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MAY 2010 VolUMe 51 nUMBer 5

Scientific ArticleS

Blunt renal trauma and the Predictors of failure of

non-operative Management 131Jon D. Simmons, MD; A. Neal Haraway, MD; Robert E. Schmieg, Jr., MD and

Juan D. Duchesne, MD

clinical Problem-Solving: i See Dead People 135Janet M. Nielsen, MD

PreSiDent’S PAge

Be Part of the Solution 140Randy Easterling, MD; MSMA President

eDitoriAl

“Draumatized” 143Michael O’Dell, MD; Associate Editor

relAteD orgAnizAtionS

Mississippi State Department of Health 139

information and Quality Healthcare 144

DePArtMentS

Poetry in Medicine 145

Physicians’ Bookshelf 146

images in Mississippi Medicine 148

the Uncommon thread 149

Una Voce 151

Placement/classified 152

ABoUt tHe coVer: “DUnleitH HiStoric inn” - Martin M. Pomphrey, Jr., MD, a semi-retired orthopaedic surgeon

sub-specializing in sports medicine who practiced with Oktibbeha County Hospital (OCH) Bone and

Joint Clinic, photographed this magnificent Greek Revival mansion located in the heart of Natchez.

Known for its stately white colonnade that surrounds the exterior of the Southern

home, Dunleith offers guests an escape from everyday life with luxurious

accommodations, first rate amenities, and award-winning cuisine. An indelible

icon, the white columns and rockers from Dunleith’s front porch call out, inviting

one to take a journey back to a simpler time and place– a time without hectic

schedules, deadlines and expectations. The Inn, located at 84 Homochitto Street,

sits on 40 acres and features 26 rooms. Members and invited guests attending the

142nd MSMA Annual Session House of Delegates & Medical Affairs Forum can

experience Dunleith at a welcome reception hosted by MSMA and the University of Mississippi Medical

Center Medical Alumni Chapter on the grounds of this magnificent site. r

2010May

VOL. LI No. 5

2010May

VOL. LI No. 5

Official Publication

of the MSMA Since 1959

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

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POSTMASTER: send address changesto Journal of the Mississippi State MedicalAssociation, P.O. Box 2548, Ridgeland, MS 39158-2548.

The views expressed in this publication reflectthe opinions of the authors and do not necessarilystate the opinions or policies of the Mississippi StateMedical Association.

Copyright© 2010, Mississippi State Medical Association.

Lucius M. Lampton, MDEditor

D. Stanley Hartness, MDMichael O’Dell, MDAssociAtE Editors

Karen A. EversMAnAging Editor

PublicAtions coMMittEE

Dwalia S. South, MDChair

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

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

and the Editors

thE AssociAtion

Randy Easterling, MDPresident

Tim J. Alford, MDPresident-Elect

J. Clay Hays, Jr., MDSecretary-Treasurer

Lee Giffin, MDSpeaker

Geri Lee Weiland, MDVice Speaker

Charmain KanoskyExecutive Director

may 2010 JOURNaL mSma 129

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130 JOURNaL mSma may 2010

Objectives: While non-operative management of renal trauma

in selected patients is now an accepted management option, predictors

of failure of this treatment strategy are still unclear. Methods: Five-

year retrospective study of all patients with blunt renal injuries man-

aged non-operatively at a Level I Trauma Center. Abstracted data

included patient demographics, initial vital signs, base deficit, associ-

ated injuries, use of blood transfusion, management, and outcomes. Pa-

tients with successful non-operative management (S-NOM) and failure

of non-operative management (F-NOM) were compared with two-

tailed Student’s t test, Fisher’s exact test, or chi-square analysis as ap-

propriate. Results: Over five years, 271 patients out of 12,252 trauma

cases (2.2%) had blunt renal injury; 239 (88%) were initially managed

non-operatively, and ten (4.1%) of these patients later requiring oper-

ation or intervention. No differences in age, sex, initial vitals, or GCS

were found between S-NOM and F-NOM. The F-NOM patients were

more seriously injured than the S-NOM patients (ISS 31 vs. 21,

p<0.001); had worse acidosis (ABG base deficit of -9.1 vs. -4.5,

p<0.001); required more blood products (12 units PRBC vs. 2.6 units

PRBC, p<0.001); and had significantly longer hospital lengths of stay

(37 days vs. 12 days, p<0.001). Angiography was used more frequently

in the F-NOM patients (40% vs 8.7%, p<0.02). In the F-NOM only 3

(30%) required direct kidney intervention: 1 nephrectomy, 1 open uri-

noma drainage and 1 open nephrostomy tube placement. All of these

patients had grade V renal injuries. The rest of the F-NOM patients had

operative interventions not directly related to their renal injuries: 1

splenectomy and 6 missed bowel injuries. Conclusion: Non-operative

management of blunt renal injuries is successful in most cases. Pa-

tients with a high base deficit, ongoing transfusion requirements, and

greater Injury Severity Scores have a higher likelihood of requiring op-

eration, but these procedures most often are to address non-renal ab-

dominal injuries. High-grade blunt renal injuries that are

hemodynamically stable can be treated expectantly on an individual

basis with close follow-up. Any patient with hemodynamic instability,

renal pedicle injury, renal artery thrombosis, or urinary extravasation

will likely require operative intervention.

KeY WorDS: KIdNey LACeRATION; BLuNT ReNAL TRAuMA;

NONOPeRATIVe MANAGeMeNT

introDUction

While non-operative management in selected patients with renal

trauma is now an accepted management option, predictors of failure of

this treatment strategy are still unclear. The objectives of non-opera-

tive management include decreasing the nephrectomy rate while also

decreasing mortality and morbidity. The current consensus is to man-

age all low grade (I-III) renal injuries non-operatively. Management of

high grade (IV-V) injuries is still on an individual basis. emergent op-

erative intervention has generally been reserved for renal associated

hemodynamic instability or ureteral injury. We report a five-year ex-

perience in non-operative management of blunt renal trauma at a rural

level 1 trauma center.

MAteriAlS AnD MetHoDS

All patients 18 years of age or older presenting to the university

of Mississippi Medical Center, an academic Level 1 Trauma Center,

with blunt renal injuries during a five-year period from January of 2000

through december of 2005 were identified through the trauma registry.

Patients who underwent initial operative management or who died in

less than 24 hours were excluded. data abstracted from chart review

and the institutional trauma registry for the patients undergoing initial

non-operative management included demographic information, pre-

senting vital signs, base deficit, Glasgow coma scale, blood transfu-

sions received throughout the entire hospitalization, associated injuries,

Injury Severity Score, management, complications, and outcome data.

• SCiENTiFiC aRTiCLES •

Blunt Renal Trauma and the Predictors ofFailure of Non-operative Management

Jon D. Simmons, MD; A. Neal Haraway, MD; Robert E. Schmieg, Jr., MD and Juan D. Duchesne, MD

ABStrAct

AUtHor inforMAtion: Drs. Simmons, Schmieg, Jr. and Duchesne are in the Department

of Surgery, Division of Trauma and Surgical Critical Care at the University of

mississippi medical Center in Jackson, mS. Dr. Haraway is in the Department of General

Surgery, Division of Urology at the University of mississippi medical Center in Jackson,

mS.

correSPonDing AUtHor: Jon D. Simmons, mD, Division of Trauma & Surgical Critical

Care, University of mississippi medical Center, 2500 N State Street, Jackson, mS 39216,

Phone: 601-984-5120, Fax: 601-815-1132, E-mail: [email protected]



Identified complications included sepsis, adult respiratory distress syn-

drome, multi-organ failure, renal failure (creatinine > 2), and active ex-

travasation or hemoperitoneum found on a follow-up computed

tomography scan. Renal injury was evaluated by computed tomogra-

phy scan with delayed images. Injury grade was assigned by trauma

surgeon review in accordance with the American Association for Sur-

gery of Trauma kidney Anatomic Injury Score grading system.1 Non-

operative management was classified as a success or failure based upon

need for later operation or intervention. Patients with successful non-

operative management (S-NOM) and failure of non-operative man-

agement (F-NOM) were compared with two-tailed Student’s t test,

Fisher’s exact test, or chi-square analysis as appropriate. This study

was approved by the university of Mississippi Institutional Review

Board.

reSUltS

In a five-year period at this academic level 1 trauma center, 271

patients out of 12,252 trauma cases (2.2%) had blunt renal injury. Ini-

tial non-operative management was chosen for 239 patients (88%). Ten

(4.1%) of these patients required later operation or intervention. No

differences in age, sex, initial vitals, or GCS were found between suc-

cessful and failed non-operative management patients.

Patients failing non-operative management (table 1) were more

seriously injured (Injury Severity Score: 31 versus 21, p<0.001); had

worse acidosis (initial arterial blood gas base deficit of -9.1 versus -

4.5, p<0.001); required more blood product transfusion (12 units ver-

sus 2.6 units of packed red blood cells transfused, p<0.001); and had

significantly longer hospital lengths of stay (37 days versus 12 days,

p<0.001). Angiography was used more frequently in patients failing

non-operative management (40% versus 8.7%, p<0.02). In the 10 pa-

tients requiring later intervention (table 2), only 3 (30%) required di-

rect kidney intervention: 1 nephrectomy, 1 open urinoma drainage and

1 open nephrostomy tube placement; all of these patients had grade V

renal injuries. The other 7 patients underwent operative interventions

not directly related to their renal injuries: 1 splenectomy and 6 missed

bowel injuries.

DiScUSSion

Management of blunt renal trauma has evolved over the past five

decades with popularization of non-operative management strategies

initially in pediatric patients followed by the adult patient population.

Selection of initial non-operative management for low-grade (grades I-

III) renal trauma is now commonly accepted. Indications for surgical

intervention have been narrowed to hemodynamic instability, pedicle

avulsion, expanding retroperitoneal hematoma, renal artery thrombosis,

and extravasation.2

Controversy remains over the role of non-operative management

of high-grade (grades IV and V) renal injuries. Several series have

demonstrated increased renal preservation after high grade injury blunt

renal injury with initial non-operative management strategies.2-6 Pro-

ponents of early surgical intervention for higher-grade renal injury have

advocated that debridement of devitalized segments and restoration of

the collecting system maximize renal function and decrease complica-

tions, including the need for delayed nephrectomy.3 The late compli-

cations of post-traumatic renovascular hypertension and renal

insufficiency after renal injury are often mentioned in concerns about

non-operative management but are fortunately quite rare.23-24 In one

small series, patients with high-grade renal injuries with devitalized

segments did not develop renovascular hypertension.23

Recent literature has suggested that early surgical intervention

may lead to increased unnecessary nephrectomies and complications.2

Santucci and Fisher’s2 review of renal trauma found widely varying

management for grade II to IV injuries, with a consensus for expectant

management in renal parenchymal injuries.7-20 They also suggested that

higher operative rates conferred higher rates of iatrogenic nephrectomy.

In comparing the management of blunt renal trauma between two large

academic trauma centers, an operative rate of 63% was associated with

an 11% nephrectomy rate in one center, while another center’s opera-

tive rate of 16% was associated with a 0% nephrectomy rate.21-22 These

data support the stance that selection of initial non-operative treatment

of blunt renal injuries can result in significantly fewer iatrogenic

nephrectomies.

Wright and colleagues examined renal and extra-renal predic-

tors of nephrectomy in blunt trauma patients using the National Trauma

data Bank.4 They found the strongest predictor of nephrectomy and

operative intervention was severity of the renal injury. In their series,

operations on other intra-abdominal organs imparted a higher risk of

nephrectomy regardless of renal injury grade.

Conclusions in the subset of patients with grade V blunt renal in-

juries have been hindered by the relative scarcity of such injuries in the

series published to date. One study including six patients with grade V

parenchymal injuries25 identified that non-operative management of

grade V parenchymal injuries resulted in fewer intensive care days,

fewer blood transfusions, and a lower mortality. These results were fur-

ther supported in another small study.26

In our study reported here, predictors of failure for non-operative

management were evaluated, including a subset of patients with high

grade injuries. In twelve patients with grade IV injuries, none required

a renal intervention. In six patients with grade V injuries, only one re-

quired later nephrectomy. Patients with failure of non-operative man-

S-NOM F-NOM P-ValueISS 21 31 <0.001

Base Deficit -4.5 -9.1 <0.001PRBCs 2.6 12 <0.001

Hospital LOS 12 days 37 days <0.001

S-NOM F-NOM P-ValueISS 21 31 <0.001

Base Deficit -4.5 -9.1 <0.001PRBCs 2.6 12 <0.001

Hospital LOS 12 days 37 days <0.001

tABle 1: STaTiSTiCaL SiGNiFiCaNCE bETwEEN S-NOm aND F-NOm

GRADE I II III IV VS-NOM 14(100%) 152(97%) 59(98%) 11(92%) 3 (50%)F-NOM* 0(0%) 5(3%) 1(2%) 1(8%) 3 (50%)*Neprectomy 0 0 0 0 1*Urinoma Drainage 0 0 0 0 2

GRADE I II III IV VS-NOM 14

(100%)152(97%)

59(98%)

11(92%)

3 (50%)

F-NOM* 0(0%)

5(3%)

1(2%)

1(8%)

3 (50%)

*Neprectomy 0 0 0 0 1*Urinoma Drainage 0 0 0 0 2

tABle 2: RESULTS by RENaL aaST ORGaN iNJURy SCORES


agement had significantly worse Injury Severity Scores, worse base

deficit, and increased number of packed red blood cells transfused com-

pared to patients with successful non-operative management. Grade

of renal injury was not predictive of failure of non-operative manage-

ment in our study. Patients requiring eventual operative intervention in

our study most commonly underwent operation for non-renal intra-ab-

dominal injuries. Our results are in agreement with those of Ramsay6

and colleagues who found that blunt renal trauma patients requiring

nephrectomy often present with high grades of renal injury, higher

transfusion requirements and a higher Injury Severity Score. The

length of hospital stay and outcome for these patients are usually related

to the associated injuries rather than the injury of the kidney itself.

Many of the past reported series have collected all renal injuries

over ten to twenty-five years or more. evolving changes in diagnostic

and treatment techniques over these prolonged time periods include in-

creased availability of diagnostic angiography, angiographic em-

bolization, and improvements in computed tomography scanning.

Application of these past studies to current patients must take into ac-

count these advances. In this study, there were no significant institu-

tional changes in the availability of these diagnostic and treatment

modalities over the study period.

As a potential limitation in this study, this retrospective review

is based upon a recent five-year experience at an academic level 1

trauma center with a large rural catchment area. Logistical delays in

transport were not examined but could potentially affect outcomes in

that patients with injuries that might have been chosen for initial non-

operative management who failed to stabilize during transportation

were selected out of our study population.

conclUSionS

Non-operative management of blunt renal injuries is successful

in most cases. Patients with a high base deficit, ongoing transfusion re-

quirements, and greater Injury Severity Scores have a higher likelihood

of requiring operation, but these procedures most often are to address

non-renal abdominal injuries. High-grade blunt renal injuries that are

hemodynamically stable can be treated expectantly on an individual

basis with close follow-up. Any patient with hemodynamic instability,

renal pedicle injury, renal artery thrombosis, or urinary extravasation

will likely require operative intervention.

referenceS

1. Moore ee, Shackford SR, Pachter HL, et al. Organ injury scaling: spleen,liver, and kidney. J Trauma. 1989;29:1664-1666.

2. Santucci, R. and Fisher, M. The Literature Increasingly Supportsexpectant Management of Renal Trauma- A Systematic Review.J Trauma. Aug, 2005;59(2):493-503.

3. davis, K., Reed, L., Santaniello, J. et.al. Predictors of the Need forNephrectomy After Renal Trauma. J Trauma. 2006;60(1):164-170.

4. Wright, JL, Nathens, AB, Rivara, FP. Renal and extrarenal Predictors ofNephrectomy from the National Trauma databank.J Urol. 2006;175(3):970-975.

5. Bozeman, C., Carver, B., Zabari, G. Selective Operative Management ofMajor Blunt Renal Trauma. J Trauma. 2004;57:305-309.

6. Ramsay, L., Soumitra, e., Makhuli, M. Factors Affecting Managementand Outcome in Blunt Renal Injury. World J Surg. 2002;26:416-419.

7. Levy JB, Baskin LS, ewalt dH, et al. Nonoperative management of bluntpediatric major renal trauma. Urology. 1993;42:418–424.

8. Moudouni SM, Patard JJ, Manunta A, et al. A conservative approach tomajor blunt renal lacerations with urinary extravasation and devitalizedrenal segments. BJU Int. 2001;87:290–294.

9. Thall eH, Stone NN, Cheng dL, et al. Conservative management ofpenetrating and blunt type III renal injuries. Br J Urol. 1996; 77:512–517.

10. Heyns CF, Van Vollenhoven P. Selective surgical management of renalstab wounds. Br J Urol. 1992;69:351–357.

11. Velmahos GC, demetriades d, Cornwell ee 3rd, et al. Selectivemanagement of renal gunshot wounds. Br J Surg. 1998;85:1121-1124.

12. Wein AJ, Arger PH, Murphy JJ. Controversial aspects of blunt renaltrauma. J Trauma. 1977;17:662–666.

13. Altman AL, Haas C, dinchman KH, et al. Selective nonoperativemanagement of blunt grade 5 renal injury. J Urol. 2000;164:27-30.

14. Matthews LA, Smith eM, Spirnak JP. Nonoperative treatment of majorblunt renal lacerations with urinary extravasation. J Urol.1997;157:2056–2058.

15. Haller JA, Jr., Papa P, drugas G, et al. Nonoperative management of solidorgan injuries in children. Is it safe? Ann Surg. 1994;219:625–628.

16. Tunberg T, Jona J. Review of multiple traumatic injuries in an urbanpediatric population. Pediatr Emerg Care. 1985;1:116–119.

17. Smith eM, elder JS, Spirnak JP. Major blunt renal trauma in the pediatricpopulation: is a nonoperative approach indicated? J Urol.1993;149:546–548.

18. Gill B, Palmer LS, Reda e, et al. Optimal renal preservation with timelypercutaneous intervention: a changing concept in the management of bluntrenal trauma in children in the 1990s. Br J Urol. 1994;74:370–374.

19. Kuzmarov IW, Morehouse dd, Gibson S. Blunt renal trauma in thepediatric population: a retrospective study. J Urol. 1981;126:648–649.

20. Toutouzas KG, Karaiskakis M, Kaminski A, et al. Nonoperativemanagement of blunt renal trauma: a prospective study. Am Surg.2002;68:1097–1103.

21. Matthews LA, Smith eM, Spirnak JP. Nonoperative treatment of majorblunt renal lacerations with urinary extravasation. J Urol.1997;157:2056–2058.

22. Santucci RA, McAninch JW, Safir M, et al. Validation of the AmericanAssociation for the Surgery of Trauma organ injury severity scale for thekidney. J Trauma. 2001;50:195–200.

23. Husmann dA, Morris JS. Attempted nonoperative management of bluntrenal lacerations extending through the corticomedullary junction: theshort-term and long-term sequelae. J Urol. 1991;143:682-684.

24. McGonigal Md, Lucas Ce, Ledgerwood AM. The effects of treatment ofrenal trauma on renal function. J Trauma. 1987; 27: 471-476.

25. Altman AL, Haas C, dinchman KH, et al. Selective nonoperativemanagement of blunt grade 5 renal injury. J Urol. 200; 164:27-30;discussion 30-21.

26. Perego KL, Little dC, Kirkpatrick AK. Conservative nonoperativemanagement of grade 5 blunt renal trauma. Journal of Urology. 2001;165: 14-15.

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A47-year-old African American male presented to the

emergency department complaining of non-exer-

tional chest pain and urinary frequency. He de-

scribed the chest pain as dull, non-radiating, lasting only a few

seconds and occurring after urination. He stated that these symp-

toms had been worsening over the past several months. The pa-

tient had a history of gastroesophageal reflux disease and obesity.

During the history he also complained of two to three months of

worsening vivid visual hallucinations of dead relatives. He became

very tearful and perseverated hallucination details. He denied any

other psychotic symptoms. He also denied any cardiac history. He

was taking esomeprazole (Nexium) and metaxalone (Skelaxin) as

needed.

In a 47-year-old male with these peculiar symptoms, I wonder if

substance abuse, metabolic derangement or an undiagnosed psychiatric

disorder might be the cause. The hallucinations might be caused by a

psychotic disorder such as schizophrenia or depression with psychotic

features, a hallucinogen or delirium. The chest pain associated with uri-

nation may be due to a urinary tract infection or cardiac abnormality. I

will obtain a complete blood count, complete metabolic panel, a urine

drug screen and further psychiatric history. There may also be a cardiac

component, considering his obesity. I will order an electrocardiogram

(eKG), cardiac biomarkers (troponin, creatine phosphokinase (CK) –

total and MB fraction) and a chest radiograph.

On examination he had a normal temperature, pulse and

respiratory rates. His blood pressure was elevated at 149/103 mm

Hg, and his body mass index was 30.1. He was a tearful African

American male with psychomotor retardation who was well

groomed and obese. His cardiac, pulmonary and abdominal ex-

aminations were unremarkable. His musculoskeletal examination

showed diffuse muscle tenderness, specifically over the thighs,

lower legs and shoulders. His strength and range of motion were

within normal limits, and his neurological examination showed

normal patellar reflexes and slow gait. The patient had normal sen-

sation in his arms and legs. He had dry skin. His mental status ex-

amination showed depressed mood with a blunted but congruent

affect. His speech was slow, and his thought process was organized

and focused on prior hallucinations of deceased relatives. He de-

nied any auditory hallucinations or suicidal or homicidal ideation.

An EKG showed normal sinus rhythm. The remainder of the re-

quested laboratory studies was in process.

The patient has an odd constellation of symptoms. diffuse mus-

cle tenderness can be caused by overexertion, fibromyalgia, viral ill-

nesses, dermatomyositis, polymyositis or a drug induced myopathy. I

am less concerned about cardiac pathology, considering his normal

eKG, normal cardiac examination and new finding of skeletal muscle

tenderness. during a brief electronic health record review, I see that he

had a normal echocardiogram 3 months earlier when he presented with

similar complaints. At that visit he was prescribed metaxalone for his

muscle aches and esomeprazole for his chest symptoms.

The chest radiograph was within normal limits. His potas-

sium was low at 3.3mEq/L. The remaining electrolytes, renal func-

tion, liver function tests and complete blood count were normal.

Urinalysis showed trace blood only. His CK was elevated at 412

U/L (50-200 U/L), and his CK-MB was elevated at 5.94 % (0.10 –

4.94%). His troponin was negative at < 0.010 ng/nl.

The negative troponin further lessens my concern for a cardiac

cause of the chest pain. His urinalysis was not suggestive of infection,

and I do not suspect a urinary cause of his pain. Given the elevated CK,

I will start intravenous fluids to prevent renal function impairment. I

will also obtain a more specific history from the patient including ques-

tions about exertion, statin use and dermatologic review of systems.

exertion can cause transient elevations of CK. Myotoxicity is a com-

mon side effect of statins. Although the patient did not admit to statin

use, one may have been prescribed, especially considering his obesity.

Also, elevated CK can be associated with both dermatomyositis and

polymyositis.

The patient reported being a truck driver; this required

heavy lifting while loading an unloading freight several times daily.

He denied any statin use or recent rashes.

While exertion from his job may account for some elevation in

his CK, it seems unlikely to account for an elevation of the current

magnitude. I rule out statin use as a cause of elevated creatine kinase

as the patient continues to deny any statin use. Because he denies

rashes, I put dermatomyositis and polymyositis lower on the differen-

tial. I also exclude fibromyalgia from the differential because he has

diffuse muscle tenderness, not point tenderness which is seen in fi-

bromyalgia. In addition, elevated CK is not seen in fibromyalgia.

The patient stated that he was feeling better after the intra-

venous fluids. He also was happy when I suggested that he could see

• CLiNiCaL PRObLEm-SOLviNG •

I See Dead People

Janet M. Nielsen, MD

AUtHor inforMAtion: Janet M. nielsen, MD is in the Department of Family medicine at

the University of mississippi medical Center in Jackson.

correSPonDing AUtHor: Janet m. Nielsen, mD, University of mississippi medical Center,

Department of Family medicine, 2500 North State Street, Jackson, mS 39216, Phone:

(601) 984-5426, Email: [email protected]

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


a psychologist at clinic to discuss his visions. He denied any cur-

rent visions or suicidal ideation. Feeling that the patient did not

have an urgent condition, I discharged him from the emergency

department with an appointment to follow up in clinic in 2 days.

This patient has elevated creatine kinase and diffuse muscle

aches. It could be due to exertion at his job, but I continue to wonder

what disorder might link all of his odd symptoms together. While re-

searching myositides, I discover that hypothyroid myopathy could be

the cause of his elevated creatine kinase and muscle weakness.1 Hy-

pothyroidism might also explain his psychiatric symptoms. I add a thy-

roid stimulating hormone (TSH) test to existing orders.

The TSH was elevated at 47.2 mcIU/ml (0.27 – 4.2).

His TSH concentration indicates that the patient likely has hy-

pothyroid myopathy and hypothyroid psychosis. up to 70% of patients

with hypothyroidism can have neuromuscular complaints including

weakness and myalgias.2 Serum creatine kinase in usually elevated in

patients with hypothyroidism but usually less than 1000 u/L.3 Psychi-

atric manifestations of hypothyroidism can include psychosis in 5-15%

of patients. The psychiatric symptoms of hypothyroidism may be re-

lated to high concentrations of the T3 receptor in the amygdala and hip-

pocampus. The most common neuropsychiatric sequelae in

hypothyroidism include psychosis, depression and cognitive disorders.

These symptoms usually occur after the manifestation on the physical

symptoms of hypothyroidism.4 Rhabdomyolysis can be more profound

with exertion in hypothyroidism.5 Both muscle symptoms and psy-

chosis can resolve with thyroid hormone replacement therapy.2,4

The patient was prescribed levothyroxine (Synthroid) 112

mcg by mouth daily as replacement therapy. At his appointment

two days later, he stated that he felt better but was still experienc-

ing most of his symptoms. He was encouraged to stay well hydrated

and to continue his levothyroxine. Six weeks later his TSH had de-

creased to 5.5 mcIU/mL, and his CK was normal at 105 U/L. His

muscle pain, chest tightness and visions had resolved.

His improvement with thyroid hormone replacement confirmed

the diagnosis of hypothyroid myopathy and hypothyroid psychosis.

KeY WorDS: HyPOTHyROIdISM, MyOPATHy, PSyCHOSIS

Acknowledgment: I thank Librarian Janet Bishoff, BS, MLS, for her

assistance.

referenceS

1. Sabatine MS. Pocket Medicine: The Massachusetts General Hospital

Handbook of Internal Medicine. 3rd ed. Philadelphia, PA:LippincottWilliams & Wilkins; 2007

2. duyff RF, Van den Bosch J, Laman dM, Potter van Loon B, LinssenWH. Neuromuscular findings in thyroid dysfunction: a prospectiveclinical and electrodiagnostic study. J Neurol Neurosurg Psychiatry.2000;(68):750-755.

3. Scott KR, Simmons Z, Boyer PJ. Hypothyroid myopathy with astrikingly elevated serum creatine kinase level. Muscle Nerve.2002;26:141-144.

4. Heinrich TW, Grahm G. Hypothyroidism presenting as psychosis:Myxedema madness revisited. Prim Care Companion J Clin Psychiatry.2003;5(6):260–266.

5. Riggs Je. Acute exertional rhabdomyolysis in hypothyroidism: the resultof a reversible defect in glycogenolysis? Mil Med. 1990;155:171-172.


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• mSDH •

* 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

Mississippi Reportable Disease Statistics

March 2009


• PRESiDENT’S PaGE •

Be Part of the Solution

March 23, 2010: a date that will live in infamy. While certainly not as

tragic as the events of december 7, 1941, in terms of lives lost in a

matter of a few short hours, HR 3590 became public law 111-148

with the stroke of President Barack Obama’s 20-something pens. In my opinion, this

culmination of 14 months of democratic deal cutting and back room negotiating will

cast a shadow across our united States as long as any other sentinel event in our

nation’s history. I continue to ask myself, “How did this happen?” Allow me a few

moments to explain.

For the past several years I have been privileged to travel across the united

States and certainly to the far corners of our great state of Mississippi. In doing so, I

have met very few physicians (and other private citizens for that matter) who have not

embraced the idea of reforming our present system of delivering health care in the united States. Interestingly enough, I have met even fewer

physicians and/or other Americans who are pleased with the method and/or manner by which this reform has come about. To add salt to the

wound, complicit in this increasingly unpopular upheaval of our health care system were such groups as the American Medical Association,

American Academy of Family Physicians, American College of Physicians and the list goes on. yet, when you talk to physicians who are

members of the aforementioned organizations, very few say they support the present flavor of health system reform or, for that matter, their

organization’s position on HR 3590. At this point, let’s all stop and collectively scratch our heads. did we not all wake up on Wednesday

morning March 24th in a cold sweat? did we not all rub our eyes, splash cold water on our faces, and hope that we were awakening from a bad

dream? We should have been as lucky as ebenezer Scrooge!

While the idea of providing health care coverage to an additional 30 million Americans (what happened to the original 47 million we

were told were uninsured a year ago?) is certainly a step in the right direction, I would remind you again that it is the manner in which this is

being done that disturbs most Americans.

For example, early in the health system reform game, liberal democrats insisted on a public option. The idea of a “government run

insurance program” was so repugnant to most Americans that united States Congressmen and/or united States Senators were verbally and

nearly physically accosted at “townhall” meetings all across America. yes, even in the liberal northeast and on the “left coast” (California),

thousands of our fellow citizens sent a resounding message that further government control of our health care was not a viable alternative.

under the guise of “listening to the electorate,” the public option was ditched. In its place, HR 3590 expands Medicaid by some 16

million. Overnight, with the stroke of a Presidential pen, we have entitled an additional 16 million Americans. Well, thank God we did not get

that dreaded “public option” (which, by the way, would have insured only 15 million). What about expanding Medicaid is not growing an

already-existing “government run health care plan”? Am I missing something?

Well, at least we still have Medicare. This government run plan has been a Godsend to both physicians and patients. Medicare, by and

large, takes care of our nation’s most vulnerable: those who have fought our wars, raised our children, gone to work every day, paid taxes, and

woven the very moral, ethical, and financial fibers that hold our nation together. In spite of Medicare’s noble mission and outstanding record, it

has been horribly mismanaged by our government and is scheduled to go under for the third time in about seven years. On top of that, HR 3590

is to be paid for in large measure by billions of dollars of cuts to our Medicare Program that is already on life support!

rAnDY eASterling, MD

2009-10 MSMA PreSiDent


To add insult to injury, efforts to fix the flawed Medicare payment system (SGR) allowing physicians to care for the elderly has

repeatedly fallen on deaf ears in Congress.

Let me get this straight! On March 23, 2010, the President of The united States signed into law a bill that expands healthcare coverage to

an additional 16 million Americans who are, with notable exceptions, fairly young and healthy. Before the ink dried on the name Obama, this

same bill diminished services and coverage to members of “the greatest generation”. Some would wonder if we have in fact lost our moral

compass in America.

Not only does HR 3590 decrease services to the Medicare population, but for the first time in the united States history all of us will be

required to pay Medicare tax on our lifetime of investments (capital gains and dividends) for the rest of our lives…so much for that “nest egg”

idea. In addition, most feel that a value added tax is just around the corner. This would, of course, be a consumption tax that would further

labor every social economic class in America. This tax would, by and large, place a disproportionate burden on the lower social economic

groups and the elderly, and, if that were not enough, physicians, who tend to be in the higher income brackets, will most likely be taxed at levels

never before seen in our nation’s history.

What is that old saying? “If you think healthcare is expensive now, just wait until it is free.”

When it is all said and done, the most disturbing development of the past 14 months of this democratic rule in Washington has been the

massive growth of our federal government. Like the waistlines of many of our patients, the united States government continues to expand.

While I feel strongly that all Americans who can afford health insurance should purchase same, where does the Constitution (remember from

junior high civics, that is the document that has served us well for over 200 years) empower the federal government to force a single united

States citizen to purchase any product, whether health insurance or anything else for that matter? So much for Ben Franklin, Thomas Jefferson,

John Hancock, etc.; well, I guess they thought it sounded like a good idea at the time!

I am reminded daily of the prophetic words of one of our constitutional framers, Thomas Jefferson, “A government big enough to give

you everything you want is big enough to take everything you have.”

While the Patient Protection and Affordable Care Act is now federal law, let’s hope that the “fat lady” has yet to sing. November 2010

elections are a few short months away. While I don’t want health system reform to be totally discarded, I do pray for a more sensible, equitable,

physician-driven, patient-centered approach to restructuring the delivery of

healthcare in America.

If health system reform is to be physician driven and patient centered, it

is incumbent on us as doctors to be the driving force. If history has taught us

anything, it is that if we are not part of the solution, then we have become part

of the problem. This is nothing short of a “call to arms.” We must organize,

talk to our patients, give to our political action committees, and call our

congressmen and senators. If you and I refuse to play a central role in health

system reform, then the federal government will be more than happy to do it for

us. Wait, I think they already have!

yours in making Mississippi healthier,

Randy Easterling, MD

President, Mississippi State Medical Association

We specialize in the business of healthcare


• EDiTORiaL •

“Draumatized”

Mashup words can capture meaning wonderfully and sometimes hysterically. I want to introduce you to a new

word, as reported to me by my wonderful and wise college professor wife. The new word, a mashup word, is

“draumatized.” There may be some potential for research and even a new class of illness being discovered here.

So what is “draumatized?” Well, it is a combination of trauma and drama. The drama is of higher order than the trauma.

“draumatized” was brought to the attention of the drs. O’dell as part of a plea invoked during earnest efforts by a relative. It

seems the person she was pleading for had experienced a minor trauma. There was a full recovery in a brief period, but the

circumstances were so dramatic as to be nearly unbelievable that some long lasting injury had not occurred. Telling the full story

might disclose the guilty, so bear with me. Think of something like totaling your car and yet walking away with insignificant

injuries. Well, it seems that for our subject a miraculous escape was not good enough. The story itself was too good to pass up so

the event was being used liberally to explain all sorts of academic, social, and other failings on the part of our otherwise good-

fortuned “victim.” The relative described the subject as having been “draumatized” and indicated the expectation that this

victimhood status should absolve any failings in the program.

empathy runs deep in the drs. O’dell household, but the obvious humor of this mashup of trauma and drama quickly

overcame the more noble sentiment of empathy. We have found the new word useful in all sorts of ways. “draumatized” might

even be a new diagnostic term for, say, the persons bringing me disability papers following a minor trauma on the job. Some of

the “draumatized” even have hired drama coaches, usually procured at a local law office, to be certain they are convincing in their

description of the trauma experienced. Let’s see, I wonder what the ICd-9M code would be? Would it fall into the 900-codes of

injury? Maybe the 800- codes of brain injury? Or under the 301-codes of histrionic personalities?

Can persons suffer from “draumatization” disorders? Maybe we are onto something here. “draumatization” disorder would

certainly explain the constant issuance of work and school excuses at most primary care offices. If “draumatization” disorder is

eventually recognized as a legitimate medical disorder then I might feel better about issuing such excuses for patients who do not

come to the office to be seen for their work-interrupting illness but nevertheless desire my issuance of an excuse. Perhaps they

were simply too “draumatized” to even come to the office. And maybe a patient with a “draumatization” disorder can be best

treated in dramatic circumstances, perhaps explaining why patients with seemingly minor illness prefer the emergency room.

As is the case with any new entity, I, like other scientific authors, recommend further study of “draumatized.” A new

National Institute of Health should consider studying this potential disorder since it clearly is a unique entity not falling in the

current silos of NIH investigation. doctors might find willing colleagues among actors who are expert in drama as we seek

collaborative research in this new area of study.

We should begin to recognize that drama is a co-morbid condition following trauma in some individuals. Certainly a scale

for drama would be useful for the ongoing treatment of victims of trauma. Like Broadway plays, I suspect the best treatment lies

in the box office. When the drama fails to bring in the crowds and receipts, it ceases to be produced.

—Michael O’Dell, MD

Associate Editor

The Pen is Mightier than the Sword!express your opinion in the JMSMA through a letter to the editor or guest editorial. The Journal MSMA welcomes letters to the editor. Letters for publication shouldbe less than 300 words. Guest editorials or comments may be longer, with an average of 600 words. All letters are subject to editing for length and clarity. If you arewriting in response to a particular article, please mention the headline and issue date in your letter. Also include your contact information. While we do not publishstreet addresses, e-mail addresses or telephone numbers, we do verify authorship, as well as try to clear up ambiguities, to protect our letter-writers.

you can submit your letter via email to [email protected] or mail to the Journal office at MSMA headquarters: P.O. Box 2548,Ridgeland, MS 39158-2548.


• i Q H •

Patient Safety and Core Prevention

IQH has successfully met performance requirements at the 18th month of our CMS 9th Statement of Work.

We recently received notification from dr. Barry M. Straube, CMS chief medical officer, director, Office of Clinical

Standards and Quality, who stated: “We are pleased that your performance in the first evaluation period, focused on the

theme areas of Patient Safety and Core Prevention, was in accordance with our expectations. On behalf of our QIO

Program management and staff at CMS, I would like to congratulate you on successfully meeting performance

requirements at the 18th month of 9th Statement of Work (SOW) core contract.”

Our IQH staff works on patient safety and prevention projects focusing on improving the quality of health care for

Medicare beneficiaries. We are very pleased with this 18th month evaluation. This accomplishment is important to us

because it reflects improvement in quality care for our Medicare beneficiaries.

To review, the projects include:

Beneficiary Protection: Case Review and Reporting Hospital Quality data for Annual Payment update

(RHQdAPu)

Core Prevention: Working with physician offices and clinics to leverage certified electronic health record (eHR)

systems in ways to help improve immunization rates for influenza and pneumonia as well as

breast cancer and colorectal cancer screenings

Patient Safety: Pressure ulcer Reduction in Nursing Home and Hospital Settings; Nursing Home Physical

Restraints; Hospital Surgical Care Improvement Project (SCIP); Methicillin-resistent

Staphylococcus Aureus (MRSA); Nursing Homes in Need; Medication Safety

Sub-National Project: Focused disparities

Tobacco Quitline Updates

IQH is now offering an alternative to telephone counseling for persons in Mississippi who want to quit using

tobacco. An interactive Web site will offer online counseling to assist Mississippians who do not want to

participate in telephone counseling. The Web site offers information on tobacco and its effect on health and gives

other resource information. Healthcare providers can also take advantage of the resources on the Web site and download

pamphlets and the fax referral form that will make referrals to the quitline quick and easy. The Web site is:

www.QuitlineMS.com.

Quitline hours have expanded to 7 a.m. to 7 p.m. Monday through Friday and on Saturday from 9 a.m. to 5:30 p.m.

—James S. McIlwain, MD

IQH President


• POETRy iN mEDiCiNE •

[Editor’s Note: This month, we print the poetry of Richard D. deShazo, MD, Chairman and Professor, Department of Medicine, Professor of

Pediatrics, and Billy S. Guyton Distinguished Professor at the University of Mississippi School of Medicine. He is board certified in the

medical specialties of internal medicine, allergy-immunology, rheumatology and geriatrics. He is also known to the listeners of Mississippi

Public Radio as the host of “Southern Remedy,” a vibrant weekly program where his passion for serving his patients is clearly evident. This

poem, entitled “Rhythms of Life,” came to deShazo one Saturday morning as he was trying to discover his proverbial “inner self.” He

explains, “ I was sitting at the breakfast table when out of the recesses of my shrinking brain came a rush of thoughts about the yin and yang,

ups and downs, ins and outs of life as a husband, father, grandfather and physician. The bottom line is that I have been more than blessed to

serve in all of these roles and continue to be committed to them. Thus, I remain an aging heterosexual¬ with an aversion to tobacco and

body odor. I hope the poem brings my colleagues a smile.” Any physician with Mississippi ties is invited to submit poems for publication in

the journal, attention: Dr. Lampton or email to him at [email protected].] —ED.

Rhythms of Life

Some highsSome lowsSome yesesSome noes.

Some goodSome bad

Some salmonSome shad.

Some progressSome stalls

Some homerunsSome foul balls.

Some sadnessSome thrillsSome solace

Some bitter pills.

Some by luckSome by will

Some with helpSome by skill.

Some with speedMore by waitSome by planSome by fate.

Some with steelSome with planksSome with scarsAll with thanks.

—Richard D. deShazo, MD

Jackson


• PHySiCiaNS’ bOOkSHELF •

“Bringing Down High Blood Pressure”

By Chad Rhoden, MD, PhDwith Sarah Wiley Schein, MS, RD, LDN

ISBN-13 978-1-59077-159-4 304 pages. Includes graphs, tables, and index. $22.95, Distributed by National Book Network

Our own edward Hill, past president of both the

Mississippi State Medical Association and the

American Medical Association, offers a blurb on the

back of Chad Rhoden's new book Bringing Down High Blood

Pressure. He comments: “This book captures the essence of what

must occur if we expect, as a society, to change successfully behavior

that will prevent cardiovascular disease. everyone who expects to

reach optimal health— whether patient or health care professional—

should own, read, and treasure this book.” As usual, edward says it well and in a concise manner! This attractive hard

bound book, which includes an index, seeks a national audience of both lay and professional readers. It is an excellent

resource for physicians to offer to their patients who seek insight into their disease and who are serious about impacting

positively their blood pressure.

Over eight chapters and 5 appendices, dr. Rhoden gives readers straightforward solutions which can be utilized both

short and long term in their lives. This book focuses on prevention, which is to be expected given Rhoden’s background. He

opens with a chapter highlighting the causes and dangers of hypertension, this nation’s number one killer. With future

chapters, he explores the benefits of a multifaceted approach to control and lower blood pressure, from exercise and weight

loss, to diet and nutrition, to stress and emotional wellness, even to alternative approaches. Have no doubt he covers all of

the bases. each of the chapters goes into extraordinary detail, which should allow most of the suggestions to be easily

incorporated into a patient’s daily routine. He also stresses to the reader the need to discuss the book and suggestions with

their physician before utilizing them. Rhoden extensively outlines the risks and benefits of various medications; he also

emphasizes the important role lifestyle changes play in the disease process and how such lifestyle changes may result in a

patient’s ability to reduce or eliminate medications.

Impressive is the plentiful practical advice on nutrition, especially the multiple tips for healthy food selection and

preparation. As well, more than 50 delicious recipes “for bringing down high blood pressure” are included over 75 pages,

with each broken down from a nutritional standpoint. There is great variety for any palate, and food categories include

appetizers, breads, salads, soups, vegetables, entrees, marinades, and desserts. The dishes do appear tasty, and include

brandy apple crisp, herb marinated lamb chops, Louisiana-style shrimp creole, hummus, gazpacho, pupusas revueltas with

chicken, crispy edamame, and pan-fried yucca.

If physicians had two hours to spend with each patient, partnering with them to improve their health, Rhoden’s

book is what we’d say. This book is a valuable and vital resource for both patients and physicians. It provides not only

helpful information for bringing down high blood pressure, but also excellent advice on how to live a healthy life. Rhoden’s

book begins the type of reflection each patient needs to garner insight in maximizing their health choices. My patients with

hypertension will benefit from reading the book and adopting many of the innovative concepts for healthy living.

Immediate and long-term solutionsFitness plans and stress management tipsPractical advice on nutrition70 delicious and healthy recipesInformation on the risks and benefits of medications

•••••

CHAD RHODEN, M.D., Ph.D.WITH SARAH WILEY SCHEIN, M.S., R.D., L.D.N.

BRINGINGDOWNHIGHBLOODPRESSURE

Immediate and long-term solutionsFitness plans and stress management tipsPractical advice on nutrition70 delicious and healthy recipesInformation on the risks and benefits of medications

•••••

CHAD RHODEN, M.D., Ph.D.WITH SARAH WILEY SCHEIN, M.S., R.D., L.D.N.

BRINGINGDOWNHIGHBLOODPRESSURE



Practicing physicians will want to utilize many of

Rhoden’s strategies not only with their patients but also with

themselves. How many of us are overweight, suffer from

hypertension or hyperlipidemia, and need insight,

suggestions, and encouragement to make changes in our

life? There’s a great deal of good information here. Rhoden

begins a conversation we need to have not only with our

patients but with ourselves. This is an exemplary book by a

fellow MSMA member, and I encourage you to give it a try.

Chad A. Rhoden, Md, Phd, of Madison, is a one of

our state’s emerging leaders in the field of disease

prevention. His particular expertise is in prevention and

management of cardiometabolic and infections disease

occurring in the occupational setting. dr. Rhoden is board

certified in preventive medicine/public health as well as

family medicine. His Phd was in exercise science and

nutrition. He lives in Madison, and comes from a family of

physicians, including two great great uncles who served our

MSMA as president. His co-author, Sarah Wiley Schein,

MS, Rd, LdN is a registered dietitian, who resides in

Wayne, Pennsylvania.

— Lucius Lampton, Editor

• imaGES iN miSSiSSiPPi mEDiCiNE •

HOSPITAL, ALCORN A & M, 1890s— These photos are of the original hospital for students at Alcorn Agricultural and

Mechanical College. This was one of the earliest hospitals for African Americans in the state. Located in Claiborne

County, four miles south of Port Gibson near the Jefferson County line, Alcorn State University was founded in 1871 as

one of the nation’s first state-supported colleges for African American students. (The campus dates back to 1828 as

Oakland College, a regional Presbyterian college which ceased operations by the time of the Civil War.) The college was

named in honor of Reconstruction Governor and Senator James L. Alcorn. The college operated as a land-grant

institution, and by 1875, the name Alcorn University was changed to Alcorn Agricultural and Mechanical College. At first

the school was exclusively for black males but in 1903 women were admitted. In 1974 Alcorn Agricultural and Mechanical

College became Alcorn State University. This hospital was not the first built for African American patients in Mississippi.

In 1852, a Natchez newspaper (The Mississippi Free Trader) noted the erection of a small infirmary exclusively for African

Americans, operated by future MSMA Vice President Luke Pryor Blackburn. (More about his later!) Anyone with

additional information on the college hospital is asked to contact Dr. Lampton. If you have an old or even somewhat

recent photograph which would be of interest to Mississippi physicians, please contact the Journal or me at

[email protected].

—Lucius Lampton, MD, Editor


• THE UNCOmmON THREaD •

When I posted my little story The Ghost on my blog it

produced an interesting set of responses, which I shall

post here, via the magic of cut and paste. The names

have been changed to protect the innocent and the commentary left in

blogger’s prose as seen on the computer screen.

Sis: Enjoyed the blog, Tom. Glad you answered when opportunity rang the bell”

Frank: “Tom, are you sure it wasn’t UPS?...They ring once and run. And, we went to RMH for the Cardiac Unit’s 2 year anniversary this

afternoon. Shook hands with my Surgeon, his PA, nurses etc., who remembered me well...when leaving, the Surgeon said ‘nice seeing you again -

you look great, Tom’.... When they made my name tag...they put Thomas (my middle name) instead of Frank....very - very spooky if you ask

me...Tom...VERY SPOOKY....!!!!”

Me: “the world is a spooky place, maybe he was in the wrong place.”

Frank: “Which Tom was in the wrong place?”

Ms CGS: “or maybe the surgeon is a closet writer/blogger/prf. of English?”

Me: “Frank, since you're the only Tom here, I think the ghost was a bit south of where he intended to be.”

Frank: “But, you see, I'm NOT the only Tom here...you have a Tom there....You are just as much of a Tom as I am....mistaken identity?”

Ms CGS: “can I play? I'll be Tom the Editor.

Frank: “hmmm...I think there are two impostors. Will the REAL Tom please stand up? (the quickest solution)”

Frank: “OMG...we all stood up at the same time...back to square one....”

I was planning to answer CGS with a suggestion that if we were going to cast an attractive woman as Tom the editor, that she would have

to be comfortable being a “domin-ed-trix,” you know, an editor that was only was able to enjoy editing when she could dress up in clothes from

Versace and edit writers really, really hard. But then something struck me. It was both the tone and the content of those final two posts which

led me to the conclusion that there was something larger going on here. So that meant it was time for me to get in gear and look into it, in only

the way a piercing mind such as mine can possibly do it. It was time for some…tat da da daaaaaah…(wait on it)… ReSeARCH.

Research is always a good answer when you have a vexing problem or coincidence to investigate. The problem becomes how, and what

to research? Clearly, this doesn’t appear to be a religious problem, although the Bible is replete with examples of Thomases who play a

prominent role in Biblical history. And, there is always the possibility that we have all been simultaneously, because of our natural tendencies to

scoff and distrust, transformed into visages of the Thomas who doubted Jesus’s resurrection, but after due consideration and running a few

preliminary mathematical equations, I rejected this as the explanation. However, those of you that want to accept this as the answer on faith

alone are welcome to do so.

r. Scott Anderson, MD

The ThomasineConfluence


Biology was always a consideration, and I had to consider the possibility that some genetic sequence that we all possess in common is

the root of our mutual Thomasine misidentification. So, I went out to the garage and fired up my dNA sequencer, used a vacuum on my

screen to suck dNA samples from each of the other Tom’s keyboards by visiting their Facebook profile using direct screen-to-screen transport

to shove the vacuum nozzle against the keyboards. I knew they wouldn’t mind the intrusion. (Frank- I’m sorry about the mess. I pushed the

blow button by mistake, but I changed the bag right after that. So the second time things went a lot better.)

I looked at the recovered dNA, and yes almost ninety-percent of our dNA sequences were similar, but eighty-five percent of our dNA

sequences match those of an earthworm, so I wasn’t able to draw any firm scientific conclusions from that. And while I don’t profess to speak

fluent earthworm, I am unaware of any earthworms that refer to one another as Tom at all, much less it having some identifiable locus in their

genome, so I was able to exclude those common sequences from consideration. The five percent remaining that the three of us Tom’s have in

common with each other, but not with earthworms seems to code for stuff like arms and legs and a four chamber heart and things like that, and

not for name specific identity. So I rejected biology.

The answer then I reasoned must come from the realm of physics: specifically I gravitated to the subject of String Theory. Because it is

such a fluid field, I adjusted and tweaked physical principles, added two unknown dimensions to account for Thomasine movement (a term I

have now created) and voila there was the answer implicit in the very underpinnings of the science.

We have only to look of the dual resonance model, first postulated by Veneziano in 1968 to see what is happening. In short, Veneziano

observed that the s- and t-channel vibrations that occurred in meson scattering were of exactly the same amplitude. On further observation the

exact phenomena was observed in N-particle amplitudes that gave us the idea of harmonic, opposing amplitudes like that occurs in a one-

dimensional model of linear string vibration. Obviously what is happening to us is an exact but opposite reaction, modulated through time by

the presence of the two unseen dimensions of the great Brucine Confluence that effected Monty Python in the same years that Veneziano was

developing his resonance model, and is only showing up now. I propose that we try to quantify B- (for Brucine) and T- (for Thomasine)

confluent amplitudes and sit back and wait on the guys in Stockholm to send us that Nobel Prize I knew I was going to get some day. I’ll start

working on the math.

— R. Scott Anderson, MD

Meridian

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

dabbles in the motion-picture industry as a screen-writer, helping form P-32, an entertainment funding entity.


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• UNa vOCE •

Shocking, Isn’t It?

Am I the only person who is cheapskate enough to actually miss the free pens and

note pads that physicians’ offices used to get from drug companies? It has been

just over a year now since this practice has been banned, and I can almost see the

bottom of my dwindling stockpile. The only gel pens we are given these days come from home

health agencies and hospices. Thankfully they are almost as numerous in our region as Southern

Baptist churches. you can’t swing a dead cat by the tail without hitting a new hospice that just

opened up on the corner.

Someone sent me this e-mail photo with the caption… “I’m sure that you have seen pharmaceutical advertising in doctors’ offices on

everything from tissues to exam table cover paper. Well, in my book, this one should get the prize. If the light stays on for more than four hours,

call your electrician!”

Although they are behind the times (since we no longer get ‘delightful’ free goodies such as this one), the e-mail only served to remind

me of how revoltingly out of hand things had gotten in the pharmaceutical marketing realm.

My feelings are hurt. My Pfizer rep never gave me one of these Viagra switch plates for my exam rooms. I did once receive a similarly

tasteless marketing piece from the company who makes the competitive erectile dysfunction drug, Levitra. This drug rep stuck one on each of

our exam room doors without permission, and the stupid things literally could not be pried off. (does the term ‘hard-on’ fail to come to mind

here?) When their rapid removal ruined the finish on the doors, I got so mad. I told the nurses that I would not ever see that rep again.

Apparently this happened in more than one office because he got fired or at least transferred to somewhere in the delta.

He also left some of those bright plastic pens that unfold themselves

slowly and expand into a reasonable semblance of virile manhood that could

then actually be used to write a prescription for the ed drug named on the

side. None of these things is as offensive to me as the television ads inflicted

on the public, and unnecessarily exposing “children of all ages” to ideas and

questions they would be just as well off not knowing…now or ever.

There are also no “free lunches” any more. In reality there never were. I

don’t remember ever enjoying any meal while I was engaged in inspecting

Cytochrome P-450 interactions and Medicare-d formulary coverage. Goodbye

to that! After listening to all that folderol, you need to ingest a few of those

proton pump inhibiting acid reflux pills they were pushing while you scarfed

your Subway sandwich. I have come to feel compassion for these

pharmaceutical sales reps who went to college and earned a marketing or

pharmacy degree but are forced by their companies into becoming lunch

caterers to physician offices.

There are things I will miss. I have a really nice collection of silk Viagra

ties. And I have so many other astoundingly inane pharmaceutical gimmes that

it would set your head spinning. I have a huge box of stuffed animals

representing dozens of different drugs… among them, Zyrtec zebras and


Dwalia South-Bitter, MD


Rhinocort rhinoceros beasts. They lie awaiting the day (like the

misfit toys they truly are) when someone actually wants them and is

actually willing to pay money for them… when some e-Bay

aficionado becomes nostalgic for the tasteless trash that has been

foisted upon the medical profession for the last quarter century.

It appears that my collection’s value grows dearer with the new

rules in place. I have a real problem with throwing things away. I am

not quite a hoarder but sometimes come uncomfortably close. With

these pharmaceutical marketing restrictions in place, I hope our office

space will become at least a bit less cluttered.

Now after all the years of their stupid shenanigans, drug

company excesses have caused activists and lobbyists to convince

Congress of the tawdry nature of these marketing practices. The drug

reps are coming in and telling the doctors that… “If you don’t like the

new regs, then you should blame the AMA. They are the ones who

put a stop to us giving you all the freebies!” Good grief, what else is

the AMA going to get the blame for? Sure, the Gulf oil spill was a

dastardly AMA plot to raise gas prices.

I know that I was never influenced to prescribe a drug by any

of those expensive little doc-toys. A Caribbean cruise might have

done the trick to entice me to write more Cialis, but shucks, now we’ll

never know, will we?

—Dwalia South-Bitter, MD

Ripley

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Physicians (specialists such as

cardiologists, ophthalmologists,

pediatricians, orthopedists,

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• PLaCEmENT/CLaSSiFiED •

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Faster is better. Sometimes you need to get quality life

insurance protection for your family - fast.

is the answer.Quick Life offers an excellent selection of personalized life insurance quotes all from highly-rated life insurance companies and offered by MSMA and The Executive Planning Group.

Online. Fast. It’s easy to get free life insurance quotes for competitively priced policies. Apply on online. We ask the right questions about your specific objectives and then guide you through the application process. We provide the important information you need to make the

right decisions for yourself and your loved ones.

If you prefer personal service, Larry Fortenberry and The Executive Planning Group can give you straight answers you need to make informed decisions.Call1-888-285-9477 or visit MSMAquicklife.com

Shave three to four weeks off the old way of doing business using technology to get you the right protection, right away!



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Life ILife ILife I

may 2010 jmsma

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