JOURNAL MSMA 321

• Clinical Problem-Solving • All Dressed Up with No Place to Go Ana-Maria Hubert, MD; Jennifer J. Bryan, MD

I

ntroduction

A 62-year-old African-American female presented to the emergency department with pain in her back, chest, abdomen, and legs. The pain had been present for a few months, and she had also lost 25 pounds over the previous 5 months. She reported nausea, vomiting, and fatigue, along with decreased appetite over the previous 2 days. The patient had a colonoscopy 3 months earlier and was diagnosed with colitis. She admitted to blood in her stools and complained of intermittent headaches in the frontal and bitemporal regions. Her review of systems was positive for low grade fever, chills, chest pain, cough, abdominal pain, dizziness, and depression. She denied edema, palpitations, shortness of breath, wheezing, diarrhea, constipation and dysuria. She had a known allergy to penicillin. She denied smoking and using alcohol or drugs. Her past medical history was significant for systemic lupus erythematosus (SLE), colitis, depression, and seizure disorder. Her home medications included mesalamine (Pentasa), hydroxychloroquine (Plaquenil), sulfasalazine (Azulfidine), tramadol (Ultram), buspirone (BuSpar), venlafaxine (Effexor), omeprazole (Prilosec), aspirin, vitamin D, fish oil, and multivitamins.

Her physical examination was unremarkable, and her vital signs were within normal limits. She was well-developed and well-nourished. She had involuntary guarding on palpation of her abdomen, but she denied pain with palpation. She had normal strength throughout her upper and lower extremities, and her range of motion was preserved.

She had a flat affect.

The patient’s symptoms are nonspecific. Based on her symptoms, she could have a malignancy, fibromyalgia (based on generalized pain), thyroid disease, an exacerbation of her colitis, depression, chronic pain, gallbladder or pancreas disorders, or an SLE flare.1 The unremarkable physical exam did not help in pointing towards a more specific cause for her symptoms. I will obtain a complete blood count because anemia Author Information: Dr. Hubert was a resident in the Department of Family Medicine at the University of Mississippi Medical Center in Jackson where Dr. Bryan is an assistant professor.

Corresponding Author: Ana-Maria Hubert, MD; Watauga Medical Center, 336 Deerfield Road, Boone, North Carolina 28607.

Ph: (828) 262-4100, (hubertussobe@yahoo.com).

322 JOURNAL MSMA October 2014

could be a cause for her symptoms and because she reported some blood in her stools. I will also obtain a complete metabolic profile since undiagnosed kidney disease is a possibility given the patient’s history of SLE. I will look closely at her liver enzymes, (especially her bilirubin) since the patient reports nausea, vomiting, and weight loss. These symptoms lead me to consider gallbladder pathology as a culprit. I will order a lipase and amylase to evaluate for possible pancreatitis and a thyroid stimulating hormone for possible hypothyroidism.1 The patient had a normal lipase, amylase, and thyroid stimulating hormone. Her complete blood count with differential showed white blood cell count (WBC) of 6.3 K/ uL, hemoglobin 12.1 g/dL, hematocrit 37.1%, and platelet count 199 K/uL. The differential revealed 82% neutrophils, 9% lymphocytes, 2% monocytes, and 7% eosinophils. Her basic metabolic profile was remarkable for a potassium of 3 mEq/L. Her liver panel showed bilirubin 0.6 mg/dL, aspartate aminotransferase (AST) 349 U/L, alanine aminotransferase (ALT) 633 U/L, alkaline phosphatase 431 U/L, total protein 5.6 g/dL, and albumin 2.9 g/dL. Elevation of the AST and ALT of more than 7 times normal limits and alkaline phosphatase more than 3 times normal limits may be consistent with acute hepatitis. A previous liver panel ordered by her gastroenterologist a month earlier showed a normal AST and ALT. Her normal hemoglobin and hematocrit values are not consistent with anemia. Hypothyroidism is unlikely given her normal thyroid stimulating hormone. Malignancy is unlikely as previously ordered tumor markers returned negative. I am unsure of the cause of her acute hepatitis. Causes of acute hepatitis include viruses, drugs, alcohol, Wilson’s disease, hemochromatosis, fatty liver or autoimmune disorders.2 To further investigate, I will order a hepatitis panel, PT/INR, and autoimmune panel due to her history of autoimmune diseases. I will discontinue all of her medications and consult the patient’s gastroenterologist and rheumatologist.

The patient was admitted to the hospital and given IV fluids. Her home medications were discontinued and the patient’s gastroenterologist ordered a liver biopsy. The gastroenterologist determined Crohn’s disease was the reason for the colitis based on a colon biopsy he did 3 months earlier. Approximately 1 month after the biopsy, the gastroenterologist prescribed sulfasalazine. Antinuclear antibod-

ies, rheumatoid factor, serum protein electrophoresis, antismooth muscle antibodies, anti-mitochondrial antibodies ,and cytomegalovirus (CMV) antibodies were ordered by her rheumatologist. On the second day of hospitalization, she complained of generalized skin discomfort. Her hepatitis panel returned negative, and iron studies were normal.

She had a low grade fever of 99˚F, and blood cultures were ordered.

Her hepatitis panel is negative indicating that a hepatitis virus is not likely to be responsible for her symptoms. Hemochromatosis is unlikely because her iron studies are normal.

The gallbladder doesn’t seem to be the problem since a gallbladder ultrasound done a few days earlier was normal. Wilson’s disease usually affects patients younger than 35 years and is associated with neurological changes, which my patient does not have. At this time I am more inclined to believe her acute hepatitis is either drug-induced, viral (nonhepatitis) or an autoimmune process.2 Her liver biopsy and the rheumatologic markers will assist in narrowing the differential.3 A liver biopsy was performed on hospital day 3. The patient was still not receiving any of her home medications.

The only medications she was receiving at this time were pantoprazole (Protonix) and hydromorphone (Dilaudid) as needed. AST, ALT, and alkaline phosphatase were slowly trending down. On hospital day 4, the patient was starting to complain of itchiness after she received hydromorphone, which was discontinued. She was prescribed morphine IV as needed in place of the hydromorphone. Her WBC was increased from 6.6 k/uL to 10.4 k/uL from the previous day.

Blood cultures were negative. CMV antibodies returned negative for immunoglobulin M but immunoglobulin G was positive. Rheumatological markers were negative. The patient also complained of sore throat and difficulty swallowing. A rapid strep test returned negative. The patient refused an esophagogastroduodenoscopy since she had one performed 5 months prior to this hospitalization. At that time, the esophagogastroduodenoscopy showed a hiatal hernia and gastritis.

I think that her acute hepatitis is likely secondary to one of her medications because her liver enzymes began to improve after her home medications were discontinued. Also, autoimmune markers are negative, making lupus or other autoimmune processes unlikely. Since her rapid strep is negative, I assume that her sore throat is secondary to a viral illness, and her difficulty swallowing is likely secondary to her sore throat. I am not worried about the small increase in her WBC since this can be attributed to pure stress or physiological changes. Positive immunoglobulin G antibodies against CMV suggest an old infection, and CMV is unlikely to have caused her hepatitis.2 On hospital day 5, the patient was noted to have mild edema involving all 4 extremities, and she complained of abdominal discomfort. On hospital day 6, the patient’s nonpitting edema increased, and she developed a generalized miliary rash and a temperature of 100.4˚F. Her WBC had

increased to 17.8 k/uL. Urinalysis and blood cultures were reordered. Her urinalysis showed 3+ leukocyte esterase and 30-49 urinary WBC, and urine culture was ordered. She was given ciprofloxacin (Cipro) for presumed urinary tract infection. Her albumin was 2.9 g/dL on admission and now was 2.3 g/dL. I discontinued her IV fluids.

In a patient with edema, first we need to determine the type of edema, pitting versus non-pitting. Pitting edema is characteristic of systemic disease, including heart disease, pregnancy, varicose veins, thrombophlebitis, and cellulitis. Non-pitting edema is associated with lymphedema, lipemia, and myxedema.

Hypoalbuminemia can be a cause of generalized edema. Causes of hypoalbuminemia include chronic hepatic failure that may result in decreased production of albumin, malnutrition, gastrointestinal or renal losses, and acute or chronic inflammation.

My patient has both acute and chronic inflammation, secondary to her Crohn’s disease.4 On hospital day 8, the patient had a low grade fever again, increased WBC to 21.7 k/uL, increasing non-pitting edema and miliary rash. Repeat urine and blood cultures were negative. A CT scan of the abdomen and pelvis was read as nonspecific body wall edema, small pericardial effusion, cholelithiasis (although a previous gallbladder ultrasound did not show stones) without evidence of obstruction, atrophic right kidney, and mild bilateral inguinal adenopathy.

Since the CT scan is inconclusive, I look to the laboratory data for more information and notice an eosinophilia. This eosinophilia has been slowly trending upwards since admission. I consider multiple causes but begin to seriously consider a drug reaction.

On day 9, her liver biopsy showed chronic granulomatous hepatitis with hypereosinophilia and a few giant cells and epithelial histiocytes suggesting granuloma. The report stated a drug reaction was a likely cause of her hepatitis.

Acid fast stains and fungal stains were negative. Mild peripheral fibrosis was noted on the biopsy report. Eosinophilia was noted, and the edema was worsening. The patient was given steroids secondary to the results of the liver biopsy and the worsening edema. A reflexive antinuclear antibody, complements 3 and 4, anti-neutrophilic cytoplasmic antibody and ferritin were ordered to evaluate for a possible vasculitis that could be causing the edema. These studies returned negative. The patient was also given a Lasix-albumin-Diuril (LAD) infusion for the swelling, since her albumin was slowly decreasing. By day 10, I consulted an infectious disease specialist due to the increasing WBC, marked hypereosinophilia, and no obvious source of infection. Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome secondary to sulfasalazine was diagnosed based on eosinophilic hepatitis, marked blood eosinophilia, rash, negative cultures, and sulfasalazine being started 2 months prior for treatment of Crohn’s colitis.

DRESS is a severe drug-induced reaction that includes a

October 2014 JOURNAL MSMA 323

severe skin eruption, fever, eosinophilia or atypical lymphocytosis, and internal organ involvement. It is characterized by a delayed onset, usually 2-6 weeks after the introduction of a new drug. The skin rash found with DRESS is a maculopapular rash and an erythematous skin eruption that can progress to exfoliative dermatitis with facial edema. Most patients present with organ involvement, and the liver is the most affected organ.

Hypereosinophilia is the third most frequently reported finding in patients with DRESS. Other symptoms that can be present include fever and peripheral lymphadenopathy.5 A scoring system called RegiSCAR was developed to aid in defining DRESS syndrome. RegiSCAR findings include fever, eosinophilia, enlarged lymph nodes, atypical lymphocytes, skin involvement, organ involvement, time of resolution, and the evaluation of other potential causes.5 Treatment of DRESS begins with withdrawal of the offending drug. Patients that have severe skin reaction (e.g. exfoliative dermatitis) are hospitalized and may require fluids, electrolyte and nutritional support, gentle skin care, and emollients. Patients with mild symptoms of DRESS, defined as no clinical, laboratory or imaging evidence of pulmonary or liver involvement and only mild elevation of liver transaminases (i.e. < 3 times the upper limit of normal), can be treated symptomatically. Topical corticosteroids can be used for relief of pruritus and skin inflammation. Patients with severe organ involvement are managed according to the organ affected. For liver involvement, the main treatment is withdrawal of the offending drug.

For patients with severe hepatitis, especially in jaundiced patients, referral to a liver transplant specialist should be made since the severe hepatitis may evolve to acute liver failure, and the only effective therapy may be liver transplantation. My patient had a severe hepatitis on presentation, which has improved rapidly, and referral to a liver transplant specialist was not warranted. If severe involvement of the lung (dyspnea, abnormal chest radiograph, hypoxemia, etc.) or kidneys (elevated creatinine, proteinuria or hematuria) is present, systemic corticosteroids are used.5-7 Patients with DRESS should be monitored clinically and through laboratory testing for resolution. Laboratory monitoring should include a complete blood count with differential, liver enzymes and liver function tests (serum aminotransferases, bilirubin, prothrombin time), blood urea nitrogen, and creatinine.5 The majority of patients with DRESS will recover completely in the weeks to months following drug withdrawal.

Avoidance of the involved drug should be recommended to family members as well since there is an underlying suspicion for a possible genetic link.5 My patient had an unusual presentation of DRESS syndrome. Her rash and eosinophilia did not develop until a few days into her hospitalization. Her initial presentation was that of acute hepatitis. What made her diagnosis even more difficult to recognize was the close association of the pruritus and rash

324 JOURNAL MSMA October 2014

with the hydromorphone administration. Another confounding factor was that her eosinophils were minimally elevated on presentation and were not in the range where most clinicians would feel compelled to order additional studies.8 After the patient was given steroids, her liver enzymes and eosinophils returned to normal, and she reported improvement in her symptoms. She has been slowly tapered off steroids, and she has not been otherwise treated for Crohn’s disease.

Key Words: fatigue, hepatitis, rash, edema, drug reaction References 1. Rosenthal TC, Majeroni BA, Pretorius R, Malik K. Fatigue: An overview.

Am Fam Med. 2008;78(10):1173-1179.

2. Friedman LS. Drug- & Toxin-Induced Liver disease. In Papadakis MA, McPhee SJ, Rabow MW. Current Medical Diagnosis & Treatment. 52nd ed. New York; McGraw-Hill:2013:662-717.

3. Suzuki A, Brunt EM, Kleiner DE et al. The use of liver biopsy evaluation in discrimination of idiopathic autoimmune hepatitis versus drug-induced liver injury. Hepatol. 2011;54(3):931-939.

4. Vincent JL, Dubois MJ, Navickis RJ, Wilkes MM. Hypoalbuminemia in acute illness: Is there a rationale for intervention? A meta-analysis of cohort studies and controlled trials. Ann Surg. 2003;237(3):319-334.

5. Cacoub P, Musette P, Descamps V, et al. The DRESS syndrome: A literature review. Am J Med. 2011;124(7):588-597.

6. Aquino RT, Vergueiro CS, Magliari ME, de Freitas TH. Sulfasalazineinduced DRESS syndrome (Drug Rash with Eosinophilia and Systemic Symptoms). Sao Paulo Med J. 2008;126(4):225-226.

7. Jose J, Klein R. Successful treatment of sulfasalazine-induced DRESS syndrome with corticosteroids and N-acetylcysteine. Pharmacotherapy.

2011;31(10):303e-310e.

8. Roufosse F, Weller PF. Practical approach to the patient with hypereosinophilia. J Allergy Clin Immunol. 2010;126(1):39-44.

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• Top Ten Facts You Need to Know • About Smoking Cessation Lucius M. Lampton, MD; William Lee Vail, M3

I

ntroduction

Tobacco abuse remains one of the leading causes of preventable illness on the planet. Physicians engaged in aggressive smoking cessation management face push-back from patients daily. Such clinical battles, however, are still worth our focused efforts. This article discusses the core facts all physicians should know to be successful in our smoking cessation efforts.

ASSESS willingness to make an attempt, ASSIST in the stop attempt, and ARRANGE for a follow-up visit.6

1. The tragic costs of tobacco use: Tobacco use is the most costly avoidable cause of morbidity and mortality in the USA, implicated yearly in 435,000 deaths and over $193 billion in medical expenses and lost productivity.1 If every smoker on Medicaid quit today, it is estimated over $14 billion could be saved in just five years.2

5. The five R’s: Physicians can educate, motivate, and raise awareness of the risks and personal relevance of smoking by asking the five R’s for smokers not ready to quit: RELEVANCE - Ask why quitting could be personally relevant. RISKS - Ask about potential risks of tobacco use.

REWARDS - Ask how quitting may make their life better.

ROADBLOCKS - Ask about barriers to quitting. REPETITION - These questions can be asked at every visit to continue motivating people trying to quit and gauge the willingness of others to try. People that relapse should be reminded that most people that have successfully quit for good made the attempt more than once.7

2. Tobacco dependence as a chronic disease: Of the estimated 45 million American smokers, 70% want to quit, 44% say they try to quit each year, and only 5% of those who try, succeed.3 Using a chronic disease model, in which health care providers recognize the long term trajectory of the disease with relapses and remissions inherent and accepted as part of the healing process with continual counseling, advice, and medication, has shown to be more effective and satisfying for patients.4

6. Medication: There are many prescription and over-thecounter options available to aid in smoking cessation.

Most effective pharmaceutical treatments involve the use of two or more drugs. The following are the three most effective treatment plans: Varenicline CHANTIX® (2 mg/d); Nicotine Patch (long-term, >14 weeks) + ad lib NRT (gum or spray); and Patch + Bupropion SR ZYBAN®. The OR (odds ratio) of success versus placebo for each are 3.1 (2.53.8), 3.6 (2.5-5.2), and 2.5 (1.9-3.4) respectively.5

3. Motivational interviewing and brief but consistent counseling work: Physicians counseling and motivating patients’ health behavioral changes work. As little as five minutes per visit means patients are 1.6 times more likely to quit smoking for good. Spending ten minutes or more means patients are 2.3 times more likely to stay smokefree. Even with pharmacotherapy, counseling and motivating always lead to higher sustained quit rates.5

7. Children and 2nd hand smoke: One effective way to motivate adults to quit is to explain the effects of 2nd hand smoke on children. Smoking in the house has been associated with SIDS, low birth weight, weak lungs, asthma, bronchitis, pneumonia, and ear infections.8

4. The five A’s: The AHRQ (Agency for Healthcare Research and Quality) recommends following the “5 A’s” practice guidelines each time a patient states that they are a smoker and desire to quit. The guidelines state that the health care provider should ASK about tobacco use, ADVISE to stop, Author Information: Mr. Vail is a third year medical student at Tulane School of Medicine. Dr. Lampton is Associate Clinical Professor of Family Medicine at Tulane School of Medicine, in the practice of family medicine in Magnolia, and is also the JMSMA Editor.

Corresponding author: Lucius M. Lampton, MD, Magnolia Clinic, 111 Magnolia Street, Magnolia, MS 39652 (lukelampton@cableone.net).

8. Cost-Effectiveness: Tobacco dependence treatment is cost effective in ways comparable to hypertension screening and cervical screening, yet it receives far less precedence in the clinical setting. Using a QALY (quality-adjustedlife-year saved) measurement in 1997, such treatments are estimated to have QALY of $3539 (2014 = $5227).9 9. Insurance and reimbursements: Medicare, many state Medicaid programs (including Mississippi), and many private insurance companies reimburse part or all of many of the combination medication therapies described above (for up to 30 days or more). Medicaid and Medicare also now reimburse for up to eight one-on-one smoking cessation counseling sessions a year.10

October 2014 JOURNAL MSMA 325

10. E-Cigarettes (Electronic Cigarettes): Some very recent data seems to assert that e-cigarettes (electronic devices that look similar to cigarettes but deliver vaporized nicotine without the associated carcinogens of cigarette smoke) are effective at helping people give up tobacco. There is still very little data available about the long term effects of e-cigarettes, and they remain controversial, with significant concern for their use outside of the cessation setting, especially among youth. Nevertheless, e-cigarettes may prove to be efficacious for people in the pre-contemplative stage of tobacco cessation.11 The Lancet published last year a randomized controlled trial which concluded: “E-cigarettes, with or without nicotine, were modestly effective at helping smokers to quit, with similar achievement of abstinence as with nicotine patches, and few adverse events…Our findings point to potential for e-cigarettes in regard to cessation effectiveness beyond that noted in the present study.” Their far greater reach, their higher acceptability among smokers than NRT, and no greater risk of adverse side effects imparted a “potential for improving population health.”12 In answering a contentious barrage of letters condemning their conclusions, the authors disagreed with assertions not to utilize e-cigarettes until more safety data is available.

They commented, “There is little question e-cigarettes are safer than smoking tobacco and are already used by millions of smokers to cut down or quit.”13 However, despite this emerging research and the clinical successes of many physicians, e-cigarettes remain a largely unproven aid for smoking cessation. A recent report of the American Medical Association’s Council on Science and Public Health reminds physicians that “the safety and efficacy of e-cigarettes have not been demonstrated scientifically.” Terming e-cigarettes an “uncontrolled experiment on the U. S. population,” the Council “strongly” discourages the medical use of e-cigarettes “until these products are found to be safe and effective.”14 Citing similar conclusions of a background paper prepared for the World Health Organization, the Council advises physicians to “educate themselves about e-cigarettes, be prepared to counsel patients about the use of these products and the potential for nicotine addiction and the potential hazards of dual use with conventional cigarettes, and be sensitive to the possibility that when patients ask about e-cigarettes, they may be asking for help to quit smoking.” The Council further recommends that physicians “promote the use of FDA-approved smoking cessation tools and resources for their patients” and be cognizant of the “risks of nicotine overdose” via e-cigarette liquid.14,15 E-cigarettes will come up in discussions with our patients. For now, the message is that the data are inconclusive and evolving regarding the therapeutic merits and safety of these products. Physicians may rationally con-

326 JOURNAL MSMA October 2014

clude that e-cigarettes appear to reduce the harm caused by conventional cigarettes in smokers who are unable (or unwilling) to cease and can be used with caution. That said, physicians should not conclude that the vapor is harmless and its long term effects inconsequential. If e-cigarettes are utilized by our patients, short-term use with an established quit date may be the safest approach for now (for many who transition to e-cigarettes never entirely quit).

The jury is still out on whether e-cigarettes are “a knight in shining armor or a Trojan horse” for physicians in our smoking cessation efforts.16

References

1. Centers for Disease Control and Prevention. Annual smoking-attributable mortality, years of potential life lost, and economic costs—United States, 1995–1999. MMWR. 2002;51(14):300-3.

2. American Legacy Foundation. Saving lives, saving money: tobacco-free states spend less on Medicaid. http://www​.americanlegacy​.org/Files/Policy​_Report_4_-_Medicaid​_Report_Technical_Notes.pdf.

3. Centers for Disease Control and Prevention. Cigarette smoking among adults—United States, 2006. MMWR. 2007;56:1157–61.

4. Conroy MB, Majchrzak NE, Regan S. et al. The association between patient-reported receipt of tobacco intervention at a primary care visit and smokers’ satisfaction with their health care. Nicotine Tob Res. 2005;7(Suppl 1):S29–34.

5. Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008.

6. Agency for Health Care Research and Quality. Five Major Steps to Intervention (The “5 A’s”). http://www.ahrq.gov/professionals/cliniciansproviders/guidelines-recommendations/tobacco/5steps.html.

7. Agency for Health Care Research and Quality. Patients Not Ready To Make A Quit Attempt Now (The “5 R’s”). http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/5rs.html.

8. Center for Disease Control and Prevention. Health Effects of Second Hand Smoke. http://www.cdc.gov/tobacco/data_statistics/fact_sheets/ secondhand_smoke/health_effects/.

9.

Cromwell J, Bartosch WJ, Fiore MC. et al. Cost effectiveness of the clinical practice recommendations in the AHCPR guideline for smoking cessation. JAMA. 1997; 278:1759–66.

10. American Lung Association. Tobacco Cessation Coverage 2012. http:// www.lung.org/assets/documents/publications/smoking-cessation/help ing-smokers-quit-2012.pdf.

11. Brown J, Beard E, Kotz D, Michie S, and West R. Real-world effective- ness of e-cigarettes when used to aid smoking cessation: A cross-section al population study. Addiction. 2014 Sep; 109(9):1531-40.

12. Bullen C, Howe C, Laugesen M, McRobbie H, Parag V, Williman J, Walker N. Electronic cigarettes for smoking cessation: a randomised con trolled trial. Lancet. 2013 Nov; 382(9905):1629-1637.

13. Bullen C, Howe C, Laugesen M, McRobbie H, Parag V, Willi man J, Walker N. Electronic cigarettes and smoking cessation: a quandary? – Authors’ reply. Lancet. 2014 Feb; 383(9915):408-409.

14. Report 2-I-14 of the American Medical Association Council on Science and Public Health, “Electronic Cigarettes, Vaping, and Health: 2014 Up- date.” Presented in advance of AMA Interim Meeting, November, 2014.

15. Grana R, Benowitz N, Glantz SA. Background Paper on E-Cigarettes (Electronic Nicotine Delivery Systems). San Francisco: Center for Tobacco Control Research and Education; University of California, San Francisco; December 2013. http://nicotinepolicy.net/documents/position_ papers/Grana_Glantz_WHO_ENDS_Report_Dec2013.pdf.

Accessed September 21, 2014.

16. Schluger NW. The electronic cigarette: a knight in shining armour or a Trojan horse? Psychiatric Bulletin. 2014 Oct; 38(5):201-203.

• President’s Page • The MSMA Physician Leadership Academy

I

Claude D. Brunson, MD 2014-15 MSMA President

n my inaugural address I said that physician leadership is a priority for MSMA and the House of Medicine. Our complex health care delivery system continues to evolve and poses both opportunity and risk to our patients and practices. The physician is the ultimate patient advocate and that speaks to the importance of the physician as the leader of the health care team. Look at the many medical practice issues and the major upheavals we experience daily in the financing and management of health care. It is obvious that the physician is the most knowledgeable and best equipped to craft workable and sustainable solutions.

We are aware of the stresses on the American economy that health care produces; we can identify the wasteful spending that can be eliminated without cutting quality; and we are the ones most invested in delivering good quality health care to our patients.

Many would correctly say physicians are leaders by the very nature of what they do. This is evident when we are called to lead the health care team or medical committees in our hospitals and facilities. It is also true that we do not routinely get formal training in the business of managing health care organizations and systems. We generally cede this level of management to others who have formal training in business administration or some similar discipline.

These professionals are important and have made significant contributions to the evolution of the modern health care delivery system. However, I believe the health care delivery system would only be strengthened by increased input from physician managers, administrators, and chief executives. Fortunately, we see more physicians seeking formal education and contributing at the highest levels of management. Our contributions make a difference. Yet, more of our colleagues need to become engaged at all levels of management.

The physician has an exceptional perspective. We see the impact health care policies have on patient care at the end of the line. It is this unique perspective that makes the physician so well suited to lead and improve the delivery of care in ways that enhance quality as well as financial efficiency.

Because effective leadership is critical to organizational success, MSMA has stepped up to the plate: we have developed the MSMA Physician Leadership Academy modeled after a successful program offered by our sister Tennessee Medical Association.

I was fortunate to meet the talented MSMA physician scholars during a recent session. They all are accomplished successful physicians who hold leadership positions in their groups, facilities, and institutions. Yet, they are committed to gaining formal training in leadership which will empower them to have an even greater impact on health care across our state and nation.

The Academy consists of six one-day sessions over a nine-month period. It is capably led by MSMA Director of Practice Strategies Phyllis Williams. The faculty was assembled to offer specific training designed to arm our physicians with skills needed to excel at every level of health care management. I am impressed with and appreciate all those involved with the Academy.

October 2014 JOURNAL MSMA 327

Physician leaders are a necessity in our rapidly evolving health care delivery system. If the system is to advance to a point where it efficiently and effectively provides the expected quality care to our citizens, physicians have to play a part in that design. Physicians are capable, committed, and possess the right qualities to improve health care delivery.

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We need to encourage and support more of our colleagues willing to gain the additional skills needed to advance to the highest levels of leadership in our health care organizations, systems, and agencies. I ask those who have attained these attributes and advanced to significant leadership positions to make a commitment and mentor younger colleagues to move them along the leadership continuum.

Now is the time for physicians to make our voices heard. It’s up to us to advocate for our patients to get access to the most advanced health care system in the world. The best way to make this happen is to become one of the physician leaders who makes the decisions about how, when, and where quality care will be delivered.

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• MSMA •

Excellence in Medicine Awards B MSMA Presents 2014

eginning during the 2014 University of Mississippi Medicine Center Awards Day ceremonies and culminating with the presentation of final awards during Annual Session’s Excellence in Medicine Awards program, nine awards were presented to deserving medical students and physicians by Mississippi State Medical Association. The deserving recipients were presented their awards by MSMA President Dr. Claude Brunson.

DR. JAMES C. WAITES LEADERSHIP AWARD

Carlos A. LaTorre, MD

The Dr. James C. Waites Leadership Award was instituted in 2001 to recognize the many contributions of Dr. Waites to his community and to organized medicine. Each year the Board of Trustees selects one physician under the age of 50 who is an outstanding leader in organized medicine and community affairs.

This year, the Board of Trustees selected Carlos A. LaTorre, MD (shown left with his wife and daughter). Dr. LaTorre is a family medicine physician at Family Medicine Clinic in Vicksburg. He is also a staff physician at River Region Health System.

Dr. LaTorre is a member of the University of Mississippi Medical Center Family Medicine Recruitment Committee and has been involved in assisting area athletic teams with sports physicals. He regularly volunteers as a speaker for area seniors and women’s groups, providing free medical information geared to their special healthcare needs.

Additionally, through his work with the Puerto Rican Association of Physical Medicine and Rehabilitation, he has conducted free carpal tunnel screenings and provided information on risk factors and treatments to the medically-underserved.

MSMA AWARD FOR EXCELLENCE IN WELLNESS PROMOTION UMMC Physicians and Medical Students Involved in the Important Work of

The Jackson Free Clinic

The Jackson Free Clinic (JFC) is operated by medical students at the University of Mississippi Medical Center in Jackson as well as volunteer physicians from the local community. It offers non-emergency medical care, including evaluation, testing, prescription drugs, and education to individuals who cannot pay. Jackson Free Clinic was created to increase access to health care and assist in restoring health and employment in an underserved population. The clinic focuses on major health care issues affecting underserved individuals by providing high quality and caring treatment and education for prevention of acute and chronic medical conditions. The clinic is staffed by volunteer medical students including, but not limited to, one upperclassman (third- or fourth-year medical student). Each Saturday, at least one volunteer physician supervises patient care.

330 JOURNAL MSMA October 2014

2014 MSMA COMMUNITY SERVICE AWARD RECIPIENTS: Helen Barnes, MD; James Anderson, MD; Aaron Shirley, MD

T

he Annual Physician Award for Community Service is given to recognize a recipientâ&#x20AC;&#x2122;s participation in civic activities for the betterment of the community. It consists of a plaque and a $500 contribution to a civic organization designated by the recipient. The award is designed to provide recognition to members of the association who are actively engaged in the practice of medicine and for the many and varied services above and beyond the call of duty which they render to their respective communities.

Helen Barnes, MD, (right) is a former professor of obstetrics and gynecology at the University of Mississippi Medical Center and one of the first African American female physicians to practice medicine in Mississippi. Dr. Barnes earned a medical degree from Howard University in Washington, DC, and completed residency training in obstetrics and gynecology at Kings County Hospital in Brooklyn, New York.

She was in private practice in Greenwood and Brooklyn and on the faculty at Tufts Medical School and University of Mississippi Medical Center. She later opened the Primary Care Clinic for Women at Jackson Medical Mall, which later became the primary clinic site for a National Center for Excellence in Womenâ&#x20AC;&#x2122;s Health at UMMC. She has served on the Statewide Health Coordinating Council and the Mississippi State Board of Medical Licensure.

James Anderson, MD, (below) has dedicated his life to serving others, both in his medical practice and through the support of important civil rights activities. Dr. Anderson earned a medical degree from Meharry Medical College in Nashville and completed an internship at Homer G. Phillips Hospital in St. Louis. Dr. Anderson returned to Mississippi and eventually moved to Jackson to establish a private practice. As the protests and demonstrations of the civil rights movement increased, Jackson became the site of many heated battles and student protestors from the north came south to join in the struggle. Those who were injured found many area doctors were reluctant to treat their wounds. Dr. Anderson treated patients without regard to race, color, religion or ability to pay, including white and Jewish students. Dr. Anderson also assisted Dr. Aaron Shirley in the founding of Jackson-Hinds Comprehensive Health Center. Over the years Dr. Anderson has served as a physician at JacksonHinds as well as Medical Director and Chief Executive Officer.

Helen Barnes, MD

James Anderson, MD

Aaron Shirley, MD, (not pictured) Chairman of the Board for the Jackson Medical Mall Foundation, has dedicated his life to others as a pioneer of rural and urban health care for the state of Mississippi. His vision for a one-stop shop health care facility for the underserved became a reality with the Jackson Medical Mall. Dr. Shirley graduated from Meharry Medical College and completed his pediatrics residency at the University of Mississippi, the first African American to accomplish this feat. In 1970, he helped to establish the Jackson Hinds Comprehensive Health Center which became the largest community health center in the state. He also established a comprehensive school-based clinic to provide health and counseling services to help reduce teen health problems and mental health issues. The clinic became a national model for school-based clinics.

October 2014 JOURNAL MSMA 331

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•

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•

MSMA BOARD OF s TRUSTEES’ resident age LIFETIME ACHIEVEMENT AWARD

Robert Smith, MD

The MSMA Board of Trustees Life Achievement Award was instituted in 2014 to honor a recipient who has dedicated his or her life to a worthy cause while making a significant impact in Mississippi’s healthcare arena and in the lives of others. Robert Smith, MD, is President and Chief Executive Officer of Mississippi Family Health Center, now known as Central Mississippi Health Services. He received a B.S. in Chemistry from Tougaloo College and a medical degree from Howard University School of Medicine. He completed additional training at the West Side Medical Clinic of Cook County Hospital in Chicago. He has held many leadership positions in Jackson-area hospitals and was the first African American physician elected to the position of Chief of Staff at Central Mississippi Medical Center. Dr. Smith served as part-time Assistant Clinical Professor of Family Medicine at the University of Mississippi School of Medicine and helped develop the Family Medicine Program. Dr. Smith was one of three co-founders of comprehensive community health centers, an initiative which began as Delta Ministry in Greenville. Today this network is the safety net for the medically-underserved and serves about a million Mississippians and 30 million nationwide.

Above: MSMA President Dr. Claude Brunson (l.) and Dr. Robert Smith (r.)

MSMA awards presented during UMMC’s 2014 Honors Day Ceremonies included: WALLACE CONERLY, MD AWARD - Nancy Salloum Harrison & John M. Bridges

Established in 2003 by the Mississippi State Medical Association in honor of A. Wallace Conerly, MD, Vice-Chancellor for Health Affairs and Dean of the School of Medicine from 1994-2003, this award is given to a senior medical student who most exemplifies Dr. Conerly’s outstanding attributes of leadership, community outreach, and service.

CARL GUSTAV EVERS, MD AWARD - Kevin John Batte & Michael O. Jennings

Given by the Mississippi State Medical Association Foundation on behalf of the many friends and colleagues of Carl Gustav Evers, MD, a Past President of the Association, Member of the AMA Council on Medical Education, and Associate Dean of Academic Affairs in the School of Medicine, it is presented to that senior medical student who demonstrates qualities of peerto-peer support, scholarship, and exceptional leadership in promoting and participating in student activities of the American Medical Association and the Mississippi State Medical Association. The award consists of a plaque and substantial cash award.

VIRGINIA STANSEL TOLBERT, MD AWARD - UMMC SCHOOL OF HEALTH RELATED PROFESSIONS - Katie Summers Fondren The Virginia Stansel Tolbert, MD Award, sponsored by the MSMA, is given on honors day to the graduating student of the University of Mississippi School of Health Related Professions (SHRP) who has the highest academic average.

VIRGINIA STANSEL TOLBERT, MD AWARD - UMMC SCHOOL OF MEDICINE – Lucas C. Ainsworth & Emily L. Brandon

The Virginia Stansel Tolbert, MD Award sponsored by the MSMA consists of a plaque and cash award and is given to a medical student who has demonstrated superior scholarship and leadership ability in campus activities. Additionally, the recipient must exhibit interest in issues which affect the profession and willingness to devote time and effort to those matters.

ROBERT S. CALDWELL, MD AWARD - Christina Marks, MD

Since 1982, Medical Assurance Company of Mississippi has presented the Robert S. Caldwell, MD Award to the top resident at the UMMC. The Caldwell Award is given in memory of the late general surgeon from Tupelo who was instrumental in the founding of MACM. The Caldwell Award is given each year in recognition of excellence in medical care, record keeping, leadership, and the teaching of medical students and fellow residents – characteristics that MACM deems valuable in a young physician. The recipient, selected by an ad hoc committee of faculty members at UMMC, is Christina G. Marks, MD, a senior resident in the Department of Radiology at the University of Mississippi Medical Center. Nominated by the UMMC faculty, Dr. Marks is recognized for her knowledge of medicine and excellence in care, as well as record documentation and leadership.

This award also recognizes an individual who is considered to be an avid teacher of medical students and fellow residents. Dr. Marks recently began a year-long breast imaging fellowship at George Washington University. After completion, she plans to pursue an interventional radiology fellowship and eventually return to practice in Jackson. r

332 JOURNAL MSMA October 2014

• Editorial • Round and Round She Goes…

Y

ou remember how it went: you sat around in a circle and were assigned the name of a fruit while the person in the middle was “it”; “it” then yelled out either specific fruits or (and this is where the bedlam came in) “Fruit Basket Turnover” and you scrambled to exchange places with a buddy while “it” tried to highjack a seat.

D. Stanley Hartness, MD JMSMA Associate Editor

From my vantage point sort of outside the circle, it seems a more ominous version evocative of the innocent childhood game is playing out in the circle of medicine. The participants, whether reluctant or willing, are physicians while the “it” can be the well-heeled corporate healthcare entity, the powerful insurance industry, or even the intrusive government bureaucracy.

To paraphrase President Obama, which I rarely am wont to do, if you like your doctor, you can keep your doctor… if you can find your doctor. And I feel certain that the wanderlust currently prevalent in the local medical community is not confined to metropolitan Jackson. Back in the summer, a colleague inquired if I’d heard about a covey of physicians relocating across town. Apparently always the last to know, I expressed surprise as he continued with a simple explanation for their move: they think the grass is greener. He then offered, “You know why it might look greener, don’t you?

More B…S…!”

With all of this switching of locations and allegiances, it only stands to reason that those who will suffer the most are our patients—especially the elderly. Case in point: the elderly gentleman accompanied by his nurse wife presented with their frustration levels off the meter. Recently hospitalized for coronary artery stenting, he was discovered to have pericarditis and subsequently underwent double bypasses—following which he developed acute cholecystitis requiring OPEN cholecystectomy! He was discharged to a nursing facility for rehab, but after three falls his wife opted to take her chances with him at home. On his release, the patient’s wife was told by his home health nurse that his physician-ofrecord, who was recently involved in the “metro shuffle”, declined to refill his prescriptions because he couldn’t remember him. On the day of his visit to me, his blood sugar was 346 while his wife was in tears.

1 2 3 4 5 6 7 8 9 10 11 12

The situation reminded me of the hyperactive animated characters on the Jumbotron at football games and you’re trying to guess which one is hiding the football. Even though I was fortunate to be able to practice in basically the same location for forty-plus years, I realize that times and circumstances change and that physicians, just as other professionals, must look out for what they feelofarethe theirMississippi own best interests.

My concern is thatAssociation such moves should be made as seamlessly Journal State Medical as possible so that our patients don’t slip through the cracks feeling as if they’re being left out in the cold withUMMC no medical home and that we’re putting our own The University of Mississippi Medical Center Attn: Dept. of Endocrinology self-interests above their welfare.

Endocrinology Division in Jackson, Miss is seeking a BC/BE Endocrinologist. Faculty candidates should submit a CV via fax to: 601-984-5608. EOE, M/F/D/V.

Fred L. Morgan 2500 North State St Jackson, MS 39216-4505 flmorgan@umc.edu

Dear Mr. Morgan: October 2014 JOURNAL MSMA 333 Thank you for your interest in the

• Scientific Articles • Dr. Kirby Bland Presents 13th Annual Hardy Surgical Forum Lecture The James D. Hardy Lecture was established to honor the founder of the Department of Surgery at the University of Mississippi Medical Center. Dr. Hardy came to the new campus of the University of Mississippi School of Medicine in 1955 with the opening of the new University Hospital and the transfer of the School of Medicine to Jackson. Dr. Hardy contributed significantly to the birth of cardiac surgery, and his research culminated in the world’s first human lung and heart transplants. Dr. Hardy rose to the presidency of the American College of Surgeons. He touched the lives of countless patients, students, and colleagues in our state and throughout the world. During his 32 years as chairman of the Department of Surgery, Dr. Hardy established a high standard of surgical care in our state and in our nation through the department that he established and the residents whom he trained.

Dr. Marc Mitchell, chair of the Department of Surgery, right, welcomed to the annual James D. Hardy Surgical Forum Dr. Kirby Bland, Fay Fletcher Kerner Professor and Chair of the University of Birmingham Department of Surgery, left, who gave the James D. Hardy Lectureship on Surgery, June 4, at the Norman C. Nelson Student Union.

D

r. Kirby I. Bland opened presenting the forum, “Breast Cancer: International Template Provided by Surgeons for Bench and Translational Research,” which was followed by chief resident presentations and lunch. Dr. Bland delivered the James D. Hardy Lecture, “Preserving Surgical Academia in the Centenary of the Flexnerian Academic Health Center.” PGY 3 presentations concluded the day.

Dr. Bland is the Fay Fletcher Kerner Professor and Chairman of the Department of Surgery at the University of Alabama Birmingham (UAB). An Alabama native, Dr. Bland received his undergraduate degree from Auburn University and medical degree from UAB. He completed his general surgery residency training at the University of Florida and a surgical oncology fellowship at M.D. Anderson Hospital.

Dr. Bland served on the faculty at the University of Lousiville, University of Florida, and was chairman of the department of surgery at Brown University, before returning to UAB to assume the role as chairman of the department of surgery in 1999.

An internationally known surgeon who has had an outstanding academic career, he has authored over 500 peer reviewed publications and 44 book chapters. Dr. Bland has been a visiting professor or given an endowed lecture 160 times.

Dr. Bland is a member of every major surgical society and has held many leadership roles, including president of the Southern Surgical Association, Society of Surgical Oncology, and the Society of Surgical Chairs. In 2009, he was elected the first vice-president of the American College of Surgeons and in 2010, president of the American Surgical Association, the highest honor which can be bestowed upon a surgeon in the United States.

334 JOURNAL MSMA October 2014

The James D. Hardy Lectureship in Surgery

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Surgical Forum Abstracts

he Department of Surgery sponsored the thirteenth James D. Hardy Surgical Forum on June 4, 2014, at the Nelson Student Union on the University of Mississippi Medical Center campus. The Hardy Forum is named to honor the first chairman of the Department of Surgery at the University of Mississippi School of Medicine. The name of this event recalls the Mississippi Surgical Forum, started by Dr. Hardy, which brought renowned teachers to Jackson annually. The Hardy Surgical Forum features presentations of original scientific investigations by post-graduate third year residents within the Division of General Surgery along with chief residents in most of the divisions within the Department of Surgery, and the James D. Hardy Lecturer in Surgery. The chief resident with the best presentation at the Hardy Forum will be awarded a prize at their graduation banquet. The Department of Surgery is committed to the excellence in research which so distinguished Dr. Hardy’s career. We hope that you will find the presentations stimulating, and we welcome your comments in the form of letters to the JMSMA editor. —Marc E. Mitchell, MD; James D. Hardy Professor and Chair, Department of Surgery

Percutaneous endoscopic cecostomy: a safe alternative for the management of neurogenic bowel —Ashley Baker, MD Pediatric bowel and bladder dysfunction: a diagnosis and treatment protocol—Rachel Baublet Head, MD Management of arterial injuries associated with posterior knee dislocations —Andi Barker, MD Surgical mortality: a comprehensive assessment —William Cauthen, MD Results of vacuum-assisted delayed primary closure of midline wounds in patients with colorectal cancer —J. Jarrett Corley, MD

Complex HPB experience: does a transplant program impact resident experience?

—Andrew Gaugler, DO What are we waiting f{OR}? analysis of UMMC operating room efficiency —Rachael Hayes, MD Reviving the lost art of video-assisted mediastinoscopy: novel therapeutic uses —Tad Kim, MD Is FAST a passing fad? —Nathan Maples, MD Multidisciplinary survey to identify safety issues in an academic surgical intensive care unit —Theressa Robertson, MD Concordance and complications of ultrasound guided breast biopsies performed by surgeons at the University of Mississippi Medical Center —Jennifer Dinning, MD Initial emergency department presentations of colorectal cancer at University of Mississippi Medical Center —Kirsten Gambrell, MD Blunt hepatic trauma: do we ever operate? —Andrew Mallette, MD Cultural evolution and the spread of health information on Twitter —Daniel Murphy, MD A technique for implantation of the CentriMag LVAD to allow ambulation and rehabilitation in patients with heart failure —Miguel Urencio, MD October 2014 JOURNAL MSMA 335

Percutaneous endoscopic cecostomy: a safe alternative for the management of neurogenic bowel Baker A, Harmon E, Nowicki M Background: Percutaneous endoscopic cecostomy (PEC) is a valid management option for constipation associated with neurogenic bowel. At our institution we use PEC as a means of establishing cecostomy access in children who have either undergone previous operations rendering their native appendix unavailable or in children who have had stenosis after open antegrade continent enema (ACE) creation. In this study we retrospectively review our institutionâ&#x20AC;&#x2122;s PEC data, focusing on length of hospital stay (LOS), longevity of cecostomy access, post-operative complication, and maintenance or achievement of fecal continence.

Methods: Retrospective identification of children who underwent PEC placement in the last 12 years was performed at our institution (n=15). All children were admitted one day prior to procedure for bowel preparation. PEC was performed under general anesthesia via a puncture and serial dilation technique, which was performed under direct endoscopic vision provided by a single Pediatric Gastroenterologist. Ultimately a Chait trapdoorŠ was placed over wire access to the cecum. All were admitted overnight for observation. Irrigation with water and glycerin was performed prior to discharge. Post-operative data assessments were abstracted from chart review.

Results: 15 children who underwent PEC placement were retrospectively evaluated. 66% (10) of children had spina bifida, 20% (3) had a history of tethered spinal cord, and 13% (2) had spinal cord injury. Average age was 13.3 years. 87% (13) of children did not have an available native appendix. 87% (13) first attempts at PEC were successful. 1 attempt failed secondary to cecal location near the right upper quadrant (previous laparoscopic ACE), and this patient underwent radiologic guided percutaneous cecostomy on hospital day 1. The second failed attempt was due to inability to endoscopically intubate the cecum. Average length of stay was 2 days. Of successful PEC placements, 46% (7) complained of granulation tissue, which was treated with silver nitrate.

20% (3) ultimately had their ChaitŠ removed secondary to dissatisfaction (average of 4.6 years after placement). 86% (13) were completely continent of stool post-operatively. Average length of follow-up was 49.6 months.

Conclusion: PEC appears to be a safe, reliable, and less invasive alternative to traditional open cecostomy. It is especially useful in children who lack a native appendix or who have channel stenosis. A major advantage of this approach is short LOS. While overall rate of complication is relatively high, most are managed conservatively in an outpatient setting. Further prospective data is certainly warranted. r

Pediatric bowel and bladder dysfunction: a diagnosis and treatment protocol Head RB, Andrews D, Harmon E Background: Pediatric Bowel and Bladder Dysfunction (BBD) can present with a varied group of symptoms such as dysuria, urinary incontinence, urinary frequency, foul urine odor, dribbling/leaking urine, or recurrent urinary tract infections. Since the symptoms for UTIs and BBD are often the same, many children seen by primary care providers are misdiagnosed. Children with BBD not treated appropriately or in a timely manner could progress to an irreversible condition known as Hinman Syndrome. We developed a protocol to serve as an evaluation and treatment guide for PCPs who care for children age 6 to 13 who present with the aforementioned symptoms. The BBD protocol will also assist in determining if and when this population should be referred to a specialist. This protocol has the potential to decrease healthcare costs, increase revenue for PCPs, and decrease the financial burden for families.

Methods: After obtaining IRB approval, 400 randomly selected primary care providers in Mississippi who treat children age 6 to 13 were sent a cover letter and pre-protocol questionnaire regarding their practice habits, approach to children with common urinary complaints, and their typical pediatric urology referral patterns. If they agreed to participate, the protocol materials were

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sent to the practitioner to use in clinical practice for at least 3 months. Protocol materials included: Bowel and Bladder Patient History Handout, Diagnostic Tools and Helpful Hints, BBD Treatment Algorithm, and supplemental materials such as Voiding diary, Bristol Stool Scale, and the Poop Journal. A post-protocol questionnaire was completed after at least 3 months to assess its usefulness in clinical practice or in referral patterns. SPSS version 18 was used to analyze the data from both pre and post protocol questionnaires.

Results: Of providers polled, 69 responded to our initial survey, 63.2% physicians, and 36.8% nurse practitioners. The majority has practiced in a pediatric setting for at least 8 years. The specifics of their practice patterns regarding urinary complaints will be outlined elsewhere and 92.6% agreed to use the protocol. Of the 63 participants who received the protocol, 21 answered the post protocol questionnaire. 95.2% found it useful for guiding their treatment and 90.5% would continue to use the protocol in their practices. Of the 4 component materials sent, the Treatment Algorithm and Diagnostic Tools and Helpful Hints received the highest marks as “somewhat” or “extremely useful”. The supplemental charts and tools were less well-accepted at 54.1%. 33.3% reported the protocol led to a complete resolution in over half of their patients, and 81% felt this protocol decreased their pediatric urology referrals for Bowel and Bladder Dysfunction.

Conclusion: Despite the low participation in the post-protocol questionnaire, the responses from this new clinical tool were extremely positive overall. We plan to expand its use in Mississippi and also track Pediatric Urology referral patterns from those who are participating. The supplemental material may be too specialized for the more difficult to manage patients and may best be reserved for those who make it into our urology practices. With the help of the BBD Protocol, this subset of children will receive more targeted treatment in a timely fashion. r

Management of arterial injuries associated with posterior knee dislocations Barker AK, Roy R, Baldwin Z Background: Knee dislocations have an associated vascular injury rate of 5-41%. Popliteal vessels are relatively fixed at the adductor hiatus and soleus fascia accounting for vulnerability. Obese patients with low impact injuries now represent the majority of patients presenting with knee dislocations. Traditional open revascularization for popliteal injury in the obese patient cohort can be technically difficult. Endovascular management may be an effective and alternative method for revascularization.

Methods: A retrospective study from 2008 was performed evaluating patients with traumatic knee dislocations. Endovascular treatment was attempted when able and outcomes recorded.

Results: There were six total patients, one underwent primary amputation for a mangled extremity. Five underwent angiography with three successful endovascular treatments and two converted to open procedures secondary to severed artery. Follow up of the three successful endovascular treatments revealed no re-occlusions. Two patients developed re-stenosis, both asymptomatic.

One required return to operating room two years later for angioplasty of in-stent re-stenosis.

Conclusion: Endovascular repair may be beneficial for early and effective revascularization as it minimizes wound-related complications and offers quicker recovery. Long-term patency of these endovascular repairs is a potential drawback. Open repair remains a future option that can be done in an optimal setting remote from traumatic injury. r

Surgical mortality: a comprehensive assessment Cauthen W, Martin L, Helling T, Mitchell M Background: Surgical mortality can be difficult to assess unless every patient that has any interaction with a surgical service can be included. We sought to determine if any of these patients, if managed differently, could have had a better outcome.

Methods: The records of all adult mortalities, age > 17, over a 9 month period were evaluated for any type of surgical interaction. All specialties of surgery were included. We then looked at the type of interaction, co-morbidities and risk assessment, cause of mortality, and possible preventability.

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Results: There were 172 patients who met the above criteria. Most of these patients (78, 47.3%) were admitted to a medical service with the trauma service being the next most common (25, 15.2%). Almost half of the patients were transferred in from another facility (84, 49.1%) and in 18 patients (16.7%) there was a perceived delay in transfer that may have affected outcome.

The majority of patients were either admitted to or seen by the following services: neurosurgery (22, 16.3%), trauma surgery (22, 16.3%), acute care surgery (20, 14.8%), vascular surgery (15, 11.1%), and cardiothoracic surgery (11, 8.1%). The remaining patients were divided between transplant/hepato-pancreato-biliary surgery, general surgery, orthopaedics, otolaryngology, urology, and various other services. Although a number of patients underwent an operation (71, 42.5%), many were seen only in consultation (54, 32.3%). In 10 patients (6.3%), there was a delay in consulting surgery which also may have affected outcome. Of those that received an operation, more than half (45, 51.8%) did so on an emergent or urgent basis. Twenty-six (36.7%) required more than one operation, and 8 (11.2%) required 3 or more operations. The impact of surgical intervention was less a factor than anticipated.

Five (3%) had a delay to primary operation, 1 (0.6%) had a delay to subsequent operation, 1 (0.6%) had the inappropriate operation done, 2 (1.2%) needed an operation and did not receive one, and 1 (0.6%) should not have received an operation. Many patients suffered an acute arrest (76, 45.2%). Twenty-five patients (14.9%) died secondary to overwhelming sepsis, and 20 (11.9%) had a lethal head injury or stroke. The majority of patients (94, 56%) eventually had their care withdrawn. Half of the patients (83) died either in the SICU or MICU. One hundred and nine (64.1%) were DNR at the time of their deaths. We determined that very few of these cases were actually preventable (2, 1.2%) while 34 (20%) were possibly preventable. Eight (4.7%) could not be determined.

Conclusion: Mortality related directly to surgical intervention is uncommon, and those services that deal with emergent patients (trauma surgery, acute care surgery, vascular surgery, neurosurgery, and cardiothoracic surgery) are the ones most likely involved. From our review of over 170 surgically related deaths spanning over 9 months at the only level one trauma center and tertiary referral center in our state, we found only 10 patients that surgical intervention might have made a difference in their overall outcome. r

Results of vacuum-assisted delayed primary closure of midline wounds in patients with colorectal cancer Corley JJ, McCoy C, Patel R, Gilliland BR, Heritage C, Lahr CJ Background: Surgical site infections (SSIs) are associated with major economic costs. It is estimated that SSIs result in nearly 1 million excess hospital days, and more than $1.6 billion in direct cost. SSI reduction efforts are a major quality-improvement priority. There is considerable variability in the literature about SSI rates. Colon and rectal surgery (CRS) is consistently associated with much higher SSI rates relative to other types of surgery. CRS SSI rates range from 5% to 45%. Risk factors include obesity, diabetes, type of procedure, technique (open vs laparoscopic), operative time, and emergency operations.

Hypothesis: Use of a wound-VAC followed by delayed primary closure will significantly decrease the incidence of surgical site infections after elective, open colon and rectal resections.

Methods: Retrospective review of all patients who underwent open resection of colon or rectal cancer from January 2008 to September 2012 by a high-volume colorectal surgeon.

Study Groups: Control (N=69): January 2008 to August 2010. All patient underwent primary midline wound closure with running subcuticular suture technique. Experimental Group (N=65): August 2010 to September 2012. All patients underwent primary wound-VAC placement with 125mm Hg continuous negative pressure therapy at operation. VAC dressings were changed every 72 hours until discharge, at which time the VAC was removed and the wound was closed with Mastisol and Steri-strips.

Outcome Variables: Primary outcome was diagnosis of SSI using NSQIP definition. Secondary outcomes were wound separation, fascial dehiscence, and development of incisional hernia.

Statistical Analysis: Univariate analysis of patient factors was performed using Studentâ&#x20AC;&#x2122;s t-test of continuous variables, and Chi-square test of dichotomous variables. For multivariate analysis, logistic regression was used to calculate odds-ratios. Significant factors of univariate analysis were included in the multivariate model.

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Results: There was no significant difference between study groups in rate of wound infection. There was also no significant difference in rates of incisional hernia or fascial dehiscence between study groups. The was a significantly increased rate of minor wound separation in the VAC closure group, with a 900% increase compared with primary closure (odds ratio=10.02, p=0.0006).

Odds of incisional hernia in the VAC group increased by 123% compared to primary closure. Odds of fascial dehiscence in VAC patients increased by 85%.

Conclusion: VAC-assisted delayed primary closure of midline abdominal wounds after open colorectal cancer resection did not decrease the incidence of major wound complications. r

Complex HPB experience: does a transplant program impact resident experience?

Gaugler AC, Earl TM, Anderson CD Background: Surgical residents perform approximately 18% of all complex hepatopancreaticobiliary (HPB) operations in the United States. Each year, the number of HPB cases done by residents increases. The number of cases required for board certification in general surgery is relatively low. Despite this steady growth, resident complex HPB experience varies widely. The aim of this study is to compare UMMC graduating residents experience in HPB surgery with the national trends and to determine the effect of the new HPB-Transplant program on resident case volume.

Methods: Case logs of graduating chief residents from June 2011 through June 2014 were examined for the total number of complex liver, pancreas, and biliary operations. The residents were divided into four groups: Pre-HPB, Post-HBP, Pre-Transplant, and Post-Transplant. Mean resident case volumes per year and group were retrospectively analyzed and compared.

Results: Before the advent of the HPB-Transplant program chief residents graduated with a mean of 8.4 liver, 3.2 complex biliary, and 8.4 pancreas cases. Those residents who completed a rotation on the HPB-Transplant service as a chief resident had a mean of 20.5 liver, 4.5 complex biliary, and 11.8 pancreas operations. Although the case numbers increased overall, only the mean number of liver operations reached statistical significance.

Conclusion: HPB-Transplant experience positively impacts graduating chief resident exposure to complex liver, biliary, and pancreatic cases. At our institution, the HPB-Transplant experience has propelled resident experience beyond the national average.

More studies are needed to determine the long-term impact of these changes in resident experience. r

What are we waiting f{OR}? analysis of UMMC operating room efficiency Hayes R, Martin L, Helling T, Gilbert N Background: The operating room is a place where uniquely definitive patient care is accomplished. It is also the single largest producer of hospital revenue (>45%). As such, it is essential that the operating room function efficiently. One minute of OR time costs between $20-30, based on the complexity of the procedure.

Methods: With the advent of EMR at UMMC, our institution began an initiative to measure how operating room time is used, relationship of room and personnel availability to posted procedure start times and overall efficiency of operating room processes. This was accomplished by instituting checkpoints in the medical record that provided data to measure these variables. The variables measured were patient arrival time, surgeon arrival, anesthesiologist arrival, pre-procedure complete, in-room time, procedure start time, procedure-finish, and out-of-room time. After collecting two years of EMR data, the data for one general surgery room was examined. The room procedure time averages were taken.

Results: The Operating Room utilization was an average 2.5 hours of an 8 hour day. The average room turnover time was 69 minutes (range 34 to 146min). Our in-room time to procedure start was 36min (range 9-66min). Our end procedure to out-of-room time was 15 minutes (range 5-101min).

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Conclusion: In examining the data, we lose a significant amount of time to turnover, with an average of over an hour from out-of-room with one procedure to in-room with the next. This is a multifactorial delay resulting from anesthesia, room cleaning and staff. We also have a long interval from in-room to procedure start. This delay is attributed to induction time, line placement and patient positioning. We can conclude from this data that our institutional use of available resources is suboptimal. We need a direct observation system to specifically note delays and reasons for delays to give a better idea of where in the system our delays are (surgeon related, anesthesia related, support staff, equipment). The issue of OR utilization needs further study. Our study is limited by the time interval using six months of data instead of the entire two years, as well as using the data from one room, rather than including all the general surgery rooms. We did not examine seasonal or day-of-the-week fluctuations. Future studies could incorporate this data and use it institute a reward/demerit system for rooms that do not run in a timely fashion. r

Reviving the lost art of video-assisted mediastinoscopy: novel therapeutic uses Kim T, Ahmed N, de Delva P Background: Video-assisted mediastinoscopy has a fundamental diagnostic role in the sampling and staging of mediastinal lymph nodes, most commonly for lung cancer. With advances in computer tomography (CT), positron emission tomography (PET), and endoscopic techniques, CT-PET fusion imaging and endoscopic ultrasound-guided sampling of mediastinal lymph nodes have dramatically reduced the utilization of mediastinoscopy. Mediastinoscopy for therapeutic use is under-recognized and has been described in only a few studies. There is significant potential for surgeons trained in mediastinoscopy to employ this technique for novel and creative uses, such as dissection of a mediastinal mass or substernal thyroid goiter or drainage of a mediastinal abscess.

Methods: We performed a retrospective review of our case series of therapeutic uses of video-assisted mediastinoscopy at the University of Mississippi Medical Center.

Results: There were 9 cases of mediastinoscopy for therapeutic use between July 2012 and February 2014: bronchogenic cyst resection (2), posterior mediastinal dissection for mobilization of large substernal thyroid goiter (4), and drainage of descending mediastinitis (3). All operations were completed successfully without postoperative complications. Neither patient who had bronchogenic cyst resection had a recurrence. Neither of the 4 patients who underwent total thyroidectomy for large substernal thyroid goiter had recurrent laryngeal nerve injury or hypocalcemia. All 3 patients who had mediastinoscopic drainage of descending mediastinitis had complete resolution without recurrence of mediastinal abscess on postoperative follow-up.

Conclusion: Expanding on the traditional use of video-assisted mediastinoscopy for cancer staging of mediastinal lymph nodes and employing mediastinoscopy for potential therapeutic goals may help obviate the need for more invasive procedures and revive a technique that in some thoracic training programs is almost a â&#x20AC;&#x153;lost art.â&#x20AC;? Therapeutic use of mediastinoscopy serves as both a reason and also a means to continue training future thoracic surgeons in this valuable and versatile technique. From the standpoints of practice-building and interdisciplinary collaboration, expertise in mediastinoscopy could potentially generate referrals from general or head and neck surgeons for thyroid goiter mobilization and for drainage of descending mediastinitis from cervical infections. Thoracic surgeons in training and in practice should maintain this skill in their armamentarium, as the story on therapeutic mediastinoscopy has not been fully told yet. r

Is FAST a passing fad?

Maples N, Martin L, Martin M Introduction: The use of Focused Assessment with Sonography in Trauma (FAST) for blunt abdominal trauma has become ubiquitous. We postulated that the use of FAST would be commonplace in a large trauma data set.

Methods: The National Trauma Data Bank (NTDB) was examined for one year to determine utilization of FAST for blunt abdominal trauma in adults (16 and older).

Results: There were 351,851 patients identified that met the above criteria. Of these only 18,486 (5.3%) had a FAST per-

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formed. Of these 103 patients underwent repeat FAST. Most of these patients were seen at a Level 1 or 2 trauma center (88.7%) ,but this did not affect the use of FAST. A total of 92,997 (26.4%) patients underwent a CT scan of the abdomen, and 476 (0.1%) had a diagnostic peritoneal lavage. In fact, 14115 patients (76>4%) also underwent a CT scan as well as a FAST. We compared the use of FAST in those patients that had a documented abdominal injury, went from the ED to the OR, and were hypotensive (SBP<90) in Table 1.

SBP<90 No FAST 7652 (91) (%) FAST (%) 759 (9) Total 8411

ABI

ABI and OR

13118 (88.7)

2564 (74)

ABI OR SBP<90 1488 (85.2)

1672 (11.3) 14790

902 (26) 3466

258 (14.8) 1746

and

Table 1. Comparison of FAST use. SBP= systolic blood pressure, ABI=Abdominal injury, OR= Operating room. We also compared the use of FAST based on physiologic criteria, degree of injury and time in the Emergency Department (ED) in Table 2.

No FAST FAST P value

SBP 114.3 112.3 <0.001

Pulse 90.3 95.7 <0.001

ISS 20.1 24.2 <0.001

ED Min 259 171 <0.001

Table 2. Comparison of physiologic factors, injury severity (ISS) and time in ED (ED Min).

Conclusion: FAST use, at least as recorded in the NTDB, is not used as frequently as thought. It does seem to be used more often in patients with suspected abdominal injury and those that need to go to the operating room. It seems FAST was used more often in those more severely injured and hemodynamically compromised and may have affected ED length of stay positively. CT scan still seems to be the diagnostic test of choice as even those who had a FAST also underwent this study. r

Multidisciplinary survey to identify safety issues in an academic surgical intensive care unit

Robertson TE, Horn KC, Risher RE, Ahmed N, Martin L, Frei L, Timberlake G, Porter J

Background: Identification of quality and safety priorities in intensive care units (ICUs) has been previously done by leader ship.

The observations of the broader ICU team have been less well studied.

Hypothesis: Safety issues would be identified differently by different surgical ICU team members.

Methods: A three question, open-ended survey was distributed employees working in or with the surgical ICU at an academic level one trauma center. Questions included the respondents role in the ICU, their opinion of the most important safety issue and the biggest challenge in their job. Responses were classified into categories by a data abstractor.

Results: 168 responses were collected from administrators (n=4), ICU attendings (n=8) attending surgeons (n=14), attending anesthesiologists (n=6), resident surgeons (n=14), resident anesthesiologists (n=9), Certified Registered Nurse Anesthetists (n=8), Consultants(n=6), nurse practitioners (n=5), nurses (RNs)(n=30), respiratory therapists (RTs)(n=11), physical therapists (PTs)(n=8), housekeepers(n=1), and other (n=22). Thirty six percent of responders (n=61) identified no safety issues in the ICU. 107 respondents identified 111 safety concerns. Concerns included team to team communication (n=23), lack of physician availability (n=8), contact precautions/hand hygiene (n=8), inadequate training (n=7), not following protocols or orders (n=7), inappropriate sedation (n=6), admission procedures (n=6), unclear orders (n=5), patient placement (n=5), staffing issues (n=5), equipment (n=4), premature discharge (n=4), family communication, (n=4), and other (n=19). The most commonly cited concern of team-to-team communication was identified by 6 surgery attendings, 4 resident surgeons, 3 RNs, 3 ICU attendings, 2 anesthesia providers, 1 RT, and 3 others.

Conclusion: Safety concerns were broad based and not limited by group of ICU team member. The major safety concerns identified in this ICU were team to team communication, contact precautions and hand hygiene, and lack of physician availability.

This provides a strong platform for agreement and change in the ICU. r

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Concordance and complications of ultrasound guided breast biopsies performed by surgeons at the University of Mississippi Medical Center Dinning J, Vick L Background: Diagnosis of breast lesions consists of clinical examination, radiological examination, and histological examination. The Breast Imaging Reporting and Data System (BI-RADS) was developed in 1993 by the American College of Radiology to standardize reporting of mammographic findings. Today, this system is used to categorize both mammography and ultrasound findings. BI-RADS categories 4 and 5 and certain category 3 lesions necessitate tissue biopsy to assist in diagnosis. Concordance of radiological and pathological findings are used to determine further management of benign and malignant lesions. Ultrasound guided biopsies have proven to be a reliable and accurate technique for obtaining histologic diagnosis in the evaluation of palpable breast masses and non-palpable lesions found by screening mammography. The goal of this quality assurance study is to determine the concordance and complication rates of ultrasound guided biopsies by general surgeons at this institution.

Methods: Data was retrospectively collected from patient records for those patients referred to the breast surgery department of the University of Mississippi Medical Center and who subsequently underwent ultrasound guided biopsy. Data was collected from July 2010 to February 2013. Radiologic findings were compared with histologic results as well as surgical specimens to determine concordance, false negative rate, accuracy of ultrasound guided biopsies, and complication rates. Results: Histological analysis of core biopsies from 76 patients showed 53 (70%) benign lesions and 23 (30%) malignant lesions. Concordance was noted in 73 patients (96%) and discordance noted in 3 patients (4%). In patient follow-up there were no false negative rates, although there were two instances where papilloma was suspected on imaging and biopsy was negative for papilloma. In both these cases papilloma was present on surgical pathology. Accuracy of surgeon performed core needle biopsies was 96%.

Conclusion: Surgeon performed ultrasound guided biopsies at this institution are an accurate method for diagnosis of suspicious breast lesions without significant complication. r

Initial emergency department presentations of colorectal cancer at the University of Mississippi Medical Center Gambrell K, Helling T, Seals S

Background: Initial emergency department (ED) presentations for colorectal cancer (CRC) range 15-25% nationwide. There was a discrepancy between initial presentations of colorectal cancer compared to nationwide statistics when reviewing UMMC electronic medical records. A large volume of these cancers present through our ED. This study addressed the significant difference in the demographics, staging, mortality/morbidity, and treatment of these CRC patients.

Methods: A single center retrospective review was conducted, collecting data from electronic medical records from June 2012 to May 2013. All patients 18 years and older with CRC initially seen in the ED were included. Outcome measures include indication for surgical resection, timing to surgical and systemic treatment, mortality/morbidity, and ultimately survival outcomes. Results: 54 patients were included in the study, representing 39% of total CRC cases for UMMC. Typical ED presenting symptoms were vague, primarily abdominal pain, weight loss, and fatigue. All those presenting with obstruction, pneumoperito-

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neum, and/or peritonitis (40%) were initially admitted to the surgery service. 46 patients (85%) had surgery. All emergent (17.8%) and urgent (6.7%) surgical cases were admitted to surgery service. Only 22% of patients were presented at multiple disciplinary tumor (MDT) board. 70% of the rectal cancers were presented.

Forty-two patients (80%) had complete pathology. There were no T1 or T2 lesions. Majority of patients had T3 lesions (67%) followed by T4 lesions (33%). Nodal disease was as follows: N0 (43%), N1 (38%), and N2 (19%). Distal metastatic disease was found in 20 patients (39%), with liver being the most common location. Staging was completed on 50 patients and is as follows: Stage II (36%), III (22%), and IV (42%).

Of the 54 patients, 23% are no longer alive. A small percent (5%) initially admitted from ED died during the initial hospitalED admission. Of those, 60% were related to emergent surgery. Most common causes of death were septic shock, cardiac arrest, and respiratory failure. Of those who had emergent surgery, about 37% died within 30 days. There was an increase in 30 day surgical complications, wound infections being the most common.

Conclusion: Most UMMC admissions were not emergent. However, ED presentations were linked to high tumor stages. A significant factor for mortality was emergent surgery. MDT was underutilized with colon cancer but not with rectal cancer. Higher 30 day surgical complications were reported, primarily wound infections. r

Blunt hepatic trauma: do we ever operate?

Mallette AC, Martin L Background: Blunt hepatic injures can be managed nonoperatively in many cases. We hypothesize that patient hemodynamics and overall injury severity rather than severity of liver injury often drive the need for surgery.

Methods: Records from the National Trauma Database (2007-2010) were searched for blunt hepatic injuries for patients over age 16. Patient demographics, presenting hemodynamic condition, injury severity score (ISS), grade of liver injury, and need for operative intervention were categorized.

Results: There were 49,495 patients identified with blunt hepatic injuries and 2943 patients (5.9%) underwent an operation on the liver with 1869 (63.5%) doing so within 2 hours of arrival. These patients were even more hemodynamically unstable (SBP 100.5 and HR 107) and slightly more severely injured (ISS 34.2) than the total group below. In the overall group the liver injury grade was 1 or 2 in 25,594 (51.7%). There were 3496 operations performed on the liver with 2886 (82.5%) being closure or repair of a liver laceration and 317 (9.1%) a partial or complete lobectomy. In addition, 9238 patients (18.7%) underwent an abdominal operation with the most common procedure being total or partial splenectomy in 3391 (6.9%) of the total patients. Despite having an abdominal operation, 6296 patients (69.2%) did not have any procedure done on the liver at all although this does not rule out hepatic packing as this is not recorded in the data. The characteristics of the patient groups are summarized in Table 1.

Abdominal Liver No

Abdominal p value Operation Operation

Operation Number (%) 40257 (81.3) 9238 (18.7) 2943 (5.9) ISS (sd) 27.8 (71.3) 33.1 (39.3) 33.7 (34.6) <0.001 SBP (sd) 122 (36.3) 107.7 (36.3) 104.5 (36.4) <0.001 HR (sd) 92 (29.3) 105 (31.2) 107.3 (29.9) <0.001 High Grade 4563 (11.3%) 2273 (24.6%) 1418 (48.2%) <0.001 Injury

Table 1. Comparison of non-operative and operative patients. Sd=standard deviation,

ISS=Injury severity score SBP=systolic blood pressure, HR=heart rate, High grade

injury=Grade 4 and 5.

Conclusion: Blunt hepatic injures uncommonly require operative intervention as in this series only 5.9% of patients actu ally had an operation on the liver. Often other intra-abdominal sources of hemorrhage are present, such as the spleen. Patient injury

severity reflected by ISS and hemodynamics often drive the need for operative intervention, but from this data the liver injury grade

also contributed as more of the high grade injuries actually had a liver operation. r

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Cultural evolution and the spread of health information on Twitter Murphy DL, Hopkins P Background: The spread of information in society has been shown to be implicit in a variety of processes from the spread of applause in an audience, the development of a lexicon, movie-going behavior, as well as health related behaviors such as smoking and obesity. This paper examines the spread of health-related words on Twitter and explores the applicability of an evolutionary paradigm to examine these data.

Methods: Using Twitter data collected in 2011, I explore the social connections of individuals using the words ‘obesity’, ‘exercise’, or ‘health’ in their tweets to determine if their connections appear to be influenced to express similar terms in their tweets.

The frequency of health-words in those connections is broken down by state and compared with the known incidence of obesity and general health per state to determine if there is any correlation.

Results: The Twitter profiles that expressed the words ‘obesity’ ‘exercise’, or ‘health’ were polled to find the Twitter profiles that they followed as well as the Twitter profiles that followed them (or friends). From a preliminary data evaluation, it appears that the profiles from the most obese states are more likely to express the specified words when they follow the individuals expressing the key words rather than when they are followed by the individuals. Conversely, the least obese states are more likely to express the key words when they are followed by profiles expressing the key words rather than when they follow those profiles.

Conclusion: These findings may support the idea that it is the influence of the less-obese states rather than the success of the health behaviors themselves spreading in the state that influence the incidence of obesity. There are several other factors that may influence these findings as well, such as the type of profiles the Twitter users choose to follow, as well as the incidence of healthrelated tweets in a particular state. To further clarify these findings, the social influence of a Twitter social network must be further clarified by analyzing the frequency of health-related tweets given different Twitter relationships (following, friends, or mutual followers) as well as the incidence of health tweets per state. r

A technique for implantation of the CentriMag LVAD to allow ambulation and rehabilitation in patients with heart failure Urencio M, Tribble C Background: The therapeutic options for decompensated heart failure includes inotropic agents, intra-aortic balloon pumps, and, in selected cases, left ventricular assist devices (LVAD’s), both short term, external devices and long term, implantable devices.

Implantable LVAD’s are not appropriate for all patients for a variety of reasons. The short term devices typically require that the patient stay in a hospital bed, as they are usually connected to cannulae that are inserted using a median sternotomy and are, thus, difficult to stabilize safely. This arrangement has the disadvantages of requiring a sternotomy (which mandates a redo sternotomy later), midline cannulas (which make it hard for patients to sit up), and immobility (with all the attendant risks of immobility). Inspired by a case report of a patient in which temporary LVAD support was achieved using a right thoracotomy, with cannulas placed through intercostal spaces, we began using this approach for selected patients in need of temporary circulatory support.

Methods: In this observational, retrospective study we reviewed our institution’s experience with CentriMag LVAD cannulae insertion via right thoracotomy from August 2009 to June 2013. We reviewed the outcomes for these patients, looking specifically at reasons for support, mobility after LVAD insertion, and the outcomes of the patients supported in this way.

Results: The CentriMag LVAD was implanted using the right thoracotomy approach in 6 patients (though one patient required the addition of a median sternotomy to obtain access to the aorta). The impetus for this type of support included 4 patients who lacked sufficient financial or social support for a long term, implantable LVAD, 1 who was considered too ill to have an im-

344 JOURNAL MSMA October 2014

plantable LVAD placed, and 1 who was thought likely to need temporary support to allow recovery from myocarditis.

Five of these 6 patients were able to walk soon after LVAD implantation and to be rehabilitated from their extremely debilitated states, while 1 continued a steady clinical decline after placement, did not experience any recovery, and had support withdrawn eventually. Four of the 6 were eventually transplanted successfully and discharged from the hospital. One patient suffered a stroke during his period of support, requiring that support be withdrawn.

Conclusion: We conclude that CentriMag LVAD implantation via a right thoracotomy is a feasible approach that can provide adequate hemodynamic support while allowing the patients to be ambulatory and while also making subsequent cardiac transplantation less complicated by avoiding a median sternotomy in most cases. r

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October 2014 JOURNAL MSMA 345

• MACM • Medical Assurance Company of Mississippi Announces New Leadership

Gerry Ann Houston, MD; Medical Director

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he Board of Directors of Medical Assurance Company of Mississippi is pleased to announce Gerry Ann Houston, MD has joined the Company as Medical Director and will serve as a liaison for insured physicians. She will assist in the development of medical policies and guidelines, conduct physician interviews as part of the application process, and consult with Claims, Underwriting, and Risk Management staff members.

Dr. Houston was in private practice until 2008 as an Oncologist with Jackson Oncology Associates. She will continue to serve as the Chief Medical Director for Hospice Ministries. Her undergraduate work was at the University of Mississippi and she is a graduate of the University of Mississippi School of Medicine. Upon graduation, she continued her training in Internal Medicine and Oncology at the UMMC. She is board certified in Internal Medicine, Medical Oncology and Hospice and Palliative Medicine. As Medical Director, Dr. Houston will attend all MACM Committee and Board of Director meetings, as well as represent the Company to various health care organizations.

“Dr. Houston brings to MACM a wealth of experience that will only help us continue to provide reliable and accessible coverage to Mississippi physicians,” Robert M. Jones, MACM CEO, said. “We are extremely fortunate to have someone of her caliber in this position and look forward to working with her for many years.”

346 JOURNAL MSMA October 2014

Robert M. Jones, President and CEO

T

he Board of Directors of MACM is pleased to announce the appointment of Robert M. Jones as the company’s President and Chief Executive Officer. He is succeeding Michael D. Houpt, who retired after 36 years of continuous service to the company.

Jones has been associated with MACM for over 27 years but officially joined MACM as Legal Counsel in January 2004. In this role, he has represented the company in corporate, insurance, and other related issues. Jones has been a frequent speaker on risk management, medical malpractice, and other medical/legal issues.

“I am excited about the future of MACM and am very humbled by the confidence and trust that the Board of Directors has placed in me,” Jones said. “MACM is a company owned and governed by Mississippi physicians. In addition to the strong physician leadership of the Board and Committees, the MACM staff is a group of people dedicated to helping our insureds by providing them with stable insurance coverage and exceptional customer service. I am looking forward to what we will all accomplish together for the physicians insured by MACM.” Before coming to MACM, Jones was in private law practice for 26 years. He received his undergraduate degree from the University of Mississippi in 1975 and his J.D. from the University of Mississippi School of Law in 1978. While in private practice, he represented physicians and medical groups with respect to general health care, corporate, real estate and business law matters. He is a member of numerous Associations including: the American Bar, Mississippi Bar, Mississippi Defense Lawyers, American Health Lawyers, and the American Association of Corporate Counsel.

• MSMA Alliance • Commit, Communicate, and Continue Danita Horn, Donna Witty, and Eileene McRae, Co-Presidents

G

reetings all!

I still cannot believe that Annual Session has come and gone—the time passed so quickly last year under the direction of our Immediate Past President, Mollie Pontius, and so much was accomplished. Thank you, Mollie, for your hard work and for leading us through a tremendously successful year!

MSMA Alliance Co-President Eileene McRae presents a $900 check to Dr. Scott Hambleton, Medical Director of the Mississippi Professionals Health Program for contribution to the MPHP Family Scholarship Fund. The funds are used to assist families in times of need during a physician’s recovery from addiction.

Danita Horn, Donna Witty, and I realize that this year will certainly pass quickly on our watch, so we have been steadfastly evaluating ways that we can, as a group, reset, rejuvenate, and renew our organization. All three of us are excited about our upcoming year as your co-presidents, and we hope you are equally excited about the fun and the fellowship we will enjoy as we work together.

By now, most of you are aware of, and I hope have joined, our “GroupMe” text messaging application. This was Danita’s idea in an effort to keep everybody up to date and on the same page relative to what is happening in all areas of our Alliance. By utilizing this means of communication, no one has to wait until they hear from a committee chair, or go to their local Alliance meeting, or come to the fall or winter board meeting to know what is happening in the areas of health, membership, legislation, or scholarship. Updates will be announced via “GroupMe,” about our various works as well as announcements made on a personal level if a member so desires. Danita has also taken the responsibility to head our strategic planning, which is a huge task.... It will be so very good to know what we plan to accomplish and how we are going to get that done. Thanks, Danita!

Donna is our “ever ready energizer bunny” working on many things but very eager and interested in growing membership— she is the past president advisor on that committee. As her interest has grown in membership, her interest in working with medical students and resident spouses has also grown. Donna also keeps Danita and me informed about much of what is happening in the American Medical Association Alliance. Thank you, Donna.

I, as always, have had a keen interest in health and our health projects. I will be the past president advisor to the health promotions committee, and I really look forward to working in that capacity. I will also do some of our traveling since I have no young children at home anymore.

One thing is for sure, we have an OUTSTANDING board, committee chairs, and membership dedicated to participation in one way or another, whether it is “hands on” work, technical support, or monetary contributions. I anticipate our members to speak up and COMMUNICATE in an effort to COMMIT to doing their individual part so we can CONTINUE the heritage of the MSMA Alliance family of medicine.

Again, Danita, Donna, and I look forward to working with you this year. We hope to see you at the State Capitol on January 17 for CSI-V, if not before then.

Respectfully, Eileene McRae

October 2014 JOURNAL MSMA 347

• Images in Mississippi Medicine • UNIVERSITY OF MISSISSIPPI SCHOOL OF MEDICINE, 1904— The beginnings of the University of Mississippi Medical Center are traced to 1903 when a two-year school of medicine was established on the Oxford campus. This broadside poster, promoting the University’s new emphasis on its scientific departments, was printed soon after the school’s creation, announcing its 1904 summer session. Note that tuition was free for all students, except those seeking law or medical degrees. Central to the medical school’s establishment was the leadership of Waller S. Leathers, MD, LLD, the brilliant physician-educator who created a functional public health system in Mississippi. A Virginia native, Leathers came to Mississippi in 1899 to chair the Zoology Department at Ole Miss, later becoming chair of the Department of Physiology and Hygiene and serving as coach of the football team. In 1903, he led the creation of the School of Medicine, and in 1904 he was made Dean of that school, then called the “Medical Department” of the University. By 1910, Leathers would become first State Health Officer of Mississippi, and he would leave the state in 1924 to become a professor of public health at Vanderbilt. He became Dean of Vanderbilt Medical School by 1928, serving until his retirement in 1945. In the early 1940s, State Health Officer Felix Underwood, who had been groomed by Leathers, with other MSMA physicianleaders, began the drive for a four year school of medicine in the state, promoting it to address state physician shortages.

The legislative champion was Hinds County Senator Hayden Campbell, who authored the legislation passed in 1950 to establish and construct a four year school and teaching hospital in Jackson on the site of Mississippi’s first insane asylum on North State Street.

The institution was dedicated on October 24, 1955, and awarded its first MD degrees in 1957. 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, Magnolia 348 JOURNAL MSMA October 2014

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PARTICIPATE IN MSMA’S DOCTOR OF THE DAY PROGRAM

Every year, MSMA staffs the Capitol Medical Unit during the legislative session with a full time nurse and a volunteer physician each day. The Doctor of the Day program runs from January through March and allows MSMA members to participate in the legislative process by being front and center at the state capitol. Doctors of the Day are only asked to provide minimal health care services to legislators and capitol staff. Doctors of the Day volunteer for half days on Monday and Friday while Tuesday, Wednesday, and Thursday are full day commitments. As Doctor of the Day, you will be introduced in the House and Senate chambers by your local legislators and thanked for your service. This is a perfect opportunity to not only “give back,” but have valuable personal time with your legislator and voice support for pro-medicine policies.

To participate in MSMA’s Doctor of the Day program, please use the interactive calendar found on MSMAonline.com. please contact Blake Bell at BBell@MSMAonline.com.