September 2013 JMSMA

September

VOL. LIV

2013

No. 9

SOMETIMES ALL YOU NEED

is CME

5 18 be there

hours of Prescribing Controlled Substances

7a-3p

St. Dominic’s Hospital Jackson, MS

FULFILLS MSBML REQUIREMENTS FOR CME ON PRESCRIBING CONTROLLED SUBSTANCES KEY NOTE SPEAKER: DR. STUART GITLOW, AMERICAN SOCIETY OF ADDICTION MEDICINE QUESTIONS? EMAIL KWALLACE@MSPROFESSIONALSHEALTH.ORG

This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of the Mississippi State Medical Association and the Mississippi Professionals Health Program. The Mississippi State Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Mississippi State Medical Association designates this live activity for a maximum of 5 AMA PRA Category I Credits. Physicians should only claim credit commensurate with the extent of their participation in the activity.

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

Publications Committee Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD, Ex-Officio Myron W. Lockey, MD, Ex-Officio and the Editors The Association James A.Rish, MD President Claude Brunson, MD President-Elect Michael Mansour, MD Secretary-Treasurer R. Lee Giffin, MD Speaker Geri Lee Weiland, MD Vice Speaker Charmain Kanosky Executive Director

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

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

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

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Copyright© 2013 Mississippi State Medical Association.

I L A SSOC

SEPTEMBER 2013

VOLUME 54

NUMBER 9

Scientific Articles

Immediate Nerve Grafts to a Median Nerve Injury in a 7-Year-Old Boy: 5-Year Follow-Up

252

William Lineaweaver, MD

Screening for Prostatic Disease

255

Shubham Gupta, MD and Charles R. Pound, MD

Just Off the Press - Info You Need to Know: Digoxin Use in Atrial Fibrillation

258

Richard L. Ogletree, Jr., PharmD

President’s Page

Inaugural Address of the 146th President

262

James A. Rish, MD; MSMA President

Departments

From the Editor: The Making of Sausages and Laws MSMA: Annual Session Recap

250 269

About The Cover:

Sunflower by Dr. Ron Cannon of Jackson - Often used to depict the sun, the sunflower (Helicanthus annuus) name is derived from the flower’s shape and image. It has been a symbol for various cultures, including the Aztecs, vegans, and religious groups.

Sunflower heads consist of 1,000 to 2,000 individual flowers, which turn to seed, joined together by a receptacle base. The large petals around the edge of a head are actually individual ray flowers.

The sunflower has a number of practical uses. Whether raw, cooked, roasted, or dried, the seeds (fruit) from the head are edible as snack food. Sunflower oil is a widespread cooking ingredient. Sunflower leaves can be used as livestock feed, while the stems and stalks contain a fiber sometimes used in paper production.

In herbal medicine, the root of the plant has been used to treat poisonous bites while the leaves were made into tea to relieve fevers, lung ailments, and diarrhea. Legend has it, Russian folk healers chop the head of a sunflower, soak the pieces in vodka and soap chips in a sunny place for nine days, and then rub the mixture on the joints of rheumatic patients as a potent liniment. Herbalists prepare decoctions of the seeds as a remedy for jaundice, malaria, heart conditions, whooping cough, and other ailments. (Wonder how that worked for them?)

This photo was taken at the Cannon home as the sunflowers had been planted in preparation for dove season. r September

VOL. LIV

2013

No. 9

Official Publication of the MSMA Since 1959

September 2013 JOURNAL MSMA 249

From the Editor: The Making of Sausages and Laws

“T

he less people know about how sausages and laws are made, the better they sleep in the night.” The German people attribute (perhaps wrongly) this famous epigram to its nineteenth century statesman Otto von Bismarck (1815-1898), who unified most of the German states and utilized a form of pragmatic politics he termed “Realpolitik.” His often frustrating and complicated deal-making in crafting legislation in the Reichstag inspired this apt reflection. Those who were present at the recent annual gathering of our association may conclude the same thing, that laws are like sausages, it’s best not seeing them made. Yes, the politics of organized medicine are not always pretty, but despite this, medical democracy via the House of Delegates usually accomplishes the proverbial “right thing.” Byzantine and arcane are the ways of the MSMA; someone usually has to take you by the hand and show you how to get things done; but this is the only place to get things done in state medicine.

This issue of the Journal reviews the 145th Annual Session of the MSMA House of Delegates, which met last month. This year’s session was more lively than most, with diverse opinions expressed which challenged the status quo.

Such is how it works and a good thing.

The competent and objective leadership of Speaker Dr. Lee Giffin, ably assisted by Vice Speaker Dr. Geri Lee Weiland and extraordinary reference committees, made the difficult process smooth and civil. The important issues were heard fairly and debated vigorously, with a reasoned and Lucius M. Lampton, MD informed consensus reached by the House in the end.

Among the most important resolutions heard regarded the editorial integrity of this Journal. The House clearly supported its journalistic integrity and requested the creation of an ad hoc committee to study the AMA’s Editorial Governance Plan of JAMA in order to craft safeguards for our Journal to “ensure editorial independence and integrity” while also respecting the MSMA’s responsibilities as publisher. Constitutional recommendations will be brought back to the House of Delegates at its 2014 Annual Session.

Contact me at lukelampton@cableone.net.

—Lucius M. “Luke” Lampton, MD, Editor

Journal Editorial Advisory Board R. Scott Anderson, MD, FACR Chair, Journal Editorial Advisory Board Radiation Oncologist and Medical Director, Anderson Regional Cancer Center, Meridian 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 Jeffrey D. Carron, MD, FAAP, FACS Associate Professor, Department of Otolaryngology & Communicative Sciences, University of Mississippi Medical Center, Jackson

Gordon (Mike) Castleberry, MD Urologist, Starkville Urology Clinic Mary Currier, MD, MPH State Health Officer Mississippi State Department of Health, Jackson Thomas E. Dobbs, MD, MPH Health Officer, District VII/VIII Mississippi State Department of Health, Hattiesburg

Owen B. Evans, MD Professor of Pediatrics and Neurology University of Mississippi Medical Center, Jackson 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 Scott Hambleton, MD Medical Director Mississippi Professionals Health Program, Ridgeland John Edward Hill, MD, FAAFP North Mississippi Medical Center, Tupelo John D. Isaacs, Jr., MD Infertility Specialist, Mississippi Fertility Institute at Women’s Specialty Center, Jackson Kent A Kirchner, MD Nephrologist G.V. Montgomery VA Medical Center, Jackson Brett C. Lampton, MD Internist/Hospitalist Baptist Memorial Hospital, Oxford

Philip L. Levin, MD President, Gulf Coast Writers Association Sharon Douglas, MD Emergency Medicine Physician, Gulfport Chair, AMA Council on Ethical & Judicial Affairs

Professor of Medicine and Associate Dean for V A William Lineaweaver, MD, FACS Education, University of Mississippi School of Medicine, Editor, Annals of Plastic Surgery Associate Chief of Staff for Education and Ethics, Medical Director G.V. Montgomery VA Medical Center, Jackson JMS Burn and Reconstruction Center, Brandon Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist The Street Clinic, Vicksburg

John F. Lucas,III, MD Surgeon Greenwood Leflore Hospital

250 JOURNAL MSMA September 2013

Gailen D. Marshall, Jr., MD, PhD, FACP Professor of Medicine and Pediatrics, Vice Chair for Research, Director, Division of Clinical Immunology and Allergy, Chief, Laboratory of Behavioral Immunology Research The University of Mississippi Medical Center, Jackson Alan R. Moore, MD Clinical Neurophysiologist Muscle and Nerve, Jackson Paul “Hal” Moore Jr., MD, FACR Radiologist Singing River Radiology Group, Pascagoula Jason G. Murphy, MD Surgeon

Surgical Clinic Associates, Jackson Ann Myers, MD Rheumatologist Mississippi Arthritis Clinic, 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, FACC Clinical Cardiologist, Hattiesburg Clinic Chris E. Wiggins, MD Orthopaedic Surgeon Bienville Orthopaedic Specialists, Pascagoula John E. Wilkaitis, MD, MBA, CPE, MS Chief Medical Officer Brentwood Behavioral Healthcare, Flowood

Medical Assurance Company of Mississippi

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As a member of MACM’s Young Physicians Advisory Council, I have the opportunity to meet with the MACM Staff once every six months.

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Physician members are actively involved in the management of the Company and on committees throughout the organization. Our voice is heard at every level.

MACM is financially stable and will be in the Mississippi market for a long time to come. This gives me great comfort since I have a full career ahead of me.

“

I like knowing that MACM discourages frivolous lawsuits by defending every claim fiercely. I think this helps improve the malpractice environment in the state. Every Mississippi physician — whether they are insured by MACM or not — benefits from this philosophy.

Angela Wingfield, MD Dermatology Gulfport, Mississippi

For over 30 years, Mississippi physicians have looked to Medical Assurance Company of Mississippi for their professional liability needs. Today, MACM is an integral part of the health care community providing a legacy of services to our insureds.

A dedicated staff and physician involvement at every level guarantees that the interests of our policyholders remain the top priority. This, combined with the many years of loyalty and support from our insureds, is what allows us to be the carrier of choice in Mississippi.

Call on us to assist with your professional liability needs.

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Working with Young Physicians September 2013 JOURNAL MSMA 251

• Scientific Articles • Immediate Nerve Grafts to a Median Nerve Injury in a 7-Year-Old Boy: 5-Year Follow-Up

A

William Lineaweaver, MD, FACS

bstract

Immediate nerve grafts to traumatic injuries can achieve functional results in selected cases. This report describes 5 cm nerve grafts placed in a median nerve injury of a 7-year-old boy.

Five years later, the patient has a functional motor and sensory outcome.

Key Words: nerve injury; nerve grafts Introduction

Conventional management of traumatic nerve injuries includes a general injunction against immediate nerve grafting.

Reasons to avoid immediate nerve grafting can include indeterminate margins of nerve injury and uncertain soft tissue coverage, either of which factors could result in failure of the repair, loss of donor nerves (a finite resource), and delay of definitive secondary repair. A failed immediate attempt at nerve grafting can therefore result in prolonged disability and compromised eventual outcome.1 In some specific cases, however, immediate nerve grafting can be performed with functional outcomes. Such procedures conform to the knowledge that the result of a nerve reconstruction is better when it is accomplished as soon as possible after the injury.2-4 The circumstances that permit consideration of immediate nerve grafting include: • Significant confirmed nerve injuries; • Clearly defined margins of nerve injury with identification of uninjured proximal and distal nerve segments; • Secure soft tissue coverage; • Anticipated difficulty with exposure for later nerve reconstruction.5 In 2006, I performed an immediate nerve graft repair of a traumatic median nerve injury in a 7-year-old boy. In 2011, I was able to re-examine him in detail.

Author Information: : Dr. William Lineaweaver is a plastic surgeon and medical director of the JMS Burn and Reconstruction Center in Jackson. This material was presented at the Plastic Surgery Conference, St. Dominic’s Hospital, Jackson, Mississippi, September 1, 2011; and at the Southeastern Society of Plastic and Reconstructive Surgeons meeting (poster session), Amelia Island, Florida, June 2-6, 2012.

Corresponding Author: William Lineaweaver, MD, FACS; Medical Director, JMS Burn and Reconstruction Center, Central Mississippi Medical Center, 1850 Chadwick Drive, Suite 1427, North Tower, 4 West, Jackson, MS 39204. (william.lineaweaver@jmsburncenters.com)

252 JOURNAL MSMA September 2013

Case Report

A detail of this case has been previously published.6 On November 22, 2006, a 7-year-old boy suffered a shotgun injury to the left wrist. The soft tissue injury extended from his distal volar forearm across the wrist crease to the base of his thenar eminence (Figure 1).

Figure 1. Shotgun pellets indicate the area of injury.

At the time of admission, I performed a debridement, repaired the superficialis tendons of the middle and ring fingers, noted a defect in the median nerve, and covered the wound with acellular dermal matrix (ACD). The hand appeared well perfused.

On November 26, I re-explored the wound, debrided residual devitalized tissue, and reapplied ACD. On November 29, the patient underwent an anteriogram demonstrating no flow in the radial and ulnar arteries. The hand was perfused by a small median artery. At surgery, I replaced a damaged segment of ulnar artery with a saphenous vein graft, repaired a 5 cm gap in the median nerve with 2 sural nerve grafts, and covered the wound with a full thickness skin graft.

The reconstructive procedures are summarized in Table 1. The patient had no complications and proceeded to hand therapy and progressive resumption of his usual activities.

Figure 2. The injured left hand is seen with the uninjured right hand.

Table 1. Summary of operative procedures Date

Procedure

11/22/06 Debridement; repair FDS ring and middle; ACD 11/26/06

Debridement; ACD

11/29/06 Arteriogram; saphenous vein graft to ulnar artery; 2 5 cm sural nerve grafts to median nerve; FTSG (FDS= flexor digitorium superficialis; ACD= acellular dermal matrix; FTSG= full thickness skin graft)

I re-examined this patient in detail on July 2, 2011. He was active in sports, had no defined physical limitations, and demonstrated symmetrical hand growth (Figure 2). He had stable, supple soft tissue coverage, full finger flexion, and intact opposition (Figure 3, 4). Doppler ultrasound demonstrated a patent ulnar artery reconstruction, and sensory examination showed 3-8 mm 2-point discrimination in the median nerve distribution (Figures 5, 6).

Discussion

This case is one of 6 cases of acute nerve repair I have performed (table 2).5,7,8 Each of these 6 patients has achieved functional results comparable to delayed reconstruction.9 The immediate procedures have the advantages of shortened time between injury and repair and relatively easy exposure of the nerve injury at the trauma site.

Three of the cases utilized sural nerves as grafts. The other 3 cases used intercostal nerves taken from rectus muscles when those muscles were harvested as flaps for soft tissue coverage.

Taking nerves from a flap harvest offers an ideal opportunity for nerve grafting since these nerves are otherwise discarded.7,8 Alternatives to autologous nerve grafts can be considered for the management of nerve gaps. Conduits, vein grafts, and muscle tissue are options that can achieve functional results.4,9,10 Autologous nerve grafts, however, consistently give superior results when compared to substitutes, especially when the nerve gap is 3 or more centimeters in length.10 This case was managed through a Center for Microsurgery and Complex Reconstruction.11 The Microsurgery Center managed 12 to 20 peripheral nerve cases a year and provided an effective framework for capturing such cases as ones with significant acute nerve injuries.12 More recently, I have practiced within the JMS Burn and Reconstruction Center. This practice utilizes a transfer center that coordinates emergency burn referrals throughout the south-

Table 2. Acute nerve graft cases Year

Injury

Nerve Grafts

Outcome

1991 Saw, left peroneal sural x 3 (3 cm)

nerve, knee

Intact motor function with ankle and toe extension; sensation to light touch

1993

Blast injury, RDN, intercostal (5 cm) left index

Intact sensation to light touch

1994

Crush injury, intercostal x 3 (7 cm) right ulnar nerve, wrist

3-4 mm 2-point discrimination

1996

Crush injury, intercostal x 4 (4 cm) right median nerve, wrist

Intact opposition; 2-3 mm 2 point discrimination

1999 Blast injury, left sural x 3 (3 cm)

ulnar nerve, arm

Forearm flexor and hand intrinsic function; 14 mm 2-point discrimination, hand

2006 Blast, left median sural x 2 (5 cm)

nerve, wrist

Intact opposition; 3-8 mm 2-point discrimination

(RDN= radial digital nerve)

September 2013 JOURNAL MSMA 253

Figure 3. The patient demonstrates full flexion.

Figure 4. The patient has intact opposition. The full thickness skin graft is supple throughout all ranges of motion.

Figure 6. The patient has 2-point discrimination in the median nerve distribution.

eastern United States.13 The practice has added emergency hand referrals to the transfer center service, and this network can now serve as an access to treatment for acute nerve injuries.

This case illustrates the level of function that can be expected following acute grafting of traumatic nerve injuries in favorable circumstances. Such cases should be identified at initial evaluations and promptly referred to be considered for appropriate surgical reconstruction.

References

1. Mackinnon S, Dellon AL. Surgery of the Peripheral Nerve. Thieme Medical Publishers Inc., New York, 1988, p. 108.

2. Ducic I, Fu R, Iorio ML. Innovative treatment of peripheral nerve injuries.

Ann Plast Surg. 2012;68:180-187.

3. Kokkalis ZT, Efstathopoulos DG, Papanustassiou ID, et al. Ulnar nerve repair in Guyon’s canal. Microsurgery 2012;32:296-302.

4. Tos P, Battiston, Ciclamini D, et al. Primary repair of crush nerve injuries by means of biological tubulization with muscle-vein-combined grafts.

Microsurgery 2012;32:358-363.

5. Sud V., Chang J, Lineaweaver W. Acute nerve grafting in traumatic injuries.

Ann Plast Surg. 2001:47,555-561.

6. Lineaweaver W. Skin graft coverage of critical marginal wounds in microsurgical cases. Microsurgery: 2013;33:315-318.

Figure 5. Doppler ultrasound demonstrates the intact ulnar artery repair.

7. Yim K, Hui KW, Ramos D, et al. Use of intercostal nerves as nerve grafts in hand reconstruction with rectus abdominis flaps. J Hand Surg 1994;19 A:238-240.

8. Bresnick S, Lineaweaver W, Hui KW. Acute reconstruction of traumatic injuries of median and ulnar nerves by grafting with intercoastal nerves from the rectus muscle. J Reconstr Microsurg. 1997;13:503-506.

9. Yang M, Rawson JL, Zhang EW, et al. Comparisons of outcomes from repair of median nerve and ulnar nerve and ulnar nerve defects with nerve grafts and tubulization. J Reconstr Microsurg. 2011;27 451-460.

10. Wang H, Lineaweaver W. Nerve conduits for nerve reconstruction. Op Tech Plast Reconstr Surg. 2003; 9: 59-66.

11. Lineaweaver W. Burn care in Mississippi. J Miss Med Assoc. 2009;50:129132.

12. Lineaweaver W, Rogers B, Oswald T. Hospital income from patients managed through a Center for Microsurgery and Complex Reconstruction.

Ann Plast Surg 2008; 60: 573-576.

13. Farner K, Lineaweaver W. Efficacy of extrapolation from national burn data for estimating patient volume in a burn unit. Ann Plast Surg. 2012: 68: 505-507.

254 JOURNAL MSMA September 2013

• Scientific Articles • Screening for Prostatic Disease Shubham Gupta, MD and Charles R. Pound, MD

I

ntroduction

Prostate related maladies are among the most prevalent health issues in men, making community level diagnosis and intervention very germane. Up to 90% of men between 45 to 80 years of age have some degree of voiding symptomatology;1 much of this is attributed to an enlarged prostate. At the same time, prostate cancer is the most common malignancy in US men. One in 6 men in the US will be diagnosed with prostate cancer, making the disease burden substantial.2 Voiding symptoms can be diagnosed with simple tests and treated safely and effectively with drug therapy. Refractory cases can be surgically managed with newer minimally invasive techniques. The practicing physician’s charge is to be able to manage urinary tract symptoms with lifestyle modifications and medical therapy to identify patients who need further workup and referral for refractory symptoms and/or cancer.

Screening for prostate cancer is as controversial as it is widespread. The American Urological Association (AUA) recommends offering screening to well informed men between the ages of 55-69 (and earlier in men who have a positive family history), are of African-American race or have other risk factors.2 On the other hand, the United States Preventive Services Task Force (USPSTF) recommends against PSA based screening for prostate cancer. However, when diagnosed early, prostate cancer remains a highly curable disease with cancer specific survival rates in excess of 85% at 15 years with a single modality of therapy.3 In this review, we hope to discuss the risks and benefits of screening and focus on recent advances in an attempt to limit screening to those men who stand to benefit most.

ing) and irritative (frequency, urgency, nocturia) components.

Collectively, these are called lower urinary tract symptoms (LUTS). In addition to BPH, other genitourinary conditions including urethral strictures, bladder dysfunction, infection, bladder cancer, and prostate cancer can cause LUTS. Medical renal disease, cardiopulmonary, and respiratory illnesses can also cause LUTS. In patients presenting with LUTS, a focused history and physical exam should be undertaken. A convenient and comprehensive way to objectively define LUTS is the AUA symptom score. This validated questionnaire measures patient-perceived severity of their disease and provides a valuable tool for initiating and following up response to therapy. A digital rectal exam (DRE) should be done to assess the prostate size and identify any suspicious nodularity. A baseline urine microscopy should be obtained. In men with significant symptomatology, a prostate-specific antigen (PSA) level should be obtained as a part of the diagnostic evaluation. In men with little or no symptomatology, a PSA should be performed after they have been appropriately counseled and have agreed to prostate cancer screening.

Patients with complicating factors like hematuria, abnormal DRE, elevated PSA, or urinary retention should be referred for urological evaluation.1 Medical therapy for LUTS is safe and effective (Table 1). This can be initiated if voiding symptoms are bothersome

11

Table 1. Treatment Options for men with moderate to severe symptoms of benign prostatic hyperplasia •

Watchful Waiting

Benign Prostatic Hyperplasia: Diagnostic Evaluation and Advances in Management

•

Drug Therapy • Alpha-adrenergic blockers • Alfuzosin • Doxazosin • Tamsulosin • Terazosin • Silodosin • 5 alpha-reductase Inhibitors • Dutasteride • Finasteride • Anticholinergic Agents • Combination Therapy • Alpha blockers and 5 alpha-reductase inhibitors • Alpha blockers and anticholinergics

Author Information: Resident, Urology, University of Mississippi Medical Center, Jackson, MS (Dr. Gupta). Professor and Chairman of Urology, University of Mississippi Medical Center, Jackson, MS (Dr. Pound) .

•

Minimally Invasive and Surgical Therapies Transurethral needle ablation (TUNA) • • Transurethral microwave therapy (TUMT) • Transurethral incision of the prostate (TUIP) • Transurethral holmium laser ablation of the prostate (HoLAP) • Photoselective vaporization of the prostate (PVP, Greenlight laser) • Transurethral resection of the prostate (TURP) • Open simple prostatectomy

Benign prostatic hyperplasia (BPH) refers to histologic evidence of prostatic glandular enlargement. It can cause urinary symptoms by mechanically obstructing the flow of urine as well as through a dynamic interaction with the bladder musculature. The constellation of voiding symptoms includes obstructive (weak stream, intermittency, straining, incomplete empty-

Corresponding Author: Charles R. Pound, MD, University of Mississippi Medical Center. 2500 N State St, Jackson MS 39216.

September 2013 JOURNAL MSMA 255

and no complicating factors exist. Alpha-blockers are the first line of therapy for LUTS. These agents cause relaxation of the prostatic and bladder neck area, thereby improving urine flow and symptoms. Several agents are available and have similar efficacy. The newer agents are prostate selective and do not require dose titration. These drugs have a relatively rapid onset of action of days to weeks and have a sustained benefit for urinary symptoms. The 5alpha-reductase inhibitors block the conversion of testosterone to the more potent dihydrotestosterone and cause a reduction in the size of prostate over time. They may take 3 to 6 months to achieve maximum efficacy. Importantly, they will cause a 50% reduction in absolute PSA values after 6 months of use, and subsequent PSA values should be corrected before interpretation. Although these agents have been shown to decrease the risk of prostate cancer, they are not used solely for chemoprevention due to concerns regarding the possible development of more aggressive prostate cancer. Combination therapy using an alpha-blocker and 5alpha-reductase inhibitor has better outcomes with regards to symptom relief, improving bladder emptying and preventing urinary retention and need for surgical therapy. In patients with predominantly irritative symptoms, anticholinergic agents may be judiciously used. Their use must be cautioned in the elderly and in cases of poor bladder emptying.

Urologic referral should be sought in patients with poor response to medical therapy. For patients with symptoms refractory to medical management or those who do not wish to be on lifelong drug therapy, several minimally invasive options exist.

These include transurethral microwave therapy, laser ablation of the prostate, photoselective vaporization of the prostate and needle ablation of the prostate. These are typically outpatient procedures with minimal morbidity and efficacy approaching that of standard transurethral resection of the prostate (TURP).

The novelty, safety, and efficacy of these procedures have made the standard TURP a rarity.

Prostate Cancer Screening: Controversies Developments

and

Recent

Prostate cancer is the most common noncutaneous cancer in US men. In 2010, an estimated 217,730 cancers were diagnosed. It is also the second most common cause of cancer- related death, accounting for approximately 32,000 deaths in 2010.2 (Early detection of prostate cancer diagnoses the disease in its early stages, lending itself to curative therapy.) Early detection of prostate cancer lends itself to curative therapy. To this end, screening has become widespread.

The components of screening for prostate cancer include a serum PSA and DRE. Digital rectal exam gives a crude estimate of prostate size and can elucidate any asymmetry, firmness or nodularity. Classically, a serum PSA level of greater than 4 ng/ml has been considered abnormal in most men. Increasingly, a lower PSA threshold of 2.5 – 3.0 ng/ml is being used, especially in men younger than 60 years of age. After evaluating for other causes of elevated PSA, a prostate biopsy may be offered.

256 JOURNAL MSMA September 2013

It is generally an office procedure under transrectal ultrasound guidance. Local anesthesia with lidocaine for a periprostatic block is used, and most men tolerate the procedure well. There is a small chance of significant bleeding and infection (1 to 4%); these are minimized with cessation of anticoagulants and antimicrobial prophylaxis.

However, prostate cancer screening is at best rather inaccurate. An elevation in PSA is not specific to the presence of prostate cancer. Infections, recent instrumentation, and BPH, can all cause elevations in PSA levels. With a PSA > 4ng/ml; there is about 20% sensitivity and 94% specificity for prostate cancer.4 Lowering the PSA threshold will improve the sensitivity, but decrease the specificity, resulting in more men being exposed to the risk of biopsy. Age-specific PSA values have been recommended with higher cutoff values for the elderly to account for benign prostatic hyperplasia.

Conversely, there is no cutoff value for ‘normal’ PSA below which the risk of prostate cancer is zero. In the placebo arm of a large chemoprevention trial, 15.2% of men with a PSA below 4.0 ng/ml had prostate cancer. Even in men with a PSA level of 0.5 ng/ml or less, 6.6% had prostate cancer on biopsy.4 In response to these well-recognized limitations of PSA, various tools have been devised to improve the performance of this test (Table 2). Free/complexed PSA provides risk stratification with a PSA between 2.5 to 10 ng/ml, especially in men who have had a previous negative biopsy. PSA velocity follows the PSA trend over several measurements and can provide valuable information.5 PSA density is measured by dividing the serum PSA value by the prostate volume on transrectal ultrasound. PSA density is especially helpful in counseling already diagnosed prostate cancer patients about management options.

Other biomarkers like pro-PSA and PCA 3 are under investiga12 tion to improve accuracy of screening.6

Table 2. Tools to Improve PSA Performance Test

PSA velocity

Calculation

Application/Notes

ΔPSA/ΔTime; at least 3 PSA levels over

Consider biopsy:

18 months should be drawn • If PSAV > 0.75 ng/ml/year when total PSA is between 4 -10 ng/ml or • If PSAV > 0.40 ng/ml/year when total PSA is less than 4 ng/ml

Free PSA

PSA fraction unbound to plasma/Total

•Used for total PSA 2.5- 10 ng/ml. No Specific cutoff. Lower the

PSA

free PSA, higher the chance of PCa

•If Free PSA >25%; <8% chance of PCa •If Free PSA <10%; > 40% chance of PCa

•Free PSA levels are affected by dialysis

PSA Density

Total PSA/ prostate volume

•PSAD > 0.15 may indicate higher risk of PCa

Measurement of PSAD requires

•PSAD >0.15 in men with diagnosed PCa is a relative

transrectal ultrasound

contraindication to active surveillance

A confounding factor in the diagnosis of prostate cancer is the clinically insignificant cancer that is unlikely to cause symptoms or cause death if left untreated. While the lifetime risk of prostate cancer diagnosis is 16%, the lifetime risk of death from prostate cancer is only 3.4%. This makes over-detection a concern. It is estimated that PSA testing results in an over-detection rate of 27% at 55 years of age, and this increases to 56% by the age of 75 years.2 However, it is not possible to ascertain whether an index patient will have clinically significant cancer without first making a diagnosis of cancer. After the diagnosis of cancer, the onus is on the counseling urologist to offer the entire array of treatment options, including active surveillance.

Despite the controversies surrounding prostate cancer screening the weight of the available evidence suggests improved mortality with its routine use. There has been a 30% decrease in prostate cancer mortality in the US after the advent of PSA screening. The improvement in mortality increases with the length of followup. Ecologic studies comparing areas where PSA screening is common to areas where it is not have generally shown an improvement in prostate cancer specific mortality.

The most definitive evidence today stems from two large randomized trials of PSA screening, which presented divergent results. The Prostate, Lung, Colorectal, and Ovarian (PLCO) cancer screening trial randomly assigned 76,693 men at ten US study centers to annual PSA + DRE screening versus usual medical care. PSA biopsy threshold was >4 ng/ml. After 10 years of follow up, no difference in mortality was noted in the two groups. Although this study failed to demonstrate a benefit to prostate cancer screening, it was limited by its significant methodological problems. There were high rates of contamination in the control arm, poor compliance with biopsy recommendations, and prescreening of patients prior to study enrollment.7 The European Randomized Study of Screening for Prostate Cancer (ERSPC), with improved methodology, demonstrated a mortality benefit in a multi-national European study involving 182,160 men. While varying screening intervals and PSA cutoffs were used by different regions, a 20% reduction in mortality was noted in the screened arm after 9 years of follow up.7 In 2010, separate data from Goteborg in Sweden, one of the participating sites in the ERSPC trial, were reported. A total of 20,000 men aged 50 to 64 years were included. Screening was done very 2 years, and a PSA cutoff of 2.5 -3.5 ng/ml was used, with lower thresholds being used in the later years of the study. After a median follow up of 14 years there was a 44% risk reduction in prostate cancer mortality. 293 men would need to be invited for screening and twelve men diagnosed with prostate cancer to prevent one death.8 This compares favorably to breast cancer screening with mammography and colorectal cancer screening with flexible sigmoidoscopy where the numbers needed to screen were 377 and 489 respectively to prevent one death.

The distillate of available data also suggests that a single PSA value should not be the sole determinant of offering a biopsy. Other variables like baseline PSA, age of patient, PSA

velocity, race, and family history should be factored in as well.

In addition, screening interval can be spaced out to every few years in low risk men with a baseline PSA below 1 ng/ml.

Conclusions

Benign prostatic hyperplasia with its associated voiding symptoms is among the most common ailments managed in the community. The diagnostic evaluation is relatively simple, and safe and effective drug therapy can be initiated for men with bothersome symptoms. For patients requiring additional interventions, newer modalities of endoscopic treatment provide durable symptom relief with few operative complications.

With regards to prostate cancer screening, it can often be confusing to parse the available data and differing guidelines from various agencies. In a large breast cancer screening program in Norway, screening mammography was associated with a 10% absolute reduction in mortality compared to the non-screening cohort.9 Comparing it with the 20% mortality reduction in the ERSPC trial or 44% mortality reduction in the Goteborg sub group provides a relevant perspective of the benefits of PSA screening. While over-detection of prostate cancer remains a problem, it is not possible to ascertain whether an index patient will have clinically significant cancer without first making a diagnosis of cancer. Prostate cancer screening with PSA and DRE should be offered, albeit after a discussion of risks and benefits, including the possibility of a positive cancer diagnosis. This should be offered to well informed men who have a life expectancy of at least 10 years and are willing to undergo further evaluation if required.

References 1. McVary KT, Roehrborn CG, Avins AL, et al. Update on AUA guideline on the management of benign prostatic hyperplasia. J Urol.

2011;185(5):1793-803.

2. Carter HB, Albertsen PC, Barry MJ, et al. Early detection of prostate cancer: AUA Guideline. J Urol. 2013 Aug;190(2):419-26.

3. Stephenson AJ, Kattan MW, Eastham JA et al. Prostate cancer-specific mortality after radical prostatectomy for patients treated in the prostatespecific antigen era. J Clin Oncol. 2009 Sep 10;27(26):4300-5.

4. Thompson IM, Ankerst DP, Chi C, et al. Operating characteristics of prostate-specific antigen in men with an initial PSA of 3.0 ng/ml or lower.

JAMA. 2005 Jul 6; 294(1):66-70.

5. Moul JW, Sun L, Hotaling JM, et al. Age adjusted prostate specific antigen and prostate specific antigen velocity cut points in prostate cancer screening. J Urol. 2007;177(2):499-503.

6. Tosoian J and Loeb S. PSA and beyond: the past, present, and future of investigative biomarkers for prostate cancer. ScientificWorldJournal.

2010; 1(10):1919-31.

7. Djavan B. Screening for prostate cancer: Practical analysis of the ERSPC and PLCO Trials. Eur Urol. 2011;59(3):365-9.

8. Hugosson J, Carlsson S, Aus G et al. Mortality results from the Gรถteborg randomised population-based prostate-cancer screening trial. Lancet Oncol. 2010, 11(8):725-32.

9. Kalager M, Zelen M, Langmark F, et al. Effect of screening mammography on breast-cancer related mortality in Norway. N Engl J Med. 2010 Sep 23;363(13):1203-10.

September 2013 JOURNAL MSMA 257

• Just Off the Press - Info You Need to Know • Digoxin Use in Atrial Fibrillation Richard L. Ogletree, Jr., PharmD

A

rticle: Whitbeck MG, Charnigo RJ, Khairy P, et al.

Increased mortality among patients taking digoxin— analysis from the AFFIRM study. Eur Heart J 2012: DOI:10.1093/eurheartj/ehs348.1

Background: Digoxin is a medication that has long been utilized for its positive inotropic and negative chronotropic activities. Recent studies have questioned its position in the treatment of heart failure or atrial fibrillation (AF). Digoxin treatment of heart failure in the DIG trial showed neither benefit nor harm as far as morbidity goes, but there were decreased hospitalizations due to heart failure in the digoxin group.2 AF trials have shown increased mortality when participants were on digoxin, but that was generally considered to be due to sicker patients on treatment.3,4 The Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) trial showed no benefit of rhythm control compared with rate control in AF patients. This led many to preferentially utilize rate control as anti-arrhythmic agents can have many adverse effects.5 Although digoxin is sometimes used for rate control, its narrow therapeutic index can limit its favor.

All-cause mortality Cardiovascular mortality Arrhythmic mortality

1.41 1.35 1.61

(1.19–1.67) P < 0.001 (1.06–1.71) P = 0.016 (1.12–2.30) P = 0.009

In the subgroups, mortality was increased in: With heart failure (ejection fraction < 40%)

1.37 (1.05–1.79) P = 0.019 Without heart failure 1.41 (1.09–1.84) P = 0.010 There was no significant digoxin–gender interaction for allcause (P = 0.70) or cardiovascular (P = 0.95) mortality.

Conclusion: Digoxin use was associated with a statistically significant increase in all-cause mortality in patients with AF after correcting for clinical characteristics and co-morbidities.

This was seen regardless of gender or of the presence or absence of heart failure. These findings call into question the use of digoxin in patients with AF. Figure 1. Kaplan–Meier curves for all-cause mortality based on digoxin use during the study.

Objective: The purpose of this project was to evaluate the benefits and harms of digoxin when used to treat AF in the AFFIRM trial.

Design: Re-analysis of a previously performed randomized controlled trial.

Methods: Multivariate Cox proportional hazards models were used to evaluate the association between digoxin and mortality in patients enrolled in the AF Follow-Up Investigation of Rhythm Management (AFFIRM) trial. Analyses were conducted in all patients and also in subsets based upon the presence or absence of heart failure (HF), as defined by a history of HF and/ or an ejection fraction <40%.

Results: Looking at the estimated hazard ratio (EHR) compared to non-use, the use of digoxin was associated with increases in:

258 JOURNAL MSMA September 2013

Figure 1. Reproduced from: Whitbeck MG, Charnigo RJ, Khairy

P, Ziada K, Bailey AL, Zegarra MM, Shah J, Morales G, Macaulay T, Sorrell VL, Campbell CL, Gurley J, Anaya P, Nasr H, Bai R, Di Biase L, Booth DC, Jondeau G, Natale A, Roy D, Smyth S, Moliterno DJ, Elayi CS. Increased mortality among patients taking digoxin-analysis from the AFFIRM study. Eur. Heart J. 2012 Nov. Used with permission.

Reviewer’s comments: Although this was a post hoc analysis, the paper is informative as it included patients with and without heart failure, and the statistical methods were robust. For sure, the use of digoxin in a-fib patients without heart failure should be questioned. It might be useful in those for whom a beta-blocker or non-dihydrodpyridine calcium channel blocker is not tolerated (such as those who become hypotensive on these agents). If it is used, low concentrations (0.5 - 0.8 ng/mL) should be targeted.

Figure 2. Kaplan–Meier curves for all-cause mortality based on digoxin use at baseline.

Figure 2: Reproduced from: Whitbeck MG, Charnigo RJ, Khairy P, Ziada K, Bailey AL, Zegarra MM, Shah J, Morales G, Macaulay T, Sorrell VL, Campbell CL, Gurley J, Anaya P, Nasr H, Bai R, Di Biase L, Booth DC, Jondeau G, Natale A, Roy D, Smyth S, Moliterno DJ, Elayi CS. Increased mortality among patients taking digoxinanalysis from the AFFIRM study. Eur. Heart J. 2012 Nov. Used with permission.

References 1. Whitbeck MG, Charnigo RJ, Khairy P, Ziada K, Bailey AL, Zegarra MM, Shah J, Morales G, Macaulay T, Sorrell VL, Campbell CL, Gurley J, Anaya P, Nasr H, Bai R, Di Biase L, Booth DC, Jondeau G, Natale A, Roy D, Smyth S, Moliterno DJ, Elayi CS. Increased mortality among patients taking digoxin-analysis from the AFFIRM study. Eur. Heart J. 2013 May; 34(20):141-148.

2. The Digitalis Investigation Group. The Effect of Digoxin on Mortality and Morbidity in Patients with Heart Failure. N Engl J Med. 1997 Feb;336(8):525–533.

3. Andrey JL, Romero S, García-Egido A, Escobar MA, Corzo R, GarciaDominguez G, Lechuga V, Gómez F. Mortality and morbidity of heart failure treated with digoxin. A propensity-matched study. Int J Clin Pract.

2011;65(12):1250–1258.

4. Cleland JGF, Cullington D. Digoxin Quo Vadis? Circ Heart Fail. 2009 Mar;2(2):81–85.

5. A Comparison of Rate Control and Rhythm Control in Patients with Atrial Fibrillation. N Engl J Med. 2002 Dec;347(23):1825–1833.

September 2013 JOURNAL MSMA 259

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260 JOURNAL MSMA September 2013

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September 2013 JOURNAL MSMA 261

• President’s Page • Inaugural Address of the 146th President James A. Rish, MD

T

hank you for the tremendous honor of allowing me to serve as your President and the voice of MSMA for the upcoming year. I am very humbled by the trust you have placed in me, and I will work tirelessly on your behalf, as well as that of your patients, to ensure that our interests are represented.

Aside from Dr. Edward Hill (who was actually from Hollandale at the time of his presidency) the last president of MSMA from Tupelo was Dr. L. C. Feemster who served this organization 100 years ago from 1913-14. Dr. Feemster was instrumental in building NMMC when he helped to secure funding from the Commonwealth Fund James A. Rish, MD in New York City who had begun a program to build hospitals in rural areas. North 2013-14 MSMA President Mississippi Medical Center now has the distinction of being one of the largest rural hospitals in the United States. As you can see, I have enormous shoes to fill.

I would be remiss if I did not recognize some very special people who have been so instrumental in my assuming this role.

I would like to thank the members of the Northeast Medical Society and the Board of Trustees who have mentored me and supported me through the years in my various leadership roles. I would also like to thank Dr. Claude Brunson who has done an outstanding job as chairman of the board under challenging circumstances.

I would also like to thank my wife, Susan, who is my best friend, my soul mate, and my biggest supporter through all the years that I have been a part of organized medicine. She has given me 3 wonderful children who happen to be here tonight: Parker, Peyton, and Preston.

I am like so many of you who got our start in organized medicine at our spouses’ urging. Susan worked at the Arkansas Medical Society when I was in my residency training. As a result I attended many meetings and events of the AMS. When we moved to Tupelo she quickly joined the Alliance, and I, the Mississippi State Medical Association. I consider this as one of the best decisions I have made over my professional career.

I am also very grateful for my mother and father-in-law, Evelyn and James Walters. Who in their right mind would let some guy just out Ole Miss with only a Biology degree and no job marry their only daughter? I am thankful that they did. They believed in me before I believed in myself. They have been my surrogate parents after the loss of both of my parents, and I love them dearly.

I would like to introduce some other very special guests that are here tonight. My brother Jeff and his wife Patti are here.

Unfortunately my brother Mark and his wife Lisa could not attend. My oldest sister Suzi Rish is here. My twin sister Julie and her husband Robbie McCord are here as well.

There are also four very dear friends who I have known since growing up as a little boy in Pontotoc, Mississippi. These are Kenny Mask, Penny Gafford, Carol Crausby, and Terri Johnston. We have shared so many laughs and wonderful times through the years, and I am honored to have them share this special time with me. Also here tonight are two of the most wonderful people we met after moving to Tupelo: Cindy Jourdan and Paula Spraggins.

One of my most vivid recollections of the first few days of medical school was meeting a guy named Abraham Rowe. We shared a cadaver together. After completing our first year of medical school he got smart and went to law school. We have remained very close friends through the years, and I am delighted to have him and his wife, Jill, join us tonight.

Lastly, I would like to thank my partners at Pulmonary Consultants. One of them, David Witty and his wife Donna are here tonight. They have become very accustomed to me being out of the office whenever the business of the association demands. I very much appreciate their ongoing sacrifice which has allowed me to function in this role.

It is a very exciting time to be involved in organized medicine. We must all be engaged now more than ever. Not since the inception of Medicare in the mid 1960’s has there been a more pivotal time in health care delivery in the United States. Here we are at the dawn of the Patient Protection and Affordable Care Act. The far reaching implications of this legislation are enormous on so many different fronts. There is a great deal of fear and uncertainty of what lies ahead. That is exactly why we must be at the table as this law becomes reality in our own practices. This is why your continued membership and engagement in this organization, as well as the various specialty societies and the AMA is so important.

We have had many successes this past year under the leadership of Dr. Steve Demetropoulos, and I thank him for his service to our organization.

262 JOURNAL MSMA September 2013

Your state medical association has successfully defended scope of practice issues on multiple fronts.

• We were instrumental in defeating anti-vaccination legislation.

• We partnered with other interested parties to pass Assignment of Benefits legislation.

• We have built on our success with the Rural Scholars Program by removing caps on the number of students that can participate in the program and actually creating a floor insuring that a minimum of 15 medical students continue to receive scholarships each academic year.

• We have been successful in establishing the Office of Physician Workforce which will provide valuable data and strategic planning with respect to our state’s healthcare infrastructure.

• We sponsored the first annual Cadaver 5K run to benefit our foundation.

• In addition your association partnered with the Mississippi State Department of Insurance to host very successful insurance forums in multiple locations around the state.

• We have enjoyed a record high membership in the organization.

• We have the most professional, talented, and dedicated staff in place that I have seen since I joined this organization 18 years ago.

Despite these and multiple other successes which time will not permit mentioning, there is much work to be done.

Since 2009 when your association published the first of a yearly series of Health Report Cards which are presented to our legislators, I am reminded of the health crisis our state faces. We have the distinction of living in a state with the highest death rate from heart disease, the highest rate of obesity which stands at 34.9%, the highest teen birth rate, the highest rate of low and very low birth weight babies, and the highest infant mortality rate at 10 per 1000 live births. We have the second highest rate of diabetes, just being edged out by Alabama. We have the third highest cancer death rate. 26% of Mississippians smoke compared to a national average of 21.2%. If that is not enough, we have the lowest number of physicians per capita of any other state.

As I said, there is much work to be done. This Report Card is our call to action. This is why we are here. This is why we exist. We must vigorously apply our intellectual treasury to solving these enormously complex issues. As all the forthcoming debate over healthcare delivery in this state and nation unfolds, we must stay focused on our most basic responsibility: that of our patient’s welfare. We cannot afford to lose sight of this. We must tenaciously engage in policy debates on their behalf.

We have already witnessed the debate on Medicaid expansion unfold within our own state. There are deeply divided opinions among us on both sides of the argument. I can assure you that this topic will continue to be frequently debated and consume a substantial amount of time and resources on the part of your association.

Whether or not Medicaid is expanded, we need to make sure that our Medicaid program meets the needs of our patients, the doctors who serve them, and all the citizens of this great state.

We have enjoyed a close working relationship with the Medicaid Director, Dr. David Dzielak. We have seen many challenges arise with the emergence of Medicaid Managed Care programs. These include an increasing number of burdensome prior authorization procedures, inadequate or very restrictive drug formularies, limited participation of specialists in the program, and marginal reimbursement rates. Now we get to look forward to post payment audits the likes of which we have grown to love in the Medicare RAC program.

One of our goals for the Medicaid program is putting a medical director in place that will represent the physician’s voice in the manner in which the program is implemented.

We also need to pursue innovative approaches in delivery of care that will achieve cost containment without sacrificing the quality of care. Along those lines we need to continue our work in developing and implementing successful and sustainable delivery models including a possible Patient Centered Medical Home Model or an Accountable Care Organization that is physician led and adhere to a core set of principles. We need to explore team based care and focus on population health.

Regardless of the delivery model going forward under the Affordable Care Act, all agree that we need to grow our physician workforce. We simply need more doctors as more of our citizens have access to healthcare.

We have seen recent success in increasing the size of our medical school classes at UMMC. We also welcome our colleagues at the new William Carey University School of Medicine. It is our sincere hope that the students and graduates from the school will partner with us and get involved in organized medicine at all levels. The stakes could not 2013-2014 MSMA President James A. Rish, MD be higher. delivers his first presidential address during Unfortunately, when it comes to increasing our number of an inaugural gala held at the Jackson Hilton, fellow physicians there are two sides of the equation. One would Saturday, August 16, 2013. effectively argue that it does very little good to increase our class

September 2013 JOURNAL MSMA 263

sizes if we do not have enough residency positions for these graduating physicians.

Funding and access to graduate medical education are reaching crisis proportions in the United States. By 2015 the number of US medical school graduates will exceed the number of graduate medical education positions that are predicted to be available.

This equates to an estimated 63,000 shortage of physicians in 2015 and 130,000 by 2025. Residency training positions have been capped since the passage of the Balanced Budget Act of 1997. Mississippi has seen a net loss of 24 residency positions in the past 20 years. No longer can a graduating medical student who has spent countless hours studying and has undertaken enormous debt, be assured of having a residency position available to them upon completion of medical school. At the AMA level your delegation has been very proactive in bringing this to the national spotlight. As a result the AMA has increased their efforts and resources in pursuing all potential sources for funding increased numbers of graduate medical education spots.

These and so many other complex issues are begging organized medicine for answers. The solutions will require significant honest intellectual input, a wide array of professional talents, and money.

From the business aspect your Board of Trustees and staff have done a superb job maintaining our association on solid financial footing. There are so many worthwhile projects that do not get considered simply because of limited non-budgeted financial resources. With increased membership and, accordingly, dues revenue, we will be able to set money aside for these very projects.

In addition an MSMA Foundation Committee, led by Dr. Helen Turner, has been appointed and charged with the task of increasing our foundation assets which can also be directed towards charitable, scientific, and educational purposes.

Not only is your membership and involvement important to our state medical association, but it is critical that we keep our finger on the pulse at the national level. There are many issues that can only be solved by national attention and coordinated grassroots legislative efforts. This means being involved in the AMA and our national specialty societies.

We have all witnessed the widespread disappointment among our state’s physicians with the AMA, particularly relating to its support of the Patient Protection & Affordable Care Act. As you recall, this ultimately lead the Mississippi State Medical Association to de-unify from the AMA, the last state to do so. Consequently there was a mass exodus of membership from the AMA in our state as well as from many of our conservative neighboring states. This served only to decrease the number of delegates and further dilute the influence of the more conservative faction of the AMA. How can retreating solve our problems?

I suspect that most of us busy hard-working physicians are not aware of the significant number of the heavy hitting issues that AMA is fighting behind the scenes on our behalf. I also suspect that you agree with the AMA’s position on these issues more than you disagree.

We are all familiar with the flawed SGR formula and share the belief that it should be repealed and replaced with a stable financial foundation for physician practices before any new payment and delivery models are adopted.

I dare say that we agree with the AMA that EHR adoption and achieving the multiple stages of meaningful use should not be mandated nor certainly penalized until the appropriate technological infrastructure is in place and issues of connectivity have been resolved.

We share our desire with the AMA to eliminate the 15 member non-elected Independent Payment Advisory Board created under the Affordable Care Act which is expected to focus on savings by cutting reimbursements to providers when certain projected per-beneficiary spending growth exceeds specified targets.

I suspect that we agree with the AMA that implementation of ICD-10 should be delayed indefinitely as it will add additional administrative burdens to physician practices at an estimated cost of $23,000.00 per physician without any improvement in quality of care.

We are all aware of the various mandates and payment reform penalties on the horizon:

• • • • •

EHR adoption achieving meaningful use physician quality reporting system electronic prescribing and the 30 day readmission payment penalty.

If you feel that the cumulative effects of these various mandates coupled with the 2% sequester cut create financial hardships making it difficult for private practice physicians and smaller hospitals to keep their doors open, then you agree with the AMA’s position.

I could go on further, but I think you get the picture. I can proudly say that each member of your board of trustees is a member of the AMA. There is simply no other organization that has the clout and lobbying resources to get our message heard by Congress and the President.

As I mentioned earlier the Mississippi State Medical Association has enjoyed recent record high membership. You obviously understand the value of membership in this organization or you would not be here tonight. However, our job is not done. I challenge each of you that when you return to your practices on Monday to actively and aggressively engage in doctor lounge advocacy to recruit our nonmember colleagues both to our MSMA and AMA. In addition to increasing our membership at the state and national level, there are numerous other goals that I would like to pursue during my tenure.

264 JOURNAL MSMA September 2013

We should continue to aggressively fight scope of practice issues from all fronts and seek to craft legislation to define and support team based care delivery such as has been passed in Virginia.

We need to continue our efforts at addressing the concerns of physicians with the Medicaid managed care plans and support innovative development and implementation of pilot delivery models of care.

With a growing number of our ranks becoming employed physicians, we need to provide advice and assistance with contract negotiations as well as crafting medical staff bylaws so as not to place the employed physician in jeopardy of their employment when speaking out on patient and physician care issues.

We need to boost our efforts at providing the tools needed to assist our fellow physicians in becoming leaders among their local medical staffs and hospital administrations.

Dr. Rish with his sons: Parker, Peyton, and Preston We must join MMPAC and vehemently support physician and patient–friendly candidates for public office, both financially and otherwise.

We need to continue the work of Dr. Demetropoulos in our support of smoke free air in Mississippi, if necessary through a referendum effort.

We need to spend the time and all available resources to educate our legislators on our pending legislative agenda.

We need to step up our efforts at building our cash reserves within the Foundation. In the future you will be called upon to support the Foundation in some manner. Please do so generously.

I recently came across an intriguing article published in the Wall Street Journal in 2012 by Dr. Ken Murray [Entire essay published: Murray K. How doctors die, J Miss Med Assoc. 2013;54(3):67-69] which pointed out that when physicians are faced with life threatening devastating illness, they often do not opt for complicated treatment and life sustaining therapies. Therefore, if advanced directives and comfort-oriented care are good enough for physicians, should they not be good enough for our patients as well? I feel that we as physicians should do a better job in taking the time to explain to our patients and their families the likelihood of success or delay in the inevitable that various life sustaining therapies provide.

I would like to see our association partner with the Alliance in their “Crossing the Finish Line with Dignity” program, and pursue the Physician Orders for Life Sustaining Therapy at the legislative level which will ensure that the wishes and desires of our patients regarding end-of-life care are respected, and they be allowed a dignified death.

These are all lofty but obtainable goals. We have the ingredients for success. We have a wide array of intellectual talent, and are well represented in a multitude of areas. We have an outstanding staff and one of the best lobbying teams at the Capitol. We have good relationships with our legislative leaders in both the house and senate. We have a governor who has pledged his support to growing the physician workforce and who understands the enormous economic potential that physician practices bring to our state.

Indeed we have a lot of strengths, but what are our obstacles? In any large organization, management is often called on to perform a SWAT analysis. That is what are our strengths, our weaknesses, our assets, and our threats? I have already spoken quite a bit about our strengths, our assets, as well as our goals. But what about our weaknesses and our threats?

I see our greatest threat as apathy and passivity. We all must get involved. We simply cannot rely on someone else to do the heavy lifting for our doctors and their patients.

Our second greatest threat lies within our own ranks. Ladies and gentlemen we must set aside our personal agendas and differences for the common good of our patients and the house of medicine. We cannot allow our own infighting to render us irrelevant in the eyes of our public policy makers. We must speak with one loud voice. Divided we will surely fail our profession and, more importantly, our patients.

Many of you are aware that I enjoy running. I started when I was a fourth year medical student, and I have not stopped since. I liken our journey as an effective medical association to training for a marathon. It takes a lot of time, motivation, dedication, and most importantly focus. You start out with simple and achievable goals and build on these successes day after day and week after week. There are many distractions along the way. If you lose sight of your goal or relax your efforts, you have to start over almost from scratch. You are constantly subjected to potential injuries and setbacks, but you keep focused and moving forward toward your ultimate goal. Folks… this is our marathon. We must remain steadfast and tireless in our efforts. I know that we are up for this task.

Thank you and may God bless each and every one of you.

September 2013 JOURNAL MSMA 265

Calling All Mississippi Physician-Photographers

Enter the JMSMA 2014 Cover Photo Contest

L

oad 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 7â&#x20AC;? or 8 x 10â&#x20AC;? Deadline: November 29, 2013 Mail to: P.O. Box 2548 Ridgeland, MS 39158-2548 or deliver to MSMA headquarters 408 W. Parkway Place, Ridgeland, MS 39157

266 JOURNAL MSMA September 2013

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

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(601) 856-7200 www.cctb.com 268 JOURNAL MSMA September 2013

COOK TAYLOR & BUSH

• MSMA • 145th Annual Session Recap MSMA Presidential Oath of Office —

Former chair of the MSMA Board of Trustees Dr. Claude Brunson administers the oath of office to Dr. James A. Rish while his wife Susan holds the Bible. Dr. Brunson was elected presidentelect and will represent MSMA as president in 2014-2015.

Actions Taken by the MSMA House of Delegates

T

he Mississippi State Medical Association House of Delegates met August 16-17 at the Norman C. Nelson Student Union on the University of Mississippi Medical Center (UMMC) Campus in Jackson. Actions taken on appropriate resolutions are listed below:

• Pursue a statewide ban on smoking in indoor public places, by legislative referendum if necessary. (recommended by • • • • • • • •

president) MSMA will serve as a clearinghouse for members’ issues with Medicaid. (recommended by president) MSMA will push the Medicaid Director and the Governor to hire a physician Medical Director at Medicaid. (recommended by president) The Board of Trustees will consider creating a physician advisory committee to work with the Medicaid Director. (recommended by president) MSMA will actively pursue the Patient-Centered Medical Home model of managed care within Medicaid. (recommended by president) MSMA will work with the Governor to develop ways to provide health care coverage for the uninsured. (recommended by president) The Council on Medical Service will study simplification and standardization of prior authorization requirements. (Res. 2) MSMA will promote the eight components of school health and encourage physicians to join local school wellness committees. (Res. 3) MSMA commends and expresses appreciation to Dr. Hannah Gay for her discovery of a functional HIV cure in an infant. (Res. 4)

September 2013 JOURNAL MSMA 269

• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

MSMA will advance a resolution at the AMA asking the Joint Commission to reevaluate pain as the fifth vital sign. (Res. 5) MSMA strongly opposes restrictive covenants in any physician’s contract. (Res. 6) Council on Constitution and Bylaws includes five members elected for staggered terms (Res. 8 & 20) Council on Constitution and Bylaws makes annual recommendations to Board of Trustees; to the House of Delegates every two years. (Res. 8 & 20) Board of Trustees will study and report on the impact hybrid election methods. (Res. 9) Board of Trustees will consider whether it is necessary to stipulate that president-elect candidates are from specific geographic locales. (Res. 10) MSMA will pursue legislation to promote Physician Orders for Life-Sustaining Contracts (POLST). (Res. 11) The 2014 Annual Session will be held in the Jackson metro area on dates determined by Board of Trustees. (Res. 12) A description of the duties of members of each council and committee will be given to candidates and the House of Delegates.

(Res. 13) Term in office for physician-under-40 slot on Board of Trustees is set for three years. (Res. 14) Young Physicians Section officers may determine when the section meeting is held. (Res. 14) Board of Trustees will consider sending a resolution to the AMA about reimbursing hospitals for physician services at comparable rates. (Res. 15) Term of office of AMA Delegates and Alternates begins when annual session ends. (Res. 18) Tell elected officials of MSMA support of rural hospitals and seek solutions to rural access problems. (Res. 19) Three councils will study whether MSMA needs a Council on ACCME Accreditation and report back. (Res. 21) MSMA will support diversity at medical schools and residency programs; Board will explore ways to increase diversity of membership. (Res. 23) Board of Trustees will consider whether to seek specific legislation to enact a Youth Concussion Law. (Res.24) MSMA will work with elected officials to pursue actively the appointment of a physician medical director at Medicaid. (Res. 25) MSMA will work with elected officials to restrict expansion of MississippiCAN and help physicians resolve CAN problems.

(Res. 26) MSMA will work with AMA to seek federal legislation to reinstate the Medicaid Deferred Compensation Plan or create other incentives. (Res. 26) MSMA will continue pursuit of a Patient Centered Medical Home as the preferred model of managed care for all Mississippians. (Res. 26) MSMA will ask AMA to work with CMS to allow interns and residents to train with a qualified primary care physician. (Res. 27) Council on Medical Service will study ways to increase awareness of immunizations and of dangers of non-medical exemptions. (Res.28) MSMA will work with elected officials to reorganize Department of Mental Health by increasing physician oversight. (Res. 31) MSMA will petition the Board of Mental Health to hire a physician in the agency head position. (Res. 31) Board of Trustees, CMS, and others seek consultation in 2013 for historical and economic truths about Medicaid expansion.

(Res. 32) Ad hoc committee to study JAMA governance policy and report back with recommendations. (Res. 33) MSMA will work with OPW to explore establishing a teaching health center in the Delta; ensure federal funding, promote specialty support. (Res.35) MSMA Board will move the association’s mission to forefront of activities and accomplish central mission. (Res.36) Committee on Publications will study impact of VITALS on the Journal and report back with recommendations. (Res. 37) Board of Trustees will use Constitution Article II as guidepost when setting policy while House is in vacation. (Res. 38) Policies amended or adopted by Board of Trustees will be submitted for ratification by House of Delegates. (Res. 38)

MSMA Election Results The 145th Annual Session of the MSMA House of Delegates adjourned Saturday, August 17. During the meeting, physicians elected officers, trustees, and council members to open positions for terms beginning in 2013. In addition, MSMA’s 2013-14 President James A. Rish, MD of Tupelo was inaugurated and took his oath of office to lead the association for the next year. Dr. Lee Voulters of Gulfport was named chair of the Board of Trustees.

270 JOURNAL MSMA September 2013

MSMA members elected the following physicians to serve on the Board: •

President-Elect: Claude Brunson, MD

•

Secretary-Treasurer: Michael Mansour, MD

•

Trustee District 2: Brett Lampton, MD

•

Trustee District 4: Bill Grantham, MD

•

Trustee District 5: Dwight Keady, MD

•

Trustee, Young Physician: David McClendon, MD

•

Trustee Resident/Fellow: Jane Beebe Jones, MD

•

Trustee Student: Savannah Duckworth The result of other races follows:

•

Associate Editor, Journal MSMA: Richard deShazo, MD

•

AMA Delegation: Claude Brunson, MD; Sharon Douglas, MD; Clay Hays, MD

•

AMA Alt Delegation: Randy Easterling, MD; Lucius Lampton, MD; James Rish, MD

•

Council on Budget and Finance: Susan Chiarito, MD; Jennifer Bryan, MD

•

Council on Constitution and Bylaws: John Cross, MD

•

Council on Legislation District 1: Michael Mansour, MD; District 2: Pearson Windham, MD; District 3: Murray Estess, MD; Resident: Julia Thompson, MD; Student: Luke Ainsworth

•

Council on Medical Education: District 2: Dewayne Gammel, MD; District 4: Jonathan Jones, MD; District 5: John Voss, MD

•

Council on Medical Service: District 4: Anthony Cloy, MD; District 5: Michael Shrock, MD; Resident: Tal Hendrix, MD; Student: Emily Brandon

•

Council on Public Information: District 1: Robert Suares, MD; District 2: Son Lam, MD; District 3: Charlotte Magnussen, MD

MSMA Awards: Community Service, Leadership, and Wellness Promotion Project Honored The Mississippi State Medical Association (MSMA) honored two physicians and a wellness promotion project during the ceremony for the 2013 Excellence in Medicine Awards.

Recipients and respective honors include: •

Carlton Gorton, MD – Dr. James C. Waites Leadership Award

•

Karl Crossen, MD – MSMA Community Service Award

•

Victor T. Copeland, MD – Robert S. Caldwell Award

•

Michael L. Jones, RN, Healthy Linkages Program – MSMA Award for Excellence in Wellness Promotion

The Dr. James C. Waites Leadership Award: Carlton Gorton, MD

Claude Brunson presented the 2013 Dr. James C. Waites Leadership Award to Dr. Carlton Gorton. Instituted in 2001, the award recognizes the many contributions of Dr. Waites, to his community and to organized medicine. Each year the MSMA Board of Trustees selects one physician under the age of 50 who is an outstanding leader in organized medicine and community affairs.

This award honors one physician under the age of 50 who is an outstanding leader in organized medicine and community affairs. Dr. Gorton, a Belzoni native, has served numerous leadership positions with MSMA, including the Board of Trustees. He currently serves as chair of the Rural Physicians Scholarship Program. The Board notes Dr. Gorton has demonstrated tremendous leadership skills in his time practicing as a physician.

Dr. Carlton Gorton graduated from the University of Mississippi Medical School in May 2000. He completed his residency at UMC in Internal Medicine and Pediatrics in June 2004 and received the Pediatrics Teaching Resident of the Year award in 2004. He is a member of the American College of Physicians, American Academy of Pediatrics, American Society of Hypertension, and the Mississippi State Medical Association (MSMA). He has practiced medicine at the Gorton Rural Health Clinic in Belzoni since November 2007. Prior to that, he practiced at GLH-Gorton Clinic in Belzoni and the Patients’ Choice Medical Center.

September 2013 JOURNAL MSMA 271

MSMA Community Service Award: Dr. Karl Crossen, MD

Dr. Karl Crossen, MD, an electrophysiologist and internist from Tupelo, was presented with the MSMA Community Service Award, which recognizes participation in civic activities for the betterment of the community. Dr. Crossen graduated from the University of South Alabama College of Medicine in 1981 in Electrophysiology. He was board-certified as a Medical Examiner in 1982, Internal Medicine in 1983, received a subspecialty of Cardiovascular Disease in 1987, and a subspecialty of Clinical Cardiac Electrophysiology in 1992. Dr. Crossen is an American College of Cardiology fellow and member of the Heart Rhythm Society and the MSMA. Dr. Crossen currently practices at North Mississippi Medical Center in Tupelo as an electrophysiologist.

Following the tragic death of Weston Reed, a soccer player in Tupelo who went into full cardiac arrest on the high school field, Dr. Crossen spearheaded efforts to create a biannual event to supply children with free sports physicals. Over 2,000 children participate in this event each year, demonstrating the tremendous impact this program has had on Dr. Crossen’s hometown community. There is a Karl Crossen, MD and James Rish, MD particular emphasis on the cardiovascular system in these physicals as Dr. Crossen provides each child with an EKG and an echocardiogram if it is needed to rule out potential congenital defects. This program took shape due primarily to Dr. Crossen’s tireless efforts to coordinate and plan each event, and his hometown of Tupelo has benefitted greatly from it. Dr. Crossen has demonstrated exemplary community service on behalf of medicine. Thanks to his efforts, children in northeast Mississippi can take part in extracurricular activities with reassurance of their health and safety.

2013 MSMA Award for Excellence in Wellness Promotion: Michael L. Jones, RN, Healthy Linkages Program

An honor graduate of the UMMC’s School of Nursing, Michael Jones has worked in the areas of orthopedic nursing, rehabilitation, and community health. Jones established and has served as the Director of Healthy Linkages for the medical center for five years. Previously, Jones worked for the Mississippi Primary Health Care Association as the Director of Clinical Quality. In this role, he served as the liaison for clinical professionals working in the state’s 21 Federally Qualified Health Centers (FQHC).

Working with other UMMC leadership, he established the Healthy Linkages program, which brings together the leadership of Mississippi’s 21 FQHC’s, the Mississippi State Department of Health, community service agencies, volunteer groups, governmental representatives, and others interested in preventive medicine and quality care. These individuals meet regularly to improve communication and discuss mechanisms for improving access to specialty care and medical homes for the state’s most vulnerable Michael L. Jones, RN and James Rish, MD citizens.

Jones’s effort has resulted in improved access to care throughout the state of Mississippi. He conceived, established, and now directs a statewide program, the UMMC Community Health Advocate Training Program, which has trained and certified approximately 1,000 advocates and trainers in faith-based and communitybased entities. Jones has shown an exceptional level of leadership, innovation, and compassion to improve the health of all Mississippians. The work he does will continue to result in long-term positive outcomes.

The Robert S. Caldwell Award: Dr. Victor Copeland, ophthalmology resident

Since 1982, Medical Assurance Company of Mississippi (MACM) has presented the Robert S. Caldwell, MD Award to the top resident at the UMMC. The Caldwell Award is given in memory of the general surgeon from Tupelo who was instrumental in the founding of MACM. Dr. Caldwell served on MACM’s first Board of Directors and was elected the Company’s first secretary.

In addition, he was President-elect of the MSMA at the time of his death. 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 is selected by an ad hoc committee of faculty members at UMMC.

272 JOURNAL MSMA September 2013

This year’s Robert S. Caldwell, MD Award winner, Dr. Victor T. Copeland, was nominated for this award because of excellence as a clinician, surgeon, and patient advocate. In July 2013, Dr. Copeland will begin a two-year Vitreo-Retinal fellowship at Wake Forest University in Winston-Salem, North Carolina. After the fellowship, he hopes to pursue a future in academic medicine. He is a member of the Association for Research in Vision and Ophthalmology (ARVO), American Academy of Ophthalmology (AAO), and the Mississippi Academy of Eye Physicians and Surgeons (MAEPS).

MSMA-Sponsored Awards Recognized, Previously Presented Awards presented at the UMC School of Medicine Honors Day Ceremony May 3, 2013 Wallace Conerly, MD Award: Kelley Christian Hankins Hill, a M-4 from Mooreville, and Savannah Elizabeth Duckworth, a M-3 from New Albany Established in 2003 by the MSMA in honor of A. Wallace Conerly, MD, Vice-Chancellor Emeritus for Health Affairs and Dean Emeritus of the School of Medicine, this award is given to a senior and junior medical student who most exemplify Dr. Conerly’s outstanding attributes of leadership, community outreach, and service.

Carl Gustav Evers, MD Award: Elizabeth Katherine Schimmel and Julia Ashley Thompson The Evers award is given by the MSMA Foundation on behalf of the many friends and colleagues of Dr. Carl Gustav Evers, a Past President of the Association, member of the American Medical Association (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 peer to peer support, scholarship, and exceptional leadership in promoting and participating in student activities of the AMA and the MSMA. This award consists of a handsome plaque and cash honor.

Virginia Stansel Tolbert, MD Award- UMC School of Medicine: Michael Olen Jennings and Richard Covey Robertson, Jr. This award consists of a plaque and cash prize and is given to a medical student who has demonstrated superior scholarship and leadership 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.

Virginia Stansel Tolbert, MD Award- UMC School of Health Related Professions: Ottis Lee Brown This award 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. This award was presented at the SHRP Honors Day Ceremony on May 24, 2013.

In Memoriam The MSMA House of Delegates paused for a moment of silence to acknowledge Resolution 1 that mourns the passing of these esteemed colleagues (to date of resolution): • Jim C. Barnett, MD of Brookhaven 1926 to 7-26-2013

• Charles H. Laney, MD of Madison 1949 to 8-4-2013

• L.H. Brandon Jr., MD of Starkville 1927 to 6-7-2013

• Glenn J. Lau, MD of Meridian 1947 to 5-6-2012

• Ronald L. Brown, MD of Gulfport 1939 to 11-9-2012

• Robert T. Lott, MD of West Point 1931 to 12-22-2012

• Cathy A. Butts, MD of Gautier 1955 to 7-6-2012

• F. L. Lummus, MD of Tupelo 1935 to 10-21-2012

• William F. Calhoun, Jr., MD of Natchez 1925 to 7-4-2013

• George D. Lyon, MD of Starkville 1953 to 2-5-2013

• James R. Cavett Jr., MD of Jackson 1920 to 6-1-2012

• Chester W. Masterson, MD of Vicksburg 1933 to 6-20-2012

• C. Ralph Daniel Jr., MD of Madison 1925 to 5-28-2013

• James R. Mayfield, MD of Carthage 1937 to 12-23-2012

• Burton Friedman, MD of Wesson 1924 to 12-6-2012

• Malcolm S. Moore, Sr. MD of Tupelo 1933 to 5-17-2012

• Richard L. George, MD of Columbus 1919 to 12-21-2012

• James S. Purdon, MD of Oxford 1950 to 3-3-2013

• Patrick H. Gill, MD of Macon 1926 to 3-3-2013

• Michael Taleff, MD of Meridian 1936 to 10-2-2012

• H. Lamar Gillespie Sr., MD of Hattiesburg 1930 to 5-2-2012

• Jerry K. Young, MD of Saltillo 1959 to 1-2-2013

• James R. Gleaves, MD of Meridian 1944 to 7-20-2013

• T. E. Wilson, III, MD of Jackson 1932 to 9-26-2012

• J. Brooks Griffin, MD of Jackson 1953 to 6-22-2013

• Jesse L. Wofford, MD of Drew 1922 to 1-26-2012

• Martin B. Harthcock, MD of Raymond 1918 to 11-26-2012

• O. B. Wooley Jr., MD of Jackson 1928 to 6-10-2013

• Laura Justice, MD of Gulfport 1945 to 3-4-2012

• Maude A. Wright, MD of Jackson 1953 to 4-16-2012

September 2013 JOURNAL MSMA 273

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