September 2015 JMSMA by Journal MSMA

VOL. LVI • NO. 9

Daniel P. Edney, MD

SEPTEMBER 2015

2015-16 MSMA President

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VOL. LVI • NO. 9 SEPTEMBER 2015

EDITOR Lucius M. Lampton, MD ASSOCIATE EDITORS D. Stanley Hartness, MD Richard D. deShazo, MD

THE ASSOCIATION President Daniel P. Edney, MD President-Elect Lee Voulters, MD

MANAGING EDITOR Karen A. Evers

Secretary-Treasurer Michael Mansour, MD

PUBLICATIONS COMMITTEE Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD and the Editors

Speaker Geri Lee Weiland, MD Vice Speaker Jeffrey A. Morris, MD Executive Director Charmain Kanosky

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.

SCIENTIFIC ARTICLES An Update on Sickle Cell Anemia in Children and Adolescents Dereck Davis, MD; Hafsat Mashegu, MD; Suvankar Majumdar, MD

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Top Ten Facts You Need to Know about Inpatient Glycemic Control 272 William B. Horton, MD and Jose S. Subauste, MD Clinical Problem-Solving Case: Hypophosphatemia 276 Masquerading as Meningitis L. Wesley Aldred, MD; Melanie McCauley, MD; Jason Pickett, MS; John O. Knight; and M. I. Ullah, MD, MPH PRESIDENT’S PAGE The Inaugural Address of the 148th President Daniel P. Edney, MD

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DEPARTMENTS From the Editor- Thanks to Dr. Jeff Terry for ICD-10 Delay 266 Lucius M. Lampton, MD MSMA Annual Session Recap 280 Personals 289 Una Voce- A Piller of the Community…A Love Story Dwaila S. South, MD

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EDITORIAL What’s Your Opinion, Doctor? Ballot Initiative 42 MSMA Board of Trustees, Tim Alford, MD and Randy Easterling, MD

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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 © 2015 Mississippi State Medical Association.

ABOUT THE COVER – DANIEL P. EDNEY, MSMA PRESIDENT 2015-16

Vicksburg physician Daniel P. Edney MD, an internist with Medical Associates of Vicksburg , was inaugurated on August 14, 2015, as the 148th president of the MSMA during a gala held at the Jackson Hilton. An expert in medical readiness for international disasters, Dr. Edney thanked his fellow physicians for their faithful service to Mississippians in his inaugural address. Photo by Rhett Visuals. VOL. LVI • NO. 9

Daniel P. Edney, MD

Official Publication

MSMA • Since 1959

SEPTEMBER 2015 • JOURNAL MSMA

SEPTEMBER 2015

2015-16 MSMA President

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F R O M

T H E

E D I T O R

Thanks to Dr. Jeff Terry for ICD-10 Delay

labama’s longtime AMA delegation chair, urologist Dr. W. Jeff Terry of Mobile, early perceived the coming disaster of ICD-10 as a malignant and senseless government crime which would steal sacred time from the physician/ patient relationship. Reminding me of Peter Finch’s “mad as hell” speech in the 1976 film Network, Jeff once vented, “How are physicians going to take care of patients anymore? There is no more time left in the day after my 12 hours of patient care and 2-3 hours of meaningful use documentation after hours. I just can’t do all of this government crap any longer!” I shared his concerns and one fall afternoon in 2011 offered to help him compose a resolution for our AMA entitled “Stop the Implementation of ICD-10.” We began writing the resolution during a televised Alabama football game and emailed it back and forth between the plays, finalizing it by halftime! I am not sure if the fire of the football game inspired its spirit, but Alabama and Mississippi’s AMA resolution became the most talked about at the Interim Meeting

in New Orleans that year. That resolution first stopped, then delayed the implementation of ICD-10 at a national level for several successive Octobers. After its passage, Jeff emerged as the national voice for physician opposition to ICD-10. He carried the fight not only to the floor of our AMA but also to the halls of Congress. At this year’s AMA meeting, he led the Southeastern states in their successful efforts to try to establish an ICD-10 grace period, during which physicians would not be penalized for errors, mistakes, and malfunctions of the system. By July 6, our AMA got CMS to agree to a one-year grace period in which “Medicare claims will not be denied or audited solely on the exact ICD-10 diagnosis codes provided.” Sadly, Jeff died unexpectedly on August 7, 2015. Without Jeff ’s crusade, would America’s physicians have been given a delay and then a grace period with ICD-10? If not for Jeff, the sky would now be falling on the heads of America’s physicians. Dear Dr. Jeff Terry showed that one physician can make a difference! Contact me at LukeLampton@cableone.net. —Lucius M. Lampton, MD, Editor

JOURNAL EDITORIAL ADVISORY BOARD Timothy J. Alford, MD Family Physician, Kosciusko Medical Clinic

Bradford J. Dye, III, MD Ear Nose & Throat Consultants, Oxford

Michael Artigues, MD Pediatrician, McComb Children’s Clinic

Daniel P. Edney, MD Executive Committee Member, National Disaster Life Support Education Consortium, Internist, The Street Clinic, Vicksburg

Diane K. Beebe, MD Professor and Chair, Department of Family Medicine, 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 Thomas E. Dobbs, MD, MPH State Epidemiologist, Mississippi State Department of Health, Hattiesburg Sharon Douglas, MD Professor of Medicine and Associate Dean for VA Education, University of Mississippi School of Medicine, Associate Chief of Staff for Education and Ethics, G.V. Montgomery VA Medical Center, Jackson

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Brett C. Lampton, MD Internist/Hospitalist, Baptist Memorial Hospital, Oxford Philip L. Levin, MD President, Gulf Coast Writers Association Emergency Medicine Physician, Gulfport

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

William Lineaweaver, MD Editor, Annals of Plastic Surgery Medical Director, JMS Burn and Reconstruction Center, Brandon

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

Michael D. Maples, MD Vice President and Chief of Medical Operations, Baptist Health Systems

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

SEPTEMBER 2015 • JOURNAL MSMA

Alan R. Moore, MD Clinical Neurophysiologist, Muscle and Nerve, Jackson Paul “Hal” Moore Jr., MD Radiologist, Singing River Radiology Group, Pascagoula Jason G. Murphy, MD Surgeon, Surgical Clinic Associates, 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 Sloan C. Youngblood, MD Assistant Medical Director, Department of Anesthesiology, University of Mississippi Medical Center, Jackson

Got Questions MACM Risk Management has answers.

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S C I E N T I F I C

A R T I C L E S

An Update on Sickle Cell Anemia in Children and Adolescents DERECK DAVIS, MD; HAFSAT MASHEGU, MD; AND SUVANKAR MAJUMDAR, MD Introduction Sickle cell disease offers an elegant example of an autosomal recessive condition that occurs simply from a single base mutation in the globin gene of the hemoglobin molecule and yet is perplexing due to the marked phenotypic variability in clinical symptoms between individuals who harbor the same genetic mutation. Some may suffer from recurrent episodes of pain requiring multiple hospitalization sand ER visits, while others may have few clinical symptoms during their lifetime. Indeed, sickle cell disease is considered a chronic illness that is associated with varied multi-organ involvement with increased risk of morbidity and early mortality; even recent medical literature shows a meager median life expectancy of about 45 years.1 Sickle cell disease has a rich history that has afforded much to the field of medicine. It was first described in 1910 by Chicago-based cardiologist James Herrick after his astute medical intern noticed “peculiar elongated and sickle shaped” cells under the microscope. In 1949, the Oregon- born Nobel Prize winning chemist Linus Pauling found that sickle cell disease resulted from abnormal hemoglobin. Subsequently in 1965, Vernon Ingram showed that the condition occurred from a single base substitution, valine for glutamic amino acid at position 6 of the β globin gene of the hemoglobin molecule, thus making it the first known “molecular disease” in the history of modern medicine. The homozygous form of the condition (HbSS) occurs in 1 in every 400 African-American live births. Compound heterozygotes may occur with hemoglobin C (HbSC), or thalassemia (HbS-thalassemia) and other rarer types that lead to different phenotypes of the condition. Generally speaking, HbSS and HbSβ⁰ thalassemia are more severe forms of SCD while HbSC and HbSβ+ thalassemia are milder forms of the disease. However, collectively, these disorders are referred to as sickle cell disease (SCD), and the clinical hallmark is acutely painful events and chronic organ damage resulting from microcirculatory vaso-occlusion. Diagnosis Sickle cell disease is diagnosed via newborn screening, allowing early referral to the pediatric hematologist for education and initiation of penicillin prophylaxis and scheduled immunizations for prevention of disease complications and mortality (table 1). At about 1 year of age, 268

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confirmatory testing is performed by high performance liquid chromatography (HPLC) to determine the genotype of sickle cell disease (table 2). TABLE 1: RECOMMENDED IMMUNIZATION SCHEDULE for children and adults with sickle cell disease (trade names used for convenience to the reader) Table_1_AP.pdf

Age 2 months

9/11/15

3:07 PM

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Immunization Pentacel, Menveo, Hep B, Prevnar 13, Rotarix OR Pediarix, MenHiBrix, Prevnar 13, Rotarix

4 months

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Pentacel, Menveo, Hep B,* Prevnar 13, Rotarix OR Pediarix, MenHiBrix, Prevnar 13, Rotarix

6 months

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Pentacel, Menveo, Hep B, Prevnar 13 OR Pediarix, MenHiBrix, Prevnar 13 MMR, Varicella, Hep A, Prevnar 13

15 months

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Pentacel, Menveo OR DTAP, MenHiBrix

18 months 2 years (24 months)

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26 months 4 - 6years

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Hep A (second dose) **Pneumovax, Menactra (if has not received Meningococcal series as above) Menactra (second dose) Kinrix, ProQuad

5 years >11 years

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12 months

•

>19 years

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**Pneumovax TdaP, HPV9 (3 dose series given at 1, 1-2 and 6 months) Menactra (First booster 3 y after primary series for children who received primary series before age <7 y, then every 5 y OR every 5 y for children who received primary series after 7th birthday Prevnar 13 Prevnar 13 followed by Pneumovax > 8 weeks later (if has not previously received prior pneumococcal vaccination)

*4 month Hep B not needed if received at birth; **Pneumovax (PPSV23) = 23 valent serotype for pneumococcus – typically given at specialty sickle cell clinic; Pediarix = DTAaP, IPV, Hepatitis B; MenHiBrix = meningococcal conjugate, Hemophilus influenzae type b; MMR= measles, mumps, rubella; Prevnar 13 (PCV13) = 13 valent serotype for pneumococcus; Pentacel = DTaP, IPV, Hib; Menveo = Meningococcal conjugate, Diphtheria; Menactra = Meningococcal conjugate, Diphtheria; Kinrix = DTaP, IPV; ProQuad = MMR, Varicella Complications The protean clinical feature of sickle cell disease is pain. Although a physician is expected to objectively treat the patients’ subjective pain, individuals with recurrent acute pain, acute-on-chronic pain and

TABLE 2: Typical laboratory finding in sickle cell disease based on newborn screen and HPLC at ≥1 year of age Newborn Hemoglobin Sickle Cell Genotype (%) based on HPLC screen Sickle Cell Disease SS

Sβ0FS thalassemia + Sβ FSA or FS thalassemia SC FSC

HbS

HbA

HbA2

HbF

HbC

6-9

<3.5

<10

7-9

>80

>3.5

<20

9-12

>60

10-30

>3.5

<20

9-14

<3.5

≤1

chronic pain are inevitably subject to the treating physicians’ unconscious bias as to whether she/he is a “substance abuser or drugseeker,” a sore topic that is often compounded by socio-politicodemographics. While undoubtedly there will be the substance abusers, the medical literature, however, consistently shows that the prevalence of substance abuse in the sickle cell disease population is not higher than the general population2-5 and illuminatingly similar to other resemblant chronic illnesses characterized by pain such as rheumatoid arthritis, fibromyalgia, etc. Screening for organ complications in sickle cell disease A brief review of the main organ complications associated with sickle cell disease is discussed below with suggested screening investigative tests (table 3) typically performed at specialty clinics. Suggested laboratory and radiologicallaboratory tests for the children and adults with sickle cell disease: TABLE 3: Suggested and radiological tests for the children and adults with sickle cell disease: Tests

Genotype of SCD

Frequency

Comments

CBC with diﬀ.

All types*

Mainly to evaluate degree of anemia

Reticulocyte count

All types*

Lactate dehydrogenase (LDH)

All types*

Every 6 months to yearly¶ Every 6 months to yearly¶ Every 6 months to yearly

Liver function test

All types*

Yearly

Indirect hyperbilirubinemia occurs from hemolysis. The presence of direct hyperbilirubinemia may indicate the presence of gallstones.

Indicates how well the bone marrow is compensating for the anemia Indicates the severity of hemolysis – a good predictor of disease severity

Ferritin

All types*

Every 6 months yearly

Evaluates for iron overload from repeated red blood cell transfusions. Patient may need iron chelation treatment.

Urinalysis

All types*

Yearly from 10 years

Transcranial Doppler Ultrasound

Yearly from 2 to HbSS, 16 years. HbSβ ⁰thalassemia

Evaluate mainly for proteinuria that may indicate the presence of nephropathy To evaluate risk for stroke

Echocardiogram

All types*

As needed

Brain MRI/MRA

All types*

As needed

Neurocognitive testing

All types*

As needed

Eye exam

All types*

Yearly from ≥ 10 years

Indicated if respiratory/cardiac symptoms presentmainly to evaluate for pulmonary artery hypertension To evaluate for silent infarcts, acute stroke or intracranial vasculopathy Neurocognitive delays can be secondary to silent stroke, and child needs IEP for school To evaluate for retinopathy

*All types refer to the most common genotypes of SCD seen in the United States i.e.*AllHbSS, andin the HbSβ+thalassemia. types referHbSC, to the mostHbSβ⁰thalassemia common genotypes of SCD seen United States i.e. HbSS, HbSC, HbSβ ⁰thalassemia and HbSβ+thalassemia. IEP: Individualized Education Plan IEP: Individualized Education Plan Every 3 months if on hydroxyurea ¶Every 3 months if on hydroxyurea ¶

Neurologic complications: Cerebrovascular disease is a devastating complication in SCD that may occur as acute ischemic stroke or silent cerebral infarction (a.k.a silent infarcts). Acute ischemic stroke is

characterized by the acute onset of neurologic deficits while silent infarcts are characterized by a normal physical examination but MRI changes consistent with small vessel disease (lacunar infarction). Screening with Transcranial Doppler ultrasound (TCD) scan, a noninvasive radiological test that measures blood flow velocity in the large intracranial vessels, has been an instrumental measure that has decreased the incidence of overt stroke by 10 fold; as a result, all children ages 2 to 16 years with HbSS and HbSβ⁰ thalassemia should receive TCD screening yearly. All patients with overt stroke are subsequently placed on lifelong red blood cell transfusion to decrease the risk of recurrent stroke. Silent strokes affect about 1/3 of children with HbSS and HbSβ⁰ thalassemia by their 14th birthday.6 Silent cerebral infarction is associated with intellectual difficulties, poor school performance and academic achievement, and risk for further silent cerebral infarction and progression to overt stroke. Currently, there are no official recommended screening tests for silent stroke in SCD, but any history of neurocognitive difficulties such as poor school performance should prompt one to evaluate for any MRI changes in the brain, as they may deceivingly appear to be doing well clinically. Renal disease: Renal disease is one of the most common causes of mortality in adults with sickle cell disease. It occurs primarily due to sickling of red blood cells and vaso-occlusion in the vasa-recta capillaries in the medulla. In a prospective 25 year observational study that evaluated 725 patients with HbSS, Powars et al. showed that the survival time for patients with HbSS after the diagnosis of renal failure, despite dialysis, was 4 years, and the median age at the time of death was 27 years. Proteinuria is a common feature in SCD and can progress to nephrotic syndrome characterized by proteinuria, edema, and hyperlipidemia. All adolescents with SCD especially carrying the HbSS/HbSβº thalassemia genotypes need to be screened yearly with a urine dipstick for proteinuria so that the necessary referral can be made to a nephrologist for further testing and treatment. Pulmonary artery hypertension: In the recent years, pulmonary artery hypertension (PAH) has been found to be one of the most serious complications in SCD that is associated with high mortality. PAH is thought to be present in about 6 to 10% of the adult sickle cell population. PAH can be associated with symptoms of fatigue, syncope, and increasing shortness of breath especially with exertion. And, while screening echocardiograms are not routinely performed, they should certainly be evaluated in patients who present with any of the above symptoms that may warrant a referral to a cardiologist for further treatment. Sickle cell retinopathy: Eye complications include iris atrophy, abnormalities of the choroid, macula and optic disc, and retinopathy, which may occur in up to 50% of individuals with SCD and are particularly more prevalent in the HbSS and HbSC genotypes. The single most important predictor of blindness is the presence of proliferative retinopathy. Proliferative retinopathy occurs from vasoocclusion of the small vessels of the retina, and similar to diabetic retinopathy, is classified into 5 stages: stage I is defined by the presence of peripheral arteriolar occlusion; stage II by the presence of

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arteriovenous anastomosis; stage III by the presence of neovascularization and sea fan formation (i.e. new vessels having the characteristic “fan” shape of the marine mollusk); stage IV by the presence of vitreous hemorrhage; and stage V as retinal detachment. Children and adults with SCD are usually asymptomatic and may go undetected until the devastating complication of vitreous hemorrhage or blindness occurs. Hence, a dilated retinal examination by an ophthalmologist is recommended every year from ≥10 years old. Treatment Hydroxyurea use in Sickle Cell Disease Although general measures of staying well-hydrated, warm during the winter months, avoidance of caffeine-containing products and excessive exercise are important in preventing pain crises, hydroxyurea and (prophylactic) blood transfusions are the two main treatment options. Nonetheless, blood transfusions carry the burden of obtaining compatible blood, risk for allo-immunization (antibody formation), transfusion related iron overload (which likely significantly contributes to overall mortality), and an overall economic impact of increased cost. Thus, a lot of emphasis has been placed on the only other alternative: hydroxyurea. Hydroxyurea is considered a chemotherapy that acts by DNA methylation. Initially and understandably so, there was an aversion to hydroxyurea use not only among patients but also among providers, but now with over 30 years and 20 years of experience in both adults and children respectively with no increased risk of malignancy, hydroxyurea is more commonly prescribed. Indeed, the recent National Heart Lung Blood guidelines (http://www.nhlbi.nih.gov/ sites/www.nhlbi.nih.gov/files/sickle-cell-disease-report.pdf ) recommend that essentially all adult patients with HbSS and HbSβ⁰ thalassemia should be prescribed hydroxyurea, and children from 9 months of age can be offered the medication. This is based on data from the Adult Multicenter Trial of Sickle Cell Anemia (MSH trial) which showed that hydroxyurea significantly decreased the time to first sickle cell pain crises, the frequency of pain crises requiring ER visits/hospitalizations frequency of acute chest syndrome, and reduced the need for blood transfusion. Moreover, the BabyHUG multicenter trial initiated at the University of Mississippi Medical Center (UMMC) under the auspices of Rathi Iyer MD (ret. pediatric hematologist-oncologist), found results that mirrored the adult population. Although medication adherence can be at times problematic with possible side effects of fatigue, nausea, abdominal pain, and general poor adherence inherent to individuals with a chronic illness, it is the authors’ personal experience that hydroxyurea adherence is much improved if commenced at an earlier age. The overall philosophy behind treatment with hydroxyurea is to achieve adequate myelosuppression to increase hemoglobin F production and hence diminish the rate of hemoglobin S production. A schema for hydroxyurea administration with dose escalation to maximum tolerated dose is shown in Table 4.8 Both males and females of reproductive age should be counseled regarding the need for contraception while taking hydroxyurea. It is also important to note

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that patients may not reap the full benefits of hydroxyurea until about 6 months of therapy. TABLE 4: Guideline for monitoring hydroxyurea therapy in children and adults

• Baseline CBC w/diff., reticulocyte count, renal and liver

function test • Start hydroxyurea at 500 mg po daily for adults • Start hydroxyurea at 15 – 20 mg/kg/day in children* • Check CBC w/diff. and reticulocyte count in 4 weeks • Increase hydroxyurea dose by about 5 mg/kg every 8 weeks • CBC w/diff. and reticulocyte count every 4 weeks with dose adjustments • Titrate to maximum tolerated dose (MTD) to: ° Absolute neutrophil count (ANC) of about 2000 OR ° 35 mg/kg/day • Check CBC w/ diff. and reticulocyte count every 2 to 3 months when at MTD • Hold hydroxyurea if patient develops myelotoxicity: ° Absolute neutrophil count < 1000 OR ° Absolute reticulocyte count < 80,000 OR ° Platelet count < 80,000 /µL ° Check CBC w/diff., reticulocyte count weekly and restart hydroxyurea reduced by 5 mg/kg and titrate again to MTD

*Liquid formulation (100mg/ml concentration) available at select pharmacies; CBC w/diff: complete blood count with differential; ANC: absolute neutrophil count; MTD: maximum tolerated dose Conclusions and Discussion Since the discovery of sickle cell disease over 100 years ago, dismally there is only one FDA approved drug, hydroxycarbamide (more commonly known as “hydroxyurea”) as a disease-modifying drug. This blunted progress is partly explicable by the previous lack of a more in-depth understanding of the underlying disease pathophysiology; traditionally, a rather banausic explanation has held that rigid sickle cell red blood cells clog the microcirculation leading to deprivation of downstream oxygen and cell death associated with infarction and pain. However, over the last two to three decades, it has come to light that vaso-occlusion is, in fact, a highly complex phenomenon with compelling evidence that a multitude of other factors play an important role including activation of platelets and prothrombotic markers, endothelial activation allowing rolling and attachment of red blood cells to the blood vessel wall, perturbations of the nitric oxide (NO) and arginine pathway from hemolysis, along with a pro-inflammatory milieu. As a consequence, a better understanding of the diseases pathophysiology has given rise to the possibility of new drugs that are currently being tested for this chronic and debilitating condition. Future Directions To name but a few, L-glutamate, an amino acid, reduces oxidative potential from red blood cell damage, and recent results from a randomized control phase 3 study showed that prescription grade L-glutamine was well tolerated and significantly decreased the incidence of sickle cell pain crises, hospitalizations from pain crises,

and incidence of acute chest syndrome compared to the placebo group. Currently, a phase 3 randomized controlled study of prasugrel, an inhibitor of platelet activation and aggregation, and a phase 2 study of SE1G1, another inhibitor of platelet activation given intravenously at spaced time intervals, are underway to evaluate whether these drugs will modulate the primary outcome of pain in sickle cell disease. For acute pain, ANX-188 (purified poloxamer), a substance that “lubricates” the blood and improves microvascular flow by lowering viscosity, is being studied to evaluate whether it will help in the treatment of acute pain and may eventually decrease or eliminate the need for intravenous opioids in the treatment of acute pain. Moreover, based on pediatric data,9 studies are underway at UMMC to evaluate the pharmacokinetic profile of intravenous (IV) citrulline, a powerful nitric oxide booster as a potential therapeutic option for treatment of a sickle cell pain crisis. And, while there is still some time to go for the much-promised gene therapy as a cure for sickle cell disease including other medical conditions, hematopoietic stem cell transplant is currently the only curative treatment option with cure rates of approximately 90% but has been generally poorly adopted due to the need of securing compatible donors, risk of morbidity from graftversus-host-disease, etc. Research is in progress in the so-called “haploidentical donors,” i.e. stem cells derived from first-degree relatives which has the potential to eliminate the headache of finding viable donors, and may mitigate some of the transplant-related complications. In summary, with better application of drugs that can target the various pathways involved in vaso-occlusion, these are exciting times for sickle cell disease that holds promise for newer therapies, in which health care providers will hopefully have a cocktail of drugs from which to choose in the management of this terrible yet fascinating condition.

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Acknowledgment We would like to thank Dr. Sandor Feldman, MD for his invaluable input in drafting the appropriate immunization schedule. References 1. Hamideh D, Alvarez O. Sickle cell disease related mortality in the United States (1999-2009). Pediatr Blood Cancer 2013;60:1482-1486. 2. Solomon LR. Pain management in adults with sickle cell disease in a medical center emergency department. J Natl Med Assoc 2010;102:1025-1032. 3. Yale SH, Nagib N, Guthrie T. Approach to the vaso-occlusive crisis in adults with sickle cell disease. Am Fam Physician 2000;61:1349-4. 4. Smith WR, Penberthy LT, Bovbjerg VE et al. Daily assessment of pain in adults with sickle cell disease. Ann Intern Med 2008;148:94-101. 5. Shapiro BS, Benjamin LJ, Payne R, Heidrich G. Sickle cell-related pain: perceptions of medical practitioners. J Pain Symptom Manage 1997;14:168-174. 6. DeBaun MR, Armstrong FD, McKinstry RC, Ware RE, Vichinsky E, Kirkham FJ. Silent cerebral infarcts: a review on a prevalent and progressive cause of neurologic injury in sickle cell anemia. Blood 2012;119:4587-4596. 7. Powars DR, Elliott-Mills DD, Chan L et al. Chronic renal failure in sickle cell disease: risk factors, clinical course, and mortality. Ann Intern Med 1991;115:614-620. 8. Yawn BP, Buchanan GR, Afenyi-Annan AN et al. Management of sickle cell disease: summary of the 2014 evidence-based report by expert panel members. JAMA 2014;312:1033-1048. 9.

Barr FE, Tirona RG, Taylor MB et al. Pharmacokinetic and safety of intravenous citrulline in children undergoing congenital heart surgery: potential therapy for postoperative pulmonary hypertension. J Thorac Cardiovasc Surg. 2007 134(2):319-326.

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Top Ten Facts You Need to Know About Inpatient Glycemic Control William B. Horton, MD and Jose S. Subauste, MD Introduction Uncontrolled hyperglycemia in hospitalized patients with or without a previous diagnosis of diabetes is associated with adverse outcomes and longer lengths of hospital stay.1 It is estimated that one-third of hospitalized patients will experience significant hyperglycemia,2 and the cost associated with hospitalization for patients with diabetes accounts for half of all healthcare expenditures for this disease.3 Many patients without preexisting diabetes will also experience stress-related hyperglycemia while hospitalized.4 Optimizing glycemic control should be a priority for all healthcare providers in the inpatient setting.

Consensus guidelines exist for the management of inpatient hyperglycemia. The American Diabetes Association and the American Association of Clinical Endocrinologists released a consensus statement on inpatient glycemic control in 2009.5 These guidelines note that insulin therapy is the preferred method for achieving inpatient glycemic control. In the ICU, IV infusion is the preferred route of insulin administration. Outside of critical care units, scheduled subcutaneous administration of insulin consisting of basal, nutritional, and supplemental (correction) components is preferred.1,5

Glycemic targets vary by patient population. In critically ill patients on IV insulin therapy, the blood glucose (BG) level should be maintained between 140 and 180 mg/dL. Targets less than 110 mg/dL are not recommended for this patient population. For noncritically ill patients treated with subcutaneous insulin, premeal glucose targets should generally be < 140 mg/dL in conjunction with random glucose targets < 180 mg/dL, as long as these targets can be safely achieved. Higher glucose ranges may be acceptable in terminally ill patients or patients with severe comorbidities. Consideration should be given to reassessing the insulin regimen if BG levels are consistently < 100 mg/dL for avoidance of hypoglycemia.5 Table 1. 1: Duration and onset of action by insulin type.by insulin type. TABLE Duration and onset ofcharacteristics action characteristics Insulin Type

Onset of action

Peak of action

Duration of action

Regular

15 – 60 min

2–4h

6–8h

Lispro

10 – 15 min

3-4h

Aspart

10 – 15 min

3-4h

Glulisine

10 – 15 min

3-4h

MEALTIME INSULINS

BASAL INSULINS NPH

1–3h

6–8h

12 – 16 h

Glargine

1–3h

No peak

Up to 24 h

Detemir

1–3h

No peak

Up to 24 h

Plasma Insulin Level

FIGURE 1: Insulin Insulincharacteristics characteristics by duration onset of action. Figure 1. by duration and onsetand of action.

Regular NPH Detemir Glargine

Time (hours)

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Inpatient hyperglycemia is best managed with insulin. Typically, oral agents have a limited role in the inpatient setting and should be discontinued during acute illness unless it is a very brief hospitalization.1,5 Metformin cannot be used when there is any possibility of the need for iodinated contrast studies or renal insufficiency.1 Sulfonylureas and metaglinides can cause unpredictable hypoglycemia in patients who are not eating consistently.1 Thiazolidinediones cause fluid retention (especially in combination with insulin), and parenteral glucagon-like peptide-1 and amylin agonists can cause nausea and should be withheld in acutely ill patients.1 Insulin works reliably and can be quickly titrated based on changes in diet or glucose levels, making it ideal in the inpatient setting. Table 1 and Figure 1 detail the onset and duration of action characteristics by insulin type. Aspart, Lispro, Glulisine

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Hypoglycemia should be prevented. Hypoglycemia (both spontaneous and iatrogenic) has been associated with higher risk of complications among hospitalized patients, including longer and more expensive hospital stays and increased mortality rates.6-8

Hospitalized patients who are elderly or severely ill are especially vulnerable to the adverse effects of hypoglycemia.6 Hypoglycemia is defined as any BG < 70 mg/dL.9 For avoidance of hypoglycemia, consideration should be given to reassessing the insulin regimen if BG < 100 mg/ dL are consistently noted. Modification of the regimen is necessary when BG values are < 70 mg/dL, unless the event is easily explained by other factors such as a missed meal.5 It is also important to avoid routine use of correctional insulin doses at bedtime so as to prevent nocturnal hypoglycemia.5

Glycemic monitoring varies by dietary needs. Bedside capillary point of care (POC) testing is the preferred method for guiding ongoing glycemic management.10 Recommendations include POC testing before meals and at bedtime in patients who are eating usual meals.5,10 POC testing should be performed every 4-6 hours in patients who are NPO or receiving continuous enteral or parenteral nutrition.5,10 More frequent POC testing, ranging from every 30 minutes to every 2 hours, is required for patients receiving IV insulin infusions.5

Treatment of inpatient hyperglycemia is cost-effective. In the Portland Diabetic Project, institution of continuous IV insulin therapy to achieve predetermined target BG values in diabetic patients undergoing open-heart surgical procedures reduced the incidence of deep sternal wound infections by 66%, resulting in a total net savings to the hospital of $4,638 per patient.11 In another study, intensive glycemic control in 1,600 patients treated in a medical ICU was associated with a total cost savings of $1,580 per patient.12 Optimization of inpatient glycemic management is not only effective in reducing morbidity and mortality but also is cost-effective.5

Transitioning from inpatient to outpatient glycemic management is important. Hospitalization provides a unique opportunity for addressing a patient’s education in diabetes management.2 Preparation for transition to the outpatient setting is an important goal of inpatient diabetes management and begins with hospital admission.5 Successful coordination of this transition requires a team approach that includes physicians, nurses, dietitians, case managers, and social workers.13 An outpatient follow-up visit with the primary care provider, endocrinologist, or diabetes educator within 1 month after discharge from the hospital is advised for all patients experiencing hyperglycemia while hospitalized.13

Clinicians should be aware of management for special clinical situations. Patients who utilize continuous insulin infusion (pump) therapy in the outpatient setting can be considered for diabetes selfmanagement while hospitalized, provided they have the mental and physical capacity to do so.5,13-15 It should be noted that nursing personnel must document basal rates and bolus doses (at least daily) if this occurs.5 Persistent hyperglycemia in patients receiving enteral nutrition should be treated with scheduled insulin doses.1 Once-daily glargine insulin, premixed human 70/30 insulin given every 8 hours, or a combination of NPH insulin given every 12 hours and regular insulin given every 6 hours have all been recommended.1,13,16,17 Patients receiving glucocorticoids should be treated with scheduled basal/bolus regimens and will likely require an increase in bolus doses while on glucocorticoid therapy.1 During glucocorticoid tapers, insulin dosing should be proactively adjusted to avoid hypoglycemia.5

Sliding scale insulin alone is insufficient treatment for sustained hyperglycemia. Scheduled basal/bolus insulin regimens mimic normal pancreas hormonal physiology and are designed to prevent hyperglycemia, whereas sliding scale insulin (SSI) alone only attempts to lower hyperglycemia after it has occurred.1 A study comparing scheduled basal/bolus insulin to SSI alone showed a significantly higher percentage of patients achieving goal glucose levels in the basal/bolus group than in the SSI group (66% vs. 38%) without an increase in hypoglycemia.18

Insulin naïve patients can safely initiate treatment by calculating total daily dose. For patients who are insulin naïve, insulin therapy can safely be initiated at a total daily dose (TDD) of 0.3-0.6 units/kg body weight.19,20 The lower starting dose is recommended for leaner patients and those with renal insufficiency, while the higher starting dose is recommended for obese patients and those on glucocorticoids.1 50% of the calculated TDD should be given as a basal component, and the remaining 50% should be split into thirds and given preprandially as the bolus component.19,20 Author Information: Internal Medicine PGY2 University of Mississippi Medical Center (Dr. Horton). Clinical Professor of Internal Medicine and Endocrinology at the G.V. “Sonny” Montgomery VA Medical Center and the University of Mississippi Medical Center (Dr. Subauste). Corresponding Author: William B. Horton, MD; 2500 North State St.; Jackson, MS 39216 (wbhorton@umc.edu).

References 1. Magaji V, Johnston JM. Inpatient management of hyperglycemia and diabetes. Clinical Diabetes 2011;29(1):3-9. 2. Levetan CS, Passaro M, Jablonski K, Kass M, Ratner RE. Unrecognized diabetes among hospitalized patients. Diabetes Care 1998;21(2):246249. 3. American Diabetes Association. Economic costs of diabetes in the US in

2007. Diabetes Care 2008;31(3):596-615. 4. Centers for Disease Control and Prevention. Crude and age-adjusted percentage of civilian, noninstitutionalized population with diagnosed diabetes, United States, 1980-2011 [article online]. Available from http://www.cdc.gov/diabetes/statistics/us/index.htm. Accessed August 2014.

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5. Moghissi ES, Korytkowski MT, Dinardo M, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Endocr Pract 2009;15(4):353-369.

14. Cook CB, Boyle ME, Cisar NS, et al. Use of continuous subcutaneous insulin infusion (insulin pump) therapy in the hospital setting: proposed guidelines and outcome measures. Diabetes Educ 2005;31(6):849-857.

6. Boucai L, Southern WN, Zonszein J. Hypoglycemia-associated mortality is not drug-associated but linked to comorbidities. Am J Med 2011;124(11):1028-1035.

15. Bailon RM, Partlow BJ, Miller-Cage V, et al. Continuous subcutaneous insulin infusion (insulin pump) therapy can be safely used in the hospital in select patients. Endocr Pract 2009; 15(1):24-29.

7. Garg R, Hurwitz S, Turchin A, Trivedi A. Hypoglycemia, with or without insulin therapy, is associated with increased mortality among hospitalized patients. Diabetes Care 2013;36(5): 1107-1110. 8. Turchin A, Matheny ME, Shubina M, et al. Hypoglycemia and clinical outcomes in patients with diabetes hospitalized in the general ward. Diabetes Care 2009;32(7): 1153-1157. 9. Cryer PE, Davis SN, Shamoon H. Hypoglycemia in diabetes. Diabetes Care 2003;26(6): 1902-1912. 10. Umpierrez GE, Hellman R, Korytkowski MT, et al. Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline. J Clin Endocrinol Metab 2012;97(1):16-38. 11. Furnary AP, Wu Y, Bookin SO. Effect of hyperglycemia and continuous intravenous insulin infusions on outcomes of cardiac surgical procedures: the Portland Diabetic Project. Endocr Pract 2004;10(Suppl 2):21-33. 12. Krinsley JS, Jones RL. Cost analysis of intensive glycemic control in critically ill adult patients. Chest 2006;129(3):644-650.

16. Korytkowski MT, Salata RJ, Koerbel GL, et al. Insulin therapy and glycemic control in hospitalized patients with diabetes during enteral nutrition therapy: a randomized controlled clinical trial. Diabetes Care 2009;32(4):594-596. 17. Leahy JL. Insulin management of diabetic patients on general medical and surgical floors. Endocr Pract 2006;12(Suppl 3):86-90. 18. Umpierrez GE, Smiley D, Zisman A, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial). Diabetes Care 2007;30(9):2181-2186. 19. Schnipper JL, Ndumele CD, Liang CL, Pendergrass ML. Effects of a subcutaneous insulin protocol, clinical education, and computerized order set on the quality of inpatient management of hyperglycemia: results of a clinical trial. J Hosp Med 2009;4(1):16-27. 20. Maynard G, Lee J, Phillips G, et al. Improved inpatient use of basal insulin, reduced hypoglycemia,andimprovedglycemiccontrol:effectofstructuredsubcutaneousinsulin orders and an insulin management algorithm. J Hosp Med 2009;4(1):3-15.

13. Clement S, Braithwaite SS, Magee MF, et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care 2004;27(2):553-591.

CELEBRATING WOMEN IN MEDICINE In September, we honor the female physicians who make up twenty five percent of our membership. Women hold eighteen percent of MSMA’s elected leadership positions. Yes ma’am to that!

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Pen > Sword

Medley & Brown

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

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P R O B L E M - S O L V I N G

C A S E

Hypophosphatemia Masquerading as Meningitis L. WESLEY ALDRED, MD; MELANIE MCCAULEY, MD; JASON PICKETT, MS; JOHN O. KNIGHT; AND M. I. ULLAH, MD, MPH

68-year-old white female with rheumatoid arthritis and osteoporosis presented to the emergency department after first responders found her unresponsive on the bathroom floor of her assisted-living facility. Initially, she was obtunded and unable to give any history. However, she was found to have a fentanyl patch in place, so emergency medicine physicians administered naloxone with some response. Once awake, she complained of headache, photophobia, and exhibited confusion. She was unable to answer standard orientation questions, and her only comprehendible statement was, “Pirates attacked my ship.” Her prescription bottles were reviewed at the bedside and were notable for fentanyl patches, alprazolam, and butalbital-aspirin-caffeine-codeine. Physical examination revealed a calm, thin white female lying on the stretcher with a cervical collar in place. She was afebrile with a respiratory rate of 22 breaths per minute, heart rate of 105 beats per minute, and blood pressure of 140/90 mmHg. She exhibited photophobia; however, the remainder of her examination, including a neurologic evaluation, was unremarkable. Assessment of neck rigidity was not possible because of the cervical collar; however, Kernig’s sign was negative. Patients who present with confusion can be quite the diagnostic dilemma, especially when no family members or medical records are present to compare their baseline mental status and functional capabilities. The initial differential diagnosis included infection, intracranial lesions, electrolyte abnormalities, and medication effects. The emergency medicine physicians worked quickly to narrow this differential. Investigative studies revealed a white blood cell (WBC) count of 21,400/mm3, and a urine drug screen positive for benzodiazepines, opiates, and barbiturates. Other blood chemical levels were as follows: acetaminophen <15 mcg/mL, salicylate <1 mg/dL, and alcohol <10 mg/dL. Her basic metabolic panel was remarkable for sodium of 130 mEq/L, potassium of 2.9 mEq/L, and calcium of 9.3 mg/dL Urinalysis was negative for WBC, leukocyte esterase, and bacteria. Chest x-ray (CXR) showed no acute infiltrates. Non-contrasted computed tomography (CT) of the

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head showed no acute intracranial abnormality. Lumbar puncture was attempted in the emergency department to obtain CSF but was unsuccessful. Given her elevated WBC count, tachycardia, and tachypnea, we were concerned for sepsis in this patient. Her CXR was negative for evidence of pneumonia, and her urinalysis was negative for evidence of urinary tract infection. With the patient meeting criteria for sepsis and exhibiting this degree of confusion, meningitis is very high on the differential. Her CT head showed no intracranial masses or acute hemorrhagic stroke. An acute ischemic event still remains in the differential since this cannot be ruled out with a non-contrasted CT head alone this early in the presentation, but she did not exhibit any focal neurologic deficits on physical exam. Her presentation was also clouded by the partial response to naloxone, which indicated that her multiple home medications were likely playing a role as well. She was mildly hyponatremic and hypokalemic on presentation, but neither of these findings would explain her degree of confusion. Given these results, we felt that meningitis was the most likely diagnosis. We admitted the patient for sepsis secondary to meningitis and started ceftriaxone, vancomycin, and ampicillin. On hospital day two, she had a brief episode of witnessed seizure-like activity which resolved with one dose of lorazepam. Although seizure activity is a known complication of meningitis, it is also a well-recognized complication of benzodiazepine withdrawal. This brought into question whether we had underestimated her home narcotic usage. We scheduled lorazepam to help prevent further withdrawal. On hospital day three the patient remained confused and developed vertical nystagmus, so we ordered a full electrolyte panel. This revealed a sharp decline in serum calcium to 7.7 mg/dL, serum magnesium of 1.6 mg/dL, and serum phosphorous of 0.6 mg/dL. Given these results, subsequent parathyroid hormone and 25-hydroxy vitamin D levels were drawn and found to be 278.3 pg/mL and 24.8 ng/mL, respectively. We aggressively replaced her electrolytes, and on hospital day

four her nystagmus and confusion resolved. Our initial concern for meningitis as the source of her constellation of symptoms abated. At that time her blood cultures returned negative for growth, she remained afebrile, and her WBC count trended

Table Table1.1:

Clinical Manifestations of Hypophosphatemia[6,7] Cardiovascular - Arrhythmias - Cardiomyopathy Respiratory - Failure to wean from the ventilator - Acute respiratory failure Muscular - Myopathy - Generalized weakness - Rhabdomyolysis Neurologic - Encephalopathy - Seizures - Coma - Peripheral Neuropathy Hematologic - Hemolytic anemia - Leukocyte dysfunction - Thrombocytopenia

Table Table2.2:

downward, so we discontinued all antibiotics. She continued to improve until discharge. On further chart review, we found that the patient had received an IV infusion of zoledronic acid for osteoporosis three days prior to admission. Looking back at our initial differential diagnosis, it was reasonable to suspect meningitis in a patient who had confusion and met diagnostic criteria for sepsis. It is unfortunate that we were not able to obtain cerebrospinal fluid because we could have ruled out meningitis earlier and started to pursue other diagnoses. Her initial response to naloxone was likely just a confounder, as she only had one fentanyl patch on her body, and most of her medication bottles were full. However, when she had her seizure on hospital day two it brought the issue back to the forefront, although this seizure was likely a result of her hypophoshatemia as well. The patient had received an infusion of zoledronate three days prior to admission as part of treatment for osteoporosis. She had a normal calcium level and renal function at the time of the infusion, and this was her second yearly bisphosphonate infusion. Bisphosphonates are inhibitors of osteoclastic bone resorption.1,2 This inhibition reduces calcium efflux from bone, which leads to a transient period of hypocalcemia.1,3,4 This hypocalcemia leads to a compensatory secondary hyperparathyroidism which serves to help maintain calcium levels, increasing phosphate lost in the urine.5 Also, the decreased osteoclastic activity directly leads to a decrease in serum phosphorus levels by decreasing the amount of phosphate released from the bone into the serum. These combined mechanisms can certainly lead to severe hypophosphatemia, as seen in our patient.

Causes of Hypophosphatemia[6] Reduced intestinal absorption - Aluminum and magnesium containing antacids, sucralfate - Post-gastrectomy - Small bowel diseases (e.g., Crohn’s disease, celiac sprue, bacterial overgrowth) - Pancreatic insufficiency Increased loss - Non-renal losses o Prolonged nasogastric suction o Vomiting o Chronic diarrhea - Renal losses o Fanconi’s syndrome o Hyperparathyroidism o Excess hormonal factors (e.g., estrogen, androgens, or corticosteroids) o Electrolyte and acid base disturbance (e.g., hypokalemia, hypomagnesemia, acidemia, and acute hypercapnea) Transcellular shifts - Respiratory alkalosis - Excess catecholamines, glucagon, and androgens - “Hungry bone syndrome”

Table 3. 3: Table

Situations in Which Patients are at Risk for Hypophosphatemia[6] Diabetic ketoacidosis Chronic alcoholism and alcohol withdrawal Nutritional repletion and hyperalimentation Recovery from burns

Most of the symptoms of hypophosphatemia are secondary to ATP depletion.6,7 In the myocardium, ATP depletion can impair the actin-myosin interaction, which leads to decreased contractility. Decreased contractility leads to decreased stroke volume, which can lead to a compensatory tachycardia.6

A known complication of hypophosphatemia in ventilated patients is difficulty in weaning from the ventilator. This is presumably caused by weakness of the respiratory muscles secondary to ATP depletion.6 Again, an impairment in the actin-myosin interaction leads to a decrease in strength of contraction, leading to decreased tidal volumes, which can lead to a compensatory tachypnea. Decreased levels of ATP can also decrease the rate of chemotaxis in polymorphonuclear leukocytes, which could have led to the leukocytosis seen in our patient.6 Furthermore, zoledronate itself has been shown to transiently increase serum concentrations of TNF-α and IL-6, which

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Table4.4: Table

Complications of IV Bisphosphonate Therapy[1] Acute phase reaction with fever, arthralgias, and myalgias Musculoskeletal pain Hypocalcemia with secondary hyperparathyroidism Ocular inflammation Osteonecrosis of the jaw may have also contributed to the leukocytosis.8 Given that tachycardia, tachypnea, and leukocytosis are diagnostic criteria for sepsis, this shows that the signs and symptoms of hypophosphatemia can mimic those of sepsis.

Hypophosphatemia has many neurologic manifestations as well. Again, ATP depletion can lead to a metabolic encephalopathy by impairing oxygen delivery to the brain.9 This can present with subtle symptoms such as irritability and paresthesia, or more debilitating symptoms such as generalized seizures and coma.9 Our patient demonstrated that the sequelae of hypophosphatemia can be severe and nonspecific, mimicking many other conditions. In cases such as this, it is important to avoid anchoring into a diagnosis early in the presentation. As the clinical picture changes, the differential diagnosis should be revisited and addressed accordingly. Clinicians should maintain a high index of suspicion for hypophosphatemia in patients who meet criteria for sepsis where the etiology of the systemic response is not readily found. Additionally we hope that cases like ours will reinforce the value of close follow up, including measurements of serum phosphorous, for patients receiving IV bisphosphonate therapy. Recognizing hypophosphatemia early in presentation can lead to appropriate repletion and prompt clinical improvement.

Key Words: Hypophosphatemia, Meningitis, Sepsis, Bisphosphonates References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Kennel K, Drake M. Adverse effects of bisphosphonates: implications for osteoporosis management. Mayo Clinic Proc. July 2009;8:632-638. Reszka AA, Rodan GA. Mechanism of action of bisphosphonates. Curr Osteoporos Rep. September 2003;1:45-52. Maalouf NM, Heller HJ, Odvina CV, Kim PJ, Sakhaee K. Bisphosphonate-induced hypocalcemia: report of 3 cases and review of literature. Endocr Pract. 2006;12:48-53. Rosen CJ, Brown S. Severe hypocalcemia after intravenous bisphosphonate therapy in occult vitamin D deficiency. N Engl J Med. 2003;348:1503-4. Liamis G, Milionis HJ, Elisaf M. Medication-induced hypophosphatemia: a review. QJM. 2010;103:449-59. Berkelhammer C, Bear RA. A clinical approach to common electrolyte problems: 3. hypoposphatemia. Can Med Assoc J. 1984;130:17-23. Subramanian R, Khardori R. Severe hypophosphatemia. Pathophysiologic implications, clinical presentations, and treatment. Medicine (Baltimore). 2000;79:1-8. Dicuonzo G, Vincenzi B, et al. Fever after zoledronic acid administration is due to increase in TNF-alpha and IL-6. J Interferon Cytokine Res. 2003; 23: 649-54. Shiber JR, Mattu A. Serum phosphate abnormalities in the emergency department. J Emerg Med. 2002; 23: 395-400. Silvis SE, DiBartolomeo AG, Aaker HM. Hypophosphatemia and neurological changes secondary to oral caloric intake: a variant of hyperalimentation syndrome. Am J Gastroenterol. 1980;73:215-222.

Author information: Drs. Aldred and McCauley are residents in the Department of Internal Medicine at the University of Mississippi Medical Center where Dr. Ullah is an associate professor of medicine. Messers. Pickett and Knight are medical students in the School of Medicine at the University of Mississippi Medical Center. Corresponding Author: L Wesley Aldred, MD; Department of Internal Medicine, University of Mississippi Medical Center, 2500 N State Street, Jackson, MS 39216. Email: ( laldred@umc.edu)

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Early detection saves lives. Help raise awareness of colon cancer screenings for an additional $31. All proceeds from the sale of this tag benefit Mississippi's 70x2020 Initiative to prevent colon cancer. For more information or order by phone, call 1-877-825-0068 For direct online ordering, visit www.umc.edu/70x2020cartag SEPTEMBER 2015 â&#x20AC;˘ JOURNAL MSMA

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M S M A

147th Annual Session Recap

Dr. Claude Brunson Receives MSMA’s Dr. James Grant Thompson Memorial Pin — During the closing session of the House of Delegates Claude Brunson (l.) of Jackson 2015-16 MSMA President Dr. Dan Edney and President-Elect Dr. Lee Voulters received the James Grant Thompson memorial past-president’s pin, given to acknowledge completion of his term as 2014-15 MSMA president. Dr. Daniel P. Edney, a Vicksburg internist, was installed as 2015-16 president of the association. Dr. Lee Voulters (r.), a Gulfport neurosurgeon, is president-elect.

Actions Taken by the MSMA House of Delegates

he Mississippi State Medical Association House of Delegates met August 13-14 at the Jackson Hilton. Actions taken on resolutions are listed below:

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Wellness

Maternal HIV Screening (Adopted) Recommends that MSMA express to its members and all other providers of prenatal care in Mississippi its endorsement of the USPSTF Grade A recommendation that clinicians screen all pregnant women for HIV, including those who present in labor and are untested and whose HIV status is unknown. WHO Goals to Reduce Mortality (Referred to Board of Trustees) MSMA will promote the adoption by all MS physicians of the international goals set by the World Health Organization and endorsed by the American College of Cardiology and the American Heart Association, to achieve a 25% reduction in premature mortality from NCDs by 2025. Support Specialty Car Tag for Colorectal Cancer Screening (Adopted) MSMA supports the 70x2020 Initiative, a statewide effort to raise awareness of colorectal cancer and the importance of recommended screenings. MSMA promotes the “get screened” specialty license plate, available for pre-order (see p. 279). Make Physician Wellness a Priority (Adopted) Seeks to support physicians by developing educational materials regarding stress-related illness, preventative health guidelines, and preventing burnout. It also recommends that MSMA identify ways to strengthen the Mississippi Professionals Health Program. SEPTEMBER 2015 • JOURNAL MSMA

Relationships • • •

• • •

William Carey University Collaboration (Adopted) Directs the Association to continue its collaborative efforts with the William Carey University College of Osteopathic Medicine to strengthen relationships and promote the training and retention of osteopathic physicians in Mississippi. UMMC Collaboration with Community Physicians (Adopted) MSMA will explore opportunities for collaboration and affiliation within teaching programs for community physicians with UMMC. Prescribing Guidelines (Referred to Board of Trustees) Physicians would benefit from easily accessible guidelines that address proper prescribing to empower more physicians to save the lives of Mississippians. This resolution directs MSMA to study proper prescribing guidelines for controlled medications and instructs MSMA to develop prescribing guidelines for Mississippi doctors by Mississippi doctors to preempt the legislature from imposing inappropriate prescribing guidelines. The Committee heard support for the resolution and referred it to the Board of Trustees which can emphasize strong collaboration with the Mississippi Board of Medical Licensure and other interested entities. MSMA Efforts to Improve Health Disparities (Adopted) Acknowledges the work of Dr. Claude Brunson and his efforts to increase the number of minority physicians and commemorate the growing diversity of MSMA’s membership by actively seeking to include all physicians in the state who are willing to join and maintain membership. Engaging Younger Members (Adopted with Title Change from Electronic Voting) Introduced to increase participation of younger physicians in the state, referred to the Board of Trustees to study ways to engage younger members in the association, including the voting process. Commend the Careers of Dr. Fred L. McMillan and Dr. James E. Keeton (Adopted) Introduced to commend Dr. McMillan for his service to Mississippi Physicians Care Network and the physicians of Mississippi and to commend Dr. Keeton upon his retirement from UMMC and express sincere appreciation for his service to physicians in Mississippi.

Medicaid • • •

Improve Access in Medicaid for Women’s Primary Care Services Funding to Lower Teen Pregnancy Establishment of a Medicaid Oversight Commission/ Board (Referred to Board of Trustees)

• • • • • •

Ongoing Opposition to Mandatory Maintenance of Certification (Referred to Board of Trustees) Oppose Ballot Initiative 42 (Referred to Board of Trustees, see p. 291 for position statement) Support Legislation to Adopt the SMBL Interstate Medical Licensure Compact. Rectify Loss of Physician Deferred Compensation (Referred to Board of Trustees) Eliminate Insurer-Imposed Barriers Used to Deny Medication and Treatments. Telemedicine as a Reimbursed Component of an Established Patient/Physician Relationship

Policy

New Officers and Board of Trustees Top row (from left to right): Dr. Clay Hays, Chairman of the Board; Dr. Dwight S. Keady, Jr., District 5 Trustee; Dr. William M. Grantham, Vice Chairman of the Board; Dr. Geri Weiland, Speaker of the House; Dr. John Mitchell, District 3 Trustee; Dr. Brett C. Lampton, District 2 Trustee; Dr. Mark Horne, Secretary of the Board; Dr. Timothy Beacham, District 1 Trustee. Bottom row (from left to right): Brock Banks, Student Trustee; Dr. David McClendon, Dr. Lee Voulters, President-Elect; Dr. Daniel Edney, President; Dr. Claude Brunson, Past-President; Dr. Joseph Austin, District 7 Trustee, Dr. Michael Mansour, Secretary-Treasurer (Not pictured: Dr. Jennifer Bryan, Young Physician Trustee; Dr. Nicole Lee, Resident/Fellow Trustee). SEPTEMBER 2015 • JOURNAL MSMA

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1 2 M S M A 3 4 5 6 7 SMA members also elected the following physicians to these 8 respective offices: 9 PRESIDENT- ELECT — Lee Voulters, MD, of Gulfport 10 BOARD OF TRUSTEES 11 12 • J. Clay Hays, Jr., MD, of Jackson—Board of Trustees, Chair • Timothy Beacham, MD, of Greenville—Trustee, Dist. 1 13 14 • John Mitchell, MD, of Jackson—Trustee, Dist. 3 15 • Nicole Lee, MD, of Jackson—Resident Rep. 16 • Brock Banks of Jackson—Medical Student Rep. 17 ASSOCIATE EDITOR, JOURNAL MSMA 2015-2018 – Richard deShazo, MD 18 COUNCIL ON BUDGET & FINANCE (AT LARGE) – Jennifer Gholson,19 MD 20MD COUNCIL ON BUDGET & FINANCE (AT LARGE)– Nathan Williamson, 21 COUNCIL ON LEGISLATION, DIST. 4– Bryan Barksdale, MD 22

Election Results

The University of Mississippi Medical Center Pulmonary, Critical Care and Sleep Medicine Division is seeking a BC/BE Pulmonologist with a special interest in Pulmonary Hypertension. Faculty candidates should submit a CV via fax to 601-984-5658. EOE, M/F/D/V.

COUNCIL ON LEGISLATION, DIST. 5 – John Halbrook, MD

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Sights from Annual Session 2

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8 1. Dr. Philip Levin snaps a selfie with AMA President Dr. Steven Stack. 2. Dr. Harvey J. Makadon, Director of the Division of Education and Training at The Fenway Institute, the National LGBT Health Education Center, Boston, and a Professor of Medicine at Harvard Medical School, gave a CME presentation on healthcare equality for LGBT patients. 3. Vocalis, UMMC’s vocal group comprised of medical students, performed the national anthem for the House of Delegates. 4. Immediate Past President Dr. Claude Brunson welcoming everyone to Dr. Edney’s inauguration. 5. Dr. Dwalia South shaking it off on the dance floor at the Inaugural Gala. 6. The Edney family: youngest daughter Meg, son Daniel, wife Lori, Dr. Edney, and his oldest daughter Meredith Salmon with her new husband. 7. Dr. Lee Voulters gives his candidate’s speech on his future presidency of MSMA. 8. MMPAC members Dr. John Clay, Dr. Clay Hayes, Mrs. Karen Morris and Dr. Dwight Keady, Jr. SEPTEMBER 2015 • JOURNAL MSMA

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P R E S I D E N T ’ S

P A G E

The Inaugural Address of the 148th President DANIEL P. EDNEY, MD ~ 2015-16 MSMA PRESIDENT August 14, 2015–Jackson Hilton -Welcome everyone to the 2015 Inaugural Gala for MSMA. Officially, it’s my inauguration as the 148th President serving our MSMA but truly it is a celebration of service. Tonight is much larger and more meaningful than a celebration for any one person but rather it is a time to reflect on another year of faithful service of the officers, staff, and members of MSMA as we all strive to promote the interests of doctors and patients in Mississippi. One of my passions is my vinyl record collection and there’s just something special about the needle hitting the groove and making music and it’s similar for us when we all come together from different backgrounds, communities, and experiences and get into the groove of organized medicine.

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One way to realize the importance of our service and its impact upon the practice of medicine in Mississippi is to imagine what the lives of doctors and patients would be like if MSMA did not exist. Without your faithful service, we would be struggling to practice medicine in a “hell hole” of medical liability. We could be dealing with a legislature and executive branch of state government that is anti-medical interests rather than the friends we have and we would have absolutely no voice on the national stage whatsoever. We would be looking at a steadily declining physician work force rather than training more doctors per year than ever before. We would have no voice or leverage in dealing with third party payers and we would have little to no influence in the world of managed care and PPO’s but instead we have MPCN and the CAP committee under the able leadership of Dr. Tom Joiner. Without MSMA, we would have no ability to influence or lead in the world of medical liability insurance. Instead, we have the strong relationship with MACM. These are all critically important issues that MSMA continues to champion but even more importantly is to understand that without all of you, there would be no MSMA. Now, before we break loose into too much self-congratulatory behavior, we still have plenty of work to do.

Immediate Past President Dr. Claude Brunson (l.) holds the Bible as Dr. Dan Edney takes the oath of office as MSMA President with his wife Lori by his side. Administering is Dr. Lee Voulters who was elected President-Elect (2016).

We can never rest on our laurels when it comes to tort reform. I have found it interesting how quickly physicians have forgotten how terrible the medical liability climate was just 10 short years ago and of course we have an entire generation of medical students, residents, fellows, and young physicians who thankfully never knew those days. So, one important issue for us to work on this year and every year is to continue to the raise awareness of all physicians regarding the need to defend and protect our hard won victory with tort reform. We all realize that we are only one Supreme Court election away from losing what we are now taking for granted. I will continue the great job of my predecessors of promoting MMPAC participation with our members. MMPAC is our first and best line of defense in this area and I’d like to publicly thank Dr Hugh Gamble and the other members of our MMPAC board for their faithful service to the profession. Secondly, is to continue our bold work regarding work forces issues. We are still at the bottom of total doctors/capita but I’m optimistic that our work over the last 5 years to increase our work force numbers will be evident with the data reported over the next 5 years. Our success in convincing the academic leadership at UMC to increase the class size and also supporting the establishment of the osteopathic school of medicine at William Carey currently is flowing into the residency years and soon these young doctors will be in the work force. The formation of the Rural Physician Scholarship Program and advocating for its funding through the legislature and the formation of the Office of Physician Work Force are also successes that are about to pay off for our doctor numbers. We must and will continue to promote these issues but I’d like to also expand the discussion to focus on retention of our doctors who are currently working. It is far more expensive to train and recruit new physicians than it is to facilitate the continued active practice of current physicians. We have done a great job of working to improve the practice climate for

Mississippi physicians but every year in Mississippi we lose competent colleagues with mature practices to suicide, substance use disorders, burn out, accidents from risky behaviors, and preventable diseases. As tragic as the loss of colleagues to premature deaths certainly is, it is also a loss to the profession when doctors retire early for any reason whether it be burn out, disillusionment, or physical/mental disability. Every doctor who practiced medicine this week is at a greater than twice the general population rate and it’s even more startling for women physicians. Doctors suffer at high rates of depression and are less likely to submit to treatment and we are notorious for neglecting our own health including screening for preventable and curable illnesses. Because of this I’ve introduced a resolution calling on the association to study how we can promote physician wellness and health. We need to begin in medical school educating students to the health hazards they will face in the profession and facilitate their getting help when needed during their training and to increase awareness of these issues throughout our practice lives. We need data looking at the rates for colon cancer screening, mammography, pap smears, prostate screenings, etc., among physicians and how much room we have for improvement. We need to look at early intervention for the diagnosis and treatment of depression and other mood disorders and certainly for substance use disorders. We need to better train the next generation of doctors in the proper diagnosis and treatment for substance use disorder in general but certainly the warning signs among ourselves. When I was a medical student, I spent more time studying parasitic diseases that I still have never seen than the amount of time I spent on a disease that I and every physician in every specialty encounters frequently-the disease of addiction. The average number of hours given in the curriculum of medical students for the entire four years is four hours nationwide.

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In residency, I became an expert in detoxing a patient but learned nothing about treating the disease that required the detox to be needed. I don’t think we are losing doctors to parasitic disease at alarming numbers but we are losing doctors every single year to the disease of addiction. Because of this I am asking the association to look at the issue of what is needed regarding teaching and training in this disease but also to evaluate how we can continue to improve our Professionals Health Program. MPHP is a jewel in the crown of MSMA and in my opinion under Dr. Scott Hambleton’s leadership, is an exemplary program nationwide but the resources devoted to saving the lives and careers of currently around 150 physicians is less than the cost of training one new doctor. Every participant in our PHP is a doctor who remains in the work force an average of an additional 25 years and they are all practicing in Mississippi. These are our friends and our partners and they are worth saving. However, the statistics suggest that there are many more doctors who need the help of our PHP and that means investing the resources needed, but if we look at it as a work force issue then the investment makes financial sense as well as doing the right thing to help our colleagues who are suffering. The third issue is that of doing our part to curb the prescription drug epidemic. This issue is gaining more and more national attention and deservedly so. As long as we have more deaths from unintentional overdoses than motor vehicle accidents, this issue will continue to gain more attention and it hurts the image of the profession as we are clearly

complicit in this fact. We have seen other state legislatures like Kentucky who have imposed draconian measures on physician’s ability to prescribe properly as a backlash to this epidemic. Drug related poisoning is the second leading cause of accidental death in Mississippi and every one of these deaths is preventable. We can do better and physicians need to lead in this effort. I’m asking the association to study the best way to positively impact this issue with other interested stake holders to develop proper prescribing guidelines “for physicians by physicians” that protect the proper practice of medicine and preempt unnecessary legislative measures as in Kentucky and yet still fulfills our mission in promoting the public health of Mississippi. An ambitious agenda to be sure and these are but a few issues of importance on our agenda for the coming few years but as C.S. Lewis said, “I have a mustard seed and am not afraid to use it!”-and the plate of MSMA is always full which is why your continued faithful service is so important. Physicians can’t make it without MSMA and MSMA can’t make it without you. So, let’s get into the groove with State Medical and make some great music. Thank you for all that you do for our profession.

Daniel P. Edney, MD

Excellence in Medicine Awards

Left to right: Dr. Lee Voulters; 2015 recipient of MSMA’s Excellence in Wellness Promotion Award Dr. Steven L. Demetropoulos; The Dr. James C. Waites Leadership Award recipient Dr. David McClendon; Community Service Award recipient Dr. John F. Hassell, Medical Director of the Good Shepherd’s Clinic in Laurel; and Claude Brunson, MD. (See Personals section next page for more on award recipients.) 288

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P E R S O N A L S Rick Boyte, MD, professor of pediatrics and division chief of pediatric palliative medicine at Batson Children’s Hospital, has been named one of six finalists for the 2015 Schwartz Center National Compassionate Caregiver of the Year (NCCY) Award. The Schwartz Center for Compassionate Healthcare, a national nonprofit leading the movement to bring compassion to every patientcaregiver interaction, selected six health-care providers throughout the U.S. for the prestigious award. “I am overwhelmed by this honor,” Dr. Boyte said. “I cannot think of anything more meaningful in health care than to be identified as a compassionate caregiver. I am deeply grateful to everyone who supported my nomination. This definitely marks a highpoint in my career.” Dr. Boyte has worked at Batson for more than 20 years and spent the first 16 of those in the Pediatric Intensive Care Unit. He credits those years and the families he encountered there with steering him towards palliative care. Palliative care began as an outgrowth of hospice care and was first recognized by the American Board of Medical Subspecialties in 2006. Unlike hospice care, palliative care begins at diagnosis and is administered concurrently with curative care and regardless of whether the result is death or cure. Dr. Boyte’s interest in palliative medicine grew into the formation of a pediatric palliative care service in 2009, which began with two full-time, dedicated people – himself and one nurse practitioner – and operated on a consult-only basis. In the last six years, the program has experienced tremendous growth, now following about 150 patients a year and developing its own inpatient and outpatient service. The outpatient service includes help for families with children who depend on a ventilator and perinatal and bereavement counseling. In 2013, Dr. Boyte spearheaded efforts to create a fellowship program in pediatric hospice and palliative medicine, one of the first in the country. The program is now hosting its second fellow. He also spearheaded efforts to bring the Schwartz Center Rounds® program to UMMC. The bi-monthly event is a multidisciplinary forum in which caregivers discuss difficult emotional and social issues that arise in caring for patients. UMMC is the only place in the state that offers the program. “I had for several years heard about Schwartz Center Rounds at hospitals in other states, so when I was asked to be a physician champion for an effort to bring Schwartz Rounds here, I jumped at it,” Boyte said. Benjamin M. Carmichael, MD - The Southern Medical Association (SMA) is proud to announce the installation of Dr. Carmichael as President for 20152016 during the SMA Annual Scientific Assembly on Saturday, October 31st. Dr. Carmichael is a long-time member of SMA and has served in many leadership roles including Councilor for Mississippi from 2009-2014. He is a member and both a past and present financial supporter of The Society of 1906 which provides financial support to the Research and Education Endowment Fund, designed to provide grants

and scholarships for medical students and physicians-in-training. SMA looks forward to working with Dr. Carmichael to help realize his vision for the Association in the coming year. Steven L. Demetropoulos, MD (pictured left page) MSMA presented the 2015 Excellence in Wellness Promotion Award to Dr. Steve Demetropoulos, Emergency Director for Singing River Health Systems in Pascagoula. The Excellence in Wellness Promotion Award recognizes an individual or entity for promoting public health and wellness in a unique and effective manner making a difference in the lives of others. Dr. Demetropoulos is a tireless advocate of the effort to make Mississippi smoke-free and used his term as MSMA President in 20122013 to deter tobacco use and protect against the dangers of secondhand smoke by promoting a statewide smoking ban. He is a passionate champion of the association’s 2014-2015 “Physicians for a Smoke-Free Mississippi” signature drive. Through his efforts, more than half of the 10,000 signatures collected were accumulated from physicians, patients, and residents of the Mississippi Gulf Coast area. “This is an important moment not only for me as a physician but also for my colleagues and patients to be recognized for their diligent effort to make Mississippi smoke-free,” said Dr. Demetropolous. He is donating his award stipend to Hospital Loma de Luz in Balfade, Honduras, a Christian charitable outreach of the Cornerstone Foundation. Randy Easterling, MD - The Board of Directors of BIPEC (Business and Industry Political Education Committee) elected Dr. Randy Easterling MD, a physician in Vicksburg, as Chair for 2015-16. Dr. Easterling, a longtime BIPEC supporter and member of the Board of Directors, succeeds Greg Cronin, President & CEO of Charter Bank, as the 25th Chairman of the organization in its 36 year history. “Dr. Easterling is well known in the political circles of Mississippi’s business and healthcare community and will be an asset as he leads BIPEC during this important election year.” “BIPEC has long been a valued organization providing needed political research and information to the business and healthcare leaders of our state,” Dr. Easterling said, “I am honored to serve.” Dr. Easterling has been in the practice of family medicine and addiction medicine in Vicksburg for the past 27 years. He is presently Medical Director of Marion Hill Chemical Dependency Unit, a 22-bed adult inpatient and 13-bed adolescent inpatient unit for substance abusers. BIPEC is a 501c6 membership organization founded in 1979 by Mississippi’s business and professional leaders. BIPEC is non-partisan, non-lobbying, and governed by a Board of Directors comprised of business leaders and trade association executives from around the state. BIPEC provides political/election research, intelligence, and insight to supporters and publishes the BIPEC Legislator “Business & Jobs” Report Card annually to assess legislator’s accountability and performance regarding business/employer issues. Lori Fulton, MD, announces the 25th Anniversary of her medical practice in obstetrics and gynecology. Dr. Fulton sees patients at her south Jackson clinic at 1963 W. McDowell Road and her north Jackson clinic (Wednesdays) at St. Dominic West Tour, 971 Lakeland Drive. “At Fulton Center for Women’s Health we offer every woman focused, compassionate care that combines traditional and innovative medical practices,” Dr. Fulton said. “We are so excited about our 25th anniversary and look forward to being part of the women’s healthcare community for years to come,” she added. Dr. Fulton’s medical services

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include obstetrics, gynecology, surgery, and ultrasound. Dr. Fulton is board certified by the American Board of Obstetrics and Gynecology. In addition to routine healthy gynecological and obstetric exams, Dr. Fulton actively treats a variety of conditions such as incontinence, heavy or painful periods, symptoms of menopause, and sexually transmitted infections. Dr. Fulton’s hospital affiliations include St. Dominic- Jackson Memorial Hospital, Baptist Hospital, and Merit Health Central. Dr. Fulton is a clinical Associate professor for the University of Mississippi Medical Center’s OB/GYN and Family Medicine departments. Believing that diversity keeps the mind sharp, Dr. Fulton is active in many local and national professional associations, has performed medical missions work in the jungles of Brazil, and is an active member of St. Mark’s Episcopal Church in Raymond. Dr. Fulton and her husband, Dr. David Jones, a local counselor and therapist, are at home in Utica. John F. Hassell, MD (pictured p. 288)- MSMA presented the Community Service Award to John F. Hassell, MD, Medical Director of the Good Shepherd’s Clinic in Laurel, Mississippi, at its 147th Annual Session in Jackson. The Community Service Award honors a member of the association who is actively engaged in the practice of medicine and has rendered service “above and beyond the call of duty” for the betterment of his/her community and the state. Good Shepherd’s Clinic is a free medical clinic in Laurel that welcomes all who come to its door seeking care regardless of the ability to pay. As the long-time medical director for the clinic, Dr. John Hassel exhibits a strong commitment to provide medical care and treatment to thousands of poor and indigent patients who would otherwise have gone untreated. “I have been blessed to be able to serve my community through the Good Shepherd’s Clinic,” said Dr. Hassell. “I’m honored by this recognition and hope to continue to provide medical care for those in need for many years to come.”

Left to right: Sam Yelverton, Eden Yelverton, Dr. Word M. Johnston, and Dr. Joe Johnston. Word M. Johnston, MD, of Mount Olive, MS was recognized as Family Physician of the Year by the Mississippi Academy of Family Physicians at its 66th Annual Conference held in Sandestin, Florida, July 21, 2015. This award is presented annually to the physician contributing the most to the development of Family Medicine in the state. It is known as the John B. Howell Memorial Award and was established in memory of Dr. Howell, a pioneer in the practice of Family Medicine and long-time delegate to the American Academy of Family Physicians. As an infant, Dr. Johnston’s family settled in Mt Olive where he

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learned to appreciate the values and principles instilled by a small community. As a young teenager, he began working at the local drug store for a pharmacist who had a profound influence on his life. Dr. Johnston graduated from the University of Mississippi Medical School and completed his family medicine residency at Richland Memorial Hospital in Columbia, SC. In 1984, Dr. Johnston returned to Mount Olive where he joined his role-model father, Dr. Joseph E. Johnston, in medical practice at Green Tree Family Medical Care. For the past 31 years he has provided his own brand of exceptional medical care combined with an equally supportive sense of empathy and compassion for his patients. Dr. Johnston has been active in his hometown and community, volunteering when needed at church, area schools or civic organizations. Dr. Johnston is known for his compassion, integrity, knowledge, judgment, and dedication to his patients, community and to the State of Mississippi. He has been praised by his associates for the care he provides for his patients and has been referred to as the “best example of a hometown doctor.” Dr. Johnston is Board Certified by the American Board of Family Medicine. Dr. Johnston is an active medical staff member of the Covington County Hospital and the Magee General Hospital. He also serves as the medical director at Arrington Living Center Nursing Home. Dr. Johnston and his wife Robin have two daughters, Ariel, 29 and Eden, 25. David McClendon, MD (pictured p. 288) - MSMA presented this year’s Excellence in Medicine Awards during its 147th Annual Session on August 14, 2015. The Dr. James C. Waites Leadership Award was presented to Dr. David McClendon. Dr. McClendon is an internist who has served as the Program Director of Hospital Medicine at Biloxi Regional Medical Center since 2012. This award honors the contributions of Dr. Waites to his community and to organized medicine by recognizing a physician under the age of 50 who is an outstanding leader in organized medicine and community affairs. A consistent advocate for his community, Dr. McClendon was selected as a 2005 Health Policy Fellow in the office of the honorable U.S. Senator Thad Cochran. Spending a full year in Washington, D.C., learning from the best, Dr. McClendon honed his skills in health policy to develop a broad view of grassroots advocacy at the community level. Dr. McClendon also serves as the Young Physicians representative to the association’s Board of Trustees. “I am incredibly humbled to carry on the name of Dr. Waites,” said Dr. McClendon upon accepting his award. “Dr. Waites was my own grandmother’s primary care physician, and his compassion toward his patients is something we should all strive for in our own practice.” Left to right: Dr. Jason Fisher, Dr. Jessica Tullos, Dr. Jordan Ingram, Dr. Meagan Taylor, Dr. Judd Reynolds and Dr. Joshua Derryberry are the second class of 3-year residents in the Forrest General Family Medicine Residency Program. They will practice at the Forrest General Hospital Family Medicine Center located on the first floor of Hattiesburg Clinic and will rotate through different departments throughout the 3-year program. Of those interviewed, Forrest General Hospital chooses only 6 candidates to become residents.

E D I T O R I A L

Ballot Initiative Measure No. 42What’s Your Opinion, Doctor? MSMA BOARD OF TRUSTEES STATES SUPPORT FOR EDUCATION: OPPOSE BALLOT INITIATIVE MEASURE NO. 42, SUPPORT ALTERNATIVE MEASURE NO. 42-A

he Mississippi State Medical Association (MSMA) affirms its strong support of public education in Mississippi. Because of the impact on our patients and our belief in representative democracy, the MSMA Board has voted to oppose ballot Initiative Measure No. 42 and to support the Legislature’s alternative titled Alternative Measure No. 42-A. Proponents of both Initiative Measure No. 42 and Alternative Measure No. 42-A made presentations to the Board of Trustees, and each was given the same amount of time. After a thorough discussion, Alternative Measure No. 42-A received solid support based on our belief that elected representatives are in the best position to make decisions regarding funding for K-12 education, higher education, public health, public safety, law enforcement and the other critical functions of state government. We found that Initiative Measure No. 42 is simply too broad in its definition. We disagree with transferring funding authority to the judiciary who could then decide the source and amount of funds used for education without regard for the impact on our patients who rely on public health and especially mental health services from the state.

MSMA Board of Trustees

Timothy J. Alford, MD

upporting education is supporting population health. Support Initiative 42.

MSMA has never been immune to the virulent and mutated politics of the day, which ignore education and literacy as chief determinants of health. We’ve heard Dr. Edward Hill again and again over the last three decades stress the importance of comprehensive K-12 health education as the key to solving so many, if not all, of our public health failings as a state. In fact, as population medicine has come of age, the realities of educational attainment as a social determinant of the health and/or chronic disease states within a population place a new moral imperative upon MSMA: to support public education. Thus, if we recognize this moral imperative, it seems obvious that MSMA should work unapologetically for passage of Initiative 42, which appears on the ballot this November, rather than support the sentiment expressed in Resolution 11, which our House of Delegates referred to our Board of Trustees for consideration and action at our recent Annual Session in August. How Mississippi got to 42 In 1997, the Mississippi Legislature passed the MAEP (Mississippi Adequate Education Program), which established a formula to insure that school districts receive sufficient funding support. The law provides that every Mississippi child, whether that child lives in a “wealthy” community or a “poor” one have the opportunity for an adequate education. MAEP has been fully funded only twice in the last eighteen years. Thus last year, after complaints without address for years to our Legislature, well over 200,000 concerned

. . .See Alford p. 292

J. Clay Hays, Jr., MD; Chairman

Randy Easterling, MD

ppose Initiative 42.

In June of this year, your Mississippi State Medical Association held its annual meeting in Jackson. MSMA’s annual meeting has for most of us been a long anticipated event at which physicians and family members from all over the state gather, renew old friendships, tell war stories, catch-up on practice and family events, and conduct the business of our association. For the past 20 years or so I have watched and participated in this exercise with great reverence and respect as the House of Delegates conducted the business of our association. I shall forever remember the long lines in Reference Committee A as we hammered out the strategy to bring about effective and fair tort reform in 2002 and 2004. The debate was crucial; the results formidable. The very delivery of healthcare in Mississippi was at stake. The 2006 annual meeting held in Vicksburg was particularly moving as your HOD heard testimony as to the devastating and seemingly insurmountable destruction that had occurred to our beloved Mississippi Gulf Coast and to the practices of our friends and colleagues in the southern most counties. Your MSMA rose to the occasion and did all she could to resuscitate the healthcare delivery system in south Mississippi. Your MSMA HOD has in the past 10 years debated and democratically passed resolutions that directly resulted in the following. 1.

Established the Mississippi Rural Physicians Scholarship Program.

Office of Physician Workforce.

. . .See Easterling p. 293

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Mississippians signed a ballot initiative that would require the Mississippi Legislature to fully fund education based upon growth in state revenue. This initiative states: “The State shall provide for the…support of an adequate and efficient system of free public schools.” Simple as that! The Legislature then approved this ballot Initiative 42 but then developed their own Trojan Horse legislative Initiative (42A), which was designed to confuse voters in an attempt to defeat the voter Initiative 42 and remove the Legislature from accountability to our children and future workforce. How our MSMA got to Initiative 42 At this year’s MSMA 147th Annual Session in Jackson, Resolution 11, now referred to the Board of Trustees, recommends that MSMA fight and defeat Initiative 42. Resolution 11 painted a doomsday scenario in which the passage of Initiative 42 would lead immediately to wrecking the public health and medical services in the state. Monies to answer the calls of the initiative would be taken from things sacred to us in medicine: the Rural Scholarship Program, the Office of Physician Workforce, the University Medical Center, the Department of Health, and other essential medical services. However, such a doomsday scenario is simply a scare tactic pushed by those in the Legislature to sink the popular initiative. Such a scenario is not based in reality and is easily perceived as a “scare tactic” if the initiative is fairly read and considered. However, with Resolution 11, MSMA has stepped squarely in the middle of a highly controversial, politically-charged debate and finds itself in the morally dubious position of standing against public education and potentially negatively affecting the outcome of the Adequate Education Initiative Measure #42. BIPEC, Mississippi’s Business and Industry Political Education Committee, was mentioned in testimony at the HOD’s reference committees as the source soliciting MSMA to stand against Measure 42. I’ll leave aside the irony of a “business” committee that states on its website that it “does not lobby issues” speaking out in favor of the current system, which is producing a less educated and prepared workforce than the rest of the country. And I won’t much try to understand how the medical community could possibly benefit from a continuation of the current underfunding of public education. What I want to address is why our Board of Trustees, in seeking what is best for both our patients and our medical practices, ought to oppose Resolution 11 and instead support Initiative 42. Here at the beginning of September, we have once again turned to Friday and Saturday football and who is running it up the middle to win the game. Where is the commiserate interest in and concern for our children’s language skills, math competency, health education, and job readiness? Does anyone care about competing with other states in something besides athletics? Does anyone realize that before health literacy there must be literacy?

not flawed. Any formula operating at such a level is going to be imperfect but the metrics of this formula and rationale are sound. The formula produces a base student cost. This amount is necessary to provide an adequate education to each student of our public schools. Each school district is required to provide up to 27% of this base student cost through ad valorem taxes. The state funds the additional amount along with federal dollars. Currently this base student cost is less than it was in 2008. In other words, Mississippi has cut funding for K-12 by 13.1% since 2008, deeper than forty other states. (Sounds like how the state and federal entities treat physicians!) Still another way to put this is that we spend $648 per student less than before the recession. Can you run your office effectively with such a cut? Following full funding of MAEP in 2008 and near full funding in 2009, Mississippi had the highest gains in 4th grade reading in the nation! Refrain 3: “You don’t just keep pouring money into troubled districts.” Response: Many leaders, some who claim to be advocates of public education, have argued that increased funding is not necessarily the answer in the more tortured districts. The State Department of Education is systematically and methodically attempting to bring failing districts out of the doldrums encumbered by minimal funding. In the meantime, the Legislature has continued to underfund each and every district. Should you penalize the good districts because of the bad? Dr. David Sistrunk, former Superintendent of the Kosciusko City Schools – one of the “good” districts – consults for the State Department of Education giving workshops and direction to the troubled districts. Dr. Sistrunk now says, “We are stuck in a legislative headlock that is beginning to significantly hurt the better districts.” Refrain 4: “The enforcement of Initiative 42 would reside in the Hinds County Court system which is a bigger mess than our Legislature.” Response: Not necessarily, and the truth is that any lawsuit enforcing this initiative is not going to “end” in a Hinds County courtroom but rather in the State Supreme Court. The initiative states that “The chancery courts of this State shall have the power to enforce this section with appropriate injunctive relief.” Interpretation of this aspect has been debated across the state, but all agree that the State Supreme Court will have final say. It appears that the Legislature has the authority to assign jurisdiction wherever it would like. Alternatively, and this would be amazing, the Legislature could avoid a lawsuit all together and actually adequately fund our public schools.

Timothy J. Alford, MD

Truth and Consequences Let me start with a review of popular disinformation (followed by the truth) being used against Initiative 42. I’ll do it by chapter and verse. Refrain 1: “You don’t fix a problem by throwing money at it --- there is too much waste in administration in our school system.” Response: MAEP funding does not pay administrative salaries. Those salaries are the responsibility of the local school districts. MAEP funds the essential elements of running a school district, including teacher salaries and basic operational costs of educating students. Anyone who looks at the facts has seen this lack of funding result in increasing class sizes many fold beyond recommended sizes. Fewer teachers mean 30 students in a class instead of 14. Ask teachers how class size impacts effectiveness? Refrain 2: “The MAEP Formula is flawed.” Response: Imperfect perhaps, but

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Refrain 5: “Fully funding education will strain other state agency budgets and force an immediate 7.8% across the board State agency cut along with tax increases.” Response: Both claims are incorrect and damagingly so, as they have sent fear waves through state agencies and confused the general electorate. As Jim Barksdale wrote in his recent “Clarion Ledger” article, “This conservative initiative specifies explicitly that funding increases are based on increases in general state revenue.” If the state economy does not grow then education funding would not increase. The impact of Initiative 42 would not be abrupt and immediate by design but rather phased in over six to seven years. Refrain 6: “There is incompetency within the State Department of Education.” Response: You obviously do not know of Dr. Cary Wright, the State Superintendent of Education. She brings 35 years of experience to our state. She was a teacher first and has been leading curriculum development and implementing educational goals for years. Her level of competence is unparalleled. Her guiding principle is placing good teachers in front of good students. Plain and simple. We should stay out of her way, heed her advice, and let her do the daunting job of being responsible for the education of 88% of the children in Mississippi. Refrain 7: “Mississippi has one of the highest per pupil K-12 expenditures in the country.” Response: The US Census Bureau has Mississippi spending $8,130 per student in 2013 which ranks 47th in the US and last in the Southeast. Alford continued top p. 294 . . . .

Truth in advertising.

Support for adequate funding for the University of Mississippi Medical Center.

Support for adequate funding for the Mississippi Department of Health.

Revamping and reconstructing State Board of Health (which resulted in a physician, by statue, being chair of that board). I could go on and on.

Who will ever forget the called special session of the HOD in the fall of 2009, when we debated the ill-conceived and ultimately devastating Affordable Care Act. In each instance and on every occasion, debate was welcomed, all sides were heard, and the association’s final position was codified by Democratic vote through a well-established, tried and true, form of representative government. The method is far from perfect but it is a damn site better than any other alternative. Now, what does this introduction have to do with Resolution 11 brought forth this past annual meeting to Reference Committee A (and, I might add, recommended for adoption by said Reference Committee)? Everything, absolutely everything. Your MSMA HOD was asked by Reference Committee A to oppose Initiative- 42, which will appear on the November 3rd statewide ballot. What, you might ask, is Initiative 42? Allow me a minute for explanation. Initiative 42, if passed, would plainly and simply bring about fundamental and profound change in the Democratic process in Mississippi. Section 201 of the Mississippi Constitution presently states “the legislature shall provide for the establishment, maintenance, and support of free public schools.” Yes, you read it correctly, the legislature (that body of men and women who meet for 90/120 days each year beginning the first Monday of January. Yes, that body that we, you and I, elected to conduct the state’s business. ) Initiative 42 would change that. Your statewide ballot on November 3rd will invite us to pass Initiative 42, which will read as follows “to protect each child’s fundamental right to educational opportunity, the state shall provide for the establishment, maintenance, and support of adequate and efficient system of free public schools. The chancery courts of the state will have the power to enforce this section with appropriate injunctive relief.” Wait a minute, did I read that correctly? Where is the word legislature (remember that body of men and women that you and I elected, that body made up of senators and representatives that you and I grew up with, went to school with, go to church with, that we attend Rotary Club and Lions Club with, and yes those individuals and their families who we care for when they are sick, and those elected officials that you and I call on at a regular basis to express our concerns about present issues). You read it correctly, the word legislature is nowhere to be found in Initiative 42. Let’s take a moment to further investigate what else is left out of Initiative/42. The words MAEP (Mississippi Adequate Education Program) or the word funding is noticeably absent. Hold on, wait a minute! We were all told that Initiative 42 was about fully “FUNDING” the “MAEP”. If so, where are the words funding and MAEP? I think you are about to catch on. Initiative 42 has little or nothing to do with fully funding MAEP and everything to do with plain ole garden variety politics! This is a flagrant attempt by a small group of individuals who want to exercise their social and progressive agenda through Initiative 42, to reconstruct how and who oversees the maintenance of K-12 public education in Mississippi, “a wolf in sheep’s clothing,” if you will.

If Initiative 42 is in fact the “Bill of Goods” we have been told, a genuine grassroots effort to improve K-12 education in the Magnolia state, then why is the Pro-Initiative 42 movement not funded by Mississippians? As of this writing, a little over $2.5 million has been raised to convince you and me to support Initiative 42. Only $900 came from Mississippians. No, wait. . . make that, 1 Mississippian gave $100 per month for 9 months. That amounts to a whopping 4/100th of 1% of the contribution to date. The remainder has come from such groups as the New Venture Fund out of Washington D.C. and the Southern Education Foundation out of Atlanta, Georgia. This is where I remind you all of the old adage “follow the money!” Now, I invite you to look at who is lending support to opposing Initiative 42. The Mississippi Manufacturing Association, Mississippi Bankers Association, Mississippi Farm Bureau Federation, Mississippi Hospital and Restaurant Association, Mississippi Poultry Association, Mississippi Realtors Association, and the Mississippi Tourism Association, only to mention a few. By the way, the aforementioned associations’ sole purpose is to bring about economic development, job creation, and a secure fundamental and viable tax base in Mississippi through proven economic principles. None of which can be accomplished without a public school system, K-12, that is not provided for through a representative form of government. Then why, praytell, are all of these associations opposing Initiative 42? Allow me to be specific. Initiative 42 would change Section 201 of the Mississippi Constitution to allow for the maintenance and support of an adequate and efficient system of free public schools to be placed squarely and firmly in the hands of one chancery court judge in Hinds County. A judge that I venture to say not a handful of us have ever heard of and even fewer of us have been given the opportunity to vote for. Hey, what happened to the legislature that you and I grew up with, went to school with, pray and fuss with, and most importantly of all, VOTED FOR. That is right, you got the message, they are “out of here”, “history”, no longer responsible to you and me (the voter) when it comes to public school K-12 education. Don’t call them to complain or express your opinion, they will no longer have jurisdiction over the largest part of our states budget. They will (the legislature), however, have the full responsibility for coming up with the amount of money this judge in Hinds County determines necessary to adequately fund K-12 in Mississippi. More about that in a moment. I would suggest to you that the premise of Initiative 42 is fundamentally sound. Public school education should be adequately funded. As the father of two children who graduated from the Vicksburg/ Warren County School System (one of whom is a public school teacher), I place a high priority on good primary and secondary education. However, Initiative 42 suggests that the current Legislature and Governor, Lieutenant Governor, and Speaker of the House have been wontonly derelict in their responsibility to provide adequate funding for K-12. Nothing can be further from the truth. Allow me to present some facts, not rumor or innuendo. Fact #1 The percent of state support for education has steadily increased over the past 4 years to record numbers. FY 2013- increased by 28.4%. FY 2014 - increased by 19.6%. FY 2015 - increased by 53.3%. FY 2016 - increased by 66.3%.

Randy Easterling, MD

FACT #2 Over $9.5 billion being spent on total K-12 education over the last 4 legislative budgets. FACT #3 $2,525,564,415 spent on total K-12 education in FY 2016 budget, more than any other year in our states history. Easterling continued bottom p. 294 . . .

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W H A T ’ S

Y O U R

O P I N I O N

D O C T O R ?

Alford continued . . .

MSMA should take a stand.

What are the facts?

As physicians, teaching is a large part of what we do but we are not professional educators. Why are we having this conversation in our medical association and community? The more fundamental question is why would MSMA really want to take on the issue of Adequate Public Education funding? Is this pertinent to us and our patients? Yes, I believe that it absolutely is pertinent! MSMA has advocated over the past decades for health literacy, school nurses, comprehensive school health education, prevention of teen pregnancy, and immunizations prior to school enrollment to name a few. Remember our health report card? Remember our Mission Statement? “The Mississippi State Medical Association is a physician organization serving as an advocate for its members, their patients, and the public health.” Every public health indicator suggests that good education leads to improved health. A poorly educated citizenry will be an unhealthy one. The current system is woefully underfunding schools, and this lack of funding will continue if Initiative 42 fails. For that reason, I ask that the Board of Trustees, after consideration of the issue, to rule against Resolution 11. Ignore the clamor of short-sighted state politics, and do what is right. I would also encourage our Board not only to stand against Resolution 11 in its board proceedings, but I also would challenge them take a bold and courageous public stand in favor of Initiative 42 on behalf of our children. Our kids are deserving of a quality education that will make them healthier in both mind and body. —Timothy J. Alford, MD; Kosciusko

Enough talk of the arguments against Prop 42. Here are the facts: 1.

Mississippi has 490,225 school children (88.4% of all children in the state) enrolled in public schools.

Mississippi has cut 6% of teachers (2000 teachers) since 2008 because of inadequate funding by our Legislature.

Teacher assistants, mandated by earlier education reforms, are becoming increasingly rare in K-2. If you have ever visited a first grade classroom, you understand how valuable a teachers’ assistant is in a room with as many as 25 six to seven year olds.

SEVENTH grade math classes are diminishing – fewer teachers. Choir and fine arts are limited – fewer teachers. High school chemistry and physics – woefully understaffed and underfunded – fewer teachers. One out of three eighth graders in Mississippi attends schools without a science lab.

Since 2008 the Legislature has ignored the law outright and has only funded education adequately twice. This Legislature has spent $1.7 billion less than the law mandated them to spend. Over the past four years this has resulted in an average $250 million per year state-wide short fall. In Kosciusko, this extrapolates to a $7 million a year short fall according to our own superintendent of schools. Other districts are experiencing proportional shortfalls. This is real, and it is hurting the education of our children. In response, 80% of the 146 school districts have raised local property taxes to compensate for lack of funding. Many communities have reached their limit and can no longer raise taxes.

Mississippi continues to dwell last amongst the lowest five other states for per pupil spending (base student cost). Adding insult to this reality is the fact that Mississippi has the highest percentage of children living in poverty.

Easterling continued . . . FACT #4 There are key educational victories through FY 2013 through FY 2015 that were funded outside of the MAEP- just to mention a few. A) Charter school act. B) Third-grade reading Gate. C) Prekindergarten collaboration. D) School consolidation. E) Dyslexia scholarships. F) Double teacher supply fund. G) Special needs voucher bill. I could go on and on. FACT #5 The 2015 legislature had an additional $170 million of unexpected revenue dumped in their laps. Admittedly, they did not put this in MAEP. They put $110 million of it (64.7%) into the pockets of public school teachers (K-12) for raises! FACT #6 Nationwide, approximately 30% of states general fund revenue is spent on K-12 education. In Mississippi, it is 40% and K-12 plus IHL plus Community Colleges is around 55%. By having said all that, has K-12 been adequately funded since MAEP was passed in 1997? Of course not! But then, neither have highways, prisons, Medicaid, Department of Public Safety, Department of Health, Department of Mental Health, University Medical Center, Department of Rehabilitation, IHL, Community Colleges, etc., etc., etc. One point is glaringly obvious: given all of the challenges facing our legislature and statewide elected leadership in the past

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Sources utilized: 1. A large body of literature establishes linkages between staff-child ratio, program quality and child outcomes: Barnett (1998). Bowman, Donovan & Burns (2001). Frede (1998); NICHD Early Child Research Network (1999); National Association for the Education of Young Children (2005). 2. American Journal of Public Health (July 1999) Vol. 89. No. 7; 1072-1077. 3. US Census, Public Elementary-Secondary Education Finance Data, 2013; http://www.census. gov/govs/school 4. W. Steven Barnett, PhD, Megan Carolan, MPP, Jen Fitzgerald, MPP. The National Institute for Early Education Research, 2011. 5. The Parents’ Campaign: info@ms.parentcampaign.org 6. A National Report Card. Third Edition “Is School Funding Fair? www.schoolfundingfairness. org 7. FORBES Magazine’s Best States for Business Guide, 2014.

4 years, K-12 has been the beneficiary of record funding. The generosity toward K-12 for the past 4 years at the hands of our present leadership has been and remains clearly unprecedented. Now back to what will happen if Initiative 42 is passed. The legislature (remember them, the folks we VOTED FOR) would be obligated by state constitution to come up with whatever sums of money this unknown Judge of Hinds County would require. Since we don’t and can’t print money in Jackson, the funding must come out of two places, the taxpayer and/or other state budgets. That is where you and I as MSMA members come into play. All of us, regardless of what or where we practice, have three fundamental things in common. We all work hard, pay high taxes, and have an uncommon vested interest in the health of all Mississippians. Let’s take a snap shot of four budgets that would be negatively impacted if Initiative 42 passed: According to the Department of Health, the estimated budget reduction that would necessitate by the passage of Initiative 42 would result in approximately $5 million of agency cuts to programs such as Maternal and Child Health, Early Intervention Sub-programs, Mississippi Qualified Health Center Grants, UMMC Centers such as the Cancer and the Tobacco Center, the School Nurse Program, Alcohol and Tobacco Enforcement Programs, Office of Preventative Health, and others. . . .See Easterling bottom p. 296

U N A

V O C E

A Piller of the Community… A Love Story

ou just had to love old Murry and Raylene.* They were what my nurse called “Regulars.” Like clockwork on each third of the month, Social Security check day, the two would have a standing ‘couple’s appointment’ at Family Medical Center. I would enter the exam room and there they would be seated antigodlin to each other, sour Murry sulled in one corner with a greasy ball cap pulled down tight and with arms and legs tightly crossed. He would be fidgeting, ‘jonesing’ for a cigarette if he’d had to wait more than ten minutes. If you want to feature a Murry doppelganger in your mind, simply envision Uncle Si from Duck Dynasty, remove his grin and most of his teeth, and add a layer of nicotine stain to the long scraggly tri-colored beard. Somehow, he always reminded me of a crippled old starving hound. Raylene would be stationed across the room clicking her crochet needles at lightning speed. Picture Raylene in her best polyester double-knit pantsuit from which the tobacco smoke could never be exorcised, cat-eye reading glasses near the end of her nose, and oily gray hair in a pony tail, highlighted around the face with a non-angelic halo of yellow. Sometimes I try to imagine what a hard-living rounder Murry was in his day, imagine what shenanigans Raylene had been forced to endure over the span of their forty-year marriage. strange DwaliaAS.long South, MDtrip it must have been. They drove about thirty miles once a month to my clinic from a small community close to the Tennessee line. They were both in their mid-60s, both obviously very chronically ill, and their office visits were covered by both Medicare and Medicaid. I once asked them why they bypassed nearer physicians in a town larger than Ripley to come to see me. Murry said, “Hell, you the only doctor we found that will set down and listen to us. That last sumbitch we went to wouldn’t even touch us when he come in the room. He’d stay bout a half a minute and run out actin’ like he smelt s- - - or something.” Murry’s main working diagnosis besides his ever worsening emphysema and sociopathic personality disorder was a severe Reflex Sympathetic Dystrophy (now known as complex regional pain syndrome) of his right leg. His lower leg had become withered and mottled from the rare but horrible residual effects of his old injuries. He ambulated with a cane and profound limp. He was incapable of making a sentence that did not include either “Damn” or “Hell,” and more often both. Of his intact but wasted leg Murry said, “I wished I could tell you it happened in Vee-et-nam, but I’uz in one hell of a dam wreck when I’uz drunk and runnin’ from the law one night about thirty years ago. If I hadna been plastered it ‘ud a kilt me. Now I just got a dam bum leg out of the deal that’ll torment me the rest uh my life. Don’t touch the hard stuff no more after that. Lurnt my lesson. Just ‘Natural Lites’ to help me sleep of a night, none a drivin.” The chart note always included at the top as their chief complaint: “Usual Check-up.” My nurse Brenda would unfailingly say, “That’s what I write down because when I ask them how we can help them today or what seems to be their trouble, they always just say ‘We are here to see the ole Doc and get our monthly dope,’ and I wasn’t about to put that in the chart!” We both agreed that their total honesty was singularly refreshing. They never feigned illness or used trickery. Their visits were never those time-wasting, narcotic seeking, whining sessions that are so often the bane of a primary care physician’s existence. As soon as I would make my appearance in the exam room, listen to Murry’s chest and ask if anything was new or different, he’d cough, grunt, shake his head, then grab his walking stick and hobble out to their pick-up for a smoke, leaving his wife to conduct the business of the office visit. Raylene’s problems also included emphysema from a lifetime of smoking, generalized osteoarthritis, osteoporosis, migraine headaches, hypertension, coronary disease and severe peripheral vascular disease. The couple was childless as Raylene had a hysterectomy in her early twenties. Most of the factual information I got on Murry’s past history was gleaned from her. I learned when quizzing her about the wreck that had ruined his leg that the accident had taken place somewhere up in McNairy County, Tennessee when she very matter of factly revealed that he’d been working as a bootlegger for what was then known as the “State Line Mob.” He had in fact been running from Sheriff Buford Pusser when his wreck had occurred, but that was something “Murry didn’t much like to brag about.” SEPTEMBER 2015 • JOURNAL MSMA

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Besides their regular medicines, what they required (according to Raylene) was “our Darvon-cet ease tablets…Murry needs three a day, but I only need two.” Seated making crucifix book-marks, baby blankets or Kleenex box covers…anything to keep her hands occupied…Raylene would look over her glasses at me and say “Doc, I reckon all we really need this month is just our dope.” So each month, Raylene got a prescription for 60 of the shiny red Darvocets-N-100’s,®** and Murry got 90. In the approximately three years I treated them they never asked for more or stronger medicine. They never called back having their medicine ‘lost or stolen,’ or tried to come in early for their appointments. Somehow this couple was endearing to me in their infirmities, in spite of their rough and tumble past and hard-scrabbled appearance. If this was all it took to make their lives a little more tolerable, I was not above doing it. Then one day, I saw Raylene’s obituary in the “Tupelo Journal.” A Corinth Funeral Home would be handling the arrangements; there would be only a graveside service. In a few days we called their house to find out what had happened to her. Murry didn’t want to talk much but said she’d had “just grabbed her chest one morning and fell over dead- a heart attack they said.” I told him that we were so very sorry for his loss and he said quietly, “We thank you, Doc,” and then he hung up the phone abruptly. When the third of the month rolled around again, Murry was a “no-show” for his appointment. When we called again to check on him, a relative of theirs answered the phone and told us that “Murry said he didn’t have nothing to live for no more after Raylene died, and so he just up and shot his self.” Everyone in our office grieved quietly for our loss of these two patients, two real and rare characters whose tough lives and visible suffering had formed a strange but enduring bond between us. Ten years later, we all still have Raylene’s handiwork with us, Bible bookmarks and crocheted crosses. They even still smell a bit like her awful brand of cigarettes. I still miss old Murry and Raylene; I never really minded them calling me ‘Doc’ or asking me for their ‘dope.’ I understood something about their rough and rowdy past ways. I understood that there would be no way of substantially changing the ungracefully aging couple they had become. I do feel that we somehow made the last years of their very trying lives a little more comfortable and they knew we genuinely cared for them. I sometimes wonder today, with all the furor surrounding physicians’ treatment of chronic pain patients, if the way I chose to provide care for this couple was wrong. Was I simply their license bearing dope supplier? Was I a “piller of the community?” Somehow, I just don’t think so.

—Dwalia S. South, MD; Ripley

*Names have been changed for HIPPA compliance. **Darvocet-n-100® (propoxyphene and acetaminophen) was a Schedule 4 opioid analgesic compound used for mild to moderate pain relief prescribed commonly by physicians since the 1950’s. It was removed from production in November 2010 by the FDA due to safety concerns. [Una Voce (With One Voice), is a column in the JMSMA featuring the prose of Dr. Dwalia S. South, chair of the MSMA Committee on Publications. For over 30 years, Dr. South has been a family doctor in her birthplace of Ripley, Mississippi. She served as the President of the Mississippi Academy of Family Physicians 1999- 2000, and as MSMA President in 2007-2008. Residing in rural Tippah County Mississippi, Dr. South continues her active clinical practice, and maintains the Green Hills family farm along with her two sons, Jesse and Jack. She is married to musician Roger Yancey.] —Ed.

Easterling continued . . .The Department of Mental Health estimated a nearly $18 million cut associated with Initiative 42, which would result in devastating impacts on the agency. Closure of work activity centers and group homes, discontinuing adult day programs and employment, prevocational programs, and termination of 362 employees within their IDD Programs. Their behavioral health programs would also be impacted, with 266 employees terminated, closure of 6 crisis stabilization unit beds, 16 adult psychiatric beds, 68 chemical dependency beds, 20 group home beds, and 29 medical psychiatric beds. These cuts would result in loss of grant funds, which would impact 925 crisis residential clients, 1,342 clients receiving physician and nursing services, 78 home and community base waiver clients, and 328 children served in therapeutic homes and family/children groups. The agency would be a risk for losing $17.6 million in Medicaid/Medicare funds, with 4,804 clients no longer receiving services. The University Medical Center estimates it would have to increase tuition by about 60% to withstand an 8% reduction in state funds (or about $14.7 million), making health professions education cost prohibitive for a vast majority of Mississippians. This type of coverage would result in closure of roughly 235 medical surgical beds, a loss of 10,500 patients annually. The Department of Rehabilitation Services would be looking at a cut of $9.3 million including loss of federally managed funds. At least 270 individuals served in homes in community based waiver programs would lose service and three community rehabilitation centers would be closed eliminating 29 jobs and ending service for 315 individuals. The remaining agency cuts would affect 1,200 clients. IHL has been told they will suffer a 7.8% decrease in budget, Community Colleges the same. At a recent faculty meeting of one of our Community Colleges (by the way Mississippi Community College System was named #1 in the nation last week and the particular Community College I am talking about are #1 of the two best in the nation). The President told his faculty that if Initiative 42 passes, he will be forced to lay off 15 faculty members. I would remind you all, that our Community College system is the very backbone of the work force development system in Mississippi. There is no doubt in my mind the funding for the Rural Scholars Program and the Office of Physician Workforce will be in serious jeopardy if Initiative 42 passes. This effort to hijack the Mississippi appropriations process has received national attention. I invite you to read Patrick Gleason’s article in the August 4, 2015 magazine entitled “Scheme to Take Education Funding Authority From Legislators Spells Trouble for Mississippi Tax Payers”. Friends and colleagues, let me be perfectly clear. I support 110%, the full funding of MAEP. I just simply want it to be done by the Democratic process. To take away my fundamental right of representative government weakens and discounts my voice. Have we not had enough of that lately? It appears more and more that the hard working, tax paying citizens have less and less to say about the way things are done. Initiative 42, in my opinion, is a huge step in the wrong direction. I ask that your board of trustees vote in support of Resolution 11; Oppose 42 . Thank you. Sincerely, Randy Easterling, MD; Past-President 2009-10

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