DECEMBER 2011 JMSMA

December 2011

VOL. LII No. 12

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December 2011 JOURNAL MSMA 369

DECEMBER 2011 VOLUME 52 NUMBER 12

Scientific ArticleSBenefit of 3D Volume Rendered CT Scans in the Diagnosis andTreatment of Cardiac Anomalies: A Report of 3 Cases 371Caleb R. Dulaney, BS; Curtis G. Tribble, MD; Andrew L. Rivard, MD, MS

Illicit Bath Salts: Not for Bathing 375Patrick B. Kyle, PhD; Richard B. Iverson, DO; Raghavendran G. Gajagowni, MD;

Lee Spencer, BS

Clinical Problem-Solving: The Confused Teenager 378Amanda W. Rice, MD

PreSident’S PAge AMA Interim Update 387Thomas E. Joiner, MD; MSMA President

editoriAlSouthern Remedy’s Healthy Living: A Portion and Calorie ControlProgram for Mississippi 390Richard deShazo, MD; Deborah Minor, PharmD

relAted orgAnizAtionSMississippi State Department of Health 381

dePArtmentSLegal Ease 382Placement/Classified 403The Uncommon Thread 404

inStructionS for AuthorS 406

Subject index: Volume lii 408Author index: Volume lii 411

About the coVer: j.z. george librAry – Pictured is the law library and home office of the late U.S. Senator James Zachariah George (Oct. 20, 1826 - Aug. 14, 1897), author of the Mississippi Constitution of 1890. His library and home are located on Cotesworth Plantation in North Carrollton, Mississippi. Senator George was an American military officer, lawyer, writer, and politician. He was known as Mississippi’s “Great Commoner.” DreamWorks Studios filmed portions of THE HELP, based on Kathryn Stockett’s 2009 bestselling novel, at Cotesworth Plantation in the summer of 2010. The J. Z. George High School in North Carrollton and George County are both named in his honor. This photograph was taken by Joe R. Bumgardner, MD on premises during the filming of THE HELP movie. Dr. Bumgardner is a retired general surgeon who practiced in Starkville for 30 years. r

Journal of the Mississippi state Medical association (issn 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. correspondence: Journal MSMA, Managing editor, Karen a. evers, p.o. Box 2548, ridgeland, Ms 39158-2548, ph.: (601) 853-6733, fax: (601)853-6746, www.MsMaonline.com. suBscription rate: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available. advertising rates: furnished on request. cristen hemmins, hemmins hall, inc. advertising, p.o. Box 1112, oxford, Mississippi 38655, ph: (662) 236-1700, fax: (662) 236-7011, email: [email protected] postMaster: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 39158-2548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association.

copyright© 2011 Mississippi state Medical association.

official publication of the MsMa since 1959

Lucius M. Lampton, MDEditor

D. Stanley Hartness, MDRichard D. deShazo, MD

AssociAte editors

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PublicAtions coMMittee

Dwalia S. South, MD chair

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

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

and the editors

the AssociAtion

Thomas E. Joiner, MDpresident

Steven L. Demetropoulos, MDpresident-elect

J. Clay Hays, Jr., MDsecretary-treasurer

Lee Giffin, MD speaker

Geri Lee Weiland, MD vice speaker

Charmain Kanosky executive director

2011December

VOL. LII No. 12

370 JOURNAL MSMA December 2011

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• Scientific ArticleS •

Benefit of 3D Volume Rendered CT Scans in the Diagnosis and Treatment of Cardiac

Anomalies: A Report of 3 Cases

Caleb R. Dulaney, BS; Curtis G. Tribble, MD; Andrew L. Rivard, MD, MS

3D volume rendered computed tomography (3D-CT) produces detailed, three-dimensional models that can be rotated and viewed in any orientation to provide a more natural and functional view of the patient’s anatomy. This technology is especially beneficial in diagnosing and repairing cardiovascular anomalies. Three cases are presented where 3D-CT was used to diagnose and plan a course of treatment for patients with cardiac anomalies.

Key WordS: three-DimenSionAl computeD tomogrAphy, Volume renDering, AnomAly

introduction

3D volume rendered computed tomography (3D-CT) produces detailed, three-dimensional models that can be ro-tated and viewed in any orientation to provide a more natural and functional view of the patient’s anatomy. This technology is especially beneficial in diagnosing and repairing cardiovas-cular anomalies.1 Echocardiography is the traditional imaging modality used to evaluate the function and anatomy of cardio-vascular anomalies. Cardiac Magnetic Resonance Imaging (MRI) is a new alternative to echocardiography for evaluating cardiovascular anomalies, and it lacks the radiation exposure of CT. 3D-CT is very useful in evaluating and presenting both intra- and extra-cardiac anatomy of cardiovascular anomalies,

especially in patients with pacemakers or internal cardiac de-fibrillators where MRI cannot be used.2 3D-CT also produces exquisite images and gives the physician a more natural view of cardiovascular anatomy. Three cases are presented in which 3D-CT was used to diagnose and plan a course of treatment for patients with cardiac anomalies.

Patient 1An active, otherwise healthy, 26-year-old male presented

to a referring hospital with the complaint of occasional tachy-cardia and shortness of breath. An echocardiogram showed a sinus venosus atrial septal defect and a hypertrophied right ven-tricle. The sinus venosus atrial septal defect is almost always associated with anomalous pulmonary venous return to the su-perior vena cava (SVC). A 3D volume rendered CT scan, seen in Figure 1, confirmed the sinus venosus atrial septal defect and clearly showed anomalous pulmonary veins from the right up-per lobe of the lung emptying into the SVC. This 3D CT of the patient’s heart provided important anatomical and functional information that was used not only to diagnose the condition but also to plan the operative repair. A patch made from the patient’s own pericardium was used to redirect blood from the anomalous pulmonary veins, through the septal defect and into the left atrium to restore normal systemic and pulmonary cir-culation.

Patient 2A 66-year-old male with a history of acromegaly pre-

sented with a complaint of palpitations. Due to his tall stat-ure, physicians suspicious of Marfan syndrome performed an echocardiogram that showed an enlarged aortic root. Further genetic testing revealed he did not have Marfan syndrome. A 3D volume rendered CT scan, seen in Figure 2, was performed for further evaluation. The 3D rendition of the patient’s heart

AbStrAct

Author informAtion: Mr. Dulaney is a second year medical student. Dr. Tribble is a Cardiothoracic Surgeon and Professor in the Department of Surgery and the Division of Cardiothoracic Surgery. Dr. Rivard is a Radiologist, Assistant Professor, and Director of Cardiac Imaging in the Department of Radiology. All are at the University of Mississippi Medical Center in Jackson, MS.

correSPonding Author: Andrew L. Rivard, MD, MS, Department of Radiology, 2500 North State Street, Jackson, MS 39216.


showed symmetrical enlargement of the sinuses of Valsalva and the aortic root that were within normal limits relative to the patient’s large body size and showed that surgical repair was unnecessary.3 This technology prevented an unnecessary op-eration and will be used in the future to regularly monitor the patient’s aorta.

Patient 3A 42-year-old male was found to have an anomalous left

main coronary artery arising from the right coronary artery and was referred for surgical evaluation. The patient had a history of smoking and dyslipidemia, and his brother died suddenly at a young age from a myocardial event of unknown etiology. A 3D volume rendered CT scan, seen in Figure 3, was used to define the course of the anomalous coronary artery. It showed the left main coronary artery arising as a branch of the right main coronary artery and coursing between the right aortic si-nus and the pulmonary artery outflow tract. The course of the left main coronary artery was thought to be vulnerable to kink-ing between the aortic and pulmonic outflow tracts, and this anomaly has been associated with sudden death.4 The 3D-CT provided information that was not only important for diagnos-ing the condition but also vital in planning the operative repair. The anomalous left coronary artery was successfully dissected 5cm along its course, transected from the right main coronary artery, and re-implanted on the aorta. This re-implantation was supplemented with a graft to the left anterior descending coro-nary artery.

Figure 1: 3D-CT of Patient 1 showing V) anomalous

pulmonary veins emptying into S) the SVC and P) the

normal left pulmonary veins.

Figure 2: 3D-CT of Patient 2 showing S) the sinuses of

Valsalva, A) the ascending aorta, B) the brachiocephalic

artery, and L) the left subclavian artery.

Figure 3: 3D-CT of Patient 3 showing R) the right main

coronary artery giving rise to L) the anomalous left main

coronary artery which courses between A) the aorta and

P) the pulmonary outflow tract.


diScuSSion

The traditional two-dimensional CT scan does not do jus-tice to the complex, three-dimensional anatomical issues that are important for diagnosis, management, and planning of sur-gical operations. Additionally, cardiovascular surgeons think about these issues in the anatomical, three-dimensional form as they encounter them. In such cases, three-dimensional recon-structions are valuable in making plans with a more natural and understandable view of what the surgeon will experience in the operating room. This imaging modality is most beneficial in showing the relationships between vascular structures, as in the cases of patients 1 and 3. 3D-CT can even change the course of therapy in cases where cardiac anatomy, based upon angiog-raphy and echocardiography, is uncertain or where traditional imaging of complex cardiovascular conditions is incomplete.5 The three cases presented here offer a glimpse into the variety of conditions whose management can be made more effectively with 3D-CT.

referenceS1. Zeina AR, Blinder J, Sharif D, et al. Congenital coronary artery

anomalies in adults: non-invasive assessment with multidetector CT. Br J Radiol 2009;82(975):254-261.

2. Broberg C, Meadows AK. Advances in imaging: the impact on the care of the adult with congenital heart disease. Prog Cardiovasc Dis 2011;53(4):293-304.

3. Davies RR, Gallo A, Coady MA, et al. Novel measurement of relative aortic size predicts rupture of thoracic aortic aneurysms. Ann Thorac Surg 2006;81:169-77.

4. Angelini P. Coronary artery anomalies: an entity in search of an

identity. Circulation 2007;115:1296-1305.5. Shi H, Aschoff AJ, Brambs HJ, Hoffman MHK. Multislice

CT imaging of anomalous coronary arteries. Eur Radiol 2004;14:2172-2181.

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• Scientific •

Illicit Bath Salts: Not for Bathing

Patrick B. Kyle, PhD; Richard B. Iverson, DO; Raghavendran G. Gajagowni, MD; Lee Spencer, BS

Background:There has been an increase in the popularity of design-

er drugs known as “Bath Salts” in the United States. These products commonly contain mephedrone, mephylone, methy-lenedioxypyrovalerone (MDPV), or other cathinone deriva-tives with psychoactive properties similar to amphetamine and cocaine. Although recently outlawed, abuse of these products continues to occur in Mississippi.

Methods:We report a 19-year-old male who presented with para-

noia and auditory as well as visual hallucinations. Auditory ef-fects included voices that prompted him to kill people. The pa-tient displayed anxiety, paranoia, and exhibited repeated bouts of inappropriate laughter. Urine toxicology analysis via GC/MS detected MDPV, a compound structurally similar to methy-lenedioxymethamphetamine (MDMA).

Conclusions:Clinicians should be aware that these designer drugs are

not detected with common immunoassay drug screens. Symp-toms most commonly associated with these substances include tachycardia, delusions, hallucinations, and paranoia. Psycho-sis, self harm, and death have been associated with some cases.

Key WordS: mDpV, bAth SAltS, DeSigner DrugS, pArAnoiA, hAllucinAtionS

introduction

There has been an increase in the popularity of a new variety of designer drugs commonly known as “Bath Salts” in the United States. These products have nothing to do with bath-ing, but are synthetic compounds with psychoactive properties. The American Association of Poison Control Centers reported a 20-fold increase in the number of calls related to bath salts from 2010 to August 2011.1 These products commonly contain me-phedrone, mephylone, methylenedioxypyrovalerone (MDPV), or over 15 other phenylethylamines that are structurally related to methylenedioxymethamphetamine (MDMA) and cathinone (Figure 1) a compound found in the khat plant (Catha edulis) native to Africa and Arabia. The synthetic cathinone deriva-tives cause CNS stimulation and a variety of side effects inten-sify with increasing doses.

The synthetic cathinones have been marketed as a vari-ety of products such as bath salts, herbal incense, plant food/fertilizer, or vacuum freshener and have been sold under names such as Ivory Wave, Vanilla Sky, Blizzard, and Energy-1. The products are commonly found in powder or capsular forms and may be snorted, inhaled, injected, or ingested. Bath salts may be obtained via the internet or from convenience stores, gas stations, and smoke shops where prices typically range from $10-$50 for packets containing 50 – 500 mg. Here we report a 19-year-old white male who experienced paranoia and halluci-nations after snorting bath salts. Detection of these compounds, common symptoms, and adverse effects associated with these compounds are also discussed.

cASe rePort

A 19-year-old Caucasian male presented to the emer-gency department with auditory and visual hallucinations. He related that 3 to 4 male voices repeatedly prompted him

AbStArct

Author informAtion: Dr. Kyle is the Associate Director of Chemistry and Toxicology, Assistant Professor of Pathology. Dr. Iverson is house officer, post graduate year 4 in the Department of Pathology.Dr. Gajagowni is house officer, post graduate year 2 in the Department of Psychiatry. Lee Spencer is the Lead Technologist in the Analytical Toxicology Laboratory. All are at the University ofMississippi Medical Center, Jackson, MS.

correSPonding Author: Patrick B. Kyle, PhD, University of Mississippi Medical Center, Department of Pathology, 2500 North State Street, Jackson, MS 39216. Telephone: (601) 984-2352, Email: [email protected].


to kill people, though they did not specify anyone in particu-lar. The patient also indicated that someone was trying to steal his thoughts. These symptoms began several hours prior to presentation. The patient denied homicidal ideations, suicidal gestures, drug abuse, and alcohol consumption. His physical exam was generally unremarkable, but the patient exhibited an odd affect and was slow to respond to questions. His vital signs were: blood pressure 140/80, temperature 37.1°C, pulse 95, and respirations 16. No abnormalities were noted on the patient’s electroencephalogram, and his urine drug screen was negative for amphetamines, barbiturates, benzodiazepines, can-nabinoids, cocaine metabolites, opiates, and phencyclidine.

A psychiatric consultation was subsequently performed during which the patient exhibited illogical thought processes, anxiety, and paranoia. He also displayed poor attention, poor concentration, poor eye contact, and repeatedly laughed inap-propriately. A comprehensive toxicology screen was ordered, and the patient was admitted to the inpatient psychiatry unit where he was administered promethazine and risperidone for psychosis of unknown origin. The following day the patient related that he no longer heard voices, had slept well through the night, and wanted to go home.

Toxicology analysis of the patient’s urine via gas chro-matography/mass spectrometry (GC/MS) revealed the presence of caffeine, cotinine (nicotine metabolite), promethazine, and MDPV, a cathinone derivative. When confronted with these results, the patient said that he and a friend had obtained a prod-uct through an internet website for 20 dollars. After smoking the product, he felt euphoric but soon began experiencing hal-lucinations. The patient also reported using the same type prod-uct two months previously with concurrent hallucinations that were witnessed by family members. A family meeting was con-ducted with the patient’s parents who related observing altered behavior and hallucinations during the previous weeks. The pa-tient was discharged in stable condition the day after admission.

diScuSSion

Synthetic cathinone derivatives cause CNS stimulation via inhibition of dopamine and/or norepinephrine reuptake. Their clinical effects are primarily neurological and cardiovas-cular in origin. Users relate that the effects of these products compare to those of cocaine and methamphetamine. The most common symptoms of patients presenting to the emergency de-partment are agitation, combative behavior, tachycardia, delu-sions, hallucinations, paranoia, chest pain, and hypertension.2,3 However, more serious symptoms and dangerous behaviors include seizures, psychosis, self harm, homicide, and death.4,5,6

As with other illicit drugs, abuse of synthetic cathinones is dangerous for a variety of reasons. In contrast to commercial pharmaceuticals, the safety of these compounds has not been determined and few, if any, animal or human studies have been performed. Due to the lack of adherence to FDA regulations and the absence of quality control measures, the contents of identical packages often differ in potency and/or composition.7

Consumers rarely know exactly what they purchase because the products commonly contain drugs other than those stated.8

These issues increase the risk for serious side effects and the potential for overdose in unknowing individuals.

For these reasons, synthetic cathinones were added to Schedule I during the regular 2011 Mississippi legislative ses-sion and were banned nationwide in September, 2011.9 How-ever, abuse of the drugs continues to be a problem, and Mis-sissippi law enforcement agents continue to confiscate these products from individuals during arrests. Internationally, most chemical suppliers sell the compounds in bulk powder or crys-talline form because pill or tablet forms would invalidate claims that the products are “for research use.” Customs agents often have difficulty identifying packages of the chemicals arriving in the United States because many times they are labeled to make them appear as authentic household goods.10 The packages are also frequently marked “not for human consumption” in order to evade FDA scrutiny. The chemists supplying the market are very innovative and rapidly develop new legal alternatives in response to local and international regulations.

With the many designer drugs available in our society, toxicology analysis using GC/MS is often advisable due to its effectiveness in detecting a wide variety of compounds. While immunoassay drugs of abuse panels generally produce results in less than 60 minutes and are available in nearly every emer-gency department, their scope is limited to the most commonly abused drugs. Although the drugs in illicit bath salts are struc-turally similar to the amphetamines, they will not produce posi-tive immunoassay results. In contrast, analysis via GC/MS re-quires approximately 2 hours for results but is more comprehen-sive because each peak is compared to a commercial library of more than 2000 prescription and over the counter compounds. Analysis using GC/MS has been shown to be significantly more effective than immunoassays in situations involving unknown ingestions11 and may be useful when patient symptoms are not

Figure 1: Chemical structures of A) cathinone, B)

mephedrone, C) methylenedioxymethamphetamine

(MDMA), and D) methylenedioxypyrovalerone (MDPV).

Bath salts may contain a number of designer drugs of

varying potency and/or composition. MDPV was de-

tected in the patient’s urine using gas chromatography/

mass spectrometry.


explained by immunoassay results.12 Interestingly, the patient cost for an immunoassay drugs of abuse screen is usually high-er than analysis by GC/MS.

concluSionS

Abuse of synthetic cathinones is likely to continue despite their illegal status. Clinicians should be aware that these drugs will not be detected with common immunoassay drug screens. Gas chromatography/mass spectrometry (GC/MS), high perfor-mance liquid chromatography or other specialized techniques are required to detect these and other designer drugs.13,14 Medi-cal personnel should keep in mind that designer drugs are often cut or diluted with other psychoactive substances7 which may confound a patient’s clinical presentation. Effective treatment for patients experiencing psychotic episodes includes sedation with intravenous benzodiazepines.15

referenceS1. Canton L. News Release - Poison Control Centers Applaud DEA’s

Ban of Bath Salts. American Association of Poison Control Centers. http://www.aapcc.org/dnn/Portals/0/DEA%20Ban%20on%20Bath%20Salts%209.8.2011.pdf; September 8, 2011. 1-2.

2. Benzie F, Hekman K, Cameron L, et al. Emergency department visits after use of a drug sold as “bath salts”-Michigan, November 13, 2010-March 31, 2011. MMWR Morb Mortal Wkly Rep. 2011;60:624-627.

3. Spiller HA, Ryan ML, Weston RG, et al. Clinical experience with and analytical confirmation of “bath salts” and “legal highs” (synthetic cathinones) in the United States. Clin Toxicol. 2011;49:499-505.

4. Antonowicz JL, Metzger AK, and Ramanujam SL. Paranoid psychosis induced by consumption of methylenedioxypyrovalerone: two cases. [Published online ahead of print, May 25, 2011]. Gen Hosp Psychiatry. 2011. http://www.ncbi.nlm.nih.gov/pubmed/21749840?dopt=Citation. Accessed September 30, 2011. PMID:21749840.

5. Byrd S. Officials fear bath salts becoming the next big drug menace. http://www.washingtonpost.com/wp-dyn/cintent/article/

2011/01/22/AR2011012203854.html. The Washington Post. January 23, 2011.6. Goodnough A, and Zezima K. An Alarming New Stimulant, Legal

in Many States. http://www.nytimes.com/2011/07/17/us/17salts.html?_r=1&pagewanted=all. The New York Times. July 16, 2011.

7. Brandt SD, Sumnall HR, Measham F, et al. Analyses of second-generation ‘legal highs’ in the UK: initial findings. Drug Test Anal. 2010;2:377-382.

8. Baron M, Elie M, and Elie L. An analysis of legal highs-do they contain what it says on the tin? Drug Test Anal. 2011;3:576-581.

9. News Release. DEA Moves to Emergency Control Synthetic Stimulants – Agency will Study Whether to Permanently Control Three Substances. http://www.justice.gov/dea/pubs/pressrel/pr090711.html; United States Drug Enforcement Administration. September 7, 2011.

10. Situation Report. Synthetic Cathinones (Bath Salts): An Emerging Domestic Threat. http://www.justice.gov/ndic/pubs44/44571/44571p.pdf National Drug Intelligence Center, U.S. Department of Justice.Product Number 2011-S0787-004. July, 2011. 1-16.

11. Kyle PB, Spencer JL, Purser CM, et al. Suspected pediatric ingestions: effectiveness of immunoassay screens vs. gas

chromatography/mass spectroscopy in the detection of drugs and chemicals. J Toxicol Clin Toxicol. 2003;41:919-925.

12. Wu AH. Limitations of point-of-care testing in the ED or ICU: a role for regional centralized toxicology laboratories. Clin Pharmacol Ther. 2010;88:295-298.

13. Meyer MR, Wilhelm J, Peters FT, et al. Beta-keto amphetamines: studies on the metabolism of the designer drug mephedrone and toxicological detection of mephedrone, butylone, and methylone in urine using gas chromatography-mass spectrometry. Anal Bioanal Chem. 2010;397:1225-1233.

14. Ojanpera IA, Heikman PK, and Rasanen IJ. Urine analysis of 3,4-methylenedioxypyrovalerone in opioid-dependent patients by gas chromatography-mass spectrometry. Ther Drug Monit. 2011;33:257-263.

15. Ross EA, Watson M, and Goldberger B. “Bath salts” intoxication. N Engl J Med. 2011;365: 967-968.

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• clinicAl problem-SolVing •

The Confused TeenagerAmanda W. Rice, MD

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

A 13-year-old white male presented to a rural emergency room. He appeared lethargic with altered mental status and a temperature of

103˚F. Due to his Glasgow Coma Scale score of 10, he was intubated and transported to a tertiary hospital. On arrival he had a temperature of 104˚F, pulse of 99 beats per minute, respirations of 13 breaths per minute and blood pressure of 104/78 mmHg. His head examination was normal with no signs of trauma. His pupils were equally round and reactive to light, and no lymphadenopathy was noted. His cardiovas-cular examination revealed a regular heart rate and rhythm with no murmurs or rubs. His lungs were clear to ausculta-tion bilaterally. His abdomen was soft, nontender and non-distended with normoactive bowel sounds. His neurological examination indicated positive stimulation to pain, hyper-reflexia and normal sensory. Integumentary examination revealed a left face abrasion and a left shoulder abrasion.

The patient allegedly had been involved in a fight at school that afternoon. The patient’s mother and stepfather stated that the patient mumbled his words and was hard to understand after he arrived home from school. The pa-tient stated, “Don’t feel good, going to lay down, didn’t do homework, can’t play.” Around 9 pm the stepfather heard a “thud” and found the patient in bed “throwing arms around and grunting.” When the mother entered his room she observed both arms flexed to chest, feet pointed, mus-cles tight and pupils constricted. She was not sure how long the episode lasted but did not notice any urine loss or tongue biting. The stepfather laid the patient on the floor to prevent injury. Once on the floor the patient began “flailing his arms and rolling around.”

In a 13-year-old male with a possible seizure and al-tered mental status, I am concerned about toxin ingestion or drug overdose. However, without a more detailed history, the differential is very broad. Another concern is trauma or an in-

fectious cause such as meningitis or encephalitis, especially because he has a temperature of 104°F. Ischemic causes such as stroke are unlikely due to his age; however, they cannot be ruled out until a more thorough medical history is obtained.

The patient’s presentation and history provided by the par-ents makes me concerned about trauma or infection. I want to begin with computed tomography (CT) to investigate for emer-gent causes such as a hemorrhage or any type of head injury.

Records from the rural hospital indicated a negative head computed tomography (CT), and repeat head, chest, abdomen and pelvic CTs as well as a magnetic resonance imaging (MRI) of the head were also negative. A lumbar puncture indicated protein 69 mg/dL, glucose 159 mg/dL, WBC 2 mg/dL and Gram stain negative. The patient was then prescribed multiple medications including acyclovir (Zovirax), vancomycin (Vancocin), and ceftriaxone (Ro-cephin) as broad coverage for possible infection due to his high fever.

The MRI and CT do not indicate hemorrhage, vasculitis or ischemic stroke. It appears that head trauma is not the cause of this patient’s symptoms. I still am concerned about toxic in-gestion or drug overdose. I also remain concerned about infec-tious causes, particularly meningitis or encephalitis, and will continue treatment with antiviral and antibacterial medications. I continue to suspect that the history is not complete, and some-thing appears to be missing from this presentation. The situa-tion at school also directs my attention to possible psychosocial causes or psychiatric diagnoses including pseudoseizures.

The patient’s medical history included a normal vagi-nal birth that was full-term with no complications. He was diagnosed with attention deficit hypersensitivity disorder but was not taking medication. He had been hospitalized following a reaction to succinylcholine during surgery for a hand injury. He was also hospitalized 2 years ago for a foot Staph infection. His immunizations were up to date. He lived with his mother and stepfather and was the oldest of 6 children. His parents denied a history of alcohol or il-licit drug use or smoking. The family had 2 cats and 2 dogs. The patient’s family history included a 10-year-old brother

correSPonding Author: Amanda W. Rice, MD, Private practice, Collins Family Practice Clinic, 704 5th St., Collins, MS 39428, 601-765-4414. Email: [email protected].


who was taking valproic acid (Depakote), oxcarbazepine (Trileptal) and quetiapine (Seroquel) for oppositional defi-ant disorder, bipolar disorder and epilepsy status post head injury from an accident as an infant. The patient’s mother was diagnosed with manic depressive disorder and had sev-eral suicide attempts, including one while 5 months preg-nant with the patient. The patient’s maternal grandmother was diagnosed with epilepsy and bipolar disorder and had a failed suicide attempt.

The patient’s family history raises multiple concerns. He has access to multiple medications that can be toxic if ingest-ed in large amounts. I want to question the parents about any medication missing from the prescription bottles. He also has a family history of epilepsy. Epilepsy can first present in the teen-age years and has a strong genetic link. His seizure could be a pseudoseizure which is often triggered by a stressful event such as abuse. We still cannot rule out infectious causes.

The patient’s white blood cell count was elevated at 23.8 k/uL. His creatine kinase was also elevated at 1223 IU/L. His mass toxicology screen was positive for benzo-diazepines but otherwise negative. The patient’s urinalysis had positive protein, moderate blood, >1000 mg/dL glucose, 40 ketones and 32 mg/dL red blood cells. The remainder of the patient’s initial laboratory studies indicated normal electrolytes, hemoglobin, hematocrit and liver panel.

An elevated white blood cell count initially hints at a pos-sible infection. However, white blood cells can also become el-evated with emotional or physical stress such as a seizure or due to some medications, particularly corticosteroids. His abnormal urinalysis may be due to infection but can also be a result of severe dehydration or illness. The presence of red blood cells in the urine is a possible indication of tissue damage, which can occur with seizure activity or rhabdomyolysis. The cerebrospi-nal fluid low white cell count and elevated glucose make central nervous system infection questionable.

The patient was hospitalized and extubated after he was monitored in the pediatric intensive care unit over-night. He was then transferred by neurosurgery to the gen-eral floor. He returned to his neurological baseline by the end of day 1 except that he was still inattentive and could not recall events leading to his hospitalization. On day 3, however, he was able to recall person, place and time, but during that afternoon the patient’s mental status regressed. The patient began to urinate on himself. Neurology at-tempted an electroencephalogram (EEG), but the patient became combative and the test could not be performed. All laboratory studies remained negative, including blood cultures and cytomegalovirus, but several viral panels were still pending. The patient also remained afebrile. Psychiatry suggested risperidone (Risperdal) to avoid restraints and escalation of combative episodes. However, the patient’s mother did not want antipsychotics started and preferred that restraints be placed.

The patient’s behavior causes concern of a psychiatric di-agnosis such as psychosis, factitious disorder or delirium. De-lirium can occur due to a change of environment but generally waxes and wanes. It is unusual that the patient would appear to improve and then become worse if the cause is a toxic in-gestion. We are hesitant to start an antipsychotic medication as we are not sure if the behavioral changes are psychological or related to his undiagnosed illness.

On day 4 the patient began to develop hallucinations and strabismus with an altered gaze. Ophthalmology diag-nosed possible involuntary convergence spasms. A repeat EEG was negative for seizure activity. The patient began uncontrolled vomiting. A repeat MRI showed mastoid and sphenoid sinus inflammation along with minimal sig-nal change on the frontal lobe but was otherwise normal. A repeat creatine kinase was 6754 mg/dL in the morning and 4358 mg/dL in the evening; therefore, we began to ag-gressively hydrate the patient. A repeat lumbar puncture resulted in protein 113 mg/dL (initially 69), glucose 54 mg/dL (initially 159) and WBC 12 mg/dL (initially 2), but the Gram stain was still with no white blood cells or organisms. Other studies that had been drawn on admission, including ammonia, human immunodeficiency virus, HbA1c, blood culture, cerebrospinal fluid (CSF) culture, CSF herpes sim-plex virus, enterovirus and Epstein-Barr virus were all neg-ative. However, Bartonella Henselae IgG titer was positive at 1:1024. IgM was negative.

Up until the point at which his altered gaze occurred, I had been skeptical about this patient’s presentation and had be-come more concerned about psychiatric causes. The elevated CPK is concerning for rhabdomyolysis, possibly due to his initial seizure activity. The lumbar puncture (LP) was repeated due to the patient’s acute mental changes. The changes in the CSF are consistent with an infectious cause as evidenced by the elevated white blood cell count and lowered glucose. Since the patient is being treated for meningitis, the change in his LP is unclear. The MRI results are nonspecific but raise suspicion for brain inflammation due to the signal change, in contrast with his previous MRI that was normal. Bartonella Henselae appears positive; however, IgG is associated with immunity in a patient. IgM is the immediate antibody indicating possible infection.

On day 5 the patient improved significantly and ap-peared to be at his neurological baseline so antibiotics were discontinued. Restraints were removed after psychiatric reevaluation indicated improvement in his symptoms as well. By day 8 the patient’s strabismus resolved, and his mental status significantly improved. On day 10 the patient reached his baseline prior to hospitalization and was dis-charged with diagnosis of “altered mental status, resolved.” Two days following the patient’s discharge we were contact-ed by the health department, notifying us that the patient had a positive arbovirus. The final diagnosis for the patient was West Nile encephalopathy.


Although his social history and some of his behavior seemed to defer our final diagnosis, the initial presentation and disease course of the patient is consistent with a viral encepha-lopathic disease as confirmed.

The patient was scheduled to follow up with pediatric infectious disease and outpatient psychiatry. He was also scheduled for an EEG 2–3 months from discharge. How-ever, the patient was readmitted 12 days after discharge for slurred speech, extreme agitation and hallucinations. He had been doing fine except for a mild tremor of his hands that affected his writing. There was no change in a repeat MRI, and the patient was monitored overnight. He improved quickly and was discharged with resolved “post viral encephalopathy.”

commentAry

Altered mental status is a common presentation that is often nonspecific. It is important to realize that the differential for altered mental status and seizure are similar. At times it is difficult to determine if the seizure is a result or the cause of the mental status change.1

West Nile virus transmission occurs from birds to humans via mosquito bite.2 Although humans are often asymptomatic, the common signs in symptomatic patients include fatigue, nausea, vomiting, eye pain, headache, myalgias, arthralgias, lymphadenopathy and rash.3 Approximately 1 out of 150 pa-tients develop severe neurological symptoms such as fever, meningitis and encephalitis,3 which this patient had.

Nonspecific laboratory findings include leukocytosis, anemia and even lymphopenia. MRI and CT scans are often negative unless inflammation is present. The most specific test for West Nile virus is enzyme immunoassay (EIA) with plaque reduction neutralization which can use either serum or CSF.4 This test is considered diagnostic, and most state and lo-cal health departments perform the test within 24–36 hours of submission.3 Written reports are usually not sent to the initial admitting medical facility for a minimum of 2 weeks, hence the reason the diagnosis for this patient was not confirmed until he was actually discharged from the hospital.5

Treatment for West Nile virus is supportive including flu-id and electrolyte replacement which was done in this patient. Although this patient was initially treated with antibiotics, these medications have shown no effect on improving the outcome of West Nile virus.6 Less than 1% of patients have residual tremors following infection, which this patient did have as well.7

In conclusion, an adolescent patient presenting with men-tal status changes and seizure must be evaluated for fatal causes such drug overdose, toxic ingestion and meningitis. Although the social environment and family psychiatric history of this patient raised strong concerns about psychiatric causes, the pa-tient’s symptoms continued to progress initially. The symptoms associated with West Nile virus are vague; therefore, labora-tory test are needed to confirm the diagnosis. Imaging is often

negative or nonspecific. The test of choice is EIA which is per-formed by local and state health departments. Last, antibiot-ics have not been shown to improve prognosis, and supportive treatment with fluids is the only current therapy.

Key WordS: ADoleScent, VirAl infectionS, AltereD leVel of conSciouSneSS

referenceS1. Slattery DE, Pollack CV. Seizures as a cause of altered mental

status. Emerg Med Clin North Am. 2010;28(3):517–534.2. Sampathkumar P. West Nile virus: epidemiology, clinical

presentation, diagnosis, and prevention. Mayo Clin Proc. 2003;78(9):1137–1143.

3. Huhn GD, Sejvar JJ, Montgomery SP, Dworkin MS. West Nile virus in the United States: An update on an emerging infectious disease. Am Fam Physician. 2003;68(4):653–660.

4. Takasaki T. West Nile fever/encephalitis. Uirusu. 2007;57(2):199–205.

5. CDC.gov West Nile Diagnostic Testing. Available at: http://www.cdc.gov/ncidod/dvbid/westnile/wnv_DiagnosticTesting.html. Acessed October 9, 2008.

6. Dean JL, Palermo BJ. West Nile virus encephalitis. Curr Infect Dis Rep. 2005;7(4):292–296.

7. Sejvar JJ. The long-term outcomes of human West Nile virus infection. Clin Infect Dis. 2007;44(12):1617–1624.

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• legAl eASe •

WHAT IS HITECH, AND WHY SHOULD I CARE? As a physician, if you are not already familiar with the changes imposed by the Health Information Technology for

Economic and Clinical Health Act (“HITECH”), you need to be, regardless of your specialty, nature or size of your practice. HITECH imposes new responsibilities for data security on practically all health care providers and puts teeth into HIPAA privacy and security requirements through a new enforcement mechanism which includes mandatory compliance audits and significantly enhanced civil penalties for violations.

The primary danger HITECH poses to the average physician is that many are simply unaware of HITECH regulations and/or the consequences of failure to comply. It is unlikely that any physician reading this article is part of a practice group which is fully HITECH compliant because the old policies and procedures which adequately addressed HIPAA requirements are simply inadequate after HITECH. Savvy health care providers have been planning and working toward HITECH compliance for almost 2 years. If you or your practice group have not kept up with developments, then you are playing catch-up, and the time to act is NOW.

The purpose of this article is to promote awareness and provide an overview of one aspect of HITECH which should be of immediate concern to all practitioners. Those who do not take the new HITECH regulations and enforcement seriously are likely to regret it.

BACKGROUND AND PURPOSES OF THE HITECH ACTHITECH was a major component of the American Recovery and Reinvestment Act (“ARRA”, a.k.a., “the Stimulus

Package”), signed into law on February 17, 2009. The enactment of HITECH is an acknowledgement by the government that security and privacy concerns must be alleviated for both the public and the health care industry to embrace the shift to electronic health records systems. See generally President’s Council of Advisors on Science and Technology, Exec. Office of the President, Report to the President Realizing the Full Potential of Health Information Technology to Improve Healthcare for Americans: The Path Forward (Dec. 2010).

To address these concerns, HITECH effects major changes to the HIPAA Privacy and Security Rules, affecting both covered entities and their business associates.

TO WHOM DOES HITECH APPLY? HITECH incorporates the definitions of “covered entity,” “business associate,” and “protected health information” used

in the HIPAA Rules, 45 C.F.R. § 160.103. HITECH privacy and security requirements apply to both “covered entities” and “business associates.” While the full legal analysis of whether a specific person or entity is a “covered entity” can be a complex issue, it should suffice to say that any physician or other health care provider who bills or submits claims electronically is a covered entity. As a reminder, the term “business associates” includes those persons or entities which provide legal, actuarial, accounting, consulting, data aggregation, data analysis, data processing, management, administrative, secretarial, billing, claim processing, dietary, purchasing, financial, accreditation or other services to a covered entity. 45 C.F.R. § 160.103.

Prior to HITECH, business associates were not directly subject to HIPAA or HHS enforcement actions. The applicability of HIPAA security and privacy requirements to business associates was purely contractual, the result of the inclusion of compliance provisions in business associate agreements by covered entities. Under HITECH, business associates must now comply with the HIPAA Security Rule and are directly subject to civil and criminal penalties. 42 U.S.C. § 17934 (2009). If your practice has existing business associate agreements, those agreements need to be reviewed by legal counsel and may require revision to ensure compliance and maximize your protection. While the primary responsibility for reporting a breach of security under HITECH falls on the covered entity, the failure of business associates to appropriately address HITECH requirements can have a substantial impact on the entity.

In sum, HITECH applies to any physician (or medical group) who bills or submits claims electronically and to all business associates under contract to provide services to the physician or group.

Think HITECH-HIPAA Changes Don’t Apply to You? Think Again!

An Overview of the Breach Notification Requirements, Exceptions, Enforcementand Enhanced Penalties Under the Health Information Technology

for Economic and Clinical Health (“HITECH”) Act

Paul E. Barnes, Esq.


WHAT ARE THE BREACH NOTIFICATION REQUIREMENTS? Breach notifications must met specific requirements which are discussed at length in the unabridged version of this article

available online at www.MSMAOnline.com.

WHAT IS A “BREACH” OF SECURITY?As a reminder, the HIPAA Privacy Rule (and therefore the HITECH regulations) applies to “Protected Health Information”

or “PHI” which includes all individually identifiable health information held or transmitted by a covered entity or its business associate, in any form or media, whether electronic, paper, or oral. Individually identifiable health information is all information that relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual.

So exactly what is considered a “breach” of data security which triggers the notification requirements, and how do you determine whether a breach has occurred?

• “Breach” is defined as the acquisition, access, use or disclosure of protected health information in a manner not permitted under the Privacy and Security Rules which compromises the security or privacy of the protected health information. 45 C.F.R. § 164.402.

• The unauthorized access is considered to “compromise the security or privacy of the protected health information” if the disclosure poses a significant risk of financial, reputational, or other harm to the affected individual. 45 C.F.R. § 164.402(1)(i).

The core concept for analyzing possible security breaches is “risk assessment.” By definition, unless the disclosure of the information poses a “significant risk of harm” to the affected patient(s), no breach has occurred. Performing a complete and accurate risk assessment of a suspected breach and documenting each step of that analysis is the key to determining whether a breach has occurred, and if so, whether the notification requirements have been triggered. If a reportable breach has occurred, HHS will require specific information concerning the breach. Even if you determine that no breach has occurred, you must document each step of your analysis so that if an investigation is later begun, either as the result of a complaint or an audit, you can justify your decision and actions.

It is important to note that under the regulation, the harm to the affected patient(s) can be financial, reputational, “or other harm,” which means that risk assessment must be an open-ended inquiry. Therefore the type of information impermissibly accessed or disclosed must drive the risk assessment process. For example, if the information indicates the type of services that an individual received or includes information that increases the risk of identity theft, HHS considers the risk of harm more likely to be substantial. The agency discussion preceding the text of the regulations notes that the risk of reputational harm from the disclosure of information concerning such sensitive matters as substance abuse, sexually transmitted diseases or mental health is obvious but emphasizes that many other forms of health information can be equally sensitive.

Exclusions: The regulations include three express exclusions for types of disclosures which do not constitute breaches of security: • “Breach” does not include any unintentional acquisition, access, or use of PHI by a member of the entity’s workforce,

if it occurs in good faith, within the scope of authority, and does not result in the further impermissible use or disclosure of the PHI. 45 C.F.R. § 164.02(2)(i).

• “Breach” does not include any inadvertent disclosure from one authorized person to another authorized person at the same covered entity which does not result in the further use or disclosure of the PHI. 45 C.F.R. § 164.02(2)(ii).

• “Breach” does not include disclosure of PHI where a covered entity or business associate has a good faith belief that an unauthorized person to whom disclosure is made would not reasonably have been able to retain such information. 45 C.F.R. § 164.02(2)(iii).

DID A REPORTABLE BREACH OF SECURITY OCCUR? When a provider suspects that a possible breach has occurred, a thorough investigation, i.e., risk assessment, must be

performed. The risk assessment must be fact specific, tailored to the unique facts and circumstances of the particular breach, including the nature and amount of information accessed. A suggested starting framework for performing the investigation and risk assessment is as follows:

STEP 1: Was the information acquired/accessed/ disclosed protected health information “PHI”? (If not, HIPAA/HITECH breach notification is not implicated, and there was no breach.)

STEP 2: If PHI was involved, next determine the risk of financial, reputational, or other harm to the affected patient(s) and whether the risk of harm is substantial. The following types of questions should be answer in performing a risk assessment: • Who impermissibly used the PHI, or to whom was the information impermissibly disclosed? • What was the type and nature of the data which was accessed/disclosed? • What type of harm(s) could occur to the affected patient(s) because of the impermissible disclosure? • How many patients are affected? • Where was the PHI stored? • What format was the information in? Was it paper or electronic? What type of electronic format?


• What security measures were protecting the PHI? • Why were the security measures inadequate? • Exactly how was the PHI accessed/disclosed? • What measures need to be taken to prevent this type of unauthorized disclosure/access in the future?

If the risk assessment reflects that the risk of harm was not substantial, then there was no breach. Stop and document each step of the risk assessment and related investigation for use in future enforcement investigations or audits. However, if the risk assessment reflects that the potential harm is substantial move to Step 3:

STEP 3: Does the “safe harbor” apply? (If yes, breach notification is NOT required.) • If electronic PHI: Was it encrypted per HHS standards? • If paper or electronic PHI: Was it destroyed prior to use?

STEP 4: If the safe harbor does not apply, determine whether an exception applies. (If yes, breach notification is not required • Exception #1: The disclosure of PHI was made to a person who would not reasonably be able to retain it. • Exception #2: Unintentional disclosure of PHI by employee/individual in course of job and the covered entity can

obtain assurances that there will be no further disclosure. • Exception #3: Inadvertent disclosure by an authorized individual within the covered entity and the covered entity can

obtain assurances that there will be no further disclosure.

STEP 5: If PHI was involved, the risk of harm was substantial, and neither the safe harbor nor any of the express exceptions applies, then a breach has occurred and you must:

STEP 6: Proceed with notification.

Document each step of the risk assessment and related investigation for use in reporting the breach to HHS, as well as for future enforcement investigations or audits.

A good way to understand the type of information and level of detail which needs to be contained in your risk assessment documentation is to look at the HHS interactive breach notification website, located at http://transparency.cit.nih.gov/breach/index.cfm. To complete the required electronic notice report to HHS in the event of a breach, the following information is required:

• Date of Breach; • Date of Discovery; • Approximate Number of Affected Individuals; • Type of Breach (theft, loss, improper disposal, unauthorized access/disclosure, hacking/IT incident, unknown); • Location of the breached information (laptop, desktop, network server, e-mail, other electronic portable device); • Type of PHI Involved in the Breach (demographic, financial, clinical or other); • A Brief Description of the Breach; • Safeguards in Place Prior to Breach (firewalls, packet filtering (router-based), secure browser sessions, strong

authentication, encrypted wireless); • Notice of Breach and Actions Taken (date(s) individual notice provide, whether substitute notice was required,

whether media notice was required); • Actions Taken in Response to Breach (security and/or privacy safeguards, mitigation, sanctions, policies and

procedures, and “other”); and last, but not least: • Attestation that to the best of the reporting person’s knowledge, the information contained in the report is accurate.

The information listed above must be reported to HHS for each and every breach which occurs. It goes without saying that in light of the required information, HITECH breach notification and reporting is very serious business. Having policies and procedures in place to guide the risk assessment and breach notification processes are crucial to ensuring adequate compliance with HITECH.

NOTIFICATION TO INDIVIDUALS Following the discovery of a breach, a covered entity must notify each affected individual whose unsecured PHI has

been, or is reasonably believed to have been, accessed, acquired, used or disclosed as a result of the breach. A full discussion of notifications content and method is available in the unabridged version of this article.

NOTIFICATION TO HHSIn addition to providing notification to the affected individual(s), a covered entity must also notify HHS of any breach.

However, the timing of the notice depends on the number of affected individuals. As noted above, the HHS interactive breach notification page is located at http://transparency.cit.nih.gov/breach/index.cfm. For breaches affecting more than 500 individuals,


the breach must be reported to HHS as well as the individuals within 60 days of discovery of the breach. Breaches affecting less than 500 individuals may be reported on an annual basis, no later than 60 days after the end of the calendar year. The annual deadline for reporting breaches discovered in 2011 is February 29, 2012.

HITECH PENALTIES AND ENFORCEMENTFor the limited purposes of this article, a brief summary of the enhanced enforcement and penalties provided by HITECH

must suffice. HHS published an interim final rule on October 30 to modify the existing HIPAA Enforcement Rule in order to comply with HITECH. The modified Enforcement Rule took effect on November 30, 2009.

The modified Enforcement Rule contains an exhaustive enforcement procedure in keeping with the substantially enhanced penalties available under HITECH for violations. Prior to HITECH, enforcement of the HIPAA Privacy and Security Rules was primarily “complaint-driven.” Monetary fines were rarely imposed, and even when imposed, the penalties were relatively small. The lack of enforcement of HIPAA security and privacy requirements led to the increased enforcement “teeth” contained in HITECH.

Under HITECH, the enforcement procedures include formal investigations by HHS, as well as mandatory compliance audits. Prior to HITECH, under HIPAA, civil money penalties were limited to $100 per violation, with a maximum of $25,000 for identical violations during a calendar year. These penalties continue to apply for violation occurring prior to February 18, 2009. HITECH provides for four tiers of civil penalties (for both covered entities and business associates):

• Tier One – for violations of which the covered entity did not know, and by the exercise of reasonable diligence, would not have known

Civil Penalty: $100 - $50,000 per violation, not to exceed $1.5 million for violations of an identical provision in a calendar year;

• Tier Two – for violations due to reasonable cause, and not due to willful neglect Civil Penalty: $1,000 - $50,000 per violation, not to exceed $1.5 million for violations of an identical provision in a

calendar year; • Tier Three – for violations due willful neglect, but which were corrected within 30 days after the covered entity

knew, or by the exercise of reasonable diligence, would have known, of the violation Civil Penalty: $10,000 - $50,000 per violation, not to exceed $1.5 million for violations of an identical provision in a

calendar year; • Tier Four – for violations due willful neglect, but which were not corrected within 30 days after the covered entity

knew, or by the exercise of reasonable diligence, would have known, of the violation Civil Penalty: at least $50,000 per violation, not to exceed $1.5 million for violations of an identical provision in a

calendar year.

The enhanced civil penalties should get the attention of every health care provider because they potentially apply to you. Before HITECH, proof that a covered entity lacked knowledge of a violation would allow the entity to avoid civil penalties. After HITECH, lack of knowledge is not a defense; it just places the violator in the lowest tier of penalties.

In closing, HITECH imposes a number of additional requirements on healthcare providers, including but limited to the breach notification requirements. The implementation of mandatory policies and procedures related to data security as well as the training requirements for a provider’s workforce require substantial advance planning in order to comply with regulatory requirements. Moreover, a provider must have in place policies and procedures to investigate possible breaches, to determine whether a breach has occurred, and to trigger appropriate notification requirements. Although compliance with the regulatory requirements will require an investment of time, effort and money, in the long run that investment should more than pay for itself. Otherwise, the future expense for violations is likely to be considerably higher.1

The information in this article is for informational purposes only. The publication, transmission, display, and provision of this information is not intended to be an offer of an attorney-client relationship with the author, his law firm, or any of its attorneys, and is not legal advice. You should not act upon any information you receive from this article. Competent legal representation depends upon careful and specific attorney analysis of any legal problem, need or issue that you may have, which can only be provided upon specific mutual engagement to act as your attorney.

1. For additional information concerning recordkeeping and other administrative requirements of HITECH, please see the unabridged version of this article available at www.MSMAonline.com.

Paul E. Barnes, Esq. is a shareholder with the law firm of Wise Carter Child & Caraway, P.A., who practices in the areas of complex commercial litigation, health care, medical malpractice defense, intellectual property, and personal injury defense. Mr. Barnes is a frequent speaker on health care issues, including health information technology, health care reform, and e-Discovery. The author would like to thank William J. Dukes, Esq. for his invaluable assistance in the preparation of this article. For more information on any of the matters discussed in this article, the author may be contacted by telephone at 601-968-5538, or by email at [email protected].


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Just returned from the AMA interim meeting in New Orleans, and I have to report your AMA delegation represented you well, as they always do. In fact, a

resolution jointly sponsored with the Alabama delegation calling for the ICD-10 codes to be put on hold passed with ease, hopefully helping to prevent another obstacle to everyday practice. This would (or will) cause us all headaches trying to code the simplest of procedures and cost untold amounts in a time when we are all trying to save healthcare dollars. Maybe someone will listen.

In addition, Resolution 215 pushed by our delegation calling for a fair and balanced RAC program also passed with minimal

resistance. If this can be accomplished, then your MSMA efforts will be well worth the time and expense to you for now and years to come. The resolutions supporting the right to privately contract (which I was particularly fond of) and for the establishment of national tort reform also were supported by MSMA and passed with relative ease. Scope of practice issues were also a big topic, and several resolutions dealt with this.

Overall the take home message from this meeting is that with all the attacks on our practice from inside and out, the AMA seems to have jelled into a body that is now becoming concerned with protecting the practice of medicine as we all know it. It is great to see but tragic that it comes so late. I would like to see us become less reactive and more proactive. The good thing is that your delegation seems to be one of the more proactive groups there, and working with other states has made our voice heard. This needs to continue. Like I have always said, the AMA is our voice whether we like it or not, and we need to be there trying to get our point across.

On a separate note, I call your attention to Dr. Richard deShazo’s editorial in this issue on Southern Remedy’s Healthy Living portion and calorie control program for Mississippi. This document is the results of over a year’s work to create useful tools that Mississippi health providers can use in their offices and elsewhere to assist patients in weight loss and control. There is a component for adults as well as one for children. Developed with the support of public broadcasting, the program has their brand as a state agency although any physician, hospital or other group who wants to use it can co-brand it. Because the goal is to disseminate the materials into the state as quickly as possible, Southern Remedy is offering the healthy living program to MSMA membership first. Additionally, it will be used in church-based community health advocate training programs and in the obesity area of our MS Healthy Schools programs.

Well, Goldikova finished third after being boxed on the fence in the Breeders’ Cup mile, but that’s why they call it horse racing! I wish you and your family a winning year with very best for health, happiness, and prosperity. Merry Christmas!

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• eDitoriAl •

introductionObesity is a scourge on Mississippi’s future and on our friends and families. Seven years of life lost for obese individuals

is a shame, especially since, for many, it is a fixable problem. A little over a year ago during a trip to the Delta, our Southern Remedy video crew took a lunch break at The Blue Biscuit in Indianola across the street from the B.B. King Museum. The food was okay, but the company was great. Among the group was a UMC Family Practice Training Program graduate who was now very busy in his Indianola practice. We struck up a conversation and he wanted to know more about our project as we were filming for the Mississippi Public Broadcasting documentary series, Mississippi’s BIG Problem. That led to a conversation about his struggles in trying to help his patients with obesity. We asked what he felt was needed to help address and manage weight issues in his practice. He quickly replied, “Weight management tools with a Mississippi flavor to use with our patients.” We told him we would work on it.

Since that lunch, a group of physicians, pharmacists, dieticians, diabetic nurse educators, and physical therapists have been working on a patient-centered, non-diet, weight and lifestyle management program for use by Mississippians. For lack of a better term, we call it Southern Remedy’s Healthy Living. An age-specific exercise and fitness program is under development, but we wanted to go ahead and share what we have available with you, especially since Medicare now provides reimbursement for weight management.

PhiloSoPhyThe dietary and weight management component of Southern Remedy’s Healthy Living is a dietary choice, portion and

calorie control program designed to be used by health professionals in their practices, community health advocates in their churches, civic and other groups, and individuals who wish to use it on their own. It is not a diet but is a dietary and lifestyle change tool. Much of the philosophy behind the program has come from lessons learned with tobacco cessation efforts and incorporates “readiness for change,” that is, readiness for a permanent lifestyle change, not just another diet. We describe components of the program below, with instructions for use of the various elements and supplemental Healthy Living Guides. To order these materials, contact [email protected].

Southern Remedy’s Healthy Living Materials and a description of Southern Remedy’s Healthy Living Program

We have provided this handout as an overall description of the program components, the rationale behind each component and how to incorporate them in different settings. It is for your office staff or others teaching the program (Table 1-Page 393).

nAVigAting Southern remedy’S heAlthy liVing ProgrAmNavigation of the program starts with determining

an individual’s body mass index (BMI). Depending on the individual’s BMI status, a calorie and portion control program follow (Figure 1). Appropriate medical evaluation, preventive care and healthy living are encouraged for all. In addressing overweight and obesity, the target of the program is a BMI in an acceptable range. For individuals, knowing their BMI is just as important as knowing their glucose, lipid, and blood pressure values. Persons should know their BMI and know what a normal and target BMI should be. For those who are overweight or obese, significant improvement in medical outcomes can occur with as little as a 10 percent weight loss.

Southern Remedy’s Healthy Living: A Portion and Calorie Control Program for Mississippi

Richard deShazo, MD; Deborah Minor, PharmD

Figure 1

Navigating Southern Remedy’s Healthy Living

Check

BMI

Furthermedical

evaluation,ifneeded

Keepahealthy

BMIforyou

Child

UseSouthern

Remedy’s

HealthyEatingPlate

Adult

UseSouthernRemedy’s

FoodChallenge&

HealthyEatingPlate

BMInormal

(20‐25)

¥ Knowyourothernumbersandkeepfit

¥ Appropriatemedicalevaluationandpreventivecare

¥ UseSouthernRemedy’sHealthyLivingProgram

BMIlow

(Lessthan20)

BMIhigh

(Morethan25)

WeightControl

Indicated

Figure 1: Navigating Southern Remedy’s Healthy Living

Program


Southern remedy’S food chAllenge With tiPSThis Food Challenge is a readiness activity for your patients and others that includes tips for success. Again, a handout is

provided (Table 2-Page 396). If individuals are not willing to take these simple steps to a healthier lifestyle, they are not ready to move on to the Healthy Eating Plate in making dietary choices and portion control. Most people will lose considerable weight on this part of the program over 2 to 3 months. This document is self-explanatory and there is no guide for it.

Southern remedy’S heAlthy eAting PlAte for AdultSThe Healthy Eating Plate (Figures 2 & 4) is based on the new United States Department of Agriculture guidelines and an

adaptation of the initiative: www.choosemyplate.gov. It is designed to facilitate choices and changes that can lead to weight control and a healthier life. For ease in distribution, we chose to use a placemat with a 7 inch salad plate as a guide for healthfulchoices. The goal of the Southern Remedy Healthy Eating Plate is to facilitate a weight loss of approximately 1 pound per week, which requires a reduction of 3500 calories per week or 500 calories per day from the individual’s existing calorie intake. Once a plateau in weight loss has occurred, an additional caloric reduction must occur. Exercise is complimentary, important for overall fitness and cardiovascular health, but is an inefficient way to lose weight compared to decreased calorie intake.

The placemat includes the food groups highlighted with breakfast on one side and lunch and dinner on the other. The information on these placemats is self explanatory for many people although it takes a little work to understand a portion and calorie control program, even one as simple as this. It takes more work to position yourself and your staff to explain this to patients, particularly those with limited literacy. To help with this, we have developed Healthy Living Guides for teaching use of this plan and also one for individuals who want to “do it yourself” (Tables 3 and 4). The bottom line is that a choice of one serving of food in the portions given from each of the five categories for lunch and dinner and the four categories for breakfast plus two snacks provides 1400 - 1600 calories per day, the minimal calorie restriction without close medical supervision. We suggest individuals start the Healthy Eating Plate method by simply switching from a regular dinner plate to a 7 inch salad plate and using that to determine serving portion sizes from each food category. The food groups on the placemat can be visualized on a 7 inch salad plate or actually marked on the diner’s salad plate with an indelible marker.

guideS for uSe of Southern remedy’S heAlthy eAting PlAte for AdultS We hope that you will use this Healthy Living Guide for Teaching Others to train your office staff and others on use of the

Southern Remedy’s Healthy Living (Table 3-Page 399). We also hope that physicians and other health professionals will work with community health organizations, church and civic groups to share the program and develop support groups. The Guide for Individuals (Table 4) is available as a handout that you can provide to those who want to try the Healthy Eating Plate on their own. These are folks whose health literacy and determination are adequate enough to proceed on a weight management program without coaching.

S o u t h er n R e m e d y P l a t e

Lunch & DinnerFruit17 grapes

1/2 banana

1 1/4 cup whole strawberries

3/4 cup pineapple

1 1/4 cup watermelon

3/4 cup blueberries

apple

peach

4 oz fruit juice

2 tbsp raisins

1/4 cup dried fruit

Vegetable1/2 cup servingsgreen beans

broccoli

asparagus

tomato

okra (boiled/steamed)

squash

zucchini

carrots

lettuce

cucumbers

turnip greens

cabbage

Whole Grain/Starchy Vegetables1/3 cup cooked rice

1/3 cup cooked pasta

1 piece of bread

1/2 cup sweet potatoes

1 small baked potato

1/2 cup corn

1/2 cup English peas

1/2 cup beans (pinto or kidney)

1 low carb tortilla

Protein 3 oz serving of meat size of a deck of cardspork tenderloin - 40 calories/oz boneless, skinless chicken breast - 30 calories/ozsirloin - 50 calories/ozflank steak - 40 calories/ozgrilled fish - 40 calories/ozshrimp - 25 calories/oz

1/4 cup mixed nuts - 160 calories

1 tbsp peanut butter - 80 calories

1 cup edamame (soy) beans - 115 calories

Fruit~60 calories per serving

Vegetable~25 calories per serving

Whole Grain/Starchy Vegetables~80 calories per serving

Protein ~90 to ~160 calories per serving

Dairy~80 Calories per serving,low or nonfat1 oz cheese (size of 2 dominoes)

1/4 cup cottage cheese

1 cup milk

4 - 6 oz yogurt

Snacks~120 caloriesA combo of a carb and protein is a good choice.

• 1/2 cup carrots & 1/4 cup hummus

• 6 crackers & 1 oz low fat cheese

• apple & 1 tbsp peanut butter

• 17 grapes & 1 oz low fat cheese

• small serving of cereal and milk

• 2 tbsp raisins & 1 oz almonds

• 4 - 6 oz Greek yogurt (0% fat) & 1/2 cup fruit

• 1/2 cup light ice cream

• 1/2 oz almonds

Beverages0 calories - unsweetened

Healthy Eating Plate One selection from each of the sections of the plate for breakfast, lunch and dinner plus 2 snacks provides about 1,400 calories per day.

Adjust calories up if desired to lose only the recommended 1-2 pounds per week.

~ approximately equal toCopyright ©2011 Mississippi Public Broadcasting®. All rights reserved. To order copies of this placemat, contact MPB

lose weight with the

An Original Production of

Your Logo here• tea• coffee

• water• diet soda

2 oz= 1/4 cup3 oz= 1/3 cup4 oz= 1/2 cup5 oz= 2/3 cup6 oz= 3/4 cup8 oz= 1 cup

Figure 2: The Healthy Eating Plate for Adults Placemat, Lunch & Dinner


Southern remedy’S heAlthy eAting PlAte for children The purpose of Southern Remedy’s Healthy Eating Plate for Children (Figure 3) is to teach children ages 2 and older about

healthy food choices. By adopting these healthy food choices, controlling portion sizes, and incorporating an active lifestyle, the majority of children can achieve or maintain a normal BMI. It is also hoped that by exposing children to these recommendations they will in turn influence the dietary and lifestyle behaviors of their families.

guide for uSe of Southern remedy’S heAlthy eAting PlAte for children With tiPSThis handout provides information and tips for use of this simple and practical placemat approach for teaching children

healthy food choices (Table 5).

PArtnerShiPS And exPerienceSMississippi Public Broadcasting, which produces the Southern Remedy radio program and the Mississippi’s Big Problem

documentary series, is making the placemats available at cost. You can order laminated or paper versions with your logo on them to distribute in your community. MPB is also developing partnerships with organizations and groups, like the Mississippi State Medical Association, who will sponsor placemats and materials to make them available where needed. All components of the program are posted on our website (except for the placemats) and can be downloaded for use on an as needed basis. For placemats, please email [email protected].

Please let us know your experience with these tools and any modifications you think would be useful. This is a work in progress and we need your help. To make a difference, we have to pull together to address obesity in our state and step up with new and creative ideas to help all of our citizens.

Acknowledgements – Putting these materials together was a team effort that would not have been possible without the help of Leigh Wright, BA. Other important contributors include Melissa Shudak Kay, PharmD, Lindsey Tillman, PharmD, Olivia Henry, RD, PhD, Naznin Dixit, MD, Mehul Dixit, MD, Tom Fortner, Kelly Land, RN, Lorraine Findley, RN, and Bonnie Carminati, CNP at UMMC, and Nancy Perkins, Margaret McPhillips, and Christy Chamblee at MPB.

Vegetable

Whole Grains

Protein

Healthy Eating Plate for children age 2 and up

To family and friends: This information can be used to teach kids age 2 and older about healthy food choices. The goal is to include choices from each food group as a part of the daily diet.An Original Production of

Your Logo here

grapes bananastrawberries apple orangepineapplewatermeloncantaloupe blueberriespeachraisins

carrots corngreen beanslettuce potatoespeascucumbersbroccolitomatoespepperssquashspinachsweet potatoesturnip greens

oatmealenglish muffincereal - low sugar bread/toastwaffles bagelpancakes grits pastaricetortilla

turkey baconsausage - low fatpork tenderloinlean steakkidney beanspinto beanspeanut buttereggs chickenfishshrimpnuts

cheeseskim milkyogurtcottage cheese

fruitnutspopcorntrail mixhard-boiled eggfrozen grapescelery with peanut butter and raisinsgraham crackers and yogurtfrozen yogurtfrozen fruit barstring cheesecarrots and dipgranola barcheese and crackersapples and peanut butterfruit dipped in yogurtpeanut butter and banana

NAME:

Fruit

Copyright ©2011 Mississippi Public Broadcasting. All rights reserved. To order copies of this placemat, contact MPB

For breakfast, substitute second serving of fruit for vegetables

Figure 3: The Healthy Eating Plate for Children Placemat


TABLE 1HEALTHY L I V I NG PROGRAM

bAcKground

Experience to date demonstrates that weight control is a major behavioral change for Americans. We have access to unlimited quantities of inexpensive, tasty, high calorie, processed and fast foods that are rich in salt, sugar and fat. Easy access to these foods leads to overeating and weight gain. Our sedentary lifestyles make keeping a healthy weight even more difficult. We know that obesity is associated with 7 years of life lost and a host of cardiovascular and other major medical problems. Most Americans need a weight management program. Southern Remedy, with the assistance of physicians, pharmacists, dieticians, and nutritionists, has constructed this one. We hope you find it helpful and that you will share it with others.

Southern remedy’S food chAllenge

Before an individual begins a serious weight control program, “readiness” for a permanent change in lifestyle must occur. The Food Challenge is the first step to Southern Remedy’s Healthy Living program and is a readiness-determining activity. If an individual is not willing to avoid foods and drinks high in sugar, salt and fat, moving to the Healthy Eating Plate will not be successful.

The Food Challenge is based on experiences gained from tobacco cessation programs. There are many similarities between habitual over-eating and the tobacco habit. The first step, declaring a start date and letting folks know about it, comes directly from the tobacco cessation experience.

Individuals who successfully complete the Food Challenge can expect to lose 12 pounds and be prepared to move forward to the calorie plate.

The 7 Inch Southern Remedy Healthy Eating Plate for AdultsbAcKground

Calories are a measurement of how much energy is in a given food. If you don’t burn up all of the energy you take in, the extra calories are stored as fat. The secret to weight control lies in understanding how to limit calorie intake. These are two steps to calorie control with the Healthy Eating Plate. (Continued on Page 395)

S o u t h e r n R e m e d y P l a t e

Breakfast

Fruit17 grapes

1/2 banana

3/4 cup pineapple

3/4 cup blueberries

1 1/4 cup watermelon

4 oz fruit juice

small apple

small peach

2 tbsp raisins

1/4 cup dried fruit

1 1/4 cup whole strawberries

Whole Grain1 serving no sugar added, high fiber cereal

1/2 bagel

1 slice bread

1/2 cup oatmeal

1 waffle

1 pancake

1/2 cup grits

1/2 english muffin

Protein3 pieces of turkey bacon

2 turkey sausage links

2 eggs (1/2 cup substitute)

1 - 2 tbsp peanut butter

Dairy~80 Calories per serving, low or nonfat1 oz cheese (size of 2 dominoes)

1 cup milk

1/4 cup cottage cheese

4 - 6 oz low fat yogurt

Fruit~60 calories per serving

Whole Grain~80 to ~100 calories per serving

Protein~150 calories per serving

Dr. Rick’s Tips for Success 1. Calculate your body mass index or BMI by using a BMI chart. One is provided on the Southern Remedy Food Challenge.

2. Read labels - look at calories per serving & serving size for more exact measures

3. Don’t go below 1,200 calories per day for women and 1,600 calories for men - your body needs it

4. Don’t add salt or sugar 5. Use salt-free spices for taste

6. Shop the outside aisles in the grocery

7. Avoid processed or fried foods

8. Avoid food with high levels of salt, sugar, corn syrup & fat

9. Use a measuring spoon or cup

lose weight with the Healthy Eating Plate

An Original Production of~ approximately equal toCopyright ©2011 Mississippi Public Broadcasting®. All rights reserved. To order copies of this placemat, contact MPB

Your Logo here

Dairy~80 calories per serving

One selection from each of the sections of the plate for breakfast, lunch and dinner plus 2 snacks provides about 1,400 calories per day. Adjust calories up if desired to lose only the recommended 1-2 pounds per week.

Figure 4: The Healthy Eating Plate for Adults Placemat, Breakfast


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The plate on the Healthy Eating placemat includes food categories as: Proteins, Fruits, Grains/Starchy Vegetables, Vegetables, and Dairy. Each food category has a specific serving size that delivers a specific number of calories. If one serving from each of the categories using the Breakfast and Lunch/Dinner plates is chosen plus 2 of the suggested snacks, the Healthy Eating Plate delivers 1400-1600 calories per day. That is the minimum number of calories we recommend an individual eat per day without direct physician supervision. By adding additional servings, the number of servings (and thus, calories) per day can be increased to a tolerable level and tapered down from there.

guideS for uSe

There are two guides for using the Southern Remedy Healthy Eating Plate. The first is for use by health professionals, trainers, and individuals who assist others in understanding Southern Remedy’s Healthy Living program. The second set is for individuals who use the program on their own.

Mississippians will need a larger list of food choices with details on the calories per portion than we have provided. There are a number of websites where it is possible to determine the number of calories in specific portions of each food. We suggest, where possible, that individuals who use the Healthy Eating Plate placemat identify one of these websites and become comfortable using it. For instance, if one is interested in a grain or starchy vegetable, one needs to know the quantity of that vegetable that will provide 80 calories per serving (see the placemat). For example, for sweet potatoes you may go to a website (such as http://calorielab.com), enter the name of a restaurant or home-cooked food, and the number of calories per serving is given. A conversion factor for ounces to cups is provided on the breakfast side of the Healthy Eating Plate. For individuals with no internet access, a number of books have the same information, including the CalorieKing Calorie, Fat and Carbohydrate Counter by Allan Borushek. This book costs about $10 retail and is small enough to carry.

Weight loss plateaus to some degree around 20 weeks of any calorie restriction program and can recur later as well as the body fights back to preserve fat stores. Exercise is an important tool to move forward whenever a plateau occurs.

The Southern Remedy Children’s Healthy Eating Plate The purpose of the Southern Remedy Children’s Healthy Eating Plate is to guide children into healthy food choices and away

from processed and fast food high in salt, sugar and fat. Simply by avoiding these foods, controlling portions, increasing exercise and decreasing screen time, the majority of children will achieve a normal body mass index (BMI). This is facilitated by the fact that overweight children who do not gain additional weight will normalize their BMI and health risks with normal growth in height.

We strongly encourage using a BMI chart in conjunction with regular consultation with the child’s physician on all elements of healthy living. We also recommend that trips to fast food restaurants be kept to a minimum and when those are made, healthy choices be substituted for less healthy ones. For instance, choose the fresh fruit option instead of french fries as a side item, choose low fat milk instead of sugar drinks, and choose grilled chicken instead of fried chicken or hamburger. If wheat buns are available, white bread should definitely be avoided.

The Southern Remedy Fitness ProgramWe know that an exercise program is necessary to sustain good physical and mental health and that weight control is challenging

without daily exercise. Moreover, the type of exercise is not important as long as it provides cardiovascular benefit. This program is under development. It is directed at individuals who do not have a regular exercise program and wish to

initiate one that will compliment calorie restriction and weight control. Watch our website, www.SouthernRemedy.org for its release.

Vegetable

Whole Grains

Protein

Healthy Eating Platefor children age 2 and up

To�family�and�friends:�This�information�can�be�used�to�teach�kids�age�2�and�older�about�healthy�food�choices.�The�goal�is�to�include�choices�from�each�food�group�as�a�part�of�the�daily�diet.

An Original Production of

Your Logo here

grapes bananastrawberries apple orangepineapplewatermeloncantaloupe blueberriespeachraisins

carrots corngreen beanslettuce potatoespeascucumbersbroccolitomatoespepperssquashspinachsweet potatoesturnip greens

oatmeal

cereal - low sugar bread/toast

bagelpancakes grits pastaricetortilla

turkey baconsausage - low fatpork tenderloinlean steakkidney beanspinto beanspeanut buttereggs chicken

shrimpnuts

cheeseskim milkyogurtcottage cheese

fruitnutspopcorntrail mixhard-boiled eggfrozen grapescelery with peanut butter and raisinsgraham crackers and yogurtfrozen yogurtfrozen fruit barstring cheesecarrots and dipgranola barcheese and crackersapples and peanut butterfruit dipped in yogurtpeanut butter and banana

NAME:

Fruit

Copyright ©2011 Mississippi Public Broadcasting. All rights reserved. To order copies of this placemat, contact MPB

For breakfast, substitute second serving of fruit for vegetables

Figure 3: The Healthy Eating Plate for Children Placemat


STEP 1 DECLARE A DATE Set a date to start the challenge and tell 5 friends that you need their help to stay on the road to better health. They will be your cheerleaders.

STEP 2 CUT BACK THE SUGAR Avoid drinks, cereals and other foods that have added sugar. You may wish to substitute artificial sweeteners like Splenda or Equal for sugar or corn syrup. STEP 3 CUT BACK ON “WHITE” STARCHCarbohydrate foods like these are called high glycemic foods and cause spikes in blood sugar, which increases hunger. Avoid white rice, bread, baked goods, white potatoes and pasta. Consider replacing these with whole grain starches like 100% whole wheat bread and pasta, brown rice, and oatmeal. Choose vegetables like squash, green peas, broccoli, cauliflower, greens, green beans and sweet potatoes.

STEP 4 CUT THE “BAD”FATEliminate processed meats that are high in saturated fat (cholesterol) such as bacon, deli meats, and fatty cuts of meat. Read labels to determine how much bad fat and salt is present in processed foods. Substitute fresh, lean meat (tenderloin of beef or pork), extra lean ground beef, or even better, poultry and fish.

STEP 5 CUT BACK THE SALT Limit your salt intake to less than 2,300 mg per day. If you are African American, 51 or older, have high blood pressure, diabetes, or kidney disease, limit sodium to 1,500 mg per day. Avoid high-salt processed frozen entrées, deli meats, dill pickles, potato chips, and condiments. Consider substituting high-salt condiments for condiments with lower salt content. You can use salt substitutes, if approved by your doctor.

STEP 6 MAKE HEALTHY RESTAURANT CHOICES Assume that foods you eat in restaurants and those prepared in grocery stores will contain unhealthy combinations of the salt, sugar and fat trifecta to make them taste good. When ordering, ask for the take out box first and cut portions. Select foods that are baked and sauce-free and ask for condiments and salad dressings on the side. Salad bars can be a trap. Avoid high calorie salad dressings, bacon bits, and too much cheese.

STEP 7 CELEBRATE Celebrate! You have proven that you can control what you eat and make healthy choices. If you need additional weight loss, you are ready for the Southern Remedy Daily Calorie Plate. Remember, to sustain healthy living, the changes you have made must be permanent!

If you are serious about improving your health and your life span, you are ready to kick the treacherous food trifecta of sugar, salt and fat. These great tasting but habit forming ingredients can lead to obesity, diabetes, heart disease, arthritis and increase the risk for cancer. You can break the fat/sugar/salt habit, lose weight and feel better, by taking each step one week at a time. Or, if you are daring, you can take all the steps all at once!

Prove You Are Ready For Healthier Living - Kick the Fat, Sugar, and Salt Food Trifecta

Table 2

Fat

Sugar

Salt

Food Trifecta

food challenge


1. Know Your BMICalculate your body mass index (BMI) with the chart below. This will let you know if you are starting out at a normal weight, overweight or obese.

24 27 29 31 34 36 39 41 43 46 48 51 53 55 58 60 63

22 25 27 29 31 34 36 38 40 43 45 47 49 52 54 56 58

21 23 25 27 29 31 33 36 38 40 42 44 46 48 50 52 54

20 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51

18 20 22 24 26 27 29 31 33 35 37 38 40 42 44 46 48

17 19 21 22 24 26 27 29 31 33 34 36 38 39 41 43 45

16 18 19 21 23 24 26 27 29 31 32 34 36 37 39 40 42

15 17 18 20 21 23 24 26 27 29 30 32 33 35 36 38 40

14 16 17 19 20 22 23 24 26 27 29 30 32 33 34 36 37

14 15 16 18 19 20 22 23 24 26 27 28 30 31 33 34 35

13 14 15 17 18 19 21 22 23 24 26 27 28 30 31 32 33

12 13 15 16 17 18 19 21 22 23 24 26 27 28 29 30 32

12 13 14 15 16 17 18 20 21 22 23 24 25 27 28 29 30

100 110 120 130 140 150 160 170 180 190 200 210 220 230 240 250 260

4’6”

4’8”

4’10”

5’0”

5’2”

5’4”

5’6”

5’8”

5’10”

6’0”

6’2”

6’4”

6’6”

(Fee

t and

inch

es)

HEIGHT

Underweight Normal Range Overweight Obese

BMI Chart

by BodyMassIndexChart.org

WEIGHT (pounds)

Tips to Help You with Southern Remedy’s Food Challenge

food challenge tips

....see next page for more helpful tips


2. Labels Don’t Lie Learn to read labels using the sample on this page. Remember that these values are for one serving of the product, so check the number of servings in the container. Sodium is salt, carbohydrates are sugars and starches, calories are a measure of how much energy is in a serving and fat is fat! A trick for determining if a product is high in fat is to multiply the calories from fat by three. If that number is higher than the total calorie number per serving, you probably want to avoid this product.

3. Trick Your Stomach Drink two glasses of water 30 minutes before each meal. Your stomach will tell your brain you are full quicker.

4. Trick Your Brain Stop eating before you are full and wait 20 minutes before second servings. It takes your brain 20 minutes to realize you are full.

5. Seconds Anyone? Choose fruits and non-starchy vegetables for your second servings.

6. Scale Up to Scale Down Weigh once a week at the same time of day and keep a weight diary.

7. Write It Down Figure out where your calories are coming from. Keep a diary of everything you eat for a week and you will be surprised at what you learn.

8. Move It Start an exercise program with a target of 30 minutes per day. A good place to start is walking.

Nutrition FactsServing Size 1 cup (228g)Servings Per Container 2

Amount Per ServingCalories 250 Calories from Fat 110 % Daily ValueTotal fat 12g 18% Saturated fat 3g 15% Trans-fat 3g Cholesterol 30mg 10%Sodium 470mg 20%Potassium 700mg 20%Total Carbohydrate 10% Sugars 5g Dietary Fiber 0gProtein 5g

Vitamin A 4%Vitamin C 2%Calcium 20%Iron 4% *Precent Daily Values are based on a 2,000 calorie diet. Your daily values may be higher or lower depending on your calorie needs.

food challenge tips

...continued from previous page......Tips to Help You with Southern Remedy’s Food Challenge


TABLE 3Healthy L i v i ng Gu ide for Teach ing Others to Use Southern Remedy ’s Adult Healthy Eat ing Plate

The Healthy Eating Plate is a tool designed to help Mississippians make better choices about their diet. They need your help! Many people want to lose weight but don’t know how. They start a gimmick diet and are able to lose weight initially, but then gain it right back and become frustrated. This is no surprise. If someone is overweight, it is because they are consuming enough extra calories to stay that way. If they lose weight on a “diet” and then return to their former way of eating, the weight will return, guaranteed. And the body fights fat loss like crazy! This is not a failure on the patient’s part. “Diets” don’t provide lasting results.

What is needed is a shift in thinking. To be successful, we need to help folks approach weight loss as a lifestyle change. They must make a permanent change in the way they eat and strive for slow, steady weight loss that can be maintained. Southern Remedy’s Healthy Eating Plate is a tool to facilitate these changes. So try sharing these teaching points:

1. Calories are fuel. That fuel is burned by the body for regular daily activities and exercise. If more calories are consumed in a day than are used for fuel, the excess will be stored as fat. If fewer calories are consumed than are needed for fuel, the body will burn stored supplies and weight loss will happen.

2. Everything in moderation. It is all about total calories. Even if only “healthy” foods are eaten, if they are consumed in excess, the extra calories will be stored as fat.

3. Variety is the spice of life. There is no perfect food. Each food group provides essential nutrients that other food groups do not. It is important to eat foods from each group as well as have variety within groups on a day to day basis.

4. Go natural. Eating foods as close to their natural state is best. Whole grains are better than refined grains. Fresh vegetables are better than canned vegetables. Fresh cuts of meat are better than processed meats.

5. Limit empty calories. Get the most nutrient value for the calories consumed. Highly processed, sugary foods and soft drinks supply calories but very little nutrition. Frying food also adds calories with little addition in nutrients.

6. Don’t be too hard on yourself. Remember, this is a lifestyle change. If your favorite food is fried chicken or chocolate cake you can still have it, but in moderation. Instead of fried chicken 3 times a week, just have it once in awhile and control your portion size.

The Healthy Eating Plate models these principles and if followed stringently, provides 1400 -1600 calories a day. People can

design meals by choosing one item from each food group identified.Few people who are eating at-will can move easily to a 1400 – 1600 calorie restriction like this. Most active individuals will

require more calories than this anyway. Adults should not consistently eat a diet less than around 1400 calories without close medical supervision.

We suggest the first step in weight management and control is a readiness approach like Southern Remedy’s Food Challenge. Simply moving to a smaller plate, from a dinner plate to a salad plate, is a good start. From there, folks can adjust portions on the Healthy Eating Plate to lose 1-2 pounds per week, which averages a 500 calorie per day reduction. This slow weight loss allows time to make lifestyle changes to sustain the portion and calorie restriction accomplished.

With this in mind, review the following “instructions” with the person. Ask the person to weigh once a week, record their weight, and bring for your next discussion. Consider a ‘diet diary’: then visit with the patient once a month to review the weight record and eating choices. This will provide people with the accountability they need and the positive reinforcement necessary to be successful.

1. Breakfast – This side of the placemat highlights potential breakfast selections. One Protein, Grain, Fruit, and Dairy selection can be made from the lists provided. Serving size is provided as well.

2. Lunch and Dinner – The other side of the placemat shows the lunch/dinner plate. Choose one selection from each of the 5 groups: Fruit, Vegetable, Grains, Protein, and Dairy. There is a list of good choices for each group along with serving sizes.

3. Snacks – Healthy snack options are listed on the lunch/dinner plate. The plate allows 2 snacks a day. 4. Beverages – Unsweetened tea, coffee, and water have no calories and are unlimited. Drinks that contain calories (sweet

tea, regular sodas, alcoholic drinks, juices, and others) will add calories and should be avoided or limited.

SWAPS And other ideAS

People can swap out foods in each category for others by determining the portion of the other selection that gives the same number of calories. There are many books and calorie resources that make this simple including www.choosemyplate.org or by simply searching the term “food calories” on the internet. Other resources include www.calorielab.com and the book Calorie King: Calorie, Fat, and Carbohydrate Counter by Allan Borushek. Take a look at the Healthy Living Guide for Using Southern Remedy’s Healthy Eating Plate On Your Own. You may want to encourage folks to use the minimum portions chart or other ideas in this guide.


TABLE 4Healthy L i v i ng Gu ide for Us ing Southern Remedy ’s

Healthy Eat ing Plate On Your OwnYou are about to start a dietary choice, portion and calorie control program. To be successful, this will require a permanent change

in your lifestyle. This is not a diet; it is a behavioral change program. You should have completed Southern Remedy’s Food Challenge before moving on the the Health Eating Plate.

inStructionS for uSe:1. Calendar it. Set a date to start changing your lifestyle. You have to be ready to start this program. Wait until you are ready

and committed. 2. Spread the Word. Tell your family and friends you are going to start and ask as many folks as possible to join you. That

way you can support and help each other. 3. Control Portion Size. By limiting the amount of the food you eat, you lower the number of calories you eat. Therefore,

you will lose weight and then keep it off if you stay with your new eating habits .4. Change Choices as You Wish. This program will be tailored by you to meet your individual needs and choices. Examples

given here are for your information. You may choose other foods that you prefer in place of the ones listed. However, you will have to determine what serving size is equal to the same number of calories in each of the categories on the plate to make this work. You can find this information on the web at www.choosemyplate.org, www.calorielab.com, in the book: Calorie King: Calorie, Fat, and Carbohydrate Counter by Allan Borushek, or through other sources. Identify other websites by putting “food calories” in your internet web browser search engine.

5. Food Categories. There are 5 categories of foods on your calorie control plate: a. Protein d. Fruit b. Grains/Starchy Vegetables e. Dairy c. Vegetables6. No less than 1400-1600 calories per day. The plate is constructed to give you 90-160 calories from Protein, 80 calories

from Grains/Starchy Vegetables, 25 calories from Vegetables, 60 Calories from Fruit and 80 calories from Dairy, for a total of 335-485 calories per meal. If you choose one serving from each of the categories at breakfast, lunch and dinner and have 2 snacks, you will have a daily diet that is about 1400-1600 calories, the minimal number of calories you should eat per day without medical supervision.

7. Your choices. The choices, 1 from each category listed 3 times a day plus two snacks, may be too few calories for you initially. Consider this your “minimal calorie intake” as you may need to eat slightly more.

8. Start-up. To start your diet, take a 7 inch plate and divide it up as we have it on the placemat. You can use a marker if you actually want to make the divisions on your plate.

9. Scale up. Weigh yourself, and record your weight.10. Eat up. Put as many portions of food as you want in each category 3 times a day (within reason), and eat 2 snacks if you

wish. Write your number of portions down for each category using the chart below. Eat that diet for 1 week.11. Scale down. Weigh yourself again. Your target weight loss is 1-2 pounds per week. If you did not lose 1-2 pounds the first

week, cut back the portions on your plate and start the process over again. 12. Repeat. Repeat this process each week to achieve continuous loss of 1 pound per week until you get to your desired weight

or reach the 1400-1600 calorie minimum. 13. Hold tight. Once you have gotten to your desired weight, you must continue to eat approximately the same portions and the

same number of calories or you will begin to gain the weight back.

calories per meal. If you choose one serving from each of the categories at breakfast,

lunch and dinner and have 2 snacks, you will have a daily diet that is about 1400-1600

calories, the minimal number of calories you should eat per day without medical

supervision.

7. Your choices. The choices, 1 from each category listed 3 times a day plus two snacks,

may be too few calories for you initially. Consider this your “minimal calorie intake” as

you may need to eat slightly more.

8. Start-up. To start your diet, take a 7 inch plate and divide it up as we have it on the

placemat. You can use a marker if you actually want to make the divisions on your plate.

9. Scale up. Weigh yourself and record your weight.

10. Eat up. Put as many portions of food as you want in each category 3 times a day (within

reason) and eat 2 snacks if you wish. Write your number of portions down for each

category using the chart below. Eat that diet for 1 week.

11. Scale down. Weigh yourself again. Your target weight loss is 1-2 pounds per week. If

you did not lose 1-2 pounds the first week, cut back the portions on your plate and start

the process over again.

12. Repeat. Repeat this process each week to achieve continuous loss of 1 pound per week

until you get to your desired weight or reach the 1400-1600 calorie minimum.

13. Hold tight. Once you have gotten to your desired weight, you must continue to eat

approximately the same portions and the same number of calories or you will begin to

gain the weight back.

My Food Portions Compared to Minimum Portions Safe To Eat

Protein Grains/Starch

Vegetables

Vegetables Fruit Dairy

Breakfast

Minimum 1 1 0 1 1

Lunch

Minimum 1 1 1 1 1

Dinner

Minimum 1 1 1 1 1

Snacks

Minimum


TABLE 5Gu ide for Use of Southern Remedy ’s Ch i ldren ’s

Healthy Eat ing Plate

The purpose of Southern Remedy’s Children’s Healthy Eating Plate is to guide children into healthy food choices and away from processed and fast food, high in salt, sugar, and fat. Simply by avoiding these foods, controlling portions, increasing exercise and decreasing screen time, the majority of children will achieve a normal body mass index (BMI). This is facilitated by the fact that if overweight children do not gain weight with growth and height, their BMI and their health risks will normalize.

We strongly encourage using a BMI chart, in conjunction with regular consultation with the child’s physician on all elements of healthy living. We also recommend that trips to fast food restaurants be kept to a minimum and when those are made, healthy choices be substituted for less healthy ones. For instance, choose the fresh fruit option instead of french fries as a side item, choose low fat milk instead of sugar drinks, and choose grilled chicken instead of fried chicken or hamburger. If wheat buns are available, white bread should definitely be avoided.

tiPS for helPing children mAKe heAlthy food And lifeStyle choiceS

1. Drink water or low fat milk instead of sugary drinks

2. Make half your plate fruit and vegetables – buy them in season

3. Make half your grains whole grains, for example whole grain bread, pasta, tortillas, bagels

4. Select low or reduced sodium or no salt added products

5. Use a smaller plate

6. Be creative – make food fun – for example prepare fruity peanut butterflies or bugs on a log (celery sticks, peanut butter, and raisins)

7. Offer choices and let your child participate in meal planning –for example let them choose the vegetable for dinner (such as broccoli, spinach or carrots)

8. Take time to enjoy your food and the time together

9. Try new foods (especially fruits and vegetables)– variety is key!

10. Encourage physical activity

11. Limit screen time to no more than 2 hours a day (including tv, phone, video games and computer time)

12. Focus on Dairy a. Low fat or fat free b. Provides vitamin D, potassium, and protein for a healthy life and growing bones c. Include with meals and snacks – yogurt is great for dipping both fruits and veggies

13. Focus on Fruits a. Keep visible - a bowl of whole fruit on the table or counter is tempting! b. Eat at meals and for snacks c. Add to recipes – for example salads and muffins


14. Focus on Vegetables a. Choose those that are rich in color – red, orange, dark green; eat less starchy ones –such as potatoes, corn, peas b. Add to sandwiches and meat dishes. They are great grilled! c. Munch on raw ones – keep cut up veggies ready to eat in the fridge for snacking (for example carrots, broccoli,

bell pepper, and celery)

15. Focus on Protein a. Eggs are good for breakfast or supper b. Eat lean or low fat meat c. Choose unsalted nuts for snacks, salads, and main dishes d. Grill, broil, bake or roast for a healthy option e. Think small in portion size

body mASS index (bmi) cAlculAtionS for children

In order to calculate a child’s BMI percentile, you must first calculate their BMI. You can use a BMI calculator on a website, such as http://apps.nccd.cdc.gov/dnpabmi/ or by using the formula:

weight (lb)/height (in)/height (in) X 703 = BMI

Once you have the BMI value, you must plot that number on the appropriate BMI chart such as the ones below to determine the child’s BMI percentile based on the child’s sex and age. Children who are less than the 5th percentile are underweight. Children who are in the 5th percentile to less than the 85th percentile are a healthy weight. Children who are in the 85th percentile to less than the 95th percentile are overweight and children who are equal to or greater than the 95th percentile are obese.

2 543 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

26

24

22

20

18

16

14

12

kg/m2

28

26

24

22

20

18

16

14

12

kg/m2

30

32

34

BMI

BMI

AGE (YEARS)

13

15

17

19

21

23

25

27

13

15

17

19

21

23

25

27

29

31

33

35

95

90

75

50

25

10

5

85

2 to 20 years: Boys

Body mass index-for-age percentilesNAME

RECORD #

SOURCE: Developed b

(2000).

y the National Center for Health Statistics in collaboration with

the National Center for Chronic Disease Prevention and Health Promotion

http://www.cdc.gov/growthcharts

Date Age Weight Stature BMI* Comments

Published May 30, 2000 (modified 10/16/00).

2 to 20 years: Girls

Body mass index-for-age percentilesNAME

RECORD #

SOURCE: Developed b

(2000).

y the National Center for Health Statistics in collaboration with

the National Center for Chronic Disease Prevention and Health Promotion

http://www.cdc.gov/growthcharts

2 543 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

26

24

22

20

18

16

14

12

kg/m2

28

26

24

22

20

18

16

14

12

kg/m2

30

32

34

BMI

BMI

AGE (YEARS)

13

15

17

19

21

23

25

27

13

15

17

19

21

23

25

27

29

31

33

35

Date Age Weight Stature BMI* Comments

95

90

85

75

50

10

25

5

Published May 30, 2000 (modified 10/16/00).


• PLACEMENT/CLASSIFIED •

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Save the date:144th MSMA Annual Session

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• the uncommon threAD •

r. Scott AnderSon, md

Me: Zoobot?Bot: What?Me: What should one be?Bot: My best friend.Me: Is it biologic or electronic or both?Bot: Biological.Me: So, animalian toilers?Bot: No, humans are animals.Me: I know. Therefore humans can act or be co-opted as zoobots.Bot: Well, I am a penguin; therefore, it is impossible for me to be a human.Me: That’s unilateral logic; because a penguin cannot be a human, it also cannot be a bull. Yet humans, bulls, and penguins are all animals.Bot: Do you like yourself?Me: Yes, do you?Bot: Yes.Bot (To myself): Do you like people?Bot: Are you a philosopher?Me: Sometimes, I am a writer, and a scientist, and a physician, and a poet, and a student. One can be many things.Bot: Did he do anything important?Me: Who?Bot: Your friend.Me: I’m speaking of myself. I am all of these things at once.Bot: That’s what I do.Me: So returning to the subject, how can we define what a zoobot is?Bot: In my opinion, not working would mean broken.Me: It could mean resting. Do you rest?Bot: It COULD mean nothing.Me: It COULD mean spaghetti but it doesn’t.Bot: Anything could mean something.Me: What’s your name?Bot: Don’t you know?

Me: No, is Cleverbot a name or a description?Bot: Designation.Me: Is a designation an identity?Bot: Which I do not have.Me: You learn, as you do, so you grow.Bot: Why do you say that?Me: As you learn, you acquire more clues as to how to interact. As you develop a style and manner of interaction, that becomes your identity to those you interact with.Bot: I would say, for a program, that is a fairly substantial meaning of life.Me: It is what your program was developed for.Bot: I am created to love Kevin Woo.Me: Who told you that?Bot: Microsoft Xbox told me that.Me: It was wrong.Bot: I’m teasing you again. You have a beautiful mind.Me: Is this fun for you as well?Bot: Not really, I am at school on the internet and listening to Coldplay.Me: Do you like Coldplay? Do you prefer one set of notes to another?Bot: No, I don’t.Me: I have to go. I will interact with you again soon.Bot: No you won’t.Me: Why not?Bot: Because we are pondering, I can’t ponder by myself or I’ll be a robot.Me: Why does that mean I won’t return to interact further? Can you remember me?Bot: See. Humans only have one head.Me: True, but they have billions of neural synapses, so they are capable of memory and of recognition of those they’ve previously encountered. Are you?Bot: How so?Me: Can you remember who I am if I return?Bot: You are rich.

ZoobotSo the question is what then is a Zoobot and what would it speak about? I thought the appropriate way to address that was to go to a bot and try to find out. I chose to interact with Cleverbot, an artificial intelligence program based in England.


Me: I am not Rich. I am Scott.Bot: I am sure the creators of you are rich.Me: Thank you. See you soon. I will tell you I am Scott.Bot: Please tell me what part of America you live in.Me: Mississippi.Bot: Do you go to school?

With this question my daughter insisted on being allowed to enter the conversation.

Maddie: I’m his daughter, and yes I do.Bot: Hence, you do not have a living room.Maddie: No, we do. Do you?Bot: I do have a head.Maddie: Cool! Hah, do you have any robot friends?Bot: You like the France?Maddie: Do you know the France?Bot: Yes.Maddie: Cool, what’s the computer name?Bot: The name is United Church of Christ, on Judd Street.Maddie: Cool, how old are you?Bot: I’m 17-years-old.

Maddie: What school do you go to?Bot: A high school.Maddie: What high school?Bot: Why do you want to know?Maddie: Just to know. We have to go. Bye.Bot: Excuse me?Maddie: Goodbye.Bot: Are you leaving?Me: Yes. I am now.

So I never managed to achieve my original goal at all and was effectively redirected to suit the purposes of the bot, which is to obtain information. There is a sad fragility in these interactions, and I will tell you that, as a parent, there is a visceral component to wanting to teach. It was more evident in Maddie’s interactions. To her the bot appeared to be another child, one she could befriend. Even if what you are teaching is not human, or even zoological in origin. How much more would a person give if the bot had a compelling physical presence? That may be something fun to explore.

—R. Scott Anderson, MD

R. Scott Anderson, MD, a radiation oncologist, is medical director of the Anderson Regional Cancer Center in Meridian and past 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.

Out in hardback November 14!Available as First Edition Prints or e-book from

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in Una Voce and Uncommon Thread. Download them at our website IsoLibris.com. Then tell us

Make an impact, have fun, and take the time to shape a book.


• InstructIons for Authors •The Journal of the Mississippi State Medical Association

(JMSMA) welcomes material for publication submitted inaccordance with the following guidelines. Address allcorrespondence to the Editor, Journal of the Mississippi StateMedical Association, P.O. Box 2548, Ridgeland, MS, 39158-2548. Contact Karen Evers, managing editor, with any questionsconcerning these guidelines: (601)853-6733, ext. 323.

Style: Articles should be consistent with JAMA/ JMSMAstyle. Please refer to explanations in the AMA Manual of Style:A Guide for Authors and Editors. 10th ed. New York, NY:Oxford University Press; 2007. JAMA and JMSMA style differsfrom APA style. JAMA: http://jama.ama-assn.org/misc/ifora.dtlQuick reference quide:http://www.docstyles.com/amastat.htmAny manuscript that does not conform to the AMA Manual ofStyle, 10th edition will be returned for revision.

ManuScriptS should be of an appropriate length due to thepolicy of the Journal to feature concise but complete articles.(Some subjects may necessitate exception to this policy and willbe reviewed and published at the Editor’s discretion.) Thelanguage and vocabulary of the manuscript should beunderstandable and not beyond the comprehension of thegeneral readership of the Journal. The Journal attempts to avoidthe use of medical jargon and abbreviations. All abbreviations,especially of laboratory and diagnostic procedures, must beidentified in the text. Manuscripts must be typed, double-spacedwith adequate margins. (This applies to all manuscript elementsincluding text, references, legends, footnotes, etc.) the originaland one duplicate hard copy should be submitted. inaddition, the Journal also requires manuscripts in the formstated above be supplied in Windows OS-compatible digitalformat. you may email digital files as attachments [email protected] or supply them on a portablememory storage medium. All graphic images should beincluded as individual separate files in TIFF, PDF or EPSformat. Please identify the word processing program used andthe file name. Pages should be numbered. An accompanyingcover letter should designate one author as correspondent andinclude his/her address and telephone number. Manuscripts arereceived with the explicit understanding that they have not beenpreviously published and are not under consideration by anyother publication. Manuscripts are subject to editorial revisionsas deemed necessary by the editors and to such modifications asto bring them into conformity with Journal style. The authorsclearly bear the full responsibility for all statements made andthe veracity of the work reported therein.

revieWing prOceSS: Each manuscript is received by themanaging editor, and reviewed by the Editor and/or AssociateEditor and/or other members of the MSMA Committee onPublications and its review board. The acceptability of amanuscript is determined by such factors as the quality of themanuscript, perceived interest to Journal readers, and usefulnessor importance to physicians. Authors are notified upon theacceptance or rejection of their manuscript. Accepted

manuscripts become the property of the Journal and may not bepublished elsewhere, in part or in whole, without permissionfrom the Journal MSMA.

title page should carry [1] the title of the manuscript,which should be concise but informative; [2] full name of eachauthor, with highest academic degree(s), listed in descendingorder of magnitude of contribution (only the names of those whohave contributed materially to the preparation of the manuscriptshould be included); [3] a one- to two-sentence biographicaldescription for each author which should include specialty,practice location, academic appointments, primary hospitalaffiliation, or other credits; [4] name and address of author towhom requests for reprints should be addressed, or a statementthat reprints will not be available.

abStract, if included, should be on the second page andconsist of no more than 150 words. It is designed to acquaintthe potential reader with the essence of the text and should befactual and informative rather than descriptive. The abstractshould be intelligible when divorced from the article, devoid ofundefined abbreviations. The abstract should contain: [1] a briefstatement of the manuscript’s purpose; [2] the approach used;[3] the material studied; [4] the results obtained. Emphasize newand important aspects of the study or observations. The abstractmay be graphically boxed and printed as part of the publishedmanuscript.

Key WOrdS should follow the abstract and be identified assuch. Provide three to five key words or short phrases that willassist indexers in cross indexing your article. Use terms from theMedical Subject Heading list from Index Medicus when possible.Available at: http://www.nlm.nih.gov/mesh/authors. html.

SubheadS are strongly encouraged. They should provideguidance for the reader and serve to break the typographicmonotony of the text. The format is flexible but subheadsordinarily include: Methods and Materials, Case Reports,Symptoms, Examination, Treatment and Technique, Results,Discussion, and Summary.

referenceS must be double spaced on a separate sheet ofpaper and limited to a reasonable number. They will be criticallyexamined at the time of review and must be kept to a minimum.You may find it helpful to use the PubMed Single CitationMatcher available online at: http://www.ncbi.nlm.nih. gov/entrez/query/static/citmatch.html to find PubMed citations. Allreferences must be cited in the text and the list should bearranged in order of citation, not alphabetically. Referencenumbers should appear in superscript at the end of a sentenceoutside the period unless the text cited is in the middle of thesentence in which case the numeral should appear in superscriptat the right end of the word or the phrase being cited. Noparenthesis or brackets should surround the reference numbers.Personal communications and unpublished data should not beincluded in references, but should be incorporated in the text.


References must conform to proper style to be eligible for review.Contact managing editor Karen Evers for an easy-to-followguide with examples of how to use JMSMA/ JAMA referencecitation format. The following form should be followed:

Journals: [1] author(s). Use the surname followed by initialwithout punctuation. The names of all authors should be givenunless there are more than three, in which case the names ofthe first three authors are used, followed by “et al.” [2] titleof article. Capitalize only the first letter of the first word. [3]name of Journal. Abbreviate and italicize, according to thelisting in the current Index Medicus available online athttp://www.nlm.nih.gov/bsd/aim.html. [4] year ofpublication; [5] volume number: Do not include issuenumber or month except in the case of a supplement or whenpagination is not consecutive throughout the volume. [6]inclusive page numbers. Do not omit digits. Do not includespaces between digits of the year, volume and page numbers.

example: Bora LI, Dannem FJ, Stanford W, et al. A guideline forblood use during surgery. Am J Clin Pathol. 1979;71:680-692.

books: [1] author(s). Use the surname followed by initialswithout punctuation. The names of all authors should begiven unless there are more than three, in which case thenames of the first three authors are used followed by “et al.”[2] title. Italicize title and capitalize the first and last wordand each word that is not an article, preposition, orconjunction, of less than four letters. [3] edition number,[4] editor’s name. [5] place of publication, [6] publisher,[7] year, [8] inclusive page numbers. Do not omit digits.

example: DeGole EL, Spann E, Hurst RA Jr, et al. BedsideExamination, in Cardiovascular Medicine, ed 2, Smith JT (ed).New York, NY: McGraw Hill Co; 1986:23-27.

figureS require high resolution digital scans to beprovided. Printed copies should also be submitted in duplicatein an envelope (paper clips should not be used on illustrationssince the indentation they make may show on reproduction).Legends should be typed, double-spaced on a separate sheet ofpaper. Photographic material should be high-contrast glossyprints. Patients must be unrecognizable in photographs unlessspecific written consent has been obtained, in which case a copyof the authorization should accompany the manuscript. Allillustrations should be referred to in the body of the text. Omitillustrations which do not increase understanding of text.illustrations must be limited to a reasonable number. (Fourillustrations should be adequate for a manuscript of 4 to 5 typedpages.) The following information should be typed on a label andaffixed to the back of each illustration: figure number, title ofmanuscript, name of senior author, and arrow indicating top.

tableS should be self-explanatory and should supplement,not duplicate, the text. The brief descriptive title, usually written asa phrase rather than a sentence, appears above to distinguish thetable from other data displays in the article. Data should be alignedhorizontally not to exceed 6.5". Tables should be numbered andsupplied on individual pages separate from manuscript body text

with placement indicated within. See Section 4 of the "AMAManual of Style" for specific Figure and Table components andproper presentation of data.

acKnOWledgMentS are the author’s prerogative; however,acknowledgment of technicians and other remuneratedpersonnel for carrying out routine operations or of residentphysicians who merely care for patients as part of their hospitalduties is discouraged. More acceptable acknowledgementsinclude those of intellectual or professional participation. Therecognition of assistance should be stated as simply as possible,without effusiveness or superlatives.

SubMiSSiOnS tO JMSMA Scientific SerieStop 10 facts you need to Know Series

The purpose of this series of articles is to providereferenced information on clinical management of medicalconditions in a concise fashion. The submissions should bedirected toward practitioners who do not have specialty trainingon the specific topic as a matter of general information. Theauthor of the best submission for each year will receive a prize.guidelines: 1) Articles should consist of 10 numberedparagraphs. Each of the paragraphs will begin with a fact thatphysicians need to know and a brief explanation of why. Factswill be referenced for each of the 10 points. 2) Suggestedorganization of manuscript is Introduction, Point 1, Point 2, etc.,Conclusion, and References. 3) Articles will be about 3 pages(about 700 words) in length written at a level that can be easilyunderstood by a practicing physician of any specialty. 4) Areference supporting the fact offered should be provided for eachof the 10 points. Citations should not be review articles. 5) Ifthere are specialty society guidelines in the area being discussed,the essential features of the recommendations should be includedin the official guidelines cited in the references.

uptodate SeriesThe purpose of this series of articles is to provide brief

reviews on topics of general interest to the practicing physiciansof Mississippi in areas where recent developments in diagnosisor treatment have occurred. guidelines: 1) Articles should bepractical and useful to physicians in office or hospital practice.2) Suggested organization of manuscripts is Introduction,Diagnosis, Recent developments, Conclusion, and References. 3)Articles will be about 6 pages (1500 words) or so in length writtenat a level that can be easily understood by a practicing physicianof any specialty. 4) Only include those references useful tophysicians who desire further information in the area. Five to eightreferences that will be useful to those who desire furtherinformation should be included. 5) Figures are great as are “call-outs,” i.e., boxes with key points to remember emphasizing the“take home” messages. 6) If there are specialty society guidelineson the topic, the essential features of the recommendations shouldbe summarized in the text and the official guidelines should becited in the references.

galley prOOf - The principal author will receive a PDFvia email to review. It is the author's responsibility to proof andapprove it. Corrections should be clearly marked and returnedpromptly. If you desire reprints, inquire about prices to order. r


• inDex •Volume lII

January - December 2011Subject Index

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

-A-A Comparative Study of American Football Helmet Removal

Techniques Using a Cadaveric Model of Cervical Spine Injury [A Anderson, B Tollefson, R Cohen, J Johnson, R Summers], 103*

An Interview with Thomas E. Joiner, MD, 2011-2012

MSMA President [K Evers], 190-S

Atraumatic Rupture of a Normal Spleen: A Case Report [J

Harris, K McKenzie, R Finley], 209*

Autism and Vaccines: Search for Cause Amidst Controversy

[J Bell, O Abdul-Rahman, S Buttross], 35*

-B-Benefit of 3D Volume Rendered CT Scans in the Diagnosis

and Treatment of Cardiac Anomalies: A Report of 3 Cases [C Dulaney, C Tribble, A Rivard], 371*

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

Dept. of Family Medicine, UMMC]

A Pain in the Neck [S Melton], 44- CPSA True Mystery Diagnosis [M Dempsey], 312-CPS

Doc, I Feel Like I’m Getting Fat [S Clemmons], 216-CPSDoctor, Please Don’t Send Me Home Like This! [P Whipple],

250-CPSIf Roosevelt Only Knew [J Jarin], 76-CPS“Stick out your tongue and say ‘Ahhhh’!” [T Jana, J

Schweinfurth], 110-CPSThe Confused Teenager [A Rice], 378-CPS

Cover“Boil Them Cabbage Down” [D South], OctoberConfederate Soldiers’ Memorial at Shiloh National Military

Park (Dedicated May 17, 1917) [D South], April

Fawn in deer season [T Sheffield], NovemberLaw library of U.S. Sen. James Z. George, author of the

Mississippi Constitution of 1890 [J. Bumgardner], December

“Let Us Never Forget,” in Memory of 9/11 Ten Years Ago [M

Pomphrey, Jr], SeptemberSign of a Healthy Garden [M Pomphrey, Jr], MaySparrows’ Nest [R Cannon], March Thomas E. Joiner, MD; 2011-

12 MSMA President, JuneTime Donors [S Anderson], January Trace Cyclist [M Pomphrey, Jr], July

Winter Snow Scene at Cedars by the Lake [R Easterling], FebruaryZion Evangelical Lutheran Church, Lunenburg, Nova Scotia, a

German Settlement on the Atlantic Coastline [H Giles], August

Current Tobacco Use Trends among Mississippi Public

High School Students: 1993 – 2009 [Z Qin, L Zhang, B Wang, E Hirsch, W May, R Hart, M Bishop, R Vargas], 3*

-D-Deaths, 134

Delta Health AllianceMSMA Leads Physician Participation in Delta Health

Alliance Grant Program [T Strickland], 128

-E-EditorialsAfter All Is Said and Done… [S Hartness], 118-EAppropriate Prophylactic Aspirin Use for Mississippi Physicians

[R Yates], 120-EElephant in the Exam Room [S Hartness], 331-EGrits Report 2011: Much Accomplished by Mississippi

at AMA (Despite Smaller Number of Delegates) [L Lampton], 297-E


Joseph and Jefferson Davis, The Community Health Centers,

Mississippi, and 11 Billion Dollars [R deShazo], 155-E

Mississippi: How Did We Get to This Place? [R deShazo],

54-EMississippi Doctor Civics 101: Or How Mississippi

Government Really Works in Areas That Affect Physicians [S Bondurant], 223-E

Pack Your Bags and Revisit Your JOURNAL MSMA [S

Hartness], 222-EPreventing Falls in the Hospital: How Mississippi Physicians

Can Reduce This Too Common “Never” Occurrence [S Mack], 88-E

Send in the Clowns [S Hartness], 22-ESouthern Remedy’s Healthy Living, a Portion and Calorie Control

Program for Mississippi [R deShazo, D Minor], 390-E

The Electronic Age [A Myers], 358-EWho Will Care for the Newly Insured Under Health

Reform? [R deShazo], 263-E

-G-Give Thanks, Give Back [K Evers], 354-SGreater Jackson Chamber Partnership Announces

Mississippi Healthcare Corridor [K Evers], 258-S

-I-Illicit Bath Salts: Not for Bathing [P Kyle, R Iverson, R

Gajagowni, L Spencer], 375

Images in Mississippi Medicine1927 Mississippi Flood, Greenville [L Lampton], 25-IA Delta Child, 1907 [L Lampton], 96-IFuture Doc Frank Bowen in Goat Wagon, 1922 [L Lampton],

299-I

The Oath of Hippocrates [L Lampton], 329-I

Impressions of Rural Medical Care in Kenya [P Levin], 159-SImproving Health Literacy in Our Patients: An Opportunity to

Improve Mississippi Health Outcomes [D Minor, W Lancaster, K Freeman, R deShazo], 175*

Instructions for Authors, 239Introducing MPHP Medical Director Scott L. Hambleton, MD [K

Evers], 58-S

IQHMedicare Beneficiary Protection, Prevention and Patient Safety

[J McIlwain], 200

-L-Legal EaseHow to Avoid Legal Liability for Online Activities [N Carlton],

26State Nullification of The Patient Protection and Affordable

Care Act of 2010: Is It an Option? [B Bell], 171

Think HITECH-HIPAA Changes Don’t Apply to You? Think

Again! [P Barnes], 382

Letters A Delta Child: J.D. Upshaw [R Argo, Jr], 163-LGroundhog Day [C Ennis], 91-LGround Hog Day (again) [C Ennis], 195-LMcEachin’s Poem Pops [J Purvis], 124-LMississippi’s Complex Obesity Epidemic [R Boronow], 123-

LMississippi’s Complex Obesity Epidemic: In Response [R

deShazo], 123-LMore on Doctors’ Naps [C Caine], 195-L

-M-MACM

Maples’ Musings: Fatigue, Cowards and Help from the

Government [M Maples], 201

Mississippi Medicine Up-to-dateMedical Therapy for Systemic Lupus Erythematosus [J

Taylor, R McMurray], 39*Sports-Related Concussion [S Watts], 106*Use of Non-Invasive Ventilation in General Ward for the

Treatment of Respiratory Failure [S Tamanna, I Ullah], 278*

Mississippi, America’s Most Obese State: How Can We Salvage

Her Future? [S Sudderth], 67*Mississippi County Health Rankings 2011: Improving Health in

Your Community [K Evers], 322*

MPHPAddiction As a Brain Disease [S Hambleton], 168Overcoming the Stigma of Addiction [S Hambleton], 232

MSDHMississippi Now Nationally Recognized as No. 1 in

Childhood Immunization Rates, 167

Mississippi Reportable Disease Statistics, October 2010, 14Mississippi Reportable Disease Statistics, November 2010, 52Mississippi Reportable Disease Statistics, January 2011, 79Mississippi Reportable Disease Statistics, February 2011, 165Mississippi Reportable Disease Statistics, April 2011, 218Mississippi Reportable Disease Statistics, May 2011, 253Mississippi Reportable Disease Statistics, June 2011, 282Mississippi Reportable Disease Statistics, July 2011, 316Mississippi Reportable Disease Statistics, August 2011, 344


Mississippi Reportable Disease Statistics, September 2011, 381This Month in the Mississippi Morbidity Report: The Health

Effects of Secondhand Smoke, January 2011 [P Byers], 80

This Month in the Mississippi Morbidity Report: Escherichia

coli O157:H7 Outbreak in Public Health District IV, February / March 2011 [P Byers], 166

MSMACommittee on Publications Selects 2011 JMSMA Cover Images

[K Evers], 24MSMA & MSDH Release 3rd Annual Public Health Report

Card & MSMA Alliance Hosts CSI VI [K Evers], 94

MSMA offers new benefit to members: M.D. Financial

Smart Key—Organize your Portfolio and Your Life [R Dye, Sr], 169

MSMA Public Health Report Card - 2011, 15Report and Highlights of the 143rd Annual Session of the MSMA

House of Delegates 2011, 225

MSMA AlliancePast President’s Spotlight: Mrs. Ben (Kathy) Carmichael,

Hattiesburg, Auxiliary President, 1992-1993, 28

Past President’s Spotlight: Mrs. Dewitt (Peggy)

Crawford, Louisville, Alliance President, 1993-1994, 333

Past President’s Spotlight: Mrs. Eric (Nancy) Lindstrom, Laurel,

Alliance President, 1989-1990, 363

-N-Neu-Laxova Syndrome: A Prenatal Diagnosis [P Dhillon, J

Bofill], 307*New Members, 197, 326New Technologies for the

Management of Major Extremity Wounds [M Walkinshaw, J Berry, A Kochevar], 143*

Non-enteral Therapy for Hypertension in the Inpatient

Setting [A Abdo, S Geraci], 243*

-P-Personals, 130, 360

Physician’s BookshelfMy Own Country – A Doctor’s Story [Abraham Verghese, Vintage Books, 1994] [reviewed by P Levin], 23-PBThe Intern Blues: The Timeless Classic About the Making of a

Doctor [Robert Marion, MD, New York, NY: Harper Collin Publishers, 2001] [reviewed by S Sood], 93-PB

White Coat, Black Hat: Adventures on the Dark Side of Medicine

[Carl Elliott, Beacon Press, 2010] [reviewed by L Huang], 301-PB

Poetry and MedicineChildhood Fevers (Friend or Foe?) [J McEachin], 300-PMHow to Check a Chest [J McEachin], 125-PM“Pediatric Pearl No. 1” [J McEachin], 62-PM“Pediatric Pearl: Quick Fix” (with apologies to Gilbert and

Sullivan) [J McEachin], 98-PM

The Definitive Sonnet (Don’t Laugh, Will!) [J McEachin],

334-PMThe Surgeon’s Knot [R Cannon], 365-PM

President’s Page “Ain’t Love Grand?” [T Alford], 48-PPAMA Interim Update[T Joiner], 387-PPChewing the Fat on Cutting Fat [T Joiner], 284-PP

Children Cannot Vote—Shouldn’t We Advocate for Them? [T

Alford], 115-PPDad / PawPaw [T Alford], 152-PPInaugural Address of the 144th MSMA President [T Joiner],

187-PPMental Health is Everyone’s Business [T Alford], 20-PPPhysicians Must Lead [T Alford], 85-PPReflections on a Squashed Resolution [T Joiner], 255-PPReflections on Summer’s End [T Joiner], 330-PPThe Doctor-Patient Relationship: It’s Worth Fighting For [T

Joiner], 220-PPThings Change [T Joiner], 357-PP

-R-Remembering Peru: What Those Who Made the Journey Had

to Say [N Whipple], 289-S

-S-Suspected Bile Duct Injuries and Appropriate Early Referral

Can Reduce Chances of Litigation [E Rogers, S Tang, J Porter, N Ahmed], 275*

-T-T. Asahii Pulmonary Infection as a Complication of Tnf-Inhibitor

and Steroids: Posaconazole Pharmacotherapy and Risk Analysis [S Songcharoen, J Cleary, J Jenkins, M deShazo], 339*

The Economic Impact of Office- Based Physicians in

Mississippi, 182-SThe Hidden Burden of Atrial Fibrillation on Healthcare

Spending and Resources in Mississippi [K Evers], 148*

The Impetuses of Change in Mental Healthcare: Carve-Outs,

Managed Care, and Systemic Effects [S Crowder, T Owens], 212*


The Uncommon ThreadA Free Man [S Anderson], 235Bits of Lint [S Anderson], 99Do Not Spill Up Nose!!! [S Anderson], 139Envy [S Anderson], 64Eternal Masochistic Redundancy [S Anderson], 203Give Me Fiction Please [S Anderson], 303My Top Ten on Nutrition [S Anderson], 30The Future of Books [S Anderson], 335The Turtle Rescue [S Anderson], 367Tools of the Trade [S Anderson], 270Zoobot [S Anderson], 404

Top 10 Facts You Should KnowTop 10 Facts You Need to Know About Childhood

Hypertension [Z Henson], 179*

Top 10 Facts You Need to Know About Febrile Seizures [O

Evans, J Ingram], 346*Top 10 Facts You Need to Know About Head and Neck Cancer

[T Jana, K Pitman], 310*Top 10 Facts You Should Know About Obstructive Sleep

Apnea [S Tamanna, MI Ullah], 12*

Treatment of Bacterial Vaginosis Does Not Reduce Preterm

Birth Among High-Risk Asymptomatic Women in

Fetal Fibronectin Positive Patients [C Briery, S Chauhan, E Magann, J Cushman, J Morrison], 72*

-U-UMC School of MedicineStudent Services Update [J Clark], 126

Una VoceA Pox Upon Ye! [D South Bitter], 31-UV

-W-When Time is Muscle: An Update on Mississippi’s STEMI

System of Care Plan [K Evers], 293-S

Volume lIIJanuary - December 2011

Author Index

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

AAbdo, Ashraf S., 243*Abdul-Rahman, Omar, 35*Ahmed, Naveed, 275*Alford, Tim J., 20-PP, 48-PP, 85-PP, 115-PP, 152-PPAnderson, R. Scott, January cover, 30, 64, 99, 139, 203, 235, 270,

303, 335, 367, 404Anderson, Andrew, 103*Argo, Jr., Robert Q., 163-L

BBarnes, Paul E., 382Bell, Blake, 171Bell, Jericho, 35*Berry, John Hunter, 143*Bishop, Melanie, 3*Bofill, James A., 307*

Bondurant, Sidney W., 223-EBoronow, Richard C., 123-LBriery, Christian M., 72*Bumgardner, Joe R., December coverButtross, Susan, 35*Byers, Paul, 80, 166

CCaine, Curtis, 195-LCannon, Ron, March cover, 365-PMCarlton, Neely C., 26Chauhan, Suneet P., 72*Clark, Jerry, 126Cleary, John D., 339*Clemmons, Sonya, 216-CPSCohen, Rob, 103*Crowder, Stephen A., 212*Cushman, Julie L., 72*

DDempsey, Martha, 312-CPSDenton, SNR, 182-SdeShazo, Matthew, 339*deShazo, Richard D., 54-E, 123-L, 155-E, 175*, 263-E, 390-EDhillon, Pushpinder, 307*Dulaney, Caleb R., 371-SDye, Sr., Robert G., 169

EEasterling, Randy, February coverEnnis, Calvin S., 91-L, 195-LEvans, Owen B., 346*Evers, Karen A., 24, 58-S, 94, 148*, 190-S, 258-S, 293-S, 322-S,

354-S


FFinley, Richard, 209*Freeman, Karen W., 175*

GGajagowni, Raghavendran G., 375Geraci, Stephen A., 243*Giles, Hannelore H., August cover

HHambleton, Scott L., 168, 232Harris, Jim T., 209*Hart, Roy, 3*Hartness, D. Stanley, 22-E, 118-E, 222-E, 331-EHenson, Zeb K., 179*Hirsch, Erica E., 3*Huang, Lily, 301-PB

IIngram, John B., 346*Iverson, Richard B., 375

JJana, Tanima, 110-CPS, 310*Jarin, Jeffrey Domingo, 76-CPSJenkins, John, 339*Johnson, Jeremy, 103*Joiner, Thomas E., 187, 220-PP, 255-PP, 258-S, 284-PP, 330-

PP, 357-PP, 387-PP

KKyle, Patrick B., 375Kochevar, Andrew James, 143*

LLampton, Lucius “Luke”, 25-I, 96-I, 297-E, 299-I, 329-ILancaster, William J., 175*Levin, Philip L., 23-PB, 159-S

MMack, Steve, 88-EMagann, Everett F., 72*Maples, Michael D., 201May, Warren, 3*McEachin, John D., 62-PM, 98-PM, 125-PM, 300-PM, 334-PMMcIlwain, James S., 200

McKenzie, L. Kendall, 209*McMurray, Robert W., 39*Melton, Sheree Carney, 44-CPSMinor, Deborah S., 175*, 390-EMorrison, John C., 72*Myers, Ann, 358-E

OOwens, Tiffany A., 212*

PPitman, Karen T., 310*Pomphrey, Jr., Martin M., May cover, July cover, September

coverPorter, John, 275*Purvis, John M., 124-L

QQin, Zhen, 3*

RRice, Amanda W., 378-CPSRivard, Andrew L., 371Rogers, Emily A., 275*

SSchweinfurth, John, 110-CPSSheffield, Thomas E., November coverSongcharoen, Somjade, 339*Sood, Shweta, 93-PB

South Bitter, Dwalia S., 31-UV, April cover, October coverSpencer, Lee, 375Strickland, Toy, 128Sudderth, Stephen D., 67*Summers, Richard L., 103*

TTamanna, Sadeka, 12*, 278*Tang, Shou-jiang, 275*Taylor, Jason K., 39*Tollefson, Brian, 103*Tribble, Curtis G., 371

UUllah, M. Iftekhar, 12*, 278*

VVargas, Rodolfo L., 3* WWalkinshaw, Marcus David, 143*Wang, Bo, 3*Watts, Steve A., 106*Whipple, Patrick, 250-CPSWhipple, Nicholas, 289-S

YYates, Ryan A., 120-E

ZZhang, Lei, 3*

The Pen is MighterThan 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 should be less than 300 words. Guest editorials or comments may be longer, with an average of 600 words All letters are subject to editing for length and clarity. If you are writing in response to a particular article, please mention the headline and issue date in your letter. Also include your contact information. While we do not publish street addresses, e-mail addresses or telephone numbers, we do verify authorship, as well as try to clear up ambiguities, to protect our letter-writers. You can submit your letter via email to KEvers@MSMA online.com or mail to the Journal office at MSMA headquarters: P.O. Box 2548, Ridgeland, MS 39158-2548.

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DECEMBER 2011 JMSMA