december 12 jmsma

December 2012

VOL. LIII No. 12

BEACON Imagine the possibilities.

You’ve heard of the Beacon Grant. It’s a $14.7 million grant to the Delta Health Alliance (DHA) from the Office of the National Coordinator for Health Information Technology with goals of building and strengthening Mississippi’s Health IT infrastructure, testing healthcare innovations and improving healthcare efficiency. What can the Grant do for my practice and my patients? DHA has established the BLUES (Better Living Utilizing Electronic Systems) Beacon Community to work with physicians and other healthcare providers across the Delta region. Your Delta BLUES Beacon is testing innovations with over 35 Delta providers, including Clinical Decision Support, Diabetic Retinopathy Screening, Medication Therapy Management, Care Transitions and Health Information Exchange. Imagine the possibilities! The Delta BLUES Beacon Program is available to physicians in ten counties across the Mississippi Delta area until March 2013. How can the BLUES Beacon guide you?

Learn more: www.DeltaHealthAlliance.org

DECEMBER 2012 JOURNAL MSMA 393

About the Cover: Spotting an Owl —Mickey Wallace, MD, an otolaryngologist in Jackson, photographed this Barred Owl (or perhaps Spootted Owl) while hunting in the Mississippi Delta. Spotted Owls Strix occidentalis resemble Barred Owls Strix varia in that both species lack ear tufts and have large, all-dark eyes. In areas where the two species’ ranges come into contact, Barred Owls tend to out-compete spotteds. They are widespread in North America, where they occur across most of the eastern half of the continent from Florida northward to southern Canada; they are also spreading westward in the north of their range. Their spread westward is causing concern as they may compete with the endangered Spotted Owl. r

JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. CORRESPONDENCE: Journal MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: (601) 853-6733, Fax: (601)853-6746, www.MSMAonline.com. SUBSCRIPTION RATE: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available. ADVERTISING RATES: furnished on request. Cristen Hemmins, Hemmins Hall, Inc. Advertising, P.O. Box 1112, Oxford, Mississippi 38655, Ph: (662) 236-1700, Fax: (662) 236-7011, email: [email protected] POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 39158-2548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association.

Copyright© 2012 Mississippi State Medical Association.

Official Publication of the MSMA Since 1959

SCientifiC ArtiCleS

Clinical Problem-Solving Case: Allergy Confusion? 396Rebecca A. Rose-Hand, MD

Coordinated Cardiac Delivery: Reducing Mortality in High Risk 400Fetal Cardiac Lesions at the University of Mississippi Medical Center Daniel J. DiBardino, MD; Jennifer C. Shores, MD; Michelle Sheth; Mary Taylor, MD;

Kenneth Liechty, MD and Jorge D. Salazar, MD

Revitalization of the University of Mississippi Children’s Heart Center: 405Report Card from the First 18 Months ExperienceDaniel J. DiBardino, MD; William J. Lancaster, BA; Walter Merrill, MD; Marc E. Mitchell, MD;

Emilee Taylor, RN; Charles Gaymes, MD; Makram Ebeid, MD; Jennifer Shores, MD; Elizabeth

Christ, MD; Mary Taylor, MD; Michelle Sheth, MD; Richard Jonas MD and Jorge D. Salazar, MD

PreSident’S PAge You Have to Have Some Skin in the Game 411Steven L. Demetropoulos MD, MSMA President

editoriAl

The Magic Kingdom 413Reed B. Hogan, II, MD

relAted orgAnizAtionS

Mississippi State Department of Health 416Office of Mississippi Physician Workforce 418MSMA Alliance 420

dePArtmentS

From the Editor 394Poetry in Medicine 414Images in Mississippi Medicine 415Uncommon Thread 421

SubjeCt index: volume liii 423Author index: volume liii 427

DECEMBER 2012 VOLUME 53 NUMBER 12

Lucius M. Lampton, MDEditor

D. Stanley Hartness, MDRichard D. deShazo, MD

AssociAtE Editors

Karen A. EversMAnAging Editor

PublicAtions coMMittEE

Dwalia S. South, MD Chair

Philip T. Merideth, MD, JDMartin M. Pomphrey, MD

Leslie E. England, MD, Ex-OfficioMyron W. Lockey, MD, Ex-Officio

and the Editors

thE AssociAtion

Steven L. Demetropoulos, MDPresident

James A. Rish, MDPresident-Elect

J. Clay Hays, Jr., MDSecretary-Treasurer

Lee Giffin, MD Speaker

Geri Lee Weiland, MD Vice Speaker

Charmain Kanosky Executive Director

394 JOURNAL MSMA DECEMBER 2012

As Mississippi’s physicians recover from last month’s divisive elections and slouch towards the looming fiscal cliff, the balm of poetry can heal

this winter weariness. The great physician Sir William Osler, a bibliophile of the first order, once commented to a group of physicians that “it is particularly poetry that has such a value in helping a man to cherish thoughts that lift him above the petty details of life, that strew his path with flowers, that make him hopeful and helpful among his fellows.” Ours is a consuming and demanding profession, both emotionally and physically, even when things are going right! We need to find comfort for our souls in this very stressful world.

For those dark and dreary winter days, the most comforting among my favorite poems is “Ulysses” by Alfred, Lord Tennyson. It is an often quoted poem, and parts of it appear here and there in books, newspapers, and movies (most recently the new James Bond movie Skyfall). The king and warrior Ulysses, years after his return from the Trojan War, faces advancing age and death. He notes that “all times I have enjoy’d greatly, have suffer’d greatly, both with those that loved me, and alone….I am a part of all that I have met.” Despite sensing his mortality, he seeks to continue his heroic adventures of past days. He adds, “Old age hath yet his honour and his toil; death closes all: but…some work of noble note, may yet be done, not unbecoming

men that strove with Gods.” Seeing the lights twinkle from distant rocks, he calls to his old soldiers: “Come, my friends, ‘tis not too late to seek a newer world…to sail beyond the sunset….Tho’ much is taken much abides; and tho’ we are not now the strength in which old days moved earth and heaven; that which we are, we are, one equal temper of heroic hearts, made weak by time and fate, but strong in will.” The poem concludes, “To strive, to seek, to find, and not to yield,” which are encouraging words for those in our profession! Find and read this poem!

After these holidays, we must re-engage politically for our profession. How can you as a physician do this? Sign up to serve as a Doctor of the Day at the Mississippi Capitol between January and April. As well, find ways to help our MSMA Alliance at the Capitol Screening Initiative on the morning of January 17th!

This Journal remains one of the few in the United States still created by physicians for physicians. It is only as good as you make it. Write an editorial, a letter, an essay, a scientific article, a case report, or take a photograph or contribute a physician portrait. Contact me at [email protected]. —Lucius M. Lampton, MD, Editor

Journal Editorial Advisory BoardR. Scott Anderson, MD, FACR

Chair, Journal Editorial Advisory Board

Radiation Oncologist and Medical Director,

Anderson Regional Cancer Center, Meridian

Diane K. Beebe, MD

Professor and Chair,

Department of Family Medicine,

University of MS Medical Center, Jackson

Claude D. Brunson, MD

Senior Advisor to the Vice Chancellor

for External Affairs,

University of Mississippi Medical Center, Jackson

Jeffrey D. Carron, MD, FAAP, FACS

Associate Professor,

Department of Otolaryngology

& Communicative Sciences,


Gordon (Mike) Castleberry, MD

Urologist, Starkville Urology Clinic

Mary Currier, MD, MPH

State Health Officer

Mississippi State Department of Health, Jackson

Thomas E. Dobbs, MD, MPH

Health Officer, District VII/VIII

Mississippi State Department of Health, Hattiesburg

Sharon Douglas, MD

Chair, AMA Council on Ethical & Judicial Affairs

Professor of Medicine and Associate Dean for V A

Education, University of Mississippi School of Medicine,

Associate Chief of Staff for Education and Ethics,

G.V. Montgomery VA Medical Center, Jackson

Daniel P. Edney, MD

Executive Committee Member,

National Disaster Life Support Education Consortium,

Internist, The Street Clinic, Vicksburg

Owen B. Evans, MD

Professor of Pediatrics and Neurology


Maxie L. Gordon, MD

Assistant Professor, Department of Psychiatry and

Human Behavior, Director of the Adult Inpatient

Psychiatry Unit and Medical Student Education,


Scott Hambleton, MD

Medical Director

Mississippi Professionals Health Program, Ridgeland

John Edward Hill, MD, FAAFP

Residency Program Director

North Mississippi Medical Center, Tupelo

John D. Isaacs, Jr., MD

Infertility Specialist,

Mississippi Fertility Institute

at Women’s Specialty Center, Jackson

Kent A Kirchner, MD

Nephrologist

G.V. Montgomery VA Medical Center, Jackson

Brett C. Lampton, MD

Internist/Hospitalist

Baptist Memorial Hospital, Oxford

Philip L. Levin, MD

President, Gulf Coast Writers Association

Emergency Medicine Physician, Gulfport

William Lineaweaver, MD, FACS

Editor, AnnalsofPlasticSurgery

Medical Director

JMS Burn and Reconstruction Center, Brandon

John F. Lucas,III, MD

Surgeon

Greenwood Leflore Hospital

Gailen D. Marshall, Jr., MD, PhD, FACP

Professor of Medicine and Pediatrics,

Vice Chair for Research,

Director, Division of Clinical Immunology and Allergy,

Chief, Laboratory of Behavioral Immunology Research

The University of Mississippi Medical Center, Jackson

Alan R. Moore, MD

Clinical Neurophysiologist

Muscle and Nerve, Jackson

Paul “Hal” Moore Jr., MD, FACR

Radiologist

Singing River Radiology Group, Pascagoula

Jason G. Murphy, MD

Surgeon

Surgical Clinic Associates, Jackson

Ann Myers, MD

Rheumatologist

Mississippi Arthritis Clinic, Jackson

Jimmy L. Stewart, Jr., MD

Program Director, Combined Internal Medicine/

Pediatrics Residency Program,

Associate Professor of Medicine and Pediatrics


Samuel Calvin Thigpen, MD

Assistant Professor of Medicine and Associate

Program Director of the Internal Medicine Residency


Thad F. Waites, MD, FACC

Clinical Cardiologist, Hattiesburg Clinic

Chris E. Wiggins, MD

Orthopaedic Surgeon

Bienville Orthopaedic Specialists, Pascagoula

John E. Wilkaitis, MD, MBA, CPE, MS

Chief Medical Officer

Brentwood Behavioral Healthcare, Flowood

From the Editor


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A 65-year-old white male presented to the emer-gency department with a problem with his pe-ripherally inserted central catheter (PICC).

Four to 5 days earlier he had noticed right-sided facial swell-ing and arm swelling around the PICC line insertion point. The PICC line had been placed for home intravenous (IV) an-tibiotics for a post-operative knee replacement infection. He also noted that since the most recent home health nurse visit, there were new blisters around the site where new tape had been used. His vital signs were slightly abnormal with a tem-perature of 99.4°F, heart rate of 103 beats per minute and a blood pressure of 143/90 mmHg. His respiratory rate and ox-ygen saturation were normal. Further exam revealed that his right arm, face and neck were swollen, erythematous, warm to the touch and tender to palpation. There were two large unbroken blisters around the insertion site of the PICC line.

The localized pain and swelling appear to be consistent with a deep vein thrombosis (DVT), and the blisters appear to be an allergic reaction to the new tape. But the patient has had a severe, known infection requiring IV antibiotics. Could the blis-ters, facial redness and swelling be due to an infection? Are they from the same cause or is there more than one thing occurring?

The blisters around the insertion site must also be con-sidered. The differential for blisters could be a previously un-diagnosed autoimmune disorder causing bullous pemphigoid. They could indicate herpes zoster or something more sinister such as Stephen-Johnson’s syndrome as the patient has had a known infection but unknown organism. With the history of infection, staph scalded skin syndrome or toxic epidermal necrolysis must also be excluded. Thankfully for our patient, the blisters were localized and not diffuse. The lack of systemic symptoms of fever and chills, in addition to the contained na-ture of the blisters, made a benign reason much more likely.

A venous Doppler of the right upper extremity showed echogenic material in the right internal jugular vein, subcla-vian vein and axillary vein. There was also echogenic materi-al in the proximal brachial vein and basilic vein. The vessels

were noncompressible. A complete metabolic panel was within normal limits. A complete blood count indicated white blood cells (WBC) 10.2 K/uL with 1% bands and 10% eosinophils. Once these results were known, the PICC line was discon-tinued. The emergency department physician administered a single dose of fondaparinux (Arixtra) for anticoagulation.

The venous Doppler confirms the diagnosis of DVT. According to the American College of Radiologists Appropri-ateness Guidelines, ultrasound is the diagnostic standard for DVT in a peripheral vein and a magnetic resonance angio-gram the standard for central veins. The likelihood of a seri-ous infection affecting the arm and face in the absence of an elevated white count is very low. The question is why would a healthy man with no previous medical problems, such as cancer or a hematologic hypercoagulable state, spontaneous-ly form a DVT? Is a PICC line enough to cause a DVT, or is there an underlying hypercoagulable state? The risk of a DVT with a PICC in the upper extremity is approximately 3%.5

The white count was noted to be normal, but the abnormal differential was noted. Eosinophilia is most commonly noted in severe allergic reactions.

The plan is to admit the patient and consult the orthope-dic surgeon who had done the knee replacement and the infec-tious disease physician who was managing the infection. They were consulted to clarify antibiotic use and duration. The pa-tient will be prescribed enoxaparin (Lovenox) 1mg/kg twice a day and warfarin. The enoxaparin will be discontinued once the patient’s INR is within the therapeutic range of 2.0-3.0.1 The fondaparinux was initially given by the ED physician, and the medication will be switched to enoxaparin on admission.

The patient was agreeable to this plan but had 2 re-quests. He wanted a primary care physician and a prostate specific antigen (PSA). He did not currently have a primary care physician, and he had heard everyone needed a PSA.

The patient completed the full course of antibiot-ics for the post-operative infection, presumed to be osteo-myelitis, and otherwise was recovering well from his knee surgery. Wound care was consulted to care for the blis-ters around the PICC insertion point. On examination the morning following admission, the patient was found to have a diffuse macular rash that blanched with pressure. It was most notable on his head and thinned out progres-sively down the body. He had an elevated PSA of 11.19 ng/mL and a WBC of 9.1 K/uL with 12.5% eosinophils.

Allergy Confusion

Rebecca A. Rose-Hand, MD

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

Author informAtion: Dr. Rose-Hand is a former resident in the Department of Family Medicine at the University of Mississippi Medical Center in Jackson.

CorreSPonding Author: University of Mississippi Medical CenterDepartment of Family Medicine, 2500 North State StreetJackson, MS 39216. Phone: 601-984-6800.

• CliniCal PRoBlEM-Solving •


The elevated PSA increased the likelihood that the DVT was due to a hypercoagulable state from a malignancy with the central catheter causing vein injury, a nidus for the clot to form. This fulfills 2 elements of Virchow’s triad: venous injury plus a hypercoagulable state.4 And it may be argued that the PICC line also provided the final elements of venous stasis and tur-bulent blood flow. However, the new rash is concerning. It is a different rash from the allergic blisters noted on admission. His normal white count and high eosinophil count makes us think that there could be an allergic component. The distri-bution and pattern of the rash suggests an allergic response.

The patient was prescribed Benadryl and pred-nisone for the severely pruritic rash. A CT scan of chest, abdomen and pelvis was done to search for oc-cult malignancy. A nuclear bone scan was also ordered to evaluate for bone metastasis from prostate cancer.

The CT scan showed prominence of the prostate gland but was otherwise unremarkable. The exam on hos-pital day 3 showed that the rash was spreading but with de-creased pruritus. The bone scan was negative for metastasis. CBC showed a WBC of 17.6 K/uL with 0.1% eosinophils.

Based on the appearance of the rash and eosinophilia, the most likely cause of the rash was the fondaparinux. The eo-sinophilia that resolved with steroids and Benadryl shows that there is a severe allergic reaction taking place; this is consis-tent with the allergic appearing rash. Rash has been reported

in 8% of patients taking fondaparinux.2 Of the patient’s new medications, including fondaparinux, enoxaparin and Cou-madin, fondaparinux has the highest rate of rash at 8%.2,3,4

Review of previous urology records indicated that the patient had a previous prostate biopsy that was ma-lignant. The length of time since this diagnosis was greater than 1 year. On the fourth day of admission, the rash was improving. The patient was discharged home and prescribed enoxaparin/Coumadin with close fol-low-up with a primary care physician and urologist.

In summary, it is believed that the patient had a DVT. El-ements of Virchow’s triad include prostate cancer by previous biopsy, which puts him at risk of hypercoagulable state, and the PICC line provided local endothelial injury with increased turbu-lent flow.5 Finally, he had blisters due to an allergic reaction to the new tape, and the rash was an allergic reaction to the fondaparinux.

Keywords: Allergic reaction, Arixtra, DVT, Prostate Cancer

References: 1. Prandoni P, Bernardi E. Upper extremity deep vein thrombosis. Current Opinion in Pulm Med. 1999;5(4):222-226.

2. Arixtra [package insert]. Research Triangle Park, NC: GlaxoSmithKline; 2010.

3. Lovenox [package insert]. Bridgewater, NJ: Sanofi Aventis; 2007.

4. Coumadin [package insert]. Princeton, NJ: Bristol-Myers Squibb Company; 2010. 5. Evans, RS, Sharp JH, Linford LH, Lloyd FJ, et al. Risk of symptomatic DVT associated with peripherally inserted central catheters. Chest. 2010; 138(4):803.

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Mississippi Chapter

HILTON JACKSON

http://www.msacc.org/RegistrationPacket2013.pdf

Mississippi Board of HealtH

MISSISSIPPI RISING

A PREVENTIVE HEALTH SYMPOSIUM

Presented in Cooperation with:


MISSISSIPPI RISING: A PREVENTIVE HEALTH SYMPOSIUM COURSE OVERVIEW The Mississippi Chapter of the American College of Cardiology is hosting a Preventive Health Symposium to engage health care professionals in promoting a healthier Mississippi. This symposium will address measures that will make a tremendous impact on cardiovascular health in Mississippi. Join fellow colleagues as we work together to raise Mississippi’s standing in national health standards and not only make Mississippians healthier but also significantly lower the cost of delivering healthcare in our state.

SCHEDULE Friday, February 8, 2013 7:00 PM - *Welcome Dinner (*Not included in registration fee. Additional registration required)

Saturday, February 9, 2013 7:30 AM Registration and Breakfast 8:00 AM Welcome 8:00 AM Morning Session 11:30 AM Lunch 1:00 PM Afternoon Session 5:00 PM Adjourn

TARGET AUDIENCE

This conference is intended for cardiovascular specialists, internists, family physicians, advanced practice nurses, nurses in cardiology and physicians assistants.

ACCREDITATION The Health Preventive Symposium is being submitted for 7.5 hours of AMA PRA Category 1 Credit ™.

REGISTRATION Registration for this conference is $50 and includes breakfast, breaks, lunch and CME certificate. Additional registration is required if attending the Welcome Dinner on Friday, February 8, 2013.

HOTEL INFORMATION This conference will be held at the Hilton Jackson. Rooms are available by contacting:

Hilton Jackson Group Rate: $99 +tax and fees 1001 East County Line Road Group Code: MS Chapter, ACC Jackson, MS 39211 Cutoff Date: January 9, 2013 601‐957‐2800

EVENT REGISTRATION: Name: _____________________________________________________

Professional Initials (Please circle): MD DO NP PA Other _____________

Practice Name:______________________________________________

Preferred address: ___________________________________________

City: _______________________ State: _____ Zip: _________________

Daytime Telephone: _______________ Email:_____________________

Welcome Dinner ‐ $250/Couple Friday, February 8, 2013 – Hilton Jackson

Meeting Registration ‐ $50

Saturday, February 9, 2013 – Hilton Jackson

PAYMENT OPTION: Make checks payable to MS Chapter, American College of Cardiology Send completed form and payment to: MS Chapter, American College of Cardiology Attn: Jenny White, PO Box 2548, Ridgeland, MS 39158 QUESTIONS: Contact Jenny White at [email protected] or 601‐853‐6733 x 332.

FACULTY Mary Currier, MD, MPH State Health Officer Mississippi State Department of Health

Sam Dagogo‐Jack, MD, FRCP Professor of Medicine & Director Division of Endocrinology, Diabetes & Metabolism A. C. Mullins Chair in Translational Research Director, General Clinical Research Center University of Tennessee Health Science Center

Richard D. deShazo, MD Billy S. Guyton Distinguished Professor Professor of Medicine and Pediatrics The University of Mississippi Medical Center

Dipti Itchhaporia, MD, FACC Chair, Board of Governors, American College of Cardiology( ACC) Robert and Georgia Roth Chair for Excellence in Cardiac Care Director of Disease Management Hoag Memorial Hospital Presbyterian, Newport Beach

Carl J. Lavie, M.D., FACC, FACP, FCCP Professor of Medicine Medical Director, Cardiac Rehabilitation and Prevention Director, Stress Testing Laboratory John Ochsner Heart and Vascular Institute Ochsner Clinical School ‐ The University of Queensland School of Medicine

Michael Mansour, FACC, FACP President MS Chapter American College of Cardiology American College of Cardiology Board of Governors

Thomas J. Payne, PhD Professor, Department of Otolaryngology and Communicative Sciences Associate Director, ACT Center for Tobacco Treatment, Education and Research University of Mississippi Medical Center

David A. Sabgir MD FACC Founding CEO, Walk with a Doc

Frank W. Smart, MD, FACC, FACP Professor and Chief Section of Cardiology LSU School of Medicine in New Orleans Director of the Cardiovascular Center of Excellence LSU Health Sciences Center

J. Clinton Smith, MD, MPH Professor Emeritus of Pediatrics (Cardiology) University of Mississippi Medical Center Medical Consultant, Mississippi Public Health Institute

Hector Ventura, MD, FACC

President LA Chapter American College of Cardiology American College of Cardiology Board of Governors Professor of Medicine Medical Director Cardiac Transplant and Heart Failure Ochsner Clinical School ‐ The University of Queensland School of Medicine

Thad Waites, MD, FACC

Immediate Past Chair, Board of Governors American College of Cardiology Director Cardiac Catheterization Laboratories Southern Heart Center (A Service of Hattiesburg Clinic, P.A.)

Janet Wright, MD, FACC

Executive Director Million Hearts Department of Health and Human Services (HHS) Centers for Disease Control and Prevention (CDC) Centers for Medicare & Medicaid Services (CMS)


Coordinated Cardiac Delivery: Reducing Mortality in High Risk Fetal Cardiac Lesions

at the University of Mississippi Medical CenterDaniel J. DiBardino, MD; Jennifer C. Shores, MD; Michelle Sheth; Mary Taylor, MD;

Kenneth Liechty, MD; Jorge D. Salazar, MD

Introduction The extensive use of prenatal ultrasound and

fetal echocardiography has resulted in an increased number of congenital anomalies being detected before birth. Identification of these anomalies in utero has a direct impact on the management of these potentially life-threatening anomalies. The accurate prenatal diagnosis of these anomalies provides time for development of a pre- and perinatal management plan, including the route and timing of delivery, to ensure the best potential outcome for these patients. It also provides time for education and discussion with the family regarding the etiology and pathophysiology of the particular anomaly, the complex management and delivery plan, and potential outcomes. The recent development of The University Center for Fetal Medicine and the Division of Congenital Heart Surgery at The Batson Children’s Hospital and The University of Mississippi Medical Center now allows patients from Mississippi and the region to receive this high level of comprehensive care close to home for the first time. In the past, these patients with complex congenital anomalies were required to travel to other distant institutions to receive care.

Complex congenital heart lesions represent one of the more striking examples of a congenital anomaly that can be impacted by accurate prenatal diagnosis and this comprehensive management approach. Fetuses diagnosed with hypoplastic left heart syndrome (HLHS) and a restrictive

or intact atrial septum or fetuses with any form of partial or totally obstructed totally anomalous pulmonary venous return (TAPVR) represent patients who are significantly at risk in the immediate delivery period. A standard delivery approach makes immediate treatment impractical, if not impossible, and results in a delay in treatment, leading to unacceptably high morbidity and mortality. Following standard delivery, either by cesarean section or vaginal routes, these patients immediately develop severe pulmonary hypertension and pulmonary vascular reactivity, resulting in systemic hypotension and pulmonary injury leading to a dramatic increase in morbidity and mortality. The institution of extracorporeal membrane oxygenation (ECMO) support, while able to restore cardiac output and lower lactate levels, does not decompress the pulmonary venous chamber in patients with either of these lesions, and high morbidity and mortality are the rule. In order to minimize the delay in treatment and resulting complications, we have instituted a program of Coordinated Cardiac Delivery (CCD) to improve the outcome of these patients.

The Coordinated Cardiac Delivery- Delivery Plan and Team Specifics

The needs of each individual fetus need to be taken into consideration when planning a CCD. It is preferable to undergo scheduled caesarian section or vaginal delivery in the operating room adjacent to the pediatric cardiac operating room. In order to minimize confusion, only the necessary personnel are present in each room. The OBGYN team and appropriate anesthesiology personnel conduct delivery, and the newborn is immediately transitioned to the NICU team, wrapped and transported o the pediatric cardiac operating room table. Here the standard NICU resuscitation is performed, including umbilical line placement and airway management coordinated with the pediatric cardiac anesthesia team. The entire pediatric cardiac surgery team is scrubbed and completely prepared for immediate operation in the case of inability to resuscitate. The appropriate sized cardiopulmonary bypass and ECMO circuits

• SCiEntifiC aRtiClES •

Author informAtion: Division of Congenital Heart Surgery (Dr. DiBardino and Dr. Salazar). Division of Pediatric Cardiology (Dr. Shores). Division of Pediatric Anesthesia (Ms. Sheth). Division of Pediatrics and Critical Care (Dr. Taylor). University Center for Fetal Medicine, Division of Pediatric Surgery (Dr. Liechty). Children’s Heart Center, University of Mississippi School of Medicine and The Blair E. Batson Children’s Hospital, Jackson.

CorreSPonding Author: Daniel J. DiBardino, MD, Division of Pediatric Cardiac Surgery, Department of Surgery, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216. Phone: (601)-984-5450 [[email protected]].


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are available and primed, and the perfusion team is on standby. Airway management is performed by the anesthesia team and is followed by transthoracic or transesophageal echocardiogram (TEE) by a pediatric cardiologist. This allows for confirmation of the diagnosis and discussion between the cardiology team and surgical team as to the final operative plan. The NICU team can transfer the newborn to the cardiac ICU or tentative or standard definitive repairs can be considered in this controlled fashion. In the latter case, the baby is positioned and prepped by the usual cardiac team members and the operation can begin.

Example CaseA fetus with a known prenatal diagnosis of HLHS

was followed by our center. Episodic fetal supraventricular tachycardia (SVT) led to close repeat echocardiographic examinations. A large aneurysmal atrial septum was seen occasionally bowing into the systemic tricuspid valve (figure 1).

The latter was thought to be related to the SVT; however this resolved by 36 weeks and the fetus developed to 2.2kg and was non-hydropic. In addition to the appearance shown, only a very small opening could ever be demonstrated in the atrial septum which was thus presumed to be restrictive. A CCD intervention was planned with the appropriate personal as previously outlined. A scheduled caesarian section was performed as first case with the cardiac team on standby in the adjacent room. Delivery was uneventful; the newborn was cyanotic and saturating 60-70% once the airway was controlled and monitors and lines placed. PGE1 infusion was initiated. TEE confirmed the diagnosis (figure 2). After discussion with cardiology, the mother was updated in the adjacent room and

the patient was prepped. Median sternotomy and aorto-right atrial bypass was performed and an open atrial septectomy was completed using pump-sucker bypass as an adjunct during the few minutes the atrial septum was open. After atrial closure, a 3.5mm Gortex tube graft was cut into two small rings and used for bilateral pulmonary artery bands in order to prevent overcirculation and heart failure during the convalescent period. Completion echocardiogram is shown in figure 3. The newborn

was subsequently extubated and began feeding. During the next week, the hybrid approach to single ventricle palliation was completed with the placement of a ductal stent in the cardiac catheterization laboratory. The patient was discharged

Figure 1. Fetal echocardiogram at 32 weeks and 6 days

gestation revealing a large aneurysmal atrial septum.

The fetus was suffering from episodes of supraventricular

tachycardia, and at times the aneurysmal septum was

seen to be bowing in and out of the tricuspid valve. Only

a small opening in the septum was ever able to be imaged

in multiple repeat studies, thus indicating likely restriction.

Coordinated Cardiac Delivery (CCD) was planned.

Figure 2. Following CCD, immediate post-birth

transesophageal echocardiogram on-table in the pediatric

cardiac operating room confirmed aneurysmal atrial

septum with a small opening.

Figure 3. Following CCD, post-birth confirmation

and immediate open atrial septectomy with bilateral

pulmonary artery banding, post-repair transesophageal

echocardiogram reveals wide open atrial septum. The

patient was transferred to the cardiac intensive care unit

with stable single ventricle hemodynamics.


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home and returned at age 4 months for the second stage of the single ventricle pathway. She was eventually discharged from this and remains with close outpatient follow-up.

Conclusion The Society of Thoracic Surgeons Congenital Database

has emerged as the standard reference for expectations in pediatric cardiac surgery.1,2 As of the most recent reports, parents of HLHS newborns can expect an average of 17% discharge mortality and much higher for certain combinations of lesions like intact septum and total anomalous venous repair.3 The hybrid approach to HLHS management is a well known alternative to standard operative management for high risk patients and it is one which we have experience. The addition of CCD to our armamentarium of ensuring stable delivery and initial management help ensure the best possible candidates for medical and surgical therapy and can possibly result in survival for even the most hopeless of lesions.

References 1. Clarke DR, Breen LS, Jacobs ML et al. Verification of data in

congenital cardiac surgery. In: 2008 Supplement to Cardiology in the Young: Databases and The Assessment of Complications associated with The Treatment of Patients with Congenital Cardiac Disease, Prepared by: The Multi-Societal Database Committee for Pediatric and Congenital Heart Disease, Jeffrey P. Jacobs, MD

(editor). Cardiol Young. 2008 Dec;18 Suppl 2:177-87.

2. O’Brien SM, Clarke DR, Jacobs JP et al. An empirically based tool for analyzing mortality associated with congenital heart surgery. J Thorac Cardiovasc Surg. 2009;138:(5):1139-53.

3. Jacobs JP, O’Brien SM, Pasquali SK et al. Richard E. Clark Paper: Variation in outcomes for benchmark operations: an analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database. Richard Clark Award recipient for best use of the STS Congenital Heart Surgery Database. Ann Thorac Surg. 2010;92(6):2184-92.

4. Dibardino DJ, McElhinney DB, Marshall AC, Bacha EA. A review of ductal stenting in hypoplastic left heart syndrome; bridge to transplantation and hybrid stage I palliation. Pediatric Cardiology 2008:29(2):251-7.

182 jOuRNAl MSMA july 2010

with the cervical or sternal splits in the study. This finding is consis-tent with a study of thirty-five patients with a substernal goiter, ofwhom twelve underwent sternotomy.12 There were no cases of woundinfection, hematoma or death. indications for a sternal split are gener-ally those of size, cancer, and atypical anatomy, dense scar from pre-vious surgery or inability to deliver the thyroid gland into the neck.13

Surgeries were carried in combination by Otolaryngologist- Head andNeck Surgeon (eNT) and cardiothoracic surgeon. The overlap of skillsets, knowledge of anatomy different areas and compilation of surgicaltechniques aid in these difficult surgeries, surgeries which were carriedout in a collegial atmosphere. Newer technology in the form of use ofthe Nim monitor and Harmonic scalpel proved to be of value. For ex-ample, after completing a lobectomy if the thresholds using the nerveintegrity monitor are elevated (suggesting damage to the recurrent la-ryngeal nerve), surgery on the opposite side can be deferred.

every patient in this series had several comorbidities.(Tableiii)The most common of these included organic heart disease, diabetesmellitus and obesity. There was also one patient who had polio in thedistant past. despite these varied and potentially serious medical prob-lems, there were no deaths in the series, complications from these co-morbidities, or prolonged hospital stay. it does pose the question ofproceeding with a total thyroidectomy with the advantage of avoidingfurther surgery in the future versus performing a lobectomy only andthus avoiding potential surgical complications and allowing for ashorter anesthesia time.

Our tendency has been to perform a lobectomy; however, as fur-ther operative experience is gained there may be a trend to total thy-roidectomy. Netterville et al have advocated total thyroidectomy withgood results.1 Others have recommended total thyroidectomy, totallobectomy or subtotal lobectomy, depending on the clinical situation.14

Regardless of the the procedure advocated, the literature suggests sur-gical excision as the treatment of choice. There have been few com-plications and a low morbidity rate in this series of patients. Notsurprisingly the rate of complications is higher in patients undergoingsubsternal thyroidectomy.15

conclUSionSubsternal goiters are often asymptomatic due to their slow

growth and may be quite large at the time of diagnosis. Of the varieddiagnostic tests, a CT scan is the most valuable as it provides data onsize, location and anatomic vagaries.

patients with substernal goiter commonly have multiple comor-bid conditions. despite this, surgery is the recommended treatment toavoid tracheal and vascular compromise as well as to exclude the pos-sibility of well differentiated thyroid cancer. Surgery can be carriedout with low morbidity and mortality, most commonly via a cervical ap-proach.

A team approach with the use of advanced technology such asthe Nim™ and Harmonic™ scalpel are valuable adjuncts in the man-agement of patients with substernal goiter.

referenceS1. Netterville Jl, Coleman SC, Smith JC, et al. management of Substernal

goiter. Laryngoscope. 1998; 108:1011-7.2. batori m, Chatelou e, Straniero A, et al. Substernal goiter. EUR Rev

Medial Pharmaco Sci. 2005; 9(6):355-9.3. batori m, Chatelou e, Straniero A. Surgical Treatment of Retrosternal

goiter. EUR Rev Medial Pharmacol Sci. 2007; 11(4):265-8.4. Chow Tl, Chan TT, Suer dT, et al. Surgical management of Substernal

goiter: local experience. Hong Kong Medical J. 2005; 11(5):360-5.5. Agha A, glockzin g, ghali N, et al. Surgical Treatment of Substernal

goiter: An Analysis of 59 patients. Surgery Today. 2008; 38(6):505-1p.6. lahey FA, Suinton mW. intrathoracic goiter. Surg Gynecol Obstet. 1934;

59:627-37.7. gardner e, gray dJ, O'Rahilly R. Anatomy, 3rd ed. philadelphia, Toronto,

london: W.b. Saunders Company; 1969:297-298.8. Cohen Jp. Substernal goiters and Sternotomy. Laryngoscope. 119:683-

688, April 2009.9. Terris dJ, bonnett A, gourin Cg, et al. minimally invasive

Thyroidectomy using the Sofferman Technique. Laryngoscope. 2005;115(6):1104-8.

10. mackle T, meeney J, Tirem C. Tracheoesophageal CompressionAssociated With Substernal goiter. Correlation of Symptoms with CrossSectional imaging Findings. J Laryngo Otol. 2007; 121(4):358-61.

11. ben Nun A, Soudack m, Retrosternal Thyroid goiter:15 years experience.ISR Med Assoc J. 2006; 8(2):106-9.

12. Sancho JJ, Kraimps Jl, Sanchez-blanco Jm, et al. increased mortalityand morbidity Associated with Thyroidectomy for intrathoracic goitersReaching the Carina Tracheal. Arch Surg. 2006; 141(1):82-5.

13. de perrot m, Fadel e, mercier O. Surgical management of mediastinalgoiters: When is a Sternotomy Required? Thoracic Cardiovasc Surg.2007; 55(1):39-43.

14. possetto b, liquori g, Rombola F. Substernal goiter: A diagnostic andTherapeutic problem. (Report of 39 surgically treated cases). Ann StarChir. 1999; 70(1):29-35.

15. pieracci Fm, Fahey TJ. Substernal Thyroidectomy is associated withincreased morbidity and mortality as compared with ConventionalCervical Thyroidectomy. Am J Surg. 205(1):1-7, July 2007.

Cardiovascular * N = 16Diabetes Mellitus n = 5Obesity n = 4Arthritis n = 4Pulmonary # n = 4Previous neoplasm n = 3Miscellaneous + n = 6* Includes hypertension, coronary artery disease,

hyperlipidemia, organic heart disease, atherosclerosis# Includes COPD, ROAD, and Pulmonary Embolus+ Includes osteoporosis gout, polio, renal disease, hepatitis,

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Introduction There is an established and well known relationship between team experience (annual institutional volume as

the most commonly utilized measurable surrogate) with clinical outcomes in the delivery of pediatric cardiac surgical care. In the era of scrutinized clinical outcomes and regional competi-tion among viable operative care lines, it is more difficult than ever to initiate and maintain a successful program. Such an initiative requires meticulous attention not only to the details of each individual patient but monitoring and tracking outcomes in the effort to identify clinical deficiencies, system issues and individual performance issues. This relentless combination of daily tasks on top of providing consistent 24 hour care can be overwhelming for a new program which is often concomitantly challenged by inexperienced team members including nurses, critical care providers and various members of the surgical team.

During a period of clinical inactivity, all patients requiring operative care for congenital heart defects were sent outside the state of Mississippi to several large centers in several different regions of the United States. In an effort to provide consistent in-state care, a senior surgeon (RAJ) was sought and contracted

and began building a base team and performing basic opera-tions on site at the University of Mississippi Medical Center. More complex operations were sent to Children’s National Medical Center in Washington, DC. In April of 2010, admin-istrative reorganization occurred in an effort to establish an independent, in-house pediatric cardiac surgery program. The first operation occurring under this revitalization was April 15, 2010, and all data from operations and procedures since then were submitted to the Society of Thoracic Surgeons Congenital Database (STSCD) in real time. The purpose of this study is to analyze the first 18 months of data from this revitalization effort with emphasis on results for the major most common pediatric heart operations. It is our hypothesis that our hospital discharge mortality for each of these procedures compares favorably with published STSCD benchmark data.

Methods All data from the divisional operations and procedures

were submitted to the STSCD. This database contains preop-erative, operative, and postoperative outcomes data on all chil-dren undergoing heart surgery at participating centers, which now totals >85% of all congenital heart surgery in the United States.1-3 It is the largest existing clinical congenital heart sur-gery data registry in the world. Data quality and reliability are assured through intrinsic verification of data and a formal pro-cess of site visits and data audits. The most recent publication from this database once again established updated benchmark outcomes with which program performance can be measured, and these data were used for comparison to our own.3

Following approval by the Institutional Review Board at the University of Mississippi Medical Center, our institutional STSCD submissions were reviewed for the 18 months from 5/15/2010 to 11/31/2011. All procedures and operations were tabulated on a Microsoft Excel spreadsheet (Microsoft Corpo-ration, One Microsoft Way, Redmond, WA) and all preopera-tive and demographic, operative and postoperative data were

Revitalization of the University of Mississippi Children’s Heart Center: Report Card

from the First 18 MonthsDaniel J. DiBardino, MD; William J. Lancaster, BA; Walter Merrill, MD; Marc E. Mitchell, MD;

Emilee Taylor, RN; Charles Gaymes, MD; Makram Ebeid, MD; Jennifer Shores, MD; Elizabeth Christ, MD; Mary Taylor, MD; Michelle Sheth, MD; Richard A. Jonas, MD and Jorge D. Salazar, MD

Author informAtion: University of Mississippi School of Medicine, Children’s Heart Center, The Blaire E. Batson Hospital for Children, University of Mississippi Medical Center, Jackson. Division of Pediatric and Congenital Heart Surgery (Dr. DiBardino, Mr. Lancaster, Ms. Taylor and Dr. Salazar). Division of Cardiothoracic Surgery (Dr. Merrill). Chairman, Department of Surgery (Dr. Mitchell). Division of Pediatric Cardiology (Dr. Ebeid and Dr. Shores). Department of Pediatrics and Critical Care (Dr. Christ and Dr. Taylor). Department of Pediatric Anesthesia (Dr. Sheth). Division of Pediatric Cardiac Surgery, Children’s National Medical Center, Washington D.C., (Dr. Jonas).

CorreSPonding Author: Daniel J. DiBardino, MD, Division of Pediatric Cardiac Surgery, Department of Surgery, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216 Phone: (601)984-5450 [[email protected]].

• SCiEntifiC •


similarly tabulated. STS database information regarding the precise details of the anatomic diagnosis and operative repairs were verified via direct review of the institutional operative notes. Representative lesions for program performance were collected, tabulated and analyzed and included operations per-formed for patients coded with the following primary cardiac diagnoses: ventricular septal defect (VSD), tetralogy of fallot (TOF), transposition of the great arteries (D-TGA), atrioven-tricular canal defect (AVC), end-stage heart failure (ESHF) and single ventricle patients (SVPs). In order to make the most ho-mogeneous SVP analysis, the results of first stage surgery for hypoplastic left heart syndrome variants (HLHS) as well as all bidirectional Glenn anastomoses (BDGs) and fontan comple-tions were each individually analyzed. The primary outcome measures for all diagnoses were discharge mortality, median length of stay and readmission for an unplanned reoperation. Our results were then compared to the most recent above men-tioned STSCD published results.3

ResultsThere were 392 cases performed between 4/15/2010 to

11/31/2011 with consistent growth between 2010 and 2011 (figure 1). Monthly volume has steadily strengthened from 5 cases in April 2010 to consistently over 20 cases per month in the latter half of the series, resulting in more than doubling of growth from 135 cases in 2010 to 257 cases thus far in 2011 (figures 2 and 3). Current data and operative scheduling trends project 400-450 total operations and procedures in the calendar year 2012 alone. As of July 1, 2011 the program expanded from 1 to 2 dedicated pediatric cardiac surgeons with the senior surgeon (JDS) performing 311 cases and the junior surgeon (DJD) 81 cases by the 18 month mark. Figures 2 and 3 dem-onstrate graphically the gradual monthly increase in case vol-ume as well as the percentage of cases performed on neonatal patients and the percentage of procedures performed through redo sternotomies, both a reflection of overall case complexity. While there were no neonates and only 4 redo sternotomies during the first two months of the new program, acuity and difficulty gradually increased through November 2011, with 11 neonatal and 18 reoperations in 33 total procedures. This was our highest total monthly number and highest acuity month-ly tally. In 2010, 21 of the 135 cases (16%) were neonates and 65 (48%) were redo sternotomies while 257 procedures in 2011 have been neonates in 70 procedures (27%) and 126 redo sternotomy (49%). For the entire experience, the over-all unadjusted hospital mortality rate for all index cases (the major index operation for each patient’s admission) was 3%. Results for the chosen diagnoses representative of program performance are listed in table 1. The only hospital discharge mortality among any of these benchmark diagnoses was in the SVP category, giving a 100% discharge survival rate among all the other categories and program performance that was above the published STSCD benchmarks in all categories (table 1).

Figure 1. Yearly growth since revitalization, totaling

393 cases from 4/15/2010 -11/30/2011.

Figure 2. Monthly operative volume for 2010, totaling

135 cases from 4/15/2010 to 12/31/2010. The fraction

of each month’s cases which were neonates (30 days

of age or less) and redo sternotomies are shown

respectively.

Figure 3. Monthly operative volume for 2011, so far

totaling 257 cases from 1/1/2011 -11/30/2011.


VSD as Primary DiagnosisThere were 40 operations and procedures performed for

a primary cardiac diagnosis of VSD, 19 in 2010 and 21 so far in 2011. Eight patients judged to be in CHF from overcircula-tion with especially small size or other complicating factors underwent pulmonary artery band (PAB) placement. Of these, 4 currently await repair while 4 have undergone subsequent PAB removal, PA reconstruction and complete repair, and in two cases multiple intervening procedures were required for pericardial drainage (n=1), airway malacia (n=1) and sternal wound complication (n=2). Twenty-three patients underwent primary VSD closure with no previous band. PAB place-ments, removals and VSD closures were often associated with other secondary procedures such as PDA ligation, sub-aortic stenosis resection, aortic valve repair and a supravalvar mitral ring resection. To date there was 100% survival to hospital discharge for all patients and procedures and median length of stay after VSD closure of 5 days.

Tetralogy of FallotThere were 22 operations and procedures performed

for a primary cardiac diagnosis of TOF. Small pulmonary arteries and/or very small (premature) patient size led to the placement of 5 systemic to pulmonary artery shunts, and 3 of these (60%) have gone onto complete repair with 2 currently awaiting repair. One patient was found to have tricuspid valve (TV) tissue causing near total obstruction of the VSD and RV hypertension at the time of attempted repair and thus under-went resection of the obstructing TV tissue and partial relief of RVOT obstruction (“banded” physiology) and returned for subsequent successful complete repair. An additional pa-tient underwent complete RVOT resection but extremely fri-able tissue precluded VSD repair; a band was placed and the child returned for band removal and successful compete re-

pair. Ten patients underwent primary complete repair. Of these, one patient was a 35-year-old adult s/p Waterston shunt in childhood who underwent complete repair with fenestrated VSD closure, 27mm pulmonary valve re-placement, PA reconstruction and Waterston shunt takedown. To date there was 100% survival to hospital discharge for all patients and proce-dures. Median length of stay after complete repair of TOF was 6 days.

Transposition of the Great ArteriesThere were 9 operations and

procedures performed for D-TGA and associated lesions such as VSD, ASD and PDA. In one case the patient has severe left ventricular outflow tract obstruction/ subpulmonary stenosis

(LVOTO/subPS) and thus underwent a systemic to pulmo-nary artery shunt procedure. This child is currently under-going evaluation for possible arterial switch and concomitant resection versus Rastelli type repair. The remaining 5 patients underwent arterial switch operation (ASO) and single stage complete repair of all associated lesions in the neonatal peri-od, including one patient at 1.8kg with an intramural coronary artery pattern. Three patients required initial management with an open sternum and delayed sternal closure 1 (n=1) or 2 (n=2) days following ASO. To date there was 100% survival to hospital discharge for all patients and procedures. Median length of stay after ASO was 9 days.

Partial and Complete Atrioventricular Canal DefectsThere were 8 patients with atrioventricular canal defects

referred for surgical repair, including one who had undergone previous pulmonary artery banding at an outside hospital. All underwent complete repair, including 3 partial defects and 5 complete or intermediate. To date there was 100% survival to hospital discharge for all patients and procedures with median length of stay following complete repair of AV canal defect was 5.5 days.

End-Stage Heart Failure ProgramIn order to keep up with the seemingly growing needs of

children and adolescents with advanced heart failure, a pedi-atric cardiac transplant and heart failure program was initiated and became active with the first transplant on 9/18/2011. In 3 months we have performed 3 orthotopic heart transplantations (OHTs) and a Bautista LV remodeling procedure for advanced heart failure. To date there was 100% survival to hospital dis-charge for all patients and procedures with no unplanned re-operation. This program currently also includes the care of

Table 1. Representative index operations reflective of program performance

from 4/15/2010 to 12/31/2010 and comparison to the most recent STS

Benchmark data. 3

Page 18 of 18

Table 1. Representative index operations reflective of program performance from 4/15/2010 to

12/31/2010 and comparison to the most recent STS Benchmark data [3].

Outcomes by procedure Procedure Number

of cases Median post-

operative length of stay

Hospital discharge

mortality rate

STS National Hospital Discharge

Mortality Norwood 10 19 days 10% 19.3%

Arterial Switch

5 9 days 0% 2.9%

Glenn 19 11 days 0% N/A

Fontan 10 9 days 0% 1.3%

AVC repair 8 5.5 days 0% 2.2%

TOF repair 15 6 days 0% 1.1%

VSD repair 27 5 days 0% 0.64%

Heart Transplant

3 22 days 0% N/A


young patients previously receiving OHTs and now living in the state of Mississippi, the ongoing follow-up of patients who may require listing and will most likely involve VAD therapy for bridge to transplant in the near future.

Single Ventricle Surgery ProgramOf the 392 total cases since programmatic reorganiza-

tion, 110 operations and procedures (28%) were performed for the ongoing care of single ventricle patients (SVPs), thus con-stituting the largest percentage patients cared for in our center and the most complex patient population in the specialty. First stage treatment for hypoplastic left heart syndrome (HLHS) variations was required in 14 patients and required 33 opera-tions to complete; 10 patients underwent a variation of Stage I Norwood operation and 4 underwent the “hybrid” transcathe-ter-surgical approach.

The 10 patients who underwent Stage I operative recon-struction were performed with a Sano shunt in 8 and a modi-fied Blalock-Taussig shunt in 2, resulting in only one opera-tive death for a 10% discharge mortality. All patients were managed with an open sternum and underwent at least 1 ex-ploration for delayed sternal closure. The 1 Stage I operative death was a respiratory event on postoperative day 58 after a successful ECMO run and decannulation. This compares very favorably with the published STS benchmark discharge mortality of 19%.3 Median length of stay following Norwood operation was 19 days. Among the 4 patients who were se-lected to undergo a combined Hybrid surgical-catheterization approach, there was 1 death from a vascular access related is-sue for a 75% hospital discharge, also comparing favorably to published data.4

There were 16 patients undergoing bidirectional Glenn anastomosis as part of second stage single ventricle palliation pathway and in 2 of these the DKS connection had to be re-done secondary to known or suspected stenosis. The sternum was left open in 3 patients, requiring delayed sternal closure. There was 100% stage II survival to hospital discharge for all patients and procedures. There were 10 Patients undergoing Fontan Stage III operation, including 3 who were complex redo-Fontans. There was 1 patient left open after surgery thus necessitating 1 delayed sternal closure, 1 patient required pigtail placement for effusion and 1 patient required thoracic duct ligation. There was 100% stage II and stage III survival to hospital discharge for all patients and procedures. Median length of stay was 11 days following Glenn and 9 days follow-ing Fontan operation.

DiscussionThe program’s first operation was performed April 15,

2010, and the first 100 cases performed without a hospital dis-charge mortality. Mississippi Medicaid named the congenital heart program its preferred program less than 1 year after its creation, and in December 2011 we were approved for “center

status” as the Children’s Heart Center at the University of Mis-sissippi Medical Center. The success of the Mississippi con-genital heart program depended on the serendipitous existence of multiple conditions. Recognition of these conditions during planning was critical as was the continued acknowledgement of these conditions during implementation. Most importantly, there was clinical need. The entire state of Mississippi had been without a stable congenital heart program for over 10 years. This meant that for a population of over 3 million people and 45,000 live births yearly, congenital heart surgical services in-state were unavailable. The implications to the individual child and family, especially those less advantaged, are staggering in terms of decreased access to care and consistency of follow up. When one considers that very few congenital heart patients re-quire only one intervention and that the very best outcomes rely on careful follow-up and subsequent management, it is easy to understand the profound implications of all of Mississippi children needing to leave the state for care.

A second set of very important conditions leading to a receptive environment for a successful program in Mississippi was both political and financial in nature. The funding real-ity for Mississippi patients with congenital heart disease was such that the vast majority of patients were covered by Missis-sippi Medicaid. The exportation of congenital heart patients out of state for care resulted in a significant financial burden on the state and, therefore, a great sense of need. This condition, coupled with the political unease associated with the absence of a stable congenital heart program in Mississippi for over a decade, led to an environment that was very open to change. A third factor leading to a receptive environment was the exis-tence of only one Children’s Hospital and an academic medi-cal center in the entire state of Mississippi. The well-known challenges of having multiple congenital heart programs in the same state or even the same city were not in existence in this case. In total, the overall environment was quite recep-tive to the creation of a successful congenital heart program. This “perfect storm” of unique conditions led the possibility of creating a “win-win” for everyone in the state: for patients, families, the Children’s Hospital and Medical Center, Mis-sissippi Medicaid and the wellbeing of Mississippi society.

Specific to the Children’s Hospital and Medical Center, recognition of the need to serve the congenital heart surgical population led to an alliance with Children’s National Medical Center, Washington, DC, in 2008 under the leadership of Dr. Richard Jonas. This important relationship helped provide for a more consistent access to care by transporting the more com-plex cases to Washington, DC for surgical management while performing the less complex cases in Mississippi on monthly visits. Dr. Jonas and his team partnered with the Mississippi leadership to begin setting up the structure necessary to house an independent program. Without this important groundwork and infrastructure-building, the success of the Mississippi pro-gram would not have been possible. Most importantly, the DC


National team impressed upon the leadership in Mississippi the absolute necessity of a comprehensive approach to the manage-ment of congenital heart disease. The essence of the message was that “if you are going to do it, you have to do it right.” What-ever the specific model for a successful congenital heart program used, all successful examples point to several essential variables and components necessary to create the possibility of success.

It is also important to recognize the serendipity of having many excellent clinicians already practicing at the Children’s National Medical Center. Although these clinicians had not been rallied in a coordinated fashion for the comprehensive management of congenital heart disease, it is important to recognize the excellent, albeit few in numbers, pediatric car-diologists, anesthesiologists, neonatologists, nurses, respiratory therapists, and many others already on the ground in Missis-sippi. In many ways these clinicians had already been proven by the trial by fire of not having a home-based surgical pro-gram to partner with in the management of these complex pa-tients. The presence and investment of these clinicians were, and are, essential factors leading to the receptive environment enabling our success. The empowerment of already present competent team members and the recruitment and integration of new members have allowed the team to grow and thrive. As we continue in growth, it will be important to remain true to the founding successful ingredients and remain a “team.”

Comment: As of the printing of this article, the UMC Congenital

Heart Program has now completed its 875th case (450 for 2012 so far) with a 2.2% overall operative mortality and 3.2% ECMO rate.

References 1. Clarke DR, Breen LS, Jacobs ML et al. Verification of data in

congenital cardiac surgery. In: 2008 Supplement to Cardiology in the Young: Databases and The Assessment of Complications associated with The Treatment of Patients with Congenital Cardiac Disease, Prepared by: The Multi-Societal Database Committee for Pediatric and Congenital Heart Disease, Jeffrey P. Jacobs, MD (editor). Cardiology in the Young, Volume 18, Issue S2 (Suppl. 2),177–187.

2. O’Brien SM, Clarke DR, Jacobs JP et al. An empirically based tool for analyzing mortality associated with congenital heart surgery. J Thorac Cardiovasc Surg. 2009;138:(5):1139-53.

3. Jacobs JP, O’Brien SM, Pasquali SK et al. Richard E. Clark Paper: Variation in outcomes for benchmark operations: an analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database. Richard Clark Award recipient for best use of the STS Congenital Heart Surgery Database. Ann Thorac Surg. 201;92(6):2184-92.

4. Dibardino DJ, McElhinney DB, Marshall AC, Bacha EA. A review of ductal stenting in hypoplastic left heart syndrome; bridge to transplantation and hybrid stage I Palliation. Pediatric Cardiology 2008:29(2):251-7.

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an outpatient if he insisted. When he started thinking about the co-pay that was associated with the outpatient testing, he decided to take the medication and wait two weeks to see if he improved.

The second patient is an 18-year-old female who came in with cold symptoms that had been going on for two days. She had sinus congestion and a cough, no fever, no chest pain or shortness of breath. She has Medicaid. She came in because it was convenient for her and she wanted to be checked out. She was diagnosed with a viral URI and prescribed over-the-counter medication in the form of Claritin and Robitussin for her cough.

The third patient is a 10-year-old boy who cut his hand while playing outside. His parents have a health savings account and so they went all over our little town looking for a doctor’s office that was available that could sew up his hand. They found one and his hand was sewn up at the doctor’s office since they did not want to pay all the additional expenses of coming to the emergency department because they have to pay for all that themselves, they found the least costly place to have the patient treated.

What was different about all these patient presentations? For one thing, do you notice that when someone has to pay for something, suddenly they seem to appreciate or value it more and they are more selective about how they want to spend their money? I would submit to you that what is missing from the whole healthcare industry today is that patients no longer have any skin in the game. Unless they have health savings accounts or high deductible insurance, they are separated from the cost of any services by the insurance companies themselves or by government-run programs like Medicaid or Medicare. When that happens, as you well know from your personal experience, if you don’t have to pay for something you do not value it nearly as much. You tend to over-utilize and you don’t have a sense of appreciation for either the service or the person providing it. If we all just had to pay some small portion for any of the services that we were provided, we would appreciate them much more and we would be much more careful in the way that we adhere to recommendations and would be much more compliant. So regardless of what type of insurance is out there, whether it is a government-supported insurance or commercial, having some personal responsibility is essential for your appreciation of the care that you receive.

So what can we do as physicians?

1. First of all we can at least bring this issue to the attention of our politicians and let them know that personal responsibilityis absolutely essential to any successful healthcare program like Medicare and Medicaid and that some level of co-pays(however small) actually help patients value care and utilize it more appropriately.

2. Second we can let our AMA delegation from the State Medical Association know that this is a principle that we wantpromoted in the AMA that personal responsibility has to be a part of successful and financially stable healthcare reform.

The only way that we will get back to sustainable healthcare in our country is if patients take responsibility for their care and that means taking financial responsibility as well and having insurance pay for catastrophic coverage as it once was intended to do.

T hree different patients present to the emergency department. Oneis a patient who has back pain. He is a 42-year-old male

that had worked all day in his yard and the next day is having pain in his back. It did not radiate down his legs and there was no numbness or weakness associated with it. The pain was severe enough though to cause him to miss work so he came to the emergency department. He was seen and evaluated. It was felt that this was musculoskeletal. He was going to be prescribed appropriate medications with anti-inflammatories and muscle relaxers but he was insistent that he wanted an MRI of his back. I explained to him that most back pain such as he has gets better in two weeks with the medication we are prescribing and the MRI would not be indicated at this point but he was still insistent. I explained to him that we do not do non-emergent MRIs thru the emergency department but that I would order one as

You Have To Have Some Skin in the Game

StEvEn l. DEMEtRoPouloS, MD2012-13 MSMa PRESiDEnt

• PRESiDEnt’S PagE •


Just what the doctor ordered

APPETIZER

This month’s recipe is for an appetizer. This is an easy appetizer that is great to throw together before a party. I take feta cheese and blend olive oil in with it until it is very creamy. Then I add a generous amount of dried basil or dried oregano or dried rosemary. You serve this on toasted slices of French baguettes that are sliced thin and put in the oven with a little bit of olive oil until they are toasty. Then pull those out and serve the feta cheese on that. Another option if you don’t want to use bread is to use sliced cucumbers or celery sticks and serve it like the old-fashioned celery-stuffed pimento cheese sticks but using feta cheese mixture instead.

Let me give you a short course on feta cheese. Feta cheese was originally developed in Greece and it uses predominantly sheep’s milk but now they can blend in up to 30% goat’s milk in the Greek feta cheese. It is generally salty and tangy and crumbles easily. Feta means “to slice” so they make it in bigger pieces and slice it up. Other countries have their version of feta cheese. The Greeks would say that feta cheese only comes from Greece. In Bulgaria they make a white cheese that is called Bulgarian feta. It comes from mostly sheep’s milk and it is a creamy, less salty-tasting feta. The French have their own version of feta cheese as well and it is again mostly sheep’s milk and it is also less tart than Greek feta. American-based feta cheese like you would buy in most of the supermarkets is mainly made from cow’s milk and it is not quite as tart as the Greek or Bulgarian feta cheese. You can usually find these different cheeses in Mediterranean specialty shops. The Bulgarian usually comes in a tin and the French is usually in a tin as well. The best way to keep any type of feta cheese is to keep it in a brine. After you open it, you put it in a plastic container and have another container in which you have mixed salt with cold water until it no longer dissolves. Pour the brine mixture over the feta cheese to completely submerge it and that keeps it from drying out. If you don’t do this, feta cheese dries out and becomes more dry and crumbly. You can keep it this way for several months. We typically buy a big chunk of the feta cheese at Sam’s and it is an American feta cheese. We put it in a big plastic container and eat off of it on a regular basis.

We recently had a dinner party and I did a feta cheese tasting. I had the French feta cheese, the Bulgarian feta cheese, and the Greek feta cheese. I mixed it up just like I described earlier and we had a taste test from eight couples. The winner was the Greek feta. Anyway, try some feta cheese for your next appetizer. You can throw in finely chopped sun-dried tomatoes. You can throw in some olives as well. I think the key though is making it creamy by adding the olive oil to make it very smooth. You can have your own taste test at your next dinner party.

Until next month’s column, “good eating.”

When your office is short-staffed, use the MSMA Online Job Bank!

Learn more: www.MSMAonlinejobs.com

When your medical office is short-staffed, you get frustrated.

When you get frustrated, you dread going to work

and you start playing hooky.

When you start playing hooky, the bills pile up.

When the bills pile up, Mama ain’t happy.

When Mama ain’t happy, ain’t nobody happy.

KEEP MAMA HAPPY.

Feta Cheese Tasting Appetizer


• EDitoRial •

The Magic KingdomReed B Hogan, II, MD

“Oh daddy,” she sighed, a shallow whispered voice, as her weak carotid pulse disappeared and her rhythm vanished to the flat line of electrical inactivity.

The eldest of my four children, Marley, 30-years-old, is full of life: active, artsy, and a great mother to three of my eight grandchildren. Since high school, her mid-teens, she experienced intermittent episodes of palpitations, feeling faint at unexpected times, chest discomfort without a cause, and a situational anxiety precipitated by the anticipation of recurrence. A colleague describes as “squirrelly girly” symptoms that young women have at the most random times. Being the typical “doctor dad,” I too was convinced that the “squirrelly girly syndrome” was rampant not only in my home but throughout society with increasing pressures both socially and situational on our young female citizens.

Shortly after the birth of her second child, after a brief stroll with her newborn, she once again proclaimed, “I’m having it again.” Questioned, she described palpitations and near-syncopal symptoms. After assuring her this was the result of childbirth, being out of shape and trying to exercise, I thankfully paused to check her pulse, which was about 180, thready and barely palpable. After attempts to break what I assumed was a supraventricular tachycardia with carotid massage, ice water, and valsalva, a rapid trip to the ER ensued. Unfortunately, as the leads were attached to her chest, she proclaimed, “It’s gone,” and indeed, she was back in normal sinus rhythm.

A cardiac workup ensued, negative, and eventually she was diagnosed with Graves disease. After ablation of her thyroid and normalizing her endocrine status, the next year or so passed with only minor episodes of palpitations, rarely enough to make her stop or alter activities.

Three years after the first ER visit, we enter the Magic Kingdom. This 30-year-old child of mine loves the world created by Walt Disney and would gladly vacation in Orlando on a monthly basis if finances and the daily grind of life allowed. Christmas season in Disney is likewise magical to me, especially when accompanied by my growing brood of children and grandchildren.

We had just finished a very late meal in the classic Disney venue, The Liberty Tree Restaurant. I had just escorted my grandbabies outside when suddenly I heard the call for help back at our table. Lethargic and laid out on a bench, my daughter was weakly arousable, diaphoretic, and with an almost undetectable pulse. Recognizing the probable SVT, my oldest son, a 3rd year Baylor medical resident and I began the usual attempts to break the attack: carotid massage, hard valsalva, and even throwing ice water on her face as we became increasingly worried about her apparent severe hypotension and increasing chest pain. We feared an impending medical disaster.

Arrival of an efficient and well-trained group of paramedics immediately revealed a heart rate of 220, profound hypotension, and an EKG revealing supraventricular tachycardia. After gaining IV access and rapidly repeating attempts to break the tachycardia, the situation only worsened. Sensing a rapid deterioration in her status, adenosine was called for and pushed with prayers for rapid conversion. I warned her she might feel some discomfort or unusual symptoms as the ACLS instructors have warned me in the past, even though I had never seen it administered in my 25 years of practice.

“Oh daddy” she sighed as her weak carotid pulse disappeared and her EKG went to the flat line of electrical inactivity. The flatline was prolonged, but within several seconds the sinus rhythm returned as did the blood pressure, cognitive functions, and my own breathing. On questioning later about the “feeling,” she replied, “I thought I was dying.”

She was loaded on a gurney, rolled across Disney Boulevard, with the Christmas parade halted by a small army of mouseketeers, roping off a small corridor to pass through to a hidden entry down to underground Disney World. She looked up to the seven dwarfs on a Christmas float waving her on, a very strange medical send-off. From an extensive underground network of support services, an ambulance awaited to transport to the local emergency department.

The miracles of medicine: since graduating 30 years ago, they never cease. The myriad of resources with diagnostic tools and medications at our disposal have me in awe. Adenosine, briefly stopping the SVT allowing the normal rhythm to resume, is amazing! Even more impressive is the current crop of cardiologists like my daughter’s physicians, Drs. Chris Waterer and Judson Coley the electrophysiologist, who can identify and obliterate the accessory nerve pathway that leads to AV nodal reentry tachycardia. These talented physicians are working on minute pathways that were almost imaginary when taught to us 30 years ago. Now they are mapable, treatable, and shown to me on a smart phone at the end of the procedure, frequently curing one of the most common arrhythmias in young women!

I’ll always be a “doctor daddy” or “granddad,” but now one much more attentive to the “squirrely girly” symptoms so commonly encountered in many of our practices. Vague, harmless sounding symptoms suggestive of anything but a life threatening rhythm disorder; I am refocused, attentive, and forever grateful for the many miracles of modern medicine. Modern Medicine-my magic kingdom. r


You Docs do indeed have egos;You despise writing “FUO”When that’s the case, you then must think,“What to ponder, what else to know??”

When you’ve exhausted all the labYou ever hoped to consider,Bring to mind a common villain---Could make you a big league hitter!

Go back to visit that History!Did you ask about a kitten,One that is less than two years old,Was the patient scratched, not bitten?

Typically, Cat scratch diseasePresents with “old” scratch, and a node.But often we don’t get this help;We shift gears to a different mode!

(FUO for ten days or moreIn a child in a Southern state,CSD is high on the list;I assure you, without debate!)

If the Physical gives no clue,And all routine lab is “no help,”A Bartonella henselae---IFA is a first class step!

Info for CSD curious:Yes! Protean presentations!Get details in ID “Red Book” For all the manifestations.

A final brief word to the wise,Since there is little left to say,“Febrile illness and a kitten,Think Bartonella henselae!”

—John D. McEachin, MD Meridian

• PoEtRy in MEDiCinE •[[This month, we print a poem by John D. McEachin, MD, a Meridian pediatrician and JMSMA’s unofficial poet laureate. This poem, written a couple of years ago, is a reflection on Cat scratch disease (CSD). McEachin reflects: “As in all phases of medicine, if you don’t think of it, you’re not going to make the diagnosis! This is a condition that is common. Statistics reveal that as much money is spent on ‘hospital’ studies for Cat scratch disease today as was spent 30 years ago when much less information was available. It is a fascinating illness that usually resolves on its own, even though multiple antimicrobial approaches are given anecdotal credit for cures. A caveat: In severely ill patients with systemic inflammatory symptoms, antimicrobials as well as corticosteroids may be advisable.” McEachin adds a personal note: “I have on two occasions been called in consultation by local Ophthalmologists to see febrile children presenting with visual loss due to neuroretinitis. (They both had CSD! In one of these children a sibling had incurred CSD at a younger age.) Each of these new cases, in addition to optic neuritis, had a classic subacute ‘Phoenix’ skin papule-at site of original scratch, regional lymphadenitis, and low-grade fever.” The physician-poet concludes: “My personal experience with CSD in Memphis and in Meridian taught me to respect it as the etiology of a multitude of complications that the medical literature has ‘yet to learn.’…By the way you don’t have to be scratched by the kitten. You can likely just be intimately touched, or perhaps licked! In fact, I jokingly referred to CDS as CTD (Cat touch disease) on occasion!” For more of Dr. McEachin’s poetry, see past JMSMAs and look for more in coming months. Any physician is invited to submit poems for publication in the journal, attention: Dr. Lampton or email me at [email protected].] —Lucius Lampton, MD, Editor

CSD


• iMagES in MiSSiSSiPPi MEDiCinE •

Main Street And Hospital, Booneville: Home of the “Mississippi Doctor” and State’s First Hill-Burton Hospital—

Booneville, located in Prentiss

County in northeast Mississippi, is a special community for your Journal because of its connection to our predecessor, the “Mississippi Doctor,” long (1926-1959) the official publication/journal of the MSMA. Booneville physician, Dr. William Henry “Wick” Anderson, who served our association as president in 1940-41, founded and edited the “Mississippi Doctor,” printing and publishing it in his hometown. In addition, Dr. Anderson was on the medical staff of Booneville’s Northeast Mississippi Hospital from 1918-1969, long serving on its board of directors. This hospital would become the first Hill-Burton Hospital in the state of Mississippi, largely through the work of Anderson. These two photos show the bustling town’s main street as well as its hospital around 1920. Named for early settler Col. Reuben Boone (a relative to Daniel, yes), Booneville was birthed as a stop on the Mobile and Ohio Railroad, finished in 1858. The village was located on the highest point on the line, and legend contends that the Chickasaws had earlier utilized the site as a refuge from storms because of its protection from the Tippah Hills. The town was the site of much fighting during the Civil War during the campaigns for Corinth and Shiloh. Booneville’s current hospital, Baptist Memorial, is a general medical and surgical hospital with 99 beds. Survey data for the latest year available shows that 14,138 patients visited the hospital’s emergency room. The hospital had a total of 1,482 admissions. Baptist Memorial Hospital Booneville joined Baptist Memorial Health Care in 1982. It established, in conjunction with the Baptist Memorial Health Care Foundation, an endowment fund to help recruit and educate physicians. If you have a photograph or image related to Mississippi medicine which would be of interest to your fellow physicians, please send as a high resolution jpg file to Dr. Lampton at [email protected] or contact the Journal]. — Lucius Lampton, MD, Editor


• MSDH •

Mississippi Reportable Disease Statistics

October 2012Figures for the current month are provisional

Totals include reports from the Department of Corrections and those not reported from a specific District. For the most

current MMR figures, visit the Mississippi State Department of Health website: www.HealthyMS.com.


• MSDH •

This Month in the Mississippi Morbidity ReportVolume 28, Number 5; November 2012

School Immunization Requirements, 2012-2013 School YearIntroduction: The list of immunizations required for school entry and child care entry is specified by the State Health Officer

and is promulgated at least annually as directed by state statute (§ 41-23-37, Mississippi Code of 1972). All vaccines are to be given at the appropriate age and intervals according to the Advisory Committee on Immunization Practices (ACIP) recommendations. The following report discusses pertussis activity and the new Tdap requirement for the 7th grade entry, outlines the Mississippi State Department of Health (MSDH) Medical Exemption Policy for vaccine exemptions, and provides a weblink for the school entry and child care entry immunization requirements for the 2012-2013 school year.

Increased Pertussis Activity in the US and Tdap Requirement: The number of reported cases of pertussis, both in the US and Mississippi, has been increasing over the last several years. In 2011 there were over 18,000 cases with 13 deaths reported in the US; 11 of the deaths were in infants <1 year of age. 2012 has been a very active year for pertussis in the US so far, with more than 35,000 cases and at least 16 pertussis related deaths reported through the week ending November 10; 14 of the deaths are in children <1 year of age. Additionally, there have been a number of pertussis outbreaks in the US in 2012, primarily in Washington, Minnesota, Wisconsin and Colorado. In these outbreaks children in early adolescence (10-14 years of age) consistently account for the highest number of cases. In the Wisconsin outbreak, children 11-12 years of age who had not received Tdap were significantly more likely to have pertussis infection than those 11-12 year olds who had received Tdap. In Mississippi, there were 49 reported cases of pertussis with no deaths in 2011. As of November 20, 2012, there are 69 reported cases and one pertussis-related death in a child <1 year of age in Mississippi.

Pertussis immunity typically wanes 5-10 years after the childhood booster vaccination leaving adolescents vulnerable to infection. Adolescents can then serve as a source of infection in children <1 year of age who have not yet been completely vaccinated against pertussis. Infants are typically at the greatest risk for severe disease and death from pertussis infections. In 2005 the ACIP first recommended Tdap for all adolescents aged 11-18 years. The ACIP also recommends vaccination against meningococcal disease and human papillomavirus (HPV) for children in this age group. Since 2006, the Centers for Disease Control and Prevention has conducted the National Immunization Survey—Teen (NIS-Teen) in order to estimate vaccine coverage for Tdap, meningococcal and human papillomavirus (HPV) in adolescents aged 13-17 years. In the most recent NIS-Teen survey for 2011 the vaccine rate for Tdap among Mississippi adolescents was about 37%. While this rate has increased from the 2010 rate of 29%, it still lags behind the US rate of 78% and is the lowest in the US. Mississippi also has some of the lowest rates in the US for meningococcal and HPV vaccination. The full NIS-Teen survey is available on the National Immunization Survey CDC website at http://www.cdc.gov/vaccines/stats-surv/nis/nis-2011-released.htm#nisteen

Tdap Requirement: For the 2012-2013 school year, Mississippi joined 41 other states in instituting a requirement for Tdap among adolescents. All students entering 7th grade are required to have documentation verifying Tdap vaccination at seven years of age or older. This includes new, current and transfer students in both private and public schools. The new requirement should reduce the disease burden among adolescents and protect those children <1 year of age, as well as provide an opportunity to emphasize the need for other adolescent vaccinations.

Medical Exemption Policy: In order to enroll in any public or private kindergarten, elementary or secondary school in Mississippi, a student must provide the school with a Certificate of Immunization Compliance (Form 121) or a Certificate of Medical Exemption (Form 122). The child’s pediatrician, family physician or an internist, who must be duly licensed in the state of Mississippi, may submit a letter requesting the medical exemption for their patient to the local public health District Health Officer. The exemption will be granted unless there is a local or statewide occurrence of disease which would indicate that the exemption will cause “undue risk to the community.” The exemption expiration date will be based on the circumstances for the exemption and will be for a minimum of one school year. The full policy can be accessed at: http://msdh.ms.gov/msdhsite/_static/41,9332,71,303.html

Child Care and School Entry Immunization Requirements: The child care immunization requirements and the school entry immunization requirements for Mississippi are available on the MSDH website at: http://msdh.ms.gov/msdhsite/_static/41,0,71,303.html

The full November 2012 Mississippi Morbidity Report is available online at: http://msdh.ms.gov/msdhsite/_static/resources/5124.pdf .


A budding venture to put more physicians to work in Mississippi has scored its first triumph with the potential of a new family medicine residency

program, only the third of its kind in the state.Dr. Diane Beebe, interim director of the newly-formed

Office of Mississippi Physician Workforce, announced that Forrest General Hospital in Hattiesburg has submitted documents for accreditation of a family medicine residency to the Accreditation Council for Graduate Medical Education that oversees all residency training.

“This shows that the Office of Mississippi Physician Workforce is up and running and on the move,” said Beebe, professor and chair of family medicine at the University of Mississippi Medical Center (UMMC), where the workforce initiative is housed.

Beebe also announced that a search is on for a permanent director of the Office of Mississippi Physician Workforce, which was launched in April to reverse Mississippi’s standing as the state with lowest per-capita supply of primary care physicians, including family physicians, general internists, pediatricians and obstetrician-gynecologists.

“By legislation, the director must be a physician,” Beebe said. “We are starting a national search and a state-wide campaign to seek qualified applicants who might be interested in this permanent, paid position.”

The new director will head an initiative funded by state lawmakers and led by a 21-member advisory board chaired by Dr. John Mitchell, a family physician from Tupelo; the board will help determine where in Mississippi physicians are needed most.

A major mission of the workforce is to support and help fund new family medicine residency programs similar to Forrest General’s.

“We want to be able to place family medicine training programs in at least one or two other places in the state over the next five years,” Beebe said. “Forrest General has been working on its program a couple of years, but the funding has been an issue.

“It takes several million dollars to start a program. The workforce provided an initial outlay of money for the hospital to get it on its way. Obviously, we have to wait for accreditation, but I definitely believe it will happen.”

Physician Workforce Office Helps Fund Residency Program to Address Doctor Shortage

• offiCE of MiSSiSSiPPi PHySiCian WoRkfoRCE •

PHYSICIANS NEEDED

Internists, Cardiologists, Ophthalmologists, Pediatricians, Orthopedists, Neurologists, Psychiatrists, etc. interested in performing consultative evaluations according to Social Security guidelines.

OR

Physicians to review Social Security disability claims at the Mississippi Department of Rehabilitation Services (MDRS) in Madison MS.

Contact us at:

Leola Meyer 601-853-5487

Toll Free 1-800-962-2230 (Ext. 5487) or

Jo Ann Summers 601- 853-5599

DISABILITY DETERMINATION SERVICES 1-800-962-2230


Shown here presenting a Mississippi Rural Physicians

scholarship check to Stephanie Caldwell, Gov. Phil Bryant

expressed the need for Mississippi to add 1,000 physicians to

its workforce by the year 2025. As one of the most medically

under served states in the country, Mississippi has the lowest

per-capita primary care physician supply in the nation. Figures

estimate the state has 8.3 doctors per 10,000 residents,

compared to the national average of 12.8 physicians per

10,000 residents. Mississippi must add 1,330 primary care

physicians to its workforce to raise its per-capita doctor count

to the national average. Studies show new doctors generate

about $2 million in economic impact in their communities,

and more doctors means better health care. The Office of

Mississippi Physician Workforce, with its 21-member advisory

board, will oversee physician workforce development needs by:

•Supporting the creation of accredited family medicine

residency programs in the state, including the awarding the

state financial support for creation of these programs;

•Encouraging the development of an adequate and

geographically distributed physician workforce in all

specialties with an evolving strategic plan;

•Assessing the current numbers, ages, types of practice,

hospital affiliations and geographic distribution of physicians

in each medical society in Mississippi;

•Assessing the current and future physician workforce needs

of Mississippi. r

Forrest General’s goal is to begin training up to six family medicine residents a year by July 2014. For now, only UMMC and North Mississippi Medical Center in Tupelo have such a program.

In order to help create others, as well as to assess and monitor the physician workforce needs of the state, the Physician Workforce office will seek more, and expanded, funding each year from the legislature, Beebe said.

The Mississippi Academy of Family Physicians first championed the Physician Workforce initiative; the Mississippi State Medical Association and UMMC supported its creation in a bill sponsored by State Rep. Sam Mims, R-McComb.

On signing the legislation in April, Gov. Phil Bryant alluded to Mississippi’s need to add an extra 1,000 physicians to its workforce by 2025.

“Expanding our state’s medical residency programs will directly increase the number of physicians who remain in Mississippi to practice… . and more doctors means better health care for our citizens,” Bryant said.

Blake Wilson, a member of the workforce’s executive committee, said its efforts will be critical in addressing the physician shortage.

“You prove it works, with programs such as the one at Forrest General, and then you hope for more funding,” said Wilson, president and CEO of the Mississippi Economic Council. “We believe Forrest General will be a model.”

For more information, visit the workforce’s website, http://www.umc.edu/opw.

We are looking for physicians to join our group to perform Consultative

Examinations for Social Security Disability in Mississippi. Part-time or full-time. No call or weekends. Travel within state will be necessary. Pay is guaranteed regardless of turnout and paid promptly regardless of time of collection. All administrative needs including scheduling, transcription, assisting and billing are provided. Physicians working for us have various background and training including, IM, FP, pain mgt, surgery, orthopedics, neurosurgery, cardiology and general practice. There is minimal risk and stress involved with this position. You will have time to enjoy your life and not be stressed out. Contact Susan Gladys 1.866.929.8766 or email [email protected]

PHYSICIANS NEEDEDGeneralist, Family Practitioner, Internist

Diane Beebe, MD

• oPW •

John Mitchell, MD


Happy Holidays!

MSMA ALLIANCE

A wish for health and happiness in the coming

year is being sent to you by members of the

Mississippi State Medical Association Alliance

Contributions by the following have been made to the MSMAA

Scholarship Fund designated to benefit medical students at the

University of Mississippi School of Medicine.

Marsha Avara Ann Blair Huffman Mollie Pontius Amy Gammel Nancy Leader Susan Rish Shoba Gaymes Nancy Lindstrom Nancy Smith Jean Hill Karen Morris Donna Witty Danita Horne Sondra Pinson Heather Wood


A Long Ago Christmas

Howard Kavanaugh MS

• una voCE •

r. SCott AnderSon, md

Editorial note: This is a story I was sent by an old friend, a retired medical physicist from Louisiana named Howard Kavanaugh. I adjusted a thing or two, but this is a wonderful tale that, with only minor adjustments, is Howard’s story. I hope you like it. —sa

“It was the best of times—it was the worst of times.”

It was the autumn of 1939 and while the rest of the nation was finally beginning to recover, the rural South was still mired in the depths of the Great Depression. Up to then I’d been a city boy, but that year my family returned home to rural Louisiana, and it was here I started school.

The school was a large wooden building painted a dark shade of red, the only one in town. The upper and the lower grades were all in there together. This was not the city. I remember watching my new schoolmates get off of the dilapidated yellow school bus that hauled them in from the farms. Skinny kids wearing bib overalls, the knees torn out and ragged at the bottom from dragging the ground around bare feet. Feet that I remembered stayed bare all winter, even when there was ice on the ground. At recess the boys played with Coke bottles pushing them along grooves they’d scraped in the dry earth of the playground, pretending they were cars, the girls carried the same bottles in their arms talking to them, pretending they were dolls. When recess ended, the bottles were left scattered on the ground and what may have been a cattle truck today hauling a new bull would be a baby named Jamie Lynn tomorrow.

It was the high school girls that turned me into a celebrity of sorts. They’d gather around me and say, “Howard, let’s see how wide you can get your mouth open.” It seemed like a strange request, but I was new here and they were a lot older, so I did as they asked. It wasn’t until I heard one of them whisper, “Look, I told you he had metal in his teeth,” that I realized that even the older girls didn’t have any idea of what fillings were. Such is the state of dental care in a town without a dentist.

Within two weeks, every person in our little village of twelve hundred souls knew who I was. The fillings weren’t the only thing that set me apart. I was the newly returned grandson of the only doctor around and was soon addressed as Lil’ Doc by one and all. A country doctor was everything to the people of that little town. It set them apart, it made them special. Folks from all around the parish came to get taken care of, and when they did, they did whatever business they could while they were there.

The barter system was very much alive, and in times of no money was the only way to get paid. People brought vegetables, fresh fish, or bushel baskets of crabs to the house to settle their bills. Office visits were two dollars and a house call was three. My grandfather never sent a bill, trusting folks to know what they owed. Because cars were few and far between, house calls were made every afternoon. Since they were after school, I was allowed to ride along, which quickly became the highlight of my day.

At one point my grandfather agreed to set up a free clinic in a small fishing encampment if they would furnish him with a building for an office. This turned out to be a log cabin with a dirt floor, and no heat, water, or electricity.

This started a new adventure for me as I became an active part of the “doctoring business.” It was up to me to bring clean sheets, two glass jugs of fresh well water (there wasn’t any plastic back then), and enough oil for the lamps and stove. As soon as we arrived, I’d fire up the stove and put water on to boil, to sterilize the instruments. When I wasn’t busy “doctoring,” I’d wander down the streets of the fish camp whose residents were all LaCombe Indians. There was a little shed where they had woven baskets and leather goods they’d made by hand out on display for sale. I didn’t have any money to buy anything, so


mostly I just stood there in the yard, looking, at one thing and then another. The occupants would sit there in the shed and look back. We never spoke. We would just watch each other. After a while I would wave goodbye to the Chief, who owned the place, and he would raise his hand and nod in return. I was sure that this was a secret Indian ritual that only he and I completely understood.

Back at home, life was ruled by the telephone. The line had to be kept open for calls to the house. The phone was a large wooden box that hung on the wall, with two large bells on the top. That old phone would make you jump right out of your skin when it rang, it was so loud. You didn’t have to worry about missing a call; you could hear it anywhere in the house, in the yard, or pretty much half way down the street.

To make a call you had to turn the crank and wait for the operator. Our phone number was 67, but nobody knew that. They just told the operator that they needed to get up with the doctor. She knew where to ring them. If the phone rang at two or three in the morning, I knew it meant my grandfather was going somewhere. Rain or cold he got up got dressed and went. I always wondered why he never told them to wait until morning came, but he never did.

Saturday nights were always busy. I always wondered how folks with no money always came up with enough to get drunk and then get into fights, but bar fights were a regular part of every weekend. They’d come by the house bleeding or throwing up, sometimes both. After they’d leave it was up to my grandmother and me to clean the floor, as Tabby, my grandfather’s housekeeper, would be off by then.

I knew Tabby wasn’t just the housekeeper, my grandmother told me all the time. She was something special. Tabby had to be the best cook in the whole parish, probably even the best cook in the whole state of Louisiana. My dad and uncle liked to tease her. She was strong in her religion, and as they had for years, they knew that they could rile her by starting a discussion on the subject of religion. One night they made the argument that there was no such place as hell, so they might as well act however they wanted, as it wasn’t going to matter anyway.

Once she’d had enough of their foolishness, she’d appeal to my grandfather to settle the argument. “Doctor Van Zant, ain’t there a hell?”

My grandfather looked up from what he was reading and replied, “Yes Tabby, there is. I know because I see a little of it every day.” That was medicine then, it hasn’t changed.

The Christmas Eve I remember most from that period, as most of them I remember, involved a house call. We drove ten miles out of town on the paved road, then turned onto a bumpy dirt road that ended at the woods edge. An old man sat on a horse drawn wagon just inside the shelter of the trees, trying to get a little break from the wind that was blowing strong and cold from the north. He greeted us and we climbed aboard and made our way through the woods until we arrived at a rough timber cabin. We stayed for a while, we didn’t get out any instruments, and when we left, all we left behind were some pills. On the drive back, my grandfather looked at me and said, “Did you see how that old man looked?”

I nodded.“He’s dying, he probably won’t make it through Christmas

Day,” he said.“Then why didn’t you do something to save him?” I asked

naively.“Things just don’t work that way sometimes. The pills we

left will ease his passage.”There were no miracle drugs then.I woke the next morning to the smell of pine wood burning in

a cast iron stove and Tabby’s high-pitched voice calling us all down for hot biscuits before church. It was a good Christmas for the parish. The telephone didn’t ring one time all day.

It was the 1930’s and times were hard, but for a 7-year-old boy growing up in Louisiana, it was truly, “the best of times.”

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• inDEx •Volume lIIIJanuary - December 2012

Subject Index

The letters used to explain in which department the matter indexed appears are as follows: “CPS” for Clinical Problem Solving”; “E,” Editorial; “L,” Letters to the Editor; “PB,” Physician’s Bookshelf; “PM,” Poetry and Medicine; “PP,” President’s Page; “S,” Special Article; “UV” Una Voce; the asterisk (*) indicates an original article in the Journal, and the author’s name follows the entry in brackets. Matters pertaining to related organizations are indexed under the medical organization.

401(k) Changes Will Help Physicians Better Understand Their Practice Retirement Plans [L Fortenberry], 305-S

-A-Abstracts from Research Day Sponsored by the American College of Physicians for the University of Mississippi Medical Center Department of Medicine (D Pepper, C Thigpen et al) 356*A Mean Spleen: Splenic Sequestration Crisis in a 53-Year-Old with Sickle Cell Disease [K Wilkinson, C Thigpen, F Criddle, J Lam], 366*A Mitral Mystery: Disparate Response to R-CHOP of Diffuse Large B-cell Lymphoma Lesions in a Patient with AIDS [K Bridges, J Hamilton, Thigpen, K Bennett, C Bigelow], 357Acute CVA in the Setting of Graves’ Thyrotoxicosis and Moyamoya: A Rare Combination [J Bennett, S French, S Ahmad], 369 Adding Fuel to the Fire: A Case of Severe Hypercalcemia in the Setting of Extrapulmonary Sarcoidoisis [A Green, R Chick, E Reiners, V Majithia], 367*

Brainstorm: A Case Report of Anti- N-Methyl-D-Aspartate Receptor Antibody Encephalitis [D Ballard, G Abraham], 363*Confusion Abounds: Posterior Reversible Encephalopathy Syndrome in the Setting of Inflammatory Breast Cancer [K Waespe, C Thigpen, D Hamilton, R Vance], 365*Cutting to the Chase: An Unusual Complication of Cocaine Use [A McCann, D Pepper, L Atchley, J Bell], 362*Don’t Play With Mismatches: Acute Hemolytic Reaction During Allogeneic Stem Cell Infusion for High Risk Myelodysplastic Syndrome [C Thigpen, K Bridges, S Elkins], 364*Double Trouble: Paraneoplastic Hypercalcemia- Hyperleukocytosis Syndrome in Cutaneous Squamous Cell Carcinoma [C Carter, C Thigpen, K Harkins], 358*Flail Chest: New Treatment for a Paradoxical Problem [J Bennett, B Dalal], 368*Getting to the GIST of the Gastrointestinal Bleed [S Boyd, S Tanner, N Ahmad, S Daram, J Sheehan], 357*Hemolytic Havoc: HELLP, DIC, and TTP in a Patient with Intrauterine Fetal Demise [J Graham, C Thigpen, Z Henson, C Bigelow], 361*

Inflammation Gone Awry: Pyoderma Gangrenosum in Newly Diagnosed Crohn’s Disease [E Reiners, Z Henson], 363*Normal Alkaline Phosphatase in Active Paget’s Disease of Bone [S French, J Subauste], 361*Now You See It, Now You Don’t: Evans Syndrome in a Patient Suspected To Have Lymphoma [B Tullos, S Gaugler, C Thigpen, Z Henson, V. E. Herrin], 365*Transarterial Chemoembolization (TACE) Associated Pancreatitis and Gastric Ulceration [K Gharaibeh, S Daram, K Ball, R Garretson], 367 *

An Interview with Charles D. “Buddy” Daughdrill, Executive Director of the Missisisppi Public Health Association [R deShazo], 278-S*An Interview with Steven L. Demetropoulos, MD, 2012- 2013 MSMA President [K Evers], 154-S*

AsclepiadBenjamin Macklin Carmichael, MD [L Lampton, K Evers], 280Harry C. Frye [L Lampton], 64 Helen B. Barnes, MD [L Lampton], 352Hugh Agnew Gamble, II [K Evers], 392


John Murrell McRae, II [K Evers], 316Kelly Scott Segars, Sr., MD [L Lampton], 171Leonard (Len) Brandon, MD, and son, Steven Brandon, MD [M Pomphrey], 100Ralph Lucius Brock [L Lampton], 136William A. “Bill” Middleton, MD [L Lampton], 32William F. Pontius, MD [L Lampton], 244

-C-Clinical Problem-Solving [presented and edited by the

Dept. of Family Medicine, UMMC]

A Common, but Unexpected, Suspect [A Morgan], 260- CPSAllergy Confusion [R Rose- Hand], 396-CPSChasing Zebras [A Pullen], 12- CPSJust a Simple Cerebral Vascular Accident? [T Phan], 111-CPSToo Old for this Joint! [C Latorre], 222-CPS

CoverAutumn Landscape [M Pomphrey, Jr.], OctoberDaylily [B Tisdale], August“Dunn’s Falls, located in Enterprise, Lauderdale Co., MS” [J Jackson], SeptemberGarden Girl [M Pomphrey, Jr.], JuneHummingbird in Nest [W Locke], MarchPresidential Portrait of Steven L. Demetropoulos, MD, May“Pretty in Pink” [C Stroud], April“Sea Treasures from the Viewbox” [W Pontius], FebruarySpotting an Owl [M Wallace], DecemberSummer Rainbow [R Cannon], JulyUnderpass Cathedral [S Hartness], NovemberYockanookany Sepia [S Hartness], January

Current Use of Intrapleural Tissue Plasminogen Activator in the Treatment of Complex Pleural Processes: A Review of the Literature and Report of 9 Cases [C Dulaney, W Merrill, S Tesseneer, L Jenkins-Lonidier, C Tribble], 216*

-D-Dietary Recommendations in Ambulatory Care: Evaluation of the Southern Remedy Healthy Eating Plate [A Smith, D Minor, L Tillman, R deShazo, W Replogle], 330*Do the Supreme Court Elections Really Matter? [R Jones], 302-SDoes One Medical School’s Admission Policy Help a Rural State “Grow Their Own” Physicians? [P Mason, J Cossman], 284*

-E-EditorialsA Look into Preconceived Ideas [E Browning], 123-EAn Interview with Dr. Randy Easterling, President, Mississippi State Board of Medical Licensure [R deShazo], 378-EAnd a Good Time was Had by All [S Hartness], 343-EBold Changes to the Norm [P Merideth], 118-EEditor Interview: A Visit with Dr. Fred L. McMillan, President of Mississippi Physicians Care Network [R deShazo], 80-EElectronic Medical Records and the End of Value: Physicians, Nurses, and Scribes [C Feind], 84-EEpicuritorial - New Feature/Old Favorite [S Hartness], 20-EFocusing on Professionalism [R Didlake, P Smith], 54-EMirror, Mirror [S Hartness], 115-E

My View from Second Year: Reflections of a Mississippi Medical Student [E Brandon], 272-ERaising the Bar, but Failing to Meet the Goal: A Young Physician Reflects on Match Day and Mississippi’s Primary Care Workforce [B Smith], 270-EThe Catastrophe of Unwed Motherhood and Teenage Pregnancy: A Physician’s Call to Action [H Matthias], 81-EThe Magic Kingdom [R Hogan, II], 413-E EXIT Procedure: A Report of the First Three Mississippi Cases [J Brewer, K Liechty, J Bofill], 104*

-F-From the Editor [L Lampton], 2, 34, 66, 102, 138, 169, 214, 246, 282, 318, 354, 394

-G-G. H. Tichenor, MD, and His Antiseptic Solution: The Mississippi Years - Part 1 of 2 [M Trotter], 88-SG. H. Tichenor, MD, and His Antiseptic Solution: The “Dr.” in Dr. Tichenor - Part 2 of 2 [M Trotter], 127-S

-I-Images in Mississippi MedicineBooneville Hospital [L Lampton], 415-I

Instructions for Authors, 28, 93, 211, 311

-J-Just Off the Press - Info You Want to Know Aspirin for Primary Prevention [R deShazo], 73


Bacterial Rhinosinusitis Guidelines [J McKee, R Ogletree, Jr.], 161Clopidogrel with Proton Pump Inhibitors [H Gwin, R Ogletree, Jr.], 274Control in Patients with Type 2 Diabetes Mellitus [L Cadwallader, R Ogletree, Jr.], 109Don’t Forget the Stethoscopes [R Ogletree, Jr.], 235Probiotics– Are They Beneficial? [L Cadwallader, R Ogletree, Jr.], 295Prophylaxis Against Post-Stroke Depression [E Lukienko, R Ogletree, Jr.], 344

-L-Letters EHR May Not Be the Oppressor: Response to EMR End of Value Editorial [C Cannon Jr.], 152-LLight at the Tunnel’s End: Response to EMR End of Value Editorial [T Wiley], 126-LPhysicians Should See Their Own Consults on the First Visit [W Jones], 87-L

-M-Message from MSMA President Steve Demetropoulos, MD - Annual Session [S Demetropoulos], 384-S

Mississippi Medicine Up-to-dateMississippi Medicine Up-to-Date: Lyme Disease-like Illnesses in the South [J Goddard, A Varela-Stokes, R Finley], 68*

MRPSP Scholars– Embracing the Vision for a Healthier Mississippi [K Evers], 299-S

MSDHReportable Disease Statistics & Morbidity Report [Paul Byers], 415Mississippi Reportable Disease Statistics - October 2011, 11Mississippi Reportable Disease Statistics - December 2011, 56

Mississippi Reportable Disease Statistics - January 2012, 74Mississippi Reportable Disease Statistics - February 2012, 110Mississippi Reportable Disease Statistics - April 2012, 164Mississippi Reportable Disease Statistics - May 2012, 237Mississippi Reportable Disease Statistics - June 2012, 265Mississippi Reportable Disease Statistics - July 2012, 296Mississippi Reportable Disease Statistics - August 2012, 337Mississippi Reportable Disease Statistics - September 2012, 370Mississippi Reportable Disease Statistics -October 2012, 414Mississippi Second in the Nation to Implement Life-Saving Cardiovascular Emergency Response Plan, 75MS Morbidity Report - June 2012, 266

MSMAIn Celebration of Health Awareness Day [K Evers], 51MSMA Cosponsors First-Ever Mississippi Rx Drug Summit [K Evers], 267-SNotice of Proposed Changes to the MSMA Constitution, 57Report and Highlights of the 144th Annual Session of the MSMA House of Deleates and Medical Affairs Forum 2012 [K Evers], 227Report of the Council on Constitution & Bylaws, 119

-N-New Members, 19

-O-Obituaries, 26

Office of Mississippi Physician Workforce, 418Outpatient Treatment of Adults with Cystic Fibrosis by Primary Care Physicians [N Chaudary], 255*

-P-Patterns of ENT Injuries in Sports- Related Accidents [B Suggs, R Cannon], 4*Personals, 21

Physician’s BookshelfDr. Dwalia South and the Literary Terrains of Medicine. Una Voce: A Collection, [Dwalia South, MD, China Grove Press, Magnolia, MS, 2011] [reviewed by L Lampton], 132-PBMore About Una Voce (The Book) [S Anderson], 134-PBThe Immortal Life of Henrietta Lacks: Evolving Medical Ethics in a Constantly Changing World [Rebecca Skloot, Crown Publishers, 2010] [reviewed by W Sherman], 309-PB

Poetry and MedicineBoatlike [W Lineaweaver], 308-PM Cat Scratch Fever [J McEachin], 414-PM

President’s Page A Good Death [S. Demetropoulos], 373-PPAnd Down the Stretch They Come! [T Joiner], 113-PPInaugural Address [S Demetropoulos], 225-PPJust What the Doctor Ordered [S Demetropoulos], 263-PPLast Random Thoughts [T Joiner], 151-PPMy Adventure Enrolling in the PMP [T Joiner], 16-PPResolve Towards a Healthier Mississippi [T Joiner], 46-PP Tort Reform [S Demetropoulos], 297-PPWhen a Colleague Refers a Patient, “Do the Right Thing” [T Joiner], 77-PPWhy Smoke-Free? [S Demetropoulos], 334-PPYou Have to Have Some Skin in the Game [S Demetropoulos], 411-PP


Prevalence and Trends in Overweight and Obesity among Mississippi Public School Students, 2005-2011 [J Kolbo, L Zhang, E Molaison, B Harbaugh, G Hudson, M Armstrong, N Werle], 140*Public School Parents’Perspectives of the Mississippi Healthy Students Act of 2007: Findings from 2009-2011 [L Southward, K Ragsdale, C McKee, A Buffington, D Baggett, T Blanchard, J Edwards], 247*

-R-Revitalization of the University of Mississippi Children’s Heart Center: Report Card from the First 18 Months Experience [D DiBardino, W Lancaster, W Merrill, M Mitchell, E Taylor, C Gaymes, M Ebeid, J Shores, E Christ, M Taylor, M Sheth, R Jonas, J Salazar], 405

-S-Series: Concepts in End of Life Care - Introduction - Death: An Important Part of Life [R Faught, S Gaugler, S Douglas], 375*Simultaneous Liver Metastasectomy at Operation for Primary Colorectal or Gynecologic Malignancy [J Corley, M Corley, C Lahr, D McIntosh, M Ridgway, N Ahmed], 36*Southern Remedy Healthy Living Fitness Program [R deShazo], 171-SSubject/Author Index Volume 53, 423Substance Use and Sexual Risk Behaviors Among Mississippi Public High School Students [J McGuire, B Wang, L Zhang], 323*

-T-Tax Revenue in Mississippi Communities Following Implementation of Smoke- free Ordinances: An Examination of Tourism and Economic Development Tax Revenues [R McMillen, S Shackelford], 319*They Come Alone or in Pairs: Ta-Tas to Go, Breast Cancer Survivor Creates Custom-Fit Prosthesis [K Evers, 340-S]

Top 10 Facts You Should KnowAbout Depression [S Chandraiah], 147* About Diabetes [R Call, M Wofford, D Riche], 175*About Endocrine Aspects in Patients Infected with the Human Immunodeficiency Virus [N Ungnapatanin, J Subauste, H Henderson, C Koch], 347*About Headaches [R deShazo, A Bond], 293*About How to Improve CPAP Compliance for the Treatment of Obstructive Sleep Apnea [S Tamanna, I Ullah], 220*About Kidney Transplantation [F Butt, A Seawright], 41*About Pit Viper Snakes and Envenomation [B Tollefson, K McKenzie, R. Galli], 9*About Secondary Causes of Diabetes Mellitus [H East, J Subauste, A Gandhi, C Koch], 380*

-U-UMC SOMLiterati Medicus- the M3/M4 Humanism in Medicine Book Club at the University of Mississippi School of Medicine [M Porter, J Graham, J Clark, S Douglas], 385

UMMCThe University of Mississippi Medical Center Division of Multicultural Affairs [J Taylor, M Westerfield], 238Una VoceHen Scratch [D South], 60-UVHow to Be a Better Patient [D South], 98-UVThe Tattoos of Life [D South], 165-UV Uncommon ThreadA Long Ago Christmas [S Anderson], 421Anderson Family Driving School (Under New Management) [S Anderson], 239Birthdays [S Anderson], 387Doctors and Magic [S Anderson], 350Stars [S Anderson], 313Supralumenal Neutrinos and “The God Particle” – A CERN Update [S Anderson], 97Welcome to 2012 [S Anderson], 30


Volume lIIIJanuary - December 2012

Author Index

The letters used to explain in which department the author’s matter indexed appears are as follows:“CPS” Clinical Problem Solving”; “E,” Editorial; “H” Hardy Abstract; “I,” Images in Mississippi Medicine; “L,” Letters to the Editor; “PB,” Physician’s Bookshelf; “PM,” Poetry and Medicine; “PP,” President’s Page; “S,” Special Article; “UV” Una Voce; the asterisk (*) indicates an original article in the Journal.

AAbraham, George, 363Ahmad, Shema R., 369Ahmed, Naveed A., 36*, 357Anderson, R. Scott, 30, 97, 134-PB, 239, 313, 350, 387, 421Armstrong, Mary G., 140*Atchley, Lance, 362

BBaggett, Dorris, 247*Ball, Kenneth, 367Ballard, Dane, 363Bell, Jericho, 362Bennett, Janelle, 368, 369Bennett, Kenneth, 357Bigelow, Carolyn, 357, 361Blanchard, Troy, 247*Bofill, James A., 104*Bond, Allyn, 293*Boyd, Stewart, 357Brandon, Emily , 272-EBrewer, Justin, 104*Bridges, J. Kevin, 357, 364Browning, Elliott, 123-EBuffington, Anne, 247*Butt, Fauzia K., 41*

CCadwallader, Lucy, 109, 295Call, Rosemary J., 275*Cannon, C. Ron, 4*, July coverCannon, Charles D., Jr., 152-LCarter, Cory, 358Chandraiah, Shambhavi, 147*Chaudary, Nauman, 255*Chick, Rebecca, 367

Christ, Elizabeth, 405*Clark, Jerry, 385Corley, J. Jarrett, 36*Corley, Mary Kinney, 36*Cossman, Jeralynn S., 284*Criddle, Frank J., 366Dalal, Bavin, 368Daram, Sumanth, 357, 367Demetropoulos, Steven J., 225-PP, 263-PP, 297-PP, 334-PP, 373-PP, 384-S, 411-PPdeShazo, Richard D., 73, 80-E, 171-S 278-S, 293*, 330* 378-EDiBardino, Daniel J., 400*, 405*Didlake, Ralph, 54-EDouglas, Sharon P., 375*, 385Dulaney, Caleb R., 216*

EEast, Honey E., 380 Ebeid, Makram, 405*Edwards, John, 247* Elkins, Stephanie, 364Evers, Karen A., 51, 154-S, 227, 267-S, 280, 299-S, 316, 340-S, 392-A, 401, 419, 420

FFaught, Rachael W., 375*Feind, Carl R. (Kel), 84-EFinley, Richard, 68*Fortenberry, H. Larry, 305-SFrench, Sarah E., 361, 369

GGalli, Robert, 9*Gandhi, Ayush, 380Garretson, Roland, 367Gaymes, Charles, 405*Gaugler, Sarah M., 365, 375*Gharaibeh, Kamel, 367Goddard, Jerome, 68*Graham, Jacob, 361, 385Green, Andrea, 367Gwin, Hannah, 274

HHamilton, Darryl, 365Hamilton, James, 357Harbaugh, Bonnie L., 140*Harkins, Kimberly, 358Hartness, D. Stanley, January cover, 20-E, 115-E, 343-E, November coverHenderson, Harold M., 347*Henson, Zeb K., 361, 363, 365Herrin, V.E., 365Hogan, II, Reed B., 413*-EHudson, Geoffrey M., 140*

JJackson, John F., September coverJenkins-Lonidier, Lora, 216*Joiner, Thomas E, 16-PP, 46-PP, 77-PP , 113-PP, 151-PPJonas, Richard A., 405*Jones, Robert M., 302-SJones, William B., 87-L


KKoch, Christian A., 347*, 380Kolbo, Jerome R., 140*

LLahr, Christopher J., 36*Lam, John T., 366Lampton, Lucius, 2, 32, 34, 64, 66, 102, 132-PB, 136, 138, 169, 171, 214, 244, 246, 280, 282, 318, 352, 354, 394, 415-ILancaster, William J., 405*Latorre, Carlos A., 222-CPSLiechty, Kenneth W., 104*, 400*Lineaweaver, William “Bill”, 308-PMLocke, Will R., March coverLukienko, Eugene, 344

MMajithia, Vikas, 367Mason, Philip B., 284*Matthias, Heddy-Dale, 81-EMcCann, Andrea, 362McEachin, John D., 414-PMMcGuire, James, 323*McIntosh, David G., 36*McKee, Colleen, 247*McKee, Jasmine, 161McKenzie, L. Kendall, 9*McMillen, Robert, 319*Merideth, Philip, 118-EMerrill, Walter H., 216*, 405*Minor, Deborah S., 330*Mitchell, Marc E., 405* Molaison, Elaine Fontenot, 140*Morgan, Andrea, 260-CPS

OOgletree, Richard “Buddy”, 73Ogletree, Richard L., Jr., 109, 161, 235, 274, 295, 344

PPepper, Dominique J., 362Phan, Thaibinh T., 111-CPSPomphrey, Martin, 100Pomphrey, Martin M., Jr., June cover, October coverPontius, W. F., February coverPorter, Maribeth, 385Pullen, Ashley B., 12-CPS

RRagsdale, Kathleen, 247*Reiners, Eric, 363, 367Replogle, William H., 330*Riche, Daniel M., 275*Ridgway, Mildred, 36*Rose-Hand, Rebecca A., 396-CPS

SSalazar, Jorge D.,400*, 405*Seawright, Ashley H., 41*Shackelford, Signe, 319*Sheehan, John J., 357Sheffield, Thomas E., November coverSherman, Whitney, 309-PBSheth, Michelle,400*, 405*Shores, Jennifer C., 400*, 405*Smith, Amanda K., 330*Smith, P. Brent, 270-ESmith, Patrick O., 54-ESouth, Dwalia S., 60-UV, 98-UV, 165-UVSouthward, Linda H., 247*Stroud, Catherine H. (Cathy), April coverSubauste, Jose S., 347*, 361, 382Suggs, Bradley J., 4*

TTamanna, Sadeka, 220*Tanner, Stephanie, 357Taylor, Emilee, 405*Taylor, Jasmine, 238Taylor, Mary, 400*, 405* Tesseneer, Stephanie, 216*

Thigpen, S. Calvin, 357, 358, 361, 364, 365, 366Tillman, Lindsey E., 330*Tisdale, Brett, August coverTollefson, Brian J., 9*Tribble, Curtis G., 216*Trotter, Michael C., 88-S, 127-STullos, Bobby W., 365

UUllah, M. Iftekhar, 220*Ungnapatanin, Nuttha, 347*

VVance, Ralph, 365Varela-Stokes, Andrea, 68*

WWaespe, Kelly, 365Wallace, Mickey, December coverWang, Bo, 323*Werle, Nichole, 140*Westerfield, Matt, 238Wiley, Thomas L., 126-LWilkinson, Kelly J., 366Wofford, Marion R., 275*

ZZhang, Lei, 140*, 323*

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