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June

2009

S. Randall Easterling, MD VOL. L

2009-2010 MSMA President

50 Years of

CONTINUOUS PUBLICATION

No. 6


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Lucius M. Lampton, MD EDITOR D. Stanley Hartness, MD Michael O’Dell, MD ASSOCIATE EDITORS Karen A. Evers MANAGING EDITOR

PUBLICATIONS COMMITTEE Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD, Ex-Officio Myron W. Lockey, MD, Ex-Officio and the Editors THE ASSOCIATION J. Patrick Barrett, MD President Randy Easterling, MD President-Elect J. Clay Hays, Jr., MD Secretary-Treasurer Lee Giffin, MD Speaker Gary Carr, MD Vice Speaker Charmain Kanosky Executive Director JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. CORRESPONDENCE: JOURNAL MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, ph.: (601) 853-6733, FAX (601)853-6746, www.MSMAonline.com. SUBSCRIPTION RATE: $73.00 per annum; $86.00 per annum for foreign subscriptions; $6.50 per copy, $7.00 per foreign copy, as available. ADVERTISING RATES: furnished on request. Cristen Hemmins, Hemmins Hall, Inc. Advertising, P.O. Box 1112, Oxford, Mississippi 38655, Ph: (662) 236-1700, Fax: (662) 236-7011, email: cristenh@watervalley.net POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 391582548. 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© 2009, Mississippi State Medical Association.

JUNE 2009

VOLUME 50

NUMBER 6

SCIENTIFIC ARTICLES Case Report: Gabapentin Abuse Alexis Polles, MD; Austin Smith, PhD and Chapman Sledge, MD

179

Role of FDG PET Imaging in the Management of Pediatric Hodgkin’s Disease: An Assessment of Stage-migration, Response Comparisons with CT and Correlation to Clincal Outcomes Vani Vijayakumar, MD; Madhava Kanakamedala, MD and Waleed F. Mourad, MD, MSc et al.

184

SPECIAL ARTICLE An Interview with Randy Easterling, MD 2009-2010 MSMA President

190

PRESIDENT’S PAGE Change is Constant J. Patrick Barrett, MD; MSMA President

200

EDITORIAL The Adventures of a Novel Influenza A Virus among Medical Virgins at a Time Near the End of the World Lucius M. Lampton, MD

204

RELATED ORGANIZATIONS Mississippi State Department of Health Information and Quality Healthcare American Medical Association

203 206 212

DEPARTMENTS Personals Una Voce Placement/Classified

208 214 216

S. RANDALL EASTERLING, MD; 2009-10 MSMA PRESIDENT - During our MSMA’s 141st Annual Session, held May 28-31 at the Oxford Conference Center, Dr. Randy Easterling of Vicksburg was installed as the 142nd president of the association. Dr. Easterling is double-boarded, as a Diplomate of the American Academy of Family Medicine and certified by the American Society of Addiction Medicine. He is in the private practice of family medicine with River Region Health System and is the medical director for Marian Hill Chemical Dependency Unit. You will find an interview with Dr. Easterling in this issue of the JMSMA. ❒

ABOUT THE COVER:

June

S. Randall Easterling, MD

VOL. L

Official Publication of the MSMA Since 1959

2009

2009-2010 MSMA President

50 Years of

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No. 6


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JOURNAL MSMA, June 2009 — Vol. 50, No. 6


SCIENTIFIC ARTICLES

Case Report: Gabapentin Abuse Alexis Polles, MD Austin Smith, PhD Chapman Sledge, MD

A

BSTRACT Clinicians treating patients with addictive and compulsive disorders have traditionally viewed gabapentin (GBP) as a safe, nonaddictive alternative to opiates, benzodiazepines, and other sedative hypnotics for the treatment of pain, migraines, anxiety, and substance-abuse-related withdrawal symptoms. Results of the current study, however, present evidence for the abuse of and possible dependence on GBP among 9 patients with a primary addiction to opiates (or opiates with sedative-hypnotics) and one patient with a primary addiction to alcohol who were treated in a residential facility. Practitioners should use caution in their prescribing practices of GBP, especially with patients who have a high risk for addictive and compulsive disorders.

KEY WORDS:

GABAPENTIN, PAIN MANAGEMENT, GABAPENTIN ABUSE,

NEURONTIN ABUSE

NEURONTIN,

INTRODUCTION Gabapentin (GPB), an anticonvulsant drug approved by the Federal Drug Administration for the treatment of epilepsy and postherpetic neuralgia, has JOURNAL MSMA, June 2009 — Vol. 50, No. 6

become increasingly popular for various off-label uses.1 For example, clinicians treating patients with addictive and compulsive disorders have traditionally viewed GBP as a safe, nonaddictive alternative to opiates, benzodiazepines, and other sedative hypnotics for the treatment of pain, migraines, anxiety, and substanceabuse-related withdrawal symptoms.2-4 Further, practitioners have typically been aggressive in their prescribing practices due to GPB’s wide dose range, limited side effects, absence of significant drug interactions, and relative safety in overdosage unless mixed with sedative hypnotics or alcohol.5 Unfortunately, however, GBP’s drawbacks seem to be more considerable than previously thought. For example, Norton presented evidence suggesting that patients may experience withdrawal effects from GBP similar to those of patients withdrawing from alcohol or benzodiazepines (e.g., agitation, irritability, anxiety, tachycardia, diaphoresis).5 Further, Barrueto, Green Howland, Hoffman, and Nelson presented a case study of a 34-year-old male treated with GBP for chronic back pain who experienced generalized seizures secondary to GBP withdrawal.6 In order to prevent withdrawal 179


symptoms, Norton encouraged clinicians to gradually taper the dosage when discontinuing GBP and warn patients of the possible negative effects of suddenly quitting the drug.5 In addition to evidence of the withdrawal effects of GBP, abuse of the drug has also been reported.7,8 Recoppa, Malcolm, and Ware presented evidence for the abuse of GBP by cocaine abusing or dependent male prison inmates in Florida.7 The Florida Department of Corrections, acting on reports of early GBP refills and GBP theft, found only 19 out of 96 prescription bottles in the possession of the inmate to whom they were prescribed. Five inmates directly admitted that they had been abusing GBP capsules (300mg/400mg). Four out of five of the inmates who came forward reported obtaining a “high” similar to that of cocaine from nasal ingestion of GBP. Inmates did not engage in abuse of other prescription drugs in their possession, suggesting that the effects of the GBP were unlikely due to learned behavior.7 In other words, it is unlikely that “classical cue conditioning of intranasal ingestion triggered this reward response of a ‘high’ similar to the effects of cocaine7” (p. 322). Also, Markowitz, Finkenbine, Myrich, King, and Carson reported the case of a 41-year old female with a history of cocaine addiction who intentionally abused GBP.8 In addition to GBP abuse among persons with histories of cocaine addiction, case histories presented in the current study clearly indicate a pattern of GBP abuse among opiate addicts and suggest the potential for dependence. Organizations such as the Joint Commission on Accreditation of Hospitals have made a push for the appropriate management of pain, and physicians certainly do not want to withhold proper treatment for pain, anxiety, or any other problem.9 Unfortunately, current evidence indicates a disturbing pattern of GBP abuse. The evidence provided below suggests that practitioners should be aware that the possibility for abuse, and even dependence, exists and should use caution in their prescribing practices of GBP, especially with patients who have a high risk for addictive and compulsive disorders.

CASE STUDIES The following case studies represent the experiences of nine patients who received treatment for a primary addiction to opiates in a residential facility, and one patient who was treated for alcohol dependence only. Among the nine patients treated for opiate addiction, seven had the following cross addictions: benzodiazepines (n=2), alcohol and cocaine (n = 1), alcohol (n = 3), muscle relaxants (n=1), and cocaine (n=1). Each patient was prescribed GBP to treat seizures, migraines, 180

pain, and/or anxiety. Also, each patient’s behavior suggested that he or she was abusing GBP, and in some cases, behavior was consistent with GBP dependence. In the case studies described, GBP doses ranged from 300 mg to 48,000 mg per day with a typical dose of approximately 1200mg per day. An overview of each case is provided below. Case 1 The patient was a 36-year-old white male whose drug of choice was opiates. The patient, who had a history of partial complex seizures, began complaining of seizures during treatment and was prescribed 600mg of GBP per day. Within hours of receiving his GBP, he took triple the recommended dose (1800mg), was confronted by staff regarding his missing medication, and eventually admitted to abusing his GBP.

Case 2 The patient was a 28-year-old white female with a history of abusing opiates and benzodiazepines. She reported that, prior to admission, she was regularly taking twice the prescribed dosage of GBP (i.e., 2400 mg, rather than the prescribed 1200 mg per day). She reported that the GBP “makes me not care” and that she used it to “numb out.” In addition, she stated that she had once attempted to overdose on GBP and that she was taking Xanax and Valium when she ran out of GBP. Case 3 The patient was a 41-year-old white female with a history of alcohol, opiate, and cocaine abuse. Over the past five years, she had been in treatment five times, and the patient’s most recent admission was due to a relapse with crack cocaine and opiates. Upon entering treatment, the patient was prescribed GBP to treat pain associated with injuries sustained during a motor vehicle accident. During treatment, the patient admitted to abusing GBP by taking significantly more than the prescribed amount.

Case 4 The patient was a 55-year-old white male who entered treatment for alcohol and opiate detoxification after being arrested for forging prescriptions of opiates. Following detoxification, the patient was placed on GBP (600 mg twice a day and 900 mg at bedtime) in order to treat headaches and pain associated with rheumatoid vasculitis and peripheral sensory neuropathy. During treatment, the patient began to abuse GBP. JOURNAL MSMA, June 2009 — Vol. 50, No. 6


While at home on a weekend pass, the patient, who was a physician, called in two prescriptions for GBP, both of which were for twice the dose that had been prescribed by his addictionologist. Further, upon returning from his pass, he attempted to obtain more GBP by requesting a prescription from his treating addictionologist. When the prescription was called in, the pharmacy notified the treating physician of the duplicate prescriptions. The patient admitted to calling in the prescriptions while on pass and to abusing GBP. Case 5 The patient was a 44-year-old white male admitted for treatment of mood disorder, anxiety, alcohol, and opiate abuse. He was prescribed GBP for pain related to traumatic arthritis. During the course of treatment, he admitted to abusing GBP. He admitted to taking more that the prescribed amount of GBP, to “parachuting” GBP by putting it under his tongue, and to snorting it on three occasions in order to achieve more rapid and intense effects.

Case 6 The patient was a 32-year-old white female who was treated for cocaine and opiate dependence. She was prescribed GBP to treat headaches and chronic back pain. Eighteen months after completing her residential treatment, she left a message via telephone for the addictionologist that her mother had died and that it was extremely urgent that he return her call. Upon calling Mrs. Smith, it became apparent that her mother had not died and that she was calling to request a prescription for GBP. The addictionologist was told by a family member that the patient’s physician was out of the office, that no other physician in the office would fill the GBP prescription, that the prescription had originally been written at the treatment facility, and that the patient urgently needed a GBP refill. The addictionologist called the pharmacist to investigate the matter. The pharmacist reported that physicians in the community were refusing to write the patient a prescription for GBP due to suspected abuse and that the patient had been caught forging prescriptions for GBP. When the addictionologist called the patient and refused to write the prescription, the patient became irate and verbally abusive. Case 7 The patient was a 41-year old white female who entered treatment after a relapse involving opiates, alcohol, and Ambien. About one month into treatment, JOURNAL MSMA, June 2009 — Vol. 50, No. 6

she was placed on GBP to treat her anxiety. Soon after being prescribed GBP, she admitted to her peers and physician that she was abusing the GBP by taking much more that the prescribed dosage.

Case 8 The patient was a 21-year-old white male who was admitted to residential treatment for abusing opiates and benzodiazepines. GBP was started during treatment to treat his anxiety. However, he was suspected of stealing samples of GBP while in treatment, had been gathering multiple prescriptions of the drug, and eventually left treatment against medical advice. Case 9 The patient was 60-year-old white female treated for alcohol dependence. Prior to treatment, the patient’s outpatient psychiatrist had prescribed GBP to help manage alcohol withdrawal symptoms. She entered residential treatment where the GBP was discontinued. During treatment, it was discovered that she had hidden GBP under her mattress and was taking the drug without the knowledge of the treatment team.

Case 10 The patient was a 28-year-old white female admitted for detoxification off oxycodone, hydrocodone, and carisoprodol. She was also prescribed GBP 800 mg 3 times a day for a chronic pain condition. She reported taking 10 GBP pills at a time 6 times a day because it “makes you feel drunk.” She reported rapid tolerance to the effects over 3 days, requiring her to stop it for 5 days before restarting it. She indicated that she used it to augment the opiods and carisoprodol or to substitute for them.

DISCUSSION Although GBP has been viewed as an effective and safe tool by many practitioners seeking a pharmacological treatment of pain, anxiety, and substanceabuse-related withdrawal symptoms for patients with addictive disease, taken together, the evidence suggests that GBP is not as benign a substance as previously thought. The evidence suggests that the potential for the abuse of, and even dependence on, GBP exists. Consistent with the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for substance abuse the above-mentioned studies all provide evidence for GBP abuse.10 For example, each person’s pattern of taking more than the prescribed amount of GBP resulted in a failure to fulfill a major role (i.e., remain sober in treat181


ment) and resulted in social and interpersonal problems due to abusing a substance while in treatment. Further, in at least three cases, patients risked legal problems due to their actions associated with obtaining GBP (i.e., selfprescribing, forging prescriptions, and stealing samples). Also, one patient admitted to snorting GBP in order to achieve more rapid and intense effects. Although there is not enough evidence to make a clear DSM-based diagnosis of dependence in any of the cases, evidence suggests that the potential for dependence is highly likely. First, evidence suggests that GBP withdrawal symptoms can occur.5,6 Second, in all cases, the patients were consistently taking more than the prescribed amount of GBP. Third, the large amounts of GBP taken also suggest that some patients may have developed a GBP tolerance. Fourth, in at least four cases, persons went to great lengths to obtain and maintain GBP, including the following methods: (a) stashing it under a mattress without the knowledge of staff, (b) stealing samples, (c) gathering multiple prescriptions, (d) forging prescriptions, and (d) self-prescribing large doses. Fifth, by abusing GBP during treatment, all of the patients sacrificed important activities (i.e., focusing on their recovery) due to their GBP abuse. Further, one patient spent time on a weekend pass calling in multiple prescriptions, which surely impacted the quality of time spent with his family and friends. The mechanism of action for GBP is unknown. However, GBP is structurally similar to g-aminobutyric acid (GABA), the main inhibitory transmitter, and GBP may augment GABA.5,7 Case study evidence from the current study suggests that, in addition to augmenting GABA, GBP could also be exerting a direct or indirect effect on opiate sights as well. Also, it is possible that the “high” reported by GBP abusers was not actually triggered by a pharmacological effect, but rather a psychological one. However, the same pattern of abuse was not observed for other advertised benign drugs. The apparent potential for abuse of and dependence on GBP described in the current study has multiple practical implications. First, professionals need to be made aware of the potential for abuse of and dependence on GBP, especially among persons with a history of opiate and/or benzodiazepine addiction. Second, professionals should ask questions about escalating doses and other evidence of abuse with persons taking GBP. Third, practitioners should closely monitor patients prescribed GBP, as one would with any drug with the potential for abuse. Fourth, a pattern of misuse should provoke consultation with a professional with a background of treating addictive illness. 182

Additionally, the findings underline the need for the development of safe pharmacological and non pharmacological treatments for pain and anxiety for persons with a history of addictive illness. Also, although GBP abuse in the current study focused primarily on persons with histories of abusing opiates, practitioners at the treatment facility from which the current case histories were treated are beginning to report abuse of GBP among people abusing high doses of methamphetamine. Logic is that it attenuates the crash of methamphetamine. The possible relationship between the use of methamphetamines and GBP deserves exploration. Finally, given the popularity of GBP (i.e., over $2.7 billion in sales in 2003) and that over 90% of the sales in 2003 were estimated to be used for off-label purposes,1 researchers need to further investigate the efficacy and potential drawbacks of GBP for other current off-label uses (e.g., Attention Deficit Disorder, Restless Leg Syndrome, Bipolar Disorder). In summary, evidence suggests that practitioners should be aware that the possibility for abuse and even dependence on GBP exists, and they should use caution in their prescribing practices of GBP, especially with patients who have a high risk for addictive and compulsive disorders.

REFERENCES 1.

2.

3. 4. 5.

6.

7. 8. 9.

Harris G, Pfizer to pay $430 million over promoting drug to doctors. The New York Times. 2004, May 14:C6. Longo LP, Parran T, Johnson B, Kinsey W. Identification and management of the drug-seeking patient. Am Fam Physician. 2000;61:21-128. Prater CD, Zylstra RG, Miller KE. Successful pain management for the recovering addicted patient. Prim Care Companion J Clin Psychiatry. 2002;4(4):125-131. Voris J, Smith NL, Rao S M, Thorne D., Flowers Q J. Gabapentin for the treatment of ethanol withdrawal. J Subst Abuse. 2003;24(2):129-132. Norton J W. Gabapentin withdrawal syndrome. Clin Neuropharmacol. 2001;24:245-246. Barrueto F, Green J, Howland MA, Hoffman RS, Nelson LS. Gabapentin withdrawal presenting as status epilepticus. J Toxicol Clin Toxicol. 2002;40(7):925-928. Reccoppa L, Malcolm R, Ware M. Gabapentin abuse in inmates with prior history of cocaine dependence. Am J Addict. 2004;13(3):321-323. Markowitz JS, Finkenbine R, Myrick H, King L, Carson WH. Gabapentin abuse in a cocaine user: implications for treatment? (correspondence) J Clin Psychopharmacol. 1997;17:423-424. Hill C. (1999, August 3). Joint commission focuses on pain management. Web site. http: //www.jcaho.org /news+room /health+care+issues/jcaho+focuses+on+pain+management. htm. Accessed May 30, 2005.

JOURNAL MSMA, June 2009 — Vol. 50, No. 6


10. First MB, ed. Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision). Washington, DC: American Psychiatric Association; 2000.

AUTHOR INFORMATION:

Alexis Polles, MD, Director of Psychiatry, COPAC Addiction Services, Brandon.

Austin Smith, PhD, Personnel Decisions International, 220 E. 42nd St., 36th Floor, New York, NY 10017.

Chapman Sledge, MD, Pine Grove Behavioral Health and Addiction Services, Next Step, 2558 Broadway Drive, Hattiesburg, MS 39402.

CORRESPONDING AUTHOR & REPRINTS: Alexis Polles, MD Director of Psychiatry 3949 Hwy 43 N. Brandon, MS 39047 Phone: 1-800-446-9727 Email: alexispolles@copacms.com

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Role of FDG PET Imaging in the Management of Pediatric Hodgkin’s Disease: An Assessment of Stage-migration, Response Comparisons with CT and Correlation to Clinical Outcomes Vani Vijayakumar, MD Madhava Kanakamedala, MD Waleed F. Mourad, MD, MSc et al.

A

BSTRACT Purpose: The aim of this study is to evaluate FDG PET image findings in children diagnosed with Hodgkin’s disease at initial staging and follow up and correlate them with Computed Tomography (CT) findings and clinical outcomes. Materials and Methods: A retrospective review of 14 pediatric patients with pathologically confirmed Hodgkin’s disease between 2004 2007, who underwent FDG PET imaging for staging and follow up was performed. Patients were treated with chemotherapy and external beam radiation therapy and two patients subsequently received autologous bone marrow transplant. Follow-up FDG PET imaging was performed at 1.0 to 12 months (mean 2 months/Median) after completion of therapy. Results: Six of 14 patients had the Positron Emission Tomography (PET) performed as part of initial staging. There was upstaging in one patient by PET. There were 34 sites identified by CT; 34 sites were identified by PET. There was concordance in 30 sites, where as 4 sites had discordance. The concordance and discordance rates were 88% and 12%, respectively. Follow up PET scans were completely negative in 8; 6 of these patients are doing well without any clinical relapse; two patients are non compliant with follow up, with unknown clinical status. The remaining six patients with PET scans have mild but persistent uptake: four of these patients however do not have clinical signs and symptoms of active disease; the remaining two patients’ clinical status is not known due to lack of followup. Unlike PET, CT demonstrated persistent disease in 184

8 patients, of whom only two showed PET uptake suggesting PET’s superiority in decreasing false positives of CT in detecting recurrences. Conclusions: Our study is consistent with other studies in demonstrating the usefulness of PET in the management of HD. PET findings can predict the course of the disease better than CT. Our focus on pediatric HD is important since the number of studies addressing the role of PET in pediatric HD is few.

KEY WORDS:

HODGKIN’S LYMPHOMA, PET SCAN, PEDIATRIC, STAGE MIGRATION

INTRODUCTION Lymphomas comprise 15% of cancers in individuals younger than 20 years of age, of which Hodgkin’s disease (HD) being more common than Non-Hodgkin’s lymphoma.1 HD most often arises in lymph nodes. Excisional biopsy of the lymph node (LN) for histopathological examination is necessary for confirmation of diagnosis and to sub classify the disease. According to the REAL (Revised European-American) Classification, the entity has been divided into classic HD and nodular lymphocyte predominance Hodgkin’s disease.2 Classic HD includes nodular sclerosing, mixed cellularity, lymphocyte depletion and lymphocyte rich disease subtypes. Previously the cases that did not fit into any classic sub-group were included in mixed cellularity but the current practice is to restrict mixed cellularity to typical JOURNAL MSMA, June 2009 — Vol. 50, No. 6


cases and to categorize the rest as HD-unclassifiable. Eighty percent of patients present with cervical lymphadenopathy and one third have B symptoms associated with them, including fever higher than 38 C, night sweats, weight loss >10% in the preceding 6 months.3 Ann Arbor staging system for HD includes clinical stage, pathological stage including Bone Marrow biopsies and the information obtained from staging laparotomy and imaging studies.4 In addition, Costwald modification of the system takes into consideration bulkiness of disease.5 Staging work-up included surgical laparotomy which was used routinely before the 1990’s with the benefit of identifying subclinical splenic disease and assessment of retroperitoneal lymphatics. This had become obsolete with increasing use of chemotherapy, newer diagnostic modalities and desire to maintain intact splenic function.6, 7 Currently CT is accepted as the modality of choice for a non-invasive assessment of the extent of the nodal disease. However, Magnetic Resonance Imaging (MRI) may have advantages in its ability to better assess the retroperitoneal nodes and bone marrow involvement.8, 9 CT criteria for lymph node involvement is size dependent (>1cm). CT has limited accuracy in detecting lymphoma in normal sized lymph nodes and due to its size-dependent results; it could give false positives in enlarged nodes from benign processes.10 Bone marrow (BM) biopsies are routinely indicated in patients with all stages of disease or with B symptoms. False negatives can occur even in bilateral BM involvement because of patchy involvement. Nuclear Imaging with Gallium-67 had a role in predicting early treatment failure in thorax with residual radiographic abnormalities during or after treatment.11 Its role was controversial even prior to the use of PET because of a concern of false positives and false negatives.12 Gallium Scans also had difficulty in assessing abdominal disease due to an increased uptake by the normal liver, spleen and bowel. The introduction of PET was welcomed by the oncology community since it has the potential to overcome the limitations of CT and Gallium Scans. PET with F18-fluoro deoxyglucose tracer is a noninvasive functional imaging modality that offers high resolution and tomographic views of the entire body. These features provide an ability to correlate the increased metabolic activity due to the disease with anatomic imaging by other modalities. PET compliments the limitations of CT in identifying the disease in normal sized lymph nodes and in excluding cancer in enlarged benign nodes.13 PET has high sensitivity and JOURNAL MSMA, June 2009 — Vol. 50, No. 6

specificity in staging lymphomas.14 PET scan is a useful technique in assessment of early relapse as well, after definitive treatment in Hodgkin’s disease.15-17

MATERIALS AND METHODS Our study is a retrospective review of electronic medical records and scans between 2004 -2007 of the pediatric patients with diagnosis of HD who underwent FDG PET imaging at the University of Mississippi Medical Center. All patients were treated with chemotherapy and external beam radiation therapy and two patients underwent additional autologous bone marrow transplantation. Post therapy FDG PET imaging was performed at 1.0 to 12 months (mean 2 months) after completion of planned treatments. Our goal is to assess and compare our results vis a vis other published results in the literature. An IRB approval was obtained for this analysis. FDG PET imaging: Patients fasted for at least 6 hours before the PET imaging. Blood glucose was measured by finger stick and imaging performed if less than 200mg/dl. PET imaging was performed using a ECAT EXACT HR+ (CTI/Siemens, Knoxville, TN, USA) scanner with an axial field of view of 15.5 cm. PET imaging was performed from mid calvarium to mid thigh in a 2D mode, 7 min/bed position of about five to six bed positions 45-60 minutes after the intravenous administration of weight adjusted adult dose of 10mCi (36 MBq) of FDG. The Ge 68 rod source was used for PET attenuation correction. Total examination time was less than 45 minutes. Iterative image reconstruction of the emission data was performed and reviewed in coronal, sagittal and transverse projections. DATA ANALYSIS All FDG PET images were reviewed by two experienced nuclear medicine physicians, while CT images were read by different radiologists with experience in specific anatomical sites of the body. The physicians were blinded to the other imaging modality. Following separate image evaluation, FDG PET and CT data sets were read side-by-side. CT size criteria for individual lymph node groups were used to evaluate whether lymph nodes were to be considered involved with HD. All lesions were assessed visually following International Harmonization Project guidelines.18 For estimation of total lesion delectability, the imaging results were tabulated for different lymph node regions: cervical, supraclavicular, paratracheal, mediastinal, hilar, axillary, celiac, para-aortic, mesenteric, iliac and inguinal, which were further classified into four anatomical groups: head 185


and neck, chest, abdomen and pelvis. Extra nodal sites were classified separately. When evaluating methods for tumor staging, a major problem is the definition of a “gold standard” with which the imaging modalities can be compared. Since in our study not all lesions could be evaluated by histology, we defined the sum of the imaging and follow-up data as the standard of reference for the extent and status of the disease. All patients were followed clinically for at least 12 months and all underwent follow up CT (14/14) and FDG PET (n=14/14). Follow up CT and PET findings were used to assess residual or recurrent disease instead of histologic verification. In patients with ‘image-diagnosed’ recurrent disease, response to subsequent therapy or tumor progression was verified. Patients with absence of disease showing neither enlarging masses on follow-up CT nor an increase metabolic activity on follow-up FDG PET (8/14) were considered ‘disease-free’.

RESULTS There were a total of 14 pediatric patients with a diagnosis of HD who underwent FDG PET scanning performed from 2004-2007. There were 6 males and 8 females with ages ranging 6-21years. Each patient underwent 2-8 FDG PET imaging studies during this time period. Among those, 7 were African Americans, 6 were whites and 1 was Hispanic. Nodular Sclerosis was the predominant histologic type. Eight patients had Stage II disease and 6 patients had Stage III disease. Of the seven African Americans, 4 had Stage III disease (57%). Of the 6 white patients, 2 patients had Stage III disease (33%). On the initial FDG imaging, all the patients had intense FDG uptake corresponding to the known lymphomatous involvement. Six of 14 patients had the PET performed as part of initial staging. There was upstaging in one patient by PET. There were 34 sites identified as abnormal by CT; 34 sites were identified by PET. There was concordance in 30 sites, where as 4 sites had discordance. The concordance and discordance ratios are: 88% and 12%. Follow up PET scans were completely negative in 8 patients; 6 of these patients are doing well without any clinical relapse (‘disease-free’). Two patients are non compliant with follow up and hence their disease status in not known. Six patients’ PET scans showed mild, persistent and stable uptake. Four of these patients however do not have clinical signs and symptoms of active disease (‘disease-free’); the remaining two patients are not seen in follow-up and their disease status is not known at this time. CT demonstrated persistent uptake in 8 patients, of whom only two had corresponding positive PET findings. 186

DISCUSSION Role of FDG PET imaging in the management of HD is not well established; experience in pediatric patients is limited. However, there are several studies in adults with lymphoma that demonstrated improved sensitivity, specificity and predictive value compared to CT.19-22 There are several limiting factors in children to interpret FDG PET images due to normal physiologic uptake in brown fat, thymic rebound after treatment and muscle uptake due to anxiety.23-25 Other limiting factors include infection, inflammation and post radiation changes. As in adults, FDG PET is being used in initial staging at diagnosis and on follow up to assess response to treatment for residual or recurrent disease in pediatric population also. Change in initial staging and patient management can occur up to 23% of time.26 Naumann et al27 demonstrated FDG PET’s usefulness in Stage I and II and observe that it is not cost effective in Stages III and IV. Miguel-Hernandez-Pampaloni28 reported a concordance rate between PET and CT of 89% and discordant rate of 11% similar to our findings of 88% and 12% on a region-by-region analysis. Similar concordant results were reported in other studies.29, 30 Although the stage migration percentages were low in our study, we attribute this to the small sample size of our study population. FDG PET has shown to have a high negative predictive value of 81-100% after treatment .31, 32 An earlier utilization of PET imaging after chemotherapy to assess response is being increasingly evaluated. Recent study by Gallamini et al33 demonstrated accurate assessment of response or relapse after two cycles of standard chemotherapy and its usefulness as a prognostic tool for further management. Residual masses on CT after completion of therapy are not uncommon and are usually due to fibrosis.34, 35 Our findings are consistent with these reports. PET can also play an important role to assess progression free survival (PFS), and help decide on second line therapies and second line therapies and, thus can improve and guide in instituting second line treatments when tumor cell burdens are still limited. For example, a study by Reinhardt et al36 showed 3 year progression free survival rate with complete or partial response or no interval change on CT scan and negative PET scan compared to positive PET scan after treatment which was statistically significant. When PET was negative, PFS was 94.1% compared to when PET was positive PFS being only 33.3%. Similarly there was high negative predictive value of 100% and low posiJOURNAL MSMA, June 2009 — Vol. 50, No. 6


tive predictive value of 18.2% of PET in the evaluation of relapse of disease in another study by Meany et al17 from Washington DC’s Children’s National Medical Center among 23 pediatric HD patients. We are unable to compare our results in terms of second line therapy due to the fact that a majority of our patients were PET negative (although CT ‘positive’) and were not instituted on any second line therapy. Although our study has several limitations including retrospective nature of analysis, small sample size and no histologic confirmation, our findings are similar to those reported in the literature as discussed above. As emphasized by many, the importance of analyzing and comparing individual institutional results to those of other reports when new technologies are introduced can not be over emphasized. Such outcome analyses are the best way to identify any possible differences in the quality assurance practices and implementation of new technologies.

CONCLUSION In our study, the stage migration with PET appears minimal, likely due to our small sample size. There is a suggestion of higher stage at initial presentation in African American children than Caucasian patients in our study. As in other reports, FDG PET imaging was valuable in the initial staging, for radiation treatment planning, and post therapy follow up to demonstrate a complete metabolic response to treatment. PET appears predictive of recurrence free and overall survival in pediatric HD in other studies, however, due to the small patient population, our results need to be interpreted with caution. We plan to confirm our results with a larger population and longer follow up in the future. REFERENCES 1.

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20. De Wit M, Bohuslavizki KH, Buchert R, et al. 18FDG PET following treatment as valid predictor for disease-free survival in Hodgkin’s lymphoma. Ann Oncol. 2001; 12:29– 37. 21. Kostakoglu L, Goldsmith SJ. Fluorine-18 fluorodeoxyglucose positron emission tomography in the staging and follow-up of lymphoma: Is it time to shift gears? Eur J Nucl Med 2000; 27:1564–1578. 22. Guay C, Lepine M, Verreault J, et al. Prognostic value of PET using 18F-FDG in Hodgkin’s disease for post-treatment evaluation. J Nucl Med 2003; 44:1225–1231. 23. Weinblatt ME, Zanzi I, Belakhlef A, et al. False-positive FDG PET imaging of the thymus of a child with Hodgkin’s disease. J Nucl Med. 1997; 38:888–890. 24. Hudson MM, Krasin MJ, Kaste SC. PET imaging in pediatric Hodgkin’s lymphoma. Pediatr Radiol. 2004; 34:190–198. 25. Kaste SC, Howard SC, McCarville EB, et al. 18F-FDG-avid sites mimicking active disease in pediatric Hodgkin’s. Pediatr Radiol. 2005; 35:141–154. 26. Wegner EA, Barrington SF, Kingston JE, et al. The impact of PET scanning on management of pediatric oncology patients. Eur J Nucl Med Mol Imaging. 2005; 32:23–30. 27. Naumann R, Beuthien-Baumann B, Reiss A, et al. Substantial impact of FDG PET imaging on the therapy decision in patients with early-stage Hodgkin’s lymphoma. Br J Cancer. 2004; 90:620–625. 28. Hernandez-Pampaloni M, Takalkar A, Yu JQ et al. F-18 FDG PET imaging and correlation with CT in staging and follow up of pediatric lymphomas. Pediatr Radiol. 2006; 36:524-531. 29. Hermann S, Wormanns D, Pixberg M, et al (2005) Staging in childhood lymphoma: differences between FDG PET and CT. Nuklearmedizin. 44:1–7. 30. Wickmann L, Luders H, Dorffel W (2003) 18-FDG PET findings in children and adolescents with Hodgkin’s disease: retrospective evaluation of the correlation to other imaging procedures in initial staging and to the predictive value of follow-up examinations. Klin Padiatr. 215:146–150. 31. Keresztes K, Lengyel Z, Devenyi K, et al. Mediastinal bulky tumour in Hodgkin’s disease and prognostic value of positron emission tomography in the evaluation of posttreatment residual masses. Acta Haematol. 2004; 112:194–199. 32. Lavely WC, Delbeke D, Greer JP, et al. FDG PET in the follow-up management of patients with newly diagnosed Hodgkin and non-Hodgkin lymphoma after first-line chemotherapy. Int J Radiat Oncol Biol Phys. 2003; 57:307– 315. 33. Gallamini A, Hutchings M, Rigacci L,et al. Early interim 2[18F]fluoro-2-deoxy-D-glucose positron emission tomography is prognostically superior to international prognostic score in advanced-stage Hodgkin’s lymphoma: a report from a joint Italian-Danish study. J Clin Oncol. 2007; 25:3746-52. 34. Weihrauch MR, Re D, Scheidhauer K, et al. Thoracic positron emission tomography using 18F-fluorodeoxyglucose for the evaluation of residual mediastinal Hodgkin disease. Blood 98:2930–2934.

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35. Montravers F, McNamara D, Landman-Parker J, et al. [(18)F]FDG in childhood lymphoma: clinical utility and impact on management. Eur J Nucl Med Mol Imaging. 29:1155–1165. 36. Reinhardt MJ, Herkel C, Altehoefer C,et al. Computed tomography and 18F-FDG positron emission tomography for therapy control of Hodgkin’s and non-Hodgkin’s lymphoma patients: when do we really need FDG PET? Ann Oncol. 2005; 16:1524-9. Epub 2005 Jun 9.

AUTHOR INFORMATION

Vani Vijayakumar, MD is affiliated with the Department of Radiology at the University of Mississippi Medical Center in Jackson. Madhava Kanakamedala, MD is affiliated with the Department of Radiation Oncology at the University of Mississippi Medical Center in Jackson. Waleed F. Mourad, MD, MSc is affiliated with the Department of Radiation Oncology at the University of Mississippi Medical Center in Jackson.

CORRESPONDING AUTHOR: Vani Vijayakumar, MD Professor, Dept. of Radiology and Medicine Chief, Division of Nuclear Medicine University of Mississippi Medical Center 2500 North State St. Jackson, MS 39216-4505

Phone: 601-984-2575 Fax: 601-984-2574 Email: VVijayakumar@radiology.umsmed.edu

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SPECIAL ARTICLE

An Interview with Randy Easterling, MD 2009-2010 MSMA President Karen A. Evers Managing Editor

[Each June the JMSMA interviews the incoming MSMA president. Here we go behind the scenes. Due to the space limitations, the answered questions do the speaking for this interview.] —ED.

FAMILY I spent most of my formative years in Long Beach, Mississippi on the Mississippi Gulf Coast. My father ran the local A&P store, and we moved there when I was in the fifth grade. I grew up in a fairly conservative home. My father was a deacon and Sunday school teacher at the First Baptist Church in Long Beach, and my mother was also a Sunday school teacher. I have an older sister who works for the Mississippi Department of Rehabilitation in the Office of Vocational Rehabilitation for the Blind. My brother is a Presbyterian minister in Thomasville, Georgia. My little sister lives in Hattiesburg, Mississippi and is the business manager for an orthodontic group. There is absolutely nothing more important to me than my family. I have been happily married for over 32 years, and I have two wonderful children. My personal philosophy for family would be that each member of the family should do what they could to meet each other’s needs. We are a very close-knit family. MILESTONES My personal philosophy toward life is that we should do whatever we can to aid and assist others. I feel that I am a very giving person, both to my family and those around. This all comes out of my Christian S. RANDALL EASTERLING FAMILY— (L. TO R.) WIFE JANIE, DR. RANDY upbringing and my faith in God, i.e., “Do EASTERLING, DAUGHTER MEGAN AND SON MATT AT THE 2004 MISSISSIPPI unto others as you would have them do unto ACADEMY OF FAMILY PRACTICE MEETING IN DESTIN, FLA. 190

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you.” As far as an event that shaped my life, it would be the values my family instilled while I was growing up. My mother and father had a happy marriage, and my brothers and sisters all got along fairly well. We were expected to work as children, and we had a lot of responsibility. I think my parents teaching me the dignity of labor and that my only limitations were self-imposed were 1990 EASTERLING FAMILY PORTRAIT— THE LATE JOHNNIE CHRISTMAS 2007— DR. AND MRS. AND STANLEY EASTERLING (CENTER) WITH THEIR CHILDREN (L. EASTERLING’S SON AND DAUGHTER, MATT probably a TO R.) DAPHNE, RANDY, AND JOE EASTERLING AND JANICE AND MEGAN significant EASTERLING TREXLER. milestone in my life. My role models were my parents. My father fought in World War II and came back as a wounded veteran. He worked for 42 years at the A&P Food Store. He did everything he could with a high school diploma to provide for his family. My mother was a stay-at-home mom until my little sister went off to college. She then went to work in a five & dime store. They were dedicated to themselves, to their family, and to their God. My proudest accomplishment is having two wonderful children, Matt and Megan, and being privileged to raise and have a close relationship with both of them.

EDUCATION I have always been interested in the healthcare field. When I finished college, I went to work as a counselor and a science teacher in a residential treatment center for disturbed adolescents in Crystal Springs, Mississippi. While I was there, I began working on my master’s degree in counseling psychology. I completed my master’s degree and worked in a mental health center for one year on the Mississippi Gulf Coast. It was at that time that I got to know several psychiatrists and became really interested in going to medical school. I then went back to Mississippi State where I taught for two years and took premed courses. I then entered medical school in Jackson in 1980, and the rest is history. MED SCHOOL There was no single event in medical school that stood out. I enjoyed the friendships that I formed with my classmates. I found most of the clinical rotations interesting and exciting. Probably, my single best experience was my third year family practice rotation in medical school when I worked with Dr. Walter Rose in Indianola, Mississippi. I actually delivered babies on my own and got to work in the emergency room the JOURNAL MSMA, June 2009 — Vol. 50, No. 6

GRADUATION FROM THE UNIVERSITY OF MISSISSIPPI SCHOOL OF MEDICINE, MAY 1984— DR. EASTERLING WITH HIS FATHER, THE LATE STANLEY EASTERLING.

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“What they say about him...”

My big concern about Dr. Easterling being president is we may never know what his opinion is. He’s so shy and reticent to offer his opinion in public. —R. Scott Anderson, MD, Vice Chair MSMA Board of Trustees

Dr. Easterling is the ultimate political dynamo and we ought to be in excellent hands at the Mississippi State House this year— as long as keeps his socks on and maintains his “new image.” —J. Patrick Barrett, MD, MSMA Immediate Past-President Dr. Randy Easterling can cure most of the ills of the political process or at least prescribe a sedative. His cure is trust and integrity and his calming demeanor can sooth most traumas caused by the legislative process. —Lt. Governor Phil Bryant

Randy, now that you shave, wear socks, and occasionally don a tie, you are the MSMA President. If you work on a few other matters, who knows, maybe AMA leadership or the Senate is next? I believe you have that future and more. —Michael L. O'Dell, MD; Chief Quality Officer and Director FMRP, North Mississippi Medical Center

The press recently referred to the late Jackson mayor Frank Melton as “bigger than life.” They apparently have not met or had any dealings with Dr. Randy Easterling for whom this phrase was obviously coined! —Stanley Hartness, MD; MSMA Past President

I remember going to what I called “Meet the Press” training with Randy. We were all being critiqued by the expert. When she came to him, she said, “Shave the beard, it makes you look old.” The next time I saw him the beard was gone. I thought “Wow, he does embrace change.” Then I wondered if we could get him to shave his head so we could pass him off as a grown fetus. That would really make him look young! —J. Clay Hayes, MD

In 1987, the face of medicine changed in Vicksburg, Mississippi. That year, the Street Clinic employed a somewhat middle-aged psychologist/MD who had just completed his residency in family medicine in Tuscaloosa, Alabama, under the leadership of our very good, but slightly crazy, Vietnam veteran friend, Dr. Phil Bobo. Prior to his arrival, the clinic was composed of distinguished conservative physicians who wore only a suit and tie to work. These associates were speechless when Dr. Easterling reported the first day with a long, hippie-style hair cut, open shirt, coatless, no tie, no socks... just stethoscope draped around his neck saying he was ready to see sick folks. Despite his laid-back demeanor, we soon realized he was hardworking, caring, outspoken and intended to make changes. Because of his dedication to his practice of medicine and despite his dress style, he and I became close friends. Since none of my children had chosen medicine as their

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profession, I looked upon him as one of my own. Now, as he takes the oath of office of our great organization, I look back on our history together and its similarities. Just as I have always been, Randy was interested in being involved in the business and politics of medicine. He joined MSMA, family practice group, West Mississippi Medical Society and became a patron of the Miss Mississippi pageant; although he says through forced pressure, going on to replace me as official pageant physician. On many occasions, he would come to my office and talk about how I became an officer, board member or president of certain organizations. I encouraged him to seek appointment on the legislative committee for MSMA, to join MMPAC, AMPAC and to run for various offices. He has followed this advice well and I salute him for many jobs well done. I am very proud of him and his achievements. Some things never change. Randy came in with a unique dress style and he begins his year in the same manner…denim and diamonds??? What radical move can we expect next? My very best wishes go with Randy and Janie for a year that will challenge but at the same time bring so many rewards. I love you and your family. —W. Briggs Hopson, MD, MSMA Past President

I first met Dr. Easterling when I was Director of Government Affairs for MSMA. From the day he was first nominated to the Council on Legislation, I knew I had my hands full. As a lobbyist, I thought he wanted my job. Most doctors hate politics; but, it is a prejudice that Dr. Easterling has overcome. When he was ready to go to the Capitol I told him he would have to wear socks, and wear a sport coat, and be nice to people. He said, “All in the same day?” The fact that he likes to go to the Capitol is scientific evidence of a character flaw. And, I learned pretty quickly that the best way to give Dr. Easterling advice is to find out what he wants to do and advise him to do it. —Charmain Kanosky, MSMA Executive Director

The Squire of Bovina deserves our thanks for making a difference in many ways for medicine in this state. Randy played a major role in securing tort reform for Mississippi physicians. He played a key role in fixing the State Board of Health, ensuring more physicians were on the board and that its chairman was a physician. He played a critical role in establishing the Rural Physicians Scholarship Program and continues to play a key role on our PAC board. Randy has done more than any other Mississippi physician in getting political powers long deaf to our issues, to hear the voice of state physicians. —Luke Lampton, MD, Magnolia; Editor, JMSMA; Chairman, Miss. State Board of Health

Dr. Easterling has been very generous of his time serving as “Doctor of the Day” at the Capitol. It has been my pleasure getting to know him over the many years he has helped us. —Sen. Walter Michel

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RECEPTION FOR FORMER LT. GOV. AMY TUCK (CENTER) — NO STRANGER TO POLITICS, DR. EASTERLING (R.) AND HIS WIFE, JANIE, (L.) HAVE HOSTED MANY POLITICAL FUNDRAISERS IN THEIR HOME.

RECEPTION FOR GOV. RONNIE MUSGROVE— DR. BRIGGS HOPSON, FORMER GOV. MUSGROVE AND DR. EASTERLING.

month I was there. It was the first time in my medical experience I was able to make independent decisions. The only tough time I had during medical school was studying a great deal. Janie and I had been married about three years, and I would come home every night and study for three to four hours. It was not a trying time, but it was a lot of hard work…a lot of hard work and a lot of discipline. I certainly could not have made it without a very loving and supportive wife. When I finished my residency I moved to Vicksburg where I began the practice of family medicine and emergency medicine with the Street Clinic in Vicksburg. Vicksburg was the only place that would allow me to do a full time family practice and also work in the emergency room. I would go to work every Monday morning, make rounds in the hospital, work the clinic all day, and then go work in the emergency room all Monday night and then work the clinic and the hospital all day Tuesday. For 13 years, my first day at work lasted about 40 hours. I also worked in the E. R. every weekend that I was on call which was every third weekend. Usually, the shifts were 24 hours. I have been in Vicksburg now for 22 years. I stopped working in the emergency room about nine years ago.

ORGANIZED MEDICINE When you moved to Vicksburg and joined the Street Clinic, Dr. Briggs Hopson made sure that you joined the Mississippi State Medical Association. It was at that time those 20 years ago, I joined MSMA. I first got involved with organized medicine when I hosted a fundraiser at my home for the then Lieutenant Governor, Amy Tuck. That was more than eight years ago. Senator Mike Chaney and Senator Walter Michel and I hosted the party. This was Amy’s first formal introduction to the Republican Party. She was a Democrat during her first term. She switched parties about a year later. It was shortly after that when I became the chairman of the Council on Legislation for MSMA. JOURNAL MSMA, June 2009 — Vol. 50, No. 6

JULY 2004 INAUGURATION OF DR. RANDY EASTERLING, MAFP PRESIDENT— MATT, JANIE, DR. EASTERLING AND MEGAN.

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I was the president of the Mississippi Academy of Family Physicians approximately five years ago. One of my goals was to try to get the Mississippi Academy of Family Physicians and the Mississippi State Medical Association to work closer with each other. I do not think I accomplished those goals. The two associations seem to be separate. This is unfortunate. The MSMA should be considered the parent association for all the specialty associations in Mississippi. Each physician should be a member of the MSMA regardless of what specialty society they are members of. All specialty societies should work hand-in-hand with MSMA to accomplish a common goal. We still have miles to go in accomplishing a good working relationship between the groups. Serving as chair of the Mississippi Medical Political Action Committee (MMPAC) has been an interesting endeavor. We are a separate group from the MSMA. We try to direct donations to those politicians who best support our agenda. This has opened a number of doors for me.

EASTERLING ROAST—CARTOONIST MARSHALL

MISSISSIPPI STATE BOARD OF MEDICAL LICENSURE RAMSEY CREATED THIS CARICATURE FOR A MISSISSIPPI ACADEMY OF FAMILY PRACTICE I have been a member of the Board of Medical Licensure for a little over two years. I was just appointed to the executive committee. I FOUNDATION FUNDRAISER ROASTING DR. EASTERLING. have found the State Board of Medical Licensure interesting; however, it has been much more policy and regulation oriented than I perceived. I went in thinking that I would have the chance to work with and assist physicians when they have drinking problems. We tend to spend a great deal of time passing policies and procedures Customized which is certainly necessary. One of the things that most doctors do Asset Management not realize about the Board of Medical Licensure is that we are not If you have $500,000 or more to there to advocate for the physicians. Mississippi State Board of invest, we invite your inquiry Medical Licensure is a statutorily established board with the sole as to our investment record, background, and fee structure. purpose to protect the public. I have enjoyed my tenure there and Call us at 601-982-4123 or hope to spend another several years in that position. COMMUNITY SERVICE I have been active in my community since I moved to Vicksburg 22 years ago. I have been on the board of directors for United Way. I am an active member of the First Baptist Church at Vicksburg and one of the two to three physicians that work at our church clinic on every fourth Thursday night of the month. We see approximately 100 patients in the evening. These individuals, by definition, do not have insurance, and I feel like we fulfill a real need there. I have also been the physician for the Miss Mississippi Pageant since 1995. This is an interesting role. It is probably a lot more work than most people think. One has to remember that Miss Mississippi Pageant girls are 17-21 years-old. They are, by and large, a great deal of fun to work with; but, they can be trying at times, shall we say a little temperamental. I have also been involved in other community things such as the medical director of the ambulance service in Vicksburg. I have also been involved in the schools when my kids were in elementary, junior high, and high school. I have raised money for Boy Scouts and again have been active in United Way. 194

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P.O. Box 16725 Jackson, MS 39236-6725 795 Woodlands Parkway, Suite 104 Ridgeland, MS 39157 601- Â&#x2021; -800-844-4123 Fax 601-366-0013 www.medleybrown.com

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PLATFORM My agenda with MSMA as the president will be, as it has been in the past, more political in nature. I feel strongly that MSMA is fundamentally a trade organization whose purpose is to exercise what influence we have over elected officials in order to protect our patients and ensure the patients have quality medical care. I will do everything within my power to encourage members to join the MMPAC and to become active with their local politicians. We physicians spend too much time complaining about issues without getting involved. We cannot get involved in politics without involving our check books. BALANCE The thing I enjoy most about being a physician is being someone’s doctor. I have, like most people, a need to be needed. I have enjoyed being the family physician for hundreds of people while in Vicksburg and take great enjoyment in them calling me their doctor. The thing I like least about being a doctor is being available 24/7 for non-emergency situations. Often, I feel as though I am pulled in a thousand different directions, and after 15, 20, or 25 years, that can be quite trying. I do not like government and insurance involvement in my patient care. I think the best healthcare decisions are made when they are made between a doctor and his or her patient. Government and/or insurance companies have very little interest in the well-being of patients, and their interest is simply more or less saving money. I do the bulk of my work early in the morning. I walk in the hospital usually about 6:00 a.m. and try to finish in the mid-to-late afternoon. When my children were little, that would allow me to be free most of the time for their events that occurred late in the afternoon and at night. Now that they have moved away from home, Janie and I have most of our evenings and weekends free to do pretty much what we want to. We should really live our lives where our personal life becomes the most important thing, and we simply make time for work. Janie and I travel some, but mostly spend time with friends and going out. We also enjoy spending time with our children. My son has just finished law school and has moved back to the Jackson area. So, we will be seeing him more often. My daughter lives in Birmingham, and we see her at least once a month. There is nothing I enjoy more than spending an evening with my wife and two children. IN CLOSING… I have a real passion for the Mississippi State Medical Association and for the American Medical Association. Not only do I fundamentally like the people that I work with at MSMA and AMA, but I have a great deal of affection for the principles for which they stand. I feel very strongly that we should only be about the business of improving healthcare for our patients. Any position we take that is not patientcentered should not be adopted by our association. Even though we will not win every battle, our strongest weapon is to have our patients on our side. ❒

NEW YEAR’S EVE WITH GOOD FRIENDS— DR. & MRS. EASTERLING, DR. JANET FISHER AND BUDDY DEES.

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PROFILE

• • • •

Stanley Randall (Randy) Easterling, MD

Family physician in private practice with the Street Clinic in Vicksburg where he chairs the Industrial Medicine Committee. Medical Director of the Marian Hill Chemical Dependency Unit in Vicksburg where he has practiced since 1987. Medical Review Officer at the Grand Gulf Nuclear Power Plant in Port Gibson and Medical Director of the Warren County Ambulance Service. Fellow of the American Board of Family Medicine, and is also board certified in Addiction Medicine and a certified Medical Review Officer.

LEGISLATIVE & POLITICAL APPOINTMENTS: • • •

Past Chair of the Mississippi Medical Political Action Committee and has served on the MMPAC board since 2001. Advisor to the Mississippi Tort Claims Board and on the BIPEC Board of Directors and Executive Committee. Appointed by Governor Barbour to a 6-year term on the State Board of Medical Licensure.

• • • •

Past President of West Mississippi Medical Society Past President and on the Board of the Mississippi Academy of Family Physicians. Served two terms on the MSMA Board of Trustees chairing for two years and chaired the MSMA Council on Legislation. Served on the Mississippi Professionals Health Program Board of Directors, and has served on the Mississippi delegation to the AMA since 2004.

ORGANIZED MEDICINE:

UNDERGRADUATE EDUCATION:

Long Beach High School, Long Beach, Mississippi 1966-1969; B.S. – Mississippi College, Clinton, Mississippi – 1969-1973

HONORS AND EXTRACURRICULAR ACTIVITIES: • • • • •

High School – Mr. Long Beach High School, 1969; Hall of Fame,1969 College – President, Student Affiliate Chapter of the American Chemical Society, Mississippi College, 1972-1973. Vice-President, Student Affiliate Chapter of the American Chemical Society, Mississippi College 1971-1972 Omicron Delta Kappa, National Leadership Fraternity. Staff Writer, The Collegian (college paper), Mississippi College

POSTGRADUATE EDUCATION:

M.S. – University of Southern Mississippi, 1977; Major: Counseling Psychology. Additional Graduate Work in Psychology: Mississippi State University (R&D Center, Jackson, Mississippi); Jackson State University; Barry College, Miami, Florida

PRE- MEDICAL EDUCATION:

Mississippi State University, Starkville, Mississippi, 1978-1980

MEDICAL EDUCATION:

University of Mississippi School of Medicine, Jackson, Medical Degree completed May 1984.

POSTGRADUATE TRAINING:

Residency: Family Medicine – College of Community Health Sciences, University of Alabama, Tuscaloosa; 1984-1987.

BOARD CERTIFICATION:

Fellow – American Board of Family Medicine, 2005; Certified, American Society of Addiction Medicine, 2002, 2009; Diplomate American Academy of Family Medicine, 1987.

CIVIC AND CHURCH:

Member, Vicksburg Rotary Club; Member, First Baptist Church, Vicksburg; Board of Directors, United Way of West Central Mississippi – 1989 to 1995; Division Chairman (Professional) – United Way of West Central Mississippi 1989 Campaign; Board of Directors, Vicksburg Rotary Club – 1990-1991; Board of Directors, John Wesley White Crusade – Fall 1992; President Elect, Vicksburg Rotary Club – 1997-1998; President, Vicksburg Rotary Club – 1998-1999; Guardian Society University Medical Center; Physician, Miss Mississippi Pageant – 1995 – Present.

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About Randy...

You're most likely to see me around: on the weekends— riding on my tractor, bush hogging, and pulling weeds. On the weekends I love to: work outside and go out with my wife.

The high school, college or pro sports teams I root for are: the Warren Central Vikings, the Ole Miss Rebels, Mississippi State Bulldogs, and the University of Alabama Crimson Tide. My favorite pro football team is the New COTTON BOWL IN DALLAS— MARK SMITH Orleans Saints. I attended the first New Orleans Saints game ever in September AND DR. EASTERLING LEAD A “HOTTY TODDY” of 1967. I was around 15-years-old at that time. I saw John Gilliam in the opening play of the Saints franchise. The Los Angeles Rams kicked off to the AS OLE MISS LED OKLAHOMA STATE. New Orleans Saints and John Gilliam ran the ball back to 100 yards for a touchdown. This was the first play of the Saints franchise, and it has been downhill since, but I do enjoy watching the Saints. I am also looking forward to another season with the Ole Miss Rebels. Last year was fantastic. We won the Cotton Bowl and ended up with an excellent season. Hopefully, the next year will be even better. If I'm watching a movie or listening to music, it's probably: The movie would likely be “Steel Magnolias” or “The Big Chill.” The music I like listening to is satellite radio, usually the oldies: 60’s and 70’s, along with several other stations I follow on satellite radio.

My favorite book is: “The Greatest Generation” by Tom Brokaw. This book was written about my father and his generation, about their sacrifice in World War II, but most importantly, when they came back from the War and build the greatest post-war economy in the history of mankind.

Latest splurge: I bought Janie a red Mercedes convertible for her birthday last year. I must say the car looks almost as good as she does. I am passionate about: 1. My relationship with God. 2. My family. 3. My patients. 4. Organized medicine and its relationship to the previous three.

Something about me not everyone knows: I have a significant learning disability. I suffer from adult ADHD. I do not take medicines for it. It is very difficult for me to read large volumes of material at one time. I am a very poor reader, and therefore, it takes more time for me to accomplish what it would many of you in much less time. I am, however, very audiovisual in nature. If I hear or see something, I will almost never forget it.

LATEST SPLURGE— DR. EASTERLING SPORTS JANIE’S

SURPRISE BIRTHDAY PRESENT

PRIOR TO GIVING HER THE RED

MERCEDES CONVERTIBLE.

Do you like to go out or stay in? I love to go out for dinner, both formal and casual, on the weekends with Janie. We usually go out with friends but occasionally just she and I will go out.

Perfect meal: from Shapley’s, my favorite restaurant…tamales, large ribeye medium rare with asparagus on the side, tossed green salad with blue cheese dressing.

Perfect day: Sleep late (until 7:00 a.m.), get up, fix a pot of coffee, eat a bowl of cereal while drinking the coffee, and watching the “Today” show. By that time, Janie gets up, and we spend the day working around the house and then go out at night. The best day would be to get up and go visit our children.

Text, email or cell phone: I do not carry my cell phone with me all the time. I would rather people page me if they want to talk to me. However, my friends do not know my pager number, so e-mail is good or call my cell phone, and if it is in close proximity, I will call back. Pets: I have a number of horses that I enjoy feeding and playing with. Favorite color: Blue.

Cologne: Tommy Bahama.

MSMA Member since: 1987.

JOURNAL MSMA, June 2009 — Vol. 50, No. 6

TAILGATING IN THE GROVE— (L. TO R.) TREVOR HAROLD AND HIS FATHER, DR. GAYLE HAROLD, DR. ARCHIE HOWARD, MARK SMITH AND DR. EASTERLING.

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JOURNAL MSMA, June 2009 — Vol. 50, No. 6


General Motors

Has Just Recognized Barksdale Cadillac as Mississippi’s Premier Cadillac Dealership. GM’s message is clear. Barksdale Cadillac is here to Stay. What that means to you, the consumer, is simply no matter where you bought your last new or pre-owned Cadillac,

Your Warranty and Service is Assured at Barksdale Cadillac. In fact, we offer the most lending options, including leasing. You see, our investment in you, our valued customer, began over a decade ago, and continues to serve the automotive needs of Mississippi as well as Louisiana from our newly redesigned and renovated dealership, conveniently located at I-55 and County Line, on the North Frontage Road in Ridgeland, directly beneath our American flag, which we fly proudly. There you will find the largest selection of new and Certified Pre-Owned Cadillacs in the state. And for even more convenience, we ask you to shop us online at www.barksdalecadillac.com. Go ahead, click on board and you can schedule service, pick out a vehicle, or even arrange financing. It’s quick and it’s easy to do. We’ll even deliver the vehicle of your choice to your home or office.

Come in Today and Test Drive the Barksdale

If you choose a traditional delivery of your new Cadillac, Certified Pre-Owned Cadillac, or one of our pristine pre-owned, low mileage trade-ins, just give us a call to let us know of your arrival at 601-519-0408. One of our GM factory trained sales or service professionals who knows your Cadillac inside and out will be happy to assist you. Or, if you are in the area, simply drop in. Our sales hours are 8:30 am to 7:00 pm. Monday through Friday and 9:00 am to 6:00 pm on Saturday. Service hours are 7:00 am to 6:00 pm. Monday through Friday and 8:00 am to 1:00 pm on Saturday. For our service customers, we also have a fleet of loaner Cadillacs ready for daytime or overnight use.

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www.barksdalecadillac.com


PRESIDENT’S PAGE

CHANGE IS CONSTANT

J. Patrick Barrett, MD 2008-09 MSMA President

I

t seems like just yesterday that I started my watch as your President. My father always told me that time goes faster and faster as we get older. I enjoyed every minute and thank all of you for being so kind. I want to thank our dedicated staff at MSMA. We’re in good hands for the foreseeable future. They are always knowledgeable and helpful. I congratulate Dr. Easterling on starting his leg of the long relay race. There is always more work to do.

We appear to be poised for major changes in medical care finance. I only hope that physician input is part of the coming decision-making process. This could affect healthcare for the next 100 years. I have often wondered what physicians from the past would think of today’s medicine. What major changes did they live through in their time? Dr. William Kirk of Winston County, Mississippi, was my great, great, great-grandfather. He was born in 1802 in Mt. Vernon, Virginia. After his medical education in New York, he moved to Alabama and then on to Mississippi in 1841. Before his death in 1885, he had lived through the massive social changes and upheavals of the Civil War and had continued to practice medicine for 20 more years. He had five sons and four daughters. Four of his five sons became doctors. Dr. Clement Thomas Kirk, my great, great-grandfather, was the second son of Dr. William Kirk. He grew up in Winston County, attended medical school in Cincinnati, Ohio, and returned to Mississippi to practice. After serving in the Confederate Medical Corps, he returned home to Mississippi to continue his practice. In 1882, he, along with several other physicians in the area, chartered and founded the Medical College of Meridian. This served as Mississippi’s only medical school until shortly after the Flexner Report in 1910 revamped all medical education. My father, Roger McNeese Barrett, was born three weeks before Dr. Clement Thomas Kirk died on the 27th of July 1917. My father was a teenager through the Great Depression and then lived through World War II. It seems as though each generation has its own social upheavals to live through. Looking back on past generations and their challenges, our present “changes” can be put into perspective. We may not have the life-transforming events of our great, great, great-grandfathers (the Civil War) or our grandfathers (the Great Depression), but we still need to meet our challenges head on. 200

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The transformation of medical care in America will affect our descendants. It is worth the effort to try to see it done right. As I prepare to take a seat on the sideline after my presidency, I encourage all of you as physicians, members of MSMA, and members of our AMA to step up to the challenge. Fight the good fight! If your grandchild or great-grandchild should become a physician, I hope he or she will look back proudly on our efforts to protect our noble profession. Thank you for the honor and privilege of serving as your President this past year. J. Patrick Barrett, MD Immediate Past President MSMA

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MSDH Mississippi Reportable Disease Statistics

April 2009

* Totals include reports from Department of Corrections and those not reported from a specific district NA - Not available (temporarily)

For the most current MMR figures, visit the Mississippi State Department of Health web site: www.HealthyMS.com

JOURNAL MSMA, June 2009 â&#x20AC;&#x201D; Vol. 50, No. 6

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EDITORIAL Journal of the Mississippi State Medical Association Volume 50, Number 6 June 2009

THE ADVENTURES OF A NOVEL INFLUENZA A VIRUS AMONG MEDICAL VIRGINS AT A TIME NEAR THE END OF THE WORLD

A

t press time, seven cases of Novel H1N1 (swine) influenza have been confirmed in Mississippi, four in Harrison County, two in Lamar County, and one in Jackson County. All seven, from different households, recovered, experiencing relatively mild cases. Although health leaders had always expected state cases of this new type of swine flu to occur, Mississippi had remained one of only four states yet to report a confirmed case by mid May. Said State Health Officer Dr. Ed Thompson at a May 15 press conference, “Swine flu is now here in Mississippi.” He added, “We will likely continue to see more and more cases in Mississippi. At this point almost all states have seen at least one case of H1N1 swine flu. It’s not uncommon at all.” Thompson has made quite clear for Mississippians that the sky is not falling and that this virus is not currently a potent killer. Rather, while not necessarily a “mild” flu, it appears epidemiologically and clinically similar to a typical flu. Thompson stated that “Most people infected with H1N1 swine flu should recover on their own.” While this new flu doesn’t appear to be causing more severe illness than the seasonal variety, the latter is without a doubt a killer. Occurring in our country from late fall through early spring, seasonal flu has an annual average of 36,000 deaths (1990-1999) and 226,000 hospitalizations (1979-2001). [CDC’s “Morbidity and Mortality Weekly Report,” 2008; 57] What physicians appear to be looking at presently is an extra typical seasonal flu epidemic without a vaccine. This should underscore, not discount, the need for vigilance, for all are medical virgins to novel flu, with no residual immunity from prior exposure or immunization. The final chapter of this novel outbreak is still unknown, and this new swine flu poses a significant and ongoing public health threat. The story began in March, when cases of a novel influenza of swine origin were identified in Mexico. The extent of the disease there was difficult to ascertain. The press reported overblown rumors of thousands of cases, with hundreds of deaths. Most cases were unevaluated and not laboratory confirmed. Access to medical care is limited in Mexico, and disease surveillance is very different than such work here. Despite its Mexican origins, the flu in the United States was not primarily a disease of Hispanics, but it was associated with travel. The first cases in the United States were in California and Texas, but it soon spread across the country. The pork industry apparently doesn’t like the medical community calling this “swine” flu, even though that’s what it is genetically, out of fear that the public will wrongly conclude that the flu can be contracted from eating pork products. Thus, to appease them, most are using the term “novel H1N1.” The CDC states that as of mid May more than 4,700 confirmed and probable cases have been reported in 47 U. S. states plus the District of Columbia, with 173 hospitalizations and at least six people having died of the disease. Closer to Mississippi, Louisiana health officials by mid May had confirmed 57 cases within its borders. Said Dr. Daniel Jernigan of the CDC: “The H1N1 virus is not going away.” He added that the virus “appears to be expanding throughout the United States.” The word “pandemic” began to be utilized, as this flu spread across the world to dozens of countries in Europe, Latin America, South America, and Asia. 204

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Our state response, which began towards the end of April and was led by Thompson and his chief medical deputy, Dr. Mary Currier, has been exemplary, with no grandstanding or panic. Thompson is in top form on a routine day, but he also performs exceedingly well in crisis, organizing the department into a focused and effective team. A similar response was seen when the Department responded to the ravages of Hurricane Gustav last year. Watching him lead the public health troops in a crisis is like watching a maestro conduct a symphony: it borders on art. In late April, after swine flu broke out in the United States, Thompson placed the department on emergency status which included daily meetings led by him with staff around the state, setting missions and goals, and reviewing problems at the local level. I participated in several of these meetings, and was thoroughly impressed with the department’s readiness. Both Thompson and Currier have been praised in the state press for the Department’s “calm, measured, and appropriate” response. (Clarion-Ledger, May 4, 2009) Governor Haley Barbour added after the first state cases were announced: “This is no time to panic; instead it is a time to be cautious and mindful of good health practices with which you and your families are already familiar. The state Department of Health is on top of the situation in Mississippi and will continue to monitor and issue guidance as necessary.” Much of the early work of the Department leadership was focused on enhanced surveillance. By early May, the Department had become inundated with respiratory specimens submitted from local hospitals and clinics for influenza testing (at press time, 636 total), and Thompson joked that his department had become the “Mississippi State Department of Swine Flu.” While none of those early specimens tested positive for swine flu, many more than were expected tested positive for seasonal flu. We docs usually aren’t looking for seasonal flu in late April and early May, at a time considered largely beyond regular flu season. This trend was present throughout the country, and the CDC indicates that the high number of seasonal flu discovered is not just due to the increased testing and reporting. There really was more seasonal flu out there much later than anyone imagined. No one felt the state could avoid cases, but the goal was to blunt the epidemic curve. The message to the public stressed good health hygiene to prevent influenza, such old public health measures as washing hands frequently, cough etiquette, and staying home if sick so as not to infect others. Also, state physicians, who were being flooded with patient requests for antivirals, were encouraged not to prescribe them unnecessarily or inappropriately. The Department, through its own and the CDC strategic stockpiles, has access to almost 600,000 courses of Tamiflu or Relenza for local use. Considering our state’s population, this is more than an adequate supply if prescribed appropriately. As cases emerge in Mississippi, the Department is also encouraging schools not to close without conferring with them. The timely arrival of summer break for schools appears to be a medical blessing. Daily online updates and weekly press updates will continue. The Department of Health website, www.HealthyMS.com, is being kept current and up to date with flu information. The Department also activated a swine flu hotline number for the general public to utilize, which has since been shut down after interest waned. The Department continues to alert state physicians of the latest medical information through its Health Alert Network (HAN). If you are a licensed physician and wish to enroll in this network, email hanhelp@msdh.state.ms.us with your name, email address and phone number. The medical community may not be able to contain the virus, but we can reduce its impact so it won’t overload the health system. While the first wave of this virus has been mild, physicians must remain vigilant. In his fine book The Great Influenza: The Story of the Deadliest Pandemic in History, New Orleans resident John Barry warns: “Influenza has to be seen as a lethal threat. A pandemic would prove more deadly than even a major bioterrorism attack, and it is more likely to occur.” This editorial’s apocalyptic title is inspired by the late physician writer Walker Percy, known for his cautionary satires, such as Love in the Ruins and The Thanatos Syndrome (my apologies to Dr. Percy). This novel influenza gives us a glimpse of the future, portending a potentially apocalyptic renewal of the age-old mortal conflict nature has waged against man. We don’t know how far or how wide this novel virus will spread, and how long it will spread. Will it fizzle, fade, and wear itself out, or mutate and mingle with another virus, coming back stronger than before? No vaccine will be available until after the first wave, much later this year at best, and this virus may come in multiple waves. As history teaches, in a world of medical virgins and novel influenza, the worst may be yet to come. — Lucius M. “Luke” Lampton, MD Editor

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IQH HOW TO GET STIMULATED!

In the recently passed American Recovery and Reinvestment Act of 2009 (ARRA), approximately $19 billon was set aside in the Health Information Technology for Economic and Clinical Health (HITECH) Act of the bill for stimulating health information technology. This legislation has also been titled, “the Stimulus Bill.” So how do we as physicians become stimulated? I am reminded of such similar “massive” legislation passed in 1965. Anyone else remember? It was the Medicare legislation which created tremendous change in health care delivery. Yet I also remember that few physicians were prepared to react to this legislation in its initial stages. With that experience, let’s be better prepared in our reactions to the current legislation. I am a believer in health care reform, especially in the use and exchange of health care information as an initial step. Former Secretary Mark Levitt has stated recently, “The Stimulus Bill has the potential to be the greatest influence on the adoption of electronic health records we’ve ever seen. I think this is really a turning point for health information technology.” So what do we do to prepare to take full advantage of this economic jolt to increase adoption and exchange of health information? We must recognize the challenge of health information technology (HIT) adoption, particularly among our small-office physician practices. In a survey by the CDC (2006), practices of five or fewer doctors handled 76% of the ambulatory office visits in that year. Yet these smaller practices have not adopted HIT to any significant degree. Only two percent of the one-to-three doctor practices had a fully functional electronic health records (EHR) system as reported in a national survey last July in the New England Journal of Medicine. It is this adoption possibility, readying small practices for EHRs and exchanging information, that holds the biggest dividends for the stimulus funding. It will be interesting to see if internet technology (IT) vendors adapt their sales approach to these practices by offering EHRs that are low cost, easy to use, standardized and interoperable, and offer adequate training for users.

WHAT ARE SOME FACTORS THAT WILL INFLUENCE SMALL-PRACTICE BUYERS?

1. Costs—one of the biggest drivers for adoption of HIT. Our EHR implementation experts at Information & Quality Healthcare (IQH) state that for a two-to-three physician-sized office, the usual cost for a fully functional EHR system to meet the requirements of the Medicare incentives offered through this stimulus legislation will total approximately $20,000 for software and $15,000 for hardware for initial startup. This estimate depends upon which system is purchased. Physicians should go beyond simply implementing a system to create only a digital version of their paper records. Also, many physicians have found value in using systems that integrate with their practice management system. This will add a feature that may well increase their return on investment by having clinical documentation to support their coding for reimbursement.

2. Vendor’s Capabilities—the question should be asked, “Is this vendor going to exist to provide support and upgrades as needs and requirements change?” A report from a large HIT consulting company stated that from its list of over 300 vendors about 20% of them no longer are seeking new customers. Practices should also determine the number of users the vendor has or whether there is backing by a larger company. Most vendors should have a minimum of 12 clients up and running on their products.

3. Fit with the Workflow—a system should be well suited to the type of practice and its specialty. Applications should be easy on the eye and be easy to use within the workflow of the practice. This is why an 206

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actual “workflow analysis” by an experienced consultant, as we offer through IQH, is extremely worthwhile. 4. Certification—the legislation specially states that the federal dollars will only apply to “certified” systems. Until further definitions are forthcoming, a practice should consider only those vendors’ products that have been certified in the past three years by the Certification Commission for Healthcare Information Technology (CCHIT), the federally recognized body for certifying EHRs.

5. Interoperability—the ability for a practice’s EHR system to exchange information with other systems within health care is the only way to maximize the use of HIT to improve quality, efficiency, effectiveness, and to lower costs. Complete and current information on each patient at the point of care is possible with current technology. It’s not the technology but the adoption of this concept that is an important feature and requirement in the HITECH legislation.

6. Training—most consultants feel that practices should require humans to go to physician offices and train all who are using the system. This helps to prevent a complicated start with the EHR system that could lead to lack of use of full system capabilities or to actual abandonment of the system due to frustration.

7. Reporting—one aspect of the “meaningful use of an EHR” that will be a requirement for participating in incentive programs will be the reporting of quality data for physician practices as well as having the ability to use this information for patient management. EHRs that have reporting capabilities and disease management tools will be essential.

If you seek additional information from IQH Technology Solutions, please contact Trannie Murphy at 601957-1575, ext 222 or tmurphy@msqio.sdps.org. —James McIlwain, MD IQH President

Good News About Bad Accounts Low Cost Collection Service Now Available To MSMA Members

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PERSONALS

Aseme

Carr

Kate N. Aseme, MD, an emergency responder of Forrest General Hospital in Hattiesburg, recently completed Homeland Security training at the Center for Domestic Preparedness (CDP) in Anniston, Ala. The CDP is operated by the United States Department of Homeland Security’s Federal Emergency Management Agency and is the only federally-chartered weapons of mass destruction (WMD) training facility in the nation. During the training session, Dr. Aseme was called upon to give a talk on Forrest General’s disaster-preparedness, including response to Hurricane Katrina. Dr. Aseme serves as director of Forrest General’s Trauma Services Department. Training at the CDP ensures that responders gain critical skills and confidence to be better prepared to effectively respond to local incidents or potential WMD incidents. The CDP provides federally-funded, interdisciplinary training for emergency responders from across the United States and U.S. Territories, for ten responder disciplines. Healthcare and Public Health training is conducted at the CDP’s Noble Training Facility, the nation’s only hospital facility dedicated to training hospital and healthcare professionals in disaster preparedness and response. Many training courses culminate at the CDP’s Chemical, Ordnance, Biological and Radiological Training Facility, the nation’s only facility featuring civilian training exercises in a true toxic environment, using chemical agents. The advanced hands-on training enables responders to effectively prevent, respond to and recover from real-world incidents involving acts of terrorism and other hazardous materials. Additional information about CDP training programs can be found at http://cdp.dhs.gov.

Gary Carr, MD, FAAFP of Hattiesburg has been elected to serve as President of the Federation of State Physician Health Programs from April 2009 – April 2011. The Federation of State Physician Health Programs (FSPHP) is the national membership organization for the nation’s state physician health programs with 46 member states. Currently serving as vice speaker of the MSMA House of Delegates, Dr. Carr has served as Medical Director of the Mississippi Professionals Health Program (MPHP) since

208

Farrell

Leader

July 1999. Under Dr. Carr’s direction, the MPHP has become nationally recognized as a model Physician Health Program. The MPHP assists physicians and other health care professionals with potentially impairing conditions such as alcohol and other drug dependencies, psychiatric illness, and other conditions which could result in professional impairment. MPHP’s success rate with its program participants exceeds 90%. MPHP and other state programs seek to help professionals with potentially impairing illness thus promoting public safety through early intervention, treatment, and monitoring of these illnesses. The FSPHP also has active associate members from most of the Canadian Provinces and other foreign countries. FSPHP serves as a membership organization for the exchange of information and evidence-based “best practices” between its member states. FSPHP has developed guidelines for the effective monitoring of potentially impaired physicians diagnosed with substance use disorders or psychiatric illnesses and is developing guidelines regarding maintenance of appropriate professional boundaries and physical impairments. Dr. Carr is from Tishomingo. He completed his undergraduate studies at Ole Miss and received his MD at the University of Mississippi School of Medicine. He is a Fellow of the American Academy of Family Physicians. Dr. Carr has added certification in addiction medicine and is a Diplomate of the American Board of Addiction Medicine. Dr. Carr is president of Oak Grove Family Clinic, PA. He is married to Debra Rosita Lee Carr, JD, LPC of Petal. The couple resides in Hattiesburg with their two daughters, Lacey and April. Jeffrey Clark, MD of Brookhaven Urology recently attended a surgical symposium in Atlanta, Georgia. While attending the symposium, he performed minimally invasive surgical procedures for symptomatic pelvic prolapse in women. The course was designed to highlight the latest surgical techniques that are minimally invasive for a very common problem experienced by a large group of women. The technique is specifically designed to target what is known as vault prolapse. This condition commonly occurs with a cystocele, a rectocele, and stress urinary

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incontinence. Dr. Clark received his Bachelor of Science degree in Biology from Birmingham Southern College in 1985 and his Doctor of Medicine degree from the University of Alabama School of Medicine in 1991. He completed his residency in Urology at the University of Mississippi School of Medicine in 1996 with a 2-year general surgery residency and a 3-year urology residency.

Richard Conn, MD of Southern Bone and Joint Specialists, P.A. in Hattiesburg has been invited to be a member of the Society for Arthritic Joint Surgery. The society is comprised of orthopaedic surgeons with special interest in total joint arthroplasty. The membership is diverse, not only geographically but in practice settings as well. The 60-member group remains small to insure its tradition and founding principles that include sharing of experiences and knowledge, camaraderie and social activities. Membership is by invitation only. Dr. Conn and Guy Vise, MD of Jackson are the only members from Mississippi. Dr. Conn, a board-certified, fellowship-trained arthritic joint replacement surgeon, will be expected to attend annual meetings and present scientific papers. Dr. Conn began his medical career at the University of Mississippi Medical Center where he received his Doctor of Medicine degree. He completed his internship/residency in orthopaedic surgery in Greenville, SC. He completed a fellowship at the Mayo Clinic in arthritic joint replacement surgery. Dr. Conn belongs to several medical organizations including the American Academy of Orthopaedic Surgery, Southern Orthopaedic Association, Southern Medical Association, American Medical Association and Mississippi Orthopaedic Society. Southern Bone and Joint Specialists, P.A. is a regional orthopaedic group with 15 physicians with offices in Hattiesburg, Columbia and Poplarville.

Richard deShazo, MD, professor of medicine and pediatrics and an allergist-immunologist at the University of Mississippi Medical Center, recently co-authored a clinical review published in The Journal of the American Medical Association: JAMA. 2009;301(13):1358-1366. The scientific article titled “Bed Bugs and Clinical Consequences of Their Bites” is co-authored by Jerome Goddard, PhD, a professor of entomology at Mississippi State University. The manuscript represents data published in 53 articles on the subject which met inclusion criteria. The review reports, “Although transmission of more than 40 human diseases has been attributed to bed bugs, there is little evidence that they are vectors of communicable disease. A variety of clinical reactions to bed bugs have been reported, including cutaneous and rarely systemic reactions. A wide range of empirical treatments, including antibiotics, antihistamines, topical and oral corticosteroids, and epinephrine, have been used for bite reactions with varying results.” The article generated a related health story in the April 13 edition of the New York Times, “Keeping Those Bed Bugs from Biting,” by Jane Brody that

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mentioned Dr. deShazo. Additionally, Dr. deShazo was interviewed and appeared on the Today Show on April 15.

Steven Farrell, MD, chief medical officer and director of the Hospital Care Service at Hattiesburg Clinic and Forrest General Hospital, has earned the Fellow in Hospital Medicine (FHM) designation from the Society of Hospital Medicine (SHM). Farrell will join approximately 500 hospitalists in the induction of the inaugural class of fellows this May at Hospital Medicine 2009 in Chicago. Becoming a fellow is an avenue for special recognition for Society members who have distinguished themselves among their colleagues and the hospital medicine specialty. “Until now, hospitalists have not had a way to distinguish themselves from their colleagues,” said SHM’s CEO Larry Wellikson, MD. “The FHM designation gives hospitalists a chance to set themselves apart and be recognized for all of their work that continues to make hospital medicine the fastest growing medical specialty in history.” To be designated as a fellow in Hospital Medicine, an applicant must be a hospitalist for five years, a member of SHM for three years, demonstrate their dedication to quality and process improvement, commitment to organizational teamwork and leadership, as well as lifelong learning and education.

Y. Susi Folse, MD of Southern Bone and Joint Specialists, P.A. received a recertification by the American Board of Physical Medicine and Rehabilitation. Dr. Folse currently teaches a medical aspects class for the athletic training program at the University of Southern Mississippi in Hattiesburg. She serves as the co-director of the USM student athletic training program. Dr. Folse received her athletic training degree from USM. She later received her medical degree from the Louisiana State University Medical Center in 1996 and also served her internship and residency in physical medicine and rehabilitation there. While at LSU, she served as associate chief resident and director of the residency sports medicine program. In addition to being a member of MSMA, Dr. Folse is a member of the American Medical Association, Southern Medical Association and Southern Physical Medicine and Rehabilitation Society. Lawrence J. Leader, DO, FACC is is now offering cardiology services through Stone County Hospital and Stone County Family Medical Clinic in Wiggins. Dr. Leader obtained his medical education from Nova Southeastern University in Miami Beach, Fla., and his internship in osteopathic medicine at Wellington Regional Medical Center in Wellington, Fla. Dr. Leader completed his residency in internal medicine at Yale University and a fellowship in cardiovascular disease at Rutgers School of Medicine and Deborah Heart & Lung Center in Browns Mills, NY. He is board certified by the American Osteopathic Board of Internal Medicine.

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Prewitt

Sandifer

Szatmary

Thomas W. Prewitt, Jr., MD has joined University of Mississippi Medical Center in Jackson as an assistant professor of surgery. He will see general surgery patients through University Physicians, part of University of Mississippi Health Care. Dr. Prewitt earned the M.D. at UMMC. He also completed an internship and residency training in general surgery at the Medical Center, where he was chief resident from 1994-95. He was a medical staff fellow in the surgery branch of the National Cancer Institute from 1990-93. He was affiliated with three North Carolina hospitals from 1995-2007: Caldwell Memorial Hospital in Lenoir, Blowing Rock Hospital and Watauga Medical Center in Boone. Before joining UMMC, he worked with Stillwater Surgical Associates in Oklahoma. He is a member of the American Society of Breast Surgeons and American College of Sports Medicine.

Randy Russell, MD†, an ophthalmologist of Oxford, ran for the 1st Congressional seat last year when Roger Wicker was appointed to the Senate to fill Trent Lott's former seat. Russell had very little time to make the decision to run, but after discussions with physician leadership, he entered the Republican primary race against two other opponents. He campaigned vigorously all over the district and received almost 25% of the primary vote. Because of the two month time frame associated with the special circumstances of this particular election, very little time was available to hold organized fundraisers. This resulted in a sizable campaign debt that is still owed. Any person wishing to help with this debt can still contribute by personal check (business checks are not allowed for federal elections) to the following address: Russell for Congress, 40 CR 233, Oxford, MS 38655. † Dr. Russell died May 15, 2009. Fred M. Sandifer, MD has joined the medical staff of Crossgates River Oaks Hospital in Brandon. Dr. Sandifer received a medical degree from Tulane University School of Medicine in New Orleans and interned at Charity Hospital of New Orleans. He completed an orthopaedic surgery residency at the Campbell Clinic in Memphis, TN. For almost 30 years, he worked in private practice in Greenwood and most recently in Clarksdale. Prior to this he worked as an orthopaedic surgeon in the United States Air Force serving at Travis Air Force Base in California. In addition to being board certified by the American Board of Orthopaedic Surgery, Dr. Sandifer is a member of the

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American Academy of Orthopaedic Surgeons. He will join Rankin Orthopaedic Specialists alongside Dr. William Lawrence.

Michael Stonnington, MD of Hattiesburg has been named president-elect for Forrest General Hospital’s medical staff. He will assume these responsibilities in January 2010. This position involves serving as a liaison between physicians and hospital administration and is a very important role in the hospital’s delivery of patient care. Dr. Stonnington is a board certified orthopaedic surgeon. He is one of the founding directors of Forrest General’s Orthopaedic Trauma Services and has been on staff at the hospital for more than eight years. He specializes in traumatology, total joint replacement and sports medicine. Dr. Stonnington received his medical training at Duke University and the University of Virginia, and is a member of the American Academy of Orthopaedic Surgeons and the Mississippi Orthopaedic Society, among other professional organizations.

Gabriella Szatmary, MD, PhD, neuro-ophthalmologist with Hattiesburg Clinic, recently completed requirements for certification by the United Council for Neurologic Subspecialties (UCNS) in the area of neuroimaging. Dr. Szatmary received her medical degree from the Semmelweis Medical School in Budapest, Hungary. She attended an ophthalmology residency at Peterfy Teaching Hospital in Budapest, Hungary, and a combined internal medicine and neurology residency at State University of New York in Buffalo, NY. Dr. Szatmary completed a fellowship in Neuro-Ophthalmology at Emory University School of Medicine in Atlanta, Ga. She also completed a neuro-radiology fellowship at Dent Neurologic Institute in Amherst, NY and Winchester, Va. She received her PhD from Semmelweis University in Budapest, Hungary on her work with emphasis on functional magnetic resonance imaging (MRI). Dr. Szatmary is a member of many professional organizations including the American Academy of Neurology, North American NeuroOphthalmology Society, American Society of Neuroimaging, the Hungarian Medical Association, Hungarian Ophthalmology Society and European NeuroOphthalmology Society. She is the founding member of the Hungarian Ophthalmology Society NeuroOphthalmology Section. She is certified by the American Board of Psychiatry and Neurology.

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Helen Turner, MD, associate vice chancellor for academic affairs at the University of Mississippi Medical Center in Jackson, received the fourth-annual Leadership Award from the Women in Higher Education - Mississippi Network. The statewide organization established the award to recognize a woman each year who demonstrates leadership and commitment to advancing women in higher education. Dr. Daniel Jones, associate vice chancellor for health affairs at the Medical Center, nominated Dr. Turner for the award. Dr. Turner holds dual degrees from the Medical Center: a Ph.D in microbiology and an M.D. Dr. Turner graduated from the School of Medicine in 1979 and joined the Medical Center faculty in 1984. As a faculty member, Turner has received recognition for teaching excellence, being named Alpha Omega Alpha teacher of the year for two years. In 2003 she became the first associate vice chancellor for academic affairs at the Medical Center. Turner has advocated for women on the faculty and staff, as well as encouraged female students, ever since joining the Medical Center faculty. Early in her career, she organized a group for female faculty to discuss issues women may face in a school of medicine. Dr. Turner has been recognized for clinical excellence and was named to “Best Doctors in the Southeast Region” and “Best Doctors in America” for several years. She was recognized by Who’s Who of American Women and received the Alumnae Achievement Award in 2003 from the Mississippi University for Women. She is also a fellow in the American College of Physicians. She serves as representative to the American Medical Association Section on Medical Schools and delegate to the AMA House of Delegates. During her career, she has been the first woman to serve as associate chief of staff for education and chief of medicine at the VAMC, associate dean for academic affairs at UMC and the second woman to be elected president of MSMA.

Lee Voulters, MD was a recent guest of talk show host Paul Gallo on Supertalk Mississippi radio. A Gulfport neurologist, Dr. Voulters discussed his experience with the British and Canadian healthcare systems and compared nationalized healthcare to the US healthcare system. Dr. Voulters is on staff at Gulfport Memorial Hospital Neurosciences and Rehabilitation Center. He came to the US in 1998 following medical school in his native London, England and a neurology residency in Ontario, Canada. He also holds an MBA from George Mason University and completed pharmacy school. Dr. Voulters is board certified in psychiatry and neurology and certified in neurorehabilitation.

Kenneth Barraza, MD; Mary Anne Kosek, MD; John Henry Nading, MD and Harold Webb, MD recently received the AMA Physician’s Recognition Award (PRA). The PRA award recognizes physicians who earn at least an average of 50 credits per year from educational activities

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that meet the AMA standards.

The Forrest General Healthcare Foundation recently announced 10 MSMA-member physicians who have been chosen as inductees for the first annual Doctor’s Hall of Fame. This hall of fame is organized by the hospital’s foundation to honor those physicians who have contributed to the improvement of healthcare in Hattiesburg, and to the growth and excellence of Forrest General Hospital. Any physician serving Forrest General who meets the specified criteria, whether they are still practicing, retired or deceased, may be nominated for this award. Out of the 30 outstanding nominees submitted for this year’s induction, the following physicians will be honored for the Doctor’s Hall of Fame 2009: • • • • • • • • • •

Ralph E. Abraham, MD Joe H. Campbell, MD Lewis E. Hatten, MD Charles J. Parkman, MD Thad F. Waites, MD Mary Clark, MD Richard H. Clark, Jr., MD Dawson B. Conerly, MD Philip W. Rogers, MD Ralph Wicker, MD

These ten outstanding physicians represent a wide range of specialties, and have offered, and continue to offer hope and healing to patients from all walks and all stages of life. A new slate of physicians will be inducted each year. Nominees must have 10 years of service on Forrest General’s medical staff, and be highly involved, not only at Forrest General, but in the community, medical societies and academia, and be considered a leader in their specialty. Inductees are chosen by a nomination sub-committee made up of members of Forrest General’s medical staff, administration and Foundation, as well as community members and retired physicians. A call for nominations will be released each spring. This year’s awards ceremony took place at a dinner on May 28 at the Lake Terrace Convention Center.

The Journal MSMA welcomes information and announcements readers would like included in an upcoming “Personals” section. Submit information on achievements and accolades by any MSMA member: such as awards, rankings, and grants, as well as special recognition earned to KEvers@MSMAonline.com. Photos submitted must be at least 300 dpi to be considered. For more information contact Karen Evers, JMSMA managing editor: (601)853-6733.

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AMA

Health Insurer Code of Conduct?

[As the AMA prepares its report back to the House of Delegates (HOD), our MSMA delegation will be following the HOD debate closely to determine how Res. 823–I-08 policy may be best implemented and monitored.] —ED.

L

ast fall, the American Medical Association’s (AMA) House of Delegates adopted a resolution brought by the Medical Society of the State of New York (MSSNY) calling for the AMA to develop a Health Insurer Code of Conduct setting forth clear and concise principles to address both medical care policies and payment issues and seek concurrence among health insurers in complying with this code of conduct as well as develop a mechanism to monitor compliance with it. Codes of conduct are hardly a new idea. Most are self-imposed by professional organizations or trade groups on their members, often in an effort to voluntarily level up their members’ general behavior, especially in the wake of legal or political scrutiny. For example, the pharmaceutical industry substantially revised its code governing interactions with health care professionals after public and professional criticism. Much of the managed care industry, in the wake of settlements governing physician profiling with New York State Attorney General Mario Cuomo Jr., signed onto the Patient Charter for Physician Performance Measurement, Reporting and Tiering Programs. In so doing, they joined the AMA, AARP, AFL-CIO, Leapfrog Group and several other national organizations in committing to minimum national standards for physician profiling by the industry. The unique aspect of this proposed code is that it is being developed by a work group of national medical specialty societies, state medical associations and the AMA, rather than from the managed care industry, and will ultimately convey a decidedly physician perspective. There could be many benefits from a Health Insurer Code of Conduct. Such a code could assist the AMA and its Federation partners as they:

• Challenge health plans to change their restrictive practices without the need for legislative or judicial intervention; • Provide valuable data and public support for the AMA’s efforts in state capitols to achieve legislative and regulatory reform that meaningfully addresses abusive health plan practices; and • Provide businesses and the general public with an excellent tool to compare the performance of health plans for the purposes of making enrollment decisions.

This AMA resolution has been well received by the press and patient advocacy groups. MSSNY has already made several thoughtful recommendations to the AMA on the construction of a Health Insurer Code of Conduct. It has urged that the code be consistent with and complementary to other AMA efforts, including AMA’s recently released National Health Insurer Report Card (NHIRC) that evaluates the health insurers’ claim processing practices. A simple, concise code of conduct that sets forth clear principles focusing not only on payment issues but also on medical care policies could enhance the value of the NHIRC. Specifically, MSSNY has suggested that the Code of Conduct include clear, general principles for the health insurance industry to follow when establishing policies and practices impacting the medical care received by their enrollees addressing each of the following four areas: Clinical Autonomy: Allowing physicians to make decisions based on patient needs without artificial barriers by doing such things as: 212

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• Easing burdens for UR/pre-authorization of diagnostic tests; • Developing formularies based on appropriate clinical evidence; and • Protecting patients from formulary changes.

Transparency: Disclosing information regarding health plan benefits and policies to help facilitate patient decisions about which plans to join, and informing providers, regulators and the public about systems that may corrupt medical care. Such disclosures might ensure: • Transparent ranking/tiering system based upon true assessments of quality; • Disclosure of incentives to health plan employees and contractors, and to providers of care; • Disclosure of reimbursement/code review and bundling policies; and • Disclosure of factors affecting requests to change prescriptions.

Corporate Integrity: Ensuring that business practices meet generally accepted standards and don’t negatively impact critical stakeholders, including requirements addressing:

• The avoidance of conflicts of interest; • Appropriate allocations of premium dollars for health care; and • Fair and timely reimbursement.

Patient safety and welfare: Ensuring patients are always put before profits.

As the AMA prepares its report back to the House of Delegates, the AMA will give careful consideration to all the issues raised by Res. 823–I-08, including:

• How the AMA should involve the health insurers? • How the AMA should involve consumers? • How the AMA should monitor adherence to the code? ❒

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UNA VOCE Caught The black limousine slowed and came to a stop a block away from the entrance of the only luxury resort in Uzbekistan. I looked out of the window at the road, and then across the back seat at my wife and daughter. I knew why I was here. I had to meet a man who had recovered a set of microfiche that detailed the assembly and disassembly of a W-79 Mod 1 warhead. As far as nuclear weapons went, it wasn’t much, about a half of a R. Scott Anderson, MD kiloton. But this one had neutron capabilities. The fiche had to be retrieved. There were no options. There was no question. I knew what I had to do. I’d done it before in Egypt. The only thing bothering me was why were my wife and daughter here? What could have possessed me to bring them on something like this? When I saw a man in a grey coat approach the vehicle I got out of the car on the street side. He motioned me to the trunk, raised it to provide cover, and handed me a briefcase. “Your papers, passports, money, and the package are all in this. What you need is sewed into the lining,” he said with no trace of an accent. “Anything else?” I asked “This,” he said, handing me a tiny weapon. “It’s fully automatic, a .17 caliber. It’s a prototype.” I looked at the weapon and turned it over; a Springfield Armory cartouche was stamped on its side. “Don’t use it unless you have to but don’t hesitate if you need to,” he instructed. “I’ll take you to your room.” He got into the front of the limo and we pulled to the door. When the doorman opened the back, I slid across the seat to follow my family. As I started to get out the contact offered his hand. “Let me help you,” he said, taking the briefcase and handing it to my wife. I got out of the car and put my arm around my daughter’s shoulders to shield her from the blast of cold wind. Walking into the lobby a baggage cart hit me and I stumbled. Through the hanging bags I saw the contact pushing my wife, the briefcase still in her hands into an elevator. I grabbed my daughter’s hand and started around the cart. I saw panic in my wife’s face as the elevator doors closed. I looked around quickly, this wasn’t a main elevator bank, there were no floors numbered above the doors. I had no idea where they were going. I started for the stairs to the Mezzanine, but stopped cold when I saw two government people checking passports. I looked across the lobby and spotted two more checking everyone as they entered the main elevators. How did I let this happen? I had no papers, no passports, no microfiche, and no wife. On top of all that, my daughter was right beside me. I couldn’t risk anything. I could only imagine how pleased the Uzbekistani police were going to be with a guy with no passport, no papers, and an automatic weapon with an identifiable U.S. manufacturer. I walked down a long hallway labeled “spa” in English, Japanese, and Cyrillic. As I passed a waste container, I dropped the weapon wrapped in my daughter’s scarf into it. Suddenly a large man in a plaid sport coat and cowboy boots was coming across the hallway with his hand extended and a big smile on his face. “Hey, doc,” he said from 50-feet away. No one there knew I was a doctor. I dropped a T-handle blade from its sheath on my wrist down into my right hand, and kept the blade up so that it was invisible. I thought, I’ll spin him and take out the left kidney as I go around. I can’t let him reach the kid. 214

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“Hey doc, remember me. It’s Brad Dorland from Laurel. You cured my prostate cancer six years ago. I’ll never forget that face. What in the hell are you doing here in Uzbekistan?” He continued. As I brought my hand around to shake his I dumped the knife into my coat pocket. “Hey Mr. Dorland, I guess you’re still in the oil business?” I said, remembering. “Yep, that’s why I’m here; I’ve got to renegotiate these leases every time these guys change governments. Hell, I know people in Mississippi that don’t change clothes as fast as these guys change leaders. But what’s a cancer doctor doing over here?” “I’m supposed to be giving a lecture on cervical cancer tomorrow, but I’ll be damned if I know if I’m going to make it.” I answered glumly. “What’s wrong doc?” He asked. “I forgot my passport up in my room, I’ve got my daughter here with me, and those government goons are checking everybody going up and down into the building. I don’t know what to do,” I explained, almost telling the truth. “I can get you up there, but we have to go through the sauna. You’re going to have to cover that young lady’s eyes though; those guys in there are naked as jaybirds….. BUZZZ ZZZZ ZZZZ BUZZZZ ZZZ ZZZ ZZZ BUZZZ ZZZZ ZZZZ BUZZZ ZZZ ZZZ

I smacked the alarm’s snooze-button and tried to go back to sleep to see how things turned out, but it was no use. Charlene had heard it. She and her pack of aggravating dogs descended on the bedroom. “Maddie has a field trip, so you’re going to have to pick up Allison at basketball practice….” I listened but I wasn’t hearing. I needed to figure out what had happened in Uzbekistan. Was Charlene okay? I think Allison was the daughter in the dream, but it was starting to fade and I wasn’t sure anymore. I was caught—caught in that area between dreams and reality where you know what’s real, but you can’t let go of what you know isn’t. It’s like dreaming you had a fight with your wife and waking up mad at her. You know it’s unreasonable, but you can’t help it. I lumbered down the steps in my robe and slippers to get my coffee. How stupid could I have been? I should have known it was a set-up when I saw the cartouche on the gun. Nobody on an op uses a marked gun, especially not a prototype. Why would they have even given me a prototype? You would have wanted a throw away. I finished my coffee and got into the shower. I never even saw the microfiche. How did I even know they were there? How would they have even gotten to Uzbekistan? I got dressed and got into my car. I think my wife was in on it. She wouldn’t have put her own child in danger, would she? I don’t think she was really panicked at all? Sure she has blonde hair and blue eyes, but she could have been recruited in Sweden, couldn’t she? Besides, what did I really know about her? We’d only been married 17 years. It was hard to concentrate on my first consult, but then, I focused. This person’s real life was in my hands, and they deserved my undivided, my full attention. By lunchtime the dream was gone. That isn’t always the case though. Two days later I was seeing a follow-up patient that I had treated for a brain tumor a year earlier. His scans were fine, no masses, no enhancement, and no hydrocephalus. “How are you doing?” I asked going in the door. “How’s the scan say I’m doing?” he countered. “If you’re as good as the scans say you are, you can get your butt right on out of here ‘cause I don’t have a bunch of time to waste on somebody that doesn’t have anything wrong with them,” I said smiling. “That’s great. I was sure you were going to find something,” he said, clearly relieved. “Why do you say that? Have you been having headaches?” I asked. “No, no nothing like that. It’s my arms.” “What’s wrong with your arms? Are they numb…weak?” I continued.

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PLACEMENT / CLASSIFIED

“Nah, they feel like I dipped them in fiberglass. They itch all the time.” He said rolling up his sleeves and extending his forearms. His arms were excoriated and red. The skin was dry. But, there was no clear rash. “You got dry skin; have you been putting anything PHYSICIANS NEEDED on them?” “Yeah, I have to. I forgot to put it on when I got out Physicians (specialists such as of the shower this morning, but I been putting that cardiologists, ophthalmologists, Cortaid on ‘em.” pediatricians, orthopedists, “When did this start. Was it after they gave you the neurologists, etc.) interested in contrast for the scans?” I thought I had the answer. performing consultative evaluations “I can tell you just when it started. It started when I had that dream,” he explained. (according to Social Security “What dream?” guidelines) should contact the “See, I dreamed my arms was all in this poison oak. Medical Relations Office. I was shucking these little beans out, and there was poison oak everywhere, it was all up against me. I woke Toll Free 1-800-962-2230 up just scratching my arms like crazy. Do you think it’s Jackson 601-853-5487 all in my head? I thought maybe it was the tumor making Leola Meyer (Ext. 5487) me think this way, but you said the scans were good.” “I think it started off in your head. You woke up scratching, your skin was dry, the scratching caused your body to release histamines and so you itched more. The more you scratched the more you itched. It’s kind of a vicious cycle. Let’s try some antihistamines and see if it goes away.” “Well, I guess that seems like a good idea,” he said, DISABILITY DETERMINATION SERVICES then his face clouded and he continued. “My arms itching 1-800-962-2230 is part of it, but that’s not what’s really worrying me. What’s bothering me is why my arms is itching. That’s what’s got me puzzled.” “Remember what I said about the histamine release…” “I know what you said. But, that’s not what’s funny about it. You know what the funny thing about all this is?” “No, what?” I asked. “I’m not even allergic to poison oak.” Both true stories, and that’s the power of dreams. —R. Scott Anderson, MD

[R. Scott Anderson, MD, a radiation oncologist, is medical director of the Anderson Regional Cancer Center in Meridian, and vice chair of the MSMA Board of Trustees. Additionally, he is an accomplished oil-painter and also dabbles in the motion-picture industry as a screen-writer and helped form P-32, an entertainment funding entity. “Una Voce” (With One Voice) is a column in the JMSMA designed by Dr. Dwalia S. South, MSMA past president and chair of the Committee on Publications. “Una Voce” features the selected prose of MSMA members. If you are a writer and would like to submit your work for consideration please send us your contribution or contact one of the editors.]—ED.

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Profile for Journal MSMA

June 2009 JMSMA  

The Journal MSMA is owned and published monthly by the Mississippi State Medical Association.

June 2009 JMSMA  

The Journal MSMA is owned and published monthly by the Mississippi State Medical Association.