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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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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]
may 2010 JOURNaL mSma 131
132 JOURNaL mSma may 2010
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
may 2010 JOURNaL mSma 133
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
may 2010 JOURNaL mSma 135
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.
136 JOURNaL mSma may 2010
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may 2010 JOURNaL mSma 137
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138 JOURNaL mSma may 2010
• 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
may 2010 JOURNaL mSma 139
• 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
140 JOURNaL mSma may 2010
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
may 2010 JOURNaL mSma 141
142 JOURNaL mSma may 2010
• 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.
may 2010 JOURNaL mSma 143
• 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
144 JOURNaL mSma may 2010
• 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
may 2010 JOURNaL mSma 145
• 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
146 JOURNaL mSma may 2010
may 2010 JOURNaL mSma 147
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
—Lucius Lampton, MD, Editor
148 JOURNaL mSma may 2010
• 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
may 2010 JOURNaL mSma 149
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.
150 JOURNaL mSma may 2010
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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
may 2010 JOURNaL mSma 151
Dwalia South-Bitter, MD
152 JOURNaL mSma may 2010
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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