VOL. LIX • NO. 9 • 2018

VOLUME LIX • NO. 9 • 2018

CME WITH MICKEY MOUSE NOVEMBER 18–2 , 201 | WALT DISNEY WORLD® Register now at MSMAonline.com/CMEDisney For more information call Becky Wells at (601) 853.6733, ext. 340.

VOL. LIX • NO. 9 • SEPTEMBER 2018

SCIENCE OF MEDICINE

EDITOR Lucius M. Lampton, MD

THE ASSOCIATION President Michael Mansour, MD

ASSOCIATE EDITORS D. Stanley Hartness, MD Richard D. deShazo, MD

President-Elect J. Clay Hays, Jr., MD

MANAGING EDITOR Karen A. Evers

Secretary-Treasurer W. Mark Horne, 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

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Cost-Effectiveness Analysis of Procedure Equipment in a Pain Clinic: 392 The Physician’s Role in Managing Healthcare Cost Lakshmi N. Kurnutala, MD; Kevin Dang, MD; Raisa Nguyen, MD; Nabil Sibai, MD A Case of Metastatic Melanoma of the Heart Diagnosed Antemortem Madison H. Williams, MD; Doris Hansen, MD; Natale Sheehan, MD

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Leaves of Three, How Bad Can It Be? Caitlin A. Cochran, BS; Danielle Keyes, MPH; Caroline Doo, MD; Thy Huynh, MD; Julie Wyatt, MD

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Top 10 Facts You Need to Know about Endometriosis Lauren H. Ramsey, PharmD; Laurie W. Fleming, PharmD

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Top 10 Facts You Need to Know about Women in Medicine Avani Patel, M3; Michelle Sheth, MD

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An Unexpected Souvenir: Lyme Disease Presenting as Temporomandibular Joint Arthritis 410 Jesse Juncong Xie, MD; Ravi Chandran, DMD, PhD; Nina Washington, MD, MPH DEPARTMENTS From the Editor – Medicine’s “Secret Sauce” Lucius M. Lampton, MD

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President’s Page – Address of the 150th President William M. Grantham, MD

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Images in Mississippi Medicine – Klan Poster Against UMMC, 1950 Lucius M. Lampton, MD

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Poetry and Medicine –Ten-Year-Old’s Injection Ruse John McEachin, MD

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RELATED ORGANIZATION – UMMC Brunson Named MSBML President

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UMMC Student Experiences at the Jackson Free Clinic Courtney Mullins, M4, UMMC SOM

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Turkey Tail Mushroom (Trametes versicolor) – This photograph was taken by Joe R. Bumgardner, MD of Starkville, a retired general surgeon who practiced there for 27 years. He writes, “While traveling en route to Natchez, I passed through Port Gibson where I encountered an unusual mushroom growing at the base of a mature water oak tree. I subsequently discovered it was one variety of a Turkey Tail mushroom.” Also known as Coriolus versicolor and Polyporus versicolor, this common mushroom is found throughout the world. Versicolor, meaning “of several colors,” reliably describes this fungus displaying typical concentric zones of rust and darker brown, or grey-brown and almost black, on the top surface of the mushroom cap. Because its shape and multiple colors are similar to those of a wild turkey, T. versicolor is commonly called Turkey Tail. This species has some medicinal uses as well. It is thought that certain chemical compounds, such as polysaccharides in Turkey Tail mushrooms, strengthen the immune system to fight cancer. The immune effects are mediated through the mushroom’s stimulation of innate immune cells, such as monocytes, natural killer cells, and dendritic cells. Medicinal mushrooms have been approved adjuncts to standard cancer treatments in Japan and China for more than 30 years, where they have an extensive clinical history of safe use as single agents or combined with radiation therapy or chemotherapy.

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F R O M

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Medicine’s “Secret Sauce” W

hat is the “secret sauce” of our profession? This phrase has been frequently used in our modern jargon since hamburger wars in the 1970s and has come to mean, according to MerriamWebster, “an element, quality, ability, or practice that makes something or someone successful or distinctive.” A fellow physician asked me what was medicine’s secret sauce, that essential element which makes physicians Lucius M. Lampton, MD succeed in our art, and I was slow to Editor answer. He then promptly told me: “The secret sauce of medicine is time. Our time as doctors, face-to-face with the patient. If you spend time with folks, they get better. You connect.

They trust. Good things happen!”

Of course, there are many things that must come together for us to work at high levels and induce positive results for patients. Such things as experience, training, autonomy, and empathy are all required ingredients of that sauce recipe. In the end, the application of those necessities coming together in interaction with the patient is the key.

So, if a physician’s time with the patient is the secret sauce, why are we allowing the modern health system to diminish at every turn the amount of time we can spend with our patients? The old world encouraged payment for volume, and the current one encourages payment for clerical work (what is called “quality”). In the future, physicians must devote themselves to giving the patient-physician relationship the time it deserves and require the brave new world of medicine to acknowledge medicine’s secret sauce.

Payors seem to think docs have unlimited time to enter superfluous data and fill out redundant paperwork. We don’t. What a waste of our talents for us to do any of that! We aren’t good clerical secretaries. We don’t need to be spending time entering data. We don’t need to be spending time handwriting narratives for insurance companies. We don’t need to be spending our time typing notes in our EHR. We need to be maximizing our time with our patients, face-to-face, looking them in the eyes, examining their bodies, and hearing their problems. Only then can the magic of medicine occur. Q Contact me at LukeLampton@cableone.net.

— Lucius M. Lampton, MD, Editor

JOURNAL EDITORIAL ADVISORY BOARD ADDICTION MEDICINE Scott L. Hambleton, MD

EMERGENCY MEDICINE Philip Levin, MD

MEDICAL STUDENT John F. G. Bobo, M2

ALLERGY/IMMUNOLOGY Stephen B. LeBlanc, MD Patricia H. Stewart, MD

EPIDEMIOLOGY/PUBLIC HEALTH Mary Margaret Currier, MD, MPH Thomas E. Dobbs, MD, MPH

NEPHROLOGY Jorge Castaneda, MD Harvey A. Gersh, MD

ANESTHESIOLOGY Douglas R. Bacon, MD John W. Bethea, Jr., MD

FAMILY MEDICINE Tim J. Alford, MD Diane K. Beebe, MD Jennifer J. Bryan, MD J. Edward Hill, MD Ben Earl Kitchens, MD James J. Withers, MD

OBSTETRICS & GYNECOLOGY Sidney W. Bondurant, MD Darden H. North, MD

GENERAL SURGERY Andrew C. Mallette, MD

OTOLARYNGOLOGY Bradford J. Dye, III, MD

HEMATOLOGY Vincent E Herrin, MD

PEDIATRIC OTOLARYNGOLOGY Jeffrey D. Carron, MD

INTERNAL MEDICINE Daniel P. Edney, MD W. Mark Horne, MD Daniel W. Jones, MD Brett C. Lampton, MD Jimmy Lee Stewart, Jr., MD

PEDIATRICS Michael Artigues, MD Owen B. Evans, MD

CARDIOVASCULAR DISEASE Cameron Guild, MD Thad F. Waites, MD CHILD & ADOLESCENT PSYCHIATRY John Elgin Wilkaitis, MD Nisha S. Withane, MD, Fellow CLINICAL NEUROPHYSIOLOGY Alan R. Moore, MD DERMATOLOGY Robert T. Brodell, MD Adam C. Byrd, MD

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ORTHOPEDIC SURGERY Chris E. Wiggins, MD

PLASTIC SURGERY William C. Lineaweaver, MD Chair, Journal Editorial Advisory Board PSYCHIATRY Beverly J. Bryant, MD June A. Powell, MD PULMONARY DISEASE Sharon P. Douglas, MD John R. Spurzem, MD RADIOLOGY P. H. (Hal) Moore, Jr., MD RHEUMATOLOGY Shweta Kishore, MD C. Ann Myers, MD UROLOGY W. Lamar Weems, MD

Robert S. Caldwell, MD, Award

recognizing excellence in patient care, documentation, and communication in a senior level resident at the University of Mississippi Medical Center

Congratulations to the this year’s award recipient!

Madison H. Williams, MD Hematology / Oncology Past Recipients 1982 Jack Foster, MD – Cardiology

2000 Ford Dye, MD – Otolaryngology

1983 Martha J. Brewer, MD – Ob-Gyn

2001 Chet Shermer, MD – Emergency Medicine

1984 Sam J. Denney, Jr., MD – Pediatrics

2002 Demondes Haynes, MD – Pulmonology

1985 William H. Coltharp, MD – Cardiothoracic Surgery 2003 Kimberly W. Crowder, MD – Ophthalmology 1986 Bobby L. Graham, Jr., MD – Medical Oncology

2004 Kentrell Liddell, MD – Family Medicine

1987 Sam Newell, MD – Neurology

2005 Christopher M. Charles, MD – Pediatrics

1988 Marc Aiken, MD – Orthopaedic Surgery

2006 Matt Runnels, MD – Gastroenterology

1989 W. Richard Rushing, MD – Ob-Gyn

2007 David L. Spencer, Jr., MD – Urology

1990 Charles G. Pigott, MD – General Surgery

2008 Lillian Joy Houston, MD – Psychiatry

1991 R. Glenn Herrington, MD – Ophthalmology

2009 Shane Michael Sims, MD – Ob-Gyn

1992 Mark G. Hausmann, MD – General Surgery

2010 Lee Murray, MD – Neurology

1993 Gary L. Smith, MD – Anesthesiology

2011 Leslie Mason, MD – Ob-Gyn

1994 Michael R. McMullan, MD – Cardiology

2012 Christopher M. Bean, MD – Urology

1995 Damea B. Benton, MD – Pediatrics

2013 Victor Copeland, MD – Ophthalmology

1996 Jeffrey D. Noblin, MD – Orthopedic Surgery

2014 Christina G. Marks, MD – Radiology

1997 Scott E. Harrison, MD – Otolaryngology

2015 James A. Moss, Jr., MD – Orthopaedic Surgery

1998 David Stuart Emerson, MD – Family Medicine

2016 Rishi A. Roy, MD – General Surgery

1999 Timothy B. Murray, MD – General Surgery

2017 Michael T. Cosulich, MD – Dermatology

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Cost-Effectiveness Analysis of Procedure Equipment in a Pain Clinic: The Physician’s Role in Managing Healthcare Cost LAKSHMI N. KURNUTALA, MD; KEVIN DANG, MD; RAISA NGUYEN, MD; NABIL SIBAI, MD

Abstract Background: With the advancements made in healthcare, healthcare costs have increased in all inpatient and outpatient locations, including pain clinics, in the past two decades.

Objectives: The first objective was to analyze the contents of the epidural and nerve block trays used in our Pain Clinic. The second objective was to remove the contents that are not used during the pain procedures and evaluate the economic savings for the hospital healthcare system. We hypothesized that small cost reductions could result in significant savings over time.

Setting: Henry Ford Hospital Pain Clinic, Detroit, Michigan.

Study design: With the help of the Program Director of Pain Medicine fellowship, nurse manager of the Pain Clinic, and purchasing department of the hospital, we analyzed the cost of an epidural tray, nerve block tray, and chlorhexidine sponge stick separately. The costs were then compared to a customized tray in which we removed items in the tray that were not being routinely used.

Results: After analysis of cost, removal of extraneous equipment from the block trays, and addition of chlorhexidine sponge sticks, the expected savings to the Pain Clinic with the customized trays totaled $10,248.75 over a 6-month period.

Table 1. Initial Analysis of Pricing of Epidural and Nerve Block Trays

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Conclusion: While the savings ($20,497.50 per year) appears to be a small amount for a multi-million dollar institution, this study confirmed our hypothesis that a single, simple solution can make a significant impact in healthcare savings over time. This also demonstrates that physicians play a key role in identifying and reducing waste, leading to lower healthcare costs.

Introduction As healthcare costs continue to rise, healthcare providers and organizations strive to decrease costs while maintaining the quality of care.1,2 With new developments in technology and complex treatment techniques come increased costs. The latest and greatest diagnostic and treatment modalities may be more accurate or effective, but their associated costs can be staggering.3,4 We hypothesize that small cost reductions can result in significant savings over time, which will ultimately reduce overall healthcare cost. Physicians are leaders in healthcare and consequently have a responsibility to provide quality care in a cost-effective manner.

Objectives and Methods We examined the contents of pre-assembled epidural and nerve block trays to determine whether there were any items that we were not routinely using and were ultimately being discarded. These trays are expensive and are purchased in large quantities. The omission of these

Table 2. Analysis of Pricing of ChloraPrepTM Applicator

unused items revealed an opportunity for potentially significant costsavings which would benefit the healthcare institution. Historically, use of the povidone-iodine solution and sponge sticks was the mainstay of establishing a sterile environment. In 2000, the use of chlorhexidine gluconate gained popularity when the Food and Drug Administration (FDA) approved ChloraPrepTM for skin preparation.5 Currently, many practitioners prefer to use ChloraPrepTM applicators because they are less irritating to the skin, dry faster, and have a longer-lasting antimicrobial profile compared to traditional iodine preparations.5 The epidural and nerve block trays both contained supplies for an iodine skin preparation, which included 3 sponge sticks and a packet of iodine solution, all of which were packaged in a separate plastic tray within the entire kit.

Then we explored the possibility of removing the unused items from the trays by creating a customized tray with the help of the manufacturing company. Subsequently, we analyzed and compared the cost of using the standard trays which include iodine plus “offthe-shelf ” ChloraPrepTM applicators versus customized trays without iodine that included the ChloraPrepTM applicators. This project was undertaken at Henry Ford Hospital (Detroit, MI) with the help of the Program Director of the Pain Medicine fellowship, nurse manager of the Pain Clinic, and the purchasing department of the hospital.

Results We analyzed the cost of an epidural tray, nerve block tray, and ChloraPrepTM applicator separately. The costs were then compared to a customized tray in which we removed items in the tray that were not being routinely used. Our current Nerve Block Trays (NBTs) and Epidural Trays (ETs) cost $13.83 and $15.75, respectively. (Table 1) After reviewing our institution’s purchasing history, we found that a total of 2090 NBTs ($28,910.97) and 940 ETs ($14,806.88) were purchased over a 6-month period from January to June 2014 for a combined total of $43,717.85. The addition of ChloraPrepTM applicators added another $3.48 to the cost of each procedure, effectively making the cost of NBTs $17.31 and ETs $19.23 each. As shown in Table 2, the

6-month combined cost increased to $54,262.25 when the price of added ChloraPrepTM applicators was included.

We then obtained quotes from 2 different companies for customized trays that included the ChloraPrepTM applicators. Table 3 shows that Company 1 quoted a price of $13.71 for NBTs and $16.34 for ETs with ChloraPrepTM applicators included. Company 2 quoted a price of $22.33 and $23.96, respectively. If we were to purchase custom kits from Company 1, our cost-of-supplies would amount to $44,013.50 in 6 months. Thus, we could reduce our cost by $10,248.75 over a 6-month period.

Discussion Cost-effectiveness analysis (CEA) is a form of analysis that examines relative costs and associated outcomes.1 Areas of cost can be divided into 7 categories: facility utilization, imaging, laboratory testing, therapy services, medications, supplies, and professional services.6 A study of almost 700 trauma admissions at the University of Michigan concluded that 35% of the total cost per patient was under the immediate control of physicians.6 Facility utilization can be viewed in terms of patient utilization in particular units, length of stay, or the cost of a visit to an outpatient clinic. Imaging costs involve the use of very expensive equipment as well as technician costs and the time needed to perform these studies. Medications account for a large portion of healthcare costs, and assessing the cost-versus-benefit ratio of medications is crucial. Acquisition costs of supplies, which our study addressed, can be affected by contract negotiations and bulk ordering along with customization of pre-assembled kits. Cost-effectiveness analysis remains a valuable tool to use within an institution to discover ways to decrease costs while maintaining the standard of care.7,8 There is an enormous amount of waste in the healthcare industry.6,8 For our particular purpose, we were consistently not using certain supplies in a standard nerve block tray and subsequently discarding them. Fortunately, we were able to achieve this cost reduction while maintaining the quality of the remainder of the tray and quality patient

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Table 3. Analysis of Pricing of Customized Trays with ChloraPrepTM Applicator Included

care standards.

In even broader terms, the basic principle of reducing equipment or supply costs can be applied to any specialty in healthcare. For example, a recent qualitative study performed by Family Medicine physicians found that individualizing treatment plans and focusing on the patient as a whole rather than adhering to strict guidelines contributed to more cost-effective healthcare.9,10,11 Cost-effectiveness analysis can often involve the comparison of two or more alternatives in which one offers an improvement but at increased cost with the goal of determining whether the intervention is “worth” the added costs.12 The difficulty remains in the fact that determining whether the benefits exceed the costs is not straightforward. Benefits are measured clinically while cost is measured quantitatively.13 Limitations of our study are a single institution and a single site, as well as the cost swing on equipment alone.

3.

4.

5.

6.

7.

8.

Conclusion Cost-effectiveness analysis is a methodologic tool that can help optimize decision-making for reducing healthcare costs and forming policies. It is our responsibility as healthcare providers to identify “bad habits,” such as repeatedly throwing away extraneous supplies. In our case, only the physician performing the nerve block procedures could identify this waste. As we prepare to adapt to a bundled payments system, it will be imperative to cut costs without jeopardizing quality of care in order to maximize reimbursement, not only for our anesthesiology specialty but for the institution as a whole. With that said, the role of the physician in identifying waste and finding alternatives to reduce waste and/or costs is solidified. Q References 1.

2.

Roberts MS. The Next Chapter in Cost-effectiveness Analysis. JAMA. 2016;316(10):1049-1050.

Kawamoto K, Martin CJ, Williams K et al. Value Driven Outcomes (VDO): A pragmatic, modular, and extensible software framework for understanding and improving healthcare costs and outcomes. J Am Med Inform Assoc.

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9.

10.

11.

12.

13.

2015;22(1):223-235.

Mark Smith, Robert Saunders, Leigh Stuckhardt, J. Michael McGinnis, Editors; Committee on the Learning Healthcare System in America; Institute of Medicine Institute of Medicine. Best care at lower cost: the path to continuously learning healthcare in America. Washington (DC): National Academies Press (US); 2013.

Keehan SP, Cuckler GA, Sisko AM et al. National health expenditure projections, 2014-2024: spending growth faster than recent trends. Health Aff (Millwood). 2015;34(8):1407-1417.

Darouiche RO, Wall MJ Jr, Itani KM et al. Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis. N Engl J Med. 2010;362(1):1826.

Lee VS, Kawamoto K, Hess R et al. Implementation of a Value-Driven Outcomes Program to Identify High Variability in Clinical Costs and Outcomes and Association with Reduced Cost and Improved Quality. JAMA. 2016;316(10):1061-1072.

Sanders GD, Neumann PJ, Basu A et al. Recommendations for Conduct, Methodological Practices, and Reporting of Cost-effectiveness Analyses: Second Panel on Cost-Effectiveness in Health and Medicine. JAMA. 2016;316(10):1093-1103.

Centers for Medicare & Medicaid Services. National health expenditures; aggregate and per capita amounts, annual percent change and percent distribution: calendar years 1960-2014. http://www.cms.gov/ research-statistics-data-and-systems/statistics-trends-and-reports/ nationalhealthexpenddata/nationalhealthaccountshistorical.html. Accessed December 30, 2016.

Young RA, Bayles B, Benold TB, Hill JH, Kumar KA, Burge S. Family physicians’ perceptions on how they deliver cost-effective care: A qualitative study from the Residency Research Network of Texas (RRNeT). Fam Med. 2013;45(5):311-318.

Chenoweth DH, Garrett J. Cost-effectiveness analysis of a worksite clinic: Is it worth the cost? AAOHN J. 2006;54(2):84-89.

Pachman JS, Stempien DE, Milles SS, O’Neill FN. The hidden savings of an on-site corporate medical center. J Occup Environ Med. 1996;38(10):1047-48.

Kocher MS, Henley MB. It is money that matters: Decision analysis and costeffectiveness analysis. Clin Orthop Relat Res. 2003;413(8):106-116.

Ryder HF, McDonough C, Tosteson AN, Lurie JD. Decision analysis and costeffectiveness analysis. Semin Spine Surg. 2009 21(4):216–222.

Author Information Associate Professor and Director of Neuroanesthesiology (Kurnutala), Department of Anesthesiology, University of Mississippi Medical Center, Jackson. (Kurnutala) (Dang) (Nguyen). Department of Anesthesiology, Henry Ford Hospital, Detroit, MI (Sibai). The authors have no financial disclosures or conflicts of interest to disclose.

Corresponding Author: Lakshmi N. Kurnutala MD; Department of Anesthesiology and Pain Medicine; University of Mississippi Medical Center, 2500 N. State St., Jackson, MS 39216. Phone: (601) 984-5900; Fax: (601) 984-5915 (lkurnutala@umc.edu).

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A Case of Metastatic Melanoma of the Heart Diagnosed Antemortem MADISON H. WILLIAMS, MD; DORIS HANSEN, MD; NATALE SHEEHAN, MD

Abstract Melanoma can commonly metastasize to the heart, yet this is rarely recognized antemortem. In addition to describing a case of metastatic melanoma of the heart, this report will briefly discuss current immunotherapies available for metastatic melanoma. Moreover, we will discuss side effects of these therapies. The importance of recognizing this rare entity will also be highlighted. Early diagnosis and treatment have a significant impact on patient outcomes.

Introduction Melanoma is an aggressive skin cancer with an incidence that is increasing rapidly in the United States, and worldwide.1 Cutaneous melanoma metastasizes most commonly to the lungs, liver, brain, and bone. Melanoma also has a propensity for cardiac involvement, with greater than 50% of autopsies of patients with metastatic melanoma demonstrating cardiac metastases.2,3 Despite the frequency of cardiac involvement, metastatic melanoma of the heart is rarely diagnosed antemortem due to non-specific clinical symptoms on presentation.

Review of current literature reveals a limited number of such cases.

Here we report a case of metastatic melanoma of the heart diagnosed antemortem.

subcentimeter pulmonary nodules. Magnetic resonance imaging of the brain was also performed and was negative for any intracranial lesions. Patient then underwent resection of the right atrial mass with reconstruction of the right atrium, along with a superior vena cava to right atrial bypass. Surgical pathology revealed metastatic melanoma with positive resection margins and lymphovascular invasion. BRAF mutation analysis was performed and returned negative. Postoperative positron emission tomography demonstrated low-level 18-fluoro-2-deoxyglucose (FDG) uptake in the cardiac atria, a mildly FDG-avid right lower lobe lung nodule, and focal uptake in the left subscapularis muscle and the manubrium.

Figure 1. Echocardiogram demonstrating right atrial mass (denoted as T)

Case Report A 64-year-old white male with heart failure with reduced ejection fraction, coronary artery disease, and left shoulder melanoma status post wide local excision 10 years prior presented with chest pain and shortness of breath with exertion. He also reported associated weakness and dizziness along with a 25-pound weight loss in the three months prior to presentation. Initial workup, including an electrocardiogram with no ST or T-wave changes and an elevated troponin, was consistent with the diagnosis of a non-ST elevation myocardial infarction. Subsequent cardiac catheterization did not reveal any stenotic lesions. However, transthoracic echocardiogram and transesophageal echocardiogram demonstrated a large right atrial mass (Figure 1) with compression of the superior vena cava concerning for a myxoma. To evaluate this mass further, computed tomography of the chest, abdomen, and pelvis was obtained which revealed a 4.5-centimeter lobulated mass in the right atrium (Figure 2), thought to be consistent with a myxoma, and several

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RV = right ventricle; LV = left ventricle; RA = right atrium; LA = left atrium

Figure 2. Computed tomography of the chest demonstrating right atrial mass (denoted as A)

Figure 3. Immune-mediated macular papular erythematous rash on upper extremities and chest

JAMA Dermatol. 2015;151(11):1206-1212.

After discussion of this case at tumor conference and review of pathology, he was treated with ipilimumab and nivolumab.

Ipilimumab is an anti-cytotoxic T-lymphocyte associated antigen 4 (CTLA-4) antibody that up-regulates anti-tumor immunity.

Ipilimumab was the first immune checkpoint inhibitor to be associated with prolonged survival in patients with metastatic melanoma.4 Nivolumab, a monoclonal antibody that targets the programmed death 1 (PD-1) receptor protein, has been shown to prolong overall survival in patients with metastatic melanoma.5 The administration of a combination of CTLA-4 immunotherapy (ipilimumab) plus PD-1 immunotherapy (nivolumab) has demonstrated improved levels of anti-melanoma activity when compared to monotherapy with either agent.6,7,8 However, combination immunotherapy is also associated with increased toxicity.8 Both ipilimumab and nivolumab can cause immune-mediated adverse reactions due to activation of T cells. These reactions include dermatitis, colitis, pneumonitis, nephritis, hypo/hyperthyroidism, and adrenal insufficiency.

This patient completed three cycles of ipilimumab and nivolumab.

His treatment course was complicated by grade II immunemediated dermatitis (Figure 3) which occurred after each cycle of immunotherapy and resolved with topical hydrocortisone. He also required hospitalization for pneumonia and central adrenal insufficiency, attributed to treatment with immunotherapy. Our patient has since been maintained on systemic corticosteroids. After this hospitalization, it was felt that our patient would be unlikely to

tolerate continued immunotherapy. Further treatment was held, and follow-up PET-CT imaging has continued to reveal no evidence of disease 5 months after starting treatment.

Discussion Metastatic melanoma of the heart is typically diagnosed postmortem rather than antemortem, as it was in this case, given that it is usually clinically silent or masked by symptoms of other visceral metastases.

Melanoma is known to commonly involve the heart, but many cases go unrecognized. As such, the majority of reported cases of metastatic melanoma of the heart are diagnosed at autopsy. Similar to other reported cases of metastatic melanoma that are diagnosed antemortem, our patient presented with non-specific symptoms, such as shortness of breath with exertion and chest pain. In contrast to many prior case reports, our patient had no significant cardiac findings on physical exam, emphasizing the importance of high clinical suspicion for cardiac metastasis in a patient with a history of melanoma.

This case demonstrates the importance of considering potential cardiac metastasis in patients who have a history of melanoma and present with cardiac symptoms. It is often clinically difficult to diagnose but is important in determining therapeutic interventions and prognosis. If cardiac metastasis is suspected, further investigation with routine echocardiogram should be performed, as this can have

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a significant impact on survival. Early diagnosis and characterization of the extent of cardiac involvement can identify patients that would benefit from surgical resection. Post-op, further systemic therapy is indicated. Cytotoxic chemotherapy has been used in the past without much success for cardiac melanoma. However, immunotherapy and targeted therapies have shown improved survival rates in patients with metastatic melanoma. Q References 1. Kohler BA, Sherman RL, Howlader N, et al. Annual report to the nation on the status of cancer, 1975-2011, featuring incidence of breast cancer subtypes by race/ethnicity, poverty, and state. J Natl Cancer Inst. 2015; 107(6).

2. Glancy DL, Roberts WC. The heart in malignant melanoma: a study of 70 autopsy cases. Am J Cardiol. 1968; 21:555-571.

3. Klatt EC, Heitz DR. Cardiac metastases. Cancer. 1990; 65:1456-1459.

4. Schadendort D, Hodi FS, Robert C, et al. Pooled analysis of long-term survival

data from phase II and phase III trials of Ipilimumab in unresectable or metastatic melanoma. J Clin Oncol. 2015; 33(17):1889-1894.

5. Robert C, Long GV, Brady B, et al. Nivolumab in previously untreated melanoma without BRAF mutation. N Engl J Med. 2015; 372(4):320-330.

6. Wolchok JD, Kluger H, Callahan MK, et al. Nivolumab plus ipilimumab in advanced melanoma. N Engl J Med. 2013; 369(2):122-133.

7. Postow MA, Chesney J, Pavlick AC et al. Nivolumab and ipilimumab versus ipilimumab in untreated melanoma. N Engl J Med. 2015; 372(21):2006-2017.

8. Larkin J, Chiarion-Silenia V, Gonzalez R et al. Combined nivolumab and ipilimumab or monotherapy in untreated melanoma. N Engl J Med. 2015; 373(1):23-34.

Author Information University of Mississippi Medical Center, Department of Internal Medicine (Williams). University of Mississippi Medical Center, Department of Internal Medicine, Division of Hematology/Oncology (Hansen; Sheehan).

Corresponding Author: Madison Williams, MD, 11118 Pomona Park Drive, San Antonio, TX 78249 (williamsm7@uthscsa.edu).

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Leaves of Three, How Bad Can It Be? CAITLIN A. COCHRAN, BS; DANIELLE KEYES, MPH; CAROLINE DOO, MD; THY HUYNH, MD; JULIE WYATT, MD

Abstract Figure 1.

Poison ivy is a common cause of allergic contact dermatitis. A rare phenomenon, black spot poison ivy, presents with poison ivy covered by black lacquer-like deposits. Another equally rare phenomenon is the development of erythema multiforme in association with severe poison ivy.1-4 The treatment of mild poison ivy contact dermatitis usually requires only topical therapies, but more severe cases require systemic approaches.1,5 A 36-year-old male with black spot poison ivy treated with topical, intramuscular, and oral steroids who subsequently developed secondary erythema multiforme is presented.

Key Words: Allergic contact dermatitis; Toxicodendron species; Black spot poison ivy; Erythema multiforme Introduction Dermatitis caused by the Anacardiaceae family includes poison ivy, poison oak, and sumac. This accounts for more cases of contact dermatitis than all other plants combined.6 More specifically, the genus Toxicodendron contains a majority of the allergenic species including those previously mentioned.7 Medical treatment is required for 25 to 40 million Americans each year.1,8 The allergen associated with the delayed type hypersensitivity reaction of Toxicodendron allergic contact dermatitis is a phenolic lipid known as urushiol.1 Patients and primary care physicians can generally appreciate the severe itching and classic linear papulovesicular rash of poison ivy. A rare presentation, black spot poison ivy, is more commonly overlooked. Another rare phenomenon that has been associated with poison ivy is secondary erythema multiforme.2-4,9 This phenomenon has been reported in individuals with more severe poison ivy allergic contact dermatitis and may represent an underreported association.2 A rebound effect can occur following treatment with both topical and systemic corticosteroids when the course of treatment is too short.1,7

Patient’s left volar forearm on day 1 depicting erythematous plaque with ulceration and black spots.

Figure 2.

Case Summary A 36-year-old male presented with a two-week history of rash on the left forearm and a secondary rash on the abdomen following contact with a vine which he documented with a series of four “selfies.” (Figure 1 and 2)

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Patient’s left volar forearm on day 3 depicting erythematous plaque with ulceration and black spots with vesicles and crust.

The rash was associated with severe pruritus, erythema, and exudate. A five-day tapering course of oral prednisone and an IM injection of 1 cc of triamcinolone 40mg/cc along with topical betamethasone 0.05% cream led to modest improvement and then a flare. (Figure 3 and 4) His past medical history was significant for celiac disease and chronic sinusitis.

Dermatologic examination revealed large edematous red plaques with erosions on bilateral ventral forearms with greater involvement of the right arm. Scattered symmetric erythematous, edematous, targetoid plaques were present on the abdomen. (Figure 5)

weeks. The patient experienced a mild headache, which resolved with ibuprofen, after the first dose of cyclosporine. The pruritus resolved within 24 hours. The rash from allergic dermatitis steadily improved and completely resolved by day 20 after cyclosporine was initiated. Mild targetoid lesions associated with erythema multiforme continued to occur even six weeks after cyclosporine was completed. No antibiotics were used during the treatment course.

A diagnosis of black spot poison ivy with secondary erythema multiforme was made. Treatment was initiated with cyclosporine 4 mg/ kg by mouth daily for one week and tapered over the subsequent two

The Anacardiaceae family of plants is widely distributed across the United States. (Table 1) Toxicodendron radicans and Toxicodendron rydbergii are the two poison ivy species that are colloquially known as Eastern (or common) poison ivy and Western (or Northern) poison ivy, respectively. The two poison oak species are Toxicodendron toxicarium (Eastern poison oak) and Toxicodendron diversilobum (Western poison oak). There is one species of poison sumac, Toxicodendron vernix.7

Figure 3.

Discussion

Identification of the plants that can cause an allergic contact dermatitis is critically important for preventing the development of allergic contact dermatitis or recurrence of the condition.1 Toxicodendron plants have compound leaves, meaning they have at least three leaflets that compose each leaf. This feature is what led to the old adage, “Leaves of three; leave them be.”7 All the Toxicodendron species possess green fruit clusters found in the angle between the leaf and twig from where it grows. The clusters of fruit will turn off-white as they mature in the fall.

Patient’s left volar forearm on day 4 depicting violaceous erythema with a linear bulla and a central black linear patch.

Additionally, Toxicodendron species will leave a “U” or “V”-shaped scar when a leaf stalk falls from the plant.1,7 The species can be further identified based on number of leaflets and growth patterns.

Toxicodendron radicans typically has oval leaflets found in groups of three with the longest and biggest leaflet found in the center. This species is commonly found along streams, trails, or roads, and usually has aerial rootlets that allow it to climb like a vine. Toxicodendron rydbergii is similar

Figure 4.

Figure 5.

Patient’s left volar forearm on day 4 depicting black spot with ulceration and crust with lymphangitis.

Patient’s abdomen on day 19 with targetoid violaceous edematous plaques.

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Table 1. Geographic distribution of the most common species in the Toxicodendron genus that cause allergic contact dermatitis in the United States.

Plant images represent the species that can be found in Mississippi.

Source: USDA, NRCS. 2018. The PLANTS Database (http://plants.usda.gov, 22 May 2018). National Plant Data Team, Greensboro, NC 27401-4901 USA.10-12

to Toxicodendron radicans but typically has thicker stems and more commonly grows like a shrub because it does not have aerial rootlets as frequently. Toxicodendron toxicarium has three to five oval leaflets per leaf and grows in sandy soils or disturbed ground in a shrub-like manner. Toxicodendron diversilobum also has three to five oval leaflets per leaf but has aerial roots allowing it to grow as a vine in canyons, riparian habitats, and on tree trunks. Finally, Toxicodendron vernix is found mostly in swampy areas as bushes with leaves composed of seven to 13 leaflets organized in pairs with a central rib and one leaflet at the end.1 (Table 1)

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Urushiol, also known as oleoresin, is a chemical compound that is found in the sap of plants in the Anacardiaceae family. The chemical compounds found in the different species are very similar; they are 1,2-dihydroxybenzenes with a 15-carbon-atom side chain in the third position.13,14 The resin canals in the plant do not communicate with the leaf surface under normal conditions, and therefore, physical contact with the plants will only cause a hypersensitivity reaction if the plant surface has been damaged.1,15 However, it is important to note that the plants will release urushiol in the absence of damage during late fall.7 The

sap of the plant is also found in the stem or other plant parts that can be present even in the absence of leaves like in the winter.1,9 Prevention is best accomplished by avoiding allergen exposure altogether. The use of skin protectants (zinc acetate, zinc carbonate, and zinc oxide) prior to exposure and rinsing of the exposed area within 30 minutes after contact can minimize the allergic reaction. If rinsing begins at ten minutes after exposure, fifty percent of the oil can be removed; however, at thirty minutes after exposure, only ten percent of the oil is removed. Patients should be advised to rinse affected areas gently as soon as possible after exposure.1,7 Urushiol is typically colorless or light yellow but turns black when it is exposed to air due to polymerization and subsequent oxidation.1 Once the sap is present on the skin, clothing, or under the nails, it can persist for weeks and even months. The urushiol present on the skin acts as a hapten, which is absorbed through the skin and taken up by Langerhans cells and macrophages in the epidermis and dermis, respectively. These cells then travel to the lymph nodes and activate CD4 T lymphocytes which subsequently produce clones of effector and memory T cells specific for the urushiol antigen. After the first exposure to the antigen, the clonal T lymphocytes will cause symptoms within 24 to 48 hours of exposure.1 Patients with poison ivy contact dermatitis will characteristically present with a generalized, pruritic, erythematous rash with vesicles and papules in a linear distribution. In rare cases, patients will present with black lacquer-like macules with surrounding edema, background erythema, and vesicles. This special variant of poison ivy will occur if the patient is exposed to a high concentration of the urushiol that is not diluted.15, 9,16 This concentrated urushiol is oxidized on exposure to air, turning black within the first 24 hours after exposure. Interestingly, this has been used as a method of identifying poison ivy in the field. When the leaves are placed on white paper, crushed, and then discarded, there will be a resulting black stain within a few minutes of exposure to the air.17 The concentrated resin or urushiol in black spot poison ivy can deposit on almost any surface, including the skin and clothing. It can present asymptomatically in some cases where they appear to be black lesions that the person cannot wash off. The same resin can deposit in clothing which, even after washing or boiling, can indefinitely cause allergic contact dermatitis.7,9 Histologic findings of allergic contact dermatitis due to poison ivy include perivascular lymphohistiocytic infiltration and subepidermal blisters with eosinophils and eosinophilic spongiosis. The black spot variant specifically demonstrates yellow amorphous material representing the urushiol in the stratum corneum along with epidermal necrosis with nucleolar fragments and neutrophils.9,15 Mild Toxicodendron allergic contact dermatitis is managed with symptomatic treatments such as lukewarm baths, calamine lotion, and oral antihistamines. The goal of topical therapy is to control the pruritus. High potency topical corticosteroids do not alter the disease progression of contact dermatitis after vesicles have formed, but they

have been shown to improve pruritic symptoms of patients.18 When more than 25% body surface area is affected, when blistering or pruritus are severe, or when there is significant involvement of the hands, face, or genitalia, systemic treatment is indicated.5 The most common systemic treatment for adults is oral prednisone up to 1–2 mg/kg/day for a period of seven to 10 days, tapered over two weeks. It is important not to prescribe a pre-packaged course of oral glucocorticoids, such as a methylprednisolone dose pack, as the dosage is too low and the taper is too short to provide adequate treatment and increases the likelihood of a relapse.1,5 Alternatively, we recommend cyclosporine at 4 mg/kg/day tapered weekly over three weeks can be used as a first line of treatment especially if the patient has relative contraindications to steroids such as diabetes.

Erythema multiforme is a hypersensitivity reaction associated with certain infections such as Herpes simplex virus and medication exposures. It has been reported after the development of severe poison ivy allergic contact dermatitis that required systemic treatment. Some authors speculate that while rare, it is also underreported.2,3 There is little correlation between the timing of systemic steroid treatment and the onset of the rash. Therefore, it is unlikely that this is a reaction to the systemic steroids.2-4 Other less common causes of contact dermatitis that have been associated with erythema multiforme and erythema multiforme-like reactions include nickel, essential oils, laurel oil, and topical triamcinolone.3,19-21 Cyclosporine is a favored treatment for intermittent or severe erythema multiforme due to its rapid onset of action and mechanism of action which targets explicitly activated helper CD4+ T lymphocytes and prevents their production of IL2.22 In summary, reactions from poison ivy can range from mild to severe.

This form of contact dermatitis can cover large portions of the body including sensitive areas like the face and genitals. It is typically associated with severe itching that can lead to scratching and secondary infection.

Rare presentations include black spot poison ivy and secondary erythema multiforme in association with severe poison ivy. Prevention of the initial rash can be achieved by avoiding the plant, using skin protectants, , and washing immediately following exposure. Appropriate treatment with topical and systemic agents can help minimize any secondary complications. Q Mythbusters • Plants with “leaves of three” are not the only types of plants that can cause an allergic contact dermatitis. Poison sumac with seven to 13 leaflets contains the same Rhus antigen.1 • Vesicular fluid does not contain antigen and, therefore, is not responsible for spreading the rash.1 • A pre-packaged course of oral methylprednisolone, such as a methylprednisolone dose pack, is not an adequate treatment for poison ivy allergic contact dermatitis and can lead to a rebound effect.5

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Acknowledgment We would like to acknowledge Dr. Stephen E. Helms for his contribution to the title of this publication.

References 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

Gladman AC. Toxicodendron Dermatitis: Poison Ivy, Oak, and Sumac. Wild Environ Med. 2006;17(2):120-128.

Werchniak AE, Schwarzenberger K. Poison ivy: An underreported cause of erythema multiforme. J Am Acad Dermatol. 2004;51(5, Supplement):S159-S160.

Cohen LM, Cohen JL. Erythema multiforme associated with contact dermatitis to poison ivy: three cases and a review of the literature. Cutis.

1998;62(3):139-142.

Schwartz RS, Downham TF 2nd. Erythema multiforme associated with Rhus contact dermatitis. Cutis. 1981;27(1):85-86.

Brodell RT, Williams L. Taking the itch out of poison ivy. Are you prescribing the right medication? Postgrad Med. 1999;106(1):69-70.

McGovern Maj MCUSATW, Barkley PhD TM. Botanical dermatology. Int J Dermatol. 1998;37(5):321-334.

Bolognia J, Jorizzo JL, Schaffer JV. Dermatoses Due to Plants. Dermatology. Vol 1. 3 ed. [Philadelphia]: Elsevier Saunders; 2012:281-287.

Epstein WL. Occupational poison ivy and oak dermatitis. Dermatol Clin.

1994;12(3):511-516.

Kurlan JG, Lucky AW. Black spot poison ivy: A report of 5 cases and a review of the literature. J Am Acad Dermatol. 2001;45(2):246-249.

Jennifer Anderson, hosted by the USDA-NRCS PLANTS Database USDA, NRCS. 2018. The PLANTS Database. http://plants.usda.gov. National Plant Data Team, Greensboro, NC: USDA, NRCS; 2018. Accessed March 30, 2018.

Mohlenbrock RH, hosted by the USDA-NRCS PLANTS Database / USDA SCS. 1991. Southern wetland flora: Field office guide to plant species. South National Technical Center, Fort Worth. Atlantic Poison Oak. USDA, NRCS. 2018. The PLANTS Database. http://plants.usda.gov. National Plant Data Team, Greensboro, NC: USDA, NRCS; 2018. Accessed March 30, 2018.

Mohlenbrock RH, hosted by the USDA-NRCS PLANTS Database / USDA SCS. 1991. Southern wetland flora: Field office guide to plant species. South

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National Technical Center, Fort Worth. Poison Sumac. USDA, NRCS. 2018.

The PLANTS Database. http://plants.usda.gov. National Plant Data Team, Greensboro, NC: USDA, NRCS; 2018. Accessed March 30, 2018.

Kligman AM. Poison ivy (rhus) dermatitis: An experimental study. AMA Arch Derm. 1958;77(2):149-180.

Schram SE, Willey A, Lee PK, Bohjanen KA, Warshaw EM. Black-spot poison ivy. Dermatitis. 2008;19(1):48-51.

McClanahan C, Asarch A, Swick BL. Black spot poison ivy. Int J Dermatol.

2014;53(6):752-753.

Mallory SB, Hurwitz RM. Black-spot poison-ivy dermatitis. Clin Dermatol.

1986;4(2):149-151.

Guin JD. The black spot test for recognizing poison ivy and related species. J Am Acad Dermatol. 1980;2(4):332-333.

Vernon HJ, Olsen EA. A controlled trial of clobetasol propionate ointment 0.05% in the treatment of experimentally induced Rhus dermatitis. J Am Acad Dermatol. 1990;23(5 Pt 1):829-832.

Huber J, deShazo R, Powell D, Duffy K, Hull C. Erythema Multiforme– Like Allergic Contact Dermatitis to Turmeric Essential Oil. Dermatitis.

2016;27(6):385-386.

Athanasiadis GI, Pfab F, Klein A, Braun-Falco M, Ring J, Ollert M. Erythema multiforme due to contact with laurel oil. Contact Dermatitis. 2007;57(2):116118.

Smart DR, Powell DL. Erythema multiforme-like allergic contact reaction to topical triamcinolone. Dermatitis. 2014;25(2):89-90.

Bakis S, Zagarella S. Intermittent oral cyclosporin for recurrent herpes simplexassociated erythema multiforme. Australas J Dermatol. 2005;46(1):18-20.

Author Information M4, Louisiana State University Health Sciences Center, Shreveport (Cochran).

University of South Alabama College of Medicine, Mobile (Keyes). PGY-2, Department of Dermatology, University of Mississippi Medical Center, Jackson. (Doo)(Huynh).

Associate Professor in Dermatology, University of Mississippi Medical Center, Jackson (Wyatt).

Corresponding Author: Julie Wyatt, MD; UMMC Department of Dermatology, 2500 N. State St.,Jackson, MS 39216.

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Top 10 Facts You Need to Know about Endometriosis LAUREN H. RAMSEY, PHARMD; LAURIE W. FLEMING, PHARMD

Introduction Endometriosis is the presence of uterine lining found outside of the uterus, usually found on or under the ovaries, fallopian tubes, bowel, bladder or behind the uterus. It is a chronic, estrogen-dependent inflammatory disease with symptoms ranging from mild to severe.

While clinical presentation can overlap with other gastrointestinal and gynecological conditions, symptoms of endometriosis typically include dysmenorrhea and menorrhagia.1

1

About one out of every 10 women is affected by endometriosis during her reproductive years. The approximate prevalence of endometriosis is 11%, with patients 25-29 years old being affected the most.2 Risk factors for endometriosis include lower body mass index, nulliparity, early menarche, irritable bowel syndrome and fibrocystic breast disease.1

2

The incidence of endometriosis is 10-fold higher in women with infertility compared to women who are fertile.

The majority of endometriosis diagnoses occur during investigation into the cause of infertility, with 21-30% of patients with infertility having comorbid endometriosis.1

3

There is a genetic link associated with the risk of having endometriosis. The risk of developing endometriosis is estimated to be four to eight times higher in patients with a first-degree relative who has the disease, with maternal and paternal factors contributing. The suggested genetic mechanism is currently considered to be polygenetic and multifactorial. However, future investigation into genetic testing may be warranted.3

4

The median time to diagnosis of endometriosis is seven years. Most women with endometriosis have an average of seven primary care office visits before a referral to a specialist.

The time to diagnosis can range from four to 10 years, and the only definitive diagnostic test is visualizing the female reproductive system through laparoscopy.4

5

Endometriosis is commonly associated with mood disorders. Of all patients with endometriosis, approximately 86.5% of patients have depressive symptoms, and 87.5% have

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with anxiety symptoms. Both age and severity of symptoms have a significant correlation with mood disorders. The delay in diagnosis of endometriosis and infertility can further exacerbate depressive symptoms in these under-diagnosed patients.5

6

Endometriosis increases the risk of pregnancy complications. Patients with endometriosis have a higher risk of ectopic pregnancy and miscarriage. It is also associated with increased risk of placenta praevia, antepartum hemorrhage, postpartum hemorrhage, and preterm births in pregnancies after 24 weeks.6

7

Pregnancy can relieve symptoms of endometriosis. The mechanism behind the relief of symptoms is thought to be due to the hormonal changes, notably the increase in progesterone, that occur during pregnancy. However, most patients do have symptom recurrence postpartum.7

8

Endometriosis is a chronic disease. Although the disease is incurable, the symptoms can be managed with pharmacological and surgical treatment. The choice of treatment is based the patients’ individual symptoms and severity, desire for future fertility, disease location, cost, and possibility of surgical measures.8

9

Several pharmacological treatment options may improve symptoms. Pharmacological treatments include oral combined contraceptives (OCP), progestins, gonadotropinreleasing hormone (GnRH) agonists, danazol, nonsteroidal antiinflammatory drugs (NSAIDs), and aromatase inhibitors (see Table 1). Oral norethindrone and depot medroxyprogesterone acetate are FDA-approved for pain associated with endometriosis. Danazol, although very effective, typically has more severe side effects, limiting its use. Aromatase inhibitors have shown some efficacy, but no sufficient data exists to recommend their routine use. Initial treatment for patients who desire fertility is OCP with an NSAID. Oral or depot medroxyprogesterone may be added to this therapy in patients who are refractory to initial therapy. The second-line treatment option is a three-month course of a GnRH agonist. In patients who have failed all of the above therapies, a 12-month course of a GnRH agonist is FDA approved.8

Table 1. Pharmacological Treatment Options8

Medication Classes and Commonly Used Agents Combined Oral Contraceptives Norethindrone/ethinyl estradiol Norethindrone/mestranol Progestins Depot medroxyprogesterone acetate Oral medroxyprogesterone acetate Norethindrone Mirena intrauterine device GnRH Agonists Goserelin Leuprolide Nafarelin Triptorelin Androgen Danazol Nonsteroidal Anti-inflammatory Drugs Naproxen Ibuprofen Ketoprofen Mefenamic acid Aromatase Inhibitors Anastrazole Letrozole

10

Surgical treatment options are also available for refractory disease. Laparoscopic surgery removal of the endometriomas is the gold-standard surgical treatment for endometriosis, with studies showing a decrease in overall pain.

Laparoscopy also improves the live birth rate, and this intervention is superior to drainage and ablation of the cyst wall. However, most patients have symptom recurrence, with a 36% chance of requiring further surgery.8,9 Hysterectomy is a surgical treatment option usually reserved for patients who have failed all other therapies. The efficacy of a hysterectomy is associated with the removal of the endometriomas and the induction of menopause. Surgery with ovary conservation was associated 6.1 times greater risk of redeveloping pain and 8.1 times greater risk of reoperation. Therefore, a hysterectomy without ovary conservation is recommended.10 Q References 1. Ballard KD, Seaman HE, De Vries CS, et al. Can symptomatology help in the diagnosis of endometriosis? Findings from a national case-control study – Part 1. BJOG. 2008; 115: 1382-1391.

2. Buck Louis GM, Hediger ML, Peterson CM, et al. Incidence of endometriosis by study population and diagnostic method: the ENDO Study. Fertil Steril.

2011; 96: 360-365.

3. Stefansson H, Geirsson RT, Steinthorsdottir V, et al. Genetic factors contribute

to the risk of developing endometriosis. Hum Reprod. 2002; 17: 555-559.

4. Nnoaham KE, Hummelshoj L, Webster P, et al. Impact of endometriosis on quality of life and work productivity: a multicenter study across ten countries.

Fertil SteriI. 2011; 96: 366-378.

5. Sepulcri RP, Amarai VF. Depressive symptoms, anxiety, and quality of life in women with pelvic endometriosis. Eur J Obstet Gynecol Reprod Biol. 2009; 142: 53-56.

6. Saraswat L, Ayansina DT, Cooper KG, et al. Pregnancy outcomes in women with endometriosis: a national record linkage study. BJOG. 2017; 124: 444452.

7. Missmer SA, Hankinson SE, Speigelman D, et al. Incidence of laparoscopically confirmed endometriosis by demographic, anthropometric and lifestyle factors. Am J Epidemiol. 2004; 160: 784-796.

8. Practice bulletin no. 114: management of endometriosis. Obstet Gynecol. 2010; 116: 223-236.

9. Duffy JM, Arambage K, Correa FJ, et al. Laparoscopic surgery for endometriosis. Cochrane Database Syst Rev. 2014; 4: 1-79.

10. Namnoum AB, Hickman TN, Goodman SB, et al. Incidence of symptom recurrence after hysterectomy for endometriosis. Fertil Steril. 1995; 64: 898902.

Author Information University of Mississippi School of Pharmacy (Ramsey). Clinical Associate Professor, University of Mississippi School of Pharmacy (Fleming).

Corresponding Author: Lauren Ramsey, PharmD. Lhramsey1@gmail.com.

(601)968-2778.

Laurie Fleming, PharmD, Clinical Assistant Professor of Pharmacy Practice, 2500 North State Street, Jackson, MS 39216. Lwfleming@umc.edu. (601)948-2620.

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The Top 10 Facts You Need to Know about Women in Medicine AVANI PATEL, M4 AND MICHELLE SHETH, MD Introduction The American Medical Association’s Women in Medicine Month, celebrated during September, serves as a platform to highlight the accomplishments of female physicians in addition to emphasizing the importance of advocacy-related efforts regarding female physicians and health issues impacting female patients. The theme for 2018 is “Celebrating Our Legacy, Embracing Our Future.”1 In fact, if you have ever given birth, received a blood transfusion, or even had lifesaving radiation therapy, then you have experienced one of the many healthsaving advancements gifted to us by women in medicine. In celebration of AMA’s Women in Medicine Month, here are facts about 10 women who have left quite the contribution to science and medicine.

1

Elizabeth Blackwell, MD: Dr. Elizabeth Blackwell was the very first female to earn the M.D. degree.

She graduated from New York’s Geneva Medical College in 1849. Dr. Blackwell initially worked as a teacher and never wanted to pursue a career in medicine; however, when a close friend who was dying suggested she would have been spared her worst suffering if her physician had been a woman, she turned to medicine. In 1857, she co-founded the New York Infirmary for Women and Children. She also authored several books addressing women and medicine.2

2

BLACKWELL

Virginia Apgar, MD: Dr. Virginia Apgar (1909-1974) was an obstetrical anesthesiologist known for developing the Apgar score in 1952.3 She standardized the evaluation of infants at birth before the era of fetal monitor. Dr. Apgar was also the first female to earn the title of full professor at the College of Physicians and Surgeons at Columbia University in 1949 and served as their director of the division of Anesthesia. Dr. Apgar was an outspoken advocate for universal vaccination for all pediatric patients during the rubella pandemic of 1965 to prevent mother to child transmission.4 Ultimately, Dr. Apgar went on to serve fifteen years with the March of Dimes in a variety of capacities.

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3

Françoise Barré-Sinoussi: Parisian scientist Francoise BarréSinoussi was distinguished for her discovery of HIV as the cause of AIDS. Barré-Sinoussi, along with Luc Montaigner, discovered that the HIV retrovirus attacked lymphocytes, a blood cell that is vital to the body’s immune system. Her discovery has been crucial in helping millions who are living with the disease and has paved the way for improved treatment methods for AIDS patients.5

4

Marie Curie: Polish mathematician and scientist, Marie Curie, collaborated with her husband, Pierre Curie, to discover two chemical elements in the periodic table, polonium and radium.

Both chemical elements are more radioactive than uranium and have been important resources for scientific experiments and advancements in medicine such as the development of the x-ray, which remains a vital diagnostic device today. Curie earned a Nobel Prize with her husband in Physics in 1903. In 1911, she earned another in Chemistry.

Following her husband’s death in 1906, Curie took her place as Professor of General Physics in the Faculty of Sciences at Sorbonne, which was the first time a woman had held this position. She was also appointed Director of the Curie Laboratory in the Radium Institute of the University of Paris, founded in 1914. In 1921, President Harding of the United States presented her with one gram of radium in recognition of her service to science.6

5

Susan Love, MD, MBA: In addition to being an author, professor and member of the National Cancer Advisory Board under President Clinton, Dr. Susan Love co-founded the National Breast Cancer Coalition. Above all, she was an advocate for her patients. In 1983, she founded Dr. Susan Love Research Foundation, an active research program centered on breast cancer cause and prevention. Dr. Love was diagnosed with leukemia in 2012 and underwent chemotherapy and a stem cell transplant. She has returned to work and is determined to find a cure for cancer.7

6

Helen B. Taussig, MD: Dr. Helen Taussig is considered the founder of pediatric cardiology for her work with “blue baby” syndrome and co-developed the corrective surgical procedure for the congenital heart defect that caused anoxemia, which was considered a vital step in the development of adult open-heart surgery in the following years. Dr. Taussig also aided in the prevention of the

thalidomide birth defect crisis in the U.S. by testifying to the FDA on the negative effects the drug had caused in Europe. Also, in 1965 Dr. Taussig was elected president of the American Heart Association. Ten years later, she received the Medal of Freedom from President Lyndon Johnson.8

7

Rosalyn Sussman Yalow: Anyone who has required a blood transfusion can thank nuclear physicist Rosalyn Yalow. She was a recipient of the Nobel Prize in Physiology/Medicine in 1977 after developing radioimmunoassay, a technique used to measure the concentration of antigens, such as hormones, in the body. Her work made it possible to screen blood donations for infectious diseases.

Later, her technique allowed scientists to prove that type-2 diabetes is caused by the body’s inability to use insulin efficiently.9

8

Gertrude Belle Elion: This American chemist is responsible for many lifesaving drugs, but one to highlight is Purinethol – the first major drug used to fight leukemia. Her career choice was inspired by the death of her maternal grandfather from cancer. Elion worked to find a cure for cancer, ultimately developing 45 treatments helping the immune system to overcome cancer.10 In 1988, Elion won the Nobel Prize for Medicine. She also created various drug treatments for urinary tract infections, gout, malaria, herpes, and the prevention of organ transplant rejection. Another notable contribution of Elion was the first antiretroviral drug to treat AIDS, azidothymidine. In 1991, Elion was inducted into the National Women’s Hall of Fame.11

9

Patricia S. Goldman-Rakic: This American neuroscientist was the first researcher to chart the frontal lobe of brain fully. Also, she studied memory cells in the prefrontal cortex and discovered that the loss of dopamine in the prefrontal lobe led to the loss of memory. Her work on memory and behavior created a foundation for treating and understanding schizophrenia, cerebral palsy, Alzheimer's disease, and Parkinson's disease.12

10

Florence Nightingale: Florence Nightingale, also known as “Lady with the Lamp,” is credited as the foundational philosopher of modern nursing. During the Crimean War, Nightingale was in charge of caring for British and allied soldiers in Turkey. After returning to England, she established a nursing school to formalize nursing education based on science. In 1907, she was the first woman to be awarded the Order of Merit. Today, International Nurses Day is celebrated annually on May 12, her birthday.13 Q

Conclusion As you take this moment to reflect on the contributions these exceptional women have made to medicine and humanity, may you be both inspired and motivated to leave a legacy as great as the women above.

References 1.

Women In Medicine. American Medical Association. https://www.ama-assn. org. Accessed July 29, 2018.

2.

Changing the Face of Medicine. Elizabeth Blackwell. U.S. National Library of Medicine. https://cfmedicine.nlm.nih.gov/physicians/biography_35.html.

Published October 14, 2003. Updated June 3, 2015. Accessed January 13, 2018.

3.

Rose, David. Virginia Apgar. March of Dimes. https://www.marchofdimes. org/mission/virginia-apgar.aspx. Published May 28, 2009. Accessed January 13, 2018.

4.

Changing the Face of Medicine | Virginia Apgar. U.S. National Library of Medicine. https://cfmedicine.nlm.nih.gov/physicians/biography_12.html.

Published October 14, 2003. Updated June 3, 2015. Accessed January 13, 2018.

5.

Nobel Media AB 2018. Françoise Barré-Sinoussi – Facts. Nobelprize.org. https://www.nobelprize.org/nobel_prizes/medicine/laureates/2008/barresinoussi-facts.html. Accessed January 13, 2018.

6.

Nobel Media AB 2018. Marie Curie – Biographical. Nobelprize.org. https:// www.nobelprize.org/nobel_prizes/physics/laureates/1903/marie-curie-bio. html. Accessed January 13, 2018.

7.

Dr. Susan Love. Dr. Susan Love Foundation. https://www.drsusanloveresearch. org/dr-susan-love. Published May 31, 2017. Accessed January 13, 2018.

8.

Changing the Face of Medicine | Helen Brooke Taussig. U.S. National Library of Medicine. https://cfmedicine.nlm.nih.gov/physicians/biography_316.html.

Published October 14, 2003. Updated June 3, 2015. Accessed January 13, 2018.

9.

Nobel Media AB 2018. Rosalyn Yalow – Facts. Nobelprize.org. https://www. nobelprize.org/nobel_prizes/medicine/laureates/1977/yalow-facts.html.

Accessed January 13, 2018.

10. Nobel Media AB 2018. Gertrude B. Elion – Facts. Nobelprize.org. https:// www.nobelprize.org/nobel_prizes/medicine/laureates/1988/elion-facts. html. Accessed January 13, 2018.

11. The Editors of Encyclopaedia Britannica. Gertrude B. Elion. Encyclopaedia Britannica. https://www.britannica.com/biography/Gertrude-B-Elion.

Published November 15, 2017. Accessed January 13, 2018.

12. The Editors of Encyclopaedia Britannica. Patricia Shoer Goldman-Rakic.

Encyclopaedia Britannica. https://www.britannica.com/biography/PatriciaShoer-Goldman-Rakic. Published December 31, 2003. Accessed January 13, 2018.

13. Selanders, Louise. Florence Nightingale. Encyclopaedia Britannica. https:// www.britannica.com/biography/Florence-Nightingale. Published December 20, 2017. Accessed January 13, 2018.

Author Information Medical Student 4th Year, School of Medicine, University of Mississippi Medical Center, Jackson, MS (Patel). Associate Professor, Department of Anesthesiology, University of Mississippi Medical Center, Jackson, MS (Sheth).

Corresponding Author: Dr. Michelle Sheth; Associate Professor, Department of Anesthesiology, University of Mississippi Medical Center, 2500 N. State St., Jackson, MS 39216.

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An Unexpected Souvenir: Lyme Disease Presenting as Temporomandibular Joint Arthritis JESSE JUNCONG XIE, MD; RAVI CHANDRAN, DMD, PHD; NINA WASHINGTON, MD, MPH

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yme disease is an infectious disease caused by bacteria of the Borrelia family, most commonly Borrelia burgdorferi in North America. It is often transmitted by the Ixodes tick.1,2 It is rare in occurrence and most cases that occur in the southern United States are secondary to travel to northeastern parts of the county.3,4 Additionally, multiple studies done in the past have shown that there is no Lyme disease in Mississippi.5,6 Lyme disease is associated with multiple inflammatory and neurological symptoms such as arthralgia, arthritis, Bell’s palsy, severe headaches, encephalitis, and temporomandibular joint (TMJ) syndrome.6,7 TMJ arthritis secondary to Lyme Disease is often missed or lower on the differential. Hereby, new onset TMJ arthritis likely associated with acute Lyme disease is reported.

A 16-year-old male was referred to pediatric rheumatology clinic in September 2015 with a 6-week history of left temporomandibular joint pain and dislocation, bilateral forearm pain, occasional right patella pain, and fatigue. Two months prior to clinical evaluation, the patient had visited Massachusetts with subsequent development of a rash at the right scalp and neck area. He was initially diagnosed with infectious poison ivy and prescribed an antibiotic and prednisone. Ten days later, he developed left-sided Bell’s palsy, low-grade fever, and left mandibular pain. Though Bell’s palsy, rash, and left mandibular pain spontaneously resolved, he subsequently developed right mandibular deviation, dislocation, and pain. The patient was referred to an orthodontist who manually reduced the mandibular dislocation, prescribed a

Figure 1.

Figure 2.

Fig 1.

Fig 2.

Red arrow on MRI imaging indicates small fluid collection at the left temporomandibular joint, suggestive of inflammation.

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Red arrow on MRI imaging indicates a larger fluid collection at the right temporomandibular joint, suggestive of inflammation.

mouth guard and ibuprofen, and referred the patient to an oral and maxillofacial surgeon. MRI of the patient’s TMJ revealed bilateral fluid collection, left greater than right, with loss of signal intensity in the left condyle suggestive of joint infection versus inflammation (Figure 1 and 2). Pediatric rheumatology was consulted for possible underlying rheumatologic process.

TMJ aspiration and cultures were negative, but the patient demonstrated elevated ESR and CRP. Given the recent history of vacation in Massachusetts, TMJ arthritis secondary to Lyme disease was suspected. The patient was started on scheduled meloxicam with subsequent improvement in pain. Positive whole cell enzyme-linked immunosorbent assay (ELISA) followed by positive Lyme IgG and IgM antibodies on Western blot confirmed suspicion for a diagnosis of Lyme disease. Repeat positive serology that was sent to Mayo Clinic again confirmed diagnosis. The patient was then treated with doxycycline.

He also received bilateral TMJ diagnostic arthroscopy followed by arthrocentesis with joint lavage and intra-articular (IAC) corticosteroid injections of the TMJ’s. He experienced significant improvement in clinical symptoms and ultimate resolution of all Lyme arthritis symptoms.

Lyme disease in North America is most commonly caused by the bacteria Borrelia burgdorferi typically transmitted by the Ixodes tick.1 Due to temperature, vegetation, and difference in tick maturation stages, true Lyme disease is usually only found in the Northern United States.6 Specifically, there is no Borrelia burgdorferi and, therefore, no Lyme disease in Mississippi.5,6,7 However, many Lyme-like illnesses still occur in the southern parts of the country though not usually caused

by B. burgdorderi.3 Lyme induced TMJ arthritis is an uncommon condition with few documented cases. According to Center for Disease Control and Prevention (CDC) criteria for Lyme disease, patients must have erythema migrans or at least one late manifestation of the three systems (musculoskeletal, nervous, or cardiovascular) plus laboratory confirmation of infection. This case of TMJ involvement caused by Borrelia burgdorferi and confirmed by ELISA followed by Western blot suggests a rare manifestation of Lyme-induced inflammatory disease.

In this particular patient, the recurrent attacks of objective joint swelling at the TMJ confirmed by MRI satisfied criteria for late manifestation of the musculoskeletal system. With three stages in its pathogenesis (early localized infection, early disseminated infection, and late disseminated infection), early recognition and treatment is key to prevention of chronic arthritic disease.8,9 NSAIDs and IAC injections aid in decreasing pain and inflammation, but doxycycline is ultimately most effective in treating this disease process.9,10 In conclusion, Lyme disease should be considered in the differential diagnosis of patients with a history of travel to the Northeastern United States presenting with TMJ syndrome, Bell’s palsy, rash, and/or fatigue.

However, given that there is no Borrelia burgdorferi in Mississippi, Lyme disease should not be included in the differential without pertinent travel history to endemic areas. Q

References 1. Shapiro, E. Lyme Disease. N Engl J Med. 2014;370:1724-31.

2. Lesnicar, G; Zerdoner, D. Temporomandibular joint involvement caused by Borrelia Burgdorferi. J Cranio Maxill Surg. 2007;35:397-400.

3. Goddard, J; Varela-Stokes, A; Finley, R. Lyme disease like illnesses in the South. J Miss State Med Assoc. 2012;53(3):68-72.

4. Wanyura, H; Wagner, T; Samolczyk-Wanyura, D. Borrelia Burgdorferi – A potential aetiological factor in TMJ disorders? Preliminary report. J Cranio Maxill Surg. 2008;36:28-33.

5. Goddard J, Sumner JW, Nicholson WL, Paddock CD, Shen J, Piesman J. Survey of ticks collected in Mississippi for Rickettsia, Ehrlichia, and Borrelia species. J Vector Ecol. 2003;28:184-9.

6. Goltz L, Varela-Stokes A, Goddard J. Survey of adult Ixodes scapularis for disease agents in Mississippi. J Vet Ecol. 2013;38:401-3.

7. Aucott, J. Posttreatment Lyme disease syndrome. Infect Dis Clinic North Am. 2015;29(2):309-23.

8. Lee, H; Chu, P; King, Brett; Rosenberg, D. Limited opening secondary to Lyme disease in an 8-year-old child. J Dent Child. 2009;76(2):165-9.

9. Harris, R. Lyme disease involving the temporomandibular joint. J Oral Maxillofac Surg. 1988; 46:78-9.

10. Lader, E. Lyme disease misdiagnosed as a temporomandibular joint disease. J Prosthet Dent. 1990,63(1):82-5.

Author Information MD, University of Mississippi School of Medicine; Internal Medicine Resident, University of Arkansas Medical Sciences, Little Rock, AR (Xie). Oral and maxillofacial surgeon, Chair, Department of Oral-Maxillofacial Surgery and Pathology, School of Dentistry, University of Mississippi Medical Center, Jackson (Chandran). Pediatric Rheumatologist, Director of Pediatric Rheumatology, Mississippi Center for Advanced Medicine (Washington).

HOT OFF THE PRESS! Images in Mississippi Medicine: A Photographic History of Medicine in Mississippi

Lucius “Luke” M. Lampton, MD and Karen A. Evers

Get your copy today @ msmaonline.com

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P R E S I D E N T ’ S

August 17, 2018 Old Capital Inn, Jackson

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his past year has truly flown by! At times I felt like I was in a whirlwind, but at all times I was blessed with the support of my fellow physicians and our MSMA staff.

While there was a lot of serious matters to deal with, the entire process has actually been fun and very rewarding.

I will fondly remember this year and cannot adequately express my gratitude to all of you for allowing me to serve as your 150th President.

Legislation is always one of the largest and most important items that MSMA has to deal with, and this year was no exception. I must tell you that I learned first hand this year how important it is to have ongoing relationships with our legislators and state leadership.

These relationships and dialogues are not just when in session but need to be ongoing throughout the year. Without the ability to talk with our state leaders and have their trust, many bills that would adversely affect our practices and patients would pass.

This is one reason why it is important for all of us to encourage our partners and colleagues to maintain membership in MSMA, we are stronger together. It is also so important to actively support MMPAC, especially with this next year being an election year.

Through MMPAC we are able to ensure that we have an opportunity to be heard. Please contribute! Dr. Hugh Gamble and the MMPAC board have done a great job, as has Garrett McInnis, in fundraising.

There were 4 bills in the house this past session that would have given APRNs independent practice.

Through the work of our MSMA staff and our relationships with leadership, we were able to defeat these bills. This particular issue will continue to be one we have to address.

This effort meant spending time at the Capitol by your staff as well as

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your officers. Dr. Jennifer Bryan and I, along with staff, met with Speaker Gunn on this issue, and there were meetings with Chairman Mims and Senator Kirby.

The Doctor of the Day program also gave us an opportunity to talk with legislators individually, and I highly encourage all of you to sign up this next session. It makes a difference! Some of the William M. Grantham, MD proposed changes in improving collaboration by the board of medical licensure helped this past session as well. Unfortunately, our patients rank as the sickest in the nation.

Going forward, we need to stress the importance of team-based care to help obtain the best possible health outcomes for our patients across the state.

Immunizations once again was an issue. There was a push for “religious exemptions” allowing parents to opt out of school-entry immunizations. This legislation was also defeated through dialogue with the legislators and seems to be something that comes up yearly because of a very vocal Anti-Vax group in our state.

We again will have to continue the ongoing dialogue and education of our leaders on the importance of immunizations. This is one bright spot for us as we are one of the most successful states nationally.

Dr. Currier and the Health Department have done a wonderful job in this effort, and we do not need to step back and allow the childhood diseases to once again show up in our state as they have in so many others.

The Medicaid tech bill came up this year and was intensely debated.

Our staff was present at the Capitol until late hours lobbying on our behalf. This bill passed at the last minute, and as a result, there were many wins for physician practices.

Notably, reimbursement rates were held steady and managed care organizations were not given the authority to cut rates at their discretion. A single Medicaid formulary remained in place, and a provision that credentialing done by Medicaid must be accepted by the MCOs. Importantly, OB/GYNs were added to the list of primary care providers in this tech bill. This was important because previously this issue had to be annually addressed in the appropriations process.

Monitoring legislative actions that affect Medicaid are a constant and important function of our staff, and they do a wonderful job!

economic impact numbers from an AMA national survey.

Highlights from this survey showed that Mississippi physicians create 51,305 direct and indirect jobs or 11 jobs per doctor. There is $8 Billion annually of economic output, $313 Million in various taxes, $3.8 Billion annually in wages and benefits. Clearly, physicians mean business for Mississippi.

As I have heard all former MSMA presidents say, one of the most rewarding things I was able to do was to travel to component society meetings around the state.

Finally, on legislation, we came closer to obtaining an increase in the state tobacco tax than we have in years. The last increase was in 2009 under Governor Barbour up to our current rate of 68 cents per pack.

The national average is about $1.71 per pack.

During these visits, it was truly a pleasure and an honor to meet with so many of you. At each visit, I was so warmly received and was able to hear your concerns on many of these issues that I have already mentioned.

We were pushing for an increase of $1.50 per pack. I had the opportunity to meet for about an hour with Governor Bryant on this issue along with our staff and representatives from the American Heart Association and American Cancer Society.

I hope that each of you will make a commitment to be more active in your component societies and help them to be vibrant and active.

This is where many of the issues we face in medicine first become apparent, and from where those issues can then be forwarded to all of our MSMA members. Thanks again for the opportunity to attend these meetings, and for the hospitality at each visit.

There was bipartisan support with both Senator Wiggins and Senator Simmons helping support this. The two senators, Dr. Demetropoulos, and I were on the Gallo radio show together, all supporting this increase to the public.

This is a huge public health issue for our state since we still have greater than 20% of Mississippians smoking. A recent survey showed that 71% of Mississippians support a tobacco tax, and we know that for every 10% increase in tax childhood smoking decreases by 7%, and overall rates decrease by 4%. Over 5 years a $1.50 per pack increase would save Medicaid over 4.2 million dollars and potentially $166 million in tax revenue.

Smoking stinks. This is an important public health and economic issue for our state, and one for which we need to continue to fight.

Besides lobbying at the legislature, I was busy talking with the board of medical licensure and leaders regarding the opioid crisis and the new regulations proposed. I testified twice to the board on your behalf, and they did incorporate some of our recommendation into the current proposal.

The opioid crisis and these regulations are complex issues that we will need to continue to evaluate and educate our members and our patients. I believe that we can make a difference and improve the opioid problems if we all work together.

I would like to thank Charmain and all of our MSMA staff for helping to make this year go as smoothly as possible. They all do outstanding work, and we are so fortunate to have them.

They help make sure that MSMA membership has value, and it does!

Not just from routine coordination with meetings or help with our legislation, but in many other ways.

• • • •

More than 270 hours of CME availability, whether it is online, here at annual session, CME in the Sand, or CME with Mickey.

Help with our practices with billing or even legal questions.

Providing leadership training for our members.

Helping assist with the production of our Journal, which I will again say is a wonderful member benefit. The Journal Editor, associate editors, publications committee, and staff have all helped make this a great benefit and value.

In closing, I cannot adequately express my gratitude for you allowing me to serve as your 150th President. This has been a most wonderful and rewarding experience that I will forever cherish. I look forward to continuing to serve and helping our MSMA this next year under Dr. Mansour’s leadership and in ensuing years.

God bless each of you and our MSMA. Q

I want you to know that you and your practices make a huge economic impact for your communities and your state. I had the pleasure along with Governor Bryant last December in releasing the

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“If If you you can think iit, t we can print it.”

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H O M E O F T H E P G A T O U R ’ S S A N D E R S O N FA R M S C H A M P I O N S H I P M I S S I S S I P P I ’ S P R E M I E R FA F A M I LY L LY Y F O C U S E D P R I VAT Y VA VA T E C L U B 3 4 5 S T. A N D R E W S D R I V E JAC K S O N , M S 601.956.1411 CC JAC K S O N . CO M

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Brunson Named MSBML President

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s senior advisor for external affairs at the University of Mississippi Medical Center, Dr. Claude Brunson forges partnerships in the community and helps find solutions to problems ranging from out-of-control opioid prescribing to flaws in the state’s mental health system.

In 2014, he was sworn in as MSMA’s president, becoming the first African-American elected to our association’s highest office.

Recently, Dr. Brunson also was awarded the first Distinguished Physician Award by the Mississippi Medical and Surgical Association.

And as of July 1, 2018, he assumed the responsibilities that come with one of the state’s top medical leadership posts when he became president of the Mississippi State Board of Medical Licensure.

That newest hat is “almost an umbrella that incorporates all the other things I do,” said Brunson, who is also a professor of anesthesiology.

“I’ve always said that the Medical Center should have a seat at the table at all of these important agencies that can have an impact on the Medical Center.”

As president, Brunson leads the Board of Medical Licensure in making sure that Mississippi residents receive safe treatment from physicians and several other groups of health care professionals. That vigilance includes suspending, withdrawing or placing restrictions on the licenses of physicians who violate the state’s medical practice act or who are dangerous to public health and safety.

“We license physicians, physician assistants, radiology assistants, podiatrists and acupuncturists. Our main job is to assess, review and license qualified practitioners to practice medicine in the state,” Brunson said. “Our prime directive is to protect the public and to make sure we have safe practitioners who are qualified for Mississippians to go to for health care.”

As part of its work, the Board of Medical Licensure is contemplating an overhaul of regulations to physician prescribing of opioid drugs in Mississippi. The policy would discourage physicians from prescribing more than a three-day supply but would allow a 10-day supply with an additional 10 days if clinically necessary, but with a new prescription and documentation of why it’s necessary.

The proposed changes also would include a requirement that providers run the name of each patient receiving an opioid prescription through the state’s online prescription monitoring

Dr. Claude Brunson President, Mississipi State Board of Medical Licensure

program to check whether the patient has already received prescriptions from other providers. That regulation would apply to patients coping with acute or chronic non-cancerous and nonterminal pain.

“One of the main things I’ve been educating on lately is the rules and regulations on opioid management in the state,” Brunson said. “I’ve been giving a lot of talks, both in the Medical Center and externally, about safe practices by physicians as they are prescribing opioids.”

Brunson, who serves on a number of national and state boards and committees, last month was recognized by the Mississippi Medical and Surgical Association as the first recipient of its Distinguished Physician Award. He spends one day a week in the operating room, and he also teaches medical students and residents aspiring to his specialty.

“When I’m in an OR and clinic setting, I get to talk to medical students and residents about the legal practice of medicine and our responsibilities and duties to our patients,” said Brunson, former chair of the Department of Anesthesiology. “Maintaining a clinical practice strengthens my ability to teach and pass on to the younger generation things that will govern their practice.” Q

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UMMC Student Experiences at the Jackson Free Clinic COURTNEY MULLINS, M4, UMMC SOM

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he Jackson Free Clinic (JFC) is a non-profit organization that provides health care services to patients without health insurance.

The clinic is open once a week on Saturdays and is run by volunteer students from the University of Mississippi Medical Center (UMMC) and volunteer physicians from the Jackson community. The clinic was started as a student initiative in 2002 and has been functioning ever since as the only medical clinic in the Jackson Metro Area that provides medical services at no cost to patients in need.

A typical day at JFC begins when all of the student volunteers arrive and are divided into teams. Teams usually consist of medical students ranging from M1s to M4s and pharmacy students. After a patient arrives, a team conducts a chart review before interviewing and examining the patient. During the patient encounter, duties are divided among the students. For example, first and second-year medical students typically practice taking vital signs and beginning the interview, third and fourth-year students will interview as well as examine the patient, while pharmacy students conduct a medication review with the patient. Afterward, the team of students will discuss

their findings, formulate a treatment plan, and present the plan to a supervising physician. On average each team will see three to five patients in a clinic day. In addition to the services administered by medical students and pharmacy students during regular patient appointments, dental students, physical therapy students, and occupational therapy students from UMMC provide their services too.

The clinic also offers specialty days with social workers, psychiatrists, and nutritionists, and emphasizes education and preventative care by offering resources for smoking cessation and HIV screening.

The hands-on experience gained from volunteering at the free clinic proves invaluable to students, especially those who are in the beginning years of their training. Brock Richardson, a second-year medical student, says, “We don’t get to see many patients during the first two years, so it’s nice to get out of the classroom and put into practice what I’ve learned.” Richardson began volunteering at the Jackson Free Clinic during his first year and says the experience has helped solidify the material presented in his classes. For other students, the clinic serves as an opportunity to build on skills learned during their clinical years.

Above, student volunteers Graham Husband, Yasmeen Abdo, Aaron Pode, Kendra Wiley, Wisam Beauti, and Hae Jeung discuss a treatment plan for a patient.

At right, student volunteers Wilson Helmhout, Julie Kramer, Sally White, and Sean Himel discuss a patient with resident physician Katherine Stachowicz.

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Student volunteers Katie Cranston, Brandon McDaniel, and Connor Tierney prepare to draw labs for a patient.

Meredith Cobb is a fourth year MD/PhD student who just completed her clinical rotations as a medical student and will spend the next three years completing her PhD. She says “It is important to me to be able to maintain my clinical skills while in the research years of my education.

The Jackson Free Clinic is such a great opportunity to continue seeing patients while working on my research.”

The free clinic also provides a medium for interdisciplinary work among students by facilitating interaction between students from different health professions. Pharmacy students and medical students work together on the patient treatment teams to deliver the most effective patient care. Fourth-year pharmacy student Payton Winghart says about volunteering at the free clinic, “It gives pharmacy students the opportunity to develop their skills interprofessionally with other healthcare students, which is something you don’t get to do often in the classroom.” In addition to participating as a member of treatment teams, pharmacy students assist patients with prescription assistance programs. Winghart reports that many of the patients seen at the free clinic are unable to afford the medications they need. There are programs available that can provide medications for uninsured patients for free or at a discounted price. Pharmacy students who volunteer at the clinic help patients fill out the necessary forms to sign up for these programs.

The Jackson Free Clinic not only functions as an opportunity for student education and experience but also serves a vital role in the community. In the past year approximately 850 medical patients, 40 physical therapy patients, and 130 patients who needed dental procedures have been seen at the free clinic. Logan Ramsey, fourthyear medical student, is currently serving as student director for the clinic. He says, “The Jackson Free Clinic is truly a unique organization within our community. We provide care to underserved patients who might otherwise slip through the cracks of our health care system. The chance to make a positive impact on the Jackson area and increase access to care is a core mission of the JFC.” Ramsey also speaks to the clinic’s role in student education, “We strive to promote a dynamic educational environment for students in different disciplines. Trainees in medicine, dentistry, pharmacy, physical and occupational therapy work together to meet a wide variety of needs and improve outcomes for our patients. This type of learning prepares students to practice in a team-based setting as we enter the health care workforce.”

The Jackson Free Clinic is self-funded and functions as a not-for-profit 501(c)3 organization. If you would like to donate to the Jackson Free Clinic, checks may be mailed to P.O. Box 4892, Jackson, MS 39296 or you can give online at jacksonfreeclinic.org. Q

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A Typical Day at JFC ...

Clockwise from top, the student workroom at the Jackson Free Clinic where each team meets to discuss their treatment plans after a patient encounter; Pharmacy students Payton Winghart and Neel Patel complete paperwork for patient assistance programs that provide patients with more affordable medication options; a group of student volunteers provide physical therapy for Jackson Free Clinic patients.

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Contact iol Jbmmbmmbjjb Jiln`X`] @]jXlng]hn today for any mortgage need! ( ) ϒ

ebZ]lnsΫ^bhXh[bXeЃgX\bmihϒgiln`X`]ϒe]h\bh`

KilnajXld @lή >e\` ή Pn] =ή Ob\`]eXh\ή JP

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SEPTEMBER • JOURNAL MSMA

421

Katherine G. Pannel, DO

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Empowering students on the Spectrum to achieve their full potential and prepare for academic success.

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Express 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 letter writers.

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.

422 VOL. 59 • NO. 9 • 2018

“Team Walker are an amazing Realtor couple and did an incredible job selling our home! Their attention to details and knowledge of the market helps on reducing your homework and saves precious time. They have done an incredible job LQ ȴQGLQJ KRPHV IRU our incoming faculty DQG IDPLO\ 7KH\ ȴQG homes that meet your needs and individual personality.

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Preferred Health Services Employee Benefit Plan (PHP) is a member owned, self-funded health benefit plan built for companies of all sizes. This

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Health Services to help their members battle the ever increasing cost of healthcare benefits.

W Real Estate, LLC. Team Walker We don’t just list & show homes.

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601-499-0952 | 2160 Main Street, Suite B, Madison MS

Congratulations

Distinguished Medical Alumnus Dr. J. Martin Tucker

to the 2018 University of Mississippi Medical Center Medical Alumni Chapter Awards Winners!

Medical Hall of Fame

Please join us in congratulating these honorees!

Nominations for 2019 Alumni Awards will be available in October 2018. Please visit alumni.umc.edu to learn more and nominate an outstanding physician.

Dr. James Keeton Dr. Herbert Langford Dr. Seshadri Raju Dr. Robert Robbins Dr. Helen Turner

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SEPTEMBER • JOURNAL MSMA

423

Calling All Mississippi Physician-Photographers Enter the 2019 Journal Cover Photo Contest

Film or Digital Shoot anything you can capture as a high-resolution image. Subjects given the highest consideration are those indicative of Mississippi.

Photos of original artwork are also acceptable.

The MSMA Committee on Publications will judge the entries on the merits of quality, composition, originality, and appropriateness to the JMSMA.

At LITHIC, we are Human I.T. Why do we call it that?

Because we understand that, even when it comes to technology, it all boils down to a personal relationship. Our goal is to take care of your IT issues, so that you can spend your time doing what you do best. After all, time is money.

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Specifications: Vertical composition.

Color slides, digital files & photos (at least 300 DPI/PPI). A hard copy print is required for judging.

Please include a brief description of the photo and information about the physician/photographer.

Submit your narrative of the image to appear as “About the cover” in the magazine.

Size: Vertical format 5 x 7” or 8 x 10” Deadline: January 1, 2019

Exclusive MSMA Member Benefit Offer: • 10% off monthly service contracts • FREE NETWORK AUDIT

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

Mail to: P.O. Box 2548 Ridgeland, MS 39158-2548 or deliver to MSMA headquarters 408 W. Parkway Place, Ridgeland, MS 39157

424 VOL. 59 • NO. 9 • 2018

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DOCTOR OF THE DAY ӍLh] i^ iol JPJ= Masmb[bXh I]X\]lmabj Xmmb`hg]hnm qXm ni m]lp] Xm na] @i[nil i^ na] @Xs Xn na] PnXn] ?XjbnieҶ F \l]X\]\ nabm Xmmb`hg]hnҶ F qXm XhrbiomҶ F \b\hӑn ^]]e F qioe\ Z] q]e[ig]\ Xn na] ?XjbnieҶ Qi gs moljlbm]ҹ F aX\ na] ijjimbn] ]rj]lb]h[]Ҷ >ina na] Eiom] Xh\ P]hXn] niid nbg] ion ni `bp] g] X qXlg q]e[ig] Xn na] Z]`bhhbh` i^ m]mmbihҶ Qalio`aion na] \Xsҹ F aX\ m]p]lXe I]`bmeXnilm [ig] oj ni g] ni naXhd g] ^il Z]bh` na]l]Ҷ F eip]\ gs ]rj]lb]h[] Xn na] ?XjbnieҼ Fh ^X[nҹ Fӑp] Z]]h ZX[d gXhs nbg]m mbh[] na]hҶ Fӑp] m]lp]\ m]p]lXe nbg]m Xm @i[nil i^ na] @XsҶ F aXp] cibh]\ ^]eeiq JPJ= g]gZ]lm bh Tabn] ?iXn OXeeb]m Xh\ ?Xeem ni =[nbih ni X\pi[Xn] ih bgjilnXhn jl]mmbh` bmmo]mҶӎ

GҶ MX`] >lXhXgҹ J@ =h]mna]mbiei`s =mmi[bXn]m i^ Jbmmbmmbjjbҹ II?

Show lawmakers the face of organized medicine.

Every day during the legislative session, the Capitol Medical Unit is staffed by a full time nurse and an MSMA volunteer physician who provides basic health care services to legislators and capitol staff. As a Doctor of the Day, you’ll see firsthand the everyday operations of the Mississippi Legislature and be recognized on both the Senate and House floors at the opening of each day’s session.

SIGN UP TODAY AT WWW.MSMAONLINE.COM/DoctorOfTheDay

I M A G E S

K

I N

M I S S I S S I P P I

M E D I C I N E

LAN POSTER AGAINST UMMC, 1950 – This poster was printed by the Jeff Davis Klan in Jackson in the spring of 1950, and it reveals the significant role the University of Mississippi Medical Center (UMMC) would play in transforming the state racially in a progressive manner, as well as early attempts to keep any federal involvement away from the institution. After a long campaign in the 1940s to expand the two-year school of medicine at Oxford into a four-year school and teaching hospital in Jackson, the Legislature finally passed House Bill 628, which was signed by Governor Fielding Wright on April 13, 1950. The final step in the creation of UMMC would require a bond vote by the citizens of Hinds County to provide the county’s share of the financial support of the hospital. Hinds County’s Board of Supervisors scheduled that bond vote in early June, and the local Klan worked hard against it. To their credit, Hinds County’s voters did not fall for the Klan claptrap and passed the bond by a wide margin. The institution was dedicated on October 24, 1955, and awarded its first MD degrees in 1957. The hospital movement, most especially the state’s embrace of the Hill-Burton Act (the Hospital Survey and Construction Act of 1946), would become the most forceful agent of racial transformation in the state, with hospitals the first public places integrated. Despite the strong support of Southern white politicians (Hill was an Alabama Senator), facilities receiving Hill-Burton funding were not allowed to discriminate on the basis of race, color, national origin, or creed, although separate but equal facilities in the same hospital were allowed until 1963, when the U. S. Supreme Court finally struck down this aspect in Simkins v. Cone, which ended racial segregation at Mississippi hospitals. Vestiges of racism in hospital staffs would remain for a period, but the medical community largely ended segregation and discrimination within its hospital walls by the mid-1960s due to this federal court case and requirements to receive federal monies. Reprinted with permission, Mississippi Department of Archives and History.

This is one of many historic images included in the new book “Images in Mississippi Medicine: A Photographic History of Medicine in Mississippi,” recently published by the MSMA under the auspices of the Commemorative Committee for the 150th Anniversary of the House of Delegates. Contact MSMA to obtain a copy. If you have an old or even somewhat recent photograph or image which would be of interest to Mississippi physicians, please send it to me at lukelampton@cableone.net or by snail mail to the Journal. Q — Lucius M. “Luke” Lampton, MD JMSMA Editor

426 VOL. 59 • NO. 9 • 2018

P O E T R Y

A N D

M E D I C I N E

Ten-Year-Oldâ&#x20AC;&#x2122;s Injection Ruse [Editorâ&#x20AC;&#x2122;s Note: This month, we print another comic poem by John D. McEachin, MD, FAAP, a 0HULGLDQ SHGLDWULFLDQ DQG WKH -RXUQDOÂśV XQRIÂżFLDO SRHW ODXUHDWH Âł7HQ <HDU 2OGÂśV ,QMHFWLRQ 5XVH´ is inspired by his long years in pediatric practice. He writes the editor that this poem, like many of KLV RWKHUV IRFXVHV RQ ÂłVRPH RI WKH FRPLFDO W\SH HYHQWV WKDW RFFXU LQ RIÂżFH SUDFWLFH WKH KXPRU RI 0' VHOI LQĂ&#x20AC;LFWLRQ DQG SDWLHQW IDPLO\ LQWHUSUHWDWLRQ RI LQVWUXFWLRQV JRQH DZU\ SOXV YDULRXV RWKHU LQFLGHQWV WKDW DGGHG WR WKH IXQ DQG ]HVW RI RXU PHGLFDO LQWHUSHUVRQDO UHODWLRQV 2QO\ KDUPOHVV HQG UHVXOWV DOORZ XV WR VPLOH DW WKRVH HYHQWV ZKLFK PDNH SULYDWH SUDFWLFH VR GHOLJKWIXO ´ )RU PRUH RI 'U 0F(DFKLQÂśV SRHWU\ VHH SDVW -060$V $Q\ SK\VLFLDQ LV LQYLWHG WR VXEPLW SRHPV IRU SXEOLFDWLRQ in the Journal, attention: Dr. Lampton or email me at lukelampton@cableone.net.] â&#x20AC;&#x201D; ED.

â&#x20AC;&#x153;Allergy shots have ceased to help; Billâ&#x20AC;&#x2122;s nose is stuffy all the time!

And he gets his shot every week!

These poor results are a crime!â&#x20AC;?

That kid knew well the shot routine â&#x20AC;&#x201C; Wait 10 minutes before you leave â&#x20AC;&#x201C; So, the script was always the same, Only his scheme was to deceive!

â&#x20AC;&#x153;Mrs. Jones, I can see your distress; Let me check with folks we employ.â&#x20AC;?

(Is he as prompt as mother states?) â&#x20AC;&#x153;Weâ&#x20AC;&#x2122;ve not recently seen that boy!â&#x20AC;?

Bill would check his watch to be sure, Then casually leave the clinic, Caressed each arm â&#x20AC;&#x201C; alternate weeks, Tenderly â&#x20AC;&#x201C; no need to panic!

â&#x20AC;&#x153;Well, I get a bill every month!

That tells me he does get a shot!â&#x20AC;? â&#x20AC;&#x153;Mrs. Jones, Iâ&#x20AC;&#x2122;ve got news for you!

For six months we have charged you NOT!â&#x20AC;?

His mother, now quite embarrassed, Shared her duped role in the charade; She had rewarded Bill, for â&#x20AC;&#x153;painâ&#x20AC;?

Each week, with popcorn and Kool-Aid!

And now, the rest of this story!

Billâ&#x20AC;&#x2122;s dear mother drove up each week, He walked in â&#x20AC;&#x201C; she stayed in the car.

Bill sat, never approached nurse Cheek!

â&#x20AC;&#x201D; John D. McEachin, MD Meridian

SEPTEMBER â&#x20AC;˘ JOURNAL MSMA

427

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430 VOL. 59 • NO. 9 • 2018