September/October - West Virginia State Medical Association

Delivering on 

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In every community, WVU providers are helping people lead 

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contents 

September/October 2010, Volume 106, No. 6 

features 

4 President’s Message 

9 Call For Papers 

32 General News 

35 New Members 

38 Robert C. Byrd Health Sciences Center of 

West Virginia University News 

39 Marshall University Joan C. Edwards School 

of Medicine News 

40 West Virginia School of Osteopathic 

Medicine News 

41 Bureau for Public Health News 

In this issue… 

Scientific & Special Articles 

10 The Utility of Screening for Chlamydia at 34-36 

Weeks Gestation 

12 Exercise Intolerance in Obese Children — is it 

Asthma? 

17 Ethylene Glycol and Methanol Poisonings: Case 

Series and Review 

24 Scedosporium Prolificans Endocarditis: Case 

Report and Review of the Literature 

28 Challenge and Change in Delivering Healthcare to 

India’s Needy 

Healthcare Summit 2010 

Highlights page 36 

42 West Virginia Medical Insurance Agency News 

44 Obituaries 

46 WESPAC Contributors 

47 Classified Ads 

48 Manuscript Guidelines/Advertisers 

Editor 

F. Thomas Sporck, MD, FACS 

Charleston 

Managing Editor/Director of Communications 

Angela L. Lanham, Dunbar 

Executive Director 

Evan H. Jenkins, Huntington 

Associate Editors 

James D. Felsen, MD, MPH, Charleston 

Douglas L. Jones, MD, White Sulphur Springs 

Steven J. Jubelirer, MD, Charleston 

Roberto Kusminsky, MD, MPH, FACS, Charleston 

Robert J. Marshall, MD, Huntington 

Martha D. Mullett, MD, Morgantown 

Louis C. Palmer, MD, Clarksburg 

The West Virginia Medical Journal is published bimonthly by the West Virginia State Medical Association, 4307 MacCorkle Ave., SE, Charleston, WV 

25304, under the direction of the Publication Committee. The views expressed in the Journal are those of the individual authors and do not necessarily 

reflect the policies or opinions of the Journal’s editor, associate editors, the WVSMA and affiliate organizations and their staff. 

WVSMA Info: PO Box 4106, Charleston, WV 25364 

1-800-257-4747 or 304-925-0342

President’s Message 

Creating Change 

To state that significant healthcare 

delivery change is coming to America 

must be the understatement of 

the decade. National Healthcare 

Reform is, according to our federal 

government, going to be rolled 

out in the next few years and has 

been created as a way to decrease 

healthcare costs, provide increased 

access and improve quality of care. 

The financial costs of U.S. 

healthcare are indeed staggering. 

In America 2.6 trillion dollars are 

spent per year on healthcare related 

activities including physicians (550 

billion), hospitals (830 billion) and 

pharmaceuticals (250 billion). This 

amount equals 17.6 percent of the 

Gross Domestic Product (GDP); the 

sum of all the paychecks made by 

every working person in America. 

This healthcare cost related to 

percentage of GDP rises yearly and 

2009 saw the greatest increase in 

healthcare spending in memory. 

The cost of U.S. healthcare is greater 

than the entire economy of France. 

Some economists have suggested that 

when the cost of healthcare rises to 

22 to 25 percent of GDP, the economy 

will begin to grind to a halt for lack 

of availability of investment capital. 

If this rate of spending continues, 

by 2054 the unthinkable happens, 

when 100 percent of GDP is spent for 

healthcare. It is obvious from these 

facts of life that the financial costs 

of healthcare are not sustainable 

and that a rationing strategy 

must be employed. Businesses, 

insurers and federal agencies are 

engaged in this rationing and 

many physicians are now seeing 

the results of these strategies. 

Access has been demonstrated 

to be incomplete if not completely 

unavailable for 15 percent of people 

living in the United States. West 

Virginia is slightly less problematic 

at 14 percent uninsured, according 

to the U.S. Census Bureau. Our 

government hopes to improve 

access to healthcare by improving 

the payment for the healthcare 

of the uninsured by means of 

new “healthcare insurance”. This 

may result in two dollars being 

taken from Medicare for doctors 

and returning one dollar in the 

form of new insurance. Insurance 

companies will be prohibited 

from failing to cover those with 

preexisting medical conditions thus 

increasing insurance availability. 

Finally, the quality of healthcare 

in America has been challenged 

over the past ten years by two main 

vehicles. The Institute of Medicine’s 

To Err is Human suggested 10 years 

ago that between 45 and 98 thousand 

deaths occur each year as a result of 

medical errors. American healthcare 

is dangerous to your health we have 

been told. There has been no mention 

of a comparison with safety of care in 

other countries. We can only imagine 

how dangerous their healthcare 

systems might be and until recently 

there were no good techniques for 

reducing the danger of medical 

errors. Preoperative timeouts and 

“order rebacks” and the like have 

been instituted by hospitals to reduce 

medical errors. The second major 

attack on the quality of American 

healthcare is given by the World 

Health’s Organization’s comparison 

of a countries’ quality of care based 

on a simple social analysis. The 

WHO ranking considers only the 

following question of a country’s 

monetary healthcare expenditures: 

Does the healthcare improve health, 

reduce health disparities, protect 

households from impoverishment 

due to medical expenses, and 

provide responsive services that 

respect the dignity of patients. 

This analysis allows countries 

without sophisticated technology to 

be compared with those countries 

 

West Virginia Medical Journal

who are financially advanced. 

Countries with helicopters or Level 

I trauma centers or neonatology 

services or liver transplantation or 

complex skull-based neurosurgery 

can be compared with those 

whose healthcare system is 

reminiscent of that which existed 

in Civil War America by means 

of this ranking scale. Show up. 

Do your best. Is that it? With such 

an analysis, America rates 37th 

among the world’s countries. The 

results of such analyses are then 

used by social groups and others 

with an agenda to devalue the 

quality of American healthcare. 

In a similar way, if I were one of 

the proud parents of the counties 

best junior high basketball team, I 

suppose I would be happy to pick an 

obtuse standard such as percentage 

of basketball games won in a season. 

If by chance this percentage was 

greater than that of the NBA’s World 

Champion L.A. Lakers, I would 

be happy to claim that the junior 

high team is the world’s best. 

These kinds of extremely artificial 

standards serve no useful purpose 

and can only serve as an attempt to 

demean the quality of care given by 

true professionals. Do not let anyone 

say that the care that you provide on 

a daily basis or that the care provided 

by American physicians is in any 

way second rate without reminding 

everyone of the comparison between 

the junior high basketball champions 

and the NBA L.A. Lakers. 

Physicians know what quality of 

care based on evidence means. The 

Cochrane collaboration, a British 

healthcare think-tank composed 

of some twenty seven thousand 

volunteers, tells us that there are 

approximately two million articles 

published in the world’s medical 

journals every year. We understand 

that a “standard-of-care” results 

when there is Class I evidence from 

scientific medical studies. These are 

the result of prospective, randomized, 

blinded, and reproducible scientific 

endeavors. Unfortunately, these 

studies take an average of seventeen 

years to conclude and cost many 

millions of dollars to perform. The 

truth is, there is no way, given these 

facts, that we can decide all the 

complex medical questions using 

such a strict scientific standard. 

An existential reality appears 

as we realize we are still forced to 

take care of patients the best way 

we can find, without having the 

best kind of scientific evidence. 

The experience could even be 

termed existential surrealism since 

the landscape of medical care is 

changing constantly with new 

medications and surgical techniques 

discovered on a daily basis. 

Other alternative paradigms to 

determine quality of care will be 

necessary. Consensus guidelines 

based on less than the best scientific 

techniques will have to be brought 

forth in the new “evidence-based 

medicine”. Literally hundreds of 

organizations have arisen to try to 

address the question of consensus 

treatment guidelines using other 

epistemological paradigms than that 

of the Class I evidence standard. 

The Department of Health and 

Human Services, the AMA’s PCPI (a 

collaboration of one hundred seventy 

national medical organizations), 

various specialty organizations 

and our government’s prominent 

Agency for Healthcare Research and 

Quality, and the Joint Commission, 

are a few which will likely play a 

prominent role in developing such 

consensus guidelines. Physicians 

will be well served to follow the 

developments of these groups. All 

of this work will result in a great 

opportunity for physicians working 

with hospitals to participate in 

the discovery, evaluation and 

implementation of such guidelines. 

This work will be very valuable and 

private physicians are encouraged 

to venture with hospitals to help 

deploy such consensus guidelines. 

Other philosophical and ethical 

concerns of American healthcare 

result when we ask: who is 

responsible for what? What part of 

healthcare is right, what is a privilege 

and what is a necessity. Should 

trauma surgeons, for example, be 

responsible that ATV and motor 

vehicular accidents result in nearly 

fifty thousand fatalities each year? 

Is it a failure of pulmonology and 

cardiology services and the like that 

four hundred and sixty five thousand 

deaths occur in this county each year 

related to smoking? These ethical 

questions remain to be answered by 

our society and its political agents 

who so far have been completely 

unwilling to address them. 

As a result of these concerns there 

is understandably a great amount 

of physician stress. Anxiety related 

to learning, choosing, coping with 

and applying quality guidelines 

is apparent. The financial stress 

related to medical education is great. 

An average student will owe one 

hundred and sixty thousand dollars 

at the moment he or she is presented 

with a M.D. or D.O. degree. It is also 

apparent that physician lifestyles 

have changed. We are told that one 

retiring doctor today will be replaced 

by 1.3 doctors and that the number of 

hospital-employed physicians over 

the next five to ten years will double 

presumably as a reaction to this stress 

and anxiety. All of this is complicated 

by the complete failure of our 

national government to accomplish 

any kind of meaningful tort reform 

and as yet to provide any meaningful 

solution to the anticipated twenty 

one percent drop in reimbursement 

to doctors from Medicare. 

Two major federal healthcare bills 

have recently been reconciled and 

signed into law. The four thousand 

plus pages of these bills will have 

great implications over the next 

several years for healthcare and for 

September/October 2010 | Vol. 106

those who provide it. These bills have 

been written by bureaucrats and 

their content is not well understood 

by those who voted for them. There 

will be many opportunities for 

physicians to participate, shape, and 

create their implementation. Due to 

the unsustainable present conditions 

and our national government’s 

reaction to these stresses, a necessary 

theme and strategy emerges for 

us as physicians to engage in this 

process. The theme and strategy of 

“creating change” therefore emerges. 

We cannot adjust to the changes 

or dodge them or accommodate 

them or react to them or accept 

them in a meaningful way. A new 

attitude of creating change with 

active participation must be adopted 

by all of us working together. 

“The best way to predict the future 

is to create it” said Bill Gates. I believe 

this is an appropriate attitude for us 

to develop moving forward. This role 

will necessarily require large broadbased 

participation from physicians 

all over the country. Physicians 

should partner with their medical 

associations large and small. Though 

many physicians were disappointed 

with recent AMA actions, we should 

work with the American Medical 

Association to try to create the 

best opportunities for change. The 

AMA signed on to the President’s 

healthcare plans without any 

guarantee of tort reform or solution to 

Medicare’s SGR. I believe following 

these disappointments, however, that 

greater participation is necessary in 

order to redirect the AMA’s course. 

In moving forward, a clear and 

concise mission statement of the West 

Virginia State Medical Association 

is in order, as well as a change 

in presentation of the WVSMA, 

including updating the WVSMA logo. 

With regards to medical 

malpractice and tort reform, we 

propose that a professional conduct 

committee of the WVSMA be 

created in order to improve the 

quality of physician testimony in 

court proceedings or depositions, 

and that such an improvement will 

result in a reduction of inappropriate 

medical malpractice cases being 

adjudicated in favor of plaintiff’s 

attorneys. We will have more to say 

about this in upcoming issues of 

the West Virginia Medical Journal. 

These are some of the things 

we want to accomplish this year. 

We hope to continue the efforts 

of our predecessors, Dr. Jimenez 

by continuing our fight to curtail 

substance abuse and Dr. Sebert’s 

vision to expand the use of 

information technology and EMR. 

To our medical students and 

residents in training in West Virginia, 

I want to say that the tradition of 

excellence in medicine in West 

Virginia and in this country is as 

strong as it has ever been. Look 

forward and take us to a prosperous 

future with all of your colleagues 

in the family of medicine and be 

assured that you will have no 

regrets regarding your decision to 

pursue the practice of medicine. 

Finally, to the physicians of 

the West Virginia State Medical 

Association and to all of West 

Virginia’s physicians: come gather 

with us as we look forward to the 

year ahead with your help and 

guidance. Remember the words that 

the young John Connor sent back 

to us from the future many years 

ago, “the future is not set, there is 

no fate but what we make it.” 

John H. Schmidt III, MD 

WVSMA President 

Congratulations 

John H. Schmidt III, MD 

West Virginia State Medical Association 

President 

2010-2011 

 

West Virginia Medical Journal

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C a l l f o r P a P e r s 

For a special CME issue to publish in the May/June 2011 West Virginia Medical Journal 

ThEME: Alzheimer’s Disease and Related Dementias 

I. Two papers will be accepted on each of 

the following topics: 

►Screening 

►Diagnosis 

►Prevention 

►Treatment Approaches 

Medication 

Cognitive 

• 

► Advances in research leading to 

a cure 

II. Special articles on statewide clinical 

resources and support resources are 

also solicited. 

III. Two non-scientific, commentary articles 

will be accepted. 

DEADLINES: 

Manuscript submission: December 31, 2010 

Reviews returned by: February 15, 2011 

Resubmissions: March 1 

Printing: 

• 

May/June 2011 issue 

Submissions must include: 

1) cover letter (include corresponding 

author’s email address) 

2) manuscript (double-spaced) 

3) short biography for each author 

4) three questions and answers pertaining to the 

manuscript (for CME Post-test Questions) 

5) a paragraph stating the objectives of the paper 

Send to angie@wvsma.com or mail to: 

Angie Lanham 

Managing Editor 

WV Medical Journal 

PO Box 4106 

Charleston, WV 25364 

6) All figures and photos must be submitted 

separately as .jpg, .tif or .pdf files. 

Scientific articles should be prepared in accordance 

with the “Uniform Requirements for Submission of 

Manuscripts to Biomedical Journals.” Please go to 

www.icmje.org for complete details. For additional 

requirements, please refer to Manuscript Guidelines 

located on the last page of every Journal or go to 

www.wvsma.com/journal and click on the link. 

For specific instructions concerning Case 

Reports go to: www.wvsma.com/journal and 

click on the “Instructions to Authors” link. 

September/October 2010 | Vol. 106

Scientific Article | 

The Utility of Screening for Chlamydia at 34-36 

Weeks Gestation 

Ellie E. Hood, MD 

Resident, Department of Obstetrics and 

Gynecology 

Robert C. Nerhood, MD 

Professor and Chair, Department of 

Obstetrics and Gynecology 

Joan C. Edwards School of Medicine 

Marshall University, Huntington 

Abstract 

Objective: To determine the utility of 

re-testing pregnant patients ≤25 years 

old at 34-36 weeks gestation for 

Chlamydia trachomatis. 

Methods: After obtaining IRB 

approval, a chart review was conducted 

on patients seen at the University Ob/ 

Gyn office and Cabell OB/Gyn Clinic 

from May 2005-November 2007. Patients 

≤25 years of age who had been tested 

for Chlamydia trachomatis (CT) at their 

initial prenatal visit and again at 34-36 

weeks gestation were included in the 

study. Data was gathered regarding 

patient age and positive or negative 

results from CT testing at the initial and 

34-36 week visits. 

Results: A total of 181 patients were 

included in the study. On the initial 

screen, 175 patients had a negative 

result and 6 a positive result. Five of 

these 6 patients had a negative test 

result when re-tested at 34-36 weeks. 

Out of the 175 patients who had a 

negative result on their initial screen, 5 

had a positive result on the 34-36 week 

screen. A chi-squared test of statistical 

significance was performed on the data. 

P-value was >0.05 meaning that having 

a negative initial screen was not 

predictive of also having a negative 

result upon re-testing at 34-36 weeks. 

Conclusion: First trimester 

Chlamydia trachomatis test results are 

not predictive of Chlamydia trachomatis 

status during the third trimester. 

Introduction 

Chlamydia trachomatis (CT) is a 

gram negative obligate intracellular 

bacteria that causes cervicitis 

and urethritis and can be easily 

treated and cured with antibiotics. 

CT infections are one of the most 

prevalent sexually transmitted 

diseases. 1 Most CT infections are 

usually asymptomatic, but they 

can cause a number of problems. 

Some concerns in the nonpregnant 

population include pelvic 

inflammatory disease, chronic pelvic 

pain, and infertility. 2 Regarding 

pregnancy, there is conflicting 

evidence about the association of 

CT with preterm labor. 3 However, 

CT is responsible for postpartum 

endomyometritis and neonatal 

conjunctivitis and pneumonia. 2 

Testing for CT has been 

recommended at the first prenatal 

visit and is routine practice. Before 

Figure 1. 

Results 

this study took place there was 

no formal recommendation to test 

for CT during the 3rd trimester. 

Consequently, our institution was 

not routinely performing the test 

during the 3rd trimester. Also, 

the prevalence of CT among West 

Virginians is low. Among the 50 

states, West Virginia ranks 49th in 

reported cases of CT. The rate of 

CT in West Virginia is 160 cases 

per 100,000 people. 1 Therefore, 

we assumed that re-screening for 

CT during the 3rd trimester was 

probably of low yield. This study was 

conducted to determine the utility 

of re-testing pregnant patients ≤25 

years old at 34-36 weeks gestation 

for Chlamydia trachomatis. This age 

group was chosen because young 

adults ages 15-24 years old acquire 

almost half of all new cases of 

sexually transmitted diseases. 11 

10 West Virginia Medical Journal

| Scientific Article 

Methods 

Approval was obtained from 

the Institutional Review Board 

before beginning our research. 

A retrospective chart review 

was performed on patients seen 

at University Obstetrics and 

Gynecology office and the Cabell 

Huntington Hospital Obstetrics 

and Gynecology clinic from May 

2005-November 2007. We included 

patients ≤25 years of age tested for 

CT using endocervical Gen-Probe at 

their initial prenatal visit and again 

at 34-36 weeks gestation. Gen-Probe 

PACE 2C system is a rapid DNA 

probe test which utilizes nucleic 

acid hybridization to screen for the 

presence of CT. The sensitivity is 

92.6 and specificity 99.810. Results 

of the CT testing from the initial 

visit and the 34-36 week visit were 

recorded. Patients were excluded 

if they were >25 years old or did 

not have both the initial CT testing 

as well as the 34-36 week test. 

Results 

One hundred eighty one (181) 

patients were included in the study. 

On the initial screen 175 patients 

tested negative for CT. Six patients 

tested positive for CT on the initial 

screen and were treated. At 34- 

36 weeks, of the 175 patients that 

originally tested negative, 170 tested 

negative again and 5 tested positive 

for CT. Of the six patients who tested 

positive at the initial screen, 5 were 

negative and 1 remained positive at 

the 34-36 week screen. See figure 1. 

A chi squared test of statistical 

significance was performed on the 

data. P-value was >0.05 meaning that 

having a negative initial screen was 

not predictive of having a negative 

result upon re-testing at 34-36 weeks. 

Discussion 

The results of our study indicate 

that first trimester Chlamydia 

trachomatis test results are not 

predictive of CT status during 

the third trimester. This finding 

was contrary to our hypothesis of 

re‐screening for CT during the 3rd 

trimester is probably of low yield. 

The risk of complications in 

the newborn due to maternal CT 

infection is significant. An infant 

born to an infected mother has a 

50-70% chance of acquiring the 

infection during a vaginal delivery. 4 

Neonatal conjunctivitis occurs 

in 20-50% of exposed infants. 5 

Unrecognized neonatal conjunctivitis 

may persist for months and cause 

corneal and conjunctival scarring. 8 

Pneumonia develops in 10-20% 

of exposed infants. 5 This infection 

causes fever and cough that interfere 

with feeding. Respiratory distress 

may also result. If left untreated, 

pneumonia caused by CT can result 

in chronic pulmonary disease. 4 There 

is conflicting evidence regarding the 

association of CT with preterm labor. 3 

It has been demonstrated that 

screening for and treating CT 

infections decreases neonatal and 

postnatal complications. 6,7 During 

the study period, new guidelines 

were published that recommended 

repeat testing during the 3rd 

trimester for all patients ≤25 years 

old and those at high-risk of 

acquiring CT. 9 The results of our 

study support this recommendation. 

In light of the significant neonatal 

and postnatal complications, as 

well as a lack of evidence linking 

CT with preterm labor, it is just as 

important, if not more important, 

to screen for Chlamydia trachomatis 

during the third trimester rather 

than the first trimester. 

References 

1. Center for Disease Control. 2006 STD 

Surveillance Report. 

2. United States Preventative Services Task 

Force Guidelines: Screening for chlamydial 

infection. 

3. Andrews, et al. Midpregnancy 

genitourinary tract infection with Chlamydia 

trachomatis: association with subsequent 

preterm delivery in women with bacterial 

vaginosis and Trichomonas vaginalis. 

American Journal of Obstetrics and 

Gynecology; 2006.194:493. 

4. Zar, H.J. Neonatal Chlamydial Infections. 

Pediatric Drugs, 2005;7(2):103-10. 

5. Remington and Klein. Infectious Disease of 

the Fetus and Newborn, 5th edition. 2001. 

W.B. Saunders Company. p770. 

6. Rours, et al. Sexually Transmitted Infection 

2006. 

7. Ismail, et al. Role of Chlamydia 

trachomatis in postpartum endometritis. 

Journal of Reproductive Medicine, 1987 

April;32(4):280-4. 

8. Forester, et al. Late follow-up of patients 

with neonatal inclusion conjunctivitis. 

American Journal of Opthomology. 1970; 

69:467. 

9. American Academy of Pediatrics and 

American College of Obstetrics and 

Gynecologists. Guidelines for Perinatal 

Care. 6th edition. 2007. 

10. Gen-Probe PACE 2C System Package 

Insert. 

11. Weinstock, H, Berman, S, Cates, W, Jr. 

Sexually Transmitted Diseases among 

American Youth: Incidence and Prevalence 

Estimates, 2000. Perspect Sex Reprod 

Health, 2004:36(1):6-10. 

September/October 2010 | Vol. 106 11


Exercise Intolerance in Obese Children — is it Asthma? 

Robert A. Kaslovsky, MD 

Pediatric Pulmonary Division Chief, 

Baystate Children’s Hospital, 

Springfield, MA 

Stephen B. Sondike, MD 

Section Head, Adolescent Medicine, 

WVU Physicians of Charleston and 

Associate Professor of Pediatrics at 

WVU Charleston Division 

Stephanie Cummings, CMA 

Abstract 

This is a pilot study designed to 

examine the frequency of asthma in 

obese children who have exertional 

dyspnea. Obese children who complained 

of breathlessness with exercise and who 

denied asthma were invited to enroll. If 

there was evidence of airflow limitation on 

spirometry, nebulized albuterol was 

administered and spirometry was 

repeated. If there was no significant 

improvement or if the baseline spirometry 

was normal, exercise testing was 

performed. A total of 20 patients (ages 

from 8 to 16 years) with BMI from 22 to 61 

were enrolled. Of the 19 who completed 

the study, 9 (47.3%) met criteria for 

asthma. Recognizing and treating asthma 

may lead to improved exercise tolerance 

and improved weight status in these 

obese individuals. 

Introduction 

Asthma is the most common 

chronic disease of childhood. It is 

estimated that 11.2% of the U.S. 

population has at some time been 

diagnosed with asthma, 1 and that 

about 5 million children across 

the U.S. are affected. 1 Asthma 

is the leading cause of school 

absenteeism due to chronic illness. 2 

Untreated asthma may result in 

serious consequences, including 

lost school or work days, costly 

hospitalizations, and possibly death. 

Obesity (defined as body mass 

index > 95th percentile for age) is 

increasing in prevalence in children. 

Data from NHANES I (1971–1974) 

to NHANES 2003–2004 show 

increases in overweight among 

all age groups: Among preschoolaged 

children, aged 2–5 years, the 

prevalence of overweight increased 

from 5.0% to 13.9%; among schoolaged 

children, aged 6–11 years, the 

prevalence of overweight increased 

from 4.0% to 18.8%; and among 

school-aged adolescents, aged 12–19 

years, the prevalence of overweight 

increased from 6.1% to 17.4%. 3 

Given the increasing prevalence 

of both asthma and obesity in 

childhood, it is possible that a link 

exists between these two conditions. 

The medical literature has few 

studies that address this question. 

Gold et al examined the incidence 

of asthma in a longitudinal study 

of 9,828 children age 6 – 14 years in 

six US cities over a five year period. 4 

Girls who were heavier at baseline 

were more likely to have asthma and 

the risk of developing asthma over 

the observation period increased with 

increasing BMI. Similarly, Castro- 

Rodriguez, et al found that girls 

who became overweight or obese 

between ages 6 and 11 were seven 

times more likely to develop new 

asthma between ages of 11 and 13 

years. 5 A relationship between BMI 

at age 6 and wheezing prevalence 

at any age was not found. In an 

analysis of outcomes of childhood 

asthma in adolescent years, Guerra, 

et al found that the mean BMI 

was higher in a group with poorly 

controlled asthma 6 suggesting that 

obesity adversely affects asthma 

control. Other studies have suggested 

that weight reduction improves 

symptoms and lung function in 

obese adults with asthma. 6.7 Obese 

individuals often have exercise 

intolerance which is attributed to 

deconditioning. The present study 

sought to provide information on the 

prevalence of undiagnosed asthma 

in obese children who complain of 

shortness of breath with exercise. 

Methodology 

Children age 6 to 18 years were 

eligible for the study if they had BMI 

> 95th percentile for age, and exercise 

induced shortness of breath (see 

figure 1). The questions outlined in 

figure 2 were asked, and to qualify 

for the study, the first two questions 

had to be answered affirmatively, 

and the last three had to be answered 

“no”. Standard spirometry was 

performed at rest, with measurement 

of forced vital capacity (FVC), and 

forced exhaled volume in one second 

(FEV1). The reference values of 

Polgar 9 for pediatric patients were 

used, with normal values for these 

parameters and for the ratio of 

FEV1/FVC being greater than 80%. 

If the test was deemed abnormal, an 

inhaled bronchodilator (albuterol) 

was administered via jet nebulizer, 

and the test was test repeated after 10 

to 15 minutes. An increase in 12% in 

FEV1 indicated a positive response 

to bronchodilator. If there was no 

response to bronchodilator, or if the 

test was deemed normal, patients 

were scheduled for an exercise 

challenge test, using a standard 

treadmill exercise protocol. 10 After 

completing the exercise protocol, 

spirometry was performed at 5, 10, 

15, and 20 minutes, and a positive 

response was a drop in FEV1 > 

12% from baseline for the diagnosis 

of exercise induced asthma to 

be made. If there was no drop in 

FEV1, the test was deemed normal, 

and the results were interpreted 

as unlikely to be asthma 

The proportion of tested children 

with asthma was calculated by 

dividing the number with either 

an abnormal spirometry with 

bronchodilator response, or a 



Figure 1. 

Flowchart of study design. 

Figure1: Flowchart of study design. 

Bronchodilator 

Repeat Spirometry 

in 15 minutes 

> 12 % 

Improvement 

Yes to Question 1 and 2 

No to Question 3,4 and 5 

FEV1 < 80% 

Predicted 

Asthma 

Figure 2. 

Screening Questionnaire 

Informed Consent 

Spirometry 

No 

Improvement 

Pulmonology 

Consult 

Asthma Study Flowchart 

Age 6 – 18 

BMI > 95th %ile for age 

Give Questionnaire 

All other responses 

Treadmill 

Testing 

Not offered study 

FEV1 > 80% 

Predicted 

> 12 % decline 

in FEV1 with 

exercise and 

bronchodilator 

response 

Asthma 

1) Do you get out of breath with exercise or physical activity? 

10 

< 12 % decline 

in FEV1 

No Asthma 

2) Do you have to stop exercising because of difficulty catching your 

breath? 

3) Do you have asthma? 

4) Are you using any inhalers/nebulizers or other treatments for 

breathing problems? 

5) Has anyone prescribed Albuterol or other medications for breathing 

problems in the last year? 

If you answer “yes” to questions 1 and 2 and “no” to questions 3, 4, and 5 

you will be eligible for the study. 

positive exercise test, by the total 

number of subjects enrolled. No other 

statistical analyses were performed. 

Results 

Twenty patients were entered 

into the study (see Table 1). Their 

ages ranged from 7 to 16 years, and 

BMI ranged from 22.1 Kg/m2 to 

61.3, Kg/m2 and nine were male. 

Mean BMI was. 37.9 Kg/m2 . Of the 

19 who completed the study, nine 

met criteria for asthma. Four had 

abnormal spirometry with significant 

bronchodilator response, another 

five had normal resting spirometry 

but had significant drop in FEV1 at 

exercise testing, and the remaining 

nine had normal spirometry and 

no drop in FEV1 post exercise. 

Discussion 

In this study, nearly half of the 

obese children and adolescents who 

become short of breath with exertion 

were found to have asthma. This 

finding suggests that many obese 

children are not just “deconditioned”, 

but may actually have exercise 

induced bronchospasm. Although 

several recent studies link obesity 

and asthma, to our knowledge this 

is the first prospective study that 

examines the frequency of asthma in 

obese children. Being able to exercise 

is an important factor in most weight 

loss programs. Gym coaches and 

teachers also tend to attribute obese 

students inability to exercise as 

being “out of shape”. Physicians and 

school officials alike should consider 

the possibility of asthma in children 

and adolescents who are overweight 

and who have difficulty exercising. 

The study was limited by several 

factors. First, the population eligible 

for enrollment was a very select 

one, drawing from obese patients 

who were referred for weight 

management to an adolescent 

cardiovascular fitness program. Other 

obese children not referred to the 



Table 1. All data subjects. Those with normal baseline spirometry are grouped together at the bottom of the table. 

Age/ 

Gender 

Height 

(cm) 

Weight 

(Kg) 

BMI 

Initial 

FVC 

Post 

Bronchodilator 

Initial 

FEV1 FVC FEV1 

Spirometry 

(FEV1) 

improvement 

Treadmill 

Test 

Likely 

Asthma 

1 8/M 133 56 31.65 2.01 1.47 2.37 2.06 40% N/A Yes 

2 14/M 181 113 34.5 3.23 1.54 3.63 2.42 57% N/A Yes 

3 11/M 143 71 34.7 2.7 2.13 2.75 2.06 -3% Positive Yes 

4 7/M 131 38 22.14 2.09 0.92 2.09 1.13 11% Positive Yes 

5 9/M 151.5 87.2 38.0 3.41 2.38 3.40 2.46 4% Positive Yes 

6 12/M 154 78.7 33.0 2.85 2.21 3.6 3.02 37% N/A Yes 

7 9/F 130.8 70.4 31.2 2.74 2.14 2.82 2.41 12% N/A Yes 

8 9/F 147 75 34.7 2.85 2.47 2.97 2.4 -2% Negative No 

9 13/F 171 138 47.18 4.38 3.71 4.29 3.93 6% Refused Unknown 

10 12/F 147 75 34.7 2.49 2.06 

Sent directly to 

treadmill test N/A Positive Yes 

11 8/M 138 59 31.0 2.23 1.53 ≈ N/A Positive Yes 

12 16/F 162.5 162 61.3 2.46 3.07 ≈ N/A Negative No 

13 12/F 148 78.5 35.8 2.86 2.47 ≈ N/A Negative No 


15 15/F 150.4 99.0 39.7 3.69 3.03 ≈ N/A Negative No 

16 13/M 170 118 40.8 4.30 3.65 ≈ N/A Negative No 

17 11/F 169 141 49.4 3.93 3.56 ≈ N/A Negative No 


19 9/M 169 141 49.4 3.95 3.56 ≈ N/A Negative No 

20 13/F 171.2 151.7 51.8 5.54 4.13 ≈ N/A Negative No 

program may also have asthma, at 

rates higher or lower than detected 

in our study. We also did not seek to 

utilize a control group of non-obese 

patients with dyspnea on exertion, 

to compare their rates of asthma to 

those of the obese study population. 

This is a small pilot study 

meant to provide information on 

the association between dyspnea 

on exertion and exercise induced 

asthma; we did not intend to imply 

causality. Larger studies are needed 

to further support this association, 

as well as to evaluate possible 

mechanisms. Future trials are needed 

to evaluate whether weight loss 

would improve asthma in overweight 

children, and conversely, whether 

improved asthma control would 

foster weight loss in this population. 

Another limitation is that an 

asthma diagnosis or any previous 

use of asthma medications excluded 

patients from entry into the study. 

Several patients were not offered 

the study because they had received 

bronchodilator medications recently 

for “bronchitis”, but still do not 

endorse an asthma diagnosis. This 

may cause us to underestimate the 

actual rates of asthma in those obese 

patients. Although those in the 

study who demonstrated exercise 

induced bronchospasm were offered 

treatment for asthma, no follow up 

data was collected on the health 

and the success with weight loss 

among our study population. While 

it would be reasonable to assume 

that treatment of their asthma makes 

it easier to exercise, and therefore 

lose weight, no data are available 

currently to confirm this hypothesis. 

It is possible that exercise-induced 

asthma may have an exacerbating 

effect on the development of obesity; 

these children may have learned at 

an early age that they do not enjoy 

physical activity, but not be certain 

why. This nearly 50 percent incidence 



of asthma in obese children confirms 

previous observations demonstrating 

a link between obesity and asthma, 

although the question whether the 

link is causal deserves further study. 

References 

1. Centers for Disease Control and 

Prevention. Behavioral Risk Factor 

Surveillance System. Available on line at 

www.cdc.gov.brfss 

2. U.S. Environmental Protection Agency. 

Information retrieved March, 2004 from 

www.epa.gov/asthma/introduction.html 

3. Centers for Disease Control and 

Prevention, June, 2008. www.cdc.gov/ 

nccdphp/dnpa/obesity/childhood/ 

prevalence.htm 

4. Gold, D.R, Damokosh, A.I., Dockery, D.W., 

Berkey, C.S. Body Mass Index as a 

Predictor of Incident Asthma in a 

Prospective Cohort of Children. Pediatric 

Pulmonology 36:514-521, 2003. 

5. Castro-Rodriguez, J.A., Holberg, C.J., 

Morgan, W.J., et al. Increased Incidence of 

Asthmalike Symptoms in Girls Who 

Become Overweight or Obese during the 

School Years. Am J Respir Crit Care Med 

163:1344-1349, 2001. 

6. Guerra, S, Wright, A.L., Morgan, W.J, et al. 

Persistence of Asthma Symptoms during 

Adolescence; Role of Obesity Age at the 

Onset of Puberty. Am J Respir Crit Care 

Med 170:78-85, 2004. 

7. Stenius-Aarniala, B, Poussa, T, 

Kvarnstrom, J, et al. Immediate and long 

term effects of weight reduction in obese 

people with asthma: randomized controlled 

study. BMJ 320:827-832, 2000. 

8. Jakala, K, Stenius-Aarniala, B, Sovijarvi, A. 

Effects of weight loss on peak flow 

variability, airways obstruction, and lung 

volumes in obese patients with asthma. 

Chest 118:1315-1321, 2000. 

9. Polgar, G, Promadhat, V. Standard values. 

In: Pulmonary Function Testing in children: 

techniques and standards. Philadelphia: 

W.B. Saunders, 1971. p 87-212. 

10. ATS/ACCP Statement on Cardiopulmonary 

Exercise Testing. Am. J. Respir. Crit. Care 

Med. 167:211-277, 2003. 


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Ethylene Glycol and Methanol Poisonings: Case Series 

and Review 

Carol A. Montjoy, MD 

Fellow, West Virginia University, Robert 

C. Byrd Health Sciences Center 

Aamer Rahman, MD 

Pulmonary/CCM, Piedmont Pulmonary 

Consultants 

Luis Teba, MD 

Professor, West Virginia University 

School of Medicine 

Abstract 

Introduction: Ethylene glycol (EG) 

and methanol (MTH) are common 

industrial solvents and are responsible for 

accidental, suicidal, and epidemic 

poisonings. 1 Since the clinical signs and 

symptoms associated with EG and MTH 

poisoning are nonspecific, it is important 

for the medical community to consider 

these toxicities given that early treatment 

prevents death. 2 The hallmark of toxic 

alcohol poisoning is a combination of a 

high anion gap metabolic acidosis and 

osmolar gap. 3 In order to determine 

laboratory abnormalities and outcomes 

associated with EG and MTH ingestion at 

our institution, a retrospective chart 

review was obtained. 

Materials and Methods: A 

retrospective chart review of all adult 

patients admitted to our institution with a 

diagnosis of EG or MTH intoxication 

during a 15-year period was done. Age, 

sex, EG and MTH levels, degree of 

acidosis, initial anion and osmolar gaps, 

renal dysfunction, length of stay in the 

hospital, need for dialysis, and ADH 

(alcohol dehydrogenase) blockade 

treatment were recorded. Hospital 

outcome included renal function and need 

for dialysis at hospital discharge. 

Results: The study population 

consisted of 14 patients.The mean pH 

was 7.02. The mean anion gap and 

osmolar gap were 21 meq/l and 48 

mOsm/l correspondingly. All patients 

underwent treatment with either ethanol 

or fomepizole and hemodialysis. At 

discharge, three patients had renal 

insufficiency not requiring dialysis; one 

remained on dialysis, while seven 

regained normal renal function. 

Conclusion: Most patients with EG 

and MTH intoxication have a decreased 

level of consciousness making an 

adequate history unobtainable. One must 

rely on laboratory data for clues in making 

a diagnosis of intoxication. A review of the 

clinical features, pharmacokinetics, 

laboratory analysis, and management of 

EG and MTH poisoning is included in this 

discussion to help raise medical 

community awareness of this entity. 

Introduction 

Ethylene glycol (EG) and methanol 

(MTH) poisonings are important 

health problems because of their 

severe morbidity and mortality. 1 

Since many of the clinical signs and 

symptoms associated with EG and 

MTH poisonings are nonspecific, 

it is important for the clinician to 

consider these toxicities since early 

treatment offers the best prognosis 

and prevents death. 2 Many hospitals 

are unable to perform EG and MTH 

measurements in a timely fashion; 

which in this case, a combination 

of a metabolic acidosis associated 

with a high anion gap and osmolar 

gap is considered the hallmark 

of toxic alcohol intoxication. 3,4 

We undertook a retrospective 

chart review of all adult patients 

admitted with a diagnosis of EG 

or MTH intoxication in order to 

identify laboratory abnormalities 

associated with ingestion as well as to 

determine outcomes. A review of the 

clinical features, pharmacokinetics, 

laboratory analysis, and management 

of EG and MTH poisonings is 

included in the discussion. 

Materials and Methods 

A retrospective chart review of 

all adult patients admitted to our 

institution with a diagnosis of EG or 

MTH intoxication during a 15-year 

period was done. Age, sex, type 

of poisoning, EG and MTH levels, 

degree of acidosis, initial anion 

gap (AG) and osmolar gap (OG), 

need for mechanical ventilation, 

antidote use, renal dysfunction, 

need for dialysis, and length 

of hospital stay were recorded. 

Hospital outcomes included renal 

function, need for dialysis at 

hospital discharge, and mortality. 

The equation used to calculate 

the OG: 

OG = Measured serum osmolarity (mOsm/L) 

– Calculated serum osmolarity (mOsm/L), 

where the measured serum 

osmolarity was obtained via 

the freezing point depression 

method. The calculated serum 

osmolarity was determined 

by the following equation: 

2*Na + Glu/18 + BUN/2.8. 

When an alcohol drip was used as 

an antidote, standard guidelines of 

the American Academy of Clinical 

Toxicology Practice Guidelines, were 

used which included a loading dose 

of 7 ml/kg of a 10% ethanol solution 

given over thirty minutes, followed 

by a continuous infusion of 1-2 ml/ 

kg/hr of a 10% ethanol solution in 

order to maintain the serum ethanol 

levels between 100 to 150 mg/dl.5 

Results 

Eleven of the 14 patients were men, 

ages 19 to 59 (mean 43). Ethylene 

glycol accounted for ten of the toxic 

alcohol levels. The mean serum EG 

and MTH levels were 111mg/dl 

(range 9 to 290) and 142mg/dl 

(range 52 to 230) respectively. The 

mean pH was 7.02 (range 6.54 to 

7.43). All patients had an increased 

anion gap metabolic acidosis and 

osmolar gap, (excluding one patient 

for whom data were unavailable) 

with a mean anion gap of 21 meq/l 

(range 15 to 31) and mean osmolar 

gap of 48 mOsm/l (range 29 to 81) 

correspondingly. Eleven required 

mechanical ventilation. Twelve 

were treated with an ethanol drip 



while two received fomepizole. All 

underwent hemodialysis. At hospital 

discharge, three had persistent renal 

insufficiency not requiring dialysis; 

one remained on dialysis, while 

seven had regained normal renal 

function. The average hospital stay 

was 8 days (range 1 to 23 days). 

Three patients died despite use of 

antidote and dialysis; all had severe 

metabolic encephalopathy from MTH 

poisoning, and death occurred after 

withdrawing support. Table 1 shows 

patient characteristics and outcomes. 

Discussion 

EG and MTH are common 

industrial solvents present in a wide 

range of solutions. These alcohols 

are responsible for accidental, 

suicidal, and epidemic poisonings. 1 

In the 2004 annual report of the 

Toxic Exposure Surveillance System 

(TESS), there were 5,562 exposures 

with 23 deaths and 979 exposures 

with 4 deaths related to EG and 

MTH toxicity respectively in the 

United States (US). 1 A review of 

the clinical presentation, diagnosis 

and treatment of EG and MTH 

intoxication will be discussed. 

Ethylene glycol: Clinical Features 

EG is a sweet-tasting substance 

that is often a component of 

antifreeze, but can also be found 

in engine coolants and hydraulic 

brake fluids. 3 Because of its sweet 

taste, ability to intoxicate, and 

relatively low cost, it is often used 

as a substitute for ethanol. 3 

Many authors describe three 

phases of EG poisoning: neurological 

phase, cardiopulmonary phase, and 

renal phase. 5 Although these stages 

may be concurrent, the classification 

offers a temporal theoretical 

description of EG poisoning. 5 

Stage 1: Neurological (30 minutes 

to 12 hours after ingestion) 

Within minutes to several 

hours after EG poisoning, transient 

inebriation and euphoria, similar to 

the symptoms of ethanol intoxication, 

may be observed. 6 EG is a more 

potent CNS depressant than ethanol; 

the degree of obtundation for an 

equivalent serum level of ethylene 

glycol is more profound than for 

ethanol. 7 Nausea and vomiting can 

also occur due to direct irritation 

of the gastrointestinal tract by 

EG as confirmed by visualization 

under endoscopy as well as the 

appearance of focal hemorrhages 

in the gastric lining at autopsy. 7 

As EG metabolism progresses, 

manifestations of central nervous 

system (CNS) depression, such 

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Table 1. Patient Characteristics and Outcomes 

EG- Ethylene glycol(mg/dl), MTH- Methanol,(mg/dl) AG-Anion gap (meq/l) 

OG-Osmolar gap(mosm/l), MV (mechanical ventilation) 



as coma, hypotonia, hyporeflexia, 

seizures, and meningismus, replace 

earlier symptoms. 3,8 Cerebral 

edema, secondary to direct cytotoxic 

damage as well as the deposition 

of calcium oxalate in the CNS, 

as verified in autopsy studies, 

contributes to CNS depression. 9 

Stage 2: Cardiopulmonary 

(12-24 hours after ingestion) 

Symptoms during this phase 3 

include shortness of breath and 

physical findings are consistent with 

congestive heart failure. 8,9 In serious 

cases, severe metabolic acidosis 

with compensatory hyperventilation 

can develop accompanied by 

multiple organ failure. Most 

deaths occur in this stage. 5 

Stage 3: Renal (24-72 

hours after ingestion) 

The third stage can include 

oliguria and flank pain indicative 

of acute tubular necrosis and renal 

failure. 5 The renal toxicity of EG is 

thought to be due to a combination 

of hydronephrosis from calcium 

oxalate crystals and a direct toxic 

effect from EG metabolites. 8 Tubular 

atrophy and interstitial fibrosis are 

poor prognostic indicators of renal 

function. 7 Recovery of renal function 

is typically complete but may require 

several months of hemodialysis. 3 

Methanol: Clinical Features 

MTH is a highly toxic alcohol 

commonly found in a variety 

of commercial products such as 

windshield wiper fluid, gas line 

antifreeze, paint strippers, and 

industrial solvent. 3 Symptoms 

and signs of MTH intoxication 

usually are limited to the CNS, 

eyes, and gastrointestinal tract. 

Initial symptoms may appear as 

soon as 12 hours post-ingestion, 

but usually develop 24 hours after 

ingestion. 10 Initial symptoms may 

resemble these of ethanol intoxication 

including drowsiness, confusion, 

nausea, and vomiting. 3 It produces 

less euphoria than ethanol. 10 Visual 

disturbances range from blurred 

vision, photophobia, visual field 

defects, and blindness. 11 Fundoscopic 

exam may reveal hyperemia of the 

optic disc or papilledema. 11 There 

may be pupillary dilation and loss 

of the pupillary reflex. 10 Visual 

changes with MTH poisoning are due 

to microtubule and mitochondrial 

destruction in the retrolaminar 

optic nerve. 10 Severity of the visual 

abnormalities is directly correlated 

with the severity of the metabolic 

acidosis. 9 Severe poisoning is 

Figure 1. 

Toxic Metabolic Activation of Ethylene Glycol. 

Thiamine 

Magnesium 

a-Hydroxy-- 

β-Ketoadipate 

Other 

Pathways 

Oxalomalate 

Formate + Carbon Dioxide 

γ=Hydroxy-a-Ketoglutarate 

Ethylene Glycol 

Glycoaldehyde 

Glycolate 

(Glycolic Acid) 

Glyoxylate 

(Glyoxylic Acid) 

Oxalate 

Calcium Oxalate 

associated with cerebral edema, 

coma, and seizures. 11 Survivors 

may develop a parkinsonism-like 

syndrome which correlates with 

CT evidence of destruction in the 

putamen and subcortical white 

matter hemorrhage. 12 Survivors 

may have permanent blindness 

or neurological deficits. 2 

Pharmacokinetics of ethylene 

glycol and methanol 

EG and MTH are rapidly absorbed 

after oral ingestion and both have a 

Alcohol 

Dehydrogenase* 

Aldehyde 

Dehydrogenase 

Calcium 

Pyridoxine 

Glycine 

* Conversion of ethylene glycol to glycoaldehyde is the rate-limiting step; 

alcohol dehydrogenase is inhibited by ethanol and 4-MP. 

This information was originally published in Emergency Medicine Reports. Reprinted with 

permission of AHC Media LLC, PO Box 740056, Atlanta, GA 30374. For subscription information, 

contact customer service at (800) 688-2421 13 . 



small volume of distribution (0.5- 

0.8 L/kg). 9 The estimated minimum 

lethal adult dose of EG and MTH is 

100 ml and 10 ml correspondingly. 3 

Both undergo metabolism through 

hepatic alcohol dehydrogenase 

(ADH) to toxic metabolites as seen in 

Figure 1 and Figure 2. 13 With normal 

renal function, the elimination half 

life of EG is 3-8 hours and that of 

MTH is 14-30 hours. 9 If ADH is 

competitively blocked by another 

agent, such as ethanol or fomepizole, 

then metabolism is halted and the 

parent compounds are eventually 

renally eliminated unchanged. 14 

Laboratory Abnormalities 

of ethylene glycol and 

methanol intoxications 

The Anion Gap 

Although determination of the 

anion gap is considered essential 

in the diagnosis of toxic alcohol 

ingestion, an anion gap acidosis 

will be observed only after the 

parent compound has been 

metabolized to its toxic by-products 

(approximately 3-6 hours depending 

on the elimination half life of the 

alcohol). 14 Glycolic acid and formic 

acid are largely responsible for the 

anion gap metabolic acidosis in 

the metabolism of EG and MTH 

respectively. 3 However, some of the 

acidosis stems from the production 

of lactate and is due to the reduction 

of nicotinamide adenine dinuleotide 

to nicotinamide adenine dinucliotide, 

reduced form. 3 Furthermore, the 

anion gap cannot be relied on as 

an accurate screening tool in cases 

where ethanol is a coingestant. 15 

An ethanol level of greater than 100 

mg/dl competitively inhibits ADH 

and will increase the elimination 

half life by fivefold or more. 14 

All patients admitted with a 

diagnosis of EG or MTH intoxication 

had an elevated anion gap (Table 

1). It is of interest that patient 

number nine presented with a very 

high ethylene glycol level with 

only a mild elevation of the anion 

gap; it is presumed that patient 

number nine presented very early 

in the course of toxicity given 

that there was not any evidence 

of other sources of intoxication. 

The Osmolar Gap 

The parent compound contributes 

to the osmolar gap because it 

is osmotically active and has a 

relatively small molecular weight. 3 

Toxic acids generated by EG and 

MTH metabolism do not contribute 

to the osmolar gap; thus, the longer 

the delay in measurement of serum 

osmolarity from the time of ingestion, 

the more likely the osmolar gap may 

approach normal values. 14 Although 

it is conventionally believed that 

an OG of less than 10 mOsm/L is 

normal, other authors have found 

that the range of normal osmol 

values within the population is 

large (-5 to +15 mOsm/L). 16 Also, 

the value of the OG depends on 

the equation used to determine 

the gap; for example, the inclusion 

of ethanol in its determination 

lowers the traditionally accepted 

OG. 16 Further, other conditions 

such as alcoholic ketoacidosis, 

Figure 2. 

Toxic Metabolic Activation of Methanol. 

lactic acidosis, renal failure are 

associated with an elevated OG. 15 

All patients admitted with 

EG or MTH poisoning had an 

elevated osmolar gap (except 

patient number nine where the OG 

data were unavailable, Table 1). 

Urinalysis 

Calcium oxalate deposition in 

tissues is one mechanism of toxicity, 

which contributes to hypocalcemia. 

Oxalate crystalluria is considered 

a hallmark of EG poisoning. 9 Up 

to 50% of patients with EG toxicity 

have calcium oxalate crystals in 

their urine and, if present, aides in 

diagnosis. 5 However, the absence 

of calcium oxalate crystaluria does 

not exclude EG poisoning. 8 

Management of ethylene glycol 

and methanol poisoning 

The first approach to a patient 

suspected to have toxic alcohol 

poisoning is appropriate airway 

management, resuscitation and 

stabilization. 2 If toxic alcohol 

poisoning is suspected, poison 

control should be contacted and 

1. Methanol 

alcohol dehydrogenase* 

Formaldehyde** 

aldehyde dehydrogenase 

2. Formaldehyde Formic Acid + 

(Formate) 

3. Formic acid 

Cofactor: tetrahydrofolate)++ 

Carbon Dioxide 

(Formate) 

and Water 

* The conversion of methanol to formaldehyde is the rate-limitng step. 

Alcohol dehydrogenase is inhibited by ethanol and 4-MP. 

** Although the formaldehyde metabolite is quite toxic, in humans it has a 

very short half-life and does not significantly contribute to toxicity. 

+ Accumulation of formate is responsible for metabolic acidosis and 

ocular toxicity in humans. 

++ Hepatic metabolism of formate is a folate-dependent process; 

administration of exogenous folinic or folic acid may increse this 

conversion. 

This information was originally published in Emergency Medicine Reports. Reprinted with 

permission of AHC Media LLC, PO Box 740056, Atlanta, GA 30374. For subscription information, 

contact customer service at (800) 688-242113. 



Table 2: Indications for the Treatment of EG and MTH Poisoning with 

Ethanol or Fomepizole 

Data are from the American Academy of Clinical Toxicology Ad Hoc Committee on the Treatment 

Guidelines for Ethylene Glycol and Methanol Poisoning. 5,10 

specific treatment goals should 

be undertaken even if a history 

of ingestion is not obtainable. 

The specific treatment goals are 

correction of metabolic acidosis, ADH 

blockade, and removal of the alcohol 

and its metabolites. Although there 

are no data to support the use of 

sodium bicarbonate for the treatment 

of toxic alcohol induced metabolic 

acidosis, most guidelines support this 

temporizing maneuver for patients 

with an arterial pH below 7.3 while 

awaiting more permanent treatment 

with hemodialysis. 3 Antidotes 

available to block the action of ADH 

include ethanol and fomepizole. 6 

The indications for use of an antidote 

have been outlined by the American 

Academy of Clinical Toxicology 

as seen in Table 2. 5,10 Standard 

dosing regimens for ethanol and 

fomepizole are available in the most 

current guidelines. 5,10 Fomepizole 

is the preferred antidote because it 

is easier to dose, does not require 

frequent blood monitoring, and it 

does not cause CNS depression. 9 

Some studies have suggested that 

fomepizole may be an effective and 

safe first line antidote for EG and 

MTH intoxication, possibly obviating 

the need for hemodialysis. 17-19 Other 

studies have alluded to this concept, 

but have called for further research 

to determine if fomepizole alone is 

adequate treatment for toxic alcohol 

ingestions. 20 Rapid removal of EG 

and MTH through hemodialysis, 

before they have been metabolized, 

remains the cornerstone of therapy. 5,10 

In general, hemodialysis is indicated 

in patients who have metabolic 

acidosis, renal compromise, visual 

symptoms (in cases of MTH toxicity), 

deterioration despite intensive 

supportive care, or electrolyte 

abnormalities unresponsive to 

conventional therapy. 5,10 Co-factor 

therapy with thiamine, pyridoxine, 

and magnesium, to enhance the 

metabolism of glycolic acid, may 

be considered; similarly, folinic 

acid administration can be used 

in cases of MTH poisoning since 

it may augment the conversion 

of toxic to nontoxic metabolites. 5 

However, there are no human 

studies to support these practices. 5 

Prognosis 

The degree of metabolic acidosis 

at admission (serum pH less than 

7.00) has been associated with a 

high mortality rate secondary to EG 

and MTH intoxication. 21-23 Coma at 

admission has a poor prognosis in EG 

and MTH overdose. 22,24‐25 Most of our 

patients admitted for EG intoxication 

who survived, regained normal 

renal function; only one remained 

on hemodialysis at discharge. 

Conclusion 

Most of our patients presented 

with a decreased level of 

consciousness and inability to 

give a good history. In addition, 

family members may be unaware 

of or embarrassed by the patients’ 

extensive drinking habits and, 

therefore, unable or unwilling to 

provide much historical content. 

Since the signs and symptoms 

of EG and MTH poisoning are 

nonspecific, the diagnosis of EG or 

MTH poisoning can be missed. The 

clinician is limited to laboratory 

analyses to support the diagnosis of 

EG or MTH intoxication. The classic 

finding are an anion gap metabolic 

acidosis with an osmolar gap, and 

seen in our group of patients. If a 

reason for a high osmolar gap is not 

obvious in a patient with an anion 

gap metabolic acidosis, EG and MTH 

poisoning must be suspected. Other 

clinical clues to intoxication include 

urinary crystals indicative of EG 

poisoning and visual complaints 

supportive of MTH poisoning. 

Supportive care, ADH blockade, 

and hemodialysis are the standard 

treatment for EG and MTH 

poisonings. Treatment must be 

started immediately. With prompt, 

aggressive treatment, most patients 

will recover renal function and 

avoid long term sequelae. 5,10 

References 

1. Watson WA., Litovitz TL, Rodgers GC, et 

al. 2004 Annual report of the American 

association of poison control centers toxic 

exposure surveillance system. Am Journal 

Emergency Medicine 2005; 23(5): 589- 

666. 

2. Jacobsen D, McMartin KE. Antidotes for 

methanol and ethylene glycol poisoning. 

Clinical Toxicology 1997; 35(2): 127-143. 



3. Abramson S, Singh AK. Treatment of the 

alcohol intoxications: ethylene glycol, 

methanol, and isopropanol. Current 

Opinion Nephrology Hypertension 2000; 9: 

695-701. 

4. Hovda KE, Hunderi OH, Rudberg N, et al. 

Anion and osmolal gaps in the diagnosis of 

methanol poisoning: clinical study in 28 

patients. Intensive Care Med 2004; 

30:1842-1846. 

5. Miller H, Barceloux DG, Krenzelok EP, et 

al. American academy of clinical toxicology 

practice guidelines on the treatment of 

ethylene glycol poisoning. Clinical 

Toxicology 1999; 37(5): 537-560. 

6. Hall JB, Schmidt GA, Wood LD. Toxicology 

in adults. In principles of critical care. New 

York, NY. The McGraw-Hill Company 2005: 

1519-1520. 

7. Davis DP, Bramwell KJ, Hamilton RS, et al. 

Ethylene glycol poisoning: case report of a 

record-high level and a review. J Emerg 

Med 1997; 15(5): 653-667. 

8. Wine H, Savitt D, Abuelo G. Ethylene 

glycol intoxication. Seminars in Dialysis 

1994; 7(5): 338-345. 

9. Kraut JA, Kurtz I. Toxic alcohol ingestions: 

clinical features, diagnosis, and 

management. Clin J Am Soc Nephrol 

2008; 3(1):208-225. 

10. Barceloux DG, Bond GR, Krenzelok EP, et 

al. American academy of clinical toxicology 

practice guidelines on the treatment of 

methanol poisoning. Clinical Toxicology 

2002; 40(4): 415-446. 

11. Kruse JA. Methanol poisoning. Intensive 

Care Med 1992; 18:391-397. 

12. McLean DR, Jacobs H, Mielke BW. 

Methanol poisoning: a clinical and 

pathological study. Ann Neurol 1980; 8: 

161-167. 

13. Hall AH. Ethylene glycol and methanol: 

poisons with toxic metabolic activation. 

Emerg Med Rpt 1992. 13(4): 29-38. 

14. Mycyk MB, Aks SE. A visual schematic for 

clarifying the temporal relationship between 

the anion and osmol gaps in toxic alcohol 

poisoning. American Journal Emergency 

Medicine 2003: 21(4): 333-335. 

15. Ammar, KA, Heckerling, PS. Ethylene 

glycol poisoning with a normal anion gap 

caused by concurrent ethanol ingestion: 

Importance of the osmolal gap. Am J 

Kidney Dis 1996; 27(1):130-133. 

16. Hoffman R, Smilkstein M, Howland M, et 

al. Osmol gaps revisited: normal values 

and limitations. Clinical Toxicology. 

1993;31(1): 81-93. 

17. Megarbane B, Borron SW, Baud FJ. 

Current recommendations for treatment of 

severe toxic alcohol poisonings. Intensive 

Care Med 2005; 31: 189-195. 

18. Megarbane B, Borron SW, Trout H, et al. 

Treatment of acute methanol poisoning 

with fomepizole. Intensive Care Med 2001; 

27:1370-1378. 

19. Hovda KE, Froyshov S, Gudmundsdottir H, 

et al. Fomepizole may change indication 

for hemodialysis in methanol poisoning: 

prospective study in seven cases. Clinical 

Nephrology 2005; 64(3): 190-197. 

20. Green R. The management of severe toxic 

alcohol ingestions at a tertiary care center 

after the introduction of femepizole. Amer J 

Emer Med 2007; 25: 799-803. 

21. Karlson-Stiber C, Persson H. Ethylene 

glycol poisoning: experiences from an 

epidemic in Sweden. Clinical Toxicology 

1992; 30(4): 565-574. 

22. Hovda KE, Hunderi H, Tafjord AB, et al. 

Methanol outbreak in Norway 2002-2004: 

epidemiology, clinical features and 

prognostic signs. J Int Med 2005; 258: 

181-190. 

23. Hassanian-Moghaddam H, Pajoumand A, 

Dadgar SM, et al. Prognostic factors in 

methanol poisoning. Human & 

Experimental Toxicology. 2007; 26: 583- 

586. 

24. Liu JJ, Daya MR, Carrasquillo O, et al. 

Prognostic factors in patients with 

methanol poisoning. Clinical Toxicology 

1998; 36(3): 175-181. 

25. Hylander B, Kjellstrand CM. Prognostic 

factors and treatment of severe ethylene 

glycol intoxication. Intensive Care Med 

1996; 22: 546-552. 

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Scedosporium Prolificans Endocarditis: Case Report and 

Review of Literature 

Sharjeel Ahmad, MD 

Fellow 

Shahzad Zia, MD 

Fellow 

Arif R. Sarwari, MD 

Associate Professor 

Section of Infectious Diseases 

Department of Medicine 

West Virginia University 

Morgantown 

Abstract 

Scedosporium prolificans is an 

emerging fungal pathogen. We report a 

case of Scedosporium prolificans 

endocarditis in an immunocompetent 

male together with a literature review. 

Introduction 

Scedosporium prolificans is 

an emerging fungal pathogen. 

Immunocompetent patients 

usually manifest disease involving 

bones and joints, endophthalmitis 

and onychomycosis. In 

immunocompromised hosts, 

disseminated infections, fungemia 

and endocarditis are a major 

source of morbidity and mortality. 

We report a case of Scedosporium 

prolificans endocarditis in an 

immunocompetent male. 

Case Report 

A 50 year old white male 

anesthesia nurse with childhood 

history of rheumatic fever but no 

other significant medical problems 

presented to the emergency room 

(ER) with a two week history of 

fever, myalgia, arthralgia, headache 

and transient visual field deficits. 

Two weeks before onset of these 

symptoms he was discharged 

from a psychiatric facility after 

attempted suicide using a single 

intravenous dose of propofol. 

Earlier, he had been seen in the ER 

with CT imaging of the brain and 

sinuses showing air-fluid levels in 

the left maxillary sinus, and had 

had treatment with clarithromycin 

for sinusitis. He had been evaluated 

by the ophthalmology service as an 

outpatient for his visual symptoms, 

described by him as “a curtain 

coming in front of the left eye” and 

was diagnosed with ocular migraine. 

At this ER visit, he had a II/VI 

holosystolic murmur, subconjunctival 

petechial hemorrhages, and bibasilar 

crackles. There were no neurological 

deficits. He was admitted to hospital 

with concern for endocarditis. 

Blood cultures were drawn and 

treatment was started on intravenous 

(IV) oxacillin and gentamicin. A 

transesophageal echocardiogram 

(TEE) showed a large mobile mass 

attached to the posterior leaflet 

of the mitral valve with severe 

mitral valve regurgitation. 

Clinical deterioration with 

development of pulmonary edema, 

septic shock and respiratory 

failure necessitated transfer to 

the intensive care unit within 24 

hours. He required endotracheal 

intubation, pressor support and 

insertion of an intra-aortic balloon 

pump. An MRI of the brain 

showed two acute to subacute 

infarcts in the posterior aspect of 

the right putamen, extending into 

the posterior limb of the internal 

capsule and the left cerebellar 

hemisphere. Ophthalmological 

evaluation showed multiple retinal 

hemorrhages and Roth spots. An 

electroencephalogram (EEG) showed 

periodic sharp wave abnormalities 

over the left frontal area. The 

hospital course was subsequently 

complicated by thrombocytopenia 

with renal and hepatic dysfunction. 

By the fourth hospital day, blood 

cultures showed yeast, with all 

six cultures subsequently positive 

for Scedosporium prolificans. He 

was started on lipid complex 

amphotericin B and underwent 

emergency mitral valve replacement. 

Histopathological evaluation of 

the mitral valve showed numerous 

spores and pseudohyphae. The blood 

culture specimens, sent to a reference 

lab for identification, showed the 

fungus to be resistant to amphotericin 

B, itraconazole and fluconazole. The 

patient remained unstable and died 

on the ninth day of admission. 

Discussion 

The genus Scedosporium 

consists of two medically important 

species: Scedosporium apiospermum 

(and its teleomorph or sexual 

state Pseudallescheria boydii) and 

Scedosporium prolificans (formerly S. 

inflatum). Infection by S. prolificans 

was first described in 1984 by 

Malloch and Salkin from a bone 

biopsy specimen in a young boy 

with post-traumatic osteomyelitis. 1 

Identification and differentiation 

from S. apiospermum are based on 

the morphological characteristics. 2 

This fungus, like S. apiospermum, 

has been recovered from soil and 

potted plants and is known to cause 

asymptomatic colonization as well 

as localized infections following 

penetrating trauma and injection 

drug use. 3 Disseminated infections 

are most commonly described in 

immunocompromised hosts. 

Asymptomatic colonization of 

different body sites is possible with 

recovery of organism demonstrated 

from sputum, bronchoalveolar 

lavage or ear swabs. 4 Localized 

infections include septic arthritis of 

the knee or ankle after penetrating 

or non-penetrating trauma, fungal 

endophthalmitis and onychomycosis. 



Disseminated infections with 

Scedosporium prolificans have been 

reported in neutropenic patients 

including those with underlying 

blood disorders such as acute 

leukemia, non-Hodgkin’s lymphoma, 

aplastic anemia and multiple 

myeloma. 5-7 Less commonly, it may 

complicate the post operative course 

of solid organ transplant recipients. 8 

The most frequent site of entry 

of this organism in disseminated 

infections appears to be the 

respiratory tract, based on the 

observation of a high frequency 

of pulmonary symptoms and 

pulmonary infiltrates. Isolated 

cases of entry into the bloodstream 

with subsequent dissemination 

through a surgical wound, a 

Hickman catheter site or an injection 

drug site have been reported. 

In neutropenic patients, 

disseminated infections present 

with shock, pneumonia and 

respiratory failure, renal failure, 

nodular erythematous cutaneous 

lesions, visual loss and central 

nervous system involvement. 7 

S. prolificans is inherently 

resistant to many antifungals. 9,10 

Echinocandins have been used 

for treatment 11 and voriconazole 

has been shown to have potent 

in vitro activity (MIC 90 

= 4mg/ 

mL). 10 Data on posaconazole 

are emerging but breakthrough 

infections in immunocompromised 

hosts have been reported. 9,12,13 The 

role of colony stimulating factors 

in the immunocompromised 

is theoretically very appealing 

but is yet undetermined. 14,15 

A review of cases of S. prolificans 

infection with cardiac involvement is 

presented in Table 1. Amphotericin 

alone or in combination with other 

antifungals was used in most of these 

patients without success; all died. The 

patient with pacemaker endocarditis 

had underlying hepatitis C and 

survived after treatment with 

five weeks of oral voriconazole. 16 

None of these patients received 

echinocandins or posaconazole. 

Our patient was immunocompetent, 

with no evidence of HIV infection. 

He had been involved in an isolated 

incident of injection drug use as 

part of his suicide attempt. It is 

known that propofol may enhance 

the growth of Staphylococcus aureus, 

Moraxella species, Candida and 

other organisms 22 but no data are 

available for Scedosporium. The 

portal of entry in him was unknown. 

Of note, the newer antifungals such 

as echinocandins, voriconazole and 

posaconazole were not available 

at the time of case presentation 

and hence sensitivity testing 

for the above was not done. 

Scedosporium prolificans infection 

with cardiac involvement is almost 

universally fatal. The inherent 

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Table 1. Cases of S. prolificans infection with cardiac involvement. 

Patient characteristics 

Reference 

No. 

Year of 

report 

Age 

(years) 

Gender Risk factor Therapy Outcome 

[16] 2006 75 M pacemaker Vor, surgery Survived 

[17] 2001 58 F 

Multiple 

myeloma, 

BMT, 

neutropenia 

Lipid AMB, 

Itr, surgery 

Died 

[18] 2000 45 M 

Leukopenia, 

neutropenia 

AMB 

Died 

[19] 1999 65 F 

Leukemia, 

neutropenia 

AMB 

Died 

[6] 1997 67 F Porcine AVR AMB, Flu Died 

[20] 1996 60 M 

AIDS, 

lymphoma, 

neutropenia 

None 

Died 

[8] 1994 50 F 

Lung 

transplant 

AMB 

Died 

[21] 1993 72 F 

Lymphoma, 

neutropenia 

AMB 

Died 

AMB, amphotericin B; AVR, aortic valve replacement; BMT, bone marrow transplant; F, female; Flu, fluconazole; G-CSF, 

granulocyte colony stimulating factor; Itr, itraconazole; M, male; MVR, mitral valve replacement ; Vor, voriconazole. 

resistance to multiple antifungals and 

the immunocompromised state of 

these patients contribute to the grave 

prognosis. Combination antifungal 

therapy, 11,23 correction of underlying 

immune defect, along with valve 

replacement surgery may hold the 

key to achieving potential cure. 

References 

1. Malloch D, Salkin IF. A new species of 

Scedosporium associated with 

osteomyelitis in humans. Mycotaxon 1984; 

21:247–255. 

2. Salkin IF, McGinnis MR, Dysktra MJ et al. 

Scedosporium inflatum, an emerging 

pathogen. J Clin Microbiol 1988; 26:498– 

503. 

3. Cortez KJ, Roilides E, Quiroz-Telles F et 

al. Infections Caused by Scedosporium 

spp. Clin Micrbiol Rev 2008; 21:157-97. 

4. López L, Gaztelurrutia L, Cuenca-Estrella 

M et al. Infection and colonization by 

Scedosporium prolificans. Enferm Infecc 

Microbiol Clin 2001; 19: 308-313. 

5. Alvarez M, Ponga BL, Rayon C et al. 

Nosocomial Outbreak Caused by 

Scedosporium prolificans (inflatum): Four 

Fatal Cases in Leukemic Patients. J Clin 

Microbiol 1995; 33: 3290-5. 

6. Berenguer J, Rodriguez-Tudela JL, 

Richard C, et al. Deep infections caused 

by Scedosporium prolificans: a report on 

16 cases in Spain and a review of the 

literature. Scedosporium Prolificans 

Spanish Study Group. Medicine 

(Baltimore) 1997; 76:256–65. 

7. Revankar SG, Patterson JE, Sutton DA et 

al. Disseminated Phaeohyphomycosis: 

Review of an Emerging Mycosis. Clin 

Infect Dis 2002; 34:467–76. 

8. Rabodonirina M, Paulus S, Thevenet F, et 

al. Disseminated Scedosporium prolificans 

(S. inflatum) infection after single-lung 

transplantation. Clin Infect Dis 1994; 

19:138–42. 

9. Cuenca-Estrella M, Gomez-Lopez A, 

Mellado E et al. Head-to-head comparison 

of the activities of currently available 

antifungal agents against 3,378 Spanish 

clinical isolates of yeasts and filamentous 

fungi. Antimicrob Agents Chemother 2006; 

50:917-21. 

10. Meletiadis J, Meis JFGM, Mouton JW et 

al. In vitro activities of new and 

conventional antifungal agents against 

clinical scedosporium isolates. J Clin 

Microbiol 2002; 46: 62-8. 

11. Steimbach WJ, Schell VA, Miller JL, 

Perfect JR. Scedosporium prolificans 

osteomyelitis in an immunocompetent child 

treated with voriconazole and caspofungin, 

as well as locally applied 

polyhexamethylene biguanide. J Clin 

Microbiol 2003; 41: 3981-5. 

12. Grenouillet F, Botterel F, Crouzet J et al. 

Scedosporium prolificans: an emerging 

pathogen in France? Med Mycol 

2009;47:343-50. 

13. Ananda-Rajah MR, Grigg A, Slavin 

MA.Breakthrough disseminated 

Scedosporium prolificans infection in a 

patient with relapsed leukaemia on 

prolonged voriconazole followed by 

posaconazole prophylaxis. Mycopathologia 

2008;166:83-6. 

Please contact authors for additional references. 


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Special Article | 

Challenge and Change in Delivering Healthcare 

to India’s Needy 

“In nothing do men more nearly approach the gods than in giving health to men.” 

~Cicero 

G. Madhavi, MD 

Medical Director, Goutami Eye Institute 

L.V. Raju, MD 

Education Coordinator, Eye Foundation 

of America 

G. Madhu 

Executive Director, Goutami Eye Institute 

V.K. Raju, MD, FRCS, FACS 

Clinical Professor of Ophthalmology, 

WVU School of Medicine; Adjunct 

Professor, GSL Medical College, 

Rajahmundry, AP; Medical Director, 

Eye Foundation of America 

In 1977, one of the authors (VKR) 

began taking “working vacations” 

in his native Andhra Pradesh (AP), 

India, to deliver eye care to the 

needy. He established mobile eye 

camps that took eye care to patients’ 

doorsteps in rural areas, where the 

majority of AP’s population lives. 

A 1981 article in the October 

issue of The West Virginia Medical 

Journal described a three-week 

1979 clinic in AP. VKR was then 

accompanied by ophthalmology 

and anesthesiology residents from 

West Virginia University’s (WVU’s) 

School of Medicine. During a 3-week 

period, the clinic saw nearly 4,000 

outpatients. This practice continued 

through the years, most recently 

with a 2008 visit to AP, where VKR 

was accompanied by WVU medical 

students Steve Otto, MD, and Brian 

Talbot, MD, who have since begun 

careers in emergency medicine. 

As the activities continued, it 

became increasingly apparent that, 

while eye camps and other, similar 

free services did make progress 

toward helping the millions who 

needed eye care, there was much 

more to be done—especially 

for India’s children, who had 

the most to lose due to lack of 

affordable, accessible eye care. 

Eye Foundation of America 

The realization that India needed 

more than eye camps to eradicate 

childhood blindness led one of the 

authors (VKR), to found the Eye 

Foundation of America (EFA) in 1979, 

a nonprofit organization that delivers 

eye care to the impoverished in many 

countries. EFA has since grown, 

thanks to generous gifts, donations 

of equipment, pharmaceuticals, 

and volunteer medical staff. 

In recent years, India has taken 

steps to liberalize rules regarding the 

importation of medical equipment 

and technology. Prior to establishing 

the foundation, well-intentioned 

physicians and others who brought 

such medical equipment and supplies 

through customs were met with 

mountains of bureaucratic red tape 

due to India’s strict laws regarding 

importing by individuals. However, 

once the Foundation was in place, 

the process went more smoothly 

because those same people were 

representing a Foundation, and 

as such, were no longer subject to 

the same rules as individuals. 

Like the global initiative, “Vision 

2020: The Right to Sight, “EFA 

also is committed to eradicating 

avoidable blindness. The EFA’s 

services are provided free to those 

who cannot pay, and often are 

delivered via outreach programs. 

In recent years, the EFA has further 

extended its reach and promoted 

greater continuity of care by building 

modern eye hospitals in rural areas, 

and by educating ophthalmologists 

and technical personnel. 

The EFA has established two 

eye institutes in rural areas of 

AP, India: Srikiran and Goutami. 

Srikiran, located in Kakinada, was 

completed in 1992. It is a modern, 

26-bed hospital and outpatient clinic 

outfitted with the latest equipment. 

Since its inception, Srikiran has seen 

more than a million patients in its 

outpatient clinics alone, and has 

trained 126 ophthalmologists and 

support staff. Goutami Institute, in 

Rajamundry, India, was founded 

in 2005. It is a modern, 90-bed eye 

hospital. One wing is dedicated to 

children’s eye problems, which are 

very prevalent (see Figures 1-3). 

Technologies used at mobile eye 

camps and both EFA hospitals have 

changed over the years to keep pace 

with advances in ophthalmologic and 

general medical care. For example, 

injected ketamine was once the 

drug of choice for anesthesia but it 

has since been replaced by newer 

techniques such as inhaled and 

monitored endotracheal anesthesia. 

Old System 

Until recently, India’s central 

and state governments favored a 

nationalized approach to health 

care. Its needy population received 

medical care at government run 

hospitals associated with the 

country’s medical schools. However, 

the government was unable to 

provide enough funding and 

resources needed to keep up with 

modern treatments and technologies. 

Public hospitals often were 

unable to provide adequate care, 

despite being staffed by highly 

qualified physicians. The system 

was literally overrun by millions 

of needy patients. Poor families 

had no recourse but to take their 

children to the hospitals that were 

least equipped to provide the 

treatments and technologies they 


| Special Article 

needed, despite having some of 

the best physicians. Those who 

were able to pay, by contrast, 

sought treatment at India’s private 

hospitals—which provided a quality 

of care comparable to the very best 

hospitals in the world. This resulted 

in a health care tradition in India that 

favored the rich, providing “separate 

and unequal” care to the poor. 

Signs of Change 

There is now encouraging 

evidence that India is willing 

to level the playing field for its 

needy patients. This is perhaps 

most apparent in AP, where the 

government rolled out a community 

initiative called “Aarogyasri,” 

(Sanskrit for “wealth of health”), in 

2008. The Initiative issues insurance 

cards to those below a designated 

poverty line, allowing them to obtain 

free treatment for more than 900 

diseases at more than 300 specialty 

hospitals throughout the state. 

Poor patients need only show their 

Aarogyasri cards at participating 

hospitals to obtain the same services 

previously available only to the 

rich. The card number is entered 

into an entirely paperless, internetbased 

computer system, where all 

Aarogyasri records are maintained. 

Aarogyasri joined the global 

Vision 2020 movement in 2008 

by adding eye problems to the 

program’s list of covered diseases. 

These included diseases of the 

cornea and vitro-retina, along with 

“squint” (strabismus). On India’s 

Children’s Day (November 14, 2008), 

Aarogyasri added other, covered 

diseases that often lead to childhood 

blindness: cataract, glaucoma, and 

retinopathy of prematurity. The 

Goutami Institute joined the network 

in 2008, and has since that time 

performed surgery on 1,152 children 

below the age of 14 years (Figure 4). 

For many years, India’s central 

government did not permit its 28 

state governments to allow the 

proliferation of private medical 

schools because they were viewed 

as incapable of maintaining the 

same standards and education as 

the government controlled system. 

The central government has relaxed 

those rules during the last 15 years, 

promoting a more entrepreneurial 

approach and allowing private 

schools and hospitals to play an 

increasingly larger role. Apollo 

Hospitals, for example, is the first 

to be successfully franchised in 

India. Headquartered in Chennai, 

India, Apollo operates 38 hospitals 

throughout South Asia. While Apollo 

Hospitals support community 

initiatives for the needy, most 

of its services are fee-based. 

Costs of Blindness 

Childhood blindness is of special 

concern to EFA, Aarogyasri, and 

Vision 2020’s efforts to eradicate 

blindness. Children often are born 

with congenital defects that lead to a 

lifetime of blindness. Resulting socioeconomic 

costs are high because 

blindness affects not only the child 

but the family and the society as 

well. Even total deafness, while a 

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Special Article | 

Figure 1A. 

Pre-op: Corneal scarring caused by 

repeated infections. 

Figure 2A. 

Pre-op: Cataracts. 

Figure 3A. 

Pre-op: Strabismus. 

Figure 1B. 

Post-op: Eye with corneal graft. 

Figure 2B. 

Post-op: Following cataract removal and 

intraocular lens implant. 

Figure 3B. 

Post-op: Strabismus surgically corrected. 

severe and sometimes devastating 

impairment, does not exert such 

a profound and lasting toll as 

blindness. We know, for example, 

that as much of 80% of learning is 

visual. Without the ability to learn, 

a child has a very limited future. 

In the case of congenital 

cataracts, a relatively inexpensive 

(approximately $400) procedure 

can restore sight, but only if it 

is done within the infant’s early 

developmental period. If the 

necessary surgery is not obtained 

within that critical period, often 

the blindness is irreversible. That 

window is small—but critical—to 

making a difference between a 

lifetime of blindness and a full 

life. Restoring a child’s sight 

opens up many opportunities, 

allowing the patient to be selfsupporting 

and productive— 

often for 70 or more years. 

While cardiac or cancer surgery 

and other, more expensive 

treatments save and prolong lives, 

such treatments may extend life 

only a few years. Giving the gift 

of sight to a child early in life 

returns benefits for many years 

and costs only a fraction of the 

thousands—sometimes hundreds 

of thousands—spent on other, more 

expensive procedures that deliver 

fewer benefits for a shorter time. 

Even when compared to other 

relatively inexpensive treatments like 

vaccinating children against common 

childhood diseases, restoring a 

child’s sight yields a maximum 

return on a small investment in 

both time and money. It also further 

benefits the child, as well as the 

family and community because they 

are no longer bound by the need 

to provide a lifetime of support. 

Vitamin A distribution, similarly 

cost-efficient, also can prevent 

blindness and other diseases. At 50 

cents a dose, twice a year, the $1 price 

tag is negligible when compared with 

the resulting return to the patient, 

the family, and the community. 

EFA currently is involved in an 

analysis of vitamin A distribution 

in 16 countries to find ways to 


| Special Article 

improve distribution of that very 

critical supplement. This analysis has 

already been completed in Cambodia, 

Ethiopia, Bangladesh, and India. 

Conclusion 

The Aarogyasri Initiative 

established by AP’s government 

is the most laudable of any healthrelated 

government activity since 

India’s Independence in 1947. It is 

to be commended for its foresight, 

and for its acknowledgement of the 

importance of providing health care 

for all, regardless of their ability to 

pay. Furthermore, India’s central 

government’s relaxation of rules 

restricting the growth of private 

hospitals and medical schools will 

also create meaningful change. 

India is actively demonstrating 

that it is coming to terms with the 

challenges and addressing the 

disparities, as well as deficiencies, 

in the old system of delivering 

medical care. In establishing 

Aarogyasri, the government of 

AP has taken a monumental step 

toward creating an affordable, 

accessible health care system. 

It has been said that the solution 

to India’s problems lies” in its 

Figure 4. 

Aarogyasri surgeries on children

General | NEWS 

New HIT Extension Center Available To Assist With 

Electronic Health Records, EHR Incentives 

By: Roger Chaufournier 

Over the next few years West 

Virginia’s healthcare industry 

will have a unique opportunity to 

transform itself through greater 

adoption of electronic health 

information technology. The 

driver of this transformation will 

be millions of dollars of federal 

funds that will provide incentive 

payments for those eligible hospitals 

and primary care providers 

who adopt certified electronic 

health record (EHR) systems. 

As part of the American 

Recovery and Reinvestment Act 

(ARRA), the Centers for Medicare 

& Medicaid Services (CMS) have 

been authorized to provide a 

reimbursement incentive for eligible 

Medicare and Medicaid providers 

(physician and hospital providers) 

who are successful in implementing 

certified electronic health records 

and achieving “meaningful use.” 

To further assist with 

implementation of electronic health 

record systems and to aid providers 

in getting ready for these federal EHR 

incentive payments, the ARRA act 

also provided funding to establish 

HIT resource centers across the U.S. 

Here in West Virginia, this new 

center is the West Virginia Regional 

Health Information Technology 

Extension Center (WVRHITEC). 

The WVRHITEC is a statewide 

resource center to aid primary care 

providers in implementing and 

using certified health information 

technology and achieving health 

improvement outcomes through 

meaningful use. The WVRHITEC 

involves a collaboration of several 

state organizations focused on 

improving healthcare quality and 

access. Key partners are the West 

Virginia Health Improvement 

Institute, the West Virginia Medical 

Institute, and the Community 

Health Network of West Virginia. 

What will the WVRHITEC do? 

The WVRHITEC will offer 

education, technical assistance, 

guidance, and information on best 

practices to support and accelerate 

healthcare centers’ and providers’ 

efforts to become meaningful 

users of certified electronic health 

record (EHR) systems. The center is 

available to all healthcare providers, 

whether or not they have adopted 

electronic health record systems. 

Its objective is to help 1,000 eligible 

healthcare providers become 

“meaningful users” of health IT by 

2011 so they can qualify for federal 

health IT incentive payments. 

Technical services by the 

WVRHITEC also will be available 

on a fee basis to all healthcare 

providers in the state. However, 

certain rural clinics and small 

practices may be eligible to receive 

these services on a subsidized basis. 

Priority for subsidized services 

will be given to primary care 

providers in small practices (fewer 

than 10 clinicians with prescriptive 

privileges), rural clinics, FQHCs and 

certain critical access hospitals. 

What services will be provided 

by the WVRHITEC? 

The WVRHITEC’s staff will 

use its HIT/EHR knowledge and 

experience to work one-on-one 

with these small practices and offer 

technical expertise in managing 

relationships with vendors, provide 

independent consultation and 

assistance with EHR implementation, 

effective use, upgrading, and ongoing 

maintenance, share knowledge 

of needed work-flow change and 

quality improvement methods. 

As has been mentioned, another 

one of the major objectives of the 

WVRHITEC is to assist providers 

to take advantage of future federal 

EHR financial incentives. Starting 

in 2011, eligible Medicare and 

Medicaid providers (physician 

and hospital providers) who are 

successful in implementing electronic 

health records and achieving 

“meaningful use,” as defined 

by the U.S. DHHS, may receive 

reimbursement payments for their 

electronic health record systems. The 

Centers for Medicare & Medicaid 

Services (CMS) will provide these 

reimbursement incentives starting 

in 2011 running through 2016. 

What is “meaningful use?” 

This is the term being used by the 

Office of the National Coordinator 

(ONC) and the Centers for Medicare 

and Medicaid (CMS) to describe 


General | NEWS (continued) 

the criteria eligible providers must 

meet to qualify to receive federal 

financial incentives for using certified 

EHRs in a meaningful manner. 

The meaningful use criteria will 

involve three stages. Stage One 

criteria have been finalized, and 

these initial objectives focus on: 

- capturing health information 

electronically in a coded format, 

- using that information to track 

key clinical conditions, 

- communicating that 

information in order to help 

coordinate care, and 

- initiating the reporting of 

clinical quality measure and 

public health information. 

CMS intends to propose, 

through future rulemaking, two 

additional stages of criteria related 

to meaningful use. (Information on 

the Medicare and Medicaid EHR 

Incentive Programs, including a 

link to the text of the final rule, 

can be found at http://www.cms. 

gov/EHRIncentivePrograms.) 

Regional extension centers also 

will help providers achieve, through 

appropriate available infrastructures, 

exchange of health information in 

compliance with applicable statutory 

and regulatory requirements, 

and patient preferences. The 

WVRHITEC will be working with 

the West Virginia Health Information 

Network on exchange activities. 

Finally, this initiative will 

leverage the ongoing work to 

integrate the medical home model 

activities already underway in West 

Virginia. These aim to transform 

our state’s healthcare delivery 

system and substantially improve 

the health of our rural population, 

which has a high prevalence of 

chronic disease, lack of access to 

care and high healthcare costs. 

What should I do if I am a 

“primary care provider” and 

want to be helped as part of 

the WVRHITEC’s activities? 

Contact the WVRHITEC office or 

sign-up via the website. Interested 

centers/providers will need to sign a 

WVRHITEC participation agreement 

and agree to its terms and conditions, 

including the annual membership fee. 

For more information about 

the West Virginia Regional Health 

Information Technology Extension 

Center and federal EHR stimulus 

payments, please visit www. 

wvrhitec.org or request information 

by calling 1-877-775-7535. 

Roger Chaufournier is Chairman 

of the West Virginia Health 

Improvement Institute and the 

Program Officer for the West 

Virginia Regional Health Information 

Technology Extension Center. 

Save the Date: November is 

“Heal that Claim” TM Month 

AMA members are encouraged to participate during 

November’s “Heal that Claim” month. Physicians 

around the country can focus on reviewing and appealing 

inappropriately paid claims and streamlining their internal 

claims process. 

“Heal that Claim” month helps physicians work towards 

the “Heal the Claims Process” campaign’s ultimate 

goal: to reduce the cost associated with ensuring accurate 

payment for physician services from as much as 14 

percent of total collections to as little as one percent. 

Contact Amy Farouk at amy.farouk@ama-assn.org or 

(312) 464-5490 for more information. Thank you for 

joining us in healing the claims process! 

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General | NEWS (continued) 

Court Decision Will Impact Healthcare 

West Virginia’s healthcare 

community is on edge following 

our State Supreme Court’s decision 

to accept the appeal of a case 

challenging the constitutionality of 

West Virginia’s cap on non-economic 

damages.The Court’s final decision 

will have a significant impact on West 

Virginia healthcare providers and 

their patients. The case, Mac- Donald 

v. City Hospital, is on appeal from 

a 2008 trial in the Berkeley County 

Circuit Court where the jury awarded 

the plaintiffs damages in excess of 

the state’s $250,000/$500,000 noneconomic 

damages cap. The trial 

judge reduced the award as required 

by state law to the maximum amount 

allowed and the plaintiffs are now 

asking our state’s highest court to 

rule the cap unconstitutional. 

This is not the first time West 

Virginia’s damages cap has come 

under attack. In two previous cases, 

the State Supreme Court upheld 

an earlier $1 million non-economic 

damages cap finding the Legislature 

acted within constitutional limits 

in 1986 when the cap was put in 

place. The West Virginia Legislature 

reduced the cap in 2003 in an effort 

to address another healthcare crisis. 

Beginning in the late 1990’s and 

early 2000’s, skyrocketing medical 

liability insurance rates forced many 

physicians to limit the services 

their practices offered, avoiding 

high risk procedures, while other 

physicians decided to leave the 

state altogether. Throughout the 

state, the crisis impacted access to 

care, and the Legislature both in 

2001 and 2003 enacted a package 

of reforms, including the lower 

non-economic damages cap. 

If the State Supreme Court 

allows the non-economic damages 

cap to stand, healthcare advocates 

predict our much improved practice 

environment and better access to 

care since the legislative reforms took 

affect will continue. The outlook, 

however, is not so positive if the 

cap is struck down. Most worry that 

without the cap, we will be forced 

back to the days when physicians 

were leaving the state and access 

to care was in jeopardy for those 

most in need of quality healthcare. 

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| New Members 

The WVSMA welcomes the following new physicians and medical students: 

Cabell County Medical Society 

Thomas Alberico, FYMS 

Lonnie Berry, FYMS 

Don Bertolotti, FYMS 

William Carr, FYMS 

Stephen Clark, FYMS 

Rachel Clarke, FYMS 

Stephen Cole, FYMS 

Sonja Dawsey, FYMS 

Sirisha Devabhaktuni, FYMS 

Shane Dragan, FYMS 

Lindsay Edwards, FYMSS 

Lora Fetty, FYMS 

Jenna Fields, FYMS 

Sean Fitzpatrick, FYMS 

Jill Goodwin, FYMS 

Rebecca Hayes, FYMS 

Sammy Hodroge, FYMS 

Ryan Hostutler, FYMS 

Kyle Johnson, FYMS 

Maureen Joyce, FYMS 

Corey Keeton, FYMS 

Nikita Khetan, FYMS 

Ziyang Lin, FYMS 

Ashley Litchfield, FYMS 

Ken Maynard, FYMS 

Deanna Miller, FYMS 

Luke Miller, FYMS 

Ganesh Murthy, FYMS 

Clifton Nicholson, FYMS 

Michael Northcutt, FYMS 

Kacey O’Malley, FYMS 

Katherine Rector, FYMS 

Miranda Rose, FYMS 

Amanda Schmitt, FYMS 

Carly Schuetz, FYMS 

Molly Seidler, FYMS 

Piyush Sovani, FYMS 

Majd Sweiss, FYMS 

Shawandra Thompson, FYMS 

Lacey Vence, FYMS 

Ravi Viradia, FYMS 

Douglas von Allmen, FYMS 

Kimberly Weaver, FYMS 

Robert Wildman, FYMS 

Laura Wilson, FYMS 

Mercer County Medical Society 

Mena Ashraf, MD 

Monongalia County Medical Society 

Stephanie Knittle, FYMS 

Please direct all membership inquiries to: Mona Thevenin, WVSMA Membership Director 


Healthcare S ummit 

2010

Robert C. Byrd Health Sciences Center of West Virginia University | NEWS 

WVU School of Medicine Names New Dean 

Arthur J. Ross 

III, M.D., M.B.A., 

dean of Chicago 

Medical School and 

vice president for 

medical affairs of 

Rosalind Franklin 

University, was 

named dean 

Dr. Ross 

of the West 

Virginia University School of 

Medicine June 4. He officially began 

his work at WVU on Aug. 16. 

A respected researcher and 

award-winning teacher, Dr. Ross, 

61, was selected by WVU Chancellor 

Christopher Colenda, M.D., M.P.H., 

following a national search. 

“Dr. Ross is an outstanding 

individual and we are very fortunate 

to have him lead the School of 

Medicine,” Chancellor Colenda said. 

“Dr. Ross has a distinguished track 

record as a pediatric surgeon and as 

an academic leader in Chicago. He 

brings vision, energy and considerable 

talent to this important position.” 

Ross is board certified in both 

general surgery and pediatric 

surgery. He graduated with honors 

from Trinity College in Hartford, 

Conn., earned his medical degree 

at Case Western Reserve University 

and did his residency at Duke 

University Medical Center. 

“I am greatly honored by this 

appointment. WVU is one of the 

nation’s finest medical schools, and I 

look forward to serving the students, 

faculty and staff as their dean,” Ross 

said. “I have every confidence that 

we can work together to make the 

school even greater and to enhance 

the way our Health Sciences Center 

meets our mission of education, 

research, patient care and outreach 

in the land-grant tradition.” 

Ross has been dean at the Chicago 

Medical School at Rosalind Franklin 

University since 2004. In 2005 he was 

also named vice president for medical 

affairs there. He has also practiced 

and served as a faculty physician at 

Children’s Hospital of Philadelphia 

- University of Pennsylvania School of 

Medicine; and at Gundersen Lutheran 

Health System, the western clinical 

campus of the University of Wisconsin 

School of Medicine and Public Health. 

While at Penn, Ross received the 

Teaching Excellence Award. Upon 

his departure from Wisconsin, the 

Health System named its new distance 

learning facility the “Ross Distance 

Education Center” in his honor. In 

2007 the Chicago Medical School 

Alumni Association awarded him 

its Outstanding Service Award. 

Ross is only the ninth person to 

hold the title of dean of the WVU 

School of Medicine since 1912. He is 

the first among the school’s deans to 

have served in that post at another 

medical school. He is also the first new 

medical dean since 1983 not drawn 

from among the university’s faculty. 

WVU Healthcare Featured on ABC News 

Doctors, nurses and patients of 

WVU Healthcare appeared in ABC 

News’ four-part series called “Secrets 

of Your Mind: Why We Do What 

We Do,” which premiered Aug. 19. 

Beginning in March, crews from 

the network videotaped in clinics, 

surgery and patient rooms, and visited 

homes of patients and physicians 

to tell the stories of how medicine, 

science and technology are working 

to solve the mysteries of the brain. 

WVU Children’s Hospital Unveils New 

Critical Care Ambulance 

Anchored by Nightline’s Martin 

Bashir and Terry Moran, the stories 

revolved around WVU’s efforts to 

treat epilepsy, obesity, head trauma, 

brain tumors, stroke and more. 

Critically ill and injured children 

from all over the state and region are 

regularly transported to West Virginia 

University Children’s Hospital. Now, 

thanks to a partnership with Jan-Care 

Ambulance, they will arrive in a stateof-the-art 

critical care ambulance. 

“Essentially, it’s a critical care 

unit on wheels,” Cheryl Jones, 

R.N., director of WVU Children’s 

Hospital, said. “It is equipped to 

do exactly what an ICU can do.” 

Inside the ambulance is everything 

you would find inside the Neonatal 

Intensive Care Unit (NICU) or 

Pediatric Intensive Care Unit (PICU) 

at WVU Children’s Hospital from 

medications to equipment. 

The ambulance is spacious 

enough to transport children from 

birth through adolescence and is 

certified as a critical care transport 

unit through the West Virginia Office 

of Emergency Medical Services. 


Marshall University Joan C. Edwards School of Medicine | NEWS 

Med School No. 16 Nationally in “Social Mission” Outcomes 

A national study published in 

the Annals of Internal Medicine ranks 

Marshall University’s medical 

school among the top 20 in the 

United States in fulfilling medical 

schools’ fundamental mission: 

training physicians to care for the 

nation’s population as a whole. 

The George Washington 

University study breaks new ground 

by providing what the journal’s 

news release called “a real-time 

and real-place report” on doctors 

who graduated between 1999 and 

2001: what their backgrounds 

are, where they work, and what 

kind of medicine they practice. 

Led by Dr. Fitzhugh Mullan, 

the researchers then calculated 

a “social mission score” for each 

medical school based on the 

percentage of graduates who practice 

primary care, who work in health 

professional shortage areas, or who 

are underrepresented minorities 

(since this group historically 

provides a disproportionate 

amount of health care to minority 

and underserved populations). 

Marshall’s Dr. John Walden 

said the study offers a longoverdue 

look at how medical 

education performs in creating a 

physician workforce that effectively 

reaches the population to provide 

treatment and preventive care. 

“It seems about 

time someone 

looked at these 

kinds of things,” 

said Dr. Walden, 

an associate dean 

and chairman of 

the Department 

of Family and 

Dr. John Walden 

Community 

Health. “The 

study is a positive take on rethinking, 

in part, priorities in medical 

education, and recognizing that 

improving the nation’s health is 

not necessarily so much about 

developing a new drug as about 

actually getting treatment to people.” 

He was matter-of-fact about 

Marshall’s No. 16 rank. “Given where 

we are and the mission of our school, 

focusing on these delivery issues 

is second nature, not something 

we’ve had to be taught,” he said. 

“We’ve done this all along without 

even knowing we were doing it.” 

The researchers noted that 

the study results differ greatly 

from rankings based on indirect 

factors such as research funding 

and reputation surveys. 

“We have essentially inverted 

the U.S. News and World Report 

rankings, for those of you that 

follow them,” Dr. Mullan told an 

audience at Dartmouth College in 

April, noting that those rankings 

are based heavily on research and 

reputation, rather than outcomes. 

Dean Charles 

H. McKown Jr., 

M.D., said the 

school’s distinction 

is especially valued 

since it results 

from unsolicited 

analytical and 

Dr. Charles McKown objective analysis. 

“Dr. Mullan is one of the nation’s 

most experienced, insightful, 

authoritative physicians, and his 

expertise in this particular field is 

essentially unchallenged,” he said. 

“Providing well-trained and highly 

skilled primary care physicians 

to practice in West Virginia 

remains the solid foundation of 

our mission. We are very proud of 

our results, and also pleased with 

our contribution – with the state’s 

other two medical schools – toward 

making primary care accessible to 

people across West Virginia.” 

Neurophysiology Lab Accredited 

Cabell 

Huntington 

Hospital’s 

Neurophysiology 

Lab recently was 

granted fiveyear 

national 

accreditation by the 

American Board 

Dr. Mark Stecker 

of Registration of 

Electroencephalographic and Evoked 

Potential Technologists (ABRET). 

Only one other neuroscience lab in 

West Virginia is ABRET-accredited. 

“This is a measure of our 

commitment to provide excellent 

neuroscience care for our patients, 

including EEGs, EMGs and 

epilepsy monitoring,” said Mark 

Stecker, MD, PhD, director of 

Marshall’s epilepsy program and 

the hospital’s neurophysiology lab. 

Under Stecker’s guidance, Cabell 

Huntington developed the region’s 

first center staffed by specialists in 

epilepsy, and the program has shown 

rapid growth in the past year. 

Stecker is a past president of the 

American Society of Neurophysiologic 

Monitoring and has served on the 

American Board of Neurophysiologic 

Monitoring. He is founding chair 

of both the American Board for the 

Accreditation of Neurophysiologic 

Monitoring Programs and the 

Neurophysiology Research 

and Education Consortium. 

September/October, 2010, Vol. 106 39

West Virginia School of Osteopathic Medicine | NEWS 

Dr. Pence Named Interim Vice President for Academic Affairs 

and Dean at WVSOM 

Lorenzo L. Pence, 

DO, FACOFP, is 

serving as the Interim 

Vice President for 

Academic Affairs 

and Dean at the West 

Virginia School of 

Dr. Pence 

Osteopathic Medicine 

(WVSOM). 

Dr. Pence, a tenured professor 

of Family Medicine, is serving in 

this position replacing Dr. Michael 

Adelman, who was appointed Acting 

President. In addition to his new 

duties as Interim Dean, Pence will 

continue to serve as associate dean of 

Graduate Medical Education, a post 

he has held since 2003. He also is the 

chief academic officer of the Mountain 

State Osteopathic Postdoctoral 

Training Institutes and chairman 

of the Southeastern Area Health 

Education Center board of directors. 

Previously, Pence served as 

director of medical education 

at three hospitals: Greenbrier 

Valley Medical Center (GVMC) 

in Ronceverte, WV, St. Vincent 

Mercy Medical Center in Toledo, 

Ohio, and The Toledo Hospital. 

He also served as the director of 

the Family Medicine program at 

GVMC , the director of the Osteopathic 

Family Medicine Program at Toledo 

Hospital, the associate director of 

the Family Medicine Residency 

program at St. Vincent Mercy Medical 

Center and the assistant dean of the 

Northwest CORE for Ohio University 

College of Osteopathic Medicine 

(OUCOM) in Athens, Ohio. 

Pence earned a Bachelor of Science 

degree from Bluefield State College in 

Bluefield, W.Va. He graduated from 

WVSOM in 1985 and completed his 

residency training in Family Medicine 

at Parkview Hospital in Toledo. 

Dr. Nemitz Named Vice President for Administration and 

External Relations at WVSOM 

James W. Nemitz, 

Ph.D., has been named 

Vice President for 

Administration and 

External Relations 

at the West Virginia 

School of Osteopathic 

Dr. Nemitz Medicine (WVSOM). 

In this position, 

Dr. Nemitz will oversee marketing 

and communications, rural outreach, 

strategic planning, space allocation, 

accreditation, special events and 

will assist with legislative issues. 

He will continue to lead WVSOM’s 

new curriculum initiative. 

Nemitz is a tenured professor 

of Anatomy with 25 years of 

service at WVSOM. Since 2004, he 

served as the Associate Dean for 

Preclinical Education overseeing 

the first two years of the program. 

Nemitz received his Bachelor 

of Science degree in Biology from 

Randolph-Macon College in 

Ashland, VA, and his Doctorate in 

Anatomy from the Medical College 

of Virginia in Richmond, VA. 

He has been the recipient of 

numerous awards and honors, 

including the George W. Northup 

D.O. Distinguished Service Award, the 

American Osteopathic Foundation’s 

Educator of the Year award, and 

Faculty Merit Foundation’s West 

Virginia Professor of the Year award. 

Dr. Schriefer Named Associate Dean for Pre-Clinical Education 

at WVSOM 

John A. Schriefer, 

Ph.D., has been named 

Associate Dean for 

Pre-Clinical Education 

at the West Virginia 

School of Osteopathic 

Medicine (WVSOM). 

Dr. Schriefer 

Dr. Schriefer, a 

tenured Professor of Pharmacology, 

replaces Dr. James W. Nemitz, who 

is Vice President for Administration 

and External Relations. During his 

25 years at WVSOM, Schriefer has 

maintained an active research lab. 

Previously, he served as chairman of 

the Research Committee and as the 

Pharmacology course coordinator. 

Schriefer received a Bachelor of 

Arts degree in Biology from the 

University of Missouri in St. Louis. 

He earned his Master of Science and 

Doctorate degrees in Pharmacology 

from Purdue University in West 

Lafayette, IN. Previously, Schriefer 

served as an Assistant Professor of 

Pharmacology at the Ponce School 

of Medicine in Ponce, Puerto Rico. 


Bureau for Public Health | NEWS 

Impact of Healthcare Reform on the Victims of 

Domestic Violence 

The new healthcare reform law will 

offer benefits to the victims of domestic, 

sexual, dating and intimate partner 

violence that they have not previously 

known. In general, the law will make 

healthcare more affordable and easier 

to obtain and it includes several new 

programs and protections to prevent 

abuse and/or ways for people to 

treat abuse before it gets worse. 

One important change is that, 

beginning on January 1, 2014, the 

law prohibits insurance companies, 

healthcare providers and health 

programs that receive federal funds 

from denying coverage to women 

who are survivors of domestic or 

sexual violence as a “pre-existing 

condition.” Incredibly, prior to 

the healthcare reform bill, seven 

states actually allowed insurers to 

deny health coverage to domestic 

violence survivors on this basis. 

Recent reviews of home visitation 

models have found that up to 48% of 

women surveyed who receive home 

visiting services report incidents 

Caregiver Consent Act 

of domestic violence. The new law 

provides $1.5 billion over 5 years to 

develop and implement evidence-based 

maternal, infant and early childhood 

visitation models to reduce infant 

and maternal mortality, improve 

prenatal, maternal and newborn 

health, prevent child injuries and 

maltreatment, improve parenting skills, 

school readiness and family economic 

self-sufficiency while reducing or 

addressing juvenile delinquency, 

crime and domestic violence. In 

formulating their plans, states are 

required to do need assessments 

and to identify at-risk communities, 

including communities with high 

concentrations of domestic violence. 

Pregnancy and domestic violence 

are tragically intertwined. Research 

shows a clear link that unintended 

pregnancies increase women and 

girls’ risk for violence, and violence 

increases women and girls’ risk for 

unintended pregnancies. Beginning 

in 2014 each state will receive funds 

for personal responsibility education 

programs aimed at reducing pregnancy 

rates in youth between 10 – 19 years 

of age. The new law allocates $75 

million a year to be apportioned 

among the states based on the size 

of a state’s youth population, but no 

state will receive less than $250,000. 

The new law establishes the 

National Prevention, Health Promotion, 

and Public Health Council to provide 

coordination and leadership at 

the federal level with respect to 

prevention, wellness, public health 

and integrative healthcare. Elsewhere 

in the law, the council is tasked 

with including domestic violence 

screening in its national priorities 

report. Screening for domestic violence 

is considered a primary prevention 

or early intervention service. 

Readers interested in violence 

prevention and related topics may 

contact the Family Violence Prevention 

Fund Policy Office at (202) 682-1212 or 

visit them online at www.endabuse.org. 

In March 2010, the WV Legislature 

passed HB 4374, the Caregiver 

Consent Act. It took effect July 

1st. The purpose of the legislation 

is to allow a caregiver, who is 

not a parent, legal custodian or 

guardian of a minor, to consent to 

healthcare for a minor through the 

use of an affidavit. The law provides 

for the revocation or termination 

of consent, provider good faith 

reliance on the affidavit, exceptions 

to an affidavit’s applicability and 

penalties for a false statement in 

an affidavit. The Department of 

Health and Human Resources has 

developed a form Affidavit, which is 

available on the WVDHHR website, 

http://www.wvdhhr.org/. It’s 

the first item in the “Links to…” 

column on the left hand menu. 

In the Act, the term “Caregiver” 

is defined as: “any person who is 

at least eighteen year of age and: 

(A) is related by blood, marriage 

or adoption to the minor, but 

who is not the legal custodian or 

guardian of the minor; or (B) has 

resided with the minor continuously 

during the immediately preceding 

period of six months or more.” 

The Act enables caregivers to 

consent to a variety of healthcare 

actions for the minor, including, 

developmental screening, mental 

health screening and treatment, 

ordinary and necessary medical 

and dental exams and treatment, 

preventive care including 

immunizations, TB testing, wellchild 

care, and non-emergency 

diagnosis and treatment. 

Further, the Act enables healthcare 

providers to accept caregiver consent 

forms, unless they know that a 

parent or legal guardian has made 

a contravening decision. It protects 

providers from criminal and civil 

liability for accepting the Caregiver 

Consent form in good faith. The aim 

of this new law it to protect both the 

providers and the caregivers while 

allowing for healthcare services 

to minors who are in need. 

September/October 2010 | Vol. 106 

1

WV Medical Insurance Agency | NEWS 

Agency Kicks Off Employee Group 

Health Benefits Marketing Campaign 

The last few months has seen the 

Agency dedicate significant time 

to the development of its employee 

group benefits program for medical 

office staffs and individual physicians. 

Employee group benefit programs 

include group medical, dental, vision, 

life, and disability insurances. 

The Agency commenced this 

activity by conducting a survey of 

area physicians (Kanawha & Putnam 

counties) on behalf of the Kanawha 

Medical Society. The response was 

overwhelming and pointed out the 

need for stable rates/premiums for 

this line of insurance. While available 

coverage exists, it was uniformly 

reported that the cost related to the 

group medical insurance is continuing 

to significantly rise each year. 

With the results of this survey, 

the Agency decided to conduct a 

statewide survey of members of 

the West Virginia State Medical 

Association. Although we are 

continuing to sporadically receive 

responses, the current results 

indicate an overwhelming request 

for assistance with group health 

insurance. Agency efforts now will 

be focused on meeting with carriers 

to determine interest in a group plan 

for WVSMA member physicians and 

their staffs. Results of our discussions 

are targeted for January 1, 2011. 

On August 25th, Agency staff 

members attended a Healthcare 

Reform Briefing for Insurance Agents 

sponsored by the Independent 

Insurance Agents of West Virginia. 

Speakers at this meeting included West 

Virginia Insurance Commissioner 

Jane L. Cline, who also is currently 

serving as President of the National 

John Snodgrass and Steve Brown pose in front of the newly developed ad poster to kickoff the Agency’s group 

employee benefits marketing campaign. 

Association of Insurance Commissions 

and therefore has been very involved 

in the implementation of the insurance 

side of healthcare reform. The 

Commissioner reported throughout her 

presentation that there are many issues 

with implementation of healthcare 

reform that remain unanswered. The 

Commissioners presentation (and 

those of her staff members) indicated 

a thorough understanding of the 

issues involved in the implementation 

of the reform and a willingness to 

accept input from all affected parties. 

Other speakers from the 

Commissioner’s office included 

Jeremiah Samples, Insurance Program 

Manager, and Nancy Malacek, 

Insurance Market Analyst, who spoke 

about the State’s involvement in high 

risk pools by utilizing the existing 

Access WV program which allows 

qualified West Virginia residents 

to purchase health insurance 

regardless of their current or 

past health conditions. 

On August 27th, at the WVSMA 

Healthcare Summit, attendees of 

the annual Agency meeting heard 

from John Snodgrass, a health 

insurance consultant to the Agency, 

and Jeremiah Samples, Insurance 

Program Manager, of the Offices of 

the Insurance Commissioner. Mr. 

Snodgrass gave an excellent overview 

of the Healthcare Reform from the 

perspective of insurance coverage 

benefits. Mr. Samples gave an update 

on the West Virginia Insurance 

Commissioner’s version of insurance 

exchanges. Both were excellent 

presentations including valuable 

information, but also confirming the 

complex nature of healthcare reform. 


WV Medical Insurance Agency | NEWS Continued 

Although the Agency is hard at 

work developing a WVSMA sponsored 

membership group health plan, the 

Agency has also kicked off a marketing 

campaign soliciting the opportunity 

to provide group health insurance 

benefits to WVSMA members and their 

staff. A mailing which will include 

a newly developed brochure will be 

sent to WVSMA members during the 

month of September. The brochure 

and the ad included in this article are 

the key elements of this campaign. 

Please do not hesitate to call the 

West Virginia Medical Insurance 

Agency for more information or to 

request a review or consultation of 

your current health insurance or 

to design a totally new plan. You 

may reach the Agency at 1-800-257- 

4747 or locally at 304-925-0342. 

At the Agency meeting during the Healthcare Summit the focus was on healthcare reform. Steve Brown, Agency 

Manager, introduces John Snodgrass to inform attendees about healthcare reform from a benefits perspective. 


3

Obituaries 

The WVSMA remembers 

our esteemed colleagues… 

Omar Ahmad El-Bash, MD 

Dr. Omar Ahmad El-Bash, 60, of 

Huntington passed away Saturday, 

September 2, 2006, at home after 

a long illness. Dr. El-Bash was 

born in Aleppo, Syria, and moved 

to the United States in 1973 with 

his beloved wife, Mawia. He was 

preceded in death by his parents and 

one brother. Dr. El-Bash is survived 

by his devoted wife, Mawia El‐Bash; 

two daughters, Reem Jones of 

Cincinnati and Lara Raghed Hawasli 

of Detroit; two sons, Dr. Feras El‐Bash 

and Dr. Salah El‐Bash, both of 

Huntington and three grandchildren, 

Hala Eve El-Bash, Jenna Layla 

Hawasli and Kadin Omar Jones; three 

sisters and many other relatives. 

Dr. El-Bash was a well‐respected 

urologist in Huntington for 25 years. 

He was the owner of the El-Bash 

Office of Urology and regularly 

practiced medicine at Cabell 

Huntington Hospital, St. Mary’s 

Hospital and the VA Hospital. As 

a physician, Dr. El‐Bash helped 

many people in the community and 

mentored several medical students. 

He obtained his medical degree 

in Cairo, Egypt and moved to the 

United States shortly after, where 

he completed his residency in New 

York. Dr. El-Bash then completed a 

fellowship in urology at Ohio State 

University. He was a board certified 

diplomat in the American Urological 

Association and a member of the 

American College of Surgeons. 

As a devout Muslim and a 

well‐loved leader among the 

Islamic Community, Dr. El-Bash 

was a member of and served as the 

treasurer for the Arab American 

Medical Association. He served as a 

trustee for the Muslim Association 

of Huntington and the Islamic 

Association of West Virginia. He 

was a founding member of the 

New Huntington Islamic Center. 

In 2005, West Virginia Governor 

Joe Manchin presented Dr. El‐Bash 

with the lifetime achievement 

award in recognition of his 

outstanding accomplishments and 

contributions to humanity for 

his involvement with the Islamic 

Association of West Virginia. 

Online condolences may 

be expressed at www.ferrellchambersfuneralhome.com. 

In lieu of 

flowers, donations and contributions 

may be made to MAH/the 

Community of Huntington and/or 

the Islamic Center of Huntington. 

Contributions should be sent to 94 

Camelot Dr., Huntington, WV 25701. 

Logan William Hovis, Jr., M.D 

Logan William Hovis, Jr., M.D., 92, 

of Vienna passed away July 8, 2010, 

at Camden-Clark Memorial Hospital. 

Dr. Hovis was born in McKees 

Rocks, PA, near Pittsburgh in 

1917, the son of Logan W. Sr. 

and Helen (Tannehill) Hovis. 

He was a member of the 

Parkersburg High School class of 

1935, and received his pre-medical 

education at West Virginia Wesleyan 

College and the University of 

Michigan in Ann Arbor before 

earning his medical degree in 

1942 from the School of Medicine 

at the University of Michigan. 

In August 1946, he opened his 

private practice in general medicine. 

At the request of several area 

surgeons, he became involved in the 

administration of anesthesia, earning 

the title of Fellow in the American 

College of Anesthesiologists in 1959. 

In 1960, Dr. Hovis and his partners, 

Drs. Robert Fankhauser, William 

Hall, and Robert Lincicome, formed 

Associated Anesthesiologists, 

which became incorporated in 

1976. Dr. Hovis closed his general 

practice in 1968, choosing to devote 

his professional practice entirely to 

anesthesiology. He was president 

and later chairman of Associated 

Anesthesiologists, Inc., until he 

retired at the end of 1984. Dr. Hovis, 

with the encouragement of Sister 

Rita Marie Von Berg, founded the 

School of Anesthesia for Nurses 

at St. Joseph’s Hospital in 1967. 

He served as its Medical Director 

until it closed in August 1985. 

Dr. Hovis’ professional credits 

include being a recipient of the 


Obituaries | Continued 

American Medical Association 

Physician’s Recognition Award 

in Continuing Medical Education 

every year since 1969, and being 

the president of the Academy 

of Medicine in Parkersburg, 

the Parkersburg BlueCross and 

Blue Shield, the West Virginia 

Academy of General Practice, and 

the West Virginia State Society of 

Anesthesiologists. He also served 

as president to the medical staffs of 

both St. Joseph’s and Camden-Clark 

Memorial hospitals. Additional 

professional memberships 

included the American Medical 

Association, the American Society of 

Anesthesiologists, the International 

Anesthesia Research Association, and 

the Southern Medical Association. 

Dr. Hovis also held an appointment 

as Clinical Assistant Professor of 

Anesthesiology at the West Virginia 

University School of Medicine. 

He is survived by his son Logan 

Hovis, III, and Logan’s son Nathan 

of Anchorage, Alaska; his daughter 

Sally Hovis and William Wallace 

of Bedford, N.H., and Sally’s son 

Christopher Welsh of Chicago, 

IL; his daughter Jacqueline Hovis 

and Timothy Paschke of Twisp, 

Wash.; his daughter Julie Hovis 

and Glen Coombe of Sumter, SC; 

his two sisters Nancy Gawthrop 

of Marietta, Ohio, and Jane Booton 

of Dayton, Ohio; and close family 

friend Dinah Porto of Vienna and her 

daughter Ashley of Pittsburgh, PA. 

In addition to his parents, 

he was preceded in death by 

Alice Ray Hovis, his beloved 

wife of over 30 years. 

Memorial donations may be 

made to the Alice Ray Hovis 

Chapel Foundation in care of the 

Parkersburg Area Community 

Foundation, P.O. Box 1762, 

Parkersburg, WV, 26102-1762 


be sent to the family at www. 

LeavittFuneralHome.com. 

Luis Loimil, MD 

Dr. Luis Loimil, 72, of 

Charleston passed away on 

Saturday, August 14, 2010. 

Dr. Loimil was a well-known 

surgeon in the Charelston 

area. He was much respected 

in both his medical and his 

personal communities. 

In the early 70s he was in 

partnership with Dr. Hill. Later 

they formed Valley Orthopedic 

Surgeons. He returned to 

private practice in 2003. 

Dr. Loimil requested no services 

but asked that, in lieu of flowers, 

donations be made to Hospice 

Care, 1606 Kanawha Bvd., West,. 

Charleston, WV 25312-2536. 

Online condolences may be sent 

to www.hardingfamily-group.com. 

Robert L. Rudolph II, MD 

Dr. Robert “Bob” L. Rudolph 

II, 60, beloved husband, father 

and granddad went home to his 

Lord and Savior on June 25, 2010, 

at his residence after a brief and 

courageous battle with cancer. 

He was born April 5, 1950, 

in Bethesda, MD, a son of the 

late Dr. Robert L. Rudolph and 

Esther Crile Pfeiffer Rudolph. 

He was a general/ 

vascular surgeon in the 

Parkersburg/Marietta area. 

His education included: Culver 

Military Academy class of 1968, a 

Bachelor of Science with Honors 

in Chemistry from Marietta 

College 1973, graduate work at 

Ohio University Department of 

Chemistry and a Doctor of Medicine 

from the University of Maryland 

in 1980. He then completed his 

general surgery residency at Baylor 

College of Medicine in 1985 and a 

vascular surgery residency at Baylor 

College of Medicine Methodist 

Hospital in 1986. His certifications 

included: Diplomate, American 

Board of Surgery with Certificate 

of Added Qualifications in general 

vascular surgery, American Board 

of Surgery with Certificate of Added 

Qualifications in surgical critical care 

and advanced trauma life support. 

His affiliations included: American 

College of Surgeons, International 

College of Surgeons, Michael E. 

DeBakey International Surgical 

Society, Society of Laparoendoscopic 

Surgeons, Society of Gastrointestinal 

Endoscopic Surgeons, West Virginia 

State Medical Association and 

Parkersburg Academy of Medicine. 

He is survived by his loving wife 

of nine years, Nannette Johnson 

Rudolph, and children, Sarah, 

Jonathan and Robert, all of the 

home, Julie Rudolph Count and 

her husband, Patrick, of Germany, 

Brooke Rudolph Stewart and her 

husband, Nick, of Williamstown, 

Molly Rudolph of Marietta, 

Jennifer Rudolph Ireland and her 

husband, Nate, of Marietta, and 

Bonnie Rudolph Lockhart and her 

husband, Chad, of Mineral Wells. His 

grandchildren include Ben, Sam and 

Emma Count of Stuttgart, Germany, 

Chloe Rudolph of Marietta, Launa 

and Briege Ireland of Marietta, and 

Conner Lockhart of Mineral Wells. 

He is also survived by his brothers, 

David Rudolph and wife, Camille, 

of Houston, TX, and Victor Rudolph 

and wife, Karen, of Durango, CO; and 

sisters, Susan Rudolph Decloedt and 

husband, John, of Milford, NH, and 

Lynn Rudolph Jones and husband, 

George, of Grosse Point Park, MI. 

He was preceded in death by 

both his parents and his previous 

wife, Dawn Denise Rudolph. 

Contributions may be made to 

Wood County Christian School, 113 

W. Ninth St., Williamstown, WV. 


be sent to the family at www. 

leavittfuneralhome.com. 


WESPAC Contributors | 

2010 WESPAC Contributors 

The WVSMA would like to thank the following physicians, residents, medical students and Alliance 

members for their contributions to WESPAC. These contributions were received as of September 7, 2010: 

Chairman’s Club ($1000) 

Patrick P. Dugan, MD 

Allan Kunkel, MD 

Dana Olson, MD 

Steve Sebert, MD 

Phillip Stevens, MD 

Charles Whitaker III, MD 

Extra Miler Plus (>$500) 

Raymond Rushden, MD 

Extra Miler ($500) 

David A. Bowman, MD 

James L. Comerci, MD 

Generoso D. Duremdes, MD 

Ahmed D. Faheem, MD 

Michael A. Kelly, MD 

Harry Marinakis, MD 

Craig M. Morgan, MD 

Frank A. Scattaregia, MD 

Michael A. Stewart, MD 

Robert Wheeler, MD 

Shirley Whitaker 

Dollar-A-Day ($365) 

Greenbrier D. Almond, MD 

Edward F. Arnett, MD 

Joseph Assaley, MD 

Gina Busch, MD 

MaryAnn Cater, DO 

D’Ann E. Duesterhoeft, MD 

Michael O. Fidler, MD 

William L. Harris, MD 

Kathy Harvey, DO 

Lisa Hrutkay, DO 

Theodore Jackson, MD 

Jay J. Kim, MD 

Paul Lee, MD 

M. Barry Louden, Jr., MD 

Sushil K. Mehrotra, MD 

Prasadarao Mukkamala, MD 

Stephen R. Powell, MD 

L. Blair Thrush, MD 

Edward Tiley III, MD 

John A. Wade, Jr., MD 

R. Austin Wallace, MD 

Mark D. White, MD 

Campaigner Plus (> $100) 

Kenneth J. Allen, MD 

Manuel A. Gomez, MD 

Mohammed Khalid Hasan, MD 

Kamalesh Patel, MD 

Finbar G. Powderly, MD 

Richard A. Rashid, MD 

Diane E. Shafer, MD 

Syed M. Siddiqi, MD 

Campaigner ($100) 

Constantino Amores, MD 

Loretto Auvil, MD 

Moutassem B. Ayoubi, MD 

Rano S. Bofill, MD 

Patrick Brown, MD 

Hoyt Burdick, MD 

James M. Carrier, MD 

William H. Carter, MD 

Patsy P. Cipoletti, MD 

W. Alva Deardorff, MD 

Thomas R. Douglass, MD 

John E. Dudich, MD 

Ruperto D. Dumapit Jr., MD 

James D. Felsen, MD 

Paul Francke III, MD 

Frederick D. Gillespie, MD 

Robert Gustafson, MD 

Hannah Hazard, MD 

Robert T. Linger Sr., MD 

Nancy N. Lohuis, MD 

Ignacio H. Luna, Jr, MD 

Tony Majestro, MD 

William Mercer, MD 

Stephen K. Milroy, MD 

William C. Morgan, Jr., MD 

Fred T. Pulido, MD 

David Ratliff, MD 

Wayne Spiggle, MD 

Sadtha Surattanont, MD 

Stanley Tao, MD 

Wilfredo A. Tiu, MD 

Byron L. Van Pelt, MD 

Ophas Vongxaiburana, MD 

John Wurtzbacher, MD 

Syed A. Zahir, MD 

Donor 

Luis A. Almase, MD 

Lynn Comerci 

Monique Gingold, MD 

Douglas W. Midcap, DO 

Kathleen Mimnagh, MD 

Babulal M. Pragani, MD 

Joseph Reed, MD 

Peter Strobl, MD 

Allison Tadros, MD 

The WESPAC Board currently has vacancies for which we are soliciting nominations. If you know someone who would be a great addition 

to the Board please contact our Director, Amy N. Tolliver, MS at amy@wvsma.com or (304) 925-0342. Self nominations are encouraged. 

Drug or Alcohol Problem? Mental Illness? 

If you have a drug or alcohol problem, or are suffering from a mental illness you can get help by 

contacting the West Virginia Medical Professionals Health Program. Information about a practitioner’s 

participation in the program is confidential. Practitioners entering the program as self-referrals without a 

complaint filed against them are not reported to their licensing board. 

West Virginia Medical Professionals Health Program 

PO Box 40027 | Charleston, WV 25364(304) 414-0400 | www.wvmphp.org 


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7

Manuscript Guidelines 

Thanks To Our Advertisers! 

Originality: All scientific and special topic 

manuscripts for the West Virginia Medical Journal will 

not be considered for publication if they have already 

been published or are described in a manuscript 

submitted or accepted for publication elsewhere. All 

scientific articles should be prepared in accordance 



www.icmje.org for complete details. 

Authors: A cover letter from the corresponding 

author should be submitted with the manuscript. All 

persons listed as authors should have participated 

sufficiently in the work to take public responsibility for 

the concept. 

Format: All articles may be submitted by email or on 

CD. Microsoft Word is preferred, but other programs 

are acceptable. All tables or figures should be 

created separately from the body of the manuscript 

as .tif, .jpg or .pdf files in a high resolution format with 

corresponding file names such as, Table 1, Figure 1, 

etc. Legends should be included for all tables and 

figures. 

References: References should be prepared in 

accordance to the “American Medical Association 

Manual of Style.” These instructions for authors are 

available online at www.jama.com. 

Photographs: Please submit high resolution digital 

files with an image size of 300 dpi at 100% of size. 

This high resolution size must be equal to 2.5” by 2.5” 

minimum size. Low resolution photos may be 

rejected or print with poor quality. 

Note to authors: The WV Medical Journal inside pages 

traditionally print in black and white. If authors wish to 

have photos and figures printed in color, there is a 

$1,000 charge per article to help defray the printing 

costs to the Association. Please indicate your preference 

when submitting an article. If your article is accepted for 

publication, you will be invoiced for the charges in 

advance of publication. 

Please address articles and cover letter to the editor at 

this address only: 

F. Thomas Sporck, M.D., F.A.C.S. 

Editor 

West Virginia Medical Journal 

P.O. Box 4106 


or email your article with cover letter to: 

Angela L. Lanham, Managing Editor 

angie@wvsma.com 

Air National Guard............................................ Back Cover 

CAMC Health Ed. and Research Institute..........................1 

Chapman Printing Co...................................................8, 47 

Cleveland Clinic......................................Inside Back Cover 

CPR Solutions Group, Inc..................................................2 

Ear, Nose & Throat Assoc. of Charleston, Inc..................16 

Eye & Ear Clinic...............................................................23 

Flaherty Sensabaugh & Bonasso PLLC..........................18 

Green Clean.....................................................................47 

HIMG................................................................................25 

Images Computer Graphics & Design.............................33 

McCabe Medical Coding and Reimbursement, LLC........ 11 

McLain Surgical Supply...................................................47 

Physician’s Business Office.............................................34 

Renal Consultants............................................................47 

Shreeniwas Jawalekar, MD..............................................47 

Stationers, Inc..................................................................47 

Suttle & Stalnaker............................................................29 

Unicare...............................................................................7 

West Virginia Medical Insurance Agency.........................43 

West Virginia Mutual Insurance Co..................................27 

West Virginia Rural Health Conference...........................15 

West Virginia University......................... Inside Front Cover 

Advertising Policy 

The WVSMA reserves the right to deny advertising space to any individual, 

company, group or association whose products or services interfere with 

the mission, objectives, endorsement agreement(s) and/or any contractual 

obligations of the WVSMA. The WVSMA, in its sole discretion, retains the 

right to decline any submitted advertisement or to discontinue publishing any 

advertisement previously accepted. The Journal does not accept paid political 

advertisements. 

The fact that an advertisement for a product, service, or company appears 

in the Journal is not a guarantee by the WVSMA of the product, service or 

company or the claims made for the product in such advertising. The WVSMA 

reserves the right to enter into endorsements, sponsorship and/or marketing 

agreements that may limit the placement of advertisements for certain 

products or services. 

Subscription Rates: 

$60 a year in the United States 

$100 a year in foreign countries 

$10 per single copy 

POSTMASTER: Send address changes to the West Virginia 

Medical Journal, P.O. Box 4106, Charleston, WV 25364. 

Periodical postage paid at Charleston, WV. 

USPS 676 740 ISSN 0043 - 3284 

Claims for back issues should be made within six months after 

publication. Microfilm editions beginning with the 1972 volume are 

available from University Microfilms International, 300 N. Zeeb Rd., 

Ann Arbor, MI 48106. 

©2009, West Virginia State Medical Association 


Manuscript Guidelines 

Thanks To Our Advertisers! 

Originality: All scientific and special topic 

manuscripts for the West Virginia Medical Journal will 

not be considered for publication if they have already 

been published or are described in a manuscript 

submitted or accepted for publication elsewhere. All 

scientific articles should be prepared in accordance 



www.icmje.org for complete details. 

Authors: A cover letter from the corresponding 

author should be submitted with the manuscript. All 

persons listed as authors should have participated 

sufficiently in the work to take public responsibility for 

the concept. 

Format: All articles may be submitted by email or on 

CD. Microsoft Word is preferred, but other programs 

are acceptable. All tables or figures should be 

created separately from the body of the manuscript 

as .tif, .jpg or .pdf files in a high resolution format with 

corresponding file names such as, Table 1, Figure 1, 

etc. Legends should be included for all tables and 

figures. 

References: References should be prepared in 

accordance to the “American Medical Association 

Manual of Style.” These instructions for authors are 

available online at www.jama.com. 

Photographs: Please submit high resolution digital 

files with an image size of 300 dpi at 100% of size. 

This high resolution size must be equal to 2.5” by 2.5” 

minimum size. Low resolution photos may be 

rejected or print with poor quality. 

Note to authors: The WV Medical Journal inside pages 

traditionally print in black and white. If authors wish to 

have photos and figures printed in color, there is a 

$1,000 charge per article to help defray the printing 

costs to the Association. Please indicate your preference 

when submitting an article. If your article is accepted for 

publication, you will be invoiced for the charges in 

advance of publication. 

Please address articles and cover letter to the editor at 

this address only: 

F. Thomas Sporck, M.D., F.A.C.S. 

Editor 


P.O. Box 4106 


or email your article with cover letter to: 

Angela L. Lanham, Managing Editor 

angie@wvsma.com 

Air National Guard............................................ Back Cover 

CAMC Health Ed. and Research Institute..........................1 

Chapman Printing Co...................................................8, 47 

Cleveland Clinic......................................Inside Back Cover 

CPR Solutions Group, Inc..................................................2 

Ear, Nose & Throat Assoc. of Charleston, Inc..................16 

Eye & Ear Clinic...............................................................23 

Flaherty Sensabaugh & Bonasso PLLC..........................18 

Green Clean.....................................................................47 

HIMG................................................................................25 

Images Computer Graphics & Design.............................33 

McCabe Medical Coding and Reimbursement, LLC........ 11 

McLain Surgical Supply...................................................47 

Physician’s Business Office.............................................34 

Renal Consultants............................................................47 

Shreeniwas Jawalekar, MD..............................................47 

Stationers, Inc..................................................................47 

Suttle & Stalnaker............................................................29 

Unicare...............................................................................7 

West Virginia Medical Insurance Agency.........................43 

West Virginia Mutual Insurance Co..................................27 

West Virginia Rural Health Conference...........................15 

West Virginia University......................... Inside Front Cover 

Advertising Policy 

The WVSMA reserves the right to deny advertising space to any individual, 

company, group or association whose products or services interfere with 

the mission, objectives, endorsement agreement(s) and/or any contractual 

obligations of the WVSMA. The WVSMA, in its sole discretion, retains the 

right to decline any submitted advertisement or to discontinue publishing any 

advertisement previously accepted. The Journal does not accept paid political 

advertisements. 

The fact that an advertisement for a product, service, or company appears 

in the Journal is not a guarantee by the WVSMA of the product, service or 

company or the claims made for the product in such advertising. The WVSMA 

reserves the right to enter into endorsements, sponsorship and/or marketing 

agreements that may limit the placement of advertisements for certain 

products or services. 

Subscription Rates: 

$60 a year in the United States 

$100 a year in foreign countries 

$10 per single copy 

POSTMASTER: Send address changes to the West Virginia 

Medical Journal, P.O. Box 4106, Charleston, WV 25364. 

Periodical postage paid at Charleston, WV. 

USPS 676 740 ISSN 0043 - 3284 

Claims for back issues should be made within six months after 

publication. Microfilm editions beginning with the 1972 volume are 

available from University Microfilms International, 300 N. Zeeb Rd., 

Ann Arbor, MI 48106. 

©2009, West Virginia State Medical Association 



P.O. Box 4106 


www.wvsma.com 

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September/October - West Virginia State Medical Association

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